Systems-based models for investigating patient safety incidents.
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ABSTRACT:
SUBMITTER: Sampson P
PROVIDER: S-EPMC8283417 | biostudies-literature | 2021 Aug
REPOSITORIES: biostudies-literature
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Systems-based models for investigating patient safety incidents.
Sampson P P Back J J Drage S S
BJA education 20210428 8
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Project description:ObjectivesMany countries and organizations have promoted the disclosure of patient safety incidents (DPSI). However, reporting frequency and quality of DPSI fall short of patient and caregiver' expectations. In this study, we examined the attitudes toward DPSI of the general public representing the Korean population.MethodsSurvey questions were developed based on a previous systematic review and qualitative research. Face-to-face interviews using paper-based questionnaires were conducted. We explored attitudes toward DPSI in various scenarios and opinions on methods to facilitate DPSI.ResultsAlmost all participants answered that it is necessary to disclose major errors (99.9%) and near misses (93.3%). A total of 96.6% (675/699) agreed that "DPSI will lead physicians to pay more attention to patient safety in the future," and 94.1% (658/699) agreed that "DPSI will make patients and their caregivers trust the physician more." Although 79.7% (558/700) agreed that "apology law will limit patients' ability to prove physicians' negligence," 95.4% (668/700) agreed with "I support the introduction of apology law." Moreover, 90.6% (634/700) agreed with "I support the introduction of mandatory DPSI."ConclusionsThis study showed the overwhelmingly positive attitude of the public toward DPSI. The positive opinion of the public about apology law suggests the possibility of introducing the disclosure policy coupled with legislation of apology law in South Korea.
| S-EPMC7046138 | biostudies-literature
Project description:ObjectiveWe aimed to explain the operational mechanism of China National Patient Safety Incidents Reporting System, analyze patterns and trends of incidents reporting, and discuss the implication of the incidents reporting to improve hospital patient safety.DesignA nationwide, registry-based, observational study design.Data sourceThe database of China National Patient Safety Incidents Reporting System.Outcome measuresOutcome measures of this study included the temporal, regional, and hospital distribution of the reports, as well as the incident type, location, parties, and possible reasons for frequently occurring incidents.ResultsDuring 2012-2017, 36,498 patient safety incidents were reported. By analyzing the time trends, we found that there was a significant upward trend on incidents reporting in China. The most common type of incidents was drug-related incidents, followed by nursing-related incidents and surgery-related incidents. The three most frequent locations of incident occurrence were Patient's Room (65.4%), Ambulatory Care Unit (8.4%), and Intensive Care Unit (7.4%). The majority of the incidents involved nurses (40.7%), followed by physicians (29.5%) and medical technologist (13.6%). About 44.4% of the incidents were attributed to the junior staff (work experience ≤5 years). In addition, incidents triggered by the senior staff (work experience >5 years) were more often associated with severe patient harm.ConclusionTo strengthen the incidents reporting system and generate useful evidence through learning from incidents reporting will be important to China's success in improving the nation's patient safety status.
| S-EPMC6371930 | biostudies-literature
Project description:PURPOSE: To consider wrong intraocular lens (IOL) implant events in cataract surgical care reported through a national incident reporting database. To propose potential solutions for such events where possible. METHODS: Thematic retrospective review of wrong IOL implantation incidents, as reported through clinical incident reporting methods in NHS care in England and Wales from 2003 to 2010, ascertained from database mining at the National Patient Safety Agency. RESULTS: In total, 164 patient safety incident (PSI) reports of wrong IOL implantation were located from the study period and considered. There were 47 reports where further surgical intervention was required. All, but one of these required IOL exchange surgery. A total of 62 reports did not provide any causal reason for the wrong IOL implantation and thus provide little if any potential learning. Inaccurate biometry (n=29), wrong IOL selection (n=21), transcription errors (n=10) and handwriting misinterpretations (n=7) were causal reasons reported and are thus potential areas for ophthalmic teams to review and improve practice. CONCLUSION: Although infrequent, biometry/IOL implant errors or wrong implants do occasionally occur during cataract care and are thus a threat to quality. There is room for improvement in incident reporting in NHS cataract care as root causation of error was usually lacking in the PSI reports. Nevertheless, lessons for improvement of care from a national incident reporting database for a frequently undertaken surgical procedure were found. Suggestions are proposed for improving quality by reducing wrong IOL problems in cataract care based on analysis of such reports.
| S-EPMC3178144 | biostudies-other
Project description:BackgroundHospitals can improve how they learn from patient safety incidents. The Green Cross method, a proactive reporting and learning method, is one strategy to meet this challenge. In it, nurses play a key role. However, describing its impact on learning from the users' perspective is important.AimThis study aimed to describe nurses' experiences of learning from patient safety incidents before and 3 months after implementing the Green Cross method in a postanaesthesia care unit.Study designA qualitative study with an inductive descriptive design with focus group interviews was conducted before and 3 months after implementing the Green Cross method to assess its impact. The data were analysed using qualitative content analysis. The study was conducted in a postanaesthesia care unit in a Norwegian hospital trust.ResultsBefore implementing the Green Cross method, participants indicated limited openness and learning, including the subcategories 'Lack of openness hampers learning', 'Adverse events were taken seriously' and 'Insufficient visible improvements'. After implementing the Green Cross method, participants indicated the emergence of a learning environment, including the subcategories 'Transparency increases learning', 'Increased patient safety awareness' and 'Committed to quality improvements'.ConclusionsImplementing the Green Cross method in a postanaesthesia care unit positively impacted openness and nurses' patient safety awareness, which is crucial for learning and improving quality.Relevance to clinical practiceThe Green Cross method could be useful for organizational learning and facilitating learning from patient safety incidents through transparency, discussion and involvement of nursing staff.
| S-EPMC11873358 | biostudies-literature
Project description:The Division were experiencing a high number of serious incidents, and the Team felt that a good safety strategy would improve the quality of care given. Through multidisciplinary engagement they wanted to learn from these, encourage reporting and focus on a fair blame culture. The ultimate aim was to increase incident reporting, decrease serious incidents and improve quality. The key aim of the project was to improve the quality of care for the woman and their babies, we reduced the incidence of serious incidents and increased the incident reporting of less serious incidents, this was based on the theory of the Heinrich Ratio which theorises that for every serious incident there will be 300 less serious / near miss incidents. The Team wanted to ensure that the multidisciplinary team were engaged and felt confident to report incidents, and would receive the appropriate feedback and support. In addition all staff involved in the incident would be involved in the investigation and be at the heart of the decision making. The key measure for improvement was the increase in incident reporting (44% increase 2011 - 2012) and the decrease in serious incidents. The figures support the theory that the increase in minor incidents being reported and managed has reduced the incidence of serious incidents. Staff engagement in the process was paramount, and this was driven by a passion to ensure the woman was at the centre of every decision or safety improvement that was made. Women and their families would be involved in the quality improvement process.
| S-EPMC4652692 | biostudies-literature
Project description:Early detection of spoilage microorganisms and food pathogens is of major importance in preventing food recalls and foodborne outbreaks. Although constant effort is invested in developing sensitive methods for rapid microbial detection, none of the current methods enables the detection of food pathogens within a few hours; therefore, development of innovative early-warning food-testing strategies are needed. Herein, we assessed a novel strategy that harnesses the microbiome signature of a food product to determine deviations in the abundance of particular community members and detect production defects. Employing the production process of barbecued (BarBQ) pastrami as a model, we characterized the microbiome profiles of the product along the production line using next-generation sequencing of the 16S rRNA gene, concentrating on the live microbiota. Following the establishment of a microbiome dataset representing a properly produced product, we were able to identify shifts in the microbiome profile of a defective batch produced under potassium lactate deficiency. With the identification of Vibrio and Lactobacillus as potential indicator bacteria for potassium lactate deficiency, rapid qPCR assays were designed for their quantification. Aligned with the microbiome profiling results, these qPCR assays were effective for rapid identification of a defective production event. This implies the use of rapid quantification targeting microbiome profile-derived indicator bacteria for in-house detection of defective batches and identification of food-safety and quality events with results obtained on the same day. The suggested strategy should pave the way toward safer and more efficient food-production systems.
2024-08-27 | GSE255249 | GEO
Project description:Patient safety in psychiatric inpatient facilities remains under-researched despite its crucial importance. This study aims to address this gap by using expert opinion to estimate the frequency of diverse patient safety incidents (PSIs) in psychiatric settings and to compare it with the existing literature. Utilizing a seven-step approach, a questionnaire based on the World Health Organization's International Classification for Patient Safety was developed and deployed. A total of 33 expert opinions were collected. Results showed a higher estimated incidence of PSIs in psychiatric settings compared to general healthcare, highlighting categories such as patient behavior, medication, and infrastructure as significant contributors. Experts emphasized the prevalence of incidents related to behavioral issues and inadequate infrastructure, areas often overlooked in the existing literature. Unlike general settings, psychiatric facilities appear more vulnerable to specific PSIs, such as those related to medication and building safety, underscoring the need for targeted safety measures. Our study suggests the existence of significant discrepancies between expert opinion and available research, with several underexplored domains in psychiatric patient safety.
| S-EPMC11591172 | biostudies-literature
Project description:BackgroundPatient safety incidents (PSIs) frequently occur in primary care and are often considered to be preventable. Better knowledge of factors contributing to PSIs is required to build safer care. The aim of this work was to describe the underlying factors, specifically the human factors, that are associated with PSIs in primary care using CADYA ("CAtégorisation des DYsfonctionnements en Ambulatoire" or "Categorization of Errors in Primary Care").MethodsWe followed a mixed method with content analysis and coding in CADYA of PSIs reported in the ESPRIT study, a French cross-sectional survey of primary care. For each incident, a main contributing factor (MD) and, if applicable, a secondary contributing factor (SD) were identified. Several descriptive keywords from an incremental glossary have been suggested to describe each identified human factor (attitudes or behaviours). A descriptive statistical analysis was then conducted.ResultsAmong the 482 PSIs reported in the ESPRIT study, from 13,438 acts reported by 127 participating general practitioners (GPs), we identified 590 contributing factors (482 MDs and 178 SDs). Overall, 35% were related to the care process, 30% to human factors, 22% to the healthcare environment and 13% to technical factors. The contributing factors, in decreasing order of frequency, were communication errors (13.7%), human factors related to healthcare providers (12.9%) and human factors related to patients (12.9%). The human factors were mainly related to 'lack of attention', 'stress', 'anger' and 'fatigue'.ConclusionsOur results tend to prove that human factors are often involved in PSIs in primary care, with GPs and patients being equally responsible. Beyond the identification of communication errors, often found in other international research, we have described the attitudes and behaviours contributing to unsafe care. Further research exploring the links between working conditions and human factors is required.
| S-EPMC6053757 | biostudies-literature
Project description:ObjectivesThe aim of this study was to investigate the scope and severity of the second victim problem among nurses by examining the experiences and effects of patient safety incidents (PSIs) on them.Participants/setting492 nurses who had experienced PSIs and provide direct care in South Korean medical institutions.DesignA cross-sectional study with anonymous online self-report questionnaires was conducted to nurses in order to examine the experiences and effects of PSIs. Scales measuring post-traumatic stress disorder (PTSD) and post-traumatic embitterment disorder (PTED) were used for a more quantitative examination of the effects of PSIs. A χ2 test was administered to find any difference in responses to difficulties due to PSIs between the direct and indirect experience of PSIs. Furthermore, linear regression analysis was conducted to investigate the factors related to scores on the PTSD and PTED scales.ResultsA statistically significant difference was observed for participants who reported having experienced sleeping disorders, with those with direct experience showing 42.4% sleeping disorders and indirect experience at 21.0%. Also, there was a statistically significant difference between the 34.3% with direct experience and the 22.1% with indirect experience regarding having considered duty or job changes (resignation). Regression analysis showed total PTSD scores for indirect experience at 11.97 points (95% CI: -17.31 to -6.63), lower than direct experience. Moreover, those who thought the medical error was not involved in PSI had a total PTED score 4.39 points (95% CI: -7.23 to -1.55) lower than those who thought it was involved.ConclusionsA considerable number of nurses experienced psychological difficulties due to PSIs at levels that could interfere with their work. The effect of PSIs on nurses with direct experience of PSIs was greater compared with those with indirect experience. There need to be psychological support programmes for nurses to alleviate the negative effects of PSIs.
| S-EPMC7783619 | biostudies-literature
Project description:OBJECTIVE:To investigate whether the daily workload per nurse (Oulu Patient Classification (OPCq)/nurse) as measured by the RAFAELA system correlates with different types of patient safety incidents and with patient mortality, and to compare the results with regressions based on the standard patients/nurse measure. SETTING:We obtained data from 36 units from four Finnish hospitals. One was a tertiary acute care hospital, and the three others were secondary acute care hospitals. PARTICIPANTS:Patients' nursing intensity (249?123 classifications), nursing resources, patient safety incidents and patient mortality were collected on a daily basis during 1?year, corresponding to 12?475 data points. Associations between OPC/nurse and patient safety incidents or mortality were estimated using unadjusted logistic regression models, and models that adjusted for ward-specific effects, and effects of day of the week, holiday and season. PRIMARY AND SECONDARY OUTCOME MEASURES:Main outcome measures were patient safety incidents and death of a patient. RESULTS:When OPC/nurse was above the assumed optimal level, the adjusted odds for a patient safety incident were 1.24 (95% CI 1.08 to 1.42) that of the assumed optimal level, and 0.79 (95% CI 0.67 to 0.93) if it was below the assumed optimal level. Corresponding estimates for patient mortality were 1.43 (95% CI 1.18 to 1.73) and 0.78 (95% CI 0.60 to 1.00), respectively. As compared with the patients/nurse classification, models estimated on basis of the RAFAELA classification system generally provided larger effect sizes, greater statistical power and better model fit, although the difference was not very large. Net benefits as calculated on the basis of decision analysis did not provide any clear evidence on which measure to prefer. CONCLUSIONS:We have demonstrated an association between daily workload per nurse and patient safety incidents and mortality. Current findings need to be replicated by future studies.
| S-EPMC5922465 | biostudies-literature