Die Generierung, Verbreitung und Anwendung von Wissen ist eine Kernaufgabe von Patientensicherheit Schweiz. Ihre wissenschaftlichen Veröffentlichungen stossen im In- und Ausland auf grosses Interesse.
What do double-check routines actually detect?
Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies.
Results In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions.
Conclusions In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process.
Source BMJ open
Authors Dr. Yvonne Pfeiffer, Chantal Zimmermann, Prof. Dr. David Schwappach, Patientensicherheit Schweiz
Was Apotheker und Ärzte, die Pflegeheimbewohner betreuen, von benutzerfreundlichen Listen zu potenziell inadäquater Verschreibung (PIP-Listen) erwarten – eine Umfrage.
Potenziell inadäquate Verschreibungen („potentially inappropriate prescribing“, PIP, inklusive potenziell inadäquate Medikation, PIM) sind verbreitet. In Praxis und Forschung können PIP-Listen verwendet werden, um die Medikation eines Patienten zu optimieren. Trotzdem werden diese selten verwendet, vermutlich aufgrund ihrer begrenzten Benutzerfreundlichkeit. Ziel dieser Studie war die Evaluation der Meinungen der Apotheker- und Ärzteschaft, die Pflegeheimbewohnende betreut, zur Benutzerfreundlichkeit, zum Kenntnisstand und zur Verwendung von PIP-Listen.
Ergebnisse Insgesamt konnten 30 Fachpersonen befragt werden, acht von ihnen im Rahmen eines Telefoninterviews. Die Teilnehmer hatten häufig (43 %, 13/30) schon von PIP-Listen gehört, und 46 % (6/13) verwendeten bereits eine PIP-Liste. Weniger erfahrene Fachpersonen hatten schon häufiger von PIP-Listen gehört als erfahrenere Kollegen. Für die Interviewten waren es am wichtigsten, dass PIP-Listen mit kurzem Zeitaufwand angewendet werden können, dass sie elektronisch verfügbar und klar strukturiert sind und dass sie Gründe angeben, weshalb eine Medikation potenziell inadäquat ist. Die Ärzteschaft bevorzugte im Vergleich zur Apothekerschaft eine an den Arzneimittelmarkt der Schweiz angepasste PIP-Liste.
Schlussfolgerung Damit PIP-Listen häufiger verwendet werden, sollten die Aspekte der Benutzerfreundlichkeit berücksichtigt werden. Personalisierbare PIP-Listen könnten eine interessante Weiterentwicklung sein.
Guideline-based indicators for adult patients with myelodysplastic syndromes
Guideline-based indicators (GBI) are measurable elements for quality of care and are currently lacking for adult patients with Myelodysplastic syndromes (MDS). The authors developed a GBI consensus for the domains of diagnosis (n = 14), therapy (n = 8), and provider/infrastructural characteristics (n = 7).
Results We screened relevant G/Rs published between 1999 and 2018 and aggregated all available information as candidate GBIs into a formalized handbook as the basis for the subsequent consensus rating procedure. An international multidisciplinary expert panel group (EPG) of acknowledged MDS experts (n = 17), health professionals (n = 7), and patient advocates (n = 5) was appointed. The EPG feedback rates for the first and second round were 82% (23 of 28) and 96% (26 of 27), respectively. A final set of 29 GBIs for the 3 domains of diagnosis (n = 14), therapy (n = 8), and provider/infrastructural characteristics (n = 7) achieved the predefined agreement score for selection (>70%).
Conclusion We identified shortcomings in standardization of patient-reported outcomes, toxicity, and geriatric assessments that need to be optimized in the future. Our GBIs represent the first comprehensive consensus on measurable elements addressing best practice performance, outcomes, and structural resources. They can be used as a standardized instrument with the goal of assessing, comparing, and fostering good quality of care within clinical development cycles in the daily care of adult MDS patients.
Source Blood advances
Authors Kristina Stojkov, Tobias Silzle, Georg Stussi, David Schwappach, Juerg Bernhard, David Bowen et al
Impact of an evidence-based intervention on urinary catheter utilization
Catheter-associated urinary tract infections (CAUTI) are a well-known complication of urinary tract catheterization, with rates ranging from 0.2-4.8 per 1,000 catheter days. The aim of this study was to decrease urinary catheterization and consequently catheter-associated urinary tract infections (CAUTI) and non-infectious complications.
Findings We included 25,880 patients [13,171 before the intervention (August-October 2016) and 12,709 after the intervention (August-October 2017)]. Catheter utilization dropped from 23.7% to 21.0% (p=0.001), and catheter-days per 100 patient-days from 17.4 to 13.5 (p=0.167). CAUTI remained stable on a low level with 0.02 infections per 100 patient-days (before) and 0.02 infections (after), (p=0.98). Measuring infections per 1,000 catheter-days, the rate was 1.02 (before) and 1.33 (after), (p=0.60). Non-infectious complications dropped significantly, from 0.79 to 0.56 events per 100 patient-days (p<0.001), and from 39.4 to 35.4 events per 1,000 catheter-days (p=0.23). Indicated catheters increased from 74.5% to 90.0% (p<0.001). Reevaluations increased from 168 to 624 per 1,000 catheter-days (p<0.001).
Conclusion In this before/after intervention study of urinary catheter utilization, a straightforward bundle of three evidence-based measures (providing a catheter indication list, promoting daily catheter evaluation, and teaching state-of-the-art catheter insertion) reduced catheter utilization and led to increases in indicated urinary catheters and daily evaluations. The intervention had an impact on non-infectious complications, whereas the CAUTI rate remained on a low level.The next step is planning the national roll-out of both the surveillance module and the intervention bundle, the components of which have been made available to the public (surveillance module, intervention bundle)
Source The Journal of Hospital Infection
Authors Dr. Alexander Schweiger, Prof. Dr. med. Jonas Marschall, PD Dr. med. Stefan P. Kuster, Judith Maag, Prof. Hugo Sax, Swissnoso Andrew Atkinson, Inselspital Bern Dr. med. Sonja Bertschy, Kantonsspital Luzern Emmanuelle Bortolin, Ente Ospidaliero Cantonale Bellinzona Dr. Gregor John, Hôpital Neuchâtelois PhD Andreas Limacher, Universität Bern Prof. Dr. David Schwappach und Dr. Stephanie Züllig, Patientensicherheit Schweiz
Supporting health professionals after an adverse event in Swiss hospitals - a cross-sectional study
The aim of this study was to identify the prevalence of organisational structures and processes for the support of second victims in Swiss hospitals.
To identify institutional policies and support for health professionals who have been involved in an adverse patient event and become traumatised from the event, also called second victims, we conducted a cross-sectional, multicentre survey study. We targeted Swiss acute care, university and psychiatric hospitals, as well as rehabilitation and speciality clinics. A 13-item questionnaire was used to collect information from hospital quality managers regarding their institutions’ policies and support practices with respect to second victims. Data were analysed using descriptive statistics.
Results Overall, respondents from 116 hospitals completed the questionnaire (response rate 50.2%). Most institutional respondents reported both that they would like to receive information about adverse events and that their institutions offer related support. Of participating institutions, 60% indicated that they actively inform their personnel about second-victim support possibilities; however, only 31% specifically train supervisory personnel to deliver that support, and only 32% have hospital-specific guidelines in place for second victim support. University, acute care and speciality clinics were more likely to use such guidelines than psychiatric and rehabilitation clinics. Analysis indicated an association between hospital size and the existence of guidelines.
Conclusions In Swiss hospitals, second victim support is generally prevalent, but often in an unstructured way. This lack of methodology increases the risk that, following adverse events, both the quantity and quality of support provided to health professionals will be insufficient. A firm commitment on the part of institutional leaders to implement related policies could foster the adoption of high-quality second victim guidelines in Swiss hospitals.
Source Swiss Medical Weekly
Authors
Franziska Reiser Crelier, MSN, Institute of Nursing Science, Department Public Health, University of Basel Switzerland
Prof. Dr. David Schwappach, Swiss Patient Safety Foundation, Zurich, Switzerland and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
PD Dr. René Schwendimann, Patient Safety Office, University Hospital Basel, Switzerland and Institute of Nursing Science, Department Public Health, University of Basel, Switzerland
Registration and Management of Never Events in Swiss Hospitals
In Switzerland, there is no mandatory reporting of never events.The aim of this study was to explore how hospitals outside mandatory never-event-regulations identify, register, and manage never events and whether practices are associated with hospital size.
Results Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a never event has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with never- event-management. Respondents reported that their hospital pays “too little attention” to the recording (46%), the analysis (34%), and the prevention (40%) of never events. All respondents rated the systematic registration and analysis of never events as very (81%) or rather important (19%) for the improvement of patient safety.
Conclusions A substantial fraction of Swiss hospitals do not have valid data on the occurrence of never events available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for never events management.
Source Journal of Patient Safety
Authors Prof. Dr. David Schwappach and Dr. Yvonne Pfeiffer from Swiss Patient Safety Foundation
Cancer care is complex, involving highly toxic drugs, critically ill patients, and various different care providers. Because it is important for clinicians to have the latest and complete information about the patient available, this study focused on patient safety issues in information management developing from health information technology (HIT) use in oncology ambulatory infusion centers.
Objective The aim was to exploratively and prospectively assess patient safety risks from an expert perspective: instead of retrospectively analyzing safety events, we assessed the information management hazards inherent to the daily work processes; instead of asking healthcare workers at the front line, we used them as information sources to construct our patient safety expert view on the hazards.
Methods The work processes of clinicians in three ambulatory infusion centers were assessed and evaluated based on interviews and observations with a nurse and a physician of each unit. The 125 identified patient safety issues were described and sorted into thematic groups.
Results A broad range of patient safety issues was identified, such as data fragmentation, or information islands, meaning that patient data are stored across different cases or software and that different professional groups do not use the same set of information.
Conclusions The current design and implementation of HIT systems do not support adequate information management: clinicians needed to play very close attention and improvise to avoid errors in using HIT and treat cancer patients safely. It is important to take the clinical front-end practice into account when evaluating or planning further HIT improvements.
Source Journal of Patient Safety
Authors Dr. Yvonne Pfeiffer; Chantal Zimmermann; Prof. Dr. David Schwappach von Patientensicherheit Schweiz.
Double checking is often considered a useful strategy to detect and prevent medication errors, especially before the administration of high-risk drugs. From a safety research perspective, the effectiveness of double checking in preventing medication errors is limited by several factors, even if they are conducted independently.
As double checking uses considerable resources of nurses’ time and cognitive capacity, there is a pressing need to know whether existing empirical evidence supports using double checking despite its mentioned shortcomings. We present a framework for classifying checking procedures and differentiating them from other medication-related safety behaviours in order to structure future research and practice. In addition, the concept of independence is discussed.
Source BMJ Quality and Safety
Authors Dr. Yvonne Pfeiffer; Chantal Zimmermann; Prof. Dr. David Schwappach von Patientensicherheit Schweiz.
Change in staff perspectives on indwelling urinary catheter use after implementation of an intervention bundle in seven Swiss acute care hospitals
Although indwelling urinary catheters (IUCs) are commonly used in acute care hospitals, an appropriate medical indication is often missing. IUCs are associated with urinary tract infections and non-infectious complications such as haematuria and urethral injury. The reduction of IUC use is therefore a key measure to increase patient safety. To promote safe urinary catheter use in Swiss hospitals, a national QI project was developed and conducted by the Swiss Patient Safety Foundation in partnership with Swissnoso, the National Center for Infection Control.
The QI project was modelled after other successful QI initiatives in the USA.The overall project goal was to reduce IUC use and to promote safe catheter insertion and maintenance by implementing an evidence-based intervention bundle in seven Swiss acute care hospitals.With the present study, we aimed to assess the changes in staff perspectives in the participating hospitals using survey data collected before and after implementation of the intervention bundle.
Conclusion Changing staff attitudes, knowledge and behaviour are important prerequisites for an effective reduction of catheter use and catheter-associated complications. We found small but significant changes in staff perceptions after implementation of an evidence-based intervention bundle. The positive trends were present in all subgroups, indicating that regardless of responsibilities and practice of catheter placement, perspectives on urinary catheter use changed over time. Efforts now need to be targeted at reinforcing and sustaining these changes, so that restrictive use of IUCs becomes an integral part of the hospital culture.
Source BMJ Open
Authors Andrea Niederhauser, Stephanie Züllig, Jonas Marschall, Alexander Schweiger, Gregor John, Stefan P Kuster, David LB Schwappach on behalf of the progress! Safe Urinary, Catheterization Collaboration Group
Speaking up about patient safety in psychiatric hospitals
The aim of this study was to examine speak up‐related behaviour and climate for the first time in psychiatric hospitals. A cross‐sectional survey was conducted among healthcare workers (HCWs) in six psychiatric hospitals with nine sites in Switzerland.
Conclusions Speaking up for patient safety is an important topic in the psychiatric healthcare setting. Speaking up to prevent harm to patients should be further promoted in psychiatric clinics as an important safety measure. In order to fully enact their role as advocates for patient safety, nurses should be empowered to voice concerns even in difficult situations. Further research is needed to gain more insights into the complex trade‐offs and considerations that influence decisions to speak up or withholding voice in the psychiatric healthcare setting.
Source International Journal of Mental Health Nursing
Authors David L. B. Schwappach PhD, MPH; Andrea Niederhauser MPH
Many of the more recent initiatives to improve patient safety target the behavior of health care staff (e.g., training, double-checking procedures, and standard operating procedures). System-based interventions have so far received less attention, even though they produce more substantial improvements, being less dependent on individuals’ behavior. One type of system-based intervention that can benefit patient safety involves improvements to hospital design. Given that people’s working environments affect their behavior, good design at a systemic level not only enables staff to
work more efficiently; it can also prevent errors and mishaps, which can have serious consequences for patients.While an increasing number of studies have demonstrated the effect of hospital design on patient safety, this knowledge is not easily accessible to clinicians, practitioners, risk managers, and other decision-makers, such as designers and architects of health care facilities. This is why the Swiss Patient Safety Foundation launched its project, «More Patient Safety by Design: Systemic Approaches for Hospitals», which is presented in this chapter.
Source Advances in Health Care Management
Authors Irene Kobler, Prof. Dr. Alfred Angerer, Prof. Dr. David Schwappach, MPH
Speaking up culture: Need of faculty working in patient safety
Speaking up behaviour of students was assessed for the first time in an Austrian academic teaching hospital. The higher the term the more frequent students reported perceived patient safety concerns or rule violations and withholding voice. These results suggest the need to adapt the curriculum concept of the faculty in order to address patient safety as a relevant topic.
Results 326 individuals completed the questionnaire (response rate 24%). 37% of responders were in their 5th- 6th clinical term, 32% were in their 7th-8th term and 31% were in the 9th-12th term. 69% of students had a specific safety concern in the past four weeks, 48% had observed an error and 68% noticed the violation of a patient safety rule. Though students perceived specific patient safety concerns, 56% did not speak up in a critical situation. All predefined barriers seemed to play an important role in inhibiting students’ voicing concerns. The scores on the psychological safety scale were overall moderately favourable. Students felt little encouraged by colleagues and, in particular, by supervisors to speak up.
Conclusion Speaking up behaviour of students was assessed for the first time in an Austrian academic teaching hospital. The higher the term the more frequent students reported perceived patient safety concerns or rule violations and withholding voice. These results suggest the need to adapt the curriculum concept of the faculty in order to address patient safety as a relevant topic.
Source PLOS ONE
Authors David Schwappach, Gerald Sendlhofer, Lars-Peter Kamolz, Wolfgang Köle, Gernot Brunner
Das unbeabsichtigte Absinken der Körpertemperatur unter 36 Grad Celsius stellt für alle chirurgischen Patientinnen und Patienten ein Risiko dar und kann gravierende Folgen für die Patientensicherheit haben.
Ziel der Leitlinie ist es, den Fachpersonen in der chirurgischen Versorgung zu helfen, eine unbeabsichtigte perioperative Hypothermie zu vermeiden. Sie enthält evidenzbasierte Empfehlungen sowie konkrete Massnahmen zur Implementierung und Umsetzung.
Die Leitlinie ist im Verbund der klinischen Fachgesellschaften in Deutschland, Österreich und der Schweiz und unter Federführung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI) entstanden. Prof. Dr. David Schwappach, wissenschaftlicher Leiter bei Patientensicherheit Schweiz, hat bei der Erarbeitung mitgewirkt.
Source AWMF online
Autoren Federführende Fachgesellschaft: Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
Sicherheitsrelevante Medikationsprozesse in Schweizer Alters- und Pflegeheimen
Die Reduktion von unerwünschten Arzneimittelereignissen bei Bewohnenden von Alters- und Pflegeheimen ist ein zentrales Anliegen der Patientensicherheit. Ziel dieser Studie war es zu ermitteln, wie häufig ausgewählte Medikationsprozesse zur Erhöhung der Medikationssicherheit in Schweizer Pflegeheimen bereits umgesetzt werden und wie sich Heime, die diese Prozesse noch nicht umsetzen, durch organisationale Merkmale charakterisieren lassen.
Ergebnisse Es nahmen 420 von 1525 eingeladenen Personen an der Befragung teil (Rücklaufquote: 27.5%). Davon gaben 65.0% an, dass in ihrer Einrichtung eine regelmäßige systematische Überprüfung der Medikation vorgesehen ist. In 9.5% der Pflegeheime wird eine Liste zur Identifikation von potenziell inadäquater Medikation eingesetzt und 6.7% der Heime haben einen standardisierten Prozess, um Nebenwirkungen von Medikamenten zu überwachen. 66.0% der teilnehmenden Heime setzen mindestens einen dieser Prozesse um, 34.0% setzen keinen der drei Prozesse um. Statistisch signifikante Unterschiede in der Umsetzung der Prozesse zeigten sich nach Standort des Pflegeheims, der Art des Dokumentationssystems für die Medikation, dem Arztmodell, der Anzahl externer Ärzte/Ärztinnen sowie dem Bezugskanal der Medikamente und der gesetzlichen Verpflichtung zur Zusammenarbeit mit Apothekern/Apothekerinnen. Keine Unterschiede zeigten sich nach Heimgröße.
Schlussfolgerung In Schweizer Alters- und Pflegeheimen sind zentrale sicherheitsrelevante Medikationsprozesse noch nicht flächendeckend umgesetzt. Besonders in Einrichtungen, in denen viele externe Belegärzte Bewohnende betreuen, ist die Umsetzung noch wenig fortgeschritten. Die organisationalen Merkmale müssen für eine erfolgreiche Implementierung von Verbesserungsmassnahmen berücksichtigt werden.
Source Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen
Autoren Andrea Niederhauser, Dr. Lea Brühwiler, Dr. Liat Fishmann, Prof. Dr. David Schwappach der Stiftung Patientensicherheit Schweiz.
Patientensicherheitsgefährdungen durch die Nutzung von IT in onkologischen Ambulatorien
Das Ziel der vorliegenden Studie von Dr. Yvonne Pfeiffer, Chantal Zimmermann und Prof. Dr. David Schwappach von Patientensicherheit Schweiz war, Patientensicherheitsgefährdungen, die bei der Nutzung von HIT (Health Information Technology) entstehen, zu identifizieren.
Zum einen wurden explorativ Patientensicherheitsgefährdungen in drei onkologischen Ambulatorien erfasst und übergeordnete Themen identifiziert. Zum anderen wurde systematisch die Anzahl an Informationsquellen erfasst, die die klinisch Tätigen nutzen müssen, um sich ein Bild vom Patienten zu machen. Dafür wurden Interviews und Beobachtungen mit je einer Pflegefachperson und einem Arzt durchgeführt.
Ergebnisse Informationsmanagement-bezogene Patientensicherheitsgefährdungen waren in der täglichen Versorgung allgegenwärtig: ausgehend von 125 erfassten Patientensicherheitsgefährdungen wurden elf Themenfelder identifiziert. Drei waren besonders relevant für die Entwicklung eines adäquaten mentalen Modells über den Patienten der klinisch Tätigen: patientenbezogene Informationen wurden nicht an einem Ort, sondern häufig fragmentiert in verschiedenen HIT-Systemen verteilt gespeichert; trotz der Einführung von HIT blieb für bestimmte Informationen die Papierdokumentation bestehen, was den Zugriff darauf erschwerte und die Anzahl an relevanten Quellen erhöhte; die mangelnde Benutzerfreundlichkeit der HIT-Systeme machte es schwierig, zeitgerecht Patienteninformation abzurufen. Klinisch Tätige mussten zwischen fünf und elf Informationsquellen nutzen, um sich ein Bild über den Patienten zu machen.
Schlussfolgerungen Gesamthaft zeigte sich, dass die Gestaltung der HIT-Systeme nur unzureichend an die Arbeitsprozesse angepasst ist und es nicht begünstigt, sich vollständig über einen Patienten zu informieren. Die identifizierten Themenfelder zeigen auf, wo zukünftige Systemgestaltung und -verbesserung ansetzen kann. Dabei ist es von großer Bedeutung, die eigentlichen Anforderungen der Arbeitsprozesse auf die Gestaltung der HIT abzustimmen und die tatsächliche Implementierung und Nutzung von HIT eng zu begleiten.
Source: ZEFQ Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen
Autoren: Dr. Yvonne Pfeiffer, Chantal Zimmermann, Prof. Dr. David Schwappach, Stiftung Patientensicherheit Schweiz
Safe vincristine use in Switzerland: Still a long way to go?
Different international organizations recommend safety measures for the use of vincristine to prevent wrong route administrations. A central recommendation is to use infusion bags instead of syringes to prevent confusion with intrathecal chemotherapy. This study aimed to investigate the implementation of safety measures for vincristine and intrathecal chemotherapies in Switzerland.
Source: Journal of Oncology Pharmacy Practice
Authors: Dr. Lea Brühwiler und Prof. Dr. David Schwappach, Stiftung Patientensicherheit Schweiz
Im Zentrum von Lean Healthcare steht die Optimierung von Prozessen und deren Ausrichtung auf die Patienten, um nicht-wertschöpfende Aktivitäten zu eliminieren. Die Gestaltung von Prozessen ist auch für die Verbesserung der Patientensicherheit zentral.
Im Kapitel «Patientensicherheit» des Buches «LHT-BOK Lean Healthcare Transformation Body of Knowledge» wird das Thema Patientensicherheit beleuchtet. Beispiele zeigen Schnittstellen zu Lean Healthcare auf.
Source: A. Angerer (Hrsg.), LHT-BOK Lean Healthcare Transformation Body of Knowledge, Edition 2018–2019. Winterthur
Authors: Kobler, I. & Schwappach, D. (2018). Stiftung Patientensicherheit Schweiz
Patient Safety in Cancer Care
Cancer care has seen large successes in terms of increased survival rates and improvements in quality of life. However, despite these achievements, many patients suffer preventable harm from treatment. Studies of patient safety in cancer care have usually focused on chemotherapy safety and have been conducted in large centers. These studies reveal that errors are more frequent in more complex therapies and that about 1-3% of adult and pediatric patients are affected by chemotherapy errors 1.
Source: eonsmagazine Winter/Spring 2019
Authors: Prof. Dr. David Schwappach
Speaking Up about Patient Safety in Perioperative Care: Differences between Academic and Nonacademic Hospitals in Austria and Switzerland
Purpose of the Study: In perioperative care, communication about patient safety concerns is both difficult and valuable. Research into speaking up has mostly been conducted in single countries; the aim of this study was to compare speaking up-related climate and behaviors in academic and nonacademic hospitals.
Source: Journal of Investigative Surgery
Authors: David Schwappach from Swiss Patient Safety Foundation, Zurich, Switzerland, Gerald Sendlhofer from Executive Department for Quality and Risk Management, Landeskrankenhaus-Universitatsklinikum Graz, Graz, Austria and Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Research Unit for Safety in Health, Medizinische Universitat Graz, Graz, Austria
Etikettierung von Laborröhrchen: ein komplexer Prozess mit hoher Fehleranfälligkeit
Fehler bei der Etikettierung von Laborproben treten in Gesundheitseinrichtungen immer wieder auf und werden häufig in Bericht – und Lernsystemen (CIRS) beschrieben. Die Analyse dieser CIRS-Berichte stellt die Verantwortlichen aufgrund der Komplexität des Prozesses der Etikettierung von Laborproben vor verschiedene Herausforderungen.
Der Prozess der Etikettierung der Probengefäße und der dazugehörigen Auftragsformulare ist in den Spitälern sehr heterogen organisiert. Uneinheitliche oder fehlende definierte Prozessabläufe führen dazu, dass Probengefäße und dazugehörige Auftragsformulare falsch oder gar nicht etikettiert werden. Um zu untersuchen, welche Fehler bei der Etikettierung von Laborproben auftreten und was zu ihrer Detektion führt, wurden die Fehlerberichte von 42 Schweizer Spitälern des CIRRNET-Netzwerks (Critical Incident Reporting & Reacting NETwork) systematisch analysiert.
Source: Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen
Authors: Dr. Olga Frank und Carmen Kerker-Specker, Stiftung Patientensicherheit Schweiz
