Avoidable Harm Research Articles

The European Drug-Drug Interaction (EuroDDI) Study Protocol: A Cross-Country Comparison of Drug-Drug Interaction Prevalence in the Older Community-Dwelling Population.

Drug-drug interactions (DDIs), highly prevalent amongst the elderly, can lead to avoidable medication-related harm. Cardiovascular and central nervous system (CNS) drugs are commonly implicated. To date, there is no consensus on how to measure DDIs, making comparisons across countries challenging. To (i) establish a common data model (CDM) to measure DDI prevalence in the older (aged ≥ 70 years) community-dwelling population of three European countries and (ii) compare and describe cardiovascular and CNS DDI prevalence rates across these countries. This cross-country study will apply a harmonised method of DDI identification and analysis using the WHO ATC classification system and national pharmacy claims data from three European countries (Ireland, Italy, Spain). Patients aged ≥ 70 years dispensed ≥ 2 medications during 2016 will be identified from each country's national database. 'Severe' cardiovascular and CNS DDIs (i.e., may result in a life-threatening event/permanent detrimental effect) will be identified using the British National Formulary and Stockley's Drug Interactions. Two separate lists of 'severe' DDIs, per medications reimbursed, will be applied to each database: (i) DDIs relevant to each individual country and (ii) DDIs relevant to all three countries. DDIs will be defined as co-dispensed (same day) and concomitantly (±7 days) dispensed. Descriptive statistics, including DDI prevalence and 95% confidence intervals, will be reported for each country. Prevalence will be pooled and compared across countries using random effects models and meta-regression, where feasible. The EuroDDI study will develop a harmonised method to measure and compare DDI prevalence across health-related databases in Europe.

Understanding the scale and nature of avoidable healthcare-associated harm for prisoners in England: protocol for a retrospective cross-sectional study

IntroductionAround 1 in 20 patients experience avoidable healthcare-associated harm worldwide. Despite longstanding concerns, there is insufficient information available about the safety of healthcare for prisoners. To address this, this study...

Multifaceted approach to reduce duplicate therapy errors in the emergency department

Medication errors continue to pose a significant risk to patient safety, accounting for half of the avoidable harm in healthcare systems around the world. In emergency departments (EDs), factors such...

Influences on safety of intrapartum electronic fetal heart rate monitoring practices: a scoping review

ObjectivesSuboptimal intrapartum electronic fetal heart rate monitoring using cardiotocography has remained a persistent problem (EFM-CTG). We aimed to identify the range of influences on the safety of using EFM-CTG in...

Facilitators of and obstacles to practitioners’ adoption of harm reduction in cannabis use: a scoping review

Abstract Background Cannabis use can generate potential avoidable harms, hence the need for effective preventive measures and treatment. Studies show the efficacy of harm reduction (HR) in minimizing undesirable consequences associated with this use. Despite its proven efficacy, HR in cannabis use remains poorly applied by many health and social services (HSS) practitioners, especially with young people. However, knowledge regarding the underlying reasons for this is limited. To fill this gap, we aimed to identify facilitators of and obstacles to HSS practitioners’ adoption of HR in cannabis use across OECD countries. Methods We conducted a scoping review, guided by Arksey and O’Malley’s model. The search strategy, executed on health databases and in the grey literature, captured 1804 studies, of which 35 were retained. Data from these studies were extracted in summary sheets for qualitative and numerical analysis. Results Facilitators and obstacles were grouped into four themes: stakeholders’ characteristics (e.g., education, practice experience); clients’ characteristics (e.g., personal, medical); factors related to HR (e.g., perceived efficacy, misconceptions); factors related to the workplace (e.g., type of workplace). Data were also extracted to describe the populations recruited in the selected studies: type of population, clientele, workplace. Conclusion Several factors might facilitate or hinder HSS practitioners’ adoption of HR in cannabis use. Taking these into consideration when translating knowledge about HR can improve its acceptability and applicability. Future research and action should focus on this when addressing practitioners’ adoption of HR.

Pharmacists' interventions on prescribing errors in Malaysia.

Prescribing errors (PEs) cause significant avoidable harm globally. In Malaysia, despite the prevalence of PEs in government healthcare facilities, there is limited research on how pharmacist staffing levels influence intervention frequency and effectiveness. This study aims to address this gap by analysing intervention trends and assessing their association with staffing levels, highlighting the correlation between increased pharmacist presence and the frequency of interventions. This retrospective cross-sectional study analysed data from the Ministry of Health's Pharmacy Management Form and the Pharmacy Board Registry from 2017 to 2019. Multivariate regression and two-way ANOVA assessed the association between the number of pharmacists, total prescriptions, and interventions on PEs in Health Clinic Outpatient Pharmacy, Hospital Outpatient Pharmacy, and Hospital Inpatient Pharmacy settings. Annually, pharmacists intervened in approximately 1.8% of total prescriptions, with the most common errors being wrong dose, wrong medication, and wrong dosing frequency. These interventions were consistent across all settings, highlighting the uniformity in pharmacists' approach to managing PEs. The regression analysis revealed a significant positive correlation between the number of pharmacists, total prescriptions, and interventions on PEs, with an adjusted R-squared value of 0.899. Both the number of pharmacists and total prescriptions received were positively significant (p < 0.05), indicating that increased pharmacist presence strongly correlates with intervention frequency. No statistically significant differences were observed in intervention rates across different settings and severity levels, suggesting that pharmacists consistently provide effective interventions irrespective of the clinical context. In conclusion, this study confirms that increasing the number of pharmacists and total prescriptions received are critical predictors of interventions on PEs in Malaysia. It underscores the vital role of pharmacists in enhancing patient safety and healthcare quality, demonstrating their effectiveness in diverse settings and their adaptability to various patient needs and challenges.

2283 Early supported discharge for fragility fractures -collaborative working to deliver responsive high quality patient-centred care

Abstract Introduction During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients &amp;gt;65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working. Methods A collaboration between the following key services was formed:-. 1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients. 3. Physiotherapy -early assessment and transfer to reablement into the community. 4. Virtual Wards –ongoing CGA and reablement in the community. Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS. Results From March 2023, the service identified 457 patients, 312 (68.7%) Female, median age 86 years. 157 (34.6%) patients had a femoral fracture and 300 (65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206 (68.7%) being discharged same day. Overall, admission was avoided in 207 (45.3%) patients and 247 (54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service. Conclusion Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.

Drug-Drug Interactions in Hospitalized Urological Patients: A Retrospective Cohort Study.

Exposure to potential drug-drug interactions (pDDIs) can be a notable source of avoidable drug-related harm that requires adequate management to prevent medical errors. We aimed to evaluate pDDIs and associated factors in hospitalized urological patients on admission, during hospitalization, and on discharge. A retrospective cohort study was conducted at the Clinic of Urology of the University Clinical Centre Kragujevac, Serbia. To detect pDDIs, we used Lexicomp, which categorizes pDDIs as follows: X (avoid combination), D (consider therapy modification), C (monitor therapy), B (no action needed), and A (no known interaction). Multiple linear regression analysis was used to identify factors associated with the number of pDDIs. More than half of the 220 included patients had at least one pDDI on admission and discharge (57.3% and 63.6%, respectively), whereas 95.0% had at least one pDDI during hospitalization. The total number and number of X, D, C, and B categories of pDDIs were the highest during hospitalization and the lowest on admission. Duration of hospitalization, arrhythmias, dementia, renal failure, cancer, surgery during hospitalization, number of prescribed drugs, and various pharmacological drug classes were risk factors for a higher number of pDDIs, while age, ischemic heart disease, hypertension, and development of infection during hospitalization were protective factors in at least one of the stages. The impact of renal colic depended on the stage and category of pDDI. More than half of the urological patients were exposed to at least one pDDIs at all stages. Medical professionals should regularly screen for pDDIs, particularly in patients with risk factors.

Estimating the economic effect of harm associated with high risk prescribing of oral non-steroidal anti-inflammatory drugs in England: population based cohort and economic modelling study

ObjectivesTo quantify prevalence, harms, and NHS costs in England of problematic oral non-steroidal anti-inflammatory drug (NSAID) prescribing in high risk groups.DesignPopulation based cohort and economic modelling study.SettingEconomic models estimating patient...

PATIENT SAFETY GOALS, AFRICA: DEVELOPMENT OF A CONTEXT FITTING TOOL FOR PATIENT SAFETY AND CARE QUALITY ASSESSMENT IN AFRICA USING THE DECIDE(HUMAN FACTORS) MODEL.

Patient safety practice refers to processes or structures which when applied, reduce the probability of adverse events resulting from exposure to the healthcare system across a range of diseases and procedures. It aims at making health care safer for both clients and staff (Kohn, Corrigan, &amp; Donaldson, 2000). It is “A framework of organized activities that createcultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it does occur.” (WHO, 2021). Quality of care is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990 and ahrq.gov., 2016). Healthcare quality is a level or value provided by any healthcare resource, as determined by some measurement (Maxwell, 1984).As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. Other definitions of healthcare quality include: “the degree of conformity with accepted principles and practices (standards), the degree of satisfying the patient’s needs, and the degree of attainment of acceptable outcomes, while making appropriate use of resources.” The Joint Commission defines care quality as “the optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm”. Care quality is also referred to as freedom from deficiencies and therefore less costly because deficiencies which often lead to customer dissatisfaction require additional costs to manage them. Quality care conforms to relevant requirements or standards - the needs and expectations of clients or patients.

Planning without Banning: Animal Research and the Argument from Avoidable Harms

AbstractThe call for a planned phase-out is at the forefront of the political debate about animal experimentation. While authorities like the European Commission start taking a strategic approach to regulatory animal testing, they refuse to develop specific roadmaps for the phase-out of animal research. I articulate the central argument that is advanced against phase-out planning in animal research, the argument from avoidable harms: By restricting research, we may incur avoidable future harms and thus, while we may regret having to use animals in ways that harm them, for the sake of avoiding future harms we must not phase out animal research. The discussion of this argument yields two Conclusions: First, it applies only to ban-based phase-out plans, but not to plans consisting of a range of other interventions known from the literature on transformative governance. Second, the premises of the argument construe animal research as a necessary evil, thus as a conflict of unequal duties. But we have a duty not just to avoid avoidable harms, but also to avoid avoidable moral conflicts. This we can only do by taking a strategic approach. Thus, what initially looks like an argument against phase-out planning is in truth an argument for ban-free phase-out planning. This finding is important for practice because it shows that while government authorities’ reluctance to issue bans may be justified, their refusal to undertake strategic planning for the phase-out of animal research is not.

Hematuria after inguinal hernia repair in a child: a case report

Inguinal hernia repair is one of the most common surgical procedures in the pediatric population. While a rare complication, bladder injury can impose a significant burden on patients. This study outlined a case of bladder injury following selective inguinal hernia repair and summarized methods to prevent this complication, aiming to emphasize the importance of not underestimating interventions labeled as “routine surgery” in order to avoid avoidable harm to patients.

Investigating the air quality surrounding new schools in England: polluted playgrounds and school buildings are a source of avoidable harm

ObjectiveTo assess levels of pollutants at the sites of new schools and whether pupils are likely to be protected from associated risks.SettingAir pollution causes damage to children’s health by increasing...

Perioperative patient safety indicators-A Delphi study.

To identify, define and achieve consensus on perioperative patient safety indicators within a Swedish context. A modified Delphi method. A purposeful sample of 22 experts, all experienced operating room nurse specialists, was recruited for this study. A questionnaire was constructed incorporating statements derived from a preceding study. The experts were asked to rate the importance of each statement concerning patient safety during the perioperative phase. The data collection occurred through an online survey platform between November 2022 and April 2023. The CREDES checklist guided the reporting of this study. The three-round Delphi study resulted in consensus on 73 statements out of 103, encompassing 74% process indicators and 26% structure indicators. Key areas of consensus included the use of the Surgical Safety Checklist and optimizing the operating room environment. Consensus was reached on perioperative safety indicators, underscoring the intricate challenges involved in ensuring patient safety in the operating room. It emphasizes the important integration of both structure and process indicators for comprehensive safety assessment during surgical procedures. Recognizing the difficulty in measuring factors like teamwork and communication, essential for patient safety, the study offers practical guidance. It underlines a balanced approach and specific consensus areas applicable in clinical practice to enhance perioperative patient safety. This study provides concrete practice guidance and establishes a structured framework for evaluating perioperative care processes. It emphasizes the critical role of professionals having the necessary skills and being present during surgical procedures. Additionally, the study underscores the paramount importance of effective communication and teamwork within the operating room team, substantively contributing to overall patient safety enhancement. The study focused on addressing the challenge of ensuring patient safety in operating rooms, acknowledging the persistent complications related to surgery despite global efforts to eliminate avoidable harm in healthcare. Consensus was reached on 73 crucial indicators for perioperative patient safety, emphasizing a balanced approach integrating both process and structure indicators for a comprehensive assessment of safety during surgical procedures. The study has a broad impact on professionals and healthcare systems, providing concrete guidance for practice and offering a structured process for evaluating perioperative care. The study is reported informed by 'Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations derived from a methodological systematic review'. No patient or public contribution.

Preliminary feasibility assessment of a targeted, pharmacist-led intervention for older adults with polypharmacy: a mixed-methods study

BackgroundPolypharmacy is associated with the prescription of inappropriate medications and avoidable medication-related harm. A novel pharmacist-led intervention aims to identify and resolve inappropriate medication prescriptions in older adults with polypharmacy.AimTo conduct a preliminary feasibility assessment of the intervention in primary care, testing whether specific components of the intervention procedures and processes can be executed as intended.MethodThe mixed-methods study was approved by the New Zealand Health and Disability Ethics Committees and public health agency. Patients from a New Zealand general practice clinic were recruited over 4 weeks to receive the intervention. The preliminary feasibility assessment included measures of intervention delivery, patient-reported outcome measures, and perspectives from ten patients and six clinicians. Data were analysed quantitatively and qualitatively to determine if a full-scale intervention trial is warranted. The study's progression criteria were based on established research and guided the decision-making process.ResultsThe intervention met the study's progression criteria, including patient recruitment, retention, and adherence to the intervention procedures. However, several modifications were identified, including: (1) enhancing patient recruitment, (2) conducting a preliminary meeting between the patient and pharmacist, (3) supporting pharmacists in maintaining a patient-centred approach, (4) reviewing the choice of patient-reported outcome measure, (5) extending the 8-week follow-up period, (6) allocating more time for pharmacists to conduct the intervention.ConclusionThe study found the intervention feasible; however, additional development is required before progressing to a full-scale trial. This intervention has the potential to effectively reduce medication-related harm and improve outcomes for older adults with polypharmacy.Trial registration number ACTRN12621000268842 Date registered: 11/03/2021

New initiation of opioids, benzodiazepines and antipsychotics following hospitalization for COVID-19.

Patients newly initiated on opioids (OP), benzodiazepines (BZD), and antipsychotics (AP) during hospitalization are often prescribed these on discharge. Implications of this practice on outcomes remains unexplored. To explore the prevalence and risk factors of new initiation of select OP, BZD and AP among patients requiring in-patient stays. Test the hypothesis that new prescriptions are associated with higher odds of readmission or death within 28 days of discharge. Single center retrospective cohort study. Patients admitted to a tertiary-level medical center with either a primary diagnosis of RT-PCR positive for COVID-19 or high index of clinical suspicion thereof. None. Exposure was the new initiation of select common OP, BZD, and AP which were continued on hospital discharge. Outcome was a composite of 28-day readmission or death following index admission. Multivariable logistic regression was used to assess patient mortality or readmission within 28 days of discharge associated with new prescriptions at discharge. One thousand three hundred and nineteen patients were included in the analysis. 11.3% (149/1319) were discharged with a new prescription of select OP, BZD, or AP either alone or in combination. OP (110/149) were most prescribed followed by BZD (41/149) and AP (22/149). After adjusting for unbalanced confounders, new prescriptions (adjusted odds ratio: 2.44, 95% confidence interval: 1.42-4.12; p = .001) were associated with readmission or death within 28 days of discharge. One in nine patients admitted with a diagnosis of COVID-19 or high clinical suspicion thereof were discharged with a new prescription of either OP, BZD or AP. New prescriptions were associated with higher odds of 28-day readmission or death. Strengthening medication reconciliation processes focused on these classes may reduce avoidable harm.

The CLABSI Playbook: Design and Implementation of a Multipronged Approach to Decrease CLABSIs.

Central line-associated blood stream infections (CLABSIs) are a quality marker for the critical care environment. They have become an area of particular interest because they cost the healthcare system close to a billion dollars per year and have a significant impact on patient safety. Through a preliminary analysis of our system's CLABSI rates, we found significantly higher rates than the national average, prompting further investigation. We decreased our CLABSI rate by over 40% from 2021 (1.6 per 1,000 line days) to the fourth quarter of 2022 (0.91) and kept the rate below or around the national rate (0.86) for the last three quarters of 2022. Through looking at current outcome data, identifying key stakeholders, developing dedicated committees, conducting root cause analyses, monitoring progress, adjusting procedures, scaling to the system, and continuously monitoring and reporting results, we have shown the efficacy of this kind of quality improvement structure and strive to reduce our hospital system's impact on avoidable healthcare-associated patient harm.

A strategic solution to preventing the harm associated with ambulance handover delays.

Ambulance handover delays arise when emergency departments become overcrowded as patients waiting prolonged periods for admission occupy clinical cubicles designed to facilitate the assessment and treatment of emergency arrivals. In response, many organisations become reliant on temporarily lodging acutely unwell patients awaiting admission in undesignated areas for care such as corridors, to provide additional space. This results in a significant risk of avoidable harm, indignity and psychological trauma for patients and has a negative effect on the well-being of healthcare professionals, since unacceptable standards of care become normalised. A two-phase strategic quality improvement project was implemented at the authors' acute trust. Ambulance handover data from between 2 November 2020 and 26 July 2021 provided a benchmark for the project. The first phase was implemented between 2 November 2021 and 26 July 2022 and aimed to reduce 60-minute ambulance handover delays. The second phase was implemented between 2 November 2022 and 26 July 2023 and aimed to eradicate 60-minute ambulance handover delays and improve overall performance. Phase one resulted in a 32% reduction in 60-minute ambulance handover delays. Phase two resulted in a 97% reduction in 60-minute ambulance handover delays. Over the course of the project there was a 24% increase in handovers completed within 15 minutes. This project demonstrates how strategic planning and collaboration between healthcare teams can reduce the potential for avoidable patient harm, while simultaneously promoting workforce well-being and retention.

Community pharmacy discharge medicines service activity as recorded in PharmOutcomes: a retrospective exploration and analysis.

Transition of care when a patient moves between healthcare locations is a risk factor for medication errors and medicines-related preventable harm. The aims of this retrospective service evaluation were to understand, by classifying and quantifying, the nature of interventions made by community pharmacy when receiving a discharge medicines service referral from a secondary care hospital, with a focus on two groups of high-risk medicines supplied at discharge-oral anticoagulants and weak opioids following hip or knee surgery. Records made on the PharmOutcomes™ platform by community pharmacists in response to referral for the NHS England discharge medicines service were analysed and summarized. This analysis was exploratory and interpretative in nature and used a convenience sample of patients who had consented for the service over 12 months from May 2022 to April 2023. During 12 months, 6811 referrals occurred, of which 71% were recorded as having different stages of the service completed on PharmOutcomes™. Medicines reconciliation, first-prescription review, and consultation stages decreased as patients progressed through the service. Slightly greater rates of completion were observed for patients receiving oral anticoagulants and for codeine or dihydrocodeine following hip and knee surgery, although overall referrals were low for this latter cohort. Through this service, community pharmacists are well placed to support the safe and effective use of medicines including oral anticoagulants and weak opioids posthospital discharge and potentially reduce incidents of avoidable harm. The variations in recorded completion rates across the three stages of the service and the apparent greater finalization rates for the high-risk medicines studied require further investigation.

E005 Immunoglobulins review prior to rituximab infusion: implications and how we can improve our service

Abstract Background/Aims Rituximab (RTX), used in the treatment of autoimmune and lymphoproliferative diseases, depletes B-cells through anti-CD20. The resulting hypogammaglobulinemia increases susceptibility to recurrent or severe infections, however the absence of a protocolised approach to measuring serum immunoglobulin levels prior to, or between, RTX infusions in our infusion unit has led to cancelled treatments, and even delivery of treatments without a timely record of immunoglobulin levels. British Society for Rheumatology guidelines recommend checking immunoglobulin levels prior to treatment, then four to six months after infusions and before any future cycles of treatment. Our aim was to optimise monitoring standards of immunoglobulin levels in patients receiving RTX infusions, thereby minimising avoidable harm and unnecessary treatment cancellations. Methods Data was collected retrospectively using electronic patient records. The analysis included sixty patients with rheumatological conditions scheduled for RTX infusions during a three-month period. Results Treatment was appropriately withheld in six patients without up-to-date immunoglobulin levels, and in one patient with active infection. However, RTX was given in 28% (17 out of 60) of patients without up-to-date immunoglobulin levels; the mean duration of time between the current cycle of RTX treatment and most up-to-date prior immunoglobulin result being 179 days (median 109 days). Of note, this exceeded 200 days for 4 of these 17 patients (24%), and an absence of pre-RTX immunoglobulin levels was observed in a further 3 of these 17 patients (18%). Although no adverse events have occurred, this represents a compromise in patient safety. Whilst there is no definitive guidance on the reasonable maximum time limit between a RTX infusion and the most up-to-date immunoglobulin levels, a departmental consensus of one month was agreed upon through discussion and literature reviews. Robust measures have been taken, using a multi-disciplinary and multi-step approach, to achieve this:1. Patient list generated one week in advance for the clinical team to review pre-screening tests, including immunoglobulins. Any missing tests can be requested in advance of the infusion date.2. Pharmacy update of their checklist to include reviewing immunoglobulins results prior to dispensing Rituximab; escalating to the clinical team if missing or abnormal result.3. If the above measures have failed, a final safety net has been agreed by the multi-disciplinary team that bloods are taken and urgently processed in the laboratory, with RTX conditionally screened by pharmacy, to reduce treatment delay from appointment cancellation. Conclusion Next steps will be to develop this into a first cycle of quality improvement. This will involve measuring changes from comparing data points prior to and after implementation of the above changes. Furthermore, rates of post-RTX infections or complications of immunodeficiency will be measured before and after the interventions to determine the impact on patient safety and minimise avoidable harm and unnecessary treatment cancellations. Disclosure U. Kalluri: None. V. Thanopoulou: None. T. Malley: None.