Adverse Events and Patient Safety in the Operating Theatre: Perspectives of 549 Surgeons

2010 ◽  
Vol 92 (6) ◽  
pp. 1-4 ◽  
Author(s):  
C Pritchard ◽  
J Brackstone ◽  
J MacFie
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Operating Theatre ◽  
Near Misses ◽  
The Uk

The Chief Medical Officer's recent report, 'Making surgery safer', was a response to widespread concern about patient safety in the operating theatre. Annually there are an estimated 129,416 'untoward events' in the UK. These range from 'near misses' (NM), in which a patient is 'nearly harmed', to an 'adverse event' (AE), usually defined as 'an unintended injury or complication, including death'.

scholarly journals An Assessment of an Educational Intervention on Resident Physician Attitudes, Knowledge, and Skills Related to Adverse Event Reporting

2010 ◽  
Vol 2 (2) ◽  
pp. 188-194 ◽  
Author(s):  
Barbara G. Jericho ◽  
Rosalie F. Tassone ◽  
Nikki M. Centomani ◽  
Jennifer Clary ◽  
Crescent Turner ◽  
...  
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Educational Intervention ◽  
Adverse Event Reporting ◽  
Physician Attitudes ◽  
Event Reporting ◽  
Near Misses ◽  
Knowledge And Skills ◽  
Process Improvements

Abstract Objective Reporting and learning from events linked to patient harm and unsafe conditions is critical to improving patient safety. Programs that engage resident physicians in adverse event reporting can enhance patient safety and simultaneously address all 6 Accreditation Council for Graduate Medical Education competencies. Yet fewer than 60% of physicians know how to report adverse events and near misses, and fewer than 40% know what to report. Our study evaluated the effect of an educational intervention on anesthesiology residents' attitudes, knowledge, and skills related to adverse event reporting and the associated follow-up. Methods In a prospective study, anesthesiology residents participated in a training program focused on the importance of reporting methods and on reporting adverse events for patient safety. Quarterly adverse event reports were analyzed retrospectively for 2 years before the intervention and prospectively for 7 quarters after the intervention. Residents also completed a survey, before and 1 year after the intervention, that evaluated their attitudes, experience, and knowledge regarding adverse event reporting. Results After the intervention, the number of adverse event reports increased from 0 per quarter to almost 30 per quarter. We identified several categories of harm events, near misses, and unsafe conditions, including reports of disruptive providers. Of the harm events associated with invasive procedures, more than half were associated with lack of attending physician supervision. We also observed significant progress in the residents' ability to appropriately file a report, improved attitudes regarding the value of reporting and available emotional support, and a reduction in the perceived impediments to reporting. Conclusions An educational intervention increased the number of adverse event reports submitted by anesthesiology residents, improved their attitudes about the importance of reporting, and produced a source for learning opportunities and process improvements in the delivery of anesthesia care.

scholarly journals Adverse Events in Home-Care Nursing Agencies and Related Factors: A Nationwide Survey in Japan

2021 ◽  
Vol 18 (5) ◽  
pp. 2546
Author(s):  
Noriko Morioka ◽  
Masayo Kashiwagi
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Home Care ◽  
Process Of Care ◽  
Related Factors ◽  
Cross Sectional ◽  
Home Care Nursing ◽  
Number Of Patients ◽  
Care Nursing

Despite the importance of patient safety in home-care nursing provided by licensed nurses in patients’ homes, little is known about the nationwide incidence of adverse events in Japan. This article describes the incidence of adverse events among home-care nursing agencies in Japan and investigates the characteristics of agencies that were associated with adverse events. A cross-sectional nationwide self-administrative questionnaire survey was conducted in March 2020. The questionnaire included the number of adverse event occurrences in three months, the process of care for patient safety, and other agency characteristics. Of 9979 agencies, 580 questionnaires were returned and 400 were included in the analysis. The number of adverse events in each agency ranged from 0 to 47, and 26.5% of the agencies did not report any adverse event cases. The median occurrence of adverse events was three. In total, 1937 adverse events occurred over three months, of which pressure ulcers were the most frequent (80.5%). Adjusting for the number of patients in a month, the percentage of patients with care-need level 3 or higher was statistically significant. Adverse events occurring in home-care nursing agencies were rare and varied widely across agencies. The patients’ higher care-need levels affected the higher number of adverse events in home-care nursing agencies.

scholarly journals Adverse medication events in a psychiatric practice: a naturalistic study

2013 ◽  
Vol 37 (12) ◽  
pp. 395-397
Author(s):  
Eugene G. Breen
Keyword(s):  
Adverse Event ◽  
Adverse Events ◽  
Adverse Drug Events ◽  
Psychiatric Training ◽  
Clinical Implications ◽  
Naturalistic Study ◽  
Near Misses ◽  
Significant Events ◽  
Core Module ◽  
Sector Service

Aims and methodTo document the number and type of adverse medication events in a psychiatric sector service. Significant new adverse events were collated by the author and team over 30 months. Intervention to prevent any adverse event was enacted as soon as any were noticed or anticipated.ResultsThirty-six significant events occurred including three deaths and nine near misses. Corrective action was taken immediately any adverse event occurred. Inadequate communication between various hospital clinics, general practitioner practices, psychiatric clinics and pharmacies was the biggest avoidable cause of adverse events.Clinical implicationsAwareness of adverse drug events is essential in psychiatry. Clear, transparent pathways of prescribing are a key requirement to reduce avoidable adverse medication events. Psychopharmacology is a core module for psychiatric training.

Surgeons in the operating theatre: preparing to lead by example

2008 ◽  
Vol 90 (9) ◽  
pp. 306-307
Author(s):  
K Woo
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Operating Theatre ◽  
Traditional Practices ◽  
Consent Forms ◽  
Operative Site ◽  
Current Climate ◽  
Theatre Staff

Surgeons, anaesthetists and theatre staff have always worked to ensure that no harm comes to their patients, particularly within the operating theatre environment. Patient safety and the prevention of adverse events underlie many of our traditional practices such as the use of identity bracelets, consent forms and marking of the operative site. Perhaps even more so today than ever, unnecessary or avoidable mistakes in the operating theatre cannot be afforded, with the current climate of increasing standards of health care and rising expectations.

Raising the safety bar: The hematology/oncology patient safety committee.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 144-144
Author(s):  
Myrna Rita Nahas ◽  
Jessica A. Zerillo ◽  
Stephen A. Cannistra ◽  
Cheryle Totte
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Peer Review ◽  
Healthcare Provider ◽  
Medical Center ◽  
Healthcare Delivery ◽  
Healthcare Providers ◽  
Oncology Patient ◽  
Near Misses ◽  
Safety Committee

144 Background: Enhancing patient safety can prevent unintended outcomes arising from defects in healthcare delivery systems. The Hematology/Oncology Patient Safety Committee (HOPSC) at Beth Israel Deaconess Medical Center (BIDMC) is a multidisciplinary team of healthcare providers that meets monthly to review inpatient and outpatient adverse events, near misses, and medical errors that impact patient safety. Methods: Our aim was to quantify and qualify the cases that the HOPSC has reviewed from 2012-2013. In order to identify trends in event reporting, we reviewed the number of events reported to the HOPSC in both the inpatient and outpatient settings. We further subdivided events into two categories: medication-related and non-medication related. Additionally, we delineated which healthcare provider initiated the reporting of each event. Results: Over the two-year period, a total number of 1,061 events were reported to the HOPSC. Of these, 259 were medication-related events. Of the events reported, 40 were by a physician/NP and 1,021 were by a nurse. There was a discrepancy in the type of event reported (24.4% medication vs. 75.6% non-medication related) as well as in the type of reporter (3.8% physician/NP vs. 96.2% nurse). Of all the events reported, 8 were escalated to the Department of Medicine Peer Review Committee. Conclusions: Through review of healthcare provider event reports, the HOPSC has identified several types of adverse events and near misses in the Hematology/Oncology division at BIDMC. The events are mostly reported by inpatient nurses and are primarily medication-related. Given this skewed reporting pattern, we will investigate the reasons why reporting by physicians, especially in the outpatient setting, is limited. Our reported outline of the HOPSC operations may also guide oncology practices elsewhere in their own development of patient safety peer review committees. [Table: see text]

Effectiveness of systems changes suggested by simulation of adverse surgical outcomes

2015 ◽  
Vol 1 (3) ◽  
pp. 83-86 ◽  
Author(s):  
Meghan E Garstka ◽  
Douglas P Slakey ◽  
Christopher A Martin ◽  
Eric R Simms ◽  
James R Korndorffer
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Surgical Outcomes ◽  
Improve Patient Safety ◽  
Healthcare Systems ◽  
Adverse Outcomes ◽  
Cause Analysis ◽  
Root Cause ◽  
Improve Patient

BackgroundSimulation of adverse outcomes (SAO) has been described as a technique to improve effectiveness of root cause analysis (RCA) in healthcare. We hypothesise that SAO can effectively identify unsuspected root causes amenable to systems changes.MethodsSystems changes were developed and tested for effectiveness in a modified simulation, which was performed eight times, recorded and analysed.ResultsIn seven of eight simulations, systems changes were effectively utilised by participants, who contacted anaesthesia using the number list and telephone provided to express concern. In six of seven simulations where anaesthesia was contacted, they provided care that avoided the adverse event. In two simulations, the adverse event transpired despite implemented systems changes, but for different reasons than originally identified. In one case, appropriate personnel were contacted but did not provide the direction necessary to avoid the adverse event, and in one case, the telephone malfunctioned.ConclusionsSystems changes suggested by SAO can effectively correct deficiencies and help improve outcomes, although adverse events can occur despite implementation. Further study of systems concepts may provide suggestions for changes that function more reliably in complex healthcare systems. The information gathered from these simulations can be used to identify potential deficiencies, prevent future errors and improve patient safety.

The Safety of Acupuncture – Evidence from the Uk

2006 ◽  
Vol 24 (1_suppl) ◽  
pp. 53-57 ◽  
Author(s):  
Adrian White
Keyword(s):  
Adverse Event ◽  
Adverse Events ◽  
Adverse Reactions ◽  
Event Rate ◽  
Adverse Event Rate ◽  
Serious Adverse Events ◽  
Positive Evidence ◽  
Safe Treatment ◽  
Significant Events ◽  
The Uk

Background Patients are attracted to acupuncture partly by its reputation for having low risks. The safety of acupuncture should be established by positive evidence. Methods Two prospective surveys were conducted among different groups of professionals in the UK, including doctors, physiotherapists and practitioners primarily trained in acupuncture. Participants monitored adverse events over a defined period of time, and reported minor and significant events on purpose designed forms. Results A total of 652 acupuncturists reported 6733 adverse reactions including tiredness in 66 229 patients, an adverse event rate of 10.2%. The most common events were tiredness (3%) bleeding or bruising (3%), aggravation of symptoms (2%) and pain at the needling site (1%). There were no serious adverse events. A total of 86 (0.1%) of the treatments was associated with an event that the practitioner judged to be significant though without persistent consequences for the patient's health. Conclusion The risks associated with acupuncture can be classified as negligible, and acupuncture is a very safe treatment in the hands of competent practitioners.

scholarly journals "PENTINGNYA PENCEGAHAN BAHAYA DAN ADVERSE EVENT SEBAGAI UPAYA MENJAGA KESELAMATAN PASIEN DI RUMAH SAKIT"

2020 ◽  
Author(s):  
Awina Milla Shilmy Sitorus
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Near Miss

Rumah sakit adalah sarana pelayanan kesehatan yang dibutuhkan ketika seseorang sakit dan membutuhkan bantuan dengan tujuan untuk menyelamatkan kondisi pasien. Keselamatan Pasien (patient safety) merupakan sesuatu yang jauh lebih penting dari pada sekedar efisiensi pelayanan. Perilaku perawat dengan kemampuan perawat sangat berperan penting dalam pelaksanaan keselamatan pasien. Perilaku yang tidak aman, lupa, kurangnyaperhatian/motivasi, kecerobohan, tidak teliti dan kemampuan yang tidak memedulikan dan menjaga keselamatan pasien berisiko untuk terjadinya kesalahan dan akan mengakibatkan cedera pada pasien, berupa Near Miss (Kejadian Nyaris Cedera/KNC) atau Adverse Event (Kejadian Tidak Diharapkan/KTD) selanjutnya pengurangan kesalahan dapat dicapai dengan memodifikasi perilaku. Perawat harus melibatkan kognitif, afektif dan tindakan yang mengutamakan keselamatan pasien (Julia, 2016).Cahyono (2008) menyatakan setiap asuhan klinis baik terkait dengan proses diagnosis, terapi, tindakan pembedahan, pemberian obat, pemeriksaan laboratorium, dsb dapat menimbulkan kerugian yang tidak diharapkan pasien baik secara fisik (cedera iatrogenik), finansial, maupun sosial. Secara lebih populer, asuhan klinis yang kemudian menimbulkan dampak yang merugikan bagi pasien akibat manajemen medis dan bukan akibat penyakit yang diderita pasien dikenal sebagai adverse events atau KTD (baik oleh dokter maupun pasien).

scholarly journals Mencegah terjadinya adverse events dengan memberikan pendidikan kesehatan tentang peran pasien dan keluarga untuk mencegah terjadinya bahaya

2020 ◽  
Author(s):  
Indri Novita Magdalena Aruan
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
World Health Organization ◽  
Near Miss ◽  
World Health ◽  
Health Organization

Keselamatan Pasien (Patient Safety) merupakan sesuatu yang jauh lebih penting dari pada sekedar efisiensi pelayanan. Perilaku perawat dengan kemampuan perawat sangat berperan penting dalam pelaksanaan keselamatan pasien. Perilaku yang tidak aman, lupa, kurangnya perhatian/motivasi, kecerobohan, tidak teliti dan kemampuan yang tidak memperdulikan dan menjaga keselamatan pasien berisiko untuk terjadinya kesalahan dan akan mengakibatkan cedera pada pasien, berupa Near Miss (Kejadian Nyaris Cedera/KNC) atau Adverse Event (Kejadian Tidak Diharapkan/KTD) selanjutnya pengurangan kesalahan dapat dicapai dengan memodifikasi perilaku. Perawat harus melibatkan kognitif, afektif dan tindakan yang mengutamakan keselamatan pasien. World Health Organization (WHO), 2014 Keselamatan pasien merupakan masalah keseahatan masyarakat global yang serius.

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.

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