Surgeon and Surgical Trainee Experiences After Adverse Patient Events.

Importance: Adverse patient events are inevitable in surgical practice. Objectives: To characterize the impact of adverse patient events on surgeons and trainees, identify coping mechanisms, and assess whether current forms of support are sufficient. Design, Setting, and Participants: In this mixed-methods study, a validated survey instrument was adapted and distributed to surgical trainees from 7 programs, and qualitative interviews were conducted with faculty from 4 surgical departments in an urban academic health system. Main Outcomes and Measures: The personal impact of adverse patient events, current coping mechanisms, and desired forms of support. Results: Of 216 invited trainees, 93 (43.1%) completed the survey (49 [52.7%] male; 60 [64.5%] in third postgraduate year or higher; 23 [24.7%] Asian or Pacific Islander, 6 [6.5%] Black, 51 [54.8%] White, and 8 [8.6%] other race; 13 [14.0%] Hispanic or Latinx ethnicity). Twenty-three of 29 (79.3%) invited faculty completed interviews (13 [56.5%] male; median [IQR] years in practice, 11.0 [7.5-20.0]). Of the trainees, 77 (82.8%) endorsed involvement in at least 1 recent adverse event. Most reported embarrassment (67 of 79 trainees [84.8%]), rumination (64 of 78 trainees [82.1%]), and fear of attempting future procedures (51 of 78 trainees [65.4%]); 28 of 78 trainees (35.9%) had considered quitting. Female trainees and trainees who identified as having a race and/or ethnicity other than non-Hispanic White consistently reported more negative consequences compared with male and White trainees. The most desired form of support was the opportunity to discuss the incident with an attending physician (76 of 78 respondents [97.4%]). Similarly, faculty described feelings of guilt and shame, loss of confidence, and distraction after adverse events. Most described the utility of confiding in peers and senior colleagues, although some expressed unwillingness to reach out. Several suggested designating a departmental point person for event debriefing. Conclusions and Relevance: In this mixed-methods study of the personal impact of adverse events on surgeons and trainees, these events were nearly universally experienced and caused significant distress. Providing formal support mechanisms for both surgical trainees and faculty may decrease stigma and restore confidence, particularly for underrepresented groups.

The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

Patient safety incidents in Irish general practice during the COVID-19 pandemic: an exploratory practice level analysis.

BACKGROUND: Patient safety is defined as the prevention of harm to patients and aims to prevent errors. This analysis explores factors associated with the reported occurrence of patient safety incidents (PSIs) in general practices in Ireland at the start of the COVID-19 pandemic. METHODS: The PRICOV-19 was a cross-sectional study to record the (re)organisation of care provided in general practice and changes implemented during the COVID-19 pandemic in 38 countries. Primary outcomes include three potential scenarios of PSIs: delayed care due to practice factors, delayed care due to patient factors, and delayed care due to triage. Exploratory variables included demographic and organisational characteristics, triage, collaboration, and strategies to safeguard staff members' well-being. RESULTS: Of the 172 participating Irish general practices, 71% (n = 122) recorded at least one potential PSI. The most frequent incident was delayed care due to patient factors (65%), followed by practice (33%) and triage (30%). Multivariate analysis showed that delayed care due to patient factors was associated with changes in the process of repeat prescriptions (OR 6.7 [CI 95% 2.5 to 19.6]). Delayed care due to practice factors was associated with suburbs/small towns (OR 4.2 [1.1 to 19.8]) and structural changes to the reception (OR 3.5 [1.2 to 11.4]). While delayed care due to patient factors was associated with having a practice population of 6000-7999 patients (OR 4.7 [1.1 to 27.6]) and delayed care due to practice factors was associated with having a practice population of 2000-3999 patients (OR 4.2 [1.2 to 17.1]). No linear associations were observed with higher or lower patient numbers for any factor. Delayed care due to triage was not associated with any exploratory variables. CONCLUSION: The COVID-19 pandemic resulted in dramatic changes in the delivery of care through general practices in Ireland. Few factors were associated with the reported occurrence of PSIs, and these did not show consistent patterns. Sustained improvements were made in relation to repeat prescriptions. The lack of consistent patterns, potentially confirms that the autonomous decisions made in general practice in response to the challenges of the COVID-19 pandemic could have benefitted patient safety (See Graphical abstract).

Enhancing patient safety: detection of in-hospital hazards and effect of training on detection (by training in a low-fidelity simulation Room of Improvement based on hospital-specific CIRS cases).

IMPORTANCE: Adequate situational awareness in patient care increases patient safety and quality of care. To improve situational awareness, an innovative, low-fidelity simulation method referred to as Room of Improvement, has proven effective in various clinical settings. OBJECTIVE: To investigate the impact after 3 months of Room of Improvement training on the ability to detect patient safety hazards during an intensive care unit shift handover, based on critical incident reporting system (CIRS) cases reported in the same hospital. METHODS: In this educational intervention, 130 healthcare professionals observed safety hazards in a Room of Improvement in a 2 (time 1 vs time 2)×2 (alone vs in a team) factorial design. The hazards were divided into immediately critical and non-critical. RESULTS: The results of 130 participants were included in the analysis. At time 1, no statistically significant differences were found between individuals and teams, either overall or for non-critical errors. At time 2, there was an increase in the detection rate of all implemented errors for teams compared with time 1, but not for individuals. The detection rate for critical errors was higher than for non-critical errors at both time points, with individual and group results at time 2 not significantly different from those at time 1. An increase in the perception of safety culture was found in the pre-post test for the questions whether the handling of errors is open and professional and whether errors are discussed in the team. DISCUSSION: Our results indicate a sustained learning effect after 12 weeks, with collaboration in teams leading to a significantly better outcome. The training improved the actual error detection rates, and participants reported improved handling and discussion of errors in their daily work. This indicates a subjectively improved safety culture among healthcare workers as a result of the situational awareness training in the Room of Improvement. As this method promotes a culture of safety, it is a promising tool for a well-functioning CIRS that closes the loop.

Effects of a special continuous quality improvement in nursing on the management of adverse care events: a retrospective study.

OBJECTIVE: To explore the application effect of the direct reporting system of adverse nursing events and special continuous nursing quality improvement measures in the management of these adverse events. METHODS: The implementation time of continuous nursing improvement based on the direct reporting system was the demarcation point. We retrospectively collected and analyzed nursing adverse event reports and hospitalization data from Xiangtan Central Hospital before implementation (2015-2018) and after implementation (2019-2022). The active reporting rate of adverse events, the composition of these events and the processing time were compared between the two groups. RESULTS: The rate of active reporting of adverse events before the implementation was lower than that after the implementation (6.7% vs. 8.1%, X2 = 25.561, P < 0.001). After the implementation of the direct reporting system for nursing events and the continuous improvement of nursing quality, the reporting proportion of first-level and second-level events decreased significantly. Moreover, the reporting proportion of third-level events increased significantly. The proportion of falls and medication errors decreased, and the proportion of unplanned extubation, infusion xerostomia and improper operation increased. The processing time of the reported nursing adverse events was significantly reduced (31.87 ± 7.83 vs. 56.87 ± 8.21, t = 18.73, P < 0.001). CONCLUSION: The direct reporting system of adverse nursing events and the continuous improvement measures for nursing quality can effectively improve the active reporting rate of adverse events, change their composition and reduce their processing time, as well as help create a safe psychological environment for both patients and nursing staff.

Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care.

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

Management of adverse events in a Moroccan regional hospital: a state of art and perspectives.

Introduction: the risk management system is useful to identify, analyze, and reduce the risk occurrence of adverse events (AEs) in health services. This system suggests useful improvements to patients and to the whole institution and also contributes to the acquisition of a collective and organizational safety culture. This study presented a state of the art of the management of AEs identified in different services of a regional hospital in the north of Morocco. Methods: this is a retrospective cross-sectional exploratory study carried out from 2017 to 2019 using observations and semi-structured interviews, which were recorded, re-transcribed, and analyzed. Data was also collected from audit reports, results of investigations of the nosocomial infection control committee and the risk management commission, AEs declaration sheets, and meetings reports. Results: a number of 83 AEs were recorded, 10 of which were urgent. The reported events were related to care, infection risk, the drugs circuit, and medico-technical events. Two hundred cases of nosocomial infections were also recorded, of which 75 occurred in the intensive care unit and 35 in the maternity service. Surgical site infections were the most frequently reported complication. Adverse events were related to organizational failure, equipment problems, and errors related to professional practices. Conclusion: our findings may guide the improvement of the event management system in order to reduce the occurrence of future incidents. Thus, improving the risk management system requires setting up training strategies for staff on the importance of this system and its mode of operation.

Analysis of Critical Incident Reports Using Natural Language Processing.

A Critical Incident Reporting System (CIRS) collects anecdotal reports from employees, which serve as a vital source of information about incidents that could potentially harm patients. OBJECTIVES: To demonstrate how natural language processing (NLP) methods can help in retrieving valuable information from such incident data. METHODS: We analyzed frequently occurring terms and sentiments as well as topics in data from the Swiss National CIRRNET database from 2006 to 2023 using NLP and BERTopic modelling. RESULTS: We grouped the topics into 10 major themes out of which 6 are related to medication. Overall, they reflect the global trends in adverse events in healthcare (surgical errors, venous thromboembolism, falls). Additionally, we identified errors related to blood testing, COVID-19, handling patients with diabetes and pediatrics. 40-50% of the messages are written in a neutral tone, 30-40% in a negative tone. CONCLUSION: The analysis of CIRS messages using text analysis tools helped in getting insights into common sources of critical incidents in Swiss healthcare institutions. In future work, we want to study more closely the relations, for example between sentiment and topics.

Development of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care.

BACKGROUND: Emergency Medical Services (EMS) are a unique setting because care for the chief complaint is given across all ages in a complex and high-risk environment that may pose a threat to patient safety. Traditionally, a reporting system is commonly used to raise awareness of adverse events (AEs); however, it could fail to detect an AE. Several methods are needed to evaluate patient safety in EMS. In this light, this study was conducted to (1) develop a national ambulance trigger tool (ATT) with a guide containing descriptions of triggers, examples of use, and categorization of near misses (NMs), no harm incidents (NHIs), and harmful incidents (HIs) and (2) use the ATT on randomly selected ambulance records. METHODS: The ambulance trigger tool was developed in a stepwise manner through (1) a literature review; (2) three sessions of structured group discussions with an expert panel having knowledge of emergency medical service, patient safety, and development of trigger tools; (3) a retrospective record review of 900 randomly selected journals with three review teams from different geographical locations; and (4) inter-rater reliability testing between reviewers. RESULTS: From the literature review, 34 triggers were derived. After removing clinically irrelevant ones and combining others through three sessions of structured discussions, 19 remained. The most common triggers identified in the 900 randomly selected records were deviation from treatment guidelines (30.4%), the patient is non conveyed after EMS assessment (20.8%), and incomplete documentation (14.4%). The positive triggers were categorized as a near miss (40.9%), no harm (3.7%), and harmful incident (0.2%). Inter-rater reliability testing showed good agreement in both sessions. CONCLUSION: This study shows that a trigger tool together with a retrospective record review can be used as a method to measure the frequency of harmful incidents, no harm incidents, and near misses in the EMS, thus complementing the traditional reporting system to realize increased patient safety.

Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support.

BACKGROUND: It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems. METHODS: A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems. RESULTS: The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others. CONCLUSIONS: Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.

A scoping review of the methodological approaches used in retrospective chart reviews to validate adverse event rates in administrative data.

Patient safety is a key quality issue for health systems. Healthcare acquired adverse events (AEs) compromise safety and quality; therefore, their reporting and monitoring is a patient safety priority. Although administrative datasets are potentially efficient tools for monitoring rates of AEs, concerns remain over the accuracy of their data. Chart review validation studies are required to explore the potential of administrative data to inform research and health policy. This review aims to present an overview of the methodological approaches and strategies used to validate rates of AEs in administrative data through chart review. This review was conducted in line with the Joanna Briggs Institute methodological framework for scoping reviews. Through database searches, 1054 sources were identified, imported into Covidence, and screened against the inclusion criteria. Articles that validated rates of AEs in administrative data through chart review were included. Data were extracted, exported to Microsoft Excel, arranged into a charting table, and presented in a tabular and descriptive format. Fifty-six studies were included. Most sources reported on surgical AEs; however, other medical specialties were also explored. Chart reviews were used in all studies; however, few agreed on terminology for the study design. Various methodological approaches and sampling strategies were used. Some studies used the Global Trigger Tool, a two-stage chart review method, whilst others used alternative single-, two-stage, or unclear approaches. The sources used samples of flagged charts (n = 24), flagged and random charts (n = 11), and random charts (n = 21). Most studies reported poor or moderate accuracy of AE rates. Some studies reported good accuracy of AE recording which highlights the potential of using administrative data for research purposes. This review highlights the potential for administrative data to provide information on AE rates and improve patient safety and healthcare quality. Nonetheless, further work is warranted to ensure that administrative data are accurate. The variation of methodological approaches taken, and sampling techniques used demonstrate a lack of consensus on best practice; therefore, further clarity and consensus are necessary to develop a more systematic approach to chart reviewing.

Safety incident reporting and barriers (SIRaB) study: Strategies and approaches for investigating patient safety events in a hospital set-up.

BACKGROUND: Unsafe patient events not only entail a clinical impact but also lead to economic burden in terms of prolonged hospitalization or unintended harm and delay in care delivery. Monitoring and time-bound investigation of patient safety events (PSEs) is of paramount importance in a healthcare set-up. OBJECTIVES: To explore the safety incident reporting behaviour and the barriers in a hospital set-up. METHODS: The study had two sections: (a) Retrospective assessment of all safety incidents in the past 1 year, and (b) Understanding the barriers of safety reporting by interviewing the major stakeholders in patient safety reporting framework. Further root cause analysis and failure mode effect analysis were performed for the situation observed. Results were statistically analyzed. RESULTS: Of the total of 106 PSEs reported voluntarily to the system, the highest reporting functional group was that of nurses (40.57%), followed by physicians (18.87%) and pharmacists (17.92%). Among the various factors identified as barriers in safety incident reporting, fear of litigation was the most observed component. The most commonly observed event was those pertaining to medication management, followed by diagnostic delay. Glitches in healthcare delivery accounted for 8.73% of the total reported PSEs, followed by 5.72% of events occurring due to inter-stakeholder communication errors. 4.22% of the PSEs were attributed to organizational managerial dysfunctionalities. Majority of medication-related PSE has moderate risk prioritization gradation. CONCLUSION: Effective training and sensitization regarding the need to report the patient unsafe incidents or near misses to the healthcare system can help avert many untoward experiences. The notion of 'No Blame No Shame' should be well inculcated within the minds of each hospital unit such that even if an error occurs, its prompt reporting does not get harmed.

Delineating patient errors in an intracavernosal injection program.

BACKGROUND: Intracavernosal injection therapy (ICI) is a well-established therapeutic strategy for men with erectile dysfunction. Complications are often related to patient error when performong ICI. AIM: The objective of this study was to examine patient errors in an established patient training program for performing ICI and identify factors that could predict major errors. METHODS: Patients enrolled in our ICI program are trained on technical aspects, and dose titration is begun. Patients are given explicit instructions during training, both verbally and in written form. Records were reviewed for men using ICI for ≥6 months. Multivariable analysis was used to define predictors of major errors. OUTCOMES: Errors were listed as minor (zero-response injection, penile bruising, expired medication) and major (errors potentially leading to priapism: dose self-titration, double injecting). RESULTS: Overall, 1368 patients met the inclusion criteria and were included in the analysis. The mean patient age was 66 ± 22 (range 29-91) years. Regarding education, 41% of patients had graduate-level education, 48% had college education, and 11% high school education. Mean follow-up was 3.2 ± 7.6 (range 0.5-12) years. The agents used were trimix (62%), bimix (35%), papaverine (2%), and prostaglandin E1 monotherapy (1%). At least 1 error occurred during self-administration in 42% of patients during their time in the program. Errors included zero response to medication due to technical error (8% of patients), penile bruising (34%), use of an expired bottle (18%), self-titration (5%), and double injecting (4% of patients); 12% of men committed ≥1 error during their time in the program. On multivariable analysis, independent predictors of the occurrence of a major error included: young age, graduate-level education, and <12 months of injection use. CLINICAL IMPLICATIONS: To the best of our knowledge, this is the first reported study to investigate ICI errors and risk factors. The identification of factors predictive of major errors allows for more tailored and intensive training in this subset of patients. STRENGTHS AND LIMITATIONS: Strengths of this study include a large patient population (1386 men) with a considerable follow-up time. Additionally, the rigorous training, education, and monitoring of the participants, as well as the use of formal definitions, enhances the accuracy and reliability of the results. Despite the strengths of the study, recall bias may be a limitation concern. CONCLUSION: The majority of patients were error free, and the majority of the errors were minor in nature. Major errors occurred in <10% of patients. Younger age, graduate-level education, and less experience with ICI were independent predictors of major errors.

Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care.

INTRODUCTION: Successful breast cancer outcomes can be jeopardised by adverse events. Understanding and integrating patients' and doctors' perspectives into care trajectories could improve patient safety. This study assessed their views on, and experiences of, medical error and patient safety. METHODS: A cross-sectional, quantitative 20-40 item questionnaire for patients attending Cork University Hospital Cancer Centre and breast cancer doctors in the Republic of Ireland was developed. Domains included demographics, medical error experience, patient safety opinions and concerns. RESULTS: 184 patients and 116 doctors completed the survey. Of the doctors, 41.4% felt patient safety had deteriorated over the previous five years and 54.3% felt patient safety measures were inadequate compared to 13.0% and 27.7% of patients respectively. Of the 30 patients who experienced medical errors/negligence claims, 18 reported permanent or long-term physical and emotional effects. Forty-two of 48 (87.5%) doctors who experienced medical errors/negligence claims reported emotional health impacts. Almost half of doctors involved in negligence claims considered early retirement. Forty-four patients and 154 doctors didn't experience errors but reported their patient safety concerns. Doctors were more concerned about communication and administrative errors, staffing and organisational factors compared to patients. Multiple barriers to error reporting were highlighted. CONCLUSION: This is the first study to assess patients' and doctors' patient safety views and medical error/negligence claims experiences in breast cancer care in Ireland. Experience of medical error/negligence claims had long-lasting implications for both groups. Doctors were concerned about a multitude of errors and causative factors. Failure to embed these findings is a missed opportunity to improve safety.

Importance of Quality of Medical Record: Differences in Patient Safety Incident Inquiry Results According to Assessment for Quality of Medical Record.

BACKGROUND: Medical record review is the gold standard method of identifying adverse events. However, the quality of medical records is a critical factor that can affect the accuracy of adverse event detection. Few studies have examined the impact of medical record quality on the identification of adverse events. OBJECTIVES: In this study, we analyze whether there were differences in screening criteria and characteristics of adverse events according to the quality of medical records evaluated in the patient safety incident inquiry in Korea. METHODS: Patient safety incident inquiry was conducted in 2019 on 7500 patients in Korea to evaluate their screening criteria, adverse events, and preventability. Furthermore, medical records quality judged by reviewers was evaluated on a 4-point scale. The χ 2 test was used to examine differences in patient safety incident inquiry results according to medical record quality. RESULTS: Cases with inadequate medical records had higher rates of identified screening criteria than those with adequate records (88.8% versus 55.7%). Medical records judged inadequate had a higher rate of confirmed adverse events than those judged adequate. "Drugs, fluids, and blood-related events," "diagnosis-related events," and "patient care-related events" were more frequently identified in cases with inadequate medical records. There was no statistically significant difference in the preventability of adverse events according to the medical record quality. CONCLUSIONS: Lower medical record quality was associated with higher rates of identified screening criteria and confirmed adverse events. Patient safety incident inquiry should specify medical record quality evaluation questions more accurately to more clearly estimate the impact of medical record quality.

Hospital Inpatient Nutrition Service Errors and Patient Safety Interventions: A Scoping Review.

OBJECTIVES: Food service errors are prevalent in healthcare hospital inpatient settings. Like medication administration errors, these mistakes can result in disastrous consequences. This scoping review aimed to identify the evidence describing hospitals' nutrition department service errors and subsequent patient safety interventions. METHODS: The review was conducted on four electronic databases, OVID MedlinePlus, PubMed, Scopus, and CINAHL, to search for articles reporting hospital food-related errors. All studies and reports on parenteral nutrition were excluded, and errors reported by departments other than nutrition services were excluded. A total of 245 studies published from 1984 to 2022 were identified. After removing duplicates, 98 abstracts were evaluated, with particular attention given to dietary errors, meal accuracy, and interventions. RESULTS: Twenty-nine articles were selected, and 14 (n = 14) were considered relevant to the review after a full-text review. More than half of the studies (n = 8) were conducted outside the United States. Eight studies (n = 8) were descriptive, retrospective, and observational; 3 were mixed-method studies (n = 3), 2 (n = 2) were quality improvement projects, and 1 was an implementation study (n = 1). Four (n = 4) studies were published before the year 2000. CONCLUSIONS: Various types of nutrition service inaccuracies were identified. The severity, causes, and stages of food service provision where errors occur were also documented. These errors were used as the basis for interventions to improve patient safety, justify implementing computerized dietary services systems, or add resources to augment dietary department service offerings. This review also generated valuable recommendations to promote patient safety by mitigating food service errors.

Publication Trends of Research on Adverse Event and Patient Safety in Nursing Research: A 8-Year Bibliometric Analysis.

BACKGROUND: Adverse events (AEs), which are associated with medical system instability, poor clinical outcomes, and increasing socioeconomic burden, represent a negative outcome of the healthcare system and profoundly influence patient safety. However, research into AEs remains at a developmental stage according to the existing literature, and no previous studies have systematically reviewed the current state of research in the field of AEs. Therefore, the aims of this study were to interpret the results of published research in the field of AEs through bibliometric analysis and to analyze the trends and patterns in the data, which will be important for subsequent innovations in the field. METHODS: A statistical and retrospective visualization bibliometric analysis was performed on July 28, 2022. The research data were extracted from the Web of Science Core Collection, and bibliometric citation analysis was performed using Microsoft Excel, VOSviewer 1.6.18, CiteSpace 6.1.R2, and the Online Analysis Platform of Literature Metrology ( http://bibliometric.com/ ). RESULTS: A total of 1035 publications on AEs were included in the analysis. The number of articles increased annually from 2014 to 2022. Among them, the United States (n = 318) made the largest contribution, and Chung-Ang University (n = 20) was the affiliation with the greatest influence in this field. Despite notable international cooperation, a regional concentration of research literature production was observed in economically more developed countries. In terms of authors, Stone ND (n = 9) was the most productive author in the research of AEs. Most of the publications concerning AEs were cited from internationally influential nursing journals, and the Journal of Nursing Management (n = 62) was the most highly published journal. Regarding referencing, the article titled "Medical error-the third leading cause of death in the US" received the greatest attention on this topic (51 citations). CONCLUSIONS: After systematically reviewed the current state of research in the field of AEs through bibliometric analysis, and AEs highlighted medication errors, patient safety, according reporting, and quality improvement as essential developments and research hotspots in this field. Furthermore, thematic analysis identified 2 new directions in research, concerned with psychological safety, nurse burnout, and with important research value and broad application prospects in the future.

Never events in plastic surgery: An analysis of surgical burns and medical malpractice litigation.

INTRODUCTION: Burns and fires in the operating room are a known risk and their prevention has contributed to many additional safety measures. Despite these safeguards, burn injuries contribute significantly to the medical malpractice landscape. The aim of the present study is to analyze malpractice litigation related to burn and fire injuries in plastic and reconstructive surgery, identify mechanisms of injury, and develop strategies for prevention. METHODS: The Westlaw and LexisNexis databases were queried for jury verdicts and settlements in malpractice lawsuits related to burn and fire injuries that occurred during plastic surgery procedures. The Boolean terms included "burn & injury & plastic", "fire & injury & "plastic surg!"" in Westlaw, and "burn & injury & "plastic surg!"", "fire & injury & "plastic surg!"" in LexisNexis. RESULTS: A total of 46 cases met the inclusion criteria for this study. Overheated surgical instruments and cautery devices were the most common mechanisms for litigation. Plastic surgeons were defendants in 40 (87%) cases. Of the included cases, 43% were ruled in favor of the defendant, while 33% were ruled in favor of the plaintiff. Mishandling of cautery devices 6 (13%), heated surgical instruments 6 (13%), and topical acids 2 (4%) were the most common types of errors encountered. CONCLUSION: Never events causing burn injury in plastic and reconstructive surgery are ultimately caused by human error or neglect. The misuse of overheated surgical instruments and cauterizing devices should be the focus for improving patient safety and reducing the risk of medical malpractice. Forcing functions and additional safeguards should be considered to minimize the risk of costly litigation and unnecessary severe harm to patients.

The Safety of Inpatient Health Care.

BACKGROUND: Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted. METHODS: We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events. RESULTS: In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%). CONCLUSIONS: Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).