Patient Safety Reporting System Research Articles

Medication-related incidents in acute care hospitals among different age groups: An analysis of national patient safety report data.

This study aimed to perform a nationwide analysis of medication errors (MEs) from hospitals using national reporting system data and to compare the ME patterns among different age groups. We analyzed medication-related incidents in acute care hospitals reported to the Korean Patient Safety Reporting and Learning System (KOPS), which is a patient safety reporting system, from July 2016 to December 2020. The stages of the medication use process, type of errors, medication class involved in MEs, and degree of harm were analyzed. Among a total of 5071 medication-related incidents, 37.7% (1911 cases) were incidents that caused patient harm and 1.2% caused long-term, permanent, and fatal harm. The proportion of medication-related incidents that resulted in harm was the highest among the <1-year-old age group (67 cases, 51.5%), followed by the elderly (≥ 65 years) (828 cases, 40.9%). The cases leading to patient death were most frequently reported in patients aged ≥65 years. Medication-related incidents occurred mainly in the administration stage (2954 cases, 58.3%), and wrong dose was the most frequently reported ME type. The most prevalent medication class occurring in the 20-64-year age group (256 cases, 11.7%) was 'antibacterials for systemic use', whereas 'contrast media' (236 cases, 11.6%) and 'blood substitutes and perfusion solutions' (98 cases, 19.3%) were the most prevalent drug classes in the ≥65- and <20-year-old age groups, respectively. It is necessary to establish guidelines for the prevention of medication-related incidents according to the medication use process and patient age group.

Enteral nutrition: An underappreciated source of patient safety events.

Enteral nutrition (EN) therapies are prescribed for patients not able to maintain adequate nutrition through the oral route. Medical errors and close calls associated with the provision of EN therapy leading to actual and potential patient harm have been reported. The purpose of this study was to determine the number, type, and severity of safety events related to the provision of EN therapies reported to a national database and provide workable recommendations from the literature to improve safety. An interdisciplinary team queried the National Center for Patient Safety (NCPS) Joint Patient Safety Reporting (JPSR) system using keywords related to EN therapy use. The team reviewed the number, type, and severity of reported events and safety codes as categorized by the NCPS and then thematically classified the narratives using the Medication Use Process (MUP). Our query revealed 1227 safety events related to the EN keywords. Thematic analysis of the top five event subtypes (n = 1030) revealed that there were 691 EN safety reports directly related to an MUP step, and the majority fell into the steps of administering (31%), followed by monitoring (28%), dispensing (26%), prescribing (11%), and transcription (4%), with many events involving more than one MUP step. Safety events associated with the provision of EN therapies leading to patient harm have been reported to the JPSR system. To improve safety related to EN use, modifications to prescribing, transcribing/documenting, dispensing, administering, and monitoring of prescribed EN therapies are needed.

Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014-2020): Findings From Taiwan Patient Safety Reporting System.

Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity. Longitudinal secondary data (over 2014-2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system. The numbers and incidence rates (per 1000 inpatient days) of reported MAEs were calculated. The harm severity levels of six major MAE categories were analyzed. Trend and generalized estimating equation analyses were conducted to investigate changes in MAE patterns. Trend analyses revealed significant decreasing trends in the number (4763-3107 per year; Jonckheere-Terpstra test = -1.952, P = 0.05) and incidence rates (0.92-0.62 per 1000 inpatient days; β = -0.5017, P = 0.00) of harmful MAEs over 7-year study period. Among the most frequently reported MAEs, tube-related events exhibited the most significant decreasing trend (28%-23.8%; Jonckheere-Terpstra test = -2.854, P = 0.00). The reported numbers, incidence rates, and severity of falls and tube-related events dropped significantly. By analyzing representative longitudinal MAE data, this study demonstrated the effectiveness of nationwide patient safety improvement campaigns in Taiwan. Our data reveal significant reductions in the reported numbers, incidence rates, and severity of several major MAEs. Specifically, our data indicate significant reductions in the incidence and severity of tube-related events, which can be beneficial for patient safety improvement efforts.

Self-Assessment of Patient Safety Reporting and Learning System in Private Hospitals in Indonesia.

Hospitals are required to implement patients safety incident (PSI) reporting, analysis, and problem-solving. Self-assessment is important for exploring gaps and strengthening PSI reporting and learning system. This study examined PSI reporting and learning systems through self-assessment based on WHO guidance, analysis of section scores by hospital class, and analysis of section relationships. This cross-sectional study was conducted on 193 health workers from 47 Indonesian non-profit private hospitals selected using non-probability sampling. Samples in each hospital consisted of seven hospital staff, including quality and patients' safety committee, infectious diseases control committee, manager/head of nursing, as well as functional staff comprising doctors, nurses, pharmacists, and nutritionists. Six aspects based on WHO guidance were measured in this study namely 1) environment for reporting, 2) reporting rules and content, 3) analysis and investigation, 4) governance, 5) action and learning, as well as 6) patients' and family engagement. The data obtained were analyzed using univariate and bivariate analysis. The results showed that the total average score was 64.7 ± 3.3, and the average score on all components of PSI reporting and learning system was minimum 59.3 and maximum 69.6 of a total score of 100. The lowest average score was found in patients' and family engagement component at 59.3 ± 8.4. Class B hospitals had higher average scores on each component than class C and D hospitals, except on the action and learning and patients' and family engagement section. There was a significant positive linear correlation between each section of PSI reporting and learning system (p-value < 0.01). The PSI reporting and learning system in hospitals is in need of improvement across all aspects. One specific area that requires attention is the implementation of mechanisms for patient and family engagement, which can play an important role in promoting safety programs.

Analyzing Health Information Technology and Electronic Medical Record System-Related Patient Safety Incidents Using Data from the Korea Patient Safety Reporting and Learning System

Purpose: At present, there are a variety of serious patient safety incidents related to problems in health information technology (HIT), specifically involving electronic medical records (EMRs). This emphasizes the need for an enhanced electronic medical record system (EMRS). As such, this study analyzed both the nature of and potential to prevent incidents associated with HIT/EMRS based on data from the Korea Patient Safety Reporting and Learning System (KOPS).Methods: This study analyzed patient safety incidents submitted to KOPS between August 2016 and December 2019. HIT keywords were used to extract HIT/EMRS incidents. Each case was reviewed to confirm whether the contributing factors were related to HIT/EMRS (HIT/EMRS-related incidents) and if the incident could have been prevented (HIT/EMRS-preventable incidents). The selected reports were summarized for general clarity (e.g., incident type, and degree of harm).Results: Of the 25,515 obtained reports, 2,664 incidents (10.4%) were HIT-related, while 2,525 (9.9%) were EMRS-related. HIT/EMRS-related incidents were the third largest type of incident followed by 'fall' and 'medication incidents.' More than 80% of HIT/EMRS-related incidents were medication-related, accounting for approximately one-third of the total number of medication incidents. Approximately 10% of HIT/EMRS-related incidents resulted in patient harm, with more than 94% of these deemed as preventable; further, sentinel events were wholly preventable.Conclusion: This study provides basic data for improving EMR use/safety standards based on real-world patient safety incidents. Such improvements entail the establishment of long-term plans, research, and incident analysis, thus ensuring a safe healthcare environment for patients and healthcare providers.

Risk Factors Preventing Immediate Fall Detection: A Study Using Zero-Inflated Negative Binomial Regression

PurposeFalls are the most common accidents in healthcare facilities, and timely intervention can have a positive effect on the hazards and trauma experienced by patients after a fall. This study determined the factors affecting the time taken to detect a fall. MethodsA total of 3,470 cases of falls reported through the Korea Patient Safety Reporting and Learning System were included in the analysis. A zero-inflated negative binomial regression method was used for this retrospective secondary data analysis study. ResultsThere were 537 patients whose falls were not detected immediately; the count model was used to predict risk factors that delayed fall detection. Women aged 60–69 years—compared to those below 60 years and an evening nursing shift, compared to a day shift—were identified as significant factors. The fall detection time of about 2,933 patients was zero; therefore, the logit model was applied to predict a patient's possibility of belonging to the group whose fall was detected immediately. Comparisons of tertiary hospitals with general hospitals and hospitals, of the evening shift with the day shift, and of the day shift with the night shift indicated significant influencing factors. ConclusionsThese findings can assist nurses in recognizing patient and hospital characteristics related to delayed fall detection. Strategies to improve patient safety in healthcare facilities that focus on patient characteristics such as age can be recommended. Furthermore, nurse staffing requires improvement to detect fall incidents immediately.

An Investigation of Human Errors in Medication Adverse Event Improvement Priority Using a Hybrid Approach.

The aim of this study was to analyze and provide an in-depth improvement priority for medication adverse events. Thus, the Human Factor Analysis and Classification System with subfactors was used in this study to analyze the adverse events. Subsequently, the improvement priority for the subfactors was determined using the hybrid approach in terms of the Analytical Hierarchy Process and the fuzzy Technique for Order of Preference by Similarity to Ideal Solution. In Of the 157 medical adverse events selected from the Taiwan Patient-safety Reporting system, 25 cases were identified as medication adverse events. The Human Factor Analysis and Classification System and root cause analysis were used to analyze the error factors and subfactors that existed in the medication adverse events. Following the analysis, the Analytical Hierarchy Process and the fuzzy Technique for Order of Preference by Similarity to Ideal Solution were used to determine the improvement priority for subfactors. The results showed that the decision errors, crew resource management, inadequate supervision, and organizational climate contained more types of subfactors than other error factors in each category. In the current study, 16 improvement priorities were identified. According to the results, the improvement priorities can assist medical staff, researchers, and decisionmakers in improving medication process deficiencies efficiently.

Swallowed Dentures: An Analysis of Denture Impaction Events in Pennsylvania

Tooth loss is a prevalent health concern affecting two-thirds of the geriatric population in the United States. Most patients replace missing teeth with dentures, which have the potential to become dislodged, swallowed, and stuck somewhere along the gastrointestinal tract (termed denture impaction). We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 68 denture impaction events reported from 2004 to 2019. An in-depth analysis revealed that patients were most often male, and the median patient age was 77 years. The most common symptoms reported by patients with denture impaction included difficult and/or painful swallowing, breathing trouble or respiratory distress, sore throat, foreign body sensation in the throat, throat obstruction preventing insertion of a tube or scope, choking, excessively thick and/or bloody oral secretions, and vomiting or regurgitation of food. The pharynx was the most common site of denture impaction, and x-ray imaging was the most common diagnostic test mentioned. The most common method of removal was surgery, and the most common surgical procedures employed were esophagogastroduodenoscopy and laryngoscopy. We believe that we have identified a category of denture impaction events that has not previously been characterized. Our study, coupled with the existing medical literature, suggests that all patients, along with their caregivers and healthcare providers, should be aware of the proactive steps to avoid denture impaction, as well as signs and symptoms of impaction for early identification and treatment. Keywords: choking, denture, denture impaction, edentulism, intubation, swallowed dentures, delayed diagnosis

How Safety Is Compromised When Hospital Equipment Is a Poor Fit for Patients Who Are Obese

Obesity is common, serious, and costly, and according to recent data, its prevalence is on the rise in the United States. Event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) indicate that some healthcare facilities do not have the necessary equipment to monitor and care for some individuals in this patient population, leading to embarrassment for patients, delays in care, and injuries to patients. An analysis of 107 events related to monitoring and patient care for patients who are obese submitted to PA-PSRS from 2009 through 2018 showed that imaging equipment, especially MRI and CT scanners, was most often implicated in event reports (49.5%; 53 events); other equipment included stretchers (24.3%; 26 events) and wheelchairs (11.2%; 12 events). Events most often occurred in an imaging department (30.8%; 33 events) or a medical/surgical unit (21.5%; 23 events). Analysts determined that 80 events (74.8%) resulted in a delay in care and that 44 events (41.1%) resulted in temporary harm to the patient, including skin tears and abrasions. Healthcare providers may not be able to prevent delays in care resulting from the unavailability of adequate equipment for patients who are obese, but they may be able to prevent harm and embarrassment for patients through proactive assessment.

Descripción de factores contribuyentes en sucesos adversos relacionados con la seguridad del paciente y su evitabilidad

ObjectiveTo assess the extent of healthcare related adverse events (AEs), their effect on patients, and their seriousness. To analyse the factors leading to the development of AEs, their relationship with the damage caused, and their degree of preventability. DesignRetrospective descriptive study. LocationPorriño, Pontevedra, Spain, Primary Care Service, from January-2014 to April-2016. Participants and/or contextReported AEs were entered into the Patient Safety Reporting and Learning System (SiNASP). MethodThe variables measured were: Near Incident (NI) an occurrence with no effect or harm on the patient; Adverse Event (AE) an occurrence that affects or harms a patient. The level of harm is classified as minimal, minor, moderate, critical, and catastrophic. Preventability was classified as little evidence of being preventable, 50% preventable, and sound evidence of being preventable. Data analysis: percentages and Chi-squared test for qualitative variables; P<.05 with SPSS.15. Data source: SiNASP. Ethical considerations: approved by the Research Ethics Committee (2016/344). ResultsThere were 166 recorded AEs (50.6% in males, and 46.4% in women. The mean age was 60.80years). Almost two-thirds 62.7% of AEs affected the patient, with 45.8% causing minimal damage, while 2.4% caused critical damages. Healthcare professionals were a contributing factor in 71.7% of the AEs, with the trend showing that poor communication and lack of protocols were related to the damage caused. Degree of preventability: 96.4%. ConclusionsMost AEs affected the patient, and were related to medication, diagnostic tests, and laboratory errors. The level of harm was related to communication problems, lack of, or deficient, protocols and a poor safety culture.

Identification of the human-oriented factors influencing AERC from the Web services

Abstract For both academia and industry, the exploration of new research applications to the nature of human beings from human-like intelligence is advantageous and challenging. Promoting the safety of hospitalized patients is particularly a top priority in the health-care industry. Thus, applications of a patient safety reporting system (PSRS) from the existing reports of Web services provide assistance to identify potential hazards, and to reduce medical errors from two opposite viewpoints: the medical professional, and the patient. Few studies based on emerged machine learning systems have examined the accident event reporting category (AERC) problems from the PSRS of advanced network infrastructure for data storage and resource sharing in viewing development of the next-generation Web. The related analysis of a knowledge gap against classification problems with implied patient safety issue is lacking, and must therefore be filled. This work proposes an enhanced hybrid method, including expert recommendations, a decision-tree C4.5 algorithm, an objective cumulative probability distribution method, the rough set LEM2 algorithm, and rule-filter processing to classify the event reporting categories, analyze their human-oriented factors, and provide meaningful decision rules under the two comparative contexts of medical professional and patient. Two real data sets were retrieved from the PSRS of existing hospital databases, based on various doctor-focused and patient-focused conditional attributes to illustrate significant activity throughout the study framework. Empirical evidence shows that the proposed model has advantages of removing irrelevant features, increasing classification accuracy, and providing a well-informed rule set in supporting knowledgeable decision-making to solve AERC problems, thereby benefiting interested parties.

Using Balanced Scorecard on Reducing Fall Incidents and Injuries Among Elderly Cancer Patients in a Medical Center in Taiwan

Summary Background Elderly cancer patients undergoing cancer treatments were vulnerable to fall incidents and injuries, an important issue in patient safety. The aims of this study were to explore the effects of using balanced scorecard management strategies on reducing fall incidents and injuries among elderly cancer patients in a medical center. Methods A prospective, intervention study was employed using records of fall incidents of elderly cancer patients retrieved from Taiwan Patient safety Reporting system (TPR). The intervention, balanced scorecard measures designed to reduce fall incident and injury, was added to the customer, internal process, learning and growth, financial perspectives of the balanced scorecard implemented by the medical center. SPSS 20.0 was used to in statistic analysis for frequency, percentage, mean, standard deviation, and Chi-square test. Results Prior to the intervention, 41 fall incidents (all sustained injury) recorded in 2010: fall incident (3.26%), fall injury (100%). With the intervention, 24 fall incidents (17 sustained injuries) recorded 2011: fall incident (1.87%; χ2 = 4.985, P = 0.026) and fall injury (62.5%; χ2 = 17.845, p Conclusion The results of present study provided references to healthcare institutes using balanced scorecard management strategies as intervention to reduce to fall incidents and injuries in elderly cancer patients and to prompt patient safety and quality of care.

Falls and Related Injuries in Hospitalized Patients With Cancer in Taiwan.

Falls and fall-related injuries are important indicators for quality of nursing care in institutions. Few studies have been conducted specifically on this topic for hospitalized patients with cancer in Taiwan. The aims of this study were to understand falls and levels of injury; to identify associations among fall-related injuries, demographics, and causes of falling; and to predict fall-related injuries in hospitalized patients with cancer. A retrospective survey design was used. Data were retrieved from the Taiwan Patient-Safety Reporting system query fall incidences for persons hospitalized with cancer at a medical center in northern Taiwan from 2010 to 2012. Data were encoded and analyzed with descriptive statistics, the chi-square test, and multiple stepwise logistic regression analysis using IBM SPSS Statistics version 18.0. One hundred fifty-six (85%) of the 184 hospitalized patients with cancer had fall-related injuries. Falling tended to be more frequent in men without a history of falls and more prevalentat night. The results of regression analysis showed that the variables being with companions at the time of a fall (OR = 5.411, 95% CI [1.619, 18.081]), lower limb weakness (OR = 0.284, 95% CI [0.097, 0.832]), postural hypotension (OR = 0.101, 95% CI [0.014, 0.733]), total score of fall risk factors (OR = 1.688, 95% CI [1.071, 2.660]), and a fall occurring at the bedside (OR = 3.493, 95% CI [1.119, 10.903]) were all positively associated with fall-related injuries, with a Nagelkerke R of 42.8%. The risk factors for falls that affect hospitalized patients with cancer are complex. Nursing staff must evaluate the risk factors and treatment methods for each patient and facilitate fall prevention measures to achieve safety-centered quality of care. This study provides an example for nursing staff when assessing factors associated with falls and working to reduce fall-related injuries among patients with cancer.

18: ASSESSMENT OF EXISTENCE OF THE REQUIREMENTS OF CLINICAL RISK MANAGEMENT IN HOSPITALS

Background and aims:At present, modern advances in health care, serious deficiencies have been identified in the quality of care and patients' safety. One way to handle these challenges is the...

Development of a Medication Error Prevention System and Its Influence on Patient Safety Culture and Initiatives

Purpose: The objective of this study was to examine patient safety culture (PSC) and patient safety initiatives (PSI) according to IT-based medication errors prevention system which is constructed in this study, and to identify the relationships among system construction, perception to the usage, PSC and PSI. Methods: The subjects were 180 nurses who work at 12 different hospitals with over 300 beds. The questionnaire included the characteristics of participants, a system construction status, the perception to the usage using electric pharmacopoeia (EP), a drug dose calculation system (DDCS), a patient safety reporting system (PSRS) and a bar-code system (BS). The data were collected from July 2011 to August 2011. Descriptive statistics, ANOVA, Pearson correlation and MANOVA were used for data analysis. Results: Systems were constructed in participating hospitals; For EP and PSRS, 83.9%, DDCS, 50%, and BS, 18.3%. The perceptions on the usage of the system were marked highest in BS as 4.54 followed by EP as 3.85. There were significant positive correlations between PSI and EP construction (r=.17, p=.028); PSRS (r=.17, p=.028) and DDCS (r=.23, p=.002). Conclusion: The developed system for improving the user experiences and reducing medication errors was found out well accepted. It is hoped that the system is helpful for PSC and PSI improvement in clinical settings.

The need for a ‘Patient Safety in Dentistry Initiative’ in the Gulf States

Patient safety is gaining increased attention throughout the world and especially since the establishment of the World Health Organization’s (WHO) World Alliance for Patient Safety (WHO, 2008). However, patient safety in dentistry is still in its infancy. In the Gulf States with the diversity of its dental workforce, many of whom were trained overseas, monitoring adverse incidents in dentistry is essential. The publication in 1999, To Err is Human (Kohn et al., 1999) followed by Crossing the Quality Chasm (Institute of Medicine, 2001) galvanised domestic and international healthcare authorities into prioritising the reduction of iatrogenic harm caused by medical intervention. This mandate was further emphasised by medicine and in particular surgery have embraced the importance of reducing the burden of iatrogenic harm through the development of patient safety reporting systems. Dentistry has lagged behind its medical colleagues in developing patient safety programmes. Some dentists may reflect that issues of patient safety pertain solely to hospital-based medicine and surgery. However, general dentistry does involve penetrating surgery such as implants along with deep injections removal or draining of infections and health monitoring, all of which can and do lead to possible avoidable iatrogenic harm to the patients. With the current trend of more complex dental procedures being undertaken in community-based practices, the potential for iatrogenic harm increases. The need for a country based and in the future a Gulf wide patient safety Reporting and Learning System is needed. In England and Wales, there is one of the largest and most comprehensive reporting systems in the world; it has recorded over 6.7 million incidents over the past 8 years (2003–present) (Lamont and Scarpello, 2009). Staff report incidents through their hospital or primary care organisation so that local action can be taken when needed. These incidents are uploaded to the national database. Healthcare staff, patients, and other members of the public can also report incidents independently through the website. Each National Reporting and Learning System report refers to an unintended or unexpected incident that could have or did lead to harm for one or more patients receiving National Health Service funded care. It includes the reporting of those incidents which did not lead to harm because an error took place but it did not harm the patient, and those which did not lead to harm because an incident was prevented from reaching the patient. These incidents are further stratified into different levels of harm. So what is needed? First, a culture shift in reporting patient safety incidents and doing so to help raise standards in dental care as well as better focused continuing education programmes and the creation of a professional understanding of common errors and incidents in dental provision. Second, strong leadership within the profession to raise patient safety higher up the dental political agenda. Thirdly, sophisticated analyses of these incidents, akin to public health surveillance methods are required to understand the burden of harm in dentistry and develop ameliorative solutions. A Gulf wide Dental Patient Safety Agency’s Reporting and Learning System should be established based upon a web-based open access method whereby the reports are submitted in an anonymous fashion from the individual organisations local risk management system. This would put the region at the forefront of patient safety in dentistry around the world and usher in a new culture of safety into the dental services.

Predicting Medical Staff Intention to Use an Online Reporting System with Modified Unified Theory of Acceptance and Use of Technology

Barriers to report incident events using an online information system (IS) may be different from those of a paper-based reporting system. The nationwide online Patient-Safety Reporting System (PSRS) contains a value judgment behind use of the system, similar to the Value of Perceived Consequence (VPC), which is seldom discussed in ISs applications of other disciplines. This study developed a more adequate research framework by integrating the VPC construct into the well-known Unified Theory of Acceptance and Use of Technology (UTAUT) model as a theoretical base to explore the predictors of medical staff's intention to use online PSRS. The results showed that management support was an important factor to influence medical staff's intention of using PSRS. The effects of factors such as performance expectancy, perceived positive, and perceived negative consequence on medical staff's intention of using PSRS were moderated by gender, age, experience, and occupation. The results proved that the modified UTAUT model is significant and useful in predicting medical staff's intention of using the nationwide online PSRS.

Medical conditions and medications as risk factors of falls in the inpatient older people: a case-control study

The majority of inpatient falls are older people who have various medical conditions and are on several medications. The purpose of this study was to examine the association between medical conditions and medications and falls in older people in hospital. Using a case-control design, we selected older people (aged 65 or over) who were reported to the Taiwan Patient-Safety Reporting System for the fall incidents in a large academic hospital in 2006 (n = 165). They were individually (1:1) matched for gender, age, and period of hospitalization with the control non-faller group. Bivariate and multivariate logistic regressions were used to compare the cases and controls to examine the association of medical conditions and medication exposure within 24 h before the falls. Bivariate analyses showed that older people with cancer, or exposure medications such as zolpidem, benzodiazepines, narcotics, and antihistamines were significantly more likely to have falls during hospitalization. After controlling for cancer, zolpidem, narcotics, and antihistamine, we found benzodiazepine (Odds ratio (OR) = 2.26, 95% confidence interval (CI) = 1.21-4.23) and benzodiazepine doses ≥1 mg/day in diazepam equivalents (OR = 2.14, 95%CI = 1.04-4.39) were still significantly associated with the falls of older people in the hospital. Strategies to prevent falls in older people in hospital should include minimizing the use of zolpidem, benzodiazepine, narcotics, and antihistamines, especially in cancer patients.