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Measures of Patient Safety: Studies of Swedish Reporting Systems and Evaluation of an Intervention Aimed at Improved Patient Safety Culture
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Unsafe health care delivery results in millions of patients suffering from injuries or death worldwide. A Swedish study estimated the prevalence of preventable adverse events as high as 8.6% in hospital care, which demonstrates that patient safety is no less a problem in Sweden than elsewhere. Reporting of adverse events has become an integral part of patient safety work. The aim of reporting is to identify patient safety problems and provide background data and information for efforts to improve patient safety. However, adverse events in health care can be captured and measured using different methods and stored in disparate systems that are not fully integrated. This makes it difficult to obtain a complete coherent picture of the frequency and nature of various types of adverse events. Another difficulty is to distinguish between adverse events and accepted complications of medical care.

The overall aim of this thesis is to generate knowledge for improved understanding of how patient safety can be measured in terms of reporting adverse events and improved by targeting patient safety culture with an intervention implemented in a Swedish county council. Three research questions have been derived from the aim: (1) To what extent can analysis of patient claims contribute to an understanding of the magnitude of the patient safety problem? (2) To what extent do data captured from different reporting systems in Sweden differ? (3) To what extent can a structured intervention that fosters learning on patient safety issues and encourages leadership commitment improve the patient safety culture in a Swedish county council from a five-year perspective?

The research is based on studies of three national reporting systems: Lex Maria to the National Board of Health and Welfare; patient claims to the County Councils´ Mutual Insurance Company; and medical data reported to the National Swedish Spine Register (Swespine). Data have also been assembled as part of an evaluation within the Patient Safety Dialogue intervention.

This thesis indicates that different Swedish reporting systems provide disparate views and have many discrepancies regarding data quality and coverage of adverse events. Patient claims seem to be an important source of information that can complement information from incident reporting systems and quality registries in health care to provide an understanding of the magnitude of the patient safety problem.

The research also shows that a structured intervention that fosters learning on patient safety issues and encourages leadership commitment can improve the culture of patient safety. However, a longer period of time and focused efforts might be required to achieve improvements across all departments within a Swedish county council.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2012. , 85 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1267
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-72594ISBN: 978-91-7393-043-7 (print)OAI: oai:DiVA.org:liu-72594DiVA: diva2:460214
Public defence
2012-01-13, Berzeliussalen, Universitetssjukhuset, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2011-12-16Bibliographically approved
List of papers
1. Reporting of Sentinel Events in Swedish Hospitals: A Comparison of Severe Adverse Events Reported by Patients and Providers
Open this publication in new window or tab >>Reporting of Sentinel Events in Swedish Hospitals: A Comparison of Severe Adverse Events Reported by Patients and Providers
2011 (English)In: Joint Commission Journal on Quality and Patient Safety, ISSN 1553-7250, E-ISSN 1938-131X, Vol. 37, no 11, 495-501 p.Article in journal (Refereed) Published
Abstract [en]

Background: Mandatory and voluntary reporting of adverse events is common in health care organizations but a more accurate understanding of the extent of patient injury may be obtained if additional sources are used. Patients in Sweden may file a claim for economic compensation from the national insurance system if they believe they have sustained an injury. The extent and pattern of reporting of serious adverse events in a mandatory national reporting system was compared with the reporting of adverse events on the basis of patient claims.

Methods: Regional sentinel event reports were compared with malpractice claims data between 1996 and 2003. A sample consisting of 113 patients with deaths or serious injuries was selected from the malpractice claims data source. The medical records of these patients were reviewed by three chief medical officers.

Results: Of the deaths or injuries associated with the 113 patients—25 deaths, 37 with more than 30% disability, and 51 with 16%-30% disability—23 (20%) had been reported by chief medical officers to the National Board of Health and Welfare as sentinel events. Most adverse events were found in orthopedic surgery, and orthopedic injuries had more serious consequences. None of the patient injuries caused by infections were reported as sentinel events. Individual errors were more frequent in cases reported as sentinel events.

Conclusions: Adverse events causing severe harm are underreported to a great extent in Sweden despite the existence of a mandatory reporting system; physicians often consider them to be complications. Health care organizations should consider using a portfolio of tools—including incident reporting, medical record review, and analysis of patient claims—to gain a comprehensive picture of adverse events.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72589 (URN)
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2017-12-08Bibliographically approved
2. What can we learn from patient claims?: Analysing of patient injuries following orthopaedic surgery
Open this publication in new window or tab >>What can we learn from patient claims?: Analysing of patient injuries following orthopaedic surgery
2012 (English)In: Patient Safety in Surgery, ISSN 1754-9493, Vol. 6, no 2, 1-6 p.Article in journal (Refereed) Published
Abstract [en]

Background: Objective data on the incidence and pattern of adverse events after orthopaedic surgical procedures remain scarce, secondary to the reluctance for encompassing reporting of surgical complications. The aim of this study was to analyze the nature of adverse events after orthopaedic surgery reported to a national database for patient claims in Sweden.

Methods: In this retrospective review data from two Swedish national databases during a 4-year period were analyzed. We used the "County Councils' Mutual Insurance Company", a national no-fault insurance system for patient claims, and the "National Patient Register at the National Board of Health and Welfare".

Results: A total of 6,029 patient claims filed after orthopaedic surgery were assessed during the study period. Of those, 3,336 (55%) were determined to be adverse events, which received financial compensation. Hospital-acquired infections and sepsis were the most common causes of adverse events (n = 741; 22%). The surgical procedure that caused the highest rate of adverse events was "decompression of spinal cord and nerve roots" (code ABC**), with 168 adverse events of 17,507 hospitals discharges (1%). One in five (36 of 168; 21.4%) injured patient was seriously disabled or died.

Conclusions: We conclude that patients undergoing spinal surgery run the highest risk of being severely injured and that these patients also experienced a high degree of serious disability. The most common adverse event was related to hospital acquired infections. Claims data obtained in a no-fault system have a high potential for identifying adverse events and learning from them.

Keyword
Insurance Claim Review, Medical Errors, Orthopaedics, Patient Safety, Patient Admission, Safety Management
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72590 (URN)10.1186/1754-9493-6-2 (DOI)
Note

On the day of the defence date the status of this article was "Manuscript".

Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2014-09-11Bibliographically approved
3. Adverse events in spine surgery in Sweden: A comparison of patient claims data and national quality register (Swespine) data
Open this publication in new window or tab >>Adverse events in spine surgery in Sweden: A comparison of patient claims data and national quality register (Swespine) data
Show others...
2011 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 82, no 6, 727-731 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose: Our knowledge of complications and adverse events in spinal surgery is limited, especially concerning incidence and consequences. We therefore investigated adverse events in spine surgery in Sweden by comparing patient claims data from the County Councils' Mutual Insurance Company register with data from the National Swedish Spine Register (Swespine).

Methods: We analyzed patient claims (n = 182) to the insurance company after spine surgery performed between 2003 and 2005. The medical records of the patients filing these claims were reviewed and compared with Swespine data for the same period.

Results: Two-thirds (119/182, 65%) of patients who claimed economic compensation from the insurance company were registered in Swespine. Of the 210 complications associated with these 182 claims, only 74 were listed in Swespine. The most common causes of compensated injuries (n = 139) were dural lesions (n = 40) and wound infections (n = 30). Clinical outcome based on global assessment, leg pain, disability, and quality of health was worse for patients who claimed economic compensation than for the total group of Swespine patients.

Interpretation: We found considerable under-reporting of complications in Swespine. Dural lesions and infections were not well recorded, although they were important reasons for problems and contributed to high levels of disability. By analyzing data from more than one source, we obtained a better understanding of the patterns of adverse events and outcomes after spine surgery.

Place, publisher, year, edition, pages
Informa, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72591 (URN)10.3109/17453674.2011.636673 (DOI)000297352700016 ()22066564 (PubMedID)
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2017-12-08Bibliographically approved
4. Patient safety dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture
Open this publication in new window or tab >>Patient safety dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture
2011 (English)In: Journal of patient safety, ISSN 1549-8425, Vol. 7, no 4, 185-92 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Patient Safety Dialogue, a local intervention inspired by walk round-style approaches, was implemented in 2005 in a Swedish county council to achieve a positive patient safety culture in health care. This paper evaluates the results and changes after 5 years of the Patient Safety Dialogue in 50 departments (37 medical and 13 psychiatric) in 3 hospitals.

METHODS: The patient safety culture maturity was rated on 5 levels that correspond with the Manchester Patient Safety Assessment Framework. The assessment was based on information supplied by the departments and discussions between clinical leaders and staff members with special patient safety assignments and representatives from a patient safety unit. Three patient safety areas were assessed: hospital-acquired infections, outcome measurements, and general patient safety. Each department was assessed 3 times: at baseline and at follow-ups at 18 and 36 months. Average scores were calculated for each of the 3 safety areas on all occasions. The departments were classified into 3 types of trajectories on the basis of the development of their scores over time.

RESULTS: More than two-thirds of the departments attained higher scores in round 3 than in round 1. Seventy-eight percent of the departments in the general patient safety area were categorized as continuously improving or developing, compared with 68% for outcome measurement and 50% for hospital-acquired infection. Approximately one-third was categorized as nonimproving, with scores in round 3 lower than or equal to the scores in round 1. The medical departments had higher scores than the psychiatric departments in all rounds.

CONCLUSIONS: Most of the 50 departments were evaluated to have improved their patient safety culture during the 5 years of the Patient Safety Dialogue, suggesting that the intervention is effective in supporting an improved patient safety culture. However, one-third of the departments did not improve during the 5-year study period.

Place, publisher, year, edition, pages
Informa, 2011
Keyword
Safety, culture, program evaluation, safety management
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72593 (URN)10.1097/PTS.0b013e318230e702 (DOI)21952549 (PubMedID)
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2013-10-25Bibliographically approved

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