A Study To Prioritize Emerging Areas Of Concern In Patient Safety- A Systematic Review

Abstract

Background: Patient safety is a global concern despite advancements in healthcare systems, as adverse events continue to impact mortality and morbidity rates.

Purpose: The purpose of this systematic review is to prioritize emerging areas of concern in patient safety, aiming to identify and understand the evolving challenges that healthcare systems face.

Methods: A search strategy was developed using 117 databases, including PubMed, Scopus, and Web of Science. Keywords included "Patient Safety", "Patient harm", "Adverse event", "Challenges in Patient Safety", and "Advancement in Patient Safety".

Results: The paper concludes by advocating for "High-Quality health systems" in developing nations, stressing the importance of a comprehensive approach to healthcare. It calls for standardized tools to capture patient harm, a learning health framework for continuous improvement, and urges policymakers to facilitate information sharing through a public coordination center.

Conclusions: Targeted surveillance and interventions are essential for recognizing progress and avoiding reliability issues. High-quality health systems are needed to improve health outcomes in developing nations, emphasizing thorough assessment, accurate diagnosis, timely treatment, and access to necessary facilities.

  • Page Number : 21-32

  • Published Date : 2022-04-14

  • Keywords
    Patient Safety, Patient Harm, Adverse Events, Patient Safety Issues, Challenges in Patient Safety, Advancements in Patient Safety

  • DOI Number

  • Authors
    Shalini Sharma and Keerti Bhusan Pradhan

References

  • Aaronson EL, Bates DW. 2021 BMJ Qual Saf 2021;30:529–532
  • Al-Mandhari, A., Al-Zakwani, I., Al-Adawi, S., Al-Barwani, S., & Jeyaseelan, L. (2016). Awareness and implementation of nine World Health Organization’s patient safety solutions among three groups of healthcare workers in Oman. BMC health services research, 16(1), 1-7.DOI 10.1186/s12913-016-1771-1
  • Azyabi, A., Karwowski, W., & Davahli, M. R. (2021). Assessing patient safety culture in hospital settings. International journal of environmental research and public health, 18(5), 2466. https://doi.org/10.3390/ ijerph18052466
  • Barach P, 2000. Revealing and forestalling clinical disasters: exercises from non-clinical close to miss detailing frameworks. BMJ. 2000;320:759-63. [PMID: 10720361]
  • Bogner MS, 1994. Human Error in Medicine. Slope, NJ: Lawrence Erlbaum Assoc; 1994.
  • C A Vincent, A Coulter 2002, Patient wellbeing: shouldn't something be said about the patient? Qual Saf Health Care 2002; 11:76–80
  • Chapman, S. M., Fitzsimons, J., Davey, N., & Lachman, P. (2014). Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool. BMJ open, 4(7).. doi:10.1136/bmjopen-2014- 005066
  • Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Goldmann, D. A., & Sharek, P. J. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine, 363(22), 2124-2134. DOI: 10.1056/NEJMsa1004404
  • Bates, D. W., & Singh, H. (2018). Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Affairs, 37(11), 1736-1743. DOI: 10.1377/hlthaff.2018.0738
  • De Feijter, J. M., de Grave, W. S., Muijtjens, A. M., Scherpbier, A. J., & Koopmans, R. P. (2012). A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. PloS one, 7(2), e31125. doi:10.1371/journal.pone.0031125
  • La Torre-Pérez, D., Hernández-Carcereny, C., Fortes Bazaga, I., Prat-Marin, A., & Bertran Luengo, M. J. (2021). Role of Patient Safety Incident Reporting Systems in Home Hospitalization. Journal of Patient Safety & Quality Improvement, 9(1), 19-27. Doi: 10.22038/psj.2021.52154.1289
  • De Vries, E. N., Ramrattan, M. A., Smorenburg, S. M., Gouma, D. J., & Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: a systematic review. Quality & safety in health care, 17(3), 216.
  • Definition of Adverse Events https://ichgcp.net/1-glossary
  • Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: building a safer health system (Vol. 6). National Academies Press
  • Elmontsri, M., Banarsee, R., & Majeed, A. (2017). Key priority areas for patient safety improvement strategy in Libya: a protocol for a modified Delphi study. BMJ open, 7(6). doi:10.1136/ bmjopen-2016-014770
  • Robb, G., et al. (2017). Title of the article. New Zealand Medical Journal, 130(1460). ISSN 1175-8716.
  • Government of India: Ministry of Health and Family Welfare. (2018). National Patient Safety Implementation Framework, 56. Retrieved from https://mohfw.gov.in/sites/default/files/national%20patient%20safety%20imple- mentation_for%20web.pdf
  • Health Ministry of. (2019). Patient Safety – Patient Safety. Patient Safety Council Malaysia. Retrieved from http://patientsafety.moh.gov.my/v2/?page_id=17
  • World Health Organization. (Year). Patient Safety. Retrieved from
  • World Health Organization. (Year). ICPS Chapter 3. Retrieved from https://www.who.int/patientsafety/taxonomy/icps_chapter3.pdf
  • Institute of Healthcare Improvement. Overview. Retrieved from http://www.ihi.org/Topics/PatientSafety/Pages/Overview.aspx
  • Isherwood, P., & Waterson, P. (2021). To err is system; a comparison of methodologies for the investigation of adverse outcomes in healthcare. Journal of Patient Safety and Risk Management, 26(2), 64-73.
  • James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety, 9(3), 122-128. DOI: 10.1097/PTS.0b013e3182948a69
  • Joint Commission International. (2023). Sentinel Event Annual Review. Retrieved from https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/03162023_sentinel-event-_annual-review_final-%28002%29.pdf
  • JCI IPSG 2021 https://www.jointcommission.org/standards/ national-patient-safety-goals/hospital-national-patient-safety-goals/
  • Jha AK, et al. 2013, BMJ Qual Saf 2013; 22:809-815. Doi: 10.1136/bmjqs-2012-001748
  • Kobayashi, K., Ando, K., Nakashima, H., Machino, M., Kanbara, S., Ito, S., ... & Imagama, S. (2021). Challenges for joint commission international accreditation: performance of orthopedic surgeons based on international patient safety goals. Nagoya Journal of Medical Science, 83(1), 87.
  • Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (1999). To Err Is Human: Building a Safer Health System. Foundation of Medicine. Washington, DC: National Academy Press.
  • Kumar, S., & Chaudhary, S. (2009). Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi. Journal of Emergencies, Trauma and Shock, 2(2), 80.
  • Kuriakose, R., Aggarwal, A., Sohi, R. K., Goel, R., Rashmi, N. C., & Gambhir, R. S. (2020). Patient safety in primary and outpatient health care. Journal of family medicine and primary care, 9(1), 7.
  • Landefeld, J., Sivaraman, R., & Arora, N. K. (2015). Barriers to improving patient safety in India: focus groups with providers in the southern state of kerala. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine, 40(2), 116-120 .DOI: https://doi.org/10.4103/0970-0218.153875
  • Lawton, R., Taylor, N., Clay-Williams, R., & Braithwaite, J. (2014). Positive deviance: a different approach to achieving patient safety. BMJ quality & safety, 23(11), 880-883. . doi:10.1136/bmjqs-2014-003115
  • Emanuel, L., Berwick, D., Conway, J., Combes, J., Hatlie, M., Leape, L., ... & Walton, M. (2009). What exactly is patient safety?. Journal of Medical Regulation, 95(1), 13-24.
  • Twum-Danso, N. A., & Pate, M. (2018). Margaret E Kruk, Anna D Gage, Catherine Arsenault, Keely Jordan, Hannah H Leslie, Sanam Roder-DeWan, Olusoji Adeyi, Pierre Barker, Bernadette Daelmans, Svetlana V Doubova, Mike English, Ezequiel García Elorrio, Frederico Guanais, Oye Gureje, Lisa R Hirschhorn, Lixin Jiang, Edward Kelley, Ephrem Tekle Lemango, Jerker Liljestrand, Address Malata, Tanya Marchant, Malebona Precious Matsoso, John G Meara, Manoj Mohanan, Youssoupha Ndiaye, Ole F Norheim, K Srinath Reddy, Alexander K Rowe, Joshua A Salomon ....
  • NABH 4th Edition standard book
  • National Advisory Group on Safety of patients in England, 2013. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
  • Nilsson, L., Borgstedt-Risberg, M., Soop, M., Nylén, U., Ålenius, C., & Rutberg, H. (2018). Incidence of adverse events in Sweden during 2013–2016: a cohort study describing the implementation of a national trigger tool. BMJ open, 8(3).doi:10.1136/ bmjopen-2017-020833
  • Ocak, S., Köseoglu, M. A., & Bertsch, A. (2015). Linkages among organisational culture, knowledge management, and patient safety performance: evidence from a state hospital in a developing country. International Journal of Management and Enterprise Development, 14(1), 11-35.
  • Ovid Wachter 2002. Ann Intern Med, Volume 136(11).June 4, 2002.850-852
  • Page 3 https://www.health.org.uk/sites/ default/files/LevelsOfHarm_0.pdf
  • Palmore, T.N., & Henderson, D.K. (2014). Annals of Internal Medicine Ideas and Opinions. Ann Intern Med. 2014, 160(10), 567–70.
  • Panesar, S. S. (2016). deSilva D, Carson-Stevens a, Cresswell KM, Salvilla SA, slight SP, et al. how safe is primary care? A systematic review. BMJ Qual Saf, 25(7), 544-553.
  • Patel, I., & Balkrishnan, R. (2010). Medication error management around the globe: an overview. Indian journal of pharmaceutical sciences, 72(5), 539. doi:10.4103/0250-474X.78518
  • Polisena et al. 2016 BMC Health Services Research DOI 10.1186/s12913-015-0886-0
  • Quality and Patient Safety – A Global Agenda. 2019;263597
  • Rasmussen et al. 2013, Rasmussen E Danskernes farligste rejse Mandag Morgen 2013.
  • Wilson, R. M., Michel, P., Olsen, S., Gibberd, R. W., Vincent, C., El-Assady, R., ... & Larizgoitia, I. (2012). Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. Bmj, 344. doi: 10.1136/bmj.e832
  • Schildmeijer, K. G. I., Unbeck, M., Ekstedt, M., Lindblad, M., & Nilsson, L. (2018). Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology. BMJ open, 8(1). doi:10.1136/ bmjopen-2017-019267
  • Shaikh, Z. M., AL-TOWYAN, S. O. L. E. I. M. A. N., & KHAN, G. (2018). Critical analysis of patient and family rights in JCI accreditation and Cbahi standards for hospitals. Int J Emerg Res Manag Technol, 6(7), 324.
  • Shojania KG, et al. 2013. BMJ Qual Saf 2013;22:273–277. doi:10.1136/bmjqs-2013-001935
  • Sinha, K. (2013). India records 5.2 million medical injuries a year. The Times of India.
  • Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456.
  • US Department of Health and Human Services, Office of Inspector General, 2011. Adverse events in hospitals: national incidence among medicare beneficiaries. OEI-06-09-00090. http://oig.hhs.gov/oei/reports/oei06-09-00090.pdf. Published November 2010. Accessed August 12, 2011
  • Wacker, J., & Kolbe, M. (2016). The challenge of learning from perioperative patient harm. Trends in Anaesthesia and Critical Care, 7, 5-10. DOI: http://dx.doi.org/10.1016/j.tacc.2016.03.003
  • Wolters Kluwer Health | Lippincott Williams and Wilkins, 2012 Reducing "Second Victim" Syndrome How We Should Handle Patient Harm J Nurs Care Qual Vol. 27, No. 1, pp. 1–5