Patient Safety Program Research Articles

Application of the Safety Attitudes Questionnaire (SAQ) in Albanian hospitals: a cross-sectional study

ObjectiveTo establish the reliability and validity of the translated version of the Safety Attitudes Questionnaire (SAQ) by evaluating its psychometric properties and to determine possible differences among nurses and physicians...

Psychoactive Medications Increase the Risk of Falls and Fall-related Injuries in Hospitalized Patients With Cirrhosis

Reducing or eliminating falls is a focus of patient safety programs as well as health policy. Falls are tied to hospital reimbursement. However, little is known about the risk of falls among hospitalized patients with cirrhosis or factors that affect risk of falling. We conducted a retrospective cohort study of inpatients with cirrhosis from 2010 to 2013 at a liver transplant center. Our primary aim was to determine the clinical factors associated with falls and fall-related injuries for patients with cirrhosis. Our secondary aim was to describe the rate ratio of falls and fall-related injuries among patients with cirrhosis compared with general medical inpatients. During the study period, there were 1749 admissions to the liver service; 55 (3.1%) resulted in falls. Patients who fell were more likely to have received benzodiazepines (50.9% vs 16.7%, P<.0001) and antipsychotic agents (30.9% vs 7.3%, P < .0001). After adjusting for hepatic encephalopathy, the respective odds of a fall after benzodiazepine or antipsychotic exposure were 6.59 (95% confidence interval [CI], 3.76-11.59) and 3.72 (95% CI, 1.90-7.06). The adjusted risk of a fall-related injury was also significantly associated with benzodiazepine and antipsychotic agents, with respective odds ratios of 3.45 (95% CI, 1.39-8.23) and 3.42 (95% CI, 1.09-8.99). Fall-related injuries occurred at a rate of 1.70/1000 patient-days for patients with cirrhosis vs 0.5/1000 patient-days for patients in the general medical service. Accordingly, the rate ratio for a fall-related injury among patients with cirrhosis was 3.37 (95% CI, 1.99-5.72; P< .0001). Psychoactive medications are associated with an increased adjusted risk of falls and fall-related injuries in hospitalized patients with cirrhosis.

Cooperative-Based Learning and the Zone of Proximal Development

Purpose. The purpose of this article is to introduce cooperative-based learning and Vygotsky’s zone of proximal development (ZPD) to the simulation literature as two important mutually supportive learning theories that may enhance the effectiveness of simulation-based instruction. Design/Methodology/Approach. A brief literature review of cooperative-based learning and Vygotsky’s zone of proximal development (ZPD) is presented, along with a description of how these two important learning theories may be applied to improve simulation-based instruction. Findings. When learning new material or skills, learners sometimes need to be assisted with moving through the disequilibrium process that can occur when the new information contrasts with their existing frames of reference or ways of knowing. Cooperative-based learning and the zone of proximal development (ZPD) can be used to assist the learner with working through the disequilibrium process, including accommodating and assimilating the new skills and information into their own practice. Limitations/Implications. Gaps in the simulation literature, including ways to implement both theories into practice, can lead to incomplete or ineffective simulation-based instruction practices. Originality/Value. Many organizations have implemented simulation into their patient safety program, but have not considered how the zone of proximal development (ZPD) and cooperative-based learning can be used to improve educational outcomes.

Prediction of clinical risks by analysis of preclinical and clinical adverse events

This study examines the ability of nonclinical adverse event observations to predict human clinical adverse events observed in drug development programs. In addition it examines the relationship between nonclinical and clinical adverse event observations to drug withdrawal and proposes a model to predict drug withdrawal based on these observations. These analyses provide risk assessments useful for both planning patient safety programs, as well as a statistical framework for assessing the future success of drug programs based on nonclinical and clinical observations.Bayesian analyses were undertaken to investigate the connection between nonclinical adverse event observations and observations of that same event in clinical trial for a large set of approved drugs. We employed the same statistical methods used to evaluate the efficacy of diagnostic tests to evaluate the ability of nonclinical studies to predict adverse events in clinical studies, and adverse events in both to predict drug withdrawal. We find that some nonclinical observations suggest higher risk for observing the same adverse event in clinical studies, particularly arrhythmias, QT prolongation, and abnormal hepatic function. However the lack of these events in nonclinical studies is found to not be a good predictor of safety in humans. Some nonclinical and clinical observations appear to be associated with high risk of drug withdrawal from market, especially arrhythmia and hepatic necrosis. We use the method to estimate the overall risk of drug withdrawal from market using the product of the risks from each nonclinical and clinical observation to create a risk profile.

Measuring diagnostic safety of inpatients: time to set sail in uncharted waters.

Measuring diagnostic safety of inpatients: time to set sail in uncharted waters.

Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework

Diagnostic errors are major contributors to harmful patient outcomes, yet they remain a relatively understudied and unmeasured area of patient safety. Although they are estimated to affect about 12 million...

Indian Pharmacopoeia Commission's Partners for Promoting Public Health

In order to promote the awareness and to monitor the adverse drugs reactions, one of the most noteworthy nation-wide programme initiated by IPC on 15th April 2011 under the aegis of Central Drugs Standard Control Organization (CDSCO), is Pharmacovigilance Programme of India (PvPI). IPC is a National Coordination Centre (NCC) for PvPI, meant for protecting the health of the public by assuring medicines safety. PvPI monitors the benefitrisk profile of medicines & generate independent, evidence based recommendations on safety of medicines & support CDSCO for formulating safety related regulatory decisions for medicines. With a view to establish a centre of excellence for pharmacovigilance in India, NCC-PvPI collaborated with the WHO-Uppsala Monitoring Centre (UMC), Sweden & participating in International Drug Monitoring Programme & now become a significant contributor for the global drug safety database. The WHO country office for India coordinates with NCC-PvPI in terms of providing technical support for organizing training programmes, awareness programmes,meetings and updating PV toolkit etc. PvPI has been continuously taken several steps for ensuring patient safety and well being of society, in this regards PvPI expanded its patient safety programme to 150 AMCs across the country & also collaborated with different National Health Programme (AEFI, NACO, RNTCP) as it has been always preeminent to established safety and efficacy of medicines used in these NHP(s). As consumers / patients are the important allies for any country's pharmacovigilance programme, PvPI has taken step towards encouraging consumers reporting by the release of medicines side effect reporting form for consumers in different regional languages. For the last two decades, pharmacovigilance has been gaining an increasing attention. It is now, high time for national authorities, multilateral agencies, nongovernmental organizations, healthcare institutions, pharmaceutical industries & lay public to work together for the effective implementation of PvPI across the country.

The patient experience of patient-centered communication with nurses in the hospital setting: a qualitative systematic review protocol.

Review question/objective The objective of this systematic review is to synthesize the eligible evidence of patients’ experience of engaging and interacting with nurses, in the medical-surgical ward setting. This review will consider the following questions: What are the expressed experiences of patients engaging and interacting in patient-centred communication with nurses? What are the beliefs, opinions and desires of patients, when engaging and interacting with nursing staff in terms of communicating in ways that meet the patients’ needs and wants? What factors do patients perceive influence (facilitate or prevent) patient-centred communication and their engagement and interaction with nursing staff? What are the experiences of patients of nurses listening to and responding to them within patient-centred communication with respect to their safety and experience of care? Inclusion criteria Types of participants The review will consider studies that include adult patients who are 18 years of age and older who have been admitted as inpatients to a medical-surgical ward. Studies and texts presenting adult inpatients to all other hospital wards settings will be excluded. Maternity, emergency department, operating room, palliative and psychiatric ward settings will be excluded. Emergency department settings are excluded as they may not include patients that are admitted to hospital. Operating room settings are excluded because of the variations in the level of consciousness that may occur to patients. Maternity, palliative care and psychiatric patients because of unique needs of care required by these patients. Studies that include patients with cognitive disorders will also be excluded. Phenomena of interest This review will consider studies that investigate patient experience of engaging and interacting with nurses at the bedside in the hospital setting and the meaningfulness of that experience.

Wie kann die Implementierung von Patientensicherheitsprogrammen gelingen? Ein Beispiel aus der Schweiz

Internationally, the implementation of patient safety programmes poses a major challenge. In the first part, we will demonstrate that various measures have been found to be effective in the literature but that they often do not reach the patient because their implementation proves difficult. Difficulties arise from both the complexity of the interventions themselves and from different organisational settings in individual hospitals. The second part specifically describes the implementation of patient safety improvement programmes in Switzerland and discusses measures intended to bridge the gap between the theory and practice of implementation in Switzerland. Then, the national pilot programme to improve patient safety in surgery is presented, which was launched by the federal Swiss government and has been implemented by the patient safety foundation. Procedures, challenges and highlights in implementing the programme in Switzerland on a national level are outlined. Finally, first (preliminary) results are presented and critically discussed.

Protocol compliance of administering parenteral medication in Dutch hospitals: an evaluation and cost estimation of the implementation

ObjectivesPreventable adverse drug events (ADEs) are closely related to administration processes of parenteral medication. The Dutch Patient Safety Program provided a protocol for administering parenteral medication to reduce the amount...

Sepsis screening.

NHS Education for Scotland has, in collaboration with the Scottish Patient Safety Programme, made the national early warning score (NEWS) and sepsis screening tool available as a smartphone app. The app provides: a NEWS calculator to alert clinicians to deteriorating patients and acute illness; a sepsis screening tool for the prompt recognition and initiation of treatment of patients with sepsis; an outline of the Sepsis 6 care bundle; and an algorithm to help identify organ dysfunction, severe sepsis, septic shock and when to escalate care. Go to tinyurl.com/sepsis-screening to download the app.

The TRANSFORM Patient Safety Project: a microsystem approach to improving outcomes on inpatient units.

Improvements in hospital patient safety have been made, but innovative approaches are needed to accelerate progress. Evidence is emerging that microsystem approaches to quality and safety improvement in hospital care are effective. We aimed to evaluate the effects of a multifaceted, microsystem-level patient safety program on clinical outcomes and safety culture on inpatient units. A 1-year prospective interventional study was conducted, followed by a 6-month sustainability phase. Four medical and surgical inpatient units within an academic university medical center were included, with registered nurses and residents representing study participants. In situ simulation training; debriefing of medical emergencies; monthly patient safety team meetings; patient safety champion role; interdisciplinary patient safety conferences; recognition program for exemplary teamwork. Hospital-acquired severe sepsis/septic shock and acute respiratory failure; unplanned transfers to higher level of care (HLOC); weighted risk-adjusted mortality. Safety culture was measured using a widely accepted, validated survey. Rates of hospital-acquired severe sepsis/septic shock and acute respiratory failure decreased on study units, from 1.78 to 0.64 (p = 0.04) and 2.44 to 0.43 per 1,000 unit discharges (p = 0.03), respectively. The mean number of days between cases of severe sepsis/septic shock increased from baseline to the intervention period (p = 0.03). Unplanned transfers to HLOC increased from 715 to 764 per 1,000 unit transfers (p = 0.08). The weighted risk-adjusted observed-to-expected mortality ratio on all study units decreased from 0.50 to 0.40 (p < 0.001). Overall scores of safety culture on study units improved after the 1-year intervention, significantly for nurses (p < 0.001), but not for residents (p = 0.06). Scores significantly improved in nine of twelve survey dimensions for nurses, compared to in four dimensions for residents. A multifaceted patient safety program suggested an association with improved hospital-acquired complications and weighted, risk-adjusted mortality, and improved nurses' perceptions of safety culture on inpatient study units.

PS-125 Improving Safety Culture, Steady Climbing The Mountain

Introduction There is a growing awareness of the importance of safety culture and a more positive patient safety culture is believed to be related to fewer adverse events in hospitals. The aim of this study was to investigate whether safety culture changed during a five years period with active safety management in a Dutch paediatric university hospital. Methods A survey was undertaken amongst paediatricians and specialised nurses by means of the Hospital Survey on Patient Safety Culture (HSOPSC) in 2009, 2011 and 2013. The study took place at the Emma Children’s Hospital, Amsterdam. Results In 2009, 2011 and 2013 we collected 269, 232 and 310 surveys, representing response rates of 66%, 57% and 61% respectively. The HSOPSC consists of 40 questions, covering 11 dimensions. We found the following significant differences between 2009 and 2013, presented in positive ratings: ‘teamwork within hospital units’: 90% - 90% - 82% ‘frequency of event reporting’: 51% - 55% - 57% ‘feedback about error’: 67% - 61% - 72% ‘staffing’: 45% - 58% - 51% ‘overall perceptions of safety’: 48% - 52% - 55% Ratings in the other dimensions were unchanged. Highest scores were seen on the dimension ‘teamwork within hospital units’ (90%, 90% and 82%) and lowest scores on the dimension ‘teamwork across hospital units’ (23%, 23% and 24%). Conclusion An ongoing patient safety programme improves some aspects in the culture, but other items stay a concern and demand more focused intervening.

Costing the Australian National Hand Hygiene Initiative

The Australian National Hand Hygiene Initiative (NHHI) is a major patient safety programme co-ordinated by Hand Hygiene Australia (HHA) and funded by the Australian Commission for Safety and Quality in Health Care. The annual costs of running this programme need to be understood to know the cost-effectiveness of a decision to sustain it as part of health services. To estimate the annual health services cost of running the NHHI; the set-up costs are excluded. A health services perspective was adopted for the costing and collected data from the 50 largest public hospitals in Australia that implemented the initiative, covering all states and territories. The costs of HHA, the costs to the state-level infection-prevention groups, the costs incurred by each acute hospital, and the costs for additional alcohol-based hand rub are all included. The programme cost AU$5.56 million each year (US$5.76, £3.63 million). Most of the cost is incurred at the hospital level (65%) and arose from the extra time taken for auditing hand hygiene compliance and doing education and training. On average, each infection control practitioner spent 5h per week on the NHHI, and the running cost per annum to their hospital was approximately AU$120,000 in 2012 (US$124,000, £78,000). Good estimates of the total costs of this programme are fundamental to understanding the cost-effectiveness of implementing the NHHI. This paper reports transparent costing methods, and the results include their uncertainty.

Patient safety: this is public health.

Avoidable patient harm is a major public health concern, and may already have surpassed heart disease as the leading cause of death in the United States. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalized in recent years, but specialist degree programs in the field remain scarce. Healthcare organizations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement.

Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national patient safety programme in the Netherlands

ObjectiveTo prevent wrong surgery, the WHO ‘Safe Surgery Checklist’ was introduced in 2008. The checklist comprises a time-out procedure (TOP): the final step before the start of the surgical procedure...

What causes near-misses and how are they mitigated?

The objectives of this study were to determine the reasons hospital RNs attribute to near-misses and the techniques they used to mitigate these near-misses to prevent serious reportable events. Our health system developed this definition for the study: A near-miss is a variation in a normal process that, if continued, could have a negative impact on patients. Study participants were RNs who completed a survey about a self-reported near-miss or another RN's near-miss they'd witnessed. Data collected included participant demographics, near-miss occurrence by day of week and time, near-miss type, and attributed causes. A total of 144 near-miss types were self-reported or witnessed by 123 respondents; of these, 43 (35%) self-reported a near-miss event and 80 (65%) witnessed a near-miss event. The respondents identified medication administration (19%) and transcription errors (10%) as the most frequent types of near-misses (N = 144). Selecting from 412 factors related to near-misses, more RNs attributed near-misses to personal factors than institutional factors. Top personal factors were not following policy and inappropriate decision making or critical assumptions. Top institutional factors were work-related interruptions and distractions, and poor communication about a patient. A total of 400 techniques were used to mitigate the near-misses, nearly one per causative factor identified. Top techniques used were stop, think, act, review (STAR) and verification of proper procedures or actions. Hospital administrators should consider both personal and institutional factors when evaluating patient-safety programs. Education about mitigating techniques for near-misses is imperative for RNs.

A segurança do paciente cirúrgico na perspectiva da vigilância sanitária — uma reflexão teórica

With the aim of preventing healthcare risks, improving health, and promoting patient safety, various measures have been implemented. Patient safety is equated to the re-duction of risk of unnecessary harm associated with healthcare to an acceptable mi-nimum. An incident that results in harm to a patient is known as Adverse Event (AE). Surgery-related AEs remain to be a global public health challenge. In Brazil, the National Health Surveillance Agency (ANVISA) and Ministry of Health have delineated actions, po-licies, and health regulation to prevent AEs, including those resulting from surgical pro-cedures. In 2013, the National Patient Safety Program was established and the actions of patient safety were regulated by ANVISA. Despite progresses in the recently established national security policy for patients, further measures are still required to improve the quality and safety of surgical care. The creation and maintenance of a safety culture in healthcare services will assure safer surgical procedures. Thus, this study aimed to discuss the primary components related to healthcare quality and patient safety that are considered as priority in healthcare services and discuss strategies employed by the government to promote safe surgical care.

Impact of Patient Safety and Legislative Standards on Healthcare Worker Vaccination Rates: A Single Center Experience

Influenza vaccination among healthcare workers (HCW) is a major component of patient safety programs to reduce transmission of influenza. Despite calls to improve national HCW vaccination rates Issued by organizations such as The Joint Commission (TJC) and Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP), rates of influenza vaccination among HCWs in New York State (NYS) have remained suboptimally low, averaging 48.4% in 2011-2012 influenza season.

A Knowledge Enhancement Patient Safety Program

INTRODUCTION: MORE−OB, an international patient safety program started in 2002, has trained over 14,400 participants. It is a 3-year program (additional years optional) in which participants (physicians, midwives, nurses, and others) facilitate communication and learn together to improve patient safety and outcomes on obstetric services. It was initiated in the United States in 2005. METHODS: Seventeen U.S. hospitals have enrolled in the program. A pretest and posttests taken by all participants assess initial and progressive knowledge accumulation (using over 1,400 pages of online educational material, simulated exercises, and workshops) on clinical aspects of obstetric care reviewed over the years of the program. RESULTS: See Table 1.CONCLUSIONS: Knowledge accumulation related to obstetric conditions increased in all health care provider groups. The differential spread among the groups narrowed by 56% resulting in a more common knowledge base, which should facilitate communication and improve patient safety and outcome on obstetric services.