Setting priorities for patient safety

Breaking the error chain with SEE: cascade analysis of endodontic errors in clinical training

The ongoing endeavors to uncover the link between the prevalent errors in clinical endodontic training and undergraduate education are founded on tentative assumptions. This investigation was aimed at determining if cascade analysis can provide an understanding of the origins and causes of errors and if the sensitivity of student reports to the impact of errors on treatment outcomes can be established.In 2021, a group of investigators from the endodontics department concerned with clinical dental education launched the Study of Endodontic Errors (SEE). Sixty-six undergraduate dental students at one dental teaching hospital submitted anonymous narratives of problems they witnessed in their root canal treatment practices. The reports were examined to determine the sequence of events and the major errors. We kept track of the consequences of treatment outcomes, both as reported by students and as deduced by investigators.In 77% of the narratives, a chain of errors was recorded. The majority of the errors that took place were related to the working length or width of root canals. A substantial portion, 86%, of these errors could have been prevented through a deeper comprehension of the concepts that underlie working length and width. 75% of the errors that initiated cascades involved losing the correct working length. When asked whether the treatment outcome was compromised, students answered affirmatively in 16% of cases in which their narratives described compromised outcomes. Unacceptable outcomes necessitating re-treatment accounted for only 3% of student-reported consequences, but when investigator-inferred consequences were considered, the percentage more than doubled (7%).Cascade analysis of student error narratives is useful in understanding the triggering chain of events, but students provide insufficient information about how treatment outcomes are affected. Misconceptions about working length and width appear to play a significant role in the propagation of procedural errors.

More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA

OBJECTIVE

To examine the real-world safety problems involving machine learning (ML)-enabled medical devices.

MATERIALS AND METHODS

We analyzed 266 safety events involving approved ML medical devices reported to the US FDA's MAUDE program between 2015 and October 2021. Events were reviewed against an existing framework for safety problems with Health IT to identify whether a reported problem was due to the ML device (device problem) or its use, and key contributors to the problem. Consequences of events were also classified.

RESULTS

Events described hazards with potential to harm (66%), actual harm (16%), consequences for healthcare delivery (9%), near misses that would have led to harm if not for intervention (4%), no harm or consequences (3%), and complaints (2%). While most events involved device problems (93%), use problems (7%) were 4 times more likely to harm (relative risk 4.2; 95% CI 2.5-7). Problems with data input to ML devices were the top contributor to events (82%).

DISCUSSION

Much of what is known about ML safety comes from case studies and the theoretical limitations of ML. We contribute a systematic analysis of ML safety problems captured as part of the FDA's routine post-market surveillance. Most problems involved devices and concerned the acquisition of data for processing by algorithms. However, problems with the use of devices were more likely to harm.

CONCLUSIONS

Safety problems with ML devices involve more than algorithms, highlighting the need for a whole-of-system approach to safe implementation with a special focus on how users interact with devices.

Assessing the healthcare quality issues for digital incident reporting in Sweden: Incident reports analysis

Objective

This study explored healthcare quality issues affecting the reporting and investigation levels of digital incident reporting systems.

Methods

A total of 38 health information technology-related incident reports (free-text narratives) were collected from one of Sweden's national incident reporting repositories. The incidents were analysed using an existing framework, i.e., the Health Information Technology Classification System, to identify the types of issues and consequences. The framework was applied in two fields, 'event description' by the reporters and 'manufacturer's measures', to assess the quality of reporting incidents by the reporters. Additionally, the contributing factors, i.e., either human or technical factors for both fields, were identified to evaluate the quality of the reported incidents.

Results

Five types of issues were identified and changes made between before-and-after investigations: Machine to software-related issues (n  =  8), machine to use-related issues (n  =  5), software to software-related issues (n  =  5), use to software-related issues (n  =  4) and use to use-related issues (n  =  1). Over two-thirds (n  =  15) of the incidents demonstrated a change in the contributing factors after the investigation. Only four incidents were identified as altering the consequences after the investigation.

Conclusion

This study shed some light on the issues of incident reporting and the gap between the reporting and investigation levels. Facilitating sufficient staff training sessions, agreeing on common terms for health information technology systems, refining the existing classifications systems, enforcing mini-root cause analysis, and ensuring unit-based local reporting and standard national reporting may help bridge the gap between reporting and investigation levels in digital incident reporting.

Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review

Objective

To summarize the research literature about safety concerns with consumer-facing health apps and their consequences.

Materials and Methods

We searched bibliographic databases including PubMed, Web of Science, Scopus, and Cochrane libraries from January 2013 to May 2019 for articles about health apps. Descriptive information about safety concerns and consequences were extracted and classified into natural categories. The review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) statement.

Results

Of the 74 studies identified, the majority were reviews of a single or a group of similar apps (n = 66, 89%), nearly half related to disease management (n = 34, 46%). A total of 80 safety concerns were identified, 67 related to the quality of information presented including incorrect or incomplete information, variation in content, and incorrect or inappropriate response to consumer needs. The remaining 13 related to app functionality including gaps in features, lack of validation for user input, delayed processing, failure to respond to health dangers, and faulty alarms. Of the 52 reports of actual or potential consequences, 5 had potential for patient harm. We also identified 66 reports about gaps in app development, including the lack of expert involvement, poor evidence base, and poor validation.

Conclusions

Safety of apps is an emerging public health issue. The available evidence shows that apps pose clinical risks to consumers. Involvement of consumers, regulators, and healthcare professionals in development and testing can improve quality. Additionally, mandatory reporting of safety concerns is needed to improve outcomes.

Critical Incidents during Anesthesia and Early Post-Anesthetic Period: A Descriptive Cross-sectional Study

INTRODUCTION

Critical incidents related to peri-operative anesthesia carry a risk of unwanted patient outcomes. Studying those helps detect problems, which is crucial in minimizing their recurrence. We aimed to identify the frequency of peri-anesthetic critical incidents.

METHODS

This is a hospital-based descriptive cross-sectional study of voluntarily reported incidents, which occurred during anesthesia or following 24 hours among patients subjected to non-cardiac surgery within the calendar year 2019. Patient characteristics, anesthesia, and surgery types, category, context, and outcome of incidents were recorded in an indigenously designed form. Incidents were assigned to attributable (patient, anesthesia or surgery) factor, and were analyzed for the system,equipment or human error contribution.

RESULTS

Altogether 464 reports were studied, which consisted of 524 incidents. Cardiovascular category comprised of 345 (65.8%) incidents. Incidents occurred in 433 (93%) otherwise healthy patients and during 258 (55.6%) spinal anesthetics. Obstetric surgery was involved in 179 (38.6%) incidents. Elective surgery and anesthesia maintenance phase included the context in 293 (63%)and 378 (72%) incidents respectively. Majority incidents 364 (69.5%) were anesthesia-attributable, with system and human error contribution in 196 (53.8%) and 152 (41.7%) cases respectively. All recovered fully except for 25 cases of mortality, which were mostly associated with patient factors, surgical urgency, and general anesthesia.

CONCLUSIONS

Critical incidents occur even in low-risk patients during anesthesia delivery. Patient factors and emergency surgery contribute to the most serious incidents.

Evaluating the implementability of Antibiotic Surgical Prophylaxis guidelines

BACKGROUND

Current Australian data highlight guideline noncompliant prescribing of antimicrobials for surgical prophylaxis. The study aim was to evaluate the implementability of the Australian national surgical prophylaxis (SAP) guidelines to identify facilitators for and barriers to compliance.

METHODS

Key stakeholders appraised the surgical prophylaxis guidelines using the GuideLine Implementability Appraisal (GLIA) tool. Questions with 100% agreement for the response 'Yes' were identified as facilitators and those with 100% agreement for 'No', a barrier. Questions that did not receive 100% agreement, but had a majority (40-60%) 'Yes' or 'No' consensus were considered as borderline facilitators and barriers respectively.

RESULTS

Ten appraisals were completed. Guideline recommendations were rated as easily identifiable and concise and were thus facilitators for implementation. The ability to measure guideline adherence and outcomes, and recommendations that were consistent with guideline user abilities and beliefs were also identified as facilitators. Borderline facilitators related to the clarity of the recommendations and whether they were explicit in what to do and in what circumstances. Evidence quality underpinning recommendations (validity), inflexibility of recommendations (flexibility) and the lack of patient data at the point of use (computability) were identified as borderline barriers to implementation. No recommendation reached agreement as being a barrier.

CONCLUSION

The GLIA appraisal demonstrated overall implementability of the current Australian national surgical prophylaxis guidelines. Facilitators (i.e., measurability) and borderline facilitators highlight strengths of the current guideline. Borderline barriers (i.e., validity, flexibility and computability) may negatively impact upon implementability. Guideline developers should consider these dimensions to optimise guideline uptake and consequently patient care.

Safety attributes in primary care: understanding the needs of patients, health professionals, and managers

OBJECTIVES

The aims of this study were (1) to identify attributes for patient safety at a primary healthcare level and (2) to analyze conceptions of patients, professionals, and managers about how these attributes are being addressed.

STUDY DESIGN

This was a qualitative study.

METHODS

Participants were recruited from three primary care settings in Brazil. A total of 37 subjects (four physicians, three nurses, three dentists, three managers, five community assistants, and 19 patients) participated on interviews about their perceptions of safety attributes at the primary care settings involved in the study. Some of these participants attended a focus group meeting. A thematic categorical analysis was carried out to interpret the interviews.

RESULTS

The main attributes for patient safety were valued by the participants. However, barriers such as discontinuity of care, interruptions during consultations, breakdowns in the communication, and ineffective teamwork were reported as frequent sources of patient safety issues. Reports of patients left unattended for excessive time because of the lack of accurate information and disruptions that took up to 35 min show that there is still a long way to go for primary care to be safe and effective in the study settings.

CONCLUSIONS

It is necessary that the strategies meet the patient safety needs more effectively and efficiently. Further research is needed to understand the complex nature of the problems that affect patient safety in these settings so that appropriate decisions can be made.

The application of the Global Trigger Tool: a systematic review

Purpose

This study describes the use of, and modifications and additions made to, the Global Trigger Tool (GTT) since its first release in 2003, and summarizes its findings with respect to counting and characterizing adverse events (AEs).

Data sources

Peer-reviewed literature up to 31st December 2014.

Study selection

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Data extraction

Two authors extracted and compiled the demographics, methodologies and results of the selected studies.

Results of data synthesis

Of the 48 studies meeting the eligibility criteria, 44 collected data from inpatient medical records and four from general practice records. Studies were undertaken in 16 countries. Over half did not follow the standard GTT protocol regarding the number of reviewers used. 'Acts of omission' were included in one quarter of studies. Incident reporting detected between 2% and 8% of AEs that were detected with the GTT. Rates of AEs varied in general inpatient studies between 7% and 40%. Infections, problems with surgical procedures and medication were the most common incident types.

Conclusion

The GTT is a flexible tool used in a range of settings with varied applications. Substantial differences in AE rates were evident across studies, most likely associated with methodological differences and disparate reviewer interpretations. AE rates should not be compared between institutions or studies. Recommendations include adding 'omission' AEs, using preventability scores for priority setting, and re-framing the GTT's purpose to understand and characterize AEs rather than just counting them.

Never Events in UK General Practice: A Survey of the Views of General Practitioners on Their Frequency and Acceptability as a Safety Improvement Approach

Supplemental digital content is available in the text.

Background

Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the United Kingdom and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to general practitioner (GPs) as a Q&SI approach, is currently unknown. The study aims to estimate (1) the frequency of 10 NEs occurring within GPs' own practices and (2) the extent to which the NE approach is perceived as acceptable for use.

Methods

General practitioners were surveyed, and mixed-effects logistic regression models examined the relationship between GP opinions of NE, estimates of NE frequency, and the characteristics of the GPs and their practices.

Results

Responses from 556 GPs in 412 practices were analyzed. Most participants (70%–88%, depending on the NE) agreed that the described incident should be designated as a NE. Three NEs were estimated to have occurred in less than 4% of practices in the last year; however, two NEs were estimated to have occurred in 45% to 61% of the practices. General practitioners reporting that a NE had occurred in their practice in the last year were significantly less likely to agree with the designation as a NE compared with GPs not reporting a NE (odds ratio, 0.42; 95% CI = 0.36–0.49).

Conclusions

The NE approach may have Q&SI potential for general practice, but further work to adapt the concept and content is required.

Epidemiology of Patient Harms in New Zealand: Protocol of a General Practice Records Review Study

Background

Knowing where and why harm occurs in general practice will assist patients, doctors, and others in making informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety.

Objective

We aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their health care, from the whole-of-health-system lens afforded by electronic general practice patient records.

Methods

“Harm” is defined as disease, injury, disability, suffering, and death, arising from the health system. The study design is a stratified, 2-level cluster, retrospective records review study. Both general practices and patients will be randomly selected so that the study’s results will apply nationally, after weighting. Stratification by practice size and rurality will allow comparisons between 6 study groups (large, medium-sized, small; urban and rural practices). Records of equal numbers of patients from each study group will be included in the study because there may be systematic differences in patient harms in different types of practices. Eight general practitioner investigators will review 3 years of electronic general practice health records (consultation notes, prescriptions, investigations, referrals, and summaries of hospital care) from 9000 patients registered in 60 general practices. Double-blinded reviews will check the concordance of reviewers’ assessments. Study data will comprise demographic data of all 9000 patients and reviewers’ assessments of whether patients experienced harm arising from health care. Where patient harm is identified, their types, preventability, severity, and outcomes will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) 18.0.

Results

We have recruited practices and collected electronic records from 9078 patients. Reviews of these records are under way. The study is expected to be completed in August 2017.

Conclusions

The design of this complex study is presented with discussion on data collection methods, sampling weights, power analysis, and statistical approach. This study will show the epidemiology of patient harms recorded in general practice records for all of New Zealand and will show whether this epidemiology differs by rural location and clinic size.

Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level

INTRODUCTION

Although incident reporting systems are widespread in health care as a strategy to reduce harm to patients, the focus has been on reporting incidents rather than responding to them. Systems containing large numbers of incidents are uniquely placed to raise awareness of, and then characterize and respond to infrequent, but significant risks. The aim of this paper is to outline a framework for the surveillance of such risks, their systematic analysis, and for the development and dissemination of population-based preventive and corrective strategies using clinical and human factors expertise.

REQUIREMENTS FOR A POPULATION-LEVEL RESPONSE

The framework outlines four system requirements: to report incidents; to aggregate them; to support and conduct a risk surveillance, review and response process; and to disseminate recommendations. Personnel requirements include a non-hierarchical multidisciplinary team comprising clinicians and subject-matter and human factors experts to provide interpretation and high-level judgement from a range of perspectives. The risk surveillance, review and response process includes searching of large incident and other databases for how and why things have gone wrong, narrative analysis by clinical experts, consultation with the health care sector, and development and pilot testing of corrective strategies. Criteria for deciding which incidents require a population-level response are outlined.

DISCUSSION

The incremental cost of a population-based response function is modest compared with the 'reporting' element. Combining clinical and human factors expertise and a systematic approach underpins the creation of credible risk identification processes and the development of preventive and corrective strategies.

Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports

OBJECTIVE

To identify the categories of problems with information technology (IT), which affect patient safety in general practice.

DESIGN

General practitioners (GPs) reported incidents online or by telephone between May 2012 and November 2013. Incidents were reviewed against an existing classification for problems associated with IT and the clinical process impacted.

PARTICIPANTS AND SETTING

87 GPs across Australia.

MAIN OUTCOME MEASURE

Types of problems, consequences and clinical processes.

RESULTS

GPs reported 90 incidents involving IT which had an observable impact on the delivery of care, including actual patient harm as well as near miss events. Practice systems and medications were the most affected clinical processes. Problems with IT disrupted clinical workflow, wasted time and caused frustration. Issues with user interfaces, routine updates to software packages and drug databases, and the migration of records from one package to another generated clinical errors that were unique to IT; some could affect many patients at once. Human factors issues gave rise to some errors that have always existed with paper records but are more likely to occur and cause harm with IT. Such errors were linked to slips in concentration, multitasking, distractions and interruptions. Problems with patient identification and hybrid records generated errors that were in principle no different to paper records.

CONCLUSIONS

Problems associated with IT include perennial risks with paper records, but additional disruptions in workflow and hazards for patients unique to IT, occasionally affecting multiple patients. Surveillance for such hazards may have general utility, but particularly in the context of migrating historical records to new systems and software updates to existing systems.

Using a quantitative risk register to promote learning from a patient safety reporting system

BACKGROUND

Patient safety reporting systems are now used in most health care delivery organizations. These systems, such as the one in use at Virginia Mason (Seattle) since 2002, can provide valuable reports of risk and harm from the front lines of patient care. In response to the challenge of how to quantify and prioritize safety opportunities, a risk register system was developed and implemented.

METHODS

Basic risk register concepts were refined to provide a systematic way to understand risks reported by staff. The risk register uses a comprehensive taxonomy of patient risk and algorithmically assigns each patient safety report to 1 of 27 risk categories in three major domains (Evaluation, Treatment, and Critical Interactions). For each category, a composite score was calculated on the basis of event rate, harm, and cost. The composite scores were used to identify the "top five" risk categories, and patient safety reports in these categories were analyzed in greater depth to find recurrent patterns of risk and associated opportunities for improvement.

RESULTS

The top five categories of risk were easy to identify and had distinctive "profiles" of rate, harm, and cost. The ability to categorize and rank risks across multiple dimensions yielded insights not previously available. These results were shared with leadership and served as input for planning quality and safety initiatives. This approach provided actionable input for the strategic planning process, while at the same time strengthening the Virginia Mason culture of safety.

CONCLUSIONS

The quantitative patient safety risk register serves as one solution to the challenge of extracting valuable safety lessons from large numbers of incident reports and could profitably be adopted by other organizations.

Surgical site infection-a population-based study in Australian adults measuring the compliance with and correct timing of appropriate antibiotic prophylaxis

Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants' medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.

Incidence of acute care adverse events and long-term health-related quality of life in patients with TSCI

BACKGROUND CONTEXT

Adverse events (AEs) with significant resultant morbidity are common during the acute hospital care of patients with traumatic spinal cord injury (TSCI). The Rick Hansen SCI Registry (RHSCIR) collects Canada-wide data on patients with TSCI, such as sociodemographic, injury, diagnosis, intervention, and health outcome details. These data contribute to an evidence base for informing best practice and improving SCI care. As the RHSCIR captures data on patients from prehospital to community phases of care, it is an invaluable resource for providing information on health outcomes resulting from TSCI, including outcomes related to AEs.

PURPOSE

To determine the incidence and types of AEs occurring in patients with TSCI during acute care and the impact on length of stay (LOS) and health-related quality of life (HRQOL).

STUDY DESIGN/SETTING

Prospective cohort study at an academic quaternary referral center.

PATIENT SAMPLE

Patients with TSCI discharged from our institution between 2008 and 2010 were identified using the RHSCIR. The RHSCIR includes patients admitted to one of the participating centers across Canada, who have been clinically diagnosed with an acute TSCI or classified as AIS A, B, C, D, or cauda equina.

OUTCOME MEASURES

Acute-phase LOS and HRQOL were assessed for impact resulting from the number and type of AEs experienced. Health-related quality of life was determined using the short-form 36 (SF-36) physical and mental component summary scores and functional independence measure.

METHODS

Data related to patients' injury, diagnoses, hospital admission, and SF-36 scores were obtained from the local RHSCIR. Data on intra-, pre-, and postoperative AEs were collected prospectively using the Spine Adverse Events Severity System data collection system, documenting all AEs experienced by each patient. Multivariate analyses were performed to determine whether patient and injury characteristics were associated with the number and type of AEs experienced and whether these were associated with LOS and HRQOL determined on follow-up.

RESULTS

One hundred seventy-one patients with TSCI were included, 81.3% were men and mean age at injury was 47.2±20.3 years. Adverse events occurred in 77.2% of patients, 14.6% experienced an intraoperative and 73.7% experienced a pre/postoperative event. The most frequent pre/postoperative AEs were urinary tract infections (UTIs) (32.2%), pneumonias (32.8%), neuropathic pain (15.2%), decubitus ulcers (14.6%), and delirium (18.7%). Length of stay was significantly affected by decubitus ulcers, delirium, pneumonias, and UTIs (p<.01), increasing 1.7 (UTIs) to 2.2 (decubitus ulcers) times compared with patients without the specific AEs. Health-related quality of life was not affected by acute care AEs but rather those identified at 1-year follow-up.

CONCLUSIONS

This prospective study found that more than 77% of patients with TSCI sustain an AE during acute hospital care, significantly higher than previously reported. We demonstrate the utility of a dedicated AE collection system and the effect of these events on health status.

Review of critical incidents in a university department of anaesthesia

In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.

CareTrack Kids-part 3. Adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review

INTRODUCTION

A high-quality health system should deliver care that is free from harm. Few large-scale studies of adverse events have been undertaken in children's healthcare internationally, and none in Australia. The aim of this study is to measure the frequency and types of adverse events encountered in Australian paediatric care in a range of healthcare settings.

METHODS AND ANALYSIS

A form of retrospective medical record review, the Institute of Healthcare Improvement's Global Trigger Tool, will be modified to collect data. Records of children aged <16 years managed during 2012 and 2013 will be reviewed. We aim to review 6000-8000 records from a sample of healthcare practices (hospitals, general practices and specialists).

ETHICS AND DISSEMINATION

Human Research Ethics Committee approvals have been received from the Sydney Children's Hospital Network, Children's Health Queensland Hospital and Health Service, and the Women's and Children's Hospital Network in South Australia. An application is under review with the Royal Australian College of General Practitioners. The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.

Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011

OBJECTIVE

To analyse patient safety events associated with England's national programme for IT (NPfIT).

METHODS

Retrospective analysis of all safety events managed by a dedicated IT safety team between September 2005 and November 2011 was undertaken. Events were reviewed against an existing classification for problems associated with IT. The proportion of reported events per problem type, consequences, source of report, resolution within 24h, time of day and day of week were examined. Sub-group analyses were undertaken for events involving patient harm and those that occurred on a large scale.

RESULTS

Of the 850 events analysed, 68% (n=574) described potentially hazardous circumstances, 24% (n=205) had an observable impact on care delivery, 4% (n=36) were a near miss, and 3% (n=22) were associated with patient harm, including three deaths (0·35%). Eleven events did not have a noticeable consequence (1%) and two were complaints (<1%). Amongst the events 1606 separate contributing problems were identified. Of these 92% were predominately associated with technical rather than human factors. Problems involving human factors were four times as likely to result in patient harm than technical problems (25% versus 8%; OR 3·98, 95%CI 1·90-8.34). Large-scale events affecting 10 or more individuals or multiple IT systems accounted for 23% (n=191) of the sample and were significantly more likely to result in a near miss (6% versus 4%) or impact the delivery of care (39% versus 20%; p<0·001).

CONCLUSION

Events associated with NPfIT reinforce that the use of IT does create hazardous circumstances and can lead to patient harm or death. Large-scale patient safety events have the potential to affect many patients and clinicians, and this suggests that addressing them should be a priority for all major IT implementations.

Prospective analysis of adverse events in surgical treatment of degenerative spondylolisthesis

BACKGROUND CONTEXT

Surgical adverse event (AE) monitoring is imprecise, of uncertain validity, and tends toward underreporting. Reports focus on specific procedures rather than outcomes in the context of presenting diagnosis. Specific intraoperative (intraop) or postoperative (postop) AEs that may be independently associated with degenerative spondylolisthesis (DS) have never been reported.

PURPOSE

The primary purpose was to assess the AE profile of surgically treated patients with L4-L5 DS. The secondary goal was to identify potential risk factors that correlate with those AEs.

STUDY DESIGN/SETTING

Prospective cohort and academic quaternary spine center.

PATIENT SAMPLE

Ninety-two patients with L4-L5 DS were treated surgically, discharged from Vancouver General Hospital between January 1, 2009 and December 31, 2010.

OUTCOME MEASURES

Incidence rates and odds ratios.

METHODS

Prospective AE data were analyzed using univariate analyses, forward selection regression models, and Spearman correlation coefficients. Results were compared with outcomes reported in the Spine Patient Outcomes Research Trial.

RESULTS

No AEs were seen in 57.6% of patients, one AE in 17.4%, and two or more AEs in 17.4%. Dural tears (6.5%) and intraop bone-implant interface failure requiring revision (3.3%) were the most common intraop AEs. Postoperatively, the most frequent AEs were urinary tract infection (10.9%), delirium (5.4%), neuropathic pain (4.4%), deep wound infection (3.3%), and superficial wound infection (3.3%). The odds of an intraop AE increased by 9% (95% confidence interval [CI] 1-18) per year of age at admission. Adjusted Charlson comorbidity index (CCI) did not correlate with number of AEs experienced. The odds of postop delirium correlated with CCI (odds ratio [OR] 3.39, 95% CI 1.12-10.24) and dural tear (OR 35.84, 95% CI 1.72-747.45). Length of stay was statistically significant and was influenced by two or more AEs, CCI, postop loss of correction, cerebrospinal fluid leak, deep wound infection, noninfected wound drainage, and gender.

CONCLUSIONS

Risk of intraop AEs, but not postop AEs, increased with increasing age. Having multiple comorbidities does not predispose to more AEs. Infections predominate among the postop AEs. Patients at increased risk of delirium or of having an increased length of hospital stay may more easily be predicted. Studies specifically designed to prospectively assess AEs have the potential to more accurately identify postop AE rates.

Using patients' experiences of adverse events to improve health service delivery and practice: protocol of a data linkage study of Australian adults age 45 and above

INTRODUCTION

Evidence of patients' experiences is fundamental to creating effective health policy and service responses, yet is missing from our knowledge of adverse events. This protocol describes explorative research redressing this significant deficit; investigating the experiences of a large cohort of recently hospitalised patients aged 45 years and above in hospitals in New South Wales (NSW), Australia.

METHODS AND ANALYSIS

The 45 and Up Study is a cohort of 265,000 adults aged 45 years and above in NSW. Patients who were hospitalised between 1 January and 30 June 2014 will be identified from this cohort using data linkage and a random sample of 20,000 invited to participate. A cross-sectional survey (including qualitative and quantitative components) will capture patients' experiences in hospital and specifically of adverse events. Approximately 25% of respondents are likely to report experiencing an adverse event. Quantitative components will capture the nature and type of events as well as common features of patients' experiences. Qualitative data provide contextual knowledge of their condition and care and the impact of the event on individuals. Respondents who do not report an adverse event will report their experience in hospital and be the control group. Statistical and thematic analysis will be used to present a patient perspective of their experiences in hospital; the characteristics of patients experiencing an adverse event; experiences of information sharing after an event (open disclosure) and the other avenues of redress pursued. Interviews with key policymakers and a document analysis will be used to create a map of the current practice.

ETHICS AND DISSEMINATION

Dissemination via a one-day workshop, peer-reviewed publications and conference presentations will enable effective clinical responses and service provision and policy responses to adverse events to be developed.

Prevalence, nature and potential preventability of adverse drug events - a population-based medical record study of 4970 adults

AIMS

To estimate the 3 month prevalence of adverse drug events (ADEs), categories of ADEs and preventable ADEs, and the preventability of ADEs among adults in Sweden. Further, to identify drug classes and organ systems associated with ADEs and estimate their seriousness.

METHODS

A random sample of 5025 adults in a Swedish county council in 2008 was drawn from the Total Population Register. All their medical records in 29 inpatient care departments in three hospitals, 110 specialized outpatient clinics and 51 primary care units were reviewed retrospectively in a stepwise manner, and complemented with register data on dispensed drugs. ADEs, including adverse drug reactions (ADRs), sub-therapeutic effects of drug therapy (STEs), drug dependence and abuse, drug intoxications from overdose, and morbidities due to drug-related untreated indication, were detected during a 3 month study period, and assessed for preventability.

RESULTS

Among 4970 included individuals, the prevalence of ADEs was 12.0% (95% confidence interval (CI) 11.1, 12.9%), and preventable ADEs 5.6% (95% CI 5.0, 6.2%). ADRs (6.9%; 95% CI 6.2, 7.6%) and STEs (6.4%; 95% CI 5.8, 7.1%) were more prevalent than the other ADEs. Of the ADEs, 38.8% (95% CI 35.8-41.9%) was preventable, varying by ADE category and seriousness. ADEs were frequently associated with nervous system and cardiovascular drugs, but the associated drugs and affected organs varied by ADE category.

CONCLUSIONS

The considerable burden of ADEs and preventable ADEs from commonly used drugs across care settings warrants large-scale efforts to redesign safer, higher quality healthcare systems. The heterogeneous nature of the ADE categories should be considered in research and clinical practice for preventing, detecting and mitigating ADEs.

The epistemology of patient safety research

Patient safety has only recently been subjected to wide-spread systematic study. Healthcare differs from other high risk industries in being more diverse and multi-contextual, and less certain and regulated. Also many patient safety problems are low-frequency events associated with many, varied contributing factors. The subject of this paper is the epistemology of patient safety (the science of the method of finding out about patient safety). Patient safety research is considered here on the background of a risk management framework which requires researchers to: •  Understand the context - as a subset of healthcare quality, services and systems research, with technical and human behavioural (cultural) components and a range of external and internal organisational influences, a wide range of research disciplines is necessary •  Identify the risks - identify the things that go wrong and the frequency and nature of different types of incidents from sources such as medical record review, observational studies, audit, incident and medico-legal reports •  Analyse the risks - deconstruct the things that go wrong, identifying contributing factors and trying to detect trends and patterns in contributing factors, detection, mitigation factors, ameliorating factors and actions taken to reduce risk •  Evaluate the risks - decide on priorities, identifying preventive and corrective strategies and judging the risk- and cost-benefit of potential corrective strategies such as standardisation or simplification of a process or device •  Manage the risk - evaluate and scope preventive and/or corrective strategies and then implement these, or place the problem on a risk register pending solution, or accept that what is needed is unaffordable •  Communicate and consult - use interactive sessions, audit, on-going feedback, reminders and patient mediated prompts •  Monitor and review the state of the problem - get baseline trends and patterns so that changes can be tracked and properly attributed to an intervention A hierarchy of levels of evidence has been proposed for clinical research and we argue that insufficient weighting has been given to lower ranked levels of research and to qualitative research, although critical interpretive synthesis is now gaining acceptance in mainstream thinking (e.g. by the Cochrane Collaboration). Fundamental challenges remain including how to grasp the elusive concept of patient safety, how to quantify, characterise and cost the problems, how to judge the extent to which harm can be attributed to errors, violations or system failures, how to identify contributing factors and the extent to which they can be implicated, how to judge whether incidents or their precursors are preventable, how to generate strong evidence to make healthcare safer and how to translate research into practice. Future directions include addressing the mundane as well as rare, dramatic events, and developing further research in non-hospital settings and in developing countries. In summary, a mixture of qualitative and quantitative methods, using information from all available data sources and combining retrospective, real time and prospective study designs, is necessary to address some of the more difficult patient safety problems.

Prevalence and perceived preventability of self-reported adverse drug events--a population-based survey of 7099 adults

Purpose

Adverse drug events (ADEs) are common and often preventable among inpatients, but self-reported ADEs have not been investigated in a representative sample of the general public. The objectives of this study were to estimate the 1-month prevalence of self-reported ADEs among the adult general public, and the perceived preventability of 2 ADE categories: adverse drug reactions (ADRs) and sub-therapeutic effects (STEs).

Methods

In this cross-sectional study, a postal survey was sent in October 2010 to a random sample of 13 931 Swedish residents aged ≥18 years. Self-reported ADEs experienced during the past month included ADRs, STEs, drug dependence, drug intoxications and morbidity due to drug-related untreated indication. ADEs could be associated with prescription, non-prescription or herbal drugs. The respondents estimated whether ADRs and STEs could have been prevented. ADE prevalences in age groups (18–44, 45–64, or ≥65 years) were compared.

Results

Of 7099 respondents (response rate 51.0%), ADEs were reported by 19.4% (95% confidence interval, 18.5–20.3%), and the prevalence did not differ by age group (p>0.05). The prevalences of self-reported ADRs, STEs, and morbidities due to drug-related untreated indications were 7.8% (7.2–8.4%), 7.6% (7.0–8.2%) and 8.1% (7.5–8.7%), respectively. The prevalence of self-reported drug dependence was 2.2% (1.9–2.6%), and drug intoxications 0.2% (0.1–0.3%). The respondents considered 19.2% (14.8–23.6%) of ADRs and STEs preventable. Although reported drugs varied between ADE categories, most ADEs were attributable to commonly dispensed drugs. Drugs reported for all and preventable events were similar.

Conclusions

One-fifth of the adult general public across age groups reported ADEs during the past month, indicating a need for prevention strategies beyond hospitalised patients. For this, the underlying causes of ADEs should increasingly be investigated. The high burden of ADEs and preventable ADEs from widely used drugs across care settings supports redesigning a safer healthcare system to adequately tackle the problem.

Using statistical text classification to identify health information technology incidents

OBJECTIVE

To examine the feasibility of using statistical text classification to automatically identify health information technology (HIT) incidents in the USA Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database.

DESIGN

We used a subset of 570 272 incidents including 1534 HIT incidents reported to MAUDE between 1 January 2008 and 1 July 2010. Text classifiers using regularized logistic regression were evaluated with both 'balanced' (50% HIT) and 'stratified' (0.297% HIT) datasets for training, validation, and testing. Dataset preparation, feature extraction, feature selection, cross-validation, classification, performance evaluation, and error analysis were performed iteratively to further improve the classifiers. Feature-selection techniques such as removing short words and stop words, stemming, lemmatization, and principal component analysis were examined.

MEASUREMENTS

κ statistic, F1 score, precision and recall.

RESULTS

Classification performance was similar on both the stratified (0.954 F1 score) and balanced (0.995 F1 score) datasets. Stemming was the most effective technique, reducing the feature set size to 79% while maintaining comparable performance. Training with balanced datasets improved recall (0.989) but reduced precision (0.165).

CONCLUSIONS

Statistical text classification appears to be a feasible method for identifying HIT reports within large databases of incidents. Automated identification should enable more HIT problems to be detected, analyzed, and addressed in a timely manner. Semi-supervised learning may be necessary when applying machine learning to big data analysis of patient safety incidents and requires further investigation.

Failures in transition: learning from incidents relating to clinical handover in acute care

The appropriate handover of patients, whereby responsibility and accountability of care is transferred between healthcare providers, is a critical component of quality healthcare delivery. This paper examines data from recent incidents relating to clinical handover in acute care settings, in order to provide a basis for the design and implementation of preventive and corrective strategies. A sample of incidents (n = 459) relating to clinical handover was extracted from an Australian health service's incident reporting system using a manual search function. Incident narratives were subjected to classification according to the system safety and quality concepts of failure type, error type, and failure detection mechanism. The most prevalent failure types associated with clinical handover were those relating to the transfer of patients without adequate handover 28.8% (n = 132), omissions of critical information about the patient's condition 19.2% (n = 88), and omissions of critical information about the patient's care plan during the handover process 14.2% (n = 65). The most prevalent failure detection mechanisms were those of expectation mismatch 35.7% (n = 174), clinical mismatch 26.9% (n = 127), and mismatch with other documentation 24.0% (n = 117). The findings suggest the need for a structured approach to handover with a recording of standardized sets of information to ensure that critical components are not omitted. Limitations of existing reporting processes are also highlighted.

CareTrack Australia: assessing the appropriateness of adult healthcare: protocol for a retrospective medical record review

Introduction In recent years in keeping with international best practice, clinical guidelines for common conditions have been developed, endorsed and disseminated by peak national and professional bodies. Yet evidence suggests that there remain considerable gaps between the care that is regarded as appropriate by such guidelines and the care received by patients. With an ageing population and increasing treatment options and expectations, healthcare is likely to become unaffordable unless more appropriate care is provided. This paper describes a study protocol that seeks to determine the percentage of healthcare encounters in which patients receive appropriate care for 22 common clinical conditions and the reasons why variations exist from the perspectives of both patients and providers. Methods/design A random stratified sample of at least 1000 eligible participants will be recruited from a representative cross section of the adult Australian population. Participants' medical records from the years 2009 and 2010 will be audited to assess the appropriateness of the care received for 22 common clinical conditions by determining the percentage of healthcare encounters at which the care provided was concordant with a set of 522 indicators of care, developed for these conditions by a panel of 43 disease experts. The knowledge, attitudes and beliefs of participants and healthcare providers will be examined through interviews and questionnaires to understand the factors influencing variations in care. Ethics and dissemination Primary ethics approvals were sought and obtained from the Hunter New England Local Health Network. The authors will submit the results of the study to a relevant journal as well as undertaking oral presentations to researchers, clinicians and policymakers.

Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research

OBJECTIVE

To estimate the relative inpatient costs of hospital-acquired conditions.

METHODS

Patient level costs were estimated using computerized costing systems that log individual utilization of inpatient services and apply sophisticated cost estimates from the hospital's general ledger. Occurrence of hospital-acquired conditions was identified using an Australian 'condition-onset' flag for diagnoses not present on admission. These were grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions to summarize data coded with ICD-10. Standard linear regression techniques were used to identify the independent contribution of hospital-acquired conditions to costs, taking into account the case-mix of a sample of acute inpatients (n = 1,699,997) treated in Australian public hospitals in Victoria (2005/06) and Queensland (2006/07).

RESULTS

The most costly types of complications were post-procedure endocrine/metabolic disorders, adding AU$21,827 to the cost of an episode, followed by MRSA (AU$19,881) and enterocolitis due to Clostridium difficile (AU$19,743). Aggregate costs to the system, however, were highest for septicaemia (AU$41.4 million), complications of cardiac and vascular implants other than septicaemia (AU$28.7 million), acute lower respiratory infections, including influenza and pneumonia (AU$27.8 million) and UTI (AU$24.7 million). Hospital-acquired complications are estimated to add 17.3% to treatment costs in this sample.

CONCLUSIONS

Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harm. Previous studies of the costs of adverse events have provided information on 'indicators' of safety problems rather than the full range of hospital-acquired conditions. Adding a cost dimension to priority-setting could result in changes to the focus of patient safety programmes and research. Financial information should be combined with information on patient outcomes to allow for cost-utility evaluation of future interventions.

Patient safety problems associated with heathcare information technology: an analysis of adverse events reported to the US Food and Drug Administration

The objective of this paper is to analyze healthcare information technology (HIT) events associated with patient harm submitted to the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database. We examined the problems in 46 relevant events submitted to MAUDE from January 2008 to July 2010 to identify natural categories of problems from a clinical perspective. CPOE and PACS were involved in 93% of the events. Adverse events were associated with medications in 41%, clinical processes in 33%, radiation in 15% and surgery in 11%. There were four deaths. Strategies to improve the safety of HIT should focus on designing safe user interfaces, integrated checks of key identifiers and decision support, and engineering safer clinical processes.

Using FDA reports to inform a classification for health information technology safety problems

OBJECTIVE

To expand an emerging classification for problems with health information technology (HIT) using reports submitted to the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database.

DESIGN

HIT events submitted to MAUDE were retrieved using a standardized search strategy. Using an emerging classification with 32 categories of HIT problems, a subset of relevant events were iteratively analyzed to identify new categories. Two coders then independently classified the remaining events into one or more categories. Free-text descriptions were analyzed to identify the consequences of events.

MEASUREMENTS

Descriptive statistics by number of reported problems per category and by consequence; inter-rater reliability analysis using the κ statistic for the major categories and consequences.

RESULTS

A search of 899 768 reports from January 2008 to July 2010 yielded 1100 reports about HIT. After removing duplicate and unrelated reports, 678 reports describing 436 events remained. The authors identified four new categories to describe problems with software functionality, system configuration, interface with devices, and network configuration; the authors' classification with 32 categories of HIT problems was expanded by the addition of these four categories. Examination of the 436 events revealed 712 problems, 96% were machine-related, and 4% were problems at the human-computer interface. Almost half (46%) of the events related to hazardous circumstances. Of the 46 events (11%) associated with patient harm, four deaths were linked to HIT problems (0.9% of 436 events).

CONCLUSIONS

Only 0.1% of the MAUDE reports searched were related to HIT. Nevertheless, Food and Drug Administration reports did prove to be a useful new source of information about the nature of software problems and their safety implications with potential to inform strategies for safe design and implementation.

Mapping the limits of safety reporting systems in health care--what lessons can we actually learn?

OBJECTIVES

To assess the utility of Australian health care incident reporting systems and determine the depth of information available within a typical system.

DESIGN AND SETTING

Incidents relating to patient misidentification occurring between 2004 and 2008 were selected from a sample extracted from a number of Australian health services' incident reporting systems using a manual search function.

MAIN OUTCOME MEASURES

Incident type, aetiology (error type) and recovery (error-detection mechanism). Analyses were performed to determine category saturation.

RESULTS

All 487 selected incidents could be classified according to incident type. The most prevalent incident type was medication being administered to the wrong patient (25.7%, 125), followed by incidents where a procedure was performed on the wrong patient (15.2%, 74) and incidents where an order for pathology or medical imaging was mislabelled (7.0%, 34). Category saturation was achieved quickly, with about half the total number of incident types identified in the first 13.5% of the incidents. All 43 incident types were classified within 76.2% of the dataset. Fifty-two incident reports (10.7%) included sufficient information to classify specific incident aetiology, and 288 reports (59.1%) had sufficient detailed information to classify a specific incident recovery mechanism.

CONCLUSIONS

Incident reporting systems enable the classification of the surface features of an incident and identify common incident types. However, current systems provide little useful information on the underlying aetiology or incident recovery functions. Our study highlights several limitations of incident reporting systems, and provides guidance for improving the use of such systems in quality and safety improvement.

Introduction of a prehospital critical incident monitoring system--final results

BACKGROUND

Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting.

HYPOTHESIS

A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting.

METHODS

This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations.

RESULTS

There were 454 incidents identified from 230 cases (mean=2.0; 95% CI 1.8-2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI=1.4-1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean=2.0; 95% CI=1.8-2.2 per case), and there were 74 incidents from 26 combined cases (mean=2.9; 95% CI=2.2-3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%).

CONCLUSIONS

The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of "near miss" type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.

Market-based control mechanisms for patient safety

A new model is proposed for enhancing patient safety using market-based control (MBC), inspired by successful approaches to environmental governance. Emissions trading, enshrined in the Kyoto protocol, set a carbon price and created a carbon market--is it possible to set a patient safety price and let the marketplace find ways of reducing clinically adverse events? To "cap and trade," a regulator would need to establish system-wide and organisation-specific targets, based on the cost of adverse events, create a safety market for trading safety credits and then police the market. Organisations are given a clear policy signal to reduce adverse event rates, are told by how much, but are free to find mechanisms best suited to their local needs. The market would inevitably generate novel ways of creating safety credits, and accountability becomes hard to evade when adverse events are explicitly measured and accounted for in an organisation's bottom line.

Predictors of complications after spinal stabilization of thoracolumbar spine injuries

BACKGROUND

The management of complications after major traumatic spinal injury and surgical stabilization is a challenge. The purpose of this study is to identify factors predictive of a complication after surgical stabilization of thoracolumbar spine injuries.

METHODS

A review of subjects prospectively enrolled in a multicenter database for spine trauma was performed. Standard demographic data, Glasgow Coma Scores, Injury Severity Score, American Spinal Injury Association score, Charlson Comorbiditiy Index (CCI), mechanism of injury, administration of methylprednisolone (National Acute Spinal Cord Injury II, III), time from injury to surgery, and surgical approach were evaluated. All perioperative complications within 6 months of surgery were recorded. Multivariate logistic regression analysis was performed to identify factors predictive of the occurrence of a complication after surgical stabilization of a thoracolumbar injury.

RESULTS

There were 230 patients (57 women, 173 men), 35% were smokers. The mean age at injury was 41.8 ± 17.8 years. The majority of patients (52%) had no neurologic deficits. Nineteen percent had complete cord injuries whereas 29% had incomplete cord injuries. The mean admission ISS was 9.2 ± 7.8, mean CCI was 0.2 ± 0.7, mean Glasgow Coma Score was 14.6 ± 1.6. NASCIS II and III was instituted in 15.5% and 4.2% of all patients, respectively; mean time from injury to surgery was 8.9 ± 59 days. The incidence of complications was 79% (minor 30%, major 49%). No factors predictive of a minor complication were identified. Factors predictive of the occurrence of a major complication were administration of high-dose steroids, ASIA score, and CCI.

CONCLUSION

The severity of neurologic injury, number of comorbidities, and use of the high-dose steroids independently increase the risk of having a major complication after surgical stabilization of thoracolumbar spine fractures.

An analysis of computer-related patient safety incidents to inform the development of a classification

OBJECTIVE

To analyze patient safety incidents associated with computer use to develop the basis for a classification of problems reported by health professionals.

DESIGN

Incidents submitted to a voluntary incident reporting database across one Australian state were retrieved and a subset (25%) was analyzed to identify 'natural categories' for classification. Two coders independently classified the remaining incidents into one or more categories. Free text descriptions were analyzed to identify contributing factors. Where available medical specialty, time of day and consequences were examined.

MEASUREMENTS

Descriptive statistics; inter-rater reliability.

RESULTS

A search of 42,616 incidents from 2003 to 2005 yielded 123 computer related incidents. After removing duplicate and unrelated incidents, 99 incidents describing 117 problems remained. A classification with 32 types of computer use problems was developed. Problems were grouped into information input (31%), transfer (20%), output (20%) and general technical (24%). Overall, 55% of problems were machine related and 45% were attributed to human-computer interaction. Delays in initiating and completing clinical tasks were a major consequence of machine related problems (70%) whereas rework was a major consequence of human-computer interaction problems (78%). While 38% (n=26) of the incidents were reported to have a noticeable consequence but no harm, 34% (n=23) had no noticeable consequence.

CONCLUSION

Only 0.2% of all incidents reported were computer related. Further work is required to expand our classification using incident reports and other sources of information about healthcare IT problems. Evidence based user interface design must focus on the safe entry and retrieval of clinical information and support users in detecting and correcting errors and malfunctions.

Spine adverse events severity system: content validation and interobserver reliability assessment

STUDY DESIGN

A prospective validation study, preliminary single-center report.

OBJECTIVE

The purpose of this study was to assess the content validity and interobserver reliability of a simple severity classification system for adverse events (AEs) associated with spinal surgery.

SUMMARY OF BACKGROUND DATA

In the surgical literature what is defined as an AE, the severity of an AE, and the reporting of AEs are variable. Consequently, valid comparison of AEs within or among specialties or surgical centers for the same or different procedures is often impossible.

METHODS

Since 2002, a Spine Adverse Events Severity system (SAVES) has been locally developed and prospectively used. AEs were graded as I (requires none/minimal treatment, minimal effect [<1-2 days] on length of stay [LOS]), II (requires treatment and/or increases LOS [3-7 days] with no long-term sequelae), III (requires treatment and/or increased LOS [>7 days] with long-term sequelae [>6 months]), and IV (death). Content validity of the grading system was assessed using the hospital chart abstraction (current defacto gold standard) compared with the SAVES from 200 randomly selected patients. Interobserver reliability was assessed in consecutive operative cases for 1 spine surgeon during a 1-year period (2006) using 3 raters (staff surgeon, fellow, and/or resident).

RESULTS

The prospectively administered form reported a higher number of surgical AEs (n = 43 vs. n = 30) and a similar number of medical AEs (n = 31 vs. n = 27). Compared with the chart, the AE form displayed substantial agreement for number (70%; weighted Kappa [wK] = 0.60) and type (75%; wK = 0.67) of AE. The interobserver reliability was near perfect (kappa = 0.8) for the actual grade of AE and moderate (kappa = 0.5) for the criteria behind the grading (i.e., clinical effect of the AE or the effect of the AE on LOS or both).

CONCLUSION

The result of this study demonstrates improved capture of surgical AEs using SAVES. Excellent interobserver reliability between surgeons at different level of training was demonstrated with minimal education or training regarding the use of SAVES.

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems

OBJECTIVES

To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare.

METHODS

Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology.

RESULTS

Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods.

CONCLUSION

A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of complex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micro-managed and controlled through a hierarchy is preferable.

Critical incident reporting in anaesthesia: a prospective internal audit

SUMMARY

Critical incident monitoring is useful in detecting new problems, identifying 'near misses' and analyzing factors or events leading to mishaps, which can be instructive for trainees. This study was aimed at investigating potential risk factors and analyze events leading to peri-operative critical incidents in order to develop a critical incident reporting system. We conducted a one year prospective analysis of voluntarily reported 24- hour-perioperative critical incidents, occurring in patients subjected to anaesthesia. During a one year period from December 2006 to December 2007, 14,134 anaesthetics were administered and 112(0.79%) critical incidents were reported with complete recovery in 71.42%(n=80) and mortality in 28.57% (n=32) cases. Incidents occurred maximally in 0-10 years age (23.21%), ASA 1(61.61%), in general surgery patients (43.75%), undergoing emergency surgery (52.46%) and during day time (75.89%). Incidence was more in the operating theatre (77.68%), during maintenance (32.04%) and post-operative phase (25.89%) and in patients who received general anaesthesia (75.89%). Critical incidents occurred clue to factors related to anaesthesia (42.85%), patient (37.50%) and surgery (16.96%). Among anaesthesia related critical incidents (42.85% n=48/112), respiratory events were maximum (66.66%) mainly at induction (37.5%) and emergence (43.75%), and factors responsible were human error (85.41%), pharmacological factors (10.41%) and equipment error (4.17%). Incidence of mortality was 22.6 per 10, 000 anaesthetics (32/14,314), mostly attributable to risk factors in patient (59.38%) as compared to anaesthesia (25%) and surgery (9.38%). There were 8 anaesthesia related deaths (5.6 per 10, 000 anaesthetics) where human error (75%) attributed to lack of judgment (67.50%) was an important causative factor. We conclude that critical incident reporting system may be a valuable part of quality assurance to develop policies to prevent recurrence and enhance patient safety measures.

Introduction of a prehospital critical incident monitoring system--pilot project results

BACKGROUND

Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited.

PROBLEM

Implementation of an incident monitoring process in a prehospital setting.

METHODS

This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations.

RESULTS

Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9-5.5%).

CONCLUSIONS

The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types. The large proportion of incidents in the "near miss" category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.

Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform

Improving quality and safety of hospital care is now firmly on the health-care agenda. Various agencies within different levels of government are pursuing initiatives targeting hospitals and health professionals that aim to identify, quantify and lessen medical error and suboptimal care. Although not denying the value of such 'top-down' initiatives, more attention may be needed towards 'bottom-up' reform led by practising physicians. This article discusses factors integral to delivery of safe, high-quality care grouped under six themes: clinical workforce, teamwork, patient participation in care decisions, indications for health-care interventions, clinical governance and information systems. Following this discussion, a 20-point action plan is proposed as an agenda for future reform capable of being led by physicians, together with some cautionary notes about relying too heavily on information technology, use of non-clinical quality personnel and quantitative evaluative approaches as primary strategies in improving quality.

Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice

PURPOSE

The purpose of this study is to evaluate the effects of a health system-wide safety improvement program (SIP) three to four years after initial implementation.

DESIGN/METHODOLOGY/APPROACH

The study employs multi-methods studies involving questionnaire surveys, focus groups, in-depth interviews, observational work, ethnographic studies, documentary analysis and literature reviews with regard to the state of New South Wales, Australia, where 90,000 health professionals, under the auspices of the Health Department, provide healthcare to a seven-million population. After enrolling many participants from various groups, the measurements included: numbers of staff trained and training quality; support for SIP; clinicians' reports of safety skills acquired, work practices changed and barriers to progress; RCAs undertaken; observation of functioning of teams; committees initiated and staff appointed to deal with adverse events; documentation and computer records of reports; and peak-level responses to adverse events.

FINDINGS

A cohort of 4 per cent of the state's health professionals has been trained and now applies safety skills and conducts RCAs. These and other senior professionals strongly support SIP, though many think further culture change is required if its benefits are to be more fully achieved and sustained. Improved information-handling systems have been adopted. Systems for reporting adverse incidents and conducting RCAs have been instituted, which are co-ordinated by NSW Health. When the appropriate structures, educational activities and systems are made available in the form of an SIP, measurable systems change might be introduced, as suggested by observations of the attitudes and behaviours of health practitioners and the increased reporting of, and action about, adverse events.

ORIGINALITY/VALUE

Few studies into health systems change employ wide-ranging research methods and metrics. This study helps to fill this gap.

Crises in clinical care: an approach to management

A "crisis" in health care is "the point in the course of a disease at which a decisive change occurs, leading either to recovery or to death". The daunting challenges faced by clinicians when confronted with a crisis are illustrated by a tragic case in which a teenage boy died after a minor surgical procedure. Crises are challenging for reasons which include: presentation with non-specific signs or symptoms, interaction of complex factors, progressive evolution, new situations, "revenge effects", inadequate assistance, and time constraints. In crises, clinicians often experience anxiety- and overload-induced performance degradation, tend to use "frequency gambling", run out of "rules" and have to work from first principles, and are prone to "confirmation bias". The effective management of crises requires formal training, usually simulator-based, and ideally in the inter-professional groups who will need to function as a team. "COVER ABCD-A SWIFT CHECK" is a pre-compiled algorithm which can be applied quickly and effectively to facilitate a systematic and effective response to the wide range of potentially lethal problems which may occur suddenly in anaesthesia. A set of 25 articles describing additional pre-compiled responses collated into a manual for the management of any crisis under anaesthesia has been published electronically as companion papers to this article. This approach to crisis management should be applied to other areas of clinical medicine as well as anaesthesia.

An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification

More needs to be done to improve safety and quality and to manage risks in health care. Existing processes are fragmented and there is no single comprehensive source of information about what goes wrong. An integrated framework for the management of safety, quality and risk is needed, with an information and incident management system based on a universal patient safety classification. The World Alliance for Patient Safety provides a platform for the development of a coherent approach; 43 desirable attributes for such an approach are discussed. An example of an incident management and information system serving a patient safety classification is presented, with a brief account of how and where it is currently used. Any such system is valueless unless it improves safety and quality. Quadruple-loop learning (personal, local, national and international) is proposed with examples of how an exemplar system has been successfully used at the various levels. There is currently an opportunity to "get it right" by international cooperation via the World Health Organization to develop an integrated framework incorporating systems that can accommodate information from all sources, manage and monitor things that go wrong, and allow the worldwide sharing of information and the dissemination of tools for the implementation of strategies which have been shown to work.

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

BACKGROUND

The purpose of the present study was to measure the incidence and type of incidents that occurred in relation to anaesthesia and surgery during a 1-year period in six Danish hospitals. Furthermore, we wanted to identify risk factors for incidents, as well as risk factors for incidents being deemed critical.

METHODS

A four-page questionnaire describing patient data, type of anaesthesia and surgery, and occurrence of incidents was filled in for all anaesthesias in the period, and subsequently processed. The incident reporting form incorporated 59 predefined adverse events. The occurrence of one or more of these events described the incident. When the reporting anaesthetist deemed that an incident had harmed the patient, that incident was defined as critical.

RESULTS

A total of 64,312 anaesthesias were reported, and in 7754 of them one or more incidents occurred. A total of 8510 incidents occurred, 4077 of them were solely related to the anaesthetic procedure, 3702 described events related to physiological alterations in the patient (physiological incidents). Three hundred and twenty-three of the incidents were deemed critical. High ASA score, high age, abdominal surgery, urgent surgery, and complex anaesthetic procedure were significant risk factors for physiological incidents and critical incidents. We could not identify a simple subset of adverse events that could adequately be used to describe the critical incidents. However, complex incidents, i.e. incidents involving more than one adverse event, were more likely to be deemed critical than simple incidents.

CONCLUSION

The incidence of incidents was 12.1%, and the incidence of critical incidents was 0.5%. Incidents were more likely to be deemed critical in patients with an ASA score of III and above undergoing urgent surgery.

Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction?

OBJECTIVE

To assess the potential contribution of the Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) to organizational learning for patient safety improvement.

PRINCIPAL FINDINGS

Patient safety improvement requires organizational learning at the system level, which entails changes in organizational routines that cut across divisions, professions, and levels of hierarchy. This learning depends on data that are varied along a number of dimensions, including structure-process-outcome and from granular to high-level; and it depends on integration of those varied data. PSIs are inexpensive, easy to use, less subject to bias than some other sources of patient safety data, and they provide reliable estimates of rates of preventable adverse events.

CONCLUSIONS

From an organizational learning perspective, PSIs have both limitations and potential contributions as sources of patient safety data. While they are not detailed or timely enough when used alone, their simplicity and reliability make them valuable as a higher-level safety performance measure. They offer one means for coordination and integration of patient safety data and activity within and across organizations.

General practitioners' attitudes toward reporting and learning from adverse events: results from a survey

OBJECTIVE

To investigate GPs' attitudes to and willingness to report and learn from adverse events and to study how a reporting system should function.

DESIGN

Survey.

SETTING

General practice in Denmark.

MAIN OUTCOME MEASURES

GPs' attitudes to exchange of experience with colleagues and others, and circumstances under which such exchange is accepted.

SUBJECTS

A structured questionnaire sent to 1198 GPs of whom 61% responded. RESULTS. GPs had a positive attitude towards discussing adverse events in the clinic with colleagues and staff and in their continuing medical education groups. The GPs had a positive attitude to reporting adverse events to a database if the system granted legal and administrative immunity to reporters. The majority preferred a reporting system located at a research institute.

CONCLUSION

GPs have a very positive attitude towards discussing and reporting adverse events. This project encourages further research and pilot projects testing concrete reporting systems.