scholarly journals Descriptive Epidemiology of Safety Events at an Academic Medical Center

2020 ◽  
Vol 17 (1) ◽  
pp. 353
Author(s):  
Alexandre R. Marra ◽  
Abdullah Algwizani ◽  
Mohammed Alzunitan ◽  
Theresa M. H. Brennan ◽  
Michael B. Edmond
Keyword(s):  
Patient Safety ◽  
Patient Care ◽  
Surveillance System ◽  
Medical Center ◽  
Academic Medical Center ◽  
Incident Reporting ◽  
Near Miss ◽  
Descriptive Epidemiology ◽  
Near Misses ◽  
Academic Medical

Background: Adverse safety events in healthcare are of great concern, and despite an increasing focus on the prevention of error and harm mitigation, the epidemiology of safety events remains incomplete. Methods: We performed an analysis of all reported safety events in an academic medical center using a voluntary incident reporting surveillance system for patient safety. Safety events were classified as: serious (reached the patient and resulted in moderate to severe harm or death); precursor (reached the patient and resulted in minimal or no detectable harm); and near miss (did not reach the patient). Results: During a three-year period, there were 31,817 events reported. Most of the safety events were precursor safety events (reached the patient and resulted in minimal harm or no detectable harm), corresponding to 77.3%. Near misses accounted for 10.8%, and unsafe conditions for 11.8%. The number of reported serious safety events was low, accounting for only 0.1% of all safety events. Conclusions: The reports analysis of these events should lead to a better understanding of risks in patient care and ways to mitigate it.

scholarly journals In-Hospital Patient Safety Events, Healthcare Costs and Utilization: An Analysis from the Incident Reporting System in an Academic Medical Center

Healthcare ◽  
2020 ◽  
Vol 8 (4) ◽  
pp. 388
Author(s):  
Yao-Wen Kuo ◽  
Jih-Shuin Jerng ◽  
Chia-Kuei Lin ◽  
Hsiao-Fang Huang ◽  
Li-Chin Chen ◽  
...  
Keyword(s):  
Patient Safety ◽  
Claims Data ◽  
Reporting System ◽  
Medical Center ◽  
Academic Medical Center ◽  
Near Miss ◽  
Study Approach ◽  
Academic Medical ◽  
Matched Comparison ◽  
And Control

The possible association of patient safety events (PSEs) with the costs and utilization remains a concern. In this retrospective analysis, we investigated adult hospitalizations at a medical center between 2010 and 2015 with or without reported PSEs. Administrative and claims data were analyzed to compare the costs and length of stay (LOS) between cases with and without PSEs of the three most common categories during the first 14 days of hospitalization. Two models, including linear regression and propensity score-matched comparison, were performed for each reference day group of hospitalizations. Of 14,181 PSEs from 424,635 hospitalizations, 69.8% were near miss or no-harm events. Costs and LOS were similar between fall cases and controls in all of the 14 reference days. In contrast, for cases of tube and line events and controls, there were consistent differences in costs and LOS in the majority of the reference days (86% and 57%, respectively). Consistent differences were less frequently seen for medication events and control events (36% and 43%, respectively). Our study approach of comparing cases with PSEs and those without any PSE showed significant differences in costs and LOS for tube and line events, and medication events. No difference in cost or LOS was found regarding fall events. Further studies exploring adjustments for event risks and harm-oriented analysis are warranted.

Assessment of hospital emergency medication kit use at a large academic medical center with automated dispensing machine technology

2020 ◽  
Vol 77 (Supplement_1) ◽  
pp. S8-S12
Author(s):  
Bradley L Smith ◽  
Monica G Griffin ◽  
Alexander Heyliger ◽  
Brianne M Ritchie
Keyword(s):  
Patient Safety ◽  
Patient Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Emergency ◽  
Process Improvements ◽  
Machine Technology ◽  
Academic Medical ◽  
Emergency Medication ◽  
Added Benefit

Abstract Purpose Hospital emergency medication kits (HEMKs) are used to provide certain critical medications in emergent situations, despite many technological advancements for patient safety and medication distribution. We sought to evaluate HEMK usage and analyze associated costs to identify and recommend process improvements. Methods Mayo Clinic in Rochester, MN, is a large multisite academic medical center with 2 hospital campuses and many ambulatory clinics. All documentation of the approximately 250 HEMKs in circulation was analyzed from January to November 2017. The primary outcome was HEMK use. Secondary outcomes included individual medication usage and associated costs. These data were then used to recommend process improvements. Results Of 880 HEMKs evaluated, 675 (76.7%) were used, resulting in expiration 23.3% of the time. A total of 1,024 emergency medications were used, most commonly for hypoglycemia. Many of these medications are also available in automated dispensing machines for patient care use. Cost analysis revealed an average annual cost of nearly $200,000 associated with HEMKs. The results of our analysis indicated little added benefit of HEMKs in the setting of automated dispensing machine optimization. Steps for HEMK retirement are described. Conclusion HEMKs offered little added benefit considering technological advancements that have been made in patient safety and medication distribution since their inception. Retirement of HEMKs is anticipated to increase pharmacy operational efficiency by using automated dispensing machine technology and appropriate emergency response protocols to ensure optimal patient care.

scholarly journals Knowledge management in the era of digital medicine: A programmatic approach to optimize patient care in an academic medical center

2017 ◽  
Vol 1 (2) ◽  
pp. e10022 ◽  
Author(s):  
Jane L. Shellum ◽  
Rick A. Nishimura ◽  
Dawn S. Milliner ◽  
Charles M. Harper ◽  
John H. Noseworthy
Keyword(s):  
Knowledge Management ◽  
Patient Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Digital Medicine ◽  
Academic Medical

Patient Safety Trilogy: Perspectives from Clinical Engineering

2013 ◽  
Vol 47 (2) ◽  
pp. 137-142 ◽  
Author(s):  
Izabella Gieras ◽  
Paul Sherman ◽  
Dennis Minsent
Keyword(s):  
Patient Safety ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Engineering ◽  
Veterans Health ◽  
Health Administration ◽  
Healthcare Technology ◽  
Academic Medical ◽  
Clinical Engineers

This article examines the role a clinical engineering or healthcare technology management (HTM) department can play in promoting patient safety from three different perspectives: a community hospital, a national government health system, and an academic medical center. After a general overview, Izabella Gieras from Huntington Hospital in Pasadena, CA, leads off by examining the growing role of human factors in healthcare technology, and describing how her facility uses clinical simulations in medical equipment evaluations. A section by Paul Sherman follows, examining patient safety initiatives from the perspective of the Veterans Health Administration with a focus on hazard alerts and recalls. Dennis Minsent from Oregon Health & Science University writes about patient safety from an academic healthcare perspective, and details how clinical engineers can engage in multidisciplinary safety opportunities.

Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center

2017 ◽  
Vol 43 (1) ◽  
pp. 5-15 ◽  
Author(s):  
William Martinez ◽  
Lisa Soleymani Lehmann ◽  
Yue-Yung Hu ◽  
Sonali Parekh Desai ◽  
Jo Shapiro
Keyword(s):  
Adverse Events ◽  
Medical Center ◽  
Academic Medical Center ◽  
Near Misses ◽  
Academic Medical

Radiation Oncology Incident Learning System (RO-ILS): Increasing stakeholder participation for safety and quality improvement.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 232-232
Author(s):  
Carl Nelson ◽  
Lori Ann Roy ◽  
H. James Wallace
Keyword(s):  
Process Improvement ◽  
Medical Center ◽  
Stakeholder Participation ◽  
Incident Reporting ◽  
Learning System ◽  
Near Miss ◽  
Radiation Quality ◽  
Near Misses ◽  
Staff Members ◽  
Physician Participation

232 Background: RO-ILS was launched in 2014 and is free, web-based and in more than 500 U.S. radiation facilities. After RO-ILS was implemented at University of Vermont Medical Center (UVMMC), reporting of radiation incidents decreased and participation by radiation staff was limited. To improve incident reporting and participation, RO-ILS was relaunched for all radiation staff members at UVMMC with emphasis on improved system access and education on RO-ILS programmatic goals. Methods: Prior to RO-ILS, safety/quality incidents at UVMMC were submitted by radiation therapists, dosimetrists and physics staff on paper forms and reviewed monthly by the Radiation Quality Committee. After implementation of RO-ILS in 2016, RO-ILS incidents were reviewed by the UVMMC RO-ILS administrators with no formalized staff feedback. Due to decreasing staff submissions, RO-ILS relaunched September 2018 with increased training, scheduled submission review to radiation staff and identification of department champions. Results: Between April 2014 and May 2019, 270 radiation incidents were reported. Prior to RO-ILS, a median 8 incidents were reported per quarter but decreased to 6 per quarter after RO-ILS. After RO-ILS relaunch, median reported incidents increased to 42 per quarter. Radiation “Near Miss” events pre RO-ILS, post RO-ILS and with RO-ILS relaunch were reduced from 78% to 34% to 9%, while “Operational/Process Improvement” submissions increased from 17% pre RO-ILS to 49% post RO-ILS to 81% after relaunch. After RO-ILS relaunch, staff participation expanded to physicians, nursing and administrative staff for the first time, and physician participation increased from 0 to 50%. Conclusions: Following implementation of RO-ILS at UVMMC, radiation incident reporting initially decreased and the proportion of “Near Miss” reports decreased. After relaunch of RO-ILS, there was substantial increase in incident reporting involving all staff. As RO-ILS evolves at UVMMC, there is continued decrease in near misses and greater emphasis on “Process Improvement”. Continued education, reporting and feedback from RO-ILS submissions is recommended to maintain this high staff participation level.

A multicentered academic medical center experience of a simulated root cause analysis (RCA) for hematology/oncology fellows.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 188-188
Author(s):  
Danielle Wallace ◽  
Denise Cochran ◽  
Jennifer Michelle Duff ◽  
Julia Lee Close ◽  
Martina Cathryn Murphy ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Medical Center ◽  
Academic Medical Center ◽  
Near Miss ◽  
Safety Skills ◽  
Clinical Patient ◽  
Root Cause ◽  
Event Flow ◽  
Flow Map

188 Background: Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Specifically, the ACGME requires trainee participation in interprofessional clinical patient safety activities, such as root cause analyses. These can be challenging to incorporate into busy schedules and are intimidating to some trainees, but simulated RCAs are a novel way to assure trainees gain important patient safety skills. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. Methods: The two-hour module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Seventeen fellows from two institutions completed pre- and post-session surveys regarding the experience. Results: There was a 47% increase in both the percentage of fellows who felt comfortable participating in live RCAs in the future, and in the number of fellows who felt comfortable with using the tools typically utilized in an RCA. 70.59% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event. Conclusions: Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills

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