scholarly journals The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 ‘near-misses’ and adverse events

2014 ◽  
Vol 8 (1) ◽  
Author(s):  
Anita J Heideveld-Chevalking ◽  
Hiske Calsbeek ◽  
Johan Damen ◽  
Hein Gooszen ◽  
André P Wolff
Keyword(s):  
Adverse Events ◽  
Reporting System ◽  
Incident Reporting ◽  
Single Center ◽  
Near Misses ◽  
Incident Reporting System ◽  
Single Center Experience ◽  
The Impact

scholarly journals Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data

2012 ◽  
Vol 33 (5) ◽  
pp. E7 ◽  
Author(s):  
Paolo Ferroli ◽  
Dario Caldiroli ◽  
Francesco Acerbi ◽  
Maurizio Scholtze ◽  
Alfonso Piro ◽  
...  
Keyword(s):  
Operating Room ◽  
Safety Culture ◽  
Human Factor ◽  
Reporting System ◽  
Organizational Factors ◽  
Incident Reporting ◽  
Neurosurgical Department ◽  
Near Misses ◽  
Incident Reporting System ◽  
Dedicated Team

Object Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results. Methods In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed. Results Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases). Conclusions Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within the environment under study. Persistence and strong commitment are required to enact the culture change essential in shifting from a paradigm of infallible operators to the philosophy of errare humanum est. For this paradigm shift to be successful, contributions from aviation and human factor experts are critical.

scholarly journals Learning from an Incident Reporting System: Developing a Strategy to Prevent Medication Errors Among Nursing Students

2021 ◽  
Author(s):  
Shwu-Fen Chiou ◽  
Kuei-Fen Liu
Keyword(s):  
Nursing Students ◽  
Medication Errors ◽  
Reporting System ◽  
Teaching Strategy ◽  
Incident Reporting ◽  
Research Approach ◽  
Near Misses ◽  
Incident Reporting System ◽  
Action Research Approach ◽  
Self Learning

Medication errors occur during clinical learning for nursing students. This study aimed to develop learning cases to prevent medication errors using analysis of data from an incident reporting system. This study utilized an action research approach to develop learning cases. These learning cases were implemented with problem-based learning (PBL) method and self-learning materials strategies. The results showed that repeated occurrences of medication errors and near misses were reduced after implementing the new teaching strategy.

scholarly journals A Survey of the Impact of Patient Adverse Events and near Misses on Anaesthetists in Australia and New Zealand

2018 ◽  
Vol 46 (5) ◽  
pp. 510-515 ◽  
Author(s):  
R. Harrison ◽  
H. Lee ◽  
A. Sharma
Keyword(s):  
Adverse Event ◽  
New Zealand ◽  
Adverse Events ◽  
Incident Reporting ◽  
Near Miss ◽  
Near Misses ◽  
Incident Reporting Systems ◽  
Safety Incident ◽  
Reporting Systems ◽  
The Impact

We conducted a cross-sectional online survey of members of the Australian and New Zealand College of Anaesthetists to investigate their experiences of adverse patient safety events and near misses, including their use of incident reporting systems and the organisational support available. There were 247 respondents. Of the 243 anaesthetists whose patients had an adverse event or near miss, 199 reported this had affected them personally or professionally; 177 reported stress, 153 anxiety, 109 sleep disturbance, and 127 lower professional confidence. Of 188 who had reported an adverse event using their local incident reporting systems, 68 were satisfied with this process, 136 received useful feedback, 114 saw local improvements, and 104 saw system changes. Two hundred and thirty-four reported feeling determined to improve, and 228 were anxious about the potential for future errors. Seventy-five anaesthetists admitted not reporting a safety incident that they knew they should have. Reasons for not reporting included an impression that nothing would improve from incident reporting, that reporting was onerous, or fears of punitive action. These findings should spur anaesthetists, anaesthetic departments and professional organisations across Australia and New Zealand to examine their support mechanisms in relation to adverse events and errors and their incident reporting mechanisms, and to attempt to improve these services where necessary.

scholarly journals Quality management in radiotherapy: A 9-year review of incident reporting within a multifacility organisation

2021 ◽  
Vol 5 ◽  
Author(s):  
Ivan Oelofse ◽  
Jaco Van Staden ◽  
Nicolene Coetzee ◽  
Joseph Steyn
Keyword(s):  
Reporting System ◽  
High Standard ◽  
Incident Reporting ◽  
Clinical Consequence ◽  
Incident Reporting System ◽  
Patient’S Rights ◽  
Dose Errors ◽  
The Difference ◽  
Incident Rate ◽  
The Impact

Background: A radiotherapy incident reporting system should (1) record and classify incidents, (2) assess the impact of incidents on patients in terms of dose errors and (3) identify areas of improvement in the incident reporting system. Such a system at the Independent Clinical Oncology Network (ICON) Oncology is investigated.Aim: An ‘incident’ is defined by ICON as ‘any occurrence that may prevent the patient from receiving the prescribed dose in the prescribed time period or may cause unplanned harm to the patient or may infringe upon the patient’s rights’.Setting: Incidents reported between December 2011 and December 2020.Methods: Incidents were analysed looking at various factors such as institutional timelines compared with major projects, incident error and areas, reporting frequencies amongst tumour-sites and professional groups.Results: Over the course of 9-years, 78 521 patients were treated at ICON’s centres and a total of 924 reports were filed involving 1355 patients. This shows an incident rate of 1.7% of all patients in radiotherapy. The difference in incident number versus patients is because one incident may involve many patients. Reporting amongst professional groups has more distinctive differences, with 86.0%, 11.6% and 2.4% reported cases per annum for radiotherapists, physicist and oncologist, respectively. For the errors in dose-delivery, 43.0% of the incidents were discovered with no dosimetric or clinical consequence, 53.6% with dosimetric consequence but no clinical consequence and 3.4% with dosimetric and clinical consequence.Conclusion: Incident reporting is not a new quality assurance (QA) indicator for radiotherapy treatment. However, it requires continuous effort and innovation to uphold and maintain a high standard of patient and staff safety within an organisation. Errors are present during every stage of the radiotherapy process, whether it be human, technical, organisational or patient related. From the statistics of all the patients treated at ICON, 0.04% have been reported to have had an associated incident that involved some form of clinical consequence. Yet, if undetected, the incident could lead to increase in dose errors to patients.

A Guide to Implementing an In-House Incident Reporting System in Outdoor Recreation and Education

2020 ◽  
Vol 12 (4) ◽  
Author(s):  
Erik Rabinowitz ◽  
Christopher Bartram
Keyword(s):  
Risk Management ◽  
Outdoor Recreation ◽  
Reporting System ◽  
Incident Reporting ◽  
System Research ◽  
Near Misses ◽  
Reporting Practices ◽  
Incident Reporting System ◽  
Outdoor Programs ◽  
Management Reporting

This article will explain prioritized steps on how to create a reporting system for the outdoor recreation organization, including the components to incorporate an effective risk management reporting system. Research reports that the majority (91%) of outdoor programs are using paper forms to report incidents and that 26% of programs do not record near misses at all (Bartram & Rabinowitz, 2018). These steps were designed collaboratively and incorporate perspectives from program management and literature. This outline may assist those seeking to further enhance their incident reporting system and improve organizational incident reporting practices.

scholarly journals Impact of Tocilizumab on Clinical Outcomes in COVID-19-Associated Cytokine Release Syndrome: A Single-Center Experience

2021 ◽  
pp. 089719002110282
Author(s):  
Karan Raja ◽  
Nicole Daniel ◽  
Susan Morrison ◽  
Ruben Patel ◽  
Jessica Gerges ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Clinical Status ◽  
Rank Test ◽  
Cytokine Release ◽  
Cytokine Release Syndrome ◽  
Single Center ◽  
Post Dose ◽  
Single Center Experience ◽  
Signed Rank Test ◽  
The Impact

Background: Tocilizumab is an interleukin-6 receptor antagonist hypothesized to blunt the uncontrolled immune response, cytokine release syndrome, in severe COVID-19 and prevent attributable morbidity and mortality. Objective: The objective of this study was to assess the impact of tocilizumab on clinical outcomes in COVID-19-associated cytokine release syndrome. Methods: Single-center, retrospective cohort study assessing sixty-nine adult patients receiving tocilizumab for suspected COVID-19 cytokine release syndrome. The primary outcome was change in WHO clinical status scale on day seven post-dose analyzed using the Wilcoxon signed rank test. Secondary outcomes assessed impact of timing of administration on clinical outcome. Safety analyses included development of neutropenia, thrombocytopenia, transaminitis, and sepsis within 7 days post-dose. Statistical analyses were conducted using Microsoft Excel. Results: No aggregate clinical change was found between day 0 and day 7. Eleven patients improved, twenty-seven worsened, and thirty-one showed no change. Clinical outcomes were weakly correlated with time from symptom onset (rs = 0.21; p = 0.08) or hospital admission (rs = -0.08; p = 0.49) to dose. In-hospital mortality was 63%. Sepsis was diagnosed in 21 patients, five of which were post-dose. Transaminitis, neutropenia, and thrombocytopenia occurred in seven, one, and six patients, respectively. Conclusion: Tocilizumab did not appear to influence clinical outcomes in our study population, irrespective of timing of administration. Adverse events were not considered drug-related.

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