Qual Saf Health Care
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Qual Saf Health Care · Feb 2009
ReviewFeedback from incident reporting: information and action to improve patient safety.
Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. ⋯ Limited research evidence exists concerning the issue of effective forms of safety feedback within healthcare. Much valuable operational knowledge resides in safety management communities within high-risk industries. Multiple means of feeding back recommended actions and safety information may be usefully employed to promote safety awareness, improve clinical processes and promote future reporting. Further work is needed to establish best practices for feedback systems in healthcare that effectively close the safety loop.
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Qual Saf Health Care · Feb 2009
A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.
Few published data exist with respect to current implementation of interventions that increase patient safety in intensive care units (ICUs) Furthermore, even less published data exist that address implementation of outcome-related methodologies of patient safety interventions in ICUs. ⋯ A model for changing the ICU microsystem at DHMC was created that enabled successful implementation of evidence-based measures by maximising the natural flow of work and fostering a team-based culture to improve patient safety. Unique to this method and unlike currently available methods that define only the delivery of the appropriate intervention as success, system success was defined in terms of both true positives, namely delivering care when it is indicated, as well as true negatives, not delivering care when there is none indicated, to offer a more comprehensive system review. Additionally, the method of data collection allowed simplified defect analysis, thereby eliminating a resource-consuming audit of data after the fact. This approach, therefore, provides a basis for adapting and redesigning the PDSA cycle so as to specifically apply this type of "disciplinary" work.