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Biblioteka

Analiza przyczyn źródłowych zdarzeń niepożądanych

Tytuł: Analiza przyczyn źródłowych zdarzeń niepożądanych (Root Cause Analysis – RCA)

Autorzy: Barbara Kutryba, Halina Kutaj-Wąsikowska, Marek Tombarkiewicz, Eugen Kuc – konsultacje
Opublikowano: Adaptacja CMJ na podstawie opracowania Duńskiego Towarzystwa Bezpieczeństwa Pacjentów, Kraków 2015
Słowa kluczowe: bezpieczeństwo opieki, RCA, analiza przyczyn źródłowych zdarzeń niepożądanych, zdarzenia niepożądane, root cause analysis, 

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Streszczenie: Przewodnik jest polską adaptacją opracowania Duńskiego Towarzystwa Bezpieczeństwa Pacjentów, powstałego w oparciu o literaturę światową oraz liczne doświadczenia duńskich szpitali w zakresie prowadzenia analizy przyczyn źródłowych zdarzeń niepożądanych. Przewodnik jest skierowany do lekarzy, pielęgniarek oraz zespołów Jakości tak w szpitalach, jak i innych organizacjach ochrony zdrowia. Celem Przewodnika jest uzyskanie umiejętności prowadzenia analizy zdarzeń niepożądanych,
które spowodowały, lub mogły spowodować poważne skutki dla pacjenta, w sposób możliwie całościowy i pogłębiony, z określeniem rzeczywistych przyczyń źródłowych zdarzenia. Przewodnik przedstawia kolejne etapy działań, wymaganych przy przeprowadzaniu analizy przyczyn źródłowych – od decyzji o przeprowadzeniu analizy, do sporządzenia końcowego raportu i jego zatwierdzenia. Przewodnik może okazać się pomocny w gromadzeniu, analizowaniu i podsumowywaniu informacji służących systemowemu podejściu do bezpieczeństwa pacjentów i popularyzacji wiedzy płynącej z analiz zdarzeń niepożądanych.

Broszura - Jak skutecznie stosować leki

Tytuł: Jak skutecznie stosować leki?

Autorzy: Opracowanie zbiorowe
Opublikowano: CMJ, Kraków 2015
Słowa kluczowe: bezpieczeństwo pacjenta, leki, stosowanie leków, suplementy diety, interakcje leków, poradnik dla pacjenta 

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Streszczenie: Broszura opracowana przez zespół Centrum Monitorowania Jakości w Ochronie Zdrowia przeznaczona dla pacjentów o tym jak skutecznie i bezpiecznie stosować leki. Broszura zawiera przydatne porady dotyczące  możliwości wystąpienia interakcji pomiędzy stosowanymi lekami a np. suplementami diety, pożywieniem, napojami innymi lekami.

Program szpitalnej polityki antybiotykowej

Tytuł: Program szpitalnej polityki antybiotykowej – materiał pomocniczy dla szpitali

Autorzy: Dr n. med. Tomasz Ozorowski, Dr n. med. Jarosław Woroń
Opublikowano: CMJ, Kraków 2015
Słowa kluczowe: bezpieczeństwo pacjenta, polityka antybiotykowa, zakażenia związane z opieką zdrowotną, zapobieganie zakażeniom, zakażenia szpitalne,

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A Review of Patient Safety Measures Based on Routinely ...

Tytuł: A Review of Patient Safety Measures Based on Routinely Collected Hospital Data

Autorzy: Carmen Tsang, William Palmer, Alex Bottle, Azeem Majeed and Paul Aylin
Opublikowano: American Journal of Medical Quality 2012 27: 154 originally published online 6 September 2011
Słowa kluczowe: dane administracyjne, zdarzenia niepożądane, choroby jatrogenne, rozwój metod badawczych, bezpieczeństwo pacjenta
Keywords: administrative data, adverse events, iatrogenic disease, instrument development, patient safety

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Abstract: The literature on patient safety measures derived from routinely collected hospital data was reviewed to inform indicator development. MEDLINE and Embase databases and Web sites were searched. Of 1738 citations, 124 studies describing the application, evaluation, or validation of hospital-based medical error or complication of care measures were reviewed. Studies were frequently conducted in the United States (n = 88) between 2005 and 2009 (n = 77) using Agency for Healthcare Research and Quality patient safety indicators (PSIs; n = 79). The most frequently cited
indicators included “postoperative hemorrhage or hematoma” and “accidental puncture and laceration.” Indicator refinement is supported by international coding algorithm translations but is hampered by data issues, including coding inconsistencies. The validity of PSIs and similar adverse event screens beyond internal measurement and the effects of organizational factors on patient harm remain uncertain. Development of PSIs in ambulatory care settings, including general practice and psychiatric care, needs consideration.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Tytuł: Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Autorzy: Editor: Ronda G. Hughes, Ph.D., M.H.S., R.N.
Opublikowano: AHRQ Publication No. 08-0043, April 2008
Słowa kluczowe: bezpieczeństwo pacjenta, jakość opieki, praktyka oparta na dowodach
Keywords: patient safety, quality care, Evidence-Based Practice

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A strategy to enhance the safety and efficiency of...

Tytuł: A strategy to enhance the safety and efficiency of handovers of ICU patients: study protocol of the pICUp study

Autorzy: Nelleke van Sluisveld, Marieke Zegers, Gert Westert, Johannes Gerardus van der Hoeven and Hub Wollersheim
Opublikowano: Implementation Science 2013, 8:67
Słowa kluczowe: intensywna terapia, bezpieczeństwo pacjentów, jakość opieki zdrowotnej, przekazanie pacjenta, readmisje pacjentów, śmiertelność szpitalna
Keywords: Intensive care, Critical care, Patient safety, Quality of healthcare, Patient handoff, Patient readmission, Hospital mortality

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Abstract
Background: To use intensive care unit (ICU) facilities efficiently and ensure high quality of care, an optimal patient flow is necessary. Discharging patients relieves the pressure on ICU beds but the risk of premature discharge must be managed carefully. Suboptimal patient discharge may result in ICU readmissions and in patients’ death. The aim of this study is to obtain insight into the safety and efficiency of current ICU discharge practices and into barriers and facilitators to the implementation of effective ICU discharge interventions, and to develop an implementation strategy tailored to the barriers and facilitators identified.
Methods/design: This study exists of five phases. Phase A: analysis of routinely registered data on variation in ICU readmissions and hospital mortality after ICU discharge of all ICUs participating in the Dutch National Intensive Care Evaluation registry (n = 83). Phase B: systematic review of effective interventions aiming to improve the efficiency and safety of the ICU discharge process. Phase C: assessing the intervention adherence with a questionnaire survey among all Dutch ICUs (n = 90). Phase D: assessing barriers and facilitators to the implementation of effective ICU discharge interventions with a questionnaire survey among all Dutch intensivists (n = 700). The questionnaire will be based on barriers and facilitators identified by focus groups (n = 4) and individual interviews with professionals of ICUs and general wards and adult discharged ICU patients (n = 25 to 30). Phase E: systematic development of an implementation strategy based on the sampled data in phase A to D, and effective implementation strategies from the literature using the intervention mapping method.
Discussion: Using theory and empirical data, an implementation strategy will be developed to improve the safety and efficiency of the ICU discharge process. The developed strategy will be evaluated in a subsequent study. The knowledge obtained in this study should be used for further implementation of ICU discharge interventions, and can be used for implementation of handover interventions in other healthcare transition settings.

Building a culture of safety through team training and engagement

Tytuł: Building a culture of safety through team training and engagement

Autorzy: Lily Thomas, Catherine Galla
Opublikowano: Postgrad Med J 2013 89: 394-401
Słowa kluczowe: błędy medyczne, kultura bezpieczeństwa pacjenta, kultura bezpieczeństwa w opiece zdrowotnej, transformacja kultury organizacyjnej
Keywords: medical errors, culture of patient safety, culture of safety in healthcare, transformation of organisational culture

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Abstract: Medical errors continue to occur despite multiple strategies devised for their prevention. Although many safety initiatives lead to improvement, they are often short lived and unsustainable. Our goal was to build a culture of patient safety within a structure that optimised teamwork and ongoing engagement of the healthcare team. Teamwork impacts the effectiveness of care, patient safety and clinical outcomes, and team training has been identified as a strategy for enhancing teamwork, reducing medical errors and building a culture of safety in healthcare. Therefore, we implemented Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based framework which was used for team training to create transformational and/or incremental changes; facilitating transformation of organisational culture, or solving specific problems. To date, TeamSTEPPS (TS) has been implemented in 14 hospitals, two Long Term Care Facilities, and outpatient areas across the North Shore LIJ Health System. 32 150 members of the healthcare team have been trained. TeamSTEPPS was piloted at a community hospital within the framework of the health system’s organisational care delivery model, the Collaborative Care Model to facilitate sustainment. AHRQ’s Hospital Survey on Patient Safety Culture, (HSOPSC), was administered before and after implementation of TeamSTEPPS, comparing the perception of patient safety by the heathcare team. Pilot hospital results of HSOPSC show significant improvement from 2007 ( pre-TeamSTEPPS) to 2010. System-wide results of HSOPSC show similar trends to those seen in the pilot hospital. Valuable lessons for organisational success from the pilot hospital enabled rapid spread of TeamSTEPPS across the rest of the health system.

Assessing patient safety culture in hospitals across countries

Tytuł: Assessing patient safety culture in hospitals across countries

Autorzy: C. WAGNER, M. SMITS, J. SORRA AND C.C. HUANG
Opublikowano: International Journal for Quality in Health Care 2013; pp. 1–9
Słowa kluczowe: bezpieczeństwo pacjenta, opieka szpitalna, ustawienie opieki, kultura jakości, zarządzanie jakością, ankiety, ogólna metodologia
Keywords: patient safety, hospital care, setting of care, quality culture, quality management, surveys, general methodology

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Abstract
Objective. It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries: the Netherlands, the USA and Taiwan.
Design. This is a cross-sectional survey study across three countries. A questionnaire, the Hospital Survey on Patient Safety Culture (Hospital SOPS), was disseminated nationwide in the Netherlands, the USA and Taiwan.
Setting. The study was conducted in 45 hospitals in the Netherlands, 622 in the USA and 74 in Taiwan.
Participants. A total of 3779 professionals from the participating hospitals in the Netherlands, 196 462 from the USA and 10 146 from Taiwan participated in the study.
Main Outcome Measures. The main outcome measures of the study were 12 dimensions of patient safety culture, e.g.
Teamwork, Organizational learning, Communication openness.
Results. Most hospitals in all three countries have high scores on teamwork within units. The area with a high potential for improvement in all three countries is Handoffs and transitions. Differences between countries exist on the following dimensions: Non-punitive response to error, Feedback and communication about error, Communication openness, Management support for patient safety and Organizational learning—continuous improvement. On the whole, US respondents were more positive about the safety culture in their hospitals than Dutch and Taiwanese respondents. Nevertheless, there are even larger differences between hospitals within a country.
Conclusions. Comparison of patient safety culture data has shown similarities and differences within and between countries. All three countries can improve areas of their patient safety culture. Countries can identify and share best practices and learn from each other.

Creating a Culture of Safety for Safe Patient Handling

Tytuł: Creating a Culture of Safety for Safe Patient Handling

Autorzy: Linda Stevens, Susan Rees, Karen V. Lamb, Deborah Dalsing
Opublikowano: Orthopaedic Nursing, May/June 2013, Volume 32, Number 3
Słowa kluczowe: urazy pracownika opieki zdrowotnej, kultura bezpieczeństwa, koordynator obsługi pacjenta, bezpieczna obsługa pacjenta, program oparty na dowodach
Keywords: healthcare worker injuries, culture of safety, patient handling coordinator, safe patient handling, evidence-based program

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Introduction: Healthcare workers who handle patients have little guidance to help them identify when to use the existing equipment for moving patients. Manual lifting of patients and healthcare worker injuries continue despite equipment installation and training. The purpose of this project was to decrease the number and severity of healthcare worker injuries by implementing a culture of safety for safe patient handling. A multicomponent safe patient handling program was deployed on one inpatient unit at a Midwest academic acute care hospital. There was a 36% decrease in the number of patient handling injuries, a 71% reduction in the number of lost work days, and a 60% reduction in costs in 1 year related to patient handling injuries. The RN Satisfaction Survey question regarding having enough help to lift move on last shift improved from 41% presurvey to 69% postsurvey.

The Patient-Reported Incident in Hospital Instrument (PRIH-I)...

Tytuł: The Patient-Reported Incident in Hospital Instrument (PRIH-I): assessments of data quality, test–retest reliability and hospital-level reliability

Autorzy: Oyvind Bjertnaes, Kjersti Eeg Skudal, Hilde Hestad Iversen, Anne Karin Lindahl
Opublikowano: BMJ Qual Saf 2013;0:1–9
Słowa kluczowe: doświadczenia pacjentów, zdarzenia w szpitalach, krajowe badanie,
Keywords: patient experiences, incidents in hospitals, national survey

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Abstract
Background The objective of this study was to test the data quality, test–retest reliability and hospital-level reliability of the Patient-Reported Incident in Hospital Instrument (PRIH-I).
Methods 13 incident questions were included in a national patient-experience survey in Norway during the spring of 2011. All questions and a composite incident index were assessed by calculating missing-item rates, test–retest reliability and hospital-level reliability. A multivariate linear regression on a global item regarding incorrect treatment was used to assess the main sources of variation in patient-perceived incorrect treatment at hospitals.
Results Five of the 13 patient-incident questions had a missing-item rate of >20%. Only one item met the criterion of 0.7 for test–retest reliability (wrong or delayed diagnosis), seven items had a score of >0.5, while the remainder had a reliability score of <0.5. However, the reliability was >0.7 for six of 10 items tested at the hospital level, and >0.6 for the remaining four items. A patient-incident index based on 12 of the incident items had no missing data, the test–retest reliability was 0.6 and the hospital-level reliability was 0.85.
Conclusions The PRIH-I comprises 13 questions about patient-perceived incidents in hospitals, and can be easily and cost-effectively included in national patient-experience surveys with an acceptable increase in respondent burden. Although the missing-item rate and test–retest reliability were poor for several items, the hospital-level reliability was satisfactory for most of the items. The incident items contribute to a patient-reported incident index, with excellent data quality and hospital-level reliability.

Just clean your hands: Measuring the effect of a patient safety...

Tytuł: Just clean your hands: Measuring the effect of a patient safety initiative on driving transformational change in a health care system

Autorzy: Giulio DiDiodato MSc, MD, MPH
Opublikowano: American Journal of Infection Control xxx (2013) 1-3
Słowa kluczowe: przestrzeganie higieny rąk, inicjatywa bezpieczeństwa pacjenta, kultura bezpieczeństwa, zmiana transformacyjna, opieka pielęgniarska, zakażenia szpitalne
Keywords: hand hygiene compliance, patient safety initiative, safety culture, transformational change, nursing care, hospital-acquired infection

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Introduction In 2007, the Ontario government introduced the Just Clean Your Hands program across all provincial hospitals. The goal of this patient safety initiative was to improve hand hygiene practices among health care providers through workplace culture change. A survey questionnaire was distributed to 729 nurses employed at a single large community-based hospital from April to July 2011. Of the 223 nurses who responded to the questionnaire, 153 had completed the program (exposed group). By using the other 70 nurses as a contemporaneous control group (nonexposed), this study demonstrates that the Just Clean Your Hands program contributed to improved hand hygiene practices, but we were unable to demonstrate positive changes in patient safety culture.

An alternative methodology for interpretation and reporting of...

Tytuł: An alternative methodology for interpretation and reporting of hand hygiene compliance data

Autorzy: Giulio DiDiodato MSc, MD, FRCPC, MPH
Opublikowano: American Journal of Infection Control 40 (2012) 332-5
Słowa kluczowe: higiena rąk, analiza Bayesa, sprawozdawczość publiczna, wskaźnik bezpieczeństwa pacjentów
Keywords: hand hygiene, Bayesian analysis, public reporting, patient safety indicator

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Abstract

Background: Since 2009, all hospitals in Ontario have been mandated to publicly report health care provider compliance with hand hygiene opportunities (http://www.health.gov.on.ca/patient_safety/index.html). Hand hygiene compliance (HHC) is reported for 2 of the 4 moments during the health care provider-patient encounter. This study analyzes the HHC data by using an alternative methodology for interpretation and reporting.
Methods: Annualized HHC data were available for fiscal years 2009 and 2010 for each of the 5 hospital corporations (6 sites) in the North Simcoe Muskoka Local Health Integration Network. The weighted average for HHC was used to estimate the overall observed rate for HHC for each hospital and reporting period. Using Bayes’ probability theorem, this estimate was used to predict the probability that any patient would experience HHC for at least 75% of hand hygiene moments. This probability was categorized as excellent (75%), above average (50%-74%), below average (25%-49%), or poor (<25%). The results were reported using a balanced scorecard display.
Results: The overall observed rates for HHC ranged from 50% to 87% (mean, 75%  11%, P ¼ .079). Using the alternative methodology for reporting, 6 of the 12 reporting periods would be categorized as excellent, 1 as above average, 2 as below average, and 3 as poor.
Conclusion: Population-level HHC data can be converted to patient-level risk information. Reporting this information to the public may increase the value and understandability of this patient safety indicator.

Patient-centered hand hygiene: The next step in infection prevention

Tytuł: Patient-centered hand hygiene: The next step in infection prevention

Autorzy: Timothy Landers RN, PhD, Said Abusalem RN, PhD, Mary-Beth Coty RN, PhD, James Bingham MS
Opublikowano: American Journal of Infection Control 40 (2012) S11-S17
Słowa kluczowe: bezpieczeństwo pacjenta, współudział pacjenta, upodmiotowienie pacjenta, powrót karetki, zakażenia związane z opieką zdrowotną
Keywords: patient safety, patient participation, patient empowerment, carriage return, healthcare-associated infection

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Abstract Hand hygiene has been recognized as the most important means of preventing  the transmission of infection, and great emphasis has been placed on ways to improve hand hygiene compliance by health care workers (HCWs). Despite increasing evidence that patients’ flora and the hospital environment are the primary source of many infections, little effort has been directed toward involving patients in their own hand hygiene. Most previous work involving patients has included patients as monitors or auditors of hand hygiene practices by their HCWs. This article reviews the evidence on the benefits of including patients more directly in hand hygiene initiatives, and uses the framework of patient-centered safety initiatives to provide recommendations for the timing and implementation of patient hand hygiene protocols. It also addresses key areas for further research, practice guideline development, and implications for training of HCWs.

Save Lives: Clean Your Hands. A global call for action at the point...

Tytuł: Save Lives: Clean Your Hands. A global call for action at the point of care

Autorzy: Claire Kilpatrick, RN, PGDipIC, MSc
Opublikowano: American Journal of Infection Control May 2009
Słowa kluczowe: bezpieczeństwo pacjenta, higiena rąk, światowe wyzwanie, zakażenia związane z opieką zdrowotną, inicjatywa bezpieczeństwa, zapobieganie zakażeniom, clean hands
Keywords: patient safety, hand hygiene, global challenge, healthcare–associated infection, safety initiative, preventing infections, czyste ręce

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Introduction As part of the World Health Organization’s (WHO) First Global Patient Safety Challenge: Clean Care Is Safer Care, 2009 is earmarked as the year to regalvanize action for hand hygiene at the point of care. With 116 countries having already pledged to address health care–associated infection (HAI) through cleaner, safer care, a 2009 WHO patient safety initiative aims to take these country pledges to the patient bedside with a unique call to action. More than 20 in-country campaigns have developed their own multimodal strategies based on the Clean Care Is Safer Care  guidelines. WHO’s vision is that by 2020, all of its Member States will have pledged to establish national, ongoing action to ensure sustained hand hygiene improvement as part of an integrated infection prevention and control program.