A cross-national comparison of incident reporting systems implemented in German and Swiss hospitals

OBJECTIVE

This study aimed to empirically compare incident reporting systems (IRS) in two European countries and to explore the relationship of IRS characteristics with context factors such as hospital characteristics and characteristics of clinical risk management (CRM).

DESIGN

We performed exploratory, secondary analyses of data on characteristics of IRS from nationwide surveys of CRM practices.

SETTING

The survey was originally sent to 2136 hospitals in Germany and Switzerland.

PARTICIPANTS

Persons responsible for CRM in 622 hospitals completed the survey (response rate 29%).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Differences between IRS in German and Swiss hospitals were assessed using Chi2, Fisher's Exact and Freeman-Halton-Tests, as appropriate. To explore interrelations between IRS characteristics and context factors (i.e. hospital and CRM characteristics) we computed Cramer's V.

RESULTS

Comparing participating hospitals across countries, Swiss hospitals had implemented IRS earlier, more frequently and more often provided introductory IRS training systematically. German hospitals had more frequently systematically implemented standardized procedures for event analyses. IRS characteristics were significantly associated with hospital characteristics such as hospital type as well as with CRM characteristics such as existence of strategic CRM objectives and of a dedicated position for central CRM coordination.

CONCLUSIONS

This study contributes to an improved understanding of differences in the way IRS are set up in two European countries and explores related context factors. This opens up new possibilities for empirically informed, strategic interventions to further improve dissemination of IRS and thus support hospitals in their efforts to move patient safety forward.

Motivational antecedents of incident reporting: evidence from a survey of nurses and physicians

QUESTIONS UNDER STUDY

Underreporting is a major issue when using incident reporting systems to improve safety in hospitals. Based on a psychological framework, this study investigated the motivational antecedents of the willingness to report into incident reporting systems in healthcare. Individual, organisational and system-related influences on the willingness to report incidents were investigated in a survey of physicians and nurses from five Swiss hospitals.

METHODS

The motivational antecedents were tested using structural equation modelling. The sample consisted of 818 respondents, 546 nurses and 230 physicians; the response rate was 32%. The willingness to report was assessed by using a self-report scale, validated with the self-reported number of reported incidents during the previous year.

RESULTS

The most important influence on the willingness to report was the transparency of the incident reporting system procedures to potential users, such as. knowing how and what kind of events to report. At the individual level, the perceived effectiveness of reporting was a relevant antecedent. At the organisational level, management support positively influenced the willingness to report. Different antecedents were found to be relevant for nurses and physicians.

CONCLUSIONS

Implications are discussed that open up alternatives for the design and implementation of incident reporting systems in healthcare. For example, the results of the study point to opportunities for making incident reporting systems more transparent and participatory and to allow for experience of how they actually improve patient safety.

Clinical risk management in hospitals: strategy, central coordination and dialogue as key enablers

OBJECTIVE

The study aims to identify key enablers fostering clinical risk management (CRM) in hospitals to guide health care in this vital area of patient safety.

METHOD

A cross-sectional survey was conducted at the national level in 324 Swiss hospitals in 2007-2008 to assess the relationship between key elements and systematic CRM. Therefore, a comprehensive monitoring instrument for CRM was used for the first time. Organizational factors (e.g. strategy, coordination, resources) and structural conditions (e.g. hospital size) were tested as key elements. CRM was assessed by evaluating its maturity (i.e. the level of CRM development) by 12 theoretically derived indices joining together essential aspects of CRM at the hospital level and the service level. Chi-square measures were used to analyse the relationships between organizational factors or structural conditions and maturity of CRM.

RESULTS

Participation in this voluntary survey was good, with CRM experts of 138 out of 324 hospitals responding (response rate 43%). Three key enablers for CRM were identified: implementing a function for central CRM coordination, assuring dialogue with and between the different hospital services, and developing strategic CRM objectives.

CONCLUSIONS

This study offers, for the first time, an assessment of the maturity of hospitals' CRM and identifies key enablers related to CRM. This is a feasible first step in guiding hospitals to shape their CRM and presents a basis for future studies, for example, linking CRM to outcome data.

Clinical risk management in mental health: a qualitative study of main risks and related organizational management practices

Background

A scientific understanding of clinical risk management (CRM) in mental health care is essential for building safer health systems and for improving patient safety. While evidence on patient safety and CRM in physical health care has increased, there is limited research on these issues in mental health care. This qualitative study provides an overview of the most important clinical risks in mental health and related organizational management practices.

Methods

We conducted in-depth expert interviews with professionals responsible for CRM in psychiatric hospitals. Interviews were transcribed and analyzed applying qualitative content analysis to thematically sort the identified risks.

Results

The main concerns for CRM in mental health are a) violence and self-destructive behavior (i.e. protecting patients and staff from other patients, and patients from themselves), b) treatment errors, especially in the process of therapy, and c) risks associated with mental illnesses (e.g. psychosis or depression). This study identified critical differences to CRM in hospitals for physical disorder and challenges specific to CRM in mental health. Firstly, many psychiatric patients do not believe that they are ill and are therefore in hospital against their will. Secondly, staff safety is a much more prominent theme for CRM in mental health care as it is directly related to the specifics of mental illnesses.

Conclusions

The current study contributes to the understanding of patient safety and raises awareness for CRM in mental health. The mental health specific overview of central risks and related organizational management practices offers a valuable basis for CRM development in mental health and an addition to CRM in general.

Assessing hospitals' clinical risk management: Development of a monitoring instrument

BACKGROUND

Clinical risk management (CRM) plays a crucial role in enabling hospitals to identify, contain, and manage risks related to patient safety. So far, no instruments are available to measure and monitor the level of implementation of CRM. Therefore, our objective was to develop an instrument for assessing CRM in hospitals.

METHODS

The instrument was developed based on a literature review, which identified key elements of CRM. These elements were then discussed with a panel of patient safety experts. A theoretical model was used to describe the level to which CRM elements have been implemented within the organization. Interviews with CRM practitioners and a pilot evaluation were conducted to revise the instrument. The first nationwide application of the instrument (138 participating Swiss hospitals) was complemented by in-depth interviews with 25 CRM practitioners in selected hospitals, for validation purposes.

RESULTS

The monitoring instrument consists of 28 main questions organized in three sections: 1) Implementation and organizational integration of CRM, 2) Strategic objectives and operational implementation of CRM at hospital level, and 3) Overview of CRM in different services. The instrument is available in four languages (English, German, French, and Italian). It allows hospitals to gather comprehensive and systematic data on their CRM practice and to identify areas for further improvement.

CONCLUSIONS

We have developed an instrument for assessing development stages of CRM in hospitals that should be feasible for a continuous monitoring of developments in this important area of patient safety.

Squash racquets. A review of physiology and medicine

Squash is a moderate to high intensity sport which demands specific fitness. Squash at any level places a high demand on the aerobic system for energy delivery during play and recovery. In addition, the sport requires bursts of intense, anaerobic physical activity involving the lactic anaerobic energy system. Players must possess appropriate levels of local muscular endurance, strength, power, flexibility and speed, combined with agility, balance and co-ordination. Irrespective of the standard of play, aerobic fitness training and specific anaerobic training should be undertaken by all who play or intend to play squash. Aerobic fitness for the individual who is new to the game and has little training background can be improved using low intensity continuous running. Training sessions and matches should be preceded by warm-up and flexibility exercises which may reduce the chance of injury and enhance readiness to perform. Despite squash being an indoor sport, it is likely that play in hot and humid weather may generate significant thermal loads with the associated elevations in heart rate. Fluid losses of 2 L/min and rectal temperatures of 39 degrees C may occur, thereby increasing the cardiovascular stress of participation and the risk of heat illness. Sudden death and other manifestations of heart disease can occur in squash, therefore advice regarding the safe participation for those with, or who have the potential to develop disease appears essential. For those under 40 years of age who are well and have no known heart disease, medical clearance is not mandatory prior to taking up squash; for such individuals, regular medical monitoring may be unnecessary. For healthy individuals older than 40 years of age irrespective of health status, but particularly for those with coronary disease or relevant risk factors, a medical checkup is recommended prior to, and at least annually after taking up squash. Healthy individuals older than 40 years of age with one or more risk factors require a medical checkup prior to commencing squash for the first time and at regular intervals (every 2 years) thereafter. These individuals should also have a medically supervised exercise test. Those individuals older than 40 years of age who have a known history of heart disease, most commonly coronary artery disease, may play squash if it is demonstrated that, on examination or following therapy or surgery, they can exercise safely to a high workload. Most eye injuries which occur in squash are related to eye/ball and eye/racquet contact. The incidence of injury is very low but such injuries may be totally preventable. Ideally, all players should wear protective eye apparatus. The "ideal' protective apparatus should comply with the Australian/New Zealand Standard for eye protectors for racquet sports. It should be recognised at the outset that there is a paucity of specific data regarding squash and pregnancy. Most women with normal pregnancies may continue to exercise and play squash particularly in the early stages of pregnancy but should notify their physician of their intention to do so. Musculo-skeletal injuries to the lower limb dominate most studies and common injuries include sprains and strains to the back and ankles. Of particular interest is the development of degenerative hip disease in elite squash players necessitating retirement or curtailment of activity in the third decade. Dealing with injuries and illness that are attributed to squash requires an approach based on prevention as well as on appropriate injury management.

[Dry chemistry in the clinical laboratory: how reliable is it?]

The performance of dry chemistry analysis systems was evaluated using the results obtained from proficiency testing 1991 of practitioner's laboratories. 59% of the participants use dry chemistry (Ektachem DT 60 Kodak, Reflotron Boehringer, Cobas Ready Roche). The evaluation reveals the following: The declared values of the control sera for the dry chemistry systems agree well with those of the conventional wet chemistry, excepting enzyme assays. The precision of the dry chemistry parameters is substantially higher than that of the wet chemistry. The overall performance of the dry chemistry analysis systems was found to be superior as compared to the wet chemistry performance. A prerequisite for dry chemistry proficiency testing are control sera of human origin.

One-step sandwich enzyme immunoassay for insulin using monoclonal antibodies

An enzyme-linked immunosorbent assay for the measurement of insulin in human serum has been developed. The test is based on the sandwich technique with two monoclonal antibodies directed against two different epitopes of insulin using coated plastic tubes as the solid phase and horse radish peroxidase as the label. The immunoreactions are completed in one step within 2 h. The horse radish peroxidase activity bound to the tube wall is measured photometrically after an additional 1-h incubation with the substrate. The standards used cover the range from 0 to 260 mU insulin/L. Employing the Enzymun-Test System ES 22 modular batch analyzer, the detection limit was found to be 3.7 mU insulin/L. Coefficients of variation (CV's) between 1.4-7.8% for intraassay precision and 5.6-10% for interassay precision were obtained over the concentration range of 17-107 mU Insulin/L. The correlation between the procedure described here (y) and a commercially available double antibody radioimmunoassay (x) is expressed by the following equation: y = 1.07x + 1.14 mU insulin/L.