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Supplemental material, sj-pdf-1-cri-10.1177_2516043520969329 for Characterising the types of paediatric adverse events detected by the global trigger tool – CareTrack Kids by Peter D Hibbert, William B Runciman, Andrew Carson-Stevens, Peter Lachman, Gavin Wheaton, Andrew R Hallahan, Adam Jaffe, Les White, Stephen Muething, Louise K Wiles, Charlotte J Molloy, Anita Deakin and Jeffrey Braithwaite in Journal of Patient Safety and Risk Management

IntroductionA common method of learning about adverse events (AEs) is by reviewing medical records using the global trigger tool (GTT). However, these studies generally report rates of harm. The aim of this study is to characterise paediatric AEs detected by the GTT using descriptive and qualitative approaches.MethodsMedical records of children aged 0–15 were reviewed for presence of harm using the GTT. Records from 2012–2013 were sampled from hospital inpatients, emergency departments, general practice and specialist paediatric practices in three Australian states. Nurses undertook a review of each record and if an AE was suspected a doctor performed a verification review of a summary created by the nurse. A qualitative content analysis was undertaken on the summary of verified AEs.ResultsA total of 232 AEs were detected from 6,689 records reviewed. Over four-fifths of the AEs (193/232, 83%) resulted in minor harm to the patient. Nearly half (112/232, 48%) related to medication/intravenous (IV) fluids. Of these, 83% (93/112) were adverse drug reactions. Problems with medical devices/equipment were the next most frequent with nearly two-thirds (32/51, 63%) of these related to intravenous devices. Problems associated with clinical processes/procedures comprise one in six AEs (38/232, 16%), of which diagnostic problems (12/38, 32%) and procedural complications (11/38, 29%) were the most frequent.ConclusionAdverse drug reactions and issues with IVs are frequently identified AEs reflecting their common use in paediatrics. The qualitative approach taken in this study allowed AE types to be characterised, which is a prerequisite for developing and prioritising improvements in practice.

Objective To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. Design A qualitative content analysis of root cause analysis investigation reports. Setting Public health services in Victoria, Australia, 2010–2015. Participants Incidents of retained surgical items as described by 31 root cause analysis investigation reports. Main Outcome Measure(s) The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. Results Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. Conclusion Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.

Introduction The use of surgical safety checklists (SSC) is an intervention aimed at reducing mortality and morbidity. Although the effectiveness of their use in surgery has been studied extensively, little is known about their practical use in Australian hospitals. The aim of this study was to observe and document the use of SSC in Australia. Methods This study employed direct observations of checklist use for surgical procedures by trained observers. Medical records were also audited to determine compliance with checklist use and to investigate whether there was any discrepancy between practice (actual care measured by direct observation) and documentation (documented care measured by an audit of records). Results Among the 11 participating hospitals, overall observed mean completion of the components of the checklist was 27%. Only one hospital used the original World Health Organization checklist. The checklist items most commonly observed to be addressed by the operating theatre staff as noted during observations were: correct patient (99%) and procedure (97%), whether the patient had any allergies (80%), and whether the instrument counts were performed correctly (56%). Findings from the direct observations conflicted with the medical record audit, where there was a higher percentage of completion (86% completion) in comparison to the 27% observed. Conclusion This is the first study of surgical checklist use within Australia. Overall completion was low across the sites included in this study. Compliance data collected from observations differed markedly from reported compliance in medical records.

Introduction The use of safety checklists in interventional radiology is an intervention aimed at reducing mortality and morbidity. Currently there is little known about their practical use in Australian radiology departments. The primary aim of this mixed methods study was to evaluate how safety checklists (SC) are used and completed in radiology departments within Australian hospitals, and attitudes towards their use as described by Australian radiologists. Methods A mixed methods approach employing both quantitative and qualitative techniques was used for this study. Direct observations of checklist use during radiological procedures were performed to determine compliance. Medical records were also audited to investigate whether there was any discrepancy between practice (actual care measured by direct observation) and documentation (documented care measured by an audit of records). A focus group with Australian radiologists was conducted to determine attitudes towards the use of checklists. Results Among the four participating radiology departments, overall observed mean completion of the components of the checklist was 38%. The checklist items most commonly observed to be addressed by the operating theatre staff as noted during observations were correct patient (80%) and procedure (60%). Findings from the direct observations conflicted with the medical record audit, where there was a higher percentage of completion (64% completion) in comparison to the 38% observed. The focus group participants spoke of barriers to the use of checklists, including the culture of radiology departments. ConclusionThis is the first study of safety checklist use in radiology within Australia. Overall completion was low across the sites included in this study. Compliance data collected from observations differed markedly from reported compliance in medical records. There remain significant barriers to the proper use of safety checklists in Australian radiology departments. Refereed/Peer-reviewed

Objective: To assess the strength of root cause analysis (RCA) recommendations and their perceived levels of effectiveness and sustainability. Design: All RCAs related to sentinel events (SEs) undertaken between the years 2010 and 2015 in the public health system in Victoria, Australia were analysed. The type and strength of each recommendation in the RCA reports were coded by an expert patient safety classifier using the US Department of Veteran Affairs type and strength criteria. Participants and setting: Thirty-six public health services. Main outcome measure(s): The proportion of RCA recommendations which were classified as 'strong' (more likely to be effective and sustainable), 'medium' (possibly effective and sustainable) or 'weak' (less likely to be effective and sustainable). Results: There were 227 RCAs in the period of study. In these RCAs, 1137 recommendations were made. Of these 8% were 'strong', 44% 'medium' and 48% were 'weak'. In 31 RCAs, or nearly 15%, only weak recommendations were made. In 24 (11%) RCAs five or more weak recommendations were made. In 165 (72%) RCAs no strong recommendations were made. The most frequent recommendation types were reviewing or enhancing a policy/guideline/documentation, and training and education. Conclusions: Only a small proportion of recommendations arising from RCAs in Victoria are 'strong'. This suggests that insights from the majority of RCAs are not likely to inform practice or process improvements. Suggested improvements include more human factors expertise and independence in investigations, more extensive application of existing tools that assist teams to prioritize recommendations that are likely to be effective, and greater use of observational and simulation techniques to understand the underlying systems factors. Time spent in repeatedly investigating similar incidents may be better spent aggregating and thematically analysing existing sources of information about patient safety. Refereed/Peer-reviewed

Purpose Radiology has lagged behind other disciplines in using medicolegal data to improve patient safety. The aim of this study was to characterize a sample of closed claims files to inform radiology practice and identify opportunities for system change. Methods A retrospective analysis of 443 medicolegal closed claims provided to the Radiology Events Register. Data were provided by 2 medical defense organizations that provide medical indemnity insurance to Australian private practitioners. We calculated a procedural risk ratio (prevalence in the closed claims dataset divided by prevalence among all diagnostic imaging procedures reimbursed by the Australian Government over the corresponding timeframe) for each modality (CT, ultrasound, radiography, MRI, nuclear medicine) and some procedures. For each closed claim, the incident type was determined, and a classification of 12 patient safety fields was conducted. Results Misdiagnosis (delay or failure to correctly read imaging) accounted for 62% of error types. Modalities and procedures at higher risk of leading to a claim were: mammography (risk ratio [RR] = 4.0, 95% CI 2.9-5.5); breast ultrasound (RR = 2.8, 95% CI 1.7-4.7); total MRI (RR = 3.4, 95% CI 2.0-5.6); total CT (RR = 1.9, 95% CI 1.5-2.5), and obstetrics and gynecology ultrasound (RR = 1.9, 95% CI 1.4-2.4). Lower-risk modalities and procedures were: cardiac ultrasound (RR = 0.1, 95% CI 0.0-0.8); radiography extremities (RR = 0.7, 95% CI 0.5-0.9); and total radiography (RR = 0.8, 95% CI 0.7-0.9). Information to inform patient safety classification was limited, with a mean of 5.8 ± 1.8 (SD) fields available. Conclusions Despite its limitations, medicolegal data deserve further attention from patient safety analysts.

Background: Surgical safety checklists have been shown to reduce deaths and complications from surgery in a range of countries. Although their effectiveness has been studied extensively, little is known about their use and the barriers and enablers to their use in Australia Aims: The aims of this project were to investigate the use of safety checklists in surgery and radiology and understand what facilitates and what hinders their use in Australian hospitals. Methods: A multi-method and phased research approach was designed to achieve these aims. Phase 1consisted of a nationwide survey of the extent of checklist use. Phase 2 involved observations and medical record audit to determine compliance with checklist use, and included qualitative discussions with hospital staff to identify barriers and enablers to their use. Phase 3 included the conduct of two formal focus groups (one with radiologists and one with surgeons) to better understand why certain barriers occurred and identify potential areas for improvement. Results: From the 1039 surveys sent out, 180 surveys were returned (a response rate of 17% in Phase 1). Checklists were in place in 91% of organisations. The majority (60%) were modified, paper checklists,and most respondents had a positive attitude to their use. The most prevalent barrier was ‘time’,whilst ‘nursing staff’, ‘general staff involvement’ and ‘culture/commitment to patient safety’ each rated equally as the highest enablers. Another important point to have come out of Phase 1 of the project is that incongruence exists between the actual usage of the safety checklist by hospitals compared to the WHO standard. This was further examined in Phase 2 of the project.Eleven surgical departments participated in Phase 2. For these, overall average completion of the checklist was 27%. The checklist items most commonly addressed by the surgical staff were: correct patient (99%), site (37%) and procedure (97%), that the consent form has been signed (36%),whether the patient has any allergies (80%), and whether the instrument counts were correct (56%). From discussions with staff, 13 broad categories were identified that related to enabling factors and17 to barriers. Four radiology departments participated in Phase 2. Checklist compliance ranged from 0-100% across the sample, with a mean of 38% completion. Checklist items most commonly addressed included correct patient and procedure (80% and 59%, respectively), and whether or not the patient had any allergies (61%). From discussions with staff, 12 broad categories were identified that related to enabling factors and six to barriers. There was no significant difference between surgery (M = 37, SD = 19) and radiology (M = 38, SD = 31) with respect to their completion of thesafety checklist. Conclusion: This project is the first national investigation conducted into the use of checklists throughout Australia. Although checklists have been received positively where they have been implemented, the completion of checklists appears to be low in both surgical and radiological settings. A number of barriers and enablers to the use of checklists were identified. There was a substantial gap between what was documented to have been done and what was actually done; this required policy change to ensure they are addressed