TY - JOUR
T1 - Using the Generic Analysis Method to Analyze Sentinel Event Reports Across Hospitals
T2 - A Retrospective Cross-Sectional Study
AU - Baartmans, Mees C
AU - Van Schoten, Steffie M
AU - Smit, Bert J
AU - Wagner, Cordula
N1 - Funding Information: The study was funded by the Dutch Ministry of Health, Welfare and Sport (no grant/award number). Publisher Copyright: © Wolters Kluwer Health, Inc. All rights reserved.
PY - 2023/4/1
Y1 - 2023/4/1
N2 - OBJECTIVES: Improving patient safety by investigating sentinel events (SEs) is hampered by the focus on isolated events within hospitals and a narrow scope of traditional root cause analysis methods. We aimed to examine if performing cross-hospital aggregate analysis of SEs applying a novel generic analysis method (GAM) bearing a human factor perspective can enhance learning from SEs.METHODS: A retrospective cross-sectional review of SE reports from 28 Dutch general hospitals using the GAM to reanalyze events was performed. A qualitative approach was used to identify contributing factors and system issues. Findings were discussed with a patient safety expert panel. Descriptive statistics and measures of associations between domains were calculated.RESULTS: Sixty-nine SE reports were reviewed. Applying the GAM provided a more holistic SE analysis than a traditional method. Of the 405 identified contributing factors in all SEs, the majority was related to the persons involved (patients and professionals, n = 146 [36.2%]) and the organization (n = 121 [30%]). The most frequently recurring pattern was the combination of factors related to the persons involved, the technology used, the tasks of professionals, and organizational factors influencing the event. Cross-hospital aggregate GAM analysis of SEs helped to identify system issues and propose more system-oriented overarching recommendations.CONCLUSIONS: This study found that applying the GAM to analyze SEs across hospitals can help to improve learning from SEs and may result in proposing stronger recommendations. The method can support hospitals, working together in a network of hospitals, to jointly learn from SEs.
AB - OBJECTIVES: Improving patient safety by investigating sentinel events (SEs) is hampered by the focus on isolated events within hospitals and a narrow scope of traditional root cause analysis methods. We aimed to examine if performing cross-hospital aggregate analysis of SEs applying a novel generic analysis method (GAM) bearing a human factor perspective can enhance learning from SEs.METHODS: A retrospective cross-sectional review of SE reports from 28 Dutch general hospitals using the GAM to reanalyze events was performed. A qualitative approach was used to identify contributing factors and system issues. Findings were discussed with a patient safety expert panel. Descriptive statistics and measures of associations between domains were calculated.RESULTS: Sixty-nine SE reports were reviewed. Applying the GAM provided a more holistic SE analysis than a traditional method. Of the 405 identified contributing factors in all SEs, the majority was related to the persons involved (patients and professionals, n = 146 [36.2%]) and the organization (n = 121 [30%]). The most frequently recurring pattern was the combination of factors related to the persons involved, the technology used, the tasks of professionals, and organizational factors influencing the event. Cross-hospital aggregate GAM analysis of SEs helped to identify system issues and propose more system-oriented overarching recommendations.CONCLUSIONS: This study found that applying the GAM to analyze SEs across hospitals can help to improve learning from SEs and may result in proposing stronger recommendations. The method can support hospitals, working together in a network of hospitals, to jointly learn from SEs.
KW - critical incident review
KW - human factors
KW - patient safety
KW - quality improvement
KW - root cause analysis
KW - sentinel event analysis
UR - http://www.scopus.com/inward/record.url?scp=85151044401&partnerID=8YFLogxK
U2 - https://doi.org/10.1097/PTS.0000000000001104
DO - https://doi.org/10.1097/PTS.0000000000001104
M3 - Article
C2 - 36652656
SN - 1549-8417
VL - 19
SP - 158
EP - 165
JO - Journal of Patient Safety
JF - Journal of Patient Safety
IS - 3
ER -