Temporary Harm Research Articles

One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals.

The objectives of this study are to determine the prevalence and preventability of adverse events requiring an unplanned higher level of care, defined as an unplanned transfer to the ICU or an in-hospital medical emergency team intervention, and to assess the type and the level of harm of each adverse event. A three-stage retrospective review process of screening, record review, and consensus judgment was performed. Six Belgian acute hospitals. During a 6-month period, all patients with an unplanned need for a higher level of care were selected. The records 6-month period, the records of all patients with an unplanned need for a higher level of care were assessed by a trained clinical team consisting of a research nurse, a physician, and a clinical pharmacist. Adverse events were found in 465 of the 830 reviewed patient records (56%). Of these, 215 (46%) were highly preventable. The overall incidence rate of patients being transferred to a higher level of care involving an adverse event was 117.6 (95% CI, 106.9-128.3) per 100,000 patient days at risk, of which 54.4 (95% CI, 47.15-61.65) per 100,000 patient days at risk involving a highly preventable adverse event. This means that 25.9% of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event. The adverse events were mainly associated with drug therapy (25.6%), surgery (23.7%), diagnosis (12.4%), and system issues (12.4%). The level of harm varied from temporary harm (55.7%) to long-term or permanent impairment (19.1%) and death (25.2%). Although the direct causality is often hard to prove, it is reasonable to consider these adverse events as a contributing factor. Adverse events were found in 56% of the reviewed records, of which almost half were considered highly preventable. This means that one fourth of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event.

Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes.

The aim of this study was to determine the impact of all-cause inpatient harms on hospital finances and patient clinical outcomes. A retrospective analysis of inpatient harm from 24 hospitals in a large multistate health system was conducted during 2009 to 2012 using the Institute of Healthcare Improvement Global Trigger Tool for Measuring Adverse Events. Inpatient harms were detected and categorized into harm (F-I), temporary harm (E), and no harm. Of the 21,007 inpatients in this study, 15,610 (74.3%) experienced no harm, 2818 (13.4%) experienced temporary harm, and 2579 (12.3%) experienced harm. A patient with harm was estimated to have higher total cost ($4617 [95% confidence interval (CI), $4364 to 4871]), higher variable cost ($1774 [95% CI, $1648 to $1900]), lower contribution margin (-$1112 [95% CI, -$1378 to -$847]), longer length of stay (2.6 d [95% CI, 2.5 to 2.8]), higher mortality probability (59%; odds ratio, 1.4 [95% CI, 1.0 to 2.0]), and higher 30-day readmission probability (74.4%; odds ratio, 2.9 [95% CI, 2.6 to 3.2]). A patient with temporary harm was estimated to have higher total cost ($2187 [95% CI, $2008 to $2366]), higher variable cost ($800 [95% CI, $709 to $892]), lower contribution margin (-$669 [95% CI, -$891 to -$446]), longer length of stay (1.3 d [95% CI, 1.2 to 1.4]), mortality probability not statistically different, and higher 30-day readmission probability (54.6%; odds ratio, 1.2 [95% CI, 1.1 to 1.4]). Total health system reduction of harm was associated with a decrease of $108 million in total cost, $48 million in variable cost, an increase of contribution margin by $18 million, and savings of 60,000 inpatient care days. This all-cause harm safety study indicates that inpatient harm has negative financial outcomes for hospitals and negative clinical outcomes for patients.

The Reliability of AHRQ Common Format Harm Scales in Rating Patient Safety Events

A study was conducted to determine the reliability of Agency for Healthcare Research & Quality (AHRQ) Common Format Harm Scale versions 1.1 and 1.2 in rating patient safety events among users of the UHC Patient Safety Net, a Web-based incident reporting tool. To test interrater agreement, UHC developed a survey tool consisting of patient event scenarios. In 2011, a survey evaluating Harm Scale v.1.1 was distributed to 921 quality, risk, and safety (QRS) managers at 89 organizations; in 2012, a second survey evaluating Harm Scale v.1.2 was sent to 13,280 managers at 102 organizations. Regardless of the version used, in 3 of 9 scenarios, fewer than 60% of respondents agreed on a single score. Interrater agreement increased for certain event scenarios with v.1.2 but decreased for other scenarios. Interrater reliability was moderate for both v.1.1 (k = 0.51) and v.1.2 (k = 0.47). Interrater agreement improved in v.1.2 when results were limited to more experienced raters but still remained in the moderate range (k = 0.58). AHRQ Common Format Harm Scale v.1.1 and v.1.2 both had moderate interrater reliability. Using Harm Scale v.1.1, respondents had difficulty distinguishing "injury limited to additional treatment" from "temporary harm," whereas, using Harm Scale v.1.2, respondents had difficulty distinguishing moderate harm from one of the adjacent levels-mild or severe harm. This study provides valuable data that can inform harm scale revision to improve the quality of aggregate safety data used to define and direct safety efforts.

Effectiveness of an electronic tool for medication reconciliation in a general surgery department.

Medication reconciliation is a key tool in the prevention of adverse drug events. To assess the impact of an electronic reconciliation tool in decreasing unintended discrepancies between medications prescribed after surgery and the patient's usual treatment. General Surgery Department of Gregorio Marañón's University General Hospital, Madrid. A pre-post intervention study with no equivalent control group was carried out between June 2009 and December 2010. Patients hospitalized in the General Surgery Department for 24 h or more, and whose prescriptions prior to admission included three or more drugs were included in the study. Patients were interviewed to gather information about their usual treatment drugs. Discrepancies between the latter and the drugs prescribed after surgery were assessed before and after the medication reconciliation electronic tool was implemented. Proportion of patients with at least one unintended discrepancy. A total of 107 patients in the pre-intervention phase and 84 patients in the post-intervention phase were included. We detected 1,678 discrepancies, 167 were found to be unintended. The number of patients with at least one unintended discrepancy was 43 (40.2 %) in the pre-intervention phase, and 38 (38.1 %) in the post-intervention phase, p = 0.885. The percentage of unintended discrepancies over the total amount of drugs reconciled was lower in the post-intervention phase than in the pre-intervention phase (6.6 vs. 10.6 %), p = 0.002. Regarding unintended discrepancies 79.2 % were grade C severity (the error reached the patient but caused no harm), 13.6 % grade D (the error reached the patient and required monitoring or intervention to preclude harm) and 7.1 % grade E (the error may have contributed to or resulted in temporary harm to the patient and required intervention). Implementation of an electronic tool facilitated the process of medication reconciliation in a general surgery unit. The proportion of unintended discrepancies over the total amount of drugs reconciled was reduced after the implementation of the reconciliation programme. However, we could not demonstrate a more significant impact due to some methodological limitations.

Aligning care initiatives to reduce medication adverse effects in nursing homes.

Medication adverse effects in nursing homes continue to be an ongoing issue in long-term care, resulting in adverse events and temporary harm that lead to increased hospitalizations. In 2014, the Office of the Inspector General report noted that among Medicare beneficiaries in Part A stays less than 35 days, 22% experienced an adverse event and 11% experienced temporary harm. Ongoing initiatives and clinical services that can be aligned to address medication adverse events are discussed within the current article.

Patient-specific risk factors of adverse drug events in adult inpatients - evidence detected using the Global Trigger Tool method.

To identify the prevalence, preventability, and severity of adverse drug events in randomly selected adult hospital inpatients, and to study the association between adverse drug events and patient-specific factors. Adverse drug events represent one of the major concerns in patient safety. A retrospective record review. The study was conducted in an 800-bed university hospital in Finland within a 12-month period. Retrospective reviews of randomly selected discharged patients' (n=463) records using the Global Trigger Tool method were undertaken. The prevalence, preventability, and severity of adverse drug events were studied, and the association between patient-specific factors and adverse drug events were examined using a binary logistic regression model and Pearson's chi-squared tests. A total of 180 adverse drug events were detected in 125 (27%) patients, of which 74 (41·1%) were preventable, and 94·4% caused temporary harm. An abnormal level of potassium in the blood was the most frequent adverse drug event (n=37). The risk of adverse drug events increased with the length of hospital stay and the increased number of drugs patients used. The patients with coronary diseases (n=130) had a 2·5 times higher risk of experiencing adverse drug events. In addition, the risk of adverse drug events during hospitalisation increased together with the co-morbidity of patients. Adverse drug events were experienced by a quarter of inpatients, while severe adverse drug events were rare. The risk of adverse drug events increased with patients' prolonged hospital stay, polypharmacy, and morbidity. In addition, information of the usefulness of the Global Trigger tool can be used for future development of the method. Patient-specific risk factors were identified using the Global Trigger Tool method revealing that more efficient monitoring of inpatients with these risk factors may be profitable for decreasing adverse drug events.

Relevance of foreign alerts and newsletters for the medication errors reporting programme in the Netherlands: an explorative retrospective study.

National reporting programmes usually collect and analyse medication error reports from healthcare providers in their own country and only disseminate guidance to healthcare providers within the borders of their country. It is unclear how much different national programmes could learn from each other. The aim of this study was therefore to explore to what extent alerts and newsletters about medication errors issued in other countries could also be relevant for the Netherlands. Ninety disseminated information items that had been issued by three national programmes (Canada, the US and the UK) in the period from June 2009 until June 2012 were collected. These items were compared with the national reporting programme Central Medication Incidents Registration (CMR-NL) in The Netherlands. Each selected item was subsequently assessed independently with six assessment criteria: is the medicine available in the Netherlands? If so, could a similar error occur in the Netherlands? Did the CMR-NL reporting programme receive any reports about a comparable (or even identical) error? If so, did these reports include any errors with serious temporary or permanent harm? Did the CMR-NL disseminate output about it?; If so, what was the dissemination date of CMR-NL? From the 90 items, 87.8% (n=79) were relevant for Dutch healthcare. For 43 of the 90 items (47.8%), the CMR-NL had received comparable (or even identical) errors but had not disseminated any alert or newsletter about these errors. The CMR-NL had disseminated an alert or newsletter for 14 of the 90 items (15.6%). This study showed for a broad range of errors that the Dutch national reporting programme could learn from the three reporting programmes in Canada, the US and the UK. National reporting programmes can benefit from sharing alerts and newsletters that enhance the learning between countries.

Impact of a Reengineered Electronic Error-Reporting System on Medication Event Reporting and Care Process Improvements at an Urban Medical Center

A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.

PPO.41 Determining Adverse Events in UK Perinatal Care using The Institute for Healthcare Improvement Perinatal Trigger Tool

IntroductionVoluntary incident reporting of errors to determine adverse events is handicapped because only 20% are reported. The Institute for Healthcare Improvement (IHI) developed the perinatal trigger tool (PTT) for accurately...

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Adverse Drug Event Detection in Pediatric Oncology and Hematology Patients: Using Medication Triggers to Identify Patient Harm in a Specialized Pediatric Patient Population

To investigate the use of a trigger tool for the detection of adverse drug events (ADE) in a pediatric hospital specializing in oncology, hematology, and other catastrophic diseases. A medication-based trigger tool package analyzed electronic health records from February 2009 to February 2013. Chart review determined whether an ADE precipitated the trigger. Severity was assigned to ADEs, and preventability was assessed. Preventable ADEs were compared with the hospital's electronic voluntary event reporting system to identify whether these ADEs had been previously identified. The positive predictive values (PPVs) of the entire trigger tool and individual triggers were calculated to assess their accuracy to detect ADEs. Trigger occurrences (n = 706) were detected in 390 patients from 6 medication triggers, 33 of which were ADEs (overall PPV = 16%). Hyaluronidase had the greatest PPV (60%). Most ADEs were category E harm (temporary harm) per the National Coordinating Council for Medication Error Reporting and Prevention index. One event was category H harm (intervention to sustain life). Naloxone was associated with the most grade 4 ADEs per the Common Terminology Criteria for Adverse Events v4.03. Twenty-one (64%) ADEs were preventable, 3 of which were submitted via the voluntary reporting system. Most of the medication-based triggers yielded low PPVs. Refining the triggers based on patients' characteristics and medication usage patterns could increase the PPVs and make them more useful for quality improvement. To efficiently detect ADEs, triggers must be revised to reflect specialized pediatric patient populations such as hematology and oncology patients.

PS-100 Reconciliation errors at Cardiology Unit admission

BackgroundThe reconciliation process detects medicines errors and is a key point in improving patient safety.PurposeTo analyse the incidence, type and seriousness of reconciliation errors at admission to a Cardiology Unit.Materials...

Analysis of 3 Serious Medication Errors in Provincial Hospital

Background: Medication errors are a common problem in Chinese hospital, with potentially harmful consequences for patients. The objective of this study was to analyze the cause of typical serious medication errors in some first-class provincial hospital to prevent medication error and improve rational use of drug and ensure patients administration security. Medication errors were collected between September 1, 2012 and August 31, 2013. 332 cases’ medication errors were categorized as harmful or not according to NCC MERP’s Index and other indexes such as type of error and causes of error. We focus on analyzing the 3 serious cases (0.9%, n = 3) among the all MEs that may have contributed to or resulted in temporary harm to the patient and required intervention, including the process and the cause and the background of the errors. The case analysis reminds us to pay more attention to prevent medication errors. The preventive medication error’s measures are explored through the analysis of the causes, such as forcing functions and constraints, automation and standardization, double-checking systems, rules and policies, information and more careful working. Conclusion: This analytical study demonstrates that medication error is an objective existent in hospital. It is especially important to ensure patient medication safety for reporting and analyzing medication error in order to explore measures preventing medication error.

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Introduction: In addition to traditional incident reporting, the MMC can augment the ability to surface AEs. Our objective is to determine the types, severity and preventability of AEs uncovered among patients discussed in a tertiary hospital PICU MMC over a specific time period and compare these with AEs reported for the same cohort through the hospital incident reporting system, the Patient Safety Network (PSN). Methods: Two independent reviewers conducted a systematic retrospective record review of patients discussed in the MMC over 8 months (Nov2011-June2012). AEs were identified and categorized as to type, severity and preventability. Discrepancies were resolved by 2nd-tier review with a PICU attending and nurse. Comparison with AEs reported via the PSN for the same cohort was performed. Descriptive statistical analysis was done, calculating proportions for categorical variables. Results: 48 cases were reviewed with 212 total AEs identified from either the MMC or PSN (4.4 AEs/patient, 29 AEs/100 patient-days). 169/212(79.7%) AEs were identified via the MMC, of which 85/169(40.1%) were specified in the MMC agenda, while 84/169(49.7%) were uncovered via chart review. 52/212(24.5%) AEs were identified via the PSN. Only 9/212(4.2%) AEs were identified through both the MMC and PSN. The most common types of AEs were similar for each group - medication errors (MMC 31.9%, PSN 51.9%), device-related events (MMC 16.0%, PSN 17.3%), and communication issues (MMC 14.2%, PSN 26.9%). MMC AEs were more severe with 60.6% requiring prolonged hospitalization/life-sustaining therapy or contributing to permanent harm/death. PSN AEs were less severe with 61.5% causing no harm and 28.9% causing only temporary harm. MMC AEs ranged in preventability, with 30% certainly preventable and 36.3% likely not preventable. PSN AEs were 98.1% preventable with no non-preventable cases reported. Conclusions: The PICU MMC with targeted chart review is a useful adjunct for AE surveillance in addition to traditional incident reporting. Overlap between the two is minimal, with the MMC providing data on unique, more severe, yet still preventable AEs. Combining data from the two systems results in more accurate AE surveillance.

Eventos adversos a medicamentos em hospital terciario: estudo piloto com rastreadores

OBJECTIVETo estimate the frequency of and to characterize the adverse drug events at a terciary care hospital.METHODSA retrospective review was carried out of 128 medical records from a hospital in Rio de Janeiro in 2007, representing 2,092 patients. The instrument used was a list of triggers, such as antidotes, abnormal laboratory analysis results and sudden suspension of treatment, among others. A simple random sample of patients aged 15 and over was extracted. Oncologic and obstetric patients were excluded as were those hospitalized for less than 48 hours or in the emergency room. Social and demographic characteristics and those of the disease of patients who underwent adverse events were compared with those of patients who did not in order to test for differences between the groups.RESULTSAround 70.0% of the medical records assessed showed at least one trigger. Adverse drug events triggers had an overall positive predictive value of 14.4%. The incidence of adverse drug events was 26.6 per 100 patients and 15.6% patients suffered one or more event. The median length of stay for patients suffering an adverse drug event was 35.2 days as against 10.7 days for those who did not (p < 0.01). The pharmacological classes most commonly associated with an adverse drug event were related to the cardiovascular system, nervous system and alimentary tract and metabolism. The most common active substances associated with an adverse drug event were tramadol, dypirone, glibenclamide and furosemide. Over 80.0% of events provoked or contributed to temporary harm to the patient and required intervention and 6.0% may have contributed to the death of the patient. It was estimated that in the hospital, 131 events involving drowsiness or fainting 33 involving falls, and 33 episodes of hemorrhage related to adverse drug effects occur annually.CONCLUSIONSAlmost one-sixth of in-patients (16,0%) suffered an adverse drug event. The instrument used may prove useful as a technique for monitoring and evaluating patient care results. Psycothropic therapy should be critically appraised given the frequency of associated events, such as excessive sedation, lethargy, and hypotension.

Use of International Classification of Diseases, Ninth Revision, Clinical Modification, Codes to Identify Inpatient Fall‐Related Injuries

To compare falls and fall-related injuries that a fall evaluator or hospital incident report identified with injuries identified according to discharge International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for the same set of inpatient episodes of care. Prospective, descriptive study. Sixteen adult general medical and surgical units in a major urban teaching hospital. All adults who sustained a fall with injury during a 5-year period (380 falls with injury). Falls that a fall evaluator or hospital incident report identified were classified according to their injury severity. Discharge abstracts provided diagnosis codes (ICD-9-CM) for the discharge, including fall-related injury codes. Three hundred forty-three inpatient falls with injury (90.2%) resulted in temporary harm to the individual; the remaining 37 falls (9.8%) resulted in more-serious harm. Sixteen of the 37 falls with injury extending hospitalization or resulting in death were identified using Centers for Medicare and Medicaid Services (CMS)-targeted injury code ranges combined with present-on-admission indicators. Of the 21 falls with injury that were not identified, nine (42.9%) lacked documentation of any injury, and seven (33.3%) identified other injuries outside the CMS-targeted injury code ranges. The CMS-targeted ICD-9-CM codes used to identify fall-related injuries in claims data do not always detect the most-serious falls.

The Global Trigger Tool shows that one out of seven patients suffers harm in Palestinian hospitals: challenges for launching a strategic safety plan

The aim of this study was to evaluate patient safety levels in Palestinian hospitals and to provide guidance for policymakers involved in safety improvement efforts. Retrospective review of hospitalized patient records using the Global Trigger Tool. Two large hospitals in Palestine: a referral teaching hospital and a nonprofit, non-governmental hospital. A total of 640 random records of discharged patients were reviewed by experienced nurses and physicians from the selected hospitals. Assessment of adverse events. Prevalence of adverse events, their preventability and harm category. Descriptive statistics and Cohen kappa coefficients were calculated. One out of seven patients (91 [14.2%]) suffered harm. Fifty-four (59.3%) of these events were preventable; 64 (70.4%) resulted in temporary harm, requiring prolonged hospitalization. Good reliability was achieved among the independent reviewers in identifying adverse events. The Global Trigger Tool showed that adverse events in Palestinian hospitals likely occur at a rate of 20 times higher than previously reported. Although reviewers reported that detecting adverse events was feasible, we identified conditions suggesting that the tool may be challenging to use in daily practice. One out of seven patients suffers harm in Palestinian hospitals. Compromised safety represents serious problems for patients, hospitals and governments and should be a high priority public health issue. We argue that direct interventions should be launched immediately to improve safety. Additional costs associated with combating adverse events should be taken into consideration, especially in regions with limited resources, as in Palestine.

Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors

Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone. A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified. A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate. Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.

An adverse event trigger tool in dentistry: A new methodology for measuring harm in the dental office

Background There is a dearth of knowledge about the type and frequency of adverse events (AEs) in dentistry. Current approaches to obtaining information rely on reviews of randomly selected records, which may not be the most efficient or effective methodology. Methods Inspired by the Institute for Healthcare Improvement's (IHI) global and outpatient trigger tools, which identifies records with characteristics (”triggers“) that are associated with AEs, the authors created the dental clinic trigger tool. The triggers included procedures for incision and drainage, failed implants and selected treatment patterns. The authors ran the trigger tool against six months of electronic health records data and compared its performance with that of a review of 50 randomly selected patient records. Results In total, 315 records were triggered, 158 (50 percent) of which were positive for one or more AEs; 17 (34 percent) of the 50 randomly selected records were positive for at least one AE. The authors assigned each AE an IHI severity ranking. Most AEs caused temporary harm, but nine were considered to have caused permanent harm according to a modified IHI severity ranking. Conclusions The study results demonstrate the promise of a directed records review approach, as the dental clinic trigger tool was more effective in identifying AEs than was a review of randomly selected records. Practical Implications All dental practices should proactively monitor the safety of the care they provide. Use of the trigger tool will help make this process more efficient and effective. There is a dearth of knowledge about the type and frequency of adverse events (AEs) in dentistry. Current approaches to obtaining information rely on reviews of randomly selected records, which may not be the most efficient or effective methodology. Inspired by the Institute for Healthcare Improvement's (IHI) global and outpatient trigger tools, which identifies records with characteristics (”triggers“) that are associated with AEs, the authors created the dental clinic trigger tool. The triggers included procedures for incision and drainage, failed implants and selected treatment patterns. The authors ran the trigger tool against six months of electronic health records data and compared its performance with that of a review of 50 randomly selected patient records. In total, 315 records were triggered, 158 (50 percent) of which were positive for one or more AEs; 17 (34 percent) of the 50 randomly selected records were positive for at least one AE. The authors assigned each AE an IHI severity ranking. Most AEs caused temporary harm, but nine were considered to have caused permanent harm according to a modified IHI severity ranking. The study results demonstrate the promise of a directed records review approach, as the dental clinic trigger tool was more effective in identifying AEs than was a review of randomly selected records. All dental practices should proactively monitor the safety of the care they provide. Use of the trigger tool will help make this process more efficient and effective.

GRP-022 Analysis of the Medicines Reconciliation Process in Different Clinical Services

BackgroundMedication errors, specifically the lack of continuity of the patient’s usual treatment, are a major cause of adverse effects in hospitalised patients, most of them preventable. Medicines reconciliation is the...