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Background: Therapeutic errors are costly and result in unplanned hospital visits. Recent poison center studies on therapeutic errors have focused on coded data from either the National Poison Data System (NPDS) or individual poison centers. Approximately 21% of therapeutic errors reported to NPDS are coded as "other incorrect dose" (OI) or "other/unknown therapeutic error" (OU). The purpose of this study was to characterize errors coded as OI or OU reported to a single poison center. Methods: Retrospective, single poison center chart review was conducted of therapeutic error exposures with at least one scenario coded as OI or OU seen in or referred to hospitals from 1/1/2000 to 9/30/2017. Cases were reviewed and re-coded to predefined or newly created scenarios. Results: A total of 3413 cases were identified. There were 726 cases assessed as not therapeutic errors and re-coded as either intentional misuse (430), adverse reaction drug (204), or other non-therapeutic errors (82). Of the remaining cases, 1726 cases were re-coded to one of the 16 existing therapeutic error scenarios. After re-coding, there remained 971 coded as OI or OU. Most were due to double, triple, quadruple, or higher than recommended dose (477/971); an additional common error was mistaken strength (81/971). The remaining scenarios occurred in fewer than 50 cases each with greater than 40 different scenarios such that additional coded scenarios would not be feasible. Conclusions: Most cases coded as OI or OU could be recoded as one of the NPDS predefined therapeutic error scenarios or non-error reasons for exposure. Considering the large proportion of double dose cases and the unique errors associated with mistaken strengths of tablets, these scenarios could be appropriate to add as new predefined coding scenarios, which would aid in future research and patient counseling. [ABSTRACT FROM AUTHOR]

Aim: this study aimed to assess nurses' views about major barriers to reporting errors and adverse events in intensive care units. Method: a descriptive analytical study was used to examine barriers to reporting such events. A questionnaire was completed by 251 nurses across seven hospitals in Iran to elicit information about their views on reporting errors and adverse events. Results: the study identified three main areas that prevented the reporting of incidents—fear of the consequences after reporting an error, procedural barriers and management barriers. Conclusion: the most important approach to overcoming barriers that prevent nurses reporting adverse events would be to develop an atmosphere within which all nurses can report errors and the reasons that led to their occurrence honestly and without fear. [ABSTRACT FROM AUTHOR]

Medical errors can involve multiple team members. Few curricula are being developed to provide instruction on disclosing medical errors that include simulation training with interprofessional team disclosure. To explore more objective evidence for the value of an educational activity on team disclosure of errors, faculty developed and assessed the effectiveness of a multimodal educational activity for learning team‐based disclosure of a medical error. This study employed a methodological triangulation research design. Participants (N = 458) included students enrolled in academic programs at three separate institutions. The activity allowed students to practice team communication while: (1) discussing a medical error within the team; (2) planning for the disclosure of the error; and (3) conducting the disclosure. Faculty assessed individual student's change in knowledge and, using a rubric, rated the performance of the student teams during a simulation with a standardized family member (SFM). Students had a high level of preexisting knowledge and demonstrated the greatest knowledge gains in questions regarding the approach to disclosure (P < .001) and timing of an apology (P < .001). Both SFMs and individual students rated the team error disclosure behavior highly (rho = 0.54; P < .001). Most participants (more than 80%) felt the activity was worth their time and that they were more comfortable with disclosing a medical error as a result of having completed the activity. This activity for interprofessional simulation of team‐based disclosure of a medical error was effective for teaching students about and how to perform this type of important disclosure. [ABSTRACT FROM AUTHOR]

Abstract Background Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events. Materials and methods Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries. Results Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts. Conclusions Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review. [ABSTRACT FROM AUTHOR]

A haemovigilance system was established in Japan in 1993 by the Japanese Red Cross (JRC) headquarters, with the initial purpose of collecting reports of adverse transfusion reactions from medical facilities. Although this is a voluntary reporting system, the JRC, in co‐operation with medical facilities, collects almost all serious adverse reactions caused by blood transfusion. Non‐haemolytic transfusion reactions account for >90% of all reported events and transfusion‐transmitted infection (TTI) account for 5–6%. The JRC haemovigilance system is supported by laboratory analyses conducted in the JRC Central Blood Institute and other laboratories. The JRC collects pre‐ and post‐transfusion blood samples from patients who have experienced adverse reactions. These samples together with repository blood samples obtained from corresponding blood donations are analysed to investigate the pathogenesis of adverse events. Data obtained using these samples are helpful in increasing our understanding of transfusion‐related events such as TTI, transfusion‐related anaphylaxis and transfusion‐related acute lung injury (TRALI). Each country has its own history of establishing blood programmes. The relationship between government, blood facilities, transfusion societies and physicians or clinical fields may differ greatly between countries, and the structure of national haemovigilance systems will differ according to these relationships. Whatever haemovigilance system is established, extensive collaboration and adequate information exchange are essential among stakeholders. Strong leadership by a national transfusion society in addition to legislative measures is required if a comprehensive national haemovigilance system is to be established. [ABSTRACT FROM AUTHOR]

Background: The first regulation on haemovigilance in South Korea was first established in 1999 by the Blood Management Act. The purpose of this act was mainly focused on management of transfusion‐transmitted infections. Aims: A more general form of haemovigilance system was needed for surveillance on the transfusion chain. Materials & Methods: A research funded by the government was initiated in 2007 for development of a haemovigilance system. Review on haemovigilance systems of other countries and development of draft report forms were proceeded on the first year. Pilot operation of the system with 46 voluntary participating institutions was conducted during 2008‐2009 including development of an online reporting system via the website. Results: The system was formally launched in a nationwide scale in 2010, financially supported continuously by the government but independently operated by the Korean Society of Blood Transfusion. The program is a centralized, stand‐alone, voluntary reporting, non‐punitive, anonymized, comprehensive system. The number of reporting hospitals and reports submitted has grown every year, with a significant increase after several administrative changes regarding financial incentives and institutional accreditation programs which requested the participation of haemovigilance. Workshops are held for participants every year, and the annual reports can be accessed on the website. Among 215 participating hospitals, 169 reported 3,375 adverse events during the fiscal year 2016. Conclusion: We have successfully operated the program for ten years, including a two‐year pilot study. We hope to further enhance the system qualitatively regarding case validation and standardization of case reporting. [ABSTRACT FROM AUTHOR]

Echocardiography is the primary diagnostic modality for congenital heart disease patients. The written report is used to communicate with the care team and organization is often divided into the body with detailed findings and the conclusions with important findings summarized. Strategies to increase workflow efficiency include batch writing of reports after performance of multiple echocardiograms and the use of report templates which may contribute to discrepancies within report leading to potential downstream medical errors. The aim of this project was to measure the rate of inconsistencies in the echocardiogram reports and through an iterative series of process improvement decrease this rate while maintaining sonographer efficiency and diagnostic accuracy. The discrepancy rate, diagnostic error rate, and sonographer productivity were collected one-year prior and during the iterative quality improvement process. The primary outcome and discrepancies in reports were determined by two reviewers: an experienced pediatric echocardiographic cardiologist and a senior sonographer. Minor discrepancies were defined as contradictions between the body and the conclusion of the report that were unlikely to affect patient care. Major discrepancies were defined as discrepancies between the body and the conclusion that had significant potential to affect patient care. Sonographer productivity was measured as studies per sonographer per month. Our primary intervention was to initiate a quarterly QI meeting and to decrease the batch writing of preliminary echocardiogram reports. No major discrepancies were identified pre- or post-intervention. The minor discrepancies decreased from 40.7 to 6%. Sonographer productivity was not significantly changed with a slight increase from 100 studies/sonographer/month during the baseline to 101 studies/sonographer/month during the intervention. There was no change in major or minor diagnostic error rate. Our quality improvement intervention increased the value of our reports by significantly decreasing minor discrepancies without negatively impacting sonographer productivity or diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Though aviation is practiced in airplanes and anesthesiology in operating rooms, the two professions have substantial parallels. Both require readiness to manage a crisis situation, where lives are at stake, at a moment's notice and with incomplete information. The determinants of quality performance in both professions extend far beyond knowledge base and formal training. The science of human factors, a prominent cornerstone of the aviation industry, has not yet found the same place in medicine, but it could change the understanding and execution of medical decision-making in profound ways. This article reviews specific components of crisis management and root cause analysis in aviation that can serve as models for improving those same aspects within anesthesiology. [ABSTRACT FROM AUTHOR]

Background: Compulsory submission of a checklist from the relevant reporting guideline is one of the most widespread journal requirements aiming to improve completeness of reporting. However, the current suboptimal levels of adherence to reporting guidelines observed in the literature may indicate that this journal policy is not having a significant effect.Findings: We explored whether authors provided the appropriate CONSORT checklist extension for their study and whether there were inconsistencies between what authors claimed on the submitted checklist and what was actually reported in the published paper. We randomly selected 12 randomized trials from three journals that provide the originally submitted checklist and analyzed six core CONSORT items. Only one paper used the appropriate checklist extension and had no inconsistencies between what was claimed in the submitted checklist and what was reported in the published paper.Conclusion: Journals should take further actions to take full advantage of the requirement for the submission of fulfilled CONSORT checklists, thus ensuring that these checklists reflect what is reported in the manuscript. [ABSTRACT FROM AUTHOR]

Background: The most important knowledge in the field of patient safety is regarding the prevention and reduction of patient safety events (PSE) during treatment and care. The similarities and patterns among the events may otherwise go unnoticed if they are not properly reported and analyzed. There is an urgent need for developing a PSE reporting system that can dynamically measure the similarities of the events and thus promote event analysis and learning effect.Methods: In this study, three prevailing algorithms of semantic similarity were implemented to measure the similarities of the 366 PSE annotated by the taxonomy of The Agency for Healthcare Research and Quality (AHRQ). The performance of each algorithm was then evaluated by a group of domain experts based on a 4-point Likert scale. The consistency between the scales of the algorithms and experts was measured and compared with the scales randomly assigned. The similarity algorithms and scores, as a self-learning and self-updating module, were then integrated into the system.Results: The result shows that the similarity scores reflect a high consistency with the experts' review than those randomly assigned. Moreover, incorporating the algorithms into our reporting system enables a mechanism to learn and update based upon PSE similarity.Conclusion: In conclusion, integrating semantic similarity algorithms into a PSE reporting system can help us learn from previous events and provide timely knowledge support to the reporters. With the knowledge base in the PSE domain, the new generation reporting system holds promise in educating healthcare providers and preventing the recurrence and serious consequences of PSE. [ABSTRACT FROM AUTHOR]

Introduction: The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. Methods: A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. Results: Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. Conclusions: Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome. [ABSTRACT FROM AUTHOR]

Objective: To establish categories of professionals' attitudes toward incident reporting by analyzing the trends in incident reporting while accounting for general risk indicators.Design: The incident reporting system was evaluated over 6 years. Reporting rates, stratified by year and profession, were estimated using the non-mandatory reported events/full-time equivalent (NM-IR/FTE) rate. Other indicators were collected using the hospital's official database. Staff attitudes toward self-reporting were analyzed. Univariate and multivariable analyses were performed.Setting: A 1000-bed Italian academic hospital.Participants: Staff of the hospital (over 3200 professionals).Interventions: None.Main Outcome Measures: NM-IT/FTE rates, self-reported rates, patient complaints/praises, work accidents among professionals and 30-day readmissions.Results: The overall reporting rate was 0.44 (95% confidence interval [CI]: 0.42-0.46) among doctors and 0.40 (95% CI: 0.39-0.41) among nurses. Between 2010 and 2015, only the doctors' reporting rate increased significantly (P = 0.04), from 0.29 (95% CI: 0.25-0.34) to 0.67 (95% CI: 0.60-0.73). Patient complaints decreased from 384 to 224 (P < 0.001) and work accidents decreased from 296 to 235 (P = 0.01), while other indicators remained constant. Multivariable logistic regression showed that self-reporting was more likely among nurses than doctors (odds ratio: 1.51; 95% CI: 1.31-1.73) and for severe events than near misses (odds ratio: 1.78; 95% CI: 1.11-2.87).Conclusions: Because the doctors' reporting rates increased during the study period, doctors may be more likely to report adverse events than nurses, although nurses reported more events. Incident reporting trends and other routinely collected risk indicators may be useful to improve our understanding and measurement of patient safety issues. [ABSTRACT FROM AUTHOR]

Introduction: Patient's safety is one of the main objective in healthcare services; however medical errors are a prevalent potential occurrence for the patients in treatment systems. Medical errors lead to an increase in mortality rate of the patients and challenges such as prolonging of the inpatient period in the hospitals and increased cost. Controlling the medical errors is very important, because these errors besides being costly, threaten the patient's safety. Aim: To evaluate the attitudes of nurses and midwives toward the causes and rates of medical errors reporting. Materials and Methods: It was a cross-sectional observational study. The study population was 140 midwives and nurses employed in Mashhad Public Hospitals. The data collection was done through Goldstone 2001 revised questionnaire. SPSS 11.5 software was used for data analysis. To analyze data, descriptive and inferential analytic statistics were used. Standard deviation and relative frequency distribution, descriptive statistics were used for calculation of the mean and the results were adjusted as tables and charts. Chi-square test was used for the inferential analysis of the data. Results: Most of midwives and nurses (39.4%) were in age range of 25 to 34 years and the lowest percentage (2.2%) were in age range of 55-59 years. The highest average of medical errors was related to employees with three-four years of work experience, while the lowest average was related to those with one-two years of work experience. The highest average of medical errors was during the evening shift, while the lowest were during the night shift. Three main causes of medical errors were considered: illegibile physician prescription orders, similarity of names in different drugs and nurse fatigueness. Conclusion: The most important causes for medical errors from the viewpoints of nurses and midwives are illegible physician's order, drug name similarity with other drugs, nurse's fatigueness and damaged label or packaging of the drug, respectively. Head nurse feedback, peer feedback, fear of punishment or job loss were considered as reasons for under reporting of medical errors. This research demonstrates the need for greater attention to be paid to the causes of medical errors. [ABSTRACT FROM AUTHOR]

Objective:In vitro dissolution testing provides useful information at clinical and preclinical stages of the drug development process. Methods: The study includes pharmaceutical papers on dissolution research published in Polish journals between 2010 and 2015. They were analyzed with regard to information provided by authors about chosen methods, performed validation, statistical reporting or assumptions used to properly compare release profiles considering the present guideline documents addressed to dissolution methodology and its validation. Results: Of all the papers included in the study, 23.86% presented at least one set of validation parameters, 63.64% gave the results of the weight uniformity test, 55.68% content determination, 97.73% dissolution testing conditions, and 50% discussed a comparison of release profiles. The assumptions for methods used to compare dissolution profiles were discussed in 6.82% of papers. By means of example analyses, we demonstrate that the outcome can be influenced by the violation of several assumptions or selection of an improper method to compare dissolution profiles. Discussion and conclusion: A clearer description of the procedures would undoubtedly increase the quality of papers in this area. [ABSTRACT FROM AUTHOR]

We here propose the implementation of a simple and effective method to enhance the quality of basic and preclinical academic research: critical incident reporting (CIR). CIR has become a standard in clinical medicine but to our knowledge has never been implemented in the context of academic basic research. We provide a simple, free, open-source software tool for implementing a CIR system in research groups, laboratories, or large institutions (LabCIRS). LabCIRS was developed, tested, and implemented in our multidisciplinary and multiprofessional neuroscience research department. It is accepted by all members of the department, has led to the emergence of a mature error culture, and has made the laboratory a safer and more communicative environment. Initial concerns that implementation of such a measure might lead to a “surveillance culture” that would stifle scientific creativity turned out to be unfounded. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to investigate the performance and limitations of a real-time transit electronic portal imaging device (EPID) dosimetry system for error detection during dynamic intensity modulated radiation therapy (IMRT) treatment delivery. Sites studied are prostate, head and neck (HN), and rectal cancer treatments.Methods: The system compares measured cumulative transit EPID image frames with predicted cumulative image frames in real-time during treatment using a χ comparison with 4 %, 4 mm criteria. The treatment site-specific thresholds (prostate, HN and rectum IMRT) were determined using initial data collected from 137 patients (274 measured treatment fractions) and a statistical process control methodology. These thresholds were then applied to data from 15 selected patients including 5 prostate, 5 HN, and 5 rectum IMRT treatments for system evaluation and classification of error sources.Results: Clinical demonstration of real-time transit EPID dosimetry in IMRT was presented. For error simulation, the system could detect gross errors (i.e. wrong patient, wrong plan, wrong gantry angle) immediately after EPID stabilisation; 2 seconds after the start of treatment. The average rate of error detection was 7.0 % (prostate = 5.6 %, HN= 8.7 % and rectum = 6.7 %). The detected errors were classified as either clinical in origin (e.g. patient anatomical changes), or non-clinical in origin (e.g. detection system errors). Classified errors were 3.2 % clinical and 3.9 % non-clinical.Conclusion: An EPID-based real-time error detection method for treatment verification during dynamic IMRT has been developed and tested for its performance and limitations. The system is able to detect gross errors in real-time, however improvement in system robustness is required to reduce the non-clinical sources of error detection. [ABSTRACT FROM AUTHOR]

Background: The number of medication errors occurring in healthcare is large and many are preventable. To analyze medication errors and evaluate whether Positive Deviance is effective in reducing them. Methods: The study was divided into three phases: (2011- Phase I, control period; 2012 - Phase II, manager intervention, and 2013 - Phase III, frontline healthcare worker intervention). In Phases II and III, the Positive Deviance method (PD) was used to mitigate medication errors classified as "C" and higher according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The errors reported were compared across the three study phases, as well as by the location of the hospital unit, shift, cause, consequence, and the professional associated with the error. Results: A total of 4013 reported medication errors were analyzed. The largest number of errors occurred at the time the medications were administered, accounting for 35.5 % of errors in Phase I; 43.1 % in Phase II, and 55.6 % in Phase III. Nursing staff was most commonly associated with errors; 46.4 % of errors in Phase I, 48.5 % in Phase II, and 58.7 % in Phase III. With each intervention, a decrease was observed in the reported error rate of 0.12 (CI 95 %, 0.18 to 0.07). Conclusion: Positive Deviance proved to be effective, primarily when healthcare professionals who were involved in errors participated, as was observed in Phase III of this study. [ABSTRACT FROM AUTHOR]

Background: Assessment and reporting of adverse events (AEs) in studies of perioperative interventions is critical given the potential for unintended and preventable iatrogenic morbidity and mortality. This focused review evaluated the quality of AE assessment and reporting in acute post-operative pain treatment trials. Since older analgesics (e.g., opioids, NSAIDs) already have a well-characterized safety profile, we concentrated on trials of pregabalin and gabapentin as a representative sample of studies where the perioperative safety profile was relatively unknown.Methods: We reviewed primary reports of trials of pregabalin and gabapentin for treatment of acute post-operative pain for: (1) adherence to the 10 recommendations from the 'CONSORT Extension for Harms,' (2) AE assessment method, (3) timing of AE assessment and reporting, and (4) assessment and reporting of AE severity.Results: We identified 31 trials of pregabalin and 59 of gabapentin. The median number of CONSORT harms recommendations that were satisfied was 7 of 10. The most common (41%) method of AE assessment was direct questioning about specific AEs by investigators. However, AE assessment method was not described in 18% of trials. AE assessments were reported for specified perioperative time points in only 24% of trials. Of greatest concern, no AE data were reported whatsoever in 8 of the included publications.Conclusions: Considerable widespread improvements are needed in AE reporting for post-operative pain treatment trials. In addition to heightened awareness among clinical investigators, mandatory journal editorial policies may further facilitate improvements in safety assessment and reporting. [ABSTRACT FROM AUTHOR]

Objective:This study synthesized research evaluation of the effectiveness of the over-reporting validity scales of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) for detecting intentionally feigned over-endorsements of symptoms using a moderated meta-analysis.Method:After identifying experimental and quasi-experimental studies for inclusion (k = 25) in which the validity scales of the MMPI-2-RF were compared between groups of respondents, moderated meta-analyses were conducted for each of its five over-reporting scales. These meta-analyses explored the general effectiveness of each scale across studies, as well as the impact that several moderators had on scale performance, including comparison group, study type (i.e. real versus simulation), age, education, sex, and diagnosis.Results:The over-reporting scales of the MMPI-2-RF act as effective general measures for the detection of malingering and over endorsement of symptoms with individual scales ranging in effectiveness from an effect size of 1.08 (Symptom Validity; FBS-r) to 1.43 (Infrequent Pathology; Fp-r), each with different patterns of moderating influence.Conclusions:The MMPI-2-RF validity scales effectively discriminate between groups of respondents presenting in either an honest manner or with patterned exaggeration and over-endorsement of symptoms. The magnitude of difference observed between honest and malingering groups was substantially narrower than might be expected using traditional cut-scores for the validity scales, making interpretation within the evaluation context particularly important. While all over-reporting scales are effective, the FBS-r and RBS scales are those least influenced by common and context specific moderating influences, such as respondent or comparison grouping. [ABSTRACT FROM AUTHOR]

Background: There is an absence of formal error tracking systems in public sector hospitals of Pakistan and also a lack of literature concerning error reporting culture in the health care sector. Nurse practitioners have front-line knowledge and rich exposure about both the organizational culture and error sharing in hospital settings. The aim of this paper was to investigate the association between organizational culture and the culture of error reporting, as perceived by nurses.Methods: The authors used the "Practice Environment Scale-Nurse Work Index Revised" to measure the six dimensions of organizational culture. Seven questions were used from the "Survey to Solicit Information about the Culture of Reporting" to measure error reporting culture in the region. Overall, 309 nurses participated in the survey, including female nurses from all designations such as supervisors, instructors, ward-heads, staff nurses and student nurses. We used SPSS 17.0 to perform a factor analysis. Furthermore, descriptive statistics, mean scores and multivariable logistic regression were used for the analysis.Results: Three areas were ranked unfavorably by nurse respondents, including: (i) the error reporting culture, (ii) staffing and resource adequacy, and (iii) nurse foundations for quality of care. Multivariable regression results revealed that all six categories of organizational culture, including: (1) nurse manager ability, leadership and support, (2) nurse participation in hospital affairs, (3) nurse participation in governance, (4) nurse foundations of quality care, (5) nurse-coworkers relations, and (6) nurse staffing and resource adequacy, were positively associated with higher odds of error reporting culture. In addition, it was found that married nurses and nurses on permanent contract were more likely to report errors at the workplace.Conclusion: Public healthcare services of Pakistan can be improved through the promotion of an error reporting culture, reducing staffing and resource shortages and the development of nursing care plans. [ABSTRACT FROM AUTHOR]

The author discusses significance of morbidity and mortality meeting in the hospitals governance process. Topics include management of medical risks by scrutinization of medical errors, methodical clinician-led case note review of adverse events caused by medical or surgical treatment, recording and investigation of deaths caused by errors and adverse events, coordinated clinical governance with safety feedback cycle and responsibilities of healthcare system for England National Health Service.

The article offers information on the ninth Biennial Conference on Signal Detection and Interpretation in Pharmacovigilance held in June 2017. Topics discussed include importance of signal detection in pharmacovigilance in the age of big data, signals detection from social media, and computerized models supporting efficient decision making in signal management.

The article discusses the annual Serious Hazards of Transfusion (SHOT) symposium held during the International Society of Blood Transfusion meeting in London, England in 2014. Topics discussed include the proposed changes in the recommendations made for the transfusion process, the several aspects reported including transfusion reactions, the roles of human factors in the process, and the risk of adverse outcomes, and the several new related studies.

In response to the EU Directive on Pharmacovigilance, the National Health Service (NHS) in England and the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK have formed a partnership to work together to simplify and increase medication error reporting, improve data report quality, maximise learning and guide practice to minimise harm from medication errors by sharing incident data. This initiative will facilitate implementation of new requirements for medication error reporting and reduce the need for duplicate data entry by frontline staff. The initiative is also intended to provide new types of feedback from the National Reporting and Learning System run by the NHS England and from the Yellow Card Scheme run by the MHRA and to improve learning at the local level by clarifying medication safety roles and identifying key safety contacts to allow better communication between local and national levels. Finally, the partnership has established a new National Medication Safety Network to provide a forum for discussing potential and recognised safety issues, and for identifying trends and actions to improve the safe use of medicines. This article describes the initiative, the structure of which may act as a template for other countries. [ABSTRACT FROM AUTHOR]

The article discusses the article "‘Applying lessons from social psychology to transform the culture of error disclosure," by J. Han, D. LaMarra, and N. Vapiwala, focusing on its impact on medical education. It considers topics such as medical culture, bias recognition, standardised patients,situational judgement tests, and virtual reality in medical education.

Imaging is no stranger to patient safety events. There was a tremendous opportunity at WakeMed in North Carolina to change the safety culture of the imag- ing services department and provide staff with a system that rewarded them for identifying safety risks. Most staff could articulate the difference between a near miss and an actual event, but very few staff knew how to report a near miss. Staff who did know how to report a near miss believed the online process was too lengthy. Staff also reported a fear of punitive action associated with reporting events. Imaging services leadership successfully developed and implemented a "Good Catch" program. One of the most important objectives of the program was to remove the negative stigma associated with near miss reporting. [ABSTRACT FROM AUTHOR]

Context. Previous studies of medication errors have largely focused on healthcare facilities and have not reported generalizable national trends among out-of-hospital medication errors. Objective. We sought to understand U.S. trends in medication errors, including the age-related risks, the involved medications, and the medical outcomes. Materials and methods. We performed a retrospective analysis of National Poison Data System (NPDS) data from the American Association of Poison Control Centers for years 2000-2012. Medication error cases were analyzed by age, gender, pharmaceutical involved, substance rank, dosing error type, management site, level of healthcare received, and medical outcome. Trends in medication error rates were analyzed using Poisson regression. Results. From 2000 to 2012, the NPDS recorded 2,913,924 calls reporting unintentional pharmaceutical-related errors that met inclusion criteria. Non-healthcare facility calls comprised 99.2% calls related to unintentional therapeutic errors. Eighty-seven percent of medication errors were managed on site. The annual medication error rate for all callers per 10,000 U.S. population increased significantly ( p < 0.0001) by 69.8% from 2000 (4.98 calls per 10,000 population) to 2012 (8.46 calls per 10,000 population). Among adults aged 20 years and older, age was positively correlating ( r = 0.96) with the rate of medication error. Analgesics were the most frequent pharmaceutical class involved in medication errors for ages 6-49 ( N = 221,061). Among ages 20-49 years, opioid-related medication errors decreased by 7.9% from 2010 to 2012. Cardiovascular drugs were the leading source of injury among all ages ( N = 14,440) and also the leading pharmaceutical class involved in medication errors among adults 50 years and older ( N = 187,760). Conclusion. Medication errors continue to be a source of preventable injury with increasing incidence across the out-of-hospital population. [ABSTRACT FROM AUTHOR]

Although potential future medical errors can best be prevented through reporting near misses, on-site error reporting is not being achieved to a satisfactory level. We surveyed 489 nurses working in 34 wards at a university hospital in Korea in regard to their understanding of factors related to error reporting. Survey items included willingness to report near misses, defensive silence, leader-member exchange, role clarity, and knowledge-sharing climate. Results indicated that defensive silence in the workplace and unclearly defined roles reduced nurses' willingness to report errors, whereas trust-based leader-member exchange (LMX) increased the intention. Knowledge-sharing climates contributed to increasing nurses' intention to report errors, even among those of a silent disposition and in settings where the quality of LMX between the nurses and head nurse was not high. [ABSTRACT FROM AUTHOR]

Incident reporting is promoted as a key tool for improving patient safety in healthcare. We analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units each year in the North West of England between 2009 and 2012; 452 (20%) of these incidents led to harm to patients. Although 1461 (65%) incidents were judged to have been preventable, there was no reduction in the rate of incidents per 1000 days between 2009 and 2012 (5.9 in 2009, 6.6 in 2012). Furthermore, in the 2012 data, there were wide variations in the incident rates between units, the median (IQR [range]) rate per 1000 patient days for individual units being 6.8 (3.8-11.0 [1.3-37.1]). The variation in the percentage that could have been avoided was narrower, with a median (IQR [range]) of 70% (61-80% [38-100%]). The most commonly reported drugs were noradrenaline (161 incidents, 92 with harm), heparins (153 incidents, 29 with harm), morphine (131 incidents, 14 with harm) and insulin (111 incidents, 54 with harm). The administration of drugs was the stage in the process where incidents were most commonly reported; it was also the stage most likely to harm patients. We conclude that the wide range in reported rates between units, and the scope for preventing many incidents, suggest that quality improvement initiatives could improve medication safety in the units studied. [ABSTRACT FROM AUTHOR]

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Background Disclosure is increasingly seen as a key component of efforts to improve safety, but does not yet reliably occur in all organizations in the U.S. Approach We describe the experience to date with disclosure in the U.S. and illustrate the issues with specific clinical examples. Both reputational and legal concerns represent substantial barriers. The evidence to date—mostly from single sites – shows that not only is disclosure the right thing to do, it also appears to decrease malpractice risk. We also discuss the related issue of compensation—practices around this vary greatly. Underlying the push for greater disclosure is also the belief that better disclosure results in an improved culture of safety, which in turn may improve the quality and safety of care. Conclusions Providers have an ethical imperative to disclosure error to patients, and the limited available evidence shows that doing so actually decreases malpractice risk. While disclosure is not yet routine practice in the U.S., the approach is clearly gaining momentum. Telling patients what happened is not enough. They also deserve an apology, and if harmed, to be made whole emotionally and financially. Greater disclosure may not only help individual patients, but may also help with improving safety overall. [ABSTRACT FROM AUTHOR]

Objective: Vascular anomalies are a diagnostic and therapeutic challenge. Errors in diagnosis lead to treatment delay, inappropriate interventions and prolonged suffering. The aim of this study was to analyze patterns of misdiagnosis among patients referred to a vascular anomalies center (VAC). This will better define the problem and may be used to refine and improve referral guidelines for patients with vascular anomalies. Patients and Methods: After IRB approval, we performed a single-center retrospective review of all patients referred to a vascular anomaly between January 1, 2008 and December 15, 2011. Evaluation of both referral and final diagnosis was made. Data regarding accuracy of diagnosis were determined and compared for both vascular tumors and malformations. Results: Mean age was 7.9 ± 7.7 (13 days - 66 years). 42% had a correct diagnosis at the time of referral. Vascular tumors were correctly diagnosed more often than vascular malformations (58% vs 38%). The most common misdiagnosis for infantile hemangioma (IH) was venous malformation (VM). The most common misdiagnosis for VM was IH. Nonspecific and historical terms such as "mass", "lymphangioma", and "cavernous hemangioma" frequently appear as the referral diagnosis. Conclusion: Referral misdiagnosis is common. IH and VM are frequently confused and if there is any uncertainty in the diagnosis, these patients should also be referred to a VAC, in addition to the more complicated anomalies. Outdated nomenclature remains prevalent and continued efforts should be made to adhere to International Society for the Study of Vascular Anomalies (ISSVA) classification. Improvements in diagnostic accuracy are likely to greatly improve patients' care. [ABSTRACT FROM AUTHOR]

The article focuses on the responsibility to report patient death due to hospital error in Japan. Topics include the reporting of patient deaths to the police in Japan, the responsibility for medical errors occurring at referring institutions, and the national general residency program in Japan. Information is provided on risk management in health care.

Objectives: To implement a communication network for safety problem identification and solution sharing among rural community pharmacists and to report participating pharmacists' perceived value and impact of the network on patient safety after 1 year of implementation. Design: Action research study. Setting: Rural community pharmacies in Nebraska from January 2010 to April 2011. Participants: Rural community pharmacists who voluntarily agreed to join the Pharmacists for Patient Safety Network in Nebraska. Intervention: Pharmacists reported errors, near misses, and safety concerns through Web-based event reporting. A rapid feedback process was used to provide patient safety solutions to consider implementing across the network. Main outcome measures: Qualitative interviews were conducted 1 year after program implementation with participating pharmacists to assess use of the reporting system, value of the disseminated safety solutions, and perceived impact on patient safety in pharmacies. Results: 30 of 38 pharmacists participating in the project completed the interviews. The communication network improved pharmacist awareness, promoted open discussion and knowledge sharing, contributed to practice vigilance, and led to incorporation of proactive safety prevention practices. Conclusion: Despite low participation in error and near-miss reporting, a dynamic communication network designed to rapidly disseminate evidence-based patient safety strategies to reduce risk was valued and effective at improving patient safety practices in rural community pharmacies. [ABSTRACT FROM AUTHOR]

The article focuses on the medical error involving deep sleep therapy at Chelmsford Private Hospital in New South Wales between 1963 and 1979, and its impact on the practice of physicians. Topics discussed include the role of mass media in exposing the error and the role of psychiatrist Harry Bailey, clinical psychiatric research that resulted to patient cruelty and death and the role of laws in regulating clinical research. The details of the use of therapy at Chelmford is described.

This study examined reasons a registered nurse would report a wrongdoing within a public teaching hospital. Of a group of 238 initial respondents, 30% reported they had observed a wrongdoing in the past year, with 68 nurses indicating they had reported a wrongdoing in the past year. The latter group was the focus of this study. They indicated through a self-report survey that incidents threatening the well-being of patients and their professional ethics were more likely to be reported within their organizations. Observer anonymity was perceived to have a small, but important effect on nurses reporting a wrongdoing in this sample. A manipulation check of the initial 238 respondents revealed a very strong tendency for nurses to overlook a serious mistake by a close peer who had a reputation of being a "competent" nurse. [ABSTRACT FROM AUTHOR]

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement. [Copyright &y& Elsevier]

Background: Errors in the transfusion process can compromise patient safety. A study was undertaken at our center to identify the errors in the transfusion process and their causes in order to reduce their occurrence by corrective and preventive actions. Methods: All near miss, no harm events and adverse events reported in the 'transfusion process' during 1 year study period were recorded, classified and analyzed at a tertiary care teaching hospital in North India. Results: In total, 285 transfusion related events were reported during the study period. Of these, there were four adverse (1.5%), 10 no harm (3.5%) and 271 (95%) near miss events. Incorrect blood component transfusion rate was 1 in 6031 component units. ABO incompatible transfusion rate was one in 15,077 component units issued or one in 26,200 PRBC units issued and acute hemolytic transfusion reaction due to ABO incompatible transfusion was 1 in 60,309 component units issued. Fifty-three percent of the antecedent near miss events were bedside events. Patient sample handling errors were the single largest category of errors (n=94, 33%) followed by errors in labeling and blood component handling and storage in user areas. Conclusions: The actual and near miss event data obtained through this initiative provided us with clear evidence about latent defects and critical points in the transfusion process so that corrective and preventive actions could be taken to reduce errors and improve transfusion safety. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to compare attitudes toward disclosing medical errors between medical students and interns. Methods: The questionnaires were administrated to 164 medical students and interns. The questionnaires consist of 3 major concepts: knowledge, attitudes toward disclosure of medical error, barriers to the disclosure of medical error. Results: Interns (56.1%) took medical errors less seriously than medical students (74.8%). Medical students (75.6%) believed that patients would want to be informed of any kind of medical errors while Interns (46.3%) thought so. Medical students (83.1%) considered that serious medical errors should be disclosed to patients. On the contrary, only 46.3% of interns believed so. Medical students (16.3%) and interns (19.5%) believed disclosing medical error would increase patients trust in doctors. Both medical students and interns pointed out worries about malpractice suits as the biggest barrier to disclosing medical error. Conclusion: The attitudes toward disclosing medical error between medical students and interns were significantly different in many aspects. Interns show more negative attitudes about disclosing medical errors than medical students. And they also take medical errors less seriously than medical students. In particular, the attitudes of the subjects in this study were greatly different from the results of a previous patients' attitudes study. These perspectives differences could work against achieving patient-centered care which is the upmost priority in the current trends in health care. The efforts to bridge these perspective gaps between patients and doctors should start from medical school by teaching medical students the importance of the disclosing medical errors [ABSTRACT FROM AUTHOR]

Background: The potential for unsafe acts to result in harm to patients is constant risks to be managed in any health care delivery system including pharmacies. The number of reported errors is influenced by a various elements including safety culture. The aim of this study is to investigate a possible relationship between reported dispensing errors and safety culture, taking into account demographic and pharmacy variables, in Swedish community pharmacies. Methods: A cross-sectional study was performed, encompassing 546 (62.8%) of the 870 Swedish community pharmacies. All staff in the pharmacies on December 1st, 2007 were included in the study. To assess safety culture domains in the pharmacies, the Safety Attitudes Questionnaire (SAQ) was used. Numbers of dispensed prescription items as well as dispensing errors for each pharmacy across the first half year of 2008 were summarised. Intercorrelations among a number of variables including SAQ survey domains, general properties of the pharmacy, demographic characteristics, and dispensing errors were calculated. A negative binomial regression model was used to further examine the relationship between the variables and dispensing errors. Results: The first analysis demonstrated a number of significant correlations between reported dispensing errors and the variables examined. Negative correlations were found with SAQ domains Teamwork Climate, Safety Climate, Job Satisfaction as well as mean age and response rates. Positive relationships were demonstrated with Stress Recognition (SAQ), number of employees, educational diversity, birth country diversity, education country diversity and number of dispensed prescription items. Variables displaying a significant relationship to errors in this analysis were included in the regression analysis. When controlling for demographic variables, only Stress Recognition, mean age, educational diversity and number of dispensed prescription items and employees, were still associated with dispensing errors. Conclusion: This study replicated previous work linking safety to errors, but went one step further and controlled for a variety of variables. Controlling rendered the relationship between Safety Climate and dispensing insignificant, while the relationship to Stress Recognition remained significant. Variables such as age and education country diversity were found also to correlate with reporting behaviour. Further studies on the demographic variables might generate interesting results. [ABSTRACT FROM AUTHOR]

Background and purpose: One of the most important physician's job difficulties is the patient's dissatisfaction and malpractice lawsuit, and its effects on their personal and professional life. Unfortunately despite of all progresses made, and new technologies in the field of disease diagnosis and management, the prevalence of medical lawsuits is increasing over the time. Medical errors can occur in any part of health care system. Epidemiological research is needed to determine how many medical errors are made in hospitals. Our goal is to determine the frequency of malpractice lawsuits, motivations, the prevalence and type of errors, and finally to give some solutions to minimize the risk of medical malpractices and to improve patient safety. Materials and methods: All malpractice lawsuits referred to forensic medicine department and medical council in Sari in the years 2006-2011 Jan were used to collect information about errors and the data were analyzed using statistical exams. Results: Among 192 cases, in 27.1 % of them medical errors were discovered. The most frequent lawsuits and medical errors were committed in 2009 (22.4%, 28.8%). The most frequent medical errors were recognized in orthopedics, dentistry, general surgery, general practice and plastic surgery, 86.5% of practitioners were male and 13.5% were female. In the majority of cases a surgical procedure was done and occurring medical error resulted in patient disability. Conclusion: The data showed that the frequency of malpractice lawsuits and medical errors were increasing during the years of study. We can drive efforts in planning reeducational and medical ethics courses, improving the insurance coverage and revising management system to reduce medical errors. [ABSTRACT FROM AUTHOR]

Background: Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. Methods: The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier "Incident type", described as odds ratios (OR) and proportional similarity indices (PSI). Results: A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI = 0.32) and from IRS and retrospective chart review (PSI = 0.31) were mainly attributable to behaviour (OR = 6.08), clinical administration (OR = 5.14), clinical process (OR = 6.73) and resources (OR = 2.06). Conclusions: IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety. [ABSTRACT FROM AUTHOR]

Background Reported adverse events (RAEs) are relatively common in the acute hospital and are associated with significant mortality and morbidity. Dementia is increasing in hospital in-patients, however there have been few studies exploring risk factors for RAEs, in particular cognitive impairment and dementia. Our objective was to identify the prevalence of RAEs in older acute medical inpatients and associated demographic, clinical or cognitive risk factors. Method A longitudinal cohort study set on acute medical wards in a large general hospital. We recruited 710 people aged over 70 years undergoing emergency medical admission. Dementia was diagnosed using operationalised DSM-IV criteria. Patients were assessed using standardised tools including the Confusion Assessment Method, mini-mental state examination, the Functional Assessment Staging scale, the APACHE scale and Charlson co-morbidity index. Data on adverse events was supplied independently by the hospital clinical risk department. Results 8.6% (95% CI 6.4-10.6) of patients experienced an RAE; 5.9% (95% CI 4.2-7.6) were patient-related and 2.7% (95% CI 1.5-3.8) system-related (incidence rate for all RAEs was 2.1 (95% CI 1.7-2.8)) per person year of hospital admission. Median length of admission was 8 days (inter-quartile range 4-17 days). Patient-related RAEs were associated with male gender, delirium, mild/moderate cognitive impairment and a FAST score of 2-6. Overall, 11.1% died during the admission-this was not associated with experiencing an RAE. Staff comments on incident forms indicated an apparent lack of understanding of the impact of cognitive impairment. Conclusions RAEs were common and associated with risk factors identifiable at admission. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Making healthcare safer is an international priority. Patient safety modules are now taught in medical schools, and methods to assess related student knowledge and attitudes have been developed. However, little is known about the attitudes and knowledge which foundation doctors are developing to patient safety and incident reporting in the healthcare workplace, since a specific assessment tool appears to be lacking. Aims To develop, content validate and pilot test an online questionnaire survey to elicit foundation doctors' knowledge and experience of patient safety and incident reporting, and assess related attitudes and behaviours. Methods Questionnaire content validity was facilitated through: a steering group; literature review; feedback from foundation year doctors and consultant staff; a modified Delphi group; and completion of a content validity index by experts. In 2010 a cross-sectional online survey of 110 foundation year 1 and 2 doctors was then undertaken in three Scottish NHS board areas, utilising the developed 25 item questionnaire. Results The questionnaire was validated, and piloted among 69 foundation year doctors who responded to the questionnaire. The pilot has provided valuable insights into trainee attitudes and experience. For example, 32 (48%) believed that most safety incidents were due to things that they could not do anything about; and 31 (43%) admitted to being involved in medication errors which were not formally reported. Conclusions The pilot study was successful in taking the first steps to developing a validated survey questionnaire for a key staff group, foundation year doctors, in a priority area. However, the findings raise concerns about trainee experience of and attitudes to reporting, and the frequency with which incidents go unreported. [ABSTRACT FROM AUTHOR]

Background and purpose: There has been no objective evaluation of the rate of medical errors in Iran; it seems a disproportionate attitude is the main hindrance to reporting of such errors. Considering the role of the chief managers in executive functioning of every institution, this study has been carried out with the aim of surveying the attitude of chief managers of Mazandaran University of Medical Sciences towards voluntary report of medical errors. Materials and methods: In this descriptive cross-sectional study, chiefs, managers, chief nurses, supervisors and head-nurses from 32 hospitals affiliated to Mazandaran University of Medical Sciences took part. A self-sufficing questionnaire in two sections containing closed questions, in order to determine experience of medical errors and also to study their attitude towards voluntary report system of medical errors in hospitals was implemented. The questionnaire was based on a review of studies and had validity and reliability of 79% in a pilot study. Results: In this study, out of 278 (54 %) of questionnaires collected, 110 (39.6%) managers had experienced medical error, 190 (%68.4) stated that in the hospital they work, errors are reported. Most chief managers (%95.7) thought that reporting the medical errors would improve patient safety. 89.6 % of the managers suggested the need for a different approach in executive policies. Majority of responders (%85) disagreed with an absolute punishment policy, in case of a medical error. Conclusion: Most hospital managers are in favor of a system for reporting and analyzing the medical errors. It seems that establishing a systematic and non-individual reporting and assessing the errors is a crucial step forward. [ABSTRACT FROM AUTHOR]

Since 1960, the collection and analysis of mortality data for anesthesia in Australia has been of significant benefit to practising anesthetists. These figures include pediatric deaths which fortunately have been rare and often inevitable because of severe underlying disease and patient risk factors. The reporting of critical incidents and serious morbidity, on the other hand, has been far less impressive. Only one state in Australia, Victoria, currently has a committee that collects morbidity data and, as this reporting is voluntary, is likely to under-represent the true numbers of critical events. There is no specific pediatric morbidity database in Australia so much of this discussion will be regarding overall anesthesia critical event reporting which includes pediatrics as a subset. [ABSTRACT FROM AUTHOR]

Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented. An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system. A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago. An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement. [ABSTRACT FROM AUTHOR]

Background Centralised incident reporting in a Dutch collaboration of nine out-of-hours services yielded very few incident reports. To improve incident reporting and the awareness of primary caregivers about patient safety issues, a local incident-reporting procedure was implemented. Aim To compare the number and nature of incident reports collected in a local incident-reporting procedure (intervention) versus the currently used centralised incident-reporting procedure. Design of study Quasi experiment. Setting Three GPs' out-of-hours services (OHSs) in the centre of the Netherlands participated over 2 years before and 2 years after the intervention. Method A local incident-reporting procedure was implemented in OHS1, in which participants were encouraged to report all occurring incidents. A local committee with peers analysed the reported incidents fortnightly in order to initiate improvements if necessary. In OHS2 and OHS3, the current centralised incident-reporting procedure was continued, where incidents were reported to an advisory committee of the board of directors of the OHSs collaboration and were assessed every 2 months. The main outcome measures were the number and nature of incidents reported. Results At baseline, participants reported fewer than 10 incidents per year each. In the follow-up period, the number of incidents reported in OHS1 increased 16-fold compared with the controls. The type of incidents reported did not alter. In the local incident-reporting procedure, improvements were implemented in a shorter time frame, but reports in the centralised incident-reporting procedure led to a more systematic addressing of general and recurring safety problems. Conclusion It is likely that a local incident-reporting procedure increases the willingness to report and facilitates faster implementation of improvements. In contrast, the central procedure, by collating reports from many settings, seems better at addressing generic and recurring safety issues. The advantages of both approaches should be combined. [ABSTRACT FROM AUTHOR]

Background: Patient identification (ID) errors in point-of-care testing (POCT) can cause test results to be transferred to the wrong patient's chart or prevent results from being transmitted and reported. Despite the implementation of patient barcoding and ongoing operator training at our institution, patient ID errors still occur with glucose POCT. The aim of this study was to develop a solution to reduce identification errors with POCT. Materials and Methods: Glucose POCT was performed by approximately 2,400 clinical operators throughout our health system. Patients are identified by scanning in wristband barcodes or by manual data entry using portable glucose meters. Meters are docked to upload data to a database server which then transmits data to any medical record matching the financial number of the test result. With a new model, meters connect to an interface manager where the patient ID (a nine-digit account number) is checked against patient registration data from admission, discharge, and transfer (ADT) feeds and only matched results are transferred to the patient's electronic medical record. With the new process, the patient ID is checked prior to testing, and testing is prevented until ID errors are resolved. Results: When averaged over a period of a month, ID errors were reduced to 3 errors/ month (0.015%) in comparison with 61.5 errors/month (0.319%) before implementing the new meters. Conclusion: Patient ID errors may occur with glucose POCT despite patient barcoding. The verification of patient identification should ideally take place at the bedside before testing occurs so that the errors can be addressed in real time. The introduction of an ADT feed directly to glucose meters reduced patient ID errors in POCT. [ABSTRACT FROM AUTHOR]