Mixed‐methods study of reported clinical cases of undesirable events, medical errors, and near misses in health care

Abstract

Health care professionals appear able to report UEs, MEs, and NMs occurring in medical care practice. They seem more willing to report and distinguish incidents related to MEs than to UEs and NMs.

Methodological issue on mixed‐methods study of reported clinical cases of undesirable events, medical errors, and near misses in health care.

“…However, the overall agreement of judgments on all codes was excellent (95%). 1 Firstly, why did the authors apply Cohen kappa? Briefly, the kappa value to assess the reliability and the agreement of a qualitative variable has two weaknesses.…”

“…Also, it is more difficult to judge negligence as one of the contributory factors, resulting in a lower degree of reliability (κ = 0.52). However, the overall agreement of judgments on all codes was excellent (95%) …”

“…We were interested to read the paper by Dimova R. and colleagues published in the June 2018 issue of Journal of Evaluation in Clinical Practice . The authors' aim was to investigate and classify the most common incidents regarding patient safety as well as their contributory factors, based on personal real‐life experiences and situations in medical care reported by health care professionals . Sixty‐five respondents participated and reported cases of undesirable events (UE), medical errors (ME), and near misses (NM) were collected, processed, and analyzed based on our original conceptual framework.…”

Effect of Daily Safety Briefing Huddles on the Reporting of Adverse Events and Near-misses

“…Patient safety is recognized as a key indicator of quality of medical care by most global health organizations and authorities, as well as by many researchers. In recent decades, medical errors and undesirable events have continued to increase globally, and present one of the most significant global challenges to modern health care, causing huge economic and societal burdens [1]. Safety concerns are broadly defined as 'patient safety events that reached the patient, regardless of whether harm occurred; near-misses or close calls, which are patient safety events that did not reach the patient [2].…”

“…AE and NM need to be identified, reported, and analysed effectively, and lessons learned need to be translated into practice and systems improvements. Patient safety reporting systems (PSRS) to identify and mitigate risks to patients who are harmed by medical care have become a priority and challenge to health care delivery over the last decades [1]. The implementation of PSRS allows analysis of accumulated data and their use for continuous improvement of medical care quality via feedback and learned lessons.…”