scholarly journals Adverse events in psychiatry: a national cohort study in Sweden with a unique psychiatric trigger tool

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Lena Nilsson ◽  
Madeleine Borgstedt-Risberg ◽  
Charlotta Brunner ◽  
Ullakarin Nyberg ◽  
Urban Nylén ◽  
...  
Keyword(s):  
Patient Safety ◽  
Cohort Study ◽  
Adverse Events ◽  
Psychiatric Care ◽  
Treatment Plan ◽  
Age Groups ◽  
Trigger Tool ◽  
Safety Research ◽  
National Cohort

Abstract Background The vast majority of patient safety research has focused on somatic health care. Although specific adverse events (AEs) within psychiatric healthcare have been explored, the overall level and nature of AEs is sparsely investigated. Methods Cohort study using a retrospective record review based on a two-step trigger tool methodology in the charts of randomly selected patients 18 years or older admitted to the psychiatric acute care departments in all Swedish regions from January 1 to June 30, 2017. Hospital care together with corresponding outpatient care were reviewed as a continuum, over a maximum of 3 months. The AEs were categorised according to type, severity and preventability. Results In total, the medical records of 2552 patients were reviewed. Among the patients, 50.4% were women and 49.6% were men. The median (range) age was 44 (18–97) years for women and 44.5 (18–93) years for men. In 438 of the reviewed records, 720 AEs were identified, corresponding to the AEs identified in 17.2% [95% confidence interval, 15.7–18.6] of the records. The majority of AEs resulted in less or moderate harm, and 46.2% were considered preventable. Prolonged disease progression and deliberate self-harm were the most common types of AEs. AEs were significantly more common in women (21.5%) than in men (12.7%) but showed no difference between age groups. Severe or catastrophic harm was found in 2.3% of the records, and the majority affected were women (61%). Triggers pointing at deficient quality of care were found in 78% of the records, with the absence of a treatment plan being the most common. Conclusions AEs are common in psychiatric care. Aside from further patient safety work, systematic interventions are also warranted to improve the quality of psychiatric care.

scholarly journals Incidence of adverse events in Sweden during 2013–2016: a cohort study describing the implementation of a national trigger tool

BMJ Open ◽  
2018 ◽  
Vol 8 (3) ◽  
pp. e020833 ◽  
Author(s):  
Lena Nilsson ◽  
Madeleine Borgstedt-Risberg ◽  
Michael Soop ◽  
Urban Nylén ◽  
Carina Ålenius ◽  
...  
Keyword(s):  
Patient Safety ◽  
Cohort Study ◽  
Adverse Events ◽  
Secondary Outcome ◽  
Trigger Tool ◽  
Retrospective Record Review ◽  
Medical Needs ◽  
Bladder Distention ◽  
National Patient ◽  
Record Review

ObjectivesTo describe the implementation of a trigger tool in Sweden and present the national incidence of adverse events (AEs) over a 4-year period during which an ongoing national patient safety initiative was terminated.DesignCohort study using retrospective record review based on a trigger tool methodology.Setting and participantsPatients ≥18 years admitted to all somatic acute care hospitals in Sweden from 2013 to 2016 were randomised into the study.Primary and secondary outcome measuresPrimary outcome measure was the incidence of AEs, and secondary measures were type of injury, severity of harm, preventability of AEs, estimated healthcare cost of AEs and incidence of AEs in patients cared for in another type of unit than the one specialised for their medical needs (‘off-site’).ResultsIn a review of 64 917 admissions, the average AE rates in 2014 (11.6%), 2015 (10.9%) and 2016 (11.4%) were significantly lower than in 2013 (13.1%). The decrease in the AE rates was seen in different age groups, in both genders and for preventable and non-preventable AEs. The decrease comprised only the least severe AEs. The types of AEs that decreased were hospital-acquired infections, urinary bladder distention and compromised vital signs. Patients cared for ‘off-site’ had 84% more preventable AEs than patients cared for in the appropriate units. The cost of increased length of stay associated with preventable AEs corresponded to 13%–14% of the total cost of somatic hospital care in Sweden.ConclusionsThe rate of AEs in Swedish somatic hospitals has decreased from 2013 to 2016. Retrospective record review can be used to monitor patient safety over time, to assess the effects of national patient safety interventions and analyse challenges to patient safety such as the increasing care of patients ‘off-site’. It was found that the economic burden of preventable AEs is high.

scholarly journals Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e047102
Author(s):  
Gemma Louch ◽  
Abigail Albutt ◽  
Joanna Harlow-Trigg ◽  
Sally Moore ◽  
Kate Smyth ◽  
...  
Keyword(s):  
Learning Disabilities ◽  
Patient Safety ◽  
Adverse Events ◽  
Grey Literature ◽  
Good Practice ◽  
Hospital Setting ◽  
Eligibility Criteria ◽  
Infant Outcomes ◽  
Safety Outcomes

ObjectivesTo produce a narrative synthesis of published academic and grey literature focusing on patient safety outcomes for people with learning disabilities in an acute hospital setting.DesignScoping review with narrative synthesis.MethodsThe review followed the six stages of the Arksey and O’Malley framework. We searched four research databases from January 2000 to March 2021, in addition to handsearching and backwards searching using terms relating to our eligibility criteria—patient safety and adverse events, learning disability and hospital setting. Following stakeholder input, we searched grey literature databases and specific websites of known organisations until March 2020. Potentially relevant articles and grey literature materials were screened against the eligibility criteria. Findings were extracted and collated in data charting forms.Results45 academic articles and 33 grey literature materials were included, and we organised the findings around six concepts: (1) adverse events, patient safety and quality of care; (2) maternal and infant outcomes; (3) postoperative outcomes; (4) role of family and carers; (5) understanding needs in hospital and (6) supporting initiatives, recommendations and good practice examples. The findings suggest inequalities and inequities for a range of specific patient safety outcomes including adverse events, quality of care, maternal and infant outcomes and postoperative outcomes, in addition to potential protective factors, such as the roles of family and carers and the extent to which health professionals are able to understand the needs of people with learning disabilities.ConclusionPeople with learning disabilities appear to experience poorer patient safety outcomes in hospital. The involvement of family and carers, and understanding and effectively meeting the needs of people with learning disabilities may play a protective role. Promising interventions and examples of good practice exist, however many of these have not been implemented consistently and warrant further robust evaluation.

scholarly journals Global Trigger Tool methodology to detect adverse events: pilot study at Academic Hospital of Udine

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
E Scarpis ◽  
S Degan ◽  
D De Corti ◽  
F Mellace ◽  
R Cocconi ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Academic Hospital ◽  
Trigger Tool ◽  
Hospital Acquired Infections ◽  
Frequent Type ◽  
Global Trigger Tool ◽  
Clinical Records ◽  
Hospital Acquired ◽  
Over Time

Abstract Introduction Identification and measurement of adverse events (AEs) is crucial for patient safety in order to monitor them over time and to implement quality improvement programs, testing if they are effective. Global Trigger Tool (GTT) has been proposed as a low-cost method, being also the most effective to detect AEs. This study aims to describe the number of triggers, the rate and level of AEs identified by GTT and the most frequent type of AE. Methods The Italian version of the GTT was used. Ten paper-based clinical records (CRs) randomly selected every 2 weeks were reviewed from January to April 2019 by three independent reviewers (two nurses, one doctor) at the Academic Hospital of Udine. The AEs rates calculated are: AEs per 1,000 patient-days, AEs per 100 admissions, percentage of admissions with an AE. AEs were classified by harm levels according to National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Results CRs reviewed were 80. Mean age of the patients was 69.3±16.4, women were 37.5%. Mean hospitalisation was 16.8±15.3. Nine were the cases of re-hospitalisation within 30 days (11.3%). The total number of trigger was 156. AEs were 31, with at least one AE on 27.5% of admissions, 38.8 AEs per 100 admissions and 23 AEs per 1,000 patient-days. AEs with harm level E, F and H were respectively 5 (16.1%), 24 (77.4%) and 2 (6.5%). The most frequent type of AE were hospital acquired infections with 15 cases (48.4%). Conclusions The most frequent type of AE was the hospital acquired infections. Rates and levels of AEs were higher than other international studies, probably because of the limited number of CRs reviewed. Key messages Global Trigger Tool is an effective method to detect adverse patient safety events in order to monitor them over time. The most frequent type of adverse events was the hospital acquired infections.

scholarly journals Segurança do paciente em hemodiálise

2018 ◽  
Vol 12 (12) ◽  
pp. 3360
Author(s):  
Renata De Paula Faria Rocha ◽  
Diana Lúcia Moura Pinho
Keyword(s):  
Quality Of Life ◽  
Patient Safety ◽  
Adverse Events ◽  
Renal Disease ◽  
Nursing Care ◽  
Descriptive Study ◽  
Virtual Library ◽  
Calidad De Vida ◽  
Article Analysis

RESUMOObjetivo: analisar a literatura acerca da segurança do paciente em hemodiálise. Método: trata-se de um estudo bibliográfico, descritivo, tipo revisão integrativa, por meio de pesquisa em artigos publicados entre os anos de 2006 a 2016, em português, inglês ou espanhol; coletados nas bases de dados Medline, Lilacs, BDENF e Biblioteca Virtual SciELO e os resultados apresentado em figura. Resultados: compôs-se a amostra deste estudo por seis artigos. Agruparam-se as informações após a análise dos artigos, em três categorias: segurança do paciente em hemodiálise; fatores que afetam a segurança do paciente em hemodiálise e estratégias para a segurança do paciente em hemodiálise. Conclusão: torna-se importante que a equipe da hemodiálise aprofunde os seus conhecimentos acerca da segurança do paciente para atuar, de forma proativa, na prevenção de eventos adversos garantindo, assim, a segurança do paciente e uma melhor qualidade de vida ao paciente com doença renal crônica em tratamento hemodialítico. Descritores: Segurança do Paciente; Enfermagem; Diálise Renal; Cuidados de Enfermagem; Enfermagem em Nefrologia; Avaliação em Enfermagem.ABSTRACT Objective: to analyze the literature on the safety of patients on hemodialysis. Method: this is a bibliographical, descriptive study, of integrative review type, through research in articles published between the years 2006 to 2016, in Portuguese, English or Spanish; collected in the databases Medline, Lilacs, BDENF and SciELO Virtual Library and the results presented in figure. Results: the sample of this study was composed by six articles. The information after article analysis was grouped into three categories: patient safety on hemodialysis; factors that affect patient safety on hemodialysis and strategies for patient safety on hemodialysis. Conclusion: it is important that the hemodialysis team deepens their knowledge about patient safety to proactively act in the prevention of adverse events, thus ensuring patient safety and a better quality of life for patients with illness renal disease on hemodialysis. Descriptors: Patient Safety; Nursing; Renal Dyalisis; Nursing Care; Nephrology Nursing; Nursing Assessment.RESUMEN Objetivo: analizar la literatura acerca de la seguridad del paciente en hemodiálisis. Método: se trata de un estudio bibliográfico y descriptivo, revisión de tipo integrador, a través de los artículos de investigación publicados entre 2006 a 2016, en portugués, Inglés o Español; recogidos en las bases de datos Medline, Lilacs, BDENF y Biblioteca Virtual SciELO y los resultados presentados en figura. Resultados: se compuso la muestra de este estudio por seis artículos. Se agruparon las informaciones después del análisis de los artículos, en tres categorías: seguridad del paciente en hemodiálisis; factores que afectan la seguridad del paciente en hemodiálisis y estrategias para la seguridad del paciente en hemodiálisis. Conclusión: es importante que el equipo de la hemodiálisis profundice sus conocimientos acerca de la seguridad del paciente para actuar de forma proactiva en la prevención de eventos adversos garantizando así la seguridad del paciente y una mejor calidad de vida al paciente con enfermedad renal crónica en tratamiento hemodialítico. Descriptores: Seguridad del Paciente; Enfermería; Diálisis Renal; Atención de Enfermería; Enfermería en Nefrología; Evaluación en Enfermería.

scholarly journals Safety culture in the context of operating room: Nurses' perception regarding notification of errors/adverse events

2018 ◽  
Vol 9 (3) ◽  
pp. 40
Author(s):  
Teresa Vinagre ◽  
Rita Marques
Keyword(s):  
Patient Safety ◽  
Pilot Study ◽  
Adverse Events ◽  
Operating Room ◽  
Safety Culture ◽  
Continuous Training ◽  
Operating Room Nurses ◽  
Quantitative Descriptive ◽  
Probabilistic Sample

The notification of errors/adverse events is one of the central aspects for the quality of care and patient safety. The purpose of this pilot study is to analyse the safety culture of the operating room in relation to the errors/adverse events and their notification, in the nurses’ perception. It is a quantitative, descriptive-exploratory pilot study. A survey “Nurses’ Perception regarding Notification of Errors/Adverse Events” was applied, consisting of 8 closed questions to an intentional non-probabilistic sample consisting of 43 nurses working in the operating room of a private hospital in Lisbon. The results showed that only 51.2% of the adverse events that caused damage to patients were always notified by the nurses. Of the various adverse events occurred, 60.5% were not reported, justified by “lack of time”. There was also a negative correlation between professional experience and the frequency of error notification (p < .05). The factors referred as those that contributed most to the occurrence of errors were, pressure to work quickly (100.0%), lack of human resources (86.0%), demotivation (86.0%), professional inexperience and hourly overload (83.7%), lack of knowledge (74.4%) and communication failures (65.1%). The perception of Patient Safety was assessed by the majority of participants as “acceptable”. In conclusion, it was evident the reduced notification of adverse events in the operation room so it becomes crucial to focus on the continuous training of health professionals, as well as work on the error, to increase a safety culture with quality.

scholarly journals Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study

2019 ◽  
Vol 6 (7) ◽  
pp. 582-589 ◽  
Author(s):  
Florian Walter ◽  
Matthew J Carr ◽  
Pearl L H Mok ◽  
Sussie Antonsen ◽  
Carsten B Pedersen ◽  
...  
Keyword(s):  
Cohort Study ◽  
Psychiatric Care ◽  
Adverse Outcomes ◽  
Inpatient Psychiatric Care ◽  
National Cohort

Postdischarge Adverse Events Among Patients Who Received Home Health Care Services

2019 ◽  
Vol 31 (4) ◽  
pp. 257-262
Author(s):  
Dennis Tsilimingras ◽  
Liying Zhang ◽  
Askar Chukmaitov
Keyword(s):  
Risk Factors ◽  
Health Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Home Health Care ◽  
Health Care Services ◽  
Home Health ◽  
Health Concern ◽  
Care Services ◽  
Safety Research

Adverse events that occur in urban and rural adults during the posthospitalization period have become a major public health concern. However, postdischarge adverse events for patients receiving home health care have been understudied. The objective of this study was to identify the prevalence and risk factors associated with postdischarge adverse events for patients who received home health care services. We analyzed data from a prospective cohort study that was conducted among patients who were hospitalized in the Tallahassee Memorial Hospital from December 2011 to October 2012. Telephone interviews were conducted by trained nurses who contacted patients within 4 weeks after discharge. Physicians reviewed cases with possible adverse events that were triaged by the nurses. The adverse events that were identified were categorized as preventable, ameliorable, and nonpreventable/nonameliorable. Nearly 39% of 85 patients who received home health care experienced postdischarge adverse events that were predominantly preventable or ameliorable. The associated risk factors were living alone (odds ratio [OR] = 7.860, p = .020), insured by Medicare or Medicaid (OR = 6.402, p = .048), type 2 diabetes mellitus (OR = 6.323, p = .004), pneumonia (OR = 5.504, p = .004), and other infections (OR = 4.618, p = .031). This study was able to identify that nearly one in every two patients who received home health care after hospital discharge experienced an adverse event. Patient safety research needs to focus in the home by developing specific interventions to avert adverse events and improve patient safety during the delivery of home health care services.

scholarly journals Pioglitazone Reduces Mortality and Adverse Events in Patients With Type 2 Diabetes and With Advanced Chronic Kidney Disease: National Cohort Study

Diabetes Care ◽  
2020 ◽  
Vol 43 (10) ◽  
pp. e152-e153 ◽  
Author(s):  
Chieh-Li Yen ◽  
Chao-Yi Wu ◽  
Lai-Chu See ◽  
Yi-Jung Li ◽  
Min-Hua Tseng ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Chronic Kidney Disease ◽  
Cohort Study ◽  
Kidney Disease ◽  
Adverse Events ◽  
Advanced Chronic Kidney Disease ◽  
National Cohort

scholarly journals Effects of frequent PATient moves on patient outcomes in a large tertiary Hospital (the PATH study): a prospective cohort study

2016 ◽  
Vol 40 (3) ◽  
pp. 324 ◽  
Author(s):  
Joan Webster ◽  
Karen New ◽  
Mary Fenn ◽  
Mary Batch ◽  
Alyson Eastgate ◽  
...  
Keyword(s):  
Patient Safety ◽  
Cohort Study ◽  
Length Of Stay ◽  
Adverse Events ◽  
Patient Outcomes ◽  
Prospective Cohort Study ◽  
Prospective Cohort ◽  
Tertiary Hospital ◽  
Tertiary Referral Hospital ◽  
Specific Patient

Objective The aim of the present study was to investigate the incidence of and patient outcomes associated with frequent patient moves. Methods In a prospective cohort study, any bed move and the reason for the move were documented. Patients were assessed on admission for anxiety, social support and delirium. Adverse events, length of stay and satisfaction were recorded. Patients moved three or more times were compared with those moved less than three times. Results In all, 566 patients admitted to a tertiary referral hospital were included in the study. Of these, 156 patients (27.6%) were moved once, 46 (8.1%) were moved twice and 28 (4.9%) were moved at least three times. Those moved three or more times were almost threefold more likely to have an adverse event recorded compared with those moved fewer times (relative risk (RR) 2.75; 95% confidence interval (CI) 1.18, 6.42; P = 0.02) and to have a hospital stay twice as long (RR 7.10; 95% CI 2.60, 11.60; P = 0.002). Levels of satisfaction and anxiety were not affected by frequent moves and there was no effect on delirium. Conclusion Frequent bed moves affect patient safety and prolong length of stay. What is known about the topic? Retrospective and qualitative studies suggest that patient safety and costs may be affected by frequent patient moves. What does this paper add? The present study is the first prospective study to assess the negative effects of frequent patient moves on specific patient outcomes, such as adverse events, length of stay and satisfaction with care. What are the implications for practitioners? Within- and between-ward moves may affect patient safety. Patients should be moved only when there is a clear and unavoidable reason for doing so.

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