...health ministries will be invited to convene experts in their countries to design specific programmes of action for improving safety in each of four domains in which a medications can cause ...inadvertant harm: health care professionals' behaviour; systems and practices of medication; medicines; patients and the public. ...WHO will use its global convening and advocacy role to pursue successful outcomes in a range of areas, including: strengthening the quality of data to monitor medication-related harm; providing guidance and developing strategies, plans, and tools to ensure that the medication process has the safety of patients at its core in all health-care settings; producing a strategy for setting out research priorities; monitoring and evaluating the impact of the challenge; continuing to engage with regulatory agencies and international actors to improve medication safety through improved packaging and labelling; and designing tools and technologies that empower patients to safely manage their own medications. 2 MA Safren, A Chapanis, A critical incident study of hospital medication errors, Hospitals, Vol. 34, Iss. 53, 1960, 65-66, 68 3 B Allegranzi, J Storr, G Dziekan, The first global patient safety challenge “Clean care is safer care”: from launch to current progress and achievements, J Hosp Infect, Vol. 65,...
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Hospital mortality is increasingly being regarded as a key indicator of patient safety, yet methodologies for assessing mortality are frequently contested and seldom point directly to areas of risk ...and solutions. The aim of our study was to classify reports of deaths due to unsafe care into broad areas of systemic failure capable of being addressed by stronger policies, procedures, and practices. The deaths were reported to a patient safety incident reporting system after mandatory reporting of such incidents was introduced.
The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement.
Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives.
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Summary Background Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the ...epidemiology of endemic health-care-associated infection in developing countries. Methods We searched electronic databases and reference lists of relevant papers for articles published 1995–2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence—including overall health-care-associated infection and major infection sites, and their microbiological cause—were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis. Findings Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients 95% CI 12·6–18·9) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7–59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance. Interpretation The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices. Funding World Health Organization.
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Colorectal cancer incidence in the UK and other high-income countries has been increasing rapidly among young adults. This is the first analysis of colorectal cancer incidence trends by sub-site and ...socioeconomic deprivation in young adults in a European country.
We examined age-specific national trends in colorectal cancer incidence among all adults (20-99 years) diagnosed during 1971-2014, using Joinpoint regression to analyse data from the population-based cancer registry for England. We fitted a generalised linear model to the incidence rates, with a maximum of two knots. We present the annual percentage change in incidence rates in up to three successive calendar periods, by sex, age, deprivation and anatomical sub-site.
Annual incidence rates among the youngest adults (20-39 years) fell slightly between 1971 and the early 1990s, but increased rapidly from then onwards. Incidence Rates (IR) among adults 20-29 years rose from 0.8 per 100,000 in 1993 to 2.8 per 100,000 in 2014, an average annual increase of 8%. An annual increase of 8.1% was observed for adults aged 30-39 years during 2005-2014. Among the two youngest age groups (20-39 years), the average annual increase for the right colon was 5.2% between 1991 and 2010, rising to 19.4% per year between 2010 (IR = 1.2) and 2014 (IR = 2.5). The large increase in incidence rates for cancers of the right colon since 2010 were more marked among the most affluent young adults. Smaller but substantial increases were observed for cancers of the left colon and rectum. Incidence rates in those aged 50 years and older remained stable or decreased over the same periods.
Despite the overall stabilising trend of colorectal cancer incidence in England, incidence rates have increased rapidly among young adults (aged 20-39 years). Changes in the prevalence of obesity and other risk factors may have affected the young population but more research is needed on the cause of the observed birth cohort effect. Extension of mass screening may not be justifiable due to the low number of newly diagnosed cases but clinicians should be alert to this trend.
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Summary Background Young people (aged 0–18 years) have been disproportionately affected by pandemic influenza A H1N1 infection. We aimed to analyse paediatric mortality to inform clinical and public ...health policies for future influenza seasons and pandemics. Methods All paediatric deaths related to pandemic influenza A H1N1 infection from June 26, 2009, to March 22, 2010 in England were identified through daily reporting systems and cross-checking of records and were validated by confirmation of influenza infection by laboratory results or death certificates. Clinicians responsible for each individual child provided detailed information about past medical history, presentation, and clinical course of the acute illness. Case estimates of influenza A H1N1 were obtained from the Health Protection Agency. The primary outcome measures were population mortality rates and case-fatality rates. Findings 70 paediatric deaths related to pandemic influenza A H1N1 were reported. Childhood mortality rate was 6 per million population. The rate was highest for children aged less than 1 year. Mortality rates were higher for Bangladeshi children (47 deaths per million population 95% CI 17–103) and Pakistani children (36 deaths per million population 18–64) than for white British children (4 deaths per million 3–6). 15 (21%) children who died were previously healthy; 45 (64%) had severe pre-existing disorders. The highest age-standardised mortality rate for a pre-existing disorder was for chronic neurological disease (1536 per million population). 19 (27%) deaths occurred before inpatient admission. Children in this subgroup were significantly more likely to have been healthy or had only mild pre-existing disorders than those who died after admission (p=0·0109). Overall, 45 (64%) children had received oseltamivir: seven within 48 h of symptom onset. Interpretation Vaccination priority should be for children at increased risk of severe illness or death from influenza. This group might include those with specified pre-existing disorders and those in some ethnic minority groups. Early pre-hospital supportive and therapeutic care is also important. Funding Department of Health, UK
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The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to ...examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.
This study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure.
5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events OR 1.61(95%CI: 1.12 to 2.27), p<0.01 and pharmacy was the hospital location where most near-misses were captured OR 3.03(95%CI: 2.04 to 4.55), p<0.01. Clinicians were significantly more likely to report death than other staff OR 3.04(95%CI: 2.43 to 3.80) p<0.01. A higher ratio of clinicians to beds correlated with reduced rate of harm reported RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03. Litigation claims per bed were significantly negatively associated with incident reports. Patient satisfaction and mortality outcomes were not significantly associated with reporting rates. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives increased reporting rates r = 0.26 (p<0.01), r = 0.17 (p = 0.04), r = 0.23 (p = 0.01), r = 0.20 (p = 0.02).
The NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall reporting rate. There were no association between size of hospital, number of staff, mortality outcomes or patient satisfaction outcomes and incident reporting rate. The study did show that hospitals where staff reported more incidents had reduced litigation claims and when clinician staffing is increased fewer incidents reporting patient harm are reported, whilst near misses remain the same. Certain specialties report more near misses than others, and doctors report more harm incidents than near misses. Staff survey results showed that open environments and reduced fear of punitive response increases incident reporting. We suggest that reporting rates should not be used to assess hospital safety. Different healthcare professionals focus on different types of safety incidents and focusing on these areas whilst creating a responsive, confidential learning environment will increase staff engagement with error disclosure.
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older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting.
to describe the factors associated with actual or potential harm ...to patients aged 65 years and older, treated in primary care, to identify action to produce safer care.
a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013.
1,591 primary care patient safety incident reports regarding patients aged 65 years and older.
we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care.
the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm).
priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.
What is remarkable about the analysis of these patient-initiated reports is that it shows broad consistency with the major categories of harm captured in established patient safety reporting systems ...(eg, healthcare-associated infection, medication error, misdiagnosis, wrong-site surgery) while also capturing the psychological, social and economic impact.
How safe is primary care? A systematic review Panesar, Sukhmeet Singh; deSilva, Debra; Carson-Stevens, Andrew ...
BMJ Quality & Safety,
07/2016, Volume:
25, Issue:
7
Journal Article, Book Review
Peer reviewed
Open access
ImportanceImproving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, ...less is known about the safety of primary care.ObjectiveWe investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm.Evidence reviewWe searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised.FindingsNine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2–3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patient's well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm.Conclusions and relevanceMillions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm.Systematic review registrationThis systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).
The World Health Organization (WHO) has announced its third global patient safety challenge, which aims to reduce the global burden of iatrogenic medication-related harm by 50% within five years. The ...intention is to match the global reach and impact of the two earlier global patient safety challenges: Clean care is safer care and Safe surgery saves lives. The third challenge, Medication without harm, invites health ministers to initiate national plans addressing four domains of medication safety: engaging patients and the public; medication as products; education, training and monitoring of health-care professionals; and systems and practices of medication management. This challenge also commits WHO to using its convening and coordinating powers to drive forward a range of global actions on medication safety. We focus on three priority areas of medication safety that most affect patients, just as hand hygiene and the surgical checklist were chosen as the flagships of the first two challenges. These three areas are high-risk situations, polypharmacy and transitions of care. Each area is associated with a substantial burden of harm and therefore, if appropriately managed, could reduce the risk of harm to many patients.
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