Patient safety incident reporting behavior and its associated factors among healthcare professionals in Hadiya zone, Ethiopia: A facility based cross-sectional study.

Background: Incidents affecting patient safety can cause unnecessary injury to a patient. It is generally accepted that incident reporting can improve patient safety. In Ethiopian public hospitals, especially in the Hadiya zone, patient safety-related incidents are commonly witnessed, but there is no evidence of reporting behavior among healthcare professionals. Purpose: This study aimed to assess patient safety incident reporting behavior and its associated factors among healthcare professionals working in public hospitals in the Hadiya zone, South Nation's, Nationalities, and Peoples' Region, Ethiopia, in 2021. Method: A cross-sectional study design was employed, among 345 healthcare professionals working in public hospitals in the Hadiya zone from August 1-30, 2021. A simple random sampling technique was used to select study participants, and a structured self-administered questionnaire which is adapted from a Hospital survey on patient safety survey and literature was used to collect the data. The data were entered into a data attraction template prepared using the Epi data software and then exported to the SPSS version 25 software for analysis. Descriptive analyses were conducted to determine the general characteristics and distributions of the data collected. An inferential statistical analysis was conducted using the logistic regression model to identify associations between outcome and predictor variables. The odds ratio with the 95 % confidence interval was used to test the associations between the outcome variable and predictor variables. Finally, statistical significance was set at p-value < 0.05. Results: From the total of 354 healthcare professionals expected, 334 participants, which gave a response rate of 94.4 %, had completed and returned the questionnaire. The result shows that overall patient safety incident reporting behavior among healthcare professionals was 28.7 % (95 % Confidence Interval (CI): (24.6, 33.2). Being a nurse professional [Adjusted Odd Ratio (AOR): 5.48, 95 % CI: (1.67, 17.80)], having job training [AOR: 2.87, 95 % CI: (1.46, 6.28)], having a team within the units [AOR=2.79, 95 %CI: (1.23, 6.28)], communication openness [AOR=2.78, 95 %CI: (1.44, 5.37)], and management support [AOR=2.8, 95 %CI; (1.40, 5.60)] were found to factor significantly associated with patient safety incident reporting behaviour. Conclusion: This study revealed that the incident-reporting behavior among healthcare professionals was low compared to previous studies. Being a nurse professional, having an on -job training, having a team within the unit, communication openness, perception of the time reporting takes, fear of administration sanction and management support were factors associated with their patient safety incident reporting behavior. Managers should focus on patient safety incidents, prepare continuous training programs, and provide open communication to improve patient safety incident reporting.

Health Workers' Perspective on Patient Safety Incident Disclosure in Indonesian Hospitals: A Mixed-Methods Study.

Purpose: This study examined how health staff in Indonesian hospitals perceived open disclosure of patient safety incidents (PSIs). Patients and Methods: This study employed a mixed method explanatory sequential approach. We surveyed 262 health workers and interviewed 12 health workers. Descriptive statistical (frequency distributions and summary measures) analysis was performed to assess the distributions of variables using SPSS. We used thematic analysis for the qualitative data analysis. Results: We discovered a good level of open disclosure practice, open disclosure system, attitude toward open disclosure and process, open disclosure according to the level of harm resulting from PSIs in the quantitative phase. The qualitative phase revealed that most participants were confused about the difference between incident reporting and incident disclosure. Furthermore, the quantitative and qualitative analyses revealed that major errors or adverse events should be disclosed. The contradictory findings may be due to a lack of awareness of incident disclosure. The important factors in disclosing the incident are effective communication, type of incident, and patient and family characteristics. Conclusion: Open disclosure is novel for Indonesian health professionals. A good open disclosure system in hospitals could address several issues such as lack of knowledge, lack of policy support, lack of training, and lack of policy. To limit the negative implications of disclosing situations, the government should develop supportive policies at the national level and organize many initiatives at the hospital level.

Healthcare Students and Medical Residents as Second Victims: A Cross-Sectional Study.

BACKGROUND: The term second victim (SV) describes healthcare professionals who remain traumatized after being involved in a patient safety incident (PSI). They can experience various emotional, psychological, and physical symptoms. The phenomenon is quite common; it has been estimated that half of hospital workers will be an SV at least once in their career. Because recent literature has reported high prevalence (>30%) among nursing students, we studied the phenomenon among the whole population of healthcare students. METHODS: We conducted a cross-sectional study with an online questionnaire among nursing students, medical students, and resident physicians at the teaching hospital of the University of the Piemonte Orientale located in Novara, Italy. The study included 387 individuals: 128 nursing students, 174 medical students, and 85 residents. RESULTS: We observed an overall PSI prevalence rate of 25.58% (lowest in medical students, 14.37%; highest in residents, 43.53%). Of these, 62.63% experienced symptoms typical of an SV. The most common temporary symptom was the feeling of working badly (51.52%), whereas the most common lasting symptom was hypervigilance (51.52%). Notably, none of the resident physicians involved in a PSI spoke to the patient or the patient's relatives. CONCLUSION: Our findings highlighted the risk incurred by healthcare students of becoming an SV, with a possible significant impact on their future professional and personal lives. Therefore, we suggest that academic institutions should play a more proactive role in providing support to those involved in a PSI.

Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety.

OBJECTIVES: The reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported. METHODS: All voluntary reports of MITS-related PSIs were retrospectively extracted from the French REX database for 'in-depth analysis'. From 2008 to 2019, we retrospectively analysed and graded events according to the WHO classification of PSIs: near miss events, no harm incidents and harmful incidents. Causes and corrective measures were analysed according to the human-technology-organization triad. RESULTS: Of the 5145 cardiothoracic surgery PSIs declared, 407 were related to MITS. Among them, MITS was performed for primary lung cancer in 317 (78%) and consisted in a lobectomy in 249 (61%) patients. PSIs were: near miss events in 42 (10%) patients, no harm incidents in 81 (20%) patients and harmful incidents in 284 (70%) patients (mild: n = 163, 40%; moderate: n = 78, 19%; severe: n = 36, 9%; and deaths: n = 7, 2%). Human factors represented the most important cause of PSIs with 267/407 (65.6%) cases, including mainly vascular injuries (n = 90; 22%) and non-vascular injuries (n = 43; 11%). Pulmonary arteries were the most affected site with 57/91 cases (62%). In all, there were 7 deaths (2%), 53 patients required second surgery (13%) and 30 required additional lung resection (7%). CONCLUSIONS: The majority of reported MITS -related PSIs were non-catastrophic. Human factors were the main cause of PSIs. Systematic reporting and analysis of these PSIs will allow surgeon and his team to avoid a large proportion of them.

A Discrete Choice Experiment to Elicit General Population Preferences Around the Factors Influencing the Choice to Make Clinical Negligence Claims.

OBJECTIVES: This article determines public stated preferences around different factors that influence the choice to make clinical negligence claims against a national healthcare system. METHODS: A large online survey was conducted using a discrete choice experiment (DCE) with the UK general population (N = 1013). DCE tasks involved a single profile and participants chose whether to make a claim for compensation (yes/no) after one of 3 randomly allocated patient safety incident (PSI) "scenarios" of different severities (mild, moderate, severe). DCE attributes described the actions of the healthcare system after a PSI and characteristics of the clinical negligence claims process. The data were modeled separately for each scenario (mild, moderate, severe) using logistic regression. Marginal effects and the probability of making a claim in a baseline case were estimated. RESULTS: Probability of choosing to claim was reduced by receipt of an apology, investigation and prevention of recurrence of the PSI, and longer time until claim decision and increased by an easy and straightforward claims process and high chance of compensation and for the mild scenario higher compensation amounts. Marginal effects and baseline case probabilities differed by scenario severity. CONCLUSIONS: The results suggest the actions of the healthcare system after a PSI and characteristics of the claims process have a larger impact on the probability of making a claim for milder PSIs. For more severe PSIs, a larger probability of making a claim was observed, and the choice was less influenced by the actions of the healthcare system after the PSI and characteristics of the claims process.

Profiles of second victim symptoms and desired support strategies among Korean nurses: A latent profile analysis.

AIMS: To clarify second victim symptoms subgroups, explore the factors affecting profile membership and determine how desired support strategies differ between the subgroups. DESIGN: A cross-sectional study using an online survey. METHODS: A total of 378 Korean staff nurses directly involved in patient safety incidents were recruited between December 2019 and February 2020. Data analyses consisted of latent profile analysis, multinomial logistic regression and analysis of variance. RESULTS: Three latent profiles were identified: 'mild symptoms', 'moderate symptoms' and 'severe symptoms'. Lower organizational support and higher non-work-related support were more likely to belong to the severe symptoms' profile. Incidents that caused temporary harm to the patient were more strongly associated with an increased likelihood of belonging to the moderate and severe symptoms profiles than no-harm events. Participants with severe symptoms agreed more with the usefulness of the support strategies than other participants; the usefulness of the psychological support strategies was rated particularly high. Participants in the mild and moderate symptoms groups agreed more strongly with the usefulness of coping strategies following patient safety incidents than psychological support. The strategy that all profiles considered the most useful was having the opportunity to take time away from clinical duties. CONCLUSION: Tailored support should be provided to nurses with factors influencing the profile membership and subgroups of second victim symptoms. IMPACT: This study confirmed the need to provide organizational support to nurses as second victims and provided valuable evidence for developing support programs tailored to the subgroups of second victim symptoms.

Creating sustained and positive changes to patient safety: reducing insulin administration errors in a district nursing service.

Administering insulin in a patient's own home is perceived as a simple nursing intervention, and one that is regularly delegated to newly qualified staff, agency and bank staff. However, without robust processes and clear, easy-to-follow nursing documentation in place, a simple nursing intervention can easily lead to an avoidable medication error and patient safety incident. This article describes the steps one trust has taken to combat insulin administration incidents. The article describes the use of a Plan, Do, Study, Act (PDSA) cycle to help test changes and roll out sustainable transformation. It describes some of the challenges faced, alongside the solutions tested and embedded into practice.

Risk Factors for Anesthesia-Related Airway Patient Safety Incidents: A Single-Center Retrospective Case-Control Analysis from 2009 to 2022.

Objective Airway-related patient safety incident (PSI) has always been the top concern of anesthesiologists because this type of incidents could severely threaten patient safety if not treated immediately and properly. This study intends to reveal the composition, prognosis, and to identify risk factors for airway related incidents reported by anesthesiologists. Methods All airway related PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and May 2022 were collected from the PSI reporting system. Patients with airway incidents reported were matched 1:1 with controls based on sex and type of surgery. Univariable and multivariable analysis were performed to find risk factors associated with airway incident occurrence, and to evaluate influence of airway PSIs on patient prognosis. Results Among 1,038 PSIs voluntarily reported by anesthesiologists during the study period, 281 cases (27.1%) were airway-related incidents, with an overall reporting incidence of 4.74 per 10,000 among 592,884 anesthesia care episodes. Only ASA physical status was found to be significant independent predictor of these airway PSIs (P = 0.020). Patients with airway PSIs reported had longer extubation time (0.72 ± 1.56 d vs. 0.16 ± 0.77 d, 95%CI: 0.29 to 0.82, P < 0.001), longer ICU length of stay (LOS) (1.63 ± 5.71 d vs. 0.19 ± 0.84 d, 95%CI: 0.57 to 2.32, P= 0.001), longer post operative LOS (10.56 ± 13.09 d vs. 7.59 ± 10.76 d, 95%CI: 0.41 to 5.53, P = 0.023), and longer total in-hospital LOS (14.99 ± 15.18 d vs. 11.62 ± 11.88 d, 95%CI: 0.46 to 6.27,P = 0.024). Conclusions This single-center retrospective case-control study describes the composition of airway-related PSIs reported by anesthesiologists within thirteen years. Airway incidents might influence patient prognosis by elongating extubation time and LOS. Airway PSI data were worth analyzing to improve patient safety.

Risk Factors for Anesthesia-Related Airway Patient Safety Incidents: A Single-Center Retrospective Case-Control Analysis from 2009 to 2022 / 中国医学科学杂志(英文版)

Objective Airway-related patient safety incident (PSI) has always been the top concern of anesthesiologists because this type of incidents could severely threaten patient safety if not treated immediately and properly. This study intends to reveal the composition, prognosis, and to identify risk factors for airway related incidents reported by anesthesiologists. Methods All airway related PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and May 2022 were collected from the PSI reporting system. Patients with airway incidents reported were matched 1:1 with controls based on sex and type of surgery. Univariable and multivariable analysis were performed to find risk factors associated with airway incident occurrence, and to evaluate influence of airway PSIs on patient prognosis. Results Among 1,038 PSIs voluntarily reported by anesthesiologists during the study period, 281 cases (27.1%) were airway-related incidents, with an overall reporting incidence of 4.74 per 10,000 among 592,884 anesthesia care episodes. Only ASA physical status was found to be significant independent predictor of these airway PSIs (P = 0.020). Patients with airway PSIs reported had longer extubation time (0.72 ± 1.56 d vs. 0.16 ± 0.77 d, 95%CI: 0.29 to 0.82, P < 0.001), longer ICU length of stay (LOS) (1.63 ± 5.71 d vs. 0.19 ± 0.84 d, 95%CI: 0.57 to 2.32, P= 0.001), longer post operative LOS (10.56 ± 13.09 d vs. 7.59 ± 10.76 d, 95%CI: 0.41 to 5.53, P = 0.023), and longer total in-hospital LOS (14.99 ± 15.18 d vs. 11.62 ± 11.88 d, 95%CI: 0.46 to 6.27,P = 0.024). Conclusions This single-center retrospective case-control study describes the composition of airway-related PSIs reported by anesthesiologists within thirteen years. Airway incidents might influence patient prognosis by elongating extubation time and LOS. Airway PSI data were worth analyzing to improve patient safety.

Characteristics of Patient Safety Incident Occurrences Reported by Japanese Homecare Nurses: A Prospective Observational Study.

Patient safety incidents (PSIs) prevention is important in healthcare because PSIs affect patients negatively and increase medical costs and resource use. However, PSI knowledge in homecare is limited. To analyze patient safety issues and strategies, we aimed to identify the characteristics and contexts of PSI occurrences in homecare settings. A prospective observational study was conducted between July and November 2017 at 27 Japanese homecare nurse (HCN) agencies. HCNs at each agency voluntarily completed PSI reports indicating whether they contributed to PSIs or were informed of a PSI by the client/informal caregiver/other care provider during a period of three months. A total of 139 PSIs were analyzed, with the most common being falls (43.9%), followed by medication errors (25.2%). Among the PSIs reported to the HCN agencies, 44 were recorded on formal incident report forms, whereas 95 were reported as PSIs that required a response (e.g., injury care) but were not recorded on formal incident report forms. Most PSIs that occurred when no HCN was visiting were not recorded as incident reports (82.1%). Developing a framework/system that can accumulate, analyze, and share information on PSIs that occur in the absence of HCNs may provide insights into PSIs experienced by HCN clients.

How safe is prehospital care? A systematic review.

BACKGROUND: As compared to other domains of healthcare, little is known about patient safety incidents (PSIs) in prehospital care. The aims of our systematic review were to identify how the prevalence and level of harm associated with PSIs in prehospital care are assessed; the frequency of PSIs in prehospital care; and the harm associated with PSIs in prehospital care. METHOD: Searches were conducted of Medline, Web of Science, PsycInfo, CINAHL, Academic Search Complete and the grey literature. Reference lists of included studies and existing related reviews were also screened. English-language, peer-reviewed studies reporting data on number/frequency of PSIs and/or harm associated with PSIs were included. Two researchers independently extracted data from the studies and carried out a critical appraisal using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). RESULTS: Of the 22 included papers, 16 (73%) used data from record reviews, and 6 (27%) from incident reports. The frequency of PSIs in prehospital care was found to be a median of 5.9 per 100 records/transports/patients. A higher prevalence of PSIs was identified within studies that used record review data (9.9 per 100 records/transports/patients) as compared to incident reports (0.3 per records/transports/patients). Across the studies that reported harm, a median of 15.6% of PSIs were found to result in harm. Studies that utilized record review data reported that a median of 6.5% of the PSIs resulted in harm. For data from incident reporting systems, a median of 54.6% of incidents were associated with harm. The mean QATSDD score was 25.6 (SD = 4.1, range = 16-34). CONCLUSIONS: This systematic review gives direction as to how to advance methods for identifying PSIs in prehospital care and assessing the extent to which patients are harmed.

Second victim phenomenon after patient safety incidents among Korean nursing students: A cross-sectional study.

BACKGROUND: Perfectionism in the medical field turns healthcare professionals into second victims of patient safety incidents. They suffer physically and psychologically, which makes them consider changing occupations. Nursing students may also have similar negative experiences during clinical practice. OBJECTIVE: To describe the second victim phenomenon among nursing students after patient safety incidents during their clinical practice. DESIGN: A descriptive cross-sectional study using an online questionnaire. SETTING AND PARTICIPANTS: Fourth-year nursing students (n = 354) who encountered patient safety incidents directly or indirectly during clinical practice. Participants were recruited through convenience and snowball sampling methods using personal contacts, professional networks, and online platforms. METHODS: The questionnaire addressed the characteristics of patient safety incidents, and physical and psychological responses after the most significant patient safety incident. Descriptive statistics and a chi-square test were performed for data analysis. RESULTS: Of the participants, 22.6% were directly involved in patient safety incidents and 77.4% had indirectly encountered patient safety incidents, such as witnessing incidents with colleagues or other healthcare professionals. After patient safety incidents, of those, 67.8% experienced shock at the time of the incident, 47.2% feared experiencing a similar incident, and 28.2% were still affected although time had passed. Additionally, 26.3% reported experiencing long-term embitterment; of them, 7.3% were experiencing severe embitterment. Furthermore, 31.9% and 27.1% of the students experienced sleeping and eating difficulties, respectively, and these rates were higher when incidents were encountered directly rather than indirectly. CONCLUSIONS: Nursing students may become second victims of patient safety incidents during clinical practice. Therefore, nursing education institutions need to develop comprehensive support strategies to help nursing students cope with experiencing the second victim phenomenon.

Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care.

BACKGROUND: The COVID-19 pandemic has resulted in the rapid reorganisation of health and social care services. Patients are already at significant risk of healthcare-associated harm and the wholesale disruption to service delivery during the pandemic stood to heighten those risks. OBJECTIVES: We explored the type and nature of patient safety incidents in French primary care settings during the COVID-19 first wave to make tentative recommendations for improvement. METHODS: A national patient safety incident reporting survey was distributed to General Practitioners (GPs) in France on 28 April 2020. Reports were coded using a classification system aligned to the WHO International Classification for Patient Safety (incident types, contributing factors, incident outcomes and severity of harm). Analysis involved data coding, processing, iterative generation of data summaries using descriptive statistical analysis. Clinicaltrials.gov: NCT04346121. RESULTS: Of 132 incidents, 58 (44%) related to delayed diagnosis, assessments and referrals. Cancellations of appointments, hospitalisations or procedures was reported in 22 (17%) of these incidents. Home confinement-related incidents accounted for 13 (10%) reports and inappropriate medication stopping for five (4%). Patients delayed attending or did not consult their general practitioner or other healthcare providers due to their fear of contracting COVID-19 infection at an in-person visit in 26 (10%) incidents or fear of burdening their GPs in eight (3%) incidents. CONCLUSION: Constraints from the first wave of the COVID-19 pandemic have contributed to patient safety incidents during non-COVID-19 care. Lessons from these incidents pinpoint where primary care services in France can focus resources to design safer systems for patients.

Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: An exploratory cross-sectional study.

BACKGROUND: A patient safety incident (PSI) is considered to have an impact on nursing students. Healthcare professionals often feel personally responsible for the unexpected patient outcome and feel as though they have failed their patient. In this way they may become second victims of the incident. Little is known about possible initiatives from hospitals or teaching institutions regarding the support of their students involved in a PSI. AIM: The study aims to examine the prevalence, symptoms and support in the aftermath of a PSI in baccalaureate nursing students. METHODS: A cross-sectional study in four teaching institutions for baccalaureate education across eleven campuses in Belgium. Students completed an online survey between February 2018 and March 2018. RESULTS: About one in three (38.4%) students were involved in a PSI during their clinical experience. Of these, 84.7% experienced second victim symptoms. Most common symptoms were hypervigilance (65.7%), stress (42.5%) and doubting knowledge and skills (40.6%). Besides negative effects, the PSI also led to a more positive attitude. Students expect most support and room for open discussion from staff nurses (80.8%). CONCLUSION: Nursing students may already become second victims during their education. PSIs have a major impact on their performance and personal life. Students have the right for a decent treatment, respect, understanding and compassion, support, transparency and the opportunity to contribute to improving procedures. Teaching institutions should therefore bear the responsibility to prepare students of the probability of the occurrence of PSIs during their clinical experience.

Second victim support structures in anaesthesia: a cross-sectional survey in Belgian anaesthesiologists.

BACKGROUND: Anaesthesiologists are prone to patient safety situations after which second victim symptoms can occur. In international literature, a majority of these second victims indicated that they were emotionally affected in the aftermath of a patient safety incident (PSI) and received little institutional support after these events. OBJECTIVE: To study the current second victim support structures in anaesthesia departments in Belgium. METHODS: An observational cross-sectional survey. Belgian anaesthesiologists and anaesthesiologists in training were contacted through e-mail from May 27th until 15 July 2020. RESULTS: In total, 456 participants completed the online survey. 73.7% (n = 336) of the participants encountered a PSI during the last year of their medical practice. 80.9% (n = 368) of respondents answered that they do discuss incidents with their colleagues. 18.0% (n = 82) discussed all incidents. 19.3% (n = 88) admitted that these incidents are never discussed in their department. 15.4% of participants (n = 70) experienced or thought that the culture is negative during these PSI discussions. 17.3% (n = 79) scored the culture neutral. Anaesthesiologists who encountered a PSI in the last years scored the support of their anaesthesia department a mean score of 1.59 (ranging from -10 to +10). A significant correlation (P < 0.05) was found between the culture during the morbidity and mortality meetings, the support after the incidents and the perceived quality of the anaesthesia department. CONCLUSION: Of the participating anaesthesiologist in Belgium, 80.9% discussed some PSIs and 18.0% discussed all PSIs as a normal part of their staff functioning with an experienced positive or neutral culture during these meetings in 84.6%. Psychological safety within the anaesthesiology departments is globally good; however, it could and should be optimized. This optimization process warrants further investigations in the future.

Incidentes de segurança do paciente na Atenção Primária à Saúde (APS) de Manaus, AM, Brasil / Patient safety incidents in Primary Healthcare in Manaus, AM, Brazil / Incidentes de seguridad del paciente en la Atención Primaria de la Salud de Manaus, AM, Brasil

A expressão "segurança do paciente" refere-se à redução a um nível mínimo aceitável do risco de dano desnecessário associado ao cuidado em saúde. Estudos internacionais indicam uma ocorrência de dois a três incidentes de segurança do paciente por 100 consultas na APS, com frequência similar no Brasil. Realizamos um estudo descritivo para identificar incidentes de segurança do paciente na APS de Manaus, AM, Brasil, em 2018, mediante notificações voluntárias de médicos selecionados por amostragem por conveniência. As 105 notificações coletadas permitiram calcular uma incidência de três incidentes de segurança por 1.000 atendimentos no trimestre estudado. Em 82% dos incidentes, houve envolvimento do usuário. Em 39 notificações (37%), houve registro de dano, sendo 33% de dano mínimo, 17% de dano moderado e dois óbitos. Os resultados implicam no incentivo a ações de educação em saúde sobre o tema voltadas aos usuários.(AU)

Patient safety means reducing the risk of unnecessary healthcare-associated damage to a minimum acceptable level. International studies show an occurrence of 2-3 patient safety incidents per 100 primary healthcare appointments, with similar frequency in Brazil. We conducted a descriptive study to identify patient safety incidents in Primary Healthcare in the Brazilian city of Manaus, state of Amazonas, in 2018, by voluntary notification of doctors selected by convenience sampling. The 105 collected notifications enabled to calculate an incidence of 3 safety incidents per 1,000 appointments in the studied quarter. In 82% of the incidents, the user was involved. In 39 notifications (37%), the damage was recorded—33% of them were minimum, 17% moderate, and 2 deaths. The results imply an incentive to actions of health education on user-related topics.(AU)

La seguridad del paciente es la reducción a un nivel mínimo aceptable de riesgo de daño innecesario asociado al cuidado de salud. Estudios internacionales indican una ocurrencia de dos a tres incidentes de seguridad del paciente por 100 consultas en la Atención Primaria de la Salud (APS), con frecuencia similar en Brasil. Realizamos un estudio descriptivo para identificar incidentes de seguridad del paciente en la APS de Manaus, Estado de Amazonas, en 2018, mediante notificaciones voluntarias de médicos seleccionados por muestreo por conveniencia. Las 105 notificaciones colectadas permitieron calcular una incidencia de tres incidentes de seguridad por 1000 atenciones en el trimestre estudiado. En el 82% de los incidentes hubo envolvimiento del usuario. En 39 notificaciones (37%) hubo registro de daño, siendo el 33% de daño mínimo, el 17% de daño moderado y dos fallecimientos. Los resultados implican en el incentivo a acciones de educación en salud sobre la cuestión, enfocadas en los usuarios.(AU)

Factors contributing to patient safety incidents in primary care: a descriptive analysis of patient safety incidents in a French study using CADYA (categorization of errors in primary care).

BACKGROUND: Patient safety incidents (PSIs) frequently occur in primary care and are often considered to be preventable. Better knowledge of factors contributing to PSIs is required to build safer care. The aim of this work was to describe the underlying factors, specifically the human factors, that are associated with PSIs in primary care using CADYA ("CAtégorisation des DYsfonctionnements en Ambulatoire" or "Categorization of Errors in Primary Care"). METHODS: We followed a mixed method with content analysis and coding in CADYA of PSIs reported in the ESPRIT study, a French cross-sectional survey of primary care. For each incident, a main contributing factor (MD) and, if applicable, a secondary contributing factor (SD) were identified. Several descriptive keywords from an incremental glossary have been suggested to describe each identified human factor (attitudes or behaviours). A descriptive statistical analysis was then conducted. RESULTS: Among the 482 PSIs reported in the ESPRIT study, from 13,438 acts reported by 127 participating general practitioners (GPs), we identified 590 contributing factors (482 MDs and 178 SDs). Overall, 35% were related to the care process, 30% to human factors, 22% to the healthcare environment and 13% to technical factors. The contributing factors, in decreasing order of frequency, were communication errors (13.7%), human factors related to healthcare providers (12.9%) and human factors related to patients (12.9%). The human factors were mainly related to 'lack of attention', 'stress', 'anger' and 'fatigue'. CONCLUSIONS: Our results tend to prove that human factors are often involved in PSIs in primary care, with GPs and patients being equally responsible. Beyond the identification of communication errors, often found in other international research, we have described the attitudes and behaviours contributing to unsafe care. Further research exploring the links between working conditions and human factors is required.

Patient safety incident reports related to traditional Japanese Kampo medicines: medication errors and adverse drug events in a university hospital for a ten-year period.

BACKGROUND: Kampo medicine is traditional Japanese medicine, which originated in ancient traditional Chinese medicine, but was introduced and developed uniquely in Japan. Today, Kampo medicines are integrated into the Japanese national health care system. Incident reporting systems are currently being widely used to collect information about patient safety incidents that occur in hospitals. However, no investigations have been conducted regarding patient safety incident reports related to Kampo medicines. The aim of this study was to survey and analyse incident reports related to Kampo medicines in a Japanese university hospital to improve future patient safety. METHODS: We selected incident reports related to Kampo medicines filed in Toyama University Hospital from May 2007 to April 2017, and investigated them in terms of medication errors and adverse drug events. RESULTS: Out of 21,324 total incident reports filed in the 10-year survey period, we discovered 108 Kampo medicine-related incident reports. However, five cases were redundantly reported; thus, the number of actual incidents was 103. Of those, 99 incidents were classified as medication errors (77 administration errors, 15 dispensing errors, and 7 prescribing errors), and four were adverse drug events, namely Kampo medicine-induced interstitial pneumonia. The Kampo medicine (crude drug) that was thought to induce interstitial pneumonia in all four cases was Scutellariae Radix, which is consistent with past reports. According to the incident severity classification system recommended by the National University Hospital Council of Japan, of the 99 medication errors, 10 incidents were classified as level 0 (an error occurred, but the patient was not affected) and 89 incidents were level 1 (an error occurred that affected the patient, but did not cause harm). Of the four adverse drug events, two incidents were classified as level 2 (patient was transiently harmed, but required no treatment), and two incidents were level 3b (patient was transiently harmed and required substantial treatment). CONCLUSIONS: There are many patient safety issues related to Kampo medicines. Patient safety awareness should be raised to prevent medication errors, especially administration errors, and adverse drug events in Kampo medicine.

Disclosure of patient safety incidents: implications from ethical and quality of care perspectives

In order to improve patient safety, it is important to manage and respond to patient safety incidents that have already occurred. Disclosure of patient safety incidents (DPSI) can be regarded as a prudent strategy, as it has the potential to decrease the number of medical disputes in advance. DPSI is defined as follows: “When a patient safety incident occurs, medical professionals preemptively explain the incident to the patients and their caregivers, express sympathy and regret for the incident, deliver apology and compensation appropriately if needed, and promise to prevent recurrence.” Although DPSI is known to be effective for reducing the number of medical lawsuits, it can be also viewed as reflecting important ethical and quality of care issues. In particular, medical professionals have an ethical imperative to conduct DPSI with the patient, if patient safety incidents have occurred. In this paper, we review the necessity of DPSI from ethical and quality of care perspectives. The ethical basis of DPSI includes autonomy, transparency, trust, and professional standards. Furthermore, DPSI will become inevitable as society comes to emphasize safer and more patient-centered care. In order to make DPSI a routine practice in South Korea, various efforts, such as the development of DPSI guidelines and educational programs, as well as the introduction of an apology law, will be required.