Development of an effective risk management system in a teaching hospital

Journal of Diabetes & Metabolic Disorders

Ali Reza Jeddian¹  Mahdi Jafari²  Hamid Ravaghi²  Nader Khalesi²  Hossein Adibi² 

[1] Shariaty Hospital, Tehran University of Medical Sciences, Tehran, Iran;Department of Health Services Management, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran

关键词: Adverse event;    Risk management;    Patient safety;   

Others  :  807233
DOI  :  10.1186/2251-6581-11-15

 received in 2012-08-22, accepted in 2012-09-06,  发布年份 2012

【 摘 要 】

Background

Unsafe health care provision is a main cause of increased mortality rate amongst hospitalized patients all over the world. A system approach to medical error and its reduction is crucial that is defined by clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury. The aim of this study was to develop and implement a risk management system in a large teaching hospital in Iran, especially of the basis of WHO guidelines and patient safety context.

Methods

WHO draft guideline and patient safety reports from different countries were reviewed for defining acceptable framework of risk management system. Also current situation of mentioned hospital in safety matter and dimensions of patient safety culture was evaluated using HSOPSC questionnaire of AHRQ. With adjustment of guidelines and hospital status, the conceptual framework was developed and next it was validated in expert panel. The members of expert panel were selected according to their role and functions and also their experiences in risk management and patient safety issues. The validated framework consisted of designating a leader and coordinator core, defining communications, and preparing the infrastructure for patient safety education and culture-building. That was developed on the basis of some values and commitments and included reactive and proactive approaches.

Results

The findings of reporting activities demonstrated that at least 3.6 percent of hospitalized patients have experienced adverse events and 5.3 percent of all deaths in the hospital related with patient safety problems. Beside the average score of 12 dimensions of patient safety culture was 46.2 percent that was considerably low. The “non-punitive responses to error” had lowest positive score with 21.2 percent.

Conclusion

It is of paramount importance for all health organizations to lay necessary foundations in order to identify safety risks and improve the quality of care. Inadequate participation of staff in education, reporting and analyzing, underreporting and uselessness of aggregated data, limitation of human and financial resources, punitive directions and management challenges for solutions were the main executive problems which could affect the effectiveness of system.

【 授权许可】

   
2012 Adibi et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Smits M, Zegers M, Groenewegen P, Timmermans DRM, Zwaan L, van der Wal G, Wagner C: Exploring the causes of adverse events in hospitals and potential prevention strategies. Qual Saf Health Care 2010, 19(5):e5.
• [2]Zegers M, Bruijne M, Wagner C, Groenewegen P, Waaijman R, van der Wal G: Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals. BMC Health Services Research 2007, 25:7-27.
• [3]Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, Etchells E, Ghali WA, Hebert P, Majumdar SR, O’ Beirne M, Palacios-Derflingher L, Reid RJ, Sheps S, Tamblyn R: The canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004, 170:1678-1686.
• [4]Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991, 324:370-376.
• [5]Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S: Adverse events in New Zealand public hospitals I: occurrence and impact. N Z Med J 2002, 115:U271.
• [6]Hayward RA, Hofer TP: Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001, 286:415-420.
• [7]Jarman B, Gault S, Alves B, Hider A, Dolan S, Cook A, Hurwitz B, Iezzoni LI: Explaining differences in English hospital death rates using routinely collected data. BMJ 1999, 318:1515-1520.
• [8]Michel P, Quenon JL, de Sarasqueta AM, Scemama O: Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ 2004, 328(7433):199.
• [9]Park RE, Brook RH, Kosecoff J, Keesey J, Rubenstein L, Keeler E, Kahn KL, Rogers WH, Chassin MR: Explaining variations in hospital death rates. Randomness, severity of illness, quality of care. JAMA 1990, 264:484-490.
• [10]Schioler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A, Svenning AR, Frolich A: Danish Adverse Event Study: [Incidence of adverse events in hospitals. A retrospective study of medical records]. Ugeskr Laeger 2001, 163:5370-5378.
• [11]Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA: Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000, 38:261-271.
• [12]Vincent C, Neale G, Woloshynowych M: Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001, 322:517-519.
• [13]Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD: The Quality in Australian Health Care Study. Med J Aust 1995, 163:458-471.
• [14]Vries E, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA: The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008, 17:216-223.
• [15]Hoonhout LH, de Bruijne MC, Wagner C, et al.: Direct medical costs of adverse events in Dutch hospitals. BMC Health Services Research 2009, 9:27. BioMed Central Full Text
• [16]Zegers M, de Bruijne MC, Wagner C, et al.: Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 2009, 18:297-302.
• [17]Zegers HWM: Adverse events among hospitalized patients: results and methodological aspects of a record review study. In Program coordinator. Edited by Wagner C. NIVEL: PhD thesis Utrecht; 2009:207.
• [18]World Health Organization World alliance for patient safety: WHO Draft Guidelines for Adverse Event Reporting and Learning Systems From information to action. Geneva; 2005. http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf webcite
• [19]Kohn LT: To err is human: building a safer health care system. Institute of Medicine; 1999:1-11. http://books.nap.edu/openbook.php?isbn=0309068371 webcite
• [20]World Health Organization: World Alliance for Patient Safety Forward Programme. Geneva; 2005. http://www.who.int/patientsafety/en/brochure_final.pdf webcite
• [21]The Joint Commission Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety. 2007. http://www.jointcommission.org/assets/1/6/2007_Annual_Report.pdf webcite
• [22]Tasmanian CT review team Risk management process: Draft guidance manual for infrastructure operators. 2003. http://www.statesecurity.tas.gov.au/docs/riskmanagement.pdf webcite
• [23]Hare C, Davies C, Shepherd M: Safer medicine administration through the use of e-learning. Nursing Times 2006, 102(16):25-27.
• [24]Neale G: Risk management in the care of medical emergencies after referral to hospital. J R Coll Physicians Lond 1998, 32(2):125-9.
• [25]Neale G, Woloshynowych M, Vincent C: Exploring the causes of adverse events in NHS hospital practice. J R Soc Med 2001, 94:322-30.
• [26]Handel DA, McConnell KJ: Emergency department length of stay and predictive demographic characteristics. Ann Emerg Med 2007, 50(3):s70.
• [27]Yarahmadi R: Performance assessment on hospital inpatients departments based on rules and policy. Health Work J 2009, 3(6):1-5.
• [28]Verbano C, Turra F: A human factors and reliability approach to clinical risk management: Evidence from Italian cases. Saf Sci 2010, 48(5):625-39.
• [29]Colorado Center for Nursing Excellence: The 2004 Colorado. Nursing Faculty Supply and Demand Study. 2007. http://www.coloradonursingcenter.org webcite
• [30]National League for Nursing: Challenges to the Nursing Discipline. 2003 edition. 2003. http://www.nln.org webcite
• [31]Moi Lin L: Healthcare Worker Safety and Welfare: Responsibility of the Hospital Administration. Int J Antimicrob Agents 2005, 26(1):S1-S6.
• [32]Zaboli R, Tofighi S, Delavari A, Mirhashemi S: Survey of Safety Management On Bagiyatallah (a.s) Hospital, 2006–07. J Mil Med 2007, 9(2):103-111.
• [33]United States General Accounting Office: ADVERSE EVENTS, Surveillance Systems for Adverse Events and Medical Errors. 2000. http://www.gao.gov/assets/110/108220.pdf webcite
• [34]Patton JM, Hoffmann KT: Patient Precautions Task Force-Hand Off Communication for Patient Safety in a 700-Bed Community Hospital System. Am J Infect Control 2007, 35(5):E137.
• [35]Anderson JG, Ramanujam R, Hensel D, Anderson MM, Sirio CA: The need for organizational change in patient safety initiatives. Int J Med Inform 2006, 75(12):809-817.
• [36]Wood RH: Aviation Safety Programs: A Management Handbook. Jeppesen Sanderson: Third edition; 2003.
• [37]Abdi Z, Maleki MR, Khosravi A: Perceptions of patient safety culture among staff of selected hospitals affiliated to Tehran University of Medical Sciences. Payesh 2011, 10(4):411-19.
• [38]Frankel A, Grillo SP, Baker EG, Huber CN, Abookire S, Grenham M, Console P, O'Quinn M, Thibault G, Gandhi TK: Patient Safety Leadership WalkRounds at Partners Healthcare: learning from implementation. Jt Comm J Qual Patient Saf 2005, 31(8):423-37.
• [39]Frankel A, Grillo SP, Pittman M, Thomas EJ, Horowitz L, Page M, Sexton B: Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Health Serv Res 2008, 43(6):2050-66.
• [40]Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK: Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf 2003, 29(1):16-26.