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A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

ABSTRACT: BACKGROUND: Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. METHODS: The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier "Incident type", described as odds ratios (OR) and proportional similarity indices (PSI). RESULTS: A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI?=?0.32) and from IRS and retrospective chart review (PSI?=?0.31) were mainly attributable to behaviour (OR?=?6.08), clinical administration (OR?=?5.14), clinical process (OR?=?6.73) and resources (OR?=?2.06). CONCLUSIONS: IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.

SUBMITTER: de Feijter JM

PROVIDER: S-EPMC3281055 | biostudies-other | 2012

REPOSITORIES: biostudies-other

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A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

de Feijter Jeantine M JM de Grave Willem S WS Muijtjens Arno M AM Scherpbier Albert J J A AJ Koopmans Richard P RP

PloS one 20120216 2

<h4>Background</h4>Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different so ...[more]

PMID: 22359567

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Project description:BackgroundDelirium is a brain condition associated with poor outcomes in rehabilitation. It is therefore important to assess delirium incidence in rehabilitation.PurposeTo develop and validate a chart-based method to identify incident delirium episodes within the electronic database of a Swiss rehabilitation clinic, and to identify a study population of validated incident delirium episodes for further research purposes.DesignRetrospective validation study.SettingsRoutinely collected inpatient clinical data from ZURZACH Care.ParticipantsAll patients undergoing rehabilitation at ZURZACH Care, Rehaklinik Bad Zurzach between 2015 and 2018 were included.MethodsWithin the study population, we identified all rehabilitation stays for which ≥2 delirium-predictive key words (common terms used to describe delirious patients) were recorded in the medical charts. We excluded all prevalent delirium episodes and defined the remaining episodes to be potentially incident. At least two physicians independently confirmed or refuted each potential incident delirium episode by reviewing the patient charts. We calculated the positive predictive value (PPV) with 95% confidence interval (95% CI) for all potential incident delirium episodes and for specific subgroups.ResultsWithin 10,515 rehabilitation stays we identified 554 potential incident delirium episodes. Overall, 125 potential incident delirium episodes were confirmed by expert review. The PPV of the chart-based method varied from 0.23 (95% CI 0.19-0.26) overall to 0.69 (95% CI 0.56-0.79) in specific subgroups.ConclusionsOur chart-based method was able to capture incident delirium episodes with low to moderate accuracy. By conducting an additional expert review of the medical charts, we identified a study population of validated incident delirium episodes. Our chart-based method contributes towards an automated detection of potential incident delirium episodes that, supplemented with expert review, efficiently yields a validated population of incident delirium episodes for research purposes.

Project description:BackgroundMedication administration error is a medication error that occurs while administering a medication to a patient. A variety of factors make pediatrics more susceptible to medication errors and its consequences. In low-income countries, like Ethiopia, there is no sufficient evidence regarding medication administration error among pediatrics. The aim of this study is, therefore, to determine the magnitude and factors associated with medication administration error among pediatric population.MethodsA prospective observational based cross sectional study design was conducted from January to April 2017. Data collection was done using pre-tested structured questionnaire and blind observation checklist to health professionals in charge of administering selected medications. A total of 1282 medication administrations were obtained using single population proportion formula from patients in the selected public hospitals and the samples were selected using multistage sampling technique. Multivariable logistic regression using odds ratio and 95% confidence interval was used to determine the relationship between the independent and dependent variables. Variables with p-value <?0.05 were considered as independent factors for medication administration error.ResultA total of 1251 medication administrations were observed from 1251 patients. The occurrence of medication administration error was 62.7% with 95% CI (59.6%, 65.0%), wrong dose being the most common type of medication administration error with an occurrence rate of 53.7%. Medications administered for pediatric patients less than 1 month age, administered by bachelor degree holder health professionals, prepared in facilities without medication preparation room, prepared in facilities without medication administration guide and administer for patients who have two or more prescribed medications were more likely to have medication administration error than their counterparts with AOR (95% CI) of 7.54(2.20-25.86), 1.52 (1.07-2.17), 13.45 (8.59-21.06), 4.11 (2.89-5.85), and 2.42 (1.62-3.61), respectively.ConclusionThis study has revealed that there is high occurrence of medication administration error among pediatric inpatients in public hospitals of Tigray, Northern Ethiopia.. Age of patients, educational level of medication administrators, availability of the medication preparation room and guide, and the number of medications given per single patient were statistically significant factors associated with occurrence of medication administration error.

Project description:IntroductionJob aids such as observation charts are commonly used to record inpatient nursing observations. For sick newborns, it is important to provide critical information, intervene, and tailor treatment to improve health outcomes, as countries work towards reducing neonatal mortality. However, inpatient vital sign readings are often poorly documented and little attention has been paid to the process of chart design as a method of improving care quality. Poorly designed charts do not meet user needs leading to increased mental effort, duplication, suboptimal documentation and fragmentation. We provide a detailed account of a process of designing a monitoring chart.MethodsWe used a Human-Centred Design (HCD) approach to co-design a newborn monitoring chart between March and May 2019 in three workshops attended by 16-21 participants each (nurses and doctors) drawn from 14 hospitals in Kenya. We used personas, user story mapping during the workshops and observed chart completion to identify challenges with current charts and design requirements. Two new charts were piloted in four hospitals between June 2019 and February 2020 and revised in a cyclical manner.ResultsChallenges were identified regarding the chart design and supply, and how staff used existing charts. Challenges to use included limited staffing, a knowledge deficit among junior staff, poor interprofessional communication, and lack of appropriate and working equipment. We identified a strong preference from participants for one chart to capture vital signs, assessment of the baby, and feed and fluid prescription and monitoring; data that were previously captured on several charts.DiscussionAdopting a Human-Centred Design approach, we designed a new comprehensive newborn monitoring chart that is unlike observation charts in the literature that only focus on vital signs. While the new chart does not address all needs, we believe that once implemented, it can help build a clearer picture of the care given to newborns.ConclusionThe chart was co-designed and piloted with the user and context in mind resulting in a unique monitoring chart that can be adopted in similar settings.

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A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

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A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

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