Number Of Reported Incidents Research Articles

Effects of Emergency Room-specialized Pharmacists on Emergency Medicine

It is difficult to say that pharmacist services in the emergency room (ER) are widespread nationwide. According to a survey of certified emergency pharmacists, the work area they are most commonly engaged in is the intensive care unit. This may be due to the lack of reimbursement for pharmacist services in ERs and the absence of operational guidelines. On the other hand, Sapporo Higashi Tokushukai Hospital has had ER specialized pharmacists (ESPs) since 2016 and has reported on the usefulness of pharmacist services in the ER at conferences and in papers. Among other things, it has been shown that the workload of emergency physicians is reduced by 1.9 h/d through the use of ESPs, and that also contributes to the increase in accurate diagnoses of drug-induced diseases and the treatment of infectious diseases. Reports on the benefits of ESP have also begun to emerge in Japan, including a significant decrease in the number of incident reports. Meanwhile, overseas reports indicate that ESPs have a significant impact on healthcare economics, such as "an annualized cost avoidance effect of more than 400 million yen." Furthermore, reports of improvements in operational guidelines and patient outcomes that support these guidelines indicate that ESPs in other countries are well-established ahead of their counterparts in Japan. We strongly hope that ESPs will increase in number and distribution in Japan in the future through the evaluation of reimbursement and formulation of operational guidelines.

Novel solutions to old problems: improving the reliability of emergency equipment provision in critical care using accessible digital solutions

Reliable provision of emergency equipment in Critical Care is key to ensure patient safety during medical emergencies and transfers. A problem was identified in incident reports and external inspections of...

Relationship between the number of times the ward nursing manual is viewed and the number of incident reports in an emergency and critical care center

Relationship between the number of times the ward nursing manual is viewed and the number of incident reports in an emergency and critical care center

Hospital Survey on Patient Safety Culture in Dental Hospitals in the Twin cities, Pakistan

Objective: The purpose of our research is to evaluate the patient safety culture at Islamabad and Rawalpindi teaching hospitals. Materials and methods: A validated and slightly modified questionnaire was sent as a google forms link via WhatsApp and email to different teaching dental hospitals in the twin cities. The returned questionnaires were examined with IBM's statistical package for social sciences (version 22).). Results: 139 complete questionnaires were analyzed and results were calculated as average positive and average negative responses. Conclusion: This pilot study demonstrated that degree of patient safety in general in the Hospitals of Pakistan was acceptable. The number of incident reports were very low. Many participants also stated that the hospital is only concerned about patient safety after an unfavorable incident occurs., but they also reported that mistakes always lead to positive outcomes and the departments coordinate well with each other. Key words: Patient safety, incident reports, dental teaching hospital.

Identifying Incident Causal Factors to Improve Aviation Transportation Safety: Proposing a Deep Learning Approach

Aviation is a complicated transportation system, and safety is of paramount importance because aircraft failure often involves casualties. Prevention is clearly the best strategy for aviation transportation safety. Learning from past incident data to prevent potential accidents from happening has proved to be a successful approach. To prevent potential safety hazards and make effective prevention plans, aviation safety experts identify primary and contributing factors from incident reports. However, safety experts’ review processes have become prohibitively expensive nowadays. The number of incident reports is increasing rapidly due to the acceleration of advances in information technologies and the growth of the commercial and private aviation transportation industries. Consequently, advanced text mining algorithms should be applied to help aviation safety experts facilitate the process of incident data extraction. This paper focuses on constructing deep-learning-based models to identify causal factors from incident reports. First, we prepare the data sets used for training, validation, and testing with approximately 200,000 qualified incident reports from the Aviation Safety Reporting System (ASRS). Then, we take an open-source natural language model, which is well trained with a large corpus of Wikipedia texts, as the baseline and fine-tune it with the texts in incident reports to make it more suited to our specific research task. Finally, we build and train an attention-based long short-term memory (LSTM) model to identify primary and contributing factors in each incident report. The solution we propose has multilabel capability and is automated and customizable, and it is more accurate and adaptable than traditional machine learning methods in extant research. This novel application of deep learning algorithms to the incident reporting system can efficiently improve aviation safety.

LO37: Reducing hemolysis of coagulation blood samples in the emergency department

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures & Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p < 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.

Improving critical incident reporting in primary care through education and involvement

BackgroundCritical incident reporting systems (CIRS) can be an important tool for the identification of organisational safety needs and thus to improve patient safety. In German primary care, CIRS use is...

School-wide implementation of positive behavioral interventions and supports in an alternative school setting: A case study.

The purpose of this 1-year case study was to identify how School-Wide Positive Behavioral Interventions and Supports (SW-PBIS) can be adapted to meet the needs of students in alternative schools and to evaluate the early impact of SW-PBIS on discipline outcomes. Suggestions for adaptations are provided at each stage of the intervention process with a focus on buy-in, training, data collection, and resource allocation. Data from this case study included information about key components of the implementation process as well as initial outcomes. Process data revealed the importance of stakeholder buy-in, training opportunities, and potential adaptations to the framework. Outcome data from the first year of implementation indicated that the number of incident reports did not significantly differ from the baseline; however, there was a reduction in defiance-related behaviors and an increase in on-task behaviors. This study contributes to the determination of the efficacy of SW-PBIS in a historically more punitive environment. Given the initial positive response and lessons learned, it is believed that, with the support of additional Tier 2 and Tier 3 interventions, SW-PBIS may be an appropriate framework to support students in alternative schools.

A 3-year review of MRI safety incidents within a UK independent sector provider of diagnostic services.

A review of MRI safety incidents conducted over a 3-year period for a large independent sector diagnostic imaging provider in the UK. The review took a systematic approach using reports logged on an internal incident reporting system that were then categorised and analysed for themes and trends. Notable cases and actions taken are also described from within the period. MRI safety-related events made up 7.5% of the total number of incident reports submitted and 15.5% of all MRI-related reports. The MR safety-related incidence report rate was 0.05% (1 per 1987 patients), which is relatively low considering the number of patients seen in our facilities each day. Internal MRI safety events indicated the main trends to be around referral of contraindicated devices (32% of reports) and failure in the screening process (21.5%—either due to unexpected implants or being unable to confirm safety). To improve practice and work to reduce incidents, advice and instructional materials were developed. The review suggests a potential approach to categorisation of MRI-related safety events which could allow comparisons to be made across organisations, helping to look for trends and guide learning. It also provides insight into the state of MRI safety within the organisation, a rationale for some of the interventions introduced to improve safety, and discussion around common issues arising in MRI safety.

Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports.

Incident reporting can be used to inform imaging departments about adverse events and near misses. To study incident reports submitted during a 5-year period at a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports. All incident reports filed between 2013 and 2017 were reviewed and categorized by modality, patient type (inpatient, outpatient or emergency center) and use of sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between factors was performed. During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. The differences in rates by modality were statistically significant (P=0.0001). There was a greater rate of incident reports in interventional radiology (1.54%) (P=0.0001) and in magnetic resonance imaging (MRI) (0.62%) (P=0.001) as compared to other imaging modalities. There was a higher incident report rate for inpatients (0.34%) as compared to outpatient (0.1%) or emergency center (0.14%) (P=0.0001). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (P=0.0001). Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential for issues are interventional radiology, sedated patients, and inpatients. The areas associated with the least risk are ultrasound (US) and radiography. Safety improvement efforts should be focused on the high-risk areas.

Training for Direct Support Staff at Group Homes for People with Chronic Mental Illness

For people with chronic mental illness, their support system (including direct support staff at group homes) play a key role in ameliorating exacerbations leading to crisis care. However, little information exists on curriculum or training programs focused on reducing exacerbations while promoting compassionate care. We developed, implemented and evaluated such a program that featured role-playing and animated videos supplemented with limited didactics. During development phase, direct support staff reviewed videos and rated them as depicting realistic situations with high acceptability. During implementation, the 6-week course (at least one staff from six different group homes not involved in the development phase) using a 3-month pre-post design found reductions in total number of incident reports and pre-specified outcomes of recipient right complaints, emergency calls, and psychiatric hospitalizations. The program demonstrated acceptability, improved care and better outcomes on some but not all outcomes. Improved training of direct support staff is possible and has positive outcomes.

Learning from defects using a comprehensive management system for incident reports in critical care.

Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P<0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety.

IMPROVING PATIENT SAFETY CULTURE IN GENERAL PRACTICE

IntroductionA positive patient safety culture is considered a main condition for patient safety. Several initiatives have been taken with the intention to improve this culture in healthcare. Because these were...

Robotic Surgery Systems

For many people, the term “robotic surgery” likely evokes one of two images. One is Asimo, the Honda robot, performing a complex heart-valve replacement with the precision and finesse of the most skilled surgeon. The other is more along the lines of an industrial robot found welding on an automotive assembly line—performing surgery by rote programming on scores of patients in a row, just like in a factory. Neither is the case. Robotic surgery is, by some accounts, the next level of minimally invasive surgery. Conventional invasive surgery involves a large incision in the body to gain access to the area and organ of interest. For example, in a conventional gallbladder removal, the surgeon first performs a laparotomy, which is an incision, usually a large one, through the abdominal wall to gain access to the interior of the torso. The problem with a laparotomy is that it is very stressful physiologically and exposes large portions of the patient’s abdominal cavity to infection. Additionally, because the incision is so large, and the surgeon needs access to a large part of the patient’s interior, the surgery is characterized by a relatively large amount of trauma to the surrounding tissue, blood loss, and postoperative pain and discomfort coupled with a prolonged healing period. To overcome the problems and side effects of the laparotomy, minimally invasive surgery was developed. Minimally invasive surgery accesses the chest or abdomen through several smaller incisions, each one typically half an inch long. Each smaller incision has a port, or a combination trocar/port is used to make the incision, to protect the surrounding tissue while a particular device is inserted through the hole. The most common items inserted are an endoscope connected to a camera, a light source (which may be part of the other devices), an insufflator, and an instrument with one or more operating channels. In the case of minimally invasive gallbladder removal, now called a laparoscopic cholecystectomy, all the associated steps (draining the gall bladder, severing it from the ducts, and removing the empty bladder) are performed through the operating channel using specially adapted instruments. In minimally invasive surgery, as few as three or four small incisions can take the place of the much larger laparotomy incision. Some surgeons also perform this procedure as “scarless surgery” by accessing the abdomen through the navel and using a specialized operating endoscope with integral illumination and operating channels. Although there technically is a scar, observers might be hard pressed to find it as it is hidden in the folds of the navel. As one would expect, the smaller incisions mean less trauma to the body as a whole, reduced blood loss, and minimal discomfort, all of which equate to a shorter healing period. Minimally invasive surgery techniques are THE FUNDAMENTALS OF ...

がん化学療法の実施に関するインシデントを再現した実地講習会のインシデント削減効果の評価

Incidents involving cancer chemotherapies may result in a critical situation. We analyzed the incident reports involving enforcement of cancer chemotherapies in terms of frequency and risk. Thereafter, we implemented practical training based on the analysis for preventing incidents.The incidence of “medication error” was the highest in frequency at 43％, followed by “line management error” 30％ and “inspected error” 27％. After training, the number of incident reports in 2009 involving enforcement of cancer chemotherapies decreased by 45％, from 40 to 22 cases. The incidence per ward nurse involving enforcement of cancer chemotherapies was significantly higher in the non-participants (17/124, 0.137) than in the participants (5/125, 0.040) of the training.The results of questionnaires gathered from the participants indicated that a lack of knowledge about the antineoplastic was the chief cause of these incidents. Our findings suggest that practical training in consideration of the frequency and risk is effective for preventing incidents.

Influence of a new nursing system, seven patients per nurse, on the number of incident reports

Influence of a new nursing system, seven patients per nurse, on the number of incident reports

Incident Reporting at a Tertiary Care Hospital in Saudi Arabia

This study aimed to examine the rates and categories of incident reports in an academic tertiary care center in Saudi Arabia both hospital-wide and in the intensive care unit (ICU). Such information would help in redesigning systems and in planning and developing strategies with the goal of improving patient safety and quality of care. In this descriptive study, we evaluated all incident reports submitted through the paper-based reporting system in the hospital and the ICU for the year 2008. Incident report rates were calculated as the number of incident reports per 1000 patient days. We also reviewed the major and minor categories of the generated reports. A total of 3041 incident reports were submitted from all hospital areas; yielding a rate of 5.8 per 1000 patient days. Sixty-two incident reports were reported from the ICU, yielding a rate of 5.8 per 1000 patient days. The most frequent type of incident reports was procedural variances (37%), followed by behavior and communication incidents (34%), hazardous and safety incidents (9.5%), and medication errors (7.4%). In the ICU, the most frequently reported type of incidents was behavior and communication incidents (30.6%), followed by procedural variances (21%) and medication errors (13%). Rates of incident reports at a tertiary care center in Saudi Arabia were low compared with reported international rates. The main categories of incident reports were related to procedural variances and behavior and communication incidents. These findings suggest that patient safety initiatives should focus primarily on these 2 domains. Additional prospective research is needed in this important area to further understand patient safety challenges and reporting practice and culture in the country.

Central or local incident reporting? A comparative study in Dutch GP out-of-hours services

Centralised incident reporting in a Dutch collaboration of nine out-of-hours services yielded very few incident reports. To improve incident reporting and the awareness of primary caregivers about patient safety issues, a local incident-reporting procedure was implemented. To compare the number and nature of incident reports collected in a local incident-reporting procedure (intervention) versus the currently used centralised incident-reporting procedure. Quasi experiment. Three GPs' out-of-hours services (OHSs) in the centre of the Netherlands participated over 2 years before and 2 years after the intervention. A local incident-reporting procedure was implemented in OHS1, in which participants were encouraged to report all occurring incidents. A local committee with peers analysed the reported incidents fortnightly in order to initiate improvements if necessary. In OHS2 and OHS3, the current centralised incident-reporting procedure was continued, where incidents were reported to an advisory committee of the board of directors of the OHSs collaboration and were assessed every 2 months. The main outcome measures were the number and nature of incidents reported. At baseline, participants reported fewer than 10 incidents per year each. In the follow-up period, the number of incidents reported in OHS1 increased 16-fold compared with the controls. The type of incidents reported did not alter. In the local incident-reporting procedure, improvements were implemented in a shorter time frame, but reports in the centralised incident-reporting procedure led to a more systematic addressing of general and recurring safety problems. It is likely that a local incident-reporting procedure increases the willingness to report and facilitates faster implementation of improvements. In contrast, the central procedure, by collating reports from many settings, seems better at addressing generic and recurring safety issues. The advantages of both approaches should be combined.

Relationship between nursing workloads and patient safety incidents

To evaluate the relationship between nursing workloads and patient safety incidents in inpatient wards of a general hospital. A retrospective data analysis was conducted involving the internal medicine wards in a teaching hospital in Japan between July 1st and December 31st, 2006. To assess associations between nursing workloads and patient safety incidents, we analyzed the following: the relationships between the level of patients' dependency and the number of incident reports; and the relationships between the presence of accidental falls and the presence of patients transferred from the intensive care unit to the wards. Fifty-five nurses worked on the wards (105 beds). The total number of incidents was 142 over the 184 days of this study. There was a positive trend between the number of incidents and the total patient dependency score. The presence of accidental falls in the wards was associated with the presence of transfers from the intensive care unit to the wards (odds ratio 3.14, 95% confidence interval: 1.48, 6.65). Greater nursing workloads may be related to the higher number of patient safety incidents in inpatient wards of hospitals.

A Consensus-Established Set of Important Indicators of Pediatric Emergency Department Performance

Quality assurance is a new and important area of research in pediatric emergency medicine (PEM). There are few studies that describe which performance indicators best represent the PEM practice. The primary study objective is to construct a set of performance indicators that have been selected by current and former pediatric emergency department (PED) medical directors as most useful in assessing PED performance. The secondary objective is to assess which indicators are currently measured to assess performance in PEDs. Current and former directors of accredited Canadian PEM programs were considered as eligible participants. A list of indicators was generated by a survey (item pool generation); this list was refined by clarifying unclear terms or eliminating redundant and unquantifiable performance indicators (item scaling); PED directors were asked to rate each item of this refined list to indicate which indicators were more useful in assessing PED performance (item prioritization). A novel ranking formula was used to prioritize those items considered most useful by a larger proportion of respondents, using the provided rating scores. Fourteen current and former medical directors were considered eligible participants. Indicators related to patient morbidity and mortality, adverse outcomes, return visits, patient length of stay (LOS), and waiting times were considered to be more useful. Less useful indicators included the number of deaths, daily census, number of incident reports, and individual physicians' admission rates. The most commonly measured PED performance indicators included the rate of patients who left without being seen, patient LOS, and the waiting time until being seen by a physician by triage category. The top quartile of performance indicators considered most useful by participants included indicators that reflected clinical outcomes, LOS, and waiting times. A dichotomy may exist between those performance indicators that PED directors considered more useful and those indicators that are currently measured.