Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events

Analysis of adverse events in general surgery. Multicenter study

INTRODUCTION

Knowledge of adverse events (AE) in acute care hospitals is a particularly relevant aspect of patient safety. Its incidence ranges from 3% to 17%, and surgery is related to the occurrence of 46%-65% of all AE.

MATERIAL AND METHODS

An observational, descriptive, retrospective, multicenter study was conducted with the participation of 31 Spanish acute-care hospitals to determine and analyze AE in general surgery services.

RESULTS

The prevalence of AE was 31.53%. The most frequent types of AE were infectious (35%). Higher ASA grades, greater complexity and urgent-type admission are factors associated with the presence of AE. The majority of patients (58.42%) were attributed a category F event (temporary harm to the patient requiring initial or prolonged hospitalization); 14.69% of AE were considered severe, while 34.22% of AE were considered preventable.

CONCLUSIONS

The prevalence of AE in General and GI Surgery (GGIS) patients is high. Most AE were infectious, and the most frequent AE was surgical site infection. Higher ASA grades, greater complexity and urgent-type admission are factors associated with the presence of AE. Most detected AE resulted in mild or moderate harm to the patients. About one-third of AE were preventable.

[Does recommending the dosing frequency in the electronic prescription improve its adequacy? Before and after study]

OBJECTIVE

To assess whether reporting the dosing frequency into the prescription module of the Institut Català de la Salut (ICS) primary care electronic clinical workstation improves the dosing frequency's adequacy of the prescriptions.

DESIGN

Before and after study with non-equivalent control of prescriptions without any change in the dosing frequency. The study periods includes from September 1st, 2019 to February 29th, 2020.

LOCATION

Primary care setting.

PARTICIPANTS

Prescriptions issued by ICS General Practitioner, during the study period of those medicines which indications have a single appropriate dosing frequency or mostly appropriate, are included.

INTERVENTION

Recommendation of the appropriate dosing frequency in the prescription module.

MAIN MEASUREMENTS

Adequacy defined as the coincidence between the prescribed dosing frequency and the appropriate dosing frequency.

RESULTS

After the intervention there was a 22.75% increase in prescriptions with adequate dosing frequency. The largest increase occurred in the medicines for the genitourinary system and sex hormones. In absolute terms, the group of anti infective for systemic use is the one that obtained more prescriptions with an adequate dosing frequency between the two periods.

CONCLUSIONS

The intervention increased the dosing frequency's adequacy leading to improvements in the safety and effectiveness of the treatments. It is evident that the design and implementation of improvements in electronic prescription systems contributes to increasing the quality of the prescription.

Relationship between adverse events prevalence, patient safety culture and patient safety perception in a single sample of patients: a cross-sectional and correlational study

OBJECTIVE

To assess the relationship between adverse events prevalence (AEP), patient safety culture (PSC) and patient safety perception (PSP).

DESIGN

Cross-sectional, ex post facto comparative study on a single sample of patients.

SETTING

Four medium-high-level hospitals were included in the study-two public and two private from Zulia State in Venezuela.

PARTICIPANTS

556 medical records and patients were studied for the prevalence and PSP study, and 397 of the healthcare providers involved in the care of these patients were surveyed for the PSC study, at two public and two private hospitals.

OUTCOME MEASUREMENT

The primary outcome of this study was the association between AEP, PSC and PSP, and according to hospital funding type, private and public.

RESULTS

An inverse association was observed between AEP and its severity and Patient Safety Culture Index (rho=-0.8, p=0.5) (95% CI 0.26-0.10) and Patient Safety Perception Index (rho=-0.6, p=0.18) (95% CI 0.10-0.28), which were protective factors for patient safety. No association was identified between PSC and PSP (rho=0.0001). No statistical differences were identified by hospital type (p=0.93) (95% CI 0.70-1.2).

CONCLUSIONS

The analysis of the variable correlations studied (AEP, PSC and PSP) within the same sample offers an interesting and useful perspective. In this sample, although no correlation was observed between the three variables as an interacting set, some correlation patterns were observed between pairs of variables that could guide further studies.

Cohort profile for development of machine learning models to predict healthcare-related adverse events (Demeter): clinical objectives, data requirements for modelling and overview of data set for 2016-2018

PURPOSE

In-hospital health-related adverse events (HAEs) are a major concern for hospitals worldwide. In high-income countries, approximately 1 in 10 patients experience HAEs associated with their hospital stay. Estimating the risk of an HAE at the individual patient level as accurately as possible is one of the first steps towards improving patient outcomes. Risk assessment can enable healthcare providers to target resources to patients in greatest need through adaptations in processes and procedures. Electronic health data facilitates the application of machine-learning methods for risk analysis. We aim, first to reveal correlations between HAE occurrence and patients' characteristics and/or the procedures they undergo during their hospitalisation, and second, to build models that allow the early identification of patients at an elevated risk of HAE.

PARTICIPANTS

143 865 adult patients hospitalised at Grenoble Alpes University Hospital (France) between 1 January 2016 and 31 December 2018.

FINDINGS TO DATE

In this set-up phase of the project, we describe the preconditions for big data analysis using machine-learning methods. We present an overview of the retrospective de-identified multisource data for a 2-year period extracted from the hospital's Clinical Data Warehouse, along with social determinants of health data from the National Institute of Statistics and Economic Studies, to be used in machine learning (artificial intelligence) training and validation. No supplementary information or evaluation on the part of medical staff will be required by the information system for risk assessment.

FUTURE PLANS

We are using this data set to develop predictive models for several general HAEs including secondary intensive care admission, prolonged hospital stay, 7-day and 30-day re-hospitalisation, nosocomial bacterial infection, hospital-acquired venous thromboembolism, and in-hospital mortality.

Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study

BACKGROUND

All health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were the following: (1) to analyze the association between IHA and the development of subsequent AEs; (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions.

METHODS

An observational cross-sectional study was conducted on hospitalized patients in May 2019 in a high-complexity hospital in Madrid, Spain. The Appropriateness Evaluation Protocol was used to measure IHA, and the methodologies of the Harvard Medical Practice Study and the European Point Prevalence Survey of Healthcare-associated Infections were used to detect and characterize AEs. The association between IHA and the subsequent.

RESULTS

A total of 558 patients in the hospital ward were studied. IHA increased the risk of subsequent occurrence of AEs (OR [95% CI]: 3.54 [1.87 to 6.69], versus appropriate) and doubled the mean AEs per patient (coefficient [95% CI]: 0.19 [0.08 to 0.30] increase, versus appropriate) after adjusting for confounders. IHA was a predictive variable of subsequent AEs and the number of AEs per patient. AEs developed after IHA were associated with scheduled admissions (78.9% of AEs, versus 27.9% after appropriate admissions; p < 0.001). Compared with AEs developed after appropriate admissions, AEs after IHA added 2.4 additional days of stay in the intensive care unit and incurred an extra cost of €166,324.9 for the studied sample.

CONCLUSIONS

Patients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns.

Occurrence and preventability of adverse events in hospitals: a retrospective study

OBJECTIVES

to analyze the incidence of preventable adverse events related to health care in adult patients admitted to public hospitals in Brazil.

METHODS

observational, analytical, retrospective study based on medical records review.

RESULTS

medical records from 370 patients were evaluated, 58 of whom had at least one adverse event. The incidence of adverse events corresponded to 15.7%. Adverse events were predominantly related to healthcare-related infection (47.1%) and procedures (24.5%). Regarding the adverse event severity, 13.7% were considered mild, 51.0% moderate, and 35.3% severe. 99% of adverse events were classified as preventable. Patients admitted to the emergency room had a 3.73 times higher risk for adverse events.

CONCLUSIONS

this study's results indicate a high incidence of avoidable adverse events and highlight the need for interventions in care practice.

Adverse events: an expensive and avoidable hospital problem

INTRODUCTION

Adverse healthcare-related events (AE) entail reduced patient safety. Estimating their frequency, characteristics, avoidability and impact is a means to identify targets for improvement in the quality of care.

METHODS

This was a descriptive observational study conducted within the Patient Safety Incident Study in Hospitals in the Community of Madrid (ESHMAD). The study was conducted in a high-complexity hospital in May 2019 through a two-phase electronic medical record review: (1) AE screening and epidemiological and clinical data collection and (2) AE review and classification and analysis of their impact, avoidability, and associated costs.

RESULTS

A total of 636 patients were studied. The prevalence of AE was 12.4%. Death during the stay was associated with the presence of AE (OR [CI95%]: 2.15 [1.07 to 4.52]) versus absence and emergency admission (OR [CI95%]: 17.11[6.63 to 46.26]) versus scheduled. A total of 70.2% of the AEs were avoidable. Avoidable AEs were associated with the presence of pressure ulcers (OR [CI95%]: 2.77 [1.39 to 5.51]), central venous catheter (OR [CI95%]: 2.58 [1.33 to 5.00]) and impaired mobility (OR [CI95%]: 2.24[1.35 to 3.71]), versus absences. They were associated too with the stays in the intensive care unit (OR [CI95%]: 2.75 [1.07 to 7.06]) versus medical service. AEs were responsible for additional costs of €909,716.8 for extra days of stay and €12,461.9 per patient with AE.

CONCLUSIONS

The prevalence of AEs was similar to that found in other studies. AEs led to worse patient outcomes and were associated with the patient's death. Although avoidable AEs were less severe, their higher frequency produced a greater impact on the patient and healthcare system.Key messagesAdverse events are one of the main problems in healthcare delivery and patients who suffer from at least one AE are double as likely to die during hospitalization.Avoidable adverse events are the most frequent in health care and they are a good target where achieve improvement areas that allow getting optimal patient safety and quality of care levels.Patients hospitalized in the ICU, with the previous presence of pressure ulcers, central venous catheter, or impaired mobility were associated with the development of avoidable AE, so optimal management of these patients would reduce the impact of AE.

Patient safety culture in Austria and recommendations of evidence-based instruments for improving patient safety

This study aimed to investigate the patient safety culture in Austria. We identified factors that contributed to a higher degree of patient safety and subsequently developed evidence-based suggestions on how to improve patient safety culture in hospitals. Moreover, we examined differences in the perception of patient safety culture among different professional groups. This study used a cross-sectional design in ten Austrian hospitals (N = 1,525). We analyzed the correlation between ten patient safety culture factors, three background characteristics (descriptive variables), and three outcome variables (patient safety grade, number of adverse events reported, and influence on patient safety). We also conducted an analysis of variance to determine the differences in patient safety culture factors among the various professional groups in hospitals. The findings revealed that all ten factors have considerable potential for improvement. The most highly rated patient safety culture factors were communication openness and supervisor/manager’s expectations and actions promoting safety; whereas, the lowest rated factor was non-punitive response to error. A comparison of the various professional groups showed significant differences in the perception of patient safety culture between nurses, doctors, and other groups. Patient safety culture in Austria seems to have considerable potential for improvement, and patient safety culture factors significantly contribute to patient safety. We determined evidence-based practices as recommendations for improving each of the patient safety factors.

Development of Consensus-Based Recommendations to Prevent/Minimize Medication Errors in the Perioperative Care of Patients with Epilepsy: A Mixed-Method

BACKGROUND

This study explored medication errors in the perioperative care of patients with epilepsy and developed consensus-based recommendations to prevent/minimize these errors.

METHODS

A mixed method was used in this study. Medication error situations were explored in semi-structured in-depth interviews with nurses (n = 12), anesthesiologists (n = 5), anesthesia technicians (n = 5), surgeons (n = 4), neurologists (n = 4), and patients with epilepsy (n = 10). The qualitative data were analyzed using the qualitative interpretive description approach. A two-round Delphi technique was used among nurses (n = 22), anesthesiologists (n = 9), anesthesia technicians (n = 7), surgeons (n = 7), and neurologists (n = 5).

RESULTS

A total of 1400 minutes of interview time was analyzed in this study. Of the panelists, 39 (78.0%) agreed that patients with epilepsy present unique challenges to providers of perioperative care that make them prone to medication errors. The interviewees in this study described 32 different medication error situations that occurred while providing perioperative care services to patients with epilepsy. In this study, 35 consensus-based recommendations to prevent/minimize medication errors in the perioperative care of patients with epilepsy were developed.

CONCLUSIONS

The findings of this study are informative to decision-makers in health care facilities and other stakeholders in health regulatory authorities who need to design measures to prevent/minimize medication errors and improve perioperative outcomes of patients with epilepsy. Studies are needed to investigate if these recommendations can be effective in preventing/reducing medication errors in the perioperative care of patients with epilepsy.

Team approach to fall reduction in paediatric ward of national referral hospital, Thimphu, Bhutan: a quality improvement initiative

Falls are common and preventable adverse events that occur in a hospital setting. Falls can cause pain, damage, increase cost and mistrust in the health system. Inpatient fall is a multifactorial event which can be reduced with multistrategic interventions.

In this project, we aimed to reduce the fall rate in paediatric ward of Jigme Dorji Wangchuck National Referral Hospital, Bhutan by 25% from the baseline over a period of 6 months by focusing on fall risk assessment, staff education on fall prevention measures and devoting more attention to patients at high risk of fall.

We tested three sets of interventions using the Plan–Do–Study–Act approach. For the first cycle, emphasis was on staff education in terms of proper use of fall risk assessment form, risk categorisation and fall prevention advice. In the second cycle, in addition to the first we introduced the ‘high risk of fall package’ and the third cycle focused on early and easy identification of high-risk patients by continuous fall risk assessment and use of high risk of fall sticker.

We observed that at the start of the quality improvement project despite our intervention the fall rate of our ward went up but as we continued adding more ideas focusing on high risk patients, we could achieve a fall reduction of 49.3% from the base line by end of third cycle. Our ward saw fall free days of almost 90 days at the end of project.

We conclude that inpatient falls occur due to multiple factors therefore a multi-pronged strategy is needed to prevent it. One of the prime preventive strategy is identifying patients who are at high risk of fall and concentrating attention to those patients.

Nurses' Perception of Patient Safety Culture in a Referral Hospital: A Cross-Sectional Study

Healthcare systems are becoming increasingly complex which is helping to promote a ‘culture of safety’ within them based on the best scientific evidence available. Indeed, creating a positive institutional culture of patient safety is reflected in health outcomes. The aim of this present study was to describe the perception of culture of safety by nurses in adult inpatient units in a tertiary hospital and to analyze adverse events reporting. It was a cross-sectional study in which 202 nurses from adult hospitalization units of the Hospital Universitario y Politécnico La Fe in Valencia (Spain) participated. The perception of safety culture was measured using the Hospital Survey on Patient Safety questionnaire version 1.0, which consists of 42 items distributed in 12 dimensions that are considered strengths or weaknesses. In addition, adverse events related to nursing care during the study period and those reported in the official hospital registry were collected. Finally, the association between safety culture and sociodemographic and labor variables was explored. A total of 148 responses to the questionnaire were analyzed (Cronbach’s alpha = 0.94), where seven dimensions and 25 items were identified as weaknesses. Two hundred and fourteen events were identified and none were reported in the official registry. Years of experience were significantly (p < 0.05) associated with safety culture. It is necessary to establish strategies to improve the perception of the safety culture of nurses, as well as to make nurses aware of the importance of notifying adverse events derived from health care.

The Korea National Patient Safety Incidents Inquiry Survey: Feasibility of Medical Record Review for Detecting Adverse Events in Regional Public Hospitals

OBJECTIVES

We aimed to examine the Korea National Patient Safety Incidents Inquiry conducted in the Republic of Korea; specifically, we assessed the validity of screening criteria, interreviewer reliability, quality of medical records, and the time required for reviewing medical records.

METHODS

A 3-stage retrospective medical record review was performed. The sensitivity and positive predictive value of the screening criteria for the adverse events were calculated, and interreviewer reliability was verified using the overall agreement rate and κ value. In addition, the results of medical record quality assessment and time required for review were analyzed.

RESULTS

There were a total of 4159 patients (55.5%) with at least 1 of the 41 screening criteria. In stage 1, the overall percent of agreement was 81.9% when all negatives from the 2 reviewers were included, and the κ value was 0.64 (95% confidence interval [CI], 0.61-0.66). In stage 2, 84.6% of cases were a perfect match, and 87.4% were a partial match. The κ values were 0.159 (95% CI, 0.12-0.20) and 0.389 (95% CI, 0.35-0.43), respectively. The mean quality assessment scores were 3.18 of 4 points in stage 1 and 3.05 of 4 points in stage 2. In stage 1, it took an average of 13.02 minutes to asses each patient file; in stage 2, it took an average of 5.06 minutes.

CONCLUSIONS

To increase the feasibility of medical record review for detecting adverse events, it is important not only to improve the reliability between reviewers but also to monitor the quality of medical records and the time required for review.

Evaluation of COVID-19 Patient Safety Compared to Non-COVID-19 Patients and Predisposing Factors of Nursing Errors

Objectives: The present study aims to determine Patient Safety in hospitalized patients with COVID-19 compared to non-COVID-19 ones and find predisposing factors of nursing errors according to nurses’ perceptions. Methods: This descriptive-comparative research employed data from 800 nurses in eight Iranian hospitals in 2021 using three researcher-made questionnaires of sociodemographic, patient safety indicators, and predisposing factors of nursing errors, with high reliability and validity. The collected data were analyzed using ANOVA, independent t-test, and the SPSS22 software. Results: The mean patient safety scores in patients with and without COVID-19 were 3.42 ± 0.17 and 3.74 ± 0.06, respectively. The highest differences in patient safety were attributed to infection control (0.66) and patient fall (0.56) dimensions. The most common causes of nursing errors were related to management (2.67 ± 1.39), and the most common predisposing factors of nursing errors were high workload, low ratio of nurses to patients, and fatigue. Conclusions: COVID-19 patients have lower safety than non-COVID ones. Also, improper management and high workload lead to nursing errors. Therefore, the authorities must devise appropriate strategies to reduce the nurses’ workload and improve patient safety, especially in COVID-19 patients.

Surgery Is in Itself a Risk Factor for the Patient

(1) Background: Adverse events (AE) affect about 1 in 10 hospitalised patients, and almost half are related to surgical care. The aim of this study is to determine the prevalence of AE in operated and non-operated patients in surgical departments in order to determine whether surgical treatment is a risk factor for AE. (2) Methods: A cross-sectional design that included 3123 patients of 34 public hospitals in the Community of Madrid determining the prevalence of AEs in operated and non-operated patients in surgical departments. (3) Results: The prevalence of AE in non-operated patients was 8.7% and in those operated was 15.8%. The frequency of AE was higher in emergency surgery (20.6% vs. 12.4%). The 48.3% of AEs led to an increase in hospital stay, and surgery was involved in 92.4% of cases. The most frequent AEs were related to hospital-acquired infection (42.63%), followed by those related to a procedure (37.72%). In the multivariate analysis, being operated on represented 2.3 times the risk of developing an AE. (4) Conclusions: Surgical sites are particularly vulnerable to AE. Surgical intervention alone is a risk factor for AE, and we must continue to work to improve the safety of both patient care and the working environment of surgical professionals.

The Analysis of Hospital Readmission Rates After the Implementation of Hospital Readmissions Reduction Program

OBJECTIVES

This study aims to analyze the impact of Hospital Readmissions Reduction Program (HRRP) on the nationwide optimization efforts of length of stay (LOS) and readmissions in the United States.

METHODS

We use the Nationwide Readmission Database between 2010 and 2016 provided in the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality. The study focuses on acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), pneumonia monitored by the HRRP and 2 conditions, septicemia, and mood disorders that were not monitored by the HRRP but had among the highest readmissions. Patient demographics and readmissions were analyzed based on insurance type, LOS, and Charlson Comorbidity Index.

RESULTS

The readmissions vary by conditions, LOS, and insurance types. Congestive heart failure has the highest readmissions among the 6 analyzed conditions at approximately 25%. The readmission rate of CHF rises to 30% for the Medicaid patients and varies between 30% and 35% by LOS. Patients with CHF with higher Charlson Comorbidity Index demonstrates the highest readmissions among 6 conditions. The patients with longer LOSs had higher readmissions, and Medicare patients have a higher reduction in readmissions in acute myocardial infarction and mood disorders compared with the other forms of payments.

CONCLUSIONS

Our figures show that targeted programs, such as HRRP, may have a positive impact on readmission rates. We, however, observe some graphical evidence that nontargeted conditions could exhibit similar trends. Because of heterogeneity in hospital and patient characteristics, it is pivotal for researcher to consider them in formal analyses.

Impact of a system to assist in clinical decision-making in primary healthcare in Catalonia: prescription Self Audit

Background

In 2008, in the context of a complete computerisation of medical records, the Institut Català de la Salut (ICS, Catalan Health Institute) implemented a system in its electronic clinical workstation (ECW) to assist decision-making at the prescription level. This system is known as Self Audit, and it supports physicians in reviewing the medication of their patients. Self Audit provides lists of patients presenting medication-related problems (MRPs) that have potential for improvement, and provides therapeutic recommendations that are easy to apply from the system itself. The aim of this study was to analyse the main results derived from the use of Self Audit in primary care (PC) in Catalonia, and the effect of an incentive-based safety indicator on the results obtained.

Methods

A descriptive cross-sectional study was carried out to analyse variations in the MRPs detected by Self Audit during 2016, 2017, and 2018 in PC in Catalonia. The effect of a safety indicator on the results obtained was also studied. This safety indicator includes the most clinically relevant MRPs (i.e., therapeutic duplications, safety alerts from the Spanish Medicines Agency, and incidences of polymedication in patients over 65 years of age). Variation in the MRPs was measured using the differences between two evaluation points (initial and final). An MRP was considered resolved if the recommendation specified in the alert was followed. The prescriptions of 6411 PC doctors of the ICS who use the ECW and provide their services to 5.8 million Catalans through 288 PC teams were analysed.

Results

Analysis of the total safety-based MRPs detected by Self Audit gave overall resolutions from April to December of 9% (21,547) in 2016, 7% (15,924) in 2017, and 1% (2392) in 2018 out of the total number of MRPs recorded in April each year. Examination of the 3 types of MRPs with the highest clinical relevance that were linked to the safety indicator gave overall resolutions of 41% in 2016 (17,358), 20% in 2017 (7655), and 21% in 2018 (8135).

Conclusions

The ICS Self Audit tool assists in reducing the number of safety-based MRPs in a systematic manner, and yields superior results for the MRPs linked to a safety indicator included in the incentives of PC physicians.

Predictive Power of the "Trigger Tool" for the detection of adverse events in general surgery: a multicenter observational validation study

Background

In spite of the global implementation of standardized surgical safety checklists and evidence-based practices, general surgery remains associated with a high residual risk of preventable perioperative complications and adverse events. This study was designed to validate the hypothesis that a new “Trigger Tool” represents a sensitive predictor of adverse events in general surgery.

Methods

An observational multicenter validation study was performed among 31 hospitals in Spain. The previously described “Trigger Tool” based on 40 specific triggers was applied to validate the predictive power of predicting adverse events in the perioperative care of surgical patients. A prediction model was used by means of a binary logistic regression analysis.

Results

The prevalence of adverse events among a total of 1,132 surgical cases included in this study was 31.53%. The “Trigger Tool” had a sensitivity and specificity of 86.27% and 79.55% respectively for predicting these adverse events. A total of 12 selected triggers of overall 40 triggers were identified for optimizing the predictive power of the “Trigger Tool”.

Conclusions

The “Trigger Tool” has a high predictive capacity for predicting adverse events in surgical procedures. We recommend a revision of the original 40 triggers to 12 selected triggers to optimize the predictive power of this tool, which will have to be validated in future studies.

Safer prescription of drugs: impact of the PREFASEG system to aid clinical decision-making in primary care in Catalonia

BACKGROUND

In 2008, the Institut Català de la Salut (ICS, Catalan Health Institute) implemented a prescription decision support system in its electronic clinical workstation (ECW), which automatically generates online alerts for general practitioners when a possible medication-related problem (MRP) is detected. This tool is known as PREFASEG, and at the time of beginning a new treatment, it automatically assesses the suitability of the treatment for the individual patient. This analysis is based on ongoing treatments, demographic characteristics, existing pathologies, and patient biochemical variables. As a result of the assessment, therapeutic recommendations are provided. The objective of this study is to present the PREFASEG tool, analyse the main alerts that it generates, and determine the degree of alert acceptance.

METHODS

A cross-sectional descriptive study was carried out to analyse the generation of MRP-related alerts detected by PREFASEG during 2016, 2017, and 2018 in primary care (PC) in Catalonia. The number of MRP alerts generated, the drugs involved, and the acceptance/rejection of the alerts were analysed. An alert was considered "accepted" when the medication that generated the alert was not prescribed, thereby following the recommendation given by the tool. The MRP alerts studied were therapeutic duplications, safety alerts issued by the Spanish Medicines Agency, and drugs not recommended for use in geriatrics. The prescriptions issued by 6411 ICS PC physicians who use the ECW and provide their services to 5.8 million Catalans through 288 PC teams were analysed.

RESULTS

During the 3 years examined, 67.2 million new prescriptions were analysed, for which PREFASEG generated 4,379,866 alerts (1 for every 15 new treatments). A total of 1,222,159 alerts (28%) were accepted. Pharmacological interactions and therapeutic duplications were the most detected alerts, representing 40 and 30% of the total alerts, respectively. The main pharmacological groups involved in the safety alerts were nonsteroidal anti-inflammatory drugs and renin-angiotensin system inhibitors.

CONCLUSIONS

During the period analysed, 28% of the prescriptions wherein a toxicity-related PREFASEG alert was generated led to treatment modification, thereby helping to prevent the generation of potential safety MRPs. However, the tool should be further improved to increase alert acceptance and thereby improve patient safety.

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.

Alternative and Complementary Therapies against Foodborne Salmonella Infections

The limitations in the therapeutic options for foodborne pathogens lead to treatments failure, especially for multidrug-resistant (MDR) Salmonella sp., worldwide. Therefore, we aimed to find alternative and complementary therapies against these resistant foodborne pathogens. Out of 100 meat products samples, the prevalence rate of salmonella was 6%, serotyped only as S. Typhimurium and S. Enteritidis. According to the antibiotic susceptibility assays, the majority of our isolates were MDR and susceptible to cefotaxime. Out of the 13 tested plant extracts, five only showed an inhibition zone in the range of 8–50 mm against both serotypes. Based on their promising activity, the oily extract of cinnamon and aqueous extract of paprika represented the highest potency. Surprisingly, a significant synergistic effect was detected between cinnamon oil and cefotaxime. Depending on Gas Chromatography/Mass Spectrometry (GC-MS), the antimicrobial activity of cinnamon oil was attributed to four components including linalool, camphor, (Z)-3-Phenylacrylaldehyde and its stereoisomer 2-Propenal-3-phenyl. The anti-virulence activities of these compounds were confirmed on the basis of computational molecular docking studies. Accordingly, we recommended the use of cinnamon oil as a food additive to fight the resistant foodborne pathogens. Additionally, we confirmed its therapeutic uses, especially when co-administrated with other antimicrobial agents.

Why an Open Disclosure Procedure Is and Is not Followed After an Avoidable Adverse Event

OBJECTIVE

The aim of the study was to analyze the relationships between factors that contribute to healthcare professionals informing and apologizing to a patient after an avoidable adverse event (AAE).

METHODS

A secondary study based on the analysis of data collected in a cross-sectional study conducted in 2014 in Spain was performed. Health professionals from hospitals and primary care completed an online survey.

RESULTS

The responses from 1087 front-line healthcare professionals were analyzed. The willingness of the professionals to fully disclose an AAE was greater among those who were backed by their institution (odds ratio [OR] = 72.6, 95% confidence interval [CI] = 37.5-140.3) and who had experience with that type of communication (OR = 2.4, 95% CI = 1.3-4.5). An apology for the patient was more likely when there was institutional support (OR = 31.3, 95% CI = 14.4-68.2), the professional was not aware of lawsuits (OR = 2.7, 95% CI = 1.2-6.1), and attributed most AAE to human error (OR = 2.2, 95% CI = 1.1-4.2). The fear of lawsuits was determined by the lack of support from the center in disclosing AAE (OR = 5.5, 95% CI = 2.8-10.6) and the belief that being open would result in negative consequences (OR = 2.0, 95% CI = 1.1-3.6).

CONCLUSIONS

The culture of safety, the experience of blame, and the expectations about the outcome from communicating an AAE to patients affect the frequency of open disclosure. Nurses are more willing than physicians to participate in open disclosure. Health care organizations must act to establish a framework of legal certainty for professionals.

Trend Analysis of Patient Safety Incidents and Their Associated Factors in Korea Using National Patient Safety Report Data (2017~2019)

This study analyzed trends in patient safety incidents (PSIs) and the factors associated with the PSIs by analyzing 2017–2019 Patient Safety Report data in Korea. We extracted 2940 records in 2017, 5889 in 2018, and 7386 in 2019, from hospitals with more than 200 beds, and used all 16,215 cases for analysis. SPSS 25.0 was used for a multi-nominal logistic regression analysis. The PSI trend analysis, the standardized Jonckheere–Terpstra test was significant. On analyzing the probability of adverse events based on near misses, the significant variables were patient age, the season when PSIs occurred, incident reporter, hospital size, the location of PSIs, the type of PSIs, and medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient sex, patient age, incident reporter, the type of PSIs, and medical department. To prevent sentinel events in PSIs, female and older patients are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities and report voluntarily.

The psychosocial impact of surgical complications on the operating surgeon: A scoping review

Background and Aim

Surgical complications are common, and their management is an integral part of surgical care. The impact on the surgeon, the “second victim” is significant, particularly in terms of psychological health. The aim of this review is to describe the nature of psychosocial consequences of surgical complications on the surgeons involved.

Method

Following scoping review protocols, we set out to identify the evidence-base for psychosocial consequences on the operating surgeon, predominantly general surgeons, following surgical complications.

Results

This scoping review identified 19 articles, mainly survey and interview based (n = 8), with all but one article from first world countries. Seven articles reported on negative emotions or depressive behavioural responses. All original studies reported on difficulty in coping (37.5%), and a range of behaviours. There was little evidence for support structures or active interventions to aid the surgeon post complication.

Conclusions

The review suggests that the psychosocial impact, following a complication, is variable but affects every surgeon irrespective of the level of impact on the patient. The main variables differentiating impact are severity, and outcome of the complication and seniority of the surgeon. Reported emotions and behaviours were generally negative and persist across the surgeon's journey towards recovery. Surgeons who manage stress well exhibit largely constructive behaviours and actively work to recover. Identification of variables underpinning complications, and affected surgeons is paramount, as is the provision of services to support recovery. Efforts should be made to proactively prevent complications, via education, awareness and to formalise support processes.

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Surgical complications negatively impact the operating surgeon (the second victim).

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Negative emotions and behaviours manifested may persist throughout surgeon’s career.

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Surgeons’ reaction can negatively influence social and professional relationships.

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Range of factors affect coping and recovery, and the support sought tend not to focus on psychosocial aspects of coping.

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Need to develop management resources for surgeons to manage the psychosocial impact.

Cross-cultural adaptation to the Spanish context and evaluation of the content validity of the Second Victim Experience and Support Tool (SVEST-E) questionnaire

OBJECTIVES

To carry out a cross-cultural adaptation of the Second Victim Experience and Support Tool (SVEST) questionnaire to the Spanish context, and to evaluate its content validity (CVI).

METHODS

The translation and cultural adaptation of a measuring instrument by means of translation and back translation conducted through the participation of 20 health professionals. The content validation was carried out through the participation of 10 experts. The content validity of each item (CVI-I), the content validity index per expert (CVI-E) and the content validity total (CVI-T) were calculated for the questionnaire. Corrections were carried out for probable random agreement and the statistical calculation Kappa (K*) modified for each item of the instrument.

RESULTS

The final instrument obtained (SVEST-E) has a CVI-Total of 0.87 and consists of 36 total items, subdivided into 7 dimensions, 2 outcome variables and a support option section maintaining the same structure as the original questionnaire. Thirty items had a CVI-I with values over ≥°0.79.

CONCLUSIONS

The SVEST-E questionnaire is an equivalent of the original and is an instrument that could help to evaluate the second victim experiences of healthcare professionals in our country. It is an instrument with adequate content validity to measure the experience of second victims in health professionals in our country.

Examining Causes and Prevention Strategies of Adverse Events in Deceased Hospital Patients: A Retrospective Patient Record Review Study in the Netherlands

OBJECTIVE

To improve patient safety and possibly prevent mortality from adverse events (AEs) in hospitals, it is important to gain insight in their underlying causes. We aimed to examine root causes and potential prevention strategies of AEs in deceased hospital patients.

METHODS

Data on 571 AEs were used from two retrospective patient record review studies of patients who died during hospitalization in the Netherlands. Trained reviewers assessed contributing factors and potential prevention strategies. The results were analyzed together with data on preventability of the AE and the relationship of the AE with the death of the patient.

RESULTS

In 47% of the AEs, patient-related causes were identified, in 35% human causes, in 9% organizational causes, and in 3% technical causes. Preventable AEs were caused by technical, organizational, and human causes (78%, 74%, and 74%, respectively) more often than by patient-related causes (33%). In addition, technical factors caused AEs leading to preventable death (78%) relatively often. Recommended strategies to prevent AEs were quality assurance/peer review, evaluation of safety behavior, improving procedures, and improving information and communication structures.

CONCLUSIONS

Human failures played an important role in the causation of AEs in Dutch hospitals, because they occurred frequently and they were frequently the cause of preventable AEs. To a lesser extent, latent organizational and technical factors were identified. Patient-related factors were often identified, but the preventability of the AEs with these causes was low. For future research into causes of AEs, we recommend combining record review with interviewing.

The Study on Safety in Hospitals in the Region of Madrid (ESHMAD) design: Screening and analysis of incidents and adverse events

BACKGROUND

A Study related to Safety in Hospitals in the Region of Madrid (ESHMAD) was carried out in order to determine the prevalence, magnitude and characteristics of adverse events in public hospitals. This work aims to define a useful methodology for the multicenter study of adverse events in the Region of Madrid, to set out the preliminary results of the hospital enrollment and to establish a model of a strategy of training of trainers for its implementation.

METHODS

ESHMAD was a multicenter, double phase study for the estimation of adverse events and incidents prevalence across the Region of Madrid. First phase comprehended a 1-day cross-sectional prevalence study, in which it was collected, through a screening guide, information about admission, patient characteristics, intrinsic and extrinsic risk factors, and the possibility of an adverse event or incident had happened during the hospitalization. Second phase was a retrospective nested cohort study, in which it was used a Modular Review Form for reviewing the positive screenings of the first phase, identifying in each possible adverse event or incident the classification of the patient safety event, clinical onset, root, and associated causes and factors, impact, and preventability. A pilot study was performed in an Internal Medicine Unit of a tertiary hospital.

RESULTS

34 public hospitals participated, belonging to 6 healthcare categories and with more than 10,000 hospitalisations aggregate capacity. 72 coordinators were enrolled in the strategy of training of trainers, which was performed through five on-site training workshops. In the pilot study, 45.2% patients were identified with at least one positive event of the screening. Of them, 48.1% (25 positive events) were identified as truly AE, with a result of 0.29 EA per analyzed patient.

CONCLUSIONS

The ESHMAD protocol allows to estimate the prevalence of adverse events, and the strategy of training of trainers facilitated the spread of the research methodology among the participants.

Incidence and preventability of adverse events in adult patients admitted to a Brazilian teaching hospital

Objective

To analyze the incidence and preventability of adverse events related to health care in adult patients admitted to a Brazilian teaching hospital.

Methods

A retrospective cohort study, in which the incidence and preventability of adverse events related to health care were based on a two-stage retrospective review of 368 medical records (nurses and pharmacist review of medical records, followed by physicians review of triggered medical records) of adult patients whose hospitalizations occurred during 2015 in a high-complexity public teaching hospital located in Brazil. Data were collected from February 2018 to February 2019.

Results

A total of 266 adverse events were observed in 124 patients. The incidence of adverse events related to health care was 33.7% (95% CI 0.29–0.39), and the incidence density was 4.97 adverse events per 100 patient-days. Adverse events were responsible for 701 additional days of hospitalization, and the estimated length of additional hospital stay attributable to them was, on average, 6.8 days per event. The most common types of events were related to general care (60; 22.6%), medications (50; 18.8%), nosocomial infection (35; 13.2%), any other type (11; 4.1%), and diagnoses (2; 0.8%). Regarding the severity of adverse events, it was found that 168 (63.2%) were mild, 55 (20.7%) were moderate, and 43 (16.2%) were severe. In addition, it was estimated that 155 (58.3%) events were preventable. The length of a patient’s hospital stay was identified as a risk factor for the occurrence of adverse events (RR 1.20; 95% CI 1.04–1.39).

Conclusions

Through knowledge of the incidence, nature, severity, preventability, and risk factors for the occurrence of adverse events, it is possible to create the opportunities to prioritize the implementation of strategies for mitigating specific events based on reliable data and concrete information.

Assessment of antibiotic resistance of infectious agents in patients with pneumonia in tertiary critical care unit and effect on clinical outcomes

OBJECTIVE

The aim of this study was to determine the prevalence of the causative agents of multi-drug resistant bacteria in pneumonia and also evaluate their mortality rates in the intensive care unit (ICU).

METHODS

This study included all the cases of hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP) in the ICU between the period of January 2018 and December 2019.

RESULTS

Seventy-four patients in pneumonia were included. Mortality rate was 45.9%. In patients with HAP had higher length of stay days in hospital and ICU, the use of sedative agents, sepsis rate and mortality rate as compared in patients with CAP (for all P < .05). Microorganism was identified in 27 (36.6%) of the patients. Respiratory samples were positive in 25.4% of patients with CAP and 60.8% of patients with HAP. Acinetobacter baumannii and Klebsiella pneumoniae were the most frequent aetiologic agents (40.7% and 22.2%, respectively). Acinetobacter baumannii was not susceptible to the third generation cephalosporin, piperacillin-tazobactam, carbapenem, fluoroquinolone and trimethoprim/sulfamethoxazole. Amongst gram-positive bacteria, the most common isolate was Staphylococcus aureus. The frequency of methicillin-resistant Staphylococcus aureus was 75% but these isolates were susceptible to vancomycin and tigecycline.

CONCLUSION

The predominance of gram-negative agents was observed in pneumonia patients and because of the high resistance to antibiotics, treatment strategies need to be reconsidered in order to improve the poor prognosis.

Cross-cultural adaptation to the Spanish context and evaluation of the content validity of the Second Victim Experience and Support Tool (SVEST-E) questionnaire

OBJECTIVES

To carry out a cross-cultural adaptation of the Second Victim Experience and Support Tool (SVEST) questionnaire to the Spanish context, and to evaluate its content validity (CVI).

METHODS

The translation and cultural adaptation of a measuring instrument by means of translation and back translation conducted through the participation of 20 health professionals. The content validation was carried out through the participation of 10 experts. The content validity of each item (CVI-I), the content validity index per expert (CVI-E) and the content validity total (CVI-T) were calculated for the questionnaire. Corrections were carried out for probable random agreement and the statistical calculation Kappa (K*) modified for each item of the instrument.

RESULTS

The final instrument obtained (SVEST-E) has a CVI-Total of 0.87 and consists of 36 total items, subdivided into 7 dimensions, 2 outcome variables and a support option section maintaining the same structure as the original questionnaire. Thirty items had a CVI-I with values over ≥̊0.79.

CONCLUSIONS

The SVEST-E questionnaire is an equivalent of the original and is an instrument that could help to evaluate the second victim experiences of healthcare professionals in our country. It is an instrument with adequate content validity to measure the experience of second victims in health professionals in our country.

Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention

AIMS

To identify and prioritize the root causes of adverse drug events (ADEs) in hospitals and to assess the ability of artificial intelligence (AI) capabilities to prevent ADEs.

DESIGN

A mixed method design was used.

METHODS

A cross-sectional study for hospitals in Spain was carried out between February and April 2019 to identify and prioritize the root causes of ADEs. A nominal group technique was also used to assess the ability of AI capabilities to prevent ADEs.

RESULTS

The main root cause of ADEs was a lack of adherence to safety protocols (64.8%), followed by identification errors (57.4%), and fragile and polymedicated patients (44.4%). An analysis of the AI capabilities to prevent the root causes of ADEs showed that identification and reading are two potentially useful capabilities.

CONCLUSION

Identification error is one of the main root causes of drug adverse events and AI capabilities could potentially prevent drug adverse events.

IMPACT

This study highlights the role of AI capabilities in safely identifying both patients and drugs, which is a crucial part of the medication administration process, and how this can prevent ADEs in hospitals.

Thymol Nanoemulsion: A New Therapeutic Option for Extensively Drug Resistant Foodborne Pathogens

Foodborne pathogens have been associated with severe and complicated diseases. Therefore, these types of infections are a concern for public health officials and food and dairy industries. Regarding the wide-spread multidrug resistant (MDR) and extensively drug resistant (XDR) foodborne pathogens such as Salmonella Enteritidis (S. Enteritidis), new and alternative therapeutic approaches are urgently needed. Therefore, we investigated the antimicrobial, anti-virulence, and immunostimulant activities of a stable formulation of thymol as thymol nanoemulsion in an in vivo approach. Notably, treatment with 2.25% thymol nanoemulsion led to a pronounced improvement in the body weight gain and feed conversion ratio in addition to decreases in the severity of clinical findings and mortality percentages of challenged chickens with XDR S. Enteritidis confirming its pronounced antimicrobial activities. Moreover, thymol nanoemulsion, at this dose, had protective effects through up-regulation of the protective cytokines and down-regulation of XDR S. Enteritidis sopB virulence gene and interleukins (IL)-4 and IL-10 cytokines as those hinder the host defenses. Furthermore, it enhanced the growth of gut Bifidobacteria species, which increases the strength of the immune system. For that, we suggested the therapeutic use of thymol nanoemulsion against resistant foodborne pathogens. Finally, we recommended the use of 2.25% thymol nanoemulsion as a feed additive for immunocompromised individuals as well as in the veterinary fields.

Variation between hospitals and reviewers in detection of adverse events identified through medical record review in Korea

OBJECTIVES

This study utilized the method of medical record review to determine characteristics of adverse events that occurred in the inpatient units of hospitals in Korea as well as the variations in adverse events between institutions.

DESIGN

A two-stage retrospective medical record review was conducted. The first stage was a nurse review, where two nurses reviewed medical records of discharged patients to determine if screening criteria had been met. In the second stage, two physicians independently reviewed medical records of patients identified in the first stage, to determine whether an adverse event had occurred.

SETTING

Inpatient units of six hospitals.

PARTICIPANTS

Medical records of 2 596 patients randomly selected were reviewed in the first stage review.

INTERVENTION(S)

N/A.

MAIN OUTCOME MEASURE(S)

Adverse events.

RESULTS

A total of 277 patients (10.7%) were confirmed to have had one or more adverse event(s), and a total of 336 adverse events were identified. Physician reviewers agreed about whether an adverse event had occurred for 141 patients (5.4%). The incidence rate of adverse events was at least 1.3% and a maximum of 19.4% for each hospital. Most preventability scores were less than four points (non-preventable), and there were large variations between reviewers and institutions.

CONCLUSIONS

Given the level of variation in the identified adverse events, further studies that include more medical institutions in their investigations are needed, and a third-party committee should be involved to address the reliability issues regarding the occurrence and characteristics of the adverse events.

Higher incidence of adverse events in isolated patients compared with non-isolated patients: a cohort study

OBJECTIVE

To determine whether isolated patients admitted to hospital have a higher incidence of adverse events (AEs), to identify their nature, impact and preventability.

DESIGN

Prospective cohort study with isolated and non-isolated patients.

SETTING

One public university hospital in the Valencian Community (southeast Spain).

PARTICIPANTS

We consecutively collected 400 patients, 200 isolated and 200 non-isolated, age ≥18 years old, to match according to date of entry, admission department, sex, age (±5 years) and disease severity from April 2017 to October 2018.

EXCLUSION CRITERIA

patients age <18 years old and/or reverse isolation patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome as the AE, defined according to the National Study of Adverse Effects linked to Hospitalisation (Estudio Nacional Sobre los Efectos Adversos) criteria. Cumulative incidence rates and AE incidence density rates were calculated.

RESULTS

The incidence of isolated patients with AEs 16.5% (95% CI 11.4% to 21.6%) compared with 9.5% (95% CI 5.4% to 13.6%) in non-isolated (p<0.03). The incidence density of patients with AEs among isolated patients was 11.8 per 1000 days/patient (95% CI 7.8 to 15.9) compared with 4.3 per 1000 days/patient (95% CI 2.4 to 6.3) among non-isolated patients (p<0.001). The incidence of AEs among isolated patients was 18.5% compared with 11% for non-isolated patients (p<0.09). Among the 37 AEs detected in 33 isolated patients, and the 22 AEs detected in 19 non-isolated patients, most corresponded to healthcare-associated infections (HAIs) for both isolated and non-isolated patients (48.6% vs 45.4%). There were significant differences with respect to the preventability of AEs, (67.6% among isolated patients compared with 52.6% among non-isolated patients).

CONCLUSIONS

AEs were significantly higher in isolated patients compared with non-isolated patients, more than half being preventable and with HAIs as the primary cause. It is essential to improve training and the safety culture of healthcare professionals relating to the care provided to this type of patient.

Impact of Nurses' Intervention in the Prevention of Falls in Hospitalized Patients

Background: Clinical safety is a crucial component of healthcare quality, focused on identifying and avoiding the risks to which patients are exposed. Among the adverse events that occur in a hospital environment, falls have a large impact (1.9–10% of annual income in acute care hospitals); they can cause pain, damage, costs, and mistrust in the health system. Our objective was to assess the effect of an educational intervention aimed at hospital nurses (systematic assessment of the risk of falls) in reducing the incidence of falls. Methods: this was a quasi-experimental study based on a sample of 581 patients in a third level hospital (Comunitat Valenciana, Spain). An educational program was given to the intervention group (n = 303), and a control group was included for comparison (n = 278). In the intervention group, the nurses participated in a training activity on the systematized assessment of the risk of falls. Analysis was undertaken using the Bayesian logistic regression model. Results: a total of 581 patients were studied (50.6% male, 49.4% female), with an average age of 68.3 (DT = 9) years. The overall incidence of falls was 1.2% (0.3% in the intervention group and 2.2% in the control group). Most of the falls occurred in people ≥65 years old (85.7%). The intervention group had a lower probability of falling than the control group (OR: 0.127; IC95%: 0.013–0.821). Neither the length of hospital stay, nor the age of the participants, had any relevant effect. Conclusions: the systematic assessment of the risk of a patient falling during hospital processes is an effective intervention to reduce the incidence of falls.

Assessment of the incidence and preventability of adverse events in hospitals: an integrative review

OBJECTIVE

To highlight the scientific production related to the use of the retrospective chart review methods to assess the incidence and preventability of adverse events in hospitals.

METHOD

An integrative review in the MEDLINE, LILACS, SCOPUS, Web of Science and EMBASE databases conducted in May 2019 with the following guiding question: What is known about the retrospective chart review methods to assess the incidence and preventability of adverse events in hospitals? Subsequently, the categorization, synthesis, and classification of the evidence levels of the included publications were performed.

RESULTS

In the 13 selected studies, the instruments adopted to assess the occurrence of adverse events were the Harvard Medical Practice Study, the Canadian Adverse Event Study, the Quality in Australian Health Care Study, and the Global Trigger Tool. Incidence ranged from 5.7 to 14.2%, while preventability ranged from 31 to 83%.

CONCLUSION

Differences in incidence and preventability were found, showing different results in the quality of care provided, the information registered in medical records, the screening criteria used, and the assessments of the reviewers.

Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis

Background

Diagnostic error is commonly defined as a missed, delayed or wrong diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review has attempted to estimate the prevalence and nature of harmful diagnostic errors in hospitalised patients.

Methods

A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochrane library from database inception through 9 July 2019. We included all studies of hospitalised adult patients that used physician review of case series of admissions and reported the frequency of diagnostic adverse events. Two reviewers independently screened studies for inclusion, extracted study characteristics and assessed risk of bias. Harmful diagnostic error rates were pooled using random-effects meta-analysis.

Results

Twenty-two studies including 80 026 patients and 760 harmful diagnostic errors from consecutive or randomly selected cohorts were pooled. The pooled rate was 0.7% (95% CI 0.5% to 1.1%). Of the 136 diagnostic errors that were described in detail, a wide range of diseases were missed, the most common being malignancy (n=15, 11%) and pulmonary embolism (n=13, 9.6%). In the USA, these estimates correspond to approximately 249 900 harmful diagnostic errors yearly.

Conclusion

Based on physician review, at least 0.7% of adult admissions involve a harmful diagnostic error. A wide range of diseases are missed, including many common diseases. Fourteen diagnoses account for more than half of all diagnostic errors. The finding that a wide range of common diagnoses are missed implies that efforts to improve diagnosis must target the basic processes of diagnosis, including both cognitive and system-related factors.

PROSPERO registration number

CRD42018115186.

Risk Analysis for Patient Safety in Surgical Departments: Cross-Sectional Design Usefulness

(1) Background: Identifying and measuring adverse events (AE) is a priority for patient safety, which allows us to define and prioritise areas for improvement and evaluate and develop solutions to improve health care quality. The aim of this work was to determine the prevalence of AEs in surgical and medical-surgical departments and to know the health impact of these AEs. (2) Methods: A cross-sectional study determining the prevalence of AEs in surgical and medical-surgical departments was conducted and a comparison was made among both clinical areas. A total of 5228 patients were admitted in 58 hospitals in Argentina, Colombia, Costa Rica, Mexico, and Peru, within the Latin American Study of Adverse Events (IBEAS), led by the Spanish Ministry of Health, the Pan American Health Organization, and the WHO Patient Safety programme. (3) Results: The global prevalence of AEs was 10.7%. However, the prevalence of AEs in surgical departments was 11.9%, while in medical-surgical departments it was 8.9%. The causes of these AEs were associated with surgical procedures (38.6%) and nosocomial infections (35.4%). About 60.6% of the AEs extended hospital stays by 30.7 days on average and 25.8% led to readmission with an average hospitalisation of 15 days. About 22.4% resulted in death, disability, or surgical reintervention. (4) Conclusions: Surgical departments were associated with a higher risk of experiencing AEs.

[How to manage risk in the surgical area. A Modal Analysis of Failures and Surgical Effects]

OBJECTIVE

First to identify the areas of improvement in the surgical area before and during the performance of a surgical procedure in general surgery through the application of a Modal Analysis of Failures and Effects. Second to establish preventive measures to avoid adverse events in the surgical area.

METHOD

A multidisciplinary working group was created in a university hospital for risk management in the General Surgery Operating Room Unit. The Modal Analysis of Faults and Effects was used. Potential risks for the patient in the ante-surgery and within the operating room were identified. The Risk Priority Index was calculated and preventive measures were established for all of them, with special interest when the Risk Priority Index was higher than 100. Preventive measures were developed based on the detected risks as well as those responsible for them.

RESULTS

We identified a greater number of risks when the patient is in the operating room than in the ante-surgery room. Those with a higher risk priority index were: anticoagulated or antiaggregated patients, urinary tract infections, osteoarticular or neuropathic problems, patients not prepared for colon surgery, errors in laterality and leaving compresses in the operative field.

CONCLUSIONS

A risk map has been developed in our organization, allowing the design of strategies to improve Patient Safety in the Surgical area. Training is a key aspect to improve Patient Safety.

The clinical and epidemiological risk factors of infections due to multi-drug resistant bacteria in an adult intensive care unit of University Hospital Center in Marrakesh-Morocco

BACKGROUND

Intensive care units (ICUs) are considered epicenters of antibiotic resistance. The aim of this study is to determine clinical risk factors, epidemiology and the causative agents of multi-drug resistant bacteria in the ICU of the University Hospital in Marrakesh-Morocco.

METHODS

A one year case control study was carried out in our 10-bed clinical and surgical ICU from March 2015 to March 2016. The epidemiological surveillance was done by collecting data in the medical records with the help of a questionnaire. The antibiotic susceptibility testing was used following the recommendations of the Antibiogram Committee of the French Society of Microbiology and the European Committee for Antimicrobial Susceptibility Testing, 2015.

RESULTS

Among the 479 admitted patients, 305 bacteria were isolated and identified as Acinetobacter baumannii (31%), Enterobactereacae species (30%), and Staphylococcus (24%), P. aeruginosa (10%) and other bacterial strains (5%). The rate of MDR bacteria acquisition was 41% (124/305) with domination of A. baumannii resistant to imipenem (70%) and followed by Extended Spectrum β-lactamases producing Enterobacteriaceae, P. aeruginosa resistant to Ceftazidime, and Methicillin-resistant S. aureus (18%, 7%, and 5% respectively). The distribution of the common nosocomial infections were dominated by pneumonia, bacteremia, and catheter-related blood stream infections (39%, 29%, and 17%) respectively. Multivariate analysis identified lack of patient isolation precautions (OR: 7.500), use of quadri or triple therapy (OR: 5.596; OR: 5.175), and mechanical ventilation (OR: 4.926), as the most significant clinical and epidemiological factors associated with acquisition of MDR bacteria. The attributable mortality, in this ICU, of patients with MDR bacteria, is about 12%.

CONCLUSIONS

The incidence of MDR was higher compared with that of developed countries. The implementation of standard infection control protocols, active surveillance of MDR and generation of data on etiological agents and their antimicrobial susceptibility patterns are urgently needed in our hospital.

Adverse events associated to the use of equipment and materials in nursing care of hospitalized patients

OBJECTIVE

To analyze the occurrence of adverse events associated to the use of equipment and materials in nursing care.

METHOD

Quantitative, descriptive study, using the electronic records of adverse events notifications in an accredited hospital.

RESULTS

A total of 1,065 adverse events were reported, of which 180 (16.9%) were related to the use of equipment and materials. The most frequent events were: loss of feeding tube (45.0%), loss of central venous catheter (15.5%), skin injury (10.5%) and accidental extubation (10.0%). The main causes and immediate actions recorded were: loss of feeding tube - removal of the tube by the patient (53.1%) and reinsertion of the device (83.9%); loss of central venous catheter - agitated or disoriented patient (32.1%) and insertion of peripheral venous catheter (46.2%); skin injury - agitated or disoriented patient (26.3%) and application of occlusive dressing (73.7%); and accidental extubation - weaning from sedation, disconnected sedation or inadequate doses of sedation (50.0%) and reintubation (50.0%). The degrees of harm were: mild (23.3%), severe (62.2%), very severe (13.9%) and extremely severe (0.6%).

CONCLUSION

The investigation of the occurrence of adverse events related to the use of equipment and materials in care can prevent and minimize harm to the patient.

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

OBJECTIVE

To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.

REVIEW METHODS

Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.

RESULTS

Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10).

CONCLUSIONS

Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.

I Hear You, but Do I Understand? The Relationship of a Shared Professional Language With Quality of Care and Job Satisfaction

In various industries, individuals from different professions have to work together in a team to achieve their collective goal. Having gone through different educations, team members speak different professional languages, which poses a challenge to communication, and coordination in interprofessional teams. A shared language is believed to improve collaboration. In this study, we examine if a shared language in interprofessional healthcare teams is associated with better relational coordination and if both are connected to higher quality of care as well as job satisfaction of the staff. We shed light on possible mechanisms between shared language, and quality of care and job satisfaction, respectively, investigating relational coordination and psychological safety as mediators. We surveyed 197 healthcare workers (HCWs) from different professions in three rehabilitation centers in Switzerland. Multiple regression analyses showed that shared language was positively related to perceived quality of care and job satisfaction. Moreover, we found evidence for a serial mediation of these relationships by relational coordination and psychological safety. We discuss implications for healthcare and other types of interprofessional teams.

Chemotherapy medication errors

Although chemotherapy is a well established treatment modality, chemotherapy errors represent a potentially serious risk of patient harm. We reviewed published research from 1980 to 2017 to understand the extent and nature of medication errors in cancer chemotherapy, and to identify effective interventions to help prevent mistakes. Chemotherapy errors occur at a rate of about one to four per 1000 orders, affect at least 1-3% of adult and paediatric oncology patients, and occur at all stages of the medication use process. Oral chemotherapy use is a particular area of growing risk. Our knowledge of chemotherapy errors is drawn primarily from single-institution studies at university hospitals and referral centres, with a particular focus on prescription orders and pharmacy practices. Although the heterogeneity of research methods and measures used in these studies limits our understanding of this issue, the rate of chemotherapy error-related injuries is generally lower than those seen in comparable studies of general medical patients. Although many interventions show promise in reducing chemotherapy errors, most have little empirical support. Additional research is needed to understand and to mitigate the risk of chemotherapy medication errors.

SOBRINA Spanish study-analysing the frequency, cost and adverse events associated with overuse in primary care: protocol for a retrospective cohort study

INTRODUCTION

Several institutions and quality national agencies have fostered the creation of recommendations on what not to do to reduce overuse in clinical practice. In primary care, their impact has hardly been studied. The frequency of adverse events (AEs) associated with doing what must not be done has not been analysed, either. The aim of this study is to measure the frequency of overuse and AEs associated with doing what must not be done (commission errors) in primary care and their cost.

METHODS AND ANALYSIS

A coordinated, multicentric, national project. A retrospective cohort study using computerised databases of primary care medical records from national agencies and regional health services will be conducted to analyse the frequency of the overuse due to ignore the do-not-do recommendations, and immediately afterwards, depending on their frequency, a representative random sample of medical records will be reviewed with algorithms (triggers) that determine the frequency of AEs associated with these recommendations. Cost will determine by summation of the direct costs due to the consultation, pharmacy, laboratory and imaging activities according to the cases.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics Committee of Primary Care Research of the Valencian Community. We aim to disseminate the findings through international peer-reviewed journals and on the website (http://www.nohacer.es/). Outcomes will be used to incorporate algorithms into the electronic history to assist in making clinical decisions.

TRIAL REGISTRATION NUMBER

NCT03482232; Pre-results.

Incidence of adverse events, preventability and mortality in gynaecological hospital admissions: A systematic review and meta-analysis

BACKGROUND

Adverse events (AEs) are unintended consequences of healthcare management that result in temporary or permanent disability, death or prolonged hospital stay. The incidence of AEs has been reported to be higher in surgical specialties compared to medical specialties but information on the incidence of AEs in gynaecology is sparse.

AIMS

To collect evidence on the incidence, preventability and mortality of AEs in gynaecological hospital admissions by conducting a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic search of the PubMed, EMBASE, and CINAHL electronic medical databases was performed. Identified articles were screened and a full-text review was conducted by two independent reviewers.

RESULTS

Of the 49 studies assessed for eligibility, three studies were included in this systematic review. Meta-analysis showed that the incidence of AEs in gynaecological hospital admissions was 10.8% (95% CI 9.4-12.1%), preventability was 52.5% (95% CI 47.3-57.7%) and mortality was 1.2% (95% CI 0-2.5%).

CONCLUSIONS

Evidence on AEs in gynaecological hospital admissions is limited. Available evidence suggests that approximately one in ten gynaecological inpatients suffer at least one AE and half of AEs are considered preventable. Further research is needed to determine strategies regarding how the incidence of preventable AEs can be reduced.

Implementation of a multimodal patient safety improvement program "SafetyLEAP" in intensive care units

Purpose Patient safety remains a top priority in healthcare. Many organizations have developed systems to monitor and prevent harm, and have invested in different approaches to quality improvement. Despite these organizational efforts to better detect adverse events, efficient resolution of safety problems remains a significant challenge. The authors developed and implemented a comprehensive multimodal patient safety improvement program called SafetyLEAP. The term "LEAP" is an acronym that highlights the three facets of the program including: a Leadership and Engagement approach; Audit and feedback; and a Planned improvement intervention. The purpose of this paper is to evaluate the implementation of the SafetyLEAP program in the intensive care units (ICUs) of three large hospitals. Design/methodology/approach A comparative case study approach was used to compare and contrast the adherence to each component of the SafetyLEAP program. The study was conducted using a convenience sample of three ( n=3) ICUs from two provinces. Two reviewers independently evaluated major adherence metrics of the SafetyLEAP program for their completeness. Analysis was performed for each individual case, and across cases. Findings A total of 257 patients were included in the study. Overall, the proportion of the SafetyLEAP tasks completed was 64.47, 100, and 26.32 percent, respectively. ICU nos 1 and 2 were able to identify opportunities for improvement, follow a quality improvement process and demonstrate positive changes in patient safety. The main factors influencing adherence were the engagement of a local champion, competing priorities, and the identification of appropriate resources. Practical implications The SafetyLEAP program allowed for the identification of processes that could result in patient harm in the ICUs. However, the success in improving patient safety was dependent on the engagement of the care teams. Originality/value The authors developed an evidence-based approach to systematically and prospectively detect, improve, and evaluate actions related to patient safety.

Adverse events related to hospital care: a retrospective medical records review in a Swiss hospital

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.