Qual Saf Health Care
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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.
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Qual Saf Health Care · Dec 2008
Do falls and falls-injuries in hospital indicate negligent care -- and how big is the risk? A retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to 2006.
Accidental falls are very common in older hospital patients -- accounting for 32% of reported adult patient safety incidents in UK National Health Service (NHS) hospitals and occurring with similar frequency in settings internationally. In countries where the population is ageing, and care is provided in inpatient settings, falls prevention is therefore a significant and growing risk-management issue. Falls may lead to a variety of harms and costs, are cited in formal complaints and can lead to claims of clinical negligence. The NHS Litigation Authority (NHSLA) negligence claims database provides a novel opportunity to systematically analyse such (falls-related) claims made against NHS organisations in England and to learn lessons for risk-management systems and claims recording. ⋯ Although falls are the highest volume patient safety incident reported in hospital trusts in England, they result in a relatively small number of negligence claims and receive a relatively low total payment (0.019% in both cases). The mean payment in closed claims is also relatively small. This may reflect the high average age of the people who fall and difficulty in establishing causation, especially where individuals are already frail when they fall. The patterns of claims and the narrative descriptions provide wider lessons for improving risk-management strategies. However, the inherent limitations and biases in the data routinely recorded for legal purposes suggest that for more informative research or actuarial claims analysis, more comprehensive and systematic data to be recorded for each incident claim are needed.
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Qual Saf Health Care · Dec 2008
Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports.
Falls in hospital inpatients are common, with reported rates ranging from 3 to 14 per 1,000 bed days. They cause physical and psychological harm, are associated with impaired rehabilitation, increased length of stay and excess cost, and lead to complaints and litigation, making them a crucial area for risk management. A National Reporting and Learning System (NRLS) for patient safety incidents in England and Wales was utilised to examine frequency of falls in hospitals specialising in acute care, rehabilitation and mental health; related harm; timing; age and gender of patients who fell; and to draw general lessons from this which might inform fall-prevention strategies. ⋯ This paper describes the largest retrospective study of hospital falls incidents and draws on data from almost 500 institutions of varying types. It describes wide variations in falls recording and reporting, and in recorded falls rates between institutions of different types and between institutions of ostensibly similar case-mix. As falls are the commonest reported patient safety incident, there is a pressing need for improvements in local reporting, recording and focused analysis of incident data, and for these data to be used at local and national level better to inform and target falls prevention, as well as to explore the reasons for large apparent differences in falls rates between institutions.
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Qual Saf Health Care · Dec 2008
Assessment of the implementation of a national patient safety alert to reduce wrong site surgery.
In 2005, guidance on how to prevent wrong site surgery in the form of a national safety alert was issued to all NHS hospital trusts in England and Wales by the National Patient Safety Agency. ⋯ The alert was effective in promoting presurgical marking and encouraging awareness of safety issues in relation to correct site surgery. However, care should be taken to monitor unintended consequences and whether change is sustained. Greater flexibility for local adaptation coupled with better design and early testing of safety alerts prior to national dissemination may facilitate more sustainable changes in practice.
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Qual Saf Health Care · Dec 2008
Effect of a diabetes order set on glycaemic management and control in the hospital.
Insulin can have favourable effects on patient outcomes when used appropriately; however, it is considered among the top five medications associated with errors in the hospital setting. ⋯ A diabetes order set with prescribing guidelines can safely and effectively be implemented in hospitals. The success of this intervention is attributed to the contribution of nurses, pharmacists and prescribers in the design and implementation of the order set, the provider education accompanying order set implementation and the feedback following implementation.