Patient Safety Reports Research Articles

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.
 

The cyclical nature of patient safety.

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent patient safety reports.

The Better Care Plan: a blueprint for improving America's healthcare system.

The United States falls far short of its potential for delivering care that is effective, efficient, safe, timely, patient-centered, and equitable. We put forward the Better Care Plan, an overarching blueprint to address the flaws in our current system. The plan calls for continuously improving care, moving all payers to risk-adjusted prospective payment, and creating national entities for collecting, analyzing, and reporting patient safety and quality-of-care outcomes data. A number of recommendations are made to achieve these goals.

Patient safety culture among healthcare professionals in Bhutan

Introduction: There is dearth of information regarding the status of patient safety culture in Bhutanese healthcare system. The aim of the study was to assess the baseline patient safety culture among the healthcare professionals working in different levels of hospitals in Bhutan. Methods: A cross-sectional study was conducted using the Hospital Survey on Patient Safety, version 2 (HSOPS2) questionnaire in 2021 in six District Hospitals (DHs), two Regional Referral Hospitals (RRHs), and one National Referral Hospital (NRH) in Bhutan. A total of 782 healthcare professionals were recruited into the study. EpiData version 3.0 and Statistical Package for Social Science (SPSS) version 28.0 were used to process data and conduct the statistical analysis on survey data including descriptive statistics and validity and reliability of survey. The internal consistency reliability of each composite measure was assessed by calculating Cronbach’s alpha score. Results: The overall level of patient safety culture was 61.28% (95% CI: 113.26, 115.27) and the percentage scores for the ten patient safety dimensions ranged from 45.13% to 82.65%. The dimension, “Teamwork within the hospital units” had the highest positive score while the dimensions, “Staffing and work pace” and “Reporting patient safety events” had the lowest positive scores. Conclusions: The healthcare professionals working in hospitals in Bhutan had average patient safety culture. To improve patient safety culture, more emphasis should be given on human resource management, patient safety event reporting system, hospital management support for patient safety and quality improvement initiatives and creating an environment that promote just and learning culture.

Assessing patient safety culture among healthcare professionals in Ibadan South-west region of Oyo State, Nigeria

Objectives Patient safety culture is essential to improve care, prevent adverse events, and deliver quality healthcare service. The levels of patient safety culture and adverse events in Nigerian healthcare institutions are still widely underreported. The main objective of this study was to assess patient safety culture among healthcare professionals in primary and secondary healthcare facilities in Ibadan South-west local government area of Oyo State, Nigeria. Methods In this cross-sectional study, investigators collected data with the English version of the Hospital Survey on Patient Safety Culture version 2.0 questionnaire. They analyzed data using the Statistical Package for the Social Sciences (SPSS) software with descriptive statistics, Pearson Correlation Analysis, and one-way analysis of variance. Results A total of 271 healthcare professionals participated in the study. Study findings showed the overall perception of patient safety culture to be 72.1%. Among patient safety dimensions, Teamwork (88.5%) and Reporting Patient Safety Events (47.4%) were the highest and lowest percentage of positive responses, respectively. Conclusions Patient safety culture is an emerging concept in Nigeria. The assessed dimensions showed the need to improve the safety culture among healthcare professionals. Therefore, stakeholders, policymakers, and managers should employ policies, strategies, and programs to enhance safety culture across all healthcare institutions.

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.

Bariatric surgeon perceptions of the safety of same-day sleeve gastrectomy in the state of Massachusetts.

During the past 2.5 years, select bariatric surgeons in the Commonwealth of Massachusetts have been implementing same-day sleeve gastrectomy (SDSG). Key reasons for this change have been to reduce risks associated with hospitalization in the context of the COVID-19 pandemic and to comply with third-party payer preference to reduce costs. We aimed to evaluate bariatric surgeons' attitudes about outcomes and morbidity between patients who are hospitalized after sleeve gastrectomy and patients who undergo SDSG. Beth Israel Deaconess Medical Center in Boston, Massachusetts (teaching hospital of Harvard Medical School). This prospective cohort study was conducted among bariatric surgeons practicing in the Commonwealth of Massachusetts. An anonymous web-based questionnaire was distributed using the Research Electronic Data Capture software. A total of 58 bariatric surgeons in Massachusetts were identified and successfully contacted based on registration with the Massachusetts Board of Registration in Medicine, membership in the American Society for Metabolic and Bariatric Surgery, and internet search. A total of 33 bariatric surgeons in Massachusetts completed the survey, yielding a response rate of 56.9%. Among the respondents, 75.76% have not performed SDSG, reporting patient safety as the major concern, and 24.24% had performed SDSG in the past. Survey responses showed no significant differences in surgeon perception between SDSG and hospitalization after surgery. Optimal patient selection was an important factor influencing surgeons' decisions with regard to performing SDSG. However, bariatric surgeons in Massachusetts are reluctant to perform SDSG.

A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability.

There is variation in microbiology testing among PICU patients with fever offering opportunities to reduce avoidable testing and treatment. Our objective is to describe the development and assess the impact of a novel comprehensive testing algorithm to support judicious testing practices and expanded diagnostic differentials for PICU patients with new fever or instability. A mixed-methods quality improvement study. Single-center academic PICU and pediatric cardiac ICU. Admitted PICU patients and physicians. A multidisciplinary team developed a clinical decision-support algorithm. We evaluated blood, endotracheal, and urine cultures, urinalyses, and broad-spectrum antibiotic use per 1,000 ICU patient-days using statistical process control charts and incident rate ratios (IRRs) and assessed clinical outcomes 24 months pre- and 18 months postimplementation. We surveyed physicians weekly for 12 months postimplementation. Blood cultures declined by 17% (IRR, 0.83; 95% CI, 0.77-0.89), endotracheal cultures by 26% (IRR, 0.74; 95% CI, 0.63-0.86), and urine cultures by 36% (IRR, 0.64; 95% CI, 0.56-0.73). There was an anticipated rise in urinalysis testing by 23% (IRR, 1.23; 95% CI, 1.14-1.33). Despite higher acuity and fewer brief hospitalizations, mortality, hospital, and PICU readmissions were stable, and PICU length of stay declined. Of the 108 physician surveys, 46 replied (43%), and 39 (85%) recently used the algorithm; 0 reported patient safety concerns, two (4%) provided constructive feedback, and 28 (61%) reported the algorithm improved patient care. A comprehensive fever algorithm was associated with reductions in blood, endotracheal, and urine cultures and anticipated increase in urinalyses. We detected no patient harm, and physicians reported improved patient care.

Patient safety in the NHS: after Francis

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses several recently published patient safety reports.

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.

Delays in Care During the COVID-19 Pandemic in the Veterans Health Administration.

The purpose of this study was to review patient safety reports in the Veterans Health Administration (VHA) related to delays during an 11-month period that included months of the COVID-19 pandemic. A retrospective descriptive analysis of COVID-19 patient safety reports related to delays that were submitted in the Joint Patient Safety Event Reporting System database to the VHA National Center of Patient Safety from January 01, 2020 to November 15, 2020 was conducted. There were 897 COVID-19 patient safety events related to delays; 200 cases were randomly selected for analysis, with 148 meeting inclusion criteria. The results showed delays in laboratory results, level of care, treatment and interventional procedures, specific aspects of care, radiology treatment, and diagnosis. Causes for delays included poor communication between staff, problems in getting laboratory results, confusion over policy, and misunderstanding of COVID-19-specific rules. Healthcare delays can be reduced during a pandemic by proactively standardizing medical processes/procedures when testing for infection, improving staff to staff communication teaching the SBAR (situation, background, assessment, and recommendations) communication model, and using simulation to identify latent safety issues and educating medical personnel on new protocols related to the pandemic. Simulation can be used to test new protocols developed during the pandemic.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.

Center for Quality Management, Kaohsiung Chang Gung Memorial Hospital, Recipient of the 2022 National Healthcare Quality Award - Excellent Center Award Accountability in Quality Management: A Team with Innovation and Excellence of Quality Management

&lt;p&gt;高雄長庚紀念醫院品質管理中心以「創新品質與病人安全管理專業」運用「資訊智能資源整合」發展「卓越醫療品質特色」等成果，榮獲2022年第23屆國家醫療品質獎―卓越中心之殊榮。中心核心團隊發展專業特色如：「智能指標管理，做為高層決策之依據」、「建立病安通報系統，確保病人安全」、「研發醫病共享決策(Shared Decision Making, SDM)輔助工具，創立國際中文版翻譯」、「開發急性腎損傷(acute kidney injury, AKI)智能照護系統」、「營造優質病安文化」、「積極人才培育專業證照」等，引領全院進行跨領域專業多元合作，提供最高品質的醫療服務。榮獲「卓越中心」象徵本院為實現正向醫品病安文化價值，全方位提升醫療品質及病人安全成效之肯定，期望藉此經驗分享，引領同儕，追求更卓越的醫療品質。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;The center of quality management, Kaohsiung Chang Gung Memorial Hospital has utilized its innovation and professionalism in quality and patient safety management to facilitate smart information and resource integration, achieving outstanding healthcare quality. In 2022, these achievements enabled the center to win the 23rd National Healthcare Quality Award in the Excellent Center category. The core management team of the center has developed the following professional features: smart index management for providing referential data to hospital executives when making decisions; establishing a patient safety report system to ensure the safety of all patients; developing the patient decision aids (PDAs) for shared decision making (SDM) and translating the international PDAs into Mandarin Chinese version; developing an acute kidney injury care system; fostering adequate patient safety culture; and promoting talent cultivation and professional certification. The center guides the entire hospital staff to participate in interdisciplinary collaboration to provide healthcare services of the highest quality. Winning the Excellent Center Award signifies approval of the efforts made by the hospital to promote positive healthcare culture and values through enhancing every aspect of healthcare quality and patient safety. By sharing its experience, the center hopes to play a leading role in the healthcare industry and help other institutions strive for excellent healthcare quality.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

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.

Persepsi Perawat Terhadap Implementasi Budaya Keselamatan Pasien Di Ruang Rawat Inap Terpadu Rumah Sakit H.Adam Malik Medan

&lt;p&gt;&lt;em&gt;Patient safety is a hospital service system that provides safer patient care. WHO (World Health Organization) publications report patient safety incidents that medical errors occur in 8% to 12% of inpatient rooms at H.Adam Malik Hospital Medan. Patient safety incidents that occur include nosocomial infections, patient falls, and medication errors. Each of these incidents exceeded the established standards. The purpose of this study was to evaluate nurses' perceptions of the implementation of patient safety culture at H.Adam Malik Hospital Medan&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;The research design used was qualitative research. The characteristics of the key informants are the head of the nursing field, the head of the room, the head of pharmacy, the nursing committee and the head of the Quality Improvement and Patient Safety (PMKP) section, while the main informants are nurses. Qualitative data collection techniques using the Triangulation method. Data analysis using qualitative descriptive with data source triangulation stages&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;The results showed that patient identification, effective communication, drug safety and risk of infection had gone well, while site marking and the risk of falling patients had not gone well.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;The conclusion of this study is that patient identification, effective communication, drug safety and risk of infection have gone well, while site marking and the risk of patients falling have not gone well. It is hoped that this can be an illustration of the application of patient safety to improve the quality of health services through the achievement of hospital achievements so that it can be used as the basis for taking a further policy and increasing the satisfaction of each patient who comes.&lt;/em&gt;&lt;/p&gt;

The Experience of Patient Safety Error for Nursing Students in COVID-19: Focusing on King's Conceptual System Theory.

Some nursing students experience errors related to patient safety, such as falls, medication administration errors, and patient identification errors during clinical practice. However, only a few nursing students report errors during clinical practice. Accordingly, the present study aimed to investigate patient safety errors that nursing students experience during clinical practice in the context of the COVID-19 pandemic. This study conducted in-depth interviews with 14 candidates for graduation from the Department of Nursing at a university in South Korea. In addition, after transcribing the collected data, a directed content analysis for the data based on King's interacting system theory was performed. As a result, four core categories were identified: (i) nursing students' perception of patient safety error occurrence, (ii) interaction between nursing students and others, (iii) interaction between nursing students and organizations, and (iv) nursing students' training needs related to patient safety errors. Consequently, this study identified the patient safety error-related experiences of nursing students during clinical practice during the COVID-19 pandemic. The results suggest that in the future, nursing education institutions must establish a system for nursing students to report patient safety errors during clinical practice for patient safety education and develop practical and targeted education strategies in cooperation with practice training hospitals.

Reflecting on patient safety in 2022.

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some major patient safety reports published in 2022, and considers the lessons to take away from them.

Rise in pharmacists reporting patient safety risks from medicines shortages, shows survey

Rise in pharmacists reporting patient safety risks from medicines shortages, shows survey

The impact of an educational program on knowledge and perception of patient safety culture among nurses in the two medical colleges of Manipur: A quasi-experimental study.

Nurses' leaders are protracted as high-leverage players who would be instrumental in initiating or bettering the culture of safety in the hospital, with no previous intervention done for the same in Manipur. The aim of this study was to assess the effectiveness of an educational intervention program on patient safety culture among nurses in Manipur. A quasi-experimental study was conducted from July 2019 to December 2021 among the 32 nurses of two tertiary-level hospitals in Manipur. A structured questionnaire and Hospital Survey on Patient Safety Culture version 2 were used (Hospital Survey on Patient Safety Culture (HSOPSC) version 2.O (AHRQ, Rockyville, Maryland, USA)). A 2-day intervention based on the WHO's Multi-Professional Patient Safety Curriculum Guide was used. Data were collected before, immediately, and 3 months after the intervention. Data were summarized using descriptive using IBM SPSS 26. Paired t-test, Chi-square test, and t-test were employed to check for differences within and between the groups, and P < 0.05 was taken as statistically significant. The mean knowledge scores were comparable between the groups at baseline (7.13 ± 3.3, 8.44 ± 3.74; P = 0.142) but differed significantly at posttest and follow-up tests (P < 0.0001). The dimensions of "staffing and work pace" and "reporting patient safety events" had the lowest positive responses from both the groups at baseline. There is a significant increase in the total safety score from baseline to posttest and follow-up in the intervention group (P < 0.001). The study asseverated the effectiveness of an educational intervention in increasing the knowledge and perception of patient safety culture, but the results highlighted the need for training at regular intervals.

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.