World Health Organization Patient Safety Research Articles

The Return on Investment value of integrating the WHO Patient Safety Curriculum in Nursing Diploma: Forecasting case study

ObjectivesTo forecast the monetary impact by using Return on Investment (ROI) when integrating the World Health Organization (WHO) patient safety curriculum within the two years of an active diploma duration for 2019 and 2021 classes based on reported Hospital-Acquired Pressure Ulcers (HAPU) events. MethodsDuring this cross-sectional study, we compared the financial impact of integrating the WHO Patient Safety Curriculum in one 2-year diploma program in Saudi Hospital for class 2019 and 2021. All 51 qualified students were identified and included in this study. Demographic and patient safety perceptions for all students in both categories were analyzed and supported by historical data and students' feedback. ResultsThe whole revenue estimation for unaffiliated students' fees during one program was found higher than the total estimated benefits from forecasting. The total monetary cost estimation was higher than the integrated Diploma's cost during the program that was paid once. The ROI is (−7.73%). The HAPU percentage was lower than the MOH benchmark. The highest mean was for the personal attitude to patient safety, and the lowest was for knowledge of error and patient safety (4.05 ± 0.66 and 3.33 ± 0.74, respectively). ConclusionsThe study indicated a negative value from business perspectives; however, the projected multiple intangible benefits on education and training of the health sector are significant.

Are the World Health Organization's Patient Safety Learning Objectives Still Up-to-Date: A Group Concept Mapping Study.

The World Health Organization (WHO) Patient Safety Curriculum Guide defines learning objectives for patient safety. Current implementation in healthcare education is insufficient. Possible explanations may be obsolescence and/or a shift in needs. We investigated whether overarching topics and specific learning objectives of the WHO Patient Safety Curriculum Guide are still up-to-date, their attributed importance, and their perceived difficulty to achieve. Experts on patient safety and medical education from 3 European countries were asked to suggest learning objectives concerning patient safety using group concept mapping. Following 3 successive steps, experts rated ideas by importance and difficulty to achieve. Correlation analyses investigated the relationship between those. Overarching topics of the learning goals (clusters) were identified with multivariate analysis. A total of 119 statements about intended learning objectives on patient safety were generated, of which 86 remained for sorting and rating. Based on multivariate analyses, 10 overarching topics (clusters) emerged. Both the learning objectives and the overarching topics showed high correspondence with the WHO Patient Safety Curriculum Guide. Strong correlations emerged between importance and difficulty ratings for learning objectives and overarching topics. The WHO Patient Safety Curriculum Guide's learning goals are still relevant and up-to-date. Remarkably, learning objectives categorized as highly important are also perceived as difficult to achieve. In summary, the insufficient implementation in medical curricula cannot be attributed to the content of the learning goals. The future focus should be on how the WHO learning goals can be implemented in existing curricular courses.

Modeling global transfusion medicine education.

Modeling global transfusion medicine education.

Implementing and Evaluating a Patient Safety Curriculum for Undergraduate Medical Students using Blackboard

Background: One of the important components of the medical school curricula is patient safety education. Aim: To introduce a WHO patient safety course in medical undergraduate curriculum College of Medicine Jouf University (COM JU) using blackboard, measuring students’ attitudes and knowledge to patient safety course pre-post intervention. Methods: A quasi-experimental Pre-program/Post-program single group design was applied in this study. A Comprehensive sample of 5th-year undergraduate medical students (COM JU) (n=56) participated in the study. The first two levels of Kirkpatrick’s evaluation of educational intervention were measured; the first level (learner satisfaction) measured using The Attitudes to Patient Safety Questionnaire (APSQ) and the second level (knowledge) where students completed locally designed multiple-choice items targeting patient safety basic information. To increase student's awareness of the course author conducted a World Health Organization (WHO) learning from errors workshop before the implementation of the course. The course was uploaded on the learning management system (Blackboard). Students' satisfaction with blackboard as a learning tool for patient safety course was measured. Results: We matched student pretest with posttest and used paired t-tests to identify mean differences.Response rate was 86.15% (n=56) of students. There was a statistically significant difference between genders regarding the importance of patient safety (p =0.004). Results of (APSQ) showed that there was a minor improvement of attitude towards patient safety after the intervention. There was a statistically significant difference between students' knowledge test pre-post intervention (pre_42.86±12.17-post_54.83 ±14.9) p 0.000. Seventy-three percent 73% (n=41) of students agreed that Blackboard provided them with a positive learning experience. Conclusion: implementing a patient safety course into undergraduate medical education improved students’ knowledge of patient safety, blackboard is an effective learning management system to teach a course online from a students' perspective.

A LIFESAVING WAKE-UP CALL FROM THE PAST: “WASH YOUR HANDS!”

Professors of the Medical School, University of Pest (1863). Marked with an X is Semmelweis. Childbed or puerperal fever has been a terrible, lethal disease and presented a substantial unsolved problem in medicine since Hippocrates. In 1847, a Hungarian obstetrician, Ignacz F. Semmelweis discovered that the incidence of childbed fever, and generally, infections in hospitals and clinics could be drastically cut by hand disinfection. Unfortunately, his observations conflicted with the established scientific and medical opinions of the time, and his concept that the only condition that mattered was cleanliness was extreme at the time. It was largely ignored, despite cutting the mortality rate by 90% both in Vienna and in his Pest clinic. He was rejected and ridiculed by the medical community simply because accepting it would have required admitting personal responsibility. The pioneer of hygiene, the “savior of mothers,” died from sepsis at the age of 47 under suspicious circumstances. However, handwashing emphasized by Dr. Semmelweis is still a critical World Health Organization patient safety initiative. Finally, we summarize lessons of his life that are far-reaching and proper even today. [READ THE ARTICLE](https://doi.org/10.33218/001c.12928)

Global Incidence and Mortality Trends due to Adverse Effects of Medical Treatment, 1990-2017: A Systematic Analysis from the Global Burden of Diseases, Injuries and Risk Factors Study.

AimTo quantify the global incidence and mortality of adverse effects of medical treatment (AEMT) and forecast the possible emerging trends of AEMT.Materials and methodsWe analyzed the latest data from the Global Burden of Disease (GBD) 2017 study. We describe the burden of AEMT based on age- and region-specific incidence and mortality rates between 1990 and 2017. Additionally, we evaluated the change of burden due to AEMT by different periods between 1990 and 2017, and compared the age-standardized incidence and mortality rates among different World Health Organization (WHO) regions.ResultsGlobally, AEMT incidence rates varied across WHO regions and countries. The estimated age-standardized average incidence rates of AEMT were 309 [95% uncertainty interval (UI), 270 to 351], 340 (298 to 384), 401 (348 to 458), and 439 (376 to 505) per 100,000 population across the world in 1990, 2000, 2010, and 2017, respectively, showing an increasing trend in the new occurrence of adverse events. The incidence rate among women (469/100,000) was higher compared to men (409/100,000) in 2017. Between 1990 and 2017, we observed an upward trend in the incidence rates of AEMT across global regions, with a substantial increase in the incidence by 42% (27 to 57) between the years 1990 and 2017, translated to an annualized rate of incline of 1.5%. In the age group of 60-64 years, the incidence rates increased by 96% in 2017 compared to 1990. The global incidence rate due to AEMT is forecasted to increase to 446.94 (433.65 to 460.22) by 2020, 478.49 (376.88 to 580.09) in 2030, and to reach 510.03 (276.58 to 743.49) per 100,000 by 2040. We observed a decline in mortality rates due to AEMT across global regions, and the annualized rate of mortality change was -0.90 percentage points between 1990 and 2017. Overall, the AEMT mortality rate was higher in men (1.73/100,000) than in women (1.48/100,000), and age-specific mortality rates showed a bimodal increase between the age group of birth to one year, and an increase in the age group of 65 years and above. The global mortality rate due to AEMT is expected to be 1.55 (1.48 to 1.61) in 2020, 1.37 (0.88 to 1.86 ) in 2030 and 1.2 deaths per 100,000 (0.08 to 2.32) by 2040.ConclusionUsing the GBD 2017 study data, we found an increase in the incidence of AEMT, and an overall decrease in the mortality rate between 1990 and 2017, with varying estimates between different countries and regions, gender and age groups. The forecast analysis displayed the same trends - an increase in AEMT incidence and a decline in mortality between 2020 and 2040. The high burden of AEMT warrants the implementation of robust policies in the healthcare system including appropriate patient safety training for the healthcare professionals, and safe culture of feedback with the implementation of electronic medical records to achieve WHO patient safety strategy goals.

Patient safety: knowledge, influence and attitude among physicians: an exploratory study

BackgroundPatient safety is regarded as a global problem by which both developed and developing worlds are affected. It is defined as avoidance and prevention of patient injuries or adverse events, which could result during health care delivery. This study aimed to identify physicians’ knowledge, influence, and attitude toward patient’s safety in the faculty of medicine, Cairo university.Materials and methodsA cross-sectional study was conducted on 187 postgraduate physicians of different specialties working in the faculty of medicine, Cairo University. Anonymous self-administered questionnaires were distributed. The questionnaire is one of a series of tools designed for evaluation of the pilot implementation of the World Health Organization patient safety curriculum for medical schools.ResultsCalculated attitude score was relatively higher than influence, then knowledge score (median scores were 4.25, 3.1, and 2.5 respectively). There was no difference in knowledge, attitude, and influence scores by different personal characteristics as gender, specialty, workplace, graduation year except for higher influence score among physician who received inpatient safety training (p = 0.016). There was a weak positive significant correlation between knowledge and influence scores and between influence and attitude scores (r = 0.25, p = 0.002; r = 0.27, p < 0.001 respectively).ConclusionHigher patient safety positive attitude than influence and knowledge is pinpointed in physicians of different specialties in the faculty of medicine, Cairo University. This raises the attention to the importance of implementation of continuing patient safety education programs.

Effects of a patient safety course using a flipped classroom approach among undergraduate nursing students: A quasi-experimental study

BackgroundThe nursing education system has changed with the increased emphasis on patient safety in healthcare settings. Early education in patient safety is crucial to preparing nurses to be competent in patient care. Therefore, providing undergraduate patient safety education courses using an innovative approach is essential to enhancing patient safety and quality in nursing care. ObjectivesThis study aimed to examine the effects of a patient safety course using a flipped classroom approach on patient safety competency among undergraduate nursing students in South Korea. DesignA pre- and post-test quasi-experimental design with a non-equivalent control group was adopted. SettingsThis study was conducted in the college of nursing at a university in Seoul, South Korea. ParticipantsA total of 75 undergraduate nursing students participated. All students enrolled in the patient safety course comprised the experimental group (n = 32); those with similar characteristics to the experimental group (age, gender, and year) but did not take the course comprised the control group (n = 43). MethodsA total of 14 sessions (28 h) addressing the topics from the World Health Organization patient safety curriculum guide were delivered using a flipped classroom approach. The teaching methods included online learning and quizzes, case studies, small and large discussions, incident report tasks, and group projects including the development of strategies for patient safety. A survey including a demographic questionnaire and the Patient Safety Competency Self-Evaluation tool was administered at the beginning and end of the fall semester. ResultsPre- and post-test results demonstrated a significant increase in students' patient safety competency including attitude, skills, and knowledge. Mean scores of patient safety competency in the experimental group were significantly higher than in the control group. ConclusionsThe flipped-classroom patient safety course was shown to be effective in improving patient safety competency in terms of attitude, skills, and knowledge among undergraduate nursing students.

Resilient Health Care as the basis for teaching patient safety – A Safety-II critique of the World Health Organisation patient safety curriculum

Resilient Health Care (RHC) is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout.

Strengths, weaknesses, opportunities, and threats analysis of integrating the World Health Organization patient safety curriculum into undergraduate medical education in Pakistan: a qualitative case study.

PurposeThe purpose of this study was to conduct a strengths, weaknesses, opportunities, and threats (SWOT) analysis of integrating the World Health Organization (WHO) patient safety curriculum into undergraduate medical education in Pakistan.MethodsA qualitative interpretive case study was conducted at Riphah International University, Islamabad, from October 2016 to June 2017. The study included 9 faculty members and 1 expert on patient safety. The interviews were audiotaped, and a thematic analysis of the transcripts was performed using NVivo software.ResultsFour themes were derived based on the need analysis model. The sub-themes derived from the collected data were arranged under the themes of strengths, weaknesses, opportunities, and threats, in accordance with the principles of SWOT analysis. The strengths identified were the need for a formal patient safety curriculum and its early integration into the undergraduate program. The weaknesses were faculty awareness and participation in development programs. The opportunities were an ongoing effort to develop an appropriate curriculum, to improve the current culture of healthcare, and to use the WHO curricular resource guide. The threats were attitudes towards patient safety in Pakistani culture, resistance to implementation from different levels, and the role of regulatory authorities.ConclusionThe theme of patient safety needs to be incorporated early into the formal medical education curriculum, with the main goals of striving to do no harm and seeing mistakes as opportunities to learn. Faculty development activities need to be organized, and faculty members should to be encouraged to participate in them. The lack of a patient safety culture was identified as the primary reason for resistance to this initiative at many levels. The WHO curriculum, amended according to local institutional culture, can be implemented appropriately with support from the corresponding regulatory bodies.

ASSESSMENT OF PATIENT SAFETY AT AL-AZHAR UNIVERSITY HOSPITALS

Background: Patient safety is a critical component of health care quality. Therefore, all health-care professionals have obligations to provide safe and qualified health care to avoid unintentional harm to patients. Objective: Assessment the levels of patient safety inside the studied departments of Al-Azhar University Hospitals. Material and methods: The present descriptive cross-sectional study was carried out from first of September, 2014 until the end of August, 2016. Data were collected using standards checklist, adapted from World Health Organization Patient Safety Friendly Hospital Initiative (PSFHI) to assess patient safety in hospital, through observation, interviews, and reviewing documents in selected hospitals. Hospitals were classified into three levels of low (lower than 50%), average (5o-70%), and high (higher than 70%) based on the compliance level with standards of patient safety. Results: The overall compliance level of patient safety standards was evaluated low in the studied hospitals, 45% in New Damietta Hospital and 46.4% in Al- Hussein Hospital. The leadership and management domain was evaluated low in the studied hospitals. Moreover, it is better in New Damietta Hospital (41.4%) than Al- Hussein Hospital (40%). The safe evidence-based clinical practice domain was evaluated average in the studied hospitals. Moreover, it was better in Al- Hussein Hospital (61.4%) than New Damietta Hospital (57.9%).Conclusion: The overall compliance level of patient safety standards was evaluated low in the studied hospitals. None of the studied hospitals assessed achieved the 20 critical patient safety standards that are necessary to enroll a hospital in the PSFHI. Necessary investments in strategic and operational planning should be considered in order to achieve 100% standards.

Multiplicity of Terms Related to Patient Safety: A Hindrance to Progress.

o many terms related to safety, yet so little progress in this area over the years! Patient safety has become a major endeavour within virtually every health care setting, yet despite the efforts of every health care professional, patients continue to be at risk of adverse events as a result of direct care and processes of care. A new term is now starting to appear in the literature: patient safety incident. This term originates from the World Health Organization (WHO), which in 2004 set up the WHO Patient Safety program and the International Classification for

Evaluating Improvement in the Care of Depressed Elderly Patients: An Empirical Approach to the WHO Patient Safety Model

Depression among the elderly is a public health issue. This paper demonstrates the value of patient safety research for future strategies in this area. The aim of the present study was to analyse the relationship between the World Health Organization (WHO) Patient Safety (PS) Model and empirical research on depressed elderly patients’ experiences of quality and safe care. The research question was: Which patients’ experiences could be linked to quality and safe care as recommended by the WHO? We adopted an implementation approach as the starting point for this interdisciplinary project. A total of 29 individual narrative-based, in-depth interviews were performed to explore patients’ experiences and two healthcare teams participated in the focus group interviews. Interpretation of the results revealed that the 23 components of the PS model were linked to elderly patients’ experiences of quality and that safe care was not achieved. There was evidence of low quality and lack of safe care due to psychological distress, stress and fatigue, the absence of involvement in decision-making, misdiagnosis, sleep problems as a result of harm from medical error and a poor physical state. Patients’ experiences of loneliness gave rise to suicidal thoughts. In conclusion, quality improvement is necessary in all components of the WHO PS model. We recommend structural, process and outcome improvements, more specifically: active involvement, shared decision-making and increased self-management.

Actuaciones ante sucesos adversos: Cuidados enfermeros en la rotura del catéter venoso central

In a intensive care unit (ICU) there are many factors that can lead to the occurrence of adverse events. A high percentage of these events are associated with the administration of drugs. Diagnostic tests, such as computed tomography, is common in critically ill patients and technique can be performed with injection of contrast agent to enhance the visualization of soft tissue. The contrast is a medication and the nurse is responsible for its proper administration. The management of the critically ill patient is complex. ICU team and radiology shares responsibility for the care and safety of the patient safety during the transfer and performing tests with contrast. The World Health Organisation patient safety strategies, recommends analysing errors and learning from them. Therefore, it was decided to investigate the causes of the category E severity adverse events that occurred in a patient who was admitted to the ICU for septic shock of abdominal origin. An abdominal computed tomography was performed with contrast which was injected through a central venous catheter. The contrast did not appear in the image. What happened? Causal analysis helped to understand what triggered the event. A care plan and an algorithm were drafted to prevent it from happening again, with the following objectives: improving knowledge, skills and promoting positive attitudes towards patient safety, working at primary, secondary and tertiary care levels.

Mobilizing political will to contain antimicrobial resistance

Vemu Lakshmi is one of several Indian physicians who had long been calling for more to be done about drug resistance. Then, last year, a whirlwind of controversy blew up in her country about the highly resistant superbugs, bacteria containing the so-called NDM-1 enzyme. [ILLUSTRATION OMITTED] Some Indian microbiologists had been flagging the urgent need for micro biological laboratory support for doctors and strict guidelines on antibiotic prescriptions and policies for quite some time;' says Lakshmi, who is professor and head of the Department of Microbiology at Nizam's Institute of Medical Sciences, in Hyderabad. Lakshmi and her colleagues knew that antimicrobial resistance would be the inevitable result of inappropriate use of antibiotics in hospitals and in the community (including sub-therapeutic doses due to ignorance about resistance mechanisms), widespread over-the-counter sales of antibiotics and patients failing to complete their courses of antibiotics. She discussed these problems in detail in an article in the Indian Journal of Medical Microbiology in 2008. The spread of the resistant bacteria in India, Pakistan and the United Kingdom of Great Britain and Northern Ireland was described in a paper published in the Lancet Infectious Diseases in August 2010. NDM-1, or New Delhi metallo-beta-lactamase, was first identified in a Swedish patient who had returned from New Delhi in 2008. Experts were particularly concerned about the fact that the enzyme was found in one of the most commonly encountered bacteria in the human population, Escherichia coli, and that at least one in 10 of the strains containing this enzyme appeared to be resistant to all known antibiotics. Antimicrobial resistance is a global problem that affects all countries. year's World Health on 7 April aims to make governments more aware of the problem and to encourage them to take measures to combat this global threat. [Antimicrobial resistance] is a real public health problem and it is emerging globally and in Europe. We have to do much more about it--both in the World Health Organization (WHO) and also in Member says Zsuzsanna Jakab, WHO Regional Director for Europe. Jakab is well aware that the struggle against antimicrobial resistance in Europe requires continuous vigilance if problems such as drug-resistant tuberculosis are not to get worse. This is the start of a process; we can and have to raise awareness among policy-makers and the public, and follow up with strategies after World Health Day Jakab says. is not the first time WHO has tackled the issue. In 2001, WHO released the Global Strategy for Containment of Antimicrobial Resistance, containing recommendations that countries could customize for their own use. But the launch in Washington DC coincided with the attacks of 11 September 2001 in the United States of (USA) and any momentum was lost in the subsequent turmoil. For Dr Gerald Dziekan, from WHO's Patient Safety Programme, the 2001 initiative nevertheless provided a start for some countries in tackling the problem. [ILLUSTRATION OMITTED] It certainly triggered the development of national plans in some countries, but all in all the response was quite weak in the sense of global awareness and coordinated action,' Dziekan says. One of the challenges governments face in Dziekan's view is enforcing laws banning over-the-counter sales of antibiotics. This is particularly difficult in [low- to middle-income] countries where there are often no doctors to prescribe medicines but people need to get the drugs somehow. But it is also in these countries where the problem is increasingly being felt. Antibiotic resistance is not confined to the emergency rooms of rich countries in Europe and North America according to Anthony So, professor at the Sanford School of Public Policy at Duke University in the USA. …

A Multifaceted Approach to Education, Observation, and Feedback in a Successful Hand Hygiene Campaign

Prevention of health care-associated infections starts with scrupulous hand hygiene (HH). Improving HH compliance is a major target for the World Health Organization Patient Safety Challenge and is one of The Joint Commission's National Patient Safety Goals. Yet, adherence to HH protocols is generally poor for health care professionals, despite interventions designed to improve compliance. At Tufts Medical Center (Boston), HH compliance rates were consistently low despite the presence of a traditional HH campaign that used communication and education. A comprehensive program incorporated strong commitment by hospital leadership-who were actively involved in responsibilities previously only performed by infection preventionists and quality and patient safety staff-dedication of financial resources, including securing a grant; collaborating with a private advertising firm in a marketing campaign; and employing a multifaceted approach to education, observation, and feedback. This campaign resulted in a rapid and sustained improvement in HH compliance: Compared with the mean HH compliance rate for the six months before the campaign (72%), postcampaign HH compliance (mean = 94%) was significantly greater (p < .0001). Factors contributing to the success of the campaign included the development of the marketing campaign to fit this academic medical center's particular culture, strong support from the medical center leadership, a multifaceted educational approach, and monthly feedback on HH compliance. A comprehensive campaign resulted in rapid and sustained improvement in HH compliance at an academic medical center after traditional communication and education strategies failed to improve HH performance.

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/ .

When the patient falls out of bed, who pays?

Patient safety advocate Sue Sheridan learned about hospital errors the hard way. She recalls how, in 1995, her newborn son suffered severe brain damage when the hospital failed to run a 'ten dollar' blood test, which would have revealed neonatal jaundice. In 2002, her husband died after the hospital failed to notify him of a diagnosis of cancer. were simple Sheridan, now based in Boise, Idaho in the USA, says: They happened not because anyone was in a hurry or because this was so complex. In other words they were mistakes that should never have happened. Beginning in October 2008, Medicare, the US-government-administered social insurance programme providing health coverage to people aged 65 and over, stopped reimbursing hospitals for specific instances of this kind of error. The Centers for Medicare & Medicaid Services (CMS) drew up a list of 'reasonably preventable' mistakes, termed 'never-events', based on consultation with a variety of stakeholders and the recommendations of the National Quality Forum, a non-profit organization in the USA mandated by law to bring together people from across the health-care spectrum on measurement issues. In quantitative terms it is unclear what 'reasonably preventable' means exactly, and there is no clear guidance in the statute on which CMS policy is based. [ILLUSTRATION OMITTED] The list features major blunders such as operating on the wrong body-part or leaving surgical instruments inside the patient's body, it also includes complications, such as severe bedsores, and certain injuries caused by patients' falls. Dr Edward Kelley, head of strategic programmes at the World Health Organization (WHO) Patient Safety Programme, notes that the 'never-events' concept has been enthusiastically supported by the business community in the USA and has also been picked up by several European countries active in WHO's Patient Safety Reporting and Learning Community of Practice. For Sheridan, the initiative makes sense in so far as it improves patients' safety, her approval is nuanced. As a widow and the mother of a boy disabled due to medical error, it is hard to understand hospitals being paid for such blatant disregard of guidelines and communication procedures. On the other hand, I understand the possible long-term negative effects of non-payment for a 'never-event'. So this has to be looked at very thoughtfully. Dr Robert Wachter, chief of medical service at the University of California, San Francisco Medical Center, also believes the concept needs careful examination particularly the issue of reasonable preventability. Originally, the 'never-events', which came out of National Quality Forum deliberations, referred to things like cutting off the wrong leg or leaving a sponge in someone's belly, he says. That those things should never happen is self-evident. But the list of 'never-events' has expanded to now cover things like bad bedsores. But do we really know how to prevent bedsores 100% of the time? No, we don't. Professor Peter Pronovost, a critical care specialist at Johns Hopkins Hospital in Baltimore, concurs: Certain complications, like an object being left inside a patient after surgery are clear-cut, he says, but there are conditions such as air embolism and pressure ulcers (bedsores), that are not so straightforward. This being the case, one might think that impartial adjudication to separate preventable from non-preventable would be a key part of the policy. It isn't. On the patient's admission to hospital, a form is filled out noting the presence or absence of certain conditions, including pressure ulcers. These forms are coded. There is no opportunity to offer nuance (e.g. the patient is 98-years-old, the patient is morbidly obese) for the simple reason that assessment is not done on a case-by-case basis. CMS has made efforts to improve the coding, allowing the examining doctor the option of replying 'don't know' for example, the coded forms remain a necessarily blunt instrument. …