scholarly journals Analysis of Patient Safety Incidents in Primary Care Reported in an Electronic Registry Application

2021 ◽  
Vol 18 (17) ◽  
pp. 8941
Author(s):  
Montserrat Gens-Barberà ◽  
Núria Hernández-Vidal ◽  
Elisa Vidal-Esteve ◽  
Yolanda Mengíbar-García ◽  
Immaculada Hospital-Guardiola ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Care Delivery ◽  
Contributing Factors ◽  
Notification System ◽  
Corporate Website ◽  
Critical Areas ◽  
Service Setting ◽  
Health Centres

Objectives: (1) To describe the epidemiology of patient safety (PS) incidents registered in an electronic notification system in primary care (PC) health centres; (2) to define a risk map; and (3) to identify the critical areas where intervention is needed. Design: Descriptive analytical study of incidents reported from 1 January to 31 December 2018, on the TPSC Cloud™ platform (The Patient Safety Company) accessible from the corporate website (Intranet) of the regional public health service. Setting: 24 Catalan Institute of Health PC health centres of the Tarragona region (Spain). Participants: Professionals from the PC health centres and a Patient Safety Functional Unit. Measurements: Data obtained from records voluntarily submitted to an electronic, standardised and anonymised form. Data recorded: healthcare unit, notifier, type of incident, risk matrix, causal and contributing factors, preventability, level of resolution and improvement actions. Results: A total of 1544 reports were reviewed and 1129 PS incidents were analysed: 25.0% of incidents did not reach the patient; 66.5% reached the patient without causing harm, and 8.5% caused adverse events. Nurses provided half of the reports (48.5%), while doctors reported more adverse events (70.8%; p < 0.01). Of the 96 adverse events, 46.9% only required observation, 34.4% caused temporary damage that required treatment, 13.5% required (or prolonged) hospitalization, and 5.2% caused severe permanent damage and/or a situation close to death. Notably, 99.2% were considered preventable. The main critical areas were: communication (27.8%), clinical-administrative management (25.1%), care delivery (23.5%) and medicines (18.4%); few incidents were related to diagnosis (3.6%). Conclusions: PS incident notification applications are adequate for reporting incidents and adverse events associated with healthcare. Approximately 75% and 10% of incidents reach the patient and cause some damage, respectively, and most cases are considered preventable. Adequate and strengthened risk management of critical areas is required to improve PS.

scholarly journals Analysis of notifications of adverse events in a private hospital

2019 ◽  
Vol 18 (3) ◽  
pp. 314-343
Author(s):  
Alcides Viana de Lima Neto ◽  
Fernanda Antunes da Silva ◽  
Genilza Maria De Oliveira Lima Brito ◽  
Tatiana Mari A Nóbrega Elias ◽  
Bruna Aderita Cortez de Sena ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Private Hospital ◽  
Medication Administration ◽  
Contributing Factors ◽  
Event Notification ◽  
Adverse Incident ◽  
Compromise Patient Safety ◽  
Current Context ◽  
Human Failure

Introducción: La seguridad del paciente, en el contexto actual, pasó a ser investigada en los diversos campos de la salud, con el objetivo de reducir la incidencia de daños y eventos adversos a los pacientes. Objetivo: Identificar y analizar los eventos adversos que comprometen la seguridad del paciente durante la asistencia de enfermería en un hospital privado. Métodos: Investigación exploratoria, documental y retrospectiva. El instrumento de recolección de datos fue el informe de notificación de eventos adversos utilizado por el hospital compuesto por cuestiones abiertas y cerradas. Resultados: Se analizaron 262 informes de notificación de eventos adversos / incidentes que ocurrieron en el período de 2015 a 2016. Se demuestra que los factores contribuyentes para la ocurrencia de los eventos adversos fueron causados por fallo humano. Del total de formularios analizados, 161 (61,83%) indicaron descuido y distracción. La omisión se destacó con 11 (4,20%) casos. La falta de atención con el paciente propició 116 (44,27%) errores en la administración de medicamentos, 46 (17,56%) fallos durante la digitación y transcripción de la prescripción médica y 35 (13,36%) fallos en la asistencia. Conclusión: Se percibe que los incidentes son causados por factores humanos y de posible reversión. Cuando son investigados, pueden ser minimizados, lo que contribuye a la calidad y seguridad en el cuidado al paciente. Introduction: patient safety, in the current context, began to be investigated in the different health fields, aiming to reduce the incidence of damages and adverse events to patients. Objective: to identify and analyze adverse events that compromise patient safety during nursing care in a private hospital. Methods: exploratory, documentary and retrospective research. The instrument of data collection was the report of adverse event notification used by the hospital composed of open and closed questions. Results: the researchers analyzed 262 reports of adverse/incident events that occurred in the period 2015 to 2016. The contributing factors for the occurrence of adverse events were caused by human failure. Of the total number of forms analyzed, 161 (61.83%) reported carelessness and distraction. The omission was highlighted with 11 (4.20%) cases. The lack of attention with the patient led to 116 (44.27%) errors in medication administration, 46 (17.56%) failures during the typing and transcription of the medical prescription and 35 (13.36%) failures in care. Conclusion: the incidents are caused by human factors, with possible reversion. When investigated, they can be minimized, which contributes to quality and safety in patient care. Introdução: A segurança do paciente, no contexto atual, passou a ser investigada nos diversos campos da saúde, com o objetivo de reduzir a incidência de danos e eventos adversos aos pacientes. Objetivo: Identificar e analisar os eventos adversos que comprometem a segurança do paciente durante a assistência de enfermagem em um hospital privado. Métodos: Pesquisa exploratória, documental e retrospectiva. O instrumento de coleta de dados foi o relatório de notificação de eventos adversos utilizado pelo hospital composto por questões abertas e fechadas. Resultados: Analisaram-se 262 relatórios de notificação de eventos adversos/incidentes que ocorreram no período de 2015 a 2016. Demonstra-se que o fatores contribuintes para a ocorrência dos eventos adversos foram causados por falha humana. Do total de formulários analisados, 161 (61,83%) apontaram descuido e distração. A omissão se destacou com 11 (4,20%) casos. A falta de atenção com o paciente propiciou 116 (44,27%) erros na administração de medicamentos, 46 (17,56%) falhas durante a digitação e transcrição da prescrição médica e 35 (13,36%) falhas na assistência. Conclusão: Percebe-se que os incidentes são causados por fatores humanos e de possível reversão. Quando investigados, podem ser minimizados, o que contribui para a qualidade e segurança no cuidado ao paciente.

scholarly journals Adverse events analysis as an educational tool to improve patient safety culture in primary care: A randomized trial

2011 ◽  
Vol 12 (1) ◽  
Author(s):  
Clara González-Formoso ◽  
María Victoria Martín-Miguel ◽  
Ma José Fernández-Domínguez ◽  
Antonio Rial ◽  
Fernando Isidro Lago-Deibe ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Randomized Trial ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Educational Tool ◽  
Improve Patient

A conceptual framework identifying sources of risk to patient safety in primary care

2012 ◽  
Vol 18 (3) ◽  
pp. 185 ◽  
Author(s):  
Logan McLeod ◽  
JoAnn Kingston-Riechers ◽  
Egon Jonsson
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Acute Care ◽  
Care Setting ◽  
Primary Care Setting ◽  
Care Delivery ◽  
Acute Care Setting ◽  
Primary Care Delivery ◽  
Potential Risks ◽  
Organisational Structures

The potential risks to patient safety in a primary care setting are different than the risks to patient safety in an acute care setting. The main differences arise from the organisational structures of primary care delivery and the greater involvement of patients in their care. To account for these differences, we present the Patient Safety in Primary Care Framework to conceptualise the sources of risk to patient safety.

scholarly journals Patient Safety in Primary Care

2020 ◽  
Vol 30 (Supplement_2) ◽  
Author(s):  
V Pedrosa
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Qualitative Methodology ◽  
Safety Management ◽  
Health Centre ◽  
Structured Interview ◽  
Quality And Safety ◽  
Training Plan ◽  
Political Sector

Abstract Introduction Patient safety and the development of quality safety processes have been gaining prominence in business management in the public and political sector, particularly in Europe, after the Quality and Safety in European Hospitals project was driven by the support of the Lisbon strategy agenda. Scientific research has also followed this trend. However, the study of patient safety management and methods is still scarce. Objectives Resorting to Cartaxo Health Centre, the research contributes to the analysis of the proposition that there is not only a lack of knowledge of the professionals who directly contact the patient about the patients safety in primary health care, but also that the methods used in practice are very intuitive and individualised by the absence of formal and institutional coordinated orientation. Methodology Using a qualitative methodology and the case study method, a semi-structured interview was conducted with 40 health professionals—among doctors, nurses, and technicians—who contacted patients, in order to identify what they know and consequently incorporate about patient safety. The interviews were conducted between February and June 2015 Results We confirmed several discrepancies between functional units. It was clarified that in the domicile the knowledge is scarcer. Conclusion We have delimited factors that do not ensure a reliable environment and culture, to improve with a training plan and institutional coordination that supports notification. The complexity of the context impacts on the nature and dimension of adverse events due to stress, workload and organization. A Taxonomy of Adverse Events was constructed and its path from the source to the solution was mapped. It's our intention to share this Taxonomy with the professionals, with a strong expectation that will improve Quality and Safety in Portuguese Primary Care.

scholarly journals World Patient Safety Day: the Tuscany region at the forefront of quality of care

2020 ◽  
Vol 32 (3) ◽  
pp. 221-222
Author(s):  
Sara Albolino ◽  
Giulia Dagliana
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Health Systems ◽  
Health Professionals ◽  
Care Delivery ◽  
Clinical Care ◽  
Patient Safety Culture ◽  
World Health ◽  
To Come ◽  
The Impact

Abstract Echoing the World Health Organization’s (WHO) request, the Patient Safety Declaration, launched by Health First Europe at the European Parliament, calls on policymakers, authorities and health professionals, patients and citizens to come together to build health systems that can help health professionals work better for patient-centred outcomes. The objective is to prevent the occurrence of adverse events arising from clinical care activities to focus resources on reducing the impact of the disease by promoting safer health systems and higher quality standards for patient safety in Europe. The Declaration intends to promote a European patient safety culture, starting with safety practices and exchanging effective practices to reduce adverse events arising from health activities. Tuscany, the fifth largest region of Italy, is strongly committed to make this happen. Its Regional Centre for Clinical Risk Management and Patient Safety and WHO Collaborating Centre (GRC Centre—Centro Gestione Rischio Clinico e Sicurezza del Paziente) aims at developing and promoting practices for safety, awareness raising and the analysis of adverse events for the constant improvement of care delivery.

Tort Claims Analysis in the Veterans Health Administration for Quality Improvement

2001 ◽  
Vol 29 (3-4) ◽  
pp. 335-345 ◽  
Author(s):  
William B. Weeks ◽  
Tina Foster ◽  
Amy E. Wallace ◽  
Erik Stalhandske
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Adverse Events ◽  
Care Delivery ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Claims Analysis ◽  
Organizational Image ◽  
Tort Claims

Tort claims have been studied for various reasons. Several studies have found that most tort claims are not related to negligent adverse events and most negligent adverse events do not result in tort claims. Several studies have examined the disposition of tort claims to understand the likelihood of payment once a claim has been made. Still others have proposed that tort-claims trend analysis may help administrators target their quality-improvement efforts and identify problems with quality that would not otherwise be captured.In this article, we conduct a tort-claims analysis to explore areas for quality improvement, specifically for patient safety, in the Veterans Health Administration (VHA). Patient safety is an increasingly highlighted aspect of health-care delivery. Failure to assure patient safety can result in bad clinical outcomes, additional costs of care, and a negative organizational image. Filing a tort claim is one way for an individual to express concern about an organization. For our analysis, we draw from resolved tort claims in the Veterans Health Administration from fiscal years 1989 to 2000.

scholarly journals What Exactly Is Patient Safety?

2009 ◽  
Vol 95 (1) ◽  
pp. 13-24 ◽  
Author(s):  
Linda Emanuel ◽  
Don Berwick ◽  
James Conway ◽  
John Combes ◽  
Martin Hatlie ◽  
...  
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Intellectual History ◽  
Cultural Change ◽  
Care Delivery ◽  
High Reliability ◽  
Health Care Systems ◽  
Care Providers ◽  
Reliability Design

ABSTRACT We articulate an intellectual history and a definition, description and model of patient safety. We define patient safety as a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. We also define patient safety as an attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events. Our description includes: why the field of patient safety exists (the high prevalence of avoidable adverse events); its nature; its essential focus of action (the microsystem); how patient safety works (e.g., high-reliability design, use of safety sciences, methods for causing change, including cultural change); and who its practitioners are (i.e., all health care workers, patients and advocates). Our simple and overarching model identifies four domains of patient safety (recipients of care, providers, therapeutics and methods) and the elements that fall within the domains. Eleven of these elements are described in this paper.

scholarly journals Patient safety in primary health care: a systematic review

2014 ◽  
Vol 30 (9) ◽  
pp. 1815-1835 ◽  
Author(s):  
Simone Grativol Marchon ◽  
Walter Vieira Mendes Junior
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Patient Safety ◽  
Primary Health Care ◽  
Healthcare Team ◽  
Contributing Factors ◽  
Cross Sectional ◽  
Team Research ◽  
Primary Health ◽  
Incident Reporting Systems

The aim of this study was to identify methodologies to evaluate incidents in primary health care, types of incidents, contributing factors, and solutions to make primary care safer. A systematic literature review was performed in the following databases: PubMed, Scopus, LILACS, SciELO, and Capes, from 2007 to 2012, in Portuguese, English, and Spanish. Thirty-three articles were selected: 26% on retrospective studies, 44% on prospective studies, including focus groups, questionnaires, and interviews, and 30% on cross-sectional studies. The most frequently used method was incident analysis from incident reporting systems (45%). The most frequent types of incidents in primary care were related to medication and diagnosis. The most relevant contributing factors were communication failures among member of the healthcare team. Research methods on patient safety in primary care are adequate and replicable, and they will likely be used more widely, thereby providing better knowledge on safety in this setting.

scholarly journals P.039 Generating choosing wisely Canada recommendations for neurology

2019 ◽  
Vol 46 (s1) ◽  
pp. S24
Author(s):  
C Beyak ◽  
F Costello ◽  
P Couillard
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Online Survey ◽  
Care Delivery ◽  
Primary Care Providers ◽  
Choosing Wisely ◽  
Board Members ◽  
Care Providers ◽  
Short List ◽  
Survey Results

Background: Many guidelines in neurology encompass the principles of Choosing Wisely Canada (CWC): resource stewardship, patient safety, and high value care. There are currently 49 medical societies with CWC recommendations excluding the Canadian Neurologic Society (CNS). Methods: A descriptive process for list generation is outlined. A review of the American Choosing Wisely recommendations was undertaken to generate an adapted list of ten recommendations. CNS board members vetted this list and an online survey was sent to each CNS member. Results: A short list of recommendations endorsed by the CNS membership at large will be presented according to the survey results. CWC promotion of the list will take place to reach specialists, primary care providers, and trainees to ensure high value neurological care delivery is the standard across Canada. Conclusions: The process to delineate CWC recommendations for neurology is outlined. Participating in the CWC movement is an important leadership initiative for the CNS. It demonstrates the commitment of Canadian neurologists to the principles of high value patient care in neurology.

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