Monitoring Preventable Adverse Events and Near Misses: Number and Type Identified Differ Depending on Method Used

Isaksson, Stina; Schwarz, Anneli; Rusner, Marie; Nordström, Sophia; Källman, Ulrika

doi:10.1097/pts.0000000000000921

Cited by 5 publications

(9 citation statements)

References 21 publications

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“…No entanto, incentiva os profissionais de saúde a registrar o acontecimento de eventos adversos para aprofundar a compreensão da frequência, padrões, tendências e riscos desses eventos, bem como, servir como um sistema de alerta (17) aos profissionais e serviço de saúde. Nesse sentido, para além do sistema fornecer um feedback de alta qualidade aos profissionais (17) , serve de equipe deve realizar com o paciente (7) .…”

Section: Tais Conteúdos São Consideradosunclassified

Validação Da Estrutura De Curso Sobre Avaliação E Registro De Lesão Por Pressão Para Enfermeiros

Baretta,

Amora Ascari,

Cezar Leal

et al. 2023

Rev. Enferm. Atual In Derme

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Objetivo: validar com especialistas os tópicos da estrutura de curso online para enfermeiros sobre avaliação e registro de lesão por pressão. Método: estudo metodológico realizado em quatro etapas: 1. Diagnóstico situacional em bases de dados, protocolos nacionais e publicações legais; 2. Referencial teórico; 3. Construção da estrutura do curso; 4. Validação da estrutura do Curso online por 13 juízes especialistas em estomaterapia/dermatologia. O critério para validação foi concordância superior a 80% analisado por meio do Índice de Validade de Conteúdo. Resultados: a versão final da estrutura do curso online apresentou IVC= 0,95 na primeira rodada, ou seja, 95% de concordância. Considerações Finais: a estrutura do curso online para enfermeiros sobre avaliação e registro de lesão por pressão foi considerada válida, constituindo-se uma tecnologia cuidativo-educacional adequada, com intuito de subsidiar enfermeiros generalistas a avaliar a lesão por pressão e efetivar o registro de forma padronizada, contribuindo para a qualificação do processo de enfermagem para uma assistência segura.

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Section: Tais Conteúdos São Consideradosunclassified

Validação Da Estrutura De Curso Sobre Avaliação E Registro De Lesão Por Pressão Para Enfermeiros

Baretta,

Amora Ascari,

Cezar Leal

et al. 2023

Rev. Enferm. Atual In Derme

View full text Add to dashboard Cite

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“…Established IRSs alone may be ineffective for improving patient safety or facilitating learning 12 13. Therefore, adopting multiple methods is advocated to obtain a comprehensive review of the events occurring in healthcare settings 14…”

Section: Introductionmentioning

confidence: 99%

“…Participants have described the method as an approach supporting patient safety work and appreciated its simplicity, visualisation and the learning opportunities through daily safety briefings 16 18. The daily safety briefings seem to be suitable for assessing an organisation’s inherent safety and foster a non-punitive culture 14…”

Section: Introductionmentioning

confidence: 99%

“… 12 13 Therefore, adopting multiple methods is advocated to obtain a comprehensive review of the events occurring in healthcare settings. 14 …”

Section: Introductionmentioning

confidence: 99%

“… 16 18 The daily safety briefings seem to be suitable for assessing an organisation’s inherent safety and foster a non-punitive culture. 14 …”

Section: Introductionmentioning

confidence: 99%

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Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals’ experiences after 3 years, including the COVID-19 pandemic period

et al. 2023

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ObjectivesUnsafe medical care causes morbidity and mortality among the hospital patients. In a postanaesthesia care unit (PACU), increasing patient safety is a joint effort between different professions. The Green Cross (GC) method is a user-friendly incident reporting method that incorporates daily safety briefings to support healthcare professionals in their daily patient safety work. Thus, this study aimed to describe healthcare professionals’ experiences with the GC method in a PACU setting 3 years after its implementation, including the period of the coronavirus disease 2019 pandemic’s three waves.DesignAn inductive, descriptive qualitative study was conducted. The data were analysed using qualitative content analysis.SettingThe study was conducted at a PACU of a university hospital in South-Eastern Norway.ParticipantsFive semistructured focus group interviews were conducted in March and April 2022. The informants (n=23) were PACU nurses (n=18) and collaborative healthcare professionals (n=5) including physicians, nurses and a pharmacist.ResultsThe theme ‘still active, but in need of revitalisation’ was created, describing the healthcare professionals’ experiences with the GC method, 3 years post implementation. The following five categories were found: ‘continuing to facilitate open communication’, ‘expressing a desire for more interprofessional collaboration regarding improvements’, ‘increasing reluctance to report’, ‘downscaling due to the pandemic’ and ‘expressing a desire to share more of what went well’.ConclusionsThis study offers information regarding the healthcare professionals’ experiences with the GC method in a PACU setting; further, it deepens the understanding of the daily patient safety work using this incident reporting method.

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Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014–2020): Findings From Taiwan Patient Safety Reporting System

Munkhtogoo,

Liu,

Hung

et al. 2024

J Patient Saf

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Objectives Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity. Methods Longitudinal secondary data (over 2014–2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system. The numbers and incidence rates (per 1000 inpatient days) of reported MAEs were calculated. The harm severity levels of six major MAE categories were analyzed. Trend and generalized estimating equation analyses were conducted to investigate changes in MAE patterns. Results Trend analyses revealed significant decreasing trends in the number (4763–3107 per year; Jonckheere-Terpstra test = −1.952, P = 0.05) and incidence rates (0.92–0.62 per 1000 inpatient days; β = −0.5017, P = 0.00) of harmful MAEs over 7-year study period. Among the most frequently reported MAEs, tube-related events exhibited the most significant decreasing trend (28%–23.8%; Jonckheere-Terpstra test = −2.854, P = 0.00). The reported numbers, incidence rates, and severity of falls and tube-related events dropped significantly. Conclusions By analyzing representative longitudinal MAE data, this study demonstrated the effectiveness of nationwide patient safety improvement campaigns in Taiwan. Our data reveal significant reductions in the reported numbers, incidence rates, and severity of several major MAEs. Specifically, our data indicate significant reductions in the incidence and severity of tube-related events, which can be beneficial for patient safety improvement efforts.

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Monitoring Preventable Adverse Events and Near Misses: Number and Type Identified Differ Depending on Method Used

Cited by 5 publications

References 21 publications

Validação Da Estrutura De Curso Sobre Avaliação E Registro De Lesão Por Pressão Para Enfermeiros

Validação Da Estrutura De Curso Sobre Avaliação E Registro De Lesão Por Pressão Para Enfermeiros

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals’ experiences after 3 years, including the COVID-19 pandemic period

Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014–2020): Findings From Taiwan Patient Safety Reporting System

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