Can patients report patient safety incidents in a hospital setting? A systematic review

IntroductionAdvance Care Planning (ACP) is an important component of patient centred end-of-life care (Houben et al. 2014; Brinkman-Stoppelenburg et al. 2014). However there is little evidence available on the safety of the process and its impact on quality of care.AimTo characterise the nature of patient safety incidents arising around the ACP process for patients approaching end-of-life.MethodThe National Reporting and Learning System (NRLS) collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports between 2005 and 2015. A mixed methods process combining structured data coding and exploratory descriptive analysis was undertaken to describe incidents underlying causes and outcomes. A thematic analysis identified areas on which to focus improvement initiatives.ResultsWe identified 67 incident reports in which patients experienced inadequate care due to issues with implementation of ACP. The most common source of error was (mis)communication of ACP (n=27) where documentation was lost or verbal handover was inaccurate. Over one third of reports (n=24) described an ACP not being followed. In the remaining reports (n=16) an ACP was not completed despite being appropriate. The most common contributory factor was inadequate staff knowledge (n=18). Common outcomes were cardiopulmonary resuscitation attempts contrary to a patient’s wishes (n=18). Other outcomes included inappropriate treatment or transfer/admission.ConclusionOur national level analysis identifies key priorities which should be explored in local contexts: specifically improving public and staff understanding and engagement with ACP and developing systems for recording and accessing ACP documentation across healthcare services.References. Brinkman-Stoppelenburg A, Rietjens JA, Van Der Heide A. The effects of advance care planning on end-of-life care: A systematic review. Palliative Medicine2014;28:1000–25.. Houben CH, Spruit MA, Groenen MT, Wouters EF, Janssen DJ. Efficacy of advance care planning: A systematic review and meta-analysis. Journal of the American Medical Directors Association2014;15:477–89.

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Learning from Patient Safety Incidents in the Emergency Department: A Systematic Review

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2019.11.015 ◽

2020 ◽

Vol 58 (2) ◽

pp. 234-244 ◽

Cited By ~ 4

Author(s):

Sara Amaniyan ◽

Bjørn Ove Faldaas ◽

Patricia A. Logan ◽

Mojtaba Vaismoradi

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Patient Safety ◽

Patient Safety Incidents

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THE IMPACT OF BARCODE MEDICATION ADMINISTRATION ON PATIENT SAFETY: A SYSTEMATIC REVIEW

International Journal of Medical and Biomedical Studies ◽

10.32553/ijmbs.v5i6.1951 ◽

2021 ◽

Vol 5 (6) ◽

Author(s):

Seham Sahal Aloufi

Keyword(s):

Systematic Review ◽

Patient Safety ◽

Medication Error ◽

Medication Errors ◽

Improve Patient Safety ◽

Hospital Setting ◽

Medication Administration ◽

Bar Code ◽

The Impact ◽

Improve Patient

Patient safety is considered as an essential feature of healthcare system. Many trials have been conducted in order to find ways to improve patient safety, and many reports indicate that medication errors pose a threat to patient safety. Thus, some studies have investigated the impact of bar code medication administration (BCMA) system on medication error reduction during the medication administration procedure. This systematic review (SR) reports the impact of BCMA system on reducing medication errors to improve patient safety; it also compares traditional medication administration with the BCMA system. The review concentrates on the effectiveness of BCMA technology on medication administration errors, and on the accuracy of medication administration. This review also focused on different designs of quantitative studies, as they are more effective at investigating the impact of the intervention than qualitative studies. The findings from this systematic review show various results depending on the nature of the hospital setting. Most of the studies agree that the BCMA system enhances compliance with the 'five rights’' requirement (right drug, right patient, right dose, right time and right route) of medication administration. In addition, BCMA technology identified medication error types that could not be identified with the traditional approach which is applying the 'five rights' of medication administration. The findings of this systematic review also confirm the impact of BCMA system in reducing medication error, preventing adverse events and increasing the accuracy of the medication administration rate. However, BCMA technology did not consistently reduce the overall errors of medication administration. Keyword: Patient Safety, Impact, BCMA, eMAR

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Contributory factors to patient safety incidents in primary care: protocol for a systematic review

Systematic Reviews ◽

10.1186/s13643-015-0052-0 ◽

2015 ◽

Vol 4 (1) ◽

Cited By ~ 4

Author(s):

Sally Giles ◽

Maria Panagioti ◽

Andrea Hernan ◽

Sudeh Cheraghi-Sohi ◽

Rebecca Lawton

Keyword(s):

Systematic Review ◽

Primary Care ◽

Patient Safety ◽

Contributory Factors ◽

Care Protocol ◽

Patient Safety Incidents

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Effect of the organizational culture for patient safety in the hospital setting: A systematic review

Aquichan ◽

10.5294/aqui.2021.21.2.3 ◽

2021 ◽

Vol 21 (2) ◽

pp. 1-16

Author(s):

Leonor Coelho da Silva ◽

Célia Pereira Caldas ◽

Cintia Silva Fassarella ◽

Patricia Simas de Souza

Keyword(s):

Systematic Review ◽

Organizational Culture ◽

Patient Safety ◽

Latin American ◽

Safety Culture ◽

Meta Analysis ◽

Effective Interaction ◽

Hospital Setting ◽

Health Sciences ◽

Cross Sectional

Objective: To identify the effect of the organizational culture on patient safety in the hospital context. Materials and methods: A systematic review, without meta-analysis, registered in PROSPERO with number CRD42020162981. Cross-sectional and observational studies were selected that assessed the safety environment and safety culture published between 2014 and 2020 in journals indexed in the EMBASE, Latin American and Caribbean Literature in Health Sciences (Literatura Latinoamericana e do Caribe em Ciências da Saúde, LILACS) via the Virtual Health Library (Biblioteca Virtual em Saúde, BVS), Medline (International Literature in Health Sciences) via PubMed, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Results: The findings show that a positive safety environment exerts a beneficial effect on the safety culture, favors the notification of events, and enables improvements in the quality of health care. Conclusions: The effective interaction between safety culture and organizational culture is still scarce in the literature. Most of the studies carried out investigate the situational diagnosis and little progress is made in terms of deepening the implications for the professional practice and the repercussions for the safety of hospitalized patients.

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Hospital Survey on Patient Safety Culture (HSPSC): a systematic review of the psychometric properties of 62 international studies

BMJ Open ◽

10.1136/bmjopen-2018-026896 ◽

2019 ◽

Vol 9 (9) ◽

pp. e026896 ◽

Cited By ~ 4

Author(s):

Patrick Waterson ◽

Eva-Maria Carman ◽

Tanja Manser ◽

Antje Hammer

Keyword(s):

Systematic Review ◽

Patient Safety ◽

Middle East ◽

Psychometric Properties ◽

Safety Culture ◽

Far East ◽

Hospital Setting ◽

Patient Safety Culture ◽

Secondary Outcome ◽

International Studies

ObjectiveTo carry out a systematic review of the psychometric properties of international studies that have used the Hospital Survey on Patient Safety Culture (HSPSC).DesignLiterature review and an analysis framework to review studies.SettingHospitals and other healthcare settings in North and South America, Europe, the Near East, the Middle East and the Far East.Data sourcesA total of 62 studies and 67 datasets made up of journal papers, book chapters and PhD theses were included in the review.Primary and secondary outcome measuresPsychometric properties (eg, internal consistency) and sample characteristics (eg, country of use, participant job roles and changes made to the original version of the HSPSC).ResultsJust over half (52%) of the studies in our sample reported internal reliabilities lower than 0.7 for at least six HSPSC dimensions. The dimensions ‘staffing’, ‘communication openness’, ‘non-punitive response to error’, ‘organisational learning’ and ‘overall perceptions of safety’ resulted in low internal consistencies in a majority of studies. The outcomes from assessing construct validity were reported in 60% of the studies. Most studies took place in a hospital setting (84%); the majority of survey participants (62%) were drawn from nursing and technical staff. Forty-two per cent of the studies did not state what modifications, if any, were made to the original US version of the instrument.ConclusionsWhile there is evidence of a growing worldwide trend in the use of the HSPSC, particularly within Europe and the Near/Middle East, our review underlines the need for caution in using the instrument. Future use of the HSPSC needs to be sensitive to the demands of care settings, the target population and other aspects of the national and local healthcare contexts. There is a need to develop guidelines covering procedures for using, adapting and translating the HSPSC, as well as reporting findings based on its use.

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Reporting and responding to patient safety incidents based on data from hospitals’ reporting systems: A systematic review

Journal of Hospital Administration ◽

10.5430/jha.v9n2p22 ◽

2020 ◽

Vol 9 (2) ◽

pp. 22

Author(s):

Ere Uibu ◽

Kaja Põlluste ◽

Margus Lember ◽

Mari Kangasniemi

Keyword(s):

Systematic Review ◽

Patient Safety ◽

Reference Lists ◽

Knowledge Dissemination ◽

Knowledge Application ◽

Reporting Systems ◽

Meta Analyses ◽

Patient Safety Incidents ◽

Insight Into

Objective: This review summarizes and synthesizes the evidence on follow-up activities regarding patient safety incidents reported in hospitals.Methods: Peer-reviewed papers were retrieved with electronic searches from CINAHL, Web of Science, PubMed and Scopus databases and with manual searches in most relevant journals and in the reference lists of included studies, limiting searches to papers published in English between 2014 and 2018. A systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Two authors extracted the data following a predefined extraction form.Results: All together 16 studies were selected for analysis. All studies described incidents and gave insight into problems, risks and unsafe situations which were responded to with recommended improvements. Recommended improvements in response to incidents involved guidelines, staff training, technical improvements and general safety improvements. Only five studies reported feedback and knowledge dissemination activities, referring to meetings, written support and visual support.Conclusions: Limited research has described the systematic use of report outcomes for knowledge application in organizations. However, the development of patient safety requires that reported incidents are responded to by knowledge application within feedback and knowledge dissemination activities. Therefore, healthcare professionals need to have sufficient competences in patient safety, and more research is needed on the content and effectiveness of the responding activities.

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