Flow of information contributing to medication incidents in home care-An analysis considering incident reporters' perspectives

AIM

To describe the contributing factors and types of reported medication incidents in home care related to the flow of information in different phases of the medication process, as reported by multi-professional healthcare groups.

DESIGN

This descriptive, qualitative study used retrospective data.

METHODS

An incident-reporting database was used to collect 14,289 incident reports from 2017 to 2019 in a city in Finland. We used this data to select medication incidents (n = 1027) related to the flow of information in home care and between home care and hospitals. Data were divided into five groups based on the medication phase: (1) prescribing, (2) dispensing, (3) administration, (4) documentation and (5) self-administration. In addition, the types of medication-related incidents were described. The data were examined using abductive content analysis. The EQUATOR SRQR checklist was used in this report.

RESULTS

Four main categories were identified from the data: (1) issues related to information management, (2) cooperation issues between different actors, (3) work environment and lack of resources and (4) factors related to healthcare workers. Cooperation issues contributed to medication-related incidents during each phase. Incomplete communication was a contributing factor to medication incidents. This occurred between home care, remote care, hospital, the client and the client's relatives. Specifically, a lack of information-sharing occurred in repatriation situations, where care transitioned between different healthcare professionals.

CONCLUSION

Healthcare professionals, organisations, clients and their relatives should focus on the efficient and safe acquisition of medications. Specifically, the use of electronic communication systems, together with oral reports and checklists for discharge situations, and timely cooperation with pharmacists should be developed to manage information flows.

RELEVANCE TO CLINICAL PRACTICE

These findings demonstrate that healthcare professionals require uniform models and strategies to accurately and safely prescribe, dispense and administer medications in home care settings. No patient or public contributions.

Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study

BACKGROUND

Monitoring workplace violence (WPV) against health care workers (HCWs) through incident reporting is crucial to drive prevention, but the actual implementation is spotty and experiences underreporting.

OBJECTIVE

This study aims to introduce a systematic WPV surveillance in 2 public referral hospitals in Italy and assess underreporting, WPV annual rates, and attributes "before" (2016-2020) and "after" its implementation (November 2021 to 2022).

METHODS

During 2016-2020, incident reporting was based on procedures and data collection forms that were neither standardized between hospitals nor specific for aggressions. We planned and implemented a standardized WPV surveillance based on (1) an incident report form for immediate and systematic event notification, adopting international standards for violence definitions; (2) second-level root cause analysis with a dedicated psychologist, assessing violence determinants and impacts and offering psychological counseling; (3) a web-based platform for centralized data collection; and (4) periodic training for workforce coordinators and newly hired workers. We used data from incident reports to estimate underreporting, defined as an observed-to-expected (from literature and the "before" period) WPV ratio less than 1, and the 12-month WPV rates (per 100 HCWs) in the "before" and "after" periods. During the latter period, we separately estimated WPV rates for first and recurrent events.

RESULTS

In the "before" period, the yearly observed-to-expected ratios were consistently below 1 and as low as 0.27, suggesting substantial violence underreporting of up to 73%. WPV annual rates declined in 1 hospital (from 1.92 in 2016 to 0.57 in 2020) and rose in the other (from 0.52 to 1.0), with the divergence being attributable to trends in underreporting. Available data were poorly informative to identify at-risk HCW subgroups. In the "after" period, the observed-to-expected ratio rose to 1.14 compared to literature and 1.91 compared to the "before" period, consistently in both hospitals. The 12-month WPV rate was 2.08 (95% CI 1.79-2.42; 1.52 and 2.35 in the 2 hospitals); one-fifth (0.41/2.08, 19.7%) was due to recurrences. Among HCWs, the youngest group (3.79; P<.001), nurses (3.19; P<.001), and male HCWs (2.62; P=.008) reported the highest rates. Emergency departments and psychiatric wards were the 2 areas at increased risk. Physical assaults were more likely in male than female HWCs (45/67, 67.2% vs 62/130, 47.7%; P=.01), but the latter experienced more mental health consequences (46/130, 35.4% vs 13/67, 19.4%; P=.02). Overall, 40.8% (53/130) of female HWCs recognized sociocultural (eg, linguistic or cultural) barriers as contributing factors for the aggression, and 30.8% (40/130) of WPV against female HCWs involved visitors as perpetrators.

CONCLUSIONS

A systematic WPV surveillance reduced underreporting. The identification of high-risk workers and characterization of violence patterns and attributes can better inform priorities and contents of preventive policies. Our evaluation provides useful information for the large-scale implementation of standardized WPV-monitoring programs.

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study

Introduction

Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy.

Aim

To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care.

Method

A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents.

Results

A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n = 626/1121). More than one in 10 (12.6%, n = 142/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular (n = 734) and central nervous (n = 273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n = 383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n = 75/467).

Conclusion

Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge.

Plain language summary

Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place.What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future.What did the researchers find? The total number of incident reports studied was 1121, and the majority (n = 626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task.What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers.

Critical Incident Reports Related to Ventilator Use: Analysis of the Japan Quality Council National Database

OBJECTIVE

This study aimed to assess the factors associated with medical device incidents.

METHODS

In this mixed-methods study, we used incident reporting data from the Japan Council for Quality Health Care. Of the 232 medical device-related reports that were downloaded, 34 (14.7%) were ventilator-associated incidents. Data related to patients, situations, and incidents were collected and coded.

RESULTS

The frequencies of ventilator-associated accidents were 20 (58.8%) during the daytime and 14 (41.2%) during the night/early morning. Ventilator-associated accidents occurred more frequently in the hospital room (n = 22 [64.7%]) than in the intensive care unit (n = 4 [11.8%]). Problems with ventilators occurred in only 4 cases (11.8%); in most cases, medical professionals experienced difficulty with the use or management of ventilators (n = 30 [88.2%]), and 50% of them were due to misuse/misapplication of ventilators (n = 17 [50.0%]). Ventilator-associated accidents were caused by an entanglement of complex factors-hardware, software, environment, liveware, and liveware-liveware interaction. Communication and alarm-related errors were reported to be related, as were intuitiveness or complicated specifications of the device.

CONCLUSIONS

Our study revealed that ventilator-associated accidents were caused by an entanglement of complex factors and were related to inadequate communication among caregivers and families. Moreover, alarms were overlooked owing to inattentiveness. Mistakes were generally caused by a lack of experience, insufficient training, or outright negligence. To reduce the occurrence of ventilator-associated accidents, hospital administrators should develop protocols for employment of new devices. Medical devices should be developed from the perspective of human engineering, which could be one of the systems approaches.

Artificial Intelligence for Identifying the Prevention of Medication Incidents Causing Serious or Moderate Harm: An Analysis Using Incident Reporters' Views

The purpose of this study was to describe incident reporters’ views identified by artificial intelligence concerning the prevention of medication incidents that were assessed, causing serious or moderate harm to patients. The information identified the most important risk management areas in these medication incidents. This was a retrospective record review using medication-related incident reports from one university hospital in Finland between January 2017 and December 2019 (n = 3496). Of these, incidents that caused serious or moderate harm to patients (n = 137) were analysed using artificial intelligence. Artificial intelligence classified reporters’ views on preventing incidents under the following main categories: (1) treatment, (2) working, (3) practices, and (4) setting and multiple sub-categories. The following risk management areas were identified: (1) verification, documentation and up-to-date drug doses, drug lists and other medication information, (2) carefulness and accuracy in managing medications, (3) ensuring the flow of information and communication regarding medication information and safeguarding continuity of patient care, (4) availability, update and compliance with instructions and guidelines, (5) multi-professional cooperation, and (6) adequate human resources, competence and suitable workload. Artificial intelligence was found to be useful and effective to classifying text-based data, such as the free text of incident reports.

Factors contributing to reported medication administration incidents in patients' homes - A text mining analysis

AIMS

To describe the characteristics of medication administration (MA) incidents reported to have occurred in patients' own homes (reporters' profession, incident types, contributing factors, patient consequence, and most common medications involved) and to identify the connection terms related to the most common contributing factors based on free text descriptions.

DESIGN

A retrospective study using descriptive statistical analysis and text mining.

METHODS

Medication administration incidents (N = 19,725) reported to have occurred in patients' homes between 2013-2018 in one district in Finland were analysed, describing the data by the reporters' occupation, incident type, contributing factors, and patient consequence. SAS® Text Miner was used to analyse free text descriptions of the MA incidents to understand contributing factors, using concept linking.

RESULTS

Most MA incidents were reported by practical (lower level) nurses (77.8%, N = 15,349). The most common category of harm was 'mild harm' (40.1%, N = 7,915) and the most common error type was omissions of drug doses (47.4%, N = 9,343). The medications most commonly described were Marevan [warfarin] (N = 2,668), insulin (N = 811), Furesis [furosemide] (N = 590), antibiotic (N = 446), and Panadol [paracetamol] (N = 416). The contributing factors most commonly reported were 'communication and flow of information' (25.5%, N = 5,038), 'patient and relatives' (22.6%, N = 4,451), 'practices' (9.9%, N = 1,959), 'education and training' (4.8%, N = 949), and 'work environment and resources' (3.0%, N = 598).

CONCLUSION

There is need for effective communication and clear responsibilities between home care patients and their relatives and health providers, about MA and its challenges in home environments. Knowledge and skills relating to safe MA are also essential.

IMPACT

These findings about MA incidents that have occurred in patients' homes and have been reported by home care professionals demonstrate the need for medication safety improvement in home care.

A comparison between Parkinson's medication errors identified through retrospective case note review versus via an incident reporting system during hospital admission

OBJECTIVE

To compare the frequency and type of inpatient Parkinson's medication errors reported through an incident report system versus those identified through retrospective case note review in a tertiary teaching hospital.

METHODS

A search of inpatient medication-related incident reports identified those pertaining to Parkinson's medication. A discharge diagnoses search identified admissions for patients with Parkinson's disease over the same time period. A retrospective case note and incident report review were performed to describe and quantify medication-related events.

KEY FINDINGS

Substantially, more medication-related problems were identified via case note review (n = 805) versus incident reporting system (n = 19). A significantly different pattern of error types was identified utilising case note review versus incident reporting, with case note review more likely to identify delayed dosing, and incident reports more likely to identify wrong dose or formulation administered errors.

CONCLUSIONS

Retrospective incident report and case note review can be used to characterise medication administration errors encountered in an inpatient setting. Incident report review alone is insufficient in estimating error rates, and dual data collection methods should be used.

[Incident Analysis in Radiography Focusing on the Experience Period of Radiological Technologist]

We investigated the causes and trends of incidents related to radiography. From April 2014 to March 2016, 384 incident reports related to radiography were posted. We analyzed based on the nature of the incidents and the experience period of radiological technologist (RT). The types of incidents were 'Incorrect examination order by medical doctor' (50.0%), 'X-ray retake' (24%), 'Incorrect examination procedure' (9.9%), 'Fall or injury of the patient under examination' (3.6%), 'selection error of X-ray detector' (3.1%), 'patient mismatch' (1.8%), 'overdose' (1.3%), and 'others' (a malfunctioning device, trouble of systems and the other) (6.5%). There was no relationship between the number of incidents per person and the experience period as RT; (7.8/person for <3 years of experience, 9.7/person for 3-10 years, 6.4/person for 11-25 years of experience, 7.4/person for <25 years of experience). The experience period as RT are related to some types of incident reduction. 'Fall or injury of the patient under examination' and 'overdose' were more frequently reported by RTs of shorter experience (<3 years and 3-10 years of experience) than RTs of longer experience (11-25 years and <25 of experience). On the other hand, 'patient mismatch' and 'selection error of X-ray detector' were more frequently reported by RTs of long experience than RTs of short experience.

Mechanical Ventilation-Related Safety Incidents in General Care Wards and ICU Settings

BACKGROUND

Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored.

METHODS

Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made.

RESULTS

We identified 261 adverse events (with at least 20 adverse events resulting in death) and 702 near-miss events related to mechanical ventilation in Japan between 2010 and 2017. Furthermore, among all adverse events, 19% (49 of 261 events) caused serious harm (residual disability or death). Human-factor issues were most frequent in both ICU/HCU and general care settings (55% and 53%, respectively), while knowledge-based errors were higher in the general care setting.

CONCLUSIONS

Human-factor issues were the most frequent reasons in both settings, while knowledge-based error rates were higher in general care. Our results suggest that proper education and training is needed to minimize patient safety incidents in facilities without respiratory therapists.

Falls among Hospitalized Patients in an Acute Care Hospital: Analyses of Incident Reports

Falls cause injuries such as fractures, skin lacerations, bleeding, and head injury, and could result in more severe medical conditions in hospitalized patients. We retrospectively investigated the incidence and characteristics of falls among hospitalized patients in an acute care hospital from incident reports by hospital staff between January and June 2013. There were 154 falls in 135 patients, 2 of which resulted in fracture. The average age of patients who fell was 63.9 (range 0 to 91) years. Many falls occurred at the bedside (68.2%). Approximately half of all falls were related to elimination (46.6%). The most common time of discovery of falls was 2:00-2:59 AM (14/154;9.1%), followed by early in the morning when patients would actively move. Fall rates in our hospital were 1.39 falls per 1,000 patient days. The department of respiratory medicine and rheumatology had the highest fall rate (3.08 falls per 1,000 patient days), followed by the departments of neurosurgery and neurology (2.98 falls per 1,000 patient days). This study revealed the characteristics of falls in an acute care hospital, and suggests that their notification in the hospital might help reduce the incidence of falls in hospitalized patients. J. Med. Invest. 65:81-84, February, 2018.

Development and implementation of a radiation therapy incident learning system compatible with local workflow and a national taxonomy

PURPOSE

Collaborative incident learning initiatives in radiation therapy promise to improve and standardize the quality of care provided by participating institutions. However, the software interfaces provided with such initiatives must accommodate all participants and thus are not optimized for the workflows of individual radiation therapy centers. This article describes the development and implementation of a radiation therapy incident learning system that is optimized for a clinical workflow and uses the taxonomy of the Canadian National System for Incident Reporting - Radiation Treatment (NSIR-RT).

METHODS

The described incident learning system is a novel version of an open-source software called the Safety and Incident Learning System (SaILS). A needs assessment was conducted prior to development to ensure SaILS (a) was intuitive and efficient (b) met changing staff needs and (c) accommodated revisions to NSIR-RT. The core functionality of SaILS includes incident reporting, investigations, tracking, and data visualization. Postlaunch modifications of SaILS were informed by discussion and a survey of radiation therapy staff.

RESULTS

There were 240 incidents detected and reported using SaILS in 2016 and the number of incidents per month tended to increase throughout the year. An increase in incident reporting occurred after switching to fully online incident reporting from an initial hybrid paper-electronic system. Incident templating functionality and a connection with our center's oncology information system were incorporated into the investigation interface to minimize repetitive data entry. A taskable actions feature was also incorporated to document outcomes of incident reports and has since been utilized for 36% of reported incidents.

CONCLUSIONS

Use of SaILS and the NSIR-RT taxonomy has improved the structure of, and staff engagement with, incident learning in our center. Software and workflow modifications informed by staff feedback improved the utility of SaILS and yielded an efficient and transparent solution to categorize incidents with the NSIR-RT taxonomy.

Analysis of inedible substance ingestion at a Japanese psychiatric hospital

BACKGROUND

Inedible substance ingestion increases the risk of ileus, poisoning, and suffocation. Prevention is especially important in a psychiatric setting. This study aimed to analyze the incidence of inedible substance ingestion in a Japanese psychiatric hospital.

METHODS

Inedible substance ingestion incidents were extracted from an incident report database spanning 2000-2012 at a 400-bed psychiatric hospital in Japan. We tabulated the frequencies of incidents in accordance with major diagnosis, ingested materials, incident levels, and time of occurrence.

RESULTS

The incidence rate was 0.09/1000 patient days, and 149 cases in 105 patients were classified as having experienced inedible substance ingestion. The most common diagnosis was dementia (n = 58), followed by schizophrenia (n = 22). Materials ingested by dementia patients were nappies or gauze attached to the patient's body after medical procedures. Materials ingested by schizophrenic patients were liquid soap, detergent or shampoo, and cigarettes. Inedible substance ingestion among dementia patients occurred mostly before or during meals. Among schizophrenic patients, the peak period of incidents was in the evening.

CONCLUSIONS

Dementia patients were overrepresented in the inedible substance ingestion incidents. Items they wore or applied to their bodies were often subject to ingestion, and such behaviours mostly occurred around meal time. Therefore, the nursing staff were able to discover them quickly and treat most of the cases free of serious consequences. In contrast, schizophrenic patients were underrepresented in the incidents, and most cases involved ingestion of detergent powder or cigarettes, resulting in more serious consequences and requiring treatment.

Learning from defects using a comprehensive management system for incident reports in critical care

Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P<0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety.

Characteristics of adverse medication events in a children's hospital

AIM

To compare adverse medication events (AMEs) reported in children, via the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) coding with events reported via other data sources.

METHOD

AME reports were retrieved using codes Y40-Y59 and X40-X44 over 6 months. Patients' charts were manually reviewed to identify events associated with error and/or harm with medicines during a hospital admission. Medication name, group, error, harm and alert documentation were recorded. Clinical incidents and pharmacist interventions were reviewed for the same period.

RESULTS

Two hundred sixty-three events from January to June 2011 were recorded by ICD-10 coding in 180 patients. After duplicated, missing or unrelated events were excluded and 146 AMEs remained. In the same period, 117 AMEs were reported as incidents and 190 as pharmacist interventions. In total, 276 children with 447 events were reported via all sources. Little duplication between data sources was evident. In total, 158 events involved harm, with 135 of these from ICD-10 coding, 16 from incident reports and 2 pharmacist interventions (including 6 events from multiple sources). Error was involved in 3% of ICD10 reports, 97% of incidents and 100% of interventions. Only 14% of harm-related events from ICD-10 were documented on the medical record clinical alert. Chemotherapy accounted for 31% of harm-related events, antimicrobials 18%, corticosteroids 14% and narcotics 12%.

CONCLUSION

Of the harm-related events, 85% were documented via ICD-10 coding with few documented in other databases. Review of ICD-10-coded AMEs can provide valuable information to improve patient safety and quality.

Pattern of underreporting falls in a general psychiatric hospital in Japan

PURPOSE

To examine the pattern of underreporting of fall incidents in a general psychiatric hospital in Japan.

DESIGN AND METHODS

All fall incidents were analyzed and stratified by ward.

FINDINGS

A discrepancy in fall rates was found in acute psychiatric and dementia wards. The following indicators were suggestive of underreporting: "zero fall/1,000 patient-days," "proportion of falls without injury," and "proportion of falls identified as occurring in the bedroom as a fall location during certain time periods."

PRACTICE IMPLICATIONS

Ward-specific fall rates, with further stratifications by time and location of the fall, were useful for identifying a pattern of underreporting.

Relationship between nursing workloads and patient safety incidents

Objective:

To evaluate the relationship between nursing workloads and patient safety incidents in inpatient wards of a general hospital.

Methods:

A retrospective data analysis was conducted involving the internal medicine wards in a teaching hospital in Japan between July 1st and December 31st, 2006. To assess associations between nursing workloads and patient safety incidents, we analyzed the following: the relationships between the level of patients’ dependency and the number of incident reports; and the relationships between the presence of accidental falls and the presence of patients transferred from the intensive care unit to the wards.

Results:

Fifty-five nurses worked on the wards (105 beds). The total number of incidents was 142 over the 184 days of this study. There was a positive trend between the number of incidents and the total patient dependency score. The presence of accidental falls in the wards was associated with the presence of transfers from the intensive care unit to the wards (odds ratio 3.14, 95% confidence interval: 1.48, 6.65).

Conclusion:

Greater nursing workloads may be related to the higher number of patient safety incidents in inpatient wards of hospitals.