Supporting Error Management and Safety Climate in Ambulatory Care Practices: The CIRSforte Study.

BACKGROUND: To improve patient safety, it is important that healthcare facilities learn from critical incidents. Tools such as reporting and learning systems and team meetings structure error management and promote learning from incidents. To enhance error management in ambulatory care practices, it is important to promote a climate of safety and ensure personnel share views on safety policies and procedures. In contrast to the hospital sector, little research has been dedicated to developing feasible approaches to supporting error management and safety climate in ambulatory care. In this study, we developed, implemented, and evaluated a multicomponent intervention to address how error management and safety climate can be improved in ambulatory care practices. METHODS: In a prospective 1-group pretest-posttest implementation study, we sought to encourage teams in German ambulatory practices to use proven methods such as guidelines, workshops, e-learning, (online) meetings, and e-mail newsletters. A pretest-posttest questionnaire was used to evaluate level and strength of safety climate and psychological behavioral determinants for systematic error management. Using 3 short surveys, we also assessed the state of error management in the participating practices. In semistructured interviews, we asked participants for their views on our intervention measures. RESULTS: Overall, 184 ambulatory care practices nationwide agreed to participate. Level of safety climate and safety climate strength (rwg) improved significantly. Of psychological behavioral determinants, significant improvements could be seen in "action/coping planning" and "action control." Seventy-six percent of practices implemented a new reporting and learning system or modified their existing system. The exchange of information between practices also increased over time. Interviews showed that the introductory workshop and provided materials such as report forms or instructions for team meetings were regarded as helpful. CONCLUSIONS: A significant improvement in safety climate level and strength, as well as participants' knowledge of how to analyze critical incidents, derive preventive measures and develop concrete plans suggest that it is important to train practice teams, to provide practical tips and tools, and to facilitate the exchange of information between practices. Future randomized and controlled intervention trials should confirm the effectiveness of our multicomponent intervention.Trial registration: Retrospectively registered on 18. November 2019 in German Clinical Trials Register No. DRKS00019053.

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

OBJECTIVE: 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.

[The analysis of CIRSmedical.de using Natural Language Processing]. / Die Analyse des CIRSmedical.de mittels Natural Language Processing.

BACKGROUND: CIRSmedical.de is a publicly accessible, cross-institutional reporting and learning system, which is organized by the German Agency for Quality in Medicine (ÄZQ). CIRSmedical.de has existed since 2005 and has published more than 6,000 event reports. Up to now it has been common practice to analyse these reports in detail or carry out systematic evaluations focusing on specific topics. A systematic evaluation of all case reports has not yet been conducted. Natural Language Processing (NLP) is an analysis strategy from the field of Artificial Intelligence for indexing texts. The examination of case reports using NLP was carried out to describe the characteristics of event reports and comments. MATERIALS AND METHODS: For this analysis 6,480 case reports from CIRSmedical.de (as of December 10, 2019) were provided by the ÄZQ as Excel files. Several free text fields were included in the analysis as well as the feedback of the CIRS team (expert commentary). Text lengths, reporting behaviour, sentiment values and keywords were examined. The algorithms for the analysis were developed with the programming language Python and the corresponding libraries NLTK and SpaCy. RESULTS: The comparison of report lengths depending on the different subject groups presented a heterogeneous picture, in terms of both the number of reports and the number of words. There are more than 4,000 reports from the field of anaesthesiology, whereby text lengths vary particularly strongly with a right-skewed distribution. There are only a few reports from the field of psychotherapy, and these are also very short. The different professional groups (nurses, doctors, other staff) write reports of about the same length. Reports and expert commentaries also differ in terms of sentiment values. Due to the length of the comments, they are more negative in terms of sentiment. Keywords can be identified but show a high heterogeneity. DISCUSSION: Systematic analysis using NLP allows for the description of text properties in event reports and comments. It is now possible to draw a conclusion about the reporters' intention, focus and mood when they report in CIRS. The sentiment analysis is an indication of the mood which the texts convey, both as a report and as a commentary. Text length analysis draws attention to different problems and tendencies: event reports are usually much shorter. Texts that are too short, however, run the risk that the information will not be readily usable for analysis. Comments are often longer, but here one faces the opposite problem: texts that are too long may not be read. The examination of texts by means of NLP helps to rethink the reason for and the form of input, both when reporting and when commenting. It is a first step in the automatic, supportive classification of texts and an improvement of the interaction between reporters and the system.

The WHO High 5s project: medication reconciliation in a German university hospital. A prospective observational cohort study.

BACKGROUND: Ensuring medication accuracy during transitions in care is one of the five highly prevalent patient safety problems focused on within the World Health Organization High 5s Project. Medication reconciliation is a standardized patient care process that can be used to address this problem. The aim of the current study is to implement medication reconciliation in a German university hospital. METHODS: The study was conducted at the Emergency Department of the University Hospital Aachen, Germany. All discrepancies between the Best Possible Medication History and the Admission Medication Order were documented and classified as documentation errors or medication errors. The type of error was also recorded. A negative binomial regression model was used to test several factors influencing the number of discrepancies. RESULTS: The medications of 105 patients were reconciled. The mean number of discrepancies per patient was 4.6± 3.6, with a total of 298 medication errors and 189 documentation errors. The most common type of medication error was the omission of a drug (n=208; 69.8 %). In the negative binomial regression analysis, the care status (p=0.0015) as well as the number of preadmission drugs (p=0.0007) were significantly associated with medication errors. DISCUSSION: A high number of discrepancies was detected and analysed. Patients admitted from nursing homes were less likely to have discrepancies in their medication reconciliation, perhaps because a structured documentation system for medications is already in place at nursing homes including error prone products (special dosage forms or food supplements). CONCLUSIONS: In this study, medication reconciliation was implemented at a German full-care university hospital. The actual number of discrepancies observed strongly indicates the need for medication reconciliation at hospital admission.

Standardization in patient safety: the WHO High 5s project.

QUALITY PROBLEM: Despite its success in other industries, process standardization in health care has been slow to gain traction or to demonstrate a positive impact on the safety of care. INTERVENTION: The High 5s project is a global patient safety initiative of the World Health Organization (WHO) to facilitate the development, implementation and evaluation of Standard Operating Protocols (SOPs) within a global learning community to achieve measurable, significant and sustainable reductions in challenging patient safety problems. GOALS: The project seeks to answer two questions: (i) Is it feasible to implement standardized health care processes in individual hospitals, among multiple hospitals within individual countries and across country boundaries? (ii) If so, what is the impact of standardization on the safety problems that the project is targeting? METHOD: The two key areas in which the High 5s project is innovative are its use of process standardization both in hospitals within a country and in multiple participating countries, and its carefully designed multi-pronged approach to evaluation. STATUS: Three SOPs-correct surgery, medication reconciliation, concentrated injectable medicines-have been developed and are being implemented and evaluated in multiple hospitals in seven participating countries. Nearly 5 years into the implementation, it is clear that this is just the beginning of what can be seen as an exercise in behavior management, asking whether health care workers can adapt their behaviors and environments to standardize care processes in widely varying hospital settings.

[After 15 years of ÄZQ: 10 years of safety for patients]. / 15 Jahre ÄZQ--10 Jahre Patientensicherheit am ÄZQ.

The German Agency for Quality in Medicine (ÄZQ) has been actively addressing the topic patient safety for ten years. ÄZQ's work in the field has focused on establishing a patient safety expert circle, publishing various articles on the subject, developing a patient safety continuing education curriculum, setting up a patient safety internet forum, and participating in the WHO initiative "Action on Patient Safety: High 5s". Furthermore, "CIRSmedical.de", a reporting and learning system for German medical professionals supported and maintained by ÄZQ, developed into the nationwide "CIRSmedical.de Network". In the following article these activities and how they relate to other national and international patient safety programs are described.

[A proposal of the medical profession for the prevention of medical errors]. / Konzept der Arzteschaft zur Behandlungsfehlerprävention.

In 2002 the Agency for Quality in Medicine developed an "action plan" to improve patient safety that can be summarized neatly as "Sensitize, inform, discuss and implement strategies". The following publication describes both the goals of this action plan and some of its implemented measures.

[The German program for disease management guidelines: evaluation by use of quality indicators]. / Nationale VersorgungsLeitlinien--Evaluation durch Qualitätsindikatoren.

The Program for National Disease Management Guidelines (German DM-CPG Program) in Germany aims at the implementation of best-practice recommendations for prevention, acute care, rehabilitation and chronic care in the setting of disease management programs and integrated health-care systems. Like other guidelines, DM-CPG need to be assessed regarding their influence on structures, processes and outcomes of care. However, quality assessment in integrated health-care systems is challenging. On the one hand, a multitude of potential domains for measurement, actors and perspectives need to be considered. On the other hand, measures need to be identified that assess the function of the diagnostic and therapeutic chain in terms of cooperation and coordination of care. The article reviews methods and use of quality indicators in the context of the German DM-CPG Program.

MedIEQ-Quality labelling of medical web content using multilingual information extraction.

Quality of Internet health information is essential because it has the potential to benefit or harm a large number of people and it is therefore essential to provide consumers with some tools to aid them in assessing the nature of the information they are accessing and how they should use it without jeopardizing their relationship with their doctor. Organizations around the world are working on establishing standards of quality in the accreditation of health-related web content. For the full success of these initiatives, they must be equipped with technologies that enable the automation of the rating process and allow the continuous monitoring of labelled web sites alerting the labelling agency. In this paper we describe the European project MedIEQ (Quality Labelling of Medical Web Content Using Multilingual Information Extraction) that integrates the efforts of relevant organizations on medical quality labelling, multilingual information retrieval and extraction and semantic resources, from six different European countries (Spain, Germany, Greece, Finland, Czech Republic and Switzerland). The main objectives of MedIEQ are: first, to develop a scheme for the quality labelling of medical web content and provide the tools supporting the creation, maintenance and access of labelling data according to this scheme and second, to specify a methodology for the content analysis of medical web sites according to the MedIEQ scheme and develop the tools that will implement it.

[Clinical practice guidelines in Germany, 1994 to 2004. From guideline methodology towards guideline implementation]. / Medizinische Leitlinien in Deutschland, 1994 bis 2004. Von der Leitlinienmethodik zur Leitlinienimplementierung.

The role of clinical practice guidelines (CPG) as a tool for continuous medical education (CME), and quality management in health care is now widely accepted in Germany. Since the 90ies, the physicians' professional associations as well as health care authorities and parliament have been introducing several incentives and regulations in order to promote the use of evidence based CPG. In the past German CPG agencies have been focussing their work on developing and optimising methodological CPG standards. Future CPG activities should address much more other key factors for the success of CPGs, such as medical relevance, practicability, effective dissemination, and implementation. The article describes the process of guideline adaptation by regional physician audit groups as a tool for CPG implementation.

[Quality management in health care: error prevention and managing errors in medicine]. / Qualitätsmanagement im Gesundheitswesen: Fehlerprävention und Umgang mit Fehlern in der Medizin.

BACKGROUND: About 3.7% of in-house-treated patients in Switzerland, the USA and Australia are victims of treatment-related health problems which probably are related to avoidable "adverse events" in more than 50% of the occurrences. Reasons are primarily systematic incidents, e.g., organizational deficiencies in the health system and only secondarly individual mistakes. As there are no systematic studies available, it is not proven if those figures can be transferred to the German Health Care System. Here, experts anticipate up to 12.000 proven treatment errors per year. PREVENTION OF AND DEALING WITH ADVERSE EVENTS: Dedicated programs for identification and prevention of adverse events should be implemented--besides systematic quality improvement--to improve professional handling and prevention of adverse events. This consists of a) assessment of the existing problem using existing data bases and/or implementation of mandatory documentation and information routines as well as reporting systems, b) development of sanction-free reporting routines within the legal framework, c) dissemination of behavior-oriented training systems for recognition and prevention of adverse events as well as incentives for the participation in such training systems, d) implementation of automatic routines for prevention of adverse events (e.g., computer-based monitoring of ADE or computer-based reminder systems based on clinical guidelines).