An analysis of general practitioners’ perspectives on patient safety incidents using critical incident technique interviews

2019 ◽  
Vol 36 (6) ◽  
pp. 736-742 ◽  
Author(s):  
Ciara Curran ◽  
Sinéad Lydon ◽  
Maureen E Kelly ◽  
Andrew W Murphy ◽  
Paul O’Connor
Keyword(s):  
Patient Safety ◽  
General Practitioners ◽  
Critical Incident ◽  
Improve Patient Safety ◽  
Critical Incident Technique ◽  
Contributory Factor ◽  
Contributory Factors ◽  
Safety Incident ◽  
The Impact ◽  
Patient Safety Incidents

Abstract Background General practitioners report difficulty in knowing how to improve patient safety. Objectives To analyse general practitioners’ perspectives of contributing factors to patient safety incidents by collecting accounts of incidents, identifying the contributory factors to these incidents, assessing the impact and likelihood of occurrence of these incidents and examining whether certain categories of contributory factors were associated with the occurrence of high-risk incidents. Methods Critical incident technique interviews were carried out with 30 general practitioners in Ireland about a patient safety incident they had experienced. The Yorkshire Contributory Factors Framework was used to classify the contributory factors to incidents. Seven subject matter experts rated the impact and likelihood of occurrence of each incident. Results A total of 26 interviews were analysed. Almost two-thirds of the patient safety incidents were rated as having a major-to-extreme impact on the patient, and over a third were judged as having at least a bimonthly likelihood of occurrence. The most commonly described active failures were ‘Medication Error’ (34.6%) and ‘Diagnostic Error’ (30.8%). ‘Situational Domain’ was identified as a contributory domain in all patient safety incidents. ‘Communication’ breakdown at both practice and other healthcare-provider interfaces (69.2%) was also a commonly cited contributory factor. There were no significant differences in the levels of risk associated with the contributory factors. Conclusions Critical incident technique interviews support the identification of contributory factors to patient safety incidents. There is a need to explore the use of the resulting data for quality and safety improvement in general practice.

scholarly journals A mixed methods analysis of lithium-related patient safety incidents in primary care

2020 ◽  
Vol 11 ◽  
pp. 204209862092274
Author(s):  
Richard Simon Young ◽  
Paul Deslandes ◽  
Jennifer Cooper ◽  
Huw Williams ◽  
Joyce Kenkre ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Mixed Methods ◽  
Improve Patient Safety ◽  
Descriptive Analysis ◽  
Learning System ◽  
Contributory Factors ◽  
Safety Incident ◽  
Patient Safety Incidents ◽  
Dispensing Errors

Background: Lithium is a drug with a narrow therapeutic range and has been associated with a number of serious adverse effects. This study aimed to characterise primary care lithium-related patient safety incidents submitted to the National Reporting and Learning System (NRLS) database with respect to incident origin, type, contributory factors and outcome. The intention was to identify ways to minimise risk to future patients by examining incidents with a range of harm outcomes. Methods: A mixed methods analysis of patient safety incident reports related to lithium was conducted. Data from healthcare organisations in England and Wales were extracted from the NRLS database. An exploratory descriptive analysis was undertaken to characterise the most frequent incident types, the associated chain of events and other contributory factors. Results: A total of 174 reports containing the term ‘lithium’ were identified. Of these, 41 were excluded and, from the remaining 133 reports, 138 incidents were identified and coded. Community pharmacies reported 100 incidents (96 dispensing related, two administration, two other), general practitioner (GP) practices filed 22 reports and 16 reports originated from other sources. A total of 99 dispensing-related incidents were recorded, 39 resulted from the wrong medication dispensed, 31 the wrong strength, 8 the wrong quantity and 21 other. A total of 128 contributory factors were identified overall; for dispensing incidents, the most common related to medication storage/packaging ( n = 41), and ‘mistakes’ ( n = 22), whereas no information regarding contributory factors was provided in 41 reports. Conclusion: Despite the established link between medication packaging and the risk of dispensing errors, our study highlighted storage and packaging as the most commonly described contributory factors to dispensing errors. The absence of certain relevant data limited the ability to fully characterise a number of reports. This highlighted the need to include clear and complete information when submitting reports. This, in turn, may help to better inform the further development of interventions designed to reduce the risk of incidents and improve patient safety.

scholarly journals Prolonged mental health sequelae among doctors and nurses involved in patient safety incidents with formal complaints and lawsuits

2019 ◽  
Vol 30 (4) ◽  
pp. 777-779
Author(s):  
Gerda Zeeman ◽  
Loes Schouten ◽  
Deborah Seys ◽  
Ellen Coeckelberghs ◽  
Philomeen Weijenborg ◽  
...  
Keyword(s):  
Mental Health ◽  
Patient Safety ◽  
Related Disorder ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Formal Complaint ◽  
The Impact ◽  
Patient Safety Incidents ◽  
Doctors And Nurses

Abstract We evaluated the presence of prolonged mental health sequelae in the aftermath of a patient safety incident and the impact of a formal complaint or lawsuit on these mental health sequelae in 19 hospitals and 2635 nurses and doctors. Of 2635 respondents, 983 (37.3%) reported a complaint and 190 (7.2%) reported a lawsuit. In both doctors and nurses prolonged mental health sequelae reflecting a stressor-related disorder were highly prevalent, each well over 20% overall. They were consistently more prevalent in case of a formal complaint or lawsuit. Lawsuits showed 2-, 3- and 4-fold increases in prevalence of mental health sequelae.

scholarly journals A Qualitative Study on Nurses’ Experiences of Reporting Patient Safety Incidents in East Nusa Tenggara, Indonesia

2021 ◽  
Vol 11 (3) ◽  
pp. 359-369
Author(s):  
Petrus Kanisius Siga Tage ◽  
Appolonaris T Berkanis ◽  
Yasinta Betan ◽  
Elisabet Batseba Pinis
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Phenomenological Approach ◽  
Incident Reporting ◽  
Nursing Managers ◽  
Safety Incident ◽  
Research Findings ◽  
Reporting Rates ◽  
Patient Safety Incidents ◽  
Safety Incident Reporting

Background: Reporting patient safety incidents is important to improve patient safety and quality of care. Barriers to report patient safety incidents in nursing may occur due to lack of knowledge and unscheduled as well as low reporting rates. Unfortunately, nurses’ experiences in reporting patient safety incidents have not been comprehensively reviewed.Purpose: The purpose of this study was to explore nurses’ experiences of reporting patient safety incidents in East Nusa Tenggara, Indonesia.Methods: A descriptive phenomenological approach was used to identify, analyze and describe the experiences of 15 nurses in reporting patient safety incidents.  Nurses having worked for more than two years, not on leave, not being infected with COVID-19 in the last 14 days, and not having a structural position were purposively recruited. Data were collected using in-depth interviews and voice recordings. The collected data were then transcribed verbatim, and thematic analysis was applied for data analysis.Results: Four main themes were found in this study, which included: (1) Priority and responsibility for services, (2) Barriers to incident reporting, (3) Learning for nurses, and (4) Support for nurses.Conclusion: The nurses experience of in reporting safety incidents is still constrained by several obstacles. It is hoped that health care organizations need to provide appropriate strategies to enhance the safety incident reporting efforts made by nurses. Based on the research findings, it is recommended that health service organizations disseminate the use of safety incident reporting forms and assist nursing managers to their subordinates by conducting supervision and motivation related to incident reporting on a scheduled and continuous basis.

scholarly journals Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis

2019 ◽  
pp. bmjspcare-2019-001824
Author(s):  
Toby Dinnen ◽  
Huw Williams ◽  
Sarah Yardley ◽  
Simon Noble ◽  
Adrian Edwards ◽  
...  
Keyword(s):  
Patient Safety ◽  
Mixed Methods ◽  
Advance Care Planning ◽  
Learning System ◽  
Care Planning ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Advance Care ◽  
National Analysis ◽  
Patient Safety Incidents

ObjectivesAdvance care planning (ACP) is essential for patient-centred care in the last phase of life. There is little evidence available on the safety of ACP. This study characterises and explores patient safety incidents arising from ACP processes in the last phase of life.MethodsThe National Reporting and Learning System collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports, April 2005–December 2015. Mixed-methods, combining structured data coding, exploratory and thematic analyses were undertaken to describe incidents, underlying causes and outcomes, and identify areas for improvement.ResultsWe identified 70 reports in which ACP caused a patient safety incident across three error categories: (1) ACP not completed despite being appropriate (23%, n=16). (2) ACP completed but not accessible or miscommunicated between professionals (40%, n=28). (3) ACP completed and accessible but not followed (37%, n=26). Themes included staff lacking the knowledge, confidence, competence or belief in trustworthiness of prior documentation to create or enact ACP. Adverse outcomes included cardiopulmonary resuscitation attempts contrary to ACP, other inappropriate treatment and/or transfer or admission.ConclusionThis national analysis identifies priority concerns and questions whether it is possible to develop strong system interventions to ensure safety and quality in ACP without significant improvement in human-dependent issues in social programmes such as ACP. Human-dependent issues (ie, varying patient, carer and professional understanding, and confidence in enacting prior ACP when required) should be explored in local contexts alongside systems development for ACP documentation.

scholarly journals Contributory factors in surgical incidents as delineated by a confidential reporting system

2018 ◽  
Vol 100 (5) ◽  
pp. 401-405 ◽  
Author(s):  
F Mushtaq ◽  
C O’Driscoll ◽  
FCT Smith ◽  
D Wilkins ◽  
N Kapur ◽  
...  
Keyword(s):  
Adverse Events ◽  
Reporting System ◽  
Contributory Factor ◽  
Systematic Analysis ◽  
Contributory Factors ◽  
Cognitive Limitations ◽  
Surgical Errors ◽  
Policies And Procedures ◽  
The Uk ◽  
Patient Safety Incidents

Background Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. Methods One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. Results The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) – with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures – those closest in time and space to the adverse event – pointed to frequent coupling with latent, systems-related contributory factors. Conclusions Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.

scholarly journals High-risk medications identified from the Danish Patient Safety Database and the challenge of dissemination

2018 ◽  
Vol 24 (1) ◽  
pp. 7-12 ◽  
Author(s):  
Pia Knudsen ◽  
Lena Graversen ◽  
Torsten Larsen
Keyword(s):  
Patient Safety ◽  
High Risk ◽  
Improve Patient Safety ◽  
Healthcare Staff ◽  
Safety Database ◽  
Danish Patient ◽  
National Patient ◽  
Medication Incidents ◽  
Patient Safety Incidents ◽  
Improve Patient

Since 2004, patient safety incidents in Denmark have been reported to a national patient safety reporting system – the Danish Patient Safety Database. The goal of the system is to improve patient safety. In 2011, a decision was made to develop a national list of high-risk medications based on the medication incidents reported to the Danish Patient Safety Database. The high-risk medications are defined as medications that have been involved in medication errors and have caused harm to patients. The purpose is to identify medications that posed a particular and preventable risk for patients. It became clear through updates that there was a group of medications that caused severe harm to the patients more frequently than others. Based on the list, the Danish Patient Safety Authority in 2015 identified seven groups of medications that require special attention from healthcare staff: antidiabetic medications, anticoagulants, low-dose methotrexate, concentrated potassium, opioids, gentamicin and digoxin. Better handling of these seven types of medication could improve patient safety significantly. For many years, Danish Patient Safety Authority has distributed tables and booklets about these high-risk medications. In addition, ‘patient safety warnings’ are issued when it is considered necessary. In spite of this, many patient safety incidents involving these medications still occur. This points to the fact that disseminating knowledge from a government level all the way to frontline healthcare staff poses a challenge. On that background, Danish Patient Safety Authority is exploring new ways to disseminate knowledge to frontline healthcare staff about patient safety incidents.

Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution Through Crew Resource Management Training

2016 ◽  
Vol 32 (5) ◽  
pp. 480-484 ◽  
Author(s):  
SreyRam Kuy ◽  
Ramon A. L. Romero
Keyword(s):  
Patient Safety ◽  
Resource Management ◽  
Adverse Events ◽  
Critical Incident ◽  
Medical Center ◽  
Crew Resource Management ◽  
Management Training ◽  
Veterans Affairs ◽  
Crew Resource Management Training ◽  
The Impact

The objective of this study was to determine whether rates of Critical Incident Tracking Network (CITN) patient safety adverse events change after implementation of crew resource management (CRM) training at a Veterans Affairs (VA) hospital. CRM training was conducted for all surgical staff at a VA hospital. Compliance with briefing and debriefing checklists was assessed for all operating room procedures. Tracking of adverse patient safety events utilizing the VA CITN events was performed. There was 100% adherence to performance of briefings and debriefings after initiation of CRM training. There were 3 CITN events in the year prior to implementation of CRM training; following CRM training, there have been zero CITN events. Following CRM training, CITN events were eliminated, and this has been sustained for 2.5 years. This is the first study to demonstrate the impact of CRM training on CITN events, specifically, in a VA medical center.

Recognizing the Ordinary as Extraordinary: Insight Into the “Way We Work” to Improve Patient Safety Outcomes

2017 ◽  
Vol 26 (4) ◽  
pp. 272-277 ◽  
Author(s):  
Elizabeth A. Henneman
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Eye Tracking ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Safety Net ◽  
Near Miss ◽  
The Impact ◽  
Risk Processes ◽  
Insight Into

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

scholarly journals Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands

BMJ Open ◽  
2019 ◽  
Vol 9 (7) ◽  
pp. e029923 ◽  
Author(s):  
Kris Vanhaecht ◽  
Deborah Seys ◽  
Loes Schouten ◽  
Luk Bruyneel ◽  
Ellen Coeckelberghs ◽  
...  
Keyword(s):  
Patient Safety ◽  
Healthcare Providers ◽  
Direct Patient Care ◽  
Secondary Outcome ◽  
Symptom Duration ◽  
Common Symptom ◽  
Patient Harm ◽  
Cross Sectional ◽  
Safety Incident ◽  
The Impact

ObjectivesTo describe healthcare providers’ symptoms evoked by patient safety incidents (PSIs), the duration of these symptoms and the association with the degree of patient harm caused by the incident.DesignCross-sectional survey.Setting32 Dutch hospitals that participate in the ‘Peer Support Collaborative’.Participants4369 healthcare providers (1619 doctors and 2750 nurses) involved in a PSI at any time during their career.InterventionsAll doctors and nurses working in direct patient care in the 32 participating hospitals were invited via email to participate in an online survey.Primary and secondary outcome measuresPrevalence of symptoms, symptom duration and its relationship with the degree of patient harm.ResultsIn total 4369 respondents were involved in a PSI and completely filled in the questionnaire. Of these, 462 reported having been involved in a PSI with permanent harm or death during the last 6 months. This had a personal, professional impact as well as impact on effective teamwork requirements. The impact of a PSI increased when the degree of patient harm was more severe. The most common symptom was hypervigilance (53.0%). The three most common symptoms related to teamwork were having doubts about knowledge and skill (27.0%), feeling unable to provide quality care (15.6%) and feeling uncomfortable within the team (15.5%). PSI with permanent harm or death was related to eightfold higher likelihood of provider-related symptoms lasting for more than 1 month and ninefold lasting longer than 6 months compared with symptoms reported when the PSI caused no harm.ConclusionThe impact of PSI remains an underestimated problem. The higher the degree of harm, the longer the symptoms last. Future studies should evaluate how these data can be integrated in evidence-based support systems.

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