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Merino P. Epidemiology of adverse events in Intensive Medicine units. Med Intensiva 2024:S2173-5727(24)00123-1. [PMID: 38763831 DOI: 10.1016/j.medine.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/23/2024] [Indexed: 05/21/2024]
Abstract
The severity of the critically ill patient, the practice of diagnostic procedures and invasive treatments, the high number of drugs administered, a high volume of data generated during the care of the critically ill patient along with a technical work environment, the stress and workload of work of professionals, are circumstances that favor the appearance of errors, turning Intensive Medicine Services into risk areas for adverse events to occur. Knowing their epidemiology is the first step to improve the safety of the care we provide to our patients, because it allows us to identify risk areas, analyze them and develop strategies to prevent the adverse events, or if this is not possible, be able to manage them. This article analyzes the main studies published to date on incidents related to safety in the field of critically ill patients.
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Affiliation(s)
- Paz Merino
- Grupo de Trabajo Planificación, Organización y Gestión, Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain.
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2
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Ben Mustapha S, Cucchiaro S, Goreux J, Delgaudine M, Boga D, Donneau AF, Diep AN, Coucke P. Comparison between the WHO-CFICPS and the PRISMA classification of safety-related events in a radiation oncology department. J Med Imaging Radiat Oncol 2023; 67:531-538. [PMID: 37138510 DOI: 10.1111/1754-9485.13536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/17/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Describing Safety-Related Events (SREs) in a radiotherapy (RT) department and comparing WHO-CFICPS (World Health Organization's Conceptual Framework For The International Classification For Patient Safety) and PRISMA (Prevention and Recovery Information System for Monitoring and Analysis) methods for classifying SREs. METHODS From February 2017 to October 2020, two Quality Managers (QMs) randomly classified 1173 SREs using 13 incident types of WHO-CFICPS. The same two QMs, reclassified the same SREs according to 20 PRISMA incident codes. Statistical analysis was performed to assess the association between the 13 incident types of WHO-CFICPS and the 20 PRISMA codes. The chi-squared and post-hoc tests using adjusted standardized residuals were applied to detect the association between the two systems. RESULTS There was a significant association between WHO-CFICPS incident types and PRISMA codes (P < 0.001). Ninety-two percent of all SREs were categorized using 4 of 13 WHO-CFICPS incident types including Clinical Process/Procedure (n = 448, 38.2%), Clinical Administration (n = 248, 21.1%), Documentation (n = 226, 19.2%) and Resources/Organizational Management (n = 15,613.3%). According to PRISMA classification, 14 of the 20 codes were used to describe the same SREs. PRISMA captured 41 Humans Skill Slips from 226 not better defined WHO-CFICPS Documentation Incidents, 38 Human Rule-based behaviour Qualification from not better defined 447 Clinical Process/Procedure and 40 Organization Management priority events from 156 not better defined WHO-CFICPS Resources/Organizational Management events (P < 0.001). CONCLUSION Although there was a significant association between WHO-CFICPS and PRISMA, The PRISMA method provides a more detailed insight into SREs compared to WHO-CFICPS in a RT department.
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Affiliation(s)
- Selma Ben Mustapha
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
| | - Séverine Cucchiaro
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
| | - Joelle Goreux
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
| | - Marie Delgaudine
- Department of Medical Imaging, Centre Hospitalier Chrétien, Liège, Belgium
| | - Deniz Boga
- University Hospital of Liège, Liege, Belgium
| | | | - Anh Nguyet Diep
- Biostatistics Unit, Faculty of Medicine, University of Liège, Liege, Belgium
| | - Philippe Coucke
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
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Maeda Y, Kawahira H, Asada Y, Yamamoto S, Shimpo M. The effect of refresher training on fact description in medical incident report writing in the Japanese language. APPLIED ERGONOMICS 2023; 109:103987. [PMID: 36716527 DOI: 10.1016/j.apergo.2023.103987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/12/2022] [Accepted: 01/25/2023] [Indexed: 06/18/2023]
Abstract
To maintain the effectiveness of the training (1st-Training Session: 1st-TS) to accurate describe facts in the medical incident reports (IRs) in Japanese, a refresher TS was designed and its effectiveness was examined. First, textual analysis showed that IRs' accuracy significantly decreased six months after the 1st-TS. Based on this result, the refresher TS was designed and conducted with 64 residents. To verify the refresher TS' effectiveness, IRs after the 1st-TS, six months later, and after the refresher TS were compared via text analysis. The results showed that the refresher TS restored the description rate of patient's background, safety check procedures, original work procedures, information on equipment used, reporter's actions, and post-incident response. The questionnaire was also administered and showed that the refresher TS contributed to residents' motivation to learn about IRs. In conclusion, the refresher TS contributed to sustaining the effect of the 1st-TS on accurately describing IRs.
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Affiliation(s)
- Yoshitaka Maeda
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Hiroshi Kawahira
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Yoshikazu Asada
- Medical Education Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Shinichi Yamamoto
- Centre for Graduate Medical Education, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Masahisa Shimpo
- Centre for Quality Improvement and Patient Safety, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
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Kang H, Yu Z, Gong Y. Initializing and Growing a Database of Health Information Technology (HIT) Events by Using TF-IDF and Biterm Topic Modeling. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2017:1024-1033. [PMID: 29854170 PMCID: PMC5977677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Health information technology (HIT) events were listed in the top 10 technology-related hazards since one in six patient safety events (PSE) is related to HIT. Although it becomes a common sense that event reporting is an effective way to accumulate typical cases for learning, the lack of HIT event databases remains a challenge. Aiming to retrieve HIT events from millions of event reports related to medical devices in FDA Manufacturer and User Facility Device Experience (MAUDE) database, we proposed a novel identification strategy composed of a structured data-based filter and an unstructured data-based classifier using both TF-IDF and biterm topic. A dataset with 97% HIT events was retrieved from the raw database of 2015 FDA MAUDE, which contains approximately 0.4~0.9% HIT events. This strategy holds promise of initializing and growing an HIT database to meet the challenges of collecting, analyzing, sharing, and learning from HIT events at an aggregated level.
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Affiliation(s)
- Hong Kang
- School of Biomedical Informatics, the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Zhiguo Yu
- School of Biomedical Informatics, the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yang Gong
- School of Biomedical Informatics, the University of Texas Health Science Center at Houston, Houston, TX, USA
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Aggarwal S, Kheriaty A. Same behavior, different provider: American medical students' attitudes toward reporting risky behaviors committed by doctors, nurses, and classmates. AJOB Empir Bioeth 2017; 9:12-18. [PMID: 28985136 DOI: 10.1080/23294515.2017.1377780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The bioethics literature lacks findings about medical students' attitudes toward reporting risky behaviors that can cause error or reduce the perceived quality of health care. A survey was administered to 159 medical students to assess their likelihood to directly approach and to report various providers-a physician, nurse, or medical student-for three behaviors (poor hand hygiene, intoxication, or disrespect of patients). For the same behavior, medical students were significantly more likely to approach a classmate, followed by a nurse and then a doctor (p < .0001), to ask for behavioral modification. Across all three health care provider types, medical students were most likely to report intoxication (p < .0001). Medical students' willingness to approach or report a provider for a risky or unprofessional behavior is influenced by the type of health care provider in question. Medical schools should implement patient safety curricula that alleviate fears about reporting superiors and create anonymous reporting systems to improve reporting rates.
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Gong Y, Kang H, Wu X, Hua L. Enhancing Patient Safety Event Reporting. A Systematic Review of System Design Features. Appl Clin Inform 2017; 8:893-909. [PMID: 28853766 DOI: 10.4338/aci-2016-02-r-0023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/25/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. Unfortunately, the value of e-reporting system (a software or web server based platform) in patient safety research is greatly overshadowed by low quality reporting. This paper aims at revealing the current status of system features, detecting potential gaps in system design, and accordingly proposing suggestions for future design and implementation of the system. METHODS Three literature databases were searched for publications that contain informative descriptions of e-reporting systems. In addition, both online publicly accessible reporting forms and systems were investigated. RESULTS 48 systems were identified and reviewed. 11 system design features and their frequencies of occurrence (Top 5: widgets (41), anonymity or confidentiality (29), hierarchy (20), validator (17), review notification (15)) were identified and summarized into a system hierarchical model. CONCLUSIONS The model indicated the current e-reporting systems are at an immature stage in their development, and discussed their future development direction toward efficient and effective systems to improve patient safety.
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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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8
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Clancy CM. The Intensive Care Unit, Patient Safety, and the Agency for Healthcare Research and Quality. Am J Med Qual 2016; 21:348-51. [PMID: 16973953 DOI: 10.1177/1062860606291989] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Carolyn M Clancy
- Agency for Healthcare Research and Quality, Rockville, Maryland, USA
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Affiliation(s)
- Carolyn M Clancy
- Agency for Healthcare Research and Quality, Rockville, Maryland, USA
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10
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Liang C, Gong Y. Knowledge Representation in Patient Safety Reporting: An Ontological Approach. JOURNAL OF DATA AND INFORMATION SCIENCE 2016; 1:75-91. [PMID: 38770358 PMCID: PMC11104324 DOI: 10.20309/jdis.201615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Purpose The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our design, implementation, and evaluation of the ontology at its initial stage. Findings We describe the design and initial outcomes of the ontology implementation. The evaluation results demonstrate the clinical validity of the ontology by a self-developed survey measurement. Research limitations The proposed ontology was developed and evaluated using a small number of information sources. Presently, US data are used, but they are not essential for the ultimate structure of the ontology. Practical implications The goal of improving patient safety can be aided through investigating patient safety reports and providing actionable knowledge to clinical practitioners. As such, constructing a domain specific ontology for patient safety reports serves as a cornerstone in information collection and text mining methods. Originality/value The use of ontologies provides abstracted representation of semantic information and enables a wealth of applications in a reporting system. Therefore, constructing such a knowledge base is recognized as a high priority in health care.
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Affiliation(s)
- Chen Liang
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston 77030, USA
| | - Yang Gong
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston 77030, USA
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11
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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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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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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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McElroy LM, Daud A, Lapin B, Ross O, Woods DM, Skaro AI, Holl JL, Ladner DP. Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system. Surgery 2014; 156:1106-15. [PMID: 25444312 DOI: 10.1016/j.surg.2014.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 05/08/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems. METHODS Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported. RESULTS A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%). DISCUSSION The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.
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Affiliation(s)
- Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Amna Daud
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brittany Lapin
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Olivia Ross
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Donna M Woods
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anton I Skaro
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jane L Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniela P Ladner
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
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15
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Martín Delgado MC, Merino de Cos P, Sirgo Rodríguez G, Álvarez Rodríguez J, Gutiérrez Cía I, Obón Azuara B, Alonso Ovies Á. Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine. Med Intensiva 2014; 39:263-71. [PMID: 25063357 DOI: 10.1016/j.medin.2014.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To explore contributing factors (CF) associated to related critical patients safety incidents. DESIGN SYREC study pos hoc analysis. SETTING A total of 79 Intensive Care Departments were involved. PATIENTS The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. MAIN VARIABLES The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. RESULTS A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. CONCLUSIONS The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss.
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Affiliation(s)
- M C Martín Delgado
- Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España.
| | - P Merino de Cos
- Servicio de Medicina Intensiva, Hospital Can Misses, Ibiza, España
| | - G Sirgo Rodríguez
- Unidad de Cuidados Intensivos, Hospital Universitario Joan XXIII, Instituto de Investigación Sanitaria Pere Virgili, Universidad Rovira i Virgili, Tarragona, España
| | - J Álvarez Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - I Gutiérrez Cía
- Servicio de Medicina Intensiva, Hospital Clínico Universitario, Zaragoza, España
| | - B Obón Azuara
- Servicio de Medicina Preventiva y Salud Pública, Hospital Clínico Universitario, Zaragoza, España
| | - Á Alonso Ovies
- Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
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Mello JFD, Barbosa SDFF. Cultura de segurança do paciente em terapia intensiva: recomendações da enfermagem. TEXTO & CONTEXTO ENFERMAGEM 2013. [DOI: 10.1590/s0104-07072013000400031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Estudo quantitativo, tipo survey, transversal e comparativo, que teve por objetivo sistematizar as recomendações dos profissionais de enfermagem acerca da segurança do paciente em duas Unidades de Terapia Intensiva adulto na Grande Florianópolis-SC, Brasil, em 2011. Resultou da resposta a uma pergunta qualitativa aplicada com o Hospital Survey on Patient Safety Culture a 97 profissionais de enfermagem, com uma taxa de resposta de 93,8%, correspondendo a 91 profissionais, sendo obtidas 267 recomendações, categorizadas conforme as dimensões do instrumento utilizado. Houve maior número de recomendações para as dimensões aprendizado organizacional e melhoria contínua, com sugestões envolvendo capacitação e treinamento; pessoal em relação ao quantitativo; e percepção geral de segurança do paciente, indicando melhoria dos procedimentos e processos e apoio da gestão hospitalar, com ênfase na melhoria dos recursos materiais e equipamentos. Destacadas por outros estudos, estas recomendações são essenciais para a promoção da segurança do paciente nas Unidades de Terapia Intensiva estudadas.
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Wang SC, Li YC, Huang HC. The effect of a workflow-based response system on hospital-wide voluntary incident reporting rates. Int J Qual Health Care 2012; 25:35-42. [DOI: 10.1093/intqhc/mzs078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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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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Rhodes A, Moreno RP, Azoulay E, Capuzzo M, Chiche JD, Eddleston J, Endacott R, Ferdinande P, Flaatten H, Guidet B, Kuhlen R, León-Gil C, Martin Delgado MC, Metnitz PG, Soares M, Sprung CL, Timsit JF, Valentin A. Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Med 2012; 38:598-605. [DOI: 10.1007/s00134-011-2462-3] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 12/28/2011] [Indexed: 10/14/2022]
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Chang IC, Hsu HM. Predicting Medical Staff Intention to Use an Online Reporting System with Modified Unified Theory of Acceptance and Use of Technology. Telemed J E Health 2012; 18:67-73. [DOI: 10.1089/tmj.2011.0048] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- I-Chiu Chang
- Department of Information Management, National Chung Cheng University, Chia-Yi, Taiwan
| | - Hui-Mei Hsu
- Department of Business Management, National Kaohsiung Normal University, Kaohsiung, Taiwan
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Abstract
Patient safety reporting systems (PSRSs) currently operate at local, regional, and national levels within health care. This article analyzes 6 different PSRSs using a World Health Organization and public health classification system. Patient safety incidents (PSIs) are reported, analyzed, mitigated, and evaluated in a variety of different ways. This results in a reduced ability to accurately compare PSIs between different PSRSs, to monitor trends in PSIs, or to reliably translate and learn from information between any individual PSRS. By applying principles from basic public health research and infectious disease surveillance systems, these hurdles may be overcome and the full potential of PSRSs could be realized.
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Affiliation(s)
- Lynn Marie Bullock
- The Center for Nursing Excellence, Greater Baltimore Medical Center, Baltimore, MD, USA
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Abstract
The success of incident reporting in improving safety, although obvious in aviation and other high-risk industries, is yet to be seen in health-care systems. An incident reporting system which would improve patient safety would allow front-end clinicians to have easy access for reporting an incident with an understanding that their report will be handled in a non-punitive manner, and that it will lead to enhanced learning regarding the causation of the incident and systemic changes which will prevent it from recurring. At present, significant problems remain with local and national incident reporting systems. These include fear of punitive action, poor safety culture in an organization, lack of understanding among clinicians about what should be reported, lack of awareness of how the reported incidents will be analysed, and how will the reports ultimately lead to changes which will improve patient safety. In particular, lack of systematic analysis of the reports and feedback directly to the clinicians are seen as major barriers to clinical engagement. In this review, robust systematic methodology of analysing incidents is discussed. This methodology is based on human factors model, and the learning paradigm which emphasizes significant shift from traditional judicial approach to understanding how 'latent errors' may play a role in a chain of events which can set up an 'active error' to occur. Feedback directly to the clinicians is extremely important for keeping them 'in the loop' for their continued engagement, and it should target different levels of analyses. In addition to high-level information on the types of incidents, the feedback should incorporate results of the analyses of active and latent factors. Finally, it should inform what actions, and at what level/stage, have been taken in response to the reported incidents. For this, local and national systems will be required to work in close cooperation, so that the lessons can be learnt and actions taken within an organization, and across organizations. In the UK, a recently introduced speciality-specific incident reporting system for anaesthesia aims to incorporate the elements of successful reporting system, as presented in this review, to achieve enhanced clinical engagement and improved patient safety.
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Affiliation(s)
- R P Mahajan
- Division of Anaesthesia and Intensive Care, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of Quality and Assurance of Safety in the Critically Ill. Clin Chest Med 2009; 30:169-79, x. [DOI: 10.1016/j.ccm.2008.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Richesson RL, Malloy JF, Paulus K, Cuthbertson D, Krischer JP. An automated standardized system for managing adverse events in clinical research networks. Drug Saf 2008; 31:807-22. [PMID: 18759506 DOI: 10.2165/00002018-200831100-00001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Multi-site clinical protocols and clinical research networks require tools to manage and monitor adverse events (AEs). To be successful, these tools must be designed to comply with applicable regulatory requirements, reflect current data standards, international directives and advances in pharmacovigilance, and be convenient and adaptable to multiple needs. We describe an Adverse Event Data Management System (AEDAMS) that is used across multiple study designs in the various clinical research networks and multi-site studies for which we provide data and technological support. Investigators enter AE data using a standardized and structured web-based data collection form. The automated AEDAMS forwards the AE information to individuals in designated roles (investigators, sponsors, Data Safety and Monitoring Boards) and manages subsequent communications in real time, as the entire reporting, review and notification is done by automatically generated emails. The system was designed to adhere to timelines and data requirements in compliance with Good Clinical Practice (International Conference on Harmonisation E6) reporting standards and US federal regulations, and can be configured to support AE management for many types of study designs and adhere to various domestic or international reporting requirements. This tool allows AEs to be collected in a standard way by multiple distributed users, facilitates accurate and timely AE reporting and reviews, and allows the centralized management of AEs. Our design justification and experience with the system are described.
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Affiliation(s)
- Rachel L Richesson
- University of South Florida College of Medicine, Tampa, Florida 33612, USA.
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Abstract
PURPOSE OF REVIEW Patient safety is attracting increasing attention. How we monitor and measure safety, however, is not well defined. In this review we describe a conceptual model for monitoring and measuring safety, describe the development of a safety scorecard, and provide an example of how this scorecard is used in the ICU. RECENT FINDINGS Our safety scorecard stratifies measures into two categories. One category uses valid rate-based measures to evaluate: How often do we provide the interventions that patients should receive? (process measure); and How often do we harm patients? (outcome measure). The second category includes measures that cannot be expressed as valid rates: How do we know we learned from defects? (structural measure); and How well have we created a culture of safety? (context measure). Measures within each domain should be important and valid, and organizations should be able to use the measures to improve patient safety. SUMMARY We present a framework for a patient safety scorecard to measure and monitor patient safety. This safety scorecard is a valid and practical tool for ICUs to track progress of efforts to improve patient safety and answer the question, how safe is my ICU?
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Taylor JA, Brownstein D, Klein EJ, Strandjord TP. Evaluation of an anonymous system to report medical errors in pediatric inpatients. J Hosp Med 2007; 2:226-33. [PMID: 17683099 DOI: 10.1002/jhm.208] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare reports of medical errors in hospitalized children submitted using an electronic, anonymous reporting system with those submitted via traditional incident reports. STUDY DESIGN During the 3-month study period in 2003, reports of medical errors from 2 units at a large children's hospital were made using an electronic, anonymous system. Three reviewers independently evaluated each report and determined whether the events described constituted a medical error. An identical procedure was used to categorize medical error data collected via incident reports from the 2 study units from 1999 to 2002. RESULTS A total of 146 reports were made using the anonymous system, 131 of which documented medical errors. The rate of reporting medical errors with the anonymous system was 2.41/100 patient-days. The rate of reporting medical errors via incident reports in 1999-2002 was 2.40/100 patient-days. However, 33.8% of all incident reports dealt with mislabeled laboratory specimens; after excluding these reports, the rate of medical errors documented via incident reports was 1.56/100 patient-days. The rate of reporting was significantly higher with the anonymous system (rate ratio 1.54, 95% confidence interval 1.26, 1.90). With the anonymous system, 25.2% of reported medical errors were near-misses compared with 12.6% of the errors reported with the incident report system (P = .001). CONCLUSIONS Implementation of the anonymous reporting system with training was associated with a statistically significant increase in the rate of reported medical errors. The reporting of near-miss events was significantly increased, suggesting this may be a useful format for gathering data on this type of medical error.
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Affiliation(s)
- James A Taylor
- Developmental Center for Evaluation and Research in Pediatric Patient Safety, Seattle, Washington, USA.
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Pietrobon R, Lima R, Shah A, Jacobs DO, Harker M, McCready M, Martins H, Richardson W. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2007; 1:5. [PMID: 17472749 PMCID: PMC1867823 DOI: 10.1186/1750-1164-1-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 05/01/2007] [Indexed: 12/20/2022]
Abstract
BACKGROUND Studies have shown that 4% of hospitalized patients suffer from an adverse event caused by the medical treatment administered. Some institutions have created systems to encourage medical workers to report these adverse events. However, these systems often prove to be inadequate and/or ineffective for reviewing the data collected and improving the outcomes in patient safety. OBJECTIVE To describe the Web-application Duke Surgery Patient Safety, designed for the anonymous reporting of adverse and near-miss events as well as scheduled reporting to surgeons and hospital administration. SOFTWARE ARCHITECTURE: DSPS was developed primarily using Java language running on a Tomcat server and with MySQL database as its backend. RESULTS Formal and field usability tests were used to aid in development of DSPS. Extensive experience with DSPS at our institution indicate that DSPS is easy to learn and use, has good speed, provides needed functionality, and is well received by both adverse-event reporters and administrators. DISCUSSION This is the first description of an open-source application for reporting patient safety, which allows the distribution of the application to other institutions in addition for its ability to adapt to the needs of different departments. DSPS provides a mechanism for anonymous reporting of adverse events and helps to administer Patient Safety initiatives. CONCLUSION The modifiable framework of DSPS allows adherence to evolving national data standards. The open-source design of DSPS permits surgical departments with existing reporting mechanisms to integrate them with DSPS. The DSPS application is distributed under the GNU General Public License.
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Affiliation(s)
- Ricardo Pietrobon
- Center for Excellence in Surgical Outcomes, Department of Surgery, Duke University Medical Center, DUMC 3094, Durham, NC 27710, USA
| | - Raquel Lima
- Center for Excellence in Surgical Outcomes, Department of Surgery, Duke University Medical Center, DUMC 3094, Durham, NC 27710, USA
| | - Anand Shah
- Center for Excellence in Surgical Outcomes, Department of Surgery, Duke University Medical Center, DUMC 3094, Durham, NC 27710, USA
| | - Danny O Jacobs
- Department of Surgery, Duke University Medical Center, DUMC 3704, Durham, NC 27710, USA
| | - Matthew Harker
- Department of Surgery, Duke University Medical Center, DUMC 3704, Durham, NC 27710, USA
| | - Mariana McCready
- Center for Excellence in Surgical Outcomes, Department of Surgery, Duke University Medical Center, DUMC 3094, Durham, NC 27710, USA
| | - Henrique Martins
- Center for Excellence in Surgical Outcomes, Department of Surgery, Duke University Medical Center, DUMC 3094, Durham, NC 27710, USA
| | - William Richardson
- Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, DUMC 3077, Durham, NC 27710, USA
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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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Antonelli M. Intensive Care Medicine and the "Cenacle principles". Intensive Care Med 2007; 33:567-9. [PMID: 17347826 DOI: 10.1007/s00134-007-0587-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Accepted: 02/19/2007] [Indexed: 11/29/2022]
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Kleinpell R, Thompson D, Kelso L, Pronovost PJ. Targeting errors in the ICU: use of a national database. Crit Care Nurs Clin North Am 2007; 18:509-14. [PMID: 17118305 DOI: 10.1016/j.ccell.2006.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors believe that as we move from viewing adverse event reporting system as punitive, and as the safety culture improves, reporting will likely increase. Voluntary incident reporting systems can be used to improve patient safety in the ICU by identifying broken or inadequate systems that lead to adverse events [26]. Voluntary external reporting systems such as the ICUSRS can be used to target errors and produce evidence-based best practice measures to improve patient safety in the ICU.
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Affiliation(s)
- Ruth Kleinpell
- Rush University College of Nursing, Chicago, IL 60612, USA.
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Sinopoli DJ, Needham DM, Thompson DA, Holzmueller CG, Dorman T, Lubomski LH, Wu AW, Morlock LL, Makary MA, Pronovost PJ. Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study. J Crit Care 2007; 22:177-83. [PMID: 17869966 DOI: 10.1016/j.jcrc.2006.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Revised: 10/18/2006] [Accepted: 11/20/2006] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study is to determine if patient safety incidents and the system-related factors contributing to them systematically differ for medical versus surgical patients in intensive care units. MATERIALS AND METHODS We conducted a multicenter prospective study of 646 incidents involving adult medical patients and 707 incidents involving adult surgical patients that were reported to an anonymous patient safety registry over a 2-year period. We compared incident characteristics, patient harm, and associated system factors for medical versus surgical patients. RESULTS The proportion of safety incidents reported for medical versus surgical patients differed for only 3 of 11 categories: equipment/devices (14% vs 19%; P = .02), "line, tube, or drain" events (8% vs 13%; P = .001), and computerized physician order entry (13% vs 6%; P < or = .001). The type of patient harm associated with incidents also did not differ. System factors were similar for medical versus surgical patients, with training and teamwork being the most important factors in both groups. CONCLUSIONS Medical and surgical patients in the intensive care unit experience very similar types of safety incidents with similar associated patient harm and system factors. Common initiatives to improve patient safety for medical and surgical patients should be undertaken with a specific focus on improving training and teamwork among the intensive care team.
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Affiliation(s)
- David J Sinopoli
- UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ 08854, USA
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Abstract
Health care interventions entail a risk of adverse events (AE), that may cause lesions, incapacities and even death in the patients. Given the complexity of the care of the critical patient, the Critical Care Services are a high risk setting for the appearance of AE in these patients, many of them avoidable. Several studies show the influence of organizational factors focused on the system in the reduction of care risk and on the result of the critical patients. The voluntary and anonymous registry and reporting systems make it possible to identify a significant percentage of these incidents, analyze the factors related (that contribute or limit), establish preventive strategies, permitting management of risk, and potentially reduce the appearance and consequences of avoidable AE with all this. Initiatives such as the ICU Safety Reporting System (ICUSRS), that use a web database as registry system and includes contributions from different sites, favor the safety and risk culture, essential in the improvement of health quality of critical patients.
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Affiliation(s)
- M C Martín
- Servicio de Medicina Intensiva, Centro Médico Delfos, Barcelona, España.
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Anderson JG, Ramanujam R, Hensel D, Anderson MM, Sirio CA. The need for organizational change in patient safety initiatives. Int J Med Inform 2006; 75:809-17. [PMID: 16870501 DOI: 10.1016/j.ijmedinf.2006.05.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 02/08/2006] [Accepted: 05/24/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study describes a computer simulation model that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system. METHODS Model parameters for the simulation model were estimated from data submitted to the MEDMARX medication error reporting system from 570 healthcare facilities in the U.S. The model's results were validated with data from the Pittsburgh Regional Healthcare Initiative consisting of 44 hospitals in Pennsylvania that have adopted the MEDMARX medication error reporting system. The model was used to examine the effects of organizational changes in response to the error reporting system. Four interventions were simulated involving the implementation of computerized physician order entry, decision support systems and a clinical pharmacist on hospital rounds. CONCLUSIONS Results of the analysis indicate that improved patient safety requires more than clinical initiatives and voluntary reporting of errors. Organizational change is essential for significant improvements in patient safety. In order to be successful, these initiatives must be designed and implemented through organizational support structures and institutionalized through enhanced education, training, and implementation of information technology that improves work flow capabilities.
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Affiliation(s)
- James G Anderson
- Department of Sociology & Anthropology, Purdue University, West Lafayette, IN 47907-2059, USA.
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Pronovost PJ, Martinez EA, Rodriguez-Paz JM. Removing “orange wires”: surfacing and hopefully learning from mistakes. Intensive Care Med 2006; 32:1467-9. [PMID: 16874491 DOI: 10.1007/s00134-006-0291-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Accepted: 06/20/2006] [Indexed: 10/24/2022]
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Pronovost P, Holzmueller CG, Needham DM, Sexton JB, Miller M, Berenholtz S, Wu AW, Perl TM, Davis R, Baker D, Winner L, Morlock L. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med 2006; 34:1988-95. [PMID: 16715029 DOI: 10.1097/01.ccm.0000226412.12612.b6] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our institution, like many, is struggling to develop measures that answer the question, How do we know we are safer? Our objectives are to present a framework to evaluate performance in patient safety and describe how we applied this model in intensive care units. DESIGN We focus on measures of safety rather than broader measures of quality. The measures will allow health care organizations to evaluate whether they are safer now than in the past by answering the following questions: How often do we harm patients? How often do patients receive the appropriate interventions? How do we know we learned from defects? How well have we created a culture of safety? The first two measures are rate based, whereas the latter two are qualitative. To improve care within institutions, caregivers must be engaged, must participate in the selection and development of measures, and must receive feedback regarding their performance. The following attributes should be considered when evaluating potential safety measures: Measures must be important to the organization, must be valid (represent what they intend to measure), must be reliable (produce similar results when used repeatedly), must be feasible (affordable to collect data), must be usable for the people expected to employ the data to improve safety, and must have universal applicability within the entire institution. SETTING Health care institutions. RESULTS Health care currently lacks a robust safety score card. We developed four aggregate measures of patient safety and present how we applied them to intensive care units in an academic medical center. The same measures are being applied to nearly 200 intensive care units as part of ongoing collaborative projects. The measures include how often do we harm patients, how often do we do what we should (i.e., use evidence-based medicine), how do we know we learned from mistakes, and how well do we improve culture. Measures collected by different departments can then be aggregated to provide a hospital level safety score card. CONCLUSION The science of measuring patient safety is immature. This article is a starting point for developing feasible and scientifically sound approaches to measure safety within an institution. Institutions will need to find a balance between measures that are scientifically sound, affordable, usable, and easily applied across the institution.
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Affiliation(s)
- Peter Pronovost
- The Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine, USA
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Abstract
In this third and last part in our series on applied medical informatics (AMI), we will examine the following: (1) a concise wrap-up of the practice steps necessary to achieve the benefits from AMI in your practice; (2) an introduction to the patient health-care record and why it is important to physicians; and (3) a look at some of the latest developments in AMI that are of interest to the chest physician.
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Affiliation(s)
- William F Bria
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, 1500 E Medical Center Dr, 3916 Taubman Center, Ann Arbor, MI 48109-0360, USA.
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Pronovost PJ, Holzmueller CG, Martinez E, Cafeo CL, Hunt D, Dickson C, Awad M, Makary MA. A Practical Tool to Learn From Defects in Patient Care. Jt Comm J Qual Patient Saf 2006; 32:102-8. [PMID: 16568924 DOI: 10.1016/s1553-7250(06)32014-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Thompson DA, Lubomski L, Holzmueller C, Wu A, Morlock L, Fahey M, Dickman F, Dorman T, Pronovost P. Integrating the Intensive Care Unit Safety Reporting System with Existing Incident Reporting Systems. Jt Comm J Qual Patient Saf 2005; 31:585-93. [PMID: 16294671 DOI: 10.1016/s1553-7250(05)31076-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Voluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety. FINDINGS A voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the exisiting systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter. RESULTS All seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems. CONCLUSION Voluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.
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Affiliation(s)
- David A Thompson
- Johns Hopkins University Schools of Medicine and Nursing, Baltimore, USA.
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Thompson D, Holzmueller C, Hunt D, Cafeo C, Sexton B, Pronovost P. A Morning Briefing: Setting the Stage for a Clinically and Operationally Good Day. Jt Comm J Qual Patient Saf 2005; 31:476-9. [PMID: 16156196 DOI: 10.1016/s1553-7250(05)31062-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This tool can be used in any setting where physicians, nurses, and other disciplines work as a team to manage patients and admission-to-discharge flow.
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Affiliation(s)
- David Thompson
- Johns Hopkins University School of Medicine, Baltimore, USA.
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