Fatal Adverse Events in Femoral Neck Fracture Patients Undergoing Hemiarthroplasty or Total Hip Arthroplasty-A Retrospective Record Review Study in a Nationwide Sample of Deceased Patients.

Objectives: Patient safety is a core component of quality of hospital care and measurable through adverse event (AE) rates. A high-risk group are femoral neck fracture patients. The Dutch clinical guideline states that the treatment of choice is cemented total hip arthroplasty (THA) or hemiarthroplasty (HA).

Using the Generic Analysis Method to Analyze Sentinel Event Reports Across Hospitals: A Retrospective Cross-Sectional Study.

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.

What Can We Learn From In-Depth Analysis of Human Errors Resulting in Diagnostic Errors in the Emergency Department: An Analysis of Serious Adverse Event Reports.

Introduction: Human error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations.

Methods: We studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors.

Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective.

Background: Hospitals in various countries such as the Netherlands investigate and analyse serious adverse events (SAEs) to learn from previous events and attempt to prevent recurrence. However, current methods for SAE analysis do not address the complexity of healthcare and investigations typically focus on single events on the hospital level. This hampers hospitals in their ambition to learn from SAEs.

Root Cause Analysis Using the Prevention and Recovery Information System for Monitoring and Analysis Method in Healthcare Facilities: A Systematic Literature Review.

Objectives: Unintended events (UEs) are prevalent in healthcare facilities, and learning from them is key to improve patient safety. The Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method is a root cause analysis method used in healthcare facilities. The aims of this systematic review are to map the use of the PRISMA-method in healthcare facilities worldwide, to assess the insights that the PRISMA-method offers, and to propose recommendations to increase its usability in healthcare facilities.