Patient Safety Solutions Research Articles

What’s in a drug name?

What’s in a drug name?

How hospital leaders implemented a safe surgery protocol in Australian hospitals

To analyse the strategies used by hospital leaders to improve compliance with the 'ensuring correct patient, correct site and correct procedure protocol'. While following such a protocol saves lives according to an international study of the World Health Organization safe surgery checklist, promoting compliance in hospitals has proved to be a regulatory challenge. Using a qualitative research design and 'responsive regulation' theory, this study explored implementation strategies used by hospital leaders in 20 Australian public hospitals. Semi-structured interviews were conducted with 72 informants to analyse how front-line leaders improved compliance with the safe surgery protocol in their hospitals. Implementation analysis of the safe surgery protocol. The use of implementation strategies located on a 'responsive regulation' pyramid. Informants identified many strategies used to improve protocol compliance typically beginning with persuasion. Supportive strategies were located on a regulatory pyramid beginning with softer interventions: persuade, enlist leaders, train, remind, relax protocol requirements, redesign hospital systems and reward compliance. In response to low and slow compliance, many hospital leaders switched to a pyramid of escalating sanctions: direct, delegate, monitor, publicly report, reprimand and penalize. A multiplex problem requires graduated and multiplex regulation. Hospital leaders proved to be responsive regulators in applying both multiple supports and sanctions that improved compliance over 3 years. These experiences with protocol implementation illustrate the multifaceted challenge of health sector regulation and offer lessons for embedding future patient safety solutions.

To make or buy patient safety solutions

For almost a decade, public and private organizations have pressured hospitals to improve their patient safety records. Since 2008, the Centers for Medicare & Medicaid Services has no longer been reimbursing hospitals for secondary diagnoses not reported during the point of admission. This ruling has motivated some hospitals to engage in safety-oriented programs to decrease adverse events. This study examined which hospitals may engage in patient safety solutions and whether they create these patient safety solutions within their structures or use suppliers in the market. We used a theoretical model that incorporates the key constructs of resource dependence theory and transaction cost economics theory to predict a hospital's reaction to Centers for Medicare & Medicaid Services "never event" regulations. We present propositions that speculate on how forces conceptualized from the resource dependence theory may affect adoption of patient safety innovations and, when they do, whether the adopting hospitals will do so internally or externally according to the transaction cost economics theory. On the basis of forces identified by the resource dependence theory, we predict that larger, teaching, safety net, horizontally integrated, highly interdependent, and public hospitals in concentrated, high public payer presence, competitive, and resource-rich environments will be more likely to engage in patient safety innovations. Following the logic of the transaction cost economics theory, we predict that of the hospitals that react positively to the never event regulation, most will internalize their innovations in patient safety solutions rather than approach the market, a choice that helps hospitals economize on transaction costs. This study helps hospital managers in their strategic thinking and planning in relation to current and future regulations related to patient safety. For researchers and policy analysts, our propositions provide the basis for empirical testing.

To make or buy patient safety solutions

To make or buy patient safety solutions

Prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia is a common problem in intensive care, and is a complex issue where prevention is both vital and multifaceted. This article explores the extent of the problem, the current research and some of the key elements within a prevention strategy, the Department of Health ventilator bundle and National Institute for Health and Clinical Excellence/National Patient Safety Agency technical patient safety solutions.

Health care team and parents' opinion about pediatric patients identification

Patient misidentification continues to be a quality and safety significant issue. The Joint Commission International listed patient identification as the first of ten life-saving patient-safety solutions. Identification wrist bands are the goal in the identification strategy. At the Hospital Nacional de Pediatría "Prof. Dr. J.P. Garrahan" we inquired about perception and agreement of this practice within hospital staff and parents. A short questionnaire was used with; in the first part a four point Lickert scale, and in the second one an open unstructured response. The questionnaire was distributed among health care workers and parent's patients. For families, the third question was not administrated. The survey explored about purpose and opportunity regarding the use of wrist band identification. A one day cutoff was made to obtain baseline data for properly use of identification bands. A total of 300 questionnaires were analyzed, 100 for each cluster (physicians, nurses, and parents); 82% responded that the wrist band should stay along the whole hospitalizing period. A range of 64% to 74% within the groups responded that it is helpful to prevent errors. There was no statistical difference between parents and physicians. Overall, percentage of patient with correct identification band in the hospital was 34%. We concluded that the wrist band identification is not a health care workers priority behavior yet. Initiatives on safety patient identifications, including families and healthcare workers, must be developed in the near future.

Segurança do paciente: desafios para a prática e a investigação em Enfermagem

doi: 10.5216/ree.v12i3.11885 Nowadays the concerns with quality of care and patient' safety in health care institutions have been globally evidenced. The movement for patient' safety began in the last decade of the twentieth century after the U.S. Institute of Medicine report publication which presented results of several studies revealing the critical situation of health care in this country. The data showed that approximately 44.000 to 98.000 from 33.6 million of hospital patients has died due to adverse events (1) . Since them the World Health Organization (WHO) has demonstrated its concern for patient' safety and has adopted this issue as high priority matter in the policy agenda for its countries members since the year of 2000. Last 2004, it was created the World Alliance for Safety Patients that aim to disseminate knowledge and found solutions. This alliance also has the goal of awareness and to gain political commitment for launching programs, generating alerts of systemic and technical aspects and conducting international campaigns that previously arrange the recommendations to ensure the safety of patients around the world (2) . It was published in May 2007 the nine solutions for adverse events prevention in the health care (3) . The current global challenges includes "Clean care is safety care" aiming to ensure better hands hygienization of the health care professionals, "Safe Surgery saves lives" aiming to improve better surgical treatment safety in all health care settings, and "Addressing the antimicrobial resistance" as a priority and focus to the World Health Day 2011 (4) . The main challenge of the experts in patient' safety that seek to reduce events in health care institutions has been the understanding, by the managers, that the cause of errors and adverse events is multifactorial and that health professionals are susceptible to commit adverse events when the technical and organizational processes are complex and poorly planned. The systems fail throughout the world and once the assistance is provided by humans there is the possibility of risk and harm promotion to patients, although what is really important now is that this reality is no longer ignored. The understanding that systems fail and allow the professionals failures spreads out reaching patients causing them adverse events allows the hospital to review its processes, to study and strengthen their defense lines. As a result f these global movements about this issue, scientific researches has been developed to identify and to understand the errors and adverse events, to adopt correctives actions and pro-actives, to analyze of the systemic fails and the cause factors and to establish strategies that ensure a safe practice, becoming better the quality of the health care and, consequently, offering a better patient' safety. A severe mistake found has been the lack of information about occurred adverse events and about its causal factors, impeding the knowledge, evaluation and the debate about the consequences of these events to the professionals, patients and familiar. This lack jeopardizes patient' safety because hinder the manager's actions to the achievement of planning and development of organizational strategies to the adoption of safe practices, minimization of the events and improving health care, setting risk for patient's security. Among the challenges for nursing when the subject are: the Patient' Safety Committee in health institutions composed by multidisciplinary team, seeking the development of a security culture inside or within these institutions and, the strengthening of a Nursing Network and Patient' Security (local, national and international) promoting rapid and effective communication of evidences, experiences and recommendations to ensure the patient' safety in the whole world. Another challenge, not least, is the scientific researches development that aims to minimize the known distance between what we know in theory and what we apply in the practice (know-do gap). Nursing needs to remodel the reasoning on existing researches about safety today in a solid path toward safer care assistance in the future. The researches on patient' safety should subsidize the decision-making and the management's intervention to modify the practice of care. The taken actions must generate results as reliable practices that make the difference in the safety of the patients, minimizing risks and changing the actual situation of the undesirable events. REFERENCES 1. Kohn LT, Corrignan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academy Press; 2001. 2. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. World Alliance for Patient Safety. Available from: http://www.who.int/patientsafety/worldalliance/en/ . 3. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. WHO launches. Nine patient safety solutions. Solutions to prevent health care-related harm. Available from: http://www.who.int/mediacentre/news/releases/2007/pr22/en/index.html . 4. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. Campaings. WHO Patient Safety campaigns. Available from: http://www.who.int/patientsafety/campaigns/en/ .

Reflections on the National Patient Safety Agency's database of medical errors

Reflections on the National Patient Safety Agency's database of medical errors

Fourth Annual Nursing Leadership Congress

In September 2008, nurse executives from around the country met in Scottsdale, Ariz, to develop practical tools and recommendations for "Driving Patient Safety Through Transformation," the theme of the fourth annual Nursing Leadership Congress. The Congress was made possible through an educational grant from McKesson and Intel in collaboration with sponsorship from the American Organization of Nurse Executives, Institute for Safe Medication Practices and National Patient Safety Foundation. This paper summarizes the Congress plenary sessions and roundtable discussions. Plenaries included the following: *Transformational Leadership: The Role of Leaders in Managing Complex Problems *Using the Baldrige Business Model as the Infrastructure for Creating a Culture of Patient Safety *Prospects for Structural Reform in Health Care Roundtables included the following: *Joy and Meaning in Work *Managing Chronic Care Across the Continuum *The Future of Acute Care Delivery in Light of Changing Reimbursement* Leveraging Transparency to Drive Patient Safety *Collaborative Partnerships for Driving a Patient Safety Agenda *Innovative Solutions for Patient Safety *Implementing the Fundamentals of the Toyota Production Model forHealthcare

NICE/NPSA Patient Safety Pilot

NICE/NPSA Patient Safety Pilot

Using OSCEs to teach WHO patient safety solutions

Using OSCEs to teach WHO patient safety solutions

Addressing Prehospital Patient Safety Using the Science of Injury Prevention andControl

There is inadequate information about the scope andcharacter of adverse events in prehospital care. However, there is ample evidence to suggest that prehospital patient safety hazards are often unique andunderrecognized. We first summarize what is currently understood about prehospital patient safety andidentify the specific aspects of emergency medical services (EMS) care that may make conventional approaches to the evaluation andimprovement of patient safety more difficult. Next we introduce the concept of using injury prevention andcontrol science to analyze prehospital adverse events andto help develop EMS patient safety solutions. Injury prevention andcontrol is a proven public health approach for the study andreduction of both intentional andunintentional injuries. It includes the use of a Haddon phase–factor matrix to identify possible interventions, especially environmental modifications that provide automatic protection. We demonstrate how this method can be used as a complementary approach in efforts to prevent injuries caused by prehospital adverse medical events.

World Health Organization - WHO launches "Nine patient safety solutions"

World Health Organization - WHO launches "Nine patient safety solutions"

Single Use of Injection Devices: Patient Safety Solutions, Volume 1, Solution 8, May 2007

Single Use of Injection Devices: Patient Safety Solutions, Volume 1, Solution 8, May 2007

Avoiding catheter and Tubing Mis-connections: Patient Safety Solutions, Volume 1, Solution 7, May 2007

The effectiveness of the surgical safety checklist (SSC) in countries with different socioeconomic backgrounds is uncertain. To evaluate the effect of the SSC in 2 different socioeconomic settings, we compared surgical site infection (SSI) rates before and after its implementation in colorectal procedures.An epidemiological retrospective study was conducted in the university hospitals in Ottawa, Canada, and Belo Horizonte, Brazil. Data were collected through chart review from the period before and after the SSC implementation.The SSI rate decreased from 27.7%-25.9% (P = .625) and from 17.0%-14.4% in Canada and Brazil, respectively (P = .448) after the SSC implementation. In Canada, there was no SSI in incomplete SSC, and in Brazil, SSI was 20.0% (P = .026).Despite high and regular completion of the SSC in the Canadian and Brazilian hospitals, respectively, there was no significant reduction of SSI after the SSC implementation in any setting. However, in Brazil, the association between incomplete SSC and higher SSI rates demonstrated the potential impact of the SSC in developing countries.The effect of the SSC on SSI may be greater in developing countries due to minor investment and consolidation of policies in SSI prevention.

Communication During Patient Hand-Overs: Patient Safety Solutions, Volume 1, Solution 3, May 2007

Communication During Patient Hand-Overs: Patient Safety Solutions, Volume 1, Solution 3, May 2007

Patient Identification: Patient Safety Solutions, Volume 1, Solution 2, May 2007

Patient Identification: Patient Safety Solutions, Volume 1, Solution 2, May 2007

Look-Alike, Sound-Alike Medication Names: Patient Safety Solutions, Volume 1, Solution 1, May 2007

Residential treatment is the most intensive and costly component of all child welfare systems per episode of care. At the same time, decisions to place in residential treatment centers are prioritized by the practice of least restrictive setting and best interest for children. There are, however, no standard evidence-based criteria for placing children in residential treatment. Clinical judgment, staffing dynamics, and other system factors are part of the decision-making process. Thus, some residential placements may be unnecessary and may be even harmful. The present study compares two models of decision-making, a multidisciplinary team approach and an objective decision support algorithm, and assesses outcomes when the two models either concur or not. Concordant decisions predicted greater clinical improvement than discordant decisions, but no differences were found in length of stay in placement. Policy implications for the decision-making process in child welfare are discussed.

Control of Concentrated Electrolyte Solutions: Patient Safety Solutions, Volume 1, Solution 5, May 2007

Control of Concentrated Electrolyte Solutions: Patient Safety Solutions, Volume 1, Solution 5, May 2007

Improved Hand Hygiene to Prevent Health Care-Associated Infections: Patient Safety Solutions, Volume 1, Solution 9, May 2007

Improved Hand Hygiene to Prevent Health Care-Associated Infections: Patient Safety Solutions, Volume 1, Solution 9, May 2007