Patient Safety Team Research Articles

GRP-165 Root Cause Analysis as an Opportunity to Improve the Safety of Paediatric Care

BackgroundPatient safety is a serious global public health issue. Causal analysis with a systematic and participatory approach is a useful tool for improving safety.PurposeTo perform a root cause analysis (RCA)...

Implementing a Patient Safety Team to reduce serious incidents.

The Division were experiencing a high number of serious incidents, and the Team felt that a good safety strategy would improve the quality of care given. Through multidisciplinary engagement they wanted to learn from these, encourage reporting and focus on a fair blame culture. The ultimate aim was to increase incident reporting, decrease serious incidents and improve quality. The key aim of the project was to improve the quality of care for the woman and their babies, we reduced the incidence of serious incidents and increased the incident reporting of less serious incidents, this was based on the theory of the Heinrich Ratio which theorises that for every serious incident there will be 300 less serious / near miss incidents. The Team wanted to ensure that the multidisciplinary team were engaged and felt confident to report incidents, and would receive the appropriate feedback and support. In addition all staff involved in the incident would be involved in the investigation and be at the heart of the decision making. The key measure for improvement was the increase in incident reporting (44% increase 2011 - 2012) and the decrease in serious incidents. The figures support the theory that the increase in minor incidents being reported and managed has reduced the incidence of serious incidents. Staff engagement in the process was paramount, and this was driven by a passion to ensure the woman was at the centre of every decision or safety improvement that was made. Women and their families would be involved in the quality improvement process.

Rapid risk assessment in acute hospital for patients with intellectual disabilities

PurposeThere is significant literature to demonstrate that people with intellectual disabilities are at higher risk of premature death, however there is relatively little evidence of research carried out on risk assessment in hospital for this patient group. This paper aims to share the outcomes from a patient safety project conducted in an acute hospital by the Trust's intellectual disabilities team.Design/methodology/approachA project structure was used, supported by the Trust patient safety team through association with the National Institute for Innovation and Improvement: leading improvement in patient safety (LIPS) programme. The aim of the project was to bring together the current evidence, to understand the risk issues for this group and develop a robust risk assessment tool that could be embedded into the care processes in acute hospitals.FindingsA six month pilot concluded that a short assessment in a familiar format was more likely to be used by nurses. Risk assessment on its own does not deliver better and safer care. It must be accompanied by a series of clear, evidence based actions that used together ensure the patients' total safety and care needs are met. This tool is used throughout the Trust and in a number of other hospitals across the eastern region. Its use has contributed to reducing length of stay and improving health outcomes.Research limitations/implicationsThe paper shows the need for further research and data gathering.Originality/valueThis study demonstrates that risk for patients with intellectual disabilities in hospital is complex. Education is essential to underpin new assessment tools for clinical practice.

Creating a culture of safety within operative neurosurgery: the design and implementation of a perioperative safety video

Surgical and medical errors result from failures in communication and handoffs as well as lack of standardization in clinical protocols and safety practices. Checklists, simulation training, and teamwork training have been shown to decrease adverse patient events and increase the safety culture of surgical teams. The goal of this project was to simplify and standardize perioperative patient safety practices and team communication processes within operative neurosurgery through the creation of an educational safety video targeted at a neurosurgical provider audience. A multidisciplinary group consisting of neurosurgeons, anesthesiologists, nurses, neuromonitoring specialists, quality champions, and a professional video production company met over several months in an iterative process to 1) determine the overall objectives of the video, 2) decide on the content and format of the video, 3) modify the proposed content and format based on stakeholder feedback, and 4) record the video and complete final revisions during postproduction. The video was launched within the authors' institution in July 2012 in conjunction with ongoing research projects to study the effects of the video on 1) multidisciplinary providers' knowledge of perioperative safety practices, 2) provider safety attitudes and safety culture in the operating room, and 3) provider behavior in performing predetermined elements of the preoperative timeout and postoperative debrief. The neurosurgical perioperative safety video can serve as a national model for how quality champions can drive changes in safety culture and provider behavior among multidisciplinary perioperative patient care teams. Ongoing research is being performed to assess the impact of the video on provider knowledge, behavior, and safety attitudes and culture.

Efektivitas Kepemimpinan dan Komunikasi Tim Keselamatan Pasien di RSI Ibnu Sina Pekanbaru Riau

Keselamatan pasien merupakan prioritas dalam aspek pelayanan di rumah sakit. Upaya penyelenggaraannya diharapkan meminimalkan risiko Kejadian Tidak Diinginkan (KTD). Komite Keselamatan Pasien di Rumah Sakit (KKP-RS) adalah wadah yang berinisitif mengajak semua stakeholder untuk memperhatikan keselamatan pasien. Karakteristik efektivitas kinerja tim harus memiliki prinsip leadership. Berbagai penelitian tentang patient safety teamwork ini terus dilakukan dan hasilnya komunikasi juga merupakan salah satu aspek yang mempengaruhi efektivitas kinerja teamwork. Tujuan penelitian adalah untuk mengevaluasi efektivitas kepemimpinan dan komunikasi kinerja tim KP-RS di RSI Ibnu Sina Pekanbaru, Riau. Jenis penelitian ini observasional, deskriptif menggunakan mixed methods dengan rancangan sequensial eksploratory. Wawancara mendalam dan observasi digunakan untuk mengeksplorasi persepsi dan perilaku yang menggambarkan efektivitas kepemimpinan dan komunikasi pada tim KP-RS. Kemudian dilakukan survei pada 20 informan untuk mengelompokkan persepsi efektivitas kedua aspek tersebut kedalam level kompetensi YAKKUM. Pengolahan data kualitatif menggunakan open code 3.6 dan data kuantitatif dengan distribusi frekuensi. Subjek penelitian adalah keseluruhan anggota tim. Hasil Penelitian menunjukan dari 42 kasus laporan insiden, terjadi 45.22% medication error, 2.38% mengakibatkan kematian dan 50% kasus tidak dilakukan analisis. Tidak ada laporan internal dan eksternal yang dilakukan oleh tim KP-RS. Evaluasi efektivitas kepemimpinan dan komunikasi masih berada pada level 2 dan 3. Kesimpulan dari penelitian adalah bahwa evaluasi efektivitas kepemimpinan dan komunikasi pada tim ini belum optimal. Fungsi, perilaku dan gaya kepemimpinan di tim KP-RS adalah passive leadership. Ronde Keselamatan Pasien (RKP), The SBAR Tools, reward and punistment adalah program yang direkomendasikan pada penelitian ini.

Improving Reporting of Outpatient Pediatric Medical Errors

Limited information exists about medical errors in ambulatory pediatrics and on effective strategies for improving their reporting. We aimed to implement nonpunitive error reporting, describe errors, and use a team-based approach to promote patient safety in an academic pediatric practice. The setting was an academic general pediatric practice in Charlotte, North Carolina, that has ∼26 000 annual visits and primarily serves a diverse, low-income, Medicaid-insured population. We assembled a multidisciplinary patient safety team to detect and analyze ambulatory medical errors by using a reporter-anonymous nonpunitive process. The team used systems analysis and rapid redesign to evaluate each error report and recommend changes to prevent patient harm. In 30 months, 216 medical errors were reported, compared with 5 reports in the year before the project. Most reports originated from nurses, physicians, and midlevel providers. The most frequently reported errors were misfiled or erroneously entered patient information (n = 68), laboratory tests delayed or not performed (n = 27), errors in medication prescriptions or dispensing (n = 24), vaccine errors (n = 21), patient not given requested appointment or referral (n = 16), and delay in office care (n = 15), which together comprised 76% of the reports. Many recommended changes were implemented. A voluntary, nonpunitive, multidisciplinary team approach was effective in improving error reporting, analyzing reported errors, and implementing interventions with the aim of reducing patient harm in an outpatient pediatric practice.

Key Performance Outcomes of Patient Safety Curricula: Root Cause Analysis, Failure Mode and Effects Analysis, and Structured Communications Skills

As colleges and schools of pharmacy develop core courses related to patient safety, course-level outcomes will need to include both knowledge and performance measures. Three key performance outcomes for patient safety coursework, measured at the course level, are the ability to perform root cause analyses and healthcare failure mode effects analyses, and the ability to generate effective safety communications using structured formats such as the Situation-Background-Assessment-Recommendation (SBAR) situational briefing model. Each of these skills is widely used in patient safety work and competence in their use is essential for a pharmacist's ability to contribute as a member of a patient safety team.

Increasing Patient Safety and Surgical Team Communication by Using a Count/Time Out Board

Communication and collaboration in patient care settings is vital for promoting the best possible patient outcomes. The counting of sponges, sharps, and instruments, and the surgical time out before the start of any surgical procedure are opportunities for the surgical team to address patient safety risks. Personnel in the surgical services department at St Luke's Episcopal Hospital, Houston, Texas, implemented the use of a hanging, magnetic, dry-erase board that includes the elements of a time out (eg, patient name and identifiers, procedure, site, allergies) and provides a means to document countable items. The board promotes team awareness of this time out and count information at all times during a procedure. Specific magnets on the count board identify items intentionally packed inside the patient to remind the team of the location of these items when the count is reconciled at the end of the procedure. In addition, a process of obtaining an radiograph of items similar to any missing items assists radiologists in identifying the location of retained surgical items. As a result of implementing both changes, our ability to locate missing items has significantly increased.

Evaluating the “Innovativeness Quotient” (IQ) in a Collaborative Model

The health care quality and patient safety movement has evolved rapidly during the past 10 years largely as a result of the Institute of Medicine (IOM) report, “To Err is Human.” Patient safety teams are using a collaborative model to improve patient outcomes. Diffusion of improvement-oriented innovations is a major challenge facing health care. Utilizing a tool to measure innovativeness, a 39-hospital patient safety collaborative was evaluated for their “Innovativeness Quotient.” Findings showed that 75.5% of the members of the collaborative who completed the survey were innovators/early adopters compared to 16% as described for the general population. The application and implications of this project are described.

Safe in their hands

PurposeThe purpose of this paper is to explore the management of the safety alert broadcast system (SABS) in England.Design/methodology/approachThis survey was part of a multi‐method study which was undertaken over an 18‐month period. The questionnaire was sent to every trust SABS liaison officer (SLO) (n=561) in England using the DH database. In total, 343 completed questionnaires were electronically returned, a response rate of 62 per cent.FindingsSABS is the means by which safety alerts from key agencies are electronically distributed to the NHS in England. Each organisation is required to have a named SLO who is required to acknowledge receipt on the Department of Health web site, indicate whether action is under way and finally confirm that action is complete. It offers a profile of this important segment of the workforce, over half of whom work in risk management, and 65 per cent of whom have no clinical background. Most spend very little of their working week managing the system itself, and are entirely dependent on the word of other managers to indicate that the trust has completed all action. Whilst the system is liked by the SLOs, concerns are expressed about the level of responsibility they are expected to assume.Practical implicationsTrusts may wish to consider the role in the light of the increasing number and complexity of the alerts being managed.Originality/valueThe paper offers a unique insight into the role and profile of those managing the interface between trusts and the patient safety team at the Department of Health.

Is Your Patient Ready for Transport? Developing an ICU Patient Transport Decision Scorecard

Transport of patients from the intensive care unit (ICU) to another area of the hospital can pose serious risks if the patient has not been assessed prior to transport. Recently, the Department of Critical Care Medicine, Calgary Health Region, experienced two adverse events during transport. A subgroup of the Department's Patient Safety and Adverse Events team developed an ICU patient transport decision scorecard. This tool was tested through Plan-Do-Study-Act cycles and further revised using human factors principles. Staff, especially novice nurses, found the tool extremely useful in determining patient preparedness for transport.

Improving Hospital Systems for the Care of Women With Major Obstetric Hemorrhage

When 2 maternal deaths due to hemorrhage occurred at New York Hospital Queens in 2000-2001, a multidisciplinary team implemented systemic change. Our objective was to improve outcomes of episodes of major obstetric hemorrhage. We report outcomes before (2000-2001) and after (2002-2005) the introduction of a patient safety program aimed at improving the care of women with major obstetric hemorrhage. Process changes were instituted in late 2001 at the direction of a multidisciplinary patient safety team. A rapid response team was formulated using the cardiac arrest team as a model. Protocols for early diagnosis, assessment, and management of patients at high risk for major obstetric hemorrhage were developed and communicated to staff. There were significant increases in cesarean births (P < .001), repeat cesarean births (P = .002), and cases of major obstetric hemorrhage (P = .02) between the periods of 2000-2001 and 2002-2005. There was a significant improvement in mortality due to hemorrhage (P = .036), lowest pH (P = .004), and lowest temperature (P < .001) when comparing 2000-2001 with 2002-2005. There were no differences in measures of severity of obstetric hemorrhage between the 2 periods, including Acute Physiology and Chronic Health Evaluation II scores, occurrence of placenta accreta and estimated blood loss. Despite a significant increase in major obstetric hemorrhage cases, we found improved outcomes and fewer maternal deaths after implementing systemic approaches to improve patient safety. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage.

Team Resource Management and patient safety

Purpose – To review three key areas of work managed by the Team Resource Management and Patient Safety Team (TRM), itself part of the Clinical Governance Support Team. Design/methodology/approach – Information has been collected from TRM staff, UK NHS Trust staff, research publications and reports. Findings – As treatment programmes become more complex and health care is delivered by multidisciplinary teams, the quality of care and of patient safety is ever more dependent on effective team working. External support and expertise can be effective in helping clinical teams achieve their full potential. Safety and team work practices from other domains such as aviation can be successfully translated into the work of clinical teams. Specific coaching input can also improve the effectiveness of teams and, where teams are recognised as having difficulty working together, external support in particular approaches and techniques can resolve team working problems. Originality/value – This review summarises the benefits of a healthcare support function which is specifically dedicated to the understanding, supporting and shaping of clinical teams.

Closing the Loop: Follow-up and Feedback in a Patient Safety Program

As health care organizations establish patient safety agendas, attention has focused on creating less cumbersome systems for reporting errors. However, experience at Brigham and Women's Hospital (Boston) suggests that more emphasis needs to be placed on what happens after a report is submitted. FOLLOW-UP AND FEEDBACK: Follow-up includes prioritizing opportunities and actions, assigning responsibility and accountability, and implementing the action plan. Feedback entails (1) follow-up to those who report issues and (2) communication to the hospital staff and clinicians about events and actions taken. Responsibility and accountability for improvements need to be assigned by senior administration to hospital leaders who can effect the needed changes. Hospital leaders, not just the members of the patient safety team, must own these changes or improvements. Events that require follow-up action are brought to the attention of risk management and the patient safety team through several mechanisms, including voluntary reporting of adverse events through a computerized safety reporting system, root cause analyses, and Patient Safety Leadership WalkRounds. Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item. However, it is the feedback to the reporter that perpetuates the influx of information and closes the loop. Developing the information-tracking database has made providing feedback easier and more reliable but significant effort is required to keep the database current.

Using Healthcare Failure Mode and Effect Analysis Tool to Review the Process of Ordering and Administrating Potassium Chloride and Potassium Phosphate

During the spring of 2004, in the Calgary Health Region (CHR) two critical incidents occurred involving patients receiving continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The outcome of these events resulted in the sudden death of both patients. The Department of Critical Care Medicine's Patient Safety and Adverse Events Team (PSAT), utilized the Healthcare Failure Mode and Effect Analysis (HFMEA) tool to review the process and conditions surrounding the ordering and administration of potassium chloride (KCI) and potassium phosphate (KPO4) in our ICUs. The HFMEA tool and the multidisciplinary team structure provided a solid framework for systematic analysis and prioritization of areas for improvement regarding the use of intravenous, high-concentration KCL and KPO4 in the ICU.

Clean Care is Safer Care: The first global challenge of the WHO World Alliance for Patient Safety

Dr. Pittet is from the Global Patient Safety Challenge, WHO World Alliance for Patient Safety; and Dr. Donaldson is from the WHO World Alliance for Patient Safety, WHO Headquarters, Geneva, Switzerland. Address reprint requests to Didier Pittet, MD, MS, Director, Infection Control Programme, University of Geneva Hospitals, 24 rue Micheli-du-Crest, 1211 Geneva-14, Switzerland. didier.pittet@hcuge.ch © World Health Organization [2005]. All rights reserved. The World Health Organization has granted SLACK Incorporated permission for the reproduction of this article. The authors thank the group of international experts and WHO members who worked to the development of the Global Patient Safety Challenge, in particular for their participation to the two international WHO Consultations, review of the available scientific evidence, writing of the WHO draft Guidelines on Hand Hygiene in Health Care, and fostering discussion among authors and members of the different task forces and working groups. The complete list of participants in the development of the guidelines documents is available at www.who.int/patientsafety/events/05/27_AprilParticipantList.pdf (accessed August 8, 2005). They also thank the patient safety team and other WHO staff from all the departments involved at HQ and in the regional offices for their work, the members of the Infection Control Programme at the University of Geneva Hospitals, and Rosemary Sudan for providing editorial assistance and outstanding support. For further information on the World Alliance or the Global Patient Safety Challenge, go to www.who.int/patientsafety/en (accessed August 8, 2005). Clean Care is Safer Care: The First Global Challenge of the WHO World Alliance for Patient Safety

KP Northwest Preoperative Briefing Project

In June 2001, members of the KP Northwest Region (KPNW) Patient Safety Team attending a Human Factors training program considered the patient safety challenges faced in the operating suite and identified pre-operative briefing as a necessary component of safe practice. After receiving the Human Factors training, the KPNW Patient Safety Team obtained sponsorship for a pilot project to develop preoperative briefing as a way to transform the patient safety culture in the KP Northwest Region's operating suites and to reduce the number of errors (especially burns). The project led to the KP Sunnyside Medical Center's current policy requiring preoperative briefing before each surgical intervention so that information regarding the patient's care is verified and shared.Since initiation of the preoperative briefings-which are increasingly being conducted on a routine basis-a trend of decreasing accidental injuries has been observed in the operating suite. In addition, recent questionnaire responses show an improved team culture of safety and an improved overall work climate (including such factors as teamwork, safety, perceptions of management, and working conditions). Measures reported by surgical teams in Orange County (California) and KPNW indicate the project can be transferred successfully. Staff are also expanding the briefings project to the ambulatory setting.

Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients

A 1999 Institute of Medicine report received national attention by highlighting system vulnerabilities within health care and indicating that medication errors are a leading cause of morbidity and mortality. One area of concern was the increased number of errors occurring in the prescribing phase of the medication-use process due to prescribers’ lack of essential drug knowledge and patient information at the time of ordering. Pharmacists’ participation in medical rounds has demonstrated a reduction in medication errors in the ordering stage. However, at most hospitals, pharmacists are not directly involved in obtaining medication histories, despite the findings of one study showing that over 70% of drug-related problems were recognized only through a patient interview and another study reporting a 51% reduction in medication errors when pharmacists were involved in obtaining medication histories. Medication errors and patient harm can result from inaccurate or incomplete histories that are subsequently used to generate medication KRISTINE M. GLEASON, B.S.PHARM., is Research Pharmacist Coordinator; JENNIFER M. GROSZEK, R.N., B.S.N., M.J., and CAROL SULLIVAN, R.N., M.B.A., are Research Nurse Coordinators, Patient Safety Team; DENISE ROONEY, R.N., B.S.N., O.C.N., is Manager, Patient Safety Team; and CYNTHIA BARNARD, M.B.A., M.S.J.S., C.P.H.Q., is Director, Quality Strategies and Patient Safety Team, Division of Quality and Operations, Northwestern Memorial Hospital (NMH), Chicago, IL. GARY A. NOSKIN, M.D., is Associate Professor of Medicine, Department of Medicine, Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, and Medical Director, Healthcare Epidemiology and Quality, NMH. Address correspondence to Ms. Gleason at the Division of Quality and Operations, Northwestern Memorial Hospital, 676 North St. Clair Street, Suite 700, Chicago, IL 60611 (kmgleaso@nmh.org). The Patient Safety Team and Failure Mode and Effects Analysis team members at Northwestern Memorial Hospital are acknowledged for their active participation and support. Karen Nordstrom, B.S.Pharm., Michael Fotis, B.S.Pharm., and Desi Kotis, Pharm.D., provided invaluable assistance and insight into this project. The dedicated clinical staff pharmacists are acknowledged for enhancing patient safety by obtaining medication and allergy histories, reconciling discrepancies in medication histories and orders, and collecting data. Supported in part by an Excellence in Academic Medicine Grant from the State of Illinois Department of Public Aid and U.S. Public Health Service grant UR8/515081. Presented at the ASHP Midyear Clinical Meeting, Atlanta, GA, December 11, 2002; the 5th Annual National Patient Safety Foundation Patient Safety Congress, Washington, DC, March 12–14, 2003; and the Institute for Healthcare Improvement 15th Annual National Forum on Quality Improvement in Health Care, New Orleans, LA, December 4, 2003.

Creating an integrated patient safety team.

CREATING A PATIENT SAFETY TEAM: In May 2001 Brigham and Women's Hospital (Boston) created the Patient Safety Team, which was incorporated into the pre-existing safety and quality infrastructure. ESTABLISHING THE PATIENT SAFETY TEAM'S GOALS AND INITIATIVES: The goal was to create the safest possible environment for patients and staff by creating a culture of safety, increasing the capacity to measure and evaluate processes, committing to change unsafe processes, and adopting new technologies. To achieve this mission, the following initiatives were established: create a culture of safety, increase event identification, improve event analysis, close the feedback loop, assess risk proactively, improve medication safety, and involve the patient. Integrating the Patient Safety Team into pre-existing committees and departments facilitated its work while helping to reinforce the multidisciplinary nature of safety efforts. It is critical that pre-existing groups feel that patient safety represents value added and is not a threat to their current roles. If a patient safety strategy and team are to be effective, commitment from the organization's leaders is essential. This team should also work with individual departments and pre-existing quality structures to drive changes to the systems of care to enable health care to become as safe as possible.