Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses.

CONTEXT: - Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm. OBJECTIVES: - To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events. DESIGN: - A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013). Event reports that involved surgical specimen management were reviewed for patients undergoing surgery during which tissue or fluid was sent to the pathology department. RESULTS: - Six hundred forty-eight surgical specimen events were reported in all stages of the specimen management process, with the most common events reported during the prelaboratory phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events (52 of 648) resulted in either the need for additional treatment or temporary or permanent harm to the patient. CONCLUSIONS: - All phases of specimen handling and processing are vulnerable to errors. These results provide a starting point for health care organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. Particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. In addition, organizations should consider the use of technology-based identification and tracking systems.

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.

BACKGROUND: In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. METHODS: We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. RESULTS: A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. CONCLUSIONS: Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of events reported in each database were related to the purpose of the database and the source of the reports, resulting in significant differences in reported event categories across the 3 systems, and (3) a public-private collaboration for investigating ventilator-related adverse events under the P5S model is feasible.

Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

BACKGROUND: Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. STUDY DESIGN: Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. RESULTS: Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. CONCLUSIONS: Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.

Outcomes of an initial set of standardized performance measures for inpatient mental health.

BACKGROUND: In January 2006, the University HealthSystem Consortium (UHC) convened a committee of experts from academic health centers to identify an initial set of important standardized performance measures for inpatient psychiatric services and to evaluate the current state of performance in these measures at eight academic health centers. METHOD: The eight UHC academic medical centers completed a retrospective review of 20 inpatient psychiatric records on patients who were 18-65 years of age with a primary diagnosis of psychosis and a length of stay > or = 2 days. The performance measures, derived from practice standards and the consensus of an interdisciplinary committee of experts, focused on the processes of care, including screening, assessment, treatment, coordination, continuity, and safety. RESULTS: Although there was variability in organizational performance in a number of the psychiatric measures, some organizations demonstrated high levels of performance. Performance measures indicating the greatest improvement opportunities for organizations included notification of outpatient mental health provider of the psychiatric hospitalization within two days; collaboration with the outpatient mental health provider and/or primary care physician; and scheduling a follow-up appointment within seven days of discharge. DISCUSSION: This initial benchmarking project in mental health at academic health centers shows that there is a range of conformity to important processes of care in the inpatient mental health setting. The results of the notification, collaboration, and continuity measures in this study highlight national concerns regarding the lack of communication and collaboration between providers in the transition through the continuum of services. Future quality measurement projects in mental health services should integrate clinical process measures with outcome measures.