Monitoring adverse events in Norwegian hospitals from 2010 to 2013

Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014-2020): Findings From Taiwan Patient Safety Reporting System

OBJECTIVES

Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity.

METHODS

Longitudinal secondary data (over 2014-2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system. The numbers and incidence rates (per 1000 inpatient days) of reported MAEs were calculated. The harm severity levels of six major MAE categories were analyzed. Trend and generalized estimating equation analyses were conducted to investigate changes in MAE patterns.

RESULTS

Trend analyses revealed significant decreasing trends in the number (4763-3107 per year; Jonckheere-Terpstra test = -1.952, P = 0.05) and incidence rates (0.92-0.62 per 1000 inpatient days; β = -0.5017, P = 0.00) of harmful MAEs over 7-year study period. Among the most frequently reported MAEs, tube-related events exhibited the most significant decreasing trend (28%-23.8%; Jonckheere-Terpstra test = -2.854, P = 0.00). The reported numbers, incidence rates, and severity of falls and tube-related events dropped significantly.

CONCLUSIONS

By analyzing representative longitudinal MAE data, this study demonstrated the effectiveness of nationwide patient safety improvement campaigns in Taiwan. Our data reveal significant reductions in the reported numbers, incidence rates, and severity of several major MAEs. Specifically, our data indicate significant reductions in the incidence and severity of tube-related events, which can be beneficial for patient safety improvement efforts.

Prevalence of Triggers and Patient Harm Identified by Global Trigger Tool in Specialized Palliative Care

Background: Global trigger tool (GTT) was developed for identification of patient harm. In palliative patients deterioration can be expected, and there are no data on whether cases classified as "patient harm" actually represents a potential for improved patient safety. Objectives: The primary aim was to test the performance and suitability of GTT in palliative care patients. The secondary aim was to pilot triggers for substandard palliative care. Design and Measurements: GTT was applied in 113 consecutive patients at a palliative ward at a Norwegian university hospital. Cases of patient harm were further evaluated to decide if the case was (a) a natural part of the disease trajectory or (b) a foreseeable consequence of treatment decisions. Potential triggers for substandard palliative care were tested. Results: Two hundred twelve triggers (1.9 per hospitalization) and 26 cases of patient harm were identified. The positive predictive value (PPV) for identifying patient harm was 0.12. The most prevalent harm was pressure ulcers (8.8%). Of the 26 cases of patient harm, 6 cases were a natural part of the disease trajectory and 10 consequences of treatment decisions. In 21 (18%) patients triggers being piloted for substandard palliative care were present, identifying 9 cases of substandard palliative care. The highest PPV (0.67) was observed for "Cessation of antibiotics less than 5 days before death." Conclusions: With the exception of pressure ulcers, GTT triggers were infrequent or had a very poor PPV for patient harm. Triggers related to overtreatment might be suitable for identifying substandard palliative care.

Compensation Claims After Hip Fracture Surgery in Norway 2008-2018

Background

Surgical complications contribute to the significant mortality following hip fractures in the elderly. The purpose of this study was to increase our knowledge of surgical complications by evaluating compensation claims following hip fracture surgery in Norway. Further, we investigated whether the size and location of performing institutions would influence surgical complications.

Methods

We collected data from the Norwegian System of Patient Injury Compensation (NPE) and the Norwegian Hip Fracture Register (NHFR) from 2008 to 2018. We classified institutions into 4 categories based on annual procedure volume and geographical location.

Results

90,601 hip fractures were registered in NHFR. NPE received 616 (.7%) claims. Of these, 221 (36%) were accepted, which accounts for .2% of all hip fractures. Men had nearly a doubled risk of ending with a compensation claim compared to women (OR: 1.8, CI, 1.4-2.4, P < .001). Hospital-acquired infection was the most frequent reason for accepted claims (27%). However, claims were rejected if patients had underlying conditions predisposing to infection. Institutions treating fewer than 152 hip fractures (first quartile) annually, had a statistically significant increased risk (OR: 1.9, CI, 1.3-2.8, P = .005) for accepted claims compared to higher volume facilities.

Discussion

The fewer registered claims in our study could be due to the relatively high early mortality and frailty in this patient group, which may decrease the likelihood of filing a complaint. Men could have undetected underlying predisposing conditions that lead to increased risk of complications. Hospital-acquired infection may be the most significant complication following hip fracture surgery in Norway. Lastly, the number of procedures performed annually in an institution influences compensation claims.

Conclusions

Our findings indicate that hospital acquired infections need greater focus following hip fracture surgery, especially in men. Lower volume hospitals may be a risk factor.

Variation in detected adverse events using trigger tools: A systematic review and meta-analysis

Background

Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely.

Objective

This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence.

Design

Systematic review and meta-analysis.

Methods

To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review.

Results

Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9–37.5; I² = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4–164.7. Overall studies’ risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation.

Conclusion

Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation.

Using the Global Trigger Tool in surgical and neurosurgical patients: A feasibility study

BACKGROUND

The Global Trigger Tool (GTT) has become a worldwide used method for estimating adverse events through a retrospective patient record review. However, little is known about the facilitators and the challenges in the GTT-implementation process. Thus, this study followed two aims: First, to apply a comprehensive set of feasibility criteria to qualitatively and systematically assess the GTT-implementation process in three departments of German university hospitals. Second, to identify the facilitators and the obstacles met in the GTT-implementation process and to derive recommendations for supporting other hospitals in implementing the GTT in clinical practice.

METHODS

The study used a qualitative documentary method based on process documentation, with written and verbal feedback from the reviewer, as well as evaluating the study sites during the implementation process. The study was conducted in three departments, each in a different German university hospital. The authors applied a comprehensive set of 22 feasibility criteria assessing the level of challenge in GTT implementation. The results were synthesized and they focused on the facilitators and the challenges.

RESULTS

Of these 22 feasibility criteria, nine were assessed as a low-level challenge, eleven regarded as a moderate-level challenge, and two with a problematic level of challenge. In particular, the lack of time and staff resources, the quality of the information in the patient records, organizational procedures, and local issues, posed major challenges in the implementation process. By contrast, the use of local coordinators and an external expert made important contributions to the GTT implementation.

CONCLUSIONS

Considering the facilitators and the obstacles beforehand may help with the implementation of the GTT in routine practice. In particular, early and effective planning can reduce or prevent critical challenges in terms of time, staff resources, and organizational aspects.

[Adverse events associated with medical care, or the dark side of health care in foreign countries: a systematic review]

A systematic review is devoted to epidemiology of adverse events in short-stay hospitals in foreign countries. It is found that dualism is an important feature of medical care, since treatment results can be not only useful, but also harmful (adverse events) associated with medical care per se. Adverse events are diagnosed in 10.68% of patients. Moreover, complications occur at previous stages of treatment in 20.91% of cases. Incidence of adverse events is 2 times higher in surgical departments and intensive care units compared to therapeutic departments. Among all adverse events, 42.83% are associated with open surgery, 16.17% with drug therapy, and 14.10% with manipulations or minimally invasive interventions. Preventable adverse events caused by human factor account for 48.24%. In other cases, adverse events are the result of side effects of medical technologies, exposure to physical environment and unsafe patient behavior. Infection associated with medical care (28.15%) prevails among other adverse events. In 51.45% of cases, adverse events are characterized by mild harm and do not prolong hospital-stay. Moderate harm requiring additional in-hospital treatment develops in 31.80% of cases. In 11.89% of cases, adverse events are life-threatening complications and/or cause disability. Moderate-to-severe harm increases hospital-stay by 8.7 days. Incidence of adverse events followed by unfavorable outcomes is 5.25%. Overall mortality and mortality from adverse events are 6.67% and 0.55%, respectively. Deaths associated with adverse events account for one in five deaths in a hospital and one in ten deaths in population of developed countries.

Ranking Quality and Patient Safety Challenges: A Nationwide Survey of Healthcare Quality Experts From General Hospitals in Spain

OBJECTIVE

The aim of the study was to identify and rank leading healthcare quality and patient safety challenges of general hospitals in Spain.

METHODS

A novel online cross-sectional survey for hospitals with 150 or more beds carried out between June and September 2018. Sample frame is hospitals of the National Catalogue of Hospitals of the Ministry of Health in Spain (N = 888). Eligibility criteria are quality experts of clinical quality and/or patient safety services of general hospitals with 150 or more beds. Challenges were ranked using a risk priority number (RPN) calculated from the product of severity, frequency, and detectability scores.

RESULTS

Targeted hospitals were 234. The contact rate was 97.4%, representing 63% of total beds nationwide. One hundred hospitals completed the questionnaire. According to the RPN, the top five challenges were incorrect hand hygiene of health professionals (mean RPN = 334.5, SD = 198.5), ineffective interprofessional communication (mean RPN = 334.3, SD = 169.5), medication errors in transitions of care (mean RPN = 254.0, SD = 151.0), low reporting rates of patient safety incidents and adverse events (mean RPN = 252.3, SD = 176.3), and antimicrobial resistance due to inappropriate use of antibiotics (mean RPN = 243.5, SD = 158.7).

CONCLUSIONS

This pioneer study of ranking quality and patient safety challenges of hospitals in Spain provides an evidence-based and context-specific foundation for quality improvement decision-making.

A Systematic Review of Methods for Medical Record Analysis to Detect Adverse Events in Hospitalized Patients

OBJECTIVE

In this systematic review, we evaluate 2 of the most used trigger tools according to the criteria of the World Health Organization for evaluating methods.

METHODS

We searched Embase, PubMed, and Cochrane databases for studies (2000-2017). Studies were included if medical record review (MRR) was performed with either the Global Trigger Tool or the Harvard Medical Practice Study in a hospital population. Quality assessment was performed in duplicate. Fifty studies were included, and results were reported for every criterion separately.

RESULTS

Medical record review reveals more adverse events (AEs) than any other method. However, at the same time, it detects different AEs. The costs of an AE were on average €4296. Considerable efforts have been made worldwide in health care to improve safety and to reduce errors. These have resulted in some positive effects. The literature showed that MRR is focused on several domains of quality of care and seems suitable for both small and large cohorts. Furthermore, we found a moderate to substantial agreement for the presence of a trigger and a moderate to good agreement for the presence of an AE.

CONCLUSIONS

Medical record review with a trigger tool is a reasonably well-researched method for the evaluation of the medical records for AEs. However, looking at the World Health Organization criteria, much research is still lacking or of moderate quality. Especially for the cost of detecting AEs, valuable information is missing. Moreover, knowledge of how MRR changes quality and safety of care should be evaluated.

Evolving Factors in Hospital Safety: A Systematic Review and Meta-Analysis of Hospital Adverse Events

OBJECTIVE

This study aimed to estimate the frequency of hospital adverse events (AEs) and explore the rate of AEs over time, and across and within hospital populations.

METHODS

Validated search terms were run in MEDLINE and EMBASE; gray literature and references of included studies were also searched. Studies of any design or language providing an estimate of AEs within the hospital were eligible. Studies were excluded if they only provided an estimate for a specific AE, a subgroup of hospital patients or children. Data were abstracted in duplicate using a standardized data abstraction form. Study quality was assessed using the Newcastle-Ottawa Scale. A random-effects meta-analysis estimated the occurrence of hospital AEs, and meta-regression explored the association between hospital AEs, and patient and hospital characteristics.

RESULTS

A total of 45,426 unique references were identified; 1,265 full-texts were reviewed and 94 studies representing 590 million admissions from 25 countries from 1961 to 2014 were included. The incidence of hospital AEs was 8.6 per 100 patient admissions (95% confidence interval [CI], 8.3 to 8.9; I2 = 100%, P < 0.001). Half of the AEs were preventable (52.6%), and a third resulted in moderate/significant harm (39.7%). The most evaluated AEs were surgical AEs, drug-related AEs, and nosocomial infections. The occurrence of AEs increased by year (95% CI, -0.05 to -0.04; P < 0.001) and patient age (95% CI = -0.15 to -0.14; P < 0.001), and varied by country income level and study characteristics. Patient sex, hospital type, hospital service, and geographical location were not associated with AEs.

CONCLUSIONS

Hospital AEs are common, and reported rates are increasing in the literature. Given the increase in AEs over time, hospitals should reinvest in improving hospital safety with a focus on interventions targeted toward the more than half of AEs that are preventable.

Longitudinal rates of hospital adverse events that contributed to death in Norway and Sweden from 2013 to 2018

Objectives

In this paper, we explore and compare types and longitudinal trends of hospital adverse events in Norway and Sweden in the years 2013–2018 with special reference to AEs that contributed to death.

Design

Acute care hospitals in both countries performed medical record reviews on randomly selected medical records from all eligible admissions. Analysis: Comparison between Norway and Sweden of linear trends from 2013–2018, and percentage rates of admissions with at least one AE according to types and severities.

Setting

Norway and Sweden have similar socio-economic and demographic characteristics, which constitutes a relevant context for cooperation, comparison and mutual learning. This setting has promoted the use of GTT to monitor national rates of AEs in hospital care in the two countries.

Participants

53 367 medical records in Norway and 88 637 medical records in Sweden were reviewed.

Results

13.2% of hospital admissions in Norway and 13.1% in Sweden were associated with an AE of all severities (E-I). 0.23% of hospital admissions in Norway and 0.26% in Sweden were associated with an AE that contributed to death (I). The differences between the two countries were not statistically significant.

Conclusions

There were no significant differences in overall rates (E-I) of AEs in Norway and Sweden, nor in rates of AEs that contributed to death (I). There was no significant change in AEs or fatal AEs in either country over the six-year time period.

National and Institutional Trends in Adverse Events Over Time: A Systematic Review and Meta-analysis of Longitudinal Retrospective Patient Record Review Studies

OBJECTIVE

This study aimed to determine if the implementation of large-scale patient safety initiatives have been successful in reducing overall and preventable adverse event rates in hospital inpatients.

DESIGN

The design used in this study was systematic review and meta-analysis.

DATA RESOURCES

We followed our published protocol (PROSPERO [CRD42019140058]) and searched the following databases: PubMed, CINAHL, PsycINFO, Cochrane Library, and Embase from inception to February 2020. The reference lists of eligible studies were also searched.

ELIGIBILITY

All longitudinal retrospective record review studies that examined adverse event rates before and after the introduction of patient safety initiatives in hospital inpatients were included.

DATA EXTRACTION

Data extraction, quality, and risk of bias assessment were carried out by 2 independent reviewers. Information on study design, setting, demographics, interventions, and safety outcome measures was extracted.

RESULTS

A total of 3894 articles were screened, and 7 articles met the eligibility criteria for our systematic review with 5 of these providing sufficient information for inclusion in the meta-analysis. The degree of heterogeneity was high among studies. The meta-analysis demonstrated a minimal risk reduction in overall adverse event rates of 0.017 (95% confidence interval, 0.002-0.032) when the lower-quality studies were excluded, with one adverse event being prevented for every 59 hospital admissions.

CONCLUSIONS

These findings are significant when the large numbers of admissions to a hospital every year are considered. Given the low numbers of large-scale implementation studies, there is a need for more research on the effectiveness of patient safety initiatives to further assess the impact of such initiatives on adverse events.

Applying the Global Trigger Tool in German Hospitals: A Pilot in Surgery and Neurosurgery

The aim of the study was to assess the feasibility and potential of the Global Trigger Tool (GTT) for identifying adverse events (AEs) in different specialties in German hospitals.

The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system

Objectives

To quantify the prevalence and nature of adverse events in acute Irish hospitals in 2015 and to assess the impact of the National Clinical Programmes and the National Clinical Guidelines on the prevalence of adverse events by comparing these results with the previously published data from 2009.

Design and methods

A retrospective chart review of 1605 admissions to eight Irish hospitals in 2015, using identical methods to those used in 2009.

Results

The percentage of admissions associated with one or more adverse events was unchanged (p=0.48) at 14% (95% CI=10.4% to 18.4%) in 2015 compared with 12.2% (95% CI=9.5% to 15.5%) in 2009. Similarly, the prevalence of preventable adverse events was unchanged (p=0.3) at 7.4% (95% CI=5.3% to 10.5%) in 2015 compared with 9.1% (95% CI=6.9% to 11.9%) in 2009. The incidence densities of preventable adverse events were 5.6 adverse events per 100 admissions (95% CI=3.4 to 8.0) in 2015 and 7.7 adverse events per 100 admissions (95% CI=5.8 to 9.6) in 2009 (p=0.23). However, the percentage of preventable adverse events due to hospital-associated infections decreased to 22.2% (95% CI=15.2% to 31.1%) in 2015 from 33.1% (95% CI=25.6% to 41.6%) in 2009 (p=0.01).

Conclusion

Adverse event rates remained stable between 2009 and 2015. The percentage of preventable adverse events related to hospital-associated infection decreased, which may represent a positive impact of the related national programmes and guidelines.

Consistency of safety monitoring using routine national databases: results using a quality of care interpretative model

Background

In the framework of targeted action for continuous safety monitoring, we aimed to evaluate the consistency of indicators derived from available databases for regular reporting.

Methods

We used a quality of care interpretative model to select characteristics from five national databases, aggregated and linked by homogeneous groups of providers. The target population included all subjects admitted to public hospitals for acute care in four regions of Italy between 2011 and 2013. The association between structures, processes and safety-related outcomes was investigated using odds ratios from generalized estimating equations logistic regression. Outcome measures included claims of malpractice and five patient safety indicators calculated from discharge abstracts using standardized algorithms.

Results

Over 3 years, claims of malpractice and sepsis increased, whereas deep vein thrombosis and pulmonary embolism decreased. Hospitals with high vs. low volume of discharges were associated with −16% lower rates of claims, but +12% increased risk of sepsis. Compared with research institutes, university clinics had −17% lower rates of claims and −41% cases of dehiscence, with a +32% increased risk of deep vein thrombosis. Local health care authorities recorded −49% deep vein thrombosis, −26% pulmonary embolism, −40% sepsis and +37% risk of claims. Hospitals submitting cases of safe practices and implementing safety recommendations showed significantly higher rates for most outcome measures.

Conclusions

Indicators from regular databases can be conveniently used to develop a national safety monitoring system for hospital care. Although deeper analysis is needed, institutions with a higher propensity to implement safe practices and recommendations consistently showed higher rates of adverse events.

Is a modified Global Trigger Tool method using automatic trigger identification valid when measuring adverse events?

OBJECTIVES

To evaluate a modified Global Trigger Tool (GTT) method with manual review of automatic triggered records to measure adverse events.

DESIGN

A cross-sectional study was performed using the original GTT method as gold standard compared to a modified GTT method.

SETTING

Medium size hospital trust in Northern Norway.

PARTICIPANTS

One thousand two hundred thirty-three records selected between March and December 2013.

MAIN OUTCOME MEASURE

Records with triggers, adverse events and number of adverse events identified. Recall (sensitivity), precision (positive predictive value), specificity and Cohen's kappa with 95 % confidence interval were calculated.

RESULTS

Both methods identified 35 adverse events per 1000 patient days. The modified GTT method with manual review of 658 automatic triggered records identified adverse events (n = 214) in 189 records and the original GTT method identified adverse events (n = 216) in 186 records. One hundred and ten identical records were identified with adverse events by both methods. Recall, precision, specificity and reliability for records identified with adverse events were respectively 0.59, 0.58, 0.92 and 0.51 for the modified GTT method. The total manual review time in the modified GTT method was 23 h while the manual review time using the original GTT method was 411 h.

CONCLUSIONS

The modified GTT method is as good as the original GTT method that complies with the GTTs aim monitoring the rate of adverse events. Resources saved by using the modified GTT method enable for increasing the sample size. The automatic trigger identification system may be developed to assess triggers in real-time to mitigate risk of adverse events.

Mitigating risk in Norwegian psychiatric care: Identifying triggers of adverse events through Global Trigger Tool for psychiatric care

BACKGROUND

Patients treated in psychiatric care are exposed to the risk of adverse events, similar to patients treated in somatic health care.

OBJECTIVES

In this article we report the findings of triggers associated with adverse events (AEs) identified by a version of the Global Trigger Tool - Psychiatry (GTT-P) adapted for Norwegian hospital-based psychiatric treatment.

METHODS

The design was a retrospective analysis of a random sample of 240 patient records from a psychiatric clinic in one Norwegian hospital. Patient records were sampled from both inpatient and outpatient psychiatric clinics in hospitals serving the northern part of the county of Trøndelag, Norway.

RESULTS

Our analysis was based on the identification of 32 potential triggers of adverse events. Eighteen of the triggers were significantly related to adverse events. No adverse events were identified in patient records that did not also contain triggers included in the Global Trigger Tool.

CONCLUSIONS

There is a clear relationship between the presence of triggers in a patient record and the likelihood of adverse events. Particularly relevant for psychiatric patients is 'suffering' as a trigger and this may also be relevant to somatic care and has implications for inclusion in the GTT-P.

Assessing the development and implementation of the Global Trigger Tool method across a large health system in Sicily

Background: The Institute for Healthcare Improvement (IHI) has proposed a new method, the Global Trigger Tool (IHI GTT), to detect and monitor adverse events (AEs) and provide information to implement improvement. In 2015, the Sicilian Health System adopted IHI GTT to assess the number, types and severity levels of AEs. The GTT was implemented in 44 of 73 Sicilian public hospitals and 18,008 clinical records (CRs) were examined. Here we present the standardized application of the GTT and the preliminary results of 14,706 reviews of CRs.

Methods: IHI GTT was adapted, developed and implemented to the local context. Reviews of CRs were conducted by 199 professionals divided into 71 review teams consisting of three individuals: two of whom had clinical knowledge and expertise, and a physician to authenticate the AE. The reviewers entered data into a dedicated IT-platform. All 44 of the public hospitals were included, with approximately 300,000 yearly inpatient admissions out of a population of approximately 5 million. In total, 14,706 randomized CRs of inpatients from medicine, surgery, obstetric and ICU wards, from June 2015 to June 2018 were reviewed.

Results: In 975 (6.6%) CRs at least one AE was found. Approximately 20,000 patients of the 300,000 discharged each year in Sicily have at least one AE. In 5,574 (37.9%) CRs at least one trigger was found. A total of 1,542 AEs were found. The analysis of ROC curve shows that the presence of two triggers in a CR indicates with high probability the presence of an AE. The most frequent type of AE was in-hospital related infection.

Conclusions: The GTT is an efficient method to identify AEs and to track improvement of care. The analysis and monitoring of some triggers is important to prevent AEs. However, it is a labor-intensive method, particularly if the CRs are paper-based.

An evaluation by the Norwegian Health Care Supervision Authorities of events involving death or injuries in maternity care

INTRODUCTION

We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities.

MATERIAL AND METHODS

We selected cases investigated by supervision authorities during 2009-2013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided.

RESULTS

During the study period, there were 303 034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium-sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable.

CONCLUSIONS

The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care.

Patient and hospital characteristics that influence incidence of adverse events in acute public hospitals in Portugal: a retrospective cohort study

Objective

To analyse the variation in the rate of adverse events (AEs) between acute hospitals and explore the extent to which some patients and hospital characteristics influence the differences in the rates of AEs.

Design

Retrospective cohort study. Chi-square test for independence and binary logistic regression models were used to identify the potential association of some patients and hospital characteristics with AEs.

Setting

Nine acute Portuguese public hospital centres.

Participants

A random sample of 4250 charts, representative of around 180 000 hospital admissions in 2013, was analysed.

Intervention

To measure adverse events based on chart review.

Main Outcome Measure

Rate of AEs.

Results

Main results: (i) AE incidence was 12.5%; (ii) 66.4% of all AEs were related to Hospital-Acquired Infection and surgical procedures; (iii) patient characteristics such as sex (female 11%; male 14.4%), age (≥65 y 16.4%; <65 y 8.5%), admission coded as elective vs. urgent (8.6% vs. 14.6%) and medical vs. surgical Diagnosis Related Group code (13.4% vs. 11.7%), all with p < 0.001, were associated with a greater occurrence of AEs. (iv) hospital characteristics such as use of reporting system (13.2% vs. 7.1%), being accredited (13.7% vs. non-accredited 11.2%), university status (15.9% vs. non-university 10.9%) and hospital size (small 12.9%; medium 9.3%; large 14.3%), all with p < 0.001, seem to be associated with a higher rate of AEs.

Conclusions

We identified some patient and hospital characteristics that might influence the rate of AEs. Based on these results, more adequate solutions to improve patient safety can be defined.

Incidence of adverse events in Sweden during 2013-2016: a cohort study describing the implementation of a national trigger tool

OBJECTIVES

To describe the implementation of a trigger tool in Sweden and present the national incidence of adverse events (AEs) over a 4-year period during which an ongoing national patient safety initiative was terminated.

DESIGN

Cohort study using retrospective record review based on a trigger tool methodology.

SETTING AND PARTICIPANTS

Patients ≥18 years admitted to all somatic acute care hospitals in Sweden from 2013 to 2016 were randomised into the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measure was the incidence of AEs, and secondary measures were type of injury, severity of harm, preventability of AEs, estimated healthcare cost of AEs and incidence of AEs in patients cared for in another type of unit than the one specialised for their medical needs ('off-site').

RESULTS

In a review of 64 917 admissions, the average AE rates in 2014 (11.6%), 2015 (10.9%) and 2016 (11.4%) were significantly lower than in 2013 (13.1%). The decrease in the AE rates was seen in different age groups, in both genders and for preventable and non-preventable AEs. The decrease comprised only the least severe AEs. The types of AEs that decreased were hospital-acquired infections, urinary bladder distention and compromised vital signs. Patients cared for 'off-site' had 84% more preventable AEs than patients cared for in the appropriate units. The cost of increased length of stay associated with preventable AEs corresponded to 13%-14% of the total cost of somatic hospital care in Sweden.

CONCLUSIONS

The rate of AEs in Swedish somatic hospitals has decreased from 2013 to 2016. Retrospective record review can be used to monitor patient safety over time, to assess the effects of national patient safety interventions and analyse challenges to patient safety such as the increasing care of patients 'off-site'. It was found that the economic burden of preventable AEs is high.

Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology

OBJECTIVE

Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare.

DESIGN

A study using retrospective record review and trigger tool methodology.

SETTING AND METHODS

Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs.

RESULTS

The patients were aged 20-79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers.

CONCLUSIONS

AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies.

[Detection of adverse events using IHI Global Trigger Tool during the adoption of a risk management system: A retrospective study over three years at a department for cardiovascular surgery in Vienna]

BACKGROUND

Several studies point in the direction that the Global Trigger Tool for Measuring Adverse Events (GTT) published by the Institute for Healthcare Improvement (IHI) is an appropriate method to detect adverse events with high specificity, sufficient sensitivity and adequate interrater and intrarater reliability. After passing a certain training period, rating teams in healthcare institutions can successfully detect and reliably compare adverse event rates on local and national levels. To date there exist no published relevant data specifically for departments of cardiovascular surgery.

METHODS

In this single-center, retrospective study adverse event rates were detected using GTT for a department of cardiovascular surgery in a Viennese hospital. Having begun to establish a risk management system in the year 2008, 120 case histories were rated by a trained team for the years 2009 and 2012 each (240 in total).

RESULTS

From 2009 to 2012 the detection rate for adverse events improved significantly from 21.1 to 42.8 events per 1,000 patient days. This change was in agreement with an improvement in the detection rate of adverse events per 100 hospital admissions (from 43.7 to 80.0) as well as an improvement in the detection rate of the proportion of patients suffering from adverse events (from 24.4 % to 42.5 %).

CONCLUSION

In the course of the introduction and continuous optimization of a risk management system, the detection rate of adverse events, as measured with GTT, could be brought up to international standards. Thus, the utility of GTT as a possible instrument to help increase patient safety and improve quality could also be established at a department of cardiovascular surgery.

Targeted identification of adverse events in coronary artery disease patients based on patient-reported outcomes

AIM

Can focusing the adverse events search to patients with poor patient-reported outcome help in targeting adverse event detection?

PATIENTS & METHODS

Coronary artery revascularization patients of the Kuopio University Hospital from June 2012 to August 2014 categorized into those with clinically significant improvement (15D score change ≥0.015, n = 81) or deterioration (change ≥-0.015, n = 64) in post-intervention health-related quality of life.

RESULTS

Major complications (27 vs 9%, p = 0.004) or post-intervention infections (16 vs 5%, p = 0.031) were more common among those with deteriorated score. They also tended to have more cardiovascular (19 vs 9%, p = 0.071) and minor complications (16 vs 7%, p = 0.118).

CONCLUSION

Patient-reported outcomes may potentially help in targeting the adverse events search so that a larger number of adverse events can be identified for efficient learning from them.

Adverse events in hospitalised cancer patients: a comparison to a general hospital population

BACKGROUND

Patients with cancer are often treated by many healthcare providers, receive complex and potentially toxic treatments that can increase the risk for iatrogenic harm. The aim of this study is to investigate whether hospitalised cancer patients are at higher risk of adverse events (AEs) compared to a general hospital population.

MATERIAL AND METHODS

A total of 6720 patient records were retrospectively reviewed comparing AEs in hospitalised cancer patients to a general hospital population in Norway, using the IHI Global Trigger Tool method.

RESULTS

24.2 percent of admissions for cancer patients had an AE compared to 17.4% of admissions of other patients (p < .001, rr 1.39, 95% CI 1.19-1.62). However, cancer patients did not have a higher rate of AEs per 1000 patient days compared to other patients, 37.1 vs. 36.0 (p = .65, rr 0.94, 95% CI 0.90-1.18). No particular cancer category is at higher risk. The rate of AEs increases by 1.05 times for each day spent in hospital. For every year increase in age, the risk for AEs increases by 1.3%. Cancer patients more often have hospital-acquired infections, other surgical complications and AEs related to medications.

CONCLUSIONS

Because of higher age, longer length of stay and surgical treatment, hospitalised cancer patients experience AEs more often than other patients.

Adverse events and in-hospital mortality: an analysis of all deaths in a Norwegian health trust during 2011

BACKGROUND

The estimated number of in-hospitals deaths due to adverse events is often different when using data from deceased patients compared with that of a population experiencing adverse events.

METHODS

The study was conducted at three hospitals in the Bergen Hospital Trust, including a 950-bed university hospital. The objective was to study the reported deaths and investigate the probable number of deaths caused by adverse events. Information about all patients who died in the hospitals during 2011 was retrieved from the electronic patient data management system and the medical records. All deaths were classified into two groups according to Norwegian law based on whether or not the death was sudden and/or unexpected. The cause of death in the latter group was further classified as being due to either natural or unnatural causes according to national requirements. An expert review panel screened the patient records for information regarding adverse events and possible (≥ 50%) preventability. Age, length of hospital stay, and Charlson Comorbidity Index were also registered.

RESULTS

There were 59,605 unique patients admitted in 2011 and 1185 registered deaths (1.98%). The mean and median ages of the deceased were 73,8 and 78 years, respectively, and the median length of stay was 5.6 days (range). Of these deaths, 290 (24.5%) were considered sudden and/or unexpected and 218 were considered to be due to natural causes. Of the 72 unnatural deaths, 16 (1.4%) were classified as preventable or probably preventable. For 18 deaths (%) it was impossible to confirm or rule out preventability.

CONCLUSIONS

Using this method, we identified a small proportion of hospital deaths that could be classified as unnatural. Furthermore, there was a ≥ 50% chance or more that 34 deaths (2.9%) were due to causes that could have been prevented.

Exploring similarities and differences in hospital adverse event rates between Norway and Sweden using Global Trigger Tool

OBJECTIVES

In this paper, we explore similarities and differences in hospital adverse event (AE) rates between Norway and Sweden by reviewing medical records with the Global Trigger Tool (GTT).

DESIGN

All acute care hospitals in both countries performed medical record reviews, except one in Norway. Records were randomly selected from all eligible admissions in 2013. Eligible admissions were patients 18 years of age or older, undergoing care with an in-hospital stay of at least 24 hours, excluding psychiatric and care and rehabilitation. Reviews were done according to GTT methodology.

SETTING

Similar contexts for healthcare and similar socioeconomic and demographic characteristics have inspired the Nordic countries to exchange experiences from measuring and monitoring quality and patient safety in healthcare. The co-operation has promoted the use of GTT to monitor national and local rates of AEs in hospital care.

PARTICIPANTS

10 986 medical records were reviewed in Norway and 19 141 medical records in Sweden.

RESULTS

No significant difference between overall AE rates was found between the two countries. The rate was 13.0% (95% CI 11.7% to 14.3%) in Norway and 14.4% (95% CI 12.6% to 16.3%) in Sweden. There were significantly higher AE rates of surgical complications in Norwegian hospitals compared with Swedish hospitals. Swedish hospitals had significantly higher rates of pressure ulcers, falls and 'other' AEs. Among more severe AEs, Norwegian hospitals had significantly higher rates of surgical complications than Swedish hospitals. Swedish hospitals had significantly higher rates of postpartum AEs.

CONCLUSIONS

The level of patient safety in acute care hospitals, as assessed by GTT, was essentially the same in both countries. The differences between the countries in the rates of several types of AEs provide new incentives for Norwegian and Swedish governing bodies to address patient safety issues.

Adverse Events at Baseline in a Chinese General Hospital: A Pilot Study of the Global Trigger Tool

OBJECTIVE

To investigate adverse events (AEs) at baseline in a Chinese general hospital using the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) and discuss the feasibility of this tool to detect AEs in China.

METHODS

A total of 10 inpatient records from the hospital were sampled randomly half a month in 2014. The records were reviewed to identify AEs according to the second edition of the IHI GTT for measuring AEs. Triggers and AEs were analyzed using Microsoft Excel 2007. Statistical analyses were performed using IBM SPSS software, version 19.0.

RESULTS

A review of 240 patient records identified 51.0% (26/51) triggers in the worksheet, and 33.3% (17/51) were associated with AEs. A total of 70 AEs were identified in 54 patients, including 65.7% (46/70) category E AEs, which represent temporary harm requiring intervention, and 34.3% (24/70) category F AEs, which represent temporary harm requiring initial or prolonged hospitalization. The average rate of AEs per 1000 patient-days was 32.1 ± 20.9. The average rate of AEs per 100 admissions was 29.2 ± 16.1. The average rate of admissions with an AE was 22.5% ± 13.9%. The most significant characteristic of patients with AEs was longer hospital stay.

CONCLUSIONS

More than one fifth of adult inpatients in the current study experienced at least one AE resulting in temporary harm, most commonly caused by surgical operations and medication. With some modifications, the IHI GTT is a feasible and effective tool for detecting the overall status of AEs in a Chinese hospital.

Does increasing the size of bi-weekly samples of records influence results when using the Global Trigger Tool? An observational study of retrospective record reviews of two different sample sizes

OBJECTIVES

To investigate the impact of increasing sample of records reviewed bi-weekly with the Global Trigger Tool method to identify adverse events in hospitalised patients.

DESIGN

Retrospective observational study.

SETTING

A Norwegian 524-bed general hospital trust.

PARTICIPANTS

1920 medical records selected from 1 January to 31 December 2010.

PRIMARY OUTCOMES

Rate, type and severity of adverse events identified in two different samples sizes of records selected as 10 and 70 records, bi-weekly.

RESULTS

In the large sample, 1.45 (95% CI 1.07 to 1.97) times more adverse events per 1000 patient days (39.3 adverse events/1000 patient days) were identified than in the small sample (27.2 adverse events/1000 patient days). Hospital-acquired infections were the most common category of adverse events in both the samples, and the distributions of the other categories of adverse events did not differ significantly between the samples. The distribution of severity level of adverse events did not differ between the samples.

CONCLUSIONS

The findings suggest that while the distribution of categories and severity are not dependent on the sample size, the rate of adverse events is. Further studies are needed to conclude if the optimal sample size may need to be adjusted based on the hospital size in order to detect a more accurate rate of adverse events.