June 19, 2012
Background: Mitigating or reducing the risk of harm associated with the delivery of healthcare is a policy priority. While the risk of harm can be reduced in some instances (i.e. preventable), what constitutes preventable harm remains unclear. A standardized and clear definition of preventable harm is the first step towards safer and more efficient healthcare delivery system. We aimed to summarize the definitions of preventable harm and its conceptualization in healthcare.
Posted in Journal Articles, READ Portal | Tagged with Prevention and control, Quality improvement, Risk management, Safety | No Comments
June 8, 2012
This is the sixth issue of Patient Safety Papers, published by Longwoods. The first five issues, published since 2005, presented reports on research studies, demonstration projects and leading practices from organizations across Canada. In this issue, we assess our progress and examine the future. To do so, we asked a selection of patient safety experts from across this country to reflect on critical patient safety initiatives in specific domains.
Articles in this issue cover various aspects of patient safety, including:
- The use of reporting systems to enhance organizational learning and create safer systems
- How teamwork and communication can contribute to patient safety events
Posted in Journal Articles, READ Portal | Tagged with Canada, Hospitals, Quality of care, Safety | No Comments
May 1, 2012
“Systems that provide healthcare workers with the opportunity to report hazards, hazardous situations, errors, close calls and adverse events make it possible for an organization that receives such reports to use these opportunities to learn and/or hold people accountable for their actions. When organizational learning is the primary goal, reporting should be confidential, voluntary and easy to perform and should lead to risk mitigation strategies following appropriate analysis; conversely, when the goal is accountability, reporting is more likely to be made mandatory. Reporting systems do not necessarily equate to safer patient care and have been criticized for capturing too many mundane events but only a small minority of important events. Reporting has been inappropriately equated with patient safety activity and mistakenly used for “measuring” system safety. However, if properly designed and supported, a reporting system can be an important component of an organizational strategy to foster a safety culture.
Healthcare is not as safe as it should or could be: rates of adverse events, defined as situations where patients suffer harm from the healthcare they receive (or not receiving care that would have helped), in acute care have been shown to be high. For example, the Canadian Adverse Events Study found that 7.5% of patients admitted to a Canadian hospital suffered an adverse event (Baker et al. 2004). The National Steering Committee on Patient Safety listed the comprehensive identification and the reporting of hazards as one of “nine key principles for action” that served as a foundation for the committee’s recommendations to make Canadian patients safer (National Steering Committee on Patient Safety 2002). Further, the committee recommended the adoption of non-punitive reporting policies within a quality improvement framework. Recently, the National System for Incident Reporting (Canadian Institute for Health Information 2011) was established by the Canadian Institute for Health Information, whose focus at the present time is incidents regarding hospital-based medication and intravenous fluids. The development of reporting systems to enhance patient safety has been proposed as a strategy in other countries; examples include the Australian Incident Monitoring System (Runciman 2002) and the National Reporting and Learning System in England and Wales (Williams and Osborn 2006).”
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April 24, 2012
“The Canadian Hospital Reporting Project (CHRP) is a national quality improvement initiative from the Canadian Institute for Health Information (CIHI). CHRP’s web-based, interactive tool gives hospital decision-makers, policy-makers and Canadians access to indicator results for more than 600 facilities from every province and territory in Canada.
CIHI selected 21 clinical and 9 financial indicators for CHRP, based on their relevance to performance measurement and quality improvement. The selected indicators measure:
- Clinical effectiveness;
- Patient safety;
- Appropriateness of care;
- Accessibility; and
- Financial performance.
These indicators were chosen after reviewing existing hospital performance indicators and collaborating with experts in the field. The goal of CHRP is to foster quality improvement, learning and action.
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April 23, 2012
“Ten years ago, in September 2002, the National Steering Committee on Patient Safety delivered its report urging the development of the Canadian Patient Safety Institute and enhanced efforts to identify and reduce the risk of patient harm across the healthcare system. Two years later, the Canadian Adverse Events Study (Baker et al. 2004) provided data on patient safety in acute care – data that reported levels of harm far greater than most suspected. Today, virtually all Canadian healthcare organizations have goals around improving the safety and quality of care, and many have implemented reporting systems that identify patient safety incidents and track the implementation of recommendations to reduce hazards. In only a decade, patient safety has been transformed from the esoteric interest of a small number of champions to an essential component of healthcare performance across Canada. Today, patient safety is a fundamental prerequisite for the healthcare system: quality is impossible unless patients are protected from unintended harm.”
Posted in Journal Articles, READ Portal | Tagged with Canada, Health care reform, Quality control, Safety | No Comments
April 20, 2012
“The safety of maternity services is of paramount importance. Maternity teams face many challenges in delivering safe care to mothers, babies and families. The King’s Fund launched an independent inquiry into the safety of maternity services in 2006. The report from that inquiry, Safe Births: Everybody’s business, made a series of recommendations about how the safety of maternity care could be improved.
Building on the recommendations from our inquiry and in partnership with the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the NHS Litigation Authority, Centre for Maternal And Child Enquiries and the National Patient Safety Agency, The King’s Fund launched the Safer Births Improvement Programme, providing customised support to 12 multidisciplinary maternity teams in England. This toolkit shares the experiences and lessons from those teams.
Improving Safety in Maternity Services: a toolkit for teams is organised around five key areas for improvement in maternity care on which the teams focused:
- teamworking
- communication
- training
- information and guidance
- staffing and leadership.
Each section begins with a brief explanation on how focusing on improvements in each area can contribute to improved safety. It then highlights some of the experiences of the maternity teams who focused on this issue and their key learning points. There are also short summaries of tools that can be used to improve safety. These provide a brief guide to how to use the tool and signpost further resources. Where available we have included examples or templates that can be used or adapted for local use. Finally, we provide more information about service improvement and the tools and techniques that can be used.”
Posted in READ Portal, Reports & Papers | Tagged with Efficiency, Health care reform, Process improvement, Safety | No Comments
March 21, 2012
“This toolkit is designed to help your hospital understand the Quality Indicators (QIs) from AHRQ, and support your use of them to successfully improve quality and patient safety in your hospital. Created by the RAND Corporation and the University HealthSystem Consortium with funding from AHRQ, it is available for all hospitals to use free of charge. The toolkit is a general guide to using improvement methods, with a particular focus on the QIs.
The AHRQ QIs use hospital administrative data to assess the quality of care provided, identify areas of concern in need of further investigation, and monitor progress over time. This toolkit focuses on the 17 Patient Safety Indicators (PSIs) and the 28 Inpatient Quality Indicators (IQIs).”
Posted in Multimedia, READ Portal | Tagged with Indicators, Patient-centered care, Process improvement, Quality improvement, Safety | No Comments
March 16, 2012
This article examines the impact of workload imbalance on healthcare providers. Specifically, it looks at the “repercussions of a patient census that is either too high or too low for a hospitalist service.” Further, “Ellis Knight, MD, MBA, FHM, senior vice president for physician and clinical integration at Palmetto Health in Columbia, S.C., recalls conducting root cause analyses after every serious adverse event when he was vice president for medical affairs at a large teaching hospital. ‘For every one of them—it was just like a broken record—every one of them, the nursing staff or the physicians involved would start the recount by saying, ‘It was a very, very busy day; we had a very high census,’’ Dr. Knight says. ‘When that happens, when you get those, what I call tsunami waves of patients coming into a unit or being admitted at one time, it can really wreak havoc and it can make even the best clinicians get rushed, take shortcuts, and make mistakes.'”
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February 22, 2012
“Background and objective: Wearing of gloves reduces transmission of organisms by healthcare workers’ hands but is not a substitute for hand hygiene. Results of previous studies have varied as to whether hand hygiene is worse when gloves are worn. Most studies have been small and used nonstandardized assessments of glove use and hand hygiene. We sought to observe whether gloves were worn when appropriate and whether hand hygiene compliance differed when gloves were worn.
Participants and setting: Healthcare workers in 56 medical or care of the elderly wards and intensive care units in 15 hospitals across England and Wales.
Methods: We observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Observers also recorded whether gloves were or were not worn for individual contacts.
Results: Gloves were used in 1,983 (26.2%) of the 7,578 moments for hand hygiene and in 551 (16.7%) of 3,292 low-risk contacts; gloves were not used in 141 (21.1%) of 669 high-risk contacts. The rate of hand hygiene compliance with glove use was 41.4% (415 of 1,002 moments), and the rate without glove use was 50.0% (1,344 of 2,686 moments). After adjusting for ward, healthcare worker type, contact risk level, and whether the hand hygiene opportunity occurred before or after a patient contact, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54–0.79]; P ! .0001).
Conclusion: The rate of glove usage is lower than previously reported. Gloves are often worn when not indicated and vice versa. The rate of compliance with hand hygiene was significantly lower when gloves were worn. Hand hygiene campaigns should consider placing greater emphasis on the World Health Organization indications for gloving and associated hand hygiene.”
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February 16, 2012
This TED Talk with Brian Goldman address the some of the issues surrounding the medical culture of denying errors. “Every doctor makes mistakes. ‘But,’ says physician Brian Goldman, ‘medicine’s culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve.’ Telling stories from his own long practice, he calls on doctors to start talking about being wrong.”
Posted in Multimedia, READ Portal | Tagged with Primary health care, Safety | No Comments
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