What to do with healthcare Incident Reporting Systems
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TLDR
Significance for public health Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety, but they are not the panacea that many believe them to be.Abstract:
Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be. They have several limitations that should be considered. Most of these limitations stem from inherent biases of voluntary reporting systems. These limitations include: i) IRS can’t be used to measure safety (error rates); ii) IRS can’t be used to compare organizations; iii) IRS can’t be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don’t generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. IRS do offer significant value; their value is found in the following: i) IRS can be used to identify local system hazards; ii) IRS can be used to aggregate experiences for uncommon conditions; iii) IRS can be used to share lessons within and across organizations; iv) IRS can be used to increase patient safety culture. Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, report and investigate them well; v) convene with diverse stakeholders to enhance the value of IRS.read more
Citations
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What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study
Jane O’Hara,Caroline Reynolds,Sally Moore,Gerry Armitage,Laura Sheard,Claire Marsh,Ian Watt,John Wright,Rebecca Lawton +8 more
TL;DR: It is suggested that patients can provide insight about safety that complements existing patient safety measurement, with a frequency of reported patient safety incidents that is similar to those obtained via case note review.
Journal ArticleDOI
Medical device-related pressure injuries: An exploratory descriptive study in an acute tertiary hospital in Australia
TL;DR: Medical device-related pressure injuries were represented in 27.9% of the entire patient cohort; primarily occurring on the ear from oxygen tubing and on the mouth from endotracheal tubes in patients in intensive care.
Journal ArticleDOI
Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety.
Alex Gillespie,Tom W. Reader +1 more
TL;DR: The Healthcare Complaints Analysis Tool as mentioned in this paper was used to analyze a benchmark national data set, conceptualize a systematic analysis, and identify the added value of complaint data. But the tool showed moderate to excellent reliability.
Journal ArticleDOI
Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors
Mary G. Amato,Mary G. Amato,Alejandra Salazar,Thu-Trang T. Hickman,Arbor J. L. Quist,Lynn A. Volk,Adam Wright,Adam Wright,Dustin McEvoy,William L. Galanter,Ross Koppel,Beverly Loudin,Jason S. Adelman,John D. McGreevey,David H. Smith,David W. Bates,Gordon D. Schiff,Gordon D. Schiff +17 more
TL;DR: Examination of medication errors potentially related to computerized prescriber order entry (CPOE) and refine a previously published taxonomy to classify them found more standardized safety reporting using a common taxonomy could help health care systems and vendors learn and implement prevention strategies.
Journal ArticleDOI
Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting
Tanya Hewitt,Samia Chreim +1 more
TL;DR: It is argued that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting, which aligns with recent calls for patient safety to be more preventive.
References
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BookDOI
To Err Is Human Building a Safer Health System
TL;DR: Boken presenterer en helhetlig strategi for hvordan myndigheter, helsepersonell, industri og forbrukere kan redusere medisinske feil.
Journal ArticleDOI
An intervention to decrease catheter-related bloodstream infections in the ICU
Peter J. Pronovost,Dale M. Needham,Sean M. Berenholtz,David J. Sinopoli,Haitao Chu,Sara E. Cosgrove,Bryan Sexton,Robert C. Hyzy,Robert J. Welsh,Gary Roth,Joseph Bander,John P. Kepros,Christine A. Goeschel +12 more
TL;DR: An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.
Journal ArticleDOI
To err is human. Building a safer health system
TL;DR: The IOM report “To Err is Human” proposes an approach for reducing medical errors and improving patient safety by designing processes that are able to ensure that patients are safe from accidental injury.
Journal ArticleDOI
Temporal Trends in Rates of Patient Harm Resulting from Medical Care
Christopher P. Landrigan,Gareth Parry,Catherine B. Bones,Andrew D. Hackbarth,Donald A. Goldmann,Paul J. Sharek +5 more
TL;DR: It is found that harms remain common, with little evidence of widespread improvement, and further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time.
Journal ArticleDOI
The fundamental topoi of relational communication
Judee K. Burgoon,Jerold L. Hale +1 more
TL;DR: In this article, a schema en douze dimensions: dominance/soumission, intimite, affection/hostilite, implication personnelle, inclusion/exclusion, confiance, profondeur/superficialite, vivacite des emotions, sang-froid, ressemblance, formalisme, socialite