In the last decade modern information technology systems have been introduced to healthcare in order to improve it. The aim of this study is to present the impact of such information system’s adoption on patient safety and efficiency within healthcare. Interviews, observations along with literature study were conducted in order to study the impact of the adoption on patient safety and efficiency at hospital’s wards where a new information system is implemented. The conclusion of this study is that such information technology systems can improve patient safety. However it is believed that the information technology system can improve efficiency in some aspects such as the communication among medical care personnel while other aspects within efficiency can be achieved if some improvements are made. Moreover the ability to access Electronic Healthcare Records is considered to be important to improve the medical care, which can increase patient safety.

No description available.

How clinicians detect and differentiate near misses from adverse events in health care is poorly understood. This study adopted a constructivist grounded theory approach and utilized document analysis and semi-structured interviews with 24 managers (middle and senior) and clinicians to examine the processes and factors associated with recognizing and recovering and learning from near misses in daily clinical practice. While safety science suggests that near misses are sources of learning to guide improvement efforts, the study identified how clinicians and managers cognitively downgrade and accept near misses as a routine part of daily practice. Such downgrading reduces the visibility of near misses and creates a paradoxical effect of promoting collective vigilance and increased safety while also encouraging violations in clinical practice. Three approaches to correcting and/or learning from near misses emerged: “doing a quick fix,” “going into the black hole,” and “closing off the swiss-cheese holes”; however, minimal organizational learning occurs. From these findings, two key paradoxes that undermine organization-level learning require further attention: (a) near misses are pervasive in everyday practice but many remain undetected and are missed learning opportunities, and (b) collective vigilance serves as both safety net and safety threat. Study findings suggest that organizational efforts are required to determine which near misses need to be reported. Organizations need to shift the culture from one of “doing a quick fix” to one that learns from near misses in daily practice; they should reinforce the benefits and reduce the risks of collective vigilance, and further encourage learning at the clinical microsystem level. Future research is required to provide insight into how individual, social, and organizational factors influence the recognition, recovery, and instructional value of near misses and safety threats in health care organizations’ daily practice.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

nÃo hà / A seguranÃa relacionada ao sistema de medicaÃÃo tem sido objeto de pesquisas recentes, principalmente, em relaÃÃo aos antibacterianos que possuem alta especificidade farmacolÃgica e podem ter sua aÃÃo prejudicada em detrimento de erros associados Ãs fases de preparo e administraÃÃo. Assim, o estudo teve como objetivo geral: Analisar os fatores comportamentais e ambientais envolvidos na ocorrÃncia de erros durante as etapas de preparo de administraÃÃo de antibacterianos. Trata-se de um estudo observacional, exploratÃrio e transversal, de natureza quantitativa, realizado entre agosto a dezembro de 2014 em Hospital da Rede Sentinela em Fortaleza. A amostra compreendeu 44% das doses de antibiÃticos das clÃnicas mÃdicas A e B, 108 e 157, respectivamente. A coleta de dados se deu em duas fases: a primeira para caracterizar o perfil sÃcio ocupacional dos profissionais de enfermagem; e a segunda para identificar as adequaÃÃes e inadequaÃÃes comportamentais e ambientais nas fases de preparo e administraÃÃo. Os dados foram organizados em tabelas e analisados por meio da estatÃstica descritiva e analÃtica. Todos os princÃpios bioÃticos foram respeitados, conforme aprovaÃÃo da pesquisa pelo Comità de Ãtica da Universidade Federal do CearÃ, protocolo nÃmero 660.897. Os resultados permitiram realizar as seguintes inferÃncias: a concretizaÃÃo do preparo e administraÃÃo dos antibacterianos foi realizada por tÃcnicos de enfermagem (100%), predominantemente do sexo feminino, na faixa etÃria de 31 a 40 anos, que concluÃram a formaÃÃo entre os Ãltimos dez a 20 anos e atuam na Ãrea por um perÃodo semelhante, no entanto, hà menos de dez anos na instituiÃÃo onde a pesquisa foi realizada. Sobre a influÃncia de fatores ambientais verificou-se que durante o preparo houve inadequaÃÃo em 136 observaÃÃes na variÃvel limpeza e em 187 na organizaÃÃo. A dimensÃo para o preparo foi inadequada na ClÃnica MÃdica A (3,8m2), e os itens iluminaÃÃo, temperatura e ruÃdo foram extremamente oscilantes nos trÃs turnos e nas duas clÃnicas, com mÃdias geralmente acima do recomendado. Quanto Ãs variÃveis comportamentais observou-se: fontes produtoras de interrupÃÃes em 145 doses durante o preparo, e, no entanto, nÃo foram estatisticamente significativas para aumentar o tempo de preparo dos antibiÃticos (p=0,776). Houve maior frequÃncia de nÃo-conformidades respectivamente nas clÃnicas A e B quanto ao itens: comportamento de utilizaÃÃo da prescriÃÃo 86 (79,6%) e 157 (100%); confirmaÃÃo do nome do paciente 68 (62,9%) e 142 (90,4%); e, monitoramento 84 (77,7%) e 82 (52,2%). Jà a ClÃnica MÃdica B apresentou maiores Ãndices de conformidade no controle do tempo de infusÃo 84 (53,5%) e checagem imediata 93 (59,2%). Fator que contribuiu para aumentar as chances de interaÃÃo medicamentosa foi a ausÃncia de diretrizes com informaÃÃes sobre o medicamento (p=0,003). A principal categoria de erro encontrada foi o erro de dose (157). Jà o antibiÃtico mais comumente utilizado foi a Piperaciclina + Tazobactan com 51 doses. Conclui-se que o ambiente de trabalho e o comportamento adotado pelos profissionais de enfermagem sÃo condiÃÃes que podem favorecer a ocorrÃncia de erros com antibiÃticos.

Background: Adverse events are poor health outcomes caused by medical care rather than the underlying disease process. Voluntary reporting is a key component to adverse event reduction; however, incident reporting systems contain many limitations. The Patient Safety Learning System (PSLS) is an electronic incident reporting system with several unique features that were designed to address the weaknesses of previous systems, including a process for physician assessment of reported events to determine their significance. The primary objectives for this study were to determine the positive predictive value of the PSLS for identifying adverse events. Secondary objectives were to identify event, patient, and system-level factors associated with true events, and to assess event rates over time. Methods: I performed a retrospective cohort study using electronic health care data collected data from the Ottawa Hospital, between April 1 2010 and September 30, 2011. We Included all reported patient safety events if they occurred in adults aged 18 and older, admitted to an inpatient ward at the Civic, General, or Heart Institute campus. Events that occurred on Psychiatry, Rehabilitation services, were excluded due to data restrictions. A Clinical Reviewer manually reviewed each event to distinguish true events from non-events. For each hospital program, we used a generalized linear mixed model (GLIMMIX) to predict true events, using the role of the reporter as a random effect. Results: Over the study period, there were 2,569 events reported by hospital staff and physicians. Of these, 660 were rated as adverse events and 1,909 were rated as near misses. This yielded an overall positive predictive value of the PSLS system of 63% (95% CI 62-65%). The variance between reporters was not significant for Critical Care, Heart Institute, Nephrology, Obstetrics and Gynecology, Surgery and Periops, therefore I used a traditional logistic regression model with a common intercept. Number of months the PSLS was available was the only significant covariate found in all programs; the direction of the relationship was the same across all programs, and showed a decrease in true events reported over time. Other common covariates included: time from admission to event, severity of illness, and admission type. All models achieved a good calibration, yet discrimination was poor (c <0.70) in all models except Heart Institute. Discrimination ranged from 65% in Critical Care to 77% in the Heart Institute. Overall, the rate of patient safety events reported for inpatients was 6.39 per 1000 patient days. After an initial learning period, from April 2010-January 2011, in which rates were low, reporting rates increased and stabilized; remaining constant from month to month. The rate of true patient safety event reporting fluctuated greatly from April 2010-January 2011, after which they began to steadily decline. Trends in reporting were similar across hospital campus, reporter, and program. The majority of patient safety events were reported by nurses (44%), and laboratory staff (42%). The remaining 14% of events were reported by the classification ‘Other,’ which included all other hospital staff, such as technicians, physicians, and administrative staff. Only 7 physicians reported events to the PSLS during my study period, therefore, they were categorized under ‘Other’. Conclusions: Despite the many unique advantages of the PSLS, the proportion of true events reported has remained low. The overall utility of statistical models to predict patient safety events is limited. The traditional patient and system-level covariates, which are used to predict risk of adverse outcomes with high accuracy, did not help us discriminate between true patient safety events from non events. It is possible that many different individual and institutional barriers are influencing reporting and perhaps reviewing behavior, which in turn leads to non-clinical variability in what gets reported and classified as a patient safety event.

Background Previous measurements of preventable death in hospital do not account for the uncertainty of preventability ratings. Objective To determine the proportion of deaths in hospital that a have high probability of being prevented with high quality care. Methods We created summaries for every death at a tertiary care hospital over 4-months. Four reviewers assigned preventability ratings to each death and latent class analysis was used to classify deaths into high and low preventability categories. Results There were 480 decedents with mean age of 73.9. Inter-rater reliability was poor with an intra-class correlation of 0.14. The best latent class model found that 6.2% (95% CI 0.00 – 15.2%) of deaths had a 31.0% probability of being rated more likely preventable than not by each reviewer. In contrast, 93.8% (95% CI 84.8 - 100.0%) of deaths had a 0.8% probability of being rated more likely preventable than not by each reviewer. The incidence of truly preventable deaths is less than the 6.2% that are deemed possibly preventable. xi Conclusion Very few deaths in hospital are preventable. The low incidence of preventable deaths and low inter-rater reliability means that peer review methodology is only sensitive to large differences in preventable death rate.

Background: In hospital critical-care and emergency settings, non-Invasive ventilation (NIV) is increasingly used in neonatal and paediatric patients as an alternative to invasive positive pressure ventilation (IPPV). Critically ill children and babies may need transfer to higher levels of care, but the emergency transport setting is lagging behind the hospital sector in terms of availability of NIV. Aim and objectives: The goal of this study was to assess the evidence on the safety and effectiveness of NIV in children during transportation. Safety outcome measures were intubation or escalation of ventilation mode (during and soon after transport) and adverse event (AE) occurrence during transport. Effectiveness outcome measures related to improvement in clinical parameters during transfer. Methods: A systematised review of the literature was conducted, based on searches of MEDLINE via PubMed, EMBASE (via Scopus), Cochrane Central Register of Controlled Trials (CENTRAL), African Index Medicus, Web of Science Citation Index and the World Health Organisation Trials Registry (ICTRP). Two reviewers independently reviewed all identified studies for eligibility, with an initial screening round followed by a full-text review of potentially relevant articles. The quality of studies meeting inclusion criteria was evaluated using an adapted quality assessment tool developed for this study. Results: A total of 1287 records were identified; of these, 12 studies met inclusion criteria. Following quality assessment, eight studies were included and four studies were excluded. There were no randomised controlled trials, quasi-randomised controlled trials or non-randomised studies of intervention, to answer the research question. The included studies were all observational in design: seven studies (n= 708) evaluated in-transport use of continuous positive airway pressure (CPAP) and one study (n=150) reported on use of high-flow nasal cannula (HFNC) in children during transport. During transport on NIV, 3/858 (0.4%) patients required either intubation (1/708; 0.1%; CPAP studies) or escalation of mode of ventilation (2/150; 1%; HFNC study). In the 24 hours following transfer, 63/650 (13%) of children transferred on NIV, were intubated. The odds of intubation within 24 hours were significantly higher for CPAP transfer 60/500 (12%) compared with HFNC 3/150(2%): OR (95% CI) 6.68 (2.40 - 18.63), p=0.00003. Adverse events, where reported, were found to occur in 2-4% of NIV transports, with use of BVM in 8/334 (2%), desaturation episodes in 9/290 (3%), apnoea in 11/290(4%) and administration of CPR in 0/290 (0%) cases being described. There was insufficient reporting of change in vital signs or clinical condition during transport for meaningful analysis. Conclusion: This study is the first systematised review indicating that NIV use in children during transport is likely to be safe. From the low-reliability evidence available, it was calculated that NIV use in children during transport would result in a 0.4% rate of intubation or escalation during transport and an in-transport adverse event rate of 2-4%. There was insufficient evidence to comment on clinical effectiveness of NIV during transfer. Following NIV transfer, 13% of patients were intubated within 24 hours, with significantly higher odds of intubation in children transported on CPAP compared with HFNC. Recommendations: Further research is needed in order to make firm recommendations regarding the safety and effectiveness of NIV during transport of children. A recommended minimum data set, for the standardised reporting of observational studies of paediatric NIV use during transport, is suggested. It is recommended that transport databases and registries are expanded to include NIV details as well as information regarding the presence or absence of pre-specified adverse events during transport.

No description available.