Patient Safety Classification Research Articles

Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: A mixed methods analysis.

About 25% of palliative medication incidents involve continuous subcutaneous infusions. Complex structural and human factor issues make these risk-prone interventions. Detailed analysis of how this safety-critical care can be improved has not been undertaken. Understanding context, contributory factors and events leading to incidents is essential. (1) Understand continuous subcutaneous infusion safety incidents and their impact on patients and families; (2) Identify targets for system improvements by learning from recurrent events and contributory factors. Following systematic identification and stratification by degree of harm, a mixed methods analysis of palliative medication incidents involving continuous subcutaneous infusions comprising quantitative descriptive analysis using the PatIent SAfety (PISA) classification system and qualitative narrative analysis of free-text reports. Palliative medication incidents (n = 7506) reported to the National Reporting and Learning System, England and Wales (2016-2021). About 1317/7506 incidents involved continuous subcutaneous infusions with 943 (72%) detailing harms. Primary incidents (most proximal to patient outcomes) leading to inappropriate medication use (including not using medication when it was needed) were underpinned by breakdowns in three major medication processes: monitoring and supply (405, 31%), administration (383, 29%) and prescribing (268, 20%). Recurring contributory factors included discontinuity of care within and between settings, inadequate time, inadequate staffing and unfamiliarity with protocols. Psychological harms for patients and families were identified. System infrastructure is needed to enable timely supply of medication and equipment, effective coordinated use of continuous subcutaneous infusions, communication and continuity of care. Training is needed to improve incident descriptions so these pinpoint precise targets for safer care.

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study

BackgroundThe COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context.MethodsWe conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript.ResultsWe identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose.ConclusionsWe have scrutinised the meaningful use of the PISA classification system’s application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

Comparison of Perception Differences among Nurses based on Harm Assessment Education in the Patient Safety Classification System

Background: Accurate harm assessment is critical in the patient safety event management system, but few studies have been published to support the need for training in harm assessment of patient safety events for nurses. Objective: The purpose of this study was to see if there was a difference in the degree of agreement between before and after nurses received training on a patient safety event harm assessment guideline. Methods: After participating in online harm assessment education, 65 subjects completed the self-report questionnaire. Data for the general characteristics of the study subjects and the frequency of respondents for each scenario were analyzed using descriptive statistics. Fleiss' kappa was calculated by estimating the inter-rater agreement among respondents for each scenario. Results: The agreement value of subjects by Fleiss' Kappa value improved from k = 0.23 before education to k = 0.31 after education, according to the harm assessment. There was no change at k = 0.30 before and after education for the harm period. Implication for Nursing & Conclusion: This study’s findings suggest that harm assessment agreement among nurses could be increased through harm assessment education. As a result, case-based education on harm assessment must be expanded, as well as related programs for practical education via patient safety event casebooks.

Family role in paediatric safety incidents: a retrospective study protocol

IntroductionHealthcare-associated harm is an international public health issue. Children are particularly vulnerable to this with 15%–35% of hospitalised children experiencing harm during medical care. While many factors increase the risk...

Nature and type of patient-reported safety incidents in primary care: cross-sectional survey of patients from Australia and England

BackgroundPatient engagement in safety has shown positive effects in preventing or reducing adverse events and potential safety risks. Capturing and utilising patient-reported safety incident data can be used for service...

Differences in the perception of harm assessment among nurses in the patient safety classification system.

Precise harm assessment by the medical staff is very important in a patient safety event reporting system but there are differences in perception due to insufficiencies in education. We developed the survey tool consisting of nine patient safety incident scenarios to investigate the interrater agreement in the harm score assigning among nurses. The survey tool was distributed to 287 nurses working at two hospitals. The overall kappa value for interrater agreement was k = 0.21 for harm and k = 0.28 for harm duration. In nine patient safety event scenarios, such as "mislabeled specimen" or "chest tube drain", when the degree of harm was not clear, the assessments of harm and harm duration were somewhat dispersed. For the quality of the patient safety incident reporting system, the accurate harm assessment of medical personnel is highly important; however, results in this study indicated that theassessment of the degree of harm by Korean nurses was not standardized. The reason for this variability could be due to the lack of education that takes harm assessment into account. Therefore, training in harm assessment and the development of programs to support this training are both necessary.

Investigating Errors in Medical Imaging: Lessons for Practice From Medicolegal Closed Claims

PurposeRadiology has lagged behind other disciplines in using medicolegal data to improve patient safety. The aim of this study was to characterize a sample of closed claims files to inform radiology practice and identify opportunities for system change. MethodsA retrospective analysis of 443 medicolegal closed claims provided to the Radiology Events Register. Data were provided by 2 medical defense organizations that provide medical indemnity insurance to Australian private practitioners. We calculated a procedural risk ratio (prevalence in the closed claims dataset divided by prevalence among all diagnostic imaging procedures reimbursed by the Australian Government over the corresponding timeframe) for each modality (CT, ultrasound, radiography, MRI, nuclear medicine) and some procedures. For each closed claim, the incident type was determined, and a classification of 12 patient safety fields was conducted. ResultsMisdiagnosis (delay or failure to correctly read imaging) accounted for 62% of error types. Modalities and procedures at higher risk of leading to a claim were: mammography (risk ratio [RR] = 4.0, 95% CI 2.9-5.5); breast ultrasound (RR = 2.8, 95% CI 1.7-4.7); total MRI (RR = 3.4, 95% CI 2.0-5.6); total CT (RR = 1.9, 95% CI 1.5-2.5), and obstetrics and gynecology ultrasound (RR = 1.9, 95% CI 1.4-2.4). Lower-risk modalities and procedures were: cardiac ultrasound (RR = 0.1, 95% CI 0.0-0.8); radiography extremities (RR = 0.7, 95% CI 0.5-0.9); and total radiography (RR = 0.8, 95% CI 0.7-0.9). Information to inform patient safety classification was limited, with a mean of 5.8 ± 1.8 (SD) fields available. ConclusionsDespite its limitations, medicolegal data deserve further attention from patient safety analysts.

Validating the Danish adaptation of the World Health Organization's International Classification for Patient Safety classification of patient safety incident types.

ObjectivesValidation of a Danish patient safety incident classification adapted from the World Health Organizaton's International Classification for Patient Safety (ICPS-WHO).DesignThirty-three hospital safety management experts classified 58 safety incident cases selected to represent all types and subtypes of the Danish adaptation of the ICPS (ICPS-DK).Outcome MeasuresTwo measures of inter-rater agreement: kappa and intra-class correlation (ICC).ResultsAn average number of incident types used per case per rater was 2.5. The mean ICC was 0.521 (range: 0.199–0.809) and the mean kappa was 0.513 (range: 0.193–0.804). Kappa and ICC showed high correlation (r = 0.99). An inverse correlation was found between the prevalence of type and inter-rater reliability. Results are discussed according to four factors known to determine the inter-rater agreement: skill and motivation of raters; clarity of case descriptions; clarity of the operational definitions of the types and the instructions guiding the coding process; adequacy of the underlying classification scheme.ConclusionsThe incident types of the ICPS-DK are adequate, exhaustive and well suited for classifying and structuring incident reports. With a mean kappa a little above 0.5 the inter-rater agreement of the classification system is considered ‘fair’ to ‘good’. The wide variation in the inter-rater reliability and low reliability and poor discrimination among the highly prevalent incident types suggest that for these types, precisely defined incident sub-types may be preferred. This evaluation of the reliability and usability of WHO's ICPS should be useful for healthcare administrations that consider or are in the process of adapting the ICPS.

Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events.

BackgroundTransfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined.ResultsTo address this problem, we sought to create a “best-of-breed” patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint.ConclusionsA common safety vocabulary can facilitate integration of information from disparate systems and processes to permit meaningful measurement and interpretation of data to improve safety within and across organizations. Formation of a “best-of-breed” classification for voluntary reporting necessitates an internal examination of localized data needs and workflow in order to design a product that enables comprehensive data capture. A team of clinical, safety, and information technology experts is necessary to integrate the data structures into the reporting system. We have found that a “best-of-breed” patient safety classification provides a solid, extensible model for adverse event analysis, healthcare leader communication, and intervention identification.

Tailoring "Best-of-Breed" Safety Classification for Patient Fall Voluntary Reporting

Voluntary safety event reporting often produces poorly defined data points, which complicate data analyses across health care settings. Such data should be restructured into a standard patient safety language translatable within and outside health care organizations. We designed and implemented a "best-of-breed" patient safety classification for data created by the Duke University Health System Safety Reporting System. We report our approach for patient fall classification. Our strategy was to deploy the International Classification for Patient Safety Framework of the World Health Organization augmented with additional data points of interest, thereby allowing for data translatability while maintaining local practices. System interface redesign using the "best-of-breed" fall classification was mindful of workflows and known reporting barriers. Custom aggregate reports were also developed. We estimated the impact of the redesigned portal on Safety Reporting System usage before and after classification through comparisons of fall report volume and report completion time. When normalized as falls per day, the rate of falls only changed slightly, indicating that the enhancement had little effect on reporting desire. Report completion time increased modestly but not significantly from a practical standpoint. The presence of structured data eliminated substantial hours dedicated to manual data management and enabled evaluation of quality improvement interventions within and outside our organization. Creation and implementation of a "best-of-breed" patient safety classification for voluntary reporting requires multidisciplinary collaboration between clinical experts, frontline clinicians, and functional and technical analysts. Formal usability evaluations of reporting systems are needed to ensure design facilitates effective data collection.

Tracing the foundations of a conceptual framework for a patient safety ontology

BackgroundIn work for the World Alliance for Patient Safety on research methods and measures and on defining key concepts for an International Patient Safety Classification (ICPS), it became apparent that...

Towards an International Classification for Patient Safety: key concepts and terms

BackgroundUnderstanding the patient safety literature has been compromised by the inconsistent use of language.ObjectivesTo identify key concepts of relevance to the International Patient Safety Classification (ICPS) proposed by the World Alliance For Patient Safety of the World Health Organization (WHO), and agree on definitions and preferred terms.MethodsSix principles were agreed upon—that the concepts and terms should: be applicable across the full spectrum of healthcare; be consistent with concepts from other WHO Classifications; have meanings as close as possible to those in colloquial use; convey the appropriate meanings with respect to patient safety; be brief and clear, without unnecessary or redundant qualifiers; be fit-for-purpose for the ICPS.ResultsDefinitions and preferred terms were agreed for 48 concepts of relevance to the ICPS; these were described and the relationships between them and the ICPS were outlined.ConclusionsThe consistent use of key concepts, definitions and preferred terms should pave the way for better understanding, for comparisons between facilities and jurisdictions, and for trends to be tracked over time. Changes and improvements, translation into other languages and alignment with other sets of patient safety definitions will be necessary. This work represents the start of an ongoing process of progressively improving a common international understanding of terms and concepts relevant to patient safety.

In terms of safety

Have your say on a new international approach to classifying patient safety information. Better classification of health information is often seen as a long way removed from the real work of making patient care safer. This is a mistaken view. Global progress on patient safety requires clear agreement about key safety terms and concepts. To date, a truly international patient safety classification has been missing. Our ability to accurately compare safety-related information across reporting and data collection systems is almost non-existent. This is a significant barrier to progress because many of the risks to patient safety are common across countries. The vision of the World Alliance for Patient Safety is simple. Can we more systematically and quickly learn from the experiences of patient harm internationally to prevent future patients being harmed throughout the world …

Effect of Supplements on Health of Girls

<h3>Background</h3> In work for the World Alliance for Patient Safety on research methods and measures and on defining key concepts for an International Patient Safety Classification (ICPS), it became apparent that there was a need to try to understand how the meaning of patient safety and underlying concepts relate to the existing safety and quality frameworks commonly used in healthcare. <h3>Objectives</h3> To unfold the concept of patient safety and how it relates to safety and quality frameworks commonly used in healthcare and to trace the evolution of the ICPS framework as a basis of the electronic capture of the component elements of patient safety. <h3>Conclusion</h3> The ICPS conceptual framework for patient safety has its origins in existing frameworks and an international consultation process. Although its 10 classes and their semantic relationships may be used as a reference model for different disciplines, it must remain dynamic in the ever-changing world of healthcare. By expanding the ICPS by examining data from all available sources, and ensuring rigorous compliance with the latest principles of informatics, a deeper interdisciplinary approach will progressively be developed to address the complex, refractory problem of reducing healthcare-associated harm.