scholarly journals Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors

2020 ◽  
Vol 9 (2) ◽  
pp. e000949
Author(s):  
Natalie Lane ◽  
Ian Hunter
Keyword(s):  
Quality Improvement ◽  
Lessons Learned ◽  
Working Environment ◽  
Healthcare Team ◽  
Prescribing Errors ◽  
Contributing Factors ◽  
Systematic Analysis ◽  
Adverse Incident ◽  
Incident Reports ◽  
Error Types

IntroductionPrescribing errors are a principal cause of preventable harm in healthcare. This study aims to establish a systematic approach to analysing prescribing-related adverse incident reports, in order to elucidate the characteristics and contributing factors of common prescribing errors and target multifaceted quality improvement initiatives.MethodsAll prescribing-related adverse incident reports submitted across one NHS board over 12 months were selected. Incidents involving commonly implicated drugs (involved in ≥10 incidents) underwent analysis to establish likely underlying causes using Reason’s Model of Accident Causation.Results330 prescribing-related adverse incident reports were identified. Commonly implicated drugs were insulin (10% of incidents), gentamicin (7%), co-amoxiclav (5%) and amoxicillin (5%). The most prevalent error types were prescribing amoxicillin when contraindicated due to allergy (5%); prescribing co-amoxiclav when contraindicated due to allergy (5%); prescribing the incorrect type of insulin (3%); and omitting to prescribe insulin (3%). Error-producing factors were identified in 86% of incidents involving commonly implicated drugs. 53% of incidents involved error-producing factors related to the working environment; 38% involved factors related to the healthcare team; and 37% involved factors related to the prescriber.DiscussionThis study establishes that systematic analysis of adverse incident reports can efficiently identify the characteristics and contributing factors of common prescribing errors, in a manner useful for targeting quality improvement. Furthermore, this study produced a number of salient findings. First, a narrow range of drugs were implicated in the majority of incidents. Second, a small number of error types were highly recurrent. Lastly, a range of contributing factors were evident, with those related to the working environment contributing to the majority of prescribing errors analysed.

scholarly journals Empower to connect and connect to empower: experience in using a humanistic approach to improve patients’ access to, and experience of, care in isolation wards during the COVID-19 outbreak in Singapore

2021 ◽  
Vol 10 (1) ◽  
pp. e000996
Author(s):  
Natalie Liling Woong ◽  
Victoria Sze Min Ekstrom ◽  
Xiaohui Xin ◽  
Crystal Lim ◽  
Evelyn Swee Kim Boon ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Psychosocial Support ◽  
Interprofessional Collaboration ◽  
Quality Improvement Project ◽  
Healthcare Team ◽  
Psychosocial Needs ◽  
Improvement Project ◽  
Support Materials ◽  
Experience Of Care ◽  
Singapore General Hospital

Patients admitted to the isolation ward during the COVID-19 outbreak face multiple psychosocial stressors including the disruptive experience of being in quarantine, anxiety over contracting a newly emerging infectious disease and limited access to their healthcare team. This quality improvement project aims to leverage on technology to improve patients’ access to, and experience of, care while in isolation.Patients admitted to two isolation wards in Singapore General Hospital (SGH) between 28 February and 19 March 2020 were each provided an iPad loaded with the MyCare application (app), curated materials and mobile games. During this period, 83 of them accessed the device and the app. MyCare app is an app developed by the nursing team in SGH as part of an existing interprofessional collaboration to help patients navigate their care during their inpatient stay. In response to COVID-19, MyCare app was supplemented with materials to address affected patients’ informational and psychosocial needs. These materials included an information sheet on COVID-19, interviews with previous severe acute respiratory syndrome survivors, psychosocial support materials, and uplifting literature, illustrated storybooks and artwork.This paper describes the process of planning for, and executing, the intervention and reports the initial results of its effect. Initial feedback indicated a positive response to the intervention. 9 out of 10 respondents (90%) rated their hospital experience with a maximum of five stars and all 10 respondents (100%) rated the psychosocial support materials with five stars. Doctors managing the patients also observed a reduction in the number of commonly asked questions following the deployment of the iPad.This quality improvement project is ongoing with plans for further research to determine how to better support the psychosocial needs of patients in isolation during a novel disease outbreak. This report is written based on the Standards for Quality Improvement Reporting Excellence guidelines.

scholarly journals Nursing preceptorship, a supportive and reflective approach for promoting a healthy working environment: a multi-methods design

2021 ◽  
pp. 205715852110252
Author(s):  
Verena Jochim ◽  
Kristina Rosengren
Keyword(s):  
Quality Improvement ◽  
Quality Indicators ◽  
Role Models ◽  
Qualitative Content Analysis ◽  
Working Environment ◽  
Eastern Region ◽  
Staff Turnover ◽  
Short Term ◽  
Annual Survey ◽  
Healthy Working

Shortage of nurses negatively influences the working environment in hospitals, by placing extra burden on newly graduated nurses. Thus, it is important to improve the knowledge and skills of nurses to increase their confidence levels. Experienced nurses serve as role models for junior nurses. This study aimed to describe and analyze a project with a nursing preceptorship in an internal medicine ward in the eastern region of Sweden. Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) were used in the multi-method approach. Quality indicators, staff turnover, short-term absence, and annual survey were analyzed using descriptive statistics. Moreover, two focus group interviews were analyzed using qualitative content analysis. The results showed marginal improvements due to quality indicators and working environment, and decreased staff turnover and short-term absenteeism. Two factors, ‘supportive working environment’ and ‘improvement in nursing’, were identified. The study concluded that selection of nurse preceptors with expertise and interest in supportive and reflective approaches is significant for promoting a healthy working environment. Moreover, interventions such as nursing preceptorship facilitate implementation (<one year) and evaluation using a multi-method design to describe, explain, and understand the possible considerations and consequences of quality improvement in healthcare.

Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned

Urology ◽  
2021 ◽  
Author(s):  
Franklin Gaylis ◽  
Ryan Nasseri ◽  
Amirali Salmasi ◽  
Christopher Anderson ◽  
Sarah Mohedin ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Continuous Quality Improvement ◽  
Lessons Learned ◽  
Continuous Quality

scholarly journals Experiences of nurses caring for respiratory patients during the first wave of the COVID-19 pandemic: an online survey study

2021 ◽  
Vol 8 (1) ◽  
pp. e000987
Author(s):  
Nicola J Roberts ◽  
Carol A Kelly ◽  
Kate A Lippiett ◽  
Emma Ray ◽  
Lindsay Welch
Keyword(s):  
Mental Health ◽  
Online Survey ◽  
Demographic Data ◽  
Geographical Location ◽  
Working Environment ◽  
Survey Study ◽  
British Thoracic Society ◽  
Healthcare Team ◽  
Free Text ◽  
The Impact

BackgroundNurses have been at the forefront of the pandemic response, involved in extensive coordination of services, screening, vaccination and front-line work in respiratory, emergency and intensive care environments. The nature of this work is often intense and stress-provoking with an inevitable psychological impact on nurses and all healthcare workers. This study focused on nurses working in respiratory areas with the aim of identifying and characterising the self-reported issues that exacerbated or alleviated their concerns during the first wave of the COVID-19 pandemic.MethodsAn online survey was developed consisting of 90 questions using a mixture of open-ended and closed questions. Participant demographic data were also collected (age, gender, ethnicity, number of years qualified, details of long-term health conditions, geographical location, nursing background/role and home life). The online survey was disseminated via social media and professional respiratory societies (British Thoracic Society, Primary Care Respiratory Society, Association of Respiratory Nurse Specialists) over a 3-week period in May 2020 and the survey closed on 1 June 2020.ResultsThe study highlights the experiences of nurses caring for respiratory patients during the first wave of the pandemic in early 2020. Concerns were expressed over the working environment, the supply and availability of adequate protective personal equipment, the quality of care individuals were able to deliver, and the impact on mental health to nurses and their families. A high number provided free-text comments around their worries and concerns about the impact on their household; these included bringing the virus home, the effect on family members worrying about them, mental health and the impact of changing working patterns, and managing with children. Although both formal and informal support were available, there were inconsistencies in provision, highlighting the importance of nursing leadership and management in ensuring equity of access to services.ConclusionsSupport for staff is essential both throughout the pandemic and afterwards, and it is important that preparation of individuals regarding building resilience is recognised. It is also clear that psychological support and services for nurses and the wider healthcare team need to be available and quickly convened in the event of similar major incidents, either global or local.

scholarly journals Coding ATC Incident Data Using HFACS: Intercoder Consensus

2011 ◽  
Vol 2011 ◽  
pp. 1-8 ◽  
Author(s):  
Liang Wang ◽  
Yaohua Wang ◽  
Xiaoqiang Yang ◽  
Kai Cheng ◽  
Haishan Yang ◽  
...  
Keyword(s):  
Human Factors ◽  
Traffic Control ◽  
Air Traffic ◽  
The Other ◽  
Contributing Factors ◽  
Factors Analysis ◽  
Air Traffic Controllers ◽  
High Hazard ◽  
Incident Reports ◽  
Comparability Of Results

Reliability studies for coding contributing factors of incident reports in high hazard industries are rarely conducted and reported. Although the Human Factors Analysis and Classification System (HFACS) appears to have a larger number of such studies completed than most other systems doubt exists as the accuracy and comparability of results between studies due to aspects of methodology and reporting. This paper reports on a trial conducted on HFACS to determine its reliability in the context of military air traffic control (ATC). Two groups participated in the trial: one group comprised of specialists in the field of human factors, and the other group comprised air traffic controllers. All participants were given standardized training via a self-paced workbook and then read 14 incident reports and coded the associated findings. The results show similarly low consensus for both groups of participants. Several reasons for the results are proposed associated with the HFACS model, the context within which incident reporting occurs in real organizations and the conduct of the studies.

A study into perioperative anaesthetic adverse events in Thailand (PAAd THAI): An analysis of suspected emergence delirium

2018 ◽  
Vol 28 (12) ◽  
pp. 347-354
Author(s):  
Tanyong Pipanmekaporn ◽  
Yodying Punjasawadwong ◽  
Manee Raksakietisak ◽  
Wimonrat Sriraj ◽  
Varinee Lekprasert ◽  
...  
Keyword(s):  
Medical Treatment ◽  
Elective Surgery ◽  
Physical Restraint ◽  
Policy Changes ◽  
Contributing Factors ◽  
Emergence Delirium ◽  
Restraint Use ◽  
Incident Reports ◽  
And Training

The purpose of this study is to demonstrate the characteristics, contributing factors and recommended policy changes associated with emergence delirium. Relevant data were extracted from the PAAd Thai database of 2,006 incident reports which were conducted from 1 January to 31 December 2015. Details pertinent to the patient, surgery, anaesthetic and systematic factors were reviewed independently. Seventeen incidents of emergence delirium were recorded. Emergence delirium was common in the following categories: male (70.6%), over 65 years of age (53%), elective surgery (76%) and orthopedic surgery (35%). Physical restraint was required in 53% (9 of 17) of cases and 14 patients (82%) required medical treatment. One patient developed postoperative delirium and required medical treatment. The study led to the following recommendations: Development of a classification of practice guidelines and a screening tool, and training for restraint use.

Lessons learned in establishing a quality improvement project to reduce hospital acquired infections in the neonatology ward at a referral hospital in Rwanda

2016 ◽  
Vol 24 (4) ◽  
pp. 341-348 ◽  
Author(s):  
Naasson Gafirimbi ◽  
Rex Wong ◽  
Eva Adomako ◽  
Jeanne Kagwiza
Keyword(s):  
Quality Improvement ◽  
Lessons Learned ◽  
Referral Hospital ◽  
Quality Improvement Project ◽  
Injection Technique ◽  
Improve Quality ◽  
Improvement Project ◽  
Content Type ◽  
Hospital Acquired

Purpose Improving healthcare quality has become a worldwide effort. Strategic problem solving (SPS) is one approach to improve quality in healthcare settings. This case study aims to illustrate the process of applying the SPS approach in implementing a quality improvement project in a referral hospital. Design/methodology/approach A project team was formed to reduce the hospital-acquired infection (HAI) rate in the neonatology unit. A new injection policy was implemented according to the root cause identified. Findings The HAI rate decreased from 6.4 per cent pre-intervention to 4.2 per cent post-intervention. The compliance of performing the aseptic injection technique significantly improved by 60 per cent. Practical implications This case study illustrated the detailed application of the SPS approach in establishing a quality improvement project to address HAI and injection technique compliance, cost-effectively. Other departments or hospitals can apply the same approach to improve quality of care. Originality/value This study helps inform other hospitals in similar settings, the steps to create a quality improvement project using the SPS approach.

An Empirical Analog Benchmarking Workflow to Improve Hydrocarbon Recovery

2021 ◽  
pp. 1-18
Author(s):  
Shaoqing Sun ◽  
David A. Pollitt
Keyword(s):  
Best Practices ◽  
Lessons Learned ◽  
Production Performance ◽  
Resource Potential ◽  
Systematic Analysis ◽  
Hydrocarbon Recovery ◽  
Field Development ◽  
Development Scenarios ◽  
Recovery Potential ◽  
Wide Range

Summary Benchmarking the recovery factor and production performance of a given reservoir against applicable analogs is a key step in field development optimization and a prerequisite in understanding the necessary actions required to improve hydrocarbon recovery. Existing benchmarking methods are principally structured to solve specific problems in individual situations and, consequently, are difficult to apply widely and consistently. This study presents an alternative empirical analog benchmarking workflow that is based upon systematic analysis of more than 1,600 reservoirs from around the world. This workflow is designed for effective, practical, and repeatable application of analog analysis to all reservoir types, development scenarios, and production challenges. It comprises five key steps: (1) definition of problems and objectives; (2) parameterization of the target reservoir; (3) quantification of resource potential; (4) assessment of production performance; and (5) identification of best practices and lessons learned. Problems of differing nature and for different objectives require different sets of analogs. This workflow advocates starting with a broad set of parameters to find a wide range of analogs for quantification of resource potential, followed by a narrowly defined set of parameters to find relevant analogs for assessment of production performance. During subsequent analysis of the chosen analogs, the focus is on isolating specific critical issues and identifying a smaller number of applicable analogs that more closely match the target reservoir with the aim to document both best practices and lessons learned. This workflow aims to inform decisions by identifying the best-in-class performers and examining in detail what differentiates them. It has been successfully applied to improve hydrocarbon recovery for carbonate, clastic, and basement reservoirs globally. The case studies provided herein demonstrate that this workflow has real-world utility in the identification of upside recovery potential and specific actions that can be taken to optimize production and recovery.

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