• R Ursprung, J E Gray, W H Edwards, J D Horbar, J Nickerson, P Plsek, P H Shiono, G K Suresh, and D A Goldmann.
• Children's Hospital Boston, Boston, MA, USA. Robert_ursprung@pediatrix.com
• Qual Saf Health Care. 2005 Aug 1; 14 (4): 284-9.

BackgroundTimely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety.ObjectivePilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU).MethodsA 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003.ResultsA total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected >or=1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4).ConclusionsReal time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free "culture of patient safety" involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

13 keywords...

hide…