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Objectives: Despite widespread use of medical devices and their increasing complexity, their contribution to unintended injury caused by healthcare (adverse events, AEs) remains relatively understudied. The aim of this study was to gain insight in the incidence and types of AEs involving medical devices (AMDEs)., Methods: Data from two patient record studies for the identification of AEs were used. Identification of AMDEs was part of these studies. Patient records of 6894 admissions of a random sample of 20 hospitals in 2011/2012 and 19 hospitals in 2015/2016 were reviewed for AMDEs by trained nurses and physicians., Results: In 98.7% of the admissions, a medical device was used. Adverse events involving medical devices were present in 2.8% of the admissions, with 24% of the AMDEs being potentially preventable. Of all AEs, in 40%, medical devices were involved. Of all potentially preventable AEs, in 44%, medical devices were involved. Implants were most often involved in potentially preventable AMDEs., Conclusions: Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

To decrease infusion pump administration errors, time-consuming training is often initiated. The aims of this study were twofold: to develop minimum competency requirements for programming and operation of infusion pumps and to develop and validate a test for nurses based on those requirements. The test was completed by 226 nurses between May and December 2017. This study demonstrates that testing is a promising method to assess the competency of nurses in using medical devices. Moreover, test acceptability among nurses is high. Using competency requirements to develop a test offers the potential to tailor training needs and reduce training time.

Background: The recent emphasis on value-based health care (VBHC) is thought to provide new opportunities for shared decision-making (SDM) in the Netherlands, especially when using patient-reported outcome measures (PROMs) in routine medical encounters. It is still largely unclear about how PROMs could be linked to SDM and what we expect from clinicians in this respect., Aim: To describe approaches and lessons learned in the fields of SDM and VBHC implementation that converge in using PROMs in medical encounters., Approach: Based on input from three Dutch forerunner case examples and available evidence about SDM and VBHC, we describe barriers and facilitators regarding the use of PROMs and SDM in the medical encounter. Barriers and facilitators were structured according to a conversational model that included monitoring and managing, team talk, option talk, choice talk, and decision talk. Key lessons learned and recommendations were synthesized., Results: The use of individual, N = 1 PROMs scores in the medical encounter has been largely achieved in the forerunner projects. Conversation on monitoring and managing is relatively well implemented, and option talk to some extent, unlike team talk, and decision talk. Aggregated PROMs information describing outcomes of treatment options seemed to be scarcely used. Experienced barriers largely corresponded to what is known from the literature, eg, perceived lack of time and lack of tools summarizing the options. Some concerns were identified about increasing health care consumption as a result of using PROMs and SDM in the medical encounter., Conclusion: Successful implementation of SDM within VBHC initiatives may not be self-evident, even though individual, N = 1 PROMs scores are being used in the medical encounter. Education and staff resources on meso and macro levels may facilitate the more time-consuming SDM aspects. It seems fruitful to especially target team talk and choice talk in redesigning clinical pathways., (© 2019 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Background Drug-related problems (DRP) following hospital discharge may cause morbidity, mortality and hospital re-admissions. It is unclear whether a clinical medication review (CMR) and counseling at discharge is a cost-effective method to reduce DRP. Objective To assess the effect of a CMR on health care utilization and to investigate whether CMR is a cost-effective method to reduce DRP in older polypharmacy patients discharged from hospital. Setting 24 community pharmacies in the Netherlands. Method A cluster-randomized controlled trial with an economic evaluation. Community pharmacies were randomized to those providing a CMR, counseling and follow-up at discharge and those providing usual care. Main outcome measures Change in the number of DRP after 1 year of follow-up and costs of health care utilization during follow-up. In 216 patients the use of health care was prospectively assessed. Missing data on effects and costs were imputed using multiple imputation techniques. Bootstrapping techniques were used to estimate the uncertainty around the differences in costs and incremental cost-effectiveness ratios. Results CMR resulted in a small reduction of DRP. The proportion of patients readmitted to the hospital during 6 months of follow-up was significantly higher in the intervention group than in the control group (46.4 vs. 20.9%; p < 0.05). Health care costs were higher in the intervention group, although not statistically significant. The costs of reducing one DRP by a CMR amounted to €8270. Conclusion A CMR in vulnerable older patients at hospital discharge led to a small reduction in DRP. Because of a significantly higher use of health care and higher number of re-hospitalisations post CMR, the present study data indicate that performing the intervention in this patient population is not cost-effective.

Objectives: Classroom-based crew resource management (CRM) training has been increasingly applied in health care to improve safe patient care. Crew resource management aims to increase participants' understanding of how certain threats can develop as well as provides tools and skills to respond to such threats. Existing literature shows promising but inconclusive results that might be explained by the quality of the implementation. The present research systematically describes the implementation from the perspective of 3 trained intensive care units (ICUs)., Methods: The design of the study was built around 3 stages of implementation: (1) the preparation, (2) the actions after the CRM training, and (3) the plans for the future. To assess all stages in 3 Dutch ICUs, 12 semistructured interviews with implementation leaders were conducted, the End-of-Course Critique questionnaire was administered, and objective measurements consisting of the number and types of plans of action were reported., Results: The results categorize initiatives that all 3 ICUs successfully launched, including the development of checklists, each using a different implementation strategy. All ICUs have taken several steps to sustain their approach for the foreseeable future. Three similarities between the units were seen at the start of the implementation: (1) acknowledgment of a performance gap in communication, (2) structural time allocated for CRM, and (3) a clear vision on how to implement CRM., Conclusions: This study shows that CRM requires preparation and implementation, both of which require time and dedication. It is promising to note that all 3 ICUs have developed multiple quality improvement initiatives and aim to continue doing so.

OBJECTIVE To investigate whether the safety culture of a hospital unit is associated with the ability to improve. DESIGN Qualitative investigation of safety culture on hospital units following a before-and-after trial on hand hygiene. SETTING VU University Medical Center, a tertiary-care hospital in the Netherlands. METHODS With support from hospital management, we implemented a hospital-wide program to improve compliance. Over 2 years, compliance was measured through direct observation, twice before, and 4 times after interventions. We analyzed changes in compliance from baseline, and selected units to evaluate safety culture using a positive deviance approach: the hospital unit with the highest hand hygiene compliance and 2 units that showed significant improvement (21% and 16%, respectively) were selected as high performing. Another 2 units showed no improvement and were selected as low performing. A blinded, independent observer conducted interviews with unit management, physicians, and nurses, based on the Hospital Survey on Patient Safety Culture. Safety culture was categorized as pathological (lowest level), reactive, bureaucratic, proactive, or generative (highest level). RESULTS Overall, 3 units showed a proactive or generative safety culture and 2 units had bureaucratic or pathological safety cultures. When comparing compliance and interview results, high-performing units showed high levels of safety culture, while low-performing units showed low levels of safety culture. CONCLUSIONS Safety culture is associated with the ability to improve hand hygiene. Interventions may not be effective when applied in units with low levels of safety culture. Although additional research is needed to corroborate our findings, the safety culture on a unit can benefit from enhancement strategies such as team-building exercises. Strengthening the safety culture before implementing interventions could aid improvement and prevent nonproductive interventions. Infect Control Hosp Epidemiol 2017;38:1277-1283.

Background: In the management of non-ST-elevation acute coronary syndrome (NSTACS) a gap between guideline-recommended care and actual practice has been reported. A systematic overview of the actual extent of this gap, its potential impact on patient-outcomes, and influential factors is lacking., Objective: To examine the extent of guideline adherence, to study associations with the occurrence of adverse cardiac events, and to identify factors associated with guideline adherence., Method: Systematic literature review, for which PUBMED, EMBASE, CINAHL, and the Cochrane library were searched until March 2016. Further, a manual search was performed using reference lists of included studies. Two reviewers independently performed quality-assessment and data extraction of the eligible studies., Results: Adherence rates varied widely within and between 45 eligible studies, ranging from less than 5.0 % to more than 95.0 % for recommendations on acute and discharge pharmacological treatment, 34.3 % - 93.0 % for risk stratification, and 16.0 % - 95.8 % for performing coronary angiography. Seven studies indicated that higher adherence rates were associated with lower mortality. Several patient-related (e.g. age, gender, co-morbidities) and organization-related (e.g. teaching hospital) factors influencing adherence were identified., Conclusion: This review showed wide variation in guideline adherence, with a substantial proportion of NST-ACS patients possibly not receiving guideline-recommended care. Consequently, lower adherence might be associated with a higher risk for poor prognosis. Future research should further investigate the complex nature of guideline adherence in NST-ACS, its impact on clinical care, and factors influencing adherence. This knowledge is essential to optimize clinical management of NSTACS patients and could guide future quality improvement initiatives.

Introduction: A language barrier has been shown to be a threat for quality of hospital care. International studies highlighted a lack of adequate noticing, reporting, and bridging of a language barrier. However, studies on the link between language proficiency and patient safety are scarce, especially in Europe. The present study investigates patient safety risks due to language barriers during hospitalization, and the way language barriers are detected, reported, and bridged in Dutch hospital care., Methods: We combined quantitative and qualitative methods in a sample of 576 ethnic minority patients who were hospitalized on 30 wards within four urban hospitals. The nursing and medical records of 17 hospital admissions of patients with language barriers were qualitatively analyzed, and complemented by 12 in-depth interviews with care providers and patients and/or their relatives to identify patient safety risks during hospitalization. The medical records of all 576 patients were screened for language barrier reports. The results were compared to patients' self-reported Dutch language proficiency. The policies of wards regarding bridging language barriers were compared with the reported use of interpreters in the medical records., Results: Situations in hospital care where a language barrier threatened patient safety included daily nursing tasks (i.e. medication administration, pain management, fluid balance management) and patient-physician interaction concerning diagnosis, risk communication and acute situations. In 30% of the patients that reported a low Dutch proficiency, no language barrier was documented in the patient record. Relatives of patients often functioned as interpreter for them and professional interpreters were hardly used., Discussion: The present study showed a wide variety of risky situations in hospital care for patients with language barriers. These risks can be reduced by adequately bridging the language barrier, which, in the first place, demands adequate detecting and reporting of a language barrier. This is currently not sufficiently done in most Dutch hospitals. Moreover, new solutions to bridge language barriers are needed for situations such as routine safety checks performed by nurses, in which a professional or even informal interpreter is not feasible., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Data in an Electronic Health Record must be recorded once, in a standardized and structured way at the point of care to be reusable within the care process as well as for secondary purposes ('collect once, use many times' (COUMT) paradigm). COUMT has not yet been fully adopted by staff in every organization. Our study intends to identify concepts that underlie its adoption and describe its current status in Dutch academic hospitals. Based on literature we have constructed a model that describes these concepts and that guided the development of a questionnaire investigating COUMT adoption. The questionnaire was sent to staff working with patient data or records in seven out of eight Dutch university hospitals. Results show high willingness of end-users to comply to COUMT in the care process. End-users agree that COUMT is important, and that they want to work in a structured and standardized way. However, end-users indicate to not actually use terminology or information standards, but often register diagnoses and procedures in free text, and experience repeated recording of data. In conclusion, we found that COUMT is currently well adopted in mind, but not yet in practice.

Rationale, Aims and Objectives: Aviation-based crew resource management trainings to optimize non-technical skills among professionals are often suggested for health care as a way to increase patient safety. Our aim was to evaluate the effect of a 2-day classroom-based crew resource management (CRM) training at emergency departments (EDs) on explicit professional oral communication (EPOC; non-technical skills)., Method: A pragmatic controlled before-after trial was conducted. Four EDs of general teaching hospitals were recruited (two intervention and two control departments). ED nurses and ED doctors were observed on their non-technical skills by means of a validated observation tool (EPOC). Our main outcome measure was the amount of EPOC observed per interaction in 30 minutes direct observations. Three outcome measures from EPOC were analysed: human interaction, anticipation on environment and an overall EPOC score. Linear and logistic mixed model analyses were performed. Models were corrected for the outcome measurement at baseline, days between training and observation, patient safety culture and error management culture at baseline., Results: A statistically significant increase after the training was found on human interaction (β=0.27, 95% CI 0.08-0.49) and the overall EPOC score (β=0.25, 95% CI 0.06-0.43), but not for anticipation on environment (OR=1.19, 95% CI .45-3.15). This means that approximately 25% more explicit communication was shown after CRM training., Conclusions: We found an increase in the use of CRM skills after classroom-based crew resource management training. This study adds to the body of evidence that CRM trainings have the potential to increase patient safety by reducing communication flaws, which play an important role in health care-related adverse events., (© 2014 John Wiley & Sons, Ltd.)

Patient data stored in Electronic Health Records (EHRs) are used during care provision but are also potentially usefully reused for other purposes. Data (re)use requires good data quality, which necessitates efforts by healthcare professionals for proper data registration. However, their commitment depends on their perception of the reuse benefits. We developed a questionnaire to investigate the perception and expectations of end-users on data registration and reuse in two university hospitals starting a joint EHR implementation. Especially personnel in direct patient care reports to spend much time (40%) on data registration and this group is not willing to spend more time with the new EHR. Additionally, approximately one third of the personnel did not yet have a clear view on future developments regarding data registration and reuse. We found only small differences between hospitals.

Background: Given growing awareness of the crucial role of nontechnical skills in providing safe patient care, crew resource management (CRM) training is being increasingly used to improve them. Implementing the plans of action that are formulated during CRM training may constitute an important first step in the successful uptake of skills. Accordingly, understanding the factors that determine why participants do or do not carry out those plans should help improve CRM training and enhance its impact. A study was conducted to examine the impact of pretraining readiness factors and posttraining barriers and facilitators on follow-up on plans of action., Methods: Three ICUs, each at a different nonacademic teaching hospital in The Netherlands, received two-day classroom-based CRM training in 2010. During the training, new ideas for safety initiatives were documented as concrete plans of action. All plans were categorized as individual (for example, "Always ask a colleague to double-check your medication"), team, or organizational. Two months before and three months after the CRM training, all ICU employees were asked to fill out a set of questionnaires., Results: Management support for patient safety before the training was a positive determinant of the number of perceived facilitators. A significant relationship was found between the perceived barriers and facilitators after CRM training and Taking Action. More barriers were negatively associated, while more facilitators were positively associated, with Taking Action. When assessed separately, none of the readiness factors were significantly associated with taking action, while when assessed together, the readiness factors were positive related to Taking Action., Discussion: To overcome the barriers and profit from the facilitators, they should be considered during the training and in regular CRM meetings afterward.

Rationale, Aims and Objectives: Loss of situation awareness (SA) by health professionals during handover is a major threat to patient safety in perinatal care. SA refers to knowing what is going on around. Adequate handover communication and process may support situation assessment, a precursor of SA. This study describes current practices and opinions of perinatal handover to identify potential improvements., Methods: Structured direct observations of shift-to-shift patient handovers (n = 70) in an academic perinatal setting were used to measure handover communication (presence and order of levels of SA: current situation, background, assessment and recommendation) and process (duration, interruptions/distractions, eye contact, active inquiry and reading information back). Afterwards, receivers' opinions of handover communication (n = 51) were measured by means of a questionnaire., Results: All levels of SA were present in 7% of handovers, the current situation in 86%, the background in 99%, an assessment in 24% and a recommendation in 46%. In 77% of handovers the background was mentioned first, followed by the current situation. Forty-four per cent of handovers took 2 minutes or more per patient. In 52% distractions occurred, in 43% there was no active inquiry, in 32% no eye contact and in 97% information was not read back. The overall mean of the receivers' opinions of handover communication was 4.1 (standard deviation ± 0.7; scale 1-5, where 5 is excellent)., Conclusions: Perinatal handovers are currently at risk for inadequate situation assessment because of variability and limitations in handover communication and process. However, receivers' opinions of handover communication were very positive, indicating a lack of awareness of patient safety threats during handover. Therefore, the staff's awareness of current limitations should be raised, for example through video reflection or simulation training., (© 2013 John Wiley & Sons, Ltd.)

Objective: To determine the change in adverse event (AE) rates and preventable AE rates over time, identify certain patient risk groups and discuss factors influencing the outcome., Design: Longitudinal retrospective patient record review study., Setting and Participants: A random sample of 21 hospitals in The Netherlands in 2004, and 20 hospitals in 2008. In each hospital, 400 patient admissions were included in 2004, and 200 in 2008., Main Outcome Measures: AEs and preventable AEs., Results: Multilevel analyses of 11 883 patient records (7.887 in 2004, 3.996 in 2008) showed that the rate of patients experiencing an AE increased from 4.1% (95% CI 3.3% to 5.1%) in 2004 to 6.2% (95% CI 5.0% to 7.6%) in 2008. The preventable AE rate remained relatively stable at 1.8% (95% CI 1.3% to 2.4%) in 2004 and 1.6% (95% CI 1.2% to 2.3%) in 2008. The risk of experiencing a preventable AE was increasingly higher for patients admitted to a surgical unit (OR 1.54 (95% CI 1.10 to 2.16) in 2004 and 3.32 (95% CI 2.17 to 5.07)) in 2008. More than 50% of all AEs were related to surgery. Indications were found that differences in the risk of experiencing a preventable AE between hospital departments were larger in 2008 than in 2004, while differences between hospitals themselves were smaller., Conclusions: Patient harm related to healthcare is a persistent problem that is hard to influence. Measuring AEs over time stresses the continuing urgency, and also identifies possible areas for improvement.

Background: Patient record review of hospitalised patients is by far the most applied method to assess adverse events (AEs) in hospitals. The diligence with which information is recorded may influence the visibility of AEs. On the other hand, poor quality of the information in patient records may be a cause or a consequence of poor quality of care and may thus be associated with higher rates of AEs. The objective of this study was to assess the relation between the quality of patient records and the occurrence of AEs., Methods: In this study, 7926 hospital admissions of 21 Dutch hospitals were analysed with a structured record review method. The occurrence of AEs, the presence of patient information and the quality of the present information (completeness, readability and adequacy) were assessed. Their association was analysed using multilevel logistic regression analyses., Results: The absence of record components was associated with lower rates of AEs, suggesting that missing record components lead to an underassessment of AEs in record-review studies. In contrast, poor quality of the information present in patient records was associated with higher rates of AEs, implying that the quality of the present patient information is a predictor of the quality of care., Conclusions: Evidence-based standards and a (electronic) format for record keeping are necessary for standardisation of recording patient information. This will improve the completeness, readability, accessibility, accuracy and exchange of patient information between healthcare providers and institutions. Better registration of patient information will benefit the quality of the healthcare process and will reduce the risk of AEs.

Objective: The objective of this study was to analyze the variation in the rates of adverse events (AEs), and preventable AEs, between hospitals and hospital departments in order to investigate the room for improvement in reducing AEs at both levels. In addition, we explored the extent to which patient, department and hospital characteristics explain differences in the rates of AEs., Design: Structured retrospective patient record review of hospital admissions., Setting: Twenty-one Dutch hospitals. Population A representative random sample of 7113 hospital admissions in 2004., Main Outcome Measures: Variation in AEs, and preventable AEs, between hospitals and hospital departments and the explanatory factors of the variation., Results: The rates of AEs varied between hospitals (P = 0.05) and hospital departments (P < 0.05). The rates of preventable AEs only varied significantly between hospital departments. The clustering of preventable AEs in hospital departments was more than twice that found in hospitals (ICC 9.5 versus 3.5%). The type of hospital explained 35% of the inter-hospital variance in AEs. Patient and department characteristics explained 23% of the inter-department variance in preventable AEs., Conclusions: In addition to interventions to improve the overall patient safety within a hospital, interventions tailored for specific departments are necessary to reduce their patient safety risks. Monitoring and comparing the performance of hospitals should not be limited to the hospital level, but should be extended to the individual department since there can be significant differences in the rates of preventable AEs between different departments within the same hospital.

Objectives: To investigate the methods used to estimate the indirect costs of health-related productivity in economic evaluations from a company's perspective., Methods: The primary literature search was conducted in Medline and Embase. Supplemental searches were conducted in the Cochrane NHS Economic Evaluation Database, the National Institute for Occupational Safety and Health database, the Ryerson International Labour, Occupational Safety and Health Index database, scans of reference lists and researcher's own literature database. Article selection was conducted independently by two researchers based on title, keywords, and abstract, and if needed, full text. Differences were resolved by a consensus procedure. Articles were selected based on seven criteria addressing study population, type of intervention, comparative intervention, outcome, costs, language and perspective, respectively. Characteristics of the measurement and valuation of health-related productivity were extracted and analyzed descriptively., Results: A total of 34 studies were included. Costs of health-related productivity were estimated using (a combination of) data related to sick leave, compensated sick leave, light or modified duty or work presenteeism. Data were collected from different sources (e.g. administrative databases, worker self-report, supervisors) and by different methods (e.g. questionnaires, interviews). Valuation varied in terms of reported time units, composition and source of the corresponding price weights, and whether additional elements, such as replacement costs, were included., Conclusions: Methods for measuring and valuing health-related productivity vary widely, hindering comparability of results and decision-making. We provide suggestions for improvement.

Objective: The objective of this study was to investigate the association between 11 patient safety culture dimensions and the implementation of 7 organizational patient safety defences., Design: Data were gathered within a cross-sectional, retrospective survey., Setting: Emergency departments (EDs) in the Netherlands., Participants: Thirty-three EDs of non-academic hospitals, which belong to the clientele of Dutch largest medical liability insurer., Main Outcome Measures: Implementation of the separate organizational patient safety defences (0 = insufficient/sufficient, 1 = good)., Results: Analyses showed that several culture dimensions were negatively or positively associated with the implementation of the patient safety defences. A culture in which hospital handoffs and transitions were perceived adequate was related to less frequent implementation of four of seven organizational patient safety defences, whereas a culture with well-perceived hospital management support for patient safety predicted more frequent implementation of four of seven organizational patient safety defences., Conclusions: Results suggest that well-perceived culture dimensions might inhibit improvements by lack of a sense of urgency as well as facilitate improvements by inducing feelings of support for organizational changes and improvements. The influence of patient safety culture appeared to be not always as straightforward as it seems to be in advance.

Objective: Using a standardized quality criteria list, we appraised the methodological quality of economic evaluations of occupational safety and health (OSH) interventions conducted from a corporate perspective., Methods: The primary literature search was conducted in Medline and Embase. Supplemental searches were conducted in the Cochrane NHS Economic Evaluation Database, the National Institute for Occupational Safety and Health (NIOSH) database, the Ryerson International Labour, Occupational Safety and Health Index, scans of reference lists, and researchers' own literature database. Independently, two researchers selected articles based on title, keywords, and abstract, and if needed, fulltext. Disagreements were resolved by a consensus procedure. Articles were selected based on seven criteria addressing study population, type of intervention, comparative intervention, outcome, costs, language, and perspective. Two reviewers independently judged methodological quality using the Consensus on Health Economic Criteria (CHEC-list), a 19-item standardized quality criteria list. Disagreements in judgment were also resolved by consensus. Data were analyzed descriptively., Results: A total of 34 studies were included. Of these, only 44% of the studies met more than 50% of the quality criteria. Of the 19 quality criteria, 8 were met by 50% or more of the studies. The 11 least fulfilled criteria related to (i) performance of a sensitivity analysis, (ii) selection of perspective, (iii) description of study population, (iv) discussion of generalizability, (v) description of competing alternatives, (vi) presentation of the research question, (vii) measurement of outcomes, (viii) measurement of costs, (ix) valuation of costs, (x) declaration of researchers' independence, and (xi) discussion of ethical and distributional issues., Conclusions: Apart from a few exceptions, the overall methodological quality of the economic evaluations of OSH interventions from a corporate perspective was poor. As such, there is a risk of biased results. The quality of future evaluations needs to be improved to increase the validity of their conclusions and recommendations.

Objectives: We explored characteristics of in-hospital care and treatment of immigrant patients to better understand the processes underlying ethnic disparities in patient safety., Methods: We conducted semistructured interviews with care providers regarding patient safety events involving immigrant patients in in-hospital medical care and treatment, for a total of 30 cases. Interviews were transcribed and qualitatively analyzed with a framework method., Results: Three key patterns were identified from the analysis. Patient safety events occur because of (1) inappropriate responses by health care providers to objective characteristics of immigrant patients, such as low Dutch language proficiency, lack of health insurance, or genetic conditions; (2) misunderstandings between patients and care providers because of differences in illness perceptions and expectations about care and treatment; and (3) inappropriate care because of providers' prejudices against or stereotypical ideas regarding immigrant patients., Conclusions: Our findings suggest that organizational and health professional practices contribute to the higher risk of patient safety events. Descriptive epidemiological research is needed to explore the impact of the 3 patterns on patient safety.

Objective: To evaluate the inter-rater agreement of the record review process of the Dutch Adverse Event study, which we aimed to improve by the involvement of two independent physician reviewers per record instead of one including a consensus procedure in case of disagreement., Methods: The inter-rater agreement within pairs of physicians (independent review between physician A+B) and between pairs of physicians (independent review between physician A+B and C+D) was measured to evaluate the record review process with two physicians including a consensus procedure, with 4,272 and 119 records, respectively., Results: The inter-rater agreement within pairs of physicians was substantial for the determination of adverse events (AEs) with a kappa of 0.64 (95% confidence interval [CI]: 0.61, 0.68). The inter-rater agreement between pairs of physicians was fair for the determination of AEs with a kappa of 0.25 (95% CI: 0.05, 0.45)., Conclusion: A record review process with two physicians per record including a consensus procedure to assess AEs is not more reliable than a record review process with one physician. Retrospective estimates of incidence of AEs from record review studies should be interpreted with caution. Improvement of the method is necessary for monitoring incidence of AEs over time at a national level.

Background: Depression is a highly prevalent condition that is associated with high levels of work absenteeism and high health care costs. Most patients are treated in primary care. A large group of patients prefers psychological treatments to antidepressants., Aims of the Study: To systematically review the evidence for the cost-effectiveness of psychological treatments, psychotherapy and counselling, in comparison with usual care or antidepressant treatment in adult primary care patients with depression., Methods: A computer-assisted search of MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library was carried out. Two independent reviewers selected studies for the review, extracted data and assessed the methodological quality of the included studies., Results: Seven studies were included in the review. Forms of psychotherapy that were evaluated were cognitive behavioural therapy, interpersonal psychotherapy and couple therapy. Usual care generally consisted of care as usually provided by the general practitioner. No conclusion can be drawn on the cost-effectiveness of the above mentioned forms of psychotherapy in comparison with usual care or antidepressant treatment. The cost-effectiveness of counselling in comparison with usual care and antidepressant therapy is yet to be established. Meta-analyses showed that psychotherapy was significantly more expensive than usual care, but not significantly more expensive than antidepressant treatment. Counselling was associated with no statistically significant differences in costs and effects in comparison with usual care in the pooled analysis., Discussion: Based on this review, no firm conclusions on the cost-effectiveness of psychotherapy and counselling in primary care can be drawn. Most studies had methodological shortcomings, which limit the generalisibility of the results., Implications for Health Policies: Given the reluctance of patients to use antidepressants and the large economic impact of depression, policy makers have a need for well designed and sufficiently powered economic evaluations of psychological treatments. The available evidence seems to indicate that psychotherapy has more substantial clinical effects than counselling. Therefore, the emphasis should be on economic evaluations of forms of psychotherapy that have proved to be clinically effective., Implications for Further Research: There are indications that the cost-effectiveness of depression treatment on the whole may be improved by incorporating psychological treatments into enhanced care models, tailored to the needs of individual patients and/or by providing them by trained nurses instead of psychologists or psychotherapists. Further research should investigate these patient tailored, stepped care treatment modalities for depression treatment.

Objectives: There were two study objectives: (i) to identify, via consensus, a key set of items for estimating the costs of productivity loss from a company's perspective and (ii) to develop recommendations for the costs of estimating productivity loss on the basis of consensus findings., Methods: A modified Delphi procedure was utilized in which a predetermined set of 26 items formed the basis for inquiry in the first round. Thirty-six experts from five stakeholder groups in the Netherlands (employers, employees, policy makers and insurers, occupational health professionals, and researchers) participated in the panel. Opinions were sought regarding the relevance and retrievability of data on items related to the following three forms of work loss: work presenteeism (ie, decreased work performance while at work), short-term absenteeism (<2 weeks), and long-term absenteeism (>2 weeks). The data were analyzed quantitatively and qualitatively. The consensus for relevance was set at 70%., Results: After two rounds, 4 items were found relevant for estimating the costs of productivity loss due to work presenteeism, 6 items were relevant for short-term absenteeism, and 11 items remained for long-term absenteeism. The retrievability of data varied. Three sets of recommendations were formulated for estimating the costs of productivity loss from a company's perspective., Conclusion: A streamlined set of relevant items has been identified via consensus and formulated into recommendations for estimating the costs of productivity loss from a company's perspective. Although not definitive, these recommendations represent an important step towards standardizing the way these costs are estimated, and, in turn, facilitate the comparability and utility of economic evaluations of occupational health interventions.