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Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study

机译：衡量威尔士NHS中的危害并告知质量改进：威尔士全国性不良事件的纵向研究

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Background, objectives and settingududDespite global activity over the past 15 years to improve patient safety, the measurement of adverse events (AEs) remains challenging.ududObjectivesududWe aimed to obtain definitive longitudinal data on harm across NHS Wales and to compare the performance of the Global Trigger Tool (GTT) with the two-stage retrospective review process, using our findings to consolidate an approach to the ongoing surveillance of harm in Wales.ududData sourcesududEleven of the 13 major Welsh NHS hospitals.ududReview methodsududThe two-stage retrospective review methodology was used to quantify harm across NHS Wales. In total, 4536 inpatient episodes were screened for AEs by research nurses. Records that were highly suggestive of AEs were further assessed by physicians. NHS-led teams undertook GTT reviews on the same case notes.ududResultsududAt least one AE was determined in 10.3% of episodes of care [95% confidence interval (CI) 9.4% to 11.2%] and 51.5% were preventable (95% CI 46.9% to 56.1%). The percentage of patients identified with AEs using the GTT methodology was lower, at 9.0% (95% CI 8.82% to 9.18%). Differences in AEs were evident across study sites. Methods were developed to profile the risk of AEs in individual organisations by producing signatures of harm for each NHS site. Analysis indicated that neither the GTT nor the two-stage process was a candidate tool for routine surveillance, and a hybrid one-stage tool (Harm2), based on phase 1 findings, was developed for ongoing AE monitoring. Using the Harm2 tool, AEs were identified in 371 out of 3352 randomly selected discharge reviews (11.3%, 95% CI 10.2% to 12.4%), and 59.6% (95% CI 55.3 to 63.9) of these were preventable. In a cohort of randomly selected deceased patient reviews, at least one AE was determined in 315 out of 1018 admissions (30.1%, 95% CI 28.1% to 33.8%), and 61.7% (95% CI 57.5% to 65.9%) of these were preventable. Factors associated with AEs in the randomly selected discharge reviews included having peripheral vascular disease [odds ratio (OR) 2.52], hemiplegia (OR 2.27) or dementia (OR 2.27). No association with chronic disease was identified in the deceased episodes of care.ududLimitationsududThe dependence on our health service partners in identifying notes to be reviewed, along with the small sample examined each month, limits the generalisability of these findings and rates were not standardised for hospital and size and level of services provided. We cannot rule out the possibility that the rates we report may be underestimated.ududConclusionududThe extent of harm detected across NHS Wales using both the two-stage retrospective review process and the new Harm2 tool conforms to the findings in the literature, but this is the first longitudinal study using these methods. With training and using a structured review process, non-physician reviewers can undertake case note review efficiently and effectively, and the rates of AEs and of the preventability and the breakdown of problems in care conform to those reported in studies in which physicians undertake these classifications. Whether the patient died or was discharged alive significantly influences the rate and composition of AEs. The Harm2 tool performed with moderate reliability in the determination of AEs.ududFuture workududFuture large-scale studies should attempt to specify types of AEs, such as hospital-acquired infections and surgical complications, to enable the surveillance of the specific types of harm as well as the overall level of AEs. In the longer term, we need to automate harm surveillance and set measures of harm alongside measures of the beneficial effects of health care.ududFundingududThe National Institute for Health Research Health Services and Delivery Research programme.
机译：背景，目标和背景 ud ud尽管在过去15年中开展了全球活动以提高患者安全性，但不良事件（AEs）的测量仍然具有挑战性。 ud ud目标 ud ud我们旨在获得有关NHS危害的确切纵向数据威尔士，并使用我们的调查结果巩固了对威尔士正在进行的损害进行监控的方法，从而将全球触发工具（GTT）的绩效与两阶段的回顾性审查过程进行了比较。 ud ud数据来源 ud ud威尔士的13家主要NHS医院。 ud ud审查方法 ud ud采用两阶段回顾性审查方法来量化威尔士NHS的危害。研究护士对总共4536例住院发作进行了AE筛查。医生进一步评估了高度提示不良事件的记录。由NHS领导的团队在相同的病例记录上进行了GTT审核。 ud udResults ud ud在10.3％的护理事件中确定了至少一种AE [95％置信区间（CI）9.4％至11.2％]和51.5％是可以预防的（95％CI为46.9％至56.1％）。使用GTT方法鉴定为AE的患者百分比较低，为9.0％（95％CI为8.82％至9.18％）。不同研究地点的AE差异很明显。通过为每个NHS站点提供危害特征来开发方法来描述单个组织中AE的风险。分析表明，GTT和两阶段过程都不是常规监视的候选工具，并且基于第一阶段的发现，开发了一种混合的一阶段工具（Harm2）来进行持续的AE监视。使用Harm2工具，在3352个随机选择的放电检查中，有371个被确认为不良事件（11.3％，95％CI为10.2％至12.4％），其中59.6％（95％CI为55.3至63.9）是可预防的。在一组随机选择的已故患者回顾中，在1018例入院患者中，有315例至少有AE（30.1％，95％CI 28.1％至33.8％）和61.7％（95％CI 57.5％至65.9％）被确定。这些是可以预防的。随机选择的出院评论中与AE相关的因素包括周围血管疾病[优势比（OR）2.52]，偏瘫（OR 2.27）或痴呆（OR 2.27）。在死者的护理过程中未发现与慢性病的关联。 ud ud限制 ud ud依靠我们的卫生服务合作伙伴来确定要审查的笔记以及每月检查的少量样本，限制了这些发现的普遍性而且对于医院以及所提供服务的规模和水平，费率尚未标准化。我们无法排除报告的比率可能被低估的可能性。 ud ud结论 ud ud使用两阶段回顾性审查程序和新的Harm2工具在威尔士NHS范围内检测到的危害程度符合文献，但这是首次使用这些方法进行纵向研究。通过培训和使用结构化的审查程序，非医师审查员可以有效地进行病例笔记审查，并且不良事件的发生率以及可预防性和医疗保健问题的分解与医师对这些分类进行研究的结果一致。患者是否死亡或活着出院显着影响AE的发生率和组成。 Harm2工具在确定AE时以中等可靠性执行。 ud ud未来工作 ud udFuture大规模研究应尝试指定AE类型，例如医院获得性感染和手术并发症，以实现对AE的监测。具体危害类型以及不良事件的整体水平。从长远来看，我们需要自动进行危害监测，并设定危害措施以及对卫生保健有益作用的措施。 ud udFunding ud ud国家卫生研究所健康服务与交付研究计划。

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