Analyzing Health Information Technology and Electronic Medical Record System-Related Patient Safety Incidents Using Data from the Korea Patient Safety Reporting and Learning System

Purpose: At present, there are a variety of serious patient safety incidents related to problems in health information technology (HIT), specifically involving electronic medical records (EMRs). This emphasizes the need for an enhanced electronic medical record system (EMRS). As such, this study analyzed both the nature of and potential to prevent incidents associated with HIT/EMRS based on data from the Korea Patient Safety Reporting and Learning System (KOPS).Methods: This study analyzed patient safety incidents submitted to KOPS between August 2016 and December 2019. HIT keywords were used to extract HIT/EMRS incidents. Each case was reviewed to confirm whether the contributing factors were related to HIT/EMRS (HIT/EMRS-related incidents) and if the incident could have been prevented (HIT/EMRS-preventable incidents). The selected reports were summarized for general clarity (e.g., incident type, and degree of harm).Results: Of the 25,515 obtained reports, 2,664 incidents (10.4%) were HIT-related, while 2,525 (9.9%) were EMRS-related. HIT/EMRS-related incidents were the third largest type of incident followed by 'fall' and 'medication incidents.' More than 80% of HIT/EMRS-related incidents were medication-related, accounting for approximately one-third of the total number of medication incidents. Approximately 10% of HIT/EMRS-related incidents resulted in patient harm, with more than 94% of these deemed as preventable; further, sentinel events were wholly preventable.Conclusion: This study provides basic data for improving EMR use/safety standards based on real-world patient safety incidents. Such improvements entail the establishment of long-term plans, research, and incident analysis, thus ensuring a safe healthcare environment for patients and healthcare providers.

Healthcare professionals’ perceptions on medication communication challenges and solutions – text mining and manual content analysis - cross-sectional study

Background Communication challenges contribute to medication incidents in hospitals, but it is unclear how communication can be improved. The aims of this study were threefold: firstly, to describe the most common communication challenges related to medication incidents as perceived by healthcare professionals across specialized hospitals for adult patients; secondly, to consider suggestions from healthcare professionals with regard to improving medication communication; and thirdly, to explore how text mining compares to manual analysis when analyzing the free-text content of survey data. Methods This was a cross-sectional, descriptive study. A digital survey was sent to professionals in two university hospital districts in Finland from November 1, 2019, to January 31, 2020. In total, 223 professionals answered the open-ended questions; respondents were primarily registered nurses (77.7 %), physicians (8.6 %), and pharmacists (7.3 %). Text mining and manual inductive content analysis were employed for qualitative data analysis. Results The communication challenges were: (1) inconsistent documentation of prescribed and administered medication; (2) failure to document orally given prescriptions; (3) nurses’ unawareness of prescriptions (given outside of ward rounds) due to a lack of oral communication from the prescribers; (4) breaks in communication during care transitions to non-communicable software; (5) incomplete home medication reconciliation at admission and discharge; (6) medication lists not being updated during the inpatient period due to a lack of clarity regarding the responsible professional; and (7) work/environmental factors during medication dispensation and the receipt of verbal prescriptions. Suggestions for communication enhancements included: (1) structured digital prescriptions; (2) guidelines and training on how to use documentation systems; (3) timely documentation of verbal prescriptions and digital documentation of administered medication; (4) communicable software within and between organizations; (5) standardized responsibilities for updating inpatients’ medication lists; (6) nomination of a responsible person for home medication reconciliation at admission and discharge; and (7) distraction-free work environment for medication communication. Text mining and manual analysis extracted similar primary results. Conclusions Non-communicable software, non-standardized medication communication processes, lack of training on standardized documentation, and unclear responsibilities compromise medication safety in hospitals. Clarification is needed regarding interdisciplinary medication communication processes, techniques, and responsibilities. Text mining shows promise for free-text analysis.

Mixed-methods study protocol: do national reporting and learning system medication incidents in palliative care reflect patient and carer concerns about medication management and safety?

IntroductionApproximately 20% of serious safety incidents involving palliative patients relate to medication. These are disproportionately reported when patients are in their usual residence when compared with hospital or hospice. While patient safety incident reporting systems can support professional learning, it is unclear whether these reports encompass patient and carer concerns with palliative medications or interpersonal safety.AimTo explore and compare perceptions of (un)safe palliative medication management from patient, carer and professional perspectives in community, hospital and hospice settings.Methods and analysisWe will use an innovative mixed-methods study design combining systematic review searching techniques with cross-sectional quantitative descriptive analysis and interpretative qualitative metasynthesis to integrate three elements: (1) Scoping review: multiple database searches for empirical studies and first-hand experiences in English (no other restrictions) to establish how patients and informal carers conceptualise safety in palliative medication management. (2)Medication incidents from the England and Wales National Reporting and Learning System: identifying and characterising reports to understand professional perspectives on suboptimal palliative medication management. (3) Comparison of 1 and 2: contextualising with stakeholder perspectives.Patient and public involvementOur team includes a funded patient and public involvement (PPI) collaborator, with experience of promoting patient-centred approaches in patient safety research. Funded discussion and dissemination events with PPI and healthcare (clinical and policy) professionals are planned.Ethics and disseminationProspective ethical approval granted: Cardiff University School of Medicine Research Ethics Committee (Ref 19/28). Our study will synthesise multivoiced constructions of patient safety in palliative care to identify implications for professional learning and actions that are relevant across health and social care. It will also identify changing or escalating patterns in palliative medication incidents due to the COVID-19 pandemic. Peer-reviewed publications, academic presentations, plain English summaries, press releases and social media will be used to disseminate to the public, researchers, clinicians and policy-makers.

Artificial Intelligence for Identifying the Prevention of Medication Incidents Causing Serious or Moderate Harm: An Analysis Using Incident Reporters’ Views

The purpose of this study was to describe incident reporters’ views identified by artificial intelligence concerning the prevention of medication incidents that were assessed, causing serious or moderate harm to patients. The information identified the most important risk management areas in these medication incidents. This was a retrospective record review using medication-related incident reports from one university hospital in Finland between January 2017 and December 2019 (n = 3496). Of these, incidents that caused serious or moderate harm to patients (n = 137) were analysed using artificial intelligence. Artificial intelligence classified reporters’ views on preventing incidents under the following main categories: (1) treatment, (2) working, (3) practices, and (4) setting and multiple sub-categories. The following risk management areas were identified: (1) verification, documentation and up-to-date drug doses, drug lists and other medication information, (2) carefulness and accuracy in managing medications, (3) ensuring the flow of information and communication regarding medication information and safeguarding continuity of patient care, (4) availability, update and compliance with instructions and guidelines, (5) multi-professional cooperation, and (6) adequate human resources, competence and suitable workload. Artificial intelligence was found to be useful and effective to classifying text-based data, such as the free text of incident reports.

Interprofessional and Intraprofessional Communication about Older People’s Medications across Transitions of Care

Communication breakdowns contribute to medication incidents involving older people across transitions of care. The purpose of this paper is to examine how interprofessional and intraprofessional communication occurs in managing older patients’ medications across transitions of care in acute and geriatric rehabilitation settings. An ethnographic design was used with semi-structured interviews, observations and focus groups undertaken in an acute tertiary referral hospital and a geriatric rehabilitation facility. Communication to manage medications was influenced by the clinical context comprising the transferring setting (preparing for transfer), receiving setting (setting after transfer) and ‘real-time’ (simultaneous communication). Three themes reflected these clinical contexts: dissemination of medication information, safe continuation of medications and barriers to collaborative communication. In transferring settings, nurses and pharmacists anticipated communication breakdowns and initiated additional communication activities to ensure safe information transfer. In receiving settings, all health professionals contributed to facilitating safe continuation of medications. Although health professionals of different disciplines sometimes communicated with each other, communication mostly occurred between health professionals of the same discipline. Lack of communication with pharmacists occurred despite all health professionals acknowledging their important role. Greater levels of proactive preparation by health professionals prior to transfers would reduce opportunities for errors relating to continuation of medications.

Medication incidents and pharmacist interventions in relation to directly acting oral anticoagulants in hospital settings: evaluation using Reason’s Accident Causation Theory

BackgroundDirect oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However DOACs medication incidents are known to be common.ObjectiveTo assess medication incidents associated with DOACs using an error theory and to analyse pharmacists’ contributions in minimising medication incidents in secondary care settings.SettingA large University tertiary academic hospital in the West Midlands of England.MethodsMedication incident data from the incident reporting system (48-months period) and pharmacist interventions data from the prescribing system (26-month period) were extracted. Reason’s Accident Causation Model was used to identify potential causality of the incidents. Pharmacists’ intervention data was thematically analysed.Main outcome measure(a) Frequency, type and potential causality of DOACs incidents, (b) Nature of pharmacists’ interventions.ResultsA total of 812 DOACs reports were included in the study (124 medication incidents and 688 intervention reports). Missing drug/omission was the most common incident type (26.6%,n = 33) followed by wrong drug (16.1%,n = 20) and wrong dose/strength (11.3%,n = 14). A high majority (89.5%,n = 111) of medication incidents were caused by active failures. Patient discharge without anticoagulation supply and failure to restart DOACs post procedure/scan were commonly recurring themes. The majority of (38.1%,n = 262) the pharmacist interventions were related to pharmacological strategy (i.e., drug or dose changes or discontinuation). Impaired renal function was the most common reason for dose adjustments.ConclusionPrescribers’ active failure rather than system errors (i.e. latent failures) are contributing to DOACs incidents. Rreinforcement of guideline adherence, prescriber education, harnessing pharmacists’ roles and mandating renal function information in prescriptions are likely to improve patient safety.

Impact of Medication Regimen Simplification on Medication Incidents in Residential Aged Care: SIMPLER Randomized Controlled Trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we investigated the impact of a structured medication regimen simplification intervention on medication incidents in residential aged care facilities (RACFs) over a 12-month follow-up. A clinical pharmacist applied the validated 5-step Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) for 96 of the 99 participating residents in the four intervention RACFs. The 143 participating residents in the comparison RACFs received usual care. Over 12 months, medication incident rates were 95 and 66 per 100 resident-years in the intervention and comparison groups, respectively (adjusted incident rate ratio (IRR) 1.13; 95% confidence interval (CI) 0.53–2.38). The 12-month pre/post incident rate almost halved among participants in the intervention group (adjusted IRR 0.56; 95%CI 0.38–0.80). A significant reduction in 12-month pre/post incident rate was also observed in the comparison group (adjusted IRR 0.67, 95%CI 0.50–0.90). Medication incidents over 12 months were often minor in severity. Declines in 12-month pre/post incident rates were observed in both study arms; however, rates were not significantly different among residents who received and did not receive a one-off structured medication regimen simplification intervention.

Lean thinking: using 6S and visual management for efficient adverse event closure

BackgroundWe focused on a busy Adult Oncology Department having over 130 staff members, with around 70 of them being physicians with different levels of specialties. A multidisciplinary committee was formed in the department, consisting of physicians, nurses, pharmacists, a medication safety representative and a quality specialist to look after all reported incidents.Local problemThe department staff at the institution in question in this study expressed their concern about the surging number of reported incidents, delays in closing reports within the set timeframe, ambiguity of individuals’ roles at the committee level and errors in using the safety reporting system (SRS). Accordingly, this study focused on the development of a visual aid through the creation of a functional process map to help clarify team roles and stipulate the steps for adverse event closure.MethodsThe Sort, Set-in order, Shine, Standardise, Sustain and Safety and visual management lean principles, as well as the eight lean wastes—Transportation, Inventory, Motion, Waiting, Overprocessing, Overproduction, Defect and Staff underutilisation—were introduced in early May 2016 and used during SRS committee meetings over 3 years.InterventionThe indicators used were the average number of days for both medication and non-medication incidents from the day of reporting until the closure. The extent that the limit was exceeded was compared.ResultsThe average number of days until closure showed a reduction from 67 to 37 and 134 to 61 between Periods I (2016) and III (2018) for medication and non-medication incidents, respectively.ConclusionsThe developed process map was a useful communication tool. It helped to sort process activities, team roles and streamline the process. It brought the average number of days until closure within the acceptable 45-day limit for medication incidents. Thus, using visual aids in the working environment is helpful in improving communication among the workers.