How will we know patients are safer? An organization-wide approach to measuring and improving safety

Measuring and improving quality in esophageal care and swallowing disorders

Evaluating clinical care through quality-related metrics is increasingly common. There are now numerous quality statements and indicators related to the medical management of benign and pre-malignant esophageal diseases. Expert consensus leveraging evidence-based recommendations from published society guidelines has been the most frequently used basis for developing esophageal quality statements. While surgical care of patients with esophageal malignancies, including squamous cell carcinoma, has also been developed, those related to benign esophageal disease now include domains of diagnosis, treatment, and monitoring for gastroesophageal reflux disease, eosinophilic esophagitis (EoE), achalasia, and Barrett's esophagus (BE). Several recent studies evaluating adherence to quality metrics affirm substantial variation in practice patterns with opportunities for improvement in care across esophageal diseases. In particular, patient education regarding treatment options in achalasia, frequency of esophageal biopsies among patients with dysphagia to evaluate for EoE, and endoscopic evaluation within a BE segment are areas identified to have need for improvement. As the management of esophageal diseases becomes more complex and interdisciplinary, adherence to quality metrics may be a source of standardization and improvement in delivery and ultimately patient outcomes. Indeed, the development of national quality databases has resulted in a significant growth in the use of these metrics for quality improvement activities and may form the basis for future inclusion in quality reporting and payment programs.

The impact of birth settings on pregnancy outcomes in the United States

In the United States, 98.3% of patients give birth in hospitals, 1.1% give birth at home, and 0.5% give birth in freestanding birth centers. This review investigated the impact of birth settings on birth outcomes in the United States. Presently, there are insufficient data to evaluate levels of maternal mortality and severe morbidity according to place of birth. Out-of-hospital births are associated with fewer interventions such as episiotomies, epidural anesthesia, operative deliveries, and cesarean deliveries. When compared with hospital births, there are increased rates of avoidable adverse perinatal outcomes in out-of-hospital births in the United States, both for those with and without risk factors. In one recent study, the neonatal mortality rates were significantly elevated for all planned home births: 13.66 per 10,000 live births (242/177,156; odds ratio, 4.19; 95% confidence interval, 3.62-4.84; P<.0001) vs 3.27 per 10,000 live births for in-hospital Certified Nurse-Midwife-attended births (745/2,280,044; odds ratio, 1). These differences increased further when patients were stratified by recognized risk factors such as breech presentation, multiple gestations, nulliparity, advanced maternal age, and postterm pregnancy. Causes of the increased perinatal morbidity and mortality include deliveries of patients with increased risks, absence of standardized criteria to exclude high-risk deliveries, and that most midwives attending out-of-hospital births in the United States do not meet the gold standard for midwifery regulation, the International Confederation of Midwives' Global Standards for Midwifery Education. As part of the informed consent process, pregnant patients interested in out-of-hospital births should be informed of its increased perinatal risks. Hospital births should be supported for all patients, especially those with increased risks.

Thematic mapping of perioperative incident reporting data to relational coordination domains

Communication failure is a common root cause of adverse clinical events. Problematic communication domains are difficult to decipher, and communication improvement strategies are scarce. This study compared perioperative incident reports (IR) identifying potential communication failures with the results of a contemporaneous peri-operative Relational Coordination (RC) survey. We hypothesised that IR-prevalent themes would map to areas-of-weakness identified in the RC survey. Perioperative IRs filed between 2018 and 2020 (n = 6,236) were manually reviewed to identify communication failures (n = 1049). The IRs were disaggregated into seven RC theory domains and compared with the RC survey. Report disaggregation ratings demonstrated a three-way inter-rater agreement of 91.2%. Of the 1,049 communication failure-related IRs, shared knowledge deficits (n = 479, 46%) or accurate communication (n = 465, 44%) were most frequently identified. Communication frequency failures (n = 3, 0.3%) were rarely coded. Comparatively, shared knowledge was the weakest domain in the RC survey, while communication frequency was the strongest, correlating well with our IR data. Linking IR with RC domains offers a novel approach to assessing the specific elements of communication failures with an acute care facility. This approach provides a deployable mechanism to trend intra- and inter-domain progress in communication success, and develop targeted interventions to mitigate against communication failure-related adverse events.

Adverse events in prehospital emergency care: a trigger tool study

Background

Prehospital emergency care has developed rapidly during the past decades. The care is given in a complex context which makes prehospital care a potential high-risk activity when it comes to patient safety. Patient safety in the prehospital setting has been only sparsely investigated. The aims of the present study were 1) To investigate the incidence of adverse events (AEs) in prehospital care and 2) To investigate the factors contributing to AEs in prehospital care.

Methods

We used a retrospective study design where 30 randomly selected prehospital medical records were screened for AEs each month in three prehospital organizations in Sweden during a period of one year. A total of 1080 prehospital medical records were included. The record review was based on the use of 11 screening criteria.

Results

The reviewers identified 46 AEs in 46 of 1080 (4.3%) prehospital medical records. Of the 46 AEs, 43 were classified as potential for harm (AE1) (4.0, 95% CI = 2.9–5.4) and three as harm identified (AE2) (0.3, 95% CI = 0.1–0.9). However, among patients with a life-threatening condition (priority 1), the risk of AE was higher (16.5%). The most common factors contributing to AEs were deviations from standard of care and missing, incomplete, or unclear documentation. The most common cause of AEs was the result of action(s) or inaction(s) by the emergency medical service (EMS) crew.

Conclusions

There were 4.3 AEs per 100 ambulance missions in Swedish prehospital care. The majority of AEs originated from deviations from standard of care and incomplete documentation. There was an increase in the risk of AE among patients who the EMS team assessed as having a life-threatening condition. Most AEs were possible to avoid.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0228-3) contains supplementary material, which is available to authorized users.

Developing a conceptual framework for patient safety culture in emergency department: A review of the literature

Patient safety culture is a critical component of modern health care. However, the high-paced, unpredictable nature of the emergency department (ED) environment may impact adversely on it. The aim of this paper is to explore the concept of patient safety culture as it may apply to emergency health care, and to propose a conceptual framework that could form the basis for interventions designed to improve it. This is a systematic review of the literature. A search was undertaken of common electronic bibliographic databases using key words such as safety culture, safety climate, and Emergency Department. Articles were analysed for consistent themes with the aim to construct a conceptual framework. Ten articles met the inclusion criteria that specifically examined safety culture in the ED. Synthesis of the literature resulted in the emergence of three overarching themes of ED practice found to impact on safety culture in the ED. These were the dimensions of patient safety culture, the factors influencing it, and the interventions for improving it. A conceptual framework was constructed that identifies elements that significantly impact the patient safety culture in the ED. This framework may assist managers and researchers to take a comprehensive approach to build an effective safety culture in ED setting.

User-Centered Collaborative Design and Development of an Inpatient Safety Dashboard

Patient safety remains a key concern in hospital care. This article summarizes the iterative participatory development, features, functions, and preliminary evaluation of a patient safety dashboard for interdisciplinary rounding teams on inpatient medical services. This electronic health record (EHR)-embedded dashboard collects real-time data covering 13 safety domains through web services and applies logic to generate stratified alerts with an interactive check-box function. The technological infrastructure is adaptable to other EHR environments. Surveyed users perceived the tool as highly usable and useful. Integration of the dashboard into clinical care is intended to promote communication about patient safety and facilitate identification and management of safety concerns.

Association of nurse work environment and safety climate on patient mortality: A cross-sectional study

BACKGROUND

There are two largely distinct research literatures on the association of the nurse work environment and the safety climate on patient outcomes.

OBJECTIVE

To determine whether hospital safety climate and work environment make comparable or distinct contributions to patient mortality.

DESIGN

Cross-sectional secondary analysis of linked datasets of Registered Nurse survey responses, adult acute care discharge records, and hospital characteristics.

SETTING

Acute care hospitals in California, Florida, New Jersey, and Pennsylvania.

PARTICIPANTS

The sample included 600 hospitals linked to 27,009 nurse survey respondents and 852,974 surgical patients.

METHODS

Nurse survey data included assessments of the nurse work environment and hospital safety climate. The outcome of interest was in-hospital mortality. Data analyses included descriptive statistics and multivariate random intercept logistic regression.

RESULTS

In a fully adjusted model, a one standard deviation increase in work environment score was associated with an 8.1% decrease in the odds of mortality (OR 0.919, p<0.001). A one-standard deviation increase in safety climate score was similarly associated with a 7.7% decrease in the odds of mortality (OR 0.923, p<0.001). However, when work environment and safety climate were modeled together, the effect of the work environment remained significant, while safety climate became a non-significant predictor of mortality odds (OR 0.940, p=0.035 vs. OR 0.971, p=0.316).

CONCLUSIONS

We found that safety climate perception is not predictive of patient mortality beyond the effect of the nurse work environment. To advance hospital safety and quality and improve patient outcomes, organizational interventions should be directed toward improving nurse work environments.

Impact of random safety analyses on structure, process and outcome indicators: multicentre study

Background

To assess the impact of a real-time random safety tool on structure, process and outcome indicators.

Methods

Prospective study conducted over a period of 12 months in two adult patient intensive care units. Safety rounds were conducted three days a week ascertaining 37 safety measures (grouped into 10 blocks). In each round, 50% of the patients and 50% of the measures were randomized. The impact of this safety tool was analysed on indicators of structure (safety culture, healthcare protocols), process (improvement proportion related to tool application, IPR) and outcome (mortality, average stay, rate of catheter-related bacteraemias and rate of ventilator-associated pneumonia, VAP).

Results

A total of 1214 patient-days were analysed. Structure indicators: the use of the safety tool was associated with an increase in the safety climate and the creation/modification of healthcare protocols (sedation/analgesia and weaning). Process indicators: Twelve of the 37 measures had an IPR > 10%; six showed a progressive decrease in the IPR over the study period. Nursing workloads and patient severity on the day of analysis were independently associated with a higher IPR in half of the blocks of variables. Outcome indicators: A significant decrease in the rate of VAP was observed.

Conclusions

The real-time random safety tool improved the care process and adherence to clinical practice guidelines and was associated with an improvement in structure, process and outcome indicators.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0245-x) contains supplementary material, which is available to authorized users.

Real-time random safety audits: A transforming tool adapted to new times

Real-time random safety audits constitute a tool designed to transfer knowledge from the sources of scientific evidence to the patient bedside. It has proven useful in critically ill patients, improving safety in the process of critical patient care, turning unsafe situations into safe ones in daily practice, and ensuring adherence to scientific evidence. In parallel, the design and methodology involved affords process indicators that will make it possible to know how we provide care for our patients, evolution over time (with regular feedback for professionals), the impact of our interventions, and benchmarking.

Patient Safety Events and Harms During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness

OBJECTIVE

This study explored the risk of patient safety events and associated nonfatal physical harms and mortality in a cohort of persons with serious mental illness. This group experiences high rates of medical comorbidity and premature mortality and may be at high risk of adverse patient safety events.

METHODS

Medical record review was conducted for medical-surgical hospitalizations occurring during 1994-2004 in a community-based cohort of Maryland adults with serious mental illness. Individuals were eligible if they died within 30 days of a medical-surgical hospitalization and if they also had at least one prior medical-surgical hospitalization within five years of death. All admissions took place at Maryland general hospitals. A case-crossover analysis examined the relationships among patient safety events, physical harms, and elevated likelihood of death within 30 days of hospitalization.

RESULTS

A total of 790 hospitalizations among 253 adults were reviewed. The mean number of patient safety events per hospitalization was 5.8, and the rate of physical harms was 142 per 100 hospitalizations. The odds of physical harm were elevated in hospitalizations in which 22 of the 34 patient safety events occurred (p<.05), including medical events (odds ratio [OR]=1.5, 95% confidence interval [CI]=1.3-1.7) and procedure-related events (OR=1.6, CI=1.2-2.0). Adjusted odds of death within 30 days of hospitalization were elevated for individuals with any patient safety event, compared with those with no event (OR=3.7, CI=1.4-10.3).

CONCLUSIONS

Patient safety events were positively associated with physical harm and 30-day mortality in nonpsychiatric hospitalizations for persons with serious mental illness.

The Role for Leaders of Health Care Organizations in Patient Safety

We review what leaders of health care systems, including chief executive officers and board members, need to know to have "patient safety literacy" and do to make their systems safe. High reliability organizations produce reliable results that are not dependent on providers being perfect. Their characteristics include the commitment of leadership to safety as a system responsibility, with a culture of safety that decreases variability with standardized care and does not condone "at-risk behavior." A business case can be made for investing resources into systems that produce good outcomes reliably. Leaders must see patient safety problems as problems with their system, not with their employees. Leaders need to give providers information to make and monitor system progress. All medical errors, including near misses, and processes associated with all adverse events may provide information for system improvement. Improving systems should produce better long-term results than educating workers to be more careful.

Testing the implementation of an electronic process-of-care checklist for use during morning medical rounds in a tertiary intensive care unit: a prospective before-after study

Background

To improve the delivery of important care processes in the ICU, morning ward round checklists have been implemented in a number of intensive care units (ICUs) internationally. Good quality evidence supporting their use as clinical support tools is lacking. With increased use of technology in clinical settings, integration of such tools into current work practices can be a challenge and requires evaluation. Having completed preliminary work revealing variations in practice and evidence supporting the construct validity of a process-of-care checklist, the need to develop, test and further validate an e(lectronic)-checklist in an ICU was identified.

Methods

A prospective, before–after study was conducted in a 19-bed general ICU within a tertiary hospital. Data collection occurred during baseline and intervention periods for 6 weeks each, with education and training conducted over a 4-week period prior to intervention. The e-checklist was used at baseline by ICU research nurses conducting post-ward round audits. During intervention, senior medical staff completed the e-checklist after patient assessments during the morning ward rounds, and research staff conducted post-ward round audits for validity testing (via concordance measurement). To examine changes in compliance over time, checklist-level data were analysed using generalised estimating equations that factored in confounding variables, and statistical process control charts were used to evaluate unit-level data. Established measures of concordance were used to evaluate e-checklist validity.

Results

Compliance with each care component improved significantly over time; the largest improvement was for pain management (42% increase; adjusted odds ratio = 23, p < 0.001), followed by glucose management (22% increase, p < 0.001) and head-of-bed elevation (19% increase, p < 0.001), both with odds ratios greater than 10. Most detected omissions were corrected by the following day. Control charts illustrated reduced variability in care compliance over time. There was good concordance between physician and auditor e-checklist responses; seven out of nine cares had kappa values above 0.8.

Conclusion

Improvements in the delivery of essential daily care processes were evidenced after the introduction of an e-checklist to the morning ward rounds in an ICU. High levels of agreement between physician and independent audit responses lend support to the validity of the e-checklist.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-015-0060-1) contains supplementary material, which is available to authorized users.

Highly reliable procedural teams: the journey to spread the universal protocol in diagnostic imaging

CONTEXT

The Joint Commission’s Universal Protocol has been widely implemented in surgical settings since publication in 2003. The elements improved patient safety in operating rooms, and the same rigor is being applied to procedures occurring in other health care arenas, in particular, diagnostic imaging.

OBJECTIVE

In 2011, Kaiser Permanente West Los Angeles’s Diagnostic Imaging Department desired to adapt previous work on Universal Protocol implementation to improve patient safety in interventional radiology and mammography procedures.

DESIGN

The teams underwent human factors training and then adapted key interventions used in surgical suites to their workflows. Time-out posters, use of whiteboards, "glitch books," and regular audits provided structure to overcome the risks that human factors present.

MAIN OUTCOME MEASURES

Staff and physician perceptions of the teamwork and safety climates in their modalities were measured using the Safety Attitudes Questionnaire at baseline and at 18 months after training. Unusual Occurrence Reports were also reviewed to identify events and near misses that could be prevented. Implementation of key process changes were identified as process measures.

RESULTS

Perception of the safety climate improved 25% in interventional radiology and 4.5% in mammography. Perception of the teamwork climate decreased 5.4% in interventional radiology and 16.6% in mammography. Unusual occurrences were underreported at baseline, and there is ongoing reluctance to document near misses.

CONCLUSION

This work provides important considerations of the impact of departmental cultures for the implementation of the Universal Protocol in procedural areas. It also reveals unexpected challenges, and requires long-term effort and focus.

Evaluating Safety Initiatives in Healthcare

Substantial attention over the last decade has focused on ensuring improvement in the increasingly complex world of healthcare. This has resulted in significant efforts in the arena of patient safety. The issue of how best to evaluate the validity of patient safety initiatives is a matter of significant discussion. Many quality improvement initiatives in healthcare are poorly developed, with few patient safety interventions sharing characteristics with evidence based medicine. We will discuss the key elements of a framework as an example to help structure our thinking and approach to answer these questions. Elements include an explanation of the theoretical basis, the use of appropriate measures, detailing of the involved processes, assessment of the initiative itself as well as the contextual factors surrounding it.

There's no place like home: boarding surgical ICU patients in other ICUs and the effect of distances from the home unit

BACKGROUND

Intensive care units (ICUs) function frequently at capacity, requiring incoming critically ill patients to be placed in alternate geographically distinct ICUs. In some medical ICU populations, "boarding" in an overflow ICU has been associated with increased mortality. We hypothesized that surgical ICU patients experience more complications when boarding in an overflow ICU and that the frequency of these complications are greatest in boarders farthest from the home unit (HU).

METHODS

A 5-year (June 2005 to June 2010) retrospective review of a prospectively maintained ICU database was performed, and demographics, severity of illness, length of stay, and incidence of ICU complications were extracted. Distances between boarding patients' rooms and the HU were measured. Complications occurring in patients located in the same floor (BUSF) and different floor (BUDF) boarding units were compared and stratified by distance from HU to the patient room. Logistic regression was used to develop control for known confounders.

RESULTS

A total of 7,793 patients were admitted to the HU and 833 to a boarding unit (BUSF, n = 712; BUDF, n = 121). Boarders were younger, had a lower length of stay, and Acute Physiology and Chronic Health Evaluation II and were more often trauma/emergency surgery patients. Compared with in-HU patients, the incidence of aspiration pneumonia (2.2% vs. 3.6%, p < 0.01) was greater in BUSF patients and highest in those farthest from the HU (odds ratio [OR], 2.39; p = 0.01). Delirium occurred less often in HU than in BUDF patients (3.3% vs. 8.3 %, p < 0.01), and both delirium (OR, 6.09, p < 0.01) and ventilator-associated pneumonia (OR, 4.49, p < 0.05) were more frequent in patients farther from the HU.

CONCLUSION

Certain ICU complications occur more frequently in boarding patients particularly if they are located on a different floor or far from the HU. When surgical ICU bed availability forces overflow admissions to non-home ICUs, greater interdisciplinary awareness, education, and training may be needed to ensure equivalent care and outcomes.

LEVEL OF EVIDENCE

Epidemiologic study, level III. Therapeutic study, level IV.

Is culture associated with patient safety in the emergency department? A study of staff perspectives

OBJECTIVE

To describe the patient safety culture of Dutch emergency departments (EDs), to examine associations between safety culture dimensions and patient safety grades as reported by ED staff and to compare these associations between nurses and physicians.

DESIGN

Cross-sectional survey conducted in 2007.

SETTING

Thirty-three non-academic EDs in the Netherlands.

PARTICIPANTS

Four hundred and eighty nurses, 159 physicians and 91 other professionals.

MAIN OUTCOME MEASURE

Self-reported level of patient safety.

RESULTS

In unadjusted analyses, all dimensions of safety culture were positively associated with the reported level of patient safety and six of these associations with patient safety were statistically significant after adjustment ('teamwork across units', 'frequency of event reporting', communication openness', 'feedback about and learning from errors', 'hospital management support for patient safety'). Differences between nurses and physicians were found on two dimensions ('frequency of event reporting' and ' hospital management support for patient safety'). Physicians tended to grade patient safety higher than nurses whilst having equal judgements on these two dimensions.

CONCLUSIONS

Staff identified several dimensions of safety culture that are associated with staff-reported safety in the ED. Physicians and nurses identified distinct dimensions of safety culture as associated with reported level of patient safety.

Visualizing Central Line -Associated Blood Stream Infection (CLABSI) Outcome Data for Decision Making by Health Care Consumers and Practitioners-An Evaluation Study

The purpose of this study was to evaluate information visualization of publicly-reported central line-associated blood stream infection (CLABSI) outcome data for decision making by diverse target audiences – health care consumers and practitioners. We describe the challenges in publicly reporting of healthcare-associated infections (HAIs) data and the interpretation of an evaluation metric. Several options for visualization of CLABSI data were designed and evaluated employing exploratory working group, two confirmatory focus groups’ observations, and experts’ committee validation of the final designs. Survey-data collection and evaluation criteria results, collected from the two focus groups, are presented and are used to develop the final recommendations for how to visualize publicly-reported CLABSI data from Maryland acute care hospitals. Both health care consumer and practitioner’s perspectives are highlighted and categorized based on the visualizations’ dimensions framework. Finally, a recommended format for visualizing CLABSI outcome data based on the evaluation study is summarized.

Validation of a novel safety climate instrument in VHA nursing homes

Improvements in nursing home safety climate could lead to enhanced resident safety. Yet safety climate has been little studied in the nursing home setting, and existing safety climate instruments have significant limitations. To investigate safety climate in Veterans Health Affairs nursing homes (Community Living Centers [CLCs]), this study had two objectives: (a) to develop a resident safety climate instrument for use in CLCs and (b) to assess this instrument's psychometric properties by administering it in a sample of CLCs. Using a standard conceptual framework, the CLC Employee Survey of Attitudes about Resident Safety was developed with the aid of an expert panel and multiple rounds of cognitive interviews. It was subsequently pilot tested in a sample of CLC employees. After refinement based on the pilot results, it was administered in a sample of five CLCs, where it was found to have adequate reliability and validity.

[Quality indicators in an intensive care unit: a two-year healthcare-associated infection surveillance program]

OBJECTIVE

To estimate quality healthcare indicators in an intensive care unit (ICU).

METHODS

A prospective observational study was conducted on all patients referred to the medical ICU of Ramón y Cajal hospital (Madrid) for more than 48 hours, from January 1 2008 to December 31 2009.

RESULTS

A total of 503 patients were included, of whom 7.4% developed a healthcare-associated infection (HAI) attributable to their stay in the ICU. The median length of stay was 5 days. A ventilator-associated pneumonia (VAP) was observed in 1.9% of patients, with a VAP rate of 3.8 per 1,000 ventilator-days. A catheter-associated urinary tract infection (CAUTI) was found in 3.6% of the patients, with a CAUTI rate of 4.5 per 1,000 catheter-days. The cumulative incidence of central line-associated bloodstream infection (CLABSI) was 1.8%, with a CLABSI rate of 2.2 per 1,000 central line-days.

CONCLUSIONS

Our results are similar to those of other studies using the same methodology. An HAI surveillance system is a key factor for implementing a healthcare quality improvement system. The obtained indicators allow intra-comparison over time and with other similar hospitals, the monitoring of infection control measures, and thus an effective improvement in healthcare quality and patient safety.

Differences in the perceptions of parents and healthcare professionals on pediatric intensive care practices

OBJECTIVE

To explore similarities and differences in perceptions on pediatric intensive care practices between parents and staff by using data from two studies.

DESIGN

A two-round Delphi method among nurses and physicians followed by an empiric survey among parents.

SETTINGS

Pediatric intensive care units at eight university medical centers.

SUBJECTS

Parents whose child has been admitted to a pediatric intensive care unit, nurses, and physicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Outcome measures were 74 satisfaction-with-care items divided into five domains: 1) information; 2) care and cure; 3) organization; 4) parental participation; and 5) professional attitude. The Delphi study was completed by 218 nurses and 46 physicians and the survey by 559 of 1042 (54%) parents. Parents rated 31 items more important than the professionals based on the standardized mean difference (Cohen's d, 0.21-1.18, p < .003). Ten of these were related to information provision. Information on the effects of medication had the largest effect size (Cohen's d 1.18, p = .001). Correct medication administration by professionals was also rated significantly more important by parents (Cohen's d 0.64, p = .001). The professionals rated 12 items more important than the parents (Cohen's d -0.23 to -0.73, p < .005), including three about multicultural care. Significant differences remained on two of the three multicultural care items when the Dutch (n = 483) and non-Dutch parents (n = 76) were separately compared with professionals. On the domain level, parents rated the domains information and parental participation more important than the professionals (Cohen's d 0.36 and 0.26, p = .001).

CONCLUSIONS

Compared with the parents' perceptions, nurses and physicians undervalued a substantial number of pediatric intensive care unit care items. This finding may reflect a gap in the understanding of parental experiences as well as incongruity in recognizing the needs of parents.

Compliance with Processes of Care in Intensive Care Units in Australia and New Zealand – A Point Prevalence Study

There are indications that compliance with routine clinical practices in intensive care units (ICU) varies widely internationally, but it is currently unknown whether this is the case throughout Australia and New Zealand. A one-day point prevalence study measured the prevalence of routine care processes being delivered in Australian and New Zealand ICUs including the assessment and/or management of: nutrition, pain, sedation, weaning from mechanical ventilation, head of bed elevation, deep venous thrombosis prophylaxis, stress ulcer prophylaxis, blood glucose, pressure areas and bowel action. Using a sample of 50 adult ICUs, prevalence data were collected for 662 patients with a median age of 65 years and a median Acute Physiology and Chronic Health Evaluation II score of 18. Wide variations in compliance were evident in several care components including: assessment of nutritional goals (74%, interquartile range [IQR] 51 to 89%), pain score (35%, IQR 17 to 62%), sedation score (89%, IQR 50 to 100%); care of ventilated patients e.g. head of bed elevation >30 degrees (33%, IQR 7 to 62%) and setting weaning plans (50%, IQR 28 to 78%); pressure area risk assessment (78%, IQR 18 to 100%) and constipation management plan (43%, IQR 6 to 87%). Care components that were delivered more consistently included nutrition delivery (100%, IQR 100 to 100%), deep venous thrombosis (96%, IQR 89 to 100%) and stress ulcer (90%, IQR 78 to 100%) prophylaxis, and checking blood sugar levels (93%, IQR 88 to 100%). This point prevalence study demonstrated variability in the delivery of ‘routine’ cares in Australian and New Zealand ICUs. This may be driven in part by lack of consensus on what is best practice in intensive care units, prompting the need for further research in this area.

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement

BACKGROUND

There is widespread interest in improving safety for patients receiving medical care, yet direct measurement of harm has been elusive. The Safety Attitudes Questionnaire is a validated measure of patient safety culture that has been associated with improved patient outcomes. We report on an attempt to use the Safety Attitude Questionnaire as an outcome measure for a patient safety implementation project.

METHODS

Operating room staffs at 63 Veterans Affairs Medical Centers were surveyed using the Safety Attitude Questionnaire before and after a medical team training (MTT) program focused on improving staff communication. Survey results before and after MTT within medical centers were compared using nonparametric statistical testing.

RESULTS

Of the 63 VA hospitals that received medical team training, 26 showed changes in the staff's attitude as measured by the Safety Attitudes Questionnaire. Improvement was most common in the "perceptions of management" domain. There was no correlation between survey response rate and measured improvement.

CONCLUSIONS

The Safety Attitudes Questionnaire demonstrated good utility as a possible proxy measure of patient safety in the implementation study of MTT. Health care organizations may consider using it to measure effectiveness of safety improvement activities.

Critical care: advances and future perspectives

Intensive care offers a standard of monitoring, intervention, and organ support that cannot be readily delivered in a general ward. Its expansion in the past few decades, including the creation of emergency and outreach teams, emphasises that intensive care has an increasingly prominent role within the hospital. Although outcomes are clearly improving, intensive care remains a nascent specialty in which we are still learning how to harness a powerful ability to manipulate physiology, biochemistry, and immunology to achieve best outcomes for the patient. The results of many multicentre studies have not lent support to, or have even confounded, expectations, drawing attention to several issues related to patient heterogeneity, trial design, and elucidation of underlying pathophysiological processes. However, these results have generated constructive introspection and reappraisal of treatments and management strategies that have benefited the patient. In addition to the medical, financial, and logistical challenges in the future, exciting opportunities will arise as new developments in diagnostic tests, therapeutic interventions, and technology are used to exploit an increasing awareness of how critical illness should be managed.

Viewing health care delivery as science: challenges, benefits, and policy implications

The need for health services research is likely to rise rapidly as the population ages, health care costs soar, and therapeutic and diagnostic choices proliferate. Building an effective and efficient health care delivery system is a national priority. Yet the national health care quality report concludes that we lack the ability to monitor progress toward even basic quality and patient safety goals effectively. The gap between the need to improve and our ability to do so exists in part because we fail to view the delivery of health care as science, we lack national improvement priorities, and we lack a national infrastructure to achieve our stated goals. We discuss key challenges implicit in correcting these failures and recommend actions to expedite progress.

Improving cardiac surgical care: a work systems approach

Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges

Concern about the quality and safety of health care persists, 10 years after the 1999 Institute of Medicine report To Err is Human. Despite growing awareness of quality and safety risks, and significant efforts to improve, progress is difficult to measure. Hospital leaders, including boards and medical staffs, are accountable to improve care, yet they often address this duty independently. Shared responsibility for quality and patient safety improvement presents unique challenges and unprecedented opportunities for boards and medical staffs. To capitalize on the pressure to improve, both groups may benefit from a better understanding of their synergistic potential. Boards should be educated about the quality of care provided in their institutions and about the challenges of valid measurement and accurate reporting. Boards strengthen their quality oversight capacity by recruiting physicians for vacant board seats. Medical staff members strengthen their role as hospital leaders when they understand the unique duties of the governing board. A quality improvement strategy rooted in synergistic efforts by the board and the medical staff may offer the greatest potential for safer care. Such a mutually advantageous approach requires a clear appreciation of roles and responsibilities and respect for differences. In this article, we review these responsibilities, describe opportunities for boards and medical staffs to collaborate as leaders, and offer recommendations for how boards and medical staff members can address the challenges of shared responsibility for quality of care.

The tangible handoff: a team approach for advancing structured communication in labor and delivery

The tangible handoff tool, a standardized, patient-specific, two-sided pocket card that guides nurses through transfer of care at each shift, is intended to improve continuity and coordination of care in labor and delivery.

[Is patient safety culture measurable and if so, how is it done?]

Safety culture is one aspect of organisational culture. It is the pattern of shared values, beliefs and attitudes concerning safety present in an organisation. In this article, Edgar Schein's three-layer model is used to demonstrate to what extent a safety culture can be directly and indirectly measured. Several methods for the assessment of safety culture are presented: questionnaires evaluating the safety climate, methods enabling teams to perform self-assessment, interviews, audits, analyses of safety reports and observation. The aim of the assessment is crucial to the choice of the appropriate mode of measurement. In healthcare, the currently most widely used instrument is questionnaires since it is comparatively simple to use and inexpensive and yields rapid results. However, the employment of additional measures (interviews, audits, analyses of safety reports) is more appropriate if the most important aspects of safety culture in a given organisation need to be covered.

[Safety and quality in intensive care medicine]

The safety and quality care are two attributes of the health care that are closely intertwined. Quality is a feature of the system that delivers health care, thereby improving it, we need a proper reorganization teamwork. Measurements of quality are intended to assess whether the process of health care reaches the desired objectives, while avoiding the processes that predispose to harm the patient. The critically ill patients are vulnerable to medical errors, and may experience side effects preventable, often associated with: medications, mechanical ventilation, and intravascular devices. The evidence currently available suggest that the safety and quality of care can be improved. In this article presents some of the strategies and interventions developed to optimize the processes of care in critically ill patients, and improve the safety culture in the ICU.

A description of current practice in epilepsy monitoring units

OBJECTIVE

In the epilepsy monitoring unit (EMU), a patient whose seizures may be under control is placed in a medication-withdrawal situation to induce seizures for direct observation and recording. This withdrawal introduces patient risk. In addition, because the EMU is a complex medical and restrictive physical environment, other risks are brought into play. Patient management to reduce danger while optimizing results should arise from current evidence, but gaps exist in the literature regarding best practice in the EMU. In this article the authors report results of two national surveys of health care practitioners in specialized epilepsy care regarding current EMU practice.

METHODS

Two surveys were developed: one comprised of 17 questions for physicians who practice in an EMU, and one comprising 26 questions for nurses who practice in an EMU. Both surveys addressed such issues as protocols for medication withdrawal and rescue procedures, patient observers, and safety issues. Surveys were distributed via Zoomerang to 1500 physician and 105 nurse members of the American Epilepsy Society. Results were tabulated and presented as percentages for each question of each survey.

RESULTS

Responses came from 257 physicians (approximately 17%) and 39 nurses (37%). More than half of the responders practiced in large academic centers. No clear consensus of practice emerged on such questions as drug withdrawal, seizure observation, and rescue protocols. Safety precautions varied.

CONCLUSION

An initial attempt to understand current practice in EMUs, our survey study showed a wide variation in practice patterns, some of which raise safety concerns. The data gathered can aid design of future studies that more directly address specific questions of safety in the EMU.

The American Association of Critical Care Nurse's Beacon Award: a framework for quality

The Beacon Award for Critical Care Excellence recognizes individual critical care units that have met rigid criteria for excellence, exhibiting high-quality standards and exceptional care of patients and their families. Used as a framework for quality, the award criteria focus on structure, process, and outcomes that enable quality to emerge in the critical care environment. The journey toward meeting Beacon Award criteria can produce long-lasting changes that transform unit-based culture and lead to sustained excellence.

Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'

BACKGROUND

Initiatives to improve patient safety have high priority among health professionals and politicians in most developed countries. Currently, however, assessment of patient safety problems relies mainly on case-based methodologies. The evidence for their efficiency and reproducibility, proving that safety of care has improved with their usage, is questionable. The exact incidence and prevalence of patient safety quality problems are unknown. Therefore, there is a need for firm, evidence-based methods to survey and develop patient safety and derived activities.

OBJECTIVE

The objective of this paper is to describe a method to select patient safety indicators and present the indicators derived through this process.

METHODS

The patient safety indicators were derived and recommended for use in a formalized consensus process based on literature review, targeted information gathering, expert consultation and rating procedures.

RESULTS

A total of 42 indicators, of which 28 originated from existing international indicator programmes, were selected. The processes and outcome indicators that were recommended for institutional-level use in Europe were 24, covering safety of care aspects such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas.

CONCLUSION

The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety.

A primer on critical care pharmacy services

The intensive care unit (ICU) continues to be a major focus of decentralized pharmacy activities in health systems that care for critically ill patients. This is not surprising, given the need for rapid decision-making involving unstable patients, the large number of powerful medications typically used per patient, the high cost of many drugs used in the ICU and, most importantly, the evidence demonstrating the benefits of having a pharmacist as part of an interdisciplinary team. The purpose of this paper is to highlight important issues to consider when introducing or developing critical care pharmacy services beginning with the establishment of basic services and continuing through practitioner development, guideline/protocol development and implementation, patient safety, residency training, and research.

Prevention of catheter-related bloodstream infections

CRBSIs are expensive, prevalent, and often fatal complications. In the past few years, several preventive interventions have been applied with excellent results toward decreasing CRBSIs. Studies show that most CRBSIs are preventable; therefore, health care organizations should strive to substantially reduce if not eliminate them. In addition to being a measure of quality of care, reducing infections will soon be a bottom-line issue, given that the Centers for Medicare and Medicaid Services announced its decision to cease paying hospitals from October 2008 for some care necessitated by "preventable complications", including CRBSIs. Therefore, health care facilities that do not make the necessary adjustments to improve the quality of their patient care and avoid harm may be economically penalized. This article reviews the available evidence on and possible barriers to the widespread use of preventive strategies. The health care community has struggled to build a culture that can eliminate the barriers obstructing high-quality care. These new approaches must facilitate collaboration among caregivers. During the past few years, much effort has been dedicated to researching causes for inadequate patient care and executing interventions to improve processes of care; only now are projects beginning to focus on evaluating whether patients are safer. This article discusses the prevention of CRBSIs and shows that substantial reductions in the rate of these infections are possible. It is no longer acceptable for health care organizations to have the goal of being at the CDC mean for rate of infections; they should strive to substantially reduce or even eliminate them. Patients deserve no less.

Advancing measurement of patient safety culture

OBJECTIVE

To examine the psychometric and unit of analysis/strength of culture issues in patient safety culture (PSC) measurement.

DATA SOURCE

Two cross-sectional surveys of health care staff in 10 Canadian health care organizations totaling 11,586 respondents.

STUDY DESIGN

A cross-validation study of a measure of PSC using survey data gathered using the Modified Stanford PSC survey (MSI-2005 and MSI-2006); a within-group agreement analysis of MSI-2006 data. Extraction Methods. Exploratory factor analyses (EFA) of the MSI-05 survey data and confirmatory factor analysis (CFA) of the MSI-06 survey data; Rwg coefficients of homogeneity were calculated for 37 units and six organizations in the MSI-06 data set to examine within-group agreement.

PRINCIPAL FINDINGS

The CFA did not yield acceptable levels of fit. EFA and reliability analysis of MSI-06 data suggest two reliable dimensions of PSC: Organization leadership for safety (alpha=0.88) and Unit leadership for safety (alpha=0.81). Within-group agreement analysis shows stronger within-unit agreement than within-organization agreement on assessed PSC dimensions.

CONCLUSIONS

The field of PSC measurement has not been able to meet strict requirements for sound measurement using conventional approaches of CFA. Additional work is needed to identify and soundly measure key dimensions of PSC. The field would also benefit from further attention to strength of culture/unit of analysis issues.

How safe is my intensive care unit? Methods for monitoring and measurement

PURPOSE OF REVIEW

Patient safety is attracting increasing attention. How we monitor and measure safety, however, is not well defined. In this review we describe a conceptual model for monitoring and measuring safety, describe the development of a safety scorecard, and provide an example of how this scorecard is used in the ICU.

RECENT FINDINGS

Our safety scorecard stratifies measures into two categories. One category uses valid rate-based measures to evaluate: How often do we provide the interventions that patients should receive? (process measure); and How often do we harm patients? (outcome measure). The second category includes measures that cannot be expressed as valid rates: How do we know we learned from defects? (structural measure); and How well have we created a culture of safety? (context measure). Measures within each domain should be important and valid, and organizations should be able to use the measures to improve patient safety.

SUMMARY

We present a framework for a patient safety scorecard to measure and monitor patient safety. This safety scorecard is a valid and practical tool for ICUs to track progress of efforts to improve patient safety and answer the question, how safe is my ICU?

Monitoring patient safety

The opportunity to improve patient safety is significant and the pressure to improve it is increasing. An approach to evaluate an organization's progress with patient safety efforts has not been clearly articulated, and existing efforts to monitor safety are likely inadequate. We present a framework to monitor patient safety, combining valid rate-based measures to evaluate outcomes and processes of care, and non-rate-based measures to evaluate structure and context of care. We present an example of how the safety scorecard from this framework is used to monitor patient safety at The Johns Hopkins Hospital and in over 150 ICUs in Michigan, New Jersey, and Rhode Island.

Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit

Adverse event reporting is a key element for improving patient safety. This study describes a new voluntary, anonymous reporting system that facilitates reporting of near-miss and patient harm events and an assessment of patient harm by the bedside care provider in a pediatric intensive care unit. The results demonstrated the effectiveness of the Patient Safety Report as a method to capture near-miss and patient harm events.