Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective

Corrective Actions Taxonomy for Healthcare Incidents (CATHI): Insights From Real-world Data on Hospital-reported Incidents

OBJECTIVES

This study aimed to develop a taxonomy for classifying corrective actions following health care incidents in a Portuguese tertiary hospital.

METHODS

The study utilized a multimethods design, combining qualitative and quantitative analyses of real-world data. Thematic analysis was performed, drawing on inductive and deductive approaches. The latter was informed by the PRISMA Medical Classification/Action Matrix and the COM-B theory.

RESULTS

A total of 4644 incidents were reported between January 1, 2021 and December 31, 2022. Each incident report is accompanied by an unstructured free-text conclusion section, whose content was manually coded using NVivo QRS. A total of 910 corrective actions were found. The process of classifying these actions, in addition to the deductive approach, served as the foundation for the development of the proposed taxonomy-the Corrective Actions Taxonomy for Healthcare Incidents (CATHI). CATHI included themes such as technology, medical devices, equipment and infrastructure, procedures, information and communication, and training, among others. The taxonomy was structured into 3 levels to allow for a more detailed classification of corrective actions. A glossary was developed to improve usability, including definitions and examples derived from real-world data.

CONCLUSIONS

CATHI provides a standardized approach to action implementation, allowing for prioritization of improvement efforts. This study has practical implications for enhancing patient safety and quality of care. Future research should validate this taxonomy in diverse health care settings.

Broadening the definition of patient-safety events: lessons from a multicentre learning health system collaborative

BACKGROUND

Improving safety in healthcare has been paramount for decades, yet despite major attention and investment, improvement has remained incremental. Patient safety is a major concern in US healthcare, leading to significant harm and economic losses annually. Accurately identifying safety events remains difficult due to methodological discrepancies and lack of standardisation. This study evaluated the feasibility of implementing a standardised case-review methodology and safety-event taxonomy across diverse hospital settings to assess opportunities for improvement (OFIs) and compare findings with traditional definitions.

METHODS

This multicentre retrospective cohort study reports data from 103 hospitals across the USA and Canada between 2016 and 2023. A multivariable logistic regression was performed to test case reviews for differences in the presence of one or more OFIs across several hospital types (bed size, academic status, urban setting, trauma level and Centres for Medicare and Medicaid Services overall star rating) and patient characteristics (age, gender, length of stay, admission and discharge code status and mortality).

RESULTS

19 181 cases were reviewed across the Learning Health System Collaborative, with a median of 107 reviews per hospital. Mortality was the most common cohort selection, studied by 91 hospitals (88%). At least one OFI was identified in 12 714 cases (66.3%). The logistic regression analysis found that all hospital characteristics and patient age, length of stay, code status and discharge disposition were significantly associated with at least one OFI. Of the 46 444 OFIs identified, 41 439 (89%) were from categories focused on omissions of care. The categories of end-of-life, documentation and treatment/care alone accounted for 25 980 OFIs (56%).

CONCLUSION

The highest volumes of safety-related OFIs were associated with omissions of care, as opposed to the traditional definition of patient safety, which primarily includes outcomes from acts of commission.

Qualitative Analysis of Severe Incidents in Forensic Psychiatric Hospitals: Toward a Model of Forensic Vigilance

Forensic vigilance is a hypothesized specialty of forensic mental health professionals which seems to play a role in maintaining safety in forensic hospitals. It is unclear exactly how forensic vigilance relates to preventing incidents. We used standardized reports of severe incidents that occurred in forensic hospitals to investigate how forensic vigilance plays a role in the occurrence of incidents. Eight forensic psychiatric hospitals in the Netherlands contributed 69 anonymized incident reports, which were investigated by means of thematic analysis and interpretative phenomenological analysis. Analysis revealed five important themes. Four core skills needed by professionals, namely observation, integration, communication and action, which each need a number of prerequisites (e.g., knowledge). The fifth theme specifies that the professional needs to "connect the dots" meaningfully. This is a highly cyclical process in which the core four skills are steps. The process is unique to the forensic context in terms of how the "dots" are connected and weighed, and which risks need to be considered. We present a model of this process and prerequisites needed in professionals. This model can inform policy makers, aid assessment of and communication between forensic professionals and can form the basis of a training for forensic mental health professionals.

Using the Generic Analysis Method to Analyze Sentinel Event Reports Across Hospitals: A Retrospective Cross-Sectional Study

OBJECTIVES

Improving patient safety by investigating sentinel events (SEs) is hampered by the focus on isolated events within hospitals and a narrow scope of traditional root cause analysis methods. We aimed to examine if performing cross-hospital aggregate analysis of SEs applying a novel generic analysis method (GAM) bearing a human factor perspective can enhance learning from SEs.

METHODS

A retrospective cross-sectional review of SE reports from 28 Dutch general hospitals using the GAM to reanalyze events was performed. A qualitative approach was used to identify contributing factors and system issues. Findings were discussed with a patient safety expert panel. Descriptive statistics and measures of associations between domains were calculated.

RESULTS

Sixty-nine SE reports were reviewed. Applying the GAM provided a more holistic SE analysis than a traditional method. Of the 405 identified contributing factors in all SEs, the majority was related to the persons involved (patients and professionals, n = 146 [36.2%]) and the organization (n = 121 [30%]). The most frequently recurring pattern was the combination of factors related to the persons involved, the technology used, the tasks of professionals, and organizational factors influencing the event. Cross-hospital aggregate GAM analysis of SEs helped to identify system issues and propose more system-oriented overarching recommendations.

CONCLUSIONS

This study found that applying the GAM to analyze SEs across hospitals can help to improve learning from SEs and may result in proposing stronger recommendations. The method can support hospitals, working together in a network of hospitals, to jointly learn from SEs.