Test-Retest Reliability of an Experienced Global Trigger Tool Review Team.

OBJECTIVES: During a comprehensive patient safety program at a 550-bed regional hospital in the Capital Region of Denmark, we observed an unexpected and unexplained doubling of the median patient harm rate from 56 to 109 harms per 1000 patient days measured by the Institute for Healthcare Improvement Global Trigger Tool (GTT). Meanwhile, other measures of patient safety, including hospital standardized mortality ratio, were stable or improving. Moreover, the review team was very experienced and stable during this period. Thus, we hypothesized that the increase in harm rate was not a true reflection of increased risk of patient harm but the result of the team getting better at identifying harms during GTT reviews. METHODS: We examined the ability of the GTT review team to reproduce the rate of harm of two separate periods in the same hospital: period 1 (January-June 2010) and period 2 (October 2011-March 2012). For each period, we examined two samples: the original sample that was drawn and used for the ongoing monitoring of harm at the hospital during the safety campaign and a second that we drew and analyzed for this study. RESULTS: We found increased harm rates both between review 1 and review 2 and between period 1 and period 2. The increase was solely in category E, minor temporary harm. CONCLUSIONS: The very experienced GTT team could not reproduce harm rates found in earlier reviews. We conclude that GTT in its present form is not a reliable measure of harm rate over time.

Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.

INTRODUCTION: Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. METHOD: Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. RESULTS: Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. CONCLUSION: With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.

INTRODUCTION: Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. METHOD: Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. RESULTS: Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. CONCLUSION: With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

Computerised Physician Order Entry (CPOE).

The purpose of this study is to examine how everyday use of the Computerised Physician Order Entry (CPOE) system in the Capital Region of Denmark has led to medication errors. The study is based on clinicians' reporting of patient safety incidents. It was found that the immediate causes of the patient safety incidents primarily relates to a) a mismatch between clinical work routines and the structure of the CPOE system, b) the complexity of the user interface, and c) lack of barriers against commonly occurring, severe errors in some areas of the CPOE system. The following was concluded: A well designed CPOE system should be intuitive, provide barriers against serious mistakes, and make the correct choice an easy one. Furthermore it was concluded that it is important that the CPOE system closely supports accepted clinical work routines and that risk assessment is performed prior to implementing new design or functionality.

Human factors methods to support the experts' review of automatically detected adverse drug events.

The European project Patient Safety through Intelligent Procedures in Medication (PSIP) aims at semi-automatically identifying and preventing Adverse Drug Events (ADEs). Data mining of the structured hospital data bases provides a list of potential ADEs, along with their frequencies and probabilities. Once a set of ADEs has been detected by data mining techniques, it is necessary to have them validated by human experts. This paper presents the methods used to support the review by clinicians and pharmacologists of these automatically detected ADEs. We use think-aloud methods and portable labs to track and record the experts reasoning and their reviewing cognitive procedures. We present preliminary results obtained with this method, which allows identifying the key data and information used to characterize the ADEs.

[Statistical process control in healthcare]. / Statistisk processtyring i sundhedsvaesenet.

Statistical process control (SPC) is a branch of statistical science which comprises methods for the study of process variation. Common cause variation is inherent in any process and predictable within limits. Special cause variation is unpredictable and indicates change in the process. The run chart is a simple tool for analysis of process variation. Run chart analysis may reveal anomalies that suggest shifts or unusual patterns that are attributable to special cause variation.

[Reporting of patient safety incidents: experience from five years with a national reporting system]. / Rapportering af utilsigtede haendelser: fem års erfaringer med et nationalt rapporteringssystem.

A national reporting system for patient safety incidents (PSI) was introduced in Denmark in 2004. This article describes the experience of the first five years of reporting. The Danish reporting system has the following characteristics: Reporting is mandatory for all healthcare professionals employed at hospitals; reporting is confidential with an option for anonymous reporting; reporting takes place in a non-punitive system. It is concluded that PSI reporting is an important element of a mature safety culture and an important source for qualitative data on an organization's patient safety performance.

[Infusion pumps and patient safety]. / Infusionspumper og patientsikkerhed.

INTRODUCTION: Infusion pumps are important clinical tools where controlled and precise infusions are needed. However, there are a number of potential risks for patient safety in their use: There is a risk of free-flow, i.e. an uncontrolled infusion that may have fatal consequences to the patient; staff is often poorly trained to use these devices, and often the devices themselves do not offer much support in this regard. MATERIAL AND METHODS: Technical and organisational data regarding the use of infusion pumps in the hospitals of the Copenhagen Hospital Corporation (CHC) were collected and analysed. Critical incidents reported to the CHC Incident Database were analysed. RESULTS: Forty-two different infusion pumps are in use by the five CHC hospitals. There was a total of 919 volumetric infusion pumps, 71% having set-based free-flow protection. Critical incidents were in 40% of cases caused by user-error, the most common being setting an incorrect infusion rate. Discontinuation of the infusion was reported in 27% of incident reports, the causes being disconnection or kinking of the infusion line; this resulted in two cases of awareness under anaesthesia. CONCLUSION: Centralising the decision process for procurement and establishing a central library of standardised equipment might well reduce patient safety risks and any under-use of equipment. Usability testing prior to procurement decisions is vital; such testing should be performed by validated methods and not simply by putting the pumps to test in a clinical setting. More knowledge about user-friendly designs of medical equipment is needed.

[Wrong-site surgery: incidence and prevention]. / Forvekslingsindgreb: forekomst og forebyggelse.

INTRODUCTION: This paper illustrates how reporting of adverse events can be used to introduce changes in an organization. Starting from reports of incidents on wrong-site surgery, a method to prevent them and its implementation in the Copenhagen Hospital Corporation (H:S) are described. MATERIALS AND METHODS: The H:S adverse event database, the Danish Patient Insurance Association and international sources were searched to estimate the extent of wrong-site surgery. A method to prevent wrong-site surgery developed by the U.S. Department of Veterans Affairs was adapted for Danish conditions. It was introduced as "The Five Steps" in H:S in May 2005, accompanied by an information campaign. RESULTS: Wrong-site surgery incidents are rare: reports in the H:S show an occurrence of 1:32,500 surgical procedures, consistent with international figures. Seven root cause analyses were performed and showed a need for a more structured identification and communication process among the members of the operating team. The Five Steps were designed to prevent such problems. None of the Five Steps is in itself new or revolutionary. The crucial parts are systematization of the identification process and increased communication among the members of the operating team. The procedure is not associated with substantial resource utilization and involves more a change in culture than an investment. The method can be widely implemented in hospitals in Denmark without major changes. CONCLUSION: Wrong-site surgery is a rare but serious adverse event. This paper describes the results of root cause analyses after reports of incidents in the H:S. The analyses showed a need for better and more structured communication and identification of patients before surgical intervention.