Critical incidents in a tertiary care clinic for internal medicine

Abstract

BackgroundReducing medical errors has become an international concern. Population-based studies consistently demonstrate inacceptable high rates of medical injury and preventable deaths. Thus, electronic critical incident reporting systems are now increasingly used in hospitals, predominantly in anesthesia. However, studies systematically analyzing critical incidents are scarce. Our aim was to describe content and causes of critical incidents in our Clinic for Internal Medicine.ResultsWe retrospectively analyzed all critical incidents reported during a 54-months period. Between implementation and analysis, 456 incidents were reported anonymously in the commercially available platform-independent, web-based critical incident reporting system. All incidents were analyzed according to the reporting profession, time point during hospitalization process, content and potential causes.Most incidents occurred on medical wards (80%). The most frequent type of incidents was medication errors (62%). These incidents primarily occurred when prescribing and/or administering drugs (30% and 29% of medication errors respectively). So-called, human errors’, i.e. occurring without apparent external factor, were the most frequently indicated cause of critical incidents (56%) followed by insufficient communication (26%). These problems primarily occurred between different groups of health care professionals and between different departments. The described types and reasons of critical incidents remained stable during the observation period.ConclusionsThe findings of our analysis of the character and type of critical incidents occurring in a tertiary care clinic for internal medicine reported in an anonymous, voluntary, electronic reporting system suggest that strategies to improve communication and medication delivery are most promising to avoid critical incidents.

Kepuasan Pasien Terhadap Penerapan Keselamatan Pasien Di Rumah Sakit

“…Jenis insiden yang paling sering terjadi adalah kesalahan pengobatan (62%). Saat meresepkan 29% dan diikuti 26% komunikasi yang kurang tepat (Scharein & Trendelenburg, 2013).…”

Detection of LytA Genes in Streptococcus pneumoniae Isolated from sputum pneumonia patients

“…Autolysin which can be found in all S. pneumococcal serotypes is the advantage of this gene compared to other genes so that this gene can be used as a target gene in detecting Streptococcus pneumoniae molecularly in detecting the causes of pneumococcal pneumonia and this is evident from the results of the study in table 6. it was seen that where the LytA gene can detect S. pneumoniae in a sample of pneumonia patients. And the LytA gene has also been used successfully to distinguish Streptococcus pneumoniae from S.viridans (Wu et al, 2015) Even so, molecular examination still has a weakness in detecting genes if the extracted sample is contaminated so that it can cause false positives or false negatives. Therefore, each check must be accompanied by positive and negative controls so that it is easier for us to interpret the correct and reliable results.…”

Incidents reported by nurse anaesthetists in the operating room

“…Similarly, Gillespie et al (2013) found that a risk of harm was associated with poor interprofessional communication and teamwork. Shortcomings in communication and teamwork were also found to be a major cause of critical incidents (Scharein & Trendelenburg, 2013). Insufficient communication has been recognised as not only a source of incidents but also a cause of patients' suffering from health care (Berglund, Westin, Svanström, & Sundler, 2012).…”