BACKGROUND AND OBJECTIVE

Proper documentation of patient safety events is important to be able to provide changes that can prevent events from occurring again. The Philippine General Hospital launched an online platform for reporting patient safety events in 2017. This paper aimed to describe the patient safety events, initial response to the event, and preventive actions done in the institution.

This is a retrospective descriptive study of patient safety event records from August 2017 to April 2022. General data of the patients, details surrounding the events, response to the event, and preventive measures done after the event were documented. Descriptive analysis was performed.

There was a total of 625 events reported with 525 total unique reports. There was an increased rate of patient safety event reports from 2021 to 2022. The average rate was 23.8 and 25.7 reports per month, respectively. Most reports were for in-patient cases and were type 3 preventable adverse events. The general initial response of healthcare personnel to the adverse events is to provide the appropriate clinical care. Preventive measures include re-orientation and event specific actions.

Documentation is crucial for patient safety events to provide solutions and prevent reoccurrence of these events that can cause harm to patients.

INTRODUCTION: Medical errors commonly occur in medical imaging departments. These errors are frequently influenced by patient safety culture. This study aimed to develop a suitable patient safety culture assessment tool for medical imaging departments. METHODS: Staff members of a teaching hospital medical imaging department were invited to complete the generic short version of the Safety Attitude Questionnaire (SAQ). Internal consistency and reliability were evaluated using Cronbach's α. Confirmatory factor analysis (CFA) was conducted to examine model fit. A cut-off of 60% was used to define the percentage positive responses (PPR). PPR values were compared between occupational groups. RESULTS: A total of 300 complete responses were received and the response rate was 75.4%. In reliability analysis, the Cronbach's α for the original 32-item SAQ was 0.941. Six subscales did not demonstrate good fit with CFA. A modified five-subscale, 22-item model (SAQ-MI) showed better fit (goodness-to-fit index ≥0.9, comparative fit index ≥ 0.9, Tucker-Lewis index ≥0.9 and root mean square error of approximation ≤0.08). The Cronbach's α for the 22 items was 0.921. The final five subscales were safety and teamwork climate, job satisfaction, stress recognition, perception of management and working condition, with PPR of 62%, 68%, 57%, 61% and 60%, respectively. Statistically significant differences in PPR were observed between radiographers, doctors and others occupational groups. CONCLUSION The modified five-factor, 22-item SAQ-MI is a suitable tool for the evaluation of patient safety culture in a medical imaging department. Differences in patient safety culture exist between occupation groups, which will inform future intervention studies.
Humans ; Surveys and Questionnaires ; Patient Safety ; Attitude of Health Personnel ; Diagnostic Imaging ; Reproducibility of Results ; Male ; Female ; Adult ; Job Satisfaction ; Factor Analysis, Statistical ; Middle Aged ; Hospitals, Teaching ; Safety Management ; Organizational Culture ; Medical Errors/prevention & control*

BACKGROUND AND OBJECTIVE

Proper documentation of patient safety events is important to be able to provide changes that can prevent events from occurring again. The Philippine General Hospital launched an online platform for reporting patient safety events in 2017. This paper aimed to describe the patient safety events, initial response to the event, and preventive actions done in the institution.

This is a retrospective descriptive study of patient safety event records from August 2017 to April 2022. General data of the patients, details surrounding the events, response to the event, and preventive measures done after the event were documented. Descriptive analysis was performed.

There was a total of 625 events reported with 525 total unique reports. There was an increased rate of patient safety event reports from 2021 to 2022. The average rate was 23.8 and 25.7 reports per month, respectively. Most reports were for in-patient cases and were type 3 preventable adverse events. The general initial response of healthcare personnel to the adverse events is to provide the appropriate clinical care. Preventive measures include re-orientation and event specific actions.

Documentation is crucial for patient safety events to provide solutions and prevent reoccurrence of these events that can cause harm to patients.

Long duty hours have been associated with significant medical errors, adverse events, and physician “burn-out”. An innovative night float (NF) system has been implemented in our internal medicine program to reduce the negative effects of long duty hours associated with conventional full-call systems. However, concerns remain if this would result in inadequate training for interns. We developed a structured questionnaire to assess junior doctors’ perceptions of the NF system compared to full calls, in areas of patient safety, medical training, and well-being. Ninety-seven (71%) of the 137 doctors polled responded. Ninety-one (94%) felt the NF system was superior to the full call system. A strong majority felt NF was beneficial for patient safety compared to full call (94% vs. 2%, p<0.001). The NF system was also perceived to reduce medical errors (94% vs. 2%, p<0.001) and reduce physician “burn-out” (95% vs. 5%, p<0.001). Beyond being a practical solution to duty-hour limitations, there was a significant perceived benefit of the NF system compared to the full call in terms of overall satisfaction, patient safety, reducing medical errors and physician “burn-out”.
After-Hours Care ; Asian Continental Ancestry Group ; Education, Medical ; Humans ; Internal Medicine ; Medical Errors ; Patient Safety ; Patient Satisfaction

PURPOSE: To evaluate the clinical features of unilateral amblyopia with myopic anisometropia at a tertiary center. METHODS: The medical records of 102 children wearing spectacles due to myopic anisometropia with an interocular difference in spherical equivalent (SE) ≥ 1.00 diopters (D) with a follow-up ≥ 1 year were reviewed. Patients were classified into mild or severe groups according to an interocular SE difference ≥ 3.00D. The frequency of amblyopia (interocular difference ≥ two lines of visual acuity [VA]) and response to patching, the magnitude of anisometropia, and the frequency of combined ocular or systemic disorders except refractive errors were compared between the two groups. The VA and refractive errors were measured four months and one year after spectacle correction and at the last follow-up. RESULTS: In all, 61 patients with mild myopic anisometropia and 41 patients with severe myopic anisometropia started to wear spectacles at a mean age of 5.2 years old and were followed-up during a mean period of 34.6 months. The frequency of amblyopia decreased more prominently in the mild group: 82.0% in the mild group vs. 92.7% in the severe group four months after spectacle correction and 45.9% in the mild group vs. 87.8% in the severe group at the last follow-up. At baseline, the mild group had anisometropia of 1.42 ± 0.66D, while the severe group had anisometropia of 5.47 ± 2.09D. The magnitude of anisometropia tended to increase by 0.42D but not significantly: +0.78D in the mild group and −0.02D in the severe group. More than half of the patients had combined disorders: 57.4% in the mild group and 53.7% in the severe group. CONCLUSIONS: Severe myopic anisometropic amblyopia at a tertiary center showed little improvement and the magnitude of anisometropia did not change.
Amblyopia ; Anisometropia ; Child ; Eyeglasses ; Follow-Up Studies ; Humans ; Medical Records ; Refractive Errors ; Visual Acuity

PURPOSE: To analyze the accuracy of ocular biometry and prediction of postoperative refraction after cataract surgery in acute primary angle-closure glaucoma (ACG) patients treated with laser iridotomy (LI). METHODS: We retrospectively reviewed the medical records of 44 patients who underwent cataract surgery after LI due to ACG (ACG group), and 37 patients who underwent cataract surgery without ocular disease other than cataract (control group) from January 2015 to May 2018. An Acrysof® single piece (SN60WF) was used as the intraocular lens. We performed preoperative ocular biometry and intraocular lens power calculations using AL-Scan®. The accuracy of the postoperative refractive power prediction was analyzed according to the anterior chamber depth (ACD) and axial length (AL). RESULTS: The preoperative ACD was 2.29 ± 0.32 mm in the ACG group and 3.15 ± 0.27 mm in the control group (p < 0.01), and the respective AL values were 22.53 ± 0.80 mm and 23.87 ± 1.38 mm (p < 0.01). Using the Haigis formula, patients with an ACD < 2.30 mm in the ACG group (0.52 ± 0.36 diopters [D]) had less accurate results in terms of the mean absolute error than patients with an ACD > 2.31 mm in the ACG group (0.27 ± 0.20 D) and control group (0.27 ± 0.20 D). There was no significant difference in the mean absoluter error between each formula in patients with an AL of < 22.0 mm or > 22.1 mm in the ACG and control groups. CONCLUSIONS: Among patients treated with LI due to ACG, those patients with an ACD > 2.31 mm showed no difference in refractory prediction compared to the control group. However, in patients with an ACD < 2.30 mm, the refractory prediction may be inaccurate when using the Haigis formula, a fourth-generation formula that takes into account the ACD.
Anterior Chamber ; Biometry ; Cataract ; Glaucoma, Angle-Closure ; Humans ; Lenses, Intraocular ; Medical Records ; Refractive Errors ; Retrospective Studies

Patient safety and medical errors have emerged as global concerns and error disclosure has been established as standards of practice in many countries. Disclosure of medical errors to patients and their families is an important part of patient-centred medical care and is essential to maintaining trust. However, physicians still hesitate to disclose errors to patients despite their belief that errors should be disclosed. Multiple barriers such as fear of medical lawsuits and punishment, fear of damaging their professional reputation, and diminished patient trust inhibit error disclosure. These barriers as well as lack of training or education programs addressing error disclosure contribute to a low estimated disclosure rate in real situations. Nowadays, the importance of patient safety education including error disclosure is emphasized and related research is increasing. In this paper, we will discuss the background of medical error disclosure and studies on education programs related to error disclosure. In this regard, we will examine the content and methods currently being taught, discuss the effects or outcomes of such education programs and obstacles or difficulties in implementing them. Finally, the direction of future error disclosure education, support systems, and education strategies will also be covered.
Disclosure ; Education ; Education, Medical ; Humans ; Medical Errors ; Patient Safety ; Punishment ; Truth Disclosure

This study is a narrative review introducing global trends in patient safety education within medical schools and exploring the status of Korean education. Core competences for patient safety include patient centeredness, teamwork, evidence- and information-based practice, quality improvement, addressing medical errors, managing human factors and system complexity, and patient safety knowledge and responsibility. According to a Korean report addressing the role of doctors, patient safety was described as a subcategory of clinical care. Doctors' roles in patient safety included taking precautions, educating patients about the side effects of drugs, and implementing rapid treatment and appropriate follow-up when patient safety is compromised. The Korean Association of Medical Colleges suggested patient safety competence as one of eight essential human and society-centered learning outcomes. They included appropriate attitude and knowledge, human factors, a systematic approach, teamwork skills, engaging with patients and carers, and dealing with common errors. Four Korean medical schools reported integration of a patient safety course in their preclinical curriculum. Studies have shown that students experience difficulty in reporting medical errors because of hierarchical culture. It seems that patient safety is considered in a narrow sense and its education is limited in Korea. Patient safety is not a topic for dealing with only adverse events, but a science to prevent and detect early system failure. Patient safety emphasizes patient perspectives, so it has a different paradigm of medical ethics and professionalism, which have doctor-centered perspectives. Medical educators in Korea should understand patient safety concepts to implement patient safety curriculum. Further research should be done on communication in hierarchical culture and patient safety education during clerkship.
Caregivers ; Curriculum ; Drug-Related Side Effects and Adverse Reactions ; Education ; Education, Medical, Undergraduate ; Ethics, Medical ; Follow-Up Studies ; Humans ; Korea ; Learning ; Medical Errors ; Mental Competency ; Patient Safety ; Professionalism ; Quality Improvement ; Schools, Medical ; Students, Medical

PURPOSE: The purpose of this study was to determine nurses' perceptions of the disclosure of patient safety incidents (DPSI), which is known to be effective in reducing medical litigation and improving the credibility of medical professionals. METHODS: Three focus group discussions were conducted with 20 nurses using semistructured guidelines. Transcribed content including a record of the progress of the focus group discussions and researchers' notes were analyzed using directed content analysis. RESULTS: Most participants thought that DPSI is necessary because of its effectiveness and for ethical justification. However, participants held varied opinions regarding the primary responsibility of DPSI. Participants agreed on the necessity of explaining the incident and expressing sympathy, apologizing, and promising appropriate compensation that are chief components of DPSI. However, they were concerned that it implies a definitive medical error. A closed organizational culture, fear of deteriorating relationships with patients, and concerns about additional work burdens were suggested as barriers to DPSI. However, the establishment of DPSI guidelines and improving the hospital organization culture were raised as facilitators of DPSI. CONCLUSION: Most nurse participants acknowledged the need for DPSI. To promote DPSI, it is necessary to develop guidelines for DPSI and provide the appropriate training. Improving the hospital organization culture is also critical to facilitate DPSI.
Compensation and Redress ; Disclosure ; Focus Groups ; Humans ; Jurisprudence ; Korea ; Medical Errors ; Organizational Culture ; Patient Rights ; Patient Safety

PURPOSE: The aim of this study was to examine degrees of nurse-nurse collaboration and nurse-physician collaboration, and investigate their relationships to the occurrence of medical errors. METHODS: A cross-sectional questionnaire survey was conducted with 264 nurses in a university hospital. The questionnaire included fivecomponent nurse-nurse collaboration and three-component nurse-physician collaboration scales. Data were analyzed using independent t-tests, ANOVA, χ2 tests, and multiple logistic regression. RESULTS: Mean score for nurse-nurse collaboration was 2.8 out of 4.0, and for nurse-physician collaboration, 3.4 out of 5.0. There were significant differences in the nurse-nurse and nurse-physician collaboration scores by nurses' preference to workplace and work unit. A significant difference was found in the nurse-nurse collaboration scores by job position. Fifty-seven (21.60%) nurses responded that they had experienced a medical error in the last six months. Logistic regression analysis revealed that nurse-physician collaboration was a significant factor associated with nurses' error experience. Nurses with higher scores for the nurse-physician relationship component were less likely to experience medical errors. CONCLUSION: Findings from this study show that nurse-nurse and nurse-physician collaboration were moderate. Negative relationship between nurse-physician collaboration and the occurrence of medical error indicates that enhancing nurse-physician collaboration would contribute to improving patient safety.
Cooperative Behavior ; Interprofessional Relations ; Logistic Models ; Medical Errors ; Patient Safety ; Physician-Nurse Relations ; Weights and Measures