Cause Of Patient Safety Incidents Research Articles

Factors contributing to under-reporting of patient safety incidents in Indonesia: leaders’ perspectives

Background: Understanding the causes of patient safety incidents is essential for improving patient safety; therefore, reporting and analysis of these incidents is a key imperative. Despite its implemention more than 15 years ago, the institutionalization of incident reporting in Indonesian hospitals is far from satisfactory. The aim of this study was to analyze the factors responsible for under-reporting of patient safety incidents in Indonesian public hospitals from the perspectives of leaders of hospitals, government departments, and independent institutions. Methods: A qualitative research methodology was adopted for this study using semi-structured interviews of key informants. 25 participants working at nine organizations (government departments, independent institutions, and public hospitals) were interviewed. The interview transcripts were analyzed using a deductive analytic approach. Nvivo 10 was used to for data processing prior to thematic analysis. Results: The key factors contributing to the under-reporting of patient safety incidents were categorized as hospital related and nonhospital related (government or independent agency). The hospital-related factors were: lack of understanding, knowledge, and responsibility for reporting; lack of leadership and institutional culture of reporting incidents; perception of reporting as an additional burden. The nonhospital-related factors were: lack of feedback and training; lack of confidentiality mechanisms in the system; absence of policy safeguards to prevent any punitive measures against the reporting hospital; lack of leadership. Conclusion: Our study identified factors contributing to the under-reporting of patient safety incidents in Indonesia. The lack of government support and absence of political will to improve patient safety incident reporting appear to be the root causes of under-reporting. Our findings call for concerted efforts involving government, independent agencies, hospitals, and other stakeholders for instituting reforms in the patient safety incident reporting system.

Factors contributing to under-reporting of patient safety incidents in Indonesia: leaders’ perspectives

Background: Understanding the causes of patient safety incidents is essential for improving patient safety; therefore, reporting and analysis of these incidents is a key imperative. Despite its implemention more than 15 years ago, the institutionalization of incident reporting in Indonesian hospitals is far from satisfactory. The aim of this study was to analyze the factors responsible for under-reporting of patient safety incidents in Indonesian public hospitals from the perspectives of leaders of hospitals, government departments, and independent institutions. Methods: A qualitative research methodology was adopted for this study using semi-structured interviews of key informants. 25 participants working at nine organizations (government departments, independent institutions, and public hospitals) were interviewed. The interview transcripts were analyzed using a deductive analytic approach. Nvivo 10 was used to for data processing prior to thematic analysis. Results: The key factors contributing to the under-reporting of patient safety incidents were categorized as hospital related and nonhospital related (government or independent agency). The hospital-related factors were: lack of understanding, knowledge, and responsibility for reporting; lack of leadership and institutional culture of reporting incidents; perception of reporting as an additional burden. The nonhospital-related factors were: lack of feedback and training; lack of confidentiality mechanisms in the system; absence of policy safeguards to prevent any punitive measures against the reporting hospital; lack of leadership. Conclusion: Our study identified factors contributing to the under-reporting of patient safety incidents in Indonesia. The lack of government support and absence of political will to improve patient safety incident reporting appear to be the root causes of under-reporting. Our findings call for concerted efforts involving government, independent agencies, hospitals, and other stakeholders for instituting reforms in the patient safety incident reporting system.

Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety.

OBJECTIVESThe reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported.METHODSAll voluntary reports of MITS-related PSIs were retrospectively extracted from the French REX database for ‘in-depth analysis’. From 2008 to 2019, we retrospectively analysed and graded events according to the WHO classification of PSIs: near miss events, no harm incidents and harmful incidents. Causes and corrective measures were analysed according to the human-technology-organization triad.RESULTSOf the 5145 cardiothoracic surgery PSIs declared, 407 were related to MITS. Among them, MITS was performed for primary lung cancer in 317 (78%) and consisted in a lobectomy in 249 (61%) patients. PSIs were: near miss events in 42 (10%) patients, no harm incidents in 81 (20%) patients and harmful incidents in 284 (70%) patients (mild: n = 163, 40%; moderate: n = 78, 19%; severe: n = 36, 9%; and deaths: n = 7, 2%). Human factors represented the most important cause of PSIs with 267/407 (65.6%) cases, including mainly vascular injuries (n = 90; 22%) and non-vascular injuries (n = 43; 11%). Pulmonary arteries were the most affected site with 57/91 cases (62%). In all, there were 7 deaths (2%), 53 patients required second surgery (13%) and 30 required additional lung resection (7%).CONCLUSIONSThe majority of reported MITS -related PSIs were non-catastrophic. Human factors were the main cause of PSIs. Systematic reporting and analysis of these PSIs will allow surgeon and his team to avoid a large proportion of them.

Factors contributing to under-reporting of patient safety incidents in Indonesia: leaders' perspectives.

Background: Understanding the causes of patient safety incidents is essential for improving patient safety; therefore, reporting and analysis of these incidents is a key imperative. Despite its implemention more than 15 years ago, the institutionalization of incident reporting in Indonesian hospitals is far from satisfactory. The aim of this study was to analyze the factors responsible for under-reporting of patient safety incidents in Indonesian public hospitals from the perspectives of leaders of hospitals, government departments, and independent institutions. Methods: A qualitative research methodology was adopted for this study using semi-structured interviews of key informants. 25 participants working at nine organizations (government departments, independent institutions, and public hospitals) were interviewed. The interview transcripts were analyzed using a deductive analytic approach. Nvivo 10 was used to for data processing prior to thematic analysis. Results: The key factors contributing to the under-reporting of patient safety incidents were categorized as hospital related and nonhospital related (government or independent agency). The hospital-related factors were: lack of understanding, knowledge, and responsibility for reporting; lack of leadership and institutional culture of reporting incidents; perception of reporting as an additional burden. The nonhospital-related factors were: lack of feedback and training; lack of confidentiality mechanisms in the system; absence of policy safeguards to prevent any punitive measures against the reporting hospital; lack of leadership. Conclusion: Our study identified factors contributing to the under-reporting of patient safety incidents in Indonesia. The lack of government support and absence of political will to improve patient safety incident reporting appear to be the root causes of under-reporting. Our findings call for concerted efforts involving government, independent agencies, hospitals, and other stakeholders for instituting reforms in the patient safety incident reporting system.

Patient Identification in Wards: What Influences Nurses’ Complicance?

Patient safety is important because people have easy information and hospital reports related to medical errors. Patient identification is the most important cause of patient safety incidents. In 2019, 12 near misses due to misidentification of patients in the inpatient, laboratory, and pharmacy at the private class D hospital in Blitar. This prompted the authors to conduct a case study and analyze the causal factors of the problems. The method used in this research is descriptive and case study approach. Identification of the root problems was done by observation and interviews with implementing inpatients rooms nurses using observation sheets. Determination of the root problems is determined through a two-stage focus group discussion (FGD) using a fishbone diagram. Six root problems were found that affect the low compliance in the implementation of patient identification in inpatient installations, they are low supervision and supervision from the leadership, no resocialization regarding patient identification, a small number of patients, lack of safety culture, lack of supporting tools, and patients’ willingness to be served quickly. Knowing the root factors that affect the officers’ compliance is essential so supervision methods that are appropriate to the conditions of the hospital can be conducted.

Clinical Pearls

The hospital should be a safe, healing and humane environment for both patients and health care providers. However, pressures from growing patient acuity, operational constraints, increasing regulatory demands, and communication and staffing issues can diminish the quality of the work environment.Connor and colleagues evaluated the use of the AACN Healthy Work Environment (HWE) Tool with interdisciplinary staff and found thatIt is critical for health care system leaders to actively evaluate work environments to provide optimal patient outcomes. The authors recommend using the HWE tool as an organizational measure to identify substandard behaviors that may affect patients’ outcomes.See Article, pp 363–371The leading cause of patient safety incidents in the hospital is communication errors. In particular, postoperative team handover interactions are often written, unstructured, and not done face-to-face, increasing the chance of miscommunication that could lead to unfavorable patient outcomes.Turner and colleagues evaluated the use of (1) a handover checklist for postoperative patients admitted to the intensive care unit (ICU), and (2) a 5-item daily communication tool After implementation, they surveyed health care professionals and found a significant improvement inFour key areas for improving future communication were noted:The authors recommend simple, fillable, daily tools for improving communication in the ICU.See Article, pp 392–397Congenital heart disease (CHD) is the leading birth defect in the United States, with approximately 25% of affected neonates requiring major surgery in the first year of life. The risk of developmental delay and neurological deficits can be costly and increases the need for long-term health care services, some continuing into adulthood.Tran and colleagues used near infrared spectroscopy (NIRS) to measure regional cerebral oxygenation saturation as a noninvasive, surrogate measure of cerebral blood flow. They hypothesized that a weaker NIRS response to a posture-change blood pressure challenge would correlate with neurodevelopmental impairments. They found the following:The authors recommend close monitoring and early screening in neonates with CHD for timely implementation of appropriate interventions to prevent neurodevelopmental delays.See Article, pp 410–416More than half of all patients in the intensive care unit (ICU) are older adults, and many experience poor outcomes and decreased quality of life after hospitalization. Although organizations such as the Society of Critical Care Medicine have established guidelines to improve care and reduce post-intensive care syndrome, most guidelines are aimed at the general adult population and not at geriatric patients.Sinvani and colleagues examined the relationship between nonadherence and 6 geriatric-focused indicators and clinical outcomes in older ICU survivors. They found thatStandardized guidelines and care bundles have increased awareness of quality and safety in ICU care, but a gap remains in the implementation of geriatric-focused interventions. The authors recommend development and implementation of multicomponent solutions for use in ICUs.See Article, pp 354–361

Do final-year medical students have sufficient prescribing competencies? A systematic literature review.

AimsPrescribing errors are an important cause of patient safety incidents and are frequently caused by junior doctors. This might be because the prescribing competence of final‐year medical students is poor as a result of inadequate clinical pharmacology and therapeutic (CPT) education. We reviewed the literature to investigate which prescribing competencies medical students should have acquired in order to prescribe safely and effectively, and whether these have been attained by the time they graduate.MethodsPubMed, EMBASE and ERIC databases were searched from the earliest dates up to and including January 2017, using the terms ‘prescribing’, ‘competence’ and ‘medical students’ in combination. Articles describing or evaluating essential prescribing competencies of final‐year medical students were included.ResultsTwenty‐five articles describing, and 47 articles evaluating, the prescribing competencies of final‐year students were included. Although there seems to be some agreement, we found no clear consensus among CPT teachers on which prescribing competencies medical students should have when they graduate. Studies showed that students had a general lack of preparedness, self‐confidence, knowledge and skills, specifically regarding general and antimicrobial prescribing and pharmacovigilance. However, the results should be interpreted with caution, given the heterogeneity and methodological weaknesses of the included studies.ConclusionsThere is considerable evidence that final‐year students have insufficient competencies to prescribe safely and effectively, although there is a need for a greater consensus among CPT teachers on the required competencies. Changes in undergraduate CPT education are urgently required in order to improve the prescribing of future doctors.

Unit-based incident reporting and root cause analysis: variation at three hospital unit types

ObjectivesTo minimise adverse events in healthcare, various large-scale incident reporting and learning systems have been developed worldwide. Nevertheless, learning from patient safety incidents is going slowly. Local, unit-based reporting systems...

Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care

ABSTRACTBackground: To improve patient safety it is necessary to identify the causes of patient safety incidents, devise solutions and measure the (cost-) effectiveness of improvement efforts.Objective: This paper provides a broad overview with practical guidance on how to improve patient safety.Methods: We used modified online Delphi procedures to reach consensus on methods to improve patient safety and to identify important features of patient safety management in primary care. Two pilot studies were carried out to assess the value of prospective risk analysis (PRA), as a means of identifying the causes of a patient safety incident.Results: A range of different methods can be used to improve patient safety but they have to be contextually specific. Practice organization, culture, diagnostic errors and medication safety were found to be important domains for further improvement. Improvement strategies for patient safety could benefit from insights gained from research on implementation of evidence-based practice. Patient involvement and prospective risk analysis are two promising and innovative strategies for improving patient safety in primary care.Conclusion: A range of methods is available to improve patient safety, but there is no ‘magic bullet.’ Besides better use of the available methods, it is important to use new and potentially more effective strategies, such as prospective risk analysis.

Linking NHS data for pediatric pharmacovigilance: Results of a Delphi survey.

BackgroundAdverse drug events are a major cause of patient safety incidents. Current systems of pharmacovigilance under-report adverse drug reactions (ADRs), especially in children, leading to delays in their identification. This is of particular concern, as children especially have an increased vulnerability to ADRs.ObjectivesThe objective was to seek consensus among healthcare professionals (HCPs) about barriers and facilitators to the linkage of routinely collected health data for pediatric pharmacovigilance in Scotland.MethodsA Delphi survey was conducted with a random sample of HCPs including nurses, pharmacists and doctors, working in primary or secondary care, in Scotland. Participants were identified from sampling frames of the target professionals such as an NHS workforce list for general practitioners and recruited by postal invitation. A total of 819 HCPs were invited to take part. Those agreeing to participate were given the option of completing the questionnaires online or as hard copy. Reminders were sent twice at a fortnightly interval. Questions content included description of professional role as well as testing for the willingness to support the proposed project and was informed by the Theoretical Domains Framework of Behavior Change (TDF) and earlier qualitative work. Three Delphi rounds were administered, including a first round for item generation.Results121 of those invited agreed to take part (15%). The first round of the Delphi study included 21 open questions and generated over a 1000 individual statements from 61 participants that returned the questionnaires (50.4%). These were rationalized to 149 items for the second round in which participants rated their views on the importance (or not) of each item on a 9-point Likert scale (strongly disagree – strongly agree). After the third round, there was consensus on items that focused on professional standards, and practical requirements, overall there was support for data linkage and a multi-professional approach.ConclusionsIt would be acceptable to stakeholders to introduce a data linkage system for pharmacovigilance as long as identified concerns are addressed. Concerns included adherence to current professional, legal and ethical standards, as well resolving practical issues.

Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme

IntroductionPrescribing errors are a major cause of patient safety incidents. Understanding the underlying factors is essential in developing interventions to address this problem. This study aimed to investigate the perceived...

What is the scale of prescribing errors committed by junior doctors? A systematic review

Prescribing errors are an important cause of patient safety incidents, generally considered to be made more frequently by junior doctors, but prevalence and causality are unclear. In order to inform the design of an educational intervention, a systematic review of the literature on prescribing errors made by junior doctors was undertaken. Searches were undertaken using the following databases: MEDLINE; EMBASE; Science and Social Sciences Citation Index; CINAHL; Health Management Information Consortium; PsychINFO; ISI Proceedings; The Proceedings of the British Pharmacological Society; Cochrane Library; National Research Register; Current Controlled Trials; and Index to Theses. Studies were selected if they reported prescribing errors committed by junior doctors in primary or secondary care, were in English, published since 1990 and undertaken in Western Europe, North America or Australasia. Twenty-four studies meeting the inclusion criteria were identified. The range of error rates was 2-514 per 1000 items prescribed and 4.2-82% of patients or charts reviewed. Considerable variation was seen in design, methods, error definitions and error rates reported. The review reveals a widespread problem that does not appear to be associated with different training models, healthcare systems or infrastructure. There was a range of designs, methods, error definitions and error rates, making meaningful conclusions difficult. No definitive study of prescribing errors has yet been conducted, and is urgently needed to provide reliable baseline data for interventions aimed at reducing errors. It is vital that future research is well constructed and generalizable using standard definitions and methods.

RSVP: a system for communication of deterioration in hospital patients

Communication failures are a prime cause of patient safety incidents. In a medical emergency, patient survival often depends on ward staff making an early and effective call for help. To improve communication with senior colleagues, ward staff need to create a picture that efficiently and reliably conveys their concerns so that they get the help that they need without delay. This can best be achieved though a structured call for help. The Reason-Story-Vital Signs-Plan system, used in the Acute Life-threatening Events--Recognition and Treatment (ALERT) course, is easy to remember in an emergency and includes the essential information enabling an experienced clinician to respond appropriate to a call for help from ward staff. The use of such a structured call for help could improve patient safety.