Enhancing Patient Safety Event Reporting. A Systematic Review of System Design Features

OBJECTIVES

Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. Unfortunately, the value of e-reporting system (a software or web server based platform) in patient safety research is greatly overshadowed by low quality reporting. This paper aims at revealing the current status of system features, detecting potential gaps in system design, and accordingly proposing suggestions for future design and implementation of the system.

METHODS

Three literature databases were searched for publications that contain informative descriptions of e-reporting systems. In addition, both online publicly accessible reporting forms and systems were investigated.

RESULTS

48 systems were identified and reviewed. 11 system design features and their frequencies of occurrence (Top 5: widgets (41), anonymity or confidentiality (29), hierarchy (20), validator (17), review notification (15)) were identified and summarized into a system hierarchical model.

CONCLUSIONS

The model indicated the current e-reporting systems are at an immature stage in their development, and discussed their future development direction toward efficient and effective systems to improve patient safety.

A real-time assessment of factors influencing medication events

Reducing medical error is critical to improving the safety and quality of healthcare. Physician stress, fatigue, and excessive workload are performance-shaping factors (PSFs) that may influence medical events (actual administration errors and near misses), but direct relationships between these factors and patient safety have not been clearly defined. This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals. During an 18-month study period, 185 physician participants working at four university-affiliated teaching hospitals reported medication events using a confidential reporting application on handheld computers. Emotional stress scores, perceived workload, patient case volume, clinical experience, total sleep, and demographic variables were also captured via the handheld computers. Medication event reports (n = 11) were then correlated with these demographic and PSFs. Medication events were associated with 36.1% higher perceived workload (p < .05), 38.6% higher inpatient caseloads (p < .01), and 55.9% higher emotional stress scores (p < .01). There was a trend for reported events to also be associated with less sleep (p = .10). These results confirm the effect of factors influencing medication events, and support attention to both provider and hospital environmental characteristics for improving patient safety.

Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians

OBJECTIVE

To determine the feasibility of capturing self-reported medication events using a handheld computer-based Medication Event Reporting Tool (MERT).

DESIGN AND PARTICIPANTS

Handheld computers operating the MERT software application were deployed among volunteer physician (n = 185) and nurse (n = 119) participants on the medical wards of four university-affiliated teaching hospitals. Participants were encouraged to complete confidential reports on the handheld computers for medication events observed during the study period.

MEASUREMENTS AND MAIN RESULTS

Demographic variables including age, gender, education level, and clinical experience were recorded for all participants. Each MERT report included details on the provider, location, timing and type of medication event recorded. Over the course of 2,311 days of clinician participation, 76 events were reported; the median time for report completion was 231 seconds. The average event reporting rate for all participants was 0.033 reports per clinician shift. Nurses had a significantly higher reporting rate compared to physicians (0.045 vs 0.026 reports/shift, p = .02). Subgroup analysis revealed that attending physicians reported events more frequently than resident physicians (0.042 vs 0.021 reports/shift, p = .03), and at a rate similar to that of nurses (p = .80). Only 5% of MERT medication events were reported to require increased monitoring or treatment.

CONCLUSIONS

A handheld-based event reporting tool is a feasible method to record medication events in inpatient hospital care units. Handheld reporting tools may hold promise to augment existing hospital reporting systems.

Reporting near-miss events in nursing homes

Since the Institute of Medicine report To Err Is Human was published in 1999, improving patient safety has become a major initiative for nurses working in all care settings. Nursing homes are a fertile environment for both a high frequency of adverse events to occur and a high number of institutional barriers to reporting them. This article outlines the barriers to reporting adverse events in nursing homes and provides support for why reporting near-miss events can serve as a means of reducing these barriers. It also provides recommendations and specific strategies for how to implement near-miss reporting systems in nursing homes such as policy changes, supportive leadership, and educating nurses about near-miss events. Further nursing research in this evolving area of patient safety is warranted.

Impact of a falls menu-driven incident-reporting system on documentation and quality improvement in nursing homes

PURPOSE

Data from incident-reporting systems have been used successfully in disciplines other than health care to improve safety. This study tested the effect of a falls menu-driven incident-reporting system (MDIRS) on quality-improvement efforts in nursing homes.

DESIGN AND METHODS

Following instrument development and testing, the intervention occurred over a 4-month period in three intervention nursing homes using the MDIRS matched with three homes using their existing narrative incident report to document falls. Data on fall incidents were collected from facility incident reports, and comparisons in incident-report documentation were made between the intervention and control groups. The minutes from quality-improvement meetings were examined to see how incident-report data were used for fall-prevention strategies.

RESULTS

Almost one third of nursing home residents among the six facilities fell during the 4-month study period. Intervention nursing homes had significantly better documentation of fall characteristics on the incident reports than did the control nursing homes. Although only one nursing home fully implemented the MDIRS intervention, all three facilities identified strengths of the system.

IMPLICATIONS

The MDIRS can have a significant impact in improving how nursing staff assess residents following a fall incident. Traditional narrative methods of documenting adverse incidents are time consuming and may not yield sufficient and accurate data. This model has the potential to enhance quality-improvement efforts and augment the current system of adverse incident reporting in nursing homes.

Reporting of unintended events in an intensive care unit: comparison between staff and observer

Background

In order to identify relevant targets for change, it is essential to know the reliability of incident staff reporting. The aim of this study is to compare the incidence and type of unintended events (UE) reported by facilitated Intensive Care Unit (ICU) staff with those recorded concurrently by an observer.

Methods

The study is a prospective data collection performed in two 4-bed multidisciplinary ICUs of a teaching hospital. The format of the UE reporting system was voluntary, facilitated and not necessarily anonymous, and used a structured form with a predetermined list of items. UEs were reported by ICU staff over a period of 4 weeks. The reporting incidence during the first fourteen days was compared with that during the second fourteen. During morning shifts in the second fourteen days, one observer in each ICU recorded any UE seen. The staff was not aware of the observers' study. The incidence of UEs reported by staff was compared with that recorded by the observers.

Results

The staff reported 36 UEs in the first fourteen days and 31 in the second.. The incidence of UE detection during morning shifts was significantly higher than during afternoon or night shifts (p < 0.001). Considering only working day morning shifts, the rate of UE reporting by the staff per 100 patient days was 26.9 (CI 95% 16.9–37.0) in the first fourteen day period and 20.3 (CI 95% 10.3–30.4) in the second. The rate of UE detection by the observers was 53.1 per 100 patient days (CI 95% 40.6–65.6), significantly higher (p < 0.001) than that reported concurrently by the staff. There was excellent agreement between staff and observers about the severity of the UEs recorded (Intraclass Correlation Coefficient 0.869). The observers recorded mainly UEs involving Airway/mechanical ventilation and Patient management, and the staff Catheter/Drain/Probe and Medication errors (p = 0.025).

Conclusion

UE incidence is strongly underreported by staff in comparison with observers. Also the types of UEs reported are different. Invaluable information about incidents in ICU can be obtained in a few days by observer monitoring.

Improving pediatric chemotherapy safety through voluntary incident reporting: lessons from the field

BACKGROUND

A multidisciplinary team within Vanderbilt Children's Hospital (VCH) designed, developed, and implemented a pediatric chemotherapy incident reporting and improvement system (CIRIS) for pediatric oncology nurse and pharmacists. The aim of this collaboration was to improve pediatric chemotherapy by translating recommendations made by the Institute of Medicine into an operational safety improvement system that is embedded into daily care processes.

METHODS

CIRIS improves chemotherapy safety by linking two distinct components: (a) a technical component that uses desktop, laptop, and portable wireless handheld computers to interface the Web-based software application for point-of-care incident reporting and on-demand retrieval of patient support information, and (b) a human component that performs process analysis, data reporting, and clinical improvement. This integrated system facilitates and supports a blame-free culture for reporting of near misses and preventable adverse drug events.

RESULTS

Between February 8, 2002, and March 9, 2003, pediatric oncology nurses and chemotherapy pharmacists electronically reported 97 chemotherapy-related incidents associated with 96 unique patients. Ordering errors were the most commonly reported incidents. CIRIS improved reporting performance demonstrated using the conventional paper-based reporting system.

Contraindications for superficial heat and therapeutic ultrasound: do sources agree?11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated

OBJECTIVES

To determine the amount of agreement among general rehabilitation sources for both superficial heating and therapeutic ultrasound contraindications.

DATA SOURCES

English-language textbook and peer-reviewed journal sources, from January 1992 to July 2002. Searches of computerized databases (HealthSTAR, CINAHL, MEDLINE, Embase) as well as Library of Congress Online Catalogs, Books in Print, and AcqWeb's Directory of Publishers and Venders.

DATA SELECTION

Sources were excluded if they (1) were published before 1992, (2) failed to address general rehabilitation audiences, or (3) were identified as a researcher's related publication with similar information on the topic.

DATA EXTRACTION

Type and number of contraindications, type of audience, year of publication, number of references, rationales, and alternative treatment strategies.

DATA SYNTHESIS

Eighteen superficial heat and 20 ultrasound sources identified anywhere from 5 to 22 and 9 to 36 contraindications/precautions, respectively. Agreement among sources was generally high but ranged from 11% to 95%, with lower agreement noted for pregnancy, metal implants, edema, skin integrity, and cognitive/communicative concerns. Seventy-two percent of superficial heat sources and 25% of ultrasound sources failed to reference at least 1 contraindication claim.

CONCLUSIONS

Agreement among contraindication sources was generally good for both superficial heat and therapeutic ultrasound. Sources varied with regard to the number of contraindications, references, and rationales cited. Greater reliance on objective data and standardized classification systems may serve to develop more uniform guidelines for superficial heat and therapeutic ultrasound.

Adverse events in acute care: an integrative literature review

An integrative literature review was conducted to investigate studies on adverse events reported in medical, health services, and nursing literature. The review was guided by the method proposed by Jackson (1980) and Ganong (1987). Three questions shaped the review: (a) What terms are used to denote adverse events? (b) What purposes drive adverse events research? and (c) What data sources are used to study adverse events? Adverse events was the dominant term, the study of adverse events as an outcome variable was the prevailing research purpose, and monitoring or screening the patient clinical record and self-reported incidents by health care professionals were the main data sources. Future research is recommended to conceptualize and study adverse events.