What Safety Events Are Reported For Ambulatory Care? Analysis of Incident Reports from a Patient Safety Organization

Sharma, Anjana E.; Yang, Janine; Rosario, Jan Bing Del; Hoskote, Mekhala; Rivadeneira, Natalie A.; Sarkar, Urmimala

doi:10.1016/j.jcjq.2020.08.010

Cited by 13 publications

(12 citation statements)

References 38 publications

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“…[1][2][3][4][5] Data from a multistate patient safety organization database confirms that medicationrelated events are still a primary cause of patient safety incidents in the ambulatory care setting, from which 45.3% of incidents were accounted to medication-related errors. 46 However, the cost of time and materials required to address a medication related-adverse event in hospital and outpatient systems is also substantial. Even for errors that do not result in harm or injury to the patient, studies show that each error requires an extra 20 minutes of time for healthcare professionals, of which most are pharmacists and nurses.…”

Section: Discussionmentioning

confidence: 99%

Identifying Potential High-Risk Medication Errors Using Telepharmacy and a Web-Based Survey Tool

2021

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Background and Introduction: Obtaining patient medication histories during emergency department (ED) admissions is an important step towards identifying potential errors that could otherwise remain in the patient’s active medication list. This is a descriptive report of a standardized, electronic data collection tool created to document potential medication errors in patients receiving high-risk medications during ED admissions. Materials and Methods: Trained pharmacy technicians completed a survey following medication history collection using a secure web platform called REDCap®. Data collected included patient-specific information, the number and type of high-risk medications, and potential medication errors identified in the collection process. Results: During a pilot period of April 2019 to October 2020, 191 patient records were completed using the survey tool. Out of a total of 1088 medications recorded, 41% were considered high-risk medications. 42% of potential medication errors were classified as high-risk medication errors. Results from this survey tool demonstrated that 58% of high-risk medication orders could potentially result in a medication error that can be carried through patient admission and discharge. Discussion: Accurate medication history and transitions of care can significantly impact patient quality of life. The cost of addressing a medication related-adverse event is also substantial. Based on published reports, annual gross savings to a hospital is estimated to be $4532 per harmful error in 2020, after adjusting for inflation. This equated to approximately $1,182,852 in estimated savings for Ascension Texas in 18 months. Nationwide, preventing potential medication errors in an outpatient setting can save on average $3.5 billion per year. Conclusion: This web-based survey tool has improved the quality and efficiency of potential error identification during medication history collection by pharmacy technicians. This information can be easily retrieved and aid in discussions regarding medication reconciliation at the leadership level and impact patient treatment outcomes by developing virtual processes that may result in fewer medication related events.

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Section: Discussionmentioning

confidence: 99%

Identifying Potential High-Risk Medication Errors Using Telepharmacy and a Web-Based Survey Tool

2021

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“…Of those, we randomly sampled 2701 events ( online supplemental file 1 ; Consolidated Standards of Reporting Trials (CONSORT) diagram); this has been described in a prior study. 10 Our sample included all events labelled as with ‘moderate harm’, ‘severe harm’ and ‘death’, as well as 200 ‘missing harm’, 200 ‘no harm’ and 600 ‘minor harm’ events. These events were coded with a variable to capture if patient or caregiver challenges were mentioned that could have contributed to the event in question.…”

Section: Methodsmentioning

confidence: 99%

Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis

et al. 2021

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ObjectivesPatients and caregivers are the primary stakeholders in ambulatory safety, given they perform daily chronic disease self-management, medication administration and outpatient follow-up. However, little attention has been given to their role in adverse events. We identified themes related to patient and caregiver factors and challenges in ambulatory safety incident reports from a Patient Safety Organization.MethodsWe conducted a mixed-methods analysis of ambulatory incident reports submitted to the Collaborative Healthcare Patient Safety Organization, including 450 hospitals or clinic members in 13 US states. We included events that had patient and/or caregiver behavioural, socioeconomic and clinical factors that may have contributed to the event. Two members of the team independently coded patient/caregiver factors, with dual coding of 20% of events. We then conducted a ‘frequent item set’ analysis to identify which factors most frequently co-occurred. We applied inductive analysis to the most frequent sets to interpret themes. Our team included a diverse stakeholder advisory council of patients, caregivers and healthcare staff.ResultsWe analysed 522 incident reports and excluded 73 for a final sample of 449 events. Our co-occurrence analysis found the following three themes: (1) clinical advice may conflict with patient priorities; (2) breakdowns in communication and patient education cause medication adverse events and (3) patients with disabilities are vulnerable to the external environment.ConclusionsAmbulatory safety reports capture both structural and behavioural factors contributing to adverse events. Actionable takeaways include the following: improving clinician counselling of patients to convey medical advice to elicit priorities, enhanced education regarding medication adverse events and expanding safety precautions for patients with disabilities at home. Ambulatory safety reporting must include patients in reporting and event review for better mitigation of future harm.

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“…Our findings support earlier research that practice teams are often satisfied with "weaker" solutions and prefer these to any attempt to deal with underlying causes. 7,11,13 If the focus is on the conduct or omissions of the staff (person-oriented perspective), person-oriented measures are developed accordingly. Forty-six reports described how staff were urged to pay more attention in the future, to concentrate harder, or to ask for help if necessary.…”

Section: Reasons For the Key Findingsmentioning

confidence: 99%

Strength of Safety Measures Introduced by Medical Practices to Prevent a Recurrence of Patient Safety Incidents: An Observational Study

et al. 2021

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The aim of this study was to analyze the strength of safety measures described in incident reports in outpatient care.Methods: An incident reporting project in German outpatient care included 184 medical practices with differing fields of specialization. The practices were invited to submit anonymous incident reports to the project team 3 times for 17 months. Using a 14-item coding scheme based on international recommendations, we deductively coded the incident reports and safety measures. Safety measures were classified as "strong" (likely to be effective and sustainable), "intermediate" (possibly effective and sustainable), or "weak" (less likely to be effective and sustainable). Results:The practices submitted 245 incident reports. In 160 of them, 243 preventive measures were described, or an average of 1.5 per report. The number of documented measures varied from 1 in 67% to 4 in 5% of them. Four preventive measures (2%) were classified as strong, 37 (15%) as intermediate, and 202 (83%) as weak. The most frequently mentioned measures were "new procedure/policy" (n = 121) and "information/notification/warning" (n = 45). Conclusions:The study provides examples of critical incidents in medical practices and for the first time examines the strength of ensuing measures introduced in outpatient care. Overall, the proportion of weak measures is (too) high, indicating that practices need more support in identifying strong measures.

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What Safety Events Are Reported For Ambulatory Care? Analysis of Incident Reports from a Patient Safety Organization

Cited by 13 publications

References 38 publications

Identifying Potential High-Risk Medication Errors Using Telepharmacy and a Web-Based Survey Tool

Identifying Potential High-Risk Medication Errors Using Telepharmacy and a Web-Based Survey Tool

Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis

Strength of Safety Measures Introduced by Medical Practices to Prevent a Recurrence of Patient Safety Incidents: An Observational Study

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