Number Of Patient Safety Incidents Research Articles

정신건강의학과 환자안전사고 분석(2017-2021)

The study was undertaken to investigate the occurrence and risk levels of patient safety incidents in the mental health department of domestic medical institutions, aiming to provide essential data for formulating strategies to prevent such incidents in the future.
 The data for this study were collected nationwide from medical institutions accredited by the Korean Institute for Healthcare Accreditation, with a focus on patient safety statistics. A total of 521 cases from comprehensive and tertiary hospitals with more than 200 beds, classified under the department of mental health and psychiatry, were analyzed. Data analysis was performed using SPSS/WIN 27.0 software, encompassing descriptive statistics, cross-tabulation analysis, and binary logistic regression.
 The results showed that the number of patient safety incidents increased slightly in 2020 and 2021 compared to 2017. However, the level of harm caused by these incidents indicated a trend of increasing near misses and decreasing adverse events from 2017 to 2021. Comprehensive hospitals had a significantly higher proportion of adverse events in patient safety incidents compared to tertiary hospitals. The results of binary logistic regression analysis revealed that comprehensive hospitals had a 2.459 times higher risk of adverse events compared to tertiary hospitals. When comparing incident types, the risk of adverse events for falls was 10.677 times higher, and for suicide and self-harm events, it was 66.103 times higher compared to medication errors. Regarding age groups, the risk of adverse events for the 20-39 age group was 3.335 times higher compared to the 0-19 age group. For the 40-59 age group, the risk was 4.911 times higher for the 60-79 age group, it was 5.340 times higher, and for the 80 years and above age group, it was 4.027 times higher . The goodness of fit test for the final model indicated a good fit, and the model's explanatory power was 30.2%.
 Based on the study results, there is a need for a systematic analysis of nursing staff levels in comprehensive hospitals and their relationship with patient safety incidents and it is crucial to prioritize comprehensive hospitals when devising patient safety incident prevention measures in mental health. Suicide and self-harm prevention, and fall prevention strategies, should be considered as indispensable components. Furthermore, it is recommended to give priority to implementing patient safety incident prevention strategies for individuals aged 60-79 years of age.

Analysis of Factors Related to Domestic Patient Safety Incidents Using Decision Tree Technique.

To address the increasing number of patient safety incidents, their scope and extent should be assessed and the situations in which they occur determined. This study employed a decision tree analysis based on patient safety incident cases to identify groups at high risk for adverse patient safety incidents and provide data to develop prevention strategies for minimizing their occurrence or recurrence. In total, 8934 patient safety incidents were analyzed using the "2021 Patient Safety Report Data", which were systematically collected by the Korea Institute for Healthcare Accreditation. A decision tree analysis (Chi-square Automatic Interaction Detection) was employed to identify the characteristics associated with the degree of risk for patient safety incidents. The groups most vulnerable to adverse events were those who experienced healthcare-associated infections (HAI) in long-term care facilities, followed by those experiencing HAI in tertiary hospitals, general hospitals, or clinics, and those experiencing fall-related events in neuropsychiatry departments of tertiary hospitals, general hospitals, or clinics. The most important factor in the degree of harm in patient safety accidents was the type of accident, followed by the type of medical institution, and then the treatment department. Particularly, HAI and falls are the most important factors determining the degree of harm in patient safety accidents.

The Correlation between the use of the SBAR Effective Communication Method and the Handover Implementation of Nurses on Patient Safety

Background: Patient safety is a system implemented in hospitals with the aim of providing patient comfort in the treatment process. One of the effective communication methods is using the Situation Background Assessment Recommendation (SBAR) approach, this communication method is used when nurses carry out handovers to achieve critical thinking skills and save time during the treatment process. The SBAR approach has proven to be an effective communication tool in acute and urgent patient care settings. This review aims to find effective communication methods to reduce or reduce the number of patient safety incidents, improve service quality and improve the quality of nursing care. Purpose: To find out the relationship between the use of the SBAR effective communication method and the implementation of handovers on patient safety. Methods: Using a Literature review research design with the journal search method using the Google Scholar and Elsevier databases. Results: Researchers found 13 articles that met the inclusion and exclusion criteria. The results of the literature review show that effective communication using the SBAR approach can reduce errors in communication between health workers and health workers with patients so as to prevent unwanted events. Therefore, effective communication with the SBAR approach can also improve the quality of hospital services and increase patient satisfaction and effective SBAR communication plays an important role in the implementation of handover of patient safety. Conclusion: The results of a systematic literature review show that there is a relationship between the use of the effective SBAR communication method and the implementation of handovers on patient safety and the effective communication method with the SBAR approach is expected to become a communication method that can improve service quality, reduce patient safety incidents and prevent the occurrence of unwanted events, and can affect patient satisfaction and nurse loyalty.

Incident analysis of patient safety in hospital: Based on feedback and supervision concept

Introduction: The concept of feedback and supervision is at the core of efforts to reduce hospital patient safety incidents. This study aimed to analyze the effect of feedback and supervision on the occurrence of patient safety incidents in hospitals. Methods: The population included 18 work units that provide services to patients with samples of the unit head or room head, the person in charge of work shifts and the person in charge of patient safety quality. Data in the form of respondents' perceptions were collected through a questionnaire using Google form and analyzed using cross-tabulation and the Pareto approach with a note that it is influential if a difference of >20% is found between the independent and the dependent variable. Results: The results showed that most of the feedback in the work unit was lacking (50.0%), and supervision in the work unit was good (55.6%). The number of patient safety incidents at the Surabaya Islamic Hospital was dominated by near-injury incidents (NII) with a green rating. The outpatient unit is the unit with the highest incidence. Feedback and supervision affect the number of patient safety incidents because they have a difference of 22.2% and 52.5%, respectively. This study has shown that hospital patient safety incidents are influenced by feedback and supervision. Conclusion: This study showed that feedback and supervision influence the incidence of patient safety incidents in hospitals. Therefore, there is a need for training on supervision at the head of the room, providing socialization and education about the importance of patient safety, and increasing the commitment of decision-makers and related stakeholders.

Exploring Changes in Patient Safety Incidents During the COVID-19 Pandemic in a Canadian Regional Hospital System: A Retrospective Time Series Analysis.

ObjectivesThe COVID-19 pandemic has placed unprecedented strain on healthcare systems and may have consequential impacts on patient safety incidents (PSIs). The primary objective of this study was to examine the impact of the COVID-19 pandemic on PSIs reported in Niagara Health.MethodsFlexible Farrington models were used to retrospectively detect weeks from January to September 2020 where PSI counts were significantly above expected counts. Incident counts were adjusted to weekly inpatient-days. Outcomes included overall incident numbers, incidents by category, and incidents by ward type.ResultsThe overall number of PSIs across Niagara Health did not increase during the first wave of the COVID-19 pandemic. However, significant increases in falls were observed, suggesting that other types of incidents decreased. Falls increased by 75% from February to March 2020, coinciding with the onset of the first wave of the pandemic. Further investigation by unit type revealed that the number of falls increased specifically on internal medicine and complex continuing care wards.ConclusionsDespite no observed changes in overall number, significant composition shifts in PSIs occurred during the first wave of the COVID-19 pandemic, with increased falls on internal medicine and complex continuing care wards. Possible explanations include restrictions on patient visitation, reduced patient contact/supervision, and/or personal protective equipment requirements. Providers should maintain a particularly high vigilance for patient falls during pandemic outbreaks, and hospitals should consider targeting resources to higher-risk locations. The results of this study reinforce the need for ongoing pandemic PSI monitoring and rapidly adaptive responses to new patient safety concerns.

Patient Safety in Emergency Departments: Improvement Is Possible

Emergency services have a high potential risk for adverse events. The working conditions are sometimes conducive to making mistakes. There are few studies that have shown improvements in specific aspects of patient safety in the emergency department, but none in the overall incidence. The general objective is to improve patient safety in our emergency services by implementing improvement actions. This is a quasi-experimental study carried out in 8 hospital emergency services. The methodology is mainly based on the EVADUR and ENEAS studies. We collect data through a face-to-face interview during their stay in the Emergency Department and carry out a telephone review 1 week later. We then inform the departments of the results and initiate improvement activities. 14 improvement measures were implemented in the different emergency services. Two years later, a reassessment was carried out using the same methodology. An initial sample of 382 cases was collected. After the improvement actions, data from 267 patients were collected. No significant differences were found between the 2 groups in terms of age, sex, triage level, hospital, care shift, average length of stay and discharge destination. In the initial evaluation, at least 1 incidence was detected in 46 patients (12.04%), and in the reevaluation, 16 patients with an incident (5.99%) were detected. The differences were statistically significant (p<0.01). The emergency services studied were able to reduce the number of patient safety incidents.

Analisis Insiden Keselamatan Pasien di Rumah Sakit Berdasarkan Pendekatan Beban Kerja dan Komunikasi

Patient safety incidents at Ahmad Yani Islamic Hospital Surabaya increased by 0.3% in 2019. If not addressed immediately, these problems can give a negative image to hospitals and patients. An error that appears and has an impact on increasing patient safety incidents, stems from a high workload and poor communication. The purpose of this study was to analyze the role of workload and communication on the occurrence of patient safety incidents in hospitals. This study uses a unit of analysis as many as 18 work units that directly provide services to patients. Participants include the head of the work unit, the person in charge of the work unit and the person in charge of the quality of the work unit with a total of 90 people. The data was obtained primarily using the instrument contained in the google form. The communication measurement tool uses the Communication Openness Measurement (COM) and the workload uses the WISN calculation. Patient safety incident data was obtained from the PMKP RS team. The analysis was carried out by means of a simple cross tabulation with interpretation using the Pareto concept. The results showed that most work units (83.3%) had a low workload, most of the work unit communication (61.1%) was not good and 33.3% of work units had a high patient safety incident rate. In the Pareto concept, the results showed that workload had no effect on patient safety incidents, while communication influenced the number of patient safety incidents. Therefore, hospitals need to fix the pattern and flow of communication as well as the need for information disclosure so that the flow of information becomes more adequate, transfer of knowledge becomes better and employee understanding of the importance of patient safety in hospitals becomes better.

508 IMPROVING PATIENT SAFETY BY REDUCING THE INCIDENCE OF MISSED MEDICATIONS IN ELECTIVE SURGICAL PATIENTS

Abstract Introduction Following a number of patient safety incidents within elective surgical admissions we sought to improve prescribing practices in elective admissions and take steps to improve similar errors recurring in the future. We found these errors particularly affected frail patients with multiple medications and patients with Parkinson’s disease. Method We formed a team of interested junior doctors. By looking at patient pathways we targeted specific areas vulnerable to error. Patients and their drug histories are scrutinised by nurses, doctors and theatre staff during their admission. We highlighted areas where small but important changes could be made. Changes were then made using iterative PDSA cycles. Firstly, the admission proforma had no column for dose or frequency in the drug history, so this was added. Secondly, we instructed the admitting team to prescribe all required medications at the patients’ pre-operative assessment. Thirdly, various prompts were provided to the on-call junior surgical team to provide assurance that all medications for elective patients had been prescribed. A two week time period was chosen to calculate the number of patients who had missed a dose of medication due to lack of prescribing. Effect, ease and sustainability in real world practice were carefully tested by individual teams. Results We found that missed doses could be reduced significantly from a 9% error rate to &amp;lt;1%. The most effective intervention resulted from changes to the proforma. Though all interventions were deemed to be effective, only two were considered maintainable in real world practice. These changes have been implemented. Conclusions Several processes in the healthcare system are set in stone, as they have been used for years, if not decades. However, we proved that simple changes in operating procedures can make a huge difference to patient safety, health and outcome.

Patient safety attitudes of health worker and its associated factors in Lung Hospital, Son La province, 2020

Patient safety is being seen as an increasingly important topic in the healthcare feld, and the rise in the number of patient safety incidents poses a challenge for hospital management. The cross-sectinal study was conduted to describle the health care professionals’ attitudes regarding patient safety. The results showed that the average score for the questionnaire was 76.8 ± 6.5. In each dimension, job satisfaction was the highest score and stress recognition was the lowest score. Three of the six dimensions achieved positively patient safety attitudes (job satisfaction, work conditions, perception of management). There was a statistically signifcant difference (p &lt; 0.05) between the main training expertise and the expertise scope. Pharmacists were better at safety attitudes than doctors, nurses, and technicians in almost all dimensions (85.1 ± 1.0) (excepted the perception of management). People who graduated from university and had postgraduate degrees had a higher score in patient safety attitudes than people who had intermediate and college degrees (77.5 ± 6.2 versus 76.4 ± 6.8). When results were calculated at each hospital, associated factors of patient safety attitudes differed in occupation and education level. Health workers who are pharmacist and post graduate have patient safety attitude scores higher than others. Evidence could help the government and hospital managers develop strategies in patient safety attitudes. Moreover, the methodology was used for future studies in patient safety attitudes.

Implementasi Patient Safety di Pelayanan Anak Rumah Sakit Umum Haji Medan Tahun 2019

The complexity of diversity, relationships, variety and specialization can provide more opportunities for mistakes, one of which is in the children's hospital services. Based on patient safety incident report data at Rumah Sakit Umum Haji Medan in January 2018 to October 2018, it is known that child care is the unit with the highest number of patient safety incidents compared to other units at 37 incidents. Implementation of patient safety by officers in children's services is the main focus that must be considered its role to prevent the occurrence of patient safety incidents. This research is a qualitative research that aims to see the extent of the implementation of patient safety in child care at Rumah Sakit Umum Haji Medan from the description of the role of health workers involved in child care, namely the role of the head of a child's SMF, the role of a pediatrician, and the role of a child nurse. Data collection was carried out by in-depth interviews with 7 informants and through observation. The results showed the implementation of patient safety in children's services has not been running optimally. This is because not all health workers in child services, namely the head of the child's SMF, pediatricians and child nurses do their part in the patient safety system. The roles carried out are still focused on the standards of each profession. It is expected that routine socialization on the implementation of patient safety, the implementation of special meetings and discussions to study the patient safety system and the existence of patient safety drivers in child care designated as the person responsible for moving every officer to implement patient safety. Keywords: Implementation, Children's Services, Patient Safety

The relationship between the perception of open disclosure of patient safety incidents, perception of patient safety culture, and ethical awareness in nurses

BackgroundScientific advances have resulted in more complex medical systems, which in turn have led to an increase in the number of patient safety incidents (PSIs). In this environment, the importance of honest disclosure of PSIs is rising, which highlight the need to settle a reliable system. This study aimed to investigate the effects of patient safety culture and ethical awareness on open disclosure of PSIs.MethodsData were collected from 389 nurses using self-reported perceptions of open disclosure of PSIs, perceptions of patient safety culture, and ethical awareness.ResultsPerception of open disclosure of PSIs was significantly correlated with ethical awareness and perception of patient safety culture. Ethical awareness had the greatest impact on perception of PSIs, and two components of the perception of patient safety culture, namely overall knowledge about patient safety and staffing, were found to have significant effects.ConclusionsTo enhance nurses’ perception of open disclosure of PSIs, educational curriculum and programs that teach and practice fundamental ethical values are needed. Furthermore, it also calls for effort on the part of healthcare institutions and the government, as well as people’s trust, to implement a legal safety net and foster patient safety culture to promote honest disclosure of PSIs to patients.

Development, implementation and impact of simple patient safety interventions in a university teaching hospital

ObjectiveTo determine the incidence of anesthesia patient safety incidents at a university teaching hospital, develop interventions to address the most common incidents, and determine the effectiveness of these interventions. Study designPre-post intervention observational. AnimalsFour thousand, one hundred forty dogs and cats anesthetized by the anesthesia service. MethodsThe study was divided into two 11.5 month periods. During each period, incidents were logged (e.g. closed adjustable pressure limiting (APL) valve, esophageal intubation, and medication error). At the end of the first period, four countermeasures were incorporated into the service’s protocols: 1) prior to any drug injection, the individual would read out aloud the drug name, patient name, and route of administration; 2) use of a uniquely colored occlusive wrap over arterial catheters; 3) a check box on the anesthesia record labeled “Technician Confirmed Intubation”; 4) a check box on the anesthesia record labeled “Technician Checked OR (operating room)”. The number of patient safety incidents during period 1 and period 2 were compared using Fisher’s Exact Test. ResultsDuring Period 1, there were 74 incidents documented in 2028 patients (3.6%) including 25 medication errors, 20 closed APL valves, and 16 of esophageal intubation. During Period 2, there were 30 incidents documented in 2112 patients (1.4%) including 14 medication errors, 5 closed APL valves, and 4 of esophageal intubation. The proportion of events during Period 2 was significantly smaller than during Period 1 (p < 0.0001). Conclusions and Clinical relevanceImplementation of four simple interventions was associated with a significant decrease in the number of incidents.

PLAN, DO, STUDY, ACT CYCLES, AS AN ALTERNATE TO ACTION RESEARCH FOR CLINICALLY BASED INQUIRY

Action Research has long been the method of choice when undertaking research in clinical practice improvement. It is a method aimed at engendering ownership by the participants in order to sustain pra ctice change. Plan, Do, Study, Act cycles (PDSA) also pro vide a cyclical approach to clinical practice improvement research and focus the clinical team ar ound a specific problem. Through focus groups and discussions with staff, the contributing factor s to a number of patient safety incidents were identified. A series of interventions were implemen ted requiring staff to intervene to mitigate patien t risk and decrease patient safety incidents. These i nterventions were introduced utilising PDSA cycles with concomitant incremental improvements in clinic al processes. Clinical practice improvement resulted in a decrease in patient safety incidents. How ever, whilst individual staff were transformed as a result of their participation in the research, th e culture in which the research was conducted did n ot change. The elements of Action Research and PDSA will be summarised and the key similarities and differences will be compared and contrasted. The in hibiting factors to using Action Research in a dynamic acute care environment will be discussed. T his study will explore how PDSA cycles, with their concurrent similarities and differences to Ac tion Research, can provide a method for researching the implementation of a system improvement solution.

Are health professionals’ perceptions of patient safety related to figures on safety incidents?

The study aims to explore whether health care professionals' perceptions of patient safety in their practice were associated with the number of patient safety incidents identified in patient records. Seventy primary care practices of general practice, general dental practice, midwifery practices and allied health care practices were used in the study. A retrospective audit of 50 patient records was performed to identify patient safety incidents in each of the practices and a survey among health professionals to identify their perceptions of patient safety. All health professions felt that 'communication breakdowns inside the practice' as well as 'communication breakdowns outside the practice' and 'reporting of patient safety concerns' were a threat to patient safety in their work setting. We found little association between the perceptions of health professionals and the number of safety incidents. The only item with a significant relation to a higher number of safety incidents referred to the perception of 'communication problems outside the practice' as a threat to patient safety. This study indicates that the assessment of professionals' perceptions may be complementary to observed safety incidents, but not linked to an objective measure of patient safety.

Prevalence and consequences of patient safety incidents in general practice in the Netherlands: a retrospective medical record review study

BackgroundPatient safety can be at stake in both hospital and general practice settings. While severe patient safety incidents have been described, quantitative studies in large samples of patients in general practice are rare. This study aimed to assess patient safety in general practice, and to show areas where potential improvements could be implemented.MethodsWe conducted a retrospective review of patient records in Dutch general practice. A random sample of 1,000 patients from 20 general practices was obtained. The number of patient safety incidents that occurred in a one-year period, their perceived underlying causes, and impact on patients' health were recorded.ResultsWe identified 211 patient safety incidents across a period of one year (95% CI: 185 until 241). A variety of types of incidents, perceived causes and consequences were found. A total of 58 patient safety incidents affected patients; seven were associated with hospital admission; none resulted in permanent disability or death.ConclusionsAlthough this large audit of medical records in general practices identified many patient safety incidents, only a few had a major impact on patients' health. Improving patient safety in this low-risk environment poses specific challenges, given the high numbers of patients and contacts in general practice.

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.

The reporting of patient safety incidents—first experiences with the chiropractic reporting and learning system (CRLS): A pilot study

Summary Objective To design and test a reporting format for patient safety incidents (PSIs) related to chiropractic practice. Design A pilot study of adverse event monitoring. Setting Field chiropractic practice and the teaching clinic of the Anglo-European College of Chiropractic. Subjects Members of the British Chiropractic Association and final year clinical students. Methods Following design of a reporting format, chiropractors and/or final year clinical students responded by completing a form and submitting this to a central collection point for analysis. Results Forms were received from seven field practitioners and from 63 students providing information on a number of PSIs. The low number of field practitioners responding prevented any summative analysis and the results are therefore presented individually. With reference to the final year clinical students, the majority of PSIs were associated with misuse of therapeutic equipment (32%) and the treatment intervention itself (31%). Conclusions Gathering information on PSIs using this format was shown to be both feasible and fit for purpose. Further work is planned to widen access and to facilitate and promote the attributes for an informed safety culture for the chiropractic profession.

Getting Doctors to Report Medical Errors: Project DISCLOSE

Despite the number of patient safety incidents that occur in hospitals, physicians currently may not have the ideal incident reporting tools for easy disclosure. A study was undertaken to assess the effectiveness of a simplified paper incident reporting process for internal medicine physicians on uncovering patient safety incidents. Thirty-nine internal medicine attending physicians were instructed to incorporate the use of a simplified paper incident reporting tool (DISCLOSE) into daily patient rounds during a three-month period. All physicians were surveyed at the conclusion of the three months. Compared with physician reporting via the hospital's traditional incident reports from the same time period, a higher number (98 incidents versus 37; a 2.6-fold increase) of incidents were uncovered using the DISCLOSE reporting tool in a larger number of error categories (58 versus 14, a 4.1-fold increase). When reviewed and classified with a five-point harm scale, 41% of events were judged to have reached patients but not caused harm, 33% to have resulted in temporary harm, and 9% of reports, though not considered events, were to indicate a "risky situation." Surveyed physicians were more satisfied with the process of submitting incident reports using the new DISCLOSE tool. A simplified incident reporting process at the point of care generated a larger number and breadth of physician disclosed error categories, and increased physician satisfaction with the process.