Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center

Martínez, William; Lehmann, Lisa Soleymani; Hu, Yue; Desai, Sonali; Shapiro, Jo

doi:10.1016/j.jcjq.2016.11.001

Cited by 11 publications

(13 citation statements)

References 53 publications

(64 reference statements)

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“…These professional boundaries might be overcome by promoting the desired mindset for M&M. As with the ‘culture of shame and blame’, which used to be infamous for its presence at M&M, these issues could be targeted with, for example, moderators and local leadership, guided by principles of Just Culture. 44 45 As mentioned in the interviews, seniors or leaders can model desired behaviour and attitudes at M&M, by openly discussing personal errors and addressing the emotional impact. This is confirmed by, to our knowledge, the only other qualitative study of M&M, conducted in internal medicine, which described this type of role-modelling at the conference.…”

Section: Discussionmentioning

confidence: 99%

Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study

2017

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ObjectivesTo explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement.DesignThis is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare.SettingDutch academic surgical department with a long tradition of M&M.ParticipantsAn interview sample of surgeons, residents and physician assistants (n=12).ResultsA total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from ‘case type’ to ‘leadership’, were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, ‘hierarchy’ and ‘team spirit’). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes.ConclusionsThis study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M.

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Section: Discussionmentioning

confidence: 99%

Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study

2017

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“…It seems more plausible that respondents correctly and honestly reported about the lack of stringent procedures of “never event” management. In particular, in larger, academic hospitals, serious adverse events may be identified and reviewed through various processes with little consistency and coordination, 25 for example, in mortality and morbidity conferences, which are quite well established in Switzerland. 26 The explicit example events we presented included typical “never events,” e.g., wrong-site surgery, and events not specifically included on existing “never event” lists, e.g., patient deterioration on a general care ward.…”

Section: Limitationsmentioning

confidence: 99%

Registration and Management of “Never Events” in Swiss Hospitals—The Perspective of Clinical Risk Managers

Schwappach

Pfeiffer

2020

J Patient Saf

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Background: In Switzerland, there is no mandatory reporting of "never events." Little is known about how hospitals in countries with no "never event" policies deal with these incidents in terms of registration and analyses. Objective: The aim of our study was to explore how hospitals outside mandatory "never event" regulations identify, register, and manage "never events" and whether practices are associated with hospital size. Methods: Cross-sectional survey data were collected from risk managers of Swiss acute care hospitals. Results: Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a "never event" has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with "never event" management. Respondents reported that their hospital pays "too little attention" to the recording (46%), the analysis (34%), and the prevention (40%) of "never events." All respondents rated the systematic registration and analysis of "never events" as very (81%) or rather important (19%) for the improvement of patient safety. Conclusions: A substantial fraction of Swiss hospitals do not have valid data on the occurrence of "never events" available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for "never events" management.

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“…The term "near miss" was also been added to the error list because it could have caused harm but is found or caught before an actual error or injury occurs. 9 When looking at error cause and prevention itʼs important to look at both ENMs. Not only can we learn from the actual error but a near miss also provides us with the thoughts, actions, and system issues that were in place when a near miss occurred.…”

Section: Medical Errors and Near Missesmentioning

confidence: 99%

Tracking medical errors and near misses in the new graduate registered nurse

Africa¹,

Shinners

2019

Nurs Forum

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This article provides a narrative that describes the current state of medical errors and near misses in the general health care setting and for new graduate registered nurses specifically. It then proposes a "wild idea" to create a national database for the reporting of errors that would act as a call to action to change our current reporting system to one of transparency and shared information for the purpose of creating needed education in both academic and practice settings. K E Y W O R D S adverse events, medical errors, near misses, new graduate registered nurses, transition-to-practice

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Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center

Cited by 11 publications

References 53 publications

Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study

Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study

Registration and Management of “Never Events” in Swiss Hospitals—The Perspective of Clinical Risk Managers

Tracking medical errors and near misses in the new graduate registered nurse

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