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McMaster C, Chan J, Liew DFL, Su E, Frauman AG, Chapman WW, Pires DEV. Developing a deep learning natural language processing algorithm for automated reporting of adverse drug reactions. J Biomed Inform 2023; 137:104265. [PMID: 36464227 DOI: 10.1016/j.jbi.2022.104265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 11/01/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
The detection of adverse drug reactions (ADRs) is critical to our understanding of the safety and risk-benefit profile of medications. With an incidence that has not changed over the last 30 years, ADRs are a significant source of patient morbidity, responsible for 5%-10% of acute care hospital admissions worldwide. Spontaneous reporting of ADRs has long been the standard method of reporting, however this approach is known to have high rates of under-reporting, a problem that limits pharmacovigilance efforts. Automated ADR reporting presents an alternative pathway to increase reporting rates, although this may be limited by over-reporting of other drug-related adverse events. We developed a deep learning natural language processing algorithm to identify ADRs in discharge summaries at a single academic hospital centre. Our model was developed in two stages: first, a pre-trained model (DeBERTa) was further pre-trained on 1.1 million unlabelled clinical documents; secondly, this model was fine-tuned to detect ADR mentions in a corpus of 861 annotated discharge summaries. This model was compared to a version without the pre-training step, and a previously published RoBERTa model pretrained on MIMIC III, which has demonstrated strong performance on other pharmacovigilance tasks. To ensure that our algorithm could differentiate ADRs from other drug-related adverse events, the annotated corpus was enriched for both validated ADR reports and confounding drug-related adverse events using. The final model demonstrated good performance with a ROC-AUC of 0.955 (95% CI 0.933 - 0.978) for the task of identifying discharge summaries containing ADR mentions, significantly outperforming the two comparator models.
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Affiliation(s)
- Christopher McMaster
- Department of Clinical Pharmacology & Therapeutics, Austin Health, Melbourne, Victoria, Australia; Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia; The Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Victoria, Australia; School of Computing and Information Systems, University of Melbourne, Melbourne, Victoria, Australia.
| | - Julia Chan
- Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia
| | - David F L Liew
- Department of Clinical Pharmacology & Therapeutics, Austin Health, Melbourne, Victoria, Australia; Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Su
- Department of Clinical Pharmacology & Therapeutics, Austin Health, Melbourne, Victoria, Australia
| | - Albert G Frauman
- Department of Clinical Pharmacology & Therapeutics, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Wendy W Chapman
- The Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Douglas E V Pires
- The Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Victoria, Australia; School of Computing and Information Systems, University of Melbourne, Melbourne, Victoria, Australia
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Assessing Patient Safety Culture in United States Hospitals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042353. [PMID: 35206542 PMCID: PMC8872500 DOI: 10.3390/ijerph19042353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 02/01/2023]
Abstract
A positive patient safety culture plays a major role in reducing medical errors and increasing productivity among healthcare staff. Furthermore, understanding staff perceptions of patient safety culture and effective patient safety factors is a first step toward enhancing quality of care and patient safety. The objectives of this study were to assess patient safety culture in hospitals in the United States and to investigate the effects of hospital and respondent characteristics on perceived patient safety culture. An analysis of 67,010 respondents in the 2018 Agency for Healthcare Research and Quality (AHRQ) comparative database was conducted with partial least squares structural equation modeling (PLS-SEM). The results revealed that perceptions of patient safety culture had a positive influence on the overall perceptions of patient safety and frequency of event reporting. Moreover, staff position, teaching status, and geographic region were found to have varying influence on the patient safety culture, overall perceptions of patient safety, and frequency of event reporting.
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Bourke EM, Greene S, Macleod D, Robinson J. "Iatrogenic Medication Errors reported to the Victorian Poisons Information Centre". Intern Med J 2020; 51:1862-1868. [PMID: 32542970 DOI: 10.1111/imj.14940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Iatrogenic medication errors are a cause of medical morbidity and mortality. They result in significant cost to the Australian healthcare system each year. There is limited Australian evidence describing the iatrogenic errors occurring within the hospital system. AIMS To examine and describe iatrogenic medication errors occurring in Victorian healthcare settings through analysis of referrals to a state Poisons Information Centre (PIC). METHODS A retrospective review of iatrogenic medication errors reported to the Victorian PIC from community and hospital healthcare settings from January 2015-December 2019. RESULTS Over a five year period, 357 iatrogenic errors were identified, 63% (n = 224) of which occurred in a hospital setting. The remaining errors occurred in a community healthcare setting. One in five patients were symptomatic from the medication error at the time of the call to the VPIC, and a change in management was required in 45% (n = 165) of all cases. 5% (n = 17) of patients developed moderate to severe clinical toxicity as determined by the recorded PSS, and 88% (n = 18) of these required critical care management. Incorrect medication dosing accounted for 62% (n = 221) of errors. Common medication dosing errors included: double dose (51%, n = 114), incorrect medication administered (14%, n = 49), incorrect route (9%, n = 31), incorrect patient (6%, n = 22) and adult dose given to a child (4%, n = 15). CONCLUSIONS Iatrogenic errors are occurring in the Victorian health care system. These errors can result in serious morbidity. Identification of causative factors and investment in preventative strategies will likely reduce associated morbidity and healthcare costs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Elyssia M Bourke
- Victorian Poisons Information Centre, 145 Studley Road, Heidelberg, 3048
| | - Shaun Greene
- Director of the Victorian Poisons Information Centre, Emergency Physician Austin Health
| | - Dawson Macleod
- Specialist in Poisons Information, Victorian Poisons Information Centre
| | - Jeff Robinson
- Specialist in Poisons Information, Victorian Poisons Information Centre
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Examining the Occurrence of Adverse Events within 72 hours of Discharge from the Intensive Care Unit. Anaesth Intensive Care 2019; 35:486-93. [DOI: 10.1177/0310057x0703500404] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for readmission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a ‘do-not-resuscitate’ order. Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.
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Schwendimann R, Blatter C, Dhaini S, Simon M, Ausserhofer D. The occurrence, types, consequences and preventability of in-hospital adverse events - a scoping review. BMC Health Serv Res 2018; 18:521. [PMID: 29973258 PMCID: PMC6032777 DOI: 10.1186/s12913-018-3335-z] [Citation(s) in RCA: 162] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background Adverse events (AEs) seriously affect patient safety and quality of care, and remain a pressing global issue. This study had three objectives: (1) to describe the proportions of patients affected by in-hospital AEs; (2) to explore the types and consequences of observed AEs; and (3) to estimate the preventability of in-hospital AEs. Methods We applied a scoping review method and concluded a comprehensive literature search in PubMed and CINAHL in May 2017 and in February 2018. Our target was retrospective medical record review studies applying the Harvard method–or similar methods using screening criteria–conducted in acute care hospital settings on adult patients (≥18 years). Results We included a total of 25 studies conducted in 27 countries across six continents. Overall, a median of 10% patients were affected by at least one AE (range: 2.9–21.9%), with a median of 7.3% (range: 0.6–30%) of AEs being fatal. Between 34.3 and 83% of AEs were considered preventable (median: 51.2%). The three most common types of AEs reported in the included studies were operative/surgical related, medication or drug/fluid related, and healthcare-associated infections. Conclusions Evidence regarding the occurrence of AEs confirms earlier estimates that a tenth of inpatient stays include adverse events, half of which are preventable. However, the incidence of in-hospital AEs varied considerably across studies, indicating methodological and contextual variations regarding this type of retrospective chart review across health care systems. For the future, automated methods for identifying AE using electronic health records have the potential to overcome various methodological issues and biases related to retrospective medical record review studies and to provide accurate data on their occurrence.
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Affiliation(s)
- René Schwendimann
- University Hospital Basel, Patient Safety Office, Spitalstr. 22, 4031, Basel, Switzerland. .,Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.
| | - Catherine Blatter
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Suzanne Dhaini
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.,American University of Beirut, School of Nursing, Beirut, Lebanon
| | - Michael Simon
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.,Inselspital Bern University Hospital, Nursing Research Unit, Bern, Switzerland
| | - Dietmar Ausserhofer
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.,College of Health Care-Professions Claudiana, Bozen, Italy
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Halfon P, Staines A, Burnand B. Adverse events related to hospital care: a retrospective medical records review in a Swiss hospital. Int J Qual Health Care 2018; 29:527-533. [PMID: 28586414 DOI: 10.1093/intqhc/mzx061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/15/2017] [Indexed: 12/16/2022] Open
Abstract
Objective Retrospective records reviews carried out in several countries have shown substantial rates of adverse events (AE) among hospitalized patients, preventable in half the cases. As no such data have been recorded in Switzerland, we estimated the incidence of AE in one acute care hospital as a basis for a safety improvement program. Design A two steps retrospective records review (screening criteria and full review of positively screened records). Setting A medium size community hospital. Participants A stratified sample of 400 surgical and 600 medical hospitalizations whose records fulfilled a set of information quality criteria. Intervention(s) Not applicable. Main outcome measure(s) Adverse events, preventable adverse events and extent of resulting harm. Results The proportion of hospitalizations with at least one AE was 12.3% (95% CI: 10.4-14.1) whereas the overall hospital incidence rate was 14.1% (95% CI: 12.0-16.2). Nearly half of AE were judged preventable, corresponding to one or more preventable AE in 6.4% of hospitalizations (95% CI: 5.0-7.8). Sixty percent of AE resulted in no or minor impairment at discharge whereas 23% resulted in severe disability. AE were twice more frequent in surgical patients, and preventable AE resulted more often in severe impairment than unpreventable AE. No death was attributed to an AE. The proportion of stays with an AE increased with age and length of stay. Conclusions The incidence of preventable AE in patients hospitalized in one Swiss hospital is comparable to previously reported rates. Further, patient safety improvement is needed, especially among older patients, and for surgical procedures.
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Affiliation(s)
- Patricia Halfon
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Route de la Corniche 10, 1010 Lausanne, Switzerland
| | - Anthony Staines
- IFROSS Institute, University of Lyon III, 18 Rue Chevreul, 69007 Lyon, France.,Hospital Federation of Vaud, Bois de Cery, 1008 Prilly, Switzerland
| | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Route de la Corniche 10, 1010 Lausanne, Switzerland
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Hosford DA, Lai EH, Riley JH, Xu CF, Danoff TM, Roses AD. Pharmacogenetics to Predict Drug-Related Adverse Events. Toxicol Pathol 2016; 32 Suppl 1:9-12. [PMID: 15209398 DOI: 10.1080/01926230490424743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Identification of reliable markers to predict drug-related adverse events (DRAEs) is an important goal of the pharmaceutical industry and others within the healthcare community. We have used genetic polymorphisms, including the most frequent source of variation (single nucleotide polymorphisms, SNPs) in the human genome, in pharmacogenetic approaches designed to predict DRAEs. Three studies exemplify the principles of using polymorphisms to identify associations in progressively larger genomic regions: polymorphic repeats within the UDP-glucuronysltransferase I (UGT1A1) gene in patients experiencing hyperbilirubinemia after administration of tranilast, an experimental drug to prevent re-stenosis following coronary revascularization; high linkage disequilibrium within the Apolipoprotein E (ApoE) gene in patients with Alzheimer Disease (AD); and the polymorphic variant HLA-B57 in patients with hypersensitivity reaction after administration of abacavir, a nucleoside reverse transcriptase inhibitor for the treatment of HIV. Together, these studies demonstrate in a stepwise manner the feasibility of using pharmacogenetic approaches to predict DRAEs.
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Affiliation(s)
- David A Hosford
- Department of Genetics Research, GlaxoSmithKline R&D, Research Triangle Park, North Carolina 27709, USA.
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Rajasekaran S, Ravi S, Aiyer SN. Incidence and preventability of adverse events in an orthopaedic unit: a prospective analysis of four thousand, nine hundred and six admissions. INTERNATIONAL ORTHOPAEDICS 2016; 40:2233-2238. [PMID: 27585910 DOI: 10.1007/s00264-016-3282-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE We aimed to identify the incidence and preventability rate of adverse events (AEs) occurring in a specialty orthopaedic unit. METHODS Four thousand nine hundred and six consecutive in-patient admissions over six months in an orthopaedic unit were prospectively analysed. The total indoor patient capacity was segregated into 25-bed units each, and AEs were recorded on a daily basis by two observers. Each event was assessed by allotting a causation score (1-6), with a score of ≥ 4 implying a systemic/individual failure of healthcare provision. A preventability score (1-6) was allotted and scores ≥ 4 were considered to be preventable. RESULTS Four hundred and sixty-seven patients (9.5 %) suffered a total of 529 AEs, including 127 readmissions; 49 patients suffering multiple events. Three hundred and thirty-three (62.9 %) events had a causation score of ≥ 4, indicating a failure of healthcare delivery systems. Three hundred and one (56.8 %) events could have been prevented with better regulation and adherence to management protocols. Hospital-acquired infections were the most common event, with surgical-site infection in 102 cases (19.2 and 2 % overall) and catheter-associated urinary tract infections noted in 45 (8.5 %) patients. Medical events included seven deep vein thrombosis, two pulmonary embolisms, five myocardial infarctions and one stroke. AEs occurred 56.3 % in the ward, 4.3 % in the intensive care unit (ICU), 6.2 % in the emergency room, and 9.0 % in the operating theatre. CONCLUSION This prospective study documented an adverse event rate of 9.5 %, of which 56 % were preventable. AEs occurred in all stages of treatment care, emphasising the need for vigilance during the entire treatment process.
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Affiliation(s)
| | - Srikesh Ravi
- Department of Orthopaedic Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
| | - Siddharth N Aiyer
- Department of Orthopaedic Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
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Rafter N, Hickey A, Conroy RM, Condell S, O'Connor P, Vaughan D, Walsh G, Williams DJ. The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals-a retrospective record review study. BMJ Qual Saf 2016; 26:111-119. [PMID: 26862223 PMCID: PMC5284341 DOI: 10.1136/bmjqs-2015-004828] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 01/14/2016] [Accepted: 01/16/2016] [Indexed: 11/11/2022]
Abstract
Introduction Irish healthcare has undergone extensive change recently with spending cuts and a focus on quality initiatives; however, little is known about adverse event occurrence. Objective To assess the frequency and nature of adverse events in Irish hospitals. Methods 1574 (53% women, mean age 54 years) randomly selected adult inpatient admissions from a sample of eight hospitals, stratified by region and size, across the Republic of Ireland in 2009 were reviewed using two-stage (nurse review of patient charts, followed by physician review of triggered charts) retrospective chart review with electronic data capture. Results were weighted to reflect the sampling strategy. The impact on adverse event rate of differing application of international adverse event criteria was also examined. Results 45% of charts were triggered. The prevalence of adverse events in admissions was 12.2% (95% CI 9.5% to 15.5%), with an incidence of 10.3 events per 100 admissions (95% CI 7.5 to 13.1). Over 70% of events were considered preventable. Two-thirds were rated as having a mild-to-moderate impact on the patient, 9.9% causing permanent impairment and 6.7% contributing to death. A mean of 6.1 added bed days was attributed to events, representing an expenditure of €5550 per event. The adverse event rate varied substantially (8.6%–17.0%) when applying different published adverse event eligibility criteria. Conclusions This first study of adverse events in Ireland reports similar rates to other countries. In a time of austerity, adverse events in adult inpatients were estimated to cost over €194 million. These results provide important baseline data on the adverse event burden and, alongside web-based chart review, provide an incentive and methodology to monitor future patient-safety initiatives.
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Affiliation(s)
- Natasha Rafter
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anne Hickey
- Division of Population Health Sciences, Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronan M Conroy
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sarah Condell
- Office of the Nursing and Midwifery Services Director, Health Service Executive, Dublin, Ireland
| | - Paul O'Connor
- Discipline of General Practice, National University of Ireland, Galway, Ireland
| | - David Vaughan
- Quality Improvement, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Gillian Walsh
- Department of Research, Royal College of Physicians of Ireland, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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Visser A, Ubbink DT, Gouma DJ, Goslings JC. Which clinical scenarios do surgeons record as complications? A benchmarking study of seven hospitals. BMJ Open 2015; 5:e007500. [PMID: 26033948 PMCID: PMC4458580 DOI: 10.1136/bmjopen-2014-007500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To investigate agreement and potential differences in the application and interpretation of the definition among surgical departments of various hospitals. DESIGN 24 cases were formulated including general, trauma, gastrointestinal and vascular surgery, and based on points of discussion about the definition and ambiguities regarding complication registration as encountered in daily practice. The cases were presented to the surgical staff and residents in seven Dutch hospitals, using the national registration system of complications and an electronic response system. RESULTS In total, 134 participants responded. Interpretation differences were particularly found regarding: (1) complications considered as logical consequences of a surgical procedure; (2) complications occurring after radiological interventions; (3) severity criteria such as when to consider a complication as a '(probably) permanent damage or function loss'; (4) registering a cancelled operation as a complication and (5) patients with serial complications during hospital stay. CONCLUSIONS The definition of surgical complications as currently applied in the Netherlands does not ensure a uniform complication registration. Improvement of this registration system is mandatory before benchmarking of these findings in the public domain is appropriate. Modifications of the current definition of a surgical complication, and improved consensus about specific clinical situations and training of surgeons might improve the quality of benchmarking.
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Affiliation(s)
- Annelies Visser
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dirk T Ubbink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J Carel Goslings
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Garrett T, Reeves D. Beliefs and Attitudes that Influence Reporting of Clinical Interventions by Pharmacists. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2009.tb00430.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Tim Garrett
- Director of Pharmacy Gosford Hospital; Gosford New South Wales
| | - Diane Reeves
- Area Medication Safety Pharmacist, Gosford Hospital; Gosford New South Wales
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Hibbert PD, Hallahan AR, Muething SE, Lachman P, Hooper TD, Wiles LK, Jaffe A, White L, Wheaton GR, Runciman WB, Dalton S, Williams HM, Braithwaite J. CareTrack Kids-part 3. Adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review. BMJ Open 2015; 5:e007750. [PMID: 25854978 PMCID: PMC4390767 DOI: 10.1136/bmjopen-2015-007750] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION A high-quality health system should deliver care that is free from harm. Few large-scale studies of adverse events have been undertaken in children's healthcare internationally, and none in Australia. The aim of this study is to measure the frequency and types of adverse events encountered in Australian paediatric care in a range of healthcare settings. METHODS AND ANALYSIS A form of retrospective medical record review, the Institute of Healthcare Improvement's Global Trigger Tool, will be modified to collect data. Records of children aged <16 years managed during 2012 and 2013 will be reviewed. We aim to review 6000-8000 records from a sample of healthcare practices (hospitals, general practices and specialists). ETHICS AND DISSEMINATION Human Research Ethics Committee approvals have been received from the Sydney Children's Hospital Network, Children's Health Queensland Hospital and Health Service, and the Women's and Children's Hospital Network in South Australia. An application is under review with the Royal Australian College of General Practitioners. The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.
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Affiliation(s)
- Peter D Hibbert
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Division of Education, Arts and Social Sciences, Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
| | - Andrew R Hallahan
- Patient Safety and Quality Unit, Children's Health Queensland Hospital and Health Service, Herston, Queensland, Australia
| | | | - Peter Lachman
- Great Ormond St Hospital, Great Ormond St, London, UK
| | - Tamara D Hooper
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Division of Education, Arts and Social Sciences, Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
| | - Louise K Wiles
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Division of Education, Arts and Social Sciences, Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
| | - Adam Jaffe
- Department of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Respiratory Medicine, Sydney Children's Hospital, Sydney Children's Hospital Network, Randwick, New South Wales, Australia
| | - Les White
- Department of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of NSW Kids and Families, New South Wales Health, North Sydney, New South Wales, Australia
| | - Gavin R Wheaton
- Division of Paediatric Medicine, Women's and Children's Health Network, South Australia, Australia
| | - William B Runciman
- Division of Education, Arts and Social Sciences, Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
- Australian Patient Safety Foundation, Adelaide, South Australia, Australia
| | - Sarah Dalton
- Emergency Department, Westmead Hospital, Western Sydney Local Health District, Westmead, New South Wales, Australia
- Clinical Excellence Commission, Sydney, New South Wales, Australia
| | | | - Jeffrey Braithwaite
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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14
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Faisy C, Davagnar C, Marlet C, Seijo M, Guillou A, Fagon JY. Des RMM à la conception d’indicateurs de qualité et de sécurité : dix ans de travaux sur les RMM en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-015-1035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Berchialla P, Scaioli G, Passi S, Gianino MM. Adverse events in hospitalized paediatric patients: a systematic review and a meta-regression analysis. J Eval Clin Pract 2014; 20:551-8. [PMID: 24797652 DOI: 10.1111/jep.12141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2014] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES To gain insight into the incidence of paediatric adverse events (AEs); to assess if there are significant differences among study results and to what extent methodological issues can explain them. METHODS From November 2012 to January 2013, systematic literature searches were conducted on PubMed, Scopus and the Cochrane Library. We selected studies from 1970 onwards that evaluated the incidence of AEs in hospitalized paediatric patients and included a minimum of 1000 patient records with the same definition of AE. Studies that reported only specific AEs or only a specific ward were not considered. Data were extracted on the method of data collection, study design, type of hospital, and the timing of the AE in relation to its discovery and the index admission (time frame). AE incidence and preventability were considered. RESULTS The pooled incidence of AEs was 2.0% (95% CI: 1.3-3.0%). Five methodological differences among studies were taken into account. Only the time frame of detected events had a statistically significant effect on the incidence of AEs (P<0.0001). The pooled incidence of preventable AEs was 46.2% (95% CI: 35.3-57.5%) with a high variability among studies. CONCLUSIONS Our meta-analysis confirms that AEs are a major public health issue. Although studies use the same definition of AE, the reported incidence of AEs and preventable AEs varied considerably. To direct prevention efforts properly, studies methodologically more homogeneous and more detailed about the standard of health care provided and the health system organization are needed.
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Affiliation(s)
- Paola Berchialla
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
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Kosiek K, Vögele A, Lainer M, Sönnichsen A, Bowie P, Godycki-Cwirko M. Validity of and interrater agreement on the LINNEAUS Euro-PC medication safety incident classification system in primary care in Poland. J Eval Clin Pract 2014; 20:369-74. [PMID: 24797492 DOI: 10.1111/jep.12138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Medication safety incidents occur in all health care sectors and cause considerable morbidity and mortality, with 8.5% of all related incidents reported estimated to occur in primary care. A common incident classification system could facilitate collective learning from the analysis of medication-related errors and improve patient safety OBJECTIVE The objective of this study was to assess the validity of a new classification system of medication safety incidents in primary care in Poland. METHODS Analysis of data from a descriptive, cross-sectional, self-reported survey on the Learning from International Networks about Errors and Understanding Safety in Primary Care (LINNEAUS Euro-PC) medication safety incident classification for primary care with assessment of 10 case-based clinical scenarios done by doctors and pharmacists form community-based family medicine clinics and pharmacies in Lodz. MAIN OUTCOME MEASURES The percentages of overall agreement on judgements and a fixed-marginal multirater kappa (κ) coefficient as statistical measures of interrater agreement for categorical items. RESULTS The overall agreement levels were: category 1 - 86.3%; category 2 - 85.6%; category 3 - 72.1%; category 4 - 71.8%; and category 5 - 70.4%. The interrater agreement between the 15 evaluators varied as follows: category 1 fixed-marginal κ = 0.144; category 5 fixed-marginal κ = 0.565; category 3 fixed-marginal κ = 0.607; category 4 fixed-marginal κ = 0.634; and category 2 fixed-marginal κ = 0.807. CONCLUSIONS This is the first known study on levels of agreement on the perception of medication safety incidents and assessment of the validity of a related classification system in primary health care in Poland. Interrater agreement in this study was surprisingly high, but still leaves room for improvement.
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LeBlanc J, Donnon T, Hutchison C, Duffy P. Development of an orthopedic surgery trauma patient handover checklist. Can J Surg 2014; 57:8-14. [PMID: 24461220 DOI: 10.1503/cjs.025912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In surgery, preoperative handover of surgical trauma patients is a process that must be made as safe as possible. We sought to determine vital clinical information to be transferred between patient care teams and to develop a standardized handover checklist. METHODS We conducted standardized small-group interviews about trauma patient handover. Based on this information, we created a questionnaire to gather perspectives from all Canadian Orthopaedic Association (COA) members about which topics they felt would be most important on a handover checklist. We analyzed the responses to develop a standardized handover checklist. RESULTS Of the 1106 COA members, 247 responded to the questionnaire. The top 7 topics felt to be most important for achieving patient safety in the handover were comorbidities, diagnosis, readiness for the operating room, stability, associated injuries, history/mechanism of injury and outstanding issues. The expert recommendations were to have handover completed the same way every day, all appropriate radiographs available, adequate time, all appropriate laboratory work and more time to spend with patients with more severe illness. CONCLUSION Our main recommendations for safe handover are to use standardized checklists specific to the patient and site needs. We provide an example of a standardized checklist that should be used for preoperative handovers. To our knowledge, this is the first checklist for handover developed by a group of experts in orthopedic surgery, which is both manageable in length and simple to use.
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Affiliation(s)
- Justin LeBlanc
- The Department of Orthopaedic Surgery, Faculty of Medicine, University of Calgary, Calgary, Alta
| | - Tyrone Donnon
- The Medical Education and Research Unit and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alta
| | - Carol Hutchison
- The Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alta
| | - Paul Duffy
- The Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alta
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Hwang JI, Chin HJ, Chang YS. Characteristics associated with the occurrence of adverse events: a retrospective medical record review using the Global Trigger Tool in a fully digitalized tertiary teaching hospital in Korea. J Eval Clin Pract 2014; 20:27-35. [PMID: 23890097 DOI: 10.1111/jep.12075] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to examine the performance of the Global Trigger Tool and to investigate characteristics associated with the occurrence of adverse events (AEs). STUDY DESIGN Retrospective medical record review. SETTING A tertiary teaching hospital, Korea. METHOD We employed two-stage review of a random sample of 630 charts for patients discharged between January and June 2011. Two quality improvement specialists reviewed the presence of AEs using 53 triggers developed by the Institute for Healthcare Improvement. Two physicians reviewed and validated the findings of adverse events. Positive predictive values for individual triggers were calculated. Logistic regression analysis was performed to determine factors associated with AEs. RESULTS Of 629 patients, 45 (7%) experienced at least one AE during their hospitalization. Among the observed AEs, 61% were preventable. The frequent types of AEs were 'procedure-related' and 'medication-related'. Six triggers had positive predictive values of greater than 50.0%: 'health care-associated infection', 'any procedure complication', 'medication: other', 'return to surgery', 'occurrence of any operative complication' and 'intubation/reintubation'. Significant factors associated with the occurrence of AEs were length of stay (OR 1.13; 95% CI 1.07 to 1.20) and the number of triggers (OR 1.49; 95% CI 1.11 to 1.98). CONCLUSION The Global Trigger Tool was useful for the detection of adverse events in a Korean hospital setting. Triggers with high positive predictive values should have priority for incorporation into routine screening systems. Furthermore, patients who stay longer in the hospital need to be closely monitored using triggers to improve patient safety.
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Affiliation(s)
- Jee-In Hwang
- Department of Nursing, Kyung Hee University, Seoul, South Korea
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Runciman WB, Baker GR, Michel P, Jauregui IL, Lilford RJ, Andermann A, Flin R, Weeks WB. The epistemology of patient safety research. INT J EVID-BASED HEA 2013; 6:476-86. [PMID: 21631839 DOI: 10.1111/j.1744-1609.2008.00117.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patient safety has only recently been subjected to wide-spread systematic study. Healthcare differs from other high risk industries in being more diverse and multi-contextual, and less certain and regulated. Also many patient safety problems are low-frequency events associated with many, varied contributing factors. The subject of this paper is the epistemology of patient safety (the science of the method of finding out about patient safety). Patient safety research is considered here on the background of a risk management framework which requires researchers to: • Understand the context - as a subset of healthcare quality, services and systems research, with technical and human behavioural (cultural) components and a range of external and internal organisational influences, a wide range of research disciplines is necessary • Identify the risks - identify the things that go wrong and the frequency and nature of different types of incidents from sources such as medical record review, observational studies, audit, incident and medico-legal reports • Analyse the risks - deconstruct the things that go wrong, identifying contributing factors and trying to detect trends and patterns in contributing factors, detection, mitigation factors, ameliorating factors and actions taken to reduce risk • Evaluate the risks - decide on priorities, identifying preventive and corrective strategies and judging the risk- and cost-benefit of potential corrective strategies such as standardisation or simplification of a process or device • Manage the risk - evaluate and scope preventive and/or corrective strategies and then implement these, or place the problem on a risk register pending solution, or accept that what is needed is unaffordable • Communicate and consult - use interactive sessions, audit, on-going feedback, reminders and patient mediated prompts • Monitor and review the state of the problem - get baseline trends and patterns so that changes can be tracked and properly attributed to an intervention A hierarchy of levels of evidence has been proposed for clinical research and we argue that insufficient weighting has been given to lower ranked levels of research and to qualitative research, although critical interpretive synthesis is now gaining acceptance in mainstream thinking (e.g. by the Cochrane Collaboration). Fundamental challenges remain including how to grasp the elusive concept of patient safety, how to quantify, characterise and cost the problems, how to judge the extent to which harm can be attributed to errors, violations or system failures, how to identify contributing factors and the extent to which they can be implicated, how to judge whether incidents or their precursors are preventable, how to generate strong evidence to make healthcare safer and how to translate research into practice. Future directions include addressing the mundane as well as rare, dramatic events, and developing further research in non-hospital settings and in developing countries. In summary, a mixture of qualitative and quantitative methods, using information from all available data sources and combining retrospective, real time and prospective study designs, is necessary to address some of the more difficult patient safety problems.
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Affiliation(s)
- William B Runciman
- The Safety and Quality Research Unit, Joanna Briggs Institute & The University of Adelaide, Australian Patient Safety Foundation, Adelaide, South Australia, Australia, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, World Alliance for Patient Safety, World Health Organization, Geneva, Switzerland, and on behalf of the Methods and Measures expert working group of the WHO World Alliance for Patient Safety Regional Center for Quality and Safety, Aquitaine, France, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, Department of Family Medicine, McGill University, Montreal, Canada, School of Psychology, University of Aberdeen, Aberdeen, UK and Dartmouth Medical School, Hanover, New Hampshire, USA
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Galadanci HS. Protecting patient safety in resource-poor settings. Best Pract Res Clin Obstet Gynaecol 2013; 27:497-508. [PMID: 23642352 DOI: 10.1016/j.bpobgyn.2013.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 03/31/2013] [Indexed: 10/26/2022]
Abstract
A crucial element in the delivery of high-quality health care is patient safety. The rate of adverse events among hospital patients is an indication of patient safety. A systematic review of in-hospital adverse events revealed the median incidence of adverse events as 9.2%; 7.4% were lethal and 43.5% preventable. All the studies in the systemic review were from developed countries, as research is lacking from developing countries. In 2012, data from 10 developing countries reported adverse events ranging from 2.5 to 18.4% per country; 30% were lethal and 83% preventable. This study places patient safety as one of the major concerns of the health policy agenda in developing countries. Human resources for health deficits in developing countries constitute a major structural constraint for ensuring patient safety. The key to reducing adverse events in health care is system-based interventions rather than clinical interventions or technologies. Patient safety skills training, effective communication, and good team work are essential in improving patient safety in developing countries. Research on patient safety is needed to address the knowledge gap in developing countries.
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Affiliation(s)
- Hadiza Shehu Galadanci
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, No. 1, Zaria Road, PMB 3254, Kano, Nigeria.
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Sears N, Baker GR, Barnsley J, Shortt S. The incidence of adverse events among home care patients. Int J Qual Health Care 2013; 25:16-28. [DOI: 10.1093/intqhc/mzs075] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Cihangir S, Borghans I, Hekkert K, Muller H, Westert G, Kool RB. A pilot study on record reviewing with a priori patient selection. BMJ Open 2013; 3:bmjopen-2013-003034. [PMID: 23872292 PMCID: PMC3717450 DOI: 10.1136/bmjopen-2013-003034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To investigate whether a priori selection of patient records using unexpectedly long length of stay (UL-LOS) leads to detection of more records with adverse events (AEs) compared to non-UL-LOS. DESIGN To investigate the opportunities of the UL-LOS, we looked for AEs in all records of patients with colorectal cancer. Within this group, we compared the number of AEs found in records of patients with a UL-LOS with the number found in records of patients who did not have a UL-LOS. SETTING Our study was done at a general hospital in The Netherlands. The hospital is medium sized with approximately 30 000 admissions on an annual basis. The hospital has two major locations in different cities where both primary and secondary care is provided. PARTICIPANTS The patient records of 191 patients with colorectal cancer were reviewed. PRIMARY AND SECONDARY OUTCOME MEASURES Number of triggers and adverse events were the primary outcome measures. RESULTS In the records of patients with colorectal cancer who had a UL-LOS, 51% of the records contained one or more AEs compared with 9% in the reference group of non-UL-LOS patients. By reviewing only the UL-LOS group with at least one trigger, we found in 84% (43 out of 51) of these records at least one adverse event. CONCLUSIONS A priori selection of patient records using the UL-LOS indicator appears to be a powerful selection method which could be an effective way for healthcare professionals to identify opportunities to improve patient safety in their day-to-day work.
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Affiliation(s)
- Sezgin Cihangir
- Dutch Hospital Data, Utrecht, The Netherlands
- (At time of research) Kiwa Prismant, Utrecht, TheNetherlands
| | - Ine Borghans
- Dutch Healthcare Inspectorate (IGZ), Utrecht, TheNetherlands
- Radboud University Nijmegen Medical Centre, Institute for Quality of Healthcare (IQ Healthcare), Nijmegen, TheNetherlands
| | - Karin Hekkert
- Dutch Hospital Data, Utrecht, The Netherlands
- (At time of research) Kiwa Prismant, Utrecht, TheNetherlands
| | - Hein Muller
- Internal Medicine, Tergooi Hospitals, Hilversum, TheNetherlands
| | - Gert Westert
- Radboud University Nijmegen Medical Centre, Institute for Quality of Healthcare (IQ Healthcare), Nijmegen, TheNetherlands
| | - Rudolf B Kool
- Radboud University Nijmegen Medical Centre, Institute for Quality of Healthcare (IQ Healthcare), Nijmegen, TheNetherlands
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Liaw ST, Rahimi A, Ray P, Taggart J, Dennis S, de Lusignan S, Jalaludin B, Yeo AET, Talaei-Khoei A. Towards an ontology for data quality in integrated chronic disease management: a realist review of the literature. Int J Med Inform 2012; 82:10-24. [PMID: 23122633 DOI: 10.1016/j.ijmedinf.2012.10.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 10/03/2012] [Accepted: 10/05/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Effective use of routine data to support integrated chronic disease management (CDM) and population health is dependent on underlying data quality (DQ) and, for cross system use of data, semantic interoperability. An ontological approach to DQ is a potential solution but research in this area is limited and fragmented. OBJECTIVE Identify mechanisms, including ontologies, to manage DQ in integrated CDM and whether improved DQ will better measure health outcomes. METHODS A realist review of English language studies (January 2001-March 2011) which addressed data quality, used ontology-based approaches and is relevant to CDM. RESULTS We screened 245 papers, excluded 26 duplicates, 135 on abstract review and 31 on full-text review; leaving 61 papers for critical appraisal. Of the 33 papers that examined ontologies in chronic disease management, 13 defined data quality and 15 used ontologies for DQ. Most saw DQ as a multidimensional construct, the most used dimensions being completeness, accuracy, correctness, consistency and timeliness. The majority of studies reported tool design and development (80%), implementation (23%), and descriptive evaluations (15%). Ontological approaches were used to address semantic interoperability, decision support, flexibility of information management and integration/linkage, and complexity of information models. CONCLUSION DQ lacks a consensus conceptual framework and definition. DQ and ontological research is relatively immature with little rigorous evaluation studies published. Ontology-based applications could support automated processes to address DQ and semantic interoperability in repositories of routinely collected data to deliver integrated CDM. We advocate moving to ontology-based design of information systems to enable more reliable use of routine data to measure health mechanisms and impacts.
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Affiliation(s)
- S T Liaw
- University of NSW School of Public Health & Community Medicine, Sydney, Australia.
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Zuckerman SL, Green CS, Carr KR, Dewan MC, Morone PJ, Mocco J. Neurosurgical checklists: a review. Neurosurg Focus 2012; 33:E2. [DOI: 10.3171/2012.9.focus12257] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Morbidity due to avoidable medical errors is a crippling reality intrinsic to health care. In particular, iatrogenic surgical errors lead to significant morbidity, decreased quality of life, and attendant costs. In recent decades there has been an increased focus on health care quality improvement, with a concomitant focus on mitigating avoidable medical errors. The most notable tool developed to this end is the surgical checklist. Checklists have been implemented in various operating rooms internationally, with overwhelmingly positive results. Comparatively, the field of neurosurgery has only minimally addressed the utility of checklists as a health care improvement measure. Literature on the use of checklists in this field has been sparse. Considering the widespread efficacy of this tool in other fields, the authors seek to raise neurosurgical awareness regarding checklists by reviewing the current literature.
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Affiliation(s)
- Scott L. Zuckerman
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
| | - Cain S. Green
- 2College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kevin R. Carr
- 3Vanderbilt University School of Medicine, Nashville; and
| | - Michael C. Dewan
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
| | - Peter J. Morone
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
| | - J Mocco
- 1Department of Neurological Surgery, Vanderbilt University School of Medicine
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Khorsandi M, Skouras C, Beatson K, Alijani A. Quality review of an adverse incident reporting system and root cause analysis of serious adverse surgical incidents in a teaching hospital of Scotland. Patient Saf Surg 2012; 6:21. [PMID: 22931540 PMCID: PMC3499447 DOI: 10.1186/1754-9493-6-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/22/2012] [Indexed: 12/02/2022] Open
Abstract
Background A significant proportion of surgical patients are unintentionally harmed during their hospital stay. Root Cause Analysis (RCA) aims to determine the aetiology of adverse incidents that lead to patient harm and produce a series of recommendations, which would minimise the risk of recurrence of similar events, if appropriately applied to clinical practice. A review of the quality of the adverse incident reporting system and the RCA of serious adverse incidents at the Department of Surgery of Ninewells hospital, in Dundee, United Kingdom was performed. Methods The Adverse Incident Management (AIM) database of the Department of Surgery of Ninewells Hospital was retrospectively reviewed. Details of all serious (red, sentinel) incidents recorded between May 2004 and December 2009, including the RCA reports and outcomes, where applicable, were reviewed. Additional related information was gathered by interviewing the involved members of staff. Results The total number of reported surgical incidents was 3142, of which 81 (2.58%) cases had been reported as red or sentinel. 19 of the 81 incidents (23.4%) had been inappropriately reported as red. In 31 reports (38.2%) vital information with regards to the details of the adverse incidents had not been recorded. In 12 cases (14.8%) the description of incidents was of poor quality. RCA was performed for 47 cases (58%) and only 12 cases (15%) received recommendations aiming to improve clinical practice. Conclusion The results of our study demonstrate the need for improvement in the quality of incident reporting. There are enormous benefits to be gained by this time and resource consuming process, however appropriate staff training on the use of this system is a pre-requisite. Furthermore, sufficient support and resources are required for the implementation of RCA recommendations in clinical practice.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith road, Edinburgh, EH16 4SA, UK.
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Cima RR, Deschamps C. Role of the surgeon in quality and safety in the operating room environment. Gen Thorac Cardiovasc Surg 2012; 61:1-8. [DOI: 10.1007/s11748-012-0111-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Indexed: 11/24/2022]
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Walker I, Reshamwalla S, Wilson I. Surgical safety checklists: do they improve outcomes? Br J Anaesth 2012; 109:47-54. [DOI: 10.1093/bja/aes175] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Iatrogenic skin injuries in hospitalized patients range from drug-related complications to those related to procedures. Common drug complications include drug reaction with eosinophilia and systemic symptoms (DRESS), linear immunoglobulin (Ig) A bullous dermatosis, Stevens-Johnson syndrome/toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. Contact dermatitis can result from surgical preparations of chlorhexidine and povidone-iodine, medical adhesives, topical postsurgical ointments, most commonly neomycin and bacitracin, and internal prostheses, including coronary stents, pacemakers, and metal joints. Complications arising from procedures include thrombosis caused by placement of peripherally inserted central catheters, pyoderma gangrenosum from sites of dermal trauma, and anetoderma of prematurity from cutaneous monitoring devices in neonates. Calcinosis cutis and decubitus ulcers are also hospital problems.
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Bosma E, Veen EJ, Roukema JA. Incidence, nature and impact of error in surgery. Br J Surg 2011; 98:1654-9. [DOI: 10.1002/bjs.7594] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2011] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Adverse events occur in 3·8–17 per cent of hospital admissions. The purpose of this study was to analyse the incidence of medical errors and assess the feasibility of an error registry for quality improvement programmes.
Methods
Errors were recorded prospectively in a complication registry between 1 June 2005 and 31 December 2007. Events were coded according to the Trauma Registry of the American College of Surgeons; the nature of events was recorded and the severity graded using the 1992 Clavien system. Recorded events were discussed by the medical staff on a daily basis and, if by consensus judged to be errors, were saved to the registry database.
Results
Of 12 121 patients admitted to the surgical ward during the study interval, 2033 (16·8 per cent) had a complication and 735 (6·1 per cent) had an error documented in the registry. Of 873 recorded errors, 607 (69·5 per cent) were of little or no consequence (Clavien grade I) and 220 (25·2 per cent) required therapeutic intervention (Clavien grade IIa and IIb). Errors leading to permanent injury (Clavien grade III) occurred in 41 instances (4·7 per cent) and five patients (0·6 per cent) died (Clavien grade IV).
Conclusion
This study shows that errors are common in surgery, and that near misses are more frequent than errors with serious consequences. It is hypothesized that registration of near misses might prevent errors with serious consequences and thus improve quality of care.
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Affiliation(s)
- E Bosma
- Department of Surgery, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - E J Veen
- Department of Surgery, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - J A Roukema
- Department of Surgery, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands
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The Problem of ""Human Error"" in Healthcare. PATIENT SAFETY 2011. [DOI: 10.1201/b10942-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010; 363:2124-34. [PMID: 21105794 DOI: 10.1056/nejmsa1004404] [Citation(s) in RCA: 698] [Impact Index Per Article: 49.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the 10 years since publication of the Institute of Medicine's report To Err Is Human, extensive efforts have been undertaken to improve patient safety. The success of these efforts remains unclear. METHODS We conducted a retrospective study of a stratified random sample of 10 hospitals in North Carolina. A total of 100 admissions per quarter from January 2002 through December 2007 were reviewed in random order by teams of nurse reviewers both within the hospitals (internal reviewers) and outside the hospitals (external reviewers) with the use of the Institute for Healthcare Improvement's Global Trigger Tool for Measuring Adverse Events. Suspected harms that were identified on initial review were evaluated by two independent physician reviewers. We evaluated changes in the rates of harm, using a random-effects Poisson regression model with adjustment for hospital-level clustering, demographic characteristics of patients, hospital service, and high-risk conditions. RESULTS Among 2341 admissions, internal reviewers identified 588 harms (25.1 harms per 100 admissions; 95% confidence interval [CI], 23.1 to 27.2) [corrected]. Multivariate analyses of harms identified by internal reviewers showed no significant changes in the overall rate of harms per 1000 patient-days (reduction factor, 0.99 per year; 95% CI, 0.94 to 1.04; P=0.61) or the rate of preventable harms. There was a reduction in preventable harms identified by external reviewers that did not reach statistical significance (reduction factor, 0.92; 95% CI, 0.85 to 1.00; P=0.06), with no significant change in the overall rate of harms (reduction factor, 0.98; 95% CI, 0.93 to 1.04; P=0.47). CONCLUSIONS In a study of 10 North Carolina hospitals, we found that harms remain common, with little evidence of widespread improvement. Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time. (Funded by the Rx Foundation.).
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Affiliation(s)
- Christopher P Landrigan
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical, Boston, MA 02115, USA.
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Steyrer J, Strunk G, Latzke M, Vetter E. Wissenskonversion und Behandlungsfehler im Krankenhaus. GERMAN JOURNAL OF HUMAN RESOURCE MANAGEMENT-ZEITSCHRIFT FUR PERSONALFORSCHUNG 2010. [DOI: 10.1177/239700221002400310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rund jeder tausendste Krankenhauspatient stirbt aufgrund vermeidbarer unerwünschter Ereignisse. Empirische Studien zeigen Zusammenhänge zwischen der Sicherheitskultur in Krankenhäusern und der Fehlerhäufigkeit. Die bisherige Forschung weist allerdings Theoriedefizite auf. Unter Heranziehung des Konzeptes der Wissenskonversion nach Nonaka und Takeuchi (1995) wird versucht, einen theoretischen Bezugsrahmen für das Lernen aus Fehlern zu erarbeiten. Auf empirischer Basis wird eine Skala entwickelt, die unterschiedliche Profile der Wissenskonversion im Umgang mit Fehlern misst. Anhand einer 420 Probanden umfassenden Stichprobe aus 11 Abteilungen von sieben Krankenhäusern gelingt der Nachweis, dass eine lernende Sicherheitskultur die Fehlerhäufigkeit zu reduzieren imstande ist. Zudem zeigt sich, dass dem Prozess der Internalisierung der höchste Stellenwert zukommt.
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Jones DN, Benveniste KA, Schultz TJ, Mandel CJ, Runciman WB. Establishing National Medical Imaging Incident Reporting Systems: Issues and Challenges. J Am Coll Radiol 2010; 7:582-92. [DOI: 10.1016/j.jacr.2010.03.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
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Medical error and decision making: Learning from the past and present in intensive care. Aust Crit Care 2010; 23:150-6. [PMID: 20594866 DOI: 10.1016/j.aucc.2010.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 05/31/2010] [Accepted: 06/04/2010] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments. PURPOSE The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care. DATA SOURCE Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein. FINDINGS Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events. CONCLUSION It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.
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The Nature and Scale of Error and Harm. PATIENT SAFETY 2010. [DOI: 10.1002/9781444323856.ch4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Attitudes to reporting medication error among differing healthcare professionals. Eur J Clin Pharmacol 2010; 66:843-53. [DOI: 10.1007/s00228-010-0838-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 05/11/2010] [Indexed: 10/19/2022]
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Jakobs OM, O'Leary EM, Cormack MF, Chong GC. A working model for the extraordinary review of clinical privileges for doctors and dentists in the Australian Capital Territory. AUST HEALTH REV 2010; 34:170-9. [PMID: 20497729 DOI: 10.1071/ah08694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Accepted: 11/26/2009] [Indexed: 11/23/2022]
Abstract
The extraordinary (unplanned) review of clinical privileges is the means by which an organisation can manage specific complaints about individual practitioners' clinical competence that require immediate investigation. To date, the extraordinary review of clinical privileges for doctors and dentists has not been the subject of much research and there is a pressing need for the evaluation and review of how different legislated and non-legislated administrative processes work and what they achieve. Although it seems a fair proposition that comprehensive processes for the evaluation of the clinical competence of doctors and dentists may improve the overall delivery of an organisation's clinical services, in fact, little is known about the relationship between the safety and quality of specific clinical services, procedures and interventions and the efficiency or effectiveness of established methodologies for the routine or the extraordinary review of clinical privileges. The authors present a model of a structured approach to the extraordinary review of clinical privileges within a clinical governance framework in the Australian Capital Territory. The assessment framework uses a primarily qualitative methodology, underpinned by a process of systematic review of clinical competence against the agreed standards of the CanMEDS Physician Competency Framework. The model is a practical, working framework that could be implemented on a hospital-, area health service- or state- and territory-wide basis in any other Australian jurisdiction.
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Affiliation(s)
- Olivia M Jakobs
- Clinical Governance Unit, Clinical Operations, ACT Health, PO Box 11, Woden, ACT 2606, Australia.
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Ksouri H, Balanant PY, Tadié JM, Heraud G, Abboud I, Lerolle N, Novara A, Fagon JY, Faisy C. Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice. Am J Crit Care 2010; 19:135-45; quiz 146. [PMID: 20194610 DOI: 10.4037/ajcc2010590] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Morbidity and mortality conferences are a tool for evaluating care management, but they lack a precise format for practice in intensive care units. OBJECTIVES To evaluate the feasibility and usefulness of regular morbidity and mortality conferences specific to intensive care units for improving quality of care and patient safety. METHODS For 1 year, a prospective study was conducted in an 18-bed intensive care unit. Events analyzed included deaths in the unit and 4 adverse events (unexpected cardiac arrest, unplanned extubation, reintubation within 24-48 hours after planned extubation, and readmission to the unit within 48 hours after discharge) considered potentially preventable in optimal intensive care practice. During conferences, events were collectively analyzed with the help of an external auditor to determine their severity, causality, and preventability. RESULTS During the study period, 260 deaths and 100 adverse events involving 300 patients were analyzed. The adverse events rate was 16.6 per 1000 patient-days. Adverse events occurred more often between noon and 4 pm (P = .001).The conference consensus was that 6.1% of deaths and 36% of adverse events were preventable. Preventable deaths were associated with iatrogenesis (P = .008), human errors (P < .001), and failure of unit management factors or communication (P = .003). Three major recommendations were made concerning standardization of care or prescription and organizational management, and no similar incidents have recurred. CONCLUSION In addition to their educational value, regular morbidity and mortality conferences formatted for intensive care units are useful for assessing quality of care and patient safety.
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Affiliation(s)
- Hatem Ksouri
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Per-Yann Balanant
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Jean-Marc Tadié
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Guillaume Heraud
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Imad Abboud
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Nicolas Lerolle
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Ana Novara
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Jean-Yves Fagon
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
| | - Christophe Faisy
- All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France
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Maamoun J. An Introduction to Patient Safety. J Med Imaging Radiat Sci 2009; 40:123-133. [DOI: 10.1016/j.jmir.2009.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 06/22/2009] [Accepted: 06/22/2009] [Indexed: 11/29/2022]
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Brady AM, Redmond R, Curtis E, Fleming S, Keenan P, Malone AM, Sheerin F. Adverse events in health care: a literature review. J Nurs Manag 2009; 17:155-64. [PMID: 19422173 DOI: 10.1111/j.1365-2834.2008.00887.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIM This paper aims to develop understanding of the nature, costs and strategies to reduce or prevent a range of adverse events experienced by people within the health care system. BACKGROUND Care interventions are not always based on safe practice and adverse events can and do occur that cause or place at risk patients lives and well-being. The nature of adverse events is diverse and can be attributed to a multitude of individual and system contributory factors and causes. EVALUATION A review of the literature was undertaken in 2006 and 2007 using the following databases: Pubmed, CINAHL, Biomed Ovid, Synergy and the British Nursing Index. This paper evaluates the literature that pertains to adverse events and seeks understanding of this complex issue. KEY ISSUES Published statistics confirm that globally, professional errors in clinical practice and care delivery occur at an unacceptably high level and result in considerable human and financial consequences. CONCLUSION Reaching understanding of the multiple factors that contribute to unsafe clinical practice situations requires a cultural shift in organizations. IMPLICATION FOR NURSING MANAGEMENT Reasons for adverse events are complex and require healthcare managers to evaluate the system issues which impact on the delivery and organization of care.
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Affiliation(s)
- Anne-Marie Brady
- School of Nursing & Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin, Ireland.
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Júdez Legaristi D, Aibar Remón C, Ortega Maján MT, Aguilella Diago V, Aranaz Andrés JM, Gutiérrez Cía I. [Incidence of adverse events in a general surgery unit]. Cir Esp 2009; 86:79-86. [PMID: 19439271 DOI: 10.1016/j.ciresp.2009.01.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 01/20/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Clinical practice is an activity accompanied by risks and uncertainties. The objectives are: to determine the incidence of patients with adverse events (AE) in a general surgery unit; to analyse the associated factors; to consider their impact and to identify the prevention possibilities. PATIENTS AND METHOD Ambispective study in patients taken care of in a general surgery unit in a tertiary hospital. Every admission was prospectively reviewed using a screening guide, with all the clinical histories that fulfilled screening criteria being examined retrospectively using a modular questionnaire. RESULTS A total of 989 histories were reviewed, the positive predictive value (PPV) of the screening guide for AE was 53%. The accumulated incidence of patients with AE was 17.8% and the incidence density of AE was 1.92 for every 100 days of hospitalisation. Intrinsic and extrinsic risk factors were associated to greater risk of EA, the most frequent events being: nosocomial infections (54.4%), surgical problems (31.8%) and problems associated with medication (7.4%). A total of 66.8% of the AE were considered moderate, with 53.5% of all AE being preventable. CONCLUSIONS The screening questionnaire was useful for the valuation of adverse events. AE are common in surgical patients which has an effect on the use of other hospital resources. The most important associated factors were: length of stay, surgical and extrinsic factors and surgical wound infection as the main AE. Two thirds of AE were considered moderate and half of all AE were considered avoidable.
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Affiliation(s)
- Diego Júdez Legaristi
- Servicio de Medicina Preventiva y Salud Pública, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
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Vozikis A. Information management of medical errors in Greece: The MERIS proposal. INTERNATIONAL JOURNAL OF INFORMATION MANAGEMENT 2009. [DOI: 10.1016/j.ijinfomgt.2008.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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The epistemology of patient safety research. INT J EVID-BASED HEA 2008. [DOI: 10.1097/01258363-200812000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Makai P, Klazinga N, Wagner C, Boncz I, Gulacsi L. Quality management and patient safety: survey results from 102 Hungarian hospitals. Health Policy 2008; 90:175-80. [PMID: 19004518 DOI: 10.1016/j.healthpol.2008.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 09/10/2008] [Accepted: 09/14/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study is to describe the development of quality management systems in Hungarian hospitals. It also aims to answer the policy question, whether a separate patient safety policy should be created additional to quality policies, on national as well as hospital level. METHOD In 2005, a questionnaire survey was conducted to evaluate the existing quality management systems in all Hungarian hospitals. The relationship between the level of the development of quality management systems, the certification status and the current level of patient safety activities was investigated using linear regression. Quality was measured with the quality management system development score (QMSDS), and patient safety by the number of patient safety activities. RESULTS 102 of 134 (76%) of the hospitals have returned the questionnaire. The average hospital has 24.5 of 35 core quality activities, and 4 of 11 patient safety activities. There is a statistically significant but weak relationship between the QMSDS and the number of patient safety activities, explaining 12% of the latter's variance. Certification (International Standards Organisation (ISO) and professional standard based) is not significantly related to patient safety. CONCLUSIONS In our study quality by QMSDS is weakly related; however, certification is not significantly related to patient safety. We conclude that separate patient safety policies seem worthwhile to be created for the hospital sector in addition to the ongoing quality improvement efforts in Hungary.
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Affiliation(s)
- Peter Makai
- Institute of Health Policy and Management, Erasmus University of Rotterdam, P.O. Box 1738, 3000DR Rotterdam, The Netherlands.
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de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008; 17:216-23. [PMID: 18519629 PMCID: PMC2569153 DOI: 10.1136/qshc.2007.023622] [Citation(s) in RCA: 1042] [Impact Index Per Article: 65.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. We performed a systematic review of the literature on in-hospital adverse events. METHODS A formal search of Embase, Cochrane and Medline was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and endpoints. Primary endpoints were incidence of in-hospital adverse events and percentage of preventability. Secondary endpoints were adverse event outcome and subdivision by provider of care, location and type of event. RESULTS Eight studies including a total of 74 485 patient records were selected. The median overall incidence of in-hospital adverse events was 9.2%, with a median percentage of preventability of 43.5%. More than half (56.3%) of patients experienced no or minor disability, whereas 7.4% of events were lethal. Operation- (39.6%) and medication-related (15.1%) events constituted the majority. We present a summary of evidence-based interventions aimed at these categories of events. CONCLUSIONS Adverse events during hospital admission affect nearly one out of 10 patients. A substantial part of these events are preventable. Since a large proportion of the in-hospital events are operation- or drug-related, interventions aimed at preventing these events have the potential to make a substantial difference.
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Affiliation(s)
- E N de Vries
- Department of Surgery, Academic Medical Centre, University of Amsterdam, The Netherlands
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Armitage H, Connolly J, Pitt R. Developing sustainable models of interprofessional learning in practice – The TUILIP project. Nurse Educ Pract 2008; 8:276-82. [DOI: 10.1016/j.nepr.2007.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Revised: 10/02/2007] [Accepted: 10/15/2007] [Indexed: 10/22/2022]
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Bentz EK, Imhof M, Pateisky N, Ott J, Huber JC, Hefler LA, Tempfer CB. Clinical outcome monitoring in a reproductive surgery unit: a prospective cohort study in 796 patients. Fertil Steril 2008; 91:2638-42. [PMID: 18554586 DOI: 10.1016/j.fertnstert.2008.03.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 03/14/2008] [Accepted: 03/18/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To systematically monitor the frequency and risk factors of adverse events (AEs) in a reproductive surgery endoscopy unit. DESIGN Prospective cohort study. SETTING Academic research institution. PATIENT(S) All consecutive surgical patients of a reproductive surgery unit from December 2005 to March 2007. INTERVENTION(S) Monitoring for predefined AEs by trained observers. MAIN OUTCOME MEASURE(S) Number of preventable and not preventable AEs, medical errors, and system problems. Univariate analysis and multivariate logistic regression were used to identify risk factors of AEs. RESULT(S) Seven hundred ninety-six women were included. We identified 60 AEs in 45 patients (risk 6%; 95% confidence interval [CI] 1%-11%). Adverse events were postoperative fever (n = 1), wound breakdown (n = 1), intraoperative or postoperative administration of packed erythrocytes (n = 6), surgical revision (n = 7), unplanned readmission (n = 5), transfer to intensive care unit (n = 1), conversion (n = 8), intraoperative organ injury (n = 9), blood loss >500 mL (n = 3), surgery canceled (n = 15), and other AEs (n = 4). Six patients (risk 0.8%; 95% CI 0-2%) had multiple AEs. One (0.01%) and 11 (1.4%) AEs were deemed due to medical errors and system problems, respectively. Twelve and 48 AEs were deemed preventable and not preventable, respectively. In a univariate and multivariate analysis, only duration of surgery (odds ratio 3.78; 95% CI 1.95-7.33) was significantly associated with having an AE. CONCLUSION(S) Clinical outcome monitoring is a useful tool for assessing the outcome quality of reproductive surgery by identifying potentially preventable AEs and associated risk factors.
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Affiliation(s)
- Eva-Katrin Bentz
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
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Haller G, Myles PS, Langley M, Stoelwinder J, McNeil J. Assessment of an unplanned admission to the intensive care unit as a global safety indicator in surgical patients. Anaesth Intensive Care 2008; 36:190-200. [PMID: 18361010 DOI: 10.1177/0310057x0803600209] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An unplanned intensive care unit admission within 24 hours of a procedure with an anaesthetist in attendance (UIA) is a recommended clinical indicator It is designed to identify preventable iatrogenic complications. Often understood as a specific anaesthetic outcome, its value has been repeatedly questioned. Iatrogenic complications however often result from successive mishaps. In the specific context of an UIA these complications can be related both to anaesthesia and surgery. UIA is therefore probably more a global indicator of the safety of surgical care (anaesthetic and surgical) rather than a specific anaesthetic outcome. Its utility as such is however unknown. The purpose of this study was to assess the value of UIA as a global measure of avoidable iatrogenic complications in surgical patients. Using computerised patient records and medical charts, all patients with an UIA over a study period of five years were identified. The proportion, cause and preventability of iatrogenic complications amongst these patients were assessed. A total of 188 UIA patients were identified by peer reviewers. Of these, 87% to 92% had a complication caused by anaesthesia and/or surgery. Anaesthesia was found to be responsible for 24% to 31% of iatrogenic complications. All other cases related to the combination of anaesthesia and surgery or surgery alone. Of these, 74% to 92% of complications were found to be preventable. Despite intrinsic limitations of the retrospective chart review method, UIA can be considered as a valuable tool to detect avoidable iatrogenic complications related to both surgical and anaesthetic care.
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Affiliation(s)
- G Haller
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Ligi I, Arnaud F, Jouve E, Tardieu S, Sambuc R, Simeoni U. Iatrogenic events in admitted neonates: a prospective cohort study. Lancet 2008; 371:404-10. [PMID: 18242414 DOI: 10.1016/s0140-6736(08)60204-4] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Iatrogenic events are increasingly recognised as an important problem in all people admitted to hospital. However, few epidemiological data are available for iatrogenic events in neonatal high-risk units. We aimed to assess the incidence, nature, preventability, and severity of iatrogenic events in a neonatal centre and to establish the association of patient characteristics with the occurrence of iatrogenic events in neonates. METHODS We undertook an observational, prospective study from Jan 1, 2005, to Sept 1, 2005, including all neonates admitted in the Division of Neonatology of an academic, tertiary neonatal centre in southern France. Iatrogenic events were defined as any event that compromised the safety margin for the patient, in the presence or absence of harm. The report of an iatrogenic event was voluntary, anonymous, and non-punitive. The primary outcome was the rate of iatrogenic events per 1000 patient days. FINDINGS A total of 388 patients were studied during 10 436 patient days. We recorded 267 iatrogenic events in 116 patients. The incidence of iatrogenic events was 25.6 per 1000 patient days. 92 (34%) were preventable and 78 (29%) were severe. Two iatrogenic events (1%) were fatal, but neither was preventable. The most severe iatrogenic events were nosocomial infections (49/62 [79%]) and respiratory events (nine of 26 [35%]). Cutaneous injuries were frequent (n=94) but generally minor (89 [95%]), as were medication errors (15/19 [76%]). Most medication errors occurred during administration stage (12/19 [63%]) and were ten-fold errors (nine of 19 [47%]). The major risk factors were low birthweight and gestational age (both p<0.0001), length of stay (p<0.0001), a central venous line (p<0.0001), mechanical ventilation (p=0.0021), and support with continuous positive airwary pressure (p=0.0076). INTERPRETATION Iatrogenic events occur frequently and are often serious in neonates, especially in infants of low birthweight. Improved knowledge of the incidence and characteristics of iatrogenic events, and continuous monitoring could help to improve quality of health care for this vulnerable population.
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Affiliation(s)
- Isabelle Ligi
- Division of Neonatology, La Conception Hospital, EA 3279, Assistance Publique-Hôpitaux de Marseille, Faculté de Médecine, Université de la Méditerranée, Marseille, France
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Venkatesh B, Miller A, Karnik A. Information Exchange in Intensive Care: How can we Improve? Intensive Care Med 2007. [DOI: 10.1007/0-387-35096-9_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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