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.

Accelerating patient safety through the innovative use of information technology.

Numerous studies have confirmed that the patient safety challenge remains tangible. Innovative use of healthcare IT (Information Technology) could play a part in the solution, if the costs of development and implementation are weighed against the major potential savings by improving quality and safety. It is suggested through the "Safe Seven"-checklist, that the design of supporting eHealth solutions lends principles from the patient safety and physical design domains.

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.

[Campaigns for patient safety and quality improvement - do they work?]. / Virker kampagner for patientsikkerhed og bedre kvalitet?

The number of published scientific articles has been increasing for several years. Implementation of evidence-based knowledge in clinical practice is, however, lagging behind. Patient safety campaigns suggest that the implementation of best practice can be accelerated. The Danish Operation Life Campaign is based on rests on a model used in the American 100K Lives Campaign in order to achieve this goal. Campaigns suffer from the inability of the methods to prove a relationship between intervention and results. However, from the patients' point of view, any improvement in quality and safety is a success.

[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.