46,196 research outputs found
An analysis of electronic health record-related patient safety incidents
The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.Peer reviewe
A safer place for patients: learning to improve patient safety
1 Every day over one million people are treated
successfully by National Health Service (NHS) acute,
ambulance and mental health trusts. However, healthcare
relies on a range of complex interactions of people,
skills, technologies and drugs, and sometimes things do
go wrong. For most countries, patient safety is now the
key issue in healthcare quality and risk management.
The Department of Health (the Department) estimates
that one in ten patients admitted to NHS hospitals will be
unintentionally harmed, a rate similar to other developed
countries. Around 50 per cent of these patient safety
incidentsa could have been avoided, if only lessons from
previous incidents had been learned.
2
There are numerous stakeholders with a role in
keeping patients safe in the NHS, many of whom require
trusts to report details of patient safety incidents and near
misses to them (Figure 2). However, a number of previous
National Audit Office reports have highlighted concerns
that the NHS has limited information on the extent and
impact of clinical and non-clinical incidents and trusts need
to learn from these incidents and share good practice across
the NHS more effectively (Appendix 1).
3 In 2000, the Chief Medical Officer’s report An
organisation with a memory
1
, identified that the key
barriers to reducing the number of patient safety incidents
were an organisational culture that inhibited reporting and
the lack of a cohesive national system for identifying and
sharing lessons learnt.
4 In response, the Department published Building a
safer NHS for patients3 detailing plans and a timetable
for promoting patient safety. The goal was to encourage
improvements in reporting and learning through the
development of a new mandatory national reporting
scheme for patient safety incidents and near misses. Central
to the plan was establishing the National Patient Safety
Agency to improve patient safety by reducing the risk of
harm through error. The National Patient Safety Agency was
expected to: collect and analyse information; assimilate
other safety-related information from a variety of existing
reporting systems; learn lessons and produce solutions.
5 We therefore examined whether the NHS has
been successful in improving the patient safety culture,
encouraging reporting and learning from patient safety
incidents. Key parts of our approach were a census of
267 NHS acute, ambulance and mental health trusts in
Autumn 2004, followed by a re-survey in August 2005
and an omnibus survey of patients (Appendix 2). We also
reviewed practices in other industries (Appendix 3) and
international healthcare systems (Appendix 4), and the
National Patient Safety Agency’s progress in developing its
National Reporting and Learning System (Appendix 5) and
other related activities (Appendix 6).
6 An organisation with a memory1
was an important
milestone in the NHS’s patient safety agenda and marked
the drive to improve reporting and learning. At the
local level the vast majority of trusts have developed a
predominantly open and fair reporting culture but with
pockets of blame and scope to improve their strategies for
sharing good practice. Indeed in our re-survey we found
that local performance had continued to improve with more
trusts reporting having an open and fair reporting culture,
more trusts with open reporting systems and improvements
in perceptions of the levels of under-reporting. At the
national level, progress on developing the national reporting
system for learning has been slower than set out in the
Department’s strategy of 2001
3
and there is a need to
improve evaluation and sharing of lessons and solutions by
all organisations with a stake in patient safety. There is also
no clear system for monitoring that lessons are learned at the
local level. Specifically:
a The safety culture within trusts is improving, driven
largely by the Department’s clinical governance
initiative
4
and the development of more effective risk
management systems in response to incentives under
initiatives such as the NHS Litigation Authority’s
Clinical Negligence Scheme for Trusts (Appendix 7).
However, trusts are still predominantly reactive in
their response to patient safety issues and parts of
some organisations still operate a blame culture.
b All trusts have established effective reporting systems
at the local level, although under-reporting remains
a problem within some groups of staff, types of
incidents and near misses. The National Patient Safety
Agency did not develop and roll out the National
Reporting and Learning System by December 2002
as originally envisaged. All trusts were linked to the
system by 31 December 2004. By August 2005, at
least 35 trusts still had not submitted any data to the
National Reporting and Learning System.
c Most trusts pointed to specific improvements
derived from lessons learnt from their local incident
reporting systems, but these are still not widely
promulgated, either within or between trusts.
The National Patient Safety Agency has provided
only limited feedback to trusts of evidence-based
solutions or actions derived from the national
reporting system. It published its first feedback report
from the Patient Safety Observatory in July 2005
Applying the trigger review method after a brief educational intervention: potential for teaching and improving safety in GP specialty training?
<p>Background:
The Trigger Review Method (TRM) is a structured approach to screening clinical records for undetected patient safety incidents (PSIs) and identifying learning and improvement opportunities. In Scotland, TRM participation can inform GP appraisal and has been included as a core component of the national primary care patient safety programme that was launched in March 2013. However, the clinical workforce needs up-skilled and the potential of TRM in GP training has yet to be tested. Current TRM training utilizes a workplace face-to-face session by a GP expert, which is not feasible. A less costly, more sustainable educational intervention is necessary to build capability at scale. We aimed to determine the feasibility and impact of TRM and a related training intervention in GP training.</p>
Methods
We recruited 25 west of Scotland GP trainees to attend a 2-hour TRM workshop. Trainees then applied TRM to 25 clinical records and returned findings within 4-weeks. A follow-up feedback workshop was held.
<p>Results:
21/25 trainees (84%) completed the task. 520 records yielded 80 undetected PSIs (15.4%). 36/80 were judged potentially preventable (45%) with 35/80 classified as causing moderate to severe harm (44%). Trainees described a range of potential learning and improvement plans. Training was positively received and appeared to be successful given these findings. TRM was valued as a safety improvement tool by most participants.</p>
<p>Conclusion:
This small study provides further evidence of TRM utility and how to teach it pragmatically. TRM is of potential value in GP patient safety curriculum delivery and preparing trainees for future safety improvement expectations.</p>
Patient safety in dentistry: development of a candidate 'never event' list for primary care
Introduction The 'never event' concept is often used in secondary care and refers to an agreed list of patient safety incidents that 'should not happen if the necessary preventative measures are in place'. Such an intervention may raise awareness of patient safety issues and inform team learning and system improvements in primary care dentistry.
Objective To identify and develop a candidate never event list for primary care dentistry.
Methods A literature review, eight workshops with dental practitioners and a modified Delphi with 'expert' groups were used to identify and agree candidate never events.
Results Two-hundred and fifty dental practitioners suggested 507 never events, reduced to 27 distinct possibilities grouped across seven themes. Most frequently occurring themes were: 'checking medical history and prescribing' (119, 23.5%) and 'infection control and decontamination' (71, 14%). 'Experts' endorsed nine candidate never event statements with one graded as 'extreme risk' (failure to check past medical history) and four as 'high risk' (for example, extracting wrong tooth).
Conclusion Consensus on a preliminary list of never events was developed. This is the first known attempt to develop this approach and an important step in determining its value to patient safety. Further work is necessary to develop the utility of this method
Prevalence and consequences of patient safety incidents in general practice in the Netherlands: a retrospective medical record review study
BACKGROUND Patient safety can be at stake in both hospital and general practice settings. While severe patient safety incidents have been described, quantitative studies in large samples of patients in general practice are rare. This study aimed to assess patient safety in general practice, and to show areas where potential improvements could be implemented. METHODS We conducted a retrospective review of patient records in Dutch general practice. A random sample of 1,000 patients from 20 general practices was obtained. The number of patient safety incidents that occurred in a one-year period, their perceived underlying causes, and impact on patients' health were recorded. RESULTS We identified 211 patient safety incidents across a period of one year (95% CI: 185 until 241). A variety of types of incidents, perceived causes and consequences were found. A total of 58 patient safety incidents affected patients; seven were associated with hospital admission; none resulted in permanent disability or death. CONCLUSIONS Although this large audit of medical records in general practices identified many patient safety incidents, only a few had a major impact on patients' health. Improving patient safety in this low-risk environment poses specific challenges, given the high numbers of patients and contacts in general practice.The Dutch Ministry of Health, Welfare and Sport (VWS) initiated the project and supported the project financially (without restrictions on the scientific work; grant number 313741)
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Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis.
BackgroundMany studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.ObjectiveTo examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.DesignHCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.SettingInpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.ParticipantsPhysicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.OutcomesEmergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.ResultsWe interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients' renal function. Most HCPs relied on being vigilant to detect patients' renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.ConclusionsOur model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs' heavy reliance on vigilance and (3) supporting HCPs' different decision-making needs for renally eliminated versus nephrotoxic medications
Repeat prescribing of medications: a system-centred risk management model for primary care organisations
Rationale, aims and objectives:
Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care.
Methods:
All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web-based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses.
Results:
Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1-33; SD = 7.13). Seven hundred sixty-seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0-34; SD = 8.0).
Conclusions:
The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System-wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally
Implementing a New Electronic Health Record System in a University Hospital : The Effect on Reported Medication Errors
Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.Peer reviewe
Implementing a New Electronic Health Record System in a University Hospital : The Effect on Reported Medication Errors
Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.Peer reviewe
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