Preventable Patient Safety Incidents Research Articles

South Korean Nurses' Experiences of Speaking up for Patient Safety and Incident Prevention.

Despite the importance of speaking up for patient safety, hesitancy to do so remains a major contributing factor to communication failure. This study aimed to investigate the experiences of South Korean nurses in speaking up to prevent patient safety incidents. Twelve nurses responsible for patient safety tasks or with experience in patient safety education were recruited from five hospitals (three university hospitals, two general hospitals) in city "B". Data were collected through open-ended questions and in-depth interviews, transcribed, and analyzed using the inductive content analysis method. The study resulted in the identification of four main categories and nine subcategories that captured commonalities among the experience of the 12 nurses. The four main categories were as follows: the current scenario of speaking up, barriers to speaking up, strategies for speaking, and confidence training. There is a scarcity of research on speaking-up experiences for patient safety among nurses in South Korean. Overall, it is necessary to overcome cultural barriers and establish an environment that encourages speaking up. In addition, developing speaking-up training programs for nursing students and novice nurses is imperative to prevent patient safety incidents.

Radiographers' perception of patient safety culture in radiology

IntroductionRadiographers play a central role in patient safety because of their knowledge of and responsibilities in relation to the imaging process. To maintain safe care, the workplace must create a safety culture that enables sustainable safety work. AimThis study aims to describe radiographers' perceptions of the patient safety culture in radiology units in Sweden. MethodsThe Swedish Hospital Survey of Patients' Safety Culture (S-HSOPSC) was used to gather descriptive data from 171 Swedish registered radiographers working in five radiology clinics distributed across 15 units. Fifty-one questionnaire items and one open-ended question were analysed, comprising perceptions of the overall safety grade, the frequency of number of reported risks and events, and 14 composites regarding patient safety dimensions. ResultsThe radiographers' concerns surrounding the patient safety culture in their workplaces related to weaknesses regarding the safety dimensions “Staffing”, “Frequency of error reporting”, “Organizational learning – continuous improvement” and “Executive management support for patient safety”. They perceived “Teamwork within the unit” to be a strength. ConclusionDespite some weaknesses in the patient safety culture, the radiographers perceived that the overall patient safety level was good, in part because of their ability to spot risks in time. The executive management, however, needed to improve their feedback on safety measures; and another reason for some weaknesses in the patient safety culture could be staffing issues such as lack of time for meetings for continuous improvement. Managers and leaders have a great responsibility to establish a patient safety culture through support and good leadership. Implications for practiceAn understanding of what creates a safety culture is important to prevent patient safety incidents.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

To describe factors that prevent patient safety incidents in connection with the radiological examination from the radiographer's perspective. Radiology plays an important role in the care chain and involves diagnostic examinations and treatments using various radiation sources and different techniques. Risks for patient safety incidents exist in every phase of a radiological examination. Appropriate use of medical imaging requires a multidisciplinary approach involving staff of different categories to meet the medical objectives and the patient's care needs. In accordance with a Safety-II approach, it is therefore important to understand why things go right and ensure that they do by supporting the conditions for right things to happen. A qualitative study with a descriptive design. Semi-structured interviews were conducted with 17 radiographers. The data were analysed using theoretical thematic analysis based on the Systems Engineering Initiative for Patient Safety model. The analysis yielded 20 sub-themes, which describe different success factors contributing to patient safety. Proactive work should focus on collaboration and sharing the necessary knowledge, internally and externally, for care in connection with the radiological examination. The radiological and peri-radiographic knowledge should include monitoring the patient's safety needs before, during and after the radiological examination. The referring clinician has a central role in writing relevant referrals and the radiographer's competence is crucial in monitoring the patient's safety needs. A good patient safety culture is required and working with standards is important.

군병원 환자참여교육이 환자안전인식, 환자참여, 의료진과의 관계에 미치는 효과

Purpose: The purpose of this study is to assess the effects of patient participation education on the patient safety perception, patient participation, and patient-provider relationship in ROK Military Hospital. Methods: A non-equivalent control group pretest-posttest design was used for the study. Participants were 135 inpatients (control group: 71; experimental group: 64). Patient participation education was provided both offline and online using picture cards and videos. This study was conducted in a military hospital from 27 May to 31 August 2021. Data were analyzed by the chi-square test, independent t-test, paired t-test, and Analysis of Covariance (ANCOVA) using SPSS program. Results: The results revealed that there was a statistically significant difference in patient safety perception (F=16.33, p<.001) and patient participation(F=17.14, p<.001) scores between the control and experimental groups. In addition, the degree of increase in patient safety perception and patient participation scores in the experimental group was significantly higher than those of the control group (t=-3.63, p<.001; t=-3.40, p<.001). However, there was no statistically significant difference in patient-provider relationship score between the control and experimental groups. Conclusion: Patient participation education can improve patient safety perception and patient participation, which are necessary to prevent patient safety incidents and improve the quality of care. We suggest to develop systematic and standardized patient participation education in various ways.

Faktor yang Berhubungan dengan Penerapan 6 Sasaran Keselamatan Pasien

Patient safety is a system that must be implemented in hospitals. This is done by the government in an effort to prevent patient safety incidents from occurring. Based on the Lumenta report (2008) that in Indonesia from 145 reported incidents of near-injury (KNC) as many as 47.6% cases, unwanted events (KTD) as many as 46.2% cases, and others as many as 6.2% cases. . The KTD rate at Raden Mattaher Hospital in 2016 was 10 cases, increasing to 13 cases in 2017 and decreasing to 7 cases in 2018. Many factors affect the implementation of patient safety, namely internal and external factors. The purpose of this study was to determine the factors associated with the implementation of 6 patient safety goals at Raden Mattaher Hospital Jambi. The design of this study used a cross-sectional study. The number of samples in this study were 80 nurses with proportional random sampling technique. The analysis used was univariate and bivariate analysis with Chi-square and Wilcoxon tests. The results of the analysis show that the average age is 33.19 years and the length of work is 9.39 years. A total of 71.2% are female, 82.5% have vocational education, 68.8% have sufficient knowledge, 56.2% are positive and 65% of respondents do not apply the 6 patient safety goals. The results of the bivariate analysis showed that there was a relationship between age, length of work and attitude with the implementation of the 6 patient safety goals.

Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines.

The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable. This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors. We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122). Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49years (IQR: 33-64years). The median length of hospital stay before death was three days (IQR: 1-11days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities. Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.

Pengalaman Perawat Menerapkan Prosedur Keselamatan Pada Klien Lanjut Usia

Patient safety procedures need to be done to prevent patient safety incidents. The purpose of the study is to explore the experience of room nurses applying patient safety procedures to elderly clients. Qualitative research design with phenomenological study approach. Participants are implementing nurses who have experience in caring for elderly patients as many as 6 nurses. Data collection was stopped when the data received were saturated through in-depth interviews. The method of analysis was the Interpretative phenomenological analysis (IPA). This research has passed the ethical clearance. Based on the results of the analysis, there are seven themes that can be found, namely understanding patient safety, the concept of elderly, forms of patient safety, supporting factors, inhibiting factors, efforts to overcome obstacles and the benefits of bothering patient safety procedures. Nurses' understanding of patient safety is an action to prevent incidents from occurring due to an action taken on the patient. In carrying out patient safety procedures for the elderly, the nurse finds several supporting and inhibiting factors. Nurses and patients feel safe when patient safety procedures are performed properly. Patient safety is a procedure that is closely related to the actions taken by the nurse. The experience of nurses in applying safety procedures to elderly clients provides a sense of security when take an action.&#x0D;  Keywords: elderly, nurse, patient safety

Applying Human Factors Methods to Improve Healthcare Risk Management Tools

The Healthcare Insurance Reciprocal of Canada (HIROC) is a not-for-profit medical malpractice insurance reciprocal that has a vision of partnering to create the safest healthcare system. Each year, patients die from preventable patient safety incidents in Canada. A proactive focus on risk management and embedding safety into healthcare systems is key to improving patient safety. HIROC conducted semi-structured interviews to help identify usability areas of interest for two primary risk management tools: The Risk Assessment Checklist and the Risk Register. A total of 16 participants from HIROC Subscribers, all with experience in risk management, quality improvement or patient safety, volunteered to partake in the semi-structured interviews. A thematic analysis of the data collected informed usability improvements. For the Risk Assessment Checklist, participants indicated that the tool is informative as it helps create risk management awareness across their organizations. Participants found the Risk Assessment Checklist interface easy to use and are pleased that submitting their self-assessments is a streamlined process. For the Risk Register, participants reported that the tool is simple and easy to use. Specifically, they find value in having an electronic system that keeps them organized and provides a way for them to track and trend their progress. Participants identified some usability concerns that the research team addressed with proposed design reflections informed by Jakob’s Ten Usability Heuristics (Nielsen, 1994).

Literature Review: Implementation of Patient Safety Goals in Hospitals in Indonesia

Background: The implementation of a good patient safety system in the hospital aims to minimize and prevent patient safety incidents. The patient safety goals is a system that aims to encourage specific improvements in patient safety. Patient safety goals are actions that must be taken by the hospital to prevent patient safety incidents that can harm patients and the hospital. Purpose: Writing this review article aims to provide an overview of the implementation of patient safety goals in hospitals in Indonesia.Methods: The method used in this article is a literature review. Article searches were conducted through Google Scholar and Portal Garuda with the keywords "patient safety goals", "hospitals", and "Indonesia". Results: The total findings of the articles were 738, but only 11 articles matched the inclusion criteria. Based on 11 articles analyzed, only 2 articles showed that the implementation of all points in the patient safety goals in the hospital had reached the target and were in accordance with the standard. Conclusion: Low compliance of officers, unsupportive facilities and infrastructure, and low management commitment are some of the factors that have not yet optimalized the implementation of patient safety goals in the hospital. Therefore, it is necessary to improve technical assistance, supervision, and support for adequate facilities and infrastructure.Keywords: patient safety goals, patient safety incidents, hospital.

Relationship on Leadership Support with Nurser Compliance Identifying Patients in the Implementation of Patient Safety in Datu Beru Central Aceh Regional General Hospital

The patient safety mission at the hospital is to prevent patient safety incidents from occurring, the number of incidents is said to be like an iceberg phenomenon. The incidence rate in Indonesia based on data from the Joint Commission International (2012) shows that as many as 13% due to surgical errors and 68% due to blood transfusion errors. This study aims to analyze the relationship between leadership support and compliance with nurses in identifying patients in the implementation of patient safety in the Datu Beru Aceh Hospital. Tengah. The research design used a quantitative analytic survey with a cross-sectional design. The population of all nurses working in the Women's Internal Medicine Room at Datu Beru Hospital, Central Aceh was 34 people. The sampling technique used total sampling. Data analysis was carried out by univariate, bivariate and multivariate with chi_square. The results of the research variable Leadership Support with Nurse Adherence obtained p-value = 0,000, meaning that there is a relationship between leadership support and nurse compliance to identify patients in the application of patient safety. Multivariate analysis of leadership support variables obtained sig value of 0.000 &lt;p = 0.05, which means that there is a significant influence of the leadership support variable on nurse compliance. There is a relationship between leadership support and the compliance of nurses to identify patients in the application of patient safety and there is a significant effect.

Effect of SBAR situational awareness technique as educational intervention on critical care nurse students' skills of patient safety

Background: Situation awareness could actively scan for risk across multiple domains. It has been defined as “the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future”. Situation awareness includes three levels; perception, comprehension, and projection. Perception is the first step in developing situation awareness as it includes students' perception of status, attributes, and dynamics of relevant elements in the ICU environment. Comprehension of the present situation is based on outputs of the perception. It includes understanding of the significance of the relevant elements. Finally, projection of future status includes the ability of students to predict the future actions of certain elements in the ICU environment. Appropriate situation awareness could increase the probability of a good task performance. In addition, feedback covers state of the ICU environment affected by both decisions and performance of the selected actions. While SBAR is acromion that represents the actual application of situational awareness through situation, background, assessment and recommendation. A representation of SBAR situational awareness has been depicted as an inner factor in the method for giving patient consideration and basic leadership that helps health care professionals to handle and process information about what is occurring. SBAR is a mechanism useful for framing any conversation, especially critical ones, requiring a practitioner's immediate attention and action to foster a culture of patient safety. Critical care nurses play an important role in their workplace related to patient safety. They should be able to recognize and analyze patient safety incidents using protocols, work in a team, learn from errors, and be able to identify actions and recommendations on how to prevent patient safety incidents through the use of SBAR situational awareness technique. Nursing students’ should recognize and understand what is going on around them. Consequently, they can plan ahead with greater knowledge to patient safety which arise the need to integrate SBAR situation awareness in their curricula.Method: A quasi experimental research design was used in this study in which two tools were used for data collection: “Self-Situational Awareness Assessment Questionnaire” and “Critical Care Nurse Students’ Safety Skills Checklist”.Results: There was a statistical significant difference between both groups of students in relation to situation awareness perception, process and skills (p &lt; .001). Moreover, there was a statistical significant difference between the study and control groups in relation to the students' practices score regarding patients’ safety standards in the post-assessment phase (p &lt; .001).Conclusion: In the current study, the SBAR situation awareness technique was used in training critical care nurse students to improve their situation awareness level to patient safety skills. Situation awareness perception, process and skills level were significantly increased for critical care nurse students who are subjected to the training program. Also, the students' skills regarding patients' safety standards practices were significantly improved. 

Patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis

Around 6% of medical encounters result in preventable patient safety incidents, and 12% of these result in severe or fatal outcomes.1 The acute medical unit (AMU) was introduced in 2004 to improve patient outcomes by allowing patients referred from general practice to receive specialist medical care faster.2 However, healthcare poses risks to all patients, and it is well documented that acutely sick patients are at heightened risk of unsafe care due to medication errors, treatment delays and complications arising from multiple care handovers.3–6 Patient safety is predicated on understanding why errors occur and using this to redesign care …

1070. Handshake Antimicrobial Stewardship as a Model to Prevent Patient Safety Incidents and Recognize Diagnostic Errors

BackgroundPatient safety incidents (PSIs), such as diagnostic errors, are common events that may lead to significant patient harm. Few studies describe the impact that antimicrobial stewardship programs (ASPs) have preventing PSIs and recognizing diagnostic errors. Handshake Stewardship has emerged as a specific ASP model that involves prospective review of hospital-wide antimicrobial ordering with a compressed “second look” of relevant clinical and historical patient data. In person recommendations are then provided directly to the medical team. The objective of this project was to evaluate the potential impact that Handshake Stewardship has on preventing PSIs and recognizing diagnostic errors.MethodsFollowing Children’s Hospital Colorado (CHCO) ASP’s implementation of the Handshake Stewardship model in October 2013, the CHCO ASP team began prospectively self-labeling interventions as “Great Catches” (GCs). These GCs were defined as any ASP intervention that “notably changed the trajectory of patient care.” Patient charts for all GCs from October 2014 through May 2018 were retrospectively reviewed and each intervention was assigned one or more descriptive category labels including: administration error, de-escalation/escalation of therapy, bug-drug mismatch, inappropriate dose/duration, potential adverse effect, alternative diagnosis, additional testing, prevent hospital admission, and epidemiology alerts. In addition, each intervention was scored using the previously validated “Safer Dx Instrument” to determine which GCs intervened on a potential diagnostic error.ResultsFrom October 2014 through May 2018 there were 87,322 admissions to CHCO. Our ASP team intervened on 6,735/87,322 (7.7%) of these admissions. Of these, 174/6,735 (2.6%) were prospectively labeled by ASP providers as GCs, of which 44/174 (25%) resulted in new infectious disease consultations.ConclusionGiven the frequency and significance of PSIs including diagnostic error, systems are needed to help recognize and prevent patient harm. The Handshake Stewardship model may help prevent PSIs and recognize diagnostic errors among hospitalized children. Disclosures All authors: No reported disclosures.

Building Usability Knowledge for Health Information Technology: A Usability-Oriented Analysis of Incident Reports.

The contribution of usability flaws to patient safety issues is acknowledged but not well-investigated. Free-text descriptions of incident reports may provide useful data to identify the connection between health information technology (HIT) usability flaws and patient safety. This article examines the feasibility of using incident reports about HIT to learn about the usability flaws that affect patient safety. We posed three questions: (1) To what extent can we gain knowledge about usability issues from incident reports? (2) What types of usability flaws, related usage problems, and negative outcomes are reported in incidents reports? (3) What are the reported usability issues that give rise to patient safety issues? A sample of 359 reports from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database was examined. Descriptions of usability flaws, usage problems, and negative outcomes were extracted and categorized. A supplementary analysis was performed on the incidents which contained the full chain going from a usability flaw up to a patient safety issue to identify the usability issues that gave rise to patient safety incidents. A total of 249 reports were included. We found that incident reports can provide knowledge about usability flaws, usage problems, and negative outcomes. Thirty-six incidents report how usability flaws affected patient safety (ranging from incidents without consequence, to death) involving electronic patient scales, imaging systems, and HIT for medication management. The most significant class of involved usability flaws is related to the reliability, the understandability, and the availability of the clinical information. Incidents reports involving HIT are an exploitable source of information to learn about usability flaws and their effects on patient safety. Results can be used to convince all stakeholders involved in the HIT system lifecycle that usability should be considered seriously to prevent patient safety incidents.

A risk-factor analysis of medical litigation judgments related to fall injuries in Korea.

The aim of this study was to find out the risk factors through analysis of seven medical malpractice judgments related to fall injuries. The risk factors were analysed by using the framework that approaches falls from a systems perspective and comprised people, organisational or environmental factors, with each factor being comprised of subfactors. The risk factors found in each of the seven judgments were aggregated into one framework. The risk factors related to patients (i.e. the people factor) were age, pain, related disease, activities and functional status, urination state, cognitive function impairment, past history of fall, blood transfusion, sleep endoscopy state and uncooperative attitude. The risk factors related to the medical staff and caregivers (i.e. people factor) were observation negligence, no fall prevention activities and negligence in managing high-risk group for fall. Organisational risk factors were a lack of workforce, a lack of training, neglecting the management of the high-risk group, neglecting the management of caregivers and the absence of a fall prevention procedure. Regarding the environment, the risk factors were found to be the emergency room, chairs without a backrest and the examination table. Identifying risk factors is essential for preventing fall accidents, since falls are preventable patient-safety incidents. Falls do not happen as a result of a single risk factor. Therefore, a systems approach is effective to identify risk factors, especially organisational and environmental factors.

Never Events in UK General Practice: A Survey of the Views of General Practitioners on Their Frequency and Acceptability as a Safety Improvement Approach.

Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the United Kingdom and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to general practitioner (GPs) as a Q&SI approach, is currently unknown. The study aims to estimate (1) the frequency of 10 NEs occurring within GPs' own practices and (2) the extent to which the NE approach is perceived as acceptable for use. General practitioners were surveyed, and mixed-effects logistic regression models examined the relationship between GP opinions of NE, estimates of NE frequency, and the characteristics of the GPs and their practices. Responses from 556 GPs in 412 practices were analyzed. Most participants (70%-88%, depending on the NE) agreed that the described incident should be designated as a NE. Three NEs were estimated to have occurred in less than 4% of practices in the last year; however, two NEs were estimated to have occurred in 45% to 61% of the practices. General practitioners reporting that a NE had occurred in their practice in the last year were significantly less likely to agree with the designation as a NE compared with GPs not reporting a NE (odds ratio, 0.42; 95% CI = 0.36-0.49). The NE approach may have Q&SI potential for general practice, but further work to adapt the concept and content is required.

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm

BackgroundEstimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of &gt; £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.AimOur aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.Methods and resultsWe developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.ConclusionThis research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.Trial registrationCurrent Controlled Trials ISRCTN07689702.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Trigger review method effective in prompting safety improvements

The trigger review method (TRM) is one way primary care professionals can learn from and prevent patient safety incidents (PSIs) through a retrospective (three months) review of clinical records of high-risk patients, such as those aged over 75 with polypharmacy. It has been introduced in Scotland as part of the Quality and Outcomes Framework.

Biometrics' new identity--measuring more physical and biological traits: Research into the characteristics that are unique to an individual is addressing the need to correctly identify people in a variety of medical, social and security contexts.

Science & Society14 December 2015free access Biometrics' new identity—measuring more physical and biological traits Research into the characteristics that are unique to an individual is addressing the need to correctly identify people in a variety of medical, social and security contexts Andrea Rinaldi Andrea Rinaldi Freelance science writer [email protected] Cagliari, Italy Search for more papers by this author Andrea Rinaldi Andrea Rinaldi Freelance science writer [email protected] Cagliari, Italy Search for more papers by this author Author Information Andrea Rinaldi1 1Cagliari, Italy EMBO Reports (2016)17:22-26https://doi.org/10.15252/embr.201541677 PDFDownload PDF of article text and main figures. ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinked InMendeleyWechatReddit Figures & Info There is no need to remember complex combinations of random numbers and characters. From now on, you are the password: your fingerprint, face, iris, gait or odour—any of your potentially unique attributes—can theoretically be used to identify you. This is the idea behind biometrics, which was once confined to the realm of spy movies and high-security facilities, but is now increasingly common in everyday security checks at borders, for secure payments and logging in to mobile devices. Beyond security, though, biometrics technology is also driving and enabling other applications that include forensic science, data sharing over networks and reducing identification errors in hospitals. Biometrics is essentially ready for mass application, as the success of the Indian Aadhaar programme demonstrates. While fingerprints and retina patterns are the most well-known biometric identifiers, they are not the only characteristics that can be used for biometric identification. Physical traits such as the shape of the face, hand or ear, the vasculature in the finger or DNA—so-called hard biometrics—as well as behavioural characteristics such as gait, signature, voice and typing patterns can all be used to identify individuals (Fig 1). Another large and rapidly expanding category—which includes characteristics such as skin or eye colour, height, weight and tattoos—is known as “soft biometrics” and provides less distinctive, less categorical information, but has the advantage that such traits can be measured from a distance without cooperation from the subject. Even body odour is being actively explored as a practicable biometric identifier (http://www.sciencedaily.com/releases/2014/02/140204073823.htm). Figure 1. Examples of biometric traits.(A) Fingerprints, palm prints, hand vasculature, hand shape and signature. (B) Face, DNA, sclera (on the eyeball), ear shape and typing patterns (keystroke dynamics). (C) Teeth (forensic odontology), gait, voice or speech, iris and retina. Some of these traits—fingerprints, palm prints, face, voice, teeth, ear shape and DNA—are also used in forensics. Reproduced with permission from: Jain AK, Ross A (2015) Bridging the gap: from biometrics to forensics. Phil Trans R Soc B 370: 20140254. Download figure Download PowerPoint Biometrics is essentially ready for mass application, as the success of the Indian Aadhaar programme demonstrates. Launched in 2010 by the Unique Identification Authority of India (https://uidai.gov.in/), the goal of the programme is to provide all 1.2 billion Indian citizens with a unique 12-digit number linked to biometric features to serve as an identification system “devoid of any classification of caste, creed, religion and geography”. In a country where hundreds of millions have no official ID and where the poor are often excluded from subsidies or social benefits—such as food coupons and cooking gas—because they cannot prove their identity, the initiative will both enable fairer access to government benefits and permit residents to access other services, like opening a bank account or applying for loans. The programme's biometric database includes two iris scans, ten digital fingerprints and a digital photo for every resident (Fig 2). An online platform will help service providers authenticate the identity of residents electronically, in a safe and quick manner. Although enrolment is voluntary, the response has been enthusiastic. So far, more than 900 million “Aadhaars” have been issued, and the number grows by one million every day. Figure 2. Recording personal features in rural India as part of the Aadhaar project.“Aadhaar” means “foundation” or “base” in most Indian languages. See main text for more details. Credit: Unique Identification Authority of India. Download figure Download PowerPoint Conventional but trusted biometric techniques such as fingerprints and face recognition are vulnerable to attacks… There is global interest in the Aadhaar scheme and the underlying biometrics technology from other governments and international organizations. “We've got to think about how we can integrate this technology into a massive effort to scale up access to financial services”, said Jim Yong Kim, President of the World Bank (http://www.worldbank.org/en/news/feature/2013/05/02/India-8217-s-Massive-I-D-Program-Exemplifies-8216-Science-of-Delivery-8217). Kim described the programme as an excellent example of the integration of technology for social welfare use and a major driver in the effort of eradicating poverty by 2030. The main challenge in the biometrics field is, needless to say, security. Conventional but trusted biometric techniques such as fingerprints and face recognition are vulnerable to attacks, for instance by presenting an artefact that imitates the unique biological trait of a person to a biometric scanner, thereby gaining illegal access to a protected device or service. Given the growing importance of biometrics, this practice, known as spoofing, is not a marginal issue and the EU-funded Tabula Rasa project has attempted to tackle the problem in an innovative way (https://www.tabularasa-euproject.org/). Researchers involved in the project assessed the vulnerability of biometric systems to spoofing, revealing that many are susceptible to attack if they are not protected by adequate countermeasures and that the most accurate biometric systems, those with low false acceptance/false rejection rates, are also the most vulnerable ones. Among the various biometric characteristics the project investigated, gait was shown to be particularly robust to direct spoofing attacks 1. “Through the project we have learned many important lessons, but also ended up with a new bunch of research questions that still remain unsolved”, said Sébastien Marcel, leader of the biometrics group at the Idiap Research Institute in Martigny, Switzerland, and Tabula Rasa coordinator. “The project mostly focused on software-based countermeasures for anti-spoofing. Thanks to the work done, it's now clear that detection of more elaborated spoofing attacks will probably require a new generation of countermeasures combining hardware-based and software-based approaches”. Research into alternative systems is thus blooming, and novel avenues are being actively explored. Recent work has shown that electrophysiological signals—dependant on the electrical properties of tissues and cells—are distinctive enough for each individual person to be used for biometric applications, with the additional bonus of being inherently difficult, though not impossible, to forge. Bioelectrical signals recorded from the heart (electrocardiography, ECG) and the brain (electroencephalography, EEG) seem particularly well suited for these purposes 2. Although no device based on electrophysiological biometry is on the market yet, the technology and the science underlying it have potential and unique features. First, electrophysiological signals are universal, meaning that while fingers can be cut off or retinas scarred, no living person can survive without a heart or brain—although the variability of individual ECG/EEG signals over time and surrounding context is still a matter of study. Second, unlike other biometric systems, both ECG and EEG signals can be monitored for prolonged periods—for example to continuously authenticate the user of a protected device after initial authentication. The Apple Watch applies the same principle of continuous monitoring, requiring the user to authenticate their identity with a password when the watch is strapped to the wrist, but then monitoring for a constant heartbeat to avoid the need for further authentication. As soon as there is an interruption in the heartbeat detected by the watch, the watch locks itself down again. Another area where biometrics is bound to have a huge impact in the near future is in healthcare. Patient misidentification is a real problem, even in countries with advanced health systems. In the UK, more than 24,000 cases of patients being mismatched to their care were reported between February 2006 and January 2007 (http://www.nrls.npsa.nhs.uk/resources/?entryid45=59824). Obviously, the misidentification of patients can have dire consequences. These stretch from errors in drug administration and surgical interventions up to the discharge of infants to the wrong families. The UK's National Health Service (NHS) lists misidentification of patients as “never events”: serious, largely preventable patient safety incidents that should not occur if the available preventative measures had been implemented (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215206/dh_132352.pdf). The current identification systems in use in healthcare mostly rely on wristbands, which usually include the patient's name and an assigned number or code. However, there are instances were wristband use is not recommended—for example, in mental health units—or when the patient may refuse to wear a wristband. In other cases, such as in emergency care environments with high patient turnover, insufficient patient identity information or the need for rapid treatment can delay wristband use. The most promising biometric identification system for medical use is vascular biometrics—the recognition of finger vein pattern using infrared light. Vein patterns differ for every individual and every finger and once developed during childhood are stable during adulthood. Light passes easily through the tissue in the finger and is absorbed by the haemoglobin in the blood, rendering an image from which vein pattern can be derived and matched to a patient profile in a database. Finger vein scanners are portable, the technology is safe and non-invasive, and several studies conducted in healthcare settings, including in emergency departments, have shown the high reliability of vascular biometrics 3. “There has been only limited penetration [of biometric identification] into the health technology arena and one reason for this is the relative ignorance of biometric systems by healthcare professionals”, wrote Max Jonas and colleagues at the University Hospital Southampton, UK, in a recent review on the topic 3. “It is a certain prediction that with the accelerating development of health informatics in hospitals, biometric identification will have to become embedded within our clinical information systems”. Next-generation biometrics may well go beyond the human body. Several works point to the possibility of identifying individuals by looking at the bacteria that inhabit their bodies. Five years ago, when the study of the human microbiome was just beginning to flourish, researchers demonstrated that skin bacteria left on inanimate objects, such as computer keyboards, can be matched to the individual who used those objects with a high degree of certainty 4. In other words, we leave unique bacterial “fingerprints” on the objects we touch. The first foreseeable applications of such an approach could be in forensics, implementing the experience from other forensic evidence methods such as human DNA or fingerprint analysis, especially under certain conditions and in particular scenarios. For example, it might be easier in some cases to recover bacterial DNA than human DNA from surfaces, given the abundance of bacterial cells on the skin and on shed epidermal cells. “Furthermore, the technique might be useful for identifying objects from which clear fingerprints cannot be obtained, like fabrics, smudged surfaces, or highly textured surfaces”, noted researchers 4. More recently, Simon Lax and colleagues at the University of Chicago, USA, have looked at the pattern of microbes recovered from mobile phones and the soles of shoes of some 90 people attending three different scientific conferences. The bacterial profiles from the shoe samples clustered into distinct groups depending on the location, as there was a clear impact of the floor microbial community on the shoe microbiome 5. This could help to trace the movements of both suspects and victims before reaching the crime scene. Researchers could also infer the identity of individuals based on the microbes associated with their smart phone surface, even spotting significant differences between the front and the back of the phone owing to the fact that while the back is mainly in contact with the hands, the front comes into contact with the face and mouth. “Microbial communities show unique structure and composition based on surface type, the identity of the person interacting with the surface, and geographic location”, the researchers concluded, stressing that delving into the personalized nature of the human microbiome and the microbial communities associated with urban environments could play a significant role in future forensic investigations 5. A team at the Harvard School of Public Health in Boston, USA, provided further evidence that personal microbial fingerprints are sufficiently distinguishable to identify an individual over time among hundreds of people. Researchers tapped into microbiome data collected from 242 individuals enrolled in the Human Microbiome Project (http://hmpdacc.org/) and derived metagenomic codes from sets of microbial taxa or genes from different body sites (skin, mouth, gut and vagina) and individuals 6. The codes were not only found to be unique between individuals, but were also largely stable over time: the gut habitat, in particular, produced the most stable codes, with more than 80% of individuals still identifiable a year after the initial sampling (Fig 3). “Linking a human DNA sample to a database of human DNA ‘fingerprints’ is the basis for forensic genetics, which is now a decades-old field. We've shown that the same sort of linking is possible using DNA sequences from microbes inhabiting the human body—no human DNA required”, said lead author Eric Franzosa in a statement (http://www.hsph.harvard.edu/news/press-releases/personal-microbiomes-contain-unique-fingerprints/). Figure 3. Microbial fingerprints.Four microbial features inferred from metagenomic sequencing collectively distinguish the starred individual from the population (≥1 features are not detected in each other individual). Reproduced with permission from 6. Download figure Download PowerPoint While it might be a while before microbiome-based biometric approaches enter the courtroom, profiling bacteria attached to pubic hairs could lead to a more straightforward forensic application. In the case of rape and sexual assaults, pubic hairs are often shed by offenders, but DNA analysis—which could pin down the perpetrator—is often hampered by the lack of sufficient genetic material from the hair. A recent study suggests that instead, the analysis of the bacterial communities living on pubic hairs could be used as a “microbial signature” for sexual crimes 7. In the absence of human biological trace evidence, bacterial DNA has the potential to provide the link between victim and offender in sexual assaults In the study, researchers sampled seven individuals, three male and four female, at the start of the study and after two and five months. Metagenomic analysis of microbial DNA extracted from the samples revealed that each individual's pubic hairs harboured distinct communities of microbes and that pubic hair microbiota was stable over time. Furthermore, it was possible to clearly distinguish between pubic hairs from the sexes, largely because of the prevalence of Lactobacillus in the female pubic hair samples and the absence of these bacteria in the male samples 7. “In the absence of human biological trace evidence, bacterial DNA has the potential to provide the link between victim and offender in sexual assaults”, said lead author Silvana Tridico, from Murdoch University, Australia, pointing to the fact that the advent of DNA profiling has resulted in an increase of sexual offenders using condoms, which they take away, post-assault. “Microbial DNA profiling of human hair may provide independent data to augment other, more traditional, forensic data”, Tridico said. “Like all novel forensic techniques, bacterial DNA profiling of hairs will require robust evaluation and validation prior to its introduction into casework”. A significant extension of these microbiome studies for biometric forensics comes from what happens when we die. Because microbes play a key role in the decomposition of cadavers, analysis of this “necrobiome” might hold important clues for estimating the time since death, and much more. For example, as measurable changes occur in the soil bacterial community during the decomposition process when a body is buried, analysis of bacteria not indigenous to the soil could be used as an indicator for locating clandestine graves. So far, results from model studies—not conducted on human remains—are promising, showing that the microbial clock that ticks in a decomposing body can be fine-tuned by characterizing microbial succession after death, ultimately permitting investigators to estimate post-mortem intervals 8. As the requirements for personal recognition become more important, biometrics finds itself at an intriguing intersection of a range of rapidly advancing disciplines. With biometric technologies creeping further into everyday life, there will be a growing impact on society, security and privacy, as well as the ethical discussions that those impacts will entail. Sidebar A: Guess my age, if you can! Biometrics is increasingly able to measure the most intimate features of the human body, but, oddly enough, it still cannot say for sure how old a person is. Indeed, objective and precise estimation of chronological age in living individuals remains a real challenge, and no unequivocal and reliable method exists. The need for age assessment involves various disparate cases. War and poverty are bringing thousands of refugees to Europe who cannot present evidence for their date of birth. If age is disputed, the process for accessing asylum, or the way one is treated in criminal proceedings, may differ substantially depending on the assigned status of “adult” or “child”. To assess a child's nutritional status, it is necessary to know his or her age. In fact, the most common indicators of undernutrition are based on height (stunting) or weight (underweight) with respect to standard values for children of the same sex and age. However, while rich countries can rely on accurate demographic information from civil registration systems, more than 230 million children under five are not registered at birth in the world most of them in Asia and sub-Saharan Africa. “In these regions, children without a certain date of birth—month and year—have zero probability of selection in large epidemiological studies on nutritional status”, said anthropologist Elisabetta Marini from the University of Cagliari, Italy. “We have shown that in sub-Saharan Africa a selection bias favouring registered children is present in demographic and health surveys, and can lead to underrate undernutrition prevalence” 9. Guessing the age of unregistered children by asking parents is prone to inaccuracies, often ending up with an undervaluation of the age of these children, especially if they are stunted. The effect of this bias is, again, the underestimation of malnutrition. “We have calculated that systematic incorrect estimation of age of 3 months can lead to a significant difference in the prevalence of malnutrition and that 6 months of bias can lead to an error up to 28%”, said Ornella Comandini, a PhD student in the Marini laboratory. In practice, age is estimated through a range of medical (X-rays of the hand and wrist, dental examination, X-rays of clavicles) and physical (height, weight, constitutional type) assessments. However, the accuracy of any of these methods has been questioned, as they are subject to influence by a number of variables, including nutritional status. Molecular approaches have also been put forward, although their application is less common. The most accredited one is racemization of aspartic acid from dentin, whereas the length of telomeres is now considered a better predictor of life span, rather than chronological age. The new kid on the block is the biological clock proposed by Steve Horvath, a geneticist and bioinformatician at the University of California at Los Angeles, USA. The method is based on the finding that DNA methylation levels across a broad spectrum of human tissues and cell types correlate with age; a median error of 3.6 years was found, but accuracy improves to 18 months for some types of cells, like those from brain cortex 10. Sidebar A Figure: A biological clock based on epigenetic signatures able to estimate the age of human tissues and cells has been recently described. Reproduced with permission from 10. References Hadid A, Evans N, Marcel S, Fierrez J (2015) Biometrics systems under spoofing attack: an evaluation methodology and lessons learned. IEEE Signal Process Mag 32: 20–30CrossrefWeb of Science®Google Scholar Riera A, Dunne S, Cester I, Ruffini G (2012) Electrophysiological biometrics: opportunities and risks. In Second Generation Biometrics: The Ethical, Legal and Social Context, E Mordini, D Tzovaras (eds), pp 149–176. Dordrecht, Germany: SpringerCrossrefGoogle Scholar Jonas M, Solangasenathirajan S, Hett D (2014) Patient identification, a review of the use of biometrics in the ICU. In Annual Update in Intensive Care and Emergency Medicine 2014, J-L Vincent (ed), pp 679–688. Cham, Switzerland: SpringerGoogle Scholar Fierer N, Lauber CL, Zhou N, McDonald D, Costello EK, Knight R (2010) Forensic identification using skin bacterial communities. Proc Natl Acad Sci USA 107: 6477–6481CrossrefCASPubMedWeb of Science®Google Scholar Lax S, Hampton-Marcell JT, Gibbons SM, Barguil Colares G, Smith D, Eisen JA, Gilbert JA (2015) Forensic analysis of the microbiome of phones and shoes. Microbiome 3: 21CrossrefPubMedWeb of Science®Google Scholar Franzosa EA, Huang K, Meadow JF, Gevers D, Lemon KP, Bohannan BJ, Huttenhower C (2015) Identifying personal microbiomes using metagenomic codes. Proc Natl Acad Sci USA 112: E2930–E2938CrossrefCASPubMedWeb of Science®Google Scholar Tridico SR, Murray DC, Addison J, Kirkbride KP, Bunce M (2014) Metagenomic analyses of bacteria on human hairs: a qualitative assessment for applications in forensic science. Investig Genet 5: 16CrossrefPubMedGoogle Scholar Metcalf JL, Wegener Parfrey L, Gonzalez A, Lauber CL, Knights D, Ackermann G, Humphrey GC, Gebert MJ, Van Treuren W, Berg-Lyons D et al (2013) A microbial clock provides an accurate estimate of the postmortem interval in a mouse model system. eLife 2: e01104CrossrefCASPubMedWeb of Science®Google Scholar Comandini O, Cabras S, Marini E (2015) Birth registration and child undernutrition in sub-Saharan Africa. Public Health Nutr doi: accession:10.1017/S136898001500333X CrossrefPubMedGoogle Scholar Horvath S (2013) DNA methylation age of human tissues and cell types. Genome Biol 14: R115CrossrefPubMedWeb of Science®Google Scholar Previous ArticleNext Article Read MoreAbout the coverClose modalView large imageVolume 17,Issue 1,January 2016Cover: This month's cover highlights the Research Article " Synaptotagmin-11 inhibits clathrin-mediated and bulk endocytosis" by Changhe Wang, Yeshi Wang, Meiqin Hu, Claire Xi Zhang and colleagues. Synaptotagmin-11 inhibits endocytosis to ensure precision in vesicle retrieval during neurotransmission. © Cover image(s) by Changhe Wang, Yeshi Wang, Meiqin Hu and Claire Xi Zhang, Beijing Institute for Brain Disorders, Capital Medical University, Beijing 100069, China. Volume 17Issue 11 January 2016In this issue FiguresReferencesRelatedDetailsLoading ...

Always think 'always events'.

The concept of 'never events' - largely preventable patient safety incidents such as surgery on the wrong body part - has been widely used in managing healthcare quality. The focus is on fixing what is wrong in an institution, although it is not possible to prevent every never event, nor do they always indicate negligence.