Adverse events and near miss reporting in the NHS

Risk Management and Patient Safety in the Artificial Intelligence Era: A Systematic Review

BACKGROUND

Healthcare systems represent complex organizations within which multiple factors (physical environment, human factor, technological devices, quality of care) interconnect to form a dense network whose imbalance is potentially able to compromise patient safety. In this scenario, the need for hospitals to expand reactive and proactive clinical risk management programs is easily understood, and artificial intelligence fits well in this context. This systematic review aims to investigate the state of the art regarding the impact of AI on clinical risk management processes. To simplify the analysis of the review outcomes and to motivate future standardized comparisons with any subsequent studies, the findings of the present review will be grouped according to the possibility of applying AI in the prevention of the different incident type groups as defined by the ICPS.

MATERIALS AND METHODS

On 3 November 2023, a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was carried out using the SCOPUS and Medline (via PubMed) databases. A total of 297 articles were identified. After the selection process, 36 articles were included in the present systematic review.

RESULTS AND DISCUSSION

The studies included in this review allowed for the identification of three main "incident type" domains: clinical process, healthcare-associated infection, and medication. Another relevant application of AI in clinical risk management concerns the topic of incident reporting.

CONCLUSIONS

This review highlighted that AI can be applied transversely in various clinical contexts to enhance patient safety and facilitate the identification of errors. It appears to be a promising tool to improve clinical risk management, although its use requires human supervision and cannot completely replace human skills. To facilitate the analysis of the present review outcome and to enable comparison with future systematic reviews, it was deemed useful to refer to a pre-existing taxonomy for the identification of adverse events. However, the results of the present study highlighted the usefulness of AI not only for risk prevention in clinical practice, but also in improving the use of an essential risk identification tool, which is incident reporting. For this reason, the taxonomy of the areas of application of AI to clinical risk processes should include an additional class relating to risk identification and analysis tools. For this purpose, it was considered convenient to use ICPS classification.

Information Technology and Value-Based Healthcare Systems: A Strategy and Framework

Value-based healthcare offers a pathway for enhancing patient satisfaction and population health and reducing healthcare costs. In addition, it provides a means to enhance physicians' perception and experience in healthcare delivery. The foundation of the said system is the notion that community wellness can only be benefited when the health effects of many people are also addressed. The provision of healthcare services incurs costs. However, a value-based model addresses this issue by establishing teams that cater to individuals with similar needs. This approach fosters expertise and efficiency, ultimately leading to cost savings without rationing. Furthermore, entrusting decision-making authority regarding healthcare delivery to the clinical team enhances doctors' professionalism and the integrity of clinician-patient interactions, resulting in more effective and relevant treatments. Currently, various information technology (IT)-based solutions are the main focus for accomplishing the desired value-based healthcare system. The establishment of a coordinated framework that can help organizations create value-based healthcare systems is covered in the current article. Additionally listed are many IT-based solutions used to create a value-based healthcare system.

Electronic unified therapy record as a clinical risk management tool in the Italian healthcare system

Digitization of health records is still struggling to take hold in the Italian healthcare context, where medical records are still largely kept manually on paper. Besides being anachronistic, this practice is particularly critical if applied to the drug chart. Poor handwriting and transcription errors can generate medication errors and thus represent a potential source of adverse events. In the present study, we attempt to test the hypothesis that the application of a computerized medical record model may represent a useful tool for managing clinical risk and medical expenditure. We shall do so through the analysis of the preliminary results of the application of such a model in two private hospitals in Northern Italy. The results, although preliminary, are encouraging. Among the benefits of digitizing drug records, we recorded a greater accuracy and adequacy of prescriptions, a reduction in the overall workload for nurses (no longer required to manually transcribe the list of drugs from one chart to another), as well as an optimization of the management of drug stocks by hospital pharmacies. The results in terms of clinical risk reduction will be monitored through a prospective cohort study that will take place in the coming months.

Patient safety management systems and activities related to promoting voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues: A cross-sectional study

Both voluntary in-hospital reporting and mandatory national-level reporting systems for patient safety issues need to work well to develop a patient safety learning system that is effective in preventing the recurrence of adverse events. Some of the hospital systems and activities may increase voluntary in-hospital reporting and mandatory national-level reporting. This study aimed to identify the hospital systems and activities that increase voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues. An anonymous mail survey of hospitals in Japan was conducted in 2017. The hospitals were selected by stratified random sampling according to number of beds. The survey examined the annual number of reported events in the voluntary in-hospital reporting system for patient safety and experience of reporting unexpected patient deaths possibly due to medical interventions to the mandatory national-level reporting system in the last 2 years. The relationship of the answer to the questions with the patient safety management systems and activities at each hospital was analyzed. The response rate was 18.8% (603/3,215). The number of in-hospital reports per bed was positively related to identifying events by referring complaints or questions of patients or family members, using root cause analysis for analyzing reported events, and developing manuals or case studies based on reported events, and negatively related to the unification and standardization of medical devices and equipment. The experience with mandatory national-level reporting of serious adverse events was positively related to identifying problematic cases by a person in charge of patient safety management from the in-hospital reporting system of complications and accidental symptoms. Enhanced feedback for reporters may promote voluntary in-hospital reporting of minor cases with low litigation risks. Developing an in-hospital mechanism that examines all serious complications and accidental symptoms may promote mandatory national-level reporting of serious adverse events with high litigation risks.

Identification of Inpatient Falls Using Automated Review of Text-Based Medical Records

OBJECTIVES

Although falls are among the most common adverse event in hospitals, they are difficult to measure and often unreported. Mechanisms to track falls include incident reporting and medical records review. Because of limitations of each method, researchers suggest multimodal approaches. Although incident reporting is commonly used, medical records review is limited by the need to read a high volume of clinical notes. Natural language processing (NLP) is 1 potential mechanism to automate this process.

METHOD

We compared automated NLP to manual chart review and incident reporting as a method to detect falls among inpatients. First, we developed an NLP algorithm to identify inpatient progress notes describing falls. Second, we compared the NLP algorithm to manual records review in identifying inpatient progress notes that describe falls. Third, we compared the NLP algorithm to the incident reporting system in identifying falls.

RESULTS

When examining individual inpatient notes, our NLP algorithm was highly specific (0.97) but had low sensitivity (0.44) when compared with our manual records review. However, when considering groups of inpatient notes, all describing the same fall, our NLP algorithm had a large improvement in sensitivity (0.80) with some loss of specificity (0.65) compared with incident reporting.

CONCLUSIONS

National language processing represents a promising method to automate review of inpatient medical records to identify falls.

Measurement and monitoring patient safety in prehospital care: a systematic review

BACKGROUND

Prehospital care is potentially hazardous with the possibility for patients to experience an adverse event. However, as compared to secondary care, little is known about how patient safety is managed in prehospital care settings.

OBJECTIVES

The objectives of this systematic review were to identify and classify the methods of measuring and monitoring patient safety that have been used in prehospital care using the five dimensions of the Measuring and Monitoring Safety (MMS) framework and use this classification to identify where there are safety 'blind spots' and make recommendations for how these deficits could be addressed.

METHODS

Searches were conducted in January 2020, with no limit on publication year, using Medline, PsycInfo, CINAHL, Web of Science and Academic Search. Reference lists of included studies and existing related reviews were also screened. English-language, peer-reviewed studies concerned with measuring and monitoring safety in prehospital care were included. Two researchers independently extracted data from studies and applied a quality appraisal tool (the Quality Assessment Tool for Studies with Diverse Designs).

RESULTS

A total of 5301 studies were screened, with 52 included in the review. A total of 73% (38/52) of the studies assessed past harm, 25% (13/52) the reliability of safety critical processes, 1.9% (1/52) sensitivity to operations, 38.5% (20/52) anticipation and preparedness and 5.8% (3/52) integration and learning. A total of 67 methods for measuring and monitoring safety were used across the included studies. Of these methods, 38.8% (26/67) were surveys, 29.9% (20/67) were patient records reviews, 14.9% (10/67) were incident reporting systems, 11.9% (8/67) were interviews or focus groups and 4.5% (3/67) were checklists.

CONCLUSIONS

There is no single method of measuring and monitoring safety in prehospital care. Arguably, most safety monitoring systems have evolved, rather than been designed. This leads to safety blind spots in which information is lacking, as well as to redundancy and duplication of effort. It is suggested that the findings from this systematic review, informed by the MMS framework, can provide a structure for critically thinking about how safety is being measured and monitored in prehospital care. This will support the design of a safety surveillance system that provides a comprehensive understanding of what is being done well, where improvements should be made and whether safety interventions have had the desired effect.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Using knowledge discovery through data mining to gain intelligence from routinely collected incident reporting in an acute English hospital

PURPOSE

Incident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study explores if intelligence from such datasets could be used to improve quality, efficiency, and safety.

DESIGN/METHODOLOGY/APPROACH

Incident reporting data recorded in one NHS acute Trust was mined for insight (n = 133,893 April 2005-July 2016 across 201 fields, 26,912,493 items). An a priori dataset was overlaid consisting of staffing, vital signs, and national safety indicators such as falls. Analysis was primarily nonlinear statistical approaches using Mathematica V11.

FINDINGS

The organization developed a deeper understanding of the use of incident reporting systems both in terms of usability and possible reflection of culture. Signals emerged which focused areas of improvement or risk. An example of this is a deeper understanding of the timing and staffing levels associated with falls. Insight into the nature and grading of reporting was also gained.

PRACTICAL IMPLICATIONS

Healthcare incident reporting data is underused and with a small amount of analysis can provide real insight and application to patient safety.

ORIGINALITY/VALUE

This study shows that insight can be gained by mining incident reporting datasets, particularly when integrated with other routinely collected data.

Identification of important factors in an inpatient fall risk prediction model to improve the quality of care using EHR and electronic administrative data: A machine-learning approach

BACKGROUND

Inpatient falls, many resulting in injury or death, are a serious problem in hospital settings. Existing falls risk assessment tools, such as the Morse Fall Scale, give a risk score based on a set of factors, but don't necessarily signal which factors are most important for predicting falls. Artificial intelligence (AI) methods provide an opportunity to improve predictive performance while also identifying the most important risk factors associated with hospital-acquired falls. We can glean insight into these risk factors by applying classification tree, bagging, random forest, and adaptive boosting methods applied to Electronic Health Record (EHR) data.

OBJECTIVE

The purpose of this study was to use tree-based machine learning methods to determine the most important predictors of inpatient falls, while also validating each via cross-validation.

MATERIALS AND METHODS

A case-control study was designed using EHR and electronic administrative data collected between January 1, 2013 to October 31, 2013 in 14 medical surgical units. The data contained 38 predictor variables which comprised of patient characteristics, admission information, assessment information, clinical data, and organizational characteristics. Classification tree, bagging, random forest, and adaptive boosting methods were used to identify the most important factors of inpatient fall-risk through variable importance measures. Sensitivity, specificity, and area under the ROC curve were computed via ten-fold cross validation and compared via pairwise t-tests. These methods were also compared to a univariate logistic regression of the Morse Fall Scale total score.

RESULTS

In terms of AUROC, bagging (0.89), random forest (0.90), and boosting (0.89) all outperformed the Morse Fall Scale (0.86) and the classification tree (0.85), but no differences were measured between bagging, random forest, and adaptive boosting, at a p-value of 0.05. History of Falls, Age, Morse Fall Scale total score, quality of gait, unit type, mental status, and number of high fall risk increasing drugs (FRIDs) were considered the most important features for predicting inpatient fall risk.

CONCLUSIONS

Machine learning methods have the potential to identify the most relevant and novel factors for the detection of hospitalized patients at risk of falling, which would improve the quality of patient care, and to more fully support healthcare provider and organizational leadership decision-making. Nurses would be able to enhance their judgement to caring for patients at risk for falls. Our study may also serve as a reference for the development of AI-based prediction models of other iatrogenic conditions. To our knowledge, this is the first study to report the importance of patient, clinical, and organizational features based on the use of AI approaches.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

In-Hospital Patient Safety Events, Healthcare Costs and Utilization: An Analysis from the Incident Reporting System in an Academic Medical Center

The possible association of patient safety events (PSEs) with the costs and utilization remains a concern. In this retrospective analysis, we investigated adult hospitalizations at a medical center between 2010 and 2015 with or without reported PSEs. Administrative and claims data were analyzed to compare the costs and length of stay (LOS) between cases with and without PSEs of the three most common categories during the first 14 days of hospitalization. Two models, including linear regression and propensity score-matched comparison, were performed for each reference day group of hospitalizations. Of 14,181 PSEs from 424,635 hospitalizations, 69.8% were near miss or no-harm events. Costs and LOS were similar between fall cases and controls in all of the 14 reference days. In contrast, for cases of tube and line events and controls, there were consistent differences in costs and LOS in the majority of the reference days (86% and 57%, respectively). Consistent differences were less frequently seen for medication events and control events (36% and 43%, respectively). Our study approach of comparing cases with PSEs and those without any PSE showed significant differences in costs and LOS for tube and line events, and medication events. No difference in cost or LOS was found regarding fall events. Further studies exploring adjustments for event risks and harm-oriented analysis are warranted.

Characteristics of recovery from near misses in primary health care nursing: A Prospective descriptive study

AIM

To describe the frequency and types of near misses and the recovery strategies employed by nurses in primary health care.

BACKGROUND

Insufficient data are available on the role of nurses in near miss events and related factors in primary health care.

METHOD

A prospective descriptive study was carried out at one Urban Primary Health Care Centre, within the Málaga-Guadalhorce Health District (Malaga, Spain), from January to December 2018. Four of the ten nurses volunteered to take part.

RESULTS

The nurses recovered 185 near misses, prevailing administrative or communication-related errors, followed by medication-related errors. No near misses were reported on the centre's anonymous error information platform.

CONCLUSIONS

A significant number of near misses occurred which could have been avoided with better communication among health care personnel. A striking finding is the failure to inform the health centre, which suggests that improvements in safety culture are needed.

IMPLICATIONS FOR NURSING MANAGEMENT

It is the responsibility and the duty of nursing management to be aware of the characteristics and frequency of near misses in primary health care, to implement strategies for improvement and to foster a culture in which the necessary information on actual or potential errors is supplied.

Senior nurses' perceptions of junior nurses' incident reporting: A qualitative study

AIM

To develop an understanding of senior nurses' ranking and perceptions of incident reporting by junior nurses.

BACKGROUND

Nurses must be encouraged to report incidents to nursing management. It is important to ascertain how senior nurses perceive their concerns, as it is crucial to ensuring that patient safety is managed.

METHOD

Qualitative study. Four focus groups explored senior nurses' perceptions of risks identified by nurses from a live incident reporting database. Data were analysed using framework analysis.

RESULTS

Five themes emerged demonstrating the differences in opinions in relation to the classification of events by senior and non-senior nurses. Senior nurses held the view that some junior nurses use incident reporting to 'vent frustration.'

CONCLUSION

There is a mismatch between senior nurses' and junior nurses' perceptions of safety incidents. Nurses need to develop the writing style and use language that red flags incidents when reporting incidents. Senior nurses need to create a positive culture where risk from incident reporting is used to improve patient safety and subsequently a positive work environment. Implications for Nursing Management Our research identified the need for joint training to promote a shared understanding among nurses as to how incident report should be completed to promote patient safety.

Registered nurses' experiences of near misses in ambulance care - A critical incident technique study

BACKGROUND

In hospitals, potentially harmful near misses occur daily exposing patients to adverse events and safety risks. The same applies to ambulance care, but it is unclear what the risks are and why near misses arise.

AIM

To explore registered nurses' experiences and behaviours associated with near misses where patient safety in the ambulance service was jeopardized.

METHODS

Based on critical incident technique, a retrospective and descriptive design with individual qualitative interviews was used. Ten men and five women from the Swedish ambulance service participated.

RESULTS

Seventy-three critical incidents of near misses constituted four main areas: Drug management; Human-technology interactions; Assessment and care and Patient protection actions. Incidents were found in drug management with incorrect drug mixing and dosage. In human-technology interactions, near misses were found in handling of electrocardiography, mechanical chest compression devices and other equipment. Misjudgement and delayed treatment were found in patient assessments and care measures while patient protection actions failed in transport safety, hygiene and local area knowledge.

CONCLUSIONS

Experiencing near misses led to stress, guilt and shame. The typical behaviour in response to near misses was to immediately correct the action. Occasionally, however, the near miss was not discovered until later without causing any harm.

A systematic review of falls in hospital for patients with communication disability: Highlighting an invisible population

BACKGROUND

Patients with communication disability, associated with impairments of speech, language, or voice, have a three-fold increased risk of adverse events in hospital. However, little research yet examines the causal relationship between communication disability and risk for specific adverse events in hospital.

OBJECTIVE

To examine the impact of a patient's communication disability on their falls risk in hospital.

METHODS

This systematic review examined 61 studies on falls of adult hospital patients with communication disability, and patients at high risk of communication disability, to determine whether or not communication disability increased risk for falls, and the nature of and reasons for any increased risk.

RESULTS

In total, 46 of the included studies (75%) reported on participants with communication disability, and the remainder included patients with health conditions placing them at high risk for communication disability. Two thirds of the studies examining falls risk identified communication disability as contributing to falls. Commonly, patients with communication disability were actively excluded from participation; measures of communication or cognition were not reported; and reasons for any increased risk of falls were not discussed.

CONCLUSIONS

There is some evidence that communication disability is associated with increased risk of falls. However, the role of communication disability in falls is under-researched, and reasons for the increased risk remain unclear. Practical applications: Including patients with communication disability in falls research is necessary to determine reasons for their increased risk of adverse events in hospital. Their inclusion might be helped by the involvement of speech-language pathologists in falls research teams.

A prototype of knowledge-based patient safety event reporting and learning system

Background

Patient falls, the most common safety events resulting in adverse patient outcomes, impose significant costs and have become a great burden to the healthcare community. Current patient fall reporting systems remain in the early stage that is far away from reaching the ultimate goal toward a safer healthcare. According to the Kirkpatrick model, the key challenge in reaction, learning, behavior and results is the realization of learning stage due to the lack of knowledge management, sharing and growing mechanism.

Methods

Based on the key contributing factors defined by AHRQ Common Formats 2.0, a hierarchical list of contributing factors for patient falls was established by expert review and discussion. Using the list as an infrastructure, we designed and developed a novel reporting system, where a strategy to identify contributing factors is intended to provide reporters knowledge support, in the form of similar cases and potential solutions. A survey containing two scenarios was conducted to evaluate the learning effect of our system.

Results

In both scenarios, potential solutions recommended by the system were annotated with correct contributing factors, and presented only when the corresponding factors were identified from the query report or selected by the user. The five experts show substantial consistency (Fleiss’ kappa > 0.6) and high agreement (ranging between fully agree and mostly agree) in the assessment of the three perspectives of the system, which verifies the effectiveness of the proposed knowledge support toward sharing and learning through the novel reporting system.

Conclusions

This study proposed a profile of contributing factors that could measure the similarity of patient safety events. Based on the profile, a knowledge-based reporting and learning system was developed to bridge the gap between surveillance, reporting, and retrospective analysis in the fall management circle. The system holds promise in improving event reporting toward better and safer healthcare.

Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety

Policy Points: Health care complaints contain valuable data on quality and safety; however, there is no reliable method of analysis to unlock their potential. We demonstrate a method to analyze health care complaints that provides reliable insights on hot spots (where harm and near misses occur) and blind spots (before admissions, after discharge, systemic and low-level problems, and errors of omission). Systematic analysis of health care complaints can improve quality and safety by providing patient-centered insights that localize issues and shed light on difficult-to-monitor problems.

CONTEXT

The use of health care complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, which we developed, was used to analyze a benchmark national data set, conceptualize a systematic analysis, and identify the added value of complaint data.

METHODS

We analyzed 1,110 health care complaints from across England. "Hot spots" were identified by mapping reported harm and near misses onto stages of care and underlying problems. "Blind spots" concerning difficult-to-monitor aspects of care were analyzed by examining access and discharge problems, systemic problems, and errors of omission.

FINDINGS

The tool showed moderate to excellent reliability. There were 1.87 problems per complaint (32% clinical, 32% relationships, and 34% management). Twenty-three percent of problems entailed major or catastrophic harm, with significant regional variation (17%-31%). Hot spots of serious harm were safety problems during examination, quality problems on the ward, and institutional problems during admission and discharge. Near misses occurred at all stages of care, with patients and family members often being involved in error detection and recovery. Complaints shed light on 3 blind spots: (1) problems arising when entering and exiting the health care system; (2) systemic failures pertaining to multiple distributed and often low-level problems; and (3) errors of omission, especially failure to acknowledge and listen to patients raising concerns.

CONCLUSIONS

The analysis of health care complaints reveals valuable and uniquely patient-centered insights on quality and safety. Hot spots of harm and near misses provide an alternative data source on adverse events and critical incidents. Analysis of entry-exit, systemic, and omission problems provides insight on blind spots that may otherwise be difficult to monitor. Benchmark data and analysis scripts are downloadable as supplementary files.

Initializing and Growing a Database of Health Information Technology (HIT) Events by Using TF-IDF and Biterm Topic Modeling

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.

Violence against emergency medical services personnel: A systematic review of the literature

BACKGROUND

Violence against emergency medical services (EMS) personnel is a growing concern. The aim of this systematic review is to synthesize the current literature on violence against EMS personnel.

METHODS

We examined literature from 2000 to 2016. Eligibility criteria included English-language, peer-reviewed studies of EMS personnel that described violence or assaults. Sixteen searches identified 2655 studies; 25 studies from nine countries met the inclusion criteria.

RESULTS

The evidence from this review demonstrates that violence is a common risk for EMS personnel. We identified three critical topic areas: changes in risk over time, economic impact of violence and, outcomes of risk-reduction interventions. There is a lack of peer reviewed research of interventions, with the result that current intervention programs have no reliable evidence base.

CONCLUSIONS

EMS leaders and personnel should work together with researchers to design, implement, evaluate and publish intervention studies designed to mitigate risks of violence to EMS personnel.

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system

BACKGROUND

Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited.

OBJECTIVE

To perform a retrospective analysis of IHT-related events, human failures and unsafe acts.

SETTING

A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan.

PARTICIPANTS

All eligible IHT-related patient safety events between January 2010 to December 2015 were included.

MAIN OUTCOME MEASURES

Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts.

RESULTS

There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm.

CONCLUSIONS

This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted.

Patient safety and quality of care in mental health: a world of its own?

Quality and safety in healthcare, as an academic discipline, has made significant progress over recent decades, and there is now an active and established community of researchers and practitioners. However, work has predominantly focused on physical health, despite broader controversy regarding the attention paid to, and significance attributed to, mental health. Work from both communities is required in order to ensure that quality and safety is actively embedded within mental health research and practice and that the academic discipline of quality and safety accurately represents the scientific knowledge that has been accumulated within the mental health community.

Enhancing Patient Safety Event Reporting. A Systematic Review of System Design Features

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.

Using Contribution Analysis to Evaluate Competency-Based Medical Education Programs: It's All About Rigor in Thinking

Competency-based medical education (CBME) aims to bring about the sequential acquisition of competencies required for practice. Although it is being adopted in centers of medical education around the globe, there is little evidence concerning whether, in comparison with traditional methods, CBME produces physicians who are better prepared for the practice environment and contributes to improved patient outcomes. Consequently, the authors, an international group of collaborators, wrote this article to provide guidance regarding the evaluation of CBME programs.CBME is a complex service intervention consisting of multiple activities that contribute to the achievement of a variety of outcomes over time. For this reason, it is difficult to apply traditional methods of program evaluation, which require conditions of control and predictability, to CBME. To address this challenge, the authors describe an approach that makes explicit the multiple potential linkages between program activities and outcomes. Referred to as contribution analysis (CA), this theory-based approach to program evaluation provides a systematic way to make credible causal claims under conditions of complexity. Although CA has yet to be applied to medical education, the authors describe how a six-step model and a postulated theory of change could be used to examine the link between CBME, physicians' preparation for practice, and patient care outcomes.The authors argue that adopting the methods of CA, particularly the rigor in thinking required to link program activities, outcomes, and theory, will serve to strengthen understanding of the impact of CBME over time.

Embedding learning from adverse incidents: a UK case study

Purpose This paper reports on a regionally based UK study uncovering what has worked well in learning from adverse incidents in hospitals. The purpose of this paper is to review the incident investigation methodology used in identifying strengths or weaknesses and explore the use of a database as a tool to embed learning. Design/methodology/approach Documentary examination was conducted of all adverse incidents reported between 1 June 2011 and 30 June 2012 by three UK National Health Service hospitals. One root cause analysis report per adverse incident for each individual hospital was sent to an advisory group for a review. Using terms of reference supplied, the advisory group feedback was analysed using an inductive thematic approach. The emergent themes led to the generation of questions which informed seven in-depth semi-structured interviews. Findings "Time" and "work pressures" were identified as barriers to using adverse incident investigations as tools for quality enhancement. Methodologically, a weakness in approach was that no criteria influenced the techniques which were used in investigating adverse incidents. Regarding the sharing of learning, the use of a database as a tool to embed learning across the region was not supported. Practical implications Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum. Originality/value The use of a database as a tool to facilitate the sharing of learning from adverse incidents across the health economy is not supported.

Patient safety incidents are common in primary care: A national prospective active incident reporting survey

BACKGROUND

The study objectives were to describe the incidence and the nature of patient safety incidents (PSIs) in primary care general practice settings, and to explore the association between these incidents and practice or organizational characteristics.

METHODS

GPs, randomly selected from a national influenza surveillance network (n = 800) across France, prospectively reported any incidents observed each day over a one-week period between May and July 2013. An incident was an event or circumstance that could have resulted, or did result, in harm to a patient, which the GP would not wish to recur. Primary outcome was the incidence of PSIs which was determined by counting reports per total number of patient encounters. Reports were categorized using existing taxonomies. The association with practice and organizational characteristics was calculated using a negative binomial regression model.

RESULTS

127 GPs (participation rate 79%) reported 317 incidents of which 270 were deemed to be a posteriori judged preventable, among 12,348 encounters. 77% had no consequences for the patient. The incidence of reported PSIs was 26 per 1000 patient encounters per week (95% CI [23‰ -28‰]). Incidents were three times more frequently related to the organization of healthcare than to knowledge and skills of health professionals, and especially to the workflow in the GPs' offices and to the communication between providers and with patients. Among GP characteristics, three were related with an increased incidence in the final multivariable model: length of consultation higher than 15 minutes, method of receiving radiological results (by fax compared to paper or email), and being in a multidisciplinary clinic compared with sole practitioners.

CONCLUSIONS

Patient safety incidents (PSIs) occurred in mean once every two days in the sampled GPs and 2% of them were associated with a definite possibility for harm. Studying the association between organizational features of general practices and PSIs remains a major challenge and one of the most important issues for safety in primary care.

A Novel Schema to Enhance Data Quality of Patient Safety Event Reports

The most important knowledge in the field of patient safety is regarding the prevention and reduction of patient safety events (PSEs). It is believed that PSE reporting systems could be a good resource to share and to learn from previous cases. However, the success of such systems in healthcare is yet to be seen. One reason is that the qualities of most PSE reports are unsatisfactory due to the lack of knowledge output from reporting systems which makes reporters report halfheartedly. In this study, we designed a PSE similarity searching model based on semantic similarity measures, and proposed a novel schema of PSE reporting system which can effectively learn from previous experiences and timely inform the subsequent actions. This system will not only help promote the report qualities but also serve as a knowledge base and education tool to guide healthcare providers in terms of preventing the recurrence of PSEs.

Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center

OBJECTIVE

There have been concerns about the workplace interpersonal conflict (WIC) among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS) widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs.

METHODS

We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship) and the three properties (disagreement, interference, and negative emotion), and analyzed relevant data.

RESULTS

Of the 147 incidents with WIC, the most common related processes were patient transfer (20%), laboratory tests (17%), surgery (16%) and medical imaging (16%). All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9%) also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57%) were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%), and the majority (67%) of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064). The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1%) than not on it (17.0%). The distributions of worker job types were similar between those with and without negative emotion (p = 0.125).

CONCLUSIONS

The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.

Critical incidents in a French department of paediatric anaesthesia

BACKGROUND

Several studies have highlighted the importance of critical incident (CI) reporting in order to enhance patient safety. We have implemented an anonymous procedure for CI reporting in our department of paediatric anaesthesia. This study aims at analysing those CIs so as to improve patient care and risk management.

MATERIAL AND METHODS

CIs were reported by the anaesthetic team using the World Health Organization classification and analysed using the ORION methodology. CIs were classified according to type, surgery and complications. Risk factors and consequences for patients and for the institution were analysed. Risk factors with high degree of harm for the patient were identified using a univariate analysis and odds ratios (OR).

RESULTS

Over an 18-month period, 114 CIs were reported for 103 patients (median age: 7.0 years [95% CI: 3.6-9.8]). We found that 29.9% of reported CIs had consequences for the patients and 76.3% were considered preventable. The two main types of CI were "respiratory" (28.8%) and "drug-related" (22.8%) incidents. The main risk factor was 'human error' (42.3%). Several consequences for the patient and the hospital were identified. An ASA score≥3 (OR: 2.52; [95% CI: 1.10-5.78]) was an independent risk factor for a high degree of patient harm.

CONCLUSION

Improving quality of care must be a priority for paediatric anaesthesiologists as most of the CIs observed are preventable and have consequences for the patient and the institution.

Advancing Competency-Based Medical Education: A Charter for Clinician-Educators

The International Competency-Based Medical Education (ICBME) Collaborators have been working since 2009 to promote understanding of competency-based medical education (CBME) and accelerate its uptake worldwide. This article presents a charter, supported by a literature-based rationale, which is meant to provide a shared mental model of CBME that will serve as a path forward in its widespread implementation.At a 2013 summit, the ICBME Collaborators laid the groundwork for this charter. Here, the fundamental principles of CBME and professional responsibilities of medical educators in its implementation process are described. The authors outline three fundamental principles: (1) Medical education must be based on the health needs of the populations served; (2) the primary focus of education and training should be the desired outcomes for learners rather than the structure and process of the educational system; and (3) the formation of a physician should be seamless across the continuum of education, training, and practice.Building on these principles, medical educators must demonstrate commitment to teaching, assessing, and role modeling the range of identified competencies. In the clinical setting, they must provide supervision that balances patient safety with the professional development of learners, being transparent with stakeholders about level of supervision needed. They must use effective and efficient assessment strategies and tools for basing transition decisions on competence rather than time in training, empowering learners to be active participants in their learning and assessment. Finally, advancing CBME requires program evaluation and research, faculty development, and a collaborative approach to realize its full potential.

The extra resource burden of in-hospital falls: a cost of falls study

OBJECTIVE

To quantify the additional hospital length of stay (LOS) and costs associated with in-hospital falls and fall injuries in acute hospitals in Australia.

DESIGN, SETTING AND PARTICIPANTS

A multisite prospective cohort study conducted during 2011-2013 in the control wards of a falls prevention trial (6-PACK). The trial included all admissions to 12 acute medical and surgical wards of six Australian hospitals. In-hospital falls data were collected from medical record reviews, daily verbal reports by ward nurse unit managers, and hospital incident reporting and administrative databases. Clinical costing data were linked for three of the six participating hospitals to calculate patient-level costs.

OUTCOME MEASURES

Hospital LOS and costs associated with in-hospital falls and fall injuries for each patient admission.

RESULTS

We found that 966 of a total of 27 026 hospital admissions (3.6%) involved at least one fall, and 313 (1.2%) at least one fall injury, a total of 1330 falls and 418 fall injuries. After adjustment for age, sex, cognitive impairment, admission type, comorbidity and clustering by hospital, patients who had an in-hospital fall had a mean increase in LOS of 8 days (95% CI, 5.8-10.4; P < 0.001) compared with non-fallers, and incurred mean additional hospital costs of $6669 (95% CI, $3888-$9450; P < 0.001). Patients with a fall-related injury had a mean increase in LOS of 4 days (95% CI, 1.8-6.6; P = 0.001) compared with those who fell without injury, and there was also a tendency to additional hospital costs (mean, $4727; 95% CI, -$568 to $10 022; P = 0.080).

CONCLUSION

Patients who experience an in-hospital fall have significantly longer hospital stays and higher costs. Programs need to target the prevention of all falls, not just the reduction of fall-related injuries.

Feasibility of a stepped wedge cluster RCT and concurrent observational sub-study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: a protocol for a pilot trial

Background

Falls among hospitalised patients impose a considerable burden on health systems globally and prevention is a priority. Some patient-level interventions have been effective in reducing falls, but others have not. An alternative and promising approach to reducing inpatient falls is through the modification of the hospital physical environment and the night lighting of hospital wards is a leading candidate for investigation. In this pilot trial, we will determine the feasibility of conducting a main trial to evaluate the effects of modified night lighting on inpatient ward level fall rates. We will test also the feasibility of collecting novel forms of patient level data through a concurrent observational sub-study.

Methods/design

A stepped wedge, cluster randomised controlled trial will be conducted in six inpatient wards over 14 months in a metropolitan teaching hospital in Brisbane (Australia). The intervention will consist of supplementary night lighting installed across all patient rooms within study wards. The planned placement of luminaires, configurations and spectral characteristics are based on prior published research and pre-trial testing and modification. We will collect data on rates of falls on study wards (falls per 1000 patient days), the proportion of patients who fall once or more, and average length of stay. We will recruit two patients per ward per month to a concurrent observational sub-study aimed at understanding potential impacts on a range of patient sleep and mobility behaviour. The effect on the environment will be monitored with sensors to detect variation in light levels and night-time room activity. We will also collect data on possible patient-level confounders including demographics, pre-admission sleep quality, reported vision, hearing impairment and functional status.

Discussion

This pragmatic pilot trial will assess the feasibility of conducting a main trial to investigate the effects of modified night lighting on inpatient fall rates using several new methods previously untested in the context of environmental modifications and patient safety. Pilot data collected through both parts of the trial will be utilised to inform sample size calculations, trial design and final data collection methods for a subsequent main trial.

Trial registration

Australian New Zealand Clinical Trials Register (ANZCTR): ACTRN12614000615684 (cluster RCT) and ACTRN12614000616673 (observational sub-study).

Date Registered: 10 June 2014 (both studies).

Protocol version: 1.2 (Dated: 01 June 2014)

Anticipated completion: September 2015

Role of Trial Sponsor: The named sponsor for this investigator-initiated trial was the Director of the Royal Brisbane and Women’s Hospital (RBWH) Safety and Quality Unit (Therese Lee, Phone: +61 7 3646 8111). The principal investigators, SC and MA, are employed by the RBWH Safety and Quality Unit. The trial sponsor has no involvement in any aspects of study design, conduct or decision to submit the report for publication. AM and MD are employed by other departments in the same organisation.

Additional Medical Costs Due to Hospital-Acquired Falls

OBJECTIVES

To explore the additional medical costs (AMCs) due to hospital-acquired falls (falls), as well as their impact on clinical services within hospitals under the nationally uniform universal health insurance system in Japan.

METHODS

With the use of administrative profiling data based on accounting systems linked with the Japanese social insurance medical fee schedule, we analyzed data from 2 teaching hospitals: Shimane University Hospital (SUH) and St. Mary's Hospital (SMH). We extracted 588 fall cases from 4669 incident reports in SUH and 1168 fall cases from 7717 incident reports in SMH that potentially incurred AMCs.

RESULTS

Additional medical costs were 364 ± 2129 USD for minor injuries and 4336 ± 3645 USD for major injuries at SUH (P < 0.001) and 114 ± 124 USD for minor injuries and 2267 ± 2811 USD for major injuries at SMH (P < 0.001). Among the clinical services provided, imaging services were the most frequently used, with 89.9% (n = 205) of 228 minor injuries at SUH and 86.7% (n = 339) of 391 minor injuries at SMH; imaging services were used in all major injury cases at both hospitals. Although the number of cases using additional procedure/surgery services was lower than those using imaging services at both hospitals, AMCs for procedure/surgery services accounted for the highest proportions of total AMCs in both hospitals.

CONCLUSIONS

Although falls with minor injuries outnumbered falls with major injuries, fall-related AMCs for the latter were higher at both teaching hospitals because procedure/surgery services were required for cases with major injuries such as femoral neck and trochanteric fractures. The findings suggest that hospital administrators and policy makers have to take appropriate measures to prevent major injuries inpatients due to hospital-acquired falls.

The role of the emergency medical dispatch centre (EMDC) and prehospital emergency care safety: results from an incident report (IR) system

Introduction

The role of the emergency medical dispatch centre (EMDC) is essential to ensure coordinated and safe prehospital care. The aim of this study was to implement an incident report (IR) system in prehospital emergency care management with a view to detecting errors occurring in this setting and guiding the implementation of safety improvement initiatives.

Methods

An ad hoc IR form for the prehospital setting was developed and implemented within the EMDC of Verona. The form included six phases (from the emergency call to hospital admission) with the relevant list of potential error modes (30 items). This descriptive observational study considered the results from 268 consecutive days between February and November 2010.

Results

During the study period, 161 error modes were detected. The majority of these errors occurred in the resource allocation and timing phase (34.2%) and in the dispatch phase (31.0%). Most of the errors were due to human factors (77.6%), and almost half of them were classified as either moderate (27.9%) or severe (19.9%). These results guided the implementation of specific corrective actions, such as the adoption of a more efficient Medical Priority Dispatch System and the development of educational initiatives targeted at both EMDC staff and the population.

Conclusions

Despite the intrinsic limits of IR methodology, results suggest how the implementation of an IR system dedicated to the emergency prehospital setting can act as a major driver for the development of a “learning organization” and improve both efficacy and safety of first aid care.

[Impact on the improvement of paediatric emergency services using a standardised model for the declaration and analysis of incidents]

INTRODUCTION

The aim of this study is to analyse changes in the incidents reported after the implementation of a new model, and study its results on patient safety.

PATIENTS AND METHODS

In 2012 an observational study with prospective collection of incidents reported between 2007 and 2011 was conducted. In May 2012 a model change was made in order to increase the number of reports, analyse their causes, and improve the feedback to the service. Professional safety representatives were assigned to every department, information and diffusion sessions were held, and a new incident reporting system was implemented. With the new model, a new observational study with prospective collection of the reports during one year was initiated, and the results compared between models.

RESULTS

In 2011, only 19 incidents were reported in the Emergency Department, and between June 1, 2012 to June 1, 2013, 106 incidents (5.6 times more). The incidents reported were medication incidents (57%), identification (26%), and procedures (7%). The most frequent causes were human (70.7%), lack of training (22.6%), and working conditions (15.1%). Some measures were implemented as a result of these incidents: a surgical checklist, unit doses of salbutamol, tables of weight-standardised doses of drugs for cardiopulmonary resuscitation.

CONCLUSIONS

The new model of reporting incidents has enhanced the reports and has allowed improvements and the implementation of preventive measures, increasing the patient safety in the Emergency Department.

A Descriptive Analysis of Incidents Reported by Community Aged Care Workers

Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care.

Cognitive diagnostic error in internal medicine

Medical error poses an important healthcare burden and a challenge for physicians and policy makers worldwide. Diagnostic error accounts for a substantial fraction of all medical mistakes. Most diagnostic errors have been associated with flaws in clinical reasoning. Empirical evidence on the cognitive mechanisms underlying such flaws and effectiveness of strategies to counteract them is scarce. Recent experimental studies, reviewed in this article, have increased our understanding of the relationship between cognitive factors and diagnostic mistakes. These studies have explored the role of cognitive biases, such as confirmation and availability bias, in diagnostic mistakes. They have suggested that confirmation bias and availability bias may indeed cause diagnostic errors. The latter bias seems to be associated with non-analytical reasoning, and was neutralized by analytical, or reflective, reasoning. Although non-analytical reasoning is a hallmark of clinical expertise, reflective reasoning was shown to improve diagnoses when cases are complex. Research on cognitive diagnostic mistakes remains a quite novel line of investigation. Follow-up studies that shine more light on the cognitive roots of, and cure for, diagnostic errors are needed.

Evaluation of clinically significant adverse events in patients discharged from a tertiary-care emergency department in Taiwan

OBJECTIVE

To investigate the reasons for the occurrence of clinically significant adverse events (CSAEs) in emergency department-discharged patients through emergency physicians' (EPs) subjective reasoning and senior EPs' objective evaluation.

DESIGN

This was a combined prospective follow-up and retrospective review of cases of consecutive adult non-traumatic patients who presented to a tertiary-care emergency department in Taiwan between 1 September 2005 and 31 July 2006. Data were extracted from 'on-duty EPs' subjective reasoning for discharging patients with CSAEs (study group) and without CSAEs (control group)' and 'objective evaluation of CSAEs by senior EPs, using clinical evidences such as recording history, physical examinations, laboratory/radiological examinations and observation of inadequacies in the basic management process (such as recording history, physical examinations, laboratory/radiological examinations and observation) as the guide'. Subjective reasons for discharging patients' improvement of symptoms, and the certainty of safety of the discharge were compared in the two groups using χ(2) statistics or t test.

RESULTS

Of the 20,512 discharged cases, there were 1370 return visits (6.7%, 95% CI 6.3% to 7%) and 165 CSAEs due to physicians' factors (0.82%, 95% CI 0.75% to 0.95%). In comparisons between the study group and the control group, only some components of discharge reasoning showed a significant difference (p<0.001). Inadequacies in the basic management process were the main cause of CSAEs (164/165).

CONCLUSION

The authors recommended that EP follow-up of the basic management processes (including history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment) using clinical evidence as a guideline should be made mandatory.

Learning from Taiwan patient-safety reporting system

OBJECTIVE

The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare.

METHOD

The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents.

RESULTS

There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10 am. Falls and endo tube incidents usually occurred between 4 and 6 am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%).

CONCLUSION

The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be stopped from happening again.

Quality and outcomes in anaesthesia: lessons from litigation

Healthcare litigation in the UK continues to grow at an alarming rate, with claims against anaesthetists and critical care physicians increasing each year. This has led to a huge financial burden for the taxpayer and a sharp increase in professional indemnity fees for individual doctors. Although such litigation should provide valuable information to educate practitioners and reduce future similar claims, there appear to be significant barriers preventing important lessons from being learned. Detailed learning opportunities are available only to the healthcare providers being sued or the expert witnesses employed to analyse the claims. Most practitioners have to rely on indemnifiers' case reports, closed-claim analyses, and ad hoc publications for information. In this review, we suggest ways in which important lessons from litigation could be brought to the attention of all clinicians. Currently, most clinicians are unable to determine whether key components of their practice such as consent, clinical decision-making, and documentation are of an acceptable standard for legal scrutiny. By reporting outcomes of Coroners' inquests, clinical and criminal negligence cases, and referrals to the General Medical Council, it would be hoped that more explicit standards of performance could be derived. Ultimately, this may not only improve patient safety, but protect practitioners from unjustifiable claims. Finally, given the critical importance of experts in the above process, we believe that a system for professional registration and regulation should be explored to ensure that they offer accurate, representative, and unbiased opinions and have the appropriate expertise in the subject matter to be analysed.

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010

We categorised and established the rates of patient safety incidents reported during 2009 and 2010 from critical care units in 12 hospital trusts in North-West England. We identified a total of 4219 incidents reported during 127, 467 calendar days of critical care with a median (IQR [range]) of 31 (26-45 [20-57]) incidents per 1000 days per trust. A median (IQR [range]) of 10 (7-13 [3.5-27]) incidents per 1000 days were associated with harm. Pressure sores were the most common cause of harm, with a median (IQR [range]) of 3.9 (1.0-6.6 [0-20.4]) incidents per 1000 days. Only 89 (2.1%) incidents described more than temporary harm, of which 12 were airway related incidents. Five incidents described the use of inappropriate arterial flush solutions. It is possible to compare rates of incident reporting in different trusts over time to determine if different methods of care are associated with different reporting rates. The wide range of reported pressure sore rates suggests that their incidence could be reduced.

Patient safety in emergency medical services: a systematic review of the literature

BACKGROUND

Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature.

OBJECTIVE

To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature.

METHODS

We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus.

RESULTS

We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second.

CONCLUSIONS

We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008*

Anaesthetic equipment plays a central role in anaesthetic practice but brings the potential for malfunction or misuse. We aimed to explore the national picture by reviewing patient safety incidents relating to anaesthetic equipment from the National Reporting and Learning System for England and Wales between 2006 and 2008. We searched the database using the system's own classification and by scrutinising the free text of relevant incidents. There were 1029 relevant incidents. Of these, 410 (39.8%) concerned patient monitoring, most commonly screen failure during anaesthesia, failure of one modality or failure to transfer data automatically from anaesthetic room to operating theatre. Problems relating to ventilators made up 185 (17.9%) of the reports. Sudden failures during anaesthesia accounted for 142 (13.8%) of these, with a further 10 cases (0.9%) where malfunction caused a sustained or increasing positive pressure in the patient's airway. Leaks made up 99 (9.6%) of incidents and 53 (5.2%) of incidents arose from the use of infusion pumps. Most (89%) of the incidents caused no patient harm; only 30 (2.9%) were judged to have led to moderate or severe harm. Although equipment was often faulty, user error or unfamiliarity also played a part. A large variety of causes led to a relatively small number of clinical scenarios, that anaesthetists should be ready, both individually and organisationally, to manage even when the cause is not apparent. We make recommendations for enhancing patient safety with respect to equipment. You can respond to this article at http://www.anaesthesiacorrespondence.com.

Clinical factors associated with the non-utilization of an anaesthesia incident reporting system

BACKGROUND

Incident reporting is a widely recommended method to measure undesirable events in anaesthesia. Under-utilization is a major weakness of voluntary incident reporting systems. Little is known about factors influencing reporting practices, particularly the clinical environment, anaesthesia team composition, severity of the incident, and perceived risk of litigation. The purpose of this study was to assess each of these, using an existing anaesthesia database.

METHODS

We performed a retrospective cohort study and analysed 46 207 surgical patients. We used multivariate analysis to identify factors associated with the non-utilization of the reporting system.

RESULTS

We found that in 7022 (15.1%) of the procedures performed, the incident reporting system was not used. Factors associated with the non-use of the system were regional anaesthesia/local anaesthesia, odds ratio (OR) 1.64 [95% confidence interval (CI) 1.03-2.62], emergency procedures OR 1.15 (95% CI: 1.05-1.27), and a consultant anaesthetist working without a trainee, OR 1.71 (95% CI: 1.03-2.82). In contrast, factors such as longer duration of surgery, OR 0.85 (95% CI: 0.76-0.94), the presence of a senior anaesthesia trainee, OR 0.86 (95% CI: 0.81-0.92), and the occurrence of severe complications with a high risk of litigation (i.e. death, nerve injuries) were less associated with a non-use of the reporting system, OR 0.65 (95% CI: 0.44-0.97). Team composition and time of day had no measurable impact on reporting practices.

CONCLUSIONS

Clinical factors play a significant role in the utilization of an anaesthesia incident reporting system and more particularly, severity of complications and higher liability risks which appear more as incentives than barriers to incident reporting.

What do primary care physicians and researchers consider the most important patient safety improvement strategies?

Background

Although it has been increasingly recognised that patient safety in primary care is important, little is known about the feasibility and effectiveness of different strategies to improve patient safety in primary care. In this study, we aimed to identify the most important strategies by consulting an international panel of primary care physicians and researchers.

Methods

A web-based survey was undertaken in an international panel of 58 individuals from eight countries with a strong primary care system. The questionnaire consisted of 38 strategies to improve patient safety. We asked the respondents whether these strategies were currently used in their own country, and whether they felt them to be important.

Results

Most of the 38 presented strategies were seen as important by a majority of the participants, but the use of strategies in daily practice varied widely. Strategies that yielded the highest scores (>70%) regarding importance included a good medical record system (82% felt this was very important, while 83% said it was implemented in more than half of the practices), good telephone access (71% importance, 83% implementation), standards for record keeping (75% importance, 62% implementation), learning culture (74% importance, 10% implementation), vocational training on patient safety for GPs (81% importance, 24% implementation) and the presence of a patient safety guideline (81% importance, 15% implementation).

Conclusion

An international panel of primary care physicians and researchers felt that many different strategies to improve patient safety were important. Highly important strategies with poor implementation included a culture that is positive for patient safety, education on patient safety for physicians, and the presence of a patient safety guideline.