Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

Background: The standardized infection ratio (SIR) is the nationally adopted metric used to track and compare catheter-associated urinary tract infections (CAUTIs) and central-line– associated bloodstream infections (CLABSIs). Despite its widespread use, the SIR may not be suitable for all settings and may not capture all catheter harm. Our objective was to look at the correlation between SIR and device use for CAUTIs and CLABSIs across community hospitals in a regional network. Methods: We compared SIR and SUR (standardized utilization ratio) for CAUTIs and CLABSIs across 43 hospitals in the Duke Infection Control Outreach Network (DICON) using a scatter plot and calculated an R2 value. Hospitals were stratified into large (>70,000 patient days), medium (30,000–70,000 patient days), and small hospitals (<30,000 patient days) based on DICON’s benchmarking for community hospitals. Results: We reviewed 24 small, 11 medium, and 8 large hospitals within DICON. Scatter plots for comparison of SIRs and SURs for CLABSIs and CAUTIs across our network hospitals are shown in Figs. 1 and 2. We detected a weak positive overall correlation between SIR and SUR for CLABSIs (0.33; R2 = 0.11), but no correlation between SIR and SUR for CAUTIs (−0.07; R2 = 0.00). Of 15 hospitals with SUR >1, 7 reported SIR <1 for CLABSIs, whereas 10 of 13 hospitals with SUR >1 reported SIR <1 for CAUTIs. Smaller hospitals showed a better correlation for CLABSI SIR and SUR (0.37) compared to medium and large hospitals (0.19 and 0.22, respectively). Conversely, smaller hospitals showed no correlation between CAUTI SIR and SUR, whereas medium and larger hospitals showed a negative correlation (−0.31 and −0.39, respectively). Conclusions: Our data reveal a weak positive correlation between SIR and SUR for CLABSIs, suggesting that central line use impacts CLABSI SIR to some extent. However, we detected no correlation between SIR and SUR for CAUTIs in smaller hospitals and a negative correlation for medium and large hospitals. Some hospitals with low CAUTI SIRs might actually have higher device use, and vice versa. Therefore, the SIR alone does not adequately reflect preventable harm related to urinary catheters. Public reporting of SIR may incentivize hospitals to focus more on urine culture stewardship rather than reducing device utilization.Funding: NoneDisclosures: None

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Application of electronic trigger tools to identify targets for improving diagnostic safety

BMJ Quality & Safety ◽

10.1136/bmjqs-2018-008086 ◽

2018 ◽

Vol 28 (2) ◽

pp. 151-159 ◽

Cited By ~ 21

Author(s):

Daniel R Murphy ◽

Ashley ND Meyer ◽

Dean F Sittig ◽

Derek W Meeks ◽

Eric J Thomas ◽

...

Keyword(s):

Adverse Event ◽

Patient Safety ◽

High Risk ◽

Health Systems ◽

Language Processing ◽

Diagnostic Errors ◽

Diagnostic Process ◽

Future Research ◽

Implementation Challenges ◽

Preventable Harm

Progress in reducing diagnostic errors remains slow partly due to poorly defined methods to identify errors, high-risk situations, and adverse events. Electronic trigger (e-trigger) tools, which mine vast amounts of patient data to identify signals indicative of a likely error or adverse event, offer a promising method to efficiently identify errors. The increasing amounts of longitudinal electronic data and maturing data warehousing techniques and infrastructure offer an unprecedented opportunity to implement new types of e-trigger tools that use algorithms to identify risks and events related to the diagnostic process. We present a knowledge discovery framework, the Safer Dx Trigger Tools Framework, that enables health systems to develop and implement e-trigger tools to identify and measure diagnostic errors using comprehensive electronic health record (EHR) data. Safer Dx e-trigger tools detect potential diagnostic events, allowing health systems to monitor event rates, study contributory factors and identify targets for improving diagnostic safety. In addition to promoting organisational learning, some e-triggers can monitor data prospectively and help identify patients at high-risk for a future adverse event, enabling clinicians, patients or safety personnel to take preventive actions proactively. Successful application of electronic algorithms requires health systems to invest in clinical informaticists, information technology professionals, patient safety professionals and clinicians, all of who work closely together to overcome development and implementation challenges. We outline key future research, including advances in natural language processing and machine learning, needed to improve effectiveness of e-triggers. Integrating diagnostic safety e-triggers in institutional patient safety strategies can accelerate progress in reducing preventable harm from diagnostic errors.

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Surgeons' Perceptions of the Causes of Preventable Harm in Arterial Surgery: A Mixed-Methods Study

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2017.10.003 ◽

2017 ◽

Vol 54 (6) ◽

pp. 778-786 ◽

Cited By ~ 4

Author(s):

Rachael Lear ◽

Anthony D. Godfrey ◽

Celia Riga ◽

Christine Norton ◽

Charles Vincent ◽

...

Keyword(s):

Mixed Methods ◽

Mixed Methods Study ◽

Preventable Harm

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Disseminating a patient-centered education bundle to reduce missed doses of pharmacologic venous thromboembolism (VTE) prophylaxis to a community hospital

Journal of Patient Safety and Risk Management ◽

10.1177/2516043520969324 ◽

2020 ◽

pp. 251604352096932

Author(s):

Oluwafemi P Owodunni ◽

Brandyn D Lau ◽

Dauryne L Shaffer ◽

Danielle McQuigg ◽

Deborah Samuel ◽

...

Keyword(s):

Venous Thromboembolism ◽

Real Time ◽

Community Hospital ◽

Post Intervention ◽

Patient Centered ◽

Record System ◽

Vte Prophylaxis ◽

Patient Refusal ◽

Preventable Harm ◽

Frequent Reason

Background Venous thromboembolism (VTE) is a leading cause of preventable harm in hospitalized patients. However, many doses of prescribed pharmacologic VTE prophylaxis are frequently missed. We investigated the effect of a patient-centered education bundle on missed doses of VTE prophylaxis in a community hospital. Methods We performed a pre-post analysis examining missed doses of VTE prophylaxis in a community hospital. A real-time alert from the electronic health record system facilitated the delivery of a patient education bundle intervention. We included all patient visits on a single floor where at least 1 dose of VTE prophylaxis was prescribed during pre- (January 1, 2018, - November 31, 2018) and post- (January 1 - June 31, 2019) intervention periods. Outcomes included any missed dose (primary) and reasons for missed doses (refusal, other [secondary]) and were compared between both periods. Results 1,614 patient visits were included. The proportion of any missed dose significantly decreased (13.8% vs. 8.2% [OR, 0.56; 95% CI, 0.48, 0.64]) between the pre-post intervention periods. Patient refusal was the most frequent reason for missed doses. In the post-intervention period, patient refusal significantly decreased from 8.8% to 5.0% (OR, 0.54; 95% CI, 0.46, 0.64). Similarly, other reasons for missed doses significantly decreased from 5.0% to 3.2% (OR, 0.62; 95% CI, 0.51, 0.77). Conclusions A real-time alert-triggered patient-centered education bundle developed and tested in an academic hospital, significantly reduced missed doses of prescribed pharmacologic VTE prophylaxis when disseminated to a community hospital.

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Using the Preventable Harm Index to improve patient safety

The Journal of Pediatrics ◽

10.1016/j.jpeds.2010.08.029 ◽

2010 ◽

Vol 157 (4) ◽

pp. A2

Author(s):

Robert W. Wilmott

Keyword(s):

Patient Safety ◽

Improve Patient Safety ◽

Preventable Harm ◽

Improve Patient

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A Toolbox for Detecting and Eliminating Preventable Harm to Patients: Current Progress and the Road Ahead

Quality Management in Health Care ◽

10.1097/qmh.0000000000000277 ◽

2020 ◽

Vol 29 (4) ◽

pp. 279-281

Author(s):

Salar Khaleghzadegan ◽

Allen Kachalia ◽

Jeffrey Natterman ◽

Laura Winner ◽

Lori Paine ◽

...

Keyword(s):

The Road ◽

Preventable Harm

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Patient Safety in Microvascular Plastic Surgery

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1693142 ◽

2019 ◽

Vol 35 (09) ◽

pp. 631-639

Author(s):

Salih Colakoglu ◽

Seth Tebockhorst ◽

Tae W. Chong ◽

David W. Mathes

Keyword(s):

Risk Factors ◽

Patient Safety ◽

Adverse Events ◽

Surgical Procedures ◽

Evidence Based ◽

Surgical Team ◽

Related Risk ◽

Prophylactic Measures ◽

Patients At Risk ◽

Preventable Harm

Patient safety is defined as freedom from accidental or preventable harm produced by medical care. The identification of patient- and procedure-related risk factors enables the surgical team to carry out prophylactic measures to reduce the rate of complications and adverse events.The purpose of this review is to identify the characteristics of patients, practitioners, and microvascular surgical procedures that place patients at risk for preventable harm, and to discuss evidence-based prevention practices that can potentially help to generate a culture of patient safety.

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The Preventable Harm Index: An Effective Motivator to Facilitate the Drive to Zero

The Journal of Pediatrics ◽

10.1016/j.jpeds.2010.05.046 ◽

2010 ◽

Vol 157 (4) ◽

pp. 681-683 ◽

Cited By ~ 33

Author(s):

Richard J. Brilli ◽

Richard E. McClead ◽

Terrance Davis ◽

Linda Stoverock ◽

Anamarie Rayburn ◽

...

Keyword(s):

Preventable Harm

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Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

BMJ ◽

10.1136/bmj.l4185 ◽

2019 ◽

pp. l4185 ◽

Cited By ~ 62

Author(s):

Maria Panagioti ◽

Kanza Khan ◽

Richard N Keers ◽

Aseel Abuzour ◽

Denham Phipps ◽

...

Keyword(s):

Systematic Review ◽

Confidence Interval ◽

Medical Care ◽

Data Extraction ◽

Meta Analysis ◽

Cost Effective ◽

Mitigation Strategies ◽

Patient Harm ◽

Pooled Prevalence ◽

Preventable Harm

Abstract Objective To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally. Design Systematic review and meta-analysis. Data sources Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched. Review methods Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I 2 statistic, and publication bias was evaluated. Results Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10). Conclusions Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.

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