Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia.

BACKGROUND: Transvaginal mesh (TVM) surgeries emerged as an innovative treatment for stress urine incontinency and/or pelvic organ prolapse in 1996. Years after rapid adoption of these surgeries into practice, they are a key example of worldwide failure of healthcare quality and patient safety. The prevalence of TVM-associated harms eventually prompted action globally, including an Australian Commonwealth Government Senate Inquiry in 2017. METHOD: We analysed 425 submissions made by women (n = 417) and their advocates (n = 8) to the Australian Senate Inquiry, and documents from 5 public hearings, using deductive and inductive coding, categorisation and thematic analysis informed by three 'linked dilemmas' from healthcare quality and safety theory. We focused on women's accounts of: a) how harms arose from TVM procedures, and b) micro, meso and macro factors that contributed to their experience. Our aim was to explain, from a patient perspective, how these harms persisted in Australian healthcare, and to identify mechanisms at micro, meso and macro levels explaining quality and safety system failure. RESULTS: Our findings suggest three mechanisms explaining quality and safety failure: 1. Individual clinicians could ignore cases of TVM injury or define them as 'non-preventable'; 2. Women could not go beyond their treating clinicians to participate in defining and governing quality and safety; and. 3. Health services set thresholds for concern based on proportion of cases harmed, not absolute number or severity of harms. CONCLUSION: We argue that privileging clinical perspectives over patient perspectives in evaluating TVM outcomes allowed micro-level actors to dismiss women's lived experience, such that women's accounts of harms had insufficient or no weight at meso and macro levels. Establishing system-wide expectations regarding responsiveness to patients, and communication of patient reported outcomes in evaluation of healthcare delivery, may help prevent similar failures.

Beyond SEP-1 Compliance: Assessing the Impact of Antibiotic Overtreatment and Fluid Overload in Suspected Septic Patients.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) developed the Severe Sepsis and Septic Shock Performance Measure bundle (SEP-1) metric to improve sepsis care, but evidence supporting this bundle is limited and harms secondary to compliance have not been investigated. OBJECTIVE: This study investigates the effect of an emergency department (ED) sepsis quality-improvement (QI) effort to improve CMS SEP-1 compliance, looking specifically at antibiotic overtreatment and harm from fluid resuscitation. METHODS: This was a retrospective observational study conducted between March and July 2021 with patients for whom a sepsis order set was initiated. The primary outcomes included the number of patients treated with antibiotics who were ultimately deemed nonseptic and the number of patients who developed pulmonary edema, with or without need for positive pressure ventilation (PPV), within 48 h of receiving a 30 mL/kg fluid bolus. Data were collected via nonblinded chart reviews, with a free marginal κ-calculation indicating excellent interrater reliability. RESULTS: The study cohort included 273 patients, 170 (62.3%) who were ultimately determined to be septic and 103 (37.7%) who were nonseptic. Of the 103 nonseptic patients, 82 (79.6%) received antibiotics in the ED. Of the 121 patients (44.3%) who received a 30 mL/kg bolus, 5 patients (4.1%) developed pulmonary edema and 0 of 121 patients required PPV within 48 h. CONCLUSIONS: The QI effort led to moderate rates of antibiotic overtreatment and very few patients developed pulmonary edema due to a 30 mL/kg fluid bolus.

Methods for determining clinical utility.

Measuring the clinical utility of a diagnostic test involves evaluating its impact on patient outcomes, clinical decision-making, and healthcare resource utilization. Determining clinical utility requires accessing patient medical history and outcomes data. These studies involve enrolling patients undergoing diagnostic tests and tracking their clinical outcomes. Researchers can determine the test's clinical utility by comparing the outcomes of patients who receive the diagnostic test to those who do not. These outcomes include benefits and harm. The highest level of evidence to support clinical utility determinations may be obtained from clinical trials. However, clinical laboratories are often not involved in clinical trials, and laboratory specialists may not be experienced in conducting such trials. Many established laboratory tests have never had clinical utility determined. Prospective studies assessing a diagnostic test's impact on clinical outcomes may require long-term patient monitoring, which is problematic. This paper presents methods that may be used to assess clinical utility.

Public inquiries, patient safety and the implementation gap.

A decade on from the Francis report, avoidable patient harm continues to occur and we have continued to see new inquiries and reviews into serious patient safety scandals. A failure to listen to patients or learn from previous investigations, a corrosive blame culture, a lack of effective leadership and an unresponsive regulatory framework are alarming and often reported themes that we review here.

A changing view on patient safety: how the Healthcare Safety Investigation Branch has brought system-focused investigations to the fore.

In this perspective, the chair designate of the Healthcare Services Safety Investigation Body (HSSIB), the new arm's length body transitioning from the Healthcare Safety Investigation Branch (HSIB), reflects on how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS, the role of HSIB over the last 5 years in identifying systemic causes of patient harm and what the future holds for HSSIB.

Medication errors in the practice of paediatric anaesthesia - a narrative review.

Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Challenges in Pharmacovigilance: Variability in the Criteria for Determining Drug-Associated Acute Kidney Injury in Retrospective, Observational Studies.

BACKGROUND: Drug-associated acute kidney injury (D-AKI) accounts for 19-26% of acute kidney injury (AKI) events in hospitalized patients and results in outcomes similar to patients with AKI from other etiologies. Diagnosing D-AKI is complex and various criteria have been used. SUMMARY: To highlight the variability in D-AKI determination, a review was conducted between January 2017 and December 2022 using PubMed. Search terms included adaptations of "drug associated kidney injury" to identify a sampling of literature discussing definitions and criteria for D-AKI evaluation. The search yielded 291 articles that were uploaded to Rayyan, a software tool used to screen and select studies. Retrospective, observational electronic health record (EHR) studies conducted in hospitalized patients were included. The final sample contained 16 studies for data extraction, representing mostly adult populations (n = 13, 81.3%) in noncritical or unspecified inpatient settings (n = 12, 75%). Nine studies (56.3%) utilized the recommended Kidney Disease: Improving Global Outcome guidelines (KDIGO) criteria to define AKI. Baseline creatinine or laboratory criteria for kidney function were provided in 10 studies (62.5%). Eleven studies (68.8%) established a temporal sequence assessment linking nephrotoxin drug exposure to an AKI event, but these criteria were inconsistent among studies using time frames as soon as 3 months prior to AKI. CONCLUSION: This review highlights the substantial variability in D-AKI criteria in select studies. Minimum expectations about what should be reported and criteria for the elements reported are needed to assure transparency, consistency, and standardization of pharmacovigilance strategies.

Identifying the patient harms to include in an in silico clinical trial.

BACKGROUND AND OBJECTIVE: Clinical trials represent a crucial step in the development and approval of medical devices. These trials involve evaluating the safety and efficacy of the device in a controlled setting with human subjects. However, traditional clinical trials can be expensive, time-consuming, and ethically challenging. Augmenting clinical trials with data from computer simulations, so called in silico clinical trials (ISCT), has the potential to address these challenges while satisfying regulatory requirements. However, determination of the patient harms in scope of an ISCT is necessary to ensure all harms are sufficiently addressed while maximizing the utility of the ISCT. This topic is currently lacking guidance. The objective of this work is to propose a general method to determine which patient harms should be included in an ISCT for a regulatory submission. METHODS: The proposed method considers the risk associated with the harm, the impact of the device on the likelihood of occurrence of the harm and the technical feasibility of evaluating the harm via ISCT. Consideration of the risk associated with the harm provides maximum clinical impact of the ISCT, in terms of focusing on those failure modes which are most relevant to the patient population. Consideration of the impact of the device on a particular harm, and the technical feasibility of modeling a particular harm supports that the technical effort is devoted to a problem that (1) is relevant to the device in question, and (2) can be solved with contemporary modeling techniques. RESULTS AND CONCLUSIONS: As a case study, the proposed method is applied to a total shoulder replacement humeral system. With this framework, it is hoped that a consistent approach to scoping an ISCT can be adopted, supporting investment in ISCT by the industry, enabling consistent review of the ISCT approach across device disciplines by regulators, and providing maximum impact of modeling technologies in support of devices to improve patient outcomes.

Status and Factors Affecting Patient Safety Culture at Dilla University Teaching Hospital: A Mixed-Method Cross-Sectional Study.

Background: Patient safety culture is now at the forefront of the global health agenda and has been designated as a human right. Assessing safety culture is seen to be a prerequisite for improving safety culture in health-care organizations. However, no research has been conducted to examine the current study setup. Therefore, this study aims at assessing the status and factors influencing patient safety culture at Dilla University Teaching Hospital. Methods: This cross-sectional institutional-based study was conducted from February to March 2022 at Dilla University Hospital. The study used both qualitative and quantitative methods. A total of 272 health professionals were included in the survey. The qualitative data was collected using Key Informant Interviews and In-depth Interviews and 10 health professionals were selected purposively to meet the study objective. Results: The overall composite positive patient safety culture response rate in the current study hospital was 37% (95% CI: 35.3, 38.8). Out of the 12 dimensions, teamwork within hospital units was the highest (75.3%), while frequency of event reporting was the lowest (20.7%) positive percentage response. Only two of the 12 dimensions scored above 50%. Factors affecting patient safety culture majorly at organizational and individual level were poor/low attitude of health professionals, poor documentation practice, and poor cooperation by clients, lack of training and continuous education, lack of standard operating procedure, Staff shortage and high work load. Conclusion: This study revealed that the overall composite positive patient safety culture response rate within the surveyed facility was alarmingly low compared to other hospitals in various countries. The results indicate that there is a need for improvement in areas such as event reporting, documentation, health-care workers' attitude, and staff training. Hospitals must prioritize patient safety by cultivating a strong safety culture through effective leadership, adequate staffing, and education to enhance overall patient care.

Benefits and harms of normal saline instillation before endotracheal suctioning in mechanically ventilated adult patients in intensive care units: A systematic literature review and meta-analysis.

OBJECTIVES: This systematic review aimed to identify the effects of normal saline instillation before endotracheal suctioning on clinical outcomes in critically ill patients on a mechanical ventilator. RESEARCH METHODOLOGY: This review was based on the guidelines of the National Evidence-based Healthcare Collaborating Agency in Korea and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Six electronic databases were searched for relevant literature. Other sources were also searched, including the reference lists of identified reports and previous systematic reviews. After the initial literature search, a two-step retrieval process was performed to select eligible studies. Then, data were collected using a newly developed form, and the risk of bias was assessed using the checklists of the Joanna Briggs Institute. Data were analyzed using both narrative syntheses and meta-analyses. RESULTS: In total, 16 studies: 13 randomized controlled trials and three quasi-experimental studies, were included. From the narrative syntheses, instilling normal saline before endotracheal suctioning was associated with a decrease in oxygen saturation, prolonged time for oxygen saturation to recover to baseline, decreased arterial pH, increased secretion amount, reduced incidence of ventilator-associated pneumonia, increased heart rate, and increased systolic blood pressure. Meta-analyses showed a significant difference in heart rate at five minutes after suctioning but no significant differences in oxygen saturation at two and five minutes after suctioning and heart rate at two minutes after suctioning. CONCLUSION: This systematic review indicated that instilling normal saline before performing endotracheal suctioning has more harmful effects than benefits. IMPLICATIONS FOR CLINICAL PRACTICE: As recommended in the current guidelines, it is necessary to refrain from routine normal saline instillation before endotracheal suctioning.

Eventos adversos em serviços de urgência e emergência: uma revisão integrativa de literatura / Adverse effects in urgency and emergency services: an integrative literature review / Eventos adversos en servicios de urgencias y emergencia: una revisión integradora de la literatura

O artigo tem o objetivo de analisar a produção científica disponível na literatura sobre os eventos adversos em serviços de urgência e emergência. Assim, realizou-se uma revisão integrativa por meio de levantamento bibliográfico em agosto de 2022, com busca nas seguintes bases de dados eletrônicas: Índice Bibliográfico Español en Ciencias de la Salud (Ibecs), Base de Dados em Enfermagem (BDENF) via Biblioteca Virtual da Saúde (BVS), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs), Medical Literature Analysis and Retrieval System Online (Medline) via PubMed e Web of Science via Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes). A busca resultou na amostra final de dez artigos, que foram descritos com base em quatro eixos temáticos, conforme tipo de serviço e desenvolvimento do estudo. Os assuntos mais abordados nas produções foram: terapia medicamentosa, incidentes relacionados à organização do serviço, falhas nas prescrições, prescrições verbais, incidentes com previsão e provisão de materiais e abastecimento. A análise das produções expõe o maior número de artigos da Espanha, do Brasil e dos Estados Unidos, com ênfase nos assuntos relacionados a eventos adversos em ambientes de urgência e emergência intra-hospitalares, demonstrando que as pesquisas sobre segurança do paciente em serviços de urgência e emergência são incipientes, assim como são escassos os estudos no Brasil voltados para as unidades de pronto atendimento.

The article aims to analyze the scientific production available in the literature on adverse events in urgency and emergency services. Thus, an integrative review was carried out with a bibliographic survey, in August 2022, with a search in the electronical databases: Spanish Bibliographic Index in Health Sciences (IBECS), Database in Nursing (BDENF) via Virtual Health Library (BVS), Latin American and Caribbean Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed and Web of Science via Portal de Periódicos da Coordination for the Improvement of Higher Education (CAPES). The search resulted in a final sample of ten articles, which were described based on four thematic axes, in accordance with the type of study development and service. The subjects most discussed in the productions were: drug therapy, incidents related to the organization of the service, failures in prescriptions, verbal prescriptions, incidents with prediction, and provision of materials and supplies. The analysis of the productions exposes the larger number of articles from Spain, Brazil, and the United States, with emphasis on subjects related to adverse events in in-hospital urgent and emergency environments, demonstrating that research on patient safety in urgency and emergency services are incipient, as well the few studies in Brazil directed to emergency care units.

Este artículo tiene como objetivo analizar la producción científica disponible en la literatura sobre eventos adversos en los servicios de urgencias y emergencia. Para ello, se realizó una revisión integradora mediante levantamiento bibliográfico, llevado a cabo en agosto de 2022, con búsqueda en las bases de datos en línea: Índice Bibliográfico Español en Ciencias de la Salud (Ibecs), Base de Datos en Enfermería (BDENF) vía Biblioteca Virtual en Salud (BVS), Literatura Latinoamericana y del Caribe en Ciencias de la Salud (Lilacs), Medical Literature Analysis and Retrieval System Online (Medline) vía PubMed y Web of Science vía Portal de Periódicos de la Coordinación de Perfeccionamiento de Personal de Nivel Superior (Capes). La búsqueda resultó en una muestra final de diez artículos, descritos a partir de cuatro ejes temáticos, de acuerdo con el tipo de servicio y desarrollo del estudio. Los temas más tratados en las producciones fueron farmacoterapia, incidentes relacionados con la organización del servicio, fallos en la prescripción, prescripción verbal, e incidentes con predicción y provisión de materiales e insumos. El análisis de las producciones expone la mayor cantidad de artículos en España, Brasil y Estados Unidos, con mayor énfasis en temas relacionados con eventos adversos en ambientes de urgencias y emergencia intrahospitalaria, demostrando que la investigación sobre seguridad del paciente en servicios de urgencias y emergencia es incipiente, así como existen pocos estudios en Brasil dirigidos a unidades de atención de emergencia.

An Estimate of Severe Harms Due to Screening Colonoscopy: A Systematic Review.

OBJECTIVE: This study aims to comprehensively assess the direct, severe harms of screening colonoscopy in the United States. Whereas other investigators have completed systematic reviews estimating the harms of all types of colonoscopy, this analysis focuses on screening colonoscopies that had adequate follow up to avoid undercounting delayed harms. DATA SOURCES: PubMed and Embase were queried for relevant studies on screening colonoscopy harms published between January 1, 2002, and April 1, 2022. STUDY SELECTION: English-language studies of screening colonoscopy for average risk patients were included. Studies must have followed patients for adequate time post procedure, defined as 30 days after colonoscopy. MAIN OUTCOMES: The primary outcome was the number of severe bleeding events and gastrointestinal (GI) perforations within 30 days of screening colonoscopy. RESULTS: A total of 1951 studies were reviewed for inclusion; 94 were reviewed in full text. Of those reviewed in full, 6 studies, including a total of 467,139 colonoscopies, met our inclusion criteria and were included in our analysis of harms related to screening colonoscopies. The rate of severe bleeding ranged credibly from 16.4 to 36.18 per 10,000 colonoscopies; the rate of perforation ranged credibly from 7.62 to 8.50 per 10,000 colonoscopies. CONCLUSIONS: This study is the first to estimate direct harms from screening colonoscopy, including harms that occur up to 30 days after the procedure. The risk of harm subsequent to screening colonoscopy is higher than previously reported and should be discussed with patients when engaging in shared decision making.

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.

BACKGROUND: The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed. OBJECTIVE: To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE. DESIGN & SETTING: We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient. RESULTS: A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003). CONCLUSION: An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable.

Knowing the frequency and characteristics of adverse events (AEs) is key to implementing actions that can prevent their occurrence. However, reporting systems are insufficient for this purpose and epidemiological studies are also required. Currently, the reviewing of clinical records is the gold standard method for knowing the frequency and characteristics of AEs. Research on AEs in a primary care setting has been limited and primarily focuses on specific types of events (medication errors, etc.) or patients. Large studies that search for any kind of AE in all patients are scarce. This study aimed to estimate the prevalence of AEs in the primary care setting and their characteristics. SETTING: all 262 primary health-care centres in the Madrid region (Spain) during the last quarter of 2018. DESIGN: cross-sectional descriptive study. Eligible population: subjects over 18 years of age who attended medical consultation over the last year (N = 2 743 719); a randomized sample stratified by age. MAIN OUTCOMES: age, sex, occurrence of an AE, number of consultations in the study period, avoidability, severity, place of occurrence, type of event, and contributory factors. The clinical records were reviewed by three teams, each composed of one doctor and one nurse trained and with expertise in patient safety. The SPSS software package (version 26) was used for the statistical analyses. The evaluators reviewed 1797 clinical records. The prevalence of AEs over the study period was 5.0% [95% confidence interval (CI): 4.0%‒6.0%], with higher values in women (5.7%; 95% CI: 4.6%‒6.8%;P = 0.10) and patients over 75 years of age (10.3%; 95% CI: 8.9%‒11.7%; P < 0.001). The overall occurrence per hundred consultations was estimated to be 1.58% (95% CI: 1.28%‒1.94%). Of the detected AEs, 71.3% (95% CI: 62.1%‒80.5%) were avoidable. Additionally, 60.6% (95% CI: 50.7%‒70.5%) were categorized as mild, 31.9% (95% CI: 22.4%‒41.4%) as moderate, and 7.4% (95% CI: 2.1%‒12.7%) as severe. Primary care was the occurrence setting in 76.6% (95% CI: 68.0%‒85.2%) of cases. The overall incidence of AEs related to medication was 53.2% (95% CI: 50.9%‒55.5%). The most frequent types of AEs were prescription errors (28.7%; 95% CI: 19.5%‒37.9%), followed by drug administration errors by patients (17.0%; 95% CI: 9.4%‒24.6%), and clinical assessment errors (11.7%; 95% CI: 5.2%‒18.2%). The most common contributory factors were those related to the patient (80.6%; 95% CI: 71.1%‒90.1%) and tasks (59.7%; 95% CI: 48.0%‒71.4%). A high prevalence of AEs (1 in 66 consultations) was observed, which was slightly higher than that reported in similar studies. About 3 out of 4 such events were considered to be avoidable and 1 out of 13 was severe. Prescription errors, drug administration errors by patients, and clinical assessment errors were the most frequent types of AEs. Graphical Abstract.

Compensated and non-compensated patient injury claims in internal carotid artery interventions in Finland, 2004-2017.

OBJECTIVES: Analysis of patient injuries offers possibilities for improving quality in patient care. The aim of this study was to identify errors and adverse events leading to patient injuries in the treatment of internal carotid artery stenosis (ICAS). METHODS: A retrospective analysis was performed on data from Finnish patient injury claims and patient insurance center decisions in the treatment of ICAS, 2004-2017. Contributing factors to injury were identified and evaluated. RESULTS: During the 14-year study period, 42 patient injury claims involving ICAS treatment were closed in Finland. One claim involved carotid artery stenting, and the other operations were carotid artery endarterectomies. Nine of the claims were compensated (seven for operations and two for evaluations). Fully trained vascular surgeons had carried out all the operations and evaluations. Stroke was the most common complaint in the claims (n = 12). Six of the compensated patients were symptomatic prior to the interventions. Injuries were related to errors in decision-making and patient selection in two cases. Four patients received compensation for nerve injury and three for stroke. No deaths were compensated as patient injuries. Most negative claim decisions were related to the injury having been unavoidable. CONCLUSION: Compensated patient injuries involving the treatment of ICAS are rare but often serious and mostly involve open surgery. Patient injury claims provide a valuable source of information for recognizing errors in care and offer possibilities to improve patient safety.

The burden of peripheral intravenous catheters in older hospital inpatients: A national cross-sectional study part of the ONE MILLION GLOBAL PERIPHERAL INTRAVENOUS CATHETERS COLLABORATION.

OBJECTIVES: To investigate the burden of peripheral intravenous catheters (PIVCs) in older hospitalised patients. METHODS: A cross-sectional prospective observational study (2014/2015) to describe the characteristics, indications and outcomes of PIVCs among patients aged ≥65 from 65 Australian hospitals. RESULTS: Amongst 2179 individual PIVCs (in 2041 patients, mean age 77.6 years, 45% female, 58% in NSW), 43% were inserted by doctors and 74% used that day, meaning 25% were 'idle'. Overall, 18% (393/2179) exhibited signs of PIVC-related complications. Most commonly exhibited PIVC-related complications were tenderness (4.1%) and local redness (1.8%). Nearly one in three (29.1%) dressings was soiled, loosened or had come off, and only 36.8% had the time and date documented on the dressing. Both infusing IV medications (aOR 1.74, 95% CI 1.28-2.38, p < 0.001) and inserting the PIVC in a non-upper limb vein (aOR 3.40 compared to forearm [reference site], 95% CI 1.62-7.17, p < 0.001) were independently associated with PIVC failure. Phlebitis was exhibited in 7% (154) of the patients. Only infusing intravenous medications increased the likelihood of developing symptoms of phlebitis (aOR 1.61, 95% CI 1.01-2.57, p = 0.05). Increasing age was inversely associated with symptoms of phlebitis. Among the 1575 patients (79%) who rated their PIVC experience using the Likert scale 0-10 (where 10 = 'best possible'), the median score was 8 (IQR 6-10). Age in highest quartile (>84 years) was independently associated with lower likelihood of a high score (aOR 0.71, 95% CI 0.54-0.94, p = 0.02). CONCLUSIONS: Given 1 in 5 PIVCs were identified with having complications, further research should focus on optimising PIVC use in older patients.

Managing nutrition support product shortages: What have we learned?

Product shortages related to the components of parenteral nutrition (PN) therapy have been well described over the past decade. The situation has more recently worsened and expanded globally because of the impact the COVID-19 pandemic has placed on supply chain issues and workforce demand. The impact of enteral nutrition (EN) product shortages is less well documented when compared with PN, and development of management strategies is often left up to the discretion of individual providers. The recent crisis in infant formula supply has heightened the national awareness of how a nutrition support product shortage can significantly impact patient safety. This review provides a historical perspective of PN and EN product shortages to gain insight into the lessons learned and applies this to strategies for managing current and future product shortages. Strategies for managing PN and EN shortages can best succeed if they are tailored to address aspects that are unique to the inpatient and outpatient care setting. In addition, patients who transition between care settings are vulnerable to harm related to product shortages if measures are not in place to communicate and address these shortages. Teamwork and communication within an organization and among key stakeholders are necessary to develop processes that aim to minimize patient harm related to product shortages.

Risk factors for and preventability of drug-related hospital revisits in older patients: A post-hoc analysis of a randomized clinical trial.

AIM: The aims of this study were (1) to identify older patients' risk factors for drug-related readmissions and (2) to assess the preventability of older patients' drug-related revisits. METHODS: Post hoc analysis of a randomized clinical trial with patients aged ≥65 years at eight wards within four hospitals in Sweden. (1) The primary outcome was risk factors for drug-related readmission within 12 months post-discharge. A Cox proportional hazards model was made with sociodemographic and clinical baseline characteristics. (2) Four hundred trial participants were randomly selected and their revisits (admissions and emergency department visits) were assessed to identify potentially preventable drug-related revisits, related diseases and causes. RESULTS: (1) Among 2637 patients (median age 81 years), 582 (22%) experienced a drug-related readmission within 12 months. Sixteen risk factors (hazard ratio >1, P < 0.05) related to age, previous hospital visits, medication use, multimorbidity and cardiovascular, liver, lung and peptic ulcer disease were identified. (2) The 400 patients experienced a total of 522 hospital revisits, of which 85 (16%) were potentially preventable drug-related revisits. The two most prevalent related diseases were heart failure (n = 24, 28%) and chronic obstructive pulmonary disease (n = 13, 15%). The two most prevalent causes were inadequate treatment (n = 23, 27%) and insufficient or no follow-up (n = 22, 26%). CONCLUSION: (1) Risk factors for drug-related readmissions in older hospitalized patients were age, previous hospital visits, medication use and multiple diseases. (2) Potentially preventable drug-related hospital revisits are common and might be prevented through adequate pharmacotherapy and continuity of care in older patients with cardiovascular or lung disease.

Interprofessional In Situ Simulation to Identify Latent Safety Threats for Quality Improvement: A Single-Center Protocol Report.

In situ simulation has frequently been used to improve team performance and provide an opportunity for the practice of critical skills and identify latent safety threats, which are undetected risks that may lead to adverse outcomes. However, the use of known quality improvement tools to prioritize and mitigate these safety threats is an area requiring further study. Over the course of 9 in situ simulations of a pediatric shock case, postcase debriefs were held to identify latent safety threats in an emergency department and a mixed pediatric and adult inpatient unit. Latent safety threats identified included structure-related threats such as inability to locate critical equipment, knowledge-based threats relating to rapid intravenous fluid administration, and communication-based threats such as lack of role designation. Identification of latent safety threats in the health care environment may assist clinician leaders in mitigating risk of patient harm. The protocol described may be adopted and applied to other critical event simulations, with structured debriefing used as a tool to identify and mitigate threats before they affect the patient.