W11 - PROFESSIONLA PRACTICE IN NURSING 4 - ACUTE AND LIFE THREATNEING ILLNESS

PATIENT SAFETY CONCERNS in canada

•Medication errors affect approximately 1 in 18 hospital stays in Canada, leading to adverse events and patient harm.

•Approximately 8-12% of hospitalized patients in Canada acquire at least one nosocomial infection during their stay.

patient safety

• hospials not always safe

  • complex places

  • teams work to save lives everyday

  • patient safety priority

what is accreditation canada

•Accreditation Canada is a national, non-profit, independent organization whose role is to help health services organizations, across Canada and internationally, examine and improve the quality of care and service they provide to their clients.

                                                               

ziman et al - study background

• adverse events and incidences remain high within healthcare

• adverses event - harmful and negative outcome that happens when a patient has been provided with medicla care

• contributing factors

  • healthcare professionals attitudes about safety

  • ineffective communication

  • poor interprofessional teamwork

  • unclear role and responsibility

  • workflow

• WHO developed surgical safety checlist

  • evidence based measured to

    • improve interprofessional communication/interaction

    • reduce medical errors

    • increse patient safety in operating room

ziman et al - three critical points

• how the checklist is used

  • prior to induction of anesthesia (briefing)

  • immediately prior to incision (time out)

  • prior to patient leaving teh or (debriefing(

  • checklist affected patient safety by improving teamwork, communication and collaboration between the 3 main professionals in the or

ziman et al - purpose of study

• gain insight into the use of the SSC, safety culture, value systems and patterns of clinical behaviour in ortho surge

• explore implementation adn practiec issues associated with introduction and ongoing usse of the scc within the or

ziman et al - study finding

• briefing - most important part of checklist however staff surgeon was msotly absent

• need for anaesthesiologist and surgeon to be present at all briefing

• some staff not paying attentin

• most important things covered

• identification of the correct patient

• operation site - correct side

• correct procedure

• prophylatic antibiotic

• allergies

• time out - led by surgical fellow/resident

• very brief confirming the side , site, confirmaiton fo antibiotics

• sometimes this was not done or was forgotten

• time out sometimes done due to scrub nurse cueing the surgeon before handing him the blade

ziman et al - the debrief session

• perceived unimportant amg participants

• porly done often skipped

• more like an after though

• surgicla perpsectives - extra time for debrief - deterrent to surgeons who are paid per case

• anesthesia - debriefs poorly timed

• suggestion to have debrief with hand over in pacu seem more favourable

ziman et al - conclusion

• checklist ocmpliance - influenced by perceived un(important0 by nurses sureons and anesthesia (all or team)

• need to further explore patients invovlement in hteir operative experience

• study found that patients had little to no involvement in the preop briefing despite their specific role on the checklist

• differences in healthcare professionals responsibilities and renumeraiton (pay affected or team memebers avaiability and presence during the ssc

• medical staff often being absent during the checklist items or unable to listen due to competing responsibilities

popescu et al - patient safety

• systems in place to support incident reporting

• complementary efforts to advance reporting and learning

• contextual factors influence aility to improve safety , learn and report

• WHO global safety action plan includes patietn safety incident reporting

• main - ensure a constant flow of information and knowledge to drive the mitigation of risk a reduction in levels of avoidable harm and improvements in safety of care

• patient safety incidents are the third leading cause of death in canada after cancer adn heart diseases

• patietn safety incidents cost the canadian healthcare systme

• canadas publicly funded healthcare delivered ….

• they have fairly robust avenue for porting incident in canada

• 6/provinces reporting systems in place

• 5 regulated some incidents reporting particualrly critical incidence

• international comaprison indicated that canada reporting system is among the best but still have far way to go

ziman et al - reporting for learning

• reporting alone cannot improve patient safety. it should be integrated with other elements of safety

  • anticipation

  • preparedness

  • resilience

  • reliability

  • culture

  • engagement of all peoples

• information regarding hazards , risks and incidents from patients adn families are able to identify patient safety issues

ziman et al - safety in hospitla

• canadian institute for health information works closely with

  • governments

  • safety organizations

  • data providers

  • policy and decision makers

  • clinicians

  • reseachers

  • the public

ziman et al - surveillance

• HAIs including those caused by ARO are threats to pt safety

• canadian nosocomial infection surveillance program facilitates adn informs the prevnetion , contorl and reduction of hais and aros in canadian acute care hospitals through active surveillance and reporting

• canadia vigilance program = health canadas surveillance program that colelcts adna ssessed reports of suspected adverse reaction or side effects from health professionals invovling drugs natural products and medical devices

ziman et al - indigneous service canada

• works with first nations, inuit and emtis communities to establish national standards for

  • safe

  • quality care adn services

  • policies and processes

  • tools and training modules

  • supporting reporting

  • tracking adn analyzing patient safety inciidents

ziman et al - conclusion

• canada is doing a lot to address aptient safety

  • collect data

  • coordinating measuring and reporting

  • sharing learnings internally and externally

  • implementing actions for improvement

• much more needs to be done

• keeping a constant focus on improving by learning from safety reporting adn beyong is necessary

reading #3 - policy framework for patient safety in canada

• patient safety is a public health crisis in cnada and globally

• policy framework componeents

  • polixy actors

  • policy context

  • guiding principles of safety

  • policy levers for patient safety

  • measures of success

  • knowledge to action

reading #3 - patient safety incidents

• third leading cause fo death after cancert adn heart disease

• every one min and 8s a patient experiences harm in canadian healthcare systme

• 23 min someone dies from a preventable safety accident

• acute settings - infections biggest cause of aptient safety incidents - 70 000 patient safety incident per year

reading #3 - safety competencies framework domains

• patient safety culture

• teamwork

• communication

• safety,risk,quality improvement

• optimize human and system factors

• recognize , respond to and disclsoed patient safety incidents

reading #3 - quality improvements

• implemeneted over the years but not substantive improvement made on patient safety despite efforts of committed healthcare providers

• leaders

• patients

• families

• candaian patient safety institute

• and others

reading #3 - progress

• policy framework adn the safety competencies within the framework allows for the advancement of the agenda of patient safety

• meeting accreditation standards forces institution address risk maangement and to strive for better patient outcomes

reading #3 - shift to safety

• shift in aptient safety and there has been increase in government assessing quality and safety of healthcare services

• measures put into palce

  • surgical placement checklist

  • steps to prevent centrla line infections

  • reducing ventilation associated pneumonia

  • medication reconciliation

risk management

• comprises of improving the quality and safety of healthcare services by uncovering and identifying the circumstances adn opportunities that put patient at risk of harm then acting to rpevent or control those risks

• four step process to amange clinical risks

  • identify the risk

  • assess the frequency and severity of the risk

  • reduce or eliminate the risk

  • assess the costs saved by reducing the risk or the costs if the risk eventuates

reading #3 - summary

• ppatient safety takes a collaborative approach

• everyones responsibility

• assessment and accreditation system improves patient safety