Patient safety is not a luxury

The National Patient Safety Agency (NPSA) was set up in 2001 in order to make changes at a national level, and lead work on improving patient safety in England and Wales. A core function of the NPSA is to identify trends and patterns in patient safety problems, using its own National Reporting and Learning System (NRLS) and data from other sources. Almost all reports to the NRLS come directly from local risk management systems; staff can also report directly to the NPSA via an electronic form. By the end of August 2005, nearly 230,000 incidents had been reported to the NRLS; 76% of these were reported from acute/general hospitals. The analysis of data in the NRLS is a function of the NPSA’s Patient Safety Observatory (PSO), which has been established to quantify, characterise and prioritise patient safety issues in order to support the NHS in making healthcare safer. The PSO works with key national organisations which hold data relevant to patient safety, such as healthcare regulators, patient’s organisations, clinical negligence bodies and national information and statistics functions. Triangulating information from different data sources enables a fuller picture of the nature and severity of patient safety incidents to be obtained. The key challenges for the PSO are to strengthen the quality of NRLS data, extend the ways in which feedback from the NRLS is provided, and continue to develop methods and tools for the systematic analysis of the huge volumes of incidents reported to the NRLS.

The electronic health record: An essential tool for advancing patient safety

The Need for Physician Leadership in Creating a Culture of Safety

Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

<sec><st>Introduction</st> One in eight babies receive neonatal care in the United Kingdom. Neonates are vulnerable to patient safety incidents due to their immature physiology and requirement for highly intensive care. Patient safety is predicated on the ability to learn from unsafe care. This study is the largest analysis of neonatal patient safety incidents reports from England and Wales to identify the most frequent and most harmful incidents on neonatal units. </sec> <sec><st>Methods</st> The National Reporting and Learning System (NRLS) database receives incident reports from all NHS organisations in England and Wales. All reports submitted from neonatal units between 1 April 2005 and 29 December 2015 were analysed. Exploratory descriptive analysis identified relationships between structured data variables in NRLS, including: type of incident, reported reason for medication error, drug name, and severity of harm outcome. The most frequent or harmful relationships were discussed by a multidisciplinary team with patient safety expertise and knowledge of national guidance. </sec> <sec><st>Results</st> A 2.2-fold increase in reporting exists from 2006 (n=5,172) to 2015 (n=16,466). Of 1 25 832 reports, over one fifth (n=28,796, 22.9%) described harmful outcomes. Errors during delivery of a treatment or procedure were most frequent (23.3%, n=6,703) with 24.4% (n=1,636/6,703) describing extravasation injury. Medication errors accounted for one fifth of reports (21.9%, n=27,522/125,832) of which 13% (n=3,570/27,520) resulted in harm. Most frequently an omission of a medication or ingredient (21.3%, n=784/3,678), wrong or unclear dose or strength (18.5%, n=679/3,678) and wrong frequency (14.5%, n=534/3,678) were reported. Gentamicin (17.4%, n=3,196/18,395), parenteral nutrition (7.07%, n=1,301/18,395) and morphine (6%, n=1,112/18,395) featured most often. Severe harm outcomes resulted from incidents involving morphine (n=5), parenteral nutrition (n=2) and calcium-related medication (n=2). </sec> <sec><st>Conclusion</st> One in five reported safety incidents resulted in iatrogenic harm to a neonate. A quarter of incidents occurred during the delivery of a treatment or procedure. We have identified the most frequent and most harmful reported patient safety incidents involving neonates over a 10 year period. Further in-depth characterisation of reports is required to inform the design of preventive interventions, particularly incidents that persist despite existing patient safety interventions used in the past decade. </sec>

The U.S. Institute of Medicine (IOM) much publicized report in “To Err is Human” (2000, National Academy Press) stated that as many as 98 000 hospitalized patients in the U.S. die each year due to preventable medical errors. This revelation about medical error and patient safety focused the public and the medical community's attention on errors in healthcare delivery including laboratory and point-of-care-testing (POCT). Errors introduced anywhere in the POCT process clearly can impact quality and place patient's safety at risk. While POCT performed by or near the patient reduces the potential of some errors, the process presents many challenges to quality with its multiple tests sites, test menus, testing devices and non-laboratory analysts, who often have little understanding of quality testing. Incoherent or no regulations and the rapid availability of test results for immediate clinical intervention can further amplify errors. System planning and management of the entire POCT process are essential to reduce errors and improve quality and patient safety.

Aims To review never and serious events related to dentistry between 2005-2014 in England.Methods Data from the National Reporting and Learning System (NRLS), with agreed data protection and intelligence governance, was used - snapshot view using the timeframe January 2005 to May 2014. The Strategic Executive Information System (STEIS) database was reported separately for 2012-2013 and 2013-2014. The free text elements from the database were analysed thematically and reclassified according to the nature of the patient safety incident (PSI).Results From the NRLS dataset, 32,263 patient safety events were reported between 1 January 2005 and 30 May 2014. Never events (NEs) from STEIS files were all wrong site extractions (WSS), reported separately for 2012-2013 and 2013-2014. The total number was 43.36 of the 43 PSIs were WSS involving: multiple extractions and bimodal age distribution (very young or over 60 years). Forty-seven percent of never events resulted in no harm, 20% low harm, 7% moderate harm, less than 1% severe harm and 23 deaths over this period (five of which were not related to dentistry). Serious harm and death risk factors included: care in an acute trust ward, peri oncological, reconstructive surgery (OMFS), patient age over 67 years with concurrent medical complexity (Ischaemic heart disease). Sixty percent of PSIs occurred in OS/OMFS in acute trust inpatients and 20% in primary care. From STEIS 2012-2013, 21 WSS were reported of which 50% occurred in oral surgery (OS) or oral and maxillofacial surgery (OMFS). The reported sites were 45% in operating theatre and 42% in dental surgery.Conclusion Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely carried out. Improved awareness and training, simplifying the reporting systems improved non-punitive support by regulators would allow the improvement of patient safety in dental practise.

BackgroundThe National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.MethodsThis study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure.Findings5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events [OR 1.61(95%CI: 1.12 to 2.27), p<0.01] and pharmacy was the hospital location where most near-misses were captured [OR 3.03(95%CI: 2.04 to 4.55), p<0.01]. Clinicians were significantly more likely to report death than other staff [OR 3.04(95%CI: 2.43 to 3.80) p<0.01]. A higher ratio of clinicians to beds correlated with reduced rate of harm reported [RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03]. Litigation claims per bed were significantly negatively associated with incident reports. Patient satisfaction and mortality outcomes were not significantly associated with reporting rates. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives increased reporting rates [r = 0.26 (p<0.01), r = 0.17 (p = 0.04), r = 0.23 (p = 0.01), r = 0.20 (p = 0.02)].ConclusionThe NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall reporting rate. There were no association between size of hospital, number of staff, mortality outcomes or patient satisfaction outcomes and incident reporting rate. The study did show that hospitals where staff reported more incidents had reduced litigation claims and when clinician staffing is increased fewer incidents reporting patient harm are reported, whilst near misses remain the same. Certain specialties report more near misses than others, and doctors report more harm incidents than near misses. Staff survey results showed that open environments and reduced fear of punitive response increases incident reporting. We suggest that reporting rates should not be used to assess hospital safety. Different healthcare professionals focus on different types of safety incidents and focusing on these areas whilst creating a responsive, confidential learning environment will increase staff engagement with error disclosure.

Nurses as key members of the healthcare team need to know about the National Reporting and Learning System (NRLS) of the National Patient Safety Agency (NPSA) and its analysis of reported patient safety incidents. Nobody wants adverse patient safety incidents to occur and when they do we need to learn the lessons to stop them or at least to minimize the likelihood of them occurring again, so far as we reasonably can. To get to know where you are going you have got to know where you have been. The NPSA report (NPSA, 2006) tells us exactly this in the context of patient safety incidents in the NHS – the summary provides an update on incidents reported to the NRLS from all sectors of the NHS. A pattern of incident types and severity is shown

In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education.The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.

Residual anaesthesia drugs in intravenous lines – a silent threat?

BackgroundEstimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of &gt; £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.AimOur aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.Methods and resultsWe developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.ConclusionThis research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.Trial registrationCurrent Controlled Trials ISRCTN07689702.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Back to table of contents Previous article Next article Legal NewsFull AccessGreat Minds Think Alike in Push To Reduce Medical ErrorsMarynell Hinton, M.A., Marynell HintonSearch for more papers by this author, M.A., senior risk managerPublished Online:4 Jun 2004https://doi.org/10.1176/pn.39.11.0390028The history of the patient safety movement is well known. In December 1994 Lucian A. Leape published the article “Error in Medicine” in the Journal of the American Medical Association that sounded the initial alarm about medical errors and their impact on patient care. This was followed in 1999 by the Institute of Medicine's (IOM) controversial report “To Err Is Human.” The IOM's report stressed that medical errors result primarily from defects in systems and not, as widely believed, from individual human error. This report galvanized organizations, hospitals, and governments across the country to embark on large-scale attempts to improve patient care and safety by reducing medical errors.A prime example of the response is the National Patient Safety Foundation's (NPSF) four-tiered approach to improving patient safety, proposed in its 1999 annual report. The NPSF called for the following goals:To establish a national focus to create leadership, research, tools, and protocols.To identify and learn from medical errors through mandatory and voluntary reporting.To raise standards and expectations for safety improvement through actions of oversight organizations, group purchasers, and professional groups.To implement safe practices at the delivery level.Extensive cognitive research has shown us that the two principal, underlying thought processes that result in human error are unintentional actions in the performance of routinized tasks and mistakes in judgment or inadequate plans of action. Specific errors appear to be based on either active failures (that is, errors or violations of rules) or latent failures (that is, errors focused on organizational and systemic processes). Latent failures are considered the most dangerous type of failures, according to James Reason in his book Human Error (Cambridge University Press, 1990).Patient Safety ResourcesAPA:www.psych.org/psych_pract/pract_mgmt/apa_patientsafety_toc21003.pdfJoint Commission on Accreditation of Healthcare Organizations:www.jcaho.orgNational Patient Safety Foundation:www.npsf.orgOn the basis of the most recent research, the current patient safety movement has moved away from blaming individuals and has adopted, instead, an approach that focuses on the systems (that is, the polices, procedures, regulations, and technological factors) that contribute to errors. This systems approach allows us to recognize where systems are weak and to develop strategies that prevent potential errors. This design is flexible; it is both proactive and reactive. It is a continuously looping process that involves in-process detection, process change, and process reassessment, according to B. A. Liang in the article “Error in Medicine: Legal Impediments to U.S. Reform,” which appeared in 1999 in volume 24 of the Journal of Health Politics, Policy, and Law.The risk management process is also a systems approach to supporting patient care. The process consists of five steps: (1) identifying potential risks, (2) evaluating potential risks, (3) choosing a risk management strategy or combination of strategies (that is, accept, avoid, minimize, or transfer risk), (4) implementing the strategy/strategies, and (5) evaluating the effectiveness of the strategy/strategies.The barriers to implementation of a systems approach to error reduction, either overall error reduction programs or the risk management process specifically, seem to fall into one of two categories: (1) lack of will and (2) concern about legal or disciplinary actions, according to Mark Crane in the article “The Godfather of Patient Safety Sees Progress,” which appeared in the August 8, 2003, issue of Medical Economics.Lack of will to change the cultural approach to error reduction is partly a result of cultural and organizational inertia, which is itself a systemic problem, and partly because individual error rates are low. As individuals, health care professionals are seldom involved personally with errors that cause harm to patients; therefore, their perceptions may not reflect an accurate appreciation of the scope of the problem.Concerns about possible legal and disciplinary repercussions for candidly addressing errors are not unrealistic. Plaintiffs' attorneys, licensing bodies, hospitals, and health plan organizations may choose to take unfair advantage of information disclosed during investigations into errors. To protect this information, many state governments have passed peer review statutes that hospitals and facilities are using.Changing cultural, individual, and group perceptions regarding the approach needed to address patient safety issues successfully will continue to take time and effort. In the meantime, incorporating the risk management process into one's practice can be a valuable tool for improving overall systems and thus improving patient safety. ▪Professional Risk Management Services Inc., the manager of the APA-endorsed Psychiatrists' Professional Liability Insurance Program. ISSUES NewArchived

IntroductionSurgical care has been a vital part of healthcare services worldwide. Several patient safety measures have been adopted universally in the operating room (OR) before, during, and following surgical procedures. Despite this, errors or near misses still occur. Nurses in the OR have a pivotal role in the identification of factors that may impact patient safety and quality of care. Therefore, exploring the OR nurses’ understanding of their roles and responsibilities for patient care and safety in the intraoperative practice, which could lead to optimal patient safety, is essential.ObjectiveThis study explored the understanding of OR nurses regarding their roles and responsibilities for patient care and safety measures in the intraoperative practice.MethodsThe study was conducted in one of the tertiary care hospitals in the United Arab Emirates. Qualitative, descriptive, exploratory research design was utilized. The data were collected using semi-structured face to face interviews. Purposive sampling included eight nurses. Data analysis was performed following Colaizzi's seven-step strategy.ResultsSeven emerging themes were identified. The main themes are: patient safety, preoperative preparation, standardization of practice, time management, staffing appropriateness, staff education and communication, and support to the patient in the OR.ConclusionOR nurse leaders may take into consideration the current findings as a reference for quality improvement projects in the hospital, considering the specific characteristics of each local setting. Although the participants consider that the environment is safe and the quality of care is high in the study setting, there is still room for improvement on workflows and processes. OR workflow should be improved especially by addressing the potential patient safety issues.

BackgroundWe undertook a prospective qualitative study to ascertain the perceptions and experience of trainee doctors in the first two years of formal core surgical training related to patient safety improvement and incident reporting. We sought to explore the beliefs, knowledge and opinions of core surgical trainees related to patient safety improvement, their understanding of existing patient safety initiatives and their experience and attitudes to incident reporting.MethodsWe identified 1133 doctors in formal core surgical training posts in the United Kingdom at this time, and we contacted these doctors to invite them to participate in our study. We received responses from 687 (60.6%) core surgical trainees, and 612 trainees (54%) agreed to participate.The study participants underwent an interview using structured questions asked by trained assessors with an opportunity to explore any particular themes identified by the trainee in more detail. Qualitative data related to the knowledge, experience and perceptions of safety improvement and incident reporting were collected.ResultsOverall, 163 surgical trainees (26.6%) reported that they felt that they could impact patient safety positively. A total of 222 trainees (36.3%) had been involved in or witnessed an adverse patient safety event, while 509 trainees (83.2%) reported that they had witnessed a ‘near-miss’ event. Only 81 trainees (13.2%) had submitted a patient safety report at some point in their career. In addition, 536 trainees (87.6%) reported that they considered a patient safety or incident report to be ‘negative’ or ‘seriously negative’ and that they would be discouraged from making these because of the negative connotations associated with them.Of the 81 core surgical trainees who had submitted a patient safety report, only nine trainees (11.1%) reported that they had received a meaningful reply and update following their report. Several themes were identified during the interviews in response to open questions. These included a perception that patient safety improvement is the responsibility of senior surgeons and managers and that surgical trainees did not feel empowered to influence patient safety improvement. Trainees expressed the view that incident reporting reflected negatively on clinicians and the standard of care provided, and there were reports of culture based on blame and the fear of litigation or complaints. Surgical trainees did not feel that incident reporting was an effective tool for patient safety improvement, and those trainees who had made patient safety reports felt that these did not result in change and that they often received no feedback.ConclusionsCore surgical trainees report that they are not well engaged in patient safety improvement and that their perceptions and experience of incident reporting are not positive. This represents a missed opportunity. We suggest that in order to recruit the surgical workforce to the improvement work and learning associated with patient safety, opportunities for focused education, training and culture change are needed from the early years of surgical training. In addition, improvements to the processes and systems that allow trainees to engage with safety improvement are needed in order to make these more user-friendly and accessible.