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Diaz CM, Egide A, Berry A, Rafferty M, Amro A, Tesorero K, Shapiro M, Ko B, Jones W, Slocum JD, Johnson J, Stey AM. Defining conditions for effective interdisciplinary care team communication in an open surgical intensive care unit: a qualitative study. BMJ Open 2023; 13:e075470. [PMID: 38097232 PMCID: PMC10729088 DOI: 10.1136/bmjopen-2023-075470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE Poor interdisciplinary care team communication has been associated with increased mortality. The study aimed to define conditions for effective interdisciplinary care team communication. DESIGN An observational cross-sectional qualitative study. SETTING A surgical intensive care unit in a large, urban, academic referral medical centre. PARTICIPANTS A total 6 interviews and 10 focus groups from February to June 2021 (N=33) were performed. Interdisciplinary clinicians who cared for critically ill patients were interviewed. Participants included intensivist, transplant, colorectal, vascular, surgical oncology, trauma faculty surgeons (n=10); emergency medicine, surgery, gynaecology, radiology physicians-in-training (n=6), advanced practice providers (n=5), nurses (n=7), fellows (n=1) and subspecialist clinicians such as respiratory therapists, pharmacists and dieticians (n=4). Audiorecorded content of interviews and focus groups were deidentified and transcribed verbatim. The study team iteratively generated the codebook. All transcripts were independently coded by two team members. PRIMARY OUTCOME Conditions for effective interdisciplinary care team communication. RESULTS We identified five themes relating to conditions for effective interdisciplinary care team communication in our surgical intensive care unit setting: role definition, formal processes, informal communication pathways, hierarchical influences and psychological safety. Participants reported that clear role definition and standardised formal communication processes empowered clinicians to engage in discussions that mitigated hierarchy and facilitated psychological safety. CONCLUSIONS Standardising communication and creating defined roles in formal processes can promote effective interdisciplinary care team communication by fostering psychological safety.
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Affiliation(s)
| | - Abahuje Egide
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Andrew Berry
- Department of Medical Social Sciences, Northwestern University, Evanston, Illinois, USA
| | - Miriam Rafferty
- 19th floor Strength+Endurance AbilityLab, Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation & Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ali Amro
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | | | - Michael Shapiro
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Bona Ko
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Whitney Jones
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - John D Slocum
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Julie Johnson
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
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Gundrosen S, Andenæs E, Aadahl P, Thomassen G. Team talk and team activity in simulated medical emergencies: a discourse analytical approach. Scand J Trauma Resusc Emerg Med 2016; 24:135. [PMID: 27842599 PMCID: PMC5109640 DOI: 10.1186/s13049-016-0325-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 11/01/2016] [Indexed: 11/23/2022] Open
Abstract
Background Communication errors can reduce patient safety, especially in emergency situations that require rapid responses by experts in a number of medical specialties. Talking to each other is crucial for utilizing the collective expertise of the team. Here we explored the functions of “team talk” (talking between team members) with an emphasis on the talk-work relationship in interdisciplinary emergency teams. Methods Five interdisciplinary medical emergency teams were observed and videotaped during in situ simulations at an emergency department at a university hospital in Norway. Team talk and simultaneous actions were transcribed and analysed. We used qualitative discourse analysis to perform structural mapping of the team talk and to analyse the function of online commentaries (real-time observations and assessments of observations based on relevant cues in the clinical situation). Results Structural mapping revealed recurring and diverse patterns. Team expansion stood out as a critical phase in the teamwork. Online commentaries that occurred during the critical phase served several functions and demonstrated the inextricable interconnections between team talk and actions. Discussion Discourse analysis allowed us to capture the dynamics and complexity of team talk during a simulated emergency situation. Even though the team talk did not follow a predefined structure, the team members managed to manoeuvre safely within the complex situation. Our results support that online commentaries contributes to shared team situation awareness. Conclusions Discourse analysis reveals naturally occurring communication strategies that trigger actions relevant for safe practice and thus provides supplemental insights into what comprises “good” team communication in medical emergencies.
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Affiliation(s)
- Stine Gundrosen
- Medical Simulation Centre, Trondheim, Norway. .,Department of Anesthesia and Intensive Care Medicine, St. OIavs Hospital, Trondheim University Hospital, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Ellen Andenæs
- Department of Language and Literature, Norwegian University of Science and Technology, Trondheim, Norway
| | - Petter Aadahl
- Medical Simulation Centre, Trondheim, Norway.,Department of Anesthesia and Intensive Care Medicine, St. OIavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gøril Thomassen
- Department of Language and Literature, Norwegian University of Science and Technology, Trondheim, Norway
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Wright J, Lawton R, O’Hara J, Armitage G, Sheard L, Marsh C, Grange A, McEachan RRC, Cocks K, Hrisos S, Thomson R, Jha V, Thorp L, Conway M, Gulab A, Walsh P, Watt I. Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BackgroundEstimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.AimOur aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.Methods and resultsWe developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.ConclusionThis research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.Trial registrationCurrent Controlled Trials ISRCTN07689702.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- John Wright
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rebecca Lawton
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jane O’Hara
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Leeds Institute of Medical Education, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Gerry Armitage
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Laura Sheard
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Claire Marsh
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Angela Grange
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rosemary RC McEachan
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kim Cocks
- York Trials Unit, University of York, York, UK
| | - Susan Hrisos
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Richard Thomson
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Vikram Jha
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Liz Thorp
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | | | - Peter Walsh
- Action against Medical Accidents, Croydon, UK
| | - Ian Watt
- Department of Health Sciences, University of York, York, UK
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Carrillo I, Mira JJ, Vicente MA, Fernandez C, Guilabert M, Ferrús L, Zavala E, Silvestre C, Pérez-Pérez P. Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents. J Med Internet Res 2016; 18:e257. [PMID: 27678308 PMCID: PMC5059483 DOI: 10.2196/jmir.5942] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/03/2016] [Accepted: 09/06/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. OBJECTIVE The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. METHODS The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA's design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. RESULTS BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). CONCLUSIONS BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use.
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Affiliation(s)
- Irene Carrillo
- Health Psychology Department, Miguel Hernández University, Elche, Spain.
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Howell AM, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A. International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process. BMJ Qual Saf 2016; 26:150-163. [PMID: 26902254 DOI: 10.1136/bmjqs-2015-004456] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 01/10/2016] [Accepted: 01/24/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. OBJECTIVE To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. METHODS After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. RESULTS Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. CONCLUSIONS We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.
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Affiliation(s)
- Ann-Marie Howell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Elaine M Burns
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK
| | - Louise Hull
- Division of Surgery, Imperial College London, London, UK
| | - Erik Mayer
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nick Sevdalis
- Department of Surgery and Cancer, Imperial College London, London, UK.,Health Service and Population Research, Centre for Implementation Science, King's College, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
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Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF, Wagner KJ. Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. BMC Anesthesiol 2016; 16:4. [PMID: 26772179 PMCID: PMC4715310 DOI: 10.1186/s12871-016-0172-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/14/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A loss of adequate Situation Awareness (SA) may play a major role in the genesis of critical incidents in anesthesia and critical care. This observational study aimed to determine the frequency of SA errors in cases of a critical incident reporting system (CIRS). METHODS Two experts independently reviewed 200 cases from the German Anesthesia CIRS. For inclusion, reports had to be related to anesthesia or critical care for an individual patient and take place in an in-hospital setting. Based on the SA framework, the frequency of SA errors was determined. Representative cases were analyzed qualitatively to illustrate the role of SA for decision-making. RESULTS SA errors were identified in 81.5%. Predominantly, errors occurred on the levels of perception (38.0%) and comprehension (31.5%). Errors on the level of projection played a minor role (12.0%). The qualitative analysis of selected cases illustrates the crucial role of SA for decision-making and performance. CONCLUSIONS SA errors are very frequent in critical incidents reported in a CIRS. The SA taxonomy was suitable to provide mechanistic insights into the central role of SA for decision-making and thus, patient safety.
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Affiliation(s)
- Christian M Schulz
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany.
| | - Veronika Krautheim
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Annika Hackemann
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Eberhard F Kochs
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Klaus J Wagner
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
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Brunsveld-Reinders AH, Arbous MS, De Vos R, De Jonge E. Incident and error reporting systems in intensive care: a systematic review of the literature. Int J Qual Health Care 2015; 28:2-13. [DOI: 10.1093/intqhc/mzv100] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2015] [Indexed: 01/19/2023] Open
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Brunsveld-Reinders AH, Arbous MS, Kuiper SG, de Jonge E. A comprehensive method to develop a checklist to increase safety of intra-hospital transport of critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:214. [PMID: 25947327 PMCID: PMC4438434 DOI: 10.1186/s13054-015-0938-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/22/2015] [Indexed: 11/23/2022]
Abstract
Introduction Transport of critically ill patients from the Intensive Care Unit (ICU) to other departments for diagnostic or therapeutic procedures is often a necessary part of the critical care process. Transport of critically ill patients is potentially dangerous with up to 70% adverse events occurring. The aim of this study was to develop a checklist to increase safety of intra-hospital transport (IHT) in critically ill patients. Method A three-step approach was used to develop an IHT checklist. First, various databases were searched for published IHT guidelines and checklists. Secondly, prospectively collected IHT incidents in the LUMC ICU were analyzed. Thirdly, interviews were held with physicians and nurses over their experiences of IHT incidents. Following this approach a checklist was developed and discussed with experts in the field. Finally, feasibility and usability of the checklist was tested. Results Eleven existing guidelines and five checklists were found. Only one checklist covered all three phases: pre-, during- and post-transport. Recommendations and checklist items mostly focused on the pre-transport phase. Documented incidents most frequently related to patient physiology and equipment malfunction and occurred most often during transport. Discussing the incidents with ICU physicians and ICU nurses resulted in important recommendations such as the introduction of a standard checklist and improved communication with the other departments. This approach resulted in a generally applicable checklist, adaptable for local circumstances. Feedback from nurses using the checklist were positive, the fill in time was 4.5 minutes per phase. Conclusion A comprehensive way to develop an intra-hospital checklist for safe transport of ICU patients to another department is described. This resulted in a checklist which is a framework to guide physicians and nurses through intra-hospital transports and provides a continuity of care to enhance patient safety. Other hospitals can customize this checklist to their own situation using the methods proposed in this paper. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0938-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anja H Brunsveld-Reinders
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300, RC, Leiden, the Netherlands.
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300, RC, Leiden, the Netherlands.
| | - Sander G Kuiper
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300, RC, Leiden, the Netherlands.
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300, RC, Leiden, the Netherlands.
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Riga M, Vozikis A, Pollalis Y, Souliotis K. MERIS (Medical Error Reporting Information System) as an innovative patient safety intervention: a health policy perspective. Health Policy 2014; 119:539-48. [PMID: 25554702 DOI: 10.1016/j.healthpol.2014.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 12/03/2014] [Accepted: 12/04/2014] [Indexed: 10/24/2022]
Abstract
The economic crisis in Greece poses the necessity to resolve problems concerning both the spiralling cost and the quality assurance in the health system. The detection and the analysis of patient adverse events and medical errors are considered crucial elements of this course. The implementation of MERIS embodies a mandatory module, which adopts the trigger tool methodology for measuring adverse events and medical errors an intensive care unit [ICU] environment, and a voluntary one with web-based public reporting methodology. A pilot implementation of MERIS running in a public hospital identified 35 adverse events, with approx. 12 additional hospital days and an extra healthcare cost of €12,000 per adverse event or of about €312,000 per annum for ICU costs only. At the same time, the voluntary module unveiled 510 reports on adverse events submitted by citizens or patients. MERIS has been evaluated as a comprehensive and effective system; it succeeded in detecting the main factors that cause adverse events and discloses severe omissions of the Greek health system. MERIS may be incorporated and run efficiently nationally, adapted to the needs and peculiarities of each hospital or clinic.
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Affiliation(s)
- Marina Riga
- Health Economics, School of Economics, Business and International Studies, Department of Economics, University of Piraeus, 80, Karaoli & Dimitriou Street, 18534 Piraeus, Greece
| | - Athanassios Vozikis
- Health Economics and Information Systems, School of Economics, Business and International Studies, Department of Economics, University of Piraeus, 80, Karaoli & Dimitriou Street, 18534 Piraeus, Greece
| | - Yannis Pollalis
- Strategic Management and Policy, School of Economics, Business and International Studies, Department of Economics, University of Piraeus, 80, Karaoli & Dimitriou Street, 18534 Piraeus, Greece
| | - Kyriakos Souliotis
- Health Policy, Faculty of Social Sciences, Department of Social and Educational Policy, University of Peloponnese, Damaskinou & Kolokotroni Str., 20100 Corinth, Greece.
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Shelton CL, Smith AF, Mort M. Opening up the black box: an introduction to qualitative research methods in anaesthesia. Anaesthesia 2014; 69:270-80. [DOI: 10.1111/anae.12517] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2013] [Indexed: 12/21/2022]
Affiliation(s)
- C. L. Shelton
- Department of Anaesthesia; University Hospital South Manchester; Manchester UK
- Lancaster Medical School; Lancaster University; Lancaster UK
| | - A. F. Smith
- Department of Anaesthesia; Royal Lancaster Infirmary; Lancaster UK
| | - M. Mort
- Department of Sociology; Lancaster Medical School; Lancaster University; Lancaster UK
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Associations Between Communication Climate and the Frequency of Medical Error Reporting Among Pharmacists Within an Inpatient Setting. J Patient Saf 2013; 9:129-33. [DOI: 10.1097/pts.0b013e318281edcb] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Medical error, disclosure and patient safety: a global view of quality care. Clin Biochem 2013; 46:1161-9. [PMID: 23578740 DOI: 10.1016/j.clinbiochem.2013.03.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 03/25/2013] [Accepted: 03/26/2013] [Indexed: 11/21/2022]
Abstract
Medical errors are a prominent issue in health care. Numerous studies point at the high prevalence of adverse events, many of which are preventable. Although there is a range of severity in errors, they all cause harm, to the patient, to the system, or both. While errors have many causes, including human interactions and system inadequacies, the focus on individuals rather than the system has led to an unsuitable culture for improving patient safety. Important areas of focus are diagnostic procedures and clinical laboratories because their results play a major role in guiding clinical decisions in patient management. Proper disclosure of medical errors and adverse events is also a key area for improvement. Globally, system improvements are beginning to take place, however, in Canada, policies on disclosure, error reporting and protection for physicians remain non-uniform. Achieving a national standard with mandatory reporting, in addition to a non-punitive system is recommended to move forward.
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Abstract
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.
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Do we need a national incident reporting system for medical imaging? J Am Coll Radiol 2012; 9:329-35. [PMID: 22554630 DOI: 10.1016/j.jacr.2011.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 11/17/2011] [Indexed: 11/23/2022]
Abstract
The essential role of an incident reporting system as a tool to improve safety and reliability has been described in high-risk industries such as aviation and nuclear power, with anesthesia being the first medical specialty to successfully integrate incident reporting into a comprehensive quality improvement strategy. Establishing an incident reporting system for medical imaging that effectively captures system errors and drives improvement in the delivery of imaging services is a key component of developing and evaluating national quality improvement initiatives in radiology. Such a national incident reporting system would be most effective if implemented as one piece of a comprehensive quality improvement strategy designed to enhance knowledge about safety, identify and learn from errors, raise standards and expectations for improvement, and create safer systems through implementation of safe practices. The potential benefits of a national incident reporting system for medical imaging include reduced morbidity and mortality, improved patient and referring physician satisfaction, reduced health care expenses and medical liability costs, and improved radiologist satisfaction. The purposes of this article are to highlight the positive impact of external reporting systems, discuss how similar advancements in quality and safety can be achieved with an incident reporting system for medical imaging in the United States, and describe current efforts within the imaging community toward achieving this goal.
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Boyle TA, Scobie AC, MacKinnon NJ, Mahaffey T. Quality-related event learning in community pharmacies: manual versus computerized reporting processes. J Am Pharm Assoc (2003) 2012; 52:498-506, 2 p following 506. [PMID: 22825230 DOI: 10.1331/japha.2012.11004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine how staff assessment of key quality-related event (QRE) reporting process characteristics (e.g., ease of use, time to use) and QRE learning (e.g., extent that continuous improvement occurs) differ in community pharmacies in which the QRE reporting process is manual versus computerized. DESIGN Cross-sectional study. SETTING Nova Scotia, Canada, in 2010. PARTICIPANTS 121 questionnaires completed by eligible respondents in pharmacies with a formal QRE reporting process. INTERVENTION Mail-based survey. MAIN OUTCOME MEASURES A list of key QRE process characteristics that affect error reporting was identified based on a review of the health care literature and piloted in 2009. The "learning from incidents" construct, as captured by Ashcroft and Parker, was used to assess QRE learning. RESULTS Regardless of process type, the key strengths of existing QRE reporting systems appear to be that they are cost effective, easy to complete, and involve low risk to operations. However, for almost all reporting and learning characteristics, staff assessments were different between the two pharmacy types (manual versus computerized QRE reporting process), with assessments being higher from staff working in pharmacies with a computerized reporting process. CONCLUSION A QRE reporting process with a notable computer or automated component may result in more positive staff assessment of various aspects of the reporting process and QRE learning.
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Affiliation(s)
- Todd A Boyle
- Gerald Schwartz School of Business, St. Francis Xavier University, 1 West St., Antigonish, Nova Scotia, Canada.
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Lawton R, McEachan RRC, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf 2012; 21:369-80. [PMID: 22421911 PMCID: PMC3332004 DOI: 10.1136/bmjqs-2011-000443] [Citation(s) in RCA: 193] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim of this systematic review was to develop a 'contributory factors framework' from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings. DESIGN A mixed-methods systematic review of the literature was conducted. DATA SOURCES Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts. ELIGIBILITY CRITERIA Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety. RESULTS 1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. CONCLUSIONS This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.
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Affiliation(s)
- Rebecca Lawton
- Institute of Psychological Sciences, University of Leeds, Leeds, UK.
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Implications of process characteristics on quality-related event reporting in community pharmacy. Res Social Adm Pharm 2011; 8:76-86. [PMID: 22169174 DOI: 10.1016/j.sapharm.2010.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 11/29/2010] [Accepted: 11/29/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND The lack of a single pharmacy regulator in Canada has led to a wide variety of processes for reporting and learning from medication errors and near misses, collectively known as quality-related events (QREs). These processes range from completely informal processes, through to primarily manual processes that rely on paper forms and incident reports stored in a binder, all the way to fully computerized processes such as anonymous online reporting to a national database. OBJECTIVES The objective of the study was to develop and test a model of the influence of various QRE reporting process characteristics on levels of QRE reporting process support and QRE reporting in Canadian community pharmacies. METHODS A questionnaire was administered to 427 pharmacy managers, pharmacists, and technicians in Nova Scotia, Canada, in 2010, with 210 questionnaires returned. Partial least squares was performed on a subgroup of the data set (N=121) to test and refine the model. Content analysis of the open-ended data provided additional support for model variables. RESULTS The final model retained all proposed variables except for anonymous reporting. The model highlights that process ease and learning capability both greatly influence the overall support for the QRE process; with these 2 variables explaining 62% of the variance in QRE process support and QRE process support explaining 34% of the variance in overall levels of QRE reporting. CONCLUSIONS The findings have implications for the creation and implementation of successful QRE reporting processes in community pharmacies. Implementing effective QRE reporting tools is paramount to ensuring that pharmacies report and learn from QREs. Dynamic QRE reporting tools that are modern, up to date, integrated into workflow, easy to use, and quick have been shown to be the most effective.
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Chousterman B, Pirracchio R. [From iatrogenesis to medical errors: review of the literature and analytical approach]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:914-922. [PMID: 22054716 DOI: 10.1016/j.annfar.2011.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 08/01/2011] [Indexed: 05/31/2023]
Abstract
Iatrogenesis and medical errors have been increasingly studied over the past years. Because of the lack of consensus concerning the definitions, it remains difficult to draw general conclusions from the published. Moreover, it is still likely to be underestimated because of underreporting. This review aims at evaluating the overall incidence of iatrogenesis and medical errors in anaesthesia and intensive care and at discussing the strategies to prevent these incidents, at the individual or systemic level.
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Affiliation(s)
- B Chousterman
- Département d'anesthésie-réanimation-Smur, hôpital Lariboisière, université Paris-7 Diderot, 2, rue Ambroise-Paré, 75010 Paris, France
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Introduction of a prehospital critical incident monitoring system--final results. Prehosp Disaster Med 2011; 25:515-20. [PMID: 21181685 DOI: 10.1017/s1049023x00008694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales NSW 2052, Australia.
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Berghäuser M, Masjosthusmann K, Rellensmann G. Risikomanagement durch CIRS-Analyse. Monatsschr Kinderheilkd 2010. [DOI: 10.1007/s00112-010-2172-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kim CH, Kim M. Defining Reported Errors on Web-based Reporting System Using ICPS From Nine Units in a Korean University Hospital. Asian Nurs Res (Korean Soc Nurs Sci) 2009; 3:167-76. [DOI: 10.1016/s1976-1317(09)60028-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 09/04/2009] [Accepted: 11/25/2009] [Indexed: 10/20/2022] Open
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Which aspects of safety culture predict incident reporting behavior in neonatal intensive care units? A multilevel analysis. Crit Care Med 2009; 37:61-7. [PMID: 19050606 DOI: 10.1097/ccm.0b013e31819300e4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Safety culture assessments are increasingly used to evaluate patient-safety programs. However, it is not clear which aspects of safety culture are most relevant in understanding incident reporting behavior, and ultimately improving patient safety. The objective of this study was to examine which aspects of safety culture predict incident reporting behavior in the neonatal intensive care unit (NICU), before and after implementation of a voluntary, nonpunitive incident reporting system. DESIGN Survey study based on a translated, validated version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. This survey incorporates two outcome measures, 11 dimensions of patient-safety culture as well as demographic data. SETTING Eight tertiary care NICUs and one surgical pediatric ICU. SUBJECTS All unit personnel. INTERVENTION Implementation of a specialty-based, voluntary, nonpunitive incident reporting system. MEASUREMENTS AND MAIN RESULTS The survey was conducted before (t = 0) and after (t = 1 yr) the intervention. PRIMARY OUTCOME number of self-reported incidents in the past 12 months. Overall response rate was 80% (n = 700) at t = 0 and 76% (n = 670) at t = 1 yr. Based on a multivariate multilevel regression prediction model, the number of self-reported incidents increased after the intervention and was positively associated with a nonpunitive response to error and negatively associated with overall perceptions of safety and hospital management support for patient safety. CONCLUSIONS A nonpunitive approach to error, hospital management support for patient safety, and overall perceptions of safety predict incident reporting behavior in the NICU. The relation between these aspects of safety culture and patient outcome requires further scrutiny and therefore remains an important issue to address in future research.
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ICS Medal Winners and Research Abstract Presentations. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Zingg U, Zala-Mezoe E, Kuenzle B, Licht A, Metzger U, Grote G, Platz A. Evaluation of critical incidents in general surgery. Br J Surg 2008; 95:1420-5. [DOI: 10.1002/bjs.6296] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
The analysis of adverse events is a central step in critical incident reporting, but has not been described in a surgical setting. The aim of this study was to develop an evaluation protocol and assess its feasibility.
Methods
All incidents were analysed by a multidisciplinary team. A coding system based on three published theories was used to assess all incidents and their underlying causes. A risk analysis was also conducted.
Results
Between July 2004 and December 2005, 9785 inpatients were treated and 139 critical incidents reported. Classification of active errors revealed 47·7 per cent to be execution failures and 45·9 per cent knowledge-based errors. The distribution of medical errors was 12·9 per cent diagnostic, 46·0 per cent treatment, 17·3 per cent preventive and 23·7 per cent other. Some 282 latent failures were identified among the 139 incidents. Risk analysis revealed a severe incident rate of 21·6 per cent.
Conclusion
This study has shown the feasibility of an evaluation protocol based on a combination of three classification systems and a risk analysis. It allows a thorough assessment of critical incidents, identification of priorities and tailored countermeasures.
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Affiliation(s)
- U Zingg
- Department of Surgery, Technology and Economics, Eidgenössische Technische Hochschule Zurich, Zurich, Switzerland
| | - E Zala-Mezoe
- Department of Management, Technology and Economics, Eidgenössische Technische Hochschule Zurich, Zurich, Switzerland
| | - B Kuenzle
- Department of Management, Technology and Economics, Eidgenössische Technische Hochschule Zurich, Zurich, Switzerland
| | - A Licht
- Department of Internal Medicine, Triemli Hospital, Technology and Economics, Eidgenössische Technische Hochschule Zurich, Zurich, Switzerland
| | - U Metzger
- Department of Surgery, Technology and Economics, Eidgenössische Technische Hochschule Zurich, Zurich, Switzerland
| | - G Grote
- Department of Management, Technology and Economics, Eidgenössische Technische Hochschule Zurich, Zurich, Switzerland
| | - A Platz
- Department of Surgery, Technology and Economics, Eidgenössische Technische Hochschule Zurich, Zurich, Switzerland
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21st ESICM Annual Congress. Intensive Care Med 2008. [PMCID: PMC2799007 DOI: 10.1007/s00134-008-1240-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Thomas AN, Panchagnula U. Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency*. Anaesthesia 2008; 63:726-33. [DOI: 10.1111/j.1365-2044.2008.05485.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zeppos L, Patman S, Berney S, Adsett JA, Bridson JM, Paratz JD. Physiotherapy in intensive care is safe: an observational study. ACTA ACUST UNITED AC 2008; 53:279-83. [PMID: 18047463 DOI: 10.1016/s0004-9514(07)70009-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
QUESTION How often do adverse events (including adverse physiological changes) occur during physiotherapy intervention in intensive care? DESIGN A multi-centre prospective observational study. PARTICIPANTS Five tertiary level university-affiliated intensive care units. OUTCOME MEASURES All physiotherapy intervention in five intensive care units over a three month period. When certain specified changes occurred during physiotherapy intervention, details were noted including diagnosis of patient, intervention, vital signs, radiological changes, co-morbidities, chemical pathology, and fluid balance. RESULTS 12 281 physiotherapy interventions were completed with 27 interventions resulting in adverse physiological changes (0.2%). This incidence was significantly lower than a previous study of adverse physiological changes (663 events in 247 patients over a 24-hour period); the incidence during physiotherapy intervention was lower than during general intensive care. Common factors in the patients who had an adverse physiological change were a deterioration in cardiovascular status (ie, decrease in blood pressure or arrhythmia) in patients on medium to high doses of inotropes/vasopressors, unstable baseline hemodynamic values, previous cardiac co-morbidities and intervention consisting of positive pressure or right side lying. CONCLUSION The incidence of adverse events during physiotherapy intervention in these five tertiary hospitals was low, demonstrating that physiotherapy intervention in intensive care is safe.
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Throckmorton T, Etchegaray J. Factors affecting incident reporting by registered nurses: the relationship of perceptions of the environment for reporting errors, knowledge of the nursing practice act, and demographics on intent to report errors. J Perianesth Nurs 2008; 22:400-12. [PMID: 18039512 DOI: 10.1016/j.jopan.2007.09.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 08/29/2007] [Accepted: 09/10/2007] [Indexed: 11/19/2022]
Abstract
Patient safety has assumed an international focus. In the past, the focus on detecting and preventing errors was up to the individual clinician, often the registered nurse. With impetus from the Institute of Medicine and other national agencies, a shift to emphasis on systems and processes and near miss and error reporting has occurred. Information from caregiver reporting has taken on new importance. This study was conducted to explore nurses' willingness to report errors of varying degrees of severity and the factors that impacted that intent. Registered nurses were selected randomly from the Texas Board of Nurse Examiners' roster and surveyed regarding perceptions of the environment for reporting, perceptions of reasons for not reporting, knowledge of the nursing practice act, and demographic variables. A majority of nurses were willing to report all levels of errors. Primary position, reasons for not reporting, and years since initial licensure were predictors of intent to report incidents with no injury and those with minimal injury. All but four nurses (99%) indicated that they would report incidents resulting in moderate to severe injury or death.
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Affiliation(s)
- Terry Throckmorton
- Department of Nursing, The Methodist Hospital, 6565 Fannin Blvd, Houston, TX 77030, USA.
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Ligi I, Arnaud F, Jouve E, Tardieu S, Sambuc R, Simeoni U. Iatrogenic events in admitted neonates: a prospective cohort study. Lancet 2008; 371:404-10. [PMID: 18242414 DOI: 10.1016/s0140-6736(08)60204-4] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Iatrogenic events are increasingly recognised as an important problem in all people admitted to hospital. However, few epidemiological data are available for iatrogenic events in neonatal high-risk units. We aimed to assess the incidence, nature, preventability, and severity of iatrogenic events in a neonatal centre and to establish the association of patient characteristics with the occurrence of iatrogenic events in neonates. METHODS We undertook an observational, prospective study from Jan 1, 2005, to Sept 1, 2005, including all neonates admitted in the Division of Neonatology of an academic, tertiary neonatal centre in southern France. Iatrogenic events were defined as any event that compromised the safety margin for the patient, in the presence or absence of harm. The report of an iatrogenic event was voluntary, anonymous, and non-punitive. The primary outcome was the rate of iatrogenic events per 1000 patient days. FINDINGS A total of 388 patients were studied during 10 436 patient days. We recorded 267 iatrogenic events in 116 patients. The incidence of iatrogenic events was 25.6 per 1000 patient days. 92 (34%) were preventable and 78 (29%) were severe. Two iatrogenic events (1%) were fatal, but neither was preventable. The most severe iatrogenic events were nosocomial infections (49/62 [79%]) and respiratory events (nine of 26 [35%]). Cutaneous injuries were frequent (n=94) but generally minor (89 [95%]), as were medication errors (15/19 [76%]). Most medication errors occurred during administration stage (12/19 [63%]) and were ten-fold errors (nine of 19 [47%]). The major risk factors were low birthweight and gestational age (both p<0.0001), length of stay (p<0.0001), a central venous line (p<0.0001), mechanical ventilation (p=0.0021), and support with continuous positive airwary pressure (p=0.0076). INTERPRETATION Iatrogenic events occur frequently and are often serious in neonates, especially in infants of low birthweight. Improved knowledge of the incidence and characteristics of iatrogenic events, and continuous monitoring could help to improve quality of health care for this vulnerable population.
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Affiliation(s)
- Isabelle Ligi
- Division of Neonatology, La Conception Hospital, EA 3279, Assistance Publique-Hôpitaux de Marseille, Faculté de Médecine, Université de la Méditerranée, Marseille, France
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Snijders C, van Lingen RA, Molendijk A, Fetter WPF. Incidents and errors in neonatal intensive care: a review of the literature. Arch Dis Child Fetal Neonatal Ed 2007; 92:F391-8. [PMID: 17376782 PMCID: PMC2675366 DOI: 10.1136/adc.2006.106419] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine the characteristics of incident reporting systems in neonatal intensive care units (NICUs) in relation to type, aetiology, outcome and preventability of incidents. METHODS Systematic review. SEARCH STRATEGY Medline, Embase, Cochrane Library. Included: relevant systematic reviews, randomised controlled trials, observational studies and qualitative research. Excluded: non-systematic reviews, expert opinions, case reports and letters. PARTICIPANTS hospital units supplying neonatal intensive care. INTERVENTION none. OUTCOME characteristics of incident reporting systems; type, aetiology, outcome and preventability of incidents. RESULTS No relevant systematic reviews or randomised controlled trials were found. Eight prospective and two retrospective studies were included. Overall, medication incidents were most frequently reported. Available data in the NICU showed that the total error rate was much higher in studies using voluntary reporting than in a study using mandatory reporting. Multi-institutional reporting identified rare but important errors. A substantial number of incidents were potentially harmful. When a system approach was used, many contributing factors were identified. Information about the impact of system changes on patient safety was scarce. CONCLUSIONS Multi-institutional, voluntary, non-punitive, system based incident reporting is likely to generate valuable information on type, aetiology, outcome and preventability of incidents in the NICU. However, the beneficial effects of incident reporting systems and consecutive system changes on patient safety are difficult to assess from the available evidence and therefore remain to be investigated.
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Affiliation(s)
- C Snijders
- Dr C Snijders, Princess Amalia Department of Paediatrics, Division of Neonatology, Isala Clinics, Sophia, PO Box 10400, 8000 GK Zwolle, The Netherlands.
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Grant MJC, Larsen GY. Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. J Nurs Care Qual 2007; 22:213-21. [PMID: 17563589 DOI: 10.1097/01.ncq.0000277777.35395.e0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adverse event reporting is a key element for improving patient safety. This study describes a new voluntary, anonymous reporting system that facilitates reporting of near-miss and patient harm events and an assessment of patient harm by the bedside care provider in a pediatric intensive care unit. The results demonstrated the effectiveness of the Patient Safety Report as a method to capture near-miss and patient harm events.
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Affiliation(s)
- Mary Jo C Grant
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Medical Center, University of Utah, Salt Lake City, UT 84113, USA.
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Evans SM, Smith BJ, Esterman A, Runciman WB, Maddern G, Stead K, Selim P, O'Shaughnessy J, Muecke S, Jones S. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care 2007; 16:169-75. [PMID: 17545341 PMCID: PMC2465009 DOI: 10.1136/qshc.2006.019349] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incident-reporting rates and change the types of incidents reported. DESIGN, SETTING AND PARTICIPANTS Non-equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia. MAIN OUTCOME MEASURES Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units. RESULTS The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10,000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p<0.001) and in emergency departments (EDs) (additional 39.5 reports/10,000 ED attendances; 95% CI 17.0 to 62.0, p<0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10,000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10,000 OBDs; 95% CI 23.9 to 94.1, p<0.001) and (c) anonymously (additional 20.2 reports/10,000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p<0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression-related incidents in intervention units. In intervention units, more reports were submitted on one-page forms than via the call centre (1005 vs 264 reports, respectively). CONCLUSIONS A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units.
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Affiliation(s)
- Sue M Evans
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
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Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Dorman T, Dickman F, Fahey M, Steinwachs DM, Engineer L, Sexton JB, Wu AW, Morlock LL. Toward learning from patient safety reporting systems. J Crit Care 2007; 21:305-15. [PMID: 17175416 DOI: 10.1016/j.jcrc.2006.07.001] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 06/23/2006] [Accepted: 07/23/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. MATERIALS AND METHODS Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm. RESULTS Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm. CONCLUSIONS The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.
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Affiliation(s)
- Peter J Pronovost
- Department of Anesthesiology & Critical Care Medicine, Quality & Safety Research Group, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.
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van der Veer S, Cornet R, de Jonge E. Design and implementation of an ICU incident registry. Int J Med Inform 2007; 76:103-8. [PMID: 17035080 DOI: 10.1016/j.ijmedinf.2006.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Revised: 08/16/2006] [Accepted: 08/21/2006] [Indexed: 11/23/2022]
Abstract
Due to its complexity intensive care is vulnerable to errors. On the ICU adults of the AMC (Amsterdam, The Netherlands) the available registries used for error reporting did not give insight in the occurrence of unwanted events, and did not lead to preventive measures. Therefore, a new registry has been developed on the basis of a literature study on the various terms and definitions that refer to unintended events, and on the methods to register and monitor them. As this registry intends to provide an overall insight into errors, a neutral term ('incident') -- which does not imply guilt or blame -- has been sought together with a broad definition. The attributes of an incident further describe the unwanted event, but they should not form an impediment for the ICU nurses and physicians to report. The properties of a registry that contribute to making it accessible and user friendly have been determined. This has resulted in an electronic registry where incidents can be reported rapidly, voluntarily, anonymously and free of legal consequences. Evaluation is required to see if the new registry indeed provides the ICU management with the intended information on the current situation on incidents. For further refinement of the design, additional development and adjustments are required. However, we expect that the awareness of errors of the ICU personnel has already improved, forming the first step to increased patient safety.
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Affiliation(s)
- Sabine van der Veer
- Clinical Engineering Department, Academic Medical Centre (AMC)-Universiteit van Amsterdam, 1100 DE Amsterdam, The Netherlands.
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Bhattacharya P, Chakraborty A, Agarwal P. Comparison of outcome of self-extubation and accidental extubation in ICU. Indian J Crit Care Med 2007. [DOI: 10.4103/0972-5229.35081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Alvarez G, Coiera E. Interdisciplinary communication: an uncharted source of medical error? J Crit Care 2006; 21:236-42; discussion 242. [PMID: 16990088 DOI: 10.1016/j.jcrc.2006.02.004] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 02/07/2006] [Indexed: 11/21/2022]
Affiliation(s)
- George Alvarez
- Center of Health Informatics, University of New South Wales, Sydney, NSW 2034, Australia.
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Abstract
BACKGROUND As the attitude to adverse events has changed from the defensive "blame and shame culture" to an open and transparent healthcare delivery system, it is timely to examine the nature of human errors and their impact on the quality of surgical health care. METHODS The approach of the review is generic rather than specific, and the account is based on the published psychologic and medical literature on the subject. CONCLUSIONS Rather than detailing the various "surgical errors," the concept of error categories within the surgical setting committed by surgeons as front-line operators is discussed. The important components of safe surgical practice identified include organizational structure with strategic control of healthcare delivery, teamwork and leadership, evidence-based practice, proficiency, continued professional development of all staff, availability of wireless health information technology, and well-embedded incident reporting and adverse events disclosure systems. In our quest for the safest possible surgical health care, there is a need for prospective observational multidisciplinary (surgeons and human factors specialists) studies as distinct for retrospective reports of adverse events. There is also need for research to establish the ideal system architecture for anonymous reporting of near miss and no harm events in surgical practice.
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Affiliation(s)
- Alfred Cuschieri
- Department of Surgery, Division of Medical Sciences, Scuola Superiore S'Anna di Studi Universitari, Pisa, Italy.
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Abstract
BACKGROUND A survey was conducted to assess the benefits and limitations of the Australian Incident Monitoring System (AIMS) as a programme to improve patient safety. METHODS A 12-point questionnaire was sent to 12 current users of AIMS in November 2002. RESULTS The AIMS provides a consistent system of coding, trending and monitoring of incident data. It promotes a patient safety culture and an awareness of system error. Other benefits include the building of teamwork and the implementation of strategies to reduce the prevalence and severity of incidents. The majority of respondents (83%) reported that AIMS investigations resulted in significant changes to equipment usage, medication prescribing or administration, clinical protocols, training programmes and falls risk assessment tools. Although 75% of users reported improvements in patient outcomes, these were difficult to measure. A major limitation of AIMS was the low rate of incident reporting by medical staff. Voluntary reporting systems did not capture all incident data and the information was often too generic for root cause analysis. There were difficulties benchmarking data and concerns were raised regarding the ownership of information. The programme requires ongoing resources to implement change strategies and to maintain incident reporting levels. On a scale of 1 (poor rating) to 10 (excellent rating) the mean benefit rating was 7.6. CONCLUSION The Australian Incident Monitoring System is beneficial as a component of a clinical risk management strategy. Usefulness could be improved by increased participation by medical staff. The level of resources required should not be underestimated if the programme is to demonstrate improvements to patient outcomes. More recent versions of AIMS promise improved capabilities and will require similar evaluation.
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Affiliation(s)
- Allan D Spigelman
- Clinical Governance, Hunter Area Health Service, and Surgical Science, University of Newcastle, Newcastle, New South Wales, Australia.
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Palevsky PM, Baldwin I, Davenport A, Goldstein S, Paganini E. Renal replacement therapy and the kidney: minimizing the impact of renal replacement therapy on recovery of acute renal failure. Curr Opin Crit Care 2005; 11:548-54. [PMID: 16292058 DOI: 10.1097/01.ccx.0000179936.21895.a3] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although renal replacement therapy is the mainstay of supportive care in patients with severe acute renal failure, its performance can have untoward effects that contribute to the prolongation of renal failure or impede the ultimate recovery of renal function. In this review, we categorize the major complications associated with renal replacement therapy and assess their impact on recovery of renal function. RECENT FINDINGS The major mechanisms by which renal replacement therapy is postulated to delay renal recovery include treatment-associated hemodynamic instability, vascular catheter-related bacteremia and sepsis, and cytokine activation by bioincompatible membranes. Clinical data regarding the role of dialysis catheter infections in delay of renal recovery are lacking. The data regarding the role of membrane biocompatibility and the modality and dose of renal replacement therapy are limited and conflicting. SUMMARY Clinical recommendations must be limited to the broad admonishment that complications during renal replacement therapy, including hemodynamic instability and catheter-related bacteremia, be minimized by using best clinical practices, while recognizing that the impact of specific practices on recovery of renal function have not been evaluated. The data do not support recommendations regarding utilization of specific membranes or the modality or dose of renal replacement therapy on the basis of their impact on recovery of renal function.
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Affiliation(s)
- Paul M Palevsky
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15240, USA.
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Graf J, von den Driesch A, Koch KC, Janssens U. Identification and characterization of errors and incidents in a medical intensive care unit. Acta Anaesthesiol Scand 2005; 49:930-9. [PMID: 16045653 DOI: 10.1111/j.1399-6576.2005.00731.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To assess the frequency, type, consequences, and associations of errors and incidents in a medical intensive care unit (ICU). METHODS Two-hundred and sixteen consecutive patients with predominantly cardiovascular and pulmonary disorders admitted between December 2002 and February 2003 were enrolled. Demographic data, SAPS II, and TISS-28 were obtained for all patients. Prior to patient enrolment all staff members (physicians, nurses, physiotherapists) were repeatedly encouraged to make use of the Incident Report Form (IRF) and detailed descriptions on how, why and when to use the IRF were provided. RESULTS During the observation period of 64 days, 50 errors involving 32 patients (15%) were reported. Patients subjected to errors were more severely ill (SAPS II 42 +/- 25 vs. 32 +/- 18, P < 0.05), had a higher hospital mortality (38% vs. 9%), and a longer ICU stay (11 +/- 18 vs. 3 +/- 5 days, P < 0.05). Gender, age and TISS-28 were equally distributed. Each day of ICU stay increased the risk by 8% (odds ratio 1.078, 95% confidence interval 1.034-1.125, P < 0.001), and by 2.3% per SAPS II point (odds ratio 1.023, 95% confidence interval 1.006-1.040, P < 0.001). The majority of errors and incidents were judged as 'human failures' (73%), and 46 errors and incidents (92%) as 'avoidable'. CONCLUSIONS The identification and characterization of errors and incidents combined with contextual information is feasible and may provide sufficient background information for areas of quality improvement. Areas with a high frequency of errors and incidents need to undergo process evaluation to avoid future occurrence.
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Affiliation(s)
- J Graf
- Medical Clinic I, University Hospital Aachen, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Capuzzo M, Nawfal I, Campi M, Valpondi V, Verri M, Alvisi R. Reporting of unintended events in an intensive care unit: comparison between staff and observer. BMC Emerg Med 2005; 5:3. [PMID: 15921517 PMCID: PMC1165974 DOI: 10.1186/1471-227x-5-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Accepted: 05/27/2005] [Indexed: 11/26/2022] Open
Abstract
Background In order to identify relevant targets for change, it is essential to know the reliability of incident staff reporting. The aim of this study is to compare the incidence and type of unintended events (UE) reported by facilitated Intensive Care Unit (ICU) staff with those recorded concurrently by an observer. Methods The study is a prospective data collection performed in two 4-bed multidisciplinary ICUs of a teaching hospital. The format of the UE reporting system was voluntary, facilitated and not necessarily anonymous, and used a structured form with a predetermined list of items. UEs were reported by ICU staff over a period of 4 weeks. The reporting incidence during the first fourteen days was compared with that during the second fourteen. During morning shifts in the second fourteen days, one observer in each ICU recorded any UE seen. The staff was not aware of the observers' study. The incidence of UEs reported by staff was compared with that recorded by the observers. Results The staff reported 36 UEs in the first fourteen days and 31 in the second.. The incidence of UE detection during morning shifts was significantly higher than during afternoon or night shifts (p < 0.001). Considering only working day morning shifts, the rate of UE reporting by the staff per 100 patient days was 26.9 (CI 95% 16.9–37.0) in the first fourteen day period and 20.3 (CI 95% 10.3–30.4) in the second. The rate of UE detection by the observers was 53.1 per 100 patient days (CI 95% 40.6–65.6), significantly higher (p < 0.001) than that reported concurrently by the staff. There was excellent agreement between staff and observers about the severity of the UEs recorded (Intraclass Correlation Coefficient 0.869). The observers recorded mainly UEs involving Airway/mechanical ventilation and Patient management, and the staff Catheter/Drain/Probe and Medication errors (p = 0.025). Conclusion UE incidence is strongly underreported by staff in comparison with observers. Also the types of UEs reported are different. Invaluable information about incidents in ICU can be obtained in a few days by observer monitoring.
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Affiliation(s)
- Maurizia Capuzzo
- Department of Surgical, Anaesthetic and Radiological Sciences, Section of Anaesthesiology and Intensive Care, University Hospital of Ferrara, Corso Giovecca 203 44100 Ferrara, Italy
| | - Imad Nawfal
- Department of Surgical, Anaesthetic and Radiological Sciences, Section of Anaesthesiology and Intensive Care, University Hospital of Ferrara, Corso Giovecca 203 44100 Ferrara, Italy
| | - Matilde Campi
- Department of Surgical, Anaesthetic and Radiological Sciences, Section of Anaesthesiology and Intensive Care, University Hospital of Ferrara, Corso Giovecca 203 44100 Ferrara, Italy
| | - Vanna Valpondi
- Department of Surgical, Anaesthetic and Radiological Sciences, Section of Anaesthesiology and Intensive Care, University Hospital of Ferrara, Corso Giovecca 203 44100 Ferrara, Italy
| | - Marco Verri
- Department of Surgical, Anaesthetic and Radiological Sciences, Section of Anaesthesiology and Intensive Care, University Hospital of Ferrara, Corso Giovecca 203 44100 Ferrara, Italy
| | - Raffaele Alvisi
- Department of Surgical, Anaesthetic and Radiological Sciences, Section of Anaesthesiology and Intensive Care, University Hospital of Ferrara, Corso Giovecca 203 44100 Ferrara, Italy
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Terror Australis Redux: Revisiting Australian Emergency Department Preparedness for Terrorism. Prehosp Disaster Med 2005. [DOI: 10.1017/s1049023x00014229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Holzmueller CG, Pronovost PJ, Dickman F, Thompson DA, Wu AW, Lubomski LH, Fahey M, Steinwachs DM, Engineer L, Jaffrey A, Morlock LL, Dorman T. Creating the web-based intensive care unit safety reporting system. J Am Med Inform Assoc 2005; 12:130-9. [PMID: 15561794 PMCID: PMC551545 DOI: 10.1197/jamia.m1408] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2003] [Accepted: 10/04/2004] [Indexed: 11/10/2022] Open
Abstract
In an effort to improve patient safety, researchers at the Johns Hopkins University designed and implemented a comprehensive Web-based Intensive Care Unit Safety Reporting System (ICUSRS). The ICUSRS collects data about adverse events and near misses from all staff in the ICU. This report reflects data on 854 reports from 18 diverse ICUs across the United States. Reporting is voluntary, and data collected is confidential, with patient, provider, and reporter information deidentified. Preliminary data include system factors reported, degree of patient harm, reporting times, and evaluations of the system. Qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter.
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Dominguez TE, Portnoy JD. Incident reporting in the information age. Crit Care Med 2005; 32:2349-50. [PMID: 15640657 DOI: 10.1097/01.ccm.0000145956.18093.7e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kalra J. Medical errors: impact on clinical laboratories and other critical areas. Clin Biochem 2004; 37:1052-62. [PMID: 15589810 DOI: 10.1016/j.clinbiochem.2004.08.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Accepted: 08/19/2004] [Indexed: 10/26/2022]
Abstract
The Institute of Medicine (IOM) report (1999) stated that the prevalence of medical errors is high in today's health care system. Some specialties in health care are more risky than others. A varying blunder/error rate of 0.1-9.3% in clinical diagnostic laboratories has been reported in the literature. Many of these errors occur in the preanalytical and postanalytical phases of testing. It has been suggested that the errors occurring in clinical diagnostic laboratories are smaller in number than those occurring elsewhere in a hospital setting. However, given the quantum of laboratory tests used in health care, even this small rate may reflect a large number of errors. The surgical specialties, emergency rooms, and intensive care units have been previously identified as areas of risk for patient safety. Though the nature of work in these specialties and their interdependence on clinical diagnostic laboratories presents abundant opportunities for error-generating behavior, many of these errors may be preventable. Appropriate attention to system factors involved in these errors and designing intelligent system approaches may help control and eliminate many of these errors in health care.
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Affiliation(s)
- Jawahar Kalra
- Department of Pathology, College of Medicine, University of Saskatchewan and Royal University Hospital, Saskatoon, Saskatchewan, Canada.
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