"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

Dissection of GTPase activating proteins reveals functional asymmetry in the COPI coat of budding yeast.

The Arf GTPase controls formation of the COPI vesicle coat. Recent structural models of COPI revealed the positioning of two Arf1 molecules in contrasting molecular environments. Each of these pockets for Arf1 is expected to also accommodate an Arf GTPase-activating protein (ArfGAP). Structural evidence and protein interactions observed between isolated domains indirectly suggests that each niche may preferentially recruit one of the two ArfGAPs known to affect COPI, Gcs1/ArfGAP1 and Glo3/ArfGAP2/3, although only partial structures are available. The functional role of the unique non-catalytic domain of either ArfGAP has not been integrated into the current COPI structural model. Here, we delineate key differences in the consequences of triggering GTP hydrolysis via the activity of one versus the other ArfGAP. We demonstrate that Glo3/ArfGAP2/3 specifically triggers Arf1 GTP hydrolysis impinging on the stability of the COPI coat. We show that the yeast homologue of AMP kinase, Snf1, phosphorylates the region of Glo3 that is critical for this effect and thereby regulates its function in the COPI-vesicle cycle. Our results revise the model of ArfGAP function in the molecular context of COPI

Vesicles: Looking inside the cell.

Advances in imaging techniques have shed new light on the structure of vesicles formed by COPI protein complexes

The yeast CLC chloride channel is proteolytically processed by the furin-like protease Kex2p in the first extracellular loop

AbstractCLC chloride channels are a family of channel proteins mediating chloride transport across the plasma membrane and intracellular membranes. The single yeast CLC protein Gef1p is localized to the Golgi and endosomal system. Investigating epitope-tagged variants of Gef1p, we found that the channel is proteolytically processed in the secretory pathway. Proteolytic cleavage occurs in the first extracellular loop of the protein at residues KR136/137 and is carried out by the Kex2p protease. Fragments mimicking the N- and C-terminal products of the cleavage reaction are non-functional when expressed alone. However, functional channels can assemble when the two fragments are co-expressed

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

BACKGROUND Retained foreign objects (RFO) after surgery are rare, serious patient safety events. In international comparisons based on routine data, Switzerland had remarkably high RFO rates. The objectives of this study were to 1) explore national key stakeholders' views on RFO as a safety problem, its preventability and need for action in Switzerland; and 2) to assess their interpretation of Switzerland's RFO incidence compared to other countries. METHODS A semi-structured expert survey was conducted among national key representatives, including clinician experts, patient advocates, health administration representatives and other relevant stakeholders (n = 21). Data were coded and analyzed to generate themes related to the study questions following a deductive approach. RESULTS Experts in this study unequivocally emphasized the tragedy for individual patients affected by RFOs. Productivity pressure and the strong economization of operating rooms were perceived as detrimental to safety culture, which was seen as essential for RFO prevention, specifically by those working in the OR. RFOs were seen as "maximally minimizable" but not completely preventable. There was strong agreement that within country differences in RFO risk between Swiss hospitals existed. On the systems level and compared to other safety issues, RFO were having less urgency for most experts. The international comparison of RFO incidences raised serious skepticism across all groups of experts. The validity of the data was questioned and the dominant interpretation of Switzerland's high RFO incidence compared to other countries was a "reporting artifact" based on high coding quality in Swiss hospitals. While most experts thought that the published RFO incidence warrants in-depth analysis of the data, there was little agreement about who's role it was to initiate any further activities. CONCLUSIONS This investigation offers valuable insights into the perspectives of significant stakeholders concerning RFOs, their root causes, and preventability. The findings demonstrate how international comparative safety data are perceived, interpreted, and utilized by national experts to derive conclusive insights

Are temporal trends in retained foreign object rates after surgery in Switzerland impacted by increasing coding intensity? A retrospective analysis of hospital routine data from 2000 to 2019.

OBJECTIVES Retained foreign objects (RFOs) after surgery can cause harm to patients and negatively impact clinician and hospital reputation. RFO incidence based on administrative data is used as a metric of patient safety. However, it is unknown how differences in coding intensity across hospitals and years impact the number of reported RFO cases. The objective of this study is to investigate the temporal trend of RFO incidence at a national level and the impact of changes in coding practices across hospitals and years. DESIGN Retrospective study using administrative hospital data. SETTING AND PARTICIPANTS 21 805 005 hospitalisations at 354 Swiss acute-care hospital sites PRIMARY AND SECONDARY OUTCOME MEASURES: RFO incidence over time, the distribution of RFOs across hospitals and the impact of differences in coding intensity across the hospitals and years. RESULTS The annual RFO rate more than doubled between 2000 and 2019 (from 4.6 to 11.8 with a peak of 17.0 in 2014) and coincided with increasing coding intensity (mean number of diagnoses: 3.4, SD 2.0 in 2000; 7.40, SD 5.2 in 2019). After adjusting for patient characteristics, two regression models confirmed that coding intensity was a significant predictor of both whether RFO cases were reported at the hospital level (OR: 12.94; 95% CI: 7.38 to 22.68) and the number of reported cases throughout the period at the national level (Incidence Rate Ratio (IRR): 5.95; 95% CI: 1.11 to 31.82). CONCLUSIONS Our results raise concerns about the use of RFO incidence for comparing hospitals, countries and years. Utilising coding indices could be employed to mitigate the effects of coding intensity on RFO rates

Barriers and facilitators to chemotherapy patients' engagement in medical error prevention

Background: Medical errors are a serious threat to chemotherapy patients. Patients can make contributions to safety but little is known about the acceptability of error-preventing behaviors and its predictors. Patients and methods: A cross-sectional survey study among chemotherapy patients treated at the oncology/hematology unit of a regional hospital was conducted. Patients were presented vignettes of errors and unsafe acts and responded to measures of attitudes, behavioral control, norms, barriers, and anticipated reaction. Results: A total of 479 patients completed the survey (52% response rate). Patients reported a high level of anticipated activity but intentions to engage for safety varied considerably between the hypothetical scenarios (range: 57%-96%, χ2 P < 0.001). Health, knowledge and staff time pressure were perceived as most important barriers. Instrumental [odds ratio (OR) = 1.3, P = 0.046] and experiential attitudes (OR = 1.4, P < 0.001), expectations attributed to clinical staff (OR = 1.2, P = 0.024) and behavioral control (OR = 1.8, P < 0.001) were predictors for patients' behaviors. Conclusions: Patients are affirmative toward engaging for safety but perceive considerable barriers. Intentions to engage in error prevention vary by clinical context and are strongly influenced by attitudes, normative and control beliefs. To successfully involve patients in medical error, prevention clinicians need to address their patients' beliefs and reduce barriers through educatio

Place-Based Climate-Proofing of Commercial and Industrial Areas: Inventory and Guidelines From a Regional Planning Perspective

In spite of all efforts to reduce greenhouse gases, climate change has become a new reality that requires regional planning to provide effective solutions. This article focuses on commercial and industrial areas (Gewerbegebiete), which are important but often overlooked spaces, by means of examples in the Berlin-Brandenburg region. The article investigates whether and how regional planning can help these areas adapt to climate change. Three commercial and industrial areas in different spatial settings are examined, using an inventory of place-based measures, general standards, and regional networking of planning actors. This inventory is based on a backcasting analysis that compares normative future images of climate-adapted commercial and industrial areas with their current local situation. Spatially differentiated guidelines for the adaptation of commercial and industrial areas are then developed from a regional planning perspective by "climate-proofing" regional plans. These guidelines provide both place-based and general solutions for integrating and governing climate adaptation measures and standards into existing frameworks using a hands-on regional planning approach