Patient Safety Incidents Research Articles

Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety - an analysis in a Finnish teaching hospital.

Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports. The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety. The study material included incident reports (n = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis. Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports,40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%). In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems. Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted. Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding. System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents.

Post-pandemic patient safety: have the characteristics of incidents with harm changed? Comparative observational study in primary care via review of medical records with a trigger tool

BackgroundThe COVID-19 pandemic generated or accelerated healthcare changes, some of which persist thereafter (e.g., healthcare reorganisation, remote consultation). Such changes entail novel risks for patient safety.MethodsAimTo compare the characteristics of patient safety incidents with harm (PSIH) in primary care before the pandemic and at present.Design and settingCross-sectional, comparative, observational study conducted within the entire Primary Care Service of the Madrid region with observations at two time points (2018 and 2021/2022).ParticipantsPatients > 18 years of age with at least one consultation in the previous year. The necessary sample size was established at N1 = 2,000 for the first time point and N2 = 2,700 for the second. Sampling was performed by simple randomisation for the first group and by clusters followed by simple randomisation for the second.Main measurementsAge, gender, presence of PSIH in the medical record, and characteristics of the PSIH, specifically avoidability, severity, place of occurrence, nature, and contributory factors. Triggers validated in primary care were employed to screen the patients’ medical records and those containing any trigger were reviewed by three nurse-physician teams who underwent previous training.AnalysisComparative analysis using Fisher’s exact test.ResultsA total of 63 PSIHs and 25 PSIHs were found for the first and second samples, respectively. The comparison of the characteristics of PSIH before the pandemic and currently was: avoidable 62% vs. 52% (p = 0.47), mild 51% vs. 48% (p = 0.57), in the primary care setting 73% vs. 64% (p = 0.47), respectively. Although no statistically significant differences were observed globally in the nature of the incidents (p = 0.13), statistically significant differences were found for diagnostic errors, with pre-pandemic rates of 6% vs. 20% at present (p < 0.05). Finally, no significant differences were found in the contributory factors.ConclusionsNo differences were found in the avoidability, severity, place of occurrence, or contributory factors of PSIHs before the pandemic and currently. In terms of the nature of these incidents, the outcomes revealed an increase in diagnostic errors (excluding diagnostic tests), which could be attributed to a greater frequency of remote consultations and a decrease in the longitudinality of care resulting from the shortage of professionals.

Coping difficulties after inpatient hospital treatment: validity and reliability of the German version of the post-discharge coping difficulty scale.

Patients transitioning between different care contexts are at increased risk of experiencing adverse events. In particular, being discharged to home after inpatient treatment involves significant risks. However, there is a lack of valid and internationally comparable assessment tools on patients' experiences of difficulties following hospital discharge. Therefore, this study aimed to adapt and validate the German version of the post-discharge coping difficulty scale (PDCDS-G). Patients were recruited at a German university hospital. 815 adult patients participated in a self-report survey following an inpatient stay of at least three days. Factorial validity of the PDCDS-G was evaluated via factor analyses. Further, examination of measurement invariance was performed. To establish criterion validity, associations with patients' self-reported health status and occurrence of patient safety were determined. Further, group differences regarding patient characteristics, hospitalization factors, and survey-related variables were examined. Factorial validity of the PDCDS-G was confirmed by a two-factorial model with good model fit. Both factors showed good to excellent reliability. The two-factor model achieved measurement invariance across all patient characteristics, hospitalization factors, and survey-related variables. Significant relationships with patients' health status and the occurrence of patient safety incidents corroborate criterion validity of the PDCDS-G. Differential associations of the two PDCDS-G factors regarding patient characteristics, hospitalization, and survey-related variables were found. Construct and criterion validity, as well as the reliability of the PDCDS-G, were verified. Further, instrument's measurement invariance was confirmed allowing use of the scale for the interpretation of group differences and comparisons between studies. The PDCDS-G provides a validated and comparable patient-reported outcomes measure for patient experiences after hospital discharge to home. The PDCDS-G can be used for patient surveys in quality or patient safety improvement in care transition processes.

Patient safety incidents in anaesthesia: a qualitative studyof trainee experience from a single UK healthcare region.

Anaesthetic training has always had patient safety as part of the curriculum. However, there is limited emphasis on what happens when things do not go to plan. Our aims were to understand the impact of involvement in patient safety incidents on anaesthetic trainees in our region, to describe the range of support currently offered and put forward suggestions for improvement. An initial electronic survey was sent to all anaesthetic trainees in a single UK healthcare region to capture qualitative and quantitative information on patient safety incidents. After completing the questionnaire, participants were asked to consent to involvement in a semi-structured interview to provide a more detailed understanding of the impact of safety incidents. Data were analysed from the questionnaires and interview transcripts using descriptive statistics and thematic analysis. Thirty-four completed questionnaires were analysed revealing 27 trainees had been involved in a patient safety incident. Ten semi-structured interviews were conducted and six themes were identified: team dynamics (including adequacy of staffing and supportive departmental culture); context of the event; reflex immediate support post-event; working environment pending completion of the investigation; personal impact (including physical and mental health); and suggestions for future support. This study has shown the significant impact of safety incidents on anaesthetic trainees in one training region in the UK and highlights the importance of implementing early, tailored debriefs led by trained facilitators, the value of a supportive work environment and the need to raise awareness of system-based approaches to learning from incident investigations. Further research should guide the format and delivery of support for trainees to provide more helpful and timely interventions after patient safety incidents and reduce the risk of future harm to both patients and trainees.

Multifactorial fall interventions for people over 65 years in the acute hospital setting: pre–post-test design

Background: Falls are the most reported patient safety incident for patients >65 years in acute hospital settings worldwide. While multifactorial fall interventions reduce the number of falls in subacute and rehabilitation settings, fall interventions in acute hospital settings are unknown. Aim: To evaluate the effectiveness of multifactorial fall interventions on the number of falls using codesigned education targeting staff and the patient and review the environment in acute hospital settings in NSW, Australia for patients over 65 years of age. Method: A pre–post-test design with a non-equivalent group was conducted. All acute hospital inpatient falls occurring both pre- and post-intervention within one health district were included in this study. The use of Quality Improvement methodology identified gaps in risk screening and assessment, education and information, communication of risk, and standardised fall prevention equipment. Codesigned interventions to address these gaps were undertaken. Results: The number of falls (p = 0.038) and injurious falls (p < 0.001) significantly decreased in the post-intervention group. There was a significant improvement in fall assessments (p < 0.001), delirium risk screening (p < 0.001), the provision of fall information (p < 0.001) and fall risk discussed at shift handover (p < 0.001) in the post-intervention group. Following the intervention, staff were significantly more likely to undertake fall education modules (p < 0.001) and develop a fall management plan (p < 0.001). Conclusion: Falls continue to have a significant economic impact on the acute hospital setting. Our findings highlight multifactorial fall interventions that included staff and patients in the development phases reduced the number of falls. Multifactorial fall interventions targeting staff, patients and the environment may influence a reduction in the number of falls and the severity of falls in the acute hospital setting.

Multicenter evaluation of patient safety incidents in lung surgery: The EPSI study

Determine the incidence of PSI occurring during perioperative care for lung surgery and their impact on postoperative outcomes at 90 days. A multicenter study was conducted in three French thoracic surgery departments. Consecutive patients aged more than 18 years, who had lung surgery (open, video-assisted or robotic) for benign or malignant diseases were included. PSI occurring during lung surgery were reported in Epithor, the French national thoracic database. The primary outcome was the incidence of perioperative PSI. Secondary outcomes were the rates of complications, readmission and mortality at 90 days. All data were prospectively entered in the Epithor database. From January 1st, 2021, to December 31st, 2021, 1919 surgical procedures were screened and finally, 953 procedures were included. PSI were observed in 305/953 procedures (32%) cumulating a total number of 369 PSI. PSI were related to: human factors in 179/369 (48.5%), organization in 101/369 (27.4%) and technology in 85/369 (23%). PSI were categorized as near-miss events in 97 (26%), no-harm incidents (HI) in 125 (34%), mild HI in 83 (22%), moderate HI in 39 (11%), severe HI in 21 (6%), and mortality in 4 (1%). The relative risk of outcome at 90 days was significantly increased according to PSI severity: no PSI/near-miss vs no-HI/HI: RR 2.02 (95% CI 1.70-2.40) for complications, 2.51 (95% CI 1.57-8.30) for readmission and 3.09 (95% CI 1.15-8.30) for mortality. Incidence of PSI in thoracic surgery may concern approximately one-third of procedures. Human factors play a crucial role in the occurrence of these PSI.

Patient Safety Culture Among Nurses: Comparison Between Public and Private Hospital in Indonesia

Aims: This study aimed to describe the patient safety culture among nurses working in both public and private hospitals in Karawang, Indonesia. By examining the perceptions and practices of nurses regarding patient safety, the research sought to identify strengths and areas for improvement within the healthcare system. The findings are intended to inform strategies for enhancing patient safety practices, thereby contributing to better healthcare outcomes for patients in the region. Methods This study employed a cross-sectional methodology to investigate the patient safety culture in the intensive care units of two private and two public hospitals in Karawang, Indonesia. The researchers utilized the Hospital Survey on Patient Safety Culture (HSPSC) to gather data on nurses' perceptions and practices regarding patient safety. To analyze the data and identify any significant differences in patient safety cultural practices between the various hospital groups, both chi-square tests and independent t-tests were conducted. This approach allowed for a comprehensive assessment of the patient safety culture within the selected hospitals, facilitating comparisons between public and private healthcare settings. Results The study included a total of 118 nurses, with 52 working in a public hospital and 66 in a private hospital. The average age of nurses in the public hospital was 36.11 years (SD: 4.78), while those in the private hospital had a lower average age of 32.45 years (SD: 3.67). The results indicated a significant difference in the scores related to patient safety culture between the two groups of nurses. Specifically, nurses in the private hospital reported a higher patient safety culture compared to their counterparts in the public hospital, highlighting the disparities in perceptions and practices regarding patient safety in these different healthcare settings. Conclusion Nurses employed in private hospitals reported a higher level of patient safety culture compared to those working in public hospitals. This finding underscores the importance of creating a comfortable work environment in healthcare settings, as it is essential for minimizing the risk of patient safety incidents. By fostering a supportive and safe atmosphere, healthcare facilities can enhance the overall quality of care provided to patients and promote better outcomes in both private and public hospitals.

Core set of indicators to evaluate healthcare workers support programmes: a consensus-based approach

Abstract Objectives Considering the widespread implementation of support programmes for healthcare workers (HCWs), there is an urgent need to establish a standardised set of indicators for their ongoing assessment. This study seeks to develop a consensus framework for evaluating interventions aimed at supporting HCWs affected by patient safety incidents (PSIs) or other distressing situations, commonly referred to as second victims (SVs). Having a core set of indicators it is crucial for facilitating comparative analyses across different organisations and time periods. Methods A qualitative study was conducted from June 2023 to March 2024. The study involved a multidisciplinary group of members part of the European Researchers Network Working on Second Victims. The consensus-building process utilised insights from a scoping review (phase 0) and a nominal group technique (phase 1) to develop a questionnaire for Delphi Rounds (phase 2). Indicators were rated on a scale of 1-5, with consensus reached if over 70% of participants rated an indicator as both feasible and sensitive scoring above 4. A consensus conference was subsequently organised. Results From an initial pool of 91 indicators, 55 were rated online, with 35 progressing to the Delphi rounds. A total of two Delphi rounds were performed and achieved response rates exceeding 60% and 80% respectively, resulting in consensus on 11 indicators for evaluating SV’ support programmes. These indicators encompass various aspects such as awareness and activation of the programmes, organisational processes and structures, institutional training provisions and assessment of the impact of the programme in the SVs. Conclusions This study endeavors to provide guidance for future SVs’ programs namely in the critical areas of programme’s awareness and activation, structural and process enhancements, and programme’s impact on SVs. Moreover, these indicators are suitable for multiple healthcare contexts and levels of implementation. Key messages • The priorities for evaluation of second victim programmes’ include their impact on healthcare workers, awareness and activation, organisational processes and structures and institutional training. • Utilizing a multidisciplinary consensus approach, we defined a set of indicators that are adaptable to diverse contexts that provide care and varying levels of second victim support implementation.

Collection and use of patient-reported experience measures: approach to improve health care

Abstract Background Patient experience is one of the fundamental determinants of healthcare quality. There is progress in the collection of PREM in national level for hospitalized patients since 2020 in Latvia. Aim Analyze (2020.-2022.) in-patients Top-box rates about communication, share-decision making, patient safety and Net Promoter Score (NPS). Methods Project starting point was 2019. Agreement with EC, Sant’Anna School, Ministry of Health and Centre for Disease Prevention and Control of Latvia. Since 2020, the collection of PREM has been taking place regularly in hospitals (around 40% from all hospitals) and on average 20% response rate of those who agreed to participate in the survey. PREM questionnaire according to HCAHPS (Consumer Assessment of Healthcare Providers and Systems) standards, including Picker Institute patient experience questions. In line with OECD (Organization for Economic Co-operation and Development) recommendations, patient safety issues are also included. Top-box rates (most positive response) and percentiles (25th - 75th) were calculated. Results Totally 17019 adult (18 years and more) patient responses were analyzed with response rate 20.3% (n = 83983). 74.6% (67.5-78.2) during hospital stay doctors always explain things in a way you could understand and sufficiently involved in the decision-making process of treatment - 75.0% (70.1-81.4). During hospital stay 4.1% (n = 601) experienced patient safety incidents which were patient-reported. The most common groups were wrong patients, medication errors, incl. adverse drug reactions and falls. Hospitals achieved a NPS of 61 for 3 year period (2020.-2022.). Conclusions Collecting information about the patient experience may be the starting point for engaging patients and moving to more patient-centered health care. The results of these in-patient PREM data can be used to identify areas of improvement and make changes to better meet the needs and expectations of their patients. Key messages • It is a good practice for the implementation of new health care quality data - patient experience reported measures at the national level. • Feedback about the patient experience on regular basis provides insight into patient needs, preferences and values, which can help to improve the quality and safety of care.

A 5-Year retrospective analysis of adverse events in dentistry at the Dental Hospital, Faculty of Dentistry, Chulalongkorn University

BackgroundPatient safety is a critical concern in dentistry. Adverse events (AEs) can harm patients, increase costs, and decrease satisfaction. Understanding AE types and frequencies is crucial for effective risk management and quality improvement. This study analyzes incident reports to identify preliminary incident patterns as a starting point for developing risk management strategies. However, under-reporting limits the ability to identify true incident patterns, highlighting the need for improved reporting systems and encouragement of incident reporting. Further research is underway to develop such a system and promote reporting to ensure sufficient data quality for effective risk management.MethodsA retrospective analysis of 1,618 incident reports from December 2018 to August 2023 was conducted. A validated classification system, developed from a 5-year retrospective analysis and approved by 14 experts, categorized patient safety incidents, aligning with Thailand’s Hospital Accreditation standards. Descriptive statistics summarized AE frequency and distribution.ResultsOf the reports, 752 were patient safety, 503 personnel safety, and 363 organizational safety incidents. Top patient safety incidents included medical record errors (176), accidental damage (66), post-operative complications (65), medical emergencies (64), and communication errors (53). Personnel safety incidents involved inappropriate working conditions (135) and work-related injuries with contact transmission risk (117). Organizational safety incidents mainly concerned policy and operational processes (131).ConclusionsThis study reveals the preliminary patterns of adverse events (AEs) in dental settings and underscores the limitations due to under-reporting, which affect the ability to fully understand true incident patterns. To effectively manage risks, there is a critical need for improving the existing incident reporting system and encouraging a culture of comprehensive reporting among dental professionals. Future efforts should focus on enhancing reporting systems to ensure high-quality data, enabling better identification of incident trends and supporting targeted risk management strategies to improve patient safety in dentistry.

Systematic Literature Review: Nurses' Work Hours and Workload Impact on Patient Safety Incidents

Patient safety is a key indicator in assessing the quality of healthcare services in hospitals, and nurses play a crucial role in maintaining that safety. However, long working hours and high workloads can affect nurses' performance, increasing the risk of fatigue, stress, and burnout, ultimately contributing to medical errors and decreased quality of care. This study aims to conduct a systematic literature review on the effect of nurses' working hours and workload on hospital patient safety incidents. Patient safety is a key indicator in assessing healthcare quality, and nurses play an essential role in maintaining patient safety during daily care. However, long working hours and high workloads can affect nurses' performance, increasing the risk of fatigue, stress, and burnout, ultimately contributing to medical errors and decreased quality of care. Through the analysis of various relevant studies, this review suggests that more flexible working hour arrangements and balanced workload management can reduce the risk of patient safety incidents and improve the quality of care provided. This study also recommends that hospital human resource management to create a healthier and safer working environment for nurses and patients.

Implementation of a Standardized Tool for Root Cause Analysis Selection.

This study sought to determine if a standardized root cause analysis (RCA2) selection algorithm, developed by the Veterans Affairs, would select high-risk events for RCA. Physician-entered incident reports for all surgical service admissions and perioperative visits were queried over 12 months in the DATIX Clinical Incident Management System. Independent reviewers assigned potential harm and event frequency scores using an institutional scoring system and then calculated and rounded average scores. These were classified using RCA2 terminology (catastrophic, major, moderate, minor for harm; frequent, occasional, uncommon, remote for frequency). The scores were then evaluated with the standardized Safety Assessment Code Matrix (SAC) algorithm from the National Patient Safety Foundation's RCA2 guidelines to determine Potential Harm Scores. The SAC combines severity and probability to determine the necessity of conducting an RCA. Catastrophic and major high-frequency events (matrix score = 3) were classified as "RCA recommended." The study then compared cases selected for RCAs using the updated RCA2 algorithm against cases selected using a current, institutional-specific RCA selection process. One hundred four cases were reviewed, comprising 20 catastrophic, 48 major harm, 26 moderate harm, and 10 minor harm events. After removing 9 high-variance cases, our institution's current selection process selected 18 cases for RCAs, including 6/20 catastrophic, 8/39 major harm, and 4/36 moderate/minor harm events. Only 17.3% of cases had an RCA completed, while the standardized RCA2 algorithm recommended investigation for 56.7% of patient safety events, based on SAC Matrix scoring. Current RCA selection processes rendered 4 RCAs on low potential harm or low-frequency events, while 45 potential high-frequency, high potential harm events did not complete RCAs. Standardizing the selection of patient safety incidents for RCA using the RCA2 algorithm improves case identification based on the event frequency and potential harm score. Thus, this algorithm has the potential to advance patient safety.

Addressing the second victim phenomenon among community pharmacists and its impact on clinical pharmacy practice: a consensus study.

The second victim phenomenon, denoting the harmful effects of patient safety incidents on healthcare practitioners, remains insufficiently examined within the pharmacy workforce. This study aimed to investigate the second victim phenomenon in community pharmacies, focusing on its triggers, impacts on pharmacists' well-being, and effects on pharmaceutical care and safety. This consensus study with the Nominal Group Technique involved 27 community pharmacists in three equal groups. The final ranks of the statements scored by participants from 5 to 1 were recalculated using the Van Breda method, combining three distinct data sets with higher values for a higher impact on the output evaluated. Statistics were applied to ascertain event distribution and investigate the potential relationships between event categories and outcomes for patients and pharmacists. "Patient-centric anxiety" (6.8) was the top mental health issue, followed by "Personal responsibility and resilience" and "Future concerns and career aspirations" (6.0 each). The dominant support was "Colleague/Peer support" (5.3). The most frequent patient safety incidents were "Inadequate pharmaceutical service" (8.0) and "Wrong drug dispensed" (7.8). Most errors (63%) were dispensing failures, primarily wrong drug dispensed (44.4%). Of these, 50% were near misses, 25.0% caused no harm, and 16.7% had serious consequences. Field notes suggest contributing factors like inadequate supervision, crowding, and storage issues. This study revealed the second victim phenomenon among pharmacists, which potentially stems from breaches in practice standards. The impact on the quality and safety of pharmaceutical care and its influence on pharmacists' well-being should be studied in further studies.

Analysis of Affecting Factors to Patient Safety Incident at Mitra Medika Amplas Hospital

Analysis of Affecting Factors to Patient Safety Incident at Mitra Medika Amplas Hospital

The current status of nurses’ psychological experience as second victims during the reconstruction of the course of event after patient safety incident in China: a mixed study

BackgroundPatient safety incidents are unavoidable and nurses, as parties involved, become second victims due to the incident itself and the way it is handled. In China, reconstructing the course of events is a crucial step in the aftermath of the incident; however, its impact on the emotional well-being of the second victim remains unclear.PurposeThe purpose of this study is to gain insight into the psychological experiences and current conditions of nurses who act as second victims during the process of reconstructing the sequence of events. Additionally, the study aims to provide justifications for supporting these individuals.MethodsAn exploratory mixed research method was adopted to understand the emotional experience of the second victim when reconstructing the passage of the incident through qualitative research. Fourteen nurses with experience as second victims were selected for semi-structured interviews using purposive sampling according to the maximum difference sampling strategy. Through quantitative research, we explored the negative psychology and support needs of the second victims when they reverted to the incident, and a self-developed questionnaire (the Cronbach’s alpha coefficient was 0.895) was used to survey 3,394 nurses with experiences as second victims in 11 tertiary hospitals in Shanxi Province.ResultsIn the qualitative part of the study, the emotional experience of the second victim’s reconstruction of the course of events after a patient safety incident could be categorized into 3 themes: negative views as initial psychological impact, avoidance as part of psychological impact, and expectations and growth in overcoming negative psychological impact. The quantitative part of the study revealed that the emotions of guilt and self-blame accounted for the highest percentage after a patient safety incident. The second victim presented a high score of 39.58 ± 5.45 for support requirements.ConclusionThis study provides a better understanding of the true emotional experiences and the need for support of the second victim in the process of reconstructing the course of events. Following a patient safety incident, nursing administrators and healthcare institutions should consider the adverse psychological effects on the second victim, prioritize their support needs during the incident’s reconstruction, create a positive safety culture, and reduce the risk of secondary victimization for these individuals.

Psychological Safety Competency Training During the Clinical Internship From the Perspective of Health Care Trainee Mentors in 11 Pan-European Countries: Mixed Methods Observational Study.

In the field of research, psychological safety has been widely recognized as a contributing factor to improving the quality of care and patient safety. However, its consideration in the curricula and traineeship pathways of residents and health care students is scarce. This study aims to determine the extent to which health care trainees acquire psychological safety competencies during their internships in clinical settings and identify what measures can be taken to promote their learning. A mixed methods observational study based on a consensus conference and an open-ended survey among a sample of health care trainee mentors from health care institutions in a pan-European context was conducted. First, we administered an ad hoc questionnaire to assess the perceived degree of acquisition or implementation and significance of competencies (knowledge, attitudes, and skills) and institutional interventions in psychological safety. Second, we asked mentors to propose measures to foster among trainees those competencies that, in the first phase of the study, obtained an average acquisition score of <3.4 (scale of 1-5). A content analysis of the information collected was carried out, and the spontaneity of each category and theme was determined. In total, 173 mentors from 11 pan-European countries completed the first questionnaire (response rate: 173/256, 67.6%), of which 63 (36.4%) participated in the second consultation. The competencies with the lowest acquisition level were related to warning a professional that their behavior posed a risk to the patient, managing their possible bad reaction, and offering support to a colleague who becomes a second victim. The mentors' proposals for improvement of this competency gap referred to training in communication skills and patient safety, safety culture, work climate, individual attitudes, a reference person for trainees, formal incorporation into the curricula of health care degrees and specialization pathways, specific systems and mechanisms to give trainees a voice, institutional risk management, regulations, guidelines and standards, supervision, and resources to support trainees. In terms of teaching methodology, the mentors recommended innovative strategies, many of them based on technological tools or solutions, including videos, seminars, lectures, workshops, simulation learning or role-playing with or without professional actors, case studies, videos with practical demonstrations or model situations, panel discussions, clinical sessions for joint analysis of patient safety incidents, and debriefings to set and discuss lessons learned. This study sought to promote psychological safety competencies as a formal part of the training of future health care professionals, facilitating the translation of international guidelines into practice and clinical settings in the pan-European context.

Translation, Adaptation, and Validation of the Japanese Version of Second Victim Experience and Support Tool-Revised.

Healthcare workers involved in, and negatively affected by, patient safety incidents are referred to as second victims. The Second Victim Experience and Support Tool-Revised (SVEST-R) can reveal the second victim's degree of negative experiences and the desirability of the support options. However, a Japanese version of the SVEST-R (J-SVESTR) has not yet been developed. This study aimed to translate and adapt the SVEST-R into Japanese and validate its psychometric properties. We performed forward and back translations of the SVEST-R and evaluated its clarity and content validity. Subsequently, we administered a cross-sectional questionnaire survey to evaluate the construct validity, internal consistency, and retest reliability of the J-SVESTR. The J-SVESTR was finalized with clarity and content validity supported by a pilot test and an expert panel. In total, 224 healthcare workers responded to the J-SVESTR survey. The 9 factors and 35 items model indicated an acceptable fit (χ2/df = 1.811, root mean square error of approximation = 0.060, comparative fit index = 0.871, Tucker-Lewis index = 0.854, standardized root mean squared residual = 0.077). Cronbach's α values ranged from 0.68 to 0.85. The intraclass correlation coefficients ranged from 0.63 to 0.87. The J-SVESTR retained 9 factors and 35 items, with no item changes from the original. The psychometric properties of the J-SVESTR are acceptable. The J-SVESTR can help investigate the actual situation and desired support options for second victims in Japan.

Psychological, physical, and professional impact on second victims in veterinary anaesthesia: a cross-sectional international survey - Part 1

ObjectiveTo investigate the psychological, physical and professional impact of veterinary patient safety incidents (PSIs) on veterinary anaesthesia professionals. Study designWe conducted an observational cross-sectional survey, inviting veterinary anaesthesiologists, anaesthesiologists in training and veterinary nurses/technicians through social media platforms from 2 June 2023 to 20 September, 2023. The questionnaire was based on Second Victim Experience and Support Survey (SVEST) and analysed using descriptive statistics and subscale scoring to assess psychological, physical and professional impacts. ResultsA total of 303 participants from 31 countries responded, including North (24%), Central (13.5%) and South America (25%), Europe (13.2%), UK (12.5%), Australia/New Zealand (8.1%) and Asia/Middle East (3.3%). A participation rate cannot be estimated. All respondents described themselves as second victims, with 70% encountering a PSI in the past 6 months. Of the 303 participants, 75% had direct involvement with the incident. Common post-incident challenges included an increased awareness for PSIs (67.1%), fear of new PSIs (62.7%), diminished confidence (56.1%), more defensive medicine practice (46.7%) and sleep disorders (43.3%). Additionally, 62.7% agreed or strongly agreed that they experienced embarrassment post-incident. After a PSI, approximately 69% of the participants reported feeling inadequate in their animal care abilities, and a similar percentage questioned their professional competence. Over half of the respondents (54.6%) became fearful of undertaking high-risk procedures. Approximately 38% of respondents considered leaving the field of anaesthesia, and over 56% harboured thoughts of leaving their job because of the stress from PSIs. Additionally, a significant proportion (69.8%) reported not taking time off work following PSIs. Conclusions and clinical relevanceThe study identifies a significant psychological, physical and professional impact on veterinary anaesthesia professionals, with notable effects on their emotional well-being and professional self-efficacy. The findings emphasize the need for supportive measures and interventions to mitigate the adverse effects experienced by these individuals.

Estimating the Effect of Disclosure of Patient Safety Incidents in Diagnosis-Related Patient Safety Incidents: A Cross-sectional Study Using Hypothetical Cases.

Disclosure of patient safety incidents (DPSIs) is a strategic measure to reduce the problems of patient safety incidents (PSIs). However, there are currently limited studies on the effects of DPSIs on resolving diagnosis-related PSIs. Therefore, this study aimed to estimate the effects of DPSIs using hypothetical cases, particularly in diagnosis-related PSIs. A survey using 2 hypothetical cases of diagnosis-related PSIs was conducted in 5 districts of Ulsan Metropolitan City, Korea, from March 18 to 21, 2021. The survey used a multistage stratified quota sampling method to recruit participants. Multiple logistic regression and linear regression analyses were performed to determine the effectiveness of DPSIs in hypothetical cases. The outcomes were the judgment of a situation as a medical error, willingness to revisit and recommend the hypothetical physician, intention to file a medical lawsuit and commence criminal proceedings against the physicians, trust score of the involved physicians, and expected amount of compensation. In total, 620 respondents, recruited based on age, sex, and region, completed the survey. The mean age was 47.6 (standard deviation, ±15.1) years. Multiple logistic regression showed that DPSIs significantly decreased the judgment of a situation as a medical error (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.79), intention to file a lawsuit (OR, 0.53; 95% CI, 0.42-0.66), and commence criminal proceedings (OR, 0.43; 95% CI, 0.34-0.55). It also increased the willingness to revisit (OR, 3.28; 95% CI, 2.37-4.55) and recommend the physician (OR, 8.21; 95% CI, 4.05-16.66). Meanwhile, the multiple linear regression demonstrated that DPSIs had a significantly positive association with the trust score of the physician (unstandardized coefficient, 1.22; 95% CI, 1.03-1.41) and a significantly negative association with the expected amount of compensation (unstandardized coefficient, -0.18; 95% CI, -0.29 to -0.06). DPSIs reduces the possibility of judging the hypothetical case as a medical error, increases the willingness to revisit and recommend the physician involved in the case, and decreases the intent to file a lawsuit and commence a criminal proceeding. Although this study implemented hypothetical cases, the results are expected to serve as empirical evidence to apply DPSIs extensively in the clinical field.

A process mining model to detect adverse patient safety events: Blood products watch

Introduction Patient safety incidents and adverse events are reported voluntarily by healthcare staff. The Global Trigger Tool, developed by the Institute for Healthcare Improvement, is used to capture unreported events. The objective of the new model is to use process mining in the context of adverse event detection to increase reporting efficiency. Methods In the first phase, the process mining model is used to discover the actual process map by querying inpatient processes using the provided log data. Transfusions of blood or blood products within 24 h after surgery, a subset of The Transfusion of Blood or Use of Blood Products trigger of Institute for Healthcare Improvement (GTT-C1) was deployed as a process pattern within the actual process map. Only detected patients were reviewed in the last phase. Results The model ran on a single hospital data set, which included 2870 patients, 1048 of which included surgeries. The model reduced the analyzed data to 57 patients. The expert group analyzed these 57 patients and defined 12 adverse events. The calculated adverse event ratio was 1.1%, comparable with other manual Global Trigger Tool studies. In addition, the reviewers’ time required decreased by 94.6%, from 138.28 to 7.52 h. Two reviewers validated the model by reviewing a sample of patients. Conclusions Process mining can be used in healthcare institutions to conduct routine surveillance and detect unreported safety events. This allows healthcare providers to allocate financial and human resources to more urgent needs and increase efficiency. Further research is needed to evaluate the model with other triggers.