Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety: – an analysis in a Finnish teaching hospital

Minna Halinen; Hanna Tiirinki; Auvo Rauhala; Sanna Kiili; Tuija Ikonen

doi:10.1186/s12873-024-01120-9

Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety: – an analysis in a Finnish teaching hospital

Översatt titel: Grundorsaker bakom patientsäkerhetsincidenter på akutmottagningen och förslag för att förbättra patientsäkerheten: – en analys på ett finskt undervisningssjukhus

Minna Halinen
, Hanna Tiirinki
, Auvo Rauhala
, Sanna Kiili
, Tuija Ikonen

Hälsovetenskaper

Forskningsoutput: Tidskriftsbidrag › Artikel › Vetenskaplig › Peer review

74 Nedladdningar (Pure)

Sammanfattning

Bakgrund
Biverkningar inträffar ofta på akutmottagningar (ED) på grund av flera riskfaktorer relaterade till olika tillstånd. Det är fortfarande oklart vilka faktorer som leder till patientsäkerhetsincidentrapporter.
Syftet med denna studie var att utforska grundorsakerna bakom ED-relaterade patientsäkerhetsincidenter som rapporterats av personal, och baserat på resultaten, föreslå lärandemål för att förbättra patientsäkerheten.
Metoder
Studiematerialet inkluderade incidentrapporter (n = 340) som gällde akuten på ett undervisningssjukhus under ett år. Vi använde en blandad metod som kombinerade kvantitativ deskriptiv statistik och kvalitativ forskning genom induktiv innehållsanalys och deduktiv Ishikawa rotorsaksanalys.
Resultat
De flesta (76,5 %) incidenter rapporterades efter patientöverföring från akutmottagningen. Sjuksköterskor rapporterade 70 % av incidenterna och läkare 7,4 %. Av rapporterna var 40 % relaterade till informationsflöde eller hantering. Incidenter utvärderades som ingen skada (29,4 %), mild (46 %), måttlig (19,7 %) och allvarlig (1,2 %) skada på patienten. De främsta konsekvenserna för organisationen var anseendeförlust (44,1 %) och extraarbete (38,9 %).
I den kvalitativa analysen hittades nio specifika problemgrupper: otillräcklig introduktion, efterlevnad av riktlinjer och protokoll, otillräckliga mänskliga resurser, bristfälliga yrkeskunskaper, brister i läkemedelshanteringen, ofullständig informationsöverföring från akutmottagningen, språkkunskaper, oprofessionellt beteende, identifieringsfel och patientberoende problem.
Sex organisatoriska teman identifierades: medicinsk personalorientering, onboarding och kompetenskrav; mänskliga resurser; elektroniska medicinska journaler och informationsöverföring; läkemedelsdokumentationssystem; interprofessionellt samarbete; resurser för specifika patientgrupper såsom geriatrik, psykisk hälsa och patienter med missbrukssyndrom. Helt mänskliga faktorrelaterade teman kunde inte definieras eftersom deras associationer till systemfaktorer var komplexa och mångfacetterade.
Individuella och organisatoriska inlärningsmål togs upp, såsom efterlevnad av korrekt användning av instruktioner och adekvat onboarding.
Slutsatser
Systemfaktorer orsakade de flesta av de patientsäkerhetsincidenter som rapporterades angående ED. Introduktion och utbildning av ED-processer är elementärt, liksom multiprofessionellt samarbete. Mer forskning behövs om lagarbete, patienter med särskilda behov och icke-kritiska patienter och rapportering av allvarliga incidenter.

Översatt titel	Grundorsaker bakom patientsäkerhetsincidenter på akutmottagningen och förslag för att förbättra patientsäkerheten: – en analys på ett finskt undervisningssjukhus
Originalspråk	Engelska
Artikelnummer	209
Tidskrift	BMC Emergency Medicine
Volym	24
DOI	https://doi.org/10.1186/s12873-024-01120-9
Status	Publicerad - 7 nov. 2024
MoE-publikationstyp	A1 Tidskriftsartikel-refererad

Finansiering

Thank language examiner Elizabeth Nyman of Turku University for language revision, Morag Tolvi for language revision and layout finishing and artist Nea Luurila for the realization of the fishbone illustration.

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10.1186/s12873-024-01120-9Licens: CC BY-NC-ND

s12873-024-01120-9Slutlig publicerad version, 1,34 MBLicens: CC BY-NC-ND

https://urn.fi/URN:NBN:fi-fe2024111290934

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title = "Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety: – an analysis in a Finnish teaching hospital",

abstract = "Background: Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports. The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety. Methods: The study material included incident reports (n = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis. Results: Most (76.5\%) incidents were reported after patient transfer from the ED. Nurses reported 70\% of incidents and physicians 7.4\%. Of the reports, 40\% were related to information flow or management. Incidents were evaluated as no harm (29.4\%), mild (46\%), moderate (19.7\%), and severe (1.2\%) harm to the patient. The main consequences for the organization were reputation loss (44.1\%) and extra work (38.9\%). In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems. Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted. Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding. Conclusions: System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents.",

author = "Minna Halinen and Hanna Tiirinki and Auvo Rauhala and Sanna Kiili and Tuija Ikonen",

year = "2024",

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doi = "10.1186/s12873-024-01120-9",

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T1 - Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety

T2 - – an analysis in a Finnish teaching hospital

AU - Halinen, Minna

AU - Tiirinki, Hanna

AU - Rauhala, Auvo

AU - Kiili, Sanna

AU - Ikonen, Tuija

PY - 2024/11/7

Y1 - 2024/11/7

N2 - Background: Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports. The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety. Methods: The study material included incident reports (n = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis. Results: Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports, 40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%). In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems. Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted. Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding. Conclusions: System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents.

AB - Background: Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports. The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety. Methods: The study material included incident reports (n = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis. Results: Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports, 40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%). In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems. Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted. Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding. Conclusions: System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents.

U2 - 10.1186/s12873-024-01120-9

DO - 10.1186/s12873-024-01120-9

M3 - Article

SN - 1471-227X

VL - 24

JO - BMC Emergency Medicine

JF - BMC Emergency Medicine

M1 - 209

ER -

Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety: – an analysis in a Finnish teaching hospital

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