Detection of medical errors in kidney transplantation: A pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

Abstract

Background Rates of medical errors and adverse events remain high for kidney transplant patients, who are particularly vulnerable due to the complexity of their disease and the kidney transplant procedure. Although institutional incident reporting systems are utilized in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems. Methods Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011 and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported. Results A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared to incident reports, more attending physicians completed the debriefings (32.0 vs. 3.5%). Discussion The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.

Challenges to the Implementation of the World Health Organization's International Classification for Patient Safety in Slovenia

“…McElroy et al 36 Assessment of a proactive, web-based clinician safety debriefing's ability to augment information about patient safety incidents obtained via traditional incident reporting systems.…”

Biovigilância: qualidade e segurança no processo de doação e transplante de órgãos e tecidos

“…Diante disso, os profissionais de saúde têm grande responsabilidade no que concerne à qualidade e à segurança na assistência ao doador e ao receptor. O comportamento dos profissionais de saúde é fator decisivo na segurança do cuidado 4 . Sendo a comunicação o fator de impacto na segurança do paciente e dos profissionais em qualquer processo de saúde, a utilização de indicadores e a análise e a divulgação de resultados podem contribuir para melhores práticas no processo de doação e transplante.…”

Cultura de segurança no processo de doação de órgãos: revisão de literatura

“…(16,24) The findings enabled the understanding that when greater patient involvement is obtained in the manipulation of medications, a greater level of treatment adherence is achieved, leading to an improvement in the patient's clinical condition, reducing infection rates, re-admission, and graft rejection. (12,(21)(22)(23) Category 2 -Culture of patient safety in the transplant units The category presents questions related to the safety culture of patients undergoing renal, (18,19) hepatic, (11) abdominal, (24) pancreatic, (20) and bone marrow transplantation, (14) in the pre-and intra-operative periods.…”

“…Studies emphasize the importance of the health team in focusing on the transmission of diseases, and it is important that the professionals ensure, by means of examination and clinical history, the absence of any signs that may indicate that the organ donor has any transmissible disease. (13)(14)(15)17,18) In addition, they point out that the organization and analysis of surgical data, as far as the donor and the recipient are concerned, are strategies for promoting a culture of patient safety. With regard to the prevention of possible irregularities and complications, it was noted that the use of prophylactic antibiotics, as well as biopsies, was strategies that could minimize the risk of infections and prevent other health events, such as early rejection.…”