Different Perspectives on Predictability and Preventability of Surgical Readmissions

Galen, Louise Sandra van; Vedder, Daisy; Boeije, Tom; Jansen, Wilma; Mullaart-Jansen, Nieke E.; Peet, Donald L. van der; So, Ralph K. L.; Nanayakkara, Prabath W.B.

doi:10.1016/j.jss.2018.02.009

Cited by 3 publications

(12 citation statements)

References 31 publications

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“…Most studies use the PRISMA-method to focus on the analysis of incidents, unintended events or near-miss events. Similar to Van Galen et al [ 18 ], Cooksley et al [ 19 ] and Fluitman et al [ 17 ], we used the PRISMA-method to gather insight into the root causes of an event, in our study the URP. To our knowledge, the current study is the first study identifying root causes of an URP to the ED with the PRISMA-method.…”

Section: Discussionmentioning

confidence: 99%

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Unplanned return presentations of older patients to the emergency department: a root cause analysis

et al. 2020

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Background In line with demographic changes, there is an increase in ED presentations and unplanned return presentations by older patients (≥70 years). It is important to know why these patients return to the ED shortly after their initial presentation. Therefore, the aim of this study was to provide insight into the root causes and potential preventability of unplanned return presentations (URP) to the ED within 30 days for older patients. Methods A prospective observational study was conducted from February 2018 to November 2018 in an academic hospital in Amsterdam. We included 83 patients, aged 70 years and older, with an URP to the ED within 30 days of the initial ED presentation. Patients, GPs and doctors at the ED were interviewed by trained interviewers and basic administrative data were collected in order to conduct a root cause analysis using the PRISMA-method. Results One hundred fifty-one root causes were identified and almost half (49%) of them were disease-related. Fifty-two percent of the patients returned to the ED within 7 days after the initial presentation. In 77% of the patients the URP was related to the initial presentation. Patients judged 17% of the URPs as potentially preventable, while doctors at the ED judged 25% and GPs 23% of the URPs as potentially preventable. In none of the cases, there was an overall agreement from all three perspectives on the judgement that an URP was potentially preventable. Conclusion Disease-related factors were most often identified for an URP and half of the patients returned to the ED within 7 days. The majority of the URPs was judged as not preventable. However, an URP should trigger healthcare workers to focus on the patient’s process of care and their needs and to anticipate on potential progression of disease. Future research should assess whether this may prevent that patients have to return to the ED.

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Section: Discussionmentioning

confidence: 99%

“…PRISMA-analysis demonstrated that four (8%) of the readmissions had active (human) related elements. In the study of van Galen et al [ 18 ] patients were asked to qualify their (probable) reasons for readmission into one or more of the five PRISMA categories: 69% of the root causes were disease-related.…”

Section: Discussionmentioning

confidence: 99%

Unplanned return presentations of older patients to the emergency department: a root cause analysis

et al. 2020

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“…In 13 studies, the original ECM was used, and in 12 studies, the ECM was modified because the current ECM did not sufficiently cover the observed types of failures (Table 2). In 4 studies, a new DRF category was added 17–19,29 . The disease-related root cause was first described by Fluitman et al 17 in 2016 and defined as “failures related to the natural progress of disease which are beyond control of patients, their carers and staff.” In these 4 studies, the DRF refers to readmissions and unplanned admissions of patients.…”

Section: Resultsmentioning

confidence: 99%

“… 20 The majority of studies (n = 16) limited the study population to one department or specialty, 14 , 15 , 17 – 19 , 21 , 22 , 24 – 26 , 28 , 29 , 32 , 33 , 35 , 36 whereas others included cases from various hospital departments. 19 , 29 , 33 , 36 – 39 …”

Section: Resultsmentioning

confidence: 99%

“… 20 , 26 , 30 , 31 , 33 In 3 studies, the report form was based on voluntary, nonpunitive reporting. 26 , 30 , 31 In some studies, the data were collected from a combination of sources; 6 studies used a combination of a report form and an interview, 19 , 22 , 27 , 28 , 34 , 35 and 2 studies used a combination of a report form, an interview, and a patient record. 32 , 36 In 3 studies, the sources underlying the data used for analysis are unknown.…”

Section: Resultsmentioning

confidence: 99%

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Root Cause Analysis Using the Prevention and Recovery Information System for Monitoring and Analysis Method in Healthcare Facilities: A Systematic Literature Review

et al. 2021

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ObjectivesUnintended events (UEs) are prevalent in healthcare facilities, and learning from them is key to improve patient safety. The Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method is a root cause analysis method used in healthcare facilities. The aims of this systematic review are to map the use of the PRISMA-method in healthcare facilities worldwide, to assess the insights that the PRISMA-method offers, and to propose recommendations to increase its usability in healthcare facilities.MethodsPubMed, EMBASE.com, CINAHL, and The Cochrane Library were systematically searched from inception to February 26, 2020. Studies were included if the PRISMA-method for analyzing UEs was applied in healthcare facilities. A quality appraisal was performed, and relevant data based on an appraisal checklist were extracted.ResultsThe search provided 2773 references, of which 25 articles reporting 10,816 UEs met our inclusion criteria. The most frequently identified root causes were human-related, followed by organizational factors. Most studies took place in the Netherlands (n = 20), and the sample size ranged from 1 to 2028 UEs. The study setting and collected data used for PRISMA varied widely. The PRISMA-method performed by multiple persons resulted in more root causes per event.ConclusionsTo better understand UEs in healthcare facilities and formulate optimal countermeasures, our recommendations to further improve the PRISMA-method mainly focus on combining information from patient files and reports with interviews, including multiple PRISMA-trained researchers in an analysis, and modify the Eindhoven Classification Model if needed.

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Opportunities to Improve the Capacity to Rescue

Klumpner

Massarweh

Kheterpal

2020

Anesthesiology Clinics

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Different Perspectives on Predictability and Preventability of Surgical Readmissions

Cited by 3 publications

References 31 publications

Unplanned return presentations of older patients to the emergency department: a root cause analysis

Unplanned return presentations of older patients to the emergency department: a root cause analysis

Root Cause Analysis Using the Prevention and Recovery Information System for Monitoring and Analysis Method in Healthcare Facilities: A Systematic Literature Review

Opportunities to Improve the Capacity to Rescue

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