Patient Safety Incident Reports Research Articles

Perceptions of U.S. and U.K. Incident Reporting Systems: A Scoping Review.

The aim of the study is to evaluate the extent, range, and nature of the literature that concerns healthcare providers' perceptions following the use of incident reporting systems (IRSs) in the United States (U.S.) and the United Kingdom (U.K.). Literature was compared describing providers' perceptions of reporting patient safety incidents using IRSs from healthcare systems built on public, private, for-profit, or nonprofit insurers in the U.S., with providers' perceptions using an IRS within a universal government supported healthcare system in the U.K. This scoping review searched literature from 4 electronic databases, producing 4863 articles between January 2010 to March 2023. Eleven U.S. and 8 U.K. articles met the inclusion criteria. Providers described system and individual barriers when using IRSs. The U.S. providers described more concerns regarding individual barriers (fear of punitive response or retaliation, feel incapable or shamed, unsure of what constitutes a patient safety incident, and concerned about litigation) than providers in the U.K. Both countries had similar responses regarding system barriers, except for U.K. providers who were more concerned than the U.S. about damage to professional culture. Providers in both countries believed incident reporting was ineffective and time consuming with hospital leaders seldom acknowledging or integrating improvement measures based on reported incidents. Sustainable improvements in patient care must be driven by hospital leadership who create just cultures where reporting of safety concerns is encouraged and respected within nonpunitive milieus.

Analysis Of Factors Influencing Patient Safety Incidents at Royal Prima Medan General Hospital in 2021

Incident safety patients must be minimized to avoid undesirable danger during maintenance in the hospital. Perception of health workers reporting patient safety incidents at the Royal Prima Medan General Hospital still needs to be higher. Low perception of health workers in writing incident Patient safety is related to individual and organizational factors. The study aims to identify the influence factor on patients' personal and corporate incident safety in the inpatient room of royal prima hospital medan. The type of research used is a method survey with a cross-sectional approach. The population in the study of health workers at the Royal Prima General Hospital in Medan was 259 people, and the sample was 119. Collection data with primary, secondary, and tertiary data was analyzed with multiple logistic regression statistical tests with a level of trust of 95%. Results study show bring individual factors (knowledge with p-value = 0.021 and experience with p-value=0.021) effect-on-patient safety incident reporting and organizational factors (organizational environment with p-value = 0.038 and power with p-value=0.014) effect on reporting incident safety patient, individual characteristics (motivation with p-value = 0.557) have no impact on writing incident safety patient And factor organization (organizational culture with p-value =0.535) has no effect to reporting incident patient safety and most influence reporting incident patient safety in Royal Prima General Hospital Medan is a knowledge variable (OR=155.6). They are recommended for a hospital for-develop system information integration related to writing incident patient safety and officer health to increase the perception of officer health through improvement, knowledge, and experience of officer health.

Leaders' Role in Fostering a Just Culture.

Just culture supports learning, encourages transparency and minimizes harm following reported patient safety incidents. Healthcare leaders have a key role in establishing and maintaining a just culture to improve patient safety at the macro, meso and micro levels of the healthcare system. In this paper, we discuss the role of leaders at various levels in the healthcare system in fostering a just culture to support the reporting of and learning from patient safety incidents. Specifically, leadership challenges related to establishing a just culture to improve patient safety are analyzed. In addition, we identify opportunities for healthcare leaders to foster a just culture.

APPLICATION OF PATIENT SAFETY INCIDENT REPORTING SYSTEM IN HOSPITALS: LITERATURE REVIEW

Patient Safety Incident Reporting for improvement of the service system and prevention of recurring patient safety incidents is a very important part and affects the quality of service, so it is necessary to evaluate the implementation of the ICP reporting system at the hospital. Objective: To ascertain the elements that impact hospital patient safety event reporting. Method: This article was written utilizing a literature review methodology. Data was gathered from database sources, and 20 articles between 2018 and 2023 were examined for PICOT analysis using the keywords patient safety incident, reporting, and health service. Results: There are three elements that affect the reporting of patient safety incidents that take place in hospitals: government, organizational, and human factors. It can be observed from features of nurse skills and patient safety culture in addition to environmental influences (individuals, organizations, and government). Cultural barriers (avoidance of conflict and fear of being blamed and penalized) and practical barriers (lack of expertise, so officers do not know how to report occurrences, lack of feedback, and lack of socialization connected to reporting incidents). Discussion: As a result of the existing literature review, no one has discussed the existence of organizational/hospital and government targets in efforts to achieve the target percentage (%) of PSI reporting. In order to improve employee motivation and involvement in reporting patient safety incidents and, ultimately, raise the standard of care provided to hospital patients, more research is required regarding the implementation of patient safety incident reporting in hospitals. Conclusion: The reporting of patient safety incidents in hospitals is influenced by three factors: personal, organizational, and governmental. Lack of feedback has been recognized as one of the weaknesses in incident reporting.

INFLUENCE ANALYSIS OF ORGANIZATIONAL FACTORS ON WORKPLACE BEHAVIOR IN THE IMPLEMENTATION OF RECORDING AND REPORTING PATIENT SAFETY INCIDENTS AT X HOSPITAL IN SURABAYA

Introductions. Work behavior is characterized by the implementation of recording and reporting patient safety incidents in accordance with applicable procedures. The problem in this research is the delay in recording and reporting patient safety incidents at Hospital This research aims to analyze the influence of organizational factors (perceived organizational support, organizational culture, ethical work climate, and trust in management) on workplace behavior in the implementation of IKP recording and reporting at Hospital X Surabaya. Method. This study used a cross-sectional design. The research was conducted in 35 work units at Hospital X Surabaya involving 77 work unit members as informants. Primary data collection using a questionnaire was carried out to measure all variables. Meanwhile, workplace behavior is measured using primary data using a questionnaire supported by using secondary data in the form of IKP reports. Meanwhile, workplace behavior is measured using primary data using a questionnaire supported by using secondary data in the form of Patient Safety Incident reports. Results & Analysis. The research results show that there are variables that have a p-value smaller than 0.05. Caring (dummy variable) from the ethical work climate variable (p-value=0.002). Conclusion. There are several recommendations given based on the results of this research. First, increasing cooperation between work unit members who support patient safety behavior related to recording and reporting patient safety incidents. Second, develop programs and policies related to the implementation of recording and reporting patient safety incidents.

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.

The benefits and opportunities: Engaging patients in identifying and reporting patient safety incidents.

There is growing recognition that patients can and should be engaged in the identification of patient safety incidents arising during their experiences across health systems. In this article, we describe the benefits that can be harnessed from engaging patients in reporting patient safety incidents; identify opportunities to support patient engagement in reporting and learning from patient safety incidents; and describe the potential role of health leaders in connecting patient experience and patient safety using patient-reported patient safety incident data.

Multifaceted Intervention to Improve Patient Safety Incident Reporting in Intensive Care Units.

Patient safety incident reporting in our institution's intensive care units (ICUs) had fallen 30% below national benchmarks during the COVID-19 pandemic. Underreporting diminishes awareness of risks and precludes organizational learning from near misses. We aimed to increase the ICU number of patient safety incident reports by 30% from 27 to 35 reports/1000 patient-days without negatively impacting culture of safety as measured by patient-care staff surveys. Single-institution prospective interventional study with 9 ICUs receiving a multifaceted intervention developed using quality improvement methodology during February-April 2022. Study intervention involved creation of patient safety peer-leadership role, feedback process, interactive dashboards for patient safety data, and education resources accessible via quick response codes. Primary outcome was patient safety incident reports/1000 patient-days. Intensive care unit patient-care staff culture of safety was assessed with surveys. Intensive care unit patient safety incident reporting increased by 48% after intervention (40 versus 27 reports/1000 patient-days [ P = 0.136]). Near misses were the most common incident report. Intensive care unit patient-care staff ratings of patient safety did not change; 80% rated patient safety as good or better after intervention versus 78% at baseline ( P = 0.465). However, significant improvement was observed for subcomponents related to learning culture and support for staff involved in patient safety incidents. Most reports (>80%) were submitted by nurses. This multifaceted quality improvement intervention increased patient safety incident reporting in the ICUs. Increases in ratings of learning culture and support for staff underline the importance of a well-functioning patient safety incident reporting system in an institutional culture of safety.

Budaya Pelaporan Insiden Keselamatan Pasien Terintegrasi Melalui SIMRS

This study aims to identify problems reporting patient safety incidents, conduct analysis, develop action plans, implement innovations in the management of integrated patient safety incident reporting culture through the Hospital Management Information System (SIMRS), and conduct evaluations. The research method used is a case report with the ADDIE approach to managing an integrated patient safety incident reporting culture through the Hospital Management Information System (SIMRS). The results showed that the culture of reporting patient safety incidents has not been optimal, incident reporting needs to be integrated through SIMRS, and there are no guidelines and standard operating procedures (SPO) for reporting patient safety incidents through SIMRS. In conclusion, incident reporting is influenced by various factors, namely human factors (not all safety incidents are reported, do not know how to report patient safety incidents using SIMRS), material (work instructions already exist (manual reporting flow SPO, reporting SPO, and writing through the Home Management Information System Hospital (SIMRS) does not yet exist) method (Integrated incident reporting flow with SIMRS does not yet exist), and machine (Reporting application through the Hospital Management Information System (SIMRS) does not yet exist).
 Keywords: Reporting Culture, Innovation, Patient Safety Incidents, Information SystemsHospital management

The evaluation of patient safety incident reporting at the Yogyakarta Gondomanan Health Center using the Health Matrix Network

Background: Based on patient safety incident data, the Ministry of Health, it is known that incident cases that occurred in the Special Region of Yogyakarta Province were 13.8%. Based on Patient safety’s policy in Indonesia namely PMK No. 11 of 2017 concerning patient safety states that every health service facility is required to have an information system that is used to improve patient safety, including the health center. The purpose of this study was to evaluate the use of the patient safety incident information system at the Gondomanan Health Center by using the Health Matrix Networks.
 Methode: This study uses a qualitative descriptive method with a case study design. Data collection used interview guidelines with 5 informants, namely the head of the health center, the patient safety team (1 doctor, 1 midwife, 1 nurse) and the dental polyclinic service coordinator (1 poly nurse). The sampling technique used purposive sampling.
 Result: There are 6 Health Matrix Network (HMN) tools that are used to measure the evaluation of patient safety information systems, namely information system resources, information system indicators, data sources, data management, CIS information products, and dissemination and use of SIK information. In terms of resource attributes or variables (policies, human resources, facilities and infrastructure and finance), health indicators, data sources, information products and the use of IKP reporting information are in accordance with the patient safety incident reporting guideline policy, and PMK No. 11 of 2017. Meanwhile, the attributes of data management and information products in the patient safety reporting information system have not been implemented optimally.
 Conclusion: The information system for reporting patient safety incidents at the Gondomanan Health Center requires improvement in procuring special SOPs for internal reporting of patient safety incidents which are part of the data management attributes.
 

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports. The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated. Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54). Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Nurses' perceptions of the influence of leadership behaviours and organisational culture on patient safety incident reporting practices.

Patient safety is a priority for all healthcare organisations. Enhancing patient safety incident reporting practices requires effective leadership behaviours at all levels in healthcare organisations. To explore nurses' perceptions of the influence of nurse managers' leadership behaviours and organisational culture on patient safety incident reporting practices. A descriptive, cross-sectional, correlational design was adopted with a convenience sample of 325 nurses from 15 Jordanian hospitals. Respondents had positive perceptions of their nurse managers' leadership behaviours and organisational culture. There was a significant positive relationship between leadership behaviours and organisational culture (r=0.423, P<0.001) and between leadership behaviours and actual incident-reporting practices (r=0.131, P<0.001). Additionally, there was a significant positive relationship between organisational culture and incident-reporting practices (r=0.250, P<0.001). Healthcare organisations must develop leaders who will foster a supportive and just culture that will enhance nurses' practice with regards to reporting patient safety incidents.

Virtual visits at the Helsinki Head and Neck Center during the COVID-19 pandemic: patient safety incidents and the experiences of patients and staff

BackgroundDuring the COVID-19 pandemic, health care had to find new ways to care for patients while reducing infection transmission. The role of telemedicine role has grown exponentially.MethodsA questionnaire on experiences and satisfaction was sent to the staff of the Head and Neck Center of Helsinki University Hospital and to otorhinolaryngology patients treated remotely between March and June 2020. Additionally, patient safety incident reports were examined for incidents involving virtual visits.ResultsStaff (response rate 30.6%, (n = 116)) opinions seemed to be quite polarized. In general, staff felt virtual visits were useful for select groups of patients and certain situations, and beneficial in addition to face-to-face visits, not instead of them. Patients (response rate 11.7%, (n = 77)) gave positive feedback on virtual visits, with savings in time (average 89 min), distance travelled (average 31.4 km) and travel expenses (average 13.84€).ConclusionsWhile telemedicine was implemented during the COVID-19 pandemic to ensure patient treatment, its usefulness after the pandemic must be examined. Evaluation of treatment pathways is critical to ensure that quality of care is upheld while new treatment protocols are introduced. Telemedicine offers the opportunity to save environmental, temporal, and monetary resources. Nonetheless, the appropriate use of telemedicine is essential, and clinicians must be offered the option to examine and treat patients face-to-face.

Planned improvement actions based on patient safety incident reports in Estonian hospitals: a document analysis

AimAim of this study was to describe and analyse associations of incidents and their improvement actions in hospital setting.MethodsIt was a retrospective document analysis of incident reporting systems’ reports registered...

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system.

Parenteral nutrition (PN)-related patient safety incidents have been associated with harm. Large-scale studies are scarce, and little is known about contributory factors. This study evaluated PN-related incident reports that described harm using a national database. A retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death. 12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors. This is the first evaluation of PN-related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high-risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.

Analysis Dimension of Healty Work Environment for Successful Patient Safety Incident Reporting: A Cross Sectional Study

Incident reporting of patient safety is the first step in improving patient safety through learning from previous incidents. However, barriers to incident reporting caused by work environment factors make the patient safety incident system not run well in various countries. This study analyzes nurses’ dimensions of a healthy work environment toward reporting patient safety incidents. This study used an observational analytic design with a cross-sectional approach. This study was conducted in a regional hospital in West Nusa Tenggara province in October - November 2022 with a total sample of 151 nurses working in the inpatient room. Sample determination used a quota sampling technique. Measurement of a healthy work environment was adopted from the HWE Tools and Measurement of incident reporting. The questionnaire was adopted from the Patient Safety Incident Reporting and Learning Systems. Data collection techniques implemented primary data questionnaires and multiple linear regression tests. The results showed a relationship between communication, collaboration, decision-making, staff suitability, recognition, and leadership to patient safety incident reporting with a p-value of 0.001 each (p &lt;0.05). The most dominant relationship is Recognition (B=0.39, p=0.001). Recognition means stimulating a person’s psychological growth and a positive mindset to complete tasks, solve problems, overcome obstacles, and bounce back from difficult situations. Therefore, individual attitudes alone are not enough to make individuals behave to report or not report incidents but must be supported by the wishes of those who have great influence in the environment and want individuals to report if an incident occurs.

Interorganizational health information exchange-related patient safety incidents: A descriptive register-based qualitative study

PurposeThe current literature related to patient safety of interorganizational health information is fragmented. This study aims to identify interorganizational health information exchange-related patient safety incidents occurring in the emergency department, emergency medical services, and home care. The research also aimed to describe the causes and consequences of these incidents. MethodsA total of sixty (n = 60) interorganizational health information exchange-related patient safety incident free text reports were analyzed. The reports were reported in the emergency department, emergency medical services, or home care between January 2016 and December 2019 in one hospital district in Finland. ResultsThe identified interorganizational health information exchange-related incidents were grouped under two main categories: “Inadequate documentation”; and “Inadequate use of information”. The causes of these incidents were grouped under the two main categories “Factors related to the healthcare professional “ and “Organizational factors”, while the consequences of these incidents fell under the two main categories “Adverse events” and “Additional actions to prevent, avoid, and correct adverse events”. ConclusionThis study shows that the inadequate documentation and use of information is mainly caused by factors related to the healthcare professional and organization, including technical problems. These incidents cause adverse events and additional actions to prevent, avoid, and correct the events. The sociotechnical perspective, including factors related to health care professionals, organization, and technology, should be emphasized in patient safety development of inter-organizational health information exchange and it will be the focus of our future research. Continuous research and development work is needed because the processes and information systems used in health care are constantly evolving.

Defining avoidable healthcare-associated harm in prisons: A mixed-method development study.

Reducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. Using a sequential mixed methods study design we first characterised and reached consensus on the types and avoidability of patient harm in prison healthcare involving analysis of 151 serious prison incidents reported to the Strategic Executive Information System (StEIS) followed by in-depth nominal group (NG) discussions with four former service users and four prison professionals. Findings of the NG discussions and StEIS analysis were then synthesised and discussed among the research team and study oversight groups to develop an operational definition of avoidable harm in prison healthcare which was subsequently tested and validated using prison patient safety incident report data derived from the National Reporting and Learning System (NRLS). Analysis of StEIS incident reports and NG discussions identified important factors influencing avoidable harm which reflected the unique prison setting, including health care delivery issues and constraints associated with the secure environment which limited access to care. These findings informed the development of a new working two-tier definition of avoidable harm using appropriate and timely intervention, which included an additional assessment of harm avoidability taking into the account the prison regime and environment. The definition was compatible with the NRLS incident report narratives and illustrated how the prison environment may influence identification of avoidable harm and judgements of avoidability. We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement.

FAKTOR YANG BERHUBUNGAN DENGAN PELAPORAN INSIDEN KESELAMATAN PASIEN OLEH PERAWAT DI RSUD PANEMBAHAN SENOPATI BANTUL YOGYAKARTA

Establishing a patient safety culture is associated with reducing the occurrence of adverse events. One important component of safety culture is the frequency of reporting patient safety incidents. Nurses are reliable information reporters for assessing patient safety outcomes including adverse events. However, nurses have obstacles in reporting patient safety incidents. This study aims to determine the factors associated with the reporting of patient safety incidents by nurses at Panembahan Senopati Hospital, Bantul. The research method is quantitative observational with cross sectional design. A sample of 189 nurses was taken using proportionate stratified random sampling. Data collection using a questionnaire. Data analysis usingspearman rank and logistic regression. The results of the analysis with incident reporting obtained the value of open communication (p value &lt;0,001); expectations &amp; promotion of patient safety by superiors (p value 0,015); feedback about errors (p value 0,007); non punitive response to mistakes (p value &lt;0,001) and management support (p value 0,084). So that the factors related to the frequency of reporting patient safety incidents at Panembahan Senopati Hospital, Bantul are non punitive responses to errors, ope communication, feedback about errors and expectations &amp; promotion of patient safety by superiors. So that hospitals can improve the culture of reporting patient safety incidents by paying attention to the factors that influence itu.

INCIDENTES DE SEGURANÇA CLASSIFICADOS COMO PROCESSO/PROCEDIMENTO CLÍNICO EM PACIENTES HOSPITALIZADOS DURANTE PANDEMIA DE COVID-19

ABSTRACT Objective: Compare reported patient safety incidents related to a clinical process/procedure among patients with laboratory-confirmed COVID-19 diagnosis and with Severe Acute Respiratory Syndrome (SARS) caused by another infectious or undetermined agent and the other patients. Results and discussion: retrospective, documentary study approved by the ethics committee in a public teaching hospital in southern Brazil. In the study, 2,191 notifications and records of COVID-19 between March and September 2020 were used. The data were submitted to descriptive analysis with frequencies of the variables in the data set, Fisher’s test to determine the associations between outcomes (classification/process/problem) and calculation of relative risk to measure its strength. The incidence of pressure ulcers was almost 3.7 times higher in patients with SARS. In the others, various tube-related incidents and events associated to the surgical process predominated. Conclusion: Intensive nursing care for patients with SARS, risk management and strengthening of good practices for the safety of all patients were relevant.