Improving Shared Situation Awareness for High-risk Therapies in Hospitalized Children

BACKGROUND: High-risk therapies (HRTs), including medications and medical devices, are an important driver of preventable harm in children’s hospitals. To facilitate shared situation awareness (SA) and thus targeted harm prevention, we aimed to increase the percentage of electronic health record (EHR) alerts with the correct descriptor of an HRT from 11% to 100% on a high-acuity hospital unit over a 6-month period. METHODS: The interdisciplinary team defined an HRT as a medication or device with a significant risk for harm that required heightened awareness. Our aim for interventions was to (1) educate staff on a new HRT algorithm; (2) develop a comprehensive table of HRTs, risks, and mitigation plans; (3) develop bedside signs for patients receiving HRTs; and (4) restructure unit huddles. Qualitative interviews with families, nurses, and medical teams were used to assess shared SA and inform the development and adaptation of interventions. The primary outcome metric was the percentage of EHR alerts for an HRT that contained a correct descriptor of the therapy for use by the care team and institutional safety leaders. RESULTS: The percentage of EHR alerts with a correct HRT descriptor increased from an average of 11% to 96%, with special cause variation noted on a statistical process control chart. Using qualitative interview data, we identified critical awareness gaps, including establishing a shared mental model between nursing staff and the medical team as well as engagement of families at the bedside to monitor for complications. CONCLUSIONS: Explicit, structured processes and huddles can increase HRT SA among the care team, patient, and family.

P12.04 Body Mass Index: a possible PICC-related complications risk factor in neuro oncological patients

BACKGROUND The use of central venous catheter with peripheral insertion (PICC) has increased rapidly in recent years particularly in cancer patients because they represent a stable and safe vascular access to administer irritants or vesicants therapies. However, the benefit provided may occasionally be affected by severe complications. An observational study conducted at our Institute, showed a significant increase of thromboembolic risk in neuro-oncological patients compared to general cancer population (16.3% vs 6.7% respectively). For this reason, it is essential to identify independent risk factors in order to avoid preventable harm. MATERIAL AND METHODS Neuro-oncological patients with PICC that developed a thromboembolic event were retrospectively analyzed. We evaluated clinical data, BMI, KPS, steroid therapies and anticoagulants at the time of positioning of the PICC and at the onset of the thrombotic event. RESULTS A total of 90 neuro-oncological patients have been analyzed. The most common histology was represented by glioblastoma, followed by anaplastic astrocytoma, primary central nervous system lymphoma, grade II glioma. 17.6% of patients were at first diagnoses, 41.6% were at the first recurrence, and the remaining patients were at the second or third recurrence. The median KPS was 90 (range 80–100), and the median ECOG was 0 (range 0–2). Overall, 14% patients developed thromboembolic events within a median time of 34.5 days (range 5–146) after PICC implantation. Among these, 64% of patients was considered overweight. No patients were on anticoagulant therapy but all were treated with a median dose of 5.5 mg of steroids (range 3,5-12), stable between PICC insertion and onset of adverse event. CONCLUSION 64% of patients who developed a thromboembolic event had BMI >28 at the time of PICC insertion, suggesting a possible trend towards a risk of developing PICC related thrombosis in overweight/obese patients. Other independent risk factors for PICC associated complications seems to be amount of previous chemotherapies administered: 82% of patients who developed thrombotic complications had already undergone at least one line of chemotherapy before PICC placement, suggesting this condition as a possible risk factor for the onset of the event. Also failed positioning attempts could damage vascular endothelium, contributing to the onset of thrombotic complications. An accurate anamnesis and a physical evaluation with particular attention to the presence of malnutrition could help in the in the early identification of independent risk factors that could farther negatively influence the outcome of neuro-oncological patients.

Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study

ObjectivesTo determine the epidemiology of healthcare harm observable in general practice records.DesignRetrospective cohort records review study.Setting72 general practice clinics were randomly selected from all 988 New Zealand clinics stratified by rurality and size; 44 clinics consented to participate.Participants9076 patient records were randomly selected from participating clinics.InterventionEight general practitioners examined patient records (2011–2013) to identify harms, harm severity and preventability. Analyses were weighted to account for the stratified sampling design and generalise findings to all New Zealand patients.Main outcome measuresHealthcare harm, severity and preventability.ResultsReviewers identified 2972 harms affecting 1505 patients aged 0–102 years. Most patients (82.0%, weighted) experienced no harm. The estimated incidence of harm was 123 per 1000 patient-years. Most harms (2160; 72.7%, 72.4% weighted) were minor, 661 (22.2%, 22.8% weighted) were moderate, and 135 (4.5%, 4.4% weighted) severe. Eleven patients died, five following a preventable harm. Of the non-fatal harms, 2411 (81.6%, 79.4% weighted) were considered not preventable. Increasing age and number of consultations were associated with increased odds of harm. Compared with patients aged ≤49 years, patients aged 50–69 had an OR of 1.77 (95% CI 1.61 to 1.94), ≥70 years OR 3.23 (95% CI 2.37 to 4.41). Compared with patients with ≤3 consultations, patients with 4–12 consultations had an OR of 7.14 (95% CI 5.21 to 9.79); ≥13 consultations OR 30.06 (95% CI 21.70 to 41.63).ConclusionsStrategic balancing of healthcare risks and benefits may improve patient safety but will not necessarily eliminate harms, which often arise from standard care. Reducing harms considered ‘not preventable’ remains a laudable challenge.

Now the Hard Part: Creating a

In 2020, the coronavirus pandemic killed 1,800,000 people, 346,000 of them Americans. In that same year, if recent estimates are correct, about the same number died as a result of medical errors, all despite the enormous effort of the past 20 years to eliminate preventable harm, an effort that has involved people at all levels: policy makers, government agencies, oversight bodies, quality improvement organizations, major health-care systems, and thousands of providers and caregivers on the frontline.

Preventable medication harm across health care settings: a systematic review and meta-analysis

Background Mitigating or reducing the risk of medication harm is a global policy priority. But evidence reflecting preventable medication harm in medical care and the factors that derive this harm remain unknown. Therefore, we aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. Methods We performed a systematic review and meta-analysis of observational studies to compare the prevalence of preventable medication harm. Searches were carried out in Medline, Cochrane library, CINAHL, Embase and PsycINFO from 2000 to 27 January 2020. Data extraction and critical appraisal was undertaken by two independent reviewers. Random-effects meta-analysis was employed followed by univariable and multivariable meta-regression. Heterogeneity was quantified using the I2 statistic, and publication bias was evaluated. PROSPERO: CRD42020164156. Results Of the 7780 articles, 81 studies involving 285,687 patients were included. The pooled prevalence for preventable medication harm was 3% (95% confidence interval (CI) 2 to 4%, I2 = 99%) and for overall medication harm was 9% (95% CI 7 to 11%, I2 = 99.5%) of all patient incidence records. The highest rates of preventable medication harm were seen in elderly patient care settings (11%, 95% 7 to 15%, n = 7), intensive care (7%, 4 to 12%, n = 6), highly specialised or surgical care (6%, 3 to 11%, n = 13) and emergency medicine (5%, 2 to 12%, n = 12). The proportion of mild preventable medication harm was 39% (28 to 51%, n = 20, I2 = 96.4%), moderate preventable harm 40% (31 to 49%, n = 22, I2 = 93.6%) and clinically severe or life-threatening preventable harm 26% (15 to 37%, n = 28, I2 = 97%). The source of the highest prevalence rates of preventable harm were at the prescribing (58%, 42 to 73%, n = 9, I2 = 94%) and monitoring (47%, 21 to 73%, n = 8, I2 = 99%) stages of medication use. Preventable harm was greatest in medicines affecting the ‘central nervous system’ and ‘cardiovascular system’. Conclusions This is the largest meta-analysis to assess preventable medication harm. We conclude that around one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Our results support the World Health Organisation’s push for the detection and mitigation of medication-related harm as being a top priority, whilst highlighting other key potential targets for remedial intervention that should be a priority focus for future research.