Patient Safety Achieving a New Standard for Care (2004) / Chapter Skim
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5 Comprehensive Patient Safety Programs in Health Care Settings
5 Comprehensive Patient Safety Programs in Health Care Settings
Pages 173-199
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From page 173... ...
A model for the introduction of safer care is presented. The application of these ideas is illustrated through two case studies -- one relating to adverse drug events and the other to postoperative deep wound and organ space infections.
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From page 174... ...
A culture of safety encompasses the following elements (adapted from Kizer, 1999) : shared beliefs and values about the health care delivery system; recruitment and training with patient safety in mind; organizational commitment to detecting and analyzing patient injuries and near misses; open communication regarding patient injury results, both within and outside the organization; and the establishment of a just culture.
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From page 175... ...
These mechanisms could include a simple computerized reporting system allowing front-line care professionals to mark possible injuries for independent review; telephone and e-mail tip lines enabling front-line professionals, patients, and family members to report potential adverse events or near misses; and a system for asking front-line health professionals, as they leave work, whether they experienced any unsafe conditions or observed any injuries or near misses during their just-completed workday.
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From page 176... ...
The most potent reward for front-line health professionals may be seeing their reports lead to real changes in systems that result in a safer care environment. Organizational Commitment to Analyzing Patient Injuries and Near Misses In parallel with a commitment to detecting as many patient injuries and near misses as possible, there should be an organizational commitment to developing a management structure for tracking and rigorously analyzing injury-related events.
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From page 177... ...
. If data to support a learning environment are to be collected, employees must be willing to report adverse events and near misses without threat of retribution.
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From page 178... ...
A balanced detection system necessarily relies on case finding through surveillance, working together with voluntary incident reporting systems. Injury surveillance uses data-based clinical trigger systems that lead to prospective expert review, as well as retrospective review of patient records identified by International Classification of Diseases (ICD)
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From page 179... ...
and intermediate process outcomes FIGURE 5-1 Use of standardized patient safety information to improve care.
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From page 180... ...
, as well as process changes that have been demonstrated to work in other settings within and outside health care delivery. Failure mode and effect analysis and hazard analysis and critical control points are used to analyze process work flow, with the aim of identifying likely failure points, rather than relying upon epidemiologic analysis of actual injuries and near misses.
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From page 181... ...
The same principle applies at a larger scale: some sources of injury, such as ADEs, hospital-acquired infections, and decubitus ulcers -- are orders of magnitude more common than some other, more sensational, sources of injury, such as wrong-side surgery. Rapid-Cycle Testing Having helped choose an aim for safety improvement and generate a list of potential changes that might lead to that goal, effective, standardized patient injury detection and reporting plays a third critical role: it allows an improvement team to determine whether a change is an improvement (Langley et al., 1996)
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From page 182... ...
182 Drug Nurse Ordering Physician Administration Physician Errors Pharmacy Errors Pharmacist Nurse/Clerk Rate Transcribing Dilution Spelling Dosage Route Time Route Nurse Scheduling Wrong Order Drug Missed Dose Age Drug/Drug ADE Weight Psychic Gender Expected Unforeseen Renal Neural Electrolyte Hemal Drug/Food Past Allergic Compliance Hepatic Reaction Drug/Lab Absorption Brand Name vs. Race Generic Drugs Patient Physiologic Pharmocologic Factors Factors Pharmacist Patient Physician Physician Dietician FIGURE 5-2 A cause-and-effect diagram of potentially preventable causes of adverse drug events.
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From page 183... ...
Among almost 40 causes originally hypothesized in the cause-and-effect diagram, the first 6 shown here accounted for 80 percent of all ADEs detected. Deployment and Implementation "Pilot and deploy" is an approach to implementing improvements that has been successful in a number of care delivery organizations.
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TWO CASE STUDIES The application of the above ideas is illustrated through two case studies. One concerns ADEs and the other postoperative deep wound and organ space infections.
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From page 185... ...
. While enhanced reporting increased ADE detection rates by an order of magnitude, prospective expert review driven by data-based clinical triggers increased detection 80-fold.
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From page 186... ...
A number of groups have used the resulting list of high-yield clinical triggers to build manual and automated ADE detection systems, with the aim of delivering safer care. More recent internal investigation has suggested that the data-based clinical triggers could be improved even further through ex amination of interactions among triggers on the list (Kim, 2003)
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From page 187... ...
Use of flumazenil Pharmacy 77.3 0.7 95.7 600 581 569 567 600 567 500 500 Total # moderate + severe ADEs 477 437 400 400 355 300 300 271 271 280 233 200 200 100 100 0 0 89 90 91 92 93 94 95 96 97 98 99(3) Year FIGURE 5-3 Detected ADE rates at a large teaching hospital, as a more effective detection system was put in place (1988–1990)
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From page 188... ...
a series of process change hypoth eses to bring the hospital closer to the established clinical ideal. Table 5-3 shows on-time antibiotic prophylaxis rates and associated postoperative deep wound and organ space infection rates over time as the hospital's process improved.
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Figure 5-4 shows rates of deep wound and organ space infections for the system as a whole as the pilot was deployed. Since initial deployment, the improvement team has shifted its attention to other aspects of the infection prevention process.
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From page 190... ...
Assuring safety and quality in health care requires an integrated effort that includes a new role for patients. With regard to adverse events and near misses, patients are possibly the last point at which event detection and prevention can occur.
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From page 191... ...
Finally, in March 2002 the Joint Commission on Accreditation of Healthcare Organizations launched the SPEAK UP campaign to help patients get involved in their care (Joint Commission on Accreditation of Healthcare Organizations, 2002)
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As a consequence, fundamental research is needed on a number of topics related to near misses to improve analysis of these events and thereby enhance patient safety. Research is also needed in a number of areas to improve analysis of adverse events.
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From page 193... ...
. This vital assumption, according to which the causes of near misses can be used predictively in preventing actual adverse events, needs to be examined for every major medical domain to optimize the cost/benefit ratio for investments in patient safety.
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From page 194... ...
In particular, patient safety systems should be designed to elicit and receive information on adverse events and near misses from patients, their families, and their designees. Mechanisms should be in place to provide feedback to patients on the disposition of this information.
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From page 195... ...
Prevention Capabilities Tools such as computerized physician order entry incorporate capabilities to prevent adverse events, for example, by checking to see whether drug interactions with negative side effects could occur. Further research is needed to convert the growing knowledge base on patient safety risks into existing and new point-of-care decision support tools.
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From page 196... ...
Nonetheless, greater standardization in the verification of adverse events is important -- for example, using highly structured definitions of events, as is the case for nosocomial infections, or tools similar to the Naranjo algorithm. Developing Data Mining Techniques for Large Patient Safety Databases The size of patient safety databases at the state and regional levels will quickly become far too great for any individual to oversee their contents.
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From page 197... ...
2003. Detecting adverse events using information technology.
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From page 198... ...
1998. Identifying adverse drug events: Development of a computer-based monitor and comparison with chart review and stimulated voluntary report.
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From page 199... ...
2003. Detecting Adverse Drug Events Using ICD-9-CM Codes.
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