Learning From Incident Reporting? Analysis of Incidents Resulting in Patient Injuries in a Web-Based System in Swedish Health Care.

OBJECTIVES: Incident reporting (IR) systems have the potential to improve patient safety if they enable learning from the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council. METHODS: The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence. RESULTS: Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline. CONCLUSIONS: The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.

Experiences from ten years of incident reporting in health care: a qualitative study among department managers and coordinators.

BACKGROUND: Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care. Using qualitative methods is a way to reveal how IR is used and perceived in health care practice. The aim of the present study was to explore the experiences of IR from two different perspectives, including heads of departments and IR coordinators, to better understand how they value the practice and their thoughts regarding future application. METHODS: Data collection was performed in Östergötland County, Sweden, where an electronic IR system was implemented in 2004, and the authorities explicitly have advocated IR from that date. A purposive sample of nine heads of departments from three hospitals were interviewed, and two focus group discussions with IR coordinators took place. Data were analysed using qualitative content analysis. RESULTS: Two main themes emerged from the data: "Incident reporting has come to stay" building on the categories entitled perceived advantages, observed changes and value of the IR system, and "Remaining challenges in incident reporting" including the categories entitled need for action, encouraged learning, continuous culture improvement, IR system development and proper use of IR. CONCLUSIONS: After 10 years, the practice of IR is widely accepted in the selected setting. IR has helped to put patient safety on the agenda, and a cultural change towards no blame has been observed. The informants suggest an increased focus on action, and further development of the tools for reporting and handling incidents.

High Rate of Implementation of Proposed Actions for Improvement With the Healthcare Failure Mode Effect Analysis Method: Evaluation of 117 Analyses.

OBJECTIVES: The aims of this study were to investigate what kind of impact the Healthcare Failure Mode Effect Analysis (HFMEA) had on the organization in 1 county council in Sweden and to evaluate the method of working for multidisciplinary teams performing HFMEA. Three main outcome measures were used: the quality of the documentation from the HFMEAs, fulfillment of the primary goal of the HFMEA, and, finally, whether proposed actions for improvement were implemented. METHODS: The study involved retrospective analysis of the documentation from 117 performed HFMEAs from 3 hospitals in the county council of Östergötland, Sweden, and interviews or questionnaires with team leaders and managers between 2006 and 2010. RESULTS: A proposed change in the organizational structure was the most common issue in the analyses. Eighty-nine percent of the written reports were of high quality. A median of 10 serious risks were detected, and 10 proposed actions (median) were made. In 78% of the HFMEAs, all or a large part of these had been implemented a few years afterward. We were unable to find factors that promoted the rate of implementation of proposed actions. Seventy-eight percent of the managers were completely satisfied with the results of the HFMEA. The mean cost per risk analysis was &OV0556;1909. CONCLUSIONS: Most of the proposed actions were implemented. The use of HFMEA can be improved using fewer team leaders but with more experience. The work involved in writing a report can be reduced without loss of impact on the organization.

Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: a qualitative study.

BACKGROUND: Patient safety culture emerges from the shared assumptions, values and norms of members of a health care organization, unit, team or other group with regard to practices that directly or indirectly influence patient safety. It has been argued that organizational culture is an amalgamation of many cultures, and that subcultures should be studied to develop a deeper understanding of an organization's culture. The aim of this study was to explore subcultures among registered nurses and nurse assistants in Sweden in terms of their assumptions, values and norms with regard to practices associated with patient safety. METHODS: The study employed an exploratory design using a qualitative method, and was conducted at two hospitals in southeast Sweden. Seven focus group interviews and two individual interviews were conducted with registered nurses and seven focus group interviews and one individual interview were conducted with nurse assistants. Manifest content analysis was used for the analysis. RESULTS: Seven patient safety culture domains (i.e. categories of assumptions, values and norms) that included practices associated with patient safety were found: responsibility, competence, cooperation, communication, work environment, management and routines. The domains corresponded with three system levels: individual, interpersonal and organizational levels. The seven domains consisted of 16 subcategories that expressed different aspects of the registered nurses and assistants nurses' patient safety culture. Half of these subcategories were shared. CONCLUSIONS: Registered nurses and nurse assistants in Sweden differ considerably with regard to patient safety subcultures. The results imply that, in order to improve patient safety culture, efforts must be tailored to both registered nurses' and nurse assistants' patient safety-related assumptions, values and norms. Such efforts must also take into account different system levels. The results of the present study could be useful to facilitate discussions about patient safety within and between different professional groups.

Factors influencing patient safety in Sweden: perceptions of patient safety officers in the county councils.

BACKGROUND: National, regional and local activities to improve patient safety in Sweden have increased over the last decade. There are high ambitions for improved patient safety in Sweden. This study surveyed health care professionals who held key positions in their county council's patient safety work to investigate their perceptions of the conditions for this work, factors they believe have been most important in reaching the current level of patient safety and factors they believe would be most important for achieving improved patient safety in the future. METHODS: The study population consisted of 218 health care professionals holding strategic positions in patient safety work in Swedish county councils. Using a questionnaire, the following topics were analysed in this study: profession/occupation; number of years involved in a designated task on patient safety issues; knowledge/overview of the county council's patient safety work; ability to influence this work; conditions for this work; and the importance of various factors for current and future levels of patient safety. RESULTS: The response rate to the questionnaire was 79%. The conditions that had the highest number of responses in complete agreement were "patients' involvement is important for patient safety" and "patient safety work has good support from the county council's management". Factors that were considered most important for achieving the current level of patient safety were root cause and risk analyses, incident reporting and the Swedish Patient Safety Law. An organizational culture that encourages reporting and avoids blame was considered most important for improved patient safety in the future, closely followed by improved communication between health care practitioners and patients. CONCLUSION: Health care professionals with important positions in the Swedish county councils' patient safety work believe that conditions for this work are somewhat constrained. They attribute the current levels of patient safety to a broad range of factors and believe that many different solutions can contribute to enhanced patient safety in the future, suggesting that this work must be multifactorial.

What can we learn from patient claims? - A retrospective analysis of incidence and patterns of adverse events after orthopaedic procedures in Sweden.

BACKGROUND: Objective data on the incidence and pattern of adverse events after orthopaedic surgical procedures remain scarce, secondary to the reluctance for encompassing reporting of surgical complications. The aim of this study was to analyze the nature of adverse events after orthopaedic surgery reported to a national database for patient claims in Sweden. METHODS: In this retrospective review data from two Swedish national databases during a 4-year period were analyzed. We used the "County Councils' Mutual Insurance Company", a national no-fault insurance system for patient claims, and the "National Patient Register at the National Board of Health and Welfare". RESULTS: A total of 6,029 patient claims filed after orthopaedic surgery were assessed during the study period. Of those, 3,336 (55%) were determined to be adverse events, which received financial compensation. Hospital-acquired infections and sepsis were the most common causes of adverse events (n = 741; 22%). The surgical procedure that caused the highest rate of adverse events was "decompression of spinal cord and nerve roots" (code ABC**), with 168 adverse events of 17,507 hospitals discharges (1%). One in five (36 of 168; 21.4%) injured patient was seriously disabled or died. CONCLUSIONS: We conclude that patients undergoing spinal surgery run the highest risk of being severely injured and that these patients also experienced a high degree of serious disability. The most common adverse event was related to hospital acquired infections. Claims data obtained in a no-fault system have a high potential for identifying adverse events and learning from them.

Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers.

BACKGROUND: Mandatory and voluntary reporting of adverse events is common in health care organizations but a more accurate understanding of the extent of patient injury may be obtained if additional sources are used. Patients in Sweden may file a claim for economic compensation from the national insurance system if they believe they have sustained an injury. The extent and pattern of reporting of serious adverse events in a mandatory national reporting system was compared with the reporting of adverse events on the basis of patient claims. METHODS: Regional sentinel event reports were compared with malpractice claims data between 1996 and 2003. A sample consisting of 113 patients with deaths or serious injuries was selected from the malpractice claims data source. The medical records of these patients were reviewed by three chief medical officers. RESULTS: Of the deaths or injuries associated with the 113 patients-25 deaths, 37 with more than 30% disability, and 51 with 16/o-30% disability-23 (20%) had been reported by chief medical officers to the National Board of Health and Welfare as sentinel events. Most adverse events were found in orthopedic surgery, and orthopedic injuries had more serious consequences. None of the patient injuries caused by infections were reported as sentinel events. Individual errors were more frequent in cases reported as sentinel events. CONCLUSIONS: Adverse events causing severe harm are underreported to a great extent in Sweden despite the existence of a mandatory reporting system; physicians often consider them to be complications. Health care organizations should consider using a portfolio of tools-including incident reporting, medical record review, and analysis of patient claims-to gain a comprehensive picture of adverse events.

Adverse events in spine surgery in Sweden: a comparison of patient claims data and national quality register (Swespine) data .

BACKGROUND AND PURPOSE: Our knowledge of complications and adverse events in spinal surgery is limited, especially concerning incidence and consequences. We therefore investigated adverse events in spine surgery in Sweden by comparing patient claims data from the County Councils' Mutual Insurance Company register with data from the National Swedish Spine Register (Swespine). METHODS: We analyzed patient claims (n = 182) to the insurance company after spine surgery performed between 2003 and 2005. The medical records of the patients filing these claims were reviewed and compared with Swespine data for the same period. RESULTS: Two-thirds (119/182, 65%) of patients who claimed economic compensation from the insurance company were registered in Swespine. Of the 210 complications associated with these 182 claims, only 74 were listed in Swespine. The most common causes of compensated injuries (n = 139) were dural lesions (n = 40) and wound infections (n = 30). Clinical outcome based on global assessment, leg pain, disability, and quality of health was worse for patients who claimed economic compensation than for the total group of Swespine patients. INTERPRETATION: We found considerable under-reporting of complications in Swespine. Dural lesions and infections were not well recorded, although they were important reasons for problems and contributed to high levels of disability. By analyzing data from more than one source, we obtained a better understanding of the patterns of adverse events and outcomes after spine surgery.

Patient safety dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture.

OBJECTIVES: Patient Safety Dialogue, a local intervention inspired by walk round-style approaches, was implemented in 2005 in a Swedish county council to achieve a positive patient safety culture in health care. This paper evaluates the results and changes after 5 years of the Patient Safety Dialogue in 50 departments (37 medical and 13 psychiatric) in 3 hospitals. METHODS: The patient safety culture maturity was rated on 5 levels that correspond with the Manchester Patient Safety Assessment Framework. The assessment was based on information supplied by the departments and discussions between clinical leaders and staff members with special patient safety assignments and representatives from a patient safety unit. Three patient safety areas were assessed: hospital-acquired infections, outcome measurements, and general patient safety. Each department was assessed 3 times: at baseline and at follow-ups at 18 and 36 months. Average scores were calculated for each of the 3 safety areas on all occasions. The departments were classified into 3 types of trajectories on the basis of the development of their scores over time. RESULTS: More than two-thirds of the departments attained higher scores in round 3 than in round 1. Seventy-eight percent of the departments in the general patient safety area were categorized as continuously improving or developing, compared with 68% for outcome measurement and 50% for hospital-acquired infection. Approximately one-third was categorized as nonimproving, with scores in round 3 lower than or equal to the scores in round 1. The medical departments had higher scores than the psychiatric departments in all rounds. CONCLUSIONS: Most of the 50 departments were evaluated to have improved their patient safety culture during the 5 years of the Patient Safety Dialogue, suggesting that the intervention is effective in supporting an improved patient safety culture. However, one-third of the departments did not improve during the 5-year study period.