Patient Safety Center Research Articles

Community Pharmacy-based Patient Safety Activities: Focused on the Regional Patient Safety Center of the Korean Pharmaceutical Association

Community Pharmacy-based Patient Safety Activities: Focused on the Regional Patient Safety Center of the Korean Pharmaceutical Association

Assessment of Health Information Technology–Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System

Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged. To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system. This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018. Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved. Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results. This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.

Cultura de segurança do paciente em ambiente hospitalar: tendências da produção brasileira

Objetivo: caracterizar a produção brasileira de teses e dissertações sobre a cultura de segurança do paciente em ambiente hospitalar, identificando as tendências dessa produção. Método: estudo de revisão narrativa, realizado no catálogo de teses e dissertações da Catálogo de Teses e Dissertações da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, realizado em janeiro de 2020. Resultados: foram revisados 23 estudos. Identificou-se como tendência estudos do tipo dissertação, produzidos pela enfermagem na região Sudeste, sob a abordagem quantitativa, utilizando questionários validados e publicados 2017. O ambiente hospitalar é o cenário principal de estudo, seguido das unidades de terapia intensiva, que abordaram a equipe de enfermagem. Houve predominância da cultura de segurança negativa ou fragilizada. Destaca-se, que o aprimoramento das práticas seguras de cuidado em saúde, pode auxiliar na consolidação e resolutividade das ações propostas pelos serviços de saúde. Considerações finais: existem necessidades e possibilidades de mudanças na qualidade dos serviços, haja vista a oportunidade de um ambiente favorável. Diante disso, existe a premência de fortalecer os Núcleos de Segurança do Paciente das instituições de saúde, sobretudo os hospitalares, o que demanda investimento institucional em gerenciamento de risco e disseminação de ações de educação permanente para fortalecer as práticas seguras.

ADHERENCE TO HAND HYGIENE IN A NEPHROLOGY SERVICE

Objective: To evaluate adherence to hand hygiene in a nephrology service. Method: Descriptive study, performed in a public hospital in Teresina, Piauí, Brazil. Adherence percentage to five moments of hand hygiene was collected in a database of Center for Patient Safety in the period from March to April 2019. Results: Adherence rate varied in all the periods analyzed, reached 25% of adherence, and there were almost no stabilization periods. By relating the variation of adherence rate with the activities performed in the same period, it may be inferred that the greatest number of professionals who participated in educational activities on hand hygiene influenced in the increased adherence rate. Conclusion: The adherence was low; therefore, it is necessary that educational interventions be constant and not punctual so that hand hygiene becomes routine inherent in care.

Campanha Diga Não à Lesão por Pressão

Pressure ulcer (PU) can be classified according to tissue impairment, etiology, healing time and tissue characteristics. Currently, it is the third type of adverse event most reported by the patient safety centers of health services in the country, according to the National Report of Incidents Related to Health Care. The classification and the identification of risk factors are essential for implementation of preventive and therapeutic actions in susceptible patients. Nutritional status is a fundamental piece for the prevention and development of PU, making it essential to integrate the interdisciplinary team in the prevention and treatment of PU, with a focus on quality, safety and patient experience. In this sense, the objective of this campaign is to disseminate knowledge, providing technical support for patient care and reducing PU rates. A mnemonic was developed with the word “CICATRIZATION”, in which each letter proposes steps that help in the identification of risk, assessment, treatment and monitoring of PU. Thus, the sequence of 12 steps established in this campaign is suggested as a measure to assist health professionals in this management

Segurança do paciente em serviços de saúde: uma análise na cidade de Salvador, Bahia

Objetivo: Avaliar a política nacional de segurança do paciente em hospitais de grande porte de Salvador. Método: Estudo de casos múltiplos em hospitais terciários. A coleta de dados ocorreu entre outubro de 2017 e outubro de 2018, com profissionais dos núcleos de segurança do paciente (NSP). Foram analisadas quatro variáveis independentes: constituição dos NSP; ações de planejamento do controle dos eventos adversos (EA); atividades técnico- -operacionais desenvolvidas pelos NSP; e ações de monitoramento dos EA no hospital. Resultados: Dos 20 NSP existentes, estudaram-se 12 (60%). Todos os hospitais possuem NSP constituídos, 91,7% têm plano de segurança do paciente, e 50% contam com profissional com dedicação exclusiva. Das instituições, 58,3% implementam todos os protocolos obrigatórios, sendo identificação do paciente (83,3%) e higienização das mãos (83,3%) os mais frequentes. Os percentuais de EA identificados foram: lesão por pressão (88,9%), queda do leito (77,8%) e erros de medicamentos (75,0%). Conclusão: Os EA aqui referidos sinalizam a necessidade de adequações em prol da segurança do paciente. Os NSP não atendem totalmente às políticas regulatórias vigentes no país, carecendo, portanto, de adequações e de controle sanitário efetivo.

World Patient Safety Day: the Tuscany region at the forefront of quality of care.

Echoing the World Health Organization's (WHO) request, the Patient Safety Declaration, launched by Health First Europe at the European Parliament, calls on policymakers, authorities and health professionals, patients and citizens to come together to build health systems that can help health professionals work better for patient-centred outcomes. The objective is to prevent the occurrence of adverse events arising from clinical care activities to focus resources on reducing the impact of the disease by promoting safer health systems and higher quality standards for patient safety in Europe. The Declaration intends to promote a European patient safety culture, starting with safety practices and exchanging effective practices to reduce adverse events arising from health activities. Tuscany, the fifth largest region of Italy, is strongly committed to make this happen. Its Regional Centre for Clinical Risk Management and Patient Safety and WHO Collaborating Centre (GRC Centre-Centro Gestione Rischio Clinico e Sicurezza del Paziente) aims at developing and promoting practices for safety, awareness raising and the analysis of adverse events for the constant improvement of care delivery.

WOMEN'S SAFETY CULTURE IN CHILDBIRTH AND RELATED INSTITUTIONAL FACTORS

ABSTRACT Objective: to analyze the safety culture of women in childbirth and related institutional factors based on the perceptions of nursing and medical professionals. Methods: a mixed, sequential explanatory study, conducted with nursing technicians, nurses and physicians of the obstetric center of a public maternity hospital in the city of Rio de Janeiro. Data collection took place from May to July 2018. The Hospital Survey on Patient Safety Culture questionnaire and descriptive statistical treatment were applied. Then, 12 semistructured interviews and thematic content analysis were applied and, finally, this data set was integrated. Results: most of the dimensions of the safety culture are weakened, especially in the areas of institutional organization, and the team lacks knowledge about the actions of the Patient Safety Center in the institution, the uniformity of care is deficient and the number of personnel for care is limited. The safety management process and work organization need adaptations. Conclusion: the safety culture of women requires improvements in team training, skilled care, work organization, and commitment of local management to qualified and safe care in hospital births.

PROTOTYPE FOR MONITORING INCIDENTS IN THE HEALTH SERVICES: INNOVATION FOR PATIENT SAFETY

ABSTRACT Objective: to describe the participatory process of building a prototype to support the development of an information management system for notification, investigation and monitoring of health incidents. Method: a methodological research study on technology development, carried out in two stages: 1) documentary analysis of primary and secondary sources related to forms and legislation on incident notification systems, from September to October 2018; 2) deliberative dialog in two sessions, with 12 managers and coordinators of the Quality and Patient Safety Center of public hospitals in the Federal District, held in November 2018. In the deliberative session there was a presentation of the prototype and discussion of its applicability and functionality for the development of an information system for risk management in the health services. Results: creation and prototyping of a tool with 4 (four) screens representing the systematic flow of data. Screen 1: Simplified notification for patients and companions. Screen 2: Notification for the health professional. Screen 3: Investigation of the event and action plan. Screen 4: Intervention and monitoring by means of indicators. Conclusion: this is a tool capable of integrating actions to reduce the occurrence of incidents based on the identification and timely intervention on the risk factors. It can be used as a facilitating basis for the development or improvement of new instruments for risk management in the health services.

IDENTIFICAÇÃO DO PORTADOR DE TRANSTORNO MENTAL AGUDO SOB O CONTEXTO DA SEGURANÇA DO PACIENTE

Objetivo analisar o processo de identificação de portadores de transtornos mentais na fase agudaem instituições de saúde.Método: estudo exploratório, qualitativo, com coleta de dados entre setembro e dezembro de2018, com um questionário digitalizado cujo link foi disponibilizado via aplicativo What-sapp®, nogrupo de profissionais vinculados à Sociedade Brasileira para a Qualidade do Cui-dado e Segurançado Paciente.Resultados: entre os 17 participantes do estudo, 64,7% pertenciam a Núcleos de Segurança doPaciente, todos especialistas (58,8% na área de segurança do paciente). Dos entrevistados, 90%não possuem em suas instituições protocolo específico para a identificação destes pacien-tes.As categorias elaboradas para as estratégias foram “Adequação do Protocolo do Ministé-rio daSaúde” e “Protocolo do Ministério da Saúde” e, para as barreiras foram “Fatores Ineren-tes aoPaciente” e “Fatores Inerentes ao Profissional”.Conclusão: identificaram-se importantes estratégias para a melhoria da identificação desta clientela.

Practice challenges in patient safety

to understand the professional practice challenges in reaching the goals and objectives of the National Patient Safety Program (Programa Nacional de Segurança do Paciente). qualitative case study, based on the Comprehensive Sociology, carried out with 31 professionals from the Patient Safety Center (Núcleo de Segurança do Paciente) and the nursing team, working in a teaching hospital. Data collection took place between May and December 2015 through interviews, observation and documentary analysis. The analysis proceeded according to the prerogatives of the Content Analysis. three categories emerged: the prescribed reality; material resources and their impact on care; and human resources related to the reality. challenges to safe professional practice are caused by inadequate physical structure, insufficient physical and human resources, but mainly invade the transition from the prescriptive reality scope.

GESTÃO DA QUALIDADE HOSPITALAR: ESTUDO DE CASO SOBRE A PREVENÇÃO DE FALHAS EM UM HOSPITAL PÚBLICO

Segundo decisão da Diretoria Colegiada da Agência Nacional de Vigilância Sanitária, todos os serviços de saúde do Brasil devem ter um Núcleo de Segurança do Paciente (NSP). Cada NSP deve elaborar um Plano de Segurança do Paciente em Serviços de Saúde (PSP) na área de cirurgia segura. Esta pesquisa objetivou analisar meios para a redução de falhas cirúrgicas em um hospital público com base em seu PSP. Para tanto, buscou-se analisar o estado atual da meta; identificar as causas da baixa adesão ao checklist e do seu mau preenchimento se for o caso; e montar um plano de ação. Trata-se de um estudo de caso descritivo, de natureza quali-quantitativa. Foram utilizados como instrumentos de coleta de dados entrevistas, análise documental e observação direta. Os resultados indicaram que a adesão e a qualidade do preenchimento dos checklists não estão satisfatórias e que as principais causas disso são: falta de treinamentos, baixa conscientização em relação à cirurgia segura, desmotivação dos profissionais, baixa participação dos gestores e comunicação deficitária entre a equipe. Por fim, montou-se um plano de ação com base nas ferramentas da gestão da qualidade e no ciclo PDCA.

KNOWLEDGE OF NURSING PROFESSIONALS ABOUT THE RISK MANAGEMENT PROCESS

Objective: To analyze the knowledge of nursing professionals about the Risk Management Process. Method: qualitative study conducted in a public maternity hospital. Data collection took place in June 2018 and was conducted through a semi-structured interview with the participation of 12 nursing professionals. Data were analyzed with the support of IRAMUTEQ Software. Results: the participants knew about risk management, but it was observed difficulties to conceptualize this process and when the actions taken in relation to the identification of a risk situation, they reported that they would trigger the patient's Safety Center, provide immediate assistance, would communicate the doctor/nurse and inform the institution's management through the ombudsman. Final Considerations: Knowledge about risk management is a theme that is far from the reality of some professionals, so it is necessary to improve the disclosure about what is risk management.

CORRECT PATIENT IDENTIFICATION: EXPERIENCE WITH THE IMPLEMENTATION OF A PATIENT SAFETY CORE

Objective: to report and evaluate the implementation of the Patient Safety Center, with emphasis on the identification of patients in a public hospital in Piauí. Method: experience report, in which the activities were performed from January to April 2019. The information for analysis came from the situations experienced by the authors in the implementation of the NSP and the patient identification process. Results: There was an improvement and facilitation in the work of the multiprofessional team enabling lower risk of patient exchange, and consequent avoidable adverse events. Conclusion: the implementation of the NSP was reported and analyzed, with a significant improvement in the organization of services, suggesting improvement with the team, highlighting the importance of protocols for better health care.

O programa nacional de segurança do paciente e as implicações nos serviços de saúde como aspecto relevante ao desenvolvimento regional

O presente estudo tem como objetivo refletir sobre o Programa Nacional de Segurança do Paciente e as implicações nos serviços de saúde como aspecto relevante ao desenvolvimento regional. Deste modo, ressalta a necessidade da implementação de ações que contribuam para a melhoria dos serviços e para a efetivação do acesso à saúde ao considerar que receber assistência à saúde é um direito de todos e dever do Estado. O profissional não possui o intuito de causar qualquer dano na assistência prestada, pois tem como objetivo principal o cuidado, porém, mesmo de forma não intencional ainda há ocorrência de eventos adversos relacionados à assistência à saúde. Diante disso, o Programa Nacional de Segurança do Paciente se torna ferramenta indispensável para incentivar o desenvolvimento de medidas preventivas para que os serviços tornem o sistema mais seguro. Na coleta de dados exploraram-se documentos da Secretaria Estadual de Saúde de Santa Catarina, relatórios da Vigilância Sanitária Estadual e estudos realizados acerca da temática, no Planalto Norte Catarinense. Os dados evidenciaram as iniciativas que se concretizaram ou estão em consolidação sob influência de aspectos históricos, políticos e culturais de cada município e a existência ou não de um Núcleo de Segurança do Paciente atuante.
 Palavras-chave: Desenvolvimento Regional. Saúde. Segurança do Paciente.

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact. As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018. The distributed survey yielded a response rate of 69% (84/122). Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events. This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peer-to-peer learning, communication, and proactive approaches to prevent future similar errors.

Success of a Resident-Led Safety Council: A Model for Satisfying CLER Pathways to Excellence Patient Safety Goals.

The Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) program focuses on aspects of the graduate medical education learning environment, such as patient safety. Data from CLER site visits reveal that many resident physicians do not receive adequate training on patient safety. We evaluated a pediatric resident-led safety council as a method to meet CLER Pathways to Excellence patient safety objectives. The Duke Pediatric Residency Safety Council (PRSC) created an infrastructure for residents to participate in department safety efforts, review safety events, and act as leaders for safety initiatives. Annual surveys were distributed to graduate medical education trainees through the institution's patient safety center and the PRSC. Survey results of safety attitudes were compared over time within the pediatrics program and between pediatrics and nonpediatrics trainees at the institution. Resident-submitted safety reports were tracked through an institutional safety event repository. From 2013 to 2017, the percentage of residents who strongly agreed that they could submit a safety report doubled (from 35% [6 of 17] to 73% [22 of 30], P = .011). The average number of safety reports submitted by a pediatrics resident per year did not significantly change during this period (from 3.0 to 3.8, P = .11). In 2017, 90% of pediatrics residents (27 of 30) agreed or strongly agreed that their concerns would be addressed if they entered a safety report. The council addressed 5 of the 7 CLER Pathways to Excellence in patient safety.

Gerofit Prehabilitation Pilot Program: Preparing Frail Older Veterans for Surgery.

Older Veterans are increasingly undergoing surgery and are at particularly high risk of postoperative morbidity and mortality. Prehabilitation has emerged as a method to improve postoperative outcomes by enhancing the patient's preoperative condition. We present data from our prehabilitation pilot project and plans for expansion and dissemination of a nationwide quality improvement effort. The infrastructure of the existing Veterans Affairs (VA) Gerofit health and exercise program was used to create our pilot. Pilot patients were screened for risk of postoperative functional decline, assessed for baseline physical function, enrolled in a personalized exercise program, and prepared to transition into the hospital for surgery. Patients (n = 9) completed an average of 17.7 prehabilitation sessions. After completing the program, 55.6% improved in ≥2 of the 5 fitness assessments completed. Postoperative outcomes including complications, 30-day mortality, and 30-day readmissions were better than predicted by the National Surgical Quality Improvement Program Surgical Risk Calculator. We have obtained institutional support for implementing similar prehabilitation programs at VA hospitals nationally through our designation as a VA Patient Safety Center for Inquiry. This is the first multi-institutional prehabilitation program for frail, older Veterans and represents an essential step toward optimizing surgical care for this vulnerable population.

Validation of self-assessment instrument for the Patient Safety Center.

To develop and validate an instrument for the self-assessment of the Patient Safety Centers in health care institutions. Non-experimental methodological study. Divided in the following stages: literature review and construction of the preliminary instrument; content validation by nine professionals with experience in Quality Management and patient safety, who contributed to the adequacy of the items in terms of clarity and relevance; finally, 12 PSC coordinators, which conducted the reliability validation of the final instrument, using Cronbach's Alpha. The instrument presented content validity regarding clarity and relevance, evidenced by an agreement level greater than 70%. The internal consistency presented high reliability, with a Cronbach's alpha of 0.857 for the general instrument, 0.825 for the domain Structure, and 0.809 for the domain Process. The instrument presented evidence of content validity and reliability for self-assessment, implementation and evaluation of the PSC in health institutions.

Wrong Site Spine Surgery in the Veterans Administration.

Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA). To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue. Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients. We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated. There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues. Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.