The importance of incident reporting in laboratory diagnostics

Uusitupa M, Pöyhönen M, Sarlund H, Laakso M, Kari A, Helenius T, Alakui-jala L, Eloranta T. Increased urinary polyamine excretion after starting a very low calorie diet. Scand J Clin Lab Invest 1993; 53: 811-819.

Urinary polyamine excretion has been suggested to reflect hypermetabolism or catabolism in different illnesses. In the present study, the excretion of urinary polyamines was examined in 12 obese subjects (3 men, 9 women aged 32-55 y, body mass index 33.3-64.7 kgm^?2) before and during a very low calorie diet (the total calorie intake 2100-3350 kJ). In addition, nitrogen balance, basal energy expenditure (BEE) and serum thyroid hormone levels were examined. During the first week on a very low calorie diet (VLCD) the mean body weight declined from 121.8 ± 27.3 to 117.4 ± 26.2kg (mean ± SD, p < 0.001), and after 12 weeks of treatment body weight was 106.6 ± 24.6 kg. Immediate reduction of BEE from 1.44 ± 0.24 to 1.34 ± 0.24 kcalmin¹ (p < 0.001) was found within the first week of therapy and BEE measured on weight-maintaining diet remained lower at 12 weeks (1.25 ± 0.27kcalmin^?1, p < 0.01). Serum free T3 decreased and reverse T3 increased significantly after starting VLCD. Nitrogen balance remained negative during the first 2 weeks on VLCD. A significant increase in total (38%), and in N1-acetyl- and N8-acetylspermidine excretions in the urine (40% and 27%, respectively, p < 0.05) was found during the first week, but later on the levels were not significantly different from the baseline levels. The changes in free T3 and reverse T3 showed moderate correlations with the changes in Nl-acetylspermidine (r = ?0.59 and r = 0.55, respectively, p < 0.05), and N8-acetylspermidine excretion rates (r = ?0.63, p < 0.05 and r = 0.47, N.S.). The present results suggest that during a very low calorie diet increased urinary acetylpolyamine excretion is a marker of catabolism.     

A practical guide to the implementation of an effective incident reporting scheme to reduce medication error on the hospital ward

This paper discusses an anonymous incident reporting scheme to reduce drug administration error on the hospital ward, as part of an effective, non-punitive, systems-focused approach to safety. Drug error is costly in terms of increased hospital stay, resources consumed, patient harm, lives lost and careers ruined. Safety initiatives that focus, not on blaming individuals, but on improving the wider system in which personnel work have been adopted in a number of branches of health care. However, in nursing, blame remains the predominant approach for dealing with error, and the ward has seen little application of the systems approach to safety. Safety interventions founded on an effective incident scheme typically pay for themselves in terms of dollar savings arising from averted harm. Recent calls for greater health-care safety require finding new ways to make drug administration safer throughout the hospital, and the scope for such safety gains on the hospital ward remains considerable.     

An evaluation of adverse incident reporting

Abstract: To examine the reliability of adverse incident-reporting systems we carried out a retrospective review of the mother and baby case notes from a series of 250 deliveries in each of two London obstetric units. Notes were screened for the presence of adverse incidents defined by lists of incidents to be reported in accordance with unit protocols. We assessed the percentage of adverse incidents reported by staff to the maternity risk manager at each unit; the percentage of incidents detected by each risk manager, but not reported; and the percentage of incidents identified only by retrospective case note review. A total of 196 adverse incidents was identified from the 500 deliveries. Staff reported 23% of these and the risk managers identified a further 22%. The remaining 55% of incidents were identified only by retrospective case-note review and not known to the risk manager. Staff reported about half the serious incidents (48%), but comparatively few of the moderately serious (24%) or minor ones (15%). The risk managers identified an additional 16% of serious incidents that staff did not report. Drug errors were analysed separately; only two were known to the risk managers and a further 44 were found by case-note review. Incident-reporting systems may produce much potentially valuable information, but seriously underestimate the true level of reportable incidents. Where one risk manager covers an entire trust, rather than a single unit, reporting rates are likely to be very much lower than in the present study. Greater clarity is needed regarding the definition of reportable incidents (including drug errors). Staff should receive continuing education about the purposes and aims of clinical risk management and incident reporting and consideration should be given to designating specific members of staff with responsibility for reporting.     

Safety of acupuncture practice in Japan: patient reactions, therapist negligence and error reduction strategies

Evidence-based approach on the safety of acupuncture had been lagging behind both in the West and the East, but reliable data based on some prospective surveys were published after the late 1990s. In the present article, we, focusing on ‘Japanese acupuncture’, review relevant case reports and prospective surveys on adverse events in Japan, assess the safety of acupuncture practice in this country, and suggest a strategy for reducing the therapists’ error. Based on the prospective surveys, it seems reasonable to suppose that serious adverse events are rare in standard practice by adequately trained acupuncturists, regardless of countries or modes of practice. Almost all of adverse reactions commonly seen in acupuncture practice—such as fatigue, drowsiness, aggravation, minor bleeding, pain on insertion and subcutaneous hemorrhage—are mild and transient, although we should be cautious of secondary injury following drowsiness and needle fainting. After demonstrating that acupuncture is inherently safe, we have been focusing on how to reduce the risk of negligence in Japan, as well as educating acupuncturists more about safe depth of insertion and infection control. Incident reporting and feedback system is a useful strategy for reducing therapist errors such as forgotten needles. For the benefit of acupuncture patients in Japan, it is important to establish mandatory postgraduate clinical training and continued education system.     

German critical incident reporting system database of prehospital emergency medicine: Analysis of reported communication and medication errors between 2005-2015

BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors.METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all.RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classification resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure.CONCLUSION: Communication deficits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.     

Improving the quality of drug error reporting

Background Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. Aim The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. Methods A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi‐disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. Results The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems‐based. Staff felt obliged to report but rarely received feedback. Implications and conclusion Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi‐centred evaluation.     

医疗安全不良事件报告管理系统的设计与临床应用

目的建立安全的医疗管理系统,提高医护人员对医疗安全不良事件报告的主动性。方法明确不良事件定义和分级、规范报告格式及报告用语、实现网络直报、鼓励主动报告、构建报告流程、形成分析、反馈、改进和信息共享的管理链。结果提高了医护人员对不良事件主动报告的认识,实现了不良事件报告数的逐年提升。结论不良事件报告系统能有效提升医护人员安全管理及隐患的防范能力。     

Factors impeding nurses from reporting adverse events

moumtzoglou a . (2010) Journal of Nursing Management 18 , 542–547
Factors impeding nurses from reporting adverse events Aim To explore the reasons why Greek nurses are reluctant to report adverse events. Background This study provides an understanding of why nurses fail to report adverse events so that we can introduce systems and develop cultures, which make this easier. Methods An exploratory study using the Adverse Events Questionnaire, which was administered to 214 nurses in 14 major Athens hospitals, comprising university as well as tertiary hospitals. Results Five main reasons for not reporting were identified. They include the fear of the press, the licensing board, the difficulty in handling an adverse event, confidence about bringing up adverse events and the complaints by patients. Moreover, clustering variables into homogeneous sets, three latent variables were extracted. They include procedures, culture and dishonour, social control, workload and tradition. Conclusion Nurses’ impeding factors for bringing up adverse events may be projected not only by cultural aspects such as professional, national and organizational cultures but also by healthcare practice structural issues such as safety systems, rules and procedures, and relevant acts and regulations. Implications for nursing management Nursing management should change management rules and establish systems so that nurses work in a blame-free culture, which examines system factors as causes of error rather than individuals.     

Clinical trial nurse's role in safety reporting

The clinical trial nurse (CTN) can have a substantial amount of responsibility for clinical trials and can perform many roles in the management of clinical trials. Although new opportunities for the registered nurse in clinical trials have emerged in recent years, there remains to be a dearth of literature surrounding the important roles of the CTN in clinical trials. The CTN is a specialty-nursing role that is unfamiliar to many, including some nurses. Therefore, it is important to address this gap in the literature and enlighten the nursing profession and others about the roles of the nurse in clinical trials. This article aims to explore and provide an overview of the CTN's role in safety reporting. Safety reporting is a significant component of clinical trials by protecting the rights, safety, and welfare of subjects. The CTN integrates and utilizes his or her knowledge, experience, skills, and sound ethical principles when performing the duties of this role. This allows the CTN to be a vital member in the safety-reporting process and in the protection of subjects.     

护理不良事件上报管理的研究进展

通过对护理不良事件的定义和护理不良事件报告系统的分类以及国内外研究现状进行回顾,归纳了护理不良事件上报管理研究中的关键问题,并就如何建立与完善我国护理不良事件报告系统,充分保障患者安全提出了相应措施,为后续开展护理不良事件上报管理研究奠定基础.     

Possible solutions for barriers in incident reporting by residents

Rationale, aims and objectives Incident reporting can contribute to safer health care. Since the rate of reporting by residents is low, it is useful to investigate which barriers exist and how these can be solved. Methods Data were collected in a large teaching hospital in the Netherlands. The hospital uses a confidential, voluntary and web‐based incident reporting system. Residents working in the hospital participated in focus group discussions to explore barriers and possible solutions. A grounded theory approach was used to analyse the transcribed discussions. Results In each focus group six to eight residents participated, resulting in a total number of 22 participants. After three focus group discussions, information saturation had been reached. Residents do not report all incidents because of a negative attitude towards incident reporting, because they experience a non‐stimulating culture and because of a lack of perceived ability to report. Residents suggest several solutions to solve the barriers: providing the possibility to report anonymously, providing feedback, creating an incident reporting culture, simplifying the procedure, clarifying what and how to report, and exciting residents to report. Conclusions Residents have useful suggestions to resolve the barriers that prevent them from reporting incidents. They include solutions that influence attitude, culture and perceived ability. These suggestions should be considered when making an effort to improve incident reporting by residents.     

护士不良事件报告行为意向影响因素及对策研究进展

从个人态度、主观规范、对报告系统的感知方面分析护士报告不良事件行为意向的影响因素,并提出倡导非责备文化、提高护士对不良事件的认知度、建立规范化不良事件术语和分类体系、报告系统网络化、创建安全性报告环境、及时有效反馈信息等改善对策。     

护士长对无惩罚性自愿报告差错制度认知调查研究

目的了解护士长对无惩罚性自愿报告差错管理方式的认知,为建立和实施这一制度提供依据。方法采用自设问卷对96名护士长无惩罚性自愿报告差错管理制度的认知进行调查。结果93．75％的护士长对国内这一制度了解或部分了解,98．96％的护士长了解或部分了解其内涵;97．92％基本知晓该制度是为了获取信息制定预防措施。结论护士长对这一制度的认可程度高,但对其有效性和实用性仍持不确定态度。因此,护理管理者应尽快转变观念,积极构建有效通畅的无惩罚性自愿报告护理差错管理制度,以提高医疗护理安全：     

Hospital patients' reports of medical errors and undesirable events in their health care

Objective To investigate hospital patients' reports of undesirable events in their health care. Design Cross‐sectional mixed methods design. Participants A total of 80 medical and surgical patients (mean age 58, 56 male). Intervention Patients were interviewed post‐discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed. Main outcome measures Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care. Results In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing (P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system. Conclusion Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety.