Comprehensive Patient Safety Program Research Articles

The Impact of TeamSTEPPS Training on Obstetric Team Attitudes and Outcomes on the Labor and Delivery Unit of a Regional Perinatal Center.

We investigated the effect of TeamSTEPPS training on teamwork perceptions and patient safety outcomes in an inpatient obstetrics setting. Physicians and nurses from the regional perinatal center were offered TeamSTEPPS instruction and administered a voluntary survey to assess subjective perceptions of team dynamics and patient safety prior to and six months following TeamSTEPPS training. Responses were analyzed using ANOVA and chi-square analysis. Objective measures of patient safety outcomes were the incidence and blood loss of postpartum hemorrhage after vaginal delivery (PPH-VD) or cesarean section (PPH-CS) and incidence of shoulder dystocia (SD). Outcomes were analyzed using Mann-Whitney and Kruskal Wallis testing. Surveys were collected from 20 physicians and 15 nurses prior to training and from 9 physicians and 20 nurses six months following training. Survey data showed an overall positive perception of teamwork and patient safety behaviors across all respondents. However, we found no significant changes in perception of team dynamics or behaviors to promote patient safety between pre- and post-training timepoints. Physicians and nurses differed in perception of team dynamics (p=0.001) and patient safety behaviors (p<0.001), with nurses reporting more negative perception of safety behaviors post-training. Physician attendees experienced a non-significant lower rate of PPH-VD and PPH-CS with unchanged blood loss, and an increased rate of SD compared to non-attendees in the six months following TeamSTEPPS training (p=0.058, p=0.20, p=0.21, respectively). Our experience with perinatal TeamSTEPPS training as a singular intervention was not demonstrative of improvement in teamwork and patient safety perceptions or incidences of obstetric emergencies suggesting that integration into a more comprehensive patient safety program and ongoing training of a larger proportion of providers per department may be necessary to realize tangible benefits of TeamSTEPPS. Our survey results also highlight important differences between physician and nursing staff perceptions.

Improving patient safety and quality in India's largest hospital network through a dashboard driven approach - The Apollo Quality Program

Background Quality and patient safety are the driving forces for resilient healthcare organizations. However, the healthcare leadership is central to the role of establishing the values of quality and patient safety in the organization. This task becomes extremely challenging when the safety culture has to be built across a large hospital network. Methods A comprehensive patient safety program, the Apollo Quality Program(AQP), structured in the form of a patient-safety dashboard was used as a tool to establish and strengthen the fabric of quality and safety across a large hospital network in India. The dashboard consisted of essential patient safety parameters that were measurable and objective. This dashboard was implemented across 41-hospitals of the network and improvement data monitored. These 41-hospitals varied in size and on basis of their bed strength they were categorized into 3 groups(A,B and C). For this study, the results have been presented from 2011 to 2021. Results The overall AQP scores improved indicating holistic enhancement of patient safety across Apollo Hospitals. Sustained progress, through the last nine years, was observed for various patient safety parameters in the AQP dashboard, across 41-hospitals of the network. Conclusion AQP is an innovative methodology that incorporates all the essential tenets of patient-safety. The programme led to a progressive improvement in patient-safety over the nine-years of its implementation. The enhancement was visible through compliance to the various parameters of AQP. The AQP empowered the leadership to retrospect and analyse each of their units’ performance for patient-safety and quality in systematic manner.

Prevalence of fall injuries and risk factors for fall among hospitalized children in a specialized childrens hospital in Saudi Arabia.

BACKGROUNDFall injuries among children during hospital stay is a major patient safety issue. Inpatient pediatric falls can lead to numerous negative consequences. In contrast to adults, there is a paucity of information on the prevalence and risk factors associated with children’s falls during hospitalization.OBJECTIVESIdentify the prevalence of fall injuries among hospitalized children and describe the demographic and environmental factors that could predict a higher risk of severe outcomes of fall.DESIGNDescriptive, cross-sectional prevalence study.SETTINGSpecialized children’s hospital.PATIENTS AND METHODSData was obtained through the electronic Safety Reporting System (SRS). All reported fall events during hospitalization in children ≤14 years of age for the period from 1 April 2015 to 30 April 2016 were included. Fall events that occurred in the day care unit and the outpatient clinic were excluded.MAIN OUTCOME MEASURESPrevalence and possible risk factors for fall events.SAMPLE SIZE48.RESULTSThe prevalence of falls among the 4860 admitted children was 9.9 (95% CI=7.5, 13.1) per 1000 patients (48/4860). A majority of the falls were among boys (n=26, 54%), in the age group from 1–5 years old (n=22, 46%), in children at high risk of falling (n=35, 73%), with normal mobility status (n=21, 44%), and with no history of previous falls (n=33, 69%). Severe injuries accounted for 25% of falls (n=12). However, falls among the moderate risk category (n=9, 69%) were more often severe than falls among the high risk category of children (n=12, 34%) (P=.03).CONCLUSIONRisk factor identification is required to prevent falls and their severe outcomes.LIMITATIONSUnderreporting and single-centered study.

Test-Retest Reliability of an Experienced Global Trigger Tool Review Team.

During a comprehensive patient safety program at a 550-bed regional hospital in the Capital Region of Denmark, we observed an unexpected and unexplained doubling of the median patient harm rate from 56 to 109 harms per 1000 patient days measured by the Institute for Healthcare Improvement Global Trigger Tool (GTT). Meanwhile, other measures of patient safety, including hospital standardized mortality ratio, were stable or improving. Moreover, the review team was very experienced and stable during this period. Thus, we hypothesized that the increase in harm rate was not a true reflection of increased risk of patient harm but the result of the team getting better at identifying harms during GTT reviews. We examined the ability of the GTT review team to reproduce the rate of harm of two separate periods in the same hospital: period 1 (January-June 2010) and period 2 (October 2011-March 2012). For each period, we examined two samples: the original sample that was drawn and used for the ongoing monitoring of harm at the hospital during the safety campaign and a second that we drew and analyzed for this study. We found increased harm rates both between review 1 and review 2 and between period 1 and period 2. The increase was solely in category E, minor temporary harm. The very experienced GTT team could not reproduce harm rates found in earlier reviews. We conclude that GTT in its present form is not a reliable measure of harm rate over time.

169: Developing a comprehensive quality and patient safety program to effectively reduce obstetrical adverse events in an integrated children’s hospital system

169: Developing a comprehensive quality and patient safety program to effectively reduce obstetrical adverse events in an integrated children’s hospital system

Reducing Pregnancy‐Related Morbidity and Mortality by Implementing a Comprehensive Quality and Patient Safety Program Beyond the Joint Commission's Perinatal Core Measures

Paper Presentation Purpose for the Program To reduce pregnancy‐related morbidity and mortality in a large, academic, high‐risk obstetric service in a large, free‐standing, pediatric hospital in the southwestern United States. Proposed Change To develop and implement an evidence‐based perinatal quality and patient safety program. Implementation, Outcomes, and Evaluation An interprofessional team reviewed the literature to identify evidence‐based structures and processes that were associated with increased process reliability and improved patient safety outcomes. With support and approval from senior‐level organization leaders and strong partnerships with key stakeholders, the program was implemented in the spring of 2012. Key structures included safety as a core value and nurse staffing and educational preparation. Key processes included daily safety briefs, safety rounds, interprofessional team simulation training, and adherence to evidence‐based care guidelines. To augment the quality and safety program and to address active and latent threats to patient safety identified during event debriefs and safety rounds, an interprofessional subgroup developed and implemented a massive transfusion protocol. The rate of obstetric adverse events (OBAE) was selected as the program's outcome measure. The OBAE rate is a composite measure of quality and comprises eight maternal and four fetal measures, calculated as the number of monthly deliveries complicated by one or more maternal or fetal adverse events, multiplied by 100. The baseline rate of OBAE through November of 2012 was 2.01%. During the next 12 months, despite a rapidly increasing delivery volume, the OBAE was reduced 37%. As of August 2014, the OBAE rate in this obstetric service was 1.05%, which reflects an additional 17.3% reduction. Implications for Nursing Practice Although obstetric patient care is delivered by teams, nurses are in a unique position to guide, influence, and lead quality and safety improvements. Nurses have nearly constant presences, are broadly trusted as patient advocates, and are able to identify and report early signs of compromise. Supported by a comprehensive quality and patient safety program in partnership with other key members of the obstetric patient care team, nurses can reduce pregnancy‐related morbidity and mortality.

A Comprehensive Patient Safety Program Can Significantly Reduce Preventable Harm, Associated Costs, and Hospital Mortality

To evaluate the effectiveness of a hospital-wide initiative to improve patient safety by implementing high-reliability practices as part of a quality improvement (QI) program aimed at reducing all preventable harm. A hospital wide quasi-experimental time series QI initiative using high-reliability concepts, microsystem-based multidisciplinary teams, and QI science tools to reduce hospital acquired harm was implemented. Extensive error prevention training was provided for all employees. Change concepts were enacted using the Institute for Healthcare Improvement's Model for Improvement. Compliance with change packages was measured. Between 2010 and 2012, the serious safety event rate decreased from 1.15 events to 0.19 event per 10 000 adjusted hospital-days, an 83.3% reduction (P<.001). Preventable harm events decreased by 53%, from a quarterly peak of 150 in the first quarter of 2010 to 71 in the fourth quarter of 2012 (P<.01). Observed hospital mortality decreased from 1.0% to 0.75% (P<.001), although severity-adjusted expected mortality actually increased slightly, and estimated harm-related hospital costs decreased by 22.0%. Hospital-wide safety climate scores increased significantly. Substantial reductions in serious safety event rate, preventable harm, hospital mortality, and cost were seen after implementation of our multifaceted approach. Measurable improvements in the safety culture were noted as well.

The Case for Simulation as Part of a Comprehensive Patient Safety Program

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Reduction of cesarean delivery rates after implementation of a comprehensive patient safety program

The objective of this paper was to review our institution's cesarean delivery rates starting in 2004 prior to the full implementation of a patient safety program including a uniform oxytocin policy until 2012 when the oxytocin policy and the safety program had been fully implemented. Cesarean delivery rates at our institution decreased incrementally from 41.6 % in 2004 to 32.7 % in 2012. The decrease in cesarean delivery rates was observed for each of the five age groups. Concerns about an increase in cesarean delivery rates after implementation of a comprehensive patient safety program including a standardized oxytocin protocol may be unfounded. Despite the increase of US national cesarean delivery rates, our study shows that it is possible to safely lower cesarean delivery rates without concomitant concerns of litigations.

A Call to “Image Gently”

In August 2011, The Joint Commission (2011) issued a sentinel event alert discussing how high-radiation dosages delivered at any one timemay cause a risk and long-term injury to patients. This has been a particular concern for pediatric patients for many years. In a study by Brenner, Elliston, Hall, and Berdon (2001) in the American Journal of Roentgenology, concern was raised about the possible induction of added cancers because of the ionizing radiation of children undergoing computed tomography (CT). More recently, Brenner and Hall (2007) published that up to 2% of all cancers in theUnited States could be because ofCT radiation exposure. Although many experts disagree on the extent of cancers that may occur from diagnostic imaging, we, as pediatric nurses, should be aware of the possible risk to our patients and the need to provide education to their caregivers. Radiation is found all around us, and we have been exposed to radiation since we were born. Radiation occurs naturally; we are laid bare to these background sources daily as we breathe air (radon gas), ingest food that has absorbed trace radioisotopes, such as potassium, and absorb particles through means of cosmic bombardment. Artificial sources of radiation can either be from nonionizing radiation, such as the type that is used in cell phones or microwaves, or from ionizing radiation used in medical imaging (International Atomic Energy Agency, 2011). Since the creation of CT scans in the early 1970s, the number of ionizing studies have risen from 2 million studies per year to more than 72 million completed in the United States during 2007 (National Council on Radiation Protection, 2009). CT scans are essential for the diagnosis of certain conditions in children such as appendicitis, head injuries, multiple trauma, and congenital heart defects (Frosh, 2011). However, it is the call of the medical community to determine whether a CT scan is necessary. If the medical

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events

American College of Surgeons' Committee on Trauma Performance Improvement and Patient Safety Program: Maximal Impact in a Mature Trauma Center

To examine the impact of an ongoing comprehensive performance improvement and patient safety (PIPS) program implemented in 2005 on mortality outcomes for trauma patients at an established American College of Surgeons (ACS)-verified Level I Trauma Center. The primary outcome measure was in-hospital mortality. Age, Injury Severity Score (ISS), and intensive care unit admissions were used as stratifying variables to examine outcomes over a 5-year period (2004-2008). Institution mortality rates were compared with the National Trauma Data Bank mortality rates stratified by ISS score. Enhancements to our comprehensive PIPS program included revision of trauma activation criteria, development of standardized protocols for initial resuscitation, massive transfusion, avoidance of over-resuscitation, tourniquet use, pelvic fracture management, emphasis on timely angiographic and surgical intervention, prompt spine clearance, reduction in time to computed tomography imaging, reduced dwell time in emergency department, evidence-based traumatic brain injury management, and multidisciplinary efforts to reduce healthcare-associated infections. In 2004 (baseline data), the in-hospital mortality rate for the most severely injured trauma patients (ISS >24) at our trauma center was 30%, consistent with the reported mortality rate from the National Trauma Data Bank for patients with this severity of injury. Over 5 years, our mortality rate decreased significantly for severely injured patients with an ISS >24, from 30.1% (2004) to 18.3% (2008), representing a 12% absolute reduction in mortality (p = 0.011). During the same 5-year time period, the proportion of elderly patients (age >65 years) cared for at our trauma center increased from 23.5% in 2004 to 30.6% in 2008 (p = 0.0002). Class I trauma activations increased significantly from 5.5% in 2004 to 15.5% in 2008 based on our reclassification. A greater percentage of patients were admitted to the intensive care unit (25.8% in 2004 to 37.3% in 2007 and 30.4% in 2008). No difference was identified in the rate of blunt (95%) or penetrating (5%) mechanism of injury in our patients over this time period. Trauma Quality Improvement Program confirmed improved trauma outcomes with observed-to-expected ratio and 95% confidence intervals of 0.64 (0.42-0.86) for all patients, 0.54 (0.15-0.91) for blunt single-system patients, and 0.78 (0.51-1.06) for blunt multisystem patients. Implementation of a multifaceted trauma PIPS program aimed at improving trauma care significantly reduced in-hospital mortality in a mature ACS Level I trauma center. Optimal care of the injured patient requires uncompromising commitment to PIPS.

Improving RCA performance: the Cornerstone Award and the power of positive reinforcement

BackgroundThe Veterans Health Administration has had a comprehensive patient safety program since 1999 that includes conducting root cause analysis (RCA) of adverse medical events. Improving the quality and timeliness of...

Patient Safety Education for Residents—A Colorado Story

To educate the next generation of physicians to be leaders in patient safety, we must give residents opportunities to identify and learn from mistakes. The Institute of Medicine raised awareness of medical errors in its 1999 landmark report,1 and in 2008 advocated that “residents should be taught error detection, correction, reporting and monitoring so they can participate fully in the hospital's quality improvement efforts.”2 During the past 2 years, 36 transitional year interns and 36 family medicine residents from 3 sites in Colorado participated in a comprehensive patient safety program. The curriculum requires each resident to report adverse events, report near misses or unsafe conditions, attend 12 patient safety lectures per year, and disclose a medical error to standardized patients in 2 separate exercises. Residents' communication skills during the disclosure are rated by the standardized patients, and residents receive feedback from attending physicians who observe the exercise. Events reported by the residents are collected, deidentified, and analyzed, and education is provided to all residents in the program. Residents are surveyed before and after the intervention regarding their attitudes and assumptions about patient safety. This curriculum is modeled after the University of Illinois at Chicago's Full Disclosure and Transparency Program.3 The experience from our program indicates that when residents are part of a culture of reporting and discussing mistakes, the fear of negative effects often associated with admitting or reporting a mistake is reduced. One resident stated, “I feel more confident about reporting incidents. Whereas [during] my first ward month I was unsure of reporting incidents that I thought were minor issues [now] I think reporting adverse events and near misses is more important than I previously thought, since seeing the actual changes that occur in response to our reports.” During the 2 years, 94% of residents submitted an adverse event report. The longer the residents are part of the program, the more they report events. In 2009, residents reported a combined 147 events at the 3 programs. In 2010, 406 events were reported, an increase of 176%. Of 553 total event reports, 165 were near misses and 141 represented unsafe conditions. Consequently, more than half of the reported events provided learning opportunities for residents and opportunities for system improvement before patients were harmed. Quality Improvement staff at the hospitals reported that, previously, close calls were almost never reported and that the opportunity to learn from these near misses has been invaluable. System changes that have occurred because of the resident reports include: Procedural changes regarding documentation Institution of a new policy regarding the safe transport of patients A change in practice to promote infection prevention Improved patient flow processes Residents are highly satisfied with the curriculum and have demonstrated an increased comfort level in reporting and disclosing medical errors. Many have affirmed that they will be champions for safety in their careers going forward. Our Patient Safety Education Program offers learning opportunities in the context of a comprehensive program for responding to adverse patient events. It has provided residents with valuable learning opportunities, allowing them to participate in quality improvement and gain experience in systems-based practice.

A comprehensive obstetrics patient safety program improves safety climate and culture

The purpose of this study was to determine the effect of an obstetrics patient safety program on staff safety culture. We implemented (1) obstetrics patient safety nurse, (2) protocol-based standardization of practice, (3) crew resource management training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting system. We administered the Safety Attitude Questionnaire on 4 occasions over 5 years (2004-2009) to all staff members that assessed teamwork and safety cultures, job satisfaction, working conditions, stress recognition, and perceptions of management. We observed significant improvements in the proportion of staff members with favorable perceptions of teamwork culture (39% in 2004 to 63% in 2009), safety culture (33% to 63%), job satisfaction (39% to 53%), and management (10% to 37%). Individual roles (obstetrics providers, residents, and nurses) also experienced improvements in safety and teamwork, with significantly better congruence between doctors and nurses. Safety programs can improve workforce perceptions of safety and an improved safety climate.

545: A comprehensive OB patient safety program reduces liability claims

545: A comprehensive OB patient safety program reduces liability claims

Safety coaches in radiology: decreasing human error and minimizing patient harm

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

543: A comprehensive OB patient safety program improves safety climate and culture

543: A comprehensive OB patient safety program improves safety climate and culture

A Comprehensive Perinatal Patient Safety Program to Reduce Preventable Adverse Outcomes and Costs of Liability Claims

To achieve the goal of safe care for mothers and infants during labor and birth, Catholic Healthcare Partners (CHP; Cincinnati) conducted on-site risk assessments at the 16 hospitals with perinatal units in 2004-2005, with follow-up visits in 2006 through 2008. ON-SITE RISK ASSESSMENTS: In addition to assessing overall organizational risk, the assessments provided each hospital a gap analysis demonstrating up-to-date and outdated practices and strategies and resources necessary to make all practices consistent with current evidence and national guidelines and standards. CRITICAL ASPECTS OF CLINICAL CARE: Review of claims and near-miss data indicate that fetal assessment, labor induction, and second-stage labor care comprise the majority of risk of perinatal harm. Therefore, these clinical areas were the focus of strategies to promote safety. To promote consistency in knowledge and practice, in 2004 a variety of strategies were recommended, including interdisciplinary fetal monitoring education and routine medical record reviews to monitor ongoing adherence to appropriate practice and documentation. Success in implementing essential structural and process components of the perinatal patient safety program have resulted in improvement from 2003 to 2008 in specific outcomes for the 16 perinatal units surveyed, including reduction of perinatal harm, number of claims, and costs of claims. The program continues to evolve with modifications as needed as more evidence becomes available to guide best perinatal practices and new guidelines/standards are published. A patient safety program guided and supported by a health care system can result in safer clinical environments in individual hospitals and in decreased risk of preventable perinatal harm and liability costs.

Establishing a Provincial Patient Safety and Learning System: Pilot Project Results and Lessons Learned

An effective safety event reporting system is an essential part of a comprehensive patient safety program. In British Columbia, we are implementing a provincial web-based event reporting tool and learning system called the BC Patient Safety and Learning System (PSLS). In this paper, we describe and report the results of our pilot study in a neonatal intensive care unit at BC Women's Hospital in Vancouver. Our approach aimed to foster a culture of safety by using the technology implementation to facilitate organizational learning about patient safety and to promote sustainable reporting behaviours. Results showed that PSLS was enthusiastically adopted by staff and enabled efficient reporting, promoted timely and complete follow-up activities and facilitated quality improvement. Our lessons learned laid the foundation for the provincial rollout of PSLS and may be of interest to those implementing similar systems elsewhere.