A literature-based economic evaluation of healthcare preventable adverse events in Europe

The European Researchers' Network Working on Second Victim (ERNST) Policy Statement on the Second Victim Phenomenon for Increasing Patient Safety

Background

The second victim phenomenon refers to the emotional trauma healthcare professionals experience following adverse events (AEs) in patient care, which can compromise their ability to provide safe care. This issue has significant implications for patient safety, with AEs leading to substantial human and economic costs.

Analysis

Current evidence indicates that AEs often result from systemic failures, profoundly affecting healthcare workers. While patient safety initiatives are in place, the psychological impact on healthcare professionals remains inadequately addressed. The European Researchers' Network Working on Second Victims (ERNST) emphasizes the need to support these professionals through peer support programs, systemic changes, and a shift toward a just culture in healthcare settings.

Policy Options

Key options include implementing peer support programs, revising the legal framework to decriminalize honest errors, and promoting just culture principles. These initiatives aim to mitigate the second victim phenomenon, enhance patient safety, and reduce healthcare costs.

Conclusion

Addressing the second victim phenomenon is essential for ensuring patient safety. By implementing supportive policies and fostering a just culture, healthcare systems can better manage the repercussions of AEs and support the wellbeing of healthcare professionals.

Development and applications of the anaesthetists' non-technical skills behavioural marker system: protocol for a systematic review

INTRODUCTION

The high incidence of unsafe anaesthetic care leads to adverse events and increases the burden on patient safety. An important reason for unsafe anaesthesia care is the lack of non-technical skills (NTS), which are defined as personal cognitive, social or interpersonal skills, among anaesthetists. The anaesthetists' NTS (ANTS) behavioural marker system has been widely used to evaluate and improve anaesthetists' behavioural performance to ensure patient safety. This protocol describes a planned systematic review aiming to determine the validity and reliability of the ANTS behavioural marker system and its application as a tool for the training and assessment of ANTS and for improving patient safety.

METHODS AND ANALYSIS

This systematic review follows the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol. Studies that applied the ANTS behavioural marker system in a meaningful way, including using the ANTS behavioural marker system to guide data collection, analysis, coding, measurement, and/or reporting, which have been published in peer-reviewed journals, will be eligible. A citation search strategy will be employed. We will search Scopus and Web of Science for publications from 2002 to May 2022, which cite the three original ANTS behavioural marker system publications by Fletcher et al. We will also search the references of the relevant reviews for additional eligible studies. For each study, two authors will independently screen papers to determine eligibility and will extract the data. The quality of the included studies will be assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists. A framework analysis approach that consists of five steps-familiarisation, identifying a thematic data extraction framework, indexing, charting, mapping and interpretation-will be used to synthesise and report the data.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. The findings will be disseminated primarily through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022297773.

The Impact of a Communication Training on the Birth Experience: Qualitative Interviews with Mothers after Giving Birth at Obstetric University Departments in Germany

(1) Background: Patient safety is a pressing issue in healthcare. Besides economical and organizational issues, human factors play a crucial role in providing safe care. Safe and clear communication on both the healthcare workers' and patients' sides contribute to the avoidance of medical errors and increase patients' and healthcare workers' satisfaction. Globally, the incidence of experiencing at least one adverse event in obstetrics is about 10%, of which half are classified as preventable. According to international research, improving communication skills may decrease preventable adverse events. The research question was to what extent communication training for pregnant women impacts the quality of communication and mutual understanding during birth. (2) Methods: Communication interventions with pregnant women were conducted in two German university obstetric departments in a mixed methods research design, based on the Health Action Process Approach. The online classes covered the awareness of personal wishes, the understanding and usage of communication strategies, self-efficacy and empathy. This study presents the qualitative results. Out of 142 mothers who answered two questionnaires before the communication training and after the birth, 24 in-depth semistructured interviews were conducted to explore the subjective impact of the communication training. The results were analyzed with qualitative content analysis. (3) Results: The majority of participants felt incentivized to be aware of their personal wishes for birth and to express them. Perceived positive experiences with sufficient competency in communication, empathy and mutual understanding outweighed negative treatments and experiences in the hospital, some of which could be attributed to structural problems. (4) Discussion: The reported positive effects of the communication training underline the need but also the potential for communication lessons to reflect and improve communication skills in obstetrics. However, negative experiences due to structural problems in the healthcare system may be buffered by communication skills but not solved.

Civil Lawsuits as an Indicator of Adverse Outcomes in Healthcare

The financial burden of adverse healthcare outcomes in Poland still remains unknown. The objective of the study was to estimate the cost of adverse healthcare outcomes in the Polish healthcare system. Cost calculation was performed on the basis of civil cases completed in Polish courts against doctors and healthcare entities. The research material consisted of 183 civil cases completed by a final judgment in 2011-2013. The case study was conducted in five out of forty-five district courts across the country. Out of 183 reviewed cases, 73 complaints ended up with favorable judgments (39.9%). The average value of the subject matter of the dispute was USD 78,675. The total expected value of lawsuits in the 183 reviewed cases was USD 11,299,020. The total amount awarded in 73 judgments from medical facilities to injured patients was USD 2,653,595, which on average means USD 36,351 per case. The average amount of awarded compensation was USD 33,317 per case. The average compensation amount in the analyzed cases was USD 11,724. The average one-time annuity for a patient was USD 11,788. The estimated costs of negative healthcare outcomes amounted to USD 8,000,000 per year.

Financial Expenses and “Losses” of the Polish Healthcare System Resulting from the Occurrence of Adverse Events

Background: The globally increasing healthcare expenditures related to the need to treat the consequences of adverse events, as well as the number of claims filed by patients (or their families) and remuneration paid as their result mean that the interest in the subject of adverse event cost management is increasing. An increase in the number of cases concerning medical errors has also occurred in Poland in recent years. The newest statistics from the Ministry of Justice demonstrate that the courts are awarding increasingly higher amounts. The goal of this work was an attempt to approximate, based on our own experiences, the impact of adverse events on the expenditures of the healthcare system in Poland, including the costs of treatment of the consequences of such events, described by the authors as “secondary harm”. Methods: Based on the analysis of 100 cases for compensation for the occurrence of a medical event, an initial estimate of the costs of primary (initial) treatment, which resulted in the occurrence of the adverse event, and the costs of subsequent hospitalisations/stays, which were its consequences. The study was conducted in the period from October 2020 to November of 2021. Results: The statistical analysis of the examined cases enabled establishing that in 62% they concerned women. Only 38% were events which applied to men. The highest number of cases concerned events which occurred in the last years, that is 2018 (35%), 2019 (23%), and 2017 (17%). The most frequent events included those related to incorrect diagnosis (the lack of correct diagnosis), which resulted in appropriate activities not being undertaken and a lack of appropriate treatment, e.g., lack of diagnosis of cancer, myocardial infarction, appendicitis, or fracture (26%). The next one was incorrect surgical treatment (17%)—the consequence of which was most frequently a need for repeated surgery and an incorrect conservative treatment of injuries. The obtained results demonstrate that significantly higher funds are spent by medical entities for “restorative” actions (on average EUR 1433, which attempt to mitigate against the negative consequences of incorrect decisions or actions in the original treatment (average cost of EUR 814)). Conclusions: The consequences of adverse events include not only health-related harm for the patient, but also long-term social, familial, or professional results. The authors of the article are of an opinion that all the conducted analyses and conclusions drawn from them should serve the improvement of patient safety. They also form an initial point for establishing recommendations and advice for the improvement of safety and quality of medical services and the reduction of healthcare-related costs. The authors propose covering the parties injured by an adverse event (subjected to “secondary harm”) with a unique, innovative programme of post-accident health care, “Health Reconstruction”.

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare

OBJECTIVE

Though healthcare is often exhorted to learn from 'high-reliability' industries, adopting tools and techniques from those sectors may not be straightforward. We sought to examine the hierarchies of risk controls approach, used in high-risk industries to rank interventions according to supposed effectiveness in reducing risk, and widely advocated as appropriate for healthcare.

DESIGN

Classification of risk controls proposed by clinical teams following proactive detection of hazards in their clinical systems. Classification was based on a widely used hierarchy of controls developed by the US National Institute for Occupational Safety and Health (NIOSH).

SETTING AND PARTICIPANTS

A range of clinical settings in four English NHS hospitals.

RESULTS

The four clinical teams in our study planned a total of 42 risk controls aimed at addressing safety hazards. Most (n = 35) could be classed as administrative controls, thus qualifying among the weakest type of interventions according to the HoC approach. Six risk controls qualified as 'engineering' controls, i.e. the intermediate level of the hierarchy. Only risk control qualified as 'substitution', classified as the strongest type of intervention by the HoC.

CONCLUSIONS

Many risk controls introduced by clinical teams may cluster towards the apparently weaker end of an established hierarchy of controls. Less clear is whether the HoC approach as currently formulated is useful for the specifics of healthcare. Valuable opportunities for safety improvement may be lost if inappropriate hierarchical models are used to guide the selection of patient safety improvement interventions. Though learning from other industries may be useful, caution is needed.