Avoidable Adverse Events Research Articles

Beyond the numbers: Classifying contributory factors and potentially avoidable adverse events in the gynaecology service of National Women's Health at Auckland District Health Board.

Adverse events (AEs) during health care are common and may have long-term consequences for patients. Although there is a tradition of reviewing morbidity and mortality in gynaecology, there is no recommended system for reporting contributory factors and potential avoidability. To identify factors that contributed to AEs in the gynaecology service at National Women's Health at Auckland District Health Board and to determine potential avoidability, with the use of a multidisciplinary morbidity review. Contributory factors from a review of AEs in gynaecology services were identified and classified as organisational and/or management factors, personnel factors and barriers to patients accessing and engaging with care. Potential avoidability of the AE was also considered. A descriptive analysis of the morbidity review of patients who had an AE from 2019 to 2022 was undertaken. One hundred and fifty-three cases of AEs were reviewed and 77 (50.3%) were associated with contributory factors. Of all cases, 45 (29.4%) had organisational factors, 54 (35.3%) had personnel factors and patient factors resulting in barriers to care contributing to 11 (7.2%) cases. Sixty-five cases (42.5%) were classified as potentially avoidable. Of these 65 cases, 38 (58.5%) had organisational factors, 48 (73.8%) had personnel factors and nine (13.9%) had barriers to care. The AE review process reported 50.3% of AEs had contributory factors that were classified as organisational, personnel and barriers to patients accessing care and that 42.5% of the AEs were potentially avoidable. These reviews can be used for making recommendations that potentially lead to improvements in gynaecology.

Tools for deprescribing in severe dementia: A scoping review

AbstractObjectivesIdentification of inappropriate medications in people living with severe dementia is a complex task which has the potential to reduce avoidable adverse events and increase quality of life. This scoping review (i) identifies published tools intended to aid deprescribing in people living with severe dementia and (ii) describes evaluations of their usefulness in clinical practice.MethodsA scoping review was undertaken, with Medline, Medline in Process, EMBASE, Cochrane Library, CINAHL, Scopus and Web of Science databases, from inception to April 2023, identifying tools for deprescribing in severe dementia. A tool was considered as any resource for deprescribing, including clinical study, scientific publication, health guideline, website, algorithm, model or framework. Two reviewers assessed the eligibility of articles through abstract and full text review. Data extracted from included studies were summarized through narrative synthesis.ResultsTwelve studies were identified from 18,633 articles screened. Tools were categorized into three groups: deprescribing interventions (n = 2), consensus‐based deprescribing criteria (n = 5), and medication‐specific recommendations (n = 5). Six studies developed tools using expert opinion and ten tools were tested in people living with severe dementia. Only one of the four studies that evaluated patient outcomes (cognitive change and adverse events) identified clear clinical benefit from medication withdrawal.ConclusionsClinical application of current deprescribing tools is limited due to the lack of evidence‐based research on the clinical effects of individual medication deprescribing in people with severe dementia. Further research on patient outcomes, including cognitive change and adverse events, will help clarify the role of these tools in clinical care.

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

A CASE REPORT: ANTIRETROVIRAL-ASSOCIATED BILATERAL GYNECOMASTIA

Highlights: Gynecomastia is a known potential side effect of efavirenz, which may manifest in HIV patients. Healthcare providers should be vigilant and address the potential adverse effects of medications prescribed to individuals with HIV, including gynecomastia. Surgeons in resource-limited areas show flexibility and can achieve satisfactory results in procedures despite limited resources and surgical options. Abstract: Background: Human Immunodeficiency Virus (HIV) patients can now access antiretroviral drugs even in resource-limited area. The majority of patients receive the fixed daily dose of an efavirenz-based antiviral (ARV) as advised by the World Health Organization (WHO), despite the fact that gynecomastia is a recognized side effect of evafirenz. Case Ilustration: We report a 31 year-old male with antiretroviral-associated gynecomastia that underwent the bilateral excision without liposuction procedure with satisfying result. Discussion: Surgeon in limited-resource area faces limited resources to perform some specific procedure. Meanwhile, limited resources also poses patients avoidable adverse events in otherwise clinical setting. The antiretroviral-associated gynecomastia is unavoidable because limited regimen choice. Surgeon needs also to adjust the surgical option to achieve satisfying result without instrument complexities. Conclusion: We reported satisfying surgical outcome in antiretroviral-associated bilateral gynecomastia patient with limited clinical setting.

Using simulation to improve confidence in the escalation of patients with learning disabilities by nurses in the acute care setting

The National Early Warning Score (NEWS) is used to collate measurements of patients’ vital functions, identifying patients who require management to prevent deterioration [1]. Not following NEWS escalation protocols is linked to adverse events and may occur due to prioritising clinical judgement over scores and communication failures [2]. Patients with learning disabilities are even more at risk of avoidable adverse events in hospital, but education to improve the understanding of the needs of these patients may be a protection against this [3]. This research assessed the improved confidence of nurses in escalation following a simulation-based course focused on escalating an unwell patient with learning difficulties. The course started with an interactive talk on how to measure NEWS by a nurse educator. A simulation-based video we created of a mismanaged scenario involving a patient with learning disabilities was shown, followed by a discussion about handover using the SBAR structure. The simulation required the attendee accurately calculating a NEWS score of an actor connected to a monitor we could control and escalate to a doctor over the phone. This simulation was shown in real time to the other attendees, and the debriefing was facilitated by a doctor trained in debriefing. Pre- and post-course questionnaires were completed by attendees to assess their nursing experience, confidence in assessing NEWS, and escalation rated on a scale of 0 (very unconfident) to 5 (very confident). The course was run 6 times for a total of 26 nurses. The median length of nursing experience was 17 months (range 1–249months). More attendees were confident (defined as 4 or 5 out of 5 in the confidence scale) in assessing NEWS, escalating to the medical team, and using SBAR post-course (96%, 96%, and 93% respectively) compared to pre-course (68%, 57%, and 54% respectively), which can be seen in Confidence of the participating nurses before and after the course. This simulation-based course focusing on care of a patient with learning disabilities has improved confidence in assessing NEWS and escalation with a structured handover to the medical team. Further research should be focused on multidisciplinary simulation on escalation in the acute care setting, and how including cases involving learning disabilities improves outcomes in this at-risk group. 1. Royal College of Physicians. National Early Warning Score (NEWS) 2 Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: 2017. 2. Ede J, Jeffs E, Vollam S, Watkinson P. A qualitative exploration of escalation of care in the acute ward setting. Nursing in Critical Care. 2020;25:171–178. 3. Louch G, Albutt A, Harlow-Trigg J, Moore S, Smyth K, Ramsey L, O’Hara JK. Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review. BMJ Open 2021;11:47102.

Adverse events: an expensive and avoidable hospital problem

Introduction Adverse healthcare-related events (AE) entail reduced patient safety. Estimating their frequency, characteristics, avoidability and impact is a means to identify targets for improvement in the quality of care. Methods This was a descriptive observational study conducted within the Patient Safety Incident Study in Hospitals in the Community of Madrid (ESHMAD). The study was conducted in a high-complexity hospital in May 2019 through a two-phase electronic medical record review: (1) AE screening and epidemiological and clinical data collection and (2) AE review and classification and analysis of their impact, avoidability, and associated costs. Results A total of 636 patients were studied. The prevalence of AE was 12.4%. Death during the stay was associated with the presence of AE (OR [CI95%]: 2.15 [1.07 to 4.52]) versus absence and emergency admission (OR [CI95%]: 17.11[6.63 to 46.26]) versus scheduled. A total of 70.2% of the AEs were avoidable. Avoidable AEs were associated with the presence of pressure ulcers (OR [CI95%]: 2.77 [1.39 to 5.51]), central venous catheter (OR [CI95%]: 2.58 [1.33 to 5.00]) and impaired mobility (OR [CI95%]: 2.24[1.35 to 3.71]), versus absences. They were associated too with the stays in the intensive care unit (OR [CI95%]: 2.75 [1.07 to 7.06]) versus medical service. AEs were responsible for additional costs of €909,716.8 for extra days of stay and €12,461.9 per patient with AE. Conclusions The prevalence of AEs was similar to that found in other studies. AEs led to worse patient outcomes and were associated with the patient’s death. Although avoidable AEs were less severe, their higher frequency produced a greater impact on the patient and healthcare system. Key messages Adverse events are one of the main problems in healthcare delivery and patients who suffer from at least one AE are double as likely to die during hospitalization. Avoidable adverse events are the most frequent in health care and they are a good target where achieve improvement areas that allow getting optimal patient safety and quality of care levels. Patients hospitalized in the ICU, with the previous presence of pressure ulcers, central venous catheter, or impaired mobility were associated with the development of avoidable AE, so optimal management of these patients would reduce the impact of AE.

A new normal for the clinician's third hand: Stethoscope hygiene and infection prevention

Health care associated infections (HAI) are a substantial problem in contemporary health care. With an estimated annual US cost of 147 billion dollars, HAIs represent avoidable adverse events, the consequence of which are increased health care costs, longer length of stays, with higher rates morbidity and mortality. This is especially true in hematology-oncology practices, as patients are commonly immunocompromised, many are neutropenic, nonintact skin is frequent due to skin graft versus host disease, and broad-spectrum antimicrobial exposure is common, all which increases the risk of iatrogenic complications.

Addressing Clinical and Therapeutic Inertia Through Comprehensive Medication Review.

Avoiding clinical and therapeutic inertia, through pharmacist-led medication therapy management, can lead to avoidance of inappropriate medication use and adverse medication events. Clinical and therapeutic inertia are terms that have been used indistinctly. One definition is inertia that appears when clinicians do not initiate or intensify therapy appropriately when therapeutic goals are not reached. Another definition is failure to advance or deintensify treatment, and in a broader sense beyond escalation or deintensification of therapy; definitions include failure to screen, make appropriate referrals, manage risk factors, and complications. Failure of clinicians to address clinical and therapeutic inertia in office or hospital visits can contribute to patients using inappropriate medications, and lead to avoidable serious adverse events. Addressing therapeutic inertia may also be a means to minimize prescription costs and improve quality of life. This case illustrates the importance of identifying and addressing the therapeutic appropriateness of medications for an older person who has been prescribed numerous medications over a long period but now has complaints of dizziness as well as the inability to afford all medications.

The Australasian ANZSCTS/ANZICS guidelines on cardiothoracic advanced life support (CALS-ANZ)

Every year, more than 15 000 patients undergo cardiac surgery in Australia and NewZealand. 1 The overall incidence of cardiac arrest after cardiac surgery is between 0.7% and5.2%. 2, 3, 4, 5, 6 Most cardiac arrests occur within 24 hours of surgery, with up to 50% occurring in the first 3 hours following intensive care unit (ICU)admission. 2, 7 Compared with other in-hospital cardiac arrests, survival in this patient population is high (75% v 39%). 2, 8 The reasons for this include the high degree of cardiac monitoring; a high proportion of reversible causes, such as pericardial tamponade or haemorrhage, and the effects of internal cardiacmassage. 9, 10, 11 The application of standard advanced life support protocols in post-surgical cardiothoracic patients may lead to avoidable adverse events, and hence, specific resuscitation protocols have been developed and established in Europe and NorthAmerica. 12

Guiding Principles for Surgical Pathways: A Tool for Improving Outcomes and Patient Safety.

Surgical activity is an important aspect for the management of health and safety processes and from an organizational perspective is one of the most complex activities performed in hospitals. It is often a defining and high value feature for any healthcare facility while being one of the most high-risk procedures for patients with the highest number of avoidable adverse events. To ensure effective management of surgical pathways, they need to be considered from the perspective of clinical governance which takes a global approach to planning and management with the goal of improving safety and quality for patients. This paper contains the main features of this objective outlined within the document issued subsequent to the State-Regional Italian Government conference. This regulatory effort includes effective recommendations to make surgical pathways safer and more efficient with particular reference to lean management, patient blood management and patient safety.

It is time to stop blaming the pandemic.

What is known about the topic? Avoidable adverse events are often being attributed to health workforce shortages associated with the coronavirus disease 2019 (COVID-19) pandemic and government funding cuts. What does this paper add? Health workforce shortages were predicted well before the COVID-19 pandemic. What are the implications for practitioners? Senior executives and leaders should unitedly take action to influence change in funding and models of care.

POSB235 Effectiveness and Cost-Effectiveness of a Collaborative Deprescribing Intervention of Proton-Pump Inhibitors on Community-Dwelling Elderly (C-SENIOR Trial): A Study Protocol

Medication safety for elderly people is an ongoing challenge. Older people are often exposed to unnecessary or inappropriate medications – medicines with a high risk of harm. There is evidence that inappropriate medications are overprescribed, accounting for a significant proportion of avoidable adverse drug events, emergency department visits and hospitalizations. This study aims to present the protocol of a study to investigate the effectiveness and cost-effectiveness of a community pharmacist-general practitioner collaborative deprescribing intervention of potential inappropriate class of medicines, focusing proton-pump inhibitors, among the community dwelling elderly.

Evaluation of the Direct Costs of Managing Adverse Drug Events in all Ages and of Avoidable Adverse Drug Events in Older Adults in Japan.

In Japan, medical costs are increasing annually, and the increase in national medical costs, particularly in the direct cost of managing adverse drug events, is high. An in-depth understanding of these costs is important for their reduction. This study aimed to calculate the direct cost of managing adverse drug events in all ages, including older adults, and that of avoidable adverse drug events in older adults. We conducted a retrospective survey on patients aged 1 year or older who visited Gifu Municipal Hospital in Japan. We investigated and calculated the direct cost of managing adverse drug events and that of avoidable adverse drug events based on the Beers Criteria Japanese version (BCJ) and “Guidelines for medical treatment and its safety in the elderly 2015” (GMTSE-2015) in inpatients and outpatients. Among 6,504 patients, 11.1% visited the hospital or were hospitalized due to adverse drug events. The direct costs per patient with adverse drug events were 21,281 and 22,590 yen (166 and 176 euros as on September 13, 2021) for outpatients, and 853,175 and 874,582 yen (6,648 and 6,815 euros) for inpatients of all ages and older adults, respectively. The direct costs of avoidable adverse drug events per patient using drugs listed in the BCJ and GMTSE-2015 for older adults were 3,212 and 3,341 yen (25 and 26 euros) for outpatients, and 55,548 and 80,246 yen (433 and 625 euros) for inpatients, respectively. In sum, considering both inpatients and outpatients in the whole country, the direct costs of managing adverse drug events were 804.53 billion and 597.19 billion yen (6,269 million and 4,653 million euros) per year for all ages and older ages, respectively. The direct cost of avoidable adverse drug events in older adults was 83.43–258.44 billion yen (650–2,013 million euros) per year. We found that, in Japan, high medical costs are often caused by managing adverse drug events, and that the costs of avoidable adverse drug events in older adults based on the BCJ and GMTSE-2015 account for a substantial proportion of the medical cost. Therefore, by using the BCJ and GMTSE-2015, avoiding adverse drug events and reducing medical costs may be possible.

Compensation claims following anterior cruciate ligament injuries reported to the patient insurance company in Sweden in 2005–2014

Background and purpose — Patients in the Swedish healthcare system are insured against avoidable adverse events via Landstingens Ömsesidiga Försäkringsbolag (LÖF). We assessed the reasons for compensation claims reported to LÖF following an ACL injury. Patients and methods — We searched the LÖF database for compensation claims related to ACL injuries reported in 2005–2014, and cross-matched claims with the Swedish National Knee Ligament Register. We then performed a review of the medical records. Results — We identified 530 eligible claims in 2005–2014. 352 (66%) claims were accepted by LÖF and 178 claims were rejected. Accepted claims corresponded to fewer than 1% of ACL surgeries performed in the same period. The most common reasons for an accepted claim were postoperative septic arthritis followed by suboptimal surgery and delay in diagnosis and treatment. Interpretation — There are different reasons for accepting a compensation claim following an ACL injury, which represents different treatment errors that can be avoided.

Organizational readiness to change as a leverage point for improving safety: a national nursing home survey

BackgroundA stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, we examined the link between organizational readiness to change and safety climate.MethodsSeven safety climate domains and organizational readiness to change were measured with validated Community Living Center/CLC Employee Survey of Attitudes about Resident Safety and Organizational Readiness to Change Assessment. Safety climate domains comprised of safety priorities, supervisor commitment to safety, senior management commitment to safety, safety attitudes, environmental safety, coworker interactions around safety, and global rating of CLC. We specified models with and without readiness to change to explain CLC- and person-level variance in safety climate domains.ResultsOne thousand three hundred ninety seven workers (frontline staff and managers) responded from 56 US Veterans Health Administration CLCs located throughout the US. Adding readiness to change reduced baseline CLC-level variance of outcomes (2.3–9.3%) by > 70% for interpersonal domains (co-workers, supervisors, and senior management). Readiness to change explained person-level variance of every safety climate domain (P < 0.05), especially for interpersonal domains.ConclusionsOrganizational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety.

Subjektive Informiertheit von Patient*innen zum Thema Patientensicherheit: Ergebnisse einer Bevölkerungsbefragung in Deutschland

IntroductionThe growing number of people with multimorbidity and polypharmacy in Germany has led to increasing complexity in health care and risks to patient safety. A high priority should therefore be placed on identifying and preventing avoidable adverse events. The patient perspective plays an important role in improving patient safety. In this study, we conducted a representative, population-based survey of knowledge, perceptions and experiences of patient safety, especially of subjectively experienced errors in health care. Our aim was, in particular, to assess patient safety from the patients’ point of view, and to analyze differences in assessments of risk and preventability between persons that felt well or poorly informed about patient safety topics. MethodsIn 2019, computer-assisted telephone interviews were conducted nationwide as part of the “TK-Monitor Patient Safety” project. Recruitment was carried out by using multistage selection and forming a stratified random sample. Adults (18 years and older) with sufficient knowledge of German were included. The survey was conducted using a structured guideline containing 21 questions concerning perceptions and experiences of patient safety, and 12 questions on sociodemographic factors. The results were analyzed both descriptively and using inferential statistical methods. ResultsOf a total of 1,000 respondents (51% female), approx. half (52%) were gainfully employed, and 57% rated their state of health as “very good” or “good”. The patients regarded data protection, medication errors, hospital infections and diagnostic (un)certainty as of major relevance to patient safety. Overall, 55% of the respondents rated their knowledge of patient safety as “very good” or “good”. The results showed that subjective knowledge was negatively associated with important outcome parameters such as having experience of medication errors or suspecting errors had been made in a medical examination or treatment. Patients that considered themselves well-informed also reckoned they could contribute towards increasing safety in health care. DiscussionThe respondents considered diagnostic uncertainty to be one of the greatest risks to their person. This shows that they recognized a need for further information and felt this need was inadequately satisfied in the German research landscape. With regard to the correlation between subjective knowledge and outcome parameters, it is also necessary to analyze whether the respondents’ subjective knowledge reflects their actual knowledge, as this would be necessary for preventive measures to be effective. This question will be the subject of further studies. ConclusionThe patient perspective is an important addition to the study of the safety of medical care in Germany. Factors influencing subjective knowledge should be investigated. Furthermore, regular surveys would be desirable in order to gain greater insight into the topic.

Structured Training for Laparoscopic Appendectomy for Residents (STAR Trial)–A Randomized Pilot Study

Laparoscopic appendectomy is a common operation that is frequently performed by junior surgical residents. We investigated the effect of a structured training program on the proficiency of junior residents in acquiring skills necessary in this operation. This is a randomized pilot trial. Between December 2014 and July 2018, twenty junior residents were recruited for this study. 11 were randomized to receive a structured training program of supervised, task-specific training. Each resident subsequently performed ten cases of laparoscopic appendectomy with their performance assessed for the last 5. The GOALS scale was used as the primary endpoint. Secondary endpoints were perioperative outcomes. The effect of intervention on these outcomes were evaluated assuming a linear mixed effect multi-level model. The study was single-blinded as the assessors did not know which group each resident belonged to. There were no statistically significant differences in the total GOALS score or any of its individual domains. After adjusting for the number of operations done within the trial, the mean difference between the total GOALS score was 0.07 (95% CI -0.76 to 0.90, P=0.866). Blood loss, hospital stay and postoperative complication rates were similar. There was suggestion of a shorter operative time (effect estimate -9.03, 95% CI -19.56 to 1.50) in the intervention arm although statistical significance was not achieved. No avoidable adverse events due to this study were recorded. Structured training program did not significantly improve surgical performance and outcomes in laparoscopic appendectomy in this pilot trial. Despite these findings, residents can still potentially mount their learning curves in laparoscopy earlier in a safe environment with such a program which is especially important in the era of minimally invasive surgery.

Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children.

Purpose of reviewReview important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children.Recent findingsCurrent evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship.SummaryThe principles of stewardship and parsimonious care can improve patient safety for children.

Improving outcomes after low-risk coronary artery bypass grafting: understanding phase of care mortality analysis, failure to rescue and recent perioperative recommendations.

Avoidable adverse events are responsible for up to 50% of deaths after low-risk coronary artery bypass grafting. This article reviews recent quality improvement efforts to improve outcomes after cardiac surgery. Systematic quality improvement methodology in cardiac surgery has improved significantly over the past decade. Contemporary efforts with phase of care mortality analysis (POCMA) focus on identifying and addressing root causes for mortality. Each patient's perioperative course is an interconnected sequence of clinical events, decisions, interventions, and treatment responses occurring across five perioperative phases. A single seminal event within a specific phase of care has been found to often trigger the eventual death of a patient. Several groups have made significant improvements to perioperative outcomes by addressing these avoidable mortality trigger events. Failing that, failure to rescue (FTR) metrics can be used to identify institutional factors responsible for poor perioperative outcomes. This ongoing focus on quality improvement serves to further improve outcomes after low-risk cardiac surgery. Modern quality improvement methodology, including POCMA and FTR analysis, has the potential to significantly improve outcomes after cardiac surgery. Larger future studies with multiinstitutional data sharing will be key to facilitate ongoing quality improvement and knowledge translation in this field.

PMU41 Clinical Pharmacy Provider Dashboards May Prevent Avoidable Adverse Events and Reduce Total Cost of Care

Medication Therapy Opportunities (MTOs) consist of avoidable medication errors and adverse drug events that may lead to patient harm as well as opportunities to optimize medication treatment. Blue Cross Blue Shield of Louisiana, in keeping with their mission to improve the health and lives of Louisianans, have launched an innovative clinical pharmacy dashboard making actionable data available to providers to minimize avoidable adverse events and optimize medication treatment. The Medication Therapy Opportunities component of the dashboard focuses on the following key elements (1) Therapy Duplication – multiple medications within the same or a similar therapeutic class taken at the same time (2) Drug-Drug Interactions – medications known to have an adverse event when taken together (3) Condition Related – medications known to exacerbate a medical condition or potential opportunity to optimize care and (4) Omissions of Care – discrepancy between guideline recommendations and/or standards of care.