Patient Safety Efforts Research Articles

Ann Scott Blouin, RN, PhD, FACHE

Ann Scott Blouin has certainly had an esteemed career, which now has taken her to be the first nurse to assume the position as executive vice president for accreditation and certification operations at The Joint Commission!

Patientensicherheitskultur – Wissen und Wissensbedarf bei Medizinstudenten

Ten years after the publication of "To Err is Human" in November1999, the development of patient safety efforts has been summa-rised in the statement "Ten years later, a million lives lost, billions of dollars wasted." This leads to the question why, despite evidence-based mea-sures for greater patient safety, they are not implemented or only implemented on a small scale. One approach to promote patient safety is the implementation of a safety culture. Such a safety culture is based on knowledge of employees about safe behaviour and their willingness to implement it. In this context it is interesting to explore the knowledge and the needs of medical students concerning patient safety. At the University of -Magdeburg 354 medical students in their clinical semesters were asked about their knowledge of specific recommendations on patient safety and about their attitude to patient safety and risk man-agement as well as their subjective need for knowledge on this subject. Only 16.7 % of the PJ (practical year) students and 11.7 % of students in all other clinical semester indicated to know the recommenda-tions for patient safety. This correlated with the answers to questions about single recommenda-tions. The importance of risk management during medical education was considered to be important by 53.3 % of the students of all clinical semesters and in particular 80.6 % of the surveyed PJ students. The answers to most questions showed a high demand for general information on patient safety. This is seen throughout all questions, especially with increasing clinical experience, and the need for information on single recommendations, such as critical incident reporting systems (CIRS), or Team Time Out. The establishment of a safety culture is described as a useful way to fewer patient injuries. This includes knowledge on recommendations for patient safety, which may contribute to the implementation of a safety culture to reduce medical errors. Our survey shows the necessity need for information on patient safety and the students desire to acquire this knowledge. Specific courses on patient safety in first-year student education and then continuing in the post-university training seems to be the right way for an improved safety culture and fewer patient injuries, which should be further evaluated.

Marginal Costs of Hospital-Acquired Conditions: Information for Priority-Setting for Patient Safety Programmes and Research

To estimate the relative inpatient costs of hospital-acquired conditions. Patient level costs were estimated using computerized costing systems that log individual utilization of inpatient services and apply sophisticated cost estimates from the hospital's general ledger. Occurrence of hospital-acquired conditions was identified using an Australian 'condition-onset' flag for diagnoses not present on admission. These were grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions to summarize data coded with ICD-10. Standard linear regression techniques were used to identify the independent contribution of hospital-acquired conditions to costs, taking into account the case-mix of a sample of acute inpatients (n = 1,699,997) treated in Australian public hospitals in Victoria (2005/06) and Queensland (2006/07). The most costly types of complications were post-procedure endocrine/metabolic disorders, adding AU$21,827 to the cost of an episode, followed by MRSA (AU$19,881) and enterocolitis due to Clostridium difficile (AU$19,743). Aggregate costs to the system, however, were highest for septicaemia (AU$41.4 million), complications of cardiac and vascular implants other than septicaemia (AU$28.7 million), acute lower respiratory infections, including influenza and pneumonia (AU$27.8 million) and UTI (AU$24.7 million). Hospital-acquired complications are estimated to add 17.3% to treatment costs in this sample. Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harm. Previous studies of the costs of adverse events have provided information on 'indicators' of safety problems rather than the full range of hospital-acquired conditions. Adding a cost dimension to priority-setting could result in changes to the focus of patient safety programmes and research. Financial information should be combined with information on patient outcomes to allow for cost-utility evaluation of future interventions.

Clustering-based methodology for analyzing near-miss reports and identifying risks in healthcare delivery

Near-miss reports are qualitative descriptions of events that could have harmed patients but did not due to a timely intervention or a convenient evolution of the circumstances. Near-miss reporting has increasingly become a relevant tool to support patient safety efforts since they provide some evidence of risk in the system before patients suffer adverse consequences. Near-misses are usually classified into pre-specified categories that correspond to sources of risk in the system or its processes. Their analysis often consists of tallying classified near-misses to determine risk priorities based on frequency within each pre-specified risk category. Our research aims to use different combinations of near-miss reports to find potential sources of risk. We propose an unsupervised bisecting k-prototypes algorithm for clustering coded near-miss reports to identify relationships between events that would not otherwise have been easily identified. Subsequent study of resulting clusters will lead to the identification of potentially dangerous, but unsuspected system interactions. We illustrate or methodology with preliminary results of its implementation at the University of South Florida Health clinics.

Critical conversations: A call for a nonprocedural “time out”

Communication failures are an ongoing threat to patient safety. Procedural "time outs" were developed as a method to enhance communication and mitigate patient harm. Nonprocedural settings generate equal risks for communication failure, yet lack a similar communication tool or practice that can be applied, particularly with a patient-driven focus. Rapidly changing clinical states and care plans are common in the hospital setting, placing patients at risk for adverse events. Certain junctures allow for the highest potential of patient harm-at the time of admission, at a change in clinical condition, and at the time of discharge. Direct communication among healthcare providers at these junctures, which we have dubbed Critical Conversations, can provide an opportunity to clarify plans of care, address or anticipate concerns, and foster greater teamwork. Information exchanged during Critical Conversations includes a combination of checklist-type items and more open-ended questions but they ultimately create a structure and expectation for communication. Integration of Critical Conversations into practice requires provider education and buy-in, as well as expectations for them to occur. Monitoring adherence, capturing stories of success, and demonstrating effectiveness may enhance implementation and continuous improvement in the process. Communication tools designed to reduce the likelihood of patient harm remain a focus of patient safety efforts. Critical Conversations are an innovative communication tool, intervention, and policy that potentially limits communication failures at critical junctures to ensure high quality and safe patient care.

Three-year prevalence of healthcare-associated infections in Dutch nursing homes

From November 2007 for a period of three years (2007-2009), we conducted an annual one-day prevalence study of healthcare-associated infections (HAIs) among nursing home residents in the Nijmegen region of The Netherlands. In the absence of national HAI definitions applicable to the nursing home setting, we used modified definitions based on US Centers for Disease Control and Prevention criteria for bloodstream infection, lower respiratory tract infection, bacterial conjunctivitis, and gastroenteritis. For the surveillance of urinary tract infection (UTI), criteria established by the Dutch Association of Elderly Care Physicians were used. Resident characteristics were recorded and data collection was performed by the attending elderly care physicians. For the three-year period, 1275, 1323, and 1772 nursing home residents were included, resulting in a prevalence of HAIs of 6.7%, 7.6% and 7.6%, in 2007, 2008 and 2009, respectively. The demographics with respect to age (mean 81 years) and sex (31% men, 69% women) were almost identical in all three years. UTI was the most prevalent HAI with 3.5%, 4.2%, and 4.1% respectively. Most HAIs occurred among residents of rehabilitation units. The prevalence of HAIs varied by nursing home (range: 0.0-32.4%). We present the results of the first prevalence study of HAIs in Dutch nursing homes. Point prevalence studies of HAIs, as part of a quality improvement cycle, are an important cornerstone of infection control programmes in nursing homes, allowing us to further increase patient safety efforts in this setting.

Medical errors II, the aftermath: Mea culpa!

Byline: G. Swaminath, R. Raguram Mistakes are a fact of life. It's the response to the error that counts. - Nikki Giovanni (American poet, 1943) Alexander Pope's famous words, To err is human, to forgive divine, apt in most situations do not seem quite appropriate while dealing with medical errors. Forgiveness suggests that there has been the committing of sin, and this is inextricably linked to fault and blame. [sup][1] safety traverses all medical specialties and affects every health-care professional. The attention to medical errors and adverse events and the resultant literature have grown exponentially over the past decade. A number of practicing physicians, however, remain unaware of the extent of the problem, the impact on patients, and the burden on the health-care system. Many are unfamiliar with strategies to reduce the risk of harm. [sup][2] When patients suffer harm, most providers of healthcare are ill prepared to respond. Abandonment of care providers and patients is common. [sup][3] The tendency to shame and blame often perpetuates the wall of silence [sup][4] between providers and patients. [sup][5] It was in response to this unsatisfactory situation that the Patient Safety Movement was founded, guided by the nonjudgmental recognition of the ubiquity of human and system errors. By understanding that error-particularly human error-is inevitable but still largely preventable, patient safety efforts focus on improving systems, creating fail-safe mechanisms that intercept error before it reaches the bedside, and on implementing measures that mitigate harm when an error involves the patient. [sup][1] Explanatory Models of Human Error There are two explanatory models of causation of human error: the person approach and the system approach. The person approach focuses on the errors of individuals, and is apt to accuse them of forgetfulness, inattention or moral failure. Followers of these approaches tend to treat errors as moral issues, assuming that bad things happen to bad people-what psychologists have called the just-world hypothesis. [sup][6] The basic premise in the system approach is that humans are fallible, and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes. These include recurrent error traps in the workplace and the organizational processes that give rise to them. The system approach identifies the conditions and systems under which individuals work, as the source of the error, with the aim of both understanding the origins of error and building defenses to avert errors or to mitigate their effects. [sup][6] The system approach acknowledges that the majority of clinical errors do not result from individual recklessness or the actions of a particular group. [sup][7] The most common systems deficiencies identified as underlying clinical errors are failures in dissemination of drug knowledge or its updating, and inadequate availability of patient information such as test results necessary for safe treatment. [sup][8] Detection of Medical Errors and Adverse Events Difficulty in identifying medical errors and adverse events creates a significant barrier to assessing risk reduction strategies. In the absence of an accurate, reliable methodology to measure errors and events, the ability to assess the impact of patient safety initiatives remains challenging. Historically, identification of medical errors and adverse events relied on incident reports, a methodology that has many pitfalls. If an error or adverse event is identified, staff may assume, mistakenly, that someone else will report it. Personnel who do report events often receive no feedback, which serves as a disincentive for reporting subsequent events. [sup][2] Staff may have valid apprehensions about reporting errors and adverse events. [sup][2] There is a natural hesitancy to point out one's own mistakes for fear of being labeled incompetent and a reluctance to point out others' mistakes for fear of being labeled a whistleblower, [sup][2] a sensationalist or an adversarial professional. …

Synergies between blood center and hospital quality systems

Blood centers have expertise in following federally mandated standards and establishing rigorous quality systems. Medicare participating hospitals and their laboratories must be compliant with the requirements of the Centers for Medicare and Medicaid Services. Following standards and experiencing unannounced surveys allow blood centers and hospitals to organize and strengthen their patient safety efforts and achieve high-reliability operations. Blood centers provide essential services to hospitals and laboratories according to written contracts; therefore, blood centers need to understand the CMS requirements for blood administration activities and supplier management within these written agreements. Sharing expertise gained from experience with the US Food and Drug Administration and professional standard-setting organizations may be an opportunity for blood centers to build deeper customer relationships and assist in the delivery of high-quality patient care.

How different are complications that affect the older adult inpatient?

ObjectiveThe incidence and cost of complications occurring in older and younger inpatients were compared.DesignSecondary analysis of hospital-recorded diagnosis and costs for multiday-stay inpatients in 68 public hospitals in two Australian...

Medication Safety in Obstetrics and Gynecology

The safe prescribing, use, administration, and monitoring of medications are an important component of patient safety efforts and are of particular importance to the obstetrician/gynecologist. Safe use of medications requires a team-based approach focused on medication safety with effective 2-way communication, use of technology to prevent and identify errors, diligent monitoring of the medication's effects on the patient, and use of standardized protocols to decrease the likelihood of a medication error.

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: A multi-center qualitative study

Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve care quality, safety and outcomes. Despite these efforts, we have limited understanding of why quality improvement efforts are successful in some hospitals and not others. Using data collected as part of a multi-center study, we closely examined quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in U.S. hospitals. We compare and contrast the experiences among hospitals to better understand 'how' and 'why' certain hospitals were more successful with practice implementation when taking into consideration specific aspects of the organizational context. This study reveals that among a number of hospitals that focused on implementing practices to prevent CLABSI, the experience and outcomes varied considerably despite using similar implementation strategies. Moreover, our findings provide important insights about how and why different quality improvement strategies might perform across organizations with differing contextual characteristics.

Epidemiology, Surveillance, and Prevention of Hepatitis C Virus Infections in Hemodialysis Patients

Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States; the prevalence in maintenance hemodialysis patients substantially exceeds that in the general population. In hemodialysis patients, HCV infection has been associated with increased occurrence of cirrhosis and hepatocellular carcinoma and increased mortality. Injection drug use and receipt of blood transfusions before 1992 has accounted for most prevalent HCV infections in the United States. However, HCV transmission among patients undergoing hemodialysis has been documented frequently. Outbreak investigations have implicated lapses in infection control practices as the cause of HCV infections. Preventing these infections is an emerging priority for renal care providers, public health agencies, and regulators. Adherence to recommended infection control practices is effective in preventing HCV transmission in hemodialysis facilities. In addition, adoption of routine screening to facilitate the detection of incident HCV infections and hemodialysis-related transmission is an essential component of patient safety and infection prevention efforts. This article describes the current epidemiology of HCV infection in US maintenance hemodialysis patients and prevention practices to decrease its incidence and transmission.

Medication error reporting in nursing homes: identifying targets for patient safety improvement

BackgroundLegislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert...

The Lesser of Two Adverse Reactions

Fundamental to complex systems are interconnected processes involved in providing high-quality patient care. A case study and a root cause analysis (RCA) illustrate a patient safety effort with unintended consequences. A 38-year-old woman presented to the hospital for odynophagia and vomiting. The patient developed Mobitz type 2, second-degree heart block temporally associated with the administration of intravenous ondansetron. RESPONSE TO THE EVENT: An Ishikawa, or fishbone, diagram conducted to enumerate potential contributing factors indicated that a key factor appeared to be an institutional restriction against using intravenous (i.v.) promethazine, which resulted in ondansetron being the only readily available i.v. anti-emetic on formulary. The anesthesia department requested that i.v. promethazine be removed from all operating and recovery room automated medication dispensing machines. The pharmacy department, given the realization that individual departments were taking independent action regarding promethazine, discussed the matter with the medical director, who issued a memo banning the use of i.v. promethazine. An institutional ban on i.v. anti-emetics such as promethazine may have resulted in an increase in the use of ondansetron and contributed to this adverse reaction. The reason to restrict promethazine is not well reported in the literature. In limiting the use of promethazine for patient safety concerns, the inadvertent increase in adverse reactions of the alternative medication, ondansetron, may have been overlooked. The resultant RCA underscores the need for careful cataloguing of adverse medication effects. Stakeholders should anticipate as many "downstream effects" of quality and patient safety improvements as possible. Comprehensive reporting of adverse medication effects will augment the emerging science of patient safety.

Observation and Measurement of Hand Hygiene and Patient Identification Improve Compliance With Patient Safety Practices

Measurement, a crucial step in any quality improvement activity, is difficult in two important patient safety processes: hand hygiene and patient identification. This study describes a program at the UCLA Medical Center, called Measure to Achieve Patient Safety (MAPS), which uses undergraduate student volunteers to carry out observations in the hospital. This program has been an important part of UCLA's efforts for quality improvement in patient safety efforts. Since 2004, approximately 20 students per year plus two student leaders have been selected to participate in the MAPS program. They were trained in techniques of measuring and observation and in professional behavior. They participated in weekly and monthly meetings with program leadership, received continuing education from the UCLA patient safety staff, and were trained in observational measurement. The students' observational results have been systematically reported to clinicians and departmental and hospital leadership. Handwashing increased from 50% to 93%, and nurses' checking of two identifiers at the time of medication administration increased from 50% to 95%. Compliance with proper patient identification at the time of nurse-to-transporter handoffs of patients for procedures increased to >90%. This unique program has made a significant contribution to UCLA's quality, safety, and service programs. MAPS has been widely accepted by the clinical staff and has also been valuable to the student volunteers. Such an approach is easily adaptable to other academic medical centers.

Setting economic priorities for patient safety programs and patient safety research using case mix costing data

Introduction Patient safety efforts are often recommended solely on judgments about the relative importance of particular adverse events in hospital care, without considering the frequency and costs of all hospital-acquired illness and injury. The objective of the study was to use patient-level cost data to estimate relative economic priorities for hospital inpatient safety efforts. Methods Patient level costs are estimated using computerized patient costing systems that initially log individual utilization of inpatient services, and then apply sophisticated cost estimates from the hospital's general ledger. The occurrence of a hospital-acquired diagnosis is identified using a new Australian 'condition-onset' flag for all diagnoses not present on admission. These diagnoses are grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions, using a recently-developed algorithm to summarize data coded with ICD-10-AM. Standard linear regression techniques are used to identify the independent contribution to inpatient costs of hospital- acquired conditions, taking into account the case mix of a sample of acute inpatients (n = 1,699,997) treated in Australian public hospitals in Victoria (2005/06) and Queensland (2006/07). Results The most costly types of adverse events were post-procedure endocrine and metabolic disorders, adding $A 21,869 to the cost of an episode, followed by (methicillinresistant staphylococcus aureus) MRSA (+$A 19,892) and enterocolitis due to Clostridium difficile (+$A 19,745). Aggregate additional costs to the system were highest for septicaemia (+$A 41.5 mil), complications of cardiac and vascular implants other than septicaemia (+$A 28.7 mil), acute lower respiratory infections -- including influenza and pneumonia ($A 28.0 mil) -- and UTI (+$A 24.7 mil). Hospital acquired complications are estimated to add 17.1% to the costs of treatment in this sample. Conclusion Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harms. Adding an economic dimension to priority-setting could result in changes to the priorities of patient safety programs. It could also provide guidance as to other areas where research into causes and prevention strategies may prove a productive investment. Financial information should be combined with information on patient harms to allow for cost-utility evaluation of future programs.

Injury and Death Associated With Incidents Reported to the Patient Safety Net

The authors retrospectively evaluated anonymously submitted inpatient medical error reports from 8 institutions participating in the University HealthSystem Consortium Patient Safety Net (PSN) in 2004 in an attempt to focus patient safety efforts on problems that were most commonly associated with harm. Of the 25,300 incidents reported, 3381 (13.3%) were associated with adverse events (AEs), and 109 (0.4%) were associated with death. Although the most commonly reported categories of incidents associated with AEs were complications of procedure/treatment/test (29%), falls (17%), and medication errors (10%), the taxonomy of the PSN limited efforts to find specific errors in care that might be addressed by attempts to improve patient safety. Skin breakdown and falls were confirmed as presenting substantial risks to hospitalized patients, in that 59% of the incidents reported in the skin integrity category and 22% of falls resulted in AEs. The benefits and limitations of a voluntary reporting system are discussed.

Psychiatry Morbidity and Mortality Rounds: Implementation and Impact

This study assessed the implementation of psychiatry morbidity and mortality rounds (M&Ms) on the clinical and educational practice in a children's hospital. Attendees to monthly M&Ms between July 2005 and May 2007 included staff and trainees from psychiatry, psychology, nursing, and social work. Cases were selected based on a priori risk criteria and each rated on the hospital's four-level risk management scale. M&Ms were reviewed for recurrent patterns that contributed to adverse patient care. Attendees completed a survey at the end of each year, evaluating the educational value of the rounds. Possible opportunities for patient care improvement were found in 80% of the cases and fell into four overlapping areas: diagnostic/formulation errors, communication problems, system-based problems, and class/culture misunderstandings. Identifying these problems led to corrective actions and positive changes in patient care. M&Ms appear to be a potentially productive venue for self-appraisal and case review to aid psychiatry programs in patient safety efforts and clinician education.

Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study

Objective:This study determined the incidence, type, nature, preventability and impact of adverse events (AEs) among hospitalised patients and potentially preventable deaths in Dutch hospitals.Methods:Using a three-stage retrospective record review process,...

Resilience in healthcare and clinical handover

Background:Understanding and applying human factors in healthcare provides significant opportunities for improving patient safety. A key human factors concept is “resilience,” which investigates how individuals, teams and organisations monitor, adapt...