"Against the silence": Development and first results of a patient survey to assess experiences of safety-related events in hospital

BACKGROUND: Involvement of patients in the detection and prevention of safety related events and medical errors have been widely recommended. However, it has also been questioned whether patients at large are willing and able to identify safety-related events in their care. The aim of this study was to develop and pilot test a brief patient safety survey applicable to inpatient care in Swiss hospitals. METHODS: A survey instrument was developed in an iterative procedure. The instrument asks patients to report whether they have experienced specific undesirable events during their hospital stay. The preliminary version was developed together with experts and tested in focus groups with patients. The adapted survey instrument was pilot-tested in random samples of patients of two Swiss hospitals (n = 400). Responders to the survey that had reported experience of any incident were sampled for qualitative interviews (n = 18). Based on the interview, the researcher classified the reported incidents as confirmed or discarded. RESULTS: The survey was generally well accepted in the focus groups and interviews. In the quantitative pilot test, 125 patients returned the survey (response rate: 31%). The mean age of responders was 55 years (range 17-91, SD 18 years) and 62.5% were female. The 125 participating patients reported 94 "definitive" and 34 "uncertain" events. 14% of the patients rated any of the experienced events as "serious". The definitive and uncertain events reported with highest frequency were phlebitis, missing hand hygiene, allergic drug reaction, unavailability of documents, and infection. 23% of patients reported some or serious concerns about their safety. The qualitative interviews indicate that both, the extent of patients' uncertainty in the classification of events and the likelihood of confirmation by the interviewer vary very much by type of incident. Unexpectedly, many patients reported problems and incidents related to food and dietary intake. Overall, the in-depth interviews confirmed experiences from the focus groups that many patients feel reluctant to report undesirable events without acknowledging the presence or absence of individual responsibility or failure. Many patients reported that they did not ask or communicate about errors or near misses with staff and some patients even develop strategies to improve their safety but do not disclose these to staff. CONCLUSION: Many patients experience undesirable events during hospitalization and a significant number of patients is seriously concerned about their safety. Surveying patients about experiences with safety-related events in hospital seems a valuable tool for identifying and monitoring problematic areas of care and undesirable events. Evidence from the qualitative interviews indicates that safety remains an unsaid word between patients and their care providers

An integrated model of care to counter high incidence of HIV and sexually transmitted diseases in men who have sex with men – initial analysis of service utilizers in Zurich

BACKGROUND: As other countries, Switzerland experiences a high or even rising incidence of HIV and sexually transmitted infections (STI) among men who have sex with men (MSM). An outpatient clinic for gay men ("Checkpoint") was opened in 2006 in Zurich (Switzerland) in order to provide sexual health services. The clinic provides counselling, testing, medical treatment and follow-up at one location under an "open-door-policy" and with a high level of personal continuity. We describe first experiences with the new service and report the characteristics of the population that utilized it. METHODS: During the 6-month evaluation period, individuals who requested counselling, testing or treatment were asked to participate in a survey at their first visit prior to the consultation. The instrument includes questions regarding personal data, reasons for presenting, sexual behaviour, and risk situations. Number and results of HIV/STI tests and treatments for STI were also recorded. RESULTS: During the evaluation period, 632 consultations were conducted and 247 patients were seen by the physician. 406 HIV tests were performed (3.4% positive). 402 men completed the entry survey (64% of all consultations). The majority of respondents had 4 and more partners during the last 12 months and engaged in either receptive, insertive or both forms of anal intercourse. More than half of the responders used drugs or alcohol to get to know other men or in conjunction with sexual activity (42% infrequently, 10% frequently and 0.5% used drugs always). The main reasons for requesting testing were a prior risk situation (46.3%), followed by routine screening without a prior risk situation (24.1%) and clarification of HIV/STI status due to a new relationship (29.6%). A fifth of men that consulted the service had no history of prior tests for HIV or other STIs. CONCLUSION: Since its first months of activity, the service achieved high levels of recognition, acceptance and demand in the MSM community. Contrary to common concepts of "testing clinics", the Checkpoint service provides post-exposure prophylaxis, HIV and STI treatment, psychological support and counselling and general medical care. It thus follows a holistic approach to health in the MSM community with the particular aim to serve as a "door opener" between the established system of care and those men that have no access to, or for any reason hesitate to utilize traditional health care

HEE-GER: a systematic review of German economic evaluations of health care published 1990–2004

BACKGROUND: Studies published in non-English languages are systematically missing in systematic reviews of growth and quality of economic evaluations of health care. The aims of this study were: to characterize German evaluations, published in English or German-language, in terms of various key parameters; to investigate methods to derive quality-of-life weights in cost-utility studies; and to examine changes in study characteristics over the years. METHODS: We conducted a country-specific systematic review of the German and English-language literature of German economic evaluations (assessment of or application to the German health care system) published 1990–2004. Generic and specialized health economic databases were searched. Two independent reviewers verified fulfillment of inclusion criteria and extracted study characteristics. RESULTS: The fulltexts of 730 articles were reviewed of which 283 fulfilled all entry criteria. 32% of included studies were published in German-language. 51% of studies evaluated pharmaceuticals and 63% were cost-effectiveness analyses. Economic appraisals concentrate on few disease categories and important health areas are strongly underrepresented. Declaration of sponsorship was associated with article language (49% English articles vs. 29% German articles, p < 0.001). The methodology used to obtain quality-of-life weights in published cost-utility studies was very diverse, poorly reported and most studies did not use German patients' or community health state valuations. CONCLUSION: Many of the German-language evaluations included in our study are likely to be missing in international reviews and may be systematically different from English-language reviews from Germany. Lack of transparency and adherence to recommended reporting practices constitute a serious problem in German economic evaluations

The equivalence of numbers: The social value of avoiding health decline: An experimental web-based study

BACKGROUND: Health economic analysis aimed at informing policy makers and supporting resource allocation decisions has to evaluate not only improvements in health but also avoided decline. Little is known however, whether the "direction" in which changes in health are experienced is important for the public in prioritizing among patients. This experimental study investigates the social value people place on avoiding (further) health decline when directly compared to curative treatments in resource allocation decisions. METHODS: 127 individuals completed an interactive survey that was published in the World Wide Web. They were confronted with a standard gamble (SG) and three person trade-off tasks, either comparing improvements in health (PTO-Up), avoided decline (PTO-Down), or both, contrasting health changes of equal magnitude differing in the direction in which they are experienced (PTO-WAD). Finally, a direct priority ranking of various interventions was obtained. RESULTS: Participants strongly prioritized improving patients' health rather than avoiding decline. The mean substitution rate between health improvements and avoided decline (WAD) ranged between 0.47 and 0.64 dependent on the intervention. Weighting PTO values according to the direction in which changes in health are experienced improved their accuracy in predicting a direct prioritization ranking. Health state utilities obtained by the standard gamble method seem not to reflect social values in resource allocation contexts. CONCLUSION: Results suggest that the utility of being cured of a given health state might not be a good approximation for the societal value of avoiding this health state, especially in cases of competition between preventive and curative interventions

Frequency of use and knowledge of the WHO-surgical checklist in Swiss hospitals: a cross-sectional online survey

BACKGROUND The WHO-surgical checklist is strongly recommended as a highly effective yet economically simple intervention to improve patient safety. Its use and potentially influential factors were investigated as little data exist on the current situation in Switzerland. METHODS A cross-sectional online survey with members (N = 1378) of three Swiss professional associations of invasive health care professionals was conducted in German, French, and Italian. The survey assessed use of, knowledge of and satisfaction with the WHO-surgical checklist. T-Tests and ANOVA were conducted to test for differences between professional groups. Bivariate correlations were computed to test for associations between measures of knowledge and satisfaction. RESULTS 1090 (79.1%) reported the use of a surgical checklist. 346 (25.1%) use the WHO-checklist, 532 (38.6%) use the Swiss Patient Safety Foundation recommendations to avoid Wrong Site Surgery, and 212 (15.7%) reported the use of other checklists. Satisfaction with checklist use was generally high (doctors: 71.9% satisfied, nurses: 60.8% satisfied) and knowledge was moderate depending on the use of the WHO-checklist. No association between measures of subjective and objective knowledge was found. CONCLUSIONS Implementation of a surgical checklist remains an important task for health care institutions in Switzerland. Although checklist use is present in Switzerland on a regular basis, a substantial group of health care personnel still do not use a checklist as a routine. Influential factors and the associations among themselves need to be addressed in future studies in more detail

Medication Safety in Oncology Care: Mapping Checking Procedures From Prescription to Administration of Chemotherapy.

PURPOSE To increase medication safety in oncology, checking procedures are increasingly applied by nurses, physicians, and pharmacists. However, little is known about the number, types, and consistency of implemented checks. The aim of the study was to assess the number and types of different checking procedures that are performed along the lifecycle of a chemotherapy prescription across three hospitals, different care settings, administration routes, and professional groups. METHODS A scheme to evaluate checking procedures and a mapping approach to illustrate the checks along the phases of the medication process were developed. Checking procedures were assessed on the basis of analysis of internal guidelines and interviews with nurses and physicians who work on wards and in ambulatory infusion units of three hospitals. RESULTS There were considerable differences in number and type of checking procedures among administration routes, professional groups, wards and ambulatory infusion units, and hospitals. During the prescribing phase, the lowest number of checks was performed. In internal guidelines, checking procedures were documented poorly, though the pharmacy process was an exception. CONCLUSION In contrast to the pharmacists, nurse and physician clinician checking procedures are less standardized within and across hospitals. The results point to different checking habits for the professional groups; for example, physicians would rather perform plausibility reviews than checks. Our evaluation scheme to categorize checks and the visualized mapping approach was feasible and understandable for practitioners

Ausgewählte sicherheitsrelevante Medikationsprozesse in Schweizer Alters- und Pflegeheimen: Status quo und Optimierungspotenziale

BACKGROUND Reducing adverse drug events in nursing homes is a central patient safety concern. The aim of this study was to assess how often selected medication processes to increase medication safety are already implemented in Swiss nursing homes and to examine how nursing homes that have not yet implemented these processes can be characterized based on their organizational features. METHODS Cross-sectional survey study among directors of nursing in Swiss nursing homes. RESULTS 420 of 1,525 invited individuals participated in the survey (response rate: 27.5 %). Of these, 65.0 % stated that regular systematic medication reviews have been provided in their institution. 9.5 % of the nursing homes use a list to identify potentially inappropriate medication, and 6.7 % of the nursing homes have a standardized process to monitor side effects of medications. 66.0 % of the participating nursing homes have implemented at least one of these three processes, 34.0 % of the participating nursing homes have not implemented any of the three processes. Statistically significant differences in process implementation were found according to the geographical location of the nursing home, the type of documentation used for medications, the physician model, the number of external general practitioners, as well as the medication supply channel and the legal obligation to cooperate with pharmacists. No differences were found with regard to the nursing home size. CONCLUSION In Swiss nursing homes, central safety-relevant medication processes have not yet been implemented nationwide. In particular, implementation is not widespread in nursing homes where medical care for their residents is provided by many different external general practitioners. The organizational features need to be taken into account to successfully implement quality improvement measures.Hintergrund Die Reduktion von unerwünschten Arzneimittelereignissen bei Bewohnenden von Alters- und Pflegeheimen ist ein zentrales Anliegen der Patientensicherheit. Ziel dieser Studie war es zu ermitteln, wie häufig ausgewählte Medikationsprozesse zur Erhöhung der Medikationssicherheit in Schweizer Pflegeheimen bereits umgesetzt werden und wie sich Heime, die diese Prozesse noch nicht umsetzen, durch organisationale Merkmale charakterisieren lassen. Methode Querschnittstudie mittels Online-Befragung von Pflegedienstleitungen in Schweizer Alters- und Pflegeheimen. Ergebnisse Es nahmen 420 von 1525 eingeladenen Personen an der Befragung teil (Rücklaufquote: 27.5%). Davon gaben 65.0% an, dass in ihrer Einrichtung eine regelmäßige systematische Überprüfung der Medikation vorgesehen ist. In 9.5% der Pflegeheime wird eine Liste zur Identifikation von potenziell inadäquater Medikation eingesetzt und 6.7% der Heime haben einen standardisierten Prozess, um Nebenwirkungen von Medikamenten zu überwachen. 66.0% der teilnehmenden Heime setzen mindestens einen dieser Prozesse um, 34.0% setzen keinen der drei Prozesse um. Statistisch signifikante Unterschiede in der Umsetzung der Prozesse zeigten sich nach Standort des Pflegeheims, der Art des Dokumentationssystems für die Medikation, dem Arztmodell, der Anzahl externer Ärzte/Ärztinnen sowie dem Bezugskanal der Medikamente und der gesetzlichen Verpflichtung zur Zusammenarbeit mit Apothekern/Apothekerinnen. Keine Unterschiede zeigten sich nach Heimgröße. Schlussfolgerung In Schweizer Alters- und Pflegeheimen sind zentrale sicherheitsrelevante Medikationsprozesse noch nicht flächendeckend umgesetzt. Besonders in Einrichtungen, in denen viele externe Belegärzte Bewohnende betreuen, ist die Umsetzung noch wenig fortgeschritten. Die organisationalen Merkmale müssen für eine erfolgreiche Implementierung von Verbesserungsmassnahmen berücksichtigt werden

Nurses' and Physicians' Perceptions of Indwelling Urinary Catheter Practices and Culture in Their Institutions.

OBJECTIVES Indwelling urinary catheters (IUCs) are commonly used devices in acute care that may lead to catheter-associated urinary tract infections or noninfectious complications. Responsibilities for IUC are usually shared between nurses and physicians, and a common mental model among the two professional groups is thus essential for a successful reduction in catheter use. The aim of this study was to determine variation in the perceptions of current practices and culture regarding IUC use between these two groups. METHODS Nurses and physicians (N = 1579) from seven Swiss hospitals completed a written survey on safe IUC use in their institution. The survey assessed participant's perceptions of current practices and culture in their institution, and their perceived responsibilities related to IUC care. t tests and logistic regression were used to examine differences in responses between physicians and nurses. RESULTS Nurses and physicians each have their own tasks but also share responsibilities for catheter placement, care, and removal. Overall, nurses were more positive than physicians about current practices and culture regarding IUC use within their institution (mean scale scores = 5.4 for nurses versus 5.1 for physicians, P < 0.001). Perceptions of the two professional groups diverged most strongly on practices to avoid unnecessary placement of IUCs, the presence of shared values and attitudes in support of restrictive catheter use, and the other group's leadership commitment. CONCLUSIONS Indwelling urinary catheter management is a strong interprofessional domain and a shared responsibility. It is crucial that measures to raise awareness and to communicate new standards target both nurses and physicians and are discussed in interprofessional formats.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal