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Adverse events and patient care-related adverse events are a challenging universal problem, among elder residents of geriatric facilities. The aim of this study was to examine which types of adverse events are characteristic of the geriatric center studied and which of the nursing staff reported this event.

Data were retrieved from the computerized adverse event management system at a large geriatric center in central Israel, and all adverse events reported over the past three years were examined.

The study findings indicate that the most common type of adverse event was falls. Older nurses with greater seniority in the facility show a higher tendency to report adverse events. In addition, registered nurses were found to report more often than practical nurses.

This study highlights the important role that nurses can play in reporting and reducing adverse events. The role of the nurse is becoming increasingly complex, especially in geriatric facilities, which serve people with complex mental and physical states who are more susceptible to adverse events to begin with.

Despite the large number of adverse events, few studies have been undertaken on adverse events in geriatrics in general, and in nursing homes and long-term facilities in particular. Answers to these questions will enable improvement in the quality of care provided and ensure a safe care environment for residents. Systematically examining types of adverse events and the characteristics of those who do and do not report them, can contribute to improvement of processes in the healthcare system in general, and in the facility in particular. Additionally, efficient investigation can improve the behavior of those who enable adverse events.

Purpose – Patient safety and adverse events continue to present significant challenges to the US health care delivery system. Mandated reporting of adverse events can be a mechanism to “coerce” hospitals to identify, evaluate, and ultimately improve the quality and safety of patient care. The objective of this study is to determine if the coercion of mandated reporting impacts hospital patient safety scores.

Methods – We utilize the US News and World Report 2012–2013 Best Hospital Rankings which includes patient safety data from US teaching hospitals. The dependent variable is a composite measure of six indicators of patient safety during and after surgery. The independent variable is state mandated reporting of hospital adverse events. Three control variables are included: Magnet accreditation status, surgical volume, and the percentage of surgical admissions.

Findings – Using ordered logistic regression (n = 670 hospitals) we find a positive, but not significant, relationship between state mandated reporting and better patient safety scores.

Implications – This finding suggests that regulatory policy may not actually prompt performance improvement, and our data point to the need for further study of both formal and informal processes to manage patient safety within the hospital.

Originality – While increased reporting of adverse events has been linked to hospitals providing safer care, no research to date has examined whether or not state-level mandates actually lead to improvements in patient safety.

The first phase of this study developed a multi‐professionally agreed list of adverse events for clinical incident reporting in Trauma and Orthopaedics. This follow‐up study aims to evaluate the effectiveness of the adverse event list.

Two follow‐up questionnaires were sent to healthcare professionals working in Trauma and Orthopaedics in two of the participating National Health Service (NHS) Trusts (n=247 for the first questionnaire and n=240 for the second questionnaire). Trends in routine incident reporting data were also monitored over a two‐year period to determine the impact of the adverse event list on levels of adverse event reporting.

The questionnaires indicated that awareness about the adverse event list was good and improved between questionnaires. However usage of the adverse event list appeared to be poor. Multiple regression analysis with the dependent variable count of orthopaedic incidents suggested that the adverse event list had little, if any impact on levels of reporting in Trauma and Orthopaedics.

The results of this study suggest that a practical tool, such as the adverse event list has little impact on incident reporting levels.

The aim of this study was to develop a multi‐professionally agreed list of adverse events, which may act as a prompt for clinical incident reporting in trauma and orthopaedics and to determine what healthcare professionals understand by the term adverse event. A modified Delphi process with healthcare professionals working in trauma and orthopaedics (242) in three NHS trusts was performed. The process involved initial brainstorming sessions, a two‐round Likert‐style postal questionnaire and final focus group discussion. The initial brainstorming sessions generated a list of 224 adverse events to be included in the first round of the postal questionnaire. They included 83 causes of adverse events, 36 health and safety related adverse events and 105 clinical adverse events. Following the second round questionnaire and focus group discussion, a final list of 20 adverse events was produced. There were variations between professional groups in terms of validity scoring of individual adverse events. Overall, medical staff gave a lower rating to the adverse events than the other two professional groups. There were also variations between professional groups in terms of response rates. The modified Delphi process proved to be a successful tool for generating a multi‐professionally agreed list of adverse events and for understanding what healthcare professionals understand by the term adverse event.

For over three decades, researchers have sought to identify factors influencing employees’ responses to wrongdoing in work settings, including organizational, contextual, and individual factors. In focusing predominantly on understanding whistle-blowing responses, however, researchers have tended to neglect inquiry into employees’ decisions to withhold concerns. The major purpose of this study was to explore the factors that influenced how staff members responded to a series of adverse events in a healthcare setting in Australia, with a particular focus on the role of perceptions and emotions.

Based on publicly accessible transcripts taken from a government inquiry that followed the event, we employed a modified grounded theory approach to explore the nature of the adverse events and how employees responded emotionally and behaviorally; we focused in particular on how organizational and contextual factors shaped key employee perceptions and emotions encouraging silence.

Our results revealed that staff members became aware of a range of adverse events over time and responded in a variety of ways, including disclosure to trusted others, confrontation, informal reporting, formal reporting, and external whistle-blowing. Based on this analysis, we developed a model of how organizational and contextual factors shape employee perceptions and emotions leading to employee silence in the face of wrongdoing.

Although limited to publicly available transcripts only, our findings provide support for the idea that perceptions and emotions play important roles in shaping employees’ responses to adverse events at work, and that decisions about whether to voice concerns about wrongdoing is an ongoing process, influenced by emotions, sensemaking, and critical events.

The purpose of this paper is to explore the reasons why Greek doctors are reluctant to report adverse events.

The paper is an exploratory study using the adverse events questionnaire, administered to 209 doctors in 14 major Athens hospitals, comprising university as well as tertiary.

The questionnaire showed a high degree of internal consistency (Cronbach's alpha 0.84), which revealed a four‐factor solution, explaining 67.4 per cent of the variance. Three dominant reasons for not reporting, with which almost or more than 50 per cent of doctors strongly or slightly agreed, were identified as no tradition for bringing up adverse events and a belief that bringing up adverse events will not lead to any improvement and workload.

Factors that dissuade doctors from bringing up adverse events may be projected not only by cultural aspects such as professional, national and organisational cultures but also by healthcare structural issues such as safety systems, rules and procedures, and relevant acts and regulations. The study has several noteworthy limitations. First, doctors' response was poor, which might conceal sample bias problems. Second, the present study identified four factors but the fourth factor was not well defined.

The study provides an understanding why physicians fail to report adverse events so that systems can be introduced and cultures developed, which make this easier.

The purpose of this study is to explore the factors that influence the reporting of adverse events related to elder abuse and neglect in nursing homes from nursing home leaders' perspectives. Good leadership requires in-depth knowledge of the care and service provided and the ability to identify and address problems that can arise in clinical practice.

A qualitative explorative design with data triangulation was used. The sample consisted of 43 participants from two levels of nursing home leadership, representing six municipalities and 21 nursing homes in Norway. Focus group interviews were undertaken with 28 ward leaders and individual interviews with 15 nursing home directors. The constant comparative method was used for the analyses.

Both ward leaders and nursing home directors described formal and informal ways of obtaining information related to elder abuse and neglect. There were differences between their perceptions of the feasibility of obtaining formal reports about abuse in the nursing home. Three main categories of influencing factors emerged: (1) organisation structural factors, (2) cultural factors and (3) abuse severity factors. A main finding is that in its present form, the Norwegian adverse event reporting system is not designed to detect abuse and neglect.

This paper provides an in-depth understanding of patient safety and factors related to reporting elder abuse in nursing homes in Norway.

The purpose of this paper is to elicit Greek doctors' and nurses' views about adverse event reporting.

This is an exploratory study using an adverse events questionnaire administered to 209 doctors and 214 nurses in 14 major Athens universities and tertiary hospitals.

The paper finds that Greek doctors and nurses prefer a strictly confidential or conditionally confidential reporting scheme. Most doctors favoured disclosing department identity, while a nursing majority argued that it should remain unknown. When asked about the person's professional affiliation that, under a confidential scheme, receives reports and gives feedback, most doctors and nurses preferred the receiver to belong to their profession. Most medical personnel preferred the mandatory model or the discretionary model with a set of guidelines exemplifying adverse event types, while a nurse majority preferred the discretionary with a set of guidelines exemplifying adverse events.

It is necessary to establish a strictly confidential, non‐punitive reporting scheme that supports learning and knowledge and one that is separate from any disciplinary scheme.

The study indicates that culture, legal and patient complaint systems do not affect healthcare professional notions with respect to reporting adverse events.

There is a strong drive within the UK's National Health Service (NHS) towards ensuring quality and reducing adverse events. This incorporates clinical governance, which applies to clinical activities, and information governance, which applies to preserving the confidentiality, availability and integrity of patient information. The purpose of this paper is to consider why humans make errors, how the current governance tools can minimise the incidence of such errors and the causatives that can increase the likelihood of an error. Errors sometimes lead to adverse events, which have to be reported. The latest adverse event reports from NHS Scotland, recently published on the BBC website, were analysed to identify major themes that emerged from the recommendations made by the investigative teams. These themes are then discussed in terms of how the current clinical governance tools should be applied to further reduce the incidence of adverse events. A revised clinical governance diagram that more clearly depicts the cross-cutting nature of the themes that emerged from the analysis is proposed. Finally some opportunities for future research are identified.

Qualitative analysis of adverse incidence reports in order to identify causatives. Used the insights delivered by this analysis in order to propose a change to Scally and Donaldson's clinical governance diagram.

A clear reliance on education and training by adverse event review teams was found, which suggests that they do not really understand what causes error, and they do not acknowledge the impact of the situation on the actors. Also – a tendency to define processes to cover all eventualities, even though some situations cannot be encoded as processes. The main insight is that there are a number of cross-cutting concerns which means that the original clinical governance diagram would benefit from a level of integration which is not currently present.

The analysed reports were severely redacted which meant that nuances of the situation could have been missed by the researcher. However, the recommendations were never redacted so the researcher focused on these.

The paper, in general, highlights the need for a more nuanced approach to clinical governance and less reliance on education and training as the universal panacea.

Over reliance on education and training puts the blame on the person, and does not acknowledge the causatives in the situation. Acknowledging the more complex nature of the problem makes adverse events less blame-worthy and more likely to lead to real learning and effective mitigation.

The author is not aware of anyone else having analysed these reports.

This paper aims to determine the one‐year incidence of, and risk factors for, perioperative adverse events during in‐patient and out‐patient anesthesia‐assisted procedures.

A quality assurance database was the primary data source. Outcome variables were death and the occurrence of any adverse event. Risk factors were ASA physical status (PS), age, duration and type of anesthesia care, number of operating rooms running, concurrency level and medical staff. Data were stratified by in‐patient or out‐patient, surgical (e.g. thoracotomy) or non‐surgical (e.g. electroconvulsive therapy), and were analyzed using Chi square, Fisher's exact test and generalized estimating equations.

Of 27,970 procedures, 49.8 percent were out‐patient and greater than 80 percent were surgical. For surgical procedures, adverse event rates were higher for in‐patient than out‐patient procedures (2.11 percent vs. 1.45 percent; p<0.001). For non‐surgical procedures, adverse event rates were similar for in‐patients and out‐patients (0.54 percent vs. 0.36 percent). The types of adverse events differed for in‐patient and out‐patient surgical procedures (p<0.001), but not for non‐surgical procedures. ASA PS, age, duration of anesthesia care, anesthesia type and medical staff assigned to the case were each associated with adverse event rates, but the association depended on the type of procedure.

In‐patient and out‐patient surgical procedures differ in the incidence of perioperative adverse events, and in risk factors, suggesting a need to develop separate monitoring strategies.

The paper is the first to assess perioperative adverse events amongst in‐patient and out‐patient procedures.