Module 2: Improving Outcomes & Preventing Harm
Evidence shows the administration of prophylactic antibiotics within 60 minutes of surgery results in fewer post surgical infections.
Research has confirmed the appropriate and effective care for patients with certain conditions, in order to impact health outcomes. Yet, such evidence-based care often is not well integrated into daily care. There exists a gap in what we know and what we do.
For example, the Canadian Diabetes Association has established guidelines for pressure control less than 130/80 mmHg and A1C less than or equal to 7.0% (Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada). In general, health care is not able to attain this consistently for even 80% of patients, let alone reach 99% and higher, the level attained by highly reliable organizations in other industries.
In many instances practitioners genuinely believe they are providing evidence-based care for most of their patients. Until it is measured, practitioners are often unaware of the gap between what we know should be in place and what is actually in place. For example, many practitioners expect PharmaNet, which is a record of prescriptions filled, to list the medications an individual is regularly taking, so that a medication history need not be verified. At one Fraser Health site, staff discovered PharmaNet was only 30% accurate in outlining what medications patients were regularly taking (Bruchet, Davidson, Buchkowsky, 2006). Data collection helps inform decision making i.e. patient safety indicators, performance scorecards.
You play an important role in implementing evidence-based practice, through:
Risk Assessment to identify risks and mitigate risks before incidents occur or a patient is harmed.
Standardization and Integration of care processes across programs, sectors and sites i.e. Care Policies, Care Protocols, Care Paths or Care Guidelines such as: prophylactic antibiotics to prevent surgical infections, hand hygiene guidelines, limited access to concentrated medications, diabetes protocols, stroke protocols, least restraint policies, Code Yellow, safety checklists.
Pre-approved Order Sets which outline the medical orders to support timely interdisciplinary management for a given diagnosis, high volume or high risk situation, in order to reduce practitioner variation and standardize care e.g. post-surgical procedures, emergency care for cardiac patients, weaning from ventilator care.
Reduction of waste and inefficiencies
Identification of successful innovations and spread elsewhere.
In today’s complex healthcare industry, safety, or patient harm, is of particular concern. Fraser Health is working in alignment with a wide variety of organizations (Safer Healthcare Now!, Institute of Safe Medication Practices - Canada, Canadian Patient Safety Institute, Accreditation Canada, BC Patient Safety and Quality Council) to focus on the following themes:
- Culture of Safety
- Infection Control
- Medication Safety
- Safer Systems for Patient Care
| Maturity of Safety Culture |
Characteristics |
| Level 1 |
Why waste our time on safety? |
| Level 2 |
We do something when we have an incident |
|
Level 3
|
We have systems in place to manage all like risks |
| Level 4 |
We are always on the alert for risks that might emerge |
| Level 5 |
Risk management is an integral part of everything we do |
- Adapted from The Manchester Patient Safety Framework (MaPSaF ) Kirk et al, QSHC, 2007
Every workplace generates its own culture of quality and safety - shared ways of thinking and behaving that lead to ‘norms’ for that setting.
A desirable culture of safety occurs when:
- No patient is harmed due to their interaction with health care;
- No family experiences the pain and frustration of caring for a loved one who is harmed;
- The organization acknowledges the risk and error-prone nature of health care, promotes open disclosure and fosters reporting, open communication and learning from adverse events in a just and trusting environment;
- No provider thinks that reporting an adverse event will compromise their career;
- Health care providers assume shared accountability with the organization to actively seek potentially harmful situations and take action to address these before harm occurs.
(Adapted from CPSI, Building the Foundation for a Safer Health System, Strategic Business Plan 2004/05to 2007/08 and BC Patient Safety and Quality Council website statement, 2010)
Fraser Health has a number of mechanisms to foster a culture of safety, including its integrated approach to risk management. Take a moment to think about the characteristics of the culture in your office practice or work setting.
Required Review - FHA Integrated Risk Management Policy (PDF)
“Moving from a culture of safety to inculcating safety as a core value of who people are within the organization…requires behavioral and cultural changes. Patient safety goals are not recited from a card each year, but become intrinsic to what everyone within the organization does. Not only do they own it and question it, they demand it from their co-workers, as well.”
- Interview with Dr. Daniel Salinas, Senior Vice President and Chief Medical Officer, Children's Healthcare of Atlanta, January 2010, Zero is a Real Number: The Children's Journey to Excellence in Paediatric Quality Outcomes, National Initiative for Children’s Healthcare Quality Forum
Embedding a culture of safety into daily work is essential to supporting staff and contributing to a safe environment for our patients. Each of us contributes to the culture by applying patient safety knowledge, skills and attitudes to our daily work (CPSI Background document to The Safety Competencies, Aug. 2009).
Engaging all members of the healthcare team as valuable sources for system improvement when patient harm occurs is pivotal to creating a culture of quality and safety.
Many patient safety events occur due to a chain of events; a series of individual system failures, each of which might not be significant, but when they are not caught before they reach the patient might align to cause an adverse effect.
Many patient safety events occur due to a chain of events. If the event results in patient harm it is considered an ‘adverse event’; if it does not, it is considered a ‘near miss’. An adverse event can happen anytime, to anyone. If you happen to be at the end of the chain, it can happen to you.
Fraser Health acknowledges this, and is actively involved in creating a ‘culture of safety’:
- improving the system that people work in
- creating an environment that is both just and trusting when reporting and reviewing harmful events, and
- shifting from the traditional ‘blame and shame’ approach to harm (‘who did this and why did they do it?’) to a learning approach (‘what conditions were present that made it possible for harm to occur?’).
You have an important role to play:
- Expect that harm might occur and identify potentially harmful situations in the system before harm does occur (‘near misses’ and ‘good catches’).
- Attend to the little problems to prevent a more significant problem further down the chain.
- Identify ways to mitigate errors before they reach the patient or result in patient harm (keep antidotes close at hand, standardize processes, train via simulation, control access to high-risk medications, etc.).
- Support your co-workers and avoid blame – seek to understand the system causes for the harm.
- Simplify and strengthen your communication; avoid multiple entries for communication, clearly communicate information at hand-offs (shift changes and on transfers), do not use confusing or unsafe abbreviations.
- Cooperate with other clinicians – it’s in the patient’s best interest.
- Avoid reliance on memory and ‘trying harder’ – create resilience in the system through the use of checklists, simple protocols, double-checks for high risk activities.
- Participate in improvements to care.
If you are interested in viewing the related videos "Beyond Blame" or "Delivering Patient Safety", contact Quality Improvement and Patient Safety at 604-535-4500 extension 757755.
When harm occurs or a complaint is expressed, we need to listen and support the patient, family and practitioners involved, and take steps to understand the patient’s experience. As a health care system, we need to report, study and learn from patient harm when it occurs, in order to make the healthcare system safer.
You can do your part:
Partner with patients : encourage and listen to your patients’ stories; include patient experiences when planning improvements
Hold regular team safety huddles and conversations that focus on barriers to patient safety in the care delivery setting;
Report harm or ‘near-misses’ so that concerns can be followed-up for an individual patient, and the system causes of harm and near-misses can be reviewed and trends identified;
Physicians - Patient Safety Learning Summaries and Morbidity and Mortality Rounds provide a rich source of information.
See Module ‘ What To Do When Harm Occurs .’
Patient outcomes are highly dependent on safe, collaborative, patient-centred team practices. Effective teamwork and communication are essential for preventing things from going wrong. Patients are vulnerable especially during transition points in their care (shift changes, transfers between levels of care, etc.) and due to communication gaps or multiple entries causing confusion. Many patient/family complaints are due to ineffective communication.
What are the characteristics of strong, high performing interdisciplinary teams?
- They view their work as serving patients’ needs.
- They assist patients to engage in decision-making and appropriately direct their own care.
- They commit to shared objectives, clear roles and responsibilities, and interdependent decision-making. To ensure continuity of care, they effectively communicate pertinent patient information across teams and, when necessary, across organizations.
(Adapted from CPSI Safety Competencies Framework, 2009)
On average, it takes 133 staff members to care for one acute care patient. The complexity of your working environment makes it essential to work and communicate cooperatively as teams. Effective communication, both within teams and between the healthcare team and patients, is founded on trust, caring and respect. Key elements are the use of diplomacy and tact, as well as respect for the wisdom patients and providers bring to health care. Disrespectful communication is detrimental to everyone, whether you receive it or witness it. Fraser Health has developed the “Keep it Real” program to assist staff in creating effective relationships.
|
S
|
Situation
A concise statement of the problem
What is going on now?
|
|
B
|
Background
Brief information related to the situation
What has happened?
|
|
A
|
Assessment
Analysis and consideration of options
What you found / think is going on? |
|
R
|
Recommendation
Request / recommend action
What do you want done?
|
S ituation, B ackground, A ssessment, R ecommendation
SBAR is a concise communication technique to increase clarity, enhance communication and foster positive relationships amongst health care providers and with patients and families.
CHAT is a similar approach ( C urrent Condition, H istory, A ssessment, and T reatment).
Leadership Walkabouts and Safety Huddles are unit-based opportunities to discuss patient safety concerns in a supportive environment. They help to identify issues early, before problems become bigger and before they cause harm to patients. Please make a note now to ask your Medical Director or Supervisor about how this is done in your area.
Fraser Health regularly uses a variety of industry and professional standards, such as:
- General healthcare standards including minimal standards for patient safety - Accreditation Canada
- Medication Safety - Institute for Safe Medication Practices (ISMP - Canada)
- Hand Hygiene – Canadian Centre for Disease Control
- Medical Imaging and Laboratory standards - Diagnostic Accreditation Program
- International Organization for Standardization (ISO) standards.
Staff are expected to know the standards of care for their area and for their profession. Ask your Supervisor or Medical Director for more information.
Two key areas of risk for patients are acquired infections and medication safety. Standards for medication safety focus on:
- clear labelling
- controlled access to and protocols for high risk medications
- clear communication patient responsibility for knowing which medications are taken and how.
GET A COPY:
Patient poster for your practice – What’s on Your Medication List?
Ask Me – template for patient personal medication list (available in English, Chinese, French, Punjabi)
All staff, physicians and volunteers are expected to do your part to reduce the rate of infection and keep patients safe by performing regular Hand Hygiene:
- Before touching a patient
- Before clean/aseptic procedures
- After a procedure or body fluid exposure risk
- After touching a patient / patient’s environment
- Before and after glove use.
A. Alcohol Based Hand Rub (ABHR):
- Is quicker than using soap and water
- Is more accessible than soap and water as is not dependent on sink location
- Provides emollients that reduce skin irritation
- Is effective in reducing organisms on hands.
Correct technique for ABHR:
- Apply a loonie size amount of ABHR in the palm of dry hands
- Spread the ABHR to cover all surfaces of both hands, including web spaces, thumbs, wrists, and the back of the hands
- Rub nail beds against the opposite palm
- Rub hands together for 15-20 seconds until dry.
B. Soap and Water is required:
- When hands are visibly soiled
- When caring for patients with diarrhea
- After 5 to 6 applications of an alcohol based hand rub to remove residual emollients.
Correct technique for Hand Hygiene with Soap and Water:
- Wet hands with water
- Apply an adequate amount of appropriate soap
- Use friction to wash all surfaces of both hands, including web spaces, thumbs, wrists, and the back of the hands
- Rub nail beds against the opposite palm
- Wash for 15-20 seconds
- Rinse thoroughly with a steady flow of warm water
- Dry hands with clean paper towels
- Use paper towels to turn off taps
- Discard paper towel.
Use Routine Practices to reduce the rate of infections:
- Gloves:for contact with body fluids, mucous membranes and non-intact skin
- Facial protection (mask & protective eyewear): when spraying of body fluids is likely or for providing care for patients with respiratory symptoms
- Gown: worn when contamination of clothing is possible
Use other mechanisms to reduce the rate of infection:
- Antibiotic stewardship
- Environmental cleaning and housekeeping services
- Appropriate use of Personal Protective Equipment (PPE) and isolation precautions
- Reprocessing standards and guidelines
- Surveillance reports and trends for infection rates
- Audits and feedback reports – hand hygiene, reprocessing, bed pans cleaning practices, etc.
- Bed accommodation algorithm
- Construction/renovation planning and support
- Mandatory reporting of communicable disease to Public Health.
For more information: Infection Prevention and Control Practitioners 604 587-4455