Jiro Takeuchi, M. Sakuma, Y. Ohta, H. Ida, T. Morimoto
{"title":"Differences in adverse drug events and medication errors among pediatric inpatients aged <3 and ≥3 years: The JADE study","authors":"Jiro Takeuchi, M. Sakuma, Y. Ohta, H. Ida, T. Morimoto","doi":"10.1177/25160435211046764","DOIUrl":"https://doi.org/10.1177/25160435211046764","url":null,"abstract":"Background Adverse drug events (ADEs) are defined as any injuries due to medication use. We hypothesized that the incidences of ADEs and medication errors (MEs) could be associated with linguistic skills of pediatric patients. Methods We analyzed data from the Japan Adverse Drug Events study on pediatric inpatients. This study included inpatients aged one months and older and less than seven years old. We compared the primary outcome of ADEs and MEs between patients aged under three years and three years and older as children typically do not acquire sufficient linguistic skills until around three years of age. Results This study included 639 patients; 412 (64%) patients aged under three years and 227 (36%) patients aged three years and older. We identified 241 ADEs in 639 patients; 152 ADEs among patients aged under three years (37 ADEs per 100 patients) and 89 ADEs among those aged three years and older (39 ADEs per 100 patients). ADEs among patients aged under three years were less likely to be found (49 ADEs) during their hospital stay than those aged three years and older (20 ADEs) (P = 0.02). Among 172 MEs identified in 639 patients, 25 MEs (15%) resulted in ADEs; 23 (92%) occurred to those aged under three years and two (8%) occurred to those aged three years and older (P = 0.0008). Conclusion ADEs were less likely to be found and MEs resulted in ADEs more frequently in patients under three years old, and these differences could be explained by differences in their linguistic skill levels.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"2 1","pages":"261 - 266"},"PeriodicalIF":0.0,"publicationDate":"2021-10-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76941567","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Knowledge knows no bounds: Patient Safety Learning and the hub","authors":"H. Hughes","doi":"10.1177/25160435211045352","DOIUrl":"https://doi.org/10.1177/25160435211045352","url":null,"abstract":"Avoidable unsafe care is one of the ten leading causes of death and disability worldwide. It has recently been described by the G20 Health and Development Partnership as ‘The Overlooked Pandemic’. While there is much good work by many people and organisations seeking to improve patient safety, many of its systemic causes are resistant to change. This results not only untold physical and emotional damage, but also inflicts a huge financial penalty, forecast to cost the global economy approximately $383.7 billion by 2022.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"7 1","pages":"195 - 197"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77075070","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Having a patient in the room changes the discussion","authors":"A. Wu","doi":"10.1177/25160435211050802","DOIUrl":"https://doi.org/10.1177/25160435211050802","url":null,"abstract":"At professional meetings and conferences dealing with patient safety and quality, I have consistently observed one key theme: having a patient or family member in the room changes everything. The tone of the discussion is kinder and more respectful, and there is greater urgency to find solutions. Their presence exerts a gravitational pull, shifting the balance of discussion toward the patient perspective. Patient participation also helps to engage and motivate health professionals to make improvements. The best way to engage is by storytelling, and the most effective stories are stories about patients, told by them. In health care today in the US, and in the rest of society, everyone has been feeling stress, exhaustion, a feeling of “just being done.” The level of this has been creeping up for the 18 months of the COVID-19 pandemic. For me, September had barely begun, but my batteries were already running down when I was recharged by a ray of hope that appeared in my email box:","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"37 1","pages":"192 - 194"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85334498","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Terri A. Zomerlei, A. Carraher, A. Chao, Shonda Vink, R. Chandawarkar
{"title":"When no news is bad news: Improving diagnostic testing communication through patient engagement","authors":"Terri A. Zomerlei, A. Carraher, A. Chao, Shonda Vink, R. Chandawarkar","doi":"10.1177/25160435211044586","DOIUrl":"https://doi.org/10.1177/25160435211044586","url":null,"abstract":"Importance Up to 17% of diagnostic test results are missed, lost or ignored despite conventional fixes such as electronic physician reminders – naïvely, patients assume: ‘No-News-is-Good-News’. These lapses can result in poor outcomes, complications, and even death. In response, Centers for Medicare and Medicaid Services (CMS)-led physician quality reporting system measure#265 emphasizes prevention. This study aims to improve the timely review of results through increasing patient engagement. Design and Participants Ninety patients undergoing diagnostic testing were included in this Internal Review Board (IRB)-approved study. Two groups, group-A (patients with medical chart access through our EHR, n = 40); and group-B (controls, n = 50) were included. Group-A was reminded via written AVS and EHR portal messages to ask about their test results at their next appointment. Controls were sent no reminders, mimicking the status- quo. Main Outcomes At subsequent visits whether patients ‘asked’ or ‘did not ask’ about their results was recorded and analyzed. Study group participants were also surveyed on their preferences for reminder communication. Results Patients that were sent reminders were up to twenty times more likely to ask their provider regarding their test results than the control group (p < 0.0001). Eighty-one percent indicated that the reminders were helpful with 90% indicating they were ‘necessary’. Neither gender nor age seemed predictive factors of patient engagement. Conclusions and Relevance This pilot study demonstrates that engaging patients in their own care through already-existing tools (AVS, EHR portal messages) improves patient-physician communication, and could lead to lower rates of missed diagnostic tests.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"190 1","pages":"221 - 224"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74879745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Davia Liba Loren, A. Lyerly, Lauren Lipira, M. Ottosen, E. Namey, Thomas Benedetti, Benjamin Dunlap, E. Thomas, Carolyn D. Prouty, T. Gallagher
{"title":"Communication regarding adverse neonatal birth events: Experiences of parents and clinicians","authors":"Davia Liba Loren, A. Lyerly, Lauren Lipira, M. Ottosen, E. Namey, Thomas Benedetti, Benjamin Dunlap, E. Thomas, Carolyn D. Prouty, T. Gallagher","doi":"10.1177/25160435211017749","DOIUrl":"https://doi.org/10.1177/25160435211017749","url":null,"abstract":"Objectives Communicating with parents about adverse birth outcomes is challenging. We sought to describe attitudes and experiences of parents and providers regarding communication about adverse newborn birth events. Methods From 2011–2012, we conducted semi-structured in-depth interviews with parents who believed they had experienced an adverse birth-related neonatal outcome and focus groups with healthcare providers who have communicated with parents about adverse newborn birth events from three geographically diverse US academic medical centers. We conducted qualitative thematic analysis to identify key themes. Results Parents and providers described unique communication challenges around adverse neonatal outcomes in six categories: 1) High expectations for a positive delivery experience and the view that birth is a life event, not a medical encounter; 2) Powerful emotions associated with birth, amplified when an adverse event occurs; 3) Rapid changes when expectations for a normal birth take a sudden negative turn; 4) Family involvement adding complexity to communication; 5) Multiple patients and providers complicating communication dynamics with inter-professional teams seeking to coordinate information and care; and, 6) Concerns about litigation surrounding the birth experience. Strategies to educate parents and enhance communication were identified by both parents and providers. Conclusion Both parents and providers experience – and may suffer as a result of – communication challenges following adverse birth events affecting the newborn. Training and resources for this care environment are needed to meet parental, extended family, and provider expectations for communication when these events occur.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"32 1","pages":"200 - 206"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75312592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I. Bertram, Jack Cantelo, William Hutton, Henry Kirkham, N. Scallan
{"title":"Sins of Omission: Are junior doctors failing to report clinical incidents, and if so, how can we better support them to do so?","authors":"I. Bertram, Jack Cantelo, William Hutton, Henry Kirkham, N. Scallan","doi":"10.1177/25160435211044588","DOIUrl":"https://doi.org/10.1177/25160435211044588","url":null,"abstract":"Objectives University Hospitals Birmingham's (UHB) Foundation Doctors should log clinical incidents via the Trust's incident reporting system. Anecdotal reports suggest under-reporting is commonplace. It is therefore important to identify the proportion of Foundation Year 1 (FY1s) who witnessed but did not report incidents and identify and weigh perceived barriers to reporting. We can then suggest strategies to address these barriers and repeat our data collection. Methodology We performed an analysis of anonymised data from the Trust's Datix Incident Reporting system alongside an anonymised survey to determine the proportion of FY1s witnessing reportable clinical incidents, and the proportion successfully reporting an incident in the 2017/18 academic year. The survey also gathered data on FY1 perceptions of barriers to reporting. We went on to discuss our results with UHB management and suggested several strategies to improve reporting, prior to repeating data collection for the 2019–20 academic year. Results 36.4% FY1 doctors surveyed in 2017–18 reported witnessing at least one clinical incident that they did not report. 37.0% FY1 doctors surveyed in 2019–20 reported the same. Respondents felt time taken to complete forms and system complexity were the key barriers to reporting. Conclusion Results show that over a third of FY1s at UHB had witnessed but not reported at least one clinical incident each year. The evidence-based strategies suggested to the trust in 2018 and 2020 included FY1 education on incident reporting, early senior clinician involvement in the reporting pathway, and a streamlined reporting system integrated with existing infrastructure. These have not been implemented.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"18 1","pages":"225 - 230"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89299661","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Elizabeth K. Reynolds, Cheryl A Connors, J. L. Taylor, R. Vasa
{"title":"A patient safety and quality improvement curriculum for child and adolescent psychiatry fellows using the Learning from Defect Tool","authors":"Elizabeth K. Reynolds, Cheryl A Connors, J. L. Taylor, R. Vasa","doi":"10.1177/25160435211044919","DOIUrl":"https://doi.org/10.1177/25160435211044919","url":null,"abstract":"The purpose of this article is to describe the development and evaluation of an 11-session patient safety and quality improvement curriculum for first-year child and adolescent psychiatry fellows. The curriculum uses the Learning from Defects tool which teaches fellows how to conduct an analysis of a safety event they have encountered in their clinical work. The Learning from Defects tool provides a structured approach to address adverse clinical events and identify system failures by providing a framework to determine what happened, examine why it happened, implement interventions to reduce the probability that a similar event will recur, and evaluate whether the interventions were effective. Six fellows participated in the curriculum during their protected didactics time. Curriculum evaluation included an assessment of fellows’ knowledge, skills, and attitudes toward patient safety and quality improvement before and immediately after the curriculum, and 6-months later. Immediately upon completion of the curriculum, fellows reported more confidence and comfort with patient safety and quality improvement-related tasks in their clinical practice. Fellows reported a positive perception of the curriculum related to their learning objectives and utility in the future career. At the 6-month follow-up, the majority of fellows continued to work on their Learning from Defects project and endorsed the intention to participate in patient safety and quality improvement work in the future. This study provides preliminary support for implementing this patient safety and quality improvement curriculum utilizing the Learning from Defects tool in child and adolescent psychiatry fellowship programs. The Learning from Defects tool offers a practical way to teach patient safety and quality improvement skills that potentially can be generalized to future clinical work.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"60 1","pages":"207 - 213"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78046459","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Clinical negligence and its cost. Should tort law apply to doctors and the NHS?","authors":"James Badenoch Q.C.","doi":"10.1177/25160435211046677","DOIUrl":"https://doi.org/10.1177/25160435211046677","url":null,"abstract":"Politicians and the media in the UK vociferously complain about the scale of damages and costs awarded in clinical negligence cases, and constantly attach the blame to the lawyers or, worse, to the injured patients or their families. Sadly the underfunding of the NHS and the increased pressure from the pandemic will make these complaints still louder. Legal ‘reforms’ directed at clinical negligence in particular have already been hinted at by ministers following the Government’s spending review, but with cost their sole target they threaten to leave the patient damaged by clinical negligence worse off than those injured by negligence in any other walk of life. The complainers and the government need to reflect on one simple fact: damages claims only succeed when it is proved or admitted that injury was avoidably caused according to expert opinion by (to paraphrase) “a mistake so bad that no doctor professing the relevant skill would make if acting with reasonable care.” It follows that the true cause of the cost to the NHS is the making of so many serious injurious mistakes which are either proved or admitted to have been negligent. When a car hits a pedestrian on a Zebra crossing no one doubts where the blame lies for the collision and the injuries and the financial consequences, and if the car’s brakes were defective the garage which carelessly serviced it will be liable. It is a logical absurdity to attach the blame for the cost of clinical negligence to the injured patients, their families or their lawyers (easy targets though they are), or to the compensation which they legally recover, and doing so diverts attention from the proper target, the causes of so many mistakes. Those causes are easy to find in the under-funding and understaffing of health care, the over-working and inadequate pay of healthcare professionals, the deterioration in working conditions and the ever downward spiral of morale in the Health Service. Added to this is the continuing failure to improve patient safety significantly even in disciplines where the causes are well known, such as maternity care, where the same seriously damaging errors have been repeated for years at great human as well as economic cost. Only when the true causes become the focus of righteous anger and are tackled and corrected by all necessary measures will it be possible to eliminate or reduce the incidence of serious and avoidable mistakes and their cost to the taxpayer. Sometimes, the avoidable mistakes are only identified as a result of the injured patients or their families taking legal action. Denying or restricting their access to justice would also mean reducing the likelihood of such errors being identified, investigated and acted upon to avoid their repetition. As to the cost of damages for clinical negligence and legal costs, the figures are instructive. The NHS is probably the 5 largest employer in the world, with some 1.5 million on its payroll. It self-insures and meets its liabilit","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"27 1","pages":"198 - 199"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83297487","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Implementation and evaluation of a good prescribing tip email to reduce junior doctors' prescribing errors","authors":"S. Cooper, R. Fitzpatrick","doi":"10.1177/25160435211036672","DOIUrl":"https://doi.org/10.1177/25160435211036672","url":null,"abstract":"Background Prescribing errors are common, occurring in 7% of in-patient medication orders in UK hospitals. Foundation Year 1 (F1) doctors have reported a lack of feedback on prescribing as a cause of errors. Aim To evaluate the effect of implementing a shared learning intervention to Foundation Year 1 doctors on their prescribing errors. Methods A shared learning intervention, ‘good prescribing tip’ emails, were designed and sent fortnightly to F1s to share feedback about common/serious prescribing errors occurring in the hospital. Ward pharmacists identified prescribing errors in newly prescribed in-patient and discharge medication orders for 2 weeks pre- and post-intervention during Winter/Spring 2017. The prevalence of prescribing errors was compared pre- and post-intervention using statistical analysis. Results Overall, there was a statistically significant reduction (p < 0.05) in the prescribing error rate between pre-intervention (441 errors in 6190 prescriptions, 7.1%) and post-intervention (245 errors in 4866 prescriptions, 5.0%). When data were analysed by ward type there was a statistically significant reduction in the prescribing error rate on medical wards (6.8% to 4.5%) and on surgical wards (8.4% to 6.2%). Conclusions It is possible to design and implement a shared learning intervention, the ‘good prescribing tip’ email. Findings suggest that this intervention contributed to a reduction in the prevalence of prescribing errors across all wards, thereby improving patient safety.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"73 1","pages":"214 - 220"},"PeriodicalIF":0.0,"publicationDate":"2021-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89440552","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
E. Deilkås, M. Haugen, Madeleine Borgstedt Risberg, H. Narbuvold, Ø. Flesland, Urban Nylén, H. Rutberg
{"title":"Longitudinal rates of hospital adverse events that contributed to death in Norway and Sweden from 2013 to 2018","authors":"E. Deilkås, M. Haugen, Madeleine Borgstedt Risberg, H. Narbuvold, Ø. Flesland, Urban Nylén, H. Rutberg","doi":"10.1177/25160435211026125","DOIUrl":"https://doi.org/10.1177/25160435211026125","url":null,"abstract":"Objectives In this paper, we explore and compare types and longitudinal trends of hospital adverse events in Norway and Sweden in the years 2013–2018 with special reference to AEs that contributed to death. Design Acute care hospitals in both countries performed medical record reviews on randomly selected medical records from all eligible admissions. Analysis: Comparison between Norway and Sweden of linear trends from 2013–2018, and percentage rates of admissions with at least one AE according to types and severities. Setting Norway and Sweden have similar socio-economic and demographic characteristics, which constitutes a relevant context for cooperation, comparison and mutual learning. This setting has promoted the use of GTT to monitor national rates of AEs in hospital care in the two countries. Participants 53 367 medical records in Norway and 88 637 medical records in Sweden were reviewed. Results 13.2% of hospital admissions in Norway and 13.1% in Sweden were associated with an AE of all severities (E-I). 0.23% of hospital admissions in Norway and 0.26% in Sweden were associated with an AE that contributed to death (I). The differences between the two countries were not statistically significant. Conclusions There were no significant differences in overall rates (E-I) of AEs in Norway and Sweden, nor in rates of AEs that contributed to death (I). There was no significant change in AEs or fatal AEs in either country over the six-year time period.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"19 1","pages":"153 - 160"},"PeriodicalIF":0.0,"publicationDate":"2021-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77724432","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}