Adverse Events In Health Care Research Articles

An evidence‐based toolkit for the development of effective and sustainable root cause analysis system safety solutions

Root cause analysis (RCA) after adverse events in healthcare is a standard practice at many institutions. However, healthcare has failed to see a dramatic improvement in patient safety over the last decade. In order to improve the RCA process, this study used systems safety science, which is based partly on human factors engineering principles and has been applied with success in other high-risk industries like aviation. A multi-institutional dataset of 334 RCA cases and 782 solutions was analyzed using qualitative methods. A team of safety science experts developed a model of 13 RCA solutions categories through an iterative process, using semi-structured interview data from 44 frontline staff members from 7 different hospital-based unit types. These categories were placed in a model and toolkit to help guide RCA teams in developing sustainable and effective solutions to prevent future adverse events. This study was limited by its retrospective review of cases and use of interviews rather than clinical observations. In conclusion, systems safety principles were used to develop guidelines for RCA teams to promote systems-level sustainable and effective solutions for adverse events.

Making Good Better: Implementing a Standardized Handoff in Pediatric Transport

BackgroundFailures in communication lead to adverse events in healthcare. Handoffs, defined as the transfer of information, responsibility, and authority from one provider to another, have been identified as a cause of communication failure compromising patient safety. Locally, there was dissatisfaction among caregivers working on the general care and intensive care units regarding the quality of information received from the pediatric transport team for transferred patients. MethodsUsing the Model for Improvement, a quality improvement team was engaged to lead this improvement effort. The team developed a standardized and scripted transport handoff process that incorporated parental input. The primary measure was provider satisfaction (reported as overall handoff score, OHS). Secondary outcomes included the use of components outlined by the Joint Commission's guidelines for safe handoff. Data were collected using a Likert-style survey and collated using Microsoft Excel. ResultsBaseline measures of OHS were 81.5 ± 19.4 (mean±SD) with an interval analysis showing no improvement (81.6±17.4, P=0.99). Further modifications were made to both education and process with an improved OHS (88.8±11.1, P<0.05). Certain specific handoff components showed the greatest improvement according to caregivers. ConclusionThis practical, low-cost quality-improvement project may help others improve handoff communication and provide safe, high-quality care.

An Analysis of the Culture in Ireland on Open Disclosure following Adverse Events in Healthcare

The aim of the paper is to assess open disclosure in Ireland following clinical adverse events in healthcare. A number of areas were examined from the patient's and healthcare team's perspectives. The barriers/constraints to open disclosure, the extent of policies, procedures or guidelines that are available for staff to consult with, inclusive of how they are implemented, harvested valuable insight. The supports available for healthcare staff following an adverse event and patients’ expectations after such an event are also encompassed to include the relationship open disclosure has on concerns regarding litigious intent. The questionnaire was disseminated to a multidisciplinary healthcare group. The questions were numbered 1–9, with a mixture of open and closed questions. A five-point Likert format was used with three questions in attitudinal/ opinion statements, regarding supports available for staff following an adverse event. A Statistical Package for Social Sciences was used to assist with the interpretation of data. This study was directed at the multidisciplinary healthcare team and senior management within the Health Service Executive (HSE) and Voluntary sectors. The oldest hospitals in Ireland are voluntary public hospitals some of them originating from the 18th century, having been established by charities and religious orders. Voluntary hospitals are partly funded by the HSE, specifically having their own governance structure. There was a response rate of 67% ( n = 192). A total 56.5% of respondents stated their organization did not have an open disclosure policy, procedure or guideline in place however, 16% of the attendees stated there was one in place. A total of 54.4% (104) acknowledged barriers/concerns surrounding open disclosure, with fear of litigious intent noted by 24% of respondents. A total of 52.3% (101) identified support availability to staff following an adverse event, 38.9% (10) felt there was little/no follow-up support, with 11.1.% (2) stating they were made to feel guilty, and associated it with being “on trial”. Findings demonstrate an unstructured approach to disclosure of adverse events in Ireland, with fear of litigation a major concern for healthcare professionals. Error awareness among the general public, the introduction of protective legislation and implementation of a national standard on open disclosure in conjunction with practical training and education will all positively and practically influence open disclosure of adverse events in Ireland.

Mapping von LEP Nursing 3 auf das ISO-Referenzterminologiemodell für Pflegeinterventionen

Information and communication technologies have been widely distributed throughout the healthcare system during the past ten years. Process optimisations, increased efficiency and efficacy as well as improved patient safety have been the positive outcomes of this evolution. Negative outcomes exist as well: scaring reports on increased mortality due to badly implemented IT systems might be the top of the pyramid. However, publications addressing computer-related adverse events in healthcare are only scarce. As the risk of e-iatrogenesis rises, this publication presents outcomes of the CIRS database in our hospital, including 312 reports during 2011 with the clinical information system being mentioned most frequently. Additionally, a framework consisting of ten technical and ten sociotechnical archetypes (TST-20) associated with adverse events is proposed. By requesting, recording, classifying and publishing computer-related adverse events, we move ahead towards the era of evidence-based medical informatics.

Editorial print issue 2012 (August 21, 2012)

Information and communication technologies have been widely distributed throughout the healthcare system during the past ten years. Process optimisations, increased efficiency and efficacy as well as improved patient safety have been the positive outcomes of this evolution. Negative outcomes exist as well: scaring reports on increased mortality due to badly implemented IT systems might be the top of the pyramid. However, publications addressing computer-related adverse events in healthcare are only scarce. As the risk of e-iatrogenesis rises, this publication presents outcomes of the CIRS database in our hospital, including 312 reports during 2011 with the clinical information system being mentioned most frequently. Additionally, a framework consisting of ten technical and ten sociotechnical archetypes (TST-20) associated with adverse events is proposed. By requesting, recording, classifying and publishing computer-related adverse events, we move ahead towards the era of evidence-based medical informatics.

Wenn das KIS Fehler macht: von Critical incidents und Adverse events im Alltag

Information and communication technologies have been widely distributed throughout the healthcare system during the past ten years. Process optimisations, increased efficiency and efficacy as well as improved patient safety have been the positive outcomes of this evolution. Negative outcomes exist as well: scaring reports on increased mortality due to badly implemented IT systems might be the top of the pyramid. However, publications addressing computer-related adverse events in healthcare are only scarce. As the risk of e-iatrogenesis rises, this publication presents outcomes of the CIRS database in our hospital, including 312 reports during 2011 with the clinical information system being mentioned most frequently. Additionally, a framework consisting of ten technical and ten sociotechnical archetypes (TST-20) associated with adverse events is proposed. By requesting, recording, classifying and publishing computer-related adverse events, we move ahead towards the era of evidence-based medical informatics.

EHealth to enhance, not to replace, the role of doctors

Information and communication technologies have been widely distributed throughout the healthcare system during the past ten years. Process optimisations, increased efficiency and efficacy as well as improved patient safety have been the positive outcomes of this evolution. Negative outcomes exist as well: scaring reports on increased mortality due to badly implemented IT systems might be the top of the pyramid. However, publications addressing computer-related adverse events in healthcare are only scarce. As the risk of e-iatrogenesis rises, this publication presents outcomes of the CIRS database in our hospital, including 312 reports during 2011 with the clinical information system being mentioned most frequently. Additionally, a framework consisting of ten technical and ten sociotechnical archetypes (TST-20) associated with adverse events is proposed. By requesting, recording, classifying and publishing computer-related adverse events, we move ahead towards the era of evidence-based medical informatics.

The social dimensions of safety incident reporting in maternity care: The influence of working relationships and group processes

Over the past twenty years there has been a growing awareness of the scale and cost of adverse events in health care. In this paper we discuss findings from a study, undertaken in 2008, investigating social and cultural influences on incident reporting in maternity care in one UK National Health Service hospital. Maternity claims account for 50% of NHS compensation expenditure, with claims arising from poor fetal heart monitoring alone amounting to £85.8 million in 2010. Earlier studies on incident reporting used case note review and staff self-reports. We used ethnographic methods to highlight the social nature of, and social processes around, incident reporting, and the use of the collegial work group as an aid to decision-making. Incident reporting was rarely an isolated, private event, but the result of a process involving group deliberation. We suggest that incident reporting in health care should be regarded as a process rather than an event and reporting policies adjusted to accommodate group processes in order to improve reporting rates. While the paper presents findings from a single site we suggest these may add to the understanding of reporting in other care areas of health care. The key contribution this paper makes is to report the existence of a process of worker peer conferral as a decision-making aid prior to incident reporting.

Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence.

Aim:To review the literature on the use of simulation in the development of non-technical skills in nursingBackground:The potential risks to patients associated with learning 'at the bedside' are becoming increasingly unacceptable, and the search for innovative education and training methods that do not expose the patient to preventable errors continues. All the evidence shows that a significant proportion of adverse events in health care is caused by problems relating to the application of the 'non-technical' skills of communication, teamwork, leadership and decision-making.Results:Simulation is positively associated with significantly improved interpersonal communication skills at patient handover, and it has also been clearly shown to improve team behaviours in a wide variety of clinical contexts and clinical personnel, associated with improved team performance in the management of crisis situations. It also enables the effective development of transferable, transformational leadership skills, and has also been demonstrated to improve students' critical thinking and clinical reasoning in complex care situations, and to aid in the development of students' self-efficacy and confidence in their own clinical abilities.Conclusion:High fidelity simulation is able to provide participants with a learning environment in which to develop non-technical skills, that is safe and controlled so that the participants are able to make mistakes, correct those mistakes in real time and learn from them, without fear of compromising patient safety. Participants in simulation are also able to rehearse the clinical management of rare, complex or crisis situations in a valid representation of clinical practice, before practising on patients.

Design of a decision support system for preventive maintenance planning in health structures

The appropriate maintenance of medical devices, including performance inspections and preventive maintenance, is fundamental in mitigating clinical risk caused by adverse events in health care. Although several models for managing and planning preventive maintenance have been developed, the problem is lacking in standard methodology and still presents an open challenge for today's health experts. This paper aims to provide and develop methodology together with support systems able to assist decision makers in constructing preventive maintenance and performance inspection plans, taking into account both the technical and economic needs of hospital clinical engineering departments. Interventions by decision makers are of crucial importance within complex situations where large numbers, types of devices and different contractual situations are involved. SISMA system has achieved optimal results with minimum expense and maximum security for patients and technicians at the University Hospital of Florence where it has been applied in actual case studies.

Error awareness to enhance paediatric prescribing amongst junior doctors: a novel evidence based educational strategy

Aims Prescribing errors are one of the most common adverse events in healthcare, with those working in paediatrics at particular risk. Junior medical staff have also been identified as at risk of being involved in such errors, due to inexperience and their responsibility of 75% of inpatient orders. Whilst much research reports systems based approaches to enhance prescribing, there are few studies concerning the role of education1. Previous research in patient safety has highlighted the importance of error awareness education to enhance professional attitudes and reduce errors, although its effectiveness is poorly investigated2. In addition, it has been postulated that knowledge of errors, so called error wisdom, can improve mental preparedness and enhance skills. Feedback systems for errors are limited by their practicalities in a shift based working pattern and are often interpreted by junior staff as a blame culture. We set out to introduce anonymous departmental prescribing feedback to enhance error awareness and error wisdom and assess its impact on medication errors and patient safety attitudes. Methods The setting was an inpatient paediatric unit with 20 junior medical staff. A patient safety attitudes questionnaire (APSQ-II) was completed at baseline. A prospective medication chart review was undertaken on a fortnightly basis for 3 months. After each review, key data was presented in a poster, offering contemporaneous and anonymous feedback (figure 1). At completion, participants again completed the APSQ-II survey. Results After the completion of the 3 month feedback period, the percentage of trainee orders containing minor errors showed a statistically significant drop from 75.9% to 25.9% (p=0.007). At baseline, the mean APSQ-II score was 124.6 and post intervention the mean was 129.7, suggesting improved patient safety attitudes, although this result was not statistically significant. Conclusions This small study has demonstrated the potential utility of this simple and easy to introduce standalone form of education. It can enhance junior doctor paediatric prescribing, reduce errors and enhance attitudes. Although further research is needed, this study suggests the importance of error awareness as a part of any programme on patient safety education.

Catching and correcting near misses: The collective vigilance and individual accountability trade-off

Despite the focus on patient safety and quality health care for the last two decades, there is still limited understanding of how interprofessional interactions at an organizational or work unit level influence how clinicians perceive and respond to safety events and errors. Within the rubric of safety events, there has been a growing interest in near misses as precursors to adverse events in health care. Given the interactive nature of the variety of professionals working together in the delivery of health care, understanding how the different clinicians experience and respond to near misses in practice is important. A constructivist grounded theory approach was employed for this study which included semi-structured interviews with 24 participants in a large teaching hospital in Canada. Findings from this study provide a deeper understanding into how different clinicians experience and respond to near misses in clinical practice. This understanding indicates that collective vigilance can potentially create risk by eroding individual professional accountability through reliance on other team members to catch and correct their errors. Further research is needed to explore in more depth the trade-offs between collective vigilance and individual accountability by relying on others to catch and correct the potentially harmful errors and avert negative outcomes.

A novel system of prescribing feedback to reduce errors: A pilot study

Prescribing errors are one of the most common adverse events in healthcare. Previous research in patient safety has highlighted the importance of error awareness education to enhance professional attitudes and reduce errors. Systems of contemporaneous prescribing feedback previous researched are limited by shift working. We introduced a departmental prescribing feedback system to address this limitation. We used a Before and After study design. The setting was a single inpatient paediatric unit and 26 Paediatric medical staff participated. Baseline assessment of prescribing errors and safety attitudes took place, followed by 3 weekly reassessments over a 3 month period. After each assessment, a feedback poster was displayed and emailed to staff, giving general and anonymous personalised feedback. 205 medication orders representing 3,280 opportunities for error were examined. There was a statistically significant reduction in the error rate (P < 0.0001) between baseline (8.8%, 69 out of 784 possibilities for error) and completion at 3 months (1.8%, 12 out of 656 possibilities for error). There was an improvement in patient safety attitudes, but this was not statistically significant. This pilot project has demonstrated an error feedback system can reduce errors. This technique could be easily adopted and introduced, warranting further research.

Revisión sistemática de la literatura acerca de la seguridad de los pacientes hospitalizados en servicios médicos

Patient safety is an issue of interest. All scenarios of health care have a risk of adverse events (AE) and determination of its incidence has been reported in virtually all medical specialties. Objective To determine the incidence reported in the medical literature of adverse events in medical departments. Design and methods An exhaustive search of biomedical databases using different strategies, search in high impact journals and a manual search of related articles. Results We reviewed 17,437 entries. After reading the abstracts and articles, and applying previously defined inclusion and exclusion criteria, we selected 10 articles that reported the incidence of adverse events in medical departments. Most studies corresponded to a historical cohort, had used an AE screening to identify high risk patients, and had used a structured review to check clinical records. None of them had as their ultimate objective to report on the impact of adverse events or characterize them. The incidence reported in medical departments ranged from 3.6% to 21.7%. The definitions of adverse events and forms of detection were similar; however the few differences put the comparability at risk. Conclusion No studies were aimed at quantifying or characterising the adverse events in health care. None of them defined what constitutes a medical department, although the results reported are within the published values for health systems. Further research is needed in this area.

Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study

OBJECTIVE:To analyze the prevalence and types of prescribing and dispensing errors occurring with high-alert medications and to propose preventive measures to avoid errors with these medications.INTRODUCTION:The prevalence of adverse events in health care has increased, and medication errors are probably the most common cause of these events. Pediatric patients are known to be a high-risk group and are an important target in medication error prevention.METHODS:Observers collected data on prescribing and dispensing errors occurring with high-alert medications for pediatric inpatients in a university hospital. In addition to classifying the types of error that occurred, we identified cases of concomitant prescribing and dispensing errors.RESULTS:One or more prescribing errors, totaling 1,632 errors, were found in 632 (89.6%) of the 705 high-alert medications that were prescribed and dispensed. We also identified at least one dispensing error in each high-alert medication dispensed, totaling 1,707 errors. Among these dispensing errors, 723 (42.4%) content errors occurred concomitantly with the prescribing errors. A subset of dispensing errors may have occurred because of poor prescription quality. The observed concomitancy should be examined carefully because improvements in the prescribing process could potentially prevent these problems.CONCLUSION:The system of drug prescribing and dispensing at the hospital investigated in this study should be improved by incorporating the best practices of medication safety and preventing medication errors. High-alert medications may be used as triggers for improving the safety of the drug-utilization system.

The role of individual diligence in improving safety

This paper aims to be a theoretical examination of the role of individuals in sponsoring and facilitating effective, systemic change in organisations. Using reports of a number of high-profile initiatives to improve patient safety, it seeks to analyse the role of individual health care professionals in developing and facilitating new systems of care that improve safety and quality. The paper uses recent work in sociology that is concerned with the phenomenon of "sociological citizenship". The authors test whether successful initiators of change in health care can be described as sociological citizens. This notion of sociological citizens is applied to a number of highly successful initiatives to improve safety and quality to extrapolate the factors associated with individual clinician leadership, which may have affected the success of such endeavours. In each of the examples analysed the initiators of change can be characterised as sociological citizens. In reviewing the roles of these charismatic individuals it is evident that they see the relational interdependence between the individuals and organisations and that they use this information to achieve both professional and organisational objectives. The paper uses a case study method to investigate the usefulness of the role of sociological citizenship in interventions that aim to improve patient safety. The paper reviews the key concepts and uses of the concept of sociological citizenship to produce a framework against which the case studies were assessed. The authors suggest that a goal of policy for improving patient safety should be directed to the problem of how hospitals and health care organisations can create the conditions for encouraging the individual diligence and care that is needed to support reliable, safe health care practices. Improving the safety and quality of health care is an important public health initiative. It has also proven to be difficult to achieve sustained reductions in the harm caused by the occurrence of adverse events in health care. The process of linking individual diligence with service outcomes may help to overcome one of the enduring struggles of health care systems around the world: the policy-practice divide. The paper directs attention towards the role of sociological citizenship in health care systems and organisations.

Review: Patient safety: a core value of nursing - so why is achieving it so difficult?

Issues of patient safety have had greatest effect when responding to failures in safety or poor performance at particular hospitals or by particular individuals. Florence Nightingale was no different. Her understanding about what we now term as patient safety grew out of her own experiences of adverse events in healthcare. She learned from those patients that died unnecessarily and she learned about what worked in order to minimise risk and harm. These lessons were so profound for her that she devoted the rest of her life to improving patient safety through, amongst other things, good basic nursing care. Interestingly, however, the need for a systematic effort to address patient safety only really began to emerge in the 1990s, both in the United Kingdom and internationally, when concern about patient safety began to rise among healthcare professionals. This paper describes the journey from the publication of the US Institute of Medicine’s seminal report To Err is Human (Kohn et al., 1999), to today. To Err is Human set out the scale of the problem for the first time, saying that deaths due to ‘medical error’ in hospitals were more common than deaths due to vehicle accidents, breast cancer or HIV/AIDS, and argued for a system-wide, nationally led response to improve patient safety. Over the last 10 years inquiries into failures in care provided by institutions or individuals have taken place regularly, along with a number of national reviews of patient safety in the NHS. This paper describes eloquently the challenges faced by the NHS as identified by these inquires and reviews; a culture of indifference or blame, acceptability that complications of care are the norm, the struggle to gain sustained implementation of change. The paper then goes on to view patient safety through the lens of perioperative care, providing a focus on culture, training, communication and team work. This is skilfully described by authors who clearly have an expert understanding and knowledge related to this field. Despite the efforts of the last decade, the authors conclude that the same challenges faced by Florence Nightingale and her peers in the 1860s remain today and calls for perioperative nurses to embrace safety science and human factors.

Patient safety: a wake‐up call

PurposeThe aim of this review is to examine factors that may explain why other industries are considered ultrasafe while progress toward preventing adverse events in health care is not considered to have reached that level.Design/methodology/approachThe paper is a narrative review.FindingsDespite a decade of intense effort, the problem of patient harm in health care facilities remains a challenge. A recent study of ten hospitals in North Carolina, which have actively engaged in patient safety initiatives, reported rates of adverse events similar to those in the Institute of Medicine report, To Err Is Human in 1999. Seven key issues and their interaction are described.Research limitations/implicationsThis review focuses on broad issues that likely impede progress generally, not on individual project or individual hospital program success stories.Originality/valueThe authors believe the difficulty in making significant headway on the patient safety agenda is due in part to the fact that it was always going to be a long (indeed never ending) struggle – aviation for example took almost 60 years to become ultra‐safe – and in part to misunderstanding the nature of the dynamics that are involved in the generation of adverse events in risk critical industries. The paper reflects on the nature of the safety initiatives that health care has tended to focus on, but which have not sufficiently taken note of central concepts of safety science, as well as on features of the health care system itself that have impeded, in the authors' view, progress on enhancing patient safety.

Never Events

Never Events

Preventing adverse healthcare events: lessons from abroad

John Tingle discusses a patient safety report from Minnesota, USA which contains some important lessons for maintaining and developing a safe and proper healthcare treatment environment.