Medication-related adverse events during hospitalization: a retrospective patient record review study in the Netherlands.

Purpose Medication-related adverse events (MRAEs) are an important priority for patient safety. Results from Dutch AE studies showed that—despite various improvement initiatives—the incidence of preventable MRAEs did not decline. The aim of this study is to describe the characteristics of MRAEs during hospitalizations using national patient data from records of patients admitted to Dutch hospitals in 2008 and 2011/2012. Methods Trained nurses and physicians reviewed the randomly selected records of 8071 patients admitted to one of 20 hospitals in 2008 or 2011/2012 during a two-stage review process. Patient and admission characteristics were collected. After identification of a MRAE, physicians determined their potential preventability, drug type, related prescribing factors, and potential consequences. Results The physicians identified 928 adverse events (AEs) in 857 admissions, of which 218 (15.2%) were medication-related. They judged 55 (18.4%) of these as preventable. Preventability of MRAEs was high in anticoagulant treatment (42.5%). Haematoma (39.0%) and intra-cerebral haemorrhage (25.5%) were common types of anticoagulant-related AEs. Anticoagulant-related AEs were often related to dosage factors (46.9%) and often resulted in an intervention (80.2%), of which 40.2% was judged as preventable. Conclusions This study provided detailed information on MRAEs during hospital admissions in The Netherlands. A substantial proportion of AEs was medication-related (15.2%), of which 18.4% was judged to be preventable. As preventability in MRAEs was especially high in anticoagulant treatment (42.5%), those medications are a threat to patient safety. Future research and new safety programs should focus on prevention of AEs related to this medication group. (aut. ref

How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review

Objectives Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.Design A multicentre retrospective patient record review.Setting and participants Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.Primary and secondary outcome measures Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.Results Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%-100%), international normalised ratio testing (range 21%-94%) and postoperative bridging (range 20%-88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients' weight.Conclusions Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.Thrombosis and Hemostasi

Measurement of generic patient reported outcome measures (PROMs) in an acute admission unit: a feasibility study.

Objective: Measuring patient-reported outcome measures (PROMs) is a challenge in Acute Admission Units (AAUs), where patients present with a variety of pathologies. Generic PROMs may be used to measure the quality of care in this population. The main objective of this study was to assess the feasibility of measuring generic PROMs in a Dutch AAU. Design: Longitudinal cohort study Setting: An AAU of a tertiary hospital in Amsterdam, the Netherlands Participants: 123 patients admitted to the AAU during 5 weeks in May and June 2015 Methods: Patients admitted to the AAU were asked to fill out a questionnaire relating to three time points: 7 days before, during, and within 2 weeks after admission. Additionally, patients were asked to report on their experienced level of safety on the AAU and the contribution of the AAU to their recovery. Results: There were significant trends in generic PROMs for all three domains. Physical functioning decreased during hospital admission and almost fully returned to the previous level after discharge. Satisfaction with social role and anxiety significantly decreased over time. Conclusions: Measuring generic PROMs in the AAU is feasible. The analysis of the PROMs took little effort and results could be reported back to the healthcare workers on the AAU quickly. Patients appreciated being asked about their own perceived health and the quality of care. Given that this is the first study focusing on PROMs in AAU patients in the Netherlands, future studies with larger sample sizes, and from other nations are needed to further investigate PROMs in this patient group to establish International reference values. (aut. ref.

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

Background Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. Objectives Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. Methods A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. Results Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69-81.99), vascular surgery (OR 13.01, 95% CI 1.83-92.30), non-elective surgery (OR 8.67, 95% CI 1.67-45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11-1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04-1.16). Conclusion Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients.Thrombosis and Hemostasi

Preoperative Anticoagulation Management in Everyday Clinical Practice: An International Comparative Analysis of Work-as-Done Using the Functional Resonance Analysis Method

ObjectivesPreoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. MethodsThe study was conducted at an Australian and European Cardiothoracic Surgery Department. A FRAM model of work-as-imagined was developed using (inter)national guidelines. Semistructured interviews with 18 involved professionals were used to develop models reflecting work-as-done at both sites, which were presented to staff for validation. Workload in hours was estimated per process step. ResultsIn both centers, work-as-done differed from work-as-imagined, such as in the division of tasks among disciplines (e.g., nurses/registrars rather than medical specialists), but control mechanisms had been developed locally to ensure safe care (e.g., crosschecking with other clinicians). Centers had organized the process differently, revealing opportunities for improvement regarding patient information and clustering of clinic visits. Presenting FRAM models to staff initiated discussion on improvement of functions in the model that are vital for success. Overall workload was estimated at 47 hours per site. ConclusionsThis FRAM analysis provided insight into PAM from the perspective of frontline clinicians, revealing essential functions, interdependencies and variability, and the relation with guidelines. Future studies are warranted to study the potential of FRAM, such as for guiding improvements in complex systems.Vascular Surger