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Jeong H, Choi EY, Lee W, Jang SG, Pyo J, Ock M. Importance of Quality of Medical Record: Differences in Patient Safety Incident Inquiry Results According to Assessment for Quality of Medical Record. J Patient Saf 2024; 20:229-235. [PMID: 38446056 DOI: 10.1097/pts.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND Medical record review is the gold standard method of identifying adverse events. However, the quality of medical records is a critical factor that can affect the accuracy of adverse event detection. Few studies have examined the impact of medical record quality on the identification of adverse events. OBJECTIVES In this study, we analyze whether there were differences in screening criteria and characteristics of adverse events according to the quality of medical records evaluated in the patient safety incident inquiry in Korea. METHODS Patient safety incident inquiry was conducted in 2019 on 7500 patients in Korea to evaluate their screening criteria, adverse events, and preventability. Furthermore, medical records quality judged by reviewers was evaluated on a 4-point scale. The χ 2 test was used to examine differences in patient safety incident inquiry results according to medical record quality. RESULTS Cases with inadequate medical records had higher rates of identified screening criteria than those with adequate records (88.8% versus 55.7%). Medical records judged inadequate had a higher rate of confirmed adverse events than those judged adequate. "Drugs, fluids, and blood-related events," "diagnosis-related events," and "patient care-related events" were more frequently identified in cases with inadequate medical records. There was no statistically significant difference in the preventability of adverse events according to the medical record quality. CONCLUSIONS Lower medical record quality was associated with higher rates of identified screening criteria and confirmed adverse events. Patient safety incident inquiry should specify medical record quality evaluation questions more accurately to more clearly estimate the impact of medical record quality.
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Affiliation(s)
| | - Eun Young Choi
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea
| | - Won Lee
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea
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Boywitt D, Kähler M, Bungard S, Höhle M, Rauh J. [Reliability of peer review-like dialogue in the German statutory quality assurance program]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2024; 186:18-26. [PMID: 38580502 DOI: 10.1016/j.zefq.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/17/2024] [Accepted: 02/19/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Quality measurement in the German statutory program for quality in health care follows a two-step process. For selected areas of health care, quality is measured via performance indicators (first step). Providers failing to achieve benchmarks in these indicators subsequently enter into a peer review process (second step) and are asked by the respective regional authority to provide a written statement regarding their indicator results. The statements are then evaluated by peers, with the goal to assess the provider's quality of care. In the past, similar peer review-based approaches to the measurement of health care quality in other countries have shown a tendency to lack reliability. So far, the reliability of this component of the German statutory program for quality in health care has not been investigated. METHOD Using logistic regression models, the influence of the respective regional authority on the peer review component of health care quality measurement in Germany was investigated using three exemplary indicators and data from 2016. RESULTS Both the probability that providers are asked to provide a statement as well as the results produced by the peer review process significantly depend on the regional authority in charge. This dependence cannot be fully explained by differences in the indicator results or by differences in case volume. CONCLUSIONS The present results are in accordance with earlier findings, which show low reliability for peer review-based approaches to quality measurement. Thus, different results produced by the peer review component of the quality measurement process may in part be due to differences in the way the review process is conducted. This heterogeneity among the regional authorities limits the reliability of this process. In order to increase reliability, the peer review process should be standardized to a higher degree, with clear review criteria, and the peers should undergo comprehensive training for the review process. Alternatively, the future peer review component could be adapted to focus rather on identification of improvement strategies than on reliable provider comparisons.
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Affiliation(s)
- Dennis Boywitt
- Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG), Berlin, Deutschland.
| | - Maximilian Kähler
- Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG), Berlin, Deutschland
| | - Sven Bungard
- Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG), Berlin, Deutschland
| | - Michael Höhle
- Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG), Berlin, Deutschland; Institut für Mathematik und Informatik, Universität Greifswald, Greifswald, Deutschland
| | - Johannes Rauh
- Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG), Berlin, Deutschland
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Strengths and weaknesses of the incident reporting system: An Italian experience. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2023. [DOI: 10.1177/25160435221150568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients’ falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators’ education, no-blame culture promotion, and organizational adjustments may improve operators’ adherence to IRS. Providers do not willingly inform patients’ relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.
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Verlaat CW, Zegers M, Klein R, van Waardenburg D, Kuiper JW, Riedijk M, Kneyber M, Timmers B, van Heerde M, Hazelzet JA, van der Hoeven J, Lemson J. Adverse Events in Pediatric Critical Care Nonsurvivors With a Low Predicted Mortality Risk: A Multicenter Case Control Study. Pediatr Crit Care Med 2023; 24:4-16. [PMID: 36521013 PMCID: PMC9799043 DOI: 10.1097/pcc.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Some patients with a low predicted mortality risk in the PICU die. The contribution of adverse events to mortality in this group is unknown. The aim of this study was to estimate the occurrence of adverse events in low-risk nonsurvivors (LN), compared with low-risk survivors (LS) and high-risk PICU survivors and nonsurvivors, and the contribution of adverse events to mortality. DESIGN Case control study. Admissions were selected from the national Dutch PICU registry, containing 53,789 PICU admissions between 2006 and 2017, in seven PICUs. PICU admissions were stratified into four groups, based on mortality risk (low/high) and outcome (death/survival). Random samples were selected from the four groups. Cases were "LN." Control groups were as follows: "LS," "high-risk nonsurvivors" (HN), and "high-risk survivors" (HS). Adverse events were identified using the validated trigger tool method. SETTING Patient chart review study. PATIENTS Children admitted to the PICU with either a low predicted mortality risk (< 1%) or high predicted mortality risk (≥ 30%). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 419 patients were included (102 LN, 107 LS, 104 HN, and 106 HS). LN had more complex chronic conditions (93.1%) than LS (72.9%; p < 0.01), HN (49.0%; p < 0.001), and HS (48.1%; p < 0.001). The occurrence of adverse events in LN (76.5%) was higher than in LS (13.1%) and HN (47.1%) ( p < 0.001). The most frequent adverse events in LN were hospital-acquired infections and drug/fluid-related adverse events. LN suffered from more severe adverse events compared with LS and HS ( p < 0.001). In 30.4% of LN, an adverse event contributed to death. In 8.8%, this adverse event was considered preventable. CONCLUSIONS Significant and preventable adverse events were found in low-risk PICU nonsurvivors. 76.5% of LN had one or more adverse events. In 30.4% of LN, an adverse event contributed to mortality.
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Affiliation(s)
- Carin W Verlaat
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Zegers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard Klein
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick van Waardenburg
- Department of Pediatric Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem Kuiper
- Department of Pediatric Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maaike Riedijk
- Department of Pediatric Intensive Care, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Martin Kneyber
- Department of Pediatric Intensive Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Brigitte Timmers
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc van Heerde
- Department of Pediatric Intensive Care, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jan A Hazelzet
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Joris Lemson
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Determining the requirements of a medical records electronic deficiency management system: a mixed-method study. RECORDS MANAGEMENT JOURNAL 2022. [DOI: 10.1108/rmj-02-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose
Despite the presence of electronic medical records systems, traditional paper-based methods are often used in many countries to document data and eliminate medical record deficiencies. These methods waste patient and hospital resources. The purpose of this study is to evaluate the traditional deficiency management system and determine the requirements of an electronic deficiency management system in settings that currently use paper records alongside electronic hospital information systems.
Design/methodology/approach
This mixed-method study was performed in three phases. First, the traditional process of medical records deficiency management was qualitatively evaluated. Second, the accuracy of identifying deficiencies by the traditional and redesigned checklists was compared. Third, the requirements for an electronic deficiency management system were discussed in focus group sessions.
Findings
Problems in the traditional system include inadequate guidelines, incomplete procedures for evaluating sheets and subsequent delays in activities. Problems also included the omission of some vital data elements and a lack of feedback about the documentation deficiencies of each documenter. There was a significant difference between the mean number of deficiencies identified by traditional and redesigned checklists (p < 0.0001). The authors proposed an electronic deficiency management system based on redesigned checklists with improved functionalities such as discriminating deficiencies based on the documenter’s role, providing systematic feedback and generating automatic reports.
Originality/value
Previous studies only examined the positive effect of audit and feedback methods to enhance the documentation of data elements in electronic and paper medical records. The authors propose an electronic deficiency management system for medical records to solve those problems. Health-care policymakers, hospital managers and health information systems developers can use the proposed system to manage deficiencies and improve medical records documentation.
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Michelson KA, Griffey RT. Why identifying adverse events in paediatric emergency care matters. BMJ Qual Saf 2022; 31:776-778. [PMID: 35863876 PMCID: PMC9859933 DOI: 10.1136/bmjqs-2022-014939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Richard T Griffey
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri, USA
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Verman S, Anjankar A. A Narrative Review of Adverse Event Detection, Monitoring, and Prevention in Indian Hospitals. Cureus 2022; 14:e29162. [PMID: 36258971 PMCID: PMC9564564 DOI: 10.7759/cureus.29162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022] Open
Abstract
An adverse event is any abnormal clinical finding associated with the use of a therapy. Adverse events are classified by reporting an event's seriousness, expectedness, and relatedness. Monitoring patient safety is of utmost importance as more and more data becomes available. In reality, very low numbers of adverse events are reported via the official path. Chart review, voluntary reporting, computerized surveillance, and direct observation can detect adverse drug events. Medication errors are commonly seen in hospitals and need provider and system-based interventions to prevent them. The need of the hour in India is to develop and implement medication safety best practices to avoid adverse events. The utility of artificial intelligence techniques in adverse event detection remains unexplored, and their accuracy and precision need to be studied in a controlled setting. There is a need to develop predictive models to assess the likelihood of adverse reactions while testing novel pharmaceutical drugs.
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Kim MJ, Seo HJ, Koo HM, Ock M, Hwang JI, Lee SI. The Korea National Patient Safety Incidents Inquiry Survey: Feasibility of Medical Record Review for Detecting Adverse Events in Regional Public Hospitals. J Patient Saf 2022; 18:389-395. [PMID: 35067623 PMCID: PMC9329038 DOI: 10.1097/pts.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We aimed to examine the Korea National Patient Safety Incidents Inquiry conducted in the Republic of Korea; specifically, we assessed the validity of screening criteria, interreviewer reliability, quality of medical records, and the time required for reviewing medical records. METHODS A 3-stage retrospective medical record review was performed. The sensitivity and positive predictive value of the screening criteria for the adverse events were calculated, and interreviewer reliability was verified using the overall agreement rate and κ value. In addition, the results of medical record quality assessment and time required for review were analyzed. RESULTS There were a total of 4159 patients (55.5%) with at least 1 of the 41 screening criteria. In stage 1, the overall percent of agreement was 81.9% when all negatives from the 2 reviewers were included, and the κ value was 0.64 (95% confidence interval [CI], 0.61-0.66). In stage 2, 84.6% of cases were a perfect match, and 87.4% were a partial match. The κ values were 0.159 (95% CI, 0.12-0.20) and 0.389 (95% CI, 0.35-0.43), respectively. The mean quality assessment scores were 3.18 of 4 points in stage 1 and 3.05 of 4 points in stage 2. In stage 1, it took an average of 13.02 minutes to asses each patient file; in stage 2, it took an average of 5.06 minutes. CONCLUSIONS To increase the feasibility of medical record review for detecting adverse events, it is important not only to improve the reliability between reviewers but also to monitor the quality of medical records and the time required for review.
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Affiliation(s)
- Min Ji Kim
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hee Jung Seo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hong Mo Koo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
- Department of Preventive Medicine, University of Ulsan College of Medicine
| | - Jee-In Hwang
- Department of Nursing Management, College of Nursing Science, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Il Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine
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Vázquez-Cornejo E, Morales-Ríos O, Hernández-Pliego G, Cicero-Oneto C, Garduño-Espinosa J. Incidence, severity, and preventability of adverse events during the induction of patients with acute lymphoblastic leukemia in a tertiary care pediatric hospital in Mexico. PLoS One 2022; 17:e0265450. [PMID: 35324939 PMCID: PMC8947076 DOI: 10.1371/journal.pone.0265450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/01/2022] [Indexed: 11/18/2022] Open
Abstract
Healthcare-associated adverse events represent a heavy burden of symptoms for pediatric oncology patients. Their description allows knowing the safety and quality of the care processes in countries with limited resources. This study aimed to describe the incidence, types, severity, and preventability of adverse events occurring in pediatric patients with acute lymphoblastic leukemia during the induction phase in a tertiary care pediatric hospital in Mexico. This study analyzed a cohort based on medical records of between 2015 and 2017. Initially, information on patients and adverse events was collected; subsequently, two pediatric oncologist reviewers independently classified adverse events, severity and preventability. Agreement between reviewers was evaluated. Adverse events incidence rates were estimated by type, severity, and preventability. One-hundred and eighty-one pediatric patients pediatric patients with acute lymphoblastic leukemia were studied. An overall adverse events rate of 51.8 per 1000 patient-days was estimated, involving 81.2% of patients during induction. Most adverse events were severe or higher (52.6%). Infectious processes were the most common severe or higher adverse event (30.5%). The presence of adverse events caused 80.2% of hospital readmissions. Of the adverse events, 10.5% were considered preventable and 53.6% could be ameliorable in severity. Improving the safety and quality of the care processes of children with acute lymphoblastic leukemia is possible, and this should contribute to the mitigation and prevention of adverse events associated morbidity and mortality during the remission induction phase.
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Affiliation(s)
- Edmundo Vázquez-Cornejo
- Department of Drug Assessment and Pharmacovigilance, Federico Gómez Children’s Hospital of Mexico, Mexico City, Mexico
- * E-mail:
| | - Olga Morales-Ríos
- Department of Drug Assessment and Pharmacovigilance, Federico Gómez Children’s Hospital of Mexico, Mexico City, Mexico
| | | | - Carlo Cicero-Oneto
- Department of Hemato-oncology, Federico Gómez Children’s Hospital of Mexico, Mexico City, Mexico
| | - Juan Garduño-Espinosa
- Department of Research, Federico Gómez Children’s Hospital of Mexico, Mexico City, Mexico
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Kim S, Shin HG, Jo AEJ, Min A, Ock M, Hwang JI, Jeong Y, Park MS, Lee JB, Chang TIK, Song E, Kim H, Lee SI. Variation between hospitals and reviewers in detection of adverse events identified through medical record review in Korea. Int J Qual Health Care 2020; 32:495-501. [PMID: 32696047 DOI: 10.1093/intqhc/mzaa079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/24/2020] [Accepted: 07/07/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES This study utilized the method of medical record review to determine characteristics of adverse events that occurred in the inpatient units of hospitals in Korea as well as the variations in adverse events between institutions. DESIGN A two-stage retrospective medical record review was conducted. The first stage was a nurse review, where two nurses reviewed medical records of discharged patients to determine if screening criteria had been met. In the second stage, two physicians independently reviewed medical records of patients identified in the first stage, to determine whether an adverse event had occurred. SETTING Inpatient units of six hospitals. PARTICIPANTS Medical records of 2 596 patients randomly selected were reviewed in the first stage review. INTERVENTION(S) N/A. MAIN OUTCOME MEASURE(S) Adverse events. RESULTS A total of 277 patients (10.7%) were confirmed to have had one or more adverse event(s), and a total of 336 adverse events were identified. Physician reviewers agreed about whether an adverse event had occurred for 141 patients (5.4%). The incidence rate of adverse events was at least 1.3% and a maximum of 19.4% for each hospital. Most preventability scores were less than four points (non-preventable), and there were large variations between reviewers and institutions. CONCLUSIONS Given the level of variation in the identified adverse events, further studies that include more medical institutions in their investigations are needed, and a third-party committee should be involved to address the reliability issues regarding the occurrence and characteristics of the adverse events.
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Affiliation(s)
- Sukyeong Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Ho Gyun Shin
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - A E Jeong Jo
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Ari Min
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea
| | - Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.,Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jee-In Hwang
- Department of Nursing Management, College of Nursing Science, Kyung Hee University, Seoul, Republic of Korea
| | - Youngjin Jeong
- Department of Family Medicine, Veterans Health Service (VHS) Medical center, Seoul, Republic of Korea
| | - Moon Sung Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Jong Bouk Lee
- Department of Urology, National Medical Center, Seoul, Republic of Korea
| | - Tae I K Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Eunhyang Song
- Department of Neurology, Seoul Metropolitan Seobuk Hospital, Seoul, South Korea
| | - Heungseon Kim
- Department of Quality Improvement, Mediplex Sejong Hospital, Incheon, Republic of Korea
| | - Sang-Il Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Ferorelli D, Solarino B, Trotta S, Mandarelli G, Tattoli L, Stefanizzi P, Bianchi FP, Tafuri S, Zotti F, Dell’Erba A. Incident Reporting System in an Italian University Hospital: A New Tool for Improving Patient Safety. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176267. [PMID: 32872189 PMCID: PMC7503737 DOI: 10.3390/ijerph17176267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 01/05/2023]
Abstract
Clinical risk management constitutes a central element in the healthcare systems in relation to the reverberation that it establishes, and as regards the optimization of clinical outcomes for the patient. The starting point for a right clinical risk management is represented by the identification of non-conforming results. The aim of the study is to carry out a systematic analysis of all data received in the first three years of adoption of a reporting system, revealing the strengths and weaknesses. The results emerged showed an increasing trend in the number of total records. Notably, 86.0% of the records came from the medical category. Moreover, 41.0% of the records reported the possible preventive measures that could have averted the event and in 30% of the reports are hints to be put in place to avoid the repetition of the events. The second experimental phase is categorizing the events reported. Implementing the reporting system, it would guarantee a virtuous cycle of learning, training and reallocation of resources. By sensitizing health workers to a correct use of the incident reporting system, it could become a virtuous error learning system. All this would lead to a reduction in litigation and an implementation of the therapeutic doctor–patient alliance.
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Affiliation(s)
- Davide Ferorelli
- Interdisciplinary Department of Medicine, Section of Legal Medicine, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (B.S.); (S.T.); (G.M.); (F.Z.); (A.D.)
- Correspondence: ; Tel.: +39-3284138388
| | - Biagio Solarino
- Interdisciplinary Department of Medicine, Section of Legal Medicine, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (B.S.); (S.T.); (G.M.); (F.Z.); (A.D.)
| | - Silvia Trotta
- Interdisciplinary Department of Medicine, Section of Legal Medicine, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (B.S.); (S.T.); (G.M.); (F.Z.); (A.D.)
| | - Gabriele Mandarelli
- Interdisciplinary Department of Medicine, Section of Legal Medicine, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (B.S.); (S.T.); (G.M.); (F.Z.); (A.D.)
| | - Lucia Tattoli
- Città della Salute e della Scienza di Torino, Turin Hospital, 10126 Torino, Italy;
| | - Pasquale Stefanizzi
- Biomedical Science and Human Oncology, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (P.S.); (F.P.B.); (S.T.)
| | - Francesco Paolo Bianchi
- Biomedical Science and Human Oncology, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (P.S.); (F.P.B.); (S.T.)
| | - Silvio Tafuri
- Biomedical Science and Human Oncology, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (P.S.); (F.P.B.); (S.T.)
| | - Fiorenza Zotti
- Interdisciplinary Department of Medicine, Section of Legal Medicine, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (B.S.); (S.T.); (G.M.); (F.Z.); (A.D.)
| | - Alessandro Dell’Erba
- Interdisciplinary Department of Medicine, Section of Legal Medicine, University of Bari, Piazza Giulio Cesare 11, 70100 Bari, Italy; (B.S.); (S.T.); (G.M.); (F.Z.); (A.D.)
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Caeymaex L, Lebeaux C, Roze JC, Danan C, Reynaud A, Jung C, Audureau E. Study on preventing adverse events in neonates (SEPREVEN): A stepped-wedge randomised controlled trial to reduce adverse event rates in the NICU. Medicine (Baltimore) 2020; 99:e20912. [PMID: 32756081 PMCID: PMC7402760 DOI: 10.1097/md.0000000000020912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Adverse events (AE) in care are recognized as a leading cause of mortality and injury in patients. Improving patients' safety is difficult to achieve. Therefore, innovative research strategies are needed to identify errors in subgroups of patients and related severity of outcomes as well as reliably measured efficiency of reproducible strategies to improve safety. This trial aims to evaluate the impact of a combined multiprofessional education program on the rate of AE in neonatal intensive care units (NICUs). METHODS AND ANALYSIS This is a stepped-wedge cluster randomised controlled trial with 3 clusters each containing 4 units. The study time period will be 20 months. The education program will be implemented within each cluster following a random sequence with a control period, a 4-month transition period and a post-educational intervention period. Eligibility criteria: for clusters: 6 NICUs from Ile-de-France and 6 NICUs from different regions in France; for patients: in-hospital during the study period (November 23, 2015 and November 2, 2017 [inclusion start dates varying by unit]) in one of the 12 NICUs; corrected gestational age ≤42 weeks upon admission; hospitalization period >2 days; and parents informed and not opposed to the use of their newborn's data. A routine occurrence reporting of medical errors and their consequence will take place during the entire study period. The intervention will combine an education to implement a standardized root cause analysis method, creation of bundles (insertion, daily goals, maintenance bundles) to prevent catheter-associated blood-stream infection and a poster to prevent extravasation injuries. OUTCOME We hypothesize a reduction from 60 (control) to 50 (intervention) AE/1000 patient-days. The primary outcome will be the rate of AE/1000 patient-days in the NICU. TRIAL REGISTRATION NUMBER NCT02598609, trial registered November 6, 2015. https://clinicaltrials.gov/ct2/show/NCT02598609. ETHICS AND DISSEMINATION Study approved by the regional ethic committee CPP Ile-de-France III (no 2014-A01751-46). The results will be published in peer-reviewed journals.
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Affiliation(s)
- Laurence Caeymaex
- Faculty of Health and CEDITEC, University Paris East Creteil
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Creteil
- Clinical Research Center (CRC), Centre Hospitalier Intercommunal de Creteil, Créteil
| | - Cecile Lebeaux
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Creteil
| | - Jean Christophe Roze
- Pediatric Intensive Care Unit Nantes, University Hospital Centre Nantes, Pays de la Loire
| | - Claude Danan
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Creteil
- Clinical Research Center (CRC), Centre Hospitalier Intercommunal de Creteil, Créteil
| | | | - Camille Jung
- Clinical Research Center (CRC), Centre Hospitalier Intercommunal de Creteil, Créteil
| | - Etienne Audureau
- Faculty of Health and CEDITEC, University Paris East Creteil
- IMRB INSERM U 955 Team CEpiA (Clinical Epidemiology and Ageing Unit), Creteil, Val de Marne
- Assistance Publique Hôpitaux de Paris (APHP), Hôpital Henri-Mondor, Clinical Research Unit (URC), Public Health Department, Créteil, France
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13
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Eulmesekian PG, Alvarez JP, Ceriani Cernadas JM, Pérez A, Berberis S, Kondratiuk Y. The occurrence of adverse events is associated with increased morbidity and mortality in children admitted to a single pediatric intensive care unit. Eur J Pediatr 2020; 179:473-482. [PMID: 31814049 DOI: 10.1007/s00431-019-03528-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/22/2019] [Accepted: 11/10/2019] [Indexed: 11/30/2022]
Abstract
Healthcare can cause harm. The goal of this study is to evaluate the association between the occurrence of adverse events (AEs) and morbidity-mortality in critically ill children. A prospective cohort study was designed. All children admitted to the Pediatric Intensive Care Unit (PICU) between August 2016 and July 2017 were followed. An AE was considered any harm associated with a healthcare-related incident. AEs were identified in two steps: first, adverse clinical incidents (ACI) were recognized through direct observation and active surveillance by PICU physicians, and then the patient safety committee evaluated every ACI to define which would be considered an AE. The outcome was hospital morbidity-mortality. There were 467 ACI registered, 249 (53.31%) were considered AEs and the rate was 4.27/100 patient days. From the 842 children included, 142 (16.86%) suffered AEs, 39 (4.63%) experienced morbidity-mortality: 33 (3.92%) died, and 6 (0.71%) had morbidity. Multivariate analysis revealed that the occurrence of AEs was significantly associated with morbidity-mortality, OR 5.70 (CI95% 2.58-12.58, p = 0.001). This association was independent of age and severity of illness score.Conclusion: Experiencing AEs significantly increased the risk of morbidity-mortality in this cohort of PICU children.What is Known:• Many children suffer healthcare-associated harm during pediatric intensive care hospitalization.What is New:• This prospective cohort study shows that experiencing adverse events during pediatric intensive care hospitalization significantly increases the risk of morbidity and mortality independent of age and severity of illness at admission.
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Affiliation(s)
- Pablo G Eulmesekian
- Pediatric Intensive Care Unit, Hospital Italiano de Buenos Aires, Perón 4190, CP 1181, Autonomous City of Buenos Aires, Argentina.
| | - Juan P Alvarez
- Pediatric Intensive Care Unit, Hospital Italiano de Buenos Aires, Perón 4190, CP 1181, Autonomous City of Buenos Aires, Argentina
| | - José M Ceriani Cernadas
- Patient Safety Committee|, Hospital Italiano de Buenos Aires, Autonomous City of Buenos Aires, Argentina
| | - Augusto Pérez
- Pediatric Intensive Care Unit, Hospital Italiano de Buenos Aires, Perón 4190, CP 1181, Autonomous City of Buenos Aires, Argentina
| | - Stefanía Berberis
- Pediatric Intensive Care Unit, Hospital Italiano de Buenos Aires, Perón 4190, CP 1181, Autonomous City of Buenos Aires, Argentina
| | - Yanel Kondratiuk
- Pediatric Intensive Care Unit, Hospital Italiano de Buenos Aires, Perón 4190, CP 1181, Autonomous City of Buenos Aires, Argentina
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14
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Klein DO, Rennenberg R, Gans R, Enting R, Koopmans R, Prins MH. Limited external reproducibility restricts the use of medical record review for benchmarking. BMJ Open Qual 2019; 8:e000564. [PMID: 31206063 PMCID: PMC6542435 DOI: 10.1136/bmjoq-2018-000564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/19/2019] [Accepted: 03/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background Medical record review (MRR) is used to assess the quality and safety in hospitals. It is increasingly used to compare institutions. Therefore, the external reproducibility should be high. In the current study, we evaluated this external reproducibility for the assessment of an adverse event (AE) in a sample of records from two university medical centres in the Netherlands, using the same review method. Methods From both hospitals, 40 medical records were randomly chosen from patient files of deceased patients that had been evaluated in the preceding years by the internal review committees. After reviewing by the external committees, we assessed the overall and kappa agreement by comparing the results of both review rounds (once by the own internal committee and once by the external committee). This was calculated for the presence of an AE, preventability and contribution to death. Results Kappa for the presence of AEs was moderate (k=0.47). For preventability, the agreement was fair (k=0.39) and poor for contribution to death (k=−0.109). Conclusion We still believe that MRR is suitable for the detection of general issues concerning patient safety. However, based on the outcomes of this study, we would advise to be careful when using MRR for benchmarking.
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Affiliation(s)
- Dorthe O Klein
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, The Netherlands
| | - Roger Rennenberg
- Department of Internal Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Rijk Gans
- Department of Internal Medicine, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Roelien Enting
- Department of Neurology, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Richard Koopmans
- Department of Internal Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Martin H Prins
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
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