Lag time in an incident reporting system at a university hospital in Japan

Development of a Novel Scoring System to Quantify the Severity of Incident Reports: An Exploratory Research Study

Incident reporting systems have been widely adopted to collect information about patient safety incidents. Much of the value of incident reports lies in the free-text section. Computer processing of semantic information may be helpful to analyze this. We developed a novel scoring system for decision making to assess the severity of incidents using the semantic characteristics of the text in incident reports, and compared its results with experts' opinions. We retrospectively analyzed free-text data from incident reports from January 2012 to September 2021 at Nagoya University Hospital, Aichi, Japan. The sample was allocated to training and validation datasets using the hold-out method. Morphological analysis was used to segment terms in the training dataset. We calculated a severity term score, a severity report score and severity group score, by report volume size, and compared these with conventional severity classifications by patient safety experts and reporters. We allocated 96,082 incident reports into two groups. We calculated 1,802 severity term scores from the 48,041 reports in the training dataset. There was a significant difference in severity report score between reports categorized as severe and not severe by experts (95% confidence interval [CI] -0.83 to -0.80, p < 0.001, d = 0.81). Severity group scores were positively associated with severity ratings from experts and reporters (correlation coefficients 0.73 [95% CI 0.63-0.80, p < 0.001] and 0.79 [95% CI 0.71-0.85, p < 0.001]) for all departments. Our severity scoring system could therefore contribute to better organizational patient safety.

Implementing an Intervention to Improve Physicians’ Incident Reporting in the Hospital Setting: A Pilot Study

Objectives: To improve patient safety, information regarding errors must be collected. This practice constitutes one of the strategies that hospital managers use to understand the types of errors that occur at their hospitals. This pilot study aimed to evaluate an intervention designed to improve error reporting percentage among physicians. Methods: The study was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and involved the following steps: receiving support and appropriate feedback from the hospital administrator, defining reporting standards, improving the incident reporting system, and having the hospital administrators set clear goals and begin a visualized feedback process. Physicians were the main target for these steps in this study. Results: The percentage of reports submitted by physicians relative to nonphysicians increased from fiscal year (FY) 2017 to FY 2018, with the largest monthly increase within 2018 occurring in November. Physician reporting was higher in FY 2018 than in FY 2017, with the greatest difference observed for December of the respective FYs (p < 0.001, analyzed using Fisher’s exact test). The percentage of reports submitted by physicians increased by 2.6% (95% confidence interval [CI]: 1.7, 3.5) from FY 2017 to FY 2018, raising the percentage to 9%. Conclusions: Based on these results, it can be said that the intervention effectively increased incident reporting among not only physicians but also nonphysician staff members. In this regard, reporting barriers were broken when hospital administrators encouraged staff to submit incident reports. Active feedback by hospital administrators—the executive class of the hospital—may encourage not only physicians, but also staff members to submit incident reports, thus effectively removing reporting barriers.

Barriers and enablers in implementing an electronic incident reporting system in a teaching hospital: A case study from Saudi Arabia

BACKGROUND

Widespread recognition of the impact of healthcare adverse events has triggered incident reporting system implementation to promote patient safety. The aim was to assess the effectiveness, usability, enablers, and barriers of the Electronic Occurrence Variance Reporting System (eOVR) in addition to end user satisfaction.

METHODS

This study comprised a cross-sectional survey two years after implementation of the eOVR. Secondary data analysis evaluated the volume of incident reporting before and after implementing the eOVR.

OUTCOME MEASURES

Primary outcome measures: satisfaction and system usability, system security, workplace safety culture, training, and reporting trends. An overall satisfaction was collected. Secondary outcome: rate of reported OVRs per 1000 admissions. Furthermore, barriers and enablers to the reporting process were explored.

RESULTS

Study findings indicate that the eOVR has been successful in terms of high satisfaction according to respondents. Most of the respondents found the system easy to access, maintained patient confidentiality and reporting anonymity. Around half the respondents indicated having a non-punitive culture of reporting in their hospital. Physicians had significantly lower scores in all primary outcomes Incident reporting increased by 33.6% (p < 0.0001) after implementing the eOVR.

CONCLUSION

Successful incident reporting systems should be easy and simple to use, accessible and include features that guarantee anonymity and confidentiality. End-users should be trained prior to launching such a system. The implementation of such systems needs to be combined with promoting a just culture in the organization, timely feedback, more involvement and focus on physicians and junior staff which will improve user satisfaction and reporting rates.

Investigation of medical error-reporting system and reporting status in Iran in 2019

INTRODUCTION

Reporting medical errors is a major challenge in patient safety and improving service quality. The purpose of the present study is to investigate the status of error reporting and the challenges of developing an error-reporting system in Iran.

METHODS

This study was designed with qualitative approach and grounded theory method in teaching hospitals affiliated to Iran University of Medical Sciences. The views of safety authorities at various levels of management, including those responsible for safety at the Ministry of Health, Vice Chancellor and Hospitals affiliated to Iran University of Medical Sciences, were investigated in 2019 regarding adverse events.

RESULTS

Four major themes were identified included iceberg reporting and disclosure, weak reporting, underreporting, and non-error disclosure. The most common problems in reporting medical error were non-involvement of physicians in the error-reporting process, structural (human and information) bugs in root cause analysis sessions, and defective error prevention approaches designed based on the failure mode and effects analysis.

DISCUSSION

Despite a large number of medical errors occurred in health-care settings, error reporting is still very low, with only a limited number of errors being reported routinely in hospitals and the rest are minor and occasional reports.

CONCLUSION

Creating a mandatory error-reporting system and requiring physicians to report and participate in error analysis sessions can create a safety culture and increase the error-reporting rate.

[Factors of reporting adverse events in a Tunisian hospital.]

INTRODUCTION

We wish to integrate an adverse events reporting system in a Tunisian University Hospital. However, before the implantation of this system, it is important to identify the factors that may influence the reporting, so it is primordial to conduct a study which aims to determine influencing factors of adverse events reporting according to the perception of health care professionals.

METHOD

A cross-sectional descriptive study was conducted between July and September 2014, using a questionnaire which was developed in the light of Reason&#8217;s works on safety culture (1990; 1997), and the Pffeifer, Manser and Wahner (2010) model of influencing factors of adverse events reporting. This questionnaire was self-administered to 46 physicians, 21 health technicians, 65 nurses and 18 practical nurses working in a Tunisian Hospital. Data analysis was conducted using SPSS.

RESULTS

The main obstacles identified were: lack of staff training (78.7%) and lack of precision on the types of events reported (76.7%). However, the three main facilitators are the establishment of a safety culture (88%), the commitment of decision makers in the safety culture (81.3%) and the absence of punishment (78, 7%).

CONCLUSION

A policy and managerial consideration of the main factors influencing reporting of adverse events, as well as suggestions from health professionals, is necessary to ensure a good adoption of the reporting system by healthcare institutions in Tunisia.

Teaching medical students to recognise and report errors

Background

Medical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of errors students see during clinical rotations. The authors developed an intervention to better understand what kinds of errors students see and to train them to identify and report errors.

Methods

A safety curriculum was delivered during the Medicine clerkship for the academic year 2015–2016. Prior to the workshop, students completed a preintervention survey to determine whether they had reported a clinical error. Subsequently, they participated in an educational workshop. Facilitated discussions about conditions contributing to errors, types of errors, prevention of errors and importance of reporting followed. Students were required to submit a simulated error report about an error they personally observed. An end-of-year survey was sent to students who participated in the curriculum to determine clinical error reporting frequency.

Results

Students submitted 282 reports. Near miss errors were seen in 64% and adverse events in 36%. National Quality Forum serious events were reported in 14%, including one death. Recommendations to prevent similar events were weak (62%). Students correctly categorised 93% near miss, 88% adverse events, 67% diagnostic, 81% treatment and 78% preventative errors. On the preintervention survey, 8.5% stated they submitted an error report to their clinical site. On the end-of-year survey, 18% confirmed submitting a formal error report.

Conclusion

Training students to recognise and report errors can be successfully integrated into a clinical clerkship and impact clinical error reporting.

A Survey of Adverse Event Reporting Practices Among US Healthcare Professionals

Introduction

The under-reporting of adverse drug events (ADEs) is an international health concern. A number of studies have assessed the root causes but, to our knowledge, little information exists relating under-reporting to practices and systems used for the recording and tracking of drug‐related adverse event observations in ambulatory settings, institutional settings, and retail pharmacies.

Objectives

Our objective was to explore the process for reporting ADEs in US hospitals, ambulatory settings, and retail pharmacies; to explore gaps and inconsistencies in the reporting process; and to identify the causes of under-reporting ADEs in these settings.

Methods

The Tufts Center for the Study of Drug Development (Tufts CSDD) interviewed 11 thought leaders and conducted a survey between May and August 2014 among US-based healthcare providers (HCPs) in diverse settings to assess their experiences with, and processes for, reporting ADEs.

Results

A total of 123 individuals completed the survey (42 % were pharmacists; 27 % were nurses; 15 % were physicians; and 16 % were classified as ‘other’). HCPs indicated that the main reasons for under-reporting were difficulty in determining the cause of the ADE, given that most patients receive multiple therapies simultaneously (66 % of respondents); that HCPs lack sufficient time to report ADEs (63 % of respondents); poor integration of ADE-reporting systems (53 % of respondents); and uncertainty about reporting procedures (52 % of respondents).

Discussion

The results of this pilot study identify that key factors contributing to the under-reporting of ADEs relate to a lack of standardized process, a lack of training and education, and a lack of integrated health information technologies.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-016-0455-4) contains supplementary material, which is available to authorized users.

Association of preventable adverse drug events with inpatients' length of stay-A propensity-matched cohort study

PURPOSE

Using clinical administrative data (CAD) of inpatients, we aimed to identify ICD-10 codes coding for potentially preventable inhospital adverse drug events (ADE) that affect the length of hospital stay (LOS) and thus patient well-being and cost.

METHODS

We retrospectively assessed CAD of all inpatient stays in 2012 of a German university hospital. Predefined ICD-10 codes indicating ADE (ADE codes) were further specified based on expert ratings of the ADE mechanism and ADE preventability in clinical routine to particularly identify preventable inhospital ADE. In a propensity-matched cohort design, we compared patients with one or more ADE codes to control patients with regard to differences in LOS for three situations: all cases with an ADE code, cases with an inhospital ADE code, and cases with a preventable inhospital ADE code.

RESULTS

Out of 54 032 cases analysed, in 8.3% (N=4 462) at least one ADE code was present. Nine of 128 evaluated ADE codes were rated as preventable in clinical routine, relating to 220 inpatients (4.9% of all identified inpatients with at least one ADE code and 0.4% of the entire cohort, respectively). Out of 48 072 evaluable inpatients for propensity score matching, 7 938 controls without ADE code and 4 006 cases with ADE code were selected. In all three settings, cases showed prolonged LOS vs controls (delta 1.13 d; 0.88 d and 1.88 d, respectively), significantly exceeding the maximum LOS as defined for each Diagnosis-Related Group.

CONCLUSION

Inpatients with ADE codes referring to inhospital, potentially preventable ADE exceeded the maximum hospital stay fully reimbursed by insurance companies, indicating unnecessary long and costly inpatient stays.

A cross-national comparison of incident reporting systems implemented in German and Swiss hospitals

OBJECTIVE

This study aimed to empirically compare incident reporting systems (IRS) in two European countries and to explore the relationship of IRS characteristics with context factors such as hospital characteristics and characteristics of clinical risk management (CRM).

DESIGN

We performed exploratory, secondary analyses of data on characteristics of IRS from nationwide surveys of CRM practices.

SETTING

The survey was originally sent to 2136 hospitals in Germany and Switzerland.

PARTICIPANTS

Persons responsible for CRM in 622 hospitals completed the survey (response rate 29%).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Differences between IRS in German and Swiss hospitals were assessed using Chi2, Fisher's Exact and Freeman-Halton-Tests, as appropriate. To explore interrelations between IRS characteristics and context factors (i.e. hospital and CRM characteristics) we computed Cramer's V.

RESULTS

Comparing participating hospitals across countries, Swiss hospitals had implemented IRS earlier, more frequently and more often provided introductory IRS training systematically. German hospitals had more frequently systematically implemented standardized procedures for event analyses. IRS characteristics were significantly associated with hospital characteristics such as hospital type as well as with CRM characteristics such as existence of strategic CRM objectives and of a dedicated position for central CRM coordination.

CONCLUSIONS

This study contributes to an improved understanding of differences in the way IRS are set up in two European countries and explores related context factors. This opens up new possibilities for empirically informed, strategic interventions to further improve dissemination of IRS and thus support hospitals in their efforts to move patient safety forward.

Incident Reporting Behaviours and Associated Factors among Nurses Working in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia

Background. A comprehensive and systematic approach to incident reporting would help learn from errors and adverse events within a healthcare facility. Objective. The aim of the study was to assess incident reporting behaviours and associated factors among nurses. Methods. An institution-based cross-sectional study was conducted from April 14 to 29, 2015. Simple random sampling technique was used to select the study participants. Data were coded, entered into Epi Info 7, and exported to SPSS version 20 software for analysis. A multivariate logistic regression model was fitted and adjusted odds ratio with 95% confidence interval was used to determine the strength of association. Results. The proportion of nurses who reported incidents was 25.4%. Training on incident reporting (Adjusted Odds Ratio (AOR) [95% CI] 2.96 [1.34-6.26]), reason to report (to help patient) (AOR [95% CI] 3.08 [1.70-5.59]), fear of administrative sanctions (AOR [95% CI] 0.27 [0.12-0.58]), fear of legal penalty (AOR [95% CI] 0.09 [0.03-0.21]), and fear of loss of prestige among colleagues (AOR [95% CI] 0.25 [0.12-0.53]) were significantly associated factors with the incident reporting behaviour of nurses. Conclusion and Recommendation. The proportion of nurses who reported incidents was very low. Establishing a system which promotes incident reporting is vital.

Characteristics of Inpatient Falls not Reported in an Incident Reporting System

An incident reporting system is the most commonly used method to identify patient safety incidents in a hospital. However, non-reporting of incidents for various reasons is a serious problem. We studied the rate of inpatient falls that were not reported in an incident reporting system but were recorded in medical charts and we evaluated characteristics of those falls by comparing with the falls reported in incident reports in a Japanese acute care hospital setting. Falls recorded in medical charts were detected by using a text mining method followed by a manual chart review. About 25% of the recorded falls were not reported in incident reports. Male patients, first fall, long lag time until recording, no witness at the time of the fall and physician profession were shown to be significant factors associated with non-reporting. Our results show that the rate of non-reporting of inpatient falls in a Japanese acute care hospital is compable to that shown in previous studies in other conutries and that the same barriers to incident reporting as those found in previous studies exist in the medical staff.

Electronic clinical safety reporting system: a benefits evaluation

Background

Eastern Health, a large health care organization in Newfoundland and Labrador (NL), started a staged implementation of an electronic occurrence reporting system (used interchangeably with “clinical safety reporting system”) in 2008, completing Phase One in 2009. The electronic clinical safety reporting system (CSRS) was designed to replace a paper-based system. The CSRS involves reporting on occurrences such as falls, safety/security issues, medication errors, treatment and procedural mishaps, medical equipment malfunctions, and close calls. The electronic system was purchased from a vendor in the United Kingdom that had implemented the system in the United Kingdom and other places, such as British Columbia. The main objective of the new system was to improve the reporting process with the goal of improving clinical safety. The project was funded jointly by Eastern Health and Canada Health Infoway.

Objective

The objectives of the evaluation were to: (1) assess the CSRS on achieving its stated objectives (particularly, the benefits realized and lessons learned), and (2) identify contributions, if any, that can be made to the emerging field of electronic clinical safety reporting.

Methods

The evaluation involved mixed methods, including extensive stakeholder participation, pre/post comparative study design, and triangulation of data where possible. The data were collected from several sources, such as project documentation, occurrence reporting records, stakeholder workshops, surveys, focus groups, and key informant interviews.

Results

The findings provided evidence that frontline staff and managers support the CSRS, identifying both benefits and areas for improvement. Many benefits were realized, such as increases in the number of occurrences reported, in occurrences reported within 48 hours, in occurrences reported by staff other than registered nurses, in close calls reported, and improved timelines for notification. There was also user satisfaction with the tool regarding ease of use, accessibility, and consistency. The implementation process encountered challenges related to customizing the software and the development of the classification system for coding occurrences. This impacted on the ability of the managers to close-out files in a timely fashion. The issues that were identified, and suggestions for improvements to the form itself, were shared with the Project Team as soon as they were noted. Changes were made to the system before the rollout.

Conclusions

There were many benefits realized from the new system that can contribute to improved clinical safety. The participants preferred the electronic system over the paper-based system. The lessons learned during the implementation process resulted in recommendations that informed the rollout of the system in Eastern Health, and in other health care organizations in the province of Newfoundland and Labrador. This study also informed the evaluation of other health organizations in the province, which was completed in 2013.

Recognition of medical errors' reporting system dimensions in educational hospitals

INTRODUCTION AND OBJECTIVE

Nowadays medical errors are one of the serious issues in the health-care system and carry to account of the patient's safety threat. The most important step for achieving safety promotion is identifying errors and their causes in order to recognize, correct and omit them. Concerning about repeating medical errors and harms, which were received via theses errors concluded to designing and establishing medical error reporting systems for hospitals and centers that are presenting therapeutic services. The aim of this study is the recognition of medical errors' reporting system dimensions in educational hospitals.

MATERIALS AND METHODS

This research is a descriptive-analytical and qualities' study, which has been carried out in Shahid Beheshti educational therapeutic center in Isfahan during 2012. In this study, relevant information was collected through 15 face to face interviews. That each of interviews take place in about 1hr and creation of five focused discussion groups through 45 min for each section, they were composed of Metron, educational supervisor, health officer, health education, and all of the head nurses. Concluded data interviews and discussion sessions were coded, then achieved results were extracted in the presence of clear-sighted persons and after their feedback perception, they were categorized. In order to make sure of information correctness, tables were presented to the research's interviewers and final the corrections were confirmed based on their view.

FINDING

The extracted information from interviews and discussion groups have been divided into nine main categories after content analyzing and subject coding and their subsets have been completely expressed. Achieved dimensions are composed of nine domains of medical error concept, error cases according to nurses' prospection, medical error reporting barriers, employees' motivational factors for error reporting, purposes of medical error reporting system, error reporting's challenges and opportunities, a desired system characteristics, and the quality of error experiences' transmission in the health-care system.

CONCLUSION

Although, appropriate achievements have been assured in Shahid Beheshti Hospital, but it seems necessary that in order to immune promotion not only in this hospital, but in the other organizations, necessary infrastructures have been provided for an error reporting system performance. An appropriate medical error reporting system could be educated and prevent the occurrence of repeated errors.

Detecting inpatient falls by using natural language processing of electronic medical records

BACKGROUND

Incident reporting is the most common method for detecting adverse events in a hospital. However, under-reporting or non-reporting and delay in submission of reports are problems that prevent early detection of serious adverse events. The aim of this study was to determine whether it is possible to promptly detect serious injuries after inpatient falls by using a natural language processing method and to determine which data source is the most suitable for this purpose.

METHODS

We tried to detect adverse events from narrative text data of electronic medical records by using a natural language processing method. We made syntactic category decision rules to detect inpatient falls from text data in electronic medical records. We compared how often the true fall events were recorded in various sources of data including progress notes, discharge summaries, image order entries and incident reports. We applied the rules to these data sources and compared F-measures to detect falls between these data sources with reference to the results of a manual chart review. The lag time between event occurrence and data submission and the degree of injury were compared.

RESULTS

We made 170 syntactic rules to detect inpatient falls by using a natural language processing method. Information on true fall events was most frequently recorded in progress notes (100%), incident reports (65.0%) and image order entries (12.5%). However, F-measure to detect falls using the rules was poor when using progress notes (0.12) and discharge summaries (0.24) compared with that when using incident reports (1.00) and image order entries (0.91). Since the results suggested that incident reports and image order entries were possible data sources for prompt detection of serious falls, we focused on a comparison of falls found by incident reports and image order entries. Injury caused by falls found by image order entries was significantly more severe than falls detected by incident reports (p<0.001), and the lag time between falls and submission of data to the hospital information system was significantly shorter in image order entries than in incident reports (p<0.001).

CONCLUSIONS

By using natural language processing of text data from image order entries, we could detect injurious falls within a shorter time than that by using incident reports. Concomitant use of this method might improve the shortcomings of an incident reporting system such as under-reporting or non-reporting and delayed submission of data on incidents.

Incident reporting at a tertiary care hospital in Saudi Arabia

OBJECTIVE

This study aimed to examine the rates and categories of incident reports in an academic tertiary care center in Saudi Arabia both hospital-wide and in the intensive care unit (ICU). Such information would help in redesigning systems and in planning and developing strategies with the goal of improving patient safety and quality of care.

METHODS

In this descriptive study, we evaluated all incident reports submitted through the paper-based reporting system in the hospital and the ICU for the year 2008. Incident report rates were calculated as the number of incident reports per 1000 patient days. We also reviewed the major and minor categories of the generated reports.

RESULTS

A total of 3041 incident reports were submitted from all hospital areas; yielding a rate of 5.8 per 1000 patient days. Sixty-two incident reports were reported from the ICU, yielding a rate of 5.8 per 1000 patient days. The most frequent type of incident reports was procedural variances (37%), followed by behavior and communication incidents (34%), hazardous and safety incidents (9.5%), and medication errors (7.4%). In the ICU, the most frequently reported type of incidents was behavior and communication incidents (30.6%), followed by procedural variances (21%) and medication errors (13%).

CONCLUSIONS

Rates of incident reports at a tertiary care center in Saudi Arabia were low compared with reported international rates. The main categories of incident reports were related to procedural variances and behavior and communication incidents. These findings suggest that patient safety initiatives should focus primarily on these 2 domains. Additional prospective research is needed in this important area to further understand patient safety challenges and reporting practice and culture in the country.