Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study.

INTRODUCTION: At least 10% of hospital admissions in high-income countries, including Australia, are associated with patient safety incidents, which contribute to patient harm ('adverse events'). When a patient is seriously harmed, an investigation or review is undertaken to reduce the risk of further incidents occurring. Despite 20 years of investigations into adverse events in healthcare, few evaluations provide evidence of their quality and effectiveness in reducing preventable harm.This study aims to develop consistent, informed and robust best practice guidance, at state and national levels, that will improve the response, learning and health system improvements arising from adverse events. METHODS AND ANALYSIS: The setting will be healthcare organisations in Australian public health systems in the states of New South Wales, Queensland, Victoria and the Australian Capital Territory. We will apply a multistage mixed-methods research design with evaluation and in-situ feasibility testing. This will include literature reviews (stage 1), an assessment of the quality of 300 adverse event investigation reports from participating hospitals (stage 2), and a policy/procedure document review from participating hospitals (stage 3) as well as focus groups and interviews on perspectives and experiences of investigations with healthcare staff and consumers (stage 4). After triangulating results from stages 1-4, we will then codesign tools and guidance for the conduct of investigations with staff and consumers (stage 5) and conduct feasibility testing on the guidance (stage 6). Participants will include healthcare safety systems policymakers and staff (n=120-255) who commission, undertake or review investigations and consumers (n=20-32) who have been impacted by adverse events. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH02007 and 2023/ETH02341).The research findings will be incorporated into best practice guidance, published in international and national journals and disseminated through conferences.

Lessons learnt on patient safety in dentistry through a 5-year nationwide database study on iatrogenic harm.

Safe delivery of care is a priority in dentistry, while basic epidemiological knowledge of patient safety incidents is still lacking. The objectives of this study were to (1) classify patient safety incidents related to primary dental care in Denmark in the period 2016-2020 and study the distribution of different types of dental treatment categories where harm occurred, (2) clarify treatment categories leading to "nerve injury" and "tooth loss" and (3) assess the financial cost of patient-harm claims. Data from the Danish Dental Compensation Act (DDCA) database was retrieved from all filed cases from 1st January 2016 until 31st December 2020 pertaining to: (1) The reason why the patient applied for treatment-related harm compensation, (2) the event that led to the alleged harm (treatment category), (3) the type of patient-harm, and (4) the financial cost of all harm compensations. A total of 9069 claims were retrieved, of which 5079 (56%) were found eligible for compensation. The three most frequent categories leading to compensation were "Root canal treatment and post preparation"(n = 2461, 48% of all approved claims), "lack of timely diagnosis and initiation of treatment" (n = 905, 18%) and "surgery" (n = 878, 17%). Damage to the root of the tooth accounted for more than half of all approved claims (54.36%), which was most frequently a result of either parietal perforation during endodontic treatment (18.54%) or instrument fracture (18.89%). Nerve injury accounted for 16.81% of the approved claims. Total cost of all compensation payments was €16,309,310, 41.1% of which was related to surgery (€6,707,430) and 20.4% (€3,322,927) to endodontic treatment. This comprehensive analysis documents that harm permeates all aspects of dentistry, especially in endodontics and surgery. Neglect or diagnostic delays contribute to 18% of claims, indicating that harm does not solely result from direct treatment. Treatment harm inflicts considerable societal costs.

Prevalence of Triggers and Patient Harm Identified by Global Trigger Tool in Specialized Palliative Care.

Background: Global trigger tool (GTT) was developed for identification of patient harm. In palliative patients deterioration can be expected, and there are no data on whether cases classified as "patient harm" actually represents a potential for improved patient safety. Objectives: The primary aim was to test the performance and suitability of GTT in palliative care patients. The secondary aim was to pilot triggers for substandard palliative care. Design and Measurements: GTT was applied in 113 consecutive patients at a palliative ward at a Norwegian university hospital. Cases of patient harm were further evaluated to decide if the case was (a) a natural part of the disease trajectory or (b) a foreseeable consequence of treatment decisions. Potential triggers for substandard palliative care were tested. Results: Two hundred twelve triggers (1.9 per hospitalization) and 26 cases of patient harm were identified. The positive predictive value (PPV) for identifying patient harm was 0.12. The most prevalent harm was pressure ulcers (8.8%). Of the 26 cases of patient harm, 6 cases were a natural part of the disease trajectory and 10 consequences of treatment decisions. In 21 (18%) patients triggers being piloted for substandard palliative care were present, identifying 9 cases of substandard palliative care. The highest PPV (0.67) was observed for "Cessation of antibiotics less than 5 days before death." Conclusions: With the exception of pressure ulcers, GTT triggers were infrequent or had a very poor PPV for patient harm. Triggers related to overtreatment might be suitable for identifying substandard palliative care.

Impactos de incidentes de segurança do paciente na enfermagem: um olhar para a segunda vítima / Impacts of patient safety incidentes on nursing: a look at the second victim Impactos de incidentes de seguridad del paciente en enfermería: una mirada hacia la segunda víctima / Impacts of patient safety incidentes on nursing: a look at the second victim Impactos de incidentes de seguridad del paciente en enfermería: una mirada hacia la segunda víctima

Objetivo: compreender os impactos para os profissionais de enfermagem como segunda vítima de incidentes de segurança do paciente. Método: estudo qualitativo aprovado pelo comitê de ética em pesquisa, do tipo exploratório-descritivo, realizado com 20 profissionais de enfermagem em hospital universitário do Sul do Brasil, entre novembro de 2021 e janeiro de 2022, por meio de entrevistas semiestruturadas analisadas a partir da análise textual discursiva. Resultados: as categorias sentimentos das segundas vítimas, demonstrando a presença de sentimentos negativos, sendo o medo o mais recorrente; e, impacto na trajetória profissional e no ambiente de trabalho, questionando sua habilidade como um bom profissional e a escolha da profissão como sendo adequada permitiram compreender o impacto no profissional de enfermagem. Considerações finais: os impactos relacionaram-se ao sentimento de culpa pelo fato ocorrido, autojulgamento, julgamento pelos pares e pelo paciente, medo do desfecho ao paciente e das consequências para si e dúvidas quanto à sua habilidade e desempenho no trabalho(AU)

Objective: to understand the impacts on nursing professionals as the second victim of patient safety incidents. Method: qualitative exploratory-descriptive study approved by the research ethics committee, carried out with 20 nursing professionals at a university hospital in southern Brazil, between November 2021 and January 2022, through semi-structured interviews analyzed from the discursive textual analysis. Results: the second victims' feelings categories, demonstrating the presence of negative feelings, with fear being the most recurrent; and impact on the professional path and on the work environment, questioning their ability as a good professional and the choice of profession as being adequate, allowed understanding the impact on the nursing professional. Final considerations: the impacts were related to the feeling of guilt for the fact that occurred, self-judgment, judgment by peers and by the patient, fear of the outcome for the patient and the consequences for himself, and doubts about his ability and performance at work(AU)

Objetivo: comprender los impactos sobre los profesionales de enfermería como segunda víctima de los incidentes de seguridad del paciente. Método: estudio cualitativo, de tipo exploratorio-descriptivo, aprobado por el comité de ética en investigación, y realizado junto a 20 profesionales de enfermería de un hospital universitario del sur de Brasil, entre noviembre de 2021 y enero de 2022, a través de entrevistas semiestructuradas analizadas a partir del análisis textual discursivo. Resultados: las categorías de sentimientos de las segundas víctimas han permitido comprender el impacto sobre el profesional de enfermería: indican la presencia de sentimientos negativos, el miedo siendo el más recurrente; el impacto en la trayectoria profesional y en el ambiente de trabajo, ya que los enfermeros cuestionan su habilidad de buen profesional y si ha sido adecuada la elección de la profesión. Consideraciones finales: los impactos se relacionaron con el sentimiento de culpa por el hecho ocurrido, el juicio propio, el juicio de los pares y del paciente, el miedo al desenlace para el paciente y las consecuencias para él mismo, y las dudas sobre su capacidad y desempeño en el trabajo(AU)

Gaming Disorder em Minorias Sexuais e de Gênero / Gaming Disorder in sexual and gender minorities / Trastorno de juego en minorías sexuales y de género

ntrodução: Os jogos eletrônicos são agora reconhecidos como um problema de saúde mental, especialmente entre a comunidade LGBTQIA+. Objetivo: explorar os efeitos do transtorno de jogo (gaming disorder) na população LGBTQIA+. Método: A revisão narrativa abordou hábitos de jogo e gaming disorder em minorias sexuais e de gênero, usando PubMed, Google Scholar, Embase e Web of Science. Das 1640 pesquisas, apenas 3 abordaram gaming disorder nessa população. Resultado: consumidores LGBTQ+ gastam mais em jogos digitais. Jogadores LGBTQIA+ consomem mais jogos de exploração de identidade, possivelmente relacionados ao estresse de minoria. Discussão: minorias sexuais têm maior risco de gaming disorder. Para indivíduos LGBTQIA+, os jogos podem servir como escape e plataforma de apoio, mas o uso problemático pode estar associado a desfechos psiquiátricos negativos. Conclusão: Os jogos online têm o potencial de serem ferramentas de apoio para minorias, no entanto, as evidências são limitadas. É necessária mais pesquisa para compreender melhor a relação entre o uso de jogos e a saúde mental da população LGBTQIA+.

ntroduction: Electronic games are now recognized as a mental health issue, especially within the LGBTQIA+ community. Objective: To explore the effects of gaming disorder in the LGBTQIA+ population. Method: The narrative review addressed gaming habits and gaming disorder in sexual and gender minorities, utilizing PubMed, Google Scholar, Embase, and Web of Science. Out of 1640 studies, only 3 focused on gaming disorder in this population. Result: LGBTQ+ consumers spend more on digital games. LGBTQIA+ players engage more in identity exploration games, possibly linked to minority stress. Discussion: Sexual minorities face a higher risk of gaming disorder. For LGBTQIA+ individuals, games can serve as an escape and support platform, but problematic use may be associated with negative psychiatric outcomes. Conclusion: Online games have the potential as support tools for minorities, but evidence is limited. Further research is needed to better understand the relationship between game use and mental health in the LGBTQIA+ population.

Introducción: Los videojuegos electrónicos son reconocidos actualmente como un problema de salud mental, especialmente dentro de la comunidad LGBTQIA+. Objetivo: Explorar los efectos del trastorno de juego (gaming disorder) en la población LGBTQIA+. Método: La revisión narrativa abordó los hábitos de juego y el gaming disorder en minorías sexuales y de género, utilizando PubMed, Google Scholar, Embase y Web of Science. De las 1640 investigaciones, solo 3 se centraron en el gaming disorder en esta población. Resultado: Los consumidores LGBTQ+ gastan más en juegos digitales. Los jugadores LGBTQIA+ consumen más juegos de exploración de identidad, posiblemente relacionados con el estrés de minoría. Discusión: Las minorías sexuales enfrentan un mayor riesgo de gaming disorder. Para los individuos LGBTQIA+, los juegos pueden servir como un escape y plataforma de apoyo, pero el uso problemático puede estar asociado con resultados psiquiátricos negativos. Conclusión: Los juegos en línea tienen el potencial como herramientas de apoyo para las minorías, pero la evidencia es limitada. Se requiere más investigación para comprender mejor la relación entre el uso de juegos y la salud mental en la población LGBTQIA+.

Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy.

BACKGROUND: Incident reporting systems were developed to identify possible and actual harm in healthcare facilities. They have the potential to capture important safety trends and to enable improvements that can mitigate the risk of future patient harm and suffering. We recently developed and validated a taxonomy specific for medical oncology designed to enhance the identification, tracking, and trending of incidents that may lead to patient harm. The current project was designed to test the ability of such a taxonomy to be applied across different organizations delivering medical oncology care and to identify specific risks that could result in future harm. METHODS: We analyzed 309 randomly selected medical oncology-related incident reports from 3 different cancer centers that had been posted between January 2019 and December 2020. Each report was assigned up to 2 incident categories. We used a 2-step process to reconcile reviewer discrepancies. In a secondary analysis, each of the incidents was reviewed and recoded to identify events which may result in major or catastrophic harm. RESULTS: Three hundred four incidents met criteria for inclusion. Three hundred incidents (98.7%) were successfully coded. Sixty-seven percent of incidents were encompassed by the following 4 of 21 categories: prescriber ordering (22%), nursing care (15%), pharmacy (14%), and relational/communication issues (15%). Of 297 evaluable incidents, 47% did not reach the patient, 44.7% reached the patient without harm, 7.7% caused minor injury, and 0.7% caused severe injury or death. Submission rates by physicians varied between the 3 sites accounting for 1.7%, 10.7%, and 16.1% of reports. Secondary analysis identified 9 distinct scenarios that may result in major or catastrophic patient harm. CONCLUSIONS: A medical oncology-specific incident reporting taxonomy has the potential to increase our understanding of inherent risks and may lead to process improvements that improve patient safety.

Preventing Potential Patient Harm Through Clinical Content Interventions During Oncology Clinical Trial Implementation.

OBJECTIVES: Clinical trial documents are complex and may have inconsistencies, leading to potential site implementation errors and may compromise participant safety. This study characterizes the frequency and type of administrative and potential patient safety interventions (PPSIs) made during the review of oncology trial documents for clinical trial implementation by centralized clinical content specialists. METHODS: A dedicated group of centralized clinical content specialists reviewed trial documents, including the protocol, laboratory manual, and pharmacy/cellular therapy manual, and collected intervention data over a 1-year period. Each trial was categorized by study phase and sponsor type, and multiple interventions could be identified per trial. Interventions were deemed administrative or PPSIs, with PPSIs further subcategorized as medication, laboratory, procedure related, or other. RESULTS: Of 585 clinical trials reviewed, 269 (46%) required intervention(s). Among 1001 interventions, 171 (17.1%) were PPSIs. Most PPSIs were medication related (45.6%), with drug dosing interventions most frequently identified (53.8%). Phase 1 trials had the highest proportion of PPSIs (0.35:1) and administrative interventions (2:1) per trial compared with all other phases. Investigator-initiated trials saw the highest proportion of PPSIs per trial (0.44:1) of all sponsor types. CONCLUSIONS: This study demonstrates a gap in patient safety when assessing trial documents for clinical trial implementation. One solution to address this gap is the utilization of a centralized team of clinical specialists to preemptively review trial documents, thereby enhancing patient safety during clinical trial conduct.

Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the National Reporting and Learning System.

INTRODUCTION: Direct oral anticoagulants (DOACs) are considered high risk medicines and are frequently associated with medication errors. The nature of incidents and associated outcomes of such incidents are poorly understood. AREAS COVERED: Using a national patient safety reporting database, the National Reporting and Learning System (NRLS), this study aimed to report the contributory factors and outcomes including severe harm and deaths related to all safety incidents involving DOACs reported in England and Wales between 2017-2019. Reason's accident causation model was used to classify the incidents. EXPERT OPINION: A total of 15,730 incident reports were analyzed. A total of 25 deaths were reported with a further 270 and 55 incidents leading to moderate and severe harm, respectively. A further 8.8% (n = 1381) of incidents were associated with low degree of harm. The majority of the incidents involved active failures (n = 13776; 87.58) including duplication of anticoagulant therapies, patients being discharged without DOACs, non-consideration of renal function, and lack of commencement of DOACs post-surgery suggesting preventability of such reported incidents. This study shows that medication incidents involving DOACs have the potential to cause severe harm and deaths, and there is a need to promote guideline adherence through education, training, and decision support technologies.

Eventos adversos na atençãoprimária à saúde / Adverse events in primary health care / Eventos adversos en la atención primaria a la salud

Objetivo: Identificar na literatura os principais fatores contribuintes para ocorrência de Eventos Adversos na Atenção Primária à Saúde. Métodos: Trata-se de uma revisão integrativa. A partir da formação da questão norteadora, foi realizada uma pesquisa nas bases de dados: MEDLINE, PubMed, BDENF, SciELO e LILACS. Ao final, foram incluídos 15 artigos. Resultados: 7 dos artigos traziam fatores ligados a medicação como principal, 3 traziam prática e procedimentos, 2 organização e gestão, 1 comunicação e 2 outros fatores. Conclusão: Percebeu-se que erros relacionados a medicação e diagnóstico são os mais comuns nas instâncias de saúde. A falha na comunicação entre funcionários e entre os serviços de saúde, além de fatores organizacionais e diagnósticos tardios também foram apontadas, sendo boa parte, evitável. A subnotificação foi comumente relatada nos artigos, revelando que os dados existentes possam não estar condizentes com a realidade. (AU)

Objective: To identify in the literature the main contributing factors for the occurrence of Adverse Events in Primary Health Care. Methods: This is an integrative review. Based on the formation of the guiding question, a research was carried out in the databases: MEDLINE, PubMed, BDENF, SciELO and LILACS. At the end, 15 articles were included. Results: 7 of the articles included factors related to medication as main, 3 had practice and procedures, 2 organization and management, 1 communication and 2 other factors. Conclusion: Errors related to medication and diagnosis are the most common in health instances. The failure to communicate between employees and between health services, in addition to organizational factors and late diagnoses were also pointed out, being mostly avoidable. Underreporting was commonly reported in the articles, revealing that existing data may not be consistent with reality. (AU)

Objetivo: Identificar en la literatura los principales factores contribuyentes para la ocurrencia de Eventos Adversos en la Atención Primaria a la Salud. Métodos: Se trata de una revisión integrativa. A partir de la formación de la cuestión orientadora, se realizó una investigación en las bases de datos: MEDLINE, PubMed, BDENF, SciELO y LILACS. Al final, se incluyeron 15 artículos. Resultados: 7 de los artículos traían factores ligados à la medicación como principal, 3 traían práctica y procedimientos, 2 orgnización y gestión, 1 comunicación y 2 otros factores. Conclusión: Se dio cuenta que errores relacionados con la medicación y el diagnóstico son los más comunes en las instancias de salud. La falla en la comunicación entre funcionarios y entre los servicios de salud, además de factores organizacionales y diagnósticos tardío también fueron señalados, siendo buena parte, evitable. La subnotificación fue comúnmente relatada en los artículos, revelando que los datos existentes pueden no estar en concordancia con la realidad. (AU)

Automated Detection of Patient Harm: Implementation and Prospective Evaluation of a Real-Time Broad-Spectrum Surveillance Application in a Hospital With Limited Resources.

OBJECTIVES: This study aimed to prospectively validate an application that automates the detection of broad categories of hospital adverse events (AEs) extracted from a basic hospital information system, and to efficiently mobilize resources to reduce the level of acquired patient harm. METHODS: Data were collected from an internally designed software, extracting results from 14 triggers indicative of patient harm, querying clinical and administrative databases including all inpatient admissions (n = 8760) from October 2019 to June 2020. Representative samples of the triggered cases were clinically validated using chart review by a consensus expert panel. The positive predictive value (PPV) of each trigger was evaluated, and the detection sensitivity of the surveillance system was estimated relative to incidence ranges in the literature. RESULTS: The system identified 394 AEs among 946 triggered cases, associated with 291 patients, yielding an overall PPV of 42%. Variability was observed among the trigger PPVs and among the estimated detection sensitivities across the harm categories, the highest being for the healthcare-associated infections. The median length of stay of patients with an AE showed to be significantly higher than the median for the overall patient population. CONCLUSIONS: This application was able to identify AEs across a broad spectrum of harm categories, in a real-time manner, while reducing the use of resources required by other harm detection methods. Such a system could serve as a promising patient safety tool for AE surveillance, allowing for timely, targeted, and resource-efficient interventions, even for hospitals with limited resources.

The Safety of Inpatient Health Care.

BACKGROUND: Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted. METHODS: We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events. RESULTS: In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%). CONCLUSIONS: Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).

The (commercialised) experience of operating: Embodied preferences, ambiguous variations and explaining widespread patient harm.

This article provides a detailed account of how surgeons perceived and used a device-procedure that caused widespread patient harm: transvaginal mesh for the treatment of pelvic floor disorders in women. Drawing from interviews with 27 surgeons in Canada, the UK, the United States and France and observations of major international medical conferences in North America and Europe between 2015 and 2018, we describe the commercially driven array of operative variations in the use of transvaginal mesh and show that surgeons' understanding of their hands-on, sensory experience with these variations is central to explaining patient harm. Surgeons often developed preferences for how to manage actual and anticipated dangers of transvaginal mesh procedures through embodied operative adjustments, but collectively the meaning of these preferences was fragmented, contested and deferred. We critically reflect on surgeons' understandings of their operative experience, including the view that such experience is not evidence. The harm in this case poses a challenge to some ways of thinking about uncertainty and errors in medical sociology, and calls for attention to a specific feature of surgical work: the extent and persistence of operative practices that elude classification as right or wrong but are still most certainly better and worse.

Dental mapractice litigance in the city of São Paulo (SP), Brazil

The relationship between patients and dentists today is more worn and less based on trust, which can lead to high rates of lawsuits related to civil liability and dental malpractice. Aim: verify if there has been an increase in the number of lawsuits related to questioned dental treatments, and against dentists registered in the city of São Paulo (SP), Brazil, from 2012 to 2017. Methods: We outlined an overview based on the list from the São Paulo Council of Dentistry containing 30,238 registered dentists in the city of São Paulo, and searched for lawsuits on the public base of the São Paulo State Court's. Results: The search, after the inclusion and exclusion criteria, found 247 lawsuits, with dental implants as the most involved specialty. The total indemnities requested ranged from R$ 227.42 to R$ 937,000.00, but no indemnity granted exceeded the amount of R$ 100,000.00. Conclusion: According to the analysis of cases, there is a progressive increase in the number of civil liability lawsuits against dentists involving dental malpractice litigance

Perspectives of Emergency Clinicians About Medical Errors Resulting in Patient Harm or Malpractice Litigation.

This cross-sectional study analyzes responses to a survey about medical error outcomes completed by emergency department attending physicians and advanced practice clinicians.

Medical malpractice in aortic valve and mitral valve replacement surgery in North America.

BACKGROUND: Aortic and mitral valve replacement are commonly performed by cardiovascular surgeons, but little data quantitatively analyzes the etiology and prevalence of medical malpractice litigations involving these operations. This study aims to analyze incidence, cause, and resolution of medical malpractice lawsuits involving aortic and mitral valve replacements, alone and in combination with coronary artery bypass and/or aortic procedures. METHODS: The Westlaw legal database was utilized to compile relevant litigations across the United States from 1994-2019. Clinical data, verdict data, demographic data, and litigation attributes were compiled. Fisher's Exact Tests and Mann-Whitney tests were performed for statistical analyses. One hundred four malpractice litigations involving aortic valve replacement and 55 litigations involving mitral valve replacement were included in this analysis. The mean age of patients was 55.2 years and proportion of female patients was 32.7% in aortic valve replacements litigations, compared to a mean age of 54.1 years and female patients in 61.8% of mitral valve replacements litigations. RESULTS: Significant relationships exist between an alleged failure to monitor the patient and defendant verdicts (P=0.01), delayed treatment and defendant verdicts (P=0.04), and incidence of infective endocarditis and plaintiff verdicts (P=0.04) in aortic valve replacement litigations. Similarly, significant relationships exist between an alleged failure to diagnose and settlement verdicts (P=0.047), and stroke incidence and defendant verdicts (P=0.03) in mitral valve replacement litigations. CONCLUSIONS: In addition to excellent surgeon patient/family communication, administering surgical treatment in a timely manner, diagnosing acting on concomitant medical conditions, and close patient monitoring may diminish medical malpractice litigation involving aortic and mitral valve replacement operations.

Back to the Basics-Is Comfort Care the Same as Do Not Resuscitate? How Misinterpreting Code Status May Lead to Potential Patient Harm.

Several research studies have shown that code status documentation is misinterpreted or incorrectly defined by a significant number of medical professionals. This misinterpretation among the medical team (i.e. equating Do Not Resuscitate (DNR) with comfort care measures only) may lead to false reporting, poor symptom management, and potentially adverse clinical outcomes. Most Hospice and Palliative Care providers are aware of these distinctions, however a shortage (and continued foreseen shortage) of Hospice and Palliative Care providers may mean these conversations and distinctions will fall to non-subspecialists, or providers of other medical specialties or degrees. The literature has demonstrated that these shortfalls and misinterpretations are present and constitute potential harm to our patients.

Tools for the investigation of adverse events: scoping review / Herramientas para investigación de eventos adversos: revisión de alcance / Ferramentas para investigação de eventos adversos: revisão de escopo*

ABSTRACT Objective: To map, in the literature, the risk management tools aimed at investigating health adverse events. Method: Scoping review according to the Joanna Brigss Institute, with acronym PCC (Population: hospitalized patients, Concept: tools for the investigation of adverse events, and Context: health institutions) carried out in MEDLINE (OVID), EMBASE, LILACS, Scopus, CINAHL, and gray literature. Results: The search totaled 825 scientific productions, 31 of which met the objective of the study, which consisted of 27 scientific articles and 4 expert consensus. It was possible to carry out a synthesis of the necessary steps for the investigation of adverse events and use of the tools according to the extent of damage. Conclusion: The practice of investigating adverse events should be guided by a thorough understanding of contributing factors, a fair culture, and the involvement of senior leadership.

RESUMEN Objetivo: Mapeo en la literatura de las herramientas de la gestión de riesgo con énfasis en la investigación de eventos adversos en salud. Método: Revisión de alcance según Joanna Brigss Institute con el acrónimo PCC (Población: pacientes ingresados, Concepto: herramientas para la investigación de eventos adversos y Contexto: instituciones de salud) realizada en las bases de datos MEDLINE (OVID), EMBASE, LILACS, Scopus, CINAHL y literatura gris. Resultados: La búsqueda llegó a un total de 825 producciones científicas, siendo que 31 lograron el objetivo del estudio, el cual fue compuesto por 27 artículos científicos y 4 consensos de expertos. Fue posible realizar una síntesis de las etapas necesarias para la investigación de eventos adversos y utilización de las herramientas de acuerdo con el grado del daño. Conclusión: La práctica de investigación de eventos adversos deberá pautarse en la comprensión exhaustiva de los factores contribuyentes, cultura justa e involucramiento de alto liderazgo.

RESUMO Objetivo: Mapear na literatura as ferramentas da gestão de risco voltadas para investigação de eventos adversos na saúde. Método: Revisão de escopo segundo o Joanna Brigss Institute, com acrônimo PCC (População: pacientes internados, Conceito: ferramentas para a investigação de eventos adversos e Contexto: instituições de saúde), realizada nas bases MEDLINE (OVID), EMBASE, LILACS, Scopus, CINAHL e literatura cinzenta. Resultados: A busca totalizou 825 produções científicas, sendo que 31 atenderam o objetivo do estudo, sendo composta por 27 artigos científicos e 4 consensos de especialistas. Foi possível realizar uma síntese das etapas necessárias para a investigação de eventos adversos e utilização das ferramentas de acordo com o grau do dano. Conclusão: A prática de investigação de eventos adversos deverá ser pautada na compreensão exaustiva dos fatores contribuintes, cultura justa e envolvimento da alta liderança.

Notificações de incidentes relacionados à segurança do paciente em hospital universitário sentinela / Notificaciones de incidentes relacionados con la seguridad del paciente en un hospital universitario centinela / Notifications of incidents related to patient safety in a sentinel university hospital

RESUMO Objetivo: analisar as notificações de incidentes relacionados à segurança do paciente em hospital universitário público sentinela. Método: Pesquisa retrospectiva, quantitativa, realizada em hospital universitário localizado no Sul do Brasil. Foram analisadas 760 notificações de incidentes ocorridos nos anos de 2015 a 2017 encaminhadas ao setor de gerência de risco da instituição. Os dados foram coletados de maio a agosto de 2018. A análise estatística descritiva se realizou com o auxílio do Statistical Package for the Social Sciences versão 20.0. Resultados: os incidentes notificados foram lesão por pressão (64,0%), seguida de quedas (25,0%), erro de medicação (9,7%), identificação incorreta do paciente (1,0%) e incidentes nos procedimentos cirúrgicos (0,3%). O período matutino, profissional enfermeiro e a unidade de terapia intensiva adulto foram os que mais realizaram as notificações. O evento adverso mais notificado estava relacionado ao erro de medicação (50,7%) seguido de quedas (26,8%). Conclusão: os resultados deste estudo contribuem para aumentar o interesse na análise dos dados de incidentes e eventos adversos, bem como para definir ou refinar as estratégias de melhoria da segurança do paciente.

RESUMEN Objetivo: analizar las notificaciones de incidentes relacionados con la seguridad del paciente en hospital universitario público centinela. Método: investigación retrospectiva, cuantitativa, realizada en hospital universitario ubicado en el Sur de Brasil. Se analizaron 760 notificaciones de incidentes ocurridos en los años 2015 a 2017 dirigidas al sector de gestión de riesgos de la institución. Los datos se recopilaron de mayo a agosto de 2018. El análisis estadístico descriptivo se realizó con la ayuda del Statistical Package for the Social Sciences versión 20.0. Resultados: los incidentes notificados fueron lesión por presión (64,0%), seguida de caídas (25,0%), error de medicación (9,7%), identificación incorrecta del paciente (1,0%) e incidentes en los procedimientos quirúrgicos (0,3%). Los que más realizaron las notificaciones fueron el profesional enfermero, período matutino y la unidad de cuidados intensivos adulto. El evento adverso más notificado estaba relacionado con el error de medicación (50,7%) seguido de caídas (26,8%). Conclusión: los resultados de este estudio contribuyen a aumentar el interés en el análisis de los datos de incidentes y eventos adversos, así como para definir o refinar las estrategias de mejora de la seguridad del paciente.

ABSTRACT Objective: to analyze the notifications of incidents related to patient safety in a sentinel public university hospital. Method: retrospective, quantitative research conducted in a university hospital located in southern Brazil. It analyzed 760 notifications of incidents that occurred in the years 2015 to 2017 forwarded to the risk management sector of the institution. Data was collected from May to August 2018. Descriptive statistical analysis was performed using the Statistical Package for the Social Sciences version 20.0. Results: the incidents reported were pressure ulcers (64.0%), followed by falls (25.0%), medication errors (9.7%), incorrect patient identification (1.0%) and incidents in surgical procedures (0.3%). The morning period, nursing professionals and adult intensive care unit were the ones that made the most notifications. The most reported adverse event was related to medication error (50.7%) followed by falls (26.8%). Conclusion: the results of this study contribute to increasing interest in the analysis of incident and adverse event data, and to defining or refining strategies to improve patient safety.