Evaluation of retrospective patient record review as a method to identify patient safety and quality information in orthopaedic care

The great benefits of modern healthcare must be weighed against the risk of patient injury due to human intervention. Studies show that adverse events (AE) are identified in up to 16.6% of all hospitalisations. As a step toward preventing AEs, efforts are made to collect patient safety information at different levels in the healthcare systems. The information is neither effectively organised nor integrated within the healthcare systems, leading to difficulty achieving systematic analysis. This may be due to the use of different methods that yield qualitatively different information about AE. The general aim of this thesis was to evaluate the capability of retrospective record review (RRR) methods to identify patient safety and quality information in orthopaedic care. In papers I and II, 395 patient records were retrospectively examined for AEs using both traditional incident reporting methods and RRR for the same cohort. More AEs were identified using RRR than by using traditional incident reporting methods. Also, paper II showed that more AEs were due to deficiencies in care processes rather than to deficiencies in technical skills. In paper III, the efficiency of an orthopaedic nursing improvement initiative, called “improvement theme months,” was evaluated using case study methodology and a RRR of 2,281 patients. Results showed significant improvement over time in performance of risk assessment for pressure ulcers and lowered pressure ulcer prevalence. We found RRR easy to use and valuable as a method to assess improvement over time. In paper IV, the RRR methods Harvard Medical Practice Study (HMPS) and Global Trigger Tool (GTT) were compared for capability to identify AEs in a sample of 350 randomly selected orthopaedic admissions. Results showed that HMPS identified more AEs than GTT did. The overall positive predictive value was 40% and 30% for HMPS and GTT methods, respectively. Retrospective record review appears to achieve wider coverage when identifying orthopaedic AEs at a local level. Given that many current methods vary considerably in quality of data gathered and in coverage, which require multiple methods to be used concurrently, the wider coverage characteristic of RRR is an advantage. Consequently, RRR could play a vital role in quality and safety information systems in order to identify, categorise, and analyse quality and patient safety problems and to provide the basis for interventions. Increased awareness, consideration of risk factors, interventions focused on multidisciplinary and interdepartmental teamwork, and strategies that focus on healthcare processes may reduce the frequency of AEs in orthopaedic care. Also, RRR can incorporate a time series display of patient safety intervention outcomes to drive change. As a method, improvement theme months may serve to organise quality and lead to safety improvement in nursing. However, we found that it was associated with a lengthy period of time before new guidelines, quality indicators, and safety initiatives were noticed and became widely used in clinical practice. To achieve sustainable and significant improvement, interventions on many levels of the organisation were needed

Adverse events in orthopedic care identified via the Global Trigger Tool in Sweden – implications on preventable prolonged hospitalizations

Background: The national incidence of adverse events (AEs) in Swedish orthopedic care has never been described. A new national database has made it possible to describe incidence, nature, preventability and consequences of AEs in Swedish orthopedic care. Methods: We used national data from a structured two-stage record review with a Swedish modification of the Global Trigger Tool. The sample was 4,994 randomly selected orthopedic admissions in 56 hospitals during 2013 and 2014. The AEs were classified according to the Swedish Patient Safety Act into preventable or non-preventable. Results: At least one AE occurred in 733 (15%, 95% CI 13.7-15.7) admissions. Of 950 identified AEs, 697 (73%) were judged preventable. More than half of the AEs (54%) were of temporary nature. The most common types of AE were healthcare-associated infections and distended urinary bladder. Patients ≥65years had more AEs (p<0.001), and were more often affected by pressure ulcer (p<0.001) and urinary tract infections (p<0.01). Distended urinary bladder was seen more frequently in patients aged 18-64 years (p=0.01). Length of stay was twice as long for patients with AEs (p<0.001). We estimate 232,000 extra hospital days due to AEs during these 2years. The pattern of AEs in orthopedic care was different compared to other hospital specialties. Conclusions: Using a national database, we found AEs in 15% of orthopedic admissions. The majority of the AEs was of temporary nature and judged preventable. Our results can be used to guide focused patient safety work

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis

Background: Adverse events (AEs) cause suffering for hospitalised children, a fragile patient group where the delivery of adequate timely care is of great importance. Objective: To report the incidence and characteristics of AEs, in paediatric inpatient care, as detected with the Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. Method: MEDLINE, Embase, Web of Science and Google Scholar were searched from inception to June 2021, without language restrictions. Studies using manual record review were included if paediatric data were reported separately. We excluded studies reporting: AEs for a specific disease/diagnosis/treatment/procedure, or deceased patients; study protocols with no AE outcomes; conference abstracts, editorials and systematic reviews; clinical incident reports as the primary data source; and studies focusing on specific AEs only. Methodological risk of bias was assessed using a tool based on the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Primary outcome was the percentage of admissions with ≥1 AEs. All statistical analyses were stratified by record review methodology (GTT/TT or HMPS) and by type of population. Meta-analyses, applying random-effects models, were carried out. The variability of the pooled estimates was characterised by 95% prediction intervals (PIs). Results: We included 32 studies from 44 publications, conducted in 15 countries totalling 33 873 paediatric admissions. The total number of AEs identified was 8577. The most common types of AEs were nosocomial infections (range, 6.8%-59.6%) for the general care population and pulmonary-related (10.5%-36.7%) for intensive care. The reported incidence rates were highly heterogeneous. The PIs for the primary outcome were 3.8%-53.8% and 6.9%-91.6% for GTT/TT studies (general and intensive care population). The equivalent PI was 0.3%-33.7% for HMPS studies (general care). The PIs for preventable AEs were 7.4%-96.2% and 4.5%-98.9% for GTT/TT studies (general and intensive care population) and 10.4%-91.8% for HMPS studies (general care). The quality assessment indicated several methodological concerns regarding the included studies. Conclusion: The reported incidence of AEs is highly variable in paediatric inpatient care research, and it is not possible to estimate a reliable single rate. Poor reporting standards and methodological differences hinder the comparison of study results

Variation in detected adverse events using trigger tools: A systematic review and meta-analysis

Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely.; This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence.; Systematic review and meta-analysis.; To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review.; Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9-37.5; I2 = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4-164.7. Overall studies' risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation.; Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

BACKGROUND Adverse events (AEs) cause suffering for hospitalised children, a fragile patient group where the delivery of adequate timely care is of great importance. OBJECTIVE To report the incidence and characteristics of AEs, in paediatric inpatient care, as detected with the Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. METHOD MEDLINE, Embase, Web of Science and Google Scholar were searched from inception to June 2021, without language restrictions. Studies using manual record review were included if paediatric data were reported separately. We excluded studies reporting: AEs for a specific disease/diagnosis/treatment/procedure, or deceased patients; study protocols with no AE outcomes; conference abstracts, editorials and systematic reviews; clinical incident reports as the primary data source; and studies focusing on specific AEs only. Methodological risk of bias was assessed using a tool based on the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Primary outcome was the percentage of admissions with ≥1 AEs. All statistical analyses were stratified by record review methodology (GTT/TT or HMPS) and by type of population. Meta-analyses, applying random-effects models, were carried out. The variability of the pooled estimates was characterised by 95% prediction intervals (PIs). RESULTS We included 32 studies from 44 publications, conducted in 15 countries totalling 33 873 paediatric admissions. The total number of AEs identified was 8577. The most common types of AEs were nosocomial infections (range, 6.8%-59.6%) for the general care population and pulmonary-related (10.5%-36.7%) for intensive care. The reported incidence rates were highly heterogeneous. The PIs for the primary outcome were 3.8%-53.8% and 6.9%-91.6% for GTT/TT studies (general and intensive care population). The equivalent PI was 0.3%-33.7% for HMPS studies (general care). The PIs for preventable AEs were 7.4%-96.2% and 4.5%-98.9% for GTT/TT studies (general and intensive care population) and 10.4%-91.8% for HMPS studies (general care). The quality assessment indicated several methodological concerns regarding the included studies. CONCLUSION The reported incidence of AEs is highly variable in paediatric inpatient care research, and it is not possible to estimate a reliable single rate. Poor reporting standards and methodological differences hinder the comparison of study results

Mapping registered nurse anaesthetists' intraoperative work: tasks, multitasking, interruptions and their causes, and interactions: a prospective observational study

Introduction Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care. Objective To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process. Methods Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool. Results High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia. Conclusion The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.</p

Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study

Objectives: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.Design: Prospective observational study using the Work Observation Method By Activity Timing tool.Setting: An OR department at a county hospital in Sweden.Participants: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).Results: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons’ and ORNs’ intraoperative time, while in RNAs’ work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs’ and surgeons’ work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.Conclusions: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.</p

The patient's experience of participation when admitted for elective surgical procedures : an interview study

PURPOSE: To describe the patient's experience of participation in their care when admitted for elective surgical procedures. MATERIALS AND METHODS: A purposive sample of 14 patients who had undergone elective surgery was included in semi-structured individual interviews at a university hospital. The data was analysed using qualitative content analysis. RESULTS: One theme was identified: Creating a meaningful relationship to enable participation in the care, based on three categories; Abilities, willingness, and a lack of experience affect participation, A professional approach with an open communication and individualized information, and The importance of structural factors. CONCLUSIONS: To meet the patient's individual needs and wishes regarding participation, meaningful relationships need to be created between patient and healthcare personnel. The results also indicate that the patients have insufficient knowledge about their role regarding participation. To improve patient participation, its meaning needs to be clarified individually to the patient, emphasizing the importance to be active involved in his or her own care