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Plint AC, Newton AS, Stang A, Cantor Z, Hayawi L, Barrowman N, Boutis K, Gouin S, Doan Q, Dixon A, Porter R, Joubert G, Sawyer S, Crawford T, Gravel J, Bhatt M, Weldon P, Millar K, Tse S, Neto G, Grewal S, Chan M, Chan K, Yung G, Kilgar J, Lynch T, Aglipay M, Dalgleish D, Farion K, Klassen TP, Johnson DW, Calder LA. How safe are paediatric emergency departments? A national prospective cohort study. BMJ Qual Saf 2022; 31:806-817. [PMID: 35853646 PMCID: PMC9606537 DOI: 10.1136/bmjqs-2021-014608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/02/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of adverse events, as well as their preventability and severity, for children treated in a paediatric emergency department. METHODS Our prospective, multicentre cohort study enrolled children presenting for care during one of 168 8-hour study shifts across nine paediatric emergency departments. Our primary outcome was an adverse event within 21 days of enrolment which was related to care provided at the enrolment visit. We identified 'flagged outcomes' (such as hospital visits, worsening symptoms) through structured telephone interviews with patients and families over the 21 days following enrolment. We screened admitted patients' health records with a validated trigger tool. For patients with flags or triggers, three reviewers independently determined whether an adverse event occurred. RESULTS We enrolled 6376 children; 6015 (94%) had follow-up data. Enrolled children had a median age of 4.3 years (IQR 1.6-9.8 years). One hundred and seventy-nine children (3.0%, 95% CI 2.6% to 3.5%) had at least one adverse event. There were 187 adverse events in total; 143 (76.5%, 95% CI 68.9% to 82.7%) were deemed preventable. Management (n=98, 52.4%) and diagnostic issues (n=36, 19.3%) were the most common types of adverse events. Seventy-nine (42.2%) events resulted in a return emergency department visit; 24 (12.8%) resulted in hospital admission; and 3 (1.6%) resulted in transfer to a critical care unit. CONCLUSION In this large-scale study, 1 in 33 children treated in a paediatric emergency department experienced an adverse event related to the care they received there. The majority of events were preventable; most were related to management and diagnostic issues. Specific patient populations were at higher risk of adverse events. We identify opportunities for improvement in care.
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Affiliation(s)
- Amy C Plint
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amanda S Newton
- Pediatrics, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Antonia Stang
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Zach Cantor
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Lamia Hayawi
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kathy Boutis
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatrics and Child Health Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Serge Gouin
- Pediatric Emergency Department, CHU Sainte-Justine, Montreal, Québec, Canada
- Pediatrics, Université de Montreal, Montreal, Québec, Canada
| | - Quynh Doan
- Evidence to Innovations, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Dixon
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Porter
- Janeway Children's Health and Rehabilitation Centre, St John's, Newfoundland and Labrador, Canada
- Pediatrics, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Gary Joubert
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Pediatrics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Scott Sawyer
- Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- Pediatric Emergency, Health Sciences Centre Winnipeg Children's Hospital, Winnipeg, Manitoba, Canada
| | - Tyrus Crawford
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Jocelyn Gravel
- Pediatric Emergency Department, CHU Sainte-Justine, Montreal, Québec, Canada
- Pediatrics, Université de Montreal, Montreal, Québec, Canada
| | - Maala Bhatt
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick Weldon
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kelly Millar
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sandy Tse
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gina Neto
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Simran Grewal
- Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Melissa Chan
- Emergency Medicine, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Kevin Chan
- Janeway Children's Health and Rehabilitation Centre, St John's, Newfoundland and Labrador, Canada
- Pediatrics, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Grant Yung
- Pediatric Emergency, Health Sciences Centre Winnipeg Children's Hospital, Winnipeg, Manitoba, Canada
| | - Jennifer Kilgar
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Pediatrics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Tim Lynch
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
- Pediatrics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Mary Aglipay
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Dale Dalgleish
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken Farion
- Pediatric Emergency, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Pediatrics and Child Health, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - David W Johnson
- Paediatrics, Alberta Health Services, Edmonton, Alberta, Canada
| | - Lisa A Calder
- Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Plint AC, Stang A, Newton AS, Dalgleish D, Aglipay M, Barrowman N, Tse S, Neto G, Farion K, Creery WD, Johnson DW, Klassen TP, Calder LA. Adverse events in the paediatric emergency department: a prospective cohort study. BMJ Qual Saf 2021; 30:216-227. [PMID: 32350128 PMCID: PMC7907581 DOI: 10.1136/bmjqs-2019-010055] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 03/09/2020] [Accepted: 04/06/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Understanding adverse events among children treated in the emergency department (ED) offers an opportunity to improve patient safety by providing evidence of where to focus efforts in a resource-restricted environment. OBJECTIVE To estimate the risk of adverse events, their type, preventability and severity, for children seen in a paediatric ED. METHODS This prospective cohort study examined outcomes of patients presenting to a paediatric ED over a 1-year period. The primary outcome was the proportion of patients with an adverse event (harm to patient related to healthcare received) related to ED care within 3 weeks of their visit. We conducted structured telephone interviews with all patients and families over a 3-week period following their visit to identify flagged outcomes (such as repeat ED visits, worsening symptoms) and screened admitted patients' health records with a validated trigger tool. For patients with flagged outcomes or triggers, three ED physicians independently determined whether an adverse event occurred. RESULTS Of 1567 eligible patients, 1367 (87.2%) were enrolled and 1319 (96.5%) reached in follow-up. Median patient age was 4.34 years (IQR 1.5 to 10.57 years) and most (n=1281; 93.7%) were discharged. Among those with follow-up, 33 (2.5%, 95% CI 1.8% to 3.5%) suffered an adverse event related to ED care. None experienced more than one event. Twenty-nine adverse events (87.9%, 95% CI 72.7% to 95.2%) were deemed preventable. The most common types of adverse events (not mutually exclusive) were management issues (51.5%), diagnostic issues (45.5%) and suboptimal follow-up (15.2%). CONCLUSION One in 40 children suffered adverse events related to ED care. A high proportion of events were preventable. Management and diagnostic issues warrant further study.
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Affiliation(s)
- Amy C Plint
- CHEO, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Antonia Stang
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Amanda S Newton
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Mary Aglipay
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nick Barrowman
- CHEO Research Institute, Ottawa, Ontario, Canada
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Sandy Tse
- CHEO, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gina Neto
- CHEO, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ken Farion
- CHEO, Ottawa, Ontario, Canada
- Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Walter David Creery
- CHEO, Ottawa, Ontario, Canada
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - David W Johnson
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Terry P Klassen
- Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa A Calder
- Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Shi C, Zhang Y, Li C, Li P, Zhu H. Using the Delphi Method to Identify Risk Factors Contributing to Adverse Events in Residential Aged Care Facilities. Risk Manag Healthc Policy 2020; 13:523-537. [PMID: 32581615 PMCID: PMC7281847 DOI: 10.2147/rmhp.s243929] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/13/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to identify risk factors associated with adverse events in residential aged care facilities in China. Patients and Methods After compiling a list of risk factors for adverse events generated from in-depth interviews with managers of residential aged care facilities, a three-round Delphi method was used to reach consensus. The synthesized risk factors were presented on a Likert scale to the expert panelists three times to validate their responses. Results The list identified 67 items as risk factors for adverse events, attached to four first-level indexes (ie, environmental facility, nursing staff, older adults' characteristics, and management factors). The experts' authority coefficient was 0.87. The positive coefficients were 82.76%, 91.67%, and 100%, and the coordination coefficients were 0.154, 0.297, and 0.313 in the first, second, and third rounds, respectively. Conclusion Using a Delphi method, this study established a consensus on risk factors contributing to adverse events and developed a risk assessment grade for use in future aged care practice and research. The resulting list is useful in prioritizing risk-reduction activities and assessing intervention or education strategies for preventing adverse events in residential aged care facilities. Impact This study fills the gap in risk identification in the Chinese residential aged care system to ensure provision of best-practice care to this vulnerable population. Nursing staff and management factors at the top of the list are not only the most common causes of adverse events but also the core elements in creating a secure and error-free environment. This list was intended to support predictive and prevention-oriented decision-making by managers and nursing supervisors to reduce preventable adverse events.
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Affiliation(s)
- Chunhong Shi
- Nursing Department, XiangNan University, Chenzhou 423000, People's Republic of China
| | - Yinhua Zhang
- Nursing Department, Hunan University of Chinese Medicine, Changsha 410208, People's Republic of China
| | - Chunyan Li
- Nursing Department, XiangNan University, Chenzhou 423000, People's Republic of China
| | - Pan Li
- Nursing Department, XiangNan University, Chenzhou 423000, People's Republic of China
| | - Haili Zhu
- Nursing Department, Hunan Academy of Traditional Chinese Medicine Affiliated Hospital, Changsha, 410006, People's Republic of China
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Petschnig W, Haslinger-Baumann E. Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40886-017-0060-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Askari R, Shafii M, Rafiei S, Abolhassani MS, Salarikhah E. Failure mode and effect analysis: improving intensive care unit risk management processes. Int J Health Care Qual Assur 2017; 30:208-215. [DOI: 10.1108/ijhcqa-04-2016-0053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Purpose
Failure modes and effects analysis (FMEA) is a practical tool to evaluate risks, discover failures in a proactive manner and propose corrective actions to reduce or eliminate potential risks. The purpose of this paper is to apply FMEA technique to examine the hazards associated with the process of service delivery in intensive care unit (ICU) of a tertiary hospital in Yazd, Iran.
Design/methodology/approach
This was a before-after study conducted between March 2013 and December 2014. By forming a FMEA team, all potential hazards associated with ICU services – their frequency and severity – were identified. Then risk priority number was calculated for each activity as an indicator representing high priority areas that need special attention and resource allocation.
Findings
Eight failure modes with highest priority scores including endotracheal tube defect, wrong placement of endotracheal tube, EVD interface, aspiration failure during suctioning, chest tube failure, tissue injury and deep vein thrombosis were selected for improvement. Findings affirmed that improvement strategies were generally satisfying and significantly decreased total failures.
Practical implications
Application of FMEA in ICUs proved to be effective in proactively decreasing the risk of failures and corrected the control measures up to acceptable levels in all eight areas of function.
Originality/value
Using a prospective risk assessment approach, such as FMEA, could be beneficial in dealing with potential failures through proposing preventive actions in a proactive manner. The method could be used as a tool for healthcare continuous quality improvement so that the method identifies both systemic and human errors, and offers practical advice to deal effectively with them.
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Abstract
Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.
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Affiliation(s)
- Marc T Edwards
- 1 QA to QI Patient Safety Organization, West Hartford, CT
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7
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Abstract
Critical incidents (CIs) are the elements that bring about an alert or wake up call for clinicians in hospital wards. They are considered critical because the safety of patients, staff or visitors is at risk. Not all CIs result in dire consequences, nor do they require Root Cause Analysis (RCA). Nonetheless, incidents affect patients and involve clinicians' interactions with each other. This paper describes the complexities embedded in two CIs in a major paediatric hospital in Australia. An anthropological ethnographic research approach enabled the researcher to observe, document, interpret and make sense of the activities of clinicians in two different clinical areas of the hospital, i.e., the Rehabilitation Unit and the Neonatal Unit (NU). Ethnographic research significantly exposes and highlights hospital dramas and shows the effects on clinicians' everyday lives. We suggest that CIs have two dimensions: a medical and a social. The medical dimension encompasses factors in the treatment and care of the patient. The social dimension encompasses the social relationships and the socio-affectivity (emotional responses and labour) of treating clinicians. Our main argument is that foregrounding of the socio-cultural dimensions of CIs informs and impacts on the medical dimensions. Our conclusions demonstrate that the social dimensions of CIs have important ramifications for clinical interactions in everyday practices and these impact on the positive learning of clinicians after a CI has occurred.
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Affiliation(s)
- Cynthia L Hunter
- a Faculty of Medicine , School of Public Health , University of Sydney, Australia and Faculty of Humanities and Social Sciences, University of Technology Sydney , Sydney , Australia
| | - Kaye Spence
- b Faculty of Medicine , School of Nursing, Dentistry and Health Sciences, University of Melbourne , Melbourne , Australia
| | - Adam Scheinberg
- c Discipline of Paediatrics and Child Health, University of Sydney , Sydney , Australia
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Stavropoulou C, Doherty C, Tosey P. How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review. Milbank Q 2016; 93:826-66. [PMID: 26626987 DOI: 10.1111/1468-0009.12166] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
CONTEXT Incident-reporting systems (IRSs) are used to gather information about patient safety incidents. Despite the financial burden they imply, however,little is known about their effectiveness. This article systematically reviews the effectiveness of IRSs as a method of improving patient safety through organizational learning. METHODS Our systematic literature review identified 2 groups of studies: (1)those comparing the effectiveness of IRSs with other methods of error reporting and (2) those examining the effectiveness of IRSs on settings, structures, and outcomes in regard to improving patient safety. We used thematic analysis to compare the effectiveness of IRSs with other methods and to synthesize what was effective, where, and why. Then, to assess the evidence concerning the ability of IRSs to facilitate organizational learning, we analyzed studies using the concepts of single-loop and double-loop learning. FINDINGS In total, we identified 43 studies, 8 that compared IRSs with other methods and 35 that explored the effectiveness of IRSs on settings, structures,and outcomes. We did not find strong evidence that IRSs performed better than other methods. We did find some evidence of single-loop learning, that is, changes to clinical settings or processes as a consequence of learning from IRSs, but little evidence of either improvements in outcomes or changes in the latent managerial factors involved in error production. In addition, there was insubstantial evidence of IRSs enabling double-loop learning, that is, a cultural change or a change in mind-set. CONCLUSIONS The results indicate that IRSs could be more effective if the criteria for what counts as an incident were explicit, they were owned and ledby clinical teams rather than centralized hospital departments, and they were embedded within organizations as part of wider safety programs.
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Abstract
Diagnostic errors are common and costly, but difficult to detect. "Trigger" tools have promise to facilitate detection, but have not been applied specifically for inpatient diagnostic error. We performed a scoping review to collate all individual "trigger" criteria that have been developed or validated that may indicate that an inpatient diagnostic error has occurred. We searched three databases and screened 8568 titles and abstracts to ultimately include 33 articles. We also developed a conceptual framework of diagnostic error outcomes using real clinical scenarios, and used it to categorize the extracted criteria. Of the multiple criteria we found related to inpatient diagnostic error and amenable to automated detection, the most common were death, transfer to a higher level of care, arrest or "code", and prolonged length of hospital stay. Several others, such as abrupt stoppage of multiple medications or change in procedure, may also be useful. Validation for general adverse event detection was done in 15 studies, but only one performed validation for diagnostic error specifically. Automated detection was used in only two studies. These criteria may be useful for developing diagnostic error detection tools.
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Affiliation(s)
- Edna C Shenvi
- Division of Biomedical Informatics, University of California, San Diego, 9500 Gilman Dr. MC 0728, La Jolla, CA 92093-0728, USA
| | - Robert El-Kareh
- Divisions of Biomedical Informatics and Hospital Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Dehnavieh R, Ebrahimipour H, Molavi-Taleghani Y, Vafaee-Najar A, Noori Hekmat S, Esmailzdeh H. Proactive risk assessment of blood transfusion process, in pediatric emergency, using the Health Care Failure Mode and Effects Analysis (HFMEA). Glob J Health Sci 2014; 7:322-31. [PMID: 25560332 PMCID: PMC4796474 DOI: 10.5539/gjhs.v7n1p322] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 12/25/2014] [Indexed: 11/12/2022] Open
Abstract
Introduction: Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology. Methodology: This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts’ panel views via the interview and focus group discussion sessions. Results: The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ (“Theory of Inventive Problem Solving.”) Conclusion: The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency.
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Affiliation(s)
- Reza Dehnavieh
- Research Center for Health Services Management, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
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Burston S, Chaboyer W, Gillespie B, Carroll R. The effect of a transforming care initiative on patient outcomes in acute surgical units: a time series study. J Adv Nurs 2014; 71:417-29. [DOI: 10.1111/jan.12508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Sarah Burston
- C/-School of Nursing and Midwifery - Gold Coast campus; Griffith University; Queensland Australia
| | - Wendy Chaboyer
- NHMRC Centre for Health Practice Innovation; Griffith Health Institute; Griffith University; Queensland Australia
| | - Brigid Gillespie
- NHMRC Centre for Health Practice Innovation; Griffith Health Institute; Griffith University; Queensland Australia
| | - Roxanne Carroll
- Gold Coast Hospital and Health Service; Southport Queensland Australia
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12
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Azzam DG, Neo CA, Itotoh FE, Aitken RJ. The Western Australian Audit of Surgical Mortality: outcomes from the first 10 years. Med J Aust 2013; 199:539-42. [DOI: 10.5694/mja13.10256] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 08/06/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Diana G Azzam
- The Western Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons (WA), Perth, WA
| | - C Adeline Neo
- The Western Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons (WA), Perth, WA
| | - Franca E Itotoh
- The Western Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons (WA), Perth, WA
| | - R James Aitken
- The Western Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons (WA), Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
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Abstract
OBJECTIVE To systematically review the literature regarding the prevalence, preventability, severity and types of adverse events (AE) in the Emergency Department (ED). METHODS We systematically searched major bibliographic databases, relevant journals and conference proceedings, and completed reference reviews of primary articles. Observational studies (cohort and case-control), quasi-experimental (e.g. before/after) studies and randomized controlled trials, were considered for inclusion if they examined a broad demographic group reflecting a significant proportion of ED patients and described the proportion of AE. Studies conducted outside of the ED setting, those examining only a subpopulation of patients (e.g. a specific entrance complaint or receiving a specific intervention), or examining only adverse drug events, were excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality with the Newcastle Ottawa Scale. RESULTS Our search identified 11,624 citations. Ten articles, representing eight observational studies, were included. Methodological quality was low to moderate with weaknesses in study group comparability, follow-up, and outcome ascertainment and reporting. There was substantial variation in the proportion of patients with AE related to ED care, ranging from 0.16% (n = 9308) to 6.0% (n = 399). Similarly, the reported preventability of AE ranged from 36% (n = 250) to 71% (n = 24). The most common types of events were related to management (3 studies), diagnosis (2 studies) and medication (2 studies). CONCLUSIONS The variability in findings and lack of high quality studies on AE in the high risk ED setting highlights the need for research in this area. Further studies with rigorous, standardized outcome assessment and reporting are required.
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Affiliation(s)
- Antonia S. Stang
- Department of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Aireen S. Wingert
- Cochrane Child Health Field, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Lisa Hartling
- Alberta Research Center for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Amy C. Plint
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
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Affiliation(s)
- David A. K. Watters
- Department of Surgery; Deakin University and Barwon Health; Geelong; Victoria; Australia
| | - Philip G. Truskett
- Department of Surgery; Prince of Wales Hospital and University of New South Wales; Sydney; New South Wales; Australia
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Abstract
Despite increased advocacy for patient safety and several large-scale programs designed to reduce preventable harm, most notably surgical checklists, recent data evaluating entire health systems suggests that we are no further ahead in improving patient safety and that hospital complications are no less frequent now than in the 1990s. We suggest that the failure to systematically measure patient safety is the reason for our limited pro gress. In addition to defining patient safety outcomes and describing their financial and clinical impact, we argue why the failure to implement patient safety measurement systems has compromised the ability to move the agenda forward. We also present an overview of how patient safety can be assessed and the strengths and weaknesses of each method and comment on some of the consequences created by the absence of a systematic measurement system.
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Affiliation(s)
- Alan J Forster
- The Ottawa Hospital, the Department of Medicine, University of Ottawa, the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont., Canada.
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Stride P, Seleem M, Nath N, Horne A, Kapitsalas C. Integration of patient safety systems in a suburban hospital. AUST HEALTH REV 2012; 36:359-62. [PMID: 22958976 DOI: 10.1071/ah11099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 03/15/2012] [Indexed: 11/23/2022]
Abstract
Public awareness of hospital misadventure is now common. In response, we describe our integrated hospital safety system, which is dependent on the linkage of multiple individual safety committees, and the presence on each committee of senior and junior multidisciplinary healthcare professionals to provide feedback to their peer groups on required improvements.
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Affiliation(s)
- Peter Stride
- Northside Clinical School of Medicine, University of Queensland, Redcliffe Hospital, Redcliffe, QLD 4020, Australia.
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Caminiti C, Diodati F, Bacchieri D, Carbognani P, Del Rio P, Iezzi E, Palli D, Raboini I, Vecchione E, Cisbani L. Evaluation of a pilot surgical adverse event detection system for Italian hospitals. Int J Qual Health Care 2012; 24:114-20. [PMID: 22279162 DOI: 10.1093/intqhc/mzr088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To devise an adverse event (AE) detection system and assess its validity and utility. DESIGN Observational, retrospective study. SETTING Six public hospitals in Northern Italy including a Teaching Hospital. PARTICIPANTS Eligible cases were all patients with at least one admission to a surgical ward, over a 3-month period. INTERVENTIONS Computerized screening of administrative data and review of flagged charts by an independent panel. MAIN OUTCOME MEASURES Number of records needed to identify an AE using this detection system. RESULTS Out of the 3310 eligible cases, 436 (13%) were extracted by computerized screening. In addition, out of the 2874 unflagged cases, 77 randomly extracted records (3%) were added to the sample, to measure unidentified cases. Nursing staff judged 108 of 504 (21%) charts positive for one or more criteria; surgeons confirmed the occurrence of AEs in 80 of 108 (74%) of these. Compared with random chart review, the number of cases needed to detect an AE, with the computerized screening suggested by this study, was reduced by two-thirds, although sensitivity was low (41%). CONCLUSIONS This approach has the potential to allow the timely identification of AEs, enabling to quickly devise interventions. This detection system could be of true benefit for hospitals that intend assessing their AEs.
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Calder LA, Forster A, Nelson M, Leclair J, Perry J, Vaillancourt C, Hebert G, Cwinn A, Wells G, Stiell I. Adverse events among patients registered in high-acuity areas of the emergency department: a prospective cohort study. CAN J EMERG MED 2010; 12:421-30. [PMID: 20880432 DOI: 10.1017/s1481803500012574] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To enhance patient safety, it is important to understand the frequency and causes of adverse events (defined as unintended injuries related to health care management). We performed this study to describe the types and risk of adverse events in high-acuity areas of the emergency department (ED). METHODS This prospective cohort study examined the outcomes of consecutive patients who received treatment at 2 tertiary care EDs. For discharged patients, we conducted a structured telephone interview 14 days after their initial visit; for admitted patients, we reviewed the inpatient charts. Three emergency physicians independently adjudicated flagged outcomes (e.g., death, return visits to the ED) to determine whether an adverse event had occurred. RESULTS We enrolled 503 patients; one-half (n = 254) were female and the median age was 57 (range 18-98) years. The majority of patients (n = 369, 73.3%) were discharged home. The most common presenting complaints were chest pain, generalized weakness and abdominal pain. Of the 107 patients with flagged outcomes, 43 (8.5%, 95% confidence interval 8.1%-8.9%) were considered to have had an adverse event through our peer review process, and over half of these (24, 55.8%) were considered preventable. The most common types of adverse events were as follows: management issues (n = 18, 41.9%), procedural complications (n = 13, 30.2%) and diagnostic issues (n = 10, 23.3%). The clinical consequences of these adverse events ranged from minor (urinary tract infection) to serious (delayed diagnosis of aortic dissection). CONCLUSION We detected a higher proportion of preventable adverse events compared with previous inpatient studies and suggest confirmation of these results is warranted among a wider selection of EDs.
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Unbeck M, Dalen N, Muren O, Lillkrona U, Härenstam KP. Healthcare processes must be improved to reduce the occurrence of orthopaedic adverse events. Scand J Caring Sci 2010; 24:671-7. [PMID: 20409063 DOI: 10.1111/j.1471-6712.2009.00760.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Maria Unbeck
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Stockholm, Sweden.
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Ardenghi D, Martinengo M, Bocciardo L, Nardi P, Tripodi G. Near miss errors in transfusion medicine: the experience of the G. Gaslini transfusion medicine service. Blood Transfus 2007; 5:210-6. [PMID: 19204777 DOI: 10.2450/2007.0010-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 07/11/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND The monitoring of near miss errors, in other words events that cannot be classified as substantial errors, but whose occurrence suggests that there is probably a critical point in a working procedure, can be useful in order to prevent these 'almost errors' from occurring again or to prevent them evolving into 'relevant errors'. STUDY DESIGN AND METHODS The methods for picking up and studying near miss errors use widely tested systems that have recently also been applied to medicine. These systems are based on the process of identifying the risk through spontaneous notifications of events (incident reporting). In our Service of Immunohaematology and Transfusion Medicine (SIMT) these reports were assessed using root cause analysis, allowing us to introduce corrective actions to eliminate or reduce the risk. RESULTS We report the distribution, type and frequency of near miss errors, divided according to the stage of the working procedure in which they occurred, and for each of them describe the possible causes and corrective actions identified. We show how the possibility of an error, with potentially harmful consequences for the patient, is present throughout the whole transfusion chain. Near miss errors in Transfusion Medicine can be included in the wider field of 'clinical risk, a problem that concerns not only SIMT, but also numerous other sectors of health care. CONCLUSION The instruments identified through this study can lower the threshold of clinical risk in a Transfusion Service.
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Affiliation(s)
- Kerin Robinson
- Kerin Robinson BHA BAppSc(MRA) MHP CMRA, Department of Health Information Management, Faculty of Health Sciences, La Trobe University, Bundoora VIC 3086, AUSTRALIA
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Abstract
OBJECTIVES To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare. METHODS Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology. RESULTS Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods. CONCLUSION A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of complex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micro-managed and controlled through a hierarchy is preferable.
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Affiliation(s)
- J Braithwaite
- Faculty of Medicine, Centre for Clinical Governance Research, Institute of Health Innovation, University of New South Wales, Sydney, NSW, Australia.
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Affiliation(s)
- Eric Camiré
- Department of Critical Care Medicine, University of Calgary, Calgary, Alta
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Mansah M, Fernandez R, Griffiths R, Chang E. Effectiveness of strategies to promote safe transition of elderly people across care settings. ACTA ACUST UNITED AC 2009. [DOI: 10.11124/jbisrir-2009-206] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Mansah M, Fernandez R, Griffiths R, Chang E. Effectiveness of strategies to promote safe transition of elderly people across care settings. ACTA ACUST UNITED AC 2009; 7:1036-1090. [PMID: 27820495 DOI: 10.11124/01938924-200907240-00001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Errors and adverse events have major impact on elderly patients due to their recurrent hospitalisation and particularly as they move between settings to receive care for comorbid chronic conditions. A range of strategies such as discharge planners, use of patients transfer sheet, medications reconciliation and patients education have been implemented to improve care transition. However, there have been no systematic reviews undertaken to evaluate the effectiveness of these strategies in a concise format for the development of evidence-based guidelines. Therefore, a systematic review is urgently needed to support clinicians in implementing safe quality care transition and also use as a front line to improve patient safety. OBJECTIVE The objective of this review is to appraise and synthesise the best available evidence in promoting a safer transfer of elderly patients across care settings. SELECTION CRITERIA Types of studies Only randomised controlled trials (RCTs) evaluating the effectiveness of strategies to promote safe transfer of elderly patients across care settings were eligible for inclusion in this review.Types of participants The review included studies undertaken in participants aged >65 years who have been transferred between care settings.The review focused on any interventions that were undertaken to reduce or minimise errors and adverse events and promote safe transition of the elderly patients from one setting to another.The primary outcome of interest was the effect of the interventions on the use of health care resources. SEARCH STRATEGY A comprehensive search of the literature published in the English language was undertaken using all major electronic databases ranging from 1966 to 2008. Reference lists and bibliographies of all possible trials and reviews of studies were searched. Relevant conference proceedings were searched; experts in the field were also contacted to identify further trials. RESULTS 12 studies were included in the review. The results indicated that comprehensive plan of care and well-trained healthcare practitioners such as nurses or pharmacists, who have current information about the patient's clinical status and care plan, ensured smoother transition from hospital to home. The use of multi-faceted interventions such as elderly patient education and collaborative team approach reduce the incidence of errors and adverse events during care transition. CONCLUSION AND IMPLICATION FOR PRACTICE There is evidence of benefits to demonstrate:1. Strategies that involve structured communication improve outcomes for elderly patients during care transition.2. Nurse-led interventions and multidisciplinary team interventions were effective in reducing readmission to hospital at one to nine months.3. Pharmacist-led interventions and multidisciplinary team led interventions reduced frequency of hospital services utilisation such as emergency visits, long-term institutions and rehabilitation clinics.4. Pharmacist-led interventions were effective in improving quality of medications prescribed by physician. In addition, significantly reduced non-adherence in patients taking four or more medication at three months.5. Nurse-led interventions effectively improved quality of life in patients receiving the interventions.6. Nurse-led and multidisciplinary team led interventions reduced costs associated with the interventions. IMPLICATION FOR RESEARCH The review has provided a guide for future research priorities which involves larger randomised controlled trials assessing transitions between hospital and in-patient settings; comprehensive standardised method to assess outcomes such as medication adherence and studies to clearly demonstrate the association between adverse events and transfer.
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Affiliation(s)
- Martha Mansah
- 1. School of Nursing & Midwifery College of Health & Sciences University of Western Sydney 2. Family and Community Health; School of Nursing and Midwifery; University of Western Sydney
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Mitchell IA, Antoniou B, Gosper JL, Mollett J, Hurwitz MD, Bessell TL. A robust clinical review process: the catalyst for clinical governance in an Australian tertiary hospital. Med J Aust 2008; 189:451-5. [DOI: 10.5694/j.1326-5377.2008.tb02120.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 06/03/2008] [Indexed: 11/17/2022]
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Abstract
BACKGROUND AND PURPOSE Adverse events (AEs) are common in acute care hospitals, but there have been few data concerning AEs in orthopedic patients. We tested and evaluated a patient safety model (the Wimmera clinical risk management model) and performed a three-stage retrospective review of records to determine the occurrence of AEs in adult orthopedic inpatients. METHODS The computerized medical and nursing records of 395 patients were included and screened for AEs using 12 criteria. Positive records were then reviewed by two senior orthopedic surgeons using a standardized protocol. An AE had to have occurred during the index admission or within the first 28 days of discharge from the Orthopedics Department. Screening of additional systems for reporting of AEs was also carried out for the same period. The number of patients suffering an AE and the number of AEs were recorded. RESULTS Altogether, 60 (15 %) of 395 patients checked in the screening of records experienced 65 AEs (16%) due to healthcare management. Of the 65 AEs, 34 were estimated to have a high degree of preventability. 47 of the 65 AEs occurred during the index admission and 18 within 28 days of discharge. In screening of local and nationwide reporting systems for the same patients, 4 additional AEs were identified-2 of which were previously unknown. 67 different AEs were detected by using the Wimmera model (17%) INTERPRETATION Using the Wimmera model with manual screening and review of records, many more AEs were detected than in all other traditional local and nationwide reporting systems used in Sweden when screening was done for the same period.
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Affiliation(s)
- Maria Unbeck
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Orthopedics, Stockholm, Sweden.
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Abstract
Background Patients discharged from the intensive care unit may be at risk of adverse events because of complex care needs.Objective To identify the types, frequency, and predictors of adverse events that occur in the 72 hours after discharge from an intensive care unit when no evidence of adverse events was apparent before discharge.Methods A predictive cohort study of 300 patients from an adult intensive care unit was undertaken. An internationally accepted protocol for chart audit was used. Frequency of adverse events was calculated, and logistic regression was used to determine independent predictors of adverse events.Results A total of 147 adverse events, 17 (11.6%) of which were defined as major, were incurred by 92 patients (30.7%). The 3 most common adverse events, hospital-incurred infection or sepsis (n = 32, 21.8%), hospital-incurred accident or injury (n = 17, 11.6%), and other complication such as deep vein thrombosis, pulmonary edema, or myocardial infarction (n = 17, 11.6%) accounted for 44.9% (n = 66) of all adverse events. Two predictors, respiratory rate less than 10/min or greater than or equal to 25/min and pulse rate exceeding 110/min, were significant independent predictors; requiring a high level of nursing care at the time of discharge was a significant predictor in univariate analysis but not in multivariate analysis.Conclusion Taking, recording, and reporting vital signs are important. Nursing care requirements of patients at discharge from the intensive care unit may be worthy of further investigation in studies of patients after discharge.
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Affiliation(s)
- Wendy Chaboyer
- Wendy Chaboyer is a professor and director of the Research Centre for Clinical and Community Practice Innovation, Griffith University Gold Coast Campus, Queensland, Australia
| | - Lukman Thalib
- Lukman Thalib is an associate professor in the Faculty of Medicine at the University of Kuwait, Safat, and is an adjunct professor with the Research Centre for Clinical and Community Practice Innovation, Griffith University Gold Coast Campus, Queensland, Australia
| | - Michelle Foster
- Michelle Foster is the nurse unit manager of the intensive care unit at Gold Coast Hospital in Southport, Queensland, Australia
| | - Carol Ball
- Carol Ball is a consultant nurse in critical care at Royal Free Hospital in London, England
| | - Brent Richards
- Brent Richards is the executive director of the Division of Surgery and Critical Care at Gold Coast Hospital in Southport, Queensland, Australia
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Abstract
Improving quality and safety of hospital care is now firmly on the health-care agenda. Various agencies within different levels of government are pursuing initiatives targeting hospitals and health professionals that aim to identify, quantify and lessen medical error and suboptimal care. Although not denying the value of such 'top-down' initiatives, more attention may be needed towards 'bottom-up' reform led by practising physicians. This article discusses factors integral to delivery of safe, high-quality care grouped under six themes: clinical workforce, teamwork, patient participation in care decisions, indications for health-care interventions, clinical governance and information systems. Following this discussion, a 20-point action plan is proposed as an agenda for future reform capable of being led by physicians, together with some cautionary notes about relying too heavily on information technology, use of non-clinical quality personnel and quantitative evaluative approaches as primary strategies in improving quality.
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Affiliation(s)
- I A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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Bellandi T, Albolino S, Tomassini CR. How to create a safety culture in the healthcare system: the experience of the Tuscany Region. Theoretical Issues in Ergonomics Science 2007. [DOI: 10.1080/14639220701193223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Evans SM, Smith BJ, Esterman A, Runciman WB, Maddern G, Stead K, Selim P, O'Shaughnessy J, Muecke S, Jones S. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care 2007; 16:169-75. [PMID: 17545341 PMCID: PMC2465009 DOI: 10.1136/qshc.2006.019349] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incident-reporting rates and change the types of incidents reported. DESIGN, SETTING AND PARTICIPANTS Non-equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia. MAIN OUTCOME MEASURES Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units. RESULTS The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10,000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p<0.001) and in emergency departments (EDs) (additional 39.5 reports/10,000 ED attendances; 95% CI 17.0 to 62.0, p<0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10,000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10,000 OBDs; 95% CI 23.9 to 94.1, p<0.001) and (c) anonymously (additional 20.2 reports/10,000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p<0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression-related incidents in intervention units. In intervention units, more reports were submitted on one-page forms than via the call centre (1005 vs 264 reports, respectively). CONCLUSIONS A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units.
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Affiliation(s)
- Sue M Evans
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
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Freestone L, Bolsin SN, Colson M, Patrick A, Creati B. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. Int J Qual Health Care 2006; 18:452-7. [PMID: 17052992 DOI: 10.1093/intqhc/mzl054] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To assess the reporting of critical incidents by anaesthetic trainees using personal digital assistants. The project also identified the reporting of 'near miss' incidents by anaesthetic trainees. DESIGN Comparison of electronic incident reporting with retrospective case note review of cases in which no incident was reported. SETTING A 400-bed university teaching hospital in Victoria. PARTICIPANTS Fourteen accredited Australian and New Zealand College of Anaesthetists (ANZCA) registrars and their training supervisors. INTERVENTIONS Registrars and supervisors underwent initial training for 1 hour and were provided with ongoing support. The cases and incidents reported to the database using the portable digital assistants were analysed. MAIN OUTCOME MEASURES These were the total number of anaesthetics reported to the database; the number of incidents reported to the database; the outcome severity of incidents reported; and the number of incidents detected in the case note review that were not reported to the database. RESULTS An incident was reported for 156 (3.5%) of 4441 anaesthetic procedures reported to the database. Of these incidents, 72 (46.2%) were 'near misses'. One incident was identified in a review of 208 case notes, which had no incidents reported electronically, and was not reported to the database electronically. This gives a reporting rate of 99.52% [95% confidence interval (CI) 96.9-100%]. CONCLUSIONS ANZCA trainees in routine anaesthetic practice can reliably use mobile computing technology to report critical incidents and 'near miss' incident data.
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Affiliation(s)
- Liadaine Freestone
- Department of Anaesthesia, The Geelong Hospital, Geelong, Victoria, Australia
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Marang-van de Mheen PJ, van Hanegem N, Kievit J. Effectiveness of routine reporting to identify minor and serious adverse outcomes in surgical patients. Qual Saf Health Care 2006; 14:378-82. [PMID: 16195574 PMCID: PMC1744069 DOI: 10.1136/qshc.2004.013250] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the effectiveness of routine reporting to identify surgical adverse outcomes in comparison with retrospective medical record review. DESIGN Independent assessment of two methods applied to one sample. Surgeons and surgical residents routinely reported all adverse outcomes for patients in their care during admission. A trained research assistant, blinded to the surgeons' reporting data, retrospectively reviewed the medical records of selected patients and registered all adverse outcomes identified from paper or electronic patient records. SETTING Dutch university hospital. STUDY SAMPLE A 5% sample of patients (N = 150) discharged in 2002 was taken; oversampling of patients undergoing reoperations, sick patients (ASA >or=3), and those undergoing technically complex surgery was done to increase the yield of adverse outcomes. MAIN OUTCOME MEASURES The number of adverse outcomes identified by each method was compared with the total number identified by either method. This was done both for all adverse outcomes and for serious adverse outcomes. RESULTS Routine reporting identified fewer adverse outcomes than medical record review (62.5% v 78.2%). Complete agreement was achieved in only 40.7% of adverse outcomes. Routine reporting identified slightly more serious adverse outcomes (84.8% v 79.5% of the total), but this difference was not statistically significant. Extrapolating these results to the total number of admissions in 2002, routine reporting underestimated the annual adverse outcome incidence by 1.8% (increasing from 14.5% to 16.3%) and the incidence of serious adverse outcomes by 0.3% (increasing from 6.9% to 7.2%). CONCLUSIONS Neither method identified all adverse outcomes. Routine reporting underestimated the incidence of minor events but was as accurate as record review in identifying serious adverse outcomes.
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Bolsin S, Patrick A, Colson M, Creatie B, Freestone L. New technology to enable personal monitoring and incident reporting can transform professional culture: the potential to favourably impact the future of health care. J Eval Clin Pract 2005; 11:499-506. [PMID: 16164592 DOI: 10.1111/j.1365-2753.2005.00567.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There have been recent exposures of poor health care performance in many countries with western health care systems. The poor performance has either related to poor or criminal practices routinely going undetected or to organizational indifference or hostility to staff raising concerns about perceived poor standards of care. The demonstration that routine performance data monitoring would have detected and prevented many of the deaths attributed to poor surgical standards in the Bristol Royal Infirmary paediatric cardiac surgery scandal and criminal behaviour in the Harold Shipman scandal has highlighted the need for routine data collection to demonstrate to both health care administrators and patients that minimum standards of clinical practice are being achieved. The recent proposal that surgical report cards represent an important minimum ethical standard for health care consent will force the medical profession to engage in the debate surrounding routine data collection for performance monitoring and other purposes. This article considers the cultural background to data collection in the medical profession and the cost implications of failing to improve data collection in the areas of performance monitoring and incident reporting. A potential solution developed by the Geelong hospital group and in use in Australia is proposed as a novel, technologically appropriate and working example of practical data collection. This model is endorsed by the professional specialties and supported by modern regulatory theory. The individual, local and system wide benefits of such personal professional data collection are outlined and the necessary prerequisites are detailed.
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Affiliation(s)
- Stephen Bolsin
- Division of Perioperative Medicine, Anaesthesia & Pain Medicine, The Geelong Hospital, Geelong, Victoria, Australia.
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Nakajima K, Kurata Y, Takeda H. A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital. Qual Saf Health Care 2005; 14:123-9. [PMID: 15805458 PMCID: PMC1743978 DOI: 10.1136/qshc.2003.008607] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PROBLEM When patient safety programs were mandated for Japanese health care institutions, a safety culture, a tool for collecting incident reports, an organizational arrangement for multidisciplinary collaboration, and interventional methods for improvement had to be established. DESIGN Observational study of effects of new patient safety programs. SETTING Osaka University Hospital, a large government-run teaching hospital. STRATEGY FOR CHANGE A voluntary and anonymous web-based incident reporting system was introduced. For the new organizational structure a clinical risk management committee, a department of clinical quality management, and area clinical risk managers were established with their respective roles clearly defined to advance the plan-do-study-act cycle and to integrate efforts. For preventive action, alert procedures, staff education, ward rounds by peers, a system oriented approach for reducing errors, and various feedback channels were introduced. EFFECTS OF CHANGE Continuous incident reporting by all hospital staff has been observed since the introduction of the new system. Several error inducing situations have been improved: wrong choice of drug in computer prescribing, maladministration of drugs due to a look-alike appearance or confusion about the manipulation of a medical device, and poor after hours service of the blood transfusion unit. Staff participation in educational seminars has been dramatically improved. Ward rounds have detected problematic procedures which needed to be dealt with. LESSONS LEARNT Patient safety programs based on a web-based incident reporting system, responsible persons, staff education, and a variety of feedback procedures can help promote a safety culture, multidisciplinary collaboration, and strong managerial leadership resulting in system oriented improvement.
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Affiliation(s)
- K Nakajima
- Department of Clinical Quality Management, Osaka University Hospital, Osaka, Japan.
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Abstract
CONTEXT Since reports on patient safety were issued by the Institute of Medicine, a number of interventions have been recommended and standards designed to improve hospital patient safety, including the Leapfrog, evidence-based safety standards. These standards are based on research conducted largely in urban hospitals, and it may not be possible to generalize them to rural hospitals. PURPOSE The absence of rural-relevant patient safety standards and interventions may diminish purchaser and public perceptions of rural hospitals, further undermining the financial stability of rural hospitals. This study sought to assess the current evidence concerning rural hospital patient safety and to identify a set of rural-relevant patient safety interventions that the majority of small rural hospitals could readily implement and that rural hospitals, purchasers, consumers, and others would find relevant and useful. These interventions should help rural hospitals prioritize patient safety efforts. METHODS As background, we reviewed literature; interviewed representatives of provider, payer, consumer, and governmental groups in 8 states; and calculated patient safety indicator rates in rural hospitals using the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project National Inpatient Sample. Based on the research literature and patient safety recommendations from national organizations, we developed a list of potentially important patient safety areas for rural hospitals. The rural relevance of these safety interventions was evaluated by a national expert panel in terms of the frequency of the problem, ability to implement, and the internal and external value to rural providers, purchasers, and consumers. FINDINGS The limited available research suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals. We identified 9 areas of patient safety and 26 priority patient safety interventions relevant to rural hospitals. CONCLUSIONS Many of the identified areas of patient safety and interventions are relevant to all types of hospitals, not just rural hospitals. However, some areas, such as transfers, are especially relevant to rural hospitals. The challenges of implementing some interventions, such as 24/7 pharmacy coverage, are significant given workforce supply and financial problems faced by many small rural hospitals. The results of this study provide an important platform for further work to test the validity and effectiveness of these interventions.
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Affiliation(s)
- Andrew F Coburn
- Maine Rural Health Research Center, Institute for Health Policy, Muskie School of Public Service, University of Southern Maine, Portland, 04104, USA.
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Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care. Med J Aust 2004; 181:428-31. [PMID: 15487958 DOI: 10.5694/j.1326-5377.2004.tb06366.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2004] [Accepted: 08/09/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine whether the quality of hospital inpatient care can be improved by using checklists and reminders in clinical pathways. DESIGN Comparison of key indicators before and after the introduction of clinical pathways incorporating daily checklists and reminders of best practice integrated into patient medical records. SETTING AND PARTICIPANTS The study, at Wimmera Base Hospital in Horsham, Victoria, included patients admitted between 1 January 1999 and 31 December 2002 with ST-elevation acute myocardial infarction (AMI) and patients admitted between 31 July 1999 and 31 December 2002 with stroke. MAIN OUTCOME MEASURES Compliance with key process measures determined as best practice for each clinical pathway. RESULTS 116 patients with AMI and 123 patients with stroke were included in the study. ST-elevation AMI. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 21.4% (95% CI, 7.3%-32.7%) for patients receiving aspirin in the emergency department; 42.7% (95% CI, 26.3%-59.0%) for eligible patients receiving beta-blockers within 24 h of admission; 48.1% (95% CI, 31.4%-64.8%) for eligible patients being prescribed beta-blockers on discharge; 43.7% (95% CI, 28.4%-59.1%) for patients having fasting lipid levels measured; and 41.2% (95% CI, 19.0%-63.5%) for eligible patients having lipid therapy. Stroke. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 40.7% (95% CI, 21.0%-60.2%) for dysphagia screening within 24 h of admission; 55.4% (95% CI, 32.9%-77.9%) for patients with ischaemic stroke receiving aspirin or clopidogrel within 24 h of admission; and 52.4% (95% CI, 33.8%-70.9%) for patients having regular neurological observations during the first 48 h after a stroke. There was a fall of 1.0 percentage point (ie, a difference of -1% [95% CI, -4.7% to 10.0%]) in the proportion of patients having a computed tomography brain scan within 24 h of admission. CONCLUSION Significant improvements in the quality of patient care can be achieved by incorporating checklists and reminders into clinical pathways.
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Affiliation(s)
- Alan M Wolff
- Clinical Risk Management Unit, Wimmera Health Care Group, Baillie Street, Horsham, VIC 3400, Australia.
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Westfall JM, Fernald DH, Staton EW, VanVorst R, West D, Pace WD. Applied Strategies for Improving Patient Safety: A Comprehensive Process To Improve Care in Rural and Frontier Communities. J Rural Health 2004; 20:355-62. [PMID: 15551852 DOI: 10.1111/j.1748-0361.2004.tb00049.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities. PURPOSE To describe a system to decrease medical errors and improve care in rural and frontier primary care offices. METHODS Applied Strategies for Improving Patient Safety (ASIPS) was a demonstration project designed to collect and analyze medical error reports and use these reports to develop and implement interventions aimed at decreasing errors. ASIPS participants were clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). This paper describes ASIPS in HPRN. FINDINGS Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS. Participants have submitted 128 reports. Diagnostic tests were involved in 26% of events; medication errors appeared in 20% of events. Communication errors were reported in 72%. Two learning groups developed "Principles for Process Improvement" for medication errors and diagnostic testing errors. Several safety "alerts" were issued to improve care, and 2 interventions were implemented to decrease errors. CONCLUSIONS A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings. Information from reports can be used to identify processes that can be improved.
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Affiliation(s)
- John M Westfall
- Department of Family Medicine, University of Colorado Health Sciences Center, Aurora, CO 80045-0508, USA.
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Abstract
This paper reviews safety initiatives in the health systems of the UK, Canada, Australia, and the US. Initiatives to tackle safety shortcomings involve public-private collaborations. Patient safety agencies (to institute learning, action and safety culture), adverse event reporting and, to a lesser extent, safety related performance indicators are currently used to design safer health systems. Their benefits are mixed, but there is little debate as to their possible side effects. Foreseeable adverse effects of multiple safety organisations stem from them being too many, too vague, too narrowly focused, threatened by the medical practice environment, and too optimistic. Safety related performance indicators are most developed in the US but suffer from inadequacies of administrative data, underreporting, variable indicator definitions, "extended" use, and low sensitivity of the diagnosis coding system, and arguable preventability of the prescribed conditions. A critical appraisal of the implications of these deficiencies is important to assure the safety of current health system safety initiatives and to establish evidence based safety. It is necessary to embed health system safety (as well as patient safety) in the societal culture, structures, and policies which promote effective, user centred, high performance care while allowing for healthy innovation.
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Affiliation(s)
- O A Arah
- Netherlands Institute for Health Sciences, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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Abstract
This paper reviews safety initiatives in the health systems of the UK, Canada, Australia, and the US. Initiatives to tackle safety shortcomings involve public-private collaborations. Patient safety agencies (to institute learning, action and safety culture), adverse event reporting and, to a lesser extent, safety related performance indicators are currently used to design safer health systems. Their benefits are mixed, but there is little debate as to their possible side effects. Foreseeable adverse effects of multiple safety organisations stem from them being too many, too vague, too narrowly focused, threatened by the medical practice environment, and too optimistic. Safety related performance indicators are most developed in the US but suffer from inadequacies of administrative data, underreporting, variable indicator definitions, "extended" use, and low sensitivity of the diagnosis coding system, and arguable preventability of the prescribed conditions. A critical appraisal of the implications of these deficiencies is important to assure the safety of current health system safety initiatives and to establish evidence based safety. It is necessary to embed health system safety (as well as patient safety) in the societal culture, structures, and policies which promote effective, user centred, high performance care while allowing for healthy innovation.
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Affiliation(s)
- O A Arah
- Netherlands Institute for Health Sciences, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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Abstract
Health care providers, hospital administrators, and politicians face competing challenges to reduce clinical errors, control expenditure, increase access and throughput, and improve quality of care. The safe management of the acutely ill inpatient presents particular difficulties. In the first of five Lancet articles on this topic we discuss patients' safety in the acute hospital. We also present a framework in which responsibility for improvement and better integration of care can be considered at the level of patient, local environment, hospital, and health care system; and the other four papers in the series will examine in greater detail methods for measuring, monitoring, and improving inpatient safety.
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Affiliation(s)
- J F Bion
- University Department of Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
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Abstract
An integrative literature review was conducted to investigate studies on adverse events reported in medical, health services, and nursing literature. The review was guided by the method proposed by Jackson (1980) and Ganong (1987). Three questions shaped the review: (a) What terms are used to denote adverse events? (b) What purposes drive adverse events research? and (c) What data sources are used to study adverse events? Adverse events was the dominant term, the study of adverse events as an outcome variable was the prevailing research purpose, and monitoring or screening the patient clinical record and self-reported incidents by health care professionals were the main data sources. Future research is recommended to conceptualize and study adverse events.
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Affiliation(s)
- Victoria A Kellogg
- Pennsylvania State University School of Nursing, 201 Health and Human Development East, University Park, PA 16802, USA
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Affiliation(s)
- Richard Baker
- Clinical Governance and Research Development Unit, Department of General Practice and Primary Care, University of Leicester, Leicester General Hospital, Leicester LE5 4PW.
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Abstract
The quality assurance movement has been unable to produce major improvements in the realm of clinical practice because of an inability to make satisfactory measurements of process and/or outcome, together with the intrinsic difficulties associated with producing change. Progress in both these areas is likely to be slow. Improvements in the quality of care occurring as a result of the introduction of information technology into clinical practice may be seen more quickly.
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Affiliation(s)
- R W Brown
- Section of Physicians, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Abstract
An emergency department provides care for a full spectrum of undifferentiated disorders and its size may influence how well it can do so. Outcomes research in emergency medicine is limited, although outcomes in severe trauma and acute coronary syndromes have been shown to be influenced by available facilities and expertise. A department can be too small to provide the full spectrum of emergency care, as has been documented with General Practice Casualty Units. Some research suggests that a critical mass is required to ensure acceptable outcomes. Small departments may operate in a hierarchical system, led by teaching hospitals setting practice standards. However, these may be opinion as much as evidence based and not broadly applicable as a universal practice standard. Small departments can be overwhelmed by trauma and other major cases or when the teaching hospital is unable to accept emergency patients or transfers because they are operating at capacity. Further outcomes research and audit of individual hospitals is required to determine a minimum optimum size for emergency departments.
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Affiliation(s)
- Brendon Smith
- Emergency Department, Bankstown Hospital, New South Wales, Australia.
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Brown KM, Naidoo H, Offenberger AE. Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program. Med J Aust 2002; 176:192; author reply 193. [PMID: 11913927 DOI: 10.5694/j.1326-5377.2002.tb04362.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2001] [Accepted: 10/31/2001] [Indexed: 11/17/2022]
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