An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review

Hegarty, Josephine; Flaherty, Sarah Jane; Saab, Mohamad M.; Goodwin, John; Walshe, Nuala; Wills, Teresa; McCarthy, Vera J. C.; Murphy, Siobhán; Cutliffe, Alana; Meehan, Eileen R.; Landers, Ciara; Lehane, Elaine; Lane, Aoife; Landers, Margaret; Kilty, Caroline; Madden, Deirdre; Tumelty, Mary-Elizabeth; Naughton, Corina

doi:10.1097/pts.0000000000000700

Cited by 20 publications

(27 citation statements)

References 34 publications

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“…Errors that caused or could have caused (also near misses and other proactive observations) severe patient harm or were categorised in the highest risk classes (IV–V) go automatically to the quality manager of the department, who reviews the coding and accepts severe reports for a root cause analysis process. The definitions of severe patient safety incidents used in previous studies vary greatly [ 19 ]. The definition used by HUS for severe MEs refers to errors that caused severe harm or have the potential to cause severe harm.…”

Section: Methodsmentioning

confidence: 99%

Implementing a New Electronic Health Record System in a University Hospital: The Effect on Reported Medication Errors

et al. 2022

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Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.

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Section: Methodsmentioning

confidence: 99%

Implementing a New Electronic Health Record System in a University Hospital: The Effect on Reported Medication Errors

et al. 2022

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“…Although no-harm and near-miss events may be anywhere between 7 and 100 times more common than AEs, systems for reporting them are much less common [62]. These less-impactful events represent latent system risks that must be reported to prevent serious consequences in the future [63].…”

Section: Potential Errors: From Minor To Major Consequencesmentioning

confidence: 99%

Patient Safety in Physiotherapy: Are Errors that Cause or Could Cause Harm Preventable?

Gonzalez-Caminal¹,

Gomez²,

Gomar-Sancho³

2023

Contemporary Topics in Patient Safety - Volume 2

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The concept of patient safety is less developed in physiotherapy than in other areas of health care. Standard physiotherapy care, whether active or passive, is largely viewed as harmless as it is not associated with serious adverse events. Physiotherapists, however, are increasingly involved in the care of in-hospital patients, in particular for early rehabilitation for patients who are critically ill or have undergone complex surgery. The increased risk of serious adverse events in such settings has contributed to an increased awareness of safety in physiotherapy. Most practitioners, however, operate in non-hospital settings, where the idea that physiotherapy causes little or no harm is more deeply entrenched and does little to foster a culture of risk awareness or encourage practitioners to report or record errors. Error reporting and recording are two basic pillars of patient safety and should be extended to all health care areas. Heightened awareness and the creation of systems that encourage reporting will gradually lead to the creation of a culture of safety in physiotherapy.

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“…This search was designed to source records from Australia, Canada, Ireland, New Zealand, the United Kingdom (UK), and USA. These countries were selected since they have similar health systems and infrastructure (Hegarty et al, 2020;United Nations Development Programme, 2019). Six separate Google searches were conducted within these countries using the terms "suicide," "self-harm," and "risk" and the domains of the selected countries.…”

Section: Information Sources and Searchmentioning

confidence: 99%

Suicide and Self-Harm Risk Assessment: A Systematic Review of Prospective Research

Saab¹,

Murphy

Meehan

et al. 2021

Archives of Suicide Research

Self Cite

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Objective: Suicide and self-harm are widespread yet underreported. Risk assessment is key to effective self-harm and suicide prevention and management. There is contradicting evidence regarding the effectiveness of risk assessment tools in predicting self-harm and suicide risk. This systematic review examines the effect of risk assessment strategies on predicting suicide and self-harm outcomes among adult healthcare service users. Method: Electronic and gray literature databases were searched for prospective research. Studies were screened and selected by independent reviewers. Quality and level of evidence assessments were conducted. Due to study heterogeneity, we present a narrative synthesis under three categories: (1) suicide-and self-harm-related outcomes; (2) clinician assessment of suicide and self-harm risk; and (3) healthcare utilization due to self-harm or suicide. Results: Twenty-one studies were included in this review. The SAD PERSONS Scale was the most used tool. It outperformed the Beck Scale for Suicide Ideation in predicting hospital admissions and stay following suicide and self-harm, yet it failed to predict repeat suicide and self-harm and was not recommended for routine use. There were mixed findings relating to clinician risk assessment, with some studies recommending clinician assessment over structured tools, whilst others found that clinician assessment failed to predict future attempts and deaths. Conclusions: There is insufficient evidence to support the use of any one tool, inclusive of clinician assessment of risk, for self-harm and suicidality. The discourse around risk assessment needs to move toward a broader discussion on the safety of patients who are at risk for self-harm and/or suicide. HIGHLIGHTSThere is insufficient evidence to support using standalone risk assessment tools. There are mixed findings relating to clinician assessment of risk. Structured professional judgment is widely accepted for risk assessment.

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An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review

Abstract: Supplemental digital content is available in the text.

Cited by 20 publications

References 34 publications

Implementing a New Electronic Health Record System in a University Hospital: The Effect on Reported Medication Errors

Implementing a New Electronic Health Record System in a University Hospital: The Effect on Reported Medication Errors

Patient Safety in Physiotherapy: Are Errors that Cause or Could Cause Harm Preventable?

Suicide and Self-Harm Risk Assessment: A Systematic Review of Prospective Research

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