Training and simulation for patient safety

The international journal of healthcare improvement Qual Saf Health Care 2010;19:i34-i43 doi:10.1136/qshc.2009.038562 OPEN ACCESS Rajesh Aggarwal1, Oliver T Mytton2, Milliard Derbrew3, David Hananel4, Mark Heydenburg5, Barry Issenberg6, Catherine MacAulay7, Mary Elizabeth Mancini8, Takeshi Morimoto9, Nathaniel Soper10, Amitai Ziv11, Richard Reznick12

1Division of Surgery, Imperial College London, UK

2Department of Health, London, UK

3Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia

4Medical Education Training International, Sarasota, Florida, USA

5Medical Equipment Services, International Aid, Spring Lake, Michigan, USA

6University of Miami Miller School of Medicine, Miami, Florida, USA

7Joint Commission International, Oak Brook, Illinois, USA

8School of Nursing, The University of Texas at Arlington, Arlington, Texas, USA

9Center for Medical Education, Kyoto University Graduate School of Medicine, Kyoto, Japan

10Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, USA

11Chaim Sheba Medical Center, Tel Aviv, Israel

12Department of Surgery, University of Toronto, Toronto, Canada Correspondence to Mr Rajesh Aggarwal, Division of Surgery, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother Building, St Mary's Hospital, Praed Street, London W2 1NY, UK; rajesh.aggarwal{at}imperial.ac.ukBackground Simulation-based medical education enables knowledge, skills and attitudes to be acquired for all healthcare professionals in a safe, educationally orientated and efficient manner. Procedure-based skills, communication, leadership and team working can be learnt, be measured and have the potential to be used as a mode of certification to become an independent practitioner.

Results Simulation-based training initially began with life-like manikins and now encompasses an entire range of systems, from synthetic models through to high fidelity simulation suites. These models can also be used for training in new technologies, for the application of existing technologies to new environments and in prototype testing. The level of simulation must be appropriate to the learners' needs and can range from focused tuition to mass trauma scenarios. The development of simulation centres is a global phenomenon which should be encouraged, although the facilities should be used within appropriate curricula that are methodologically sound and cost-effective.

Discussion A review of current techniques reveals that simulation can successfully promote the competencies of medical expert, communicator and collaborator. Further work is required to develop the exact role of simulation as a training mechanism for scholarly skills, professionalism, management and health advocacy.

Funding The project was funded by WHO Patient Safety.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

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Ignaz Semmelweis and the birth of infection control

The international journal of healthcare improvement Qual Saf Health Care 2004;13:233-234 doi:10.1136/qshc.2004.010918 Heroes and martyrs of quality and safetyM Best, D Neuhauser

Department of Epidemiology and Biostatistics, Case School of Medicine, Case Western Reserve University, Cleveland, Ohio, USACorrespondence to:? Professor D Neuhauser? Department of Epidemiology and Biostatistics, Case School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4945, USA; dvncase.eduWorldwide, sepsis is the cause of death in about 1400 people each day.1 Many of these people develop sepsis from infections acquired as patients while in a hospital. Infections acquired in the hospital are called nosocomial infections. They are the most common complications of hospitalized patients, with 5–10% of patients in acute care hospitals acquiring at least one infection. Nosocomial infections occur in 2 million patients per year in the United States, causing 90 000 deaths and resulting in $4.5–5.7 billion in additional patient care costs.2

Influenza virus, Legionnaires’ disease, bacterial meningitis, measles, West Nile virus, tularemia, hepatitis A, rotavirus, Norwalk virus, multidrug resistant Pseudomonas, super-resistant Klebsiella, methicillin resistant Staphylococcus aureus (MRSA), and vancomycin resistant Enterococcus are just a few of the infectious organisms and diseases that may be contracted while in hospital. Infection control is essential to limit the spread of these diseases. Cross-infection of patients by the contaminated hands of healthcare workers is a major method of spreading infectious agents. Hand hygiene is noted to be the single most important factor for infection control. Even today, hand washing is performed only one third to one half as often as it should be.3

Known as the “father of infection control”, Dr Ignaz (or Ignac) Semmelweis (fig 1) was a Hungarian born physician who received his MD degree in Vienna in 1844. In 1847 he was given a 2 year appointment …

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Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review

The international journal of healthcare improvement BMJ Qual Saf 2012;21:448-456 doi:10.1136/bmjqs-2011-000585 Edward Etchells1,3,6, Marika Koo2,3, Nick Daneman1,3,6, Andrew McDonald1,3,6, Michael Baker4,6, Anne Matlow1,5,6, Murray Krahn4,6, Nicole Mittmann2,3,6

1University of Toronto Centre for Patient Safety Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

2Health Outcomes and Pharmacoeconomics (HOPE) Research Centre HOPE Research Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

3Sunnybrook Health Sciences Centre, Toronto, Canada

4University Health Network Toronto, Ontario, Canada

5Hospital for Sick Children, Toronto, Ontario, Canada

6University of Toronto, Toronto, Ontario, Canada Correspondence to Dr Edward Etchells, 2075 Bayview Avenue H469, Toronto M4N 3M5, Ontario, Canada; edward.etchells{at}sunnybrook.caContributors EE contributed to the conception and design of the study, analysed and interpreted the data, and was one of the principle writers of the research article. MK contributed to the concept and design of the study, collected, analysed and interpreted the data, and contributed to the writing and editing of the research article. ND contributed to the concept and design of the analysis, edited and reviewed each draft of the research article. AMc contributed to the concept and design of the analysis, edited and reviewed each draft of the research article. MB contributed to the concept of the study and edited each draft of the research article. AM contributed to the methodology of the study and participated in editing the research article. MK contributed to the conception and design of the study and reviewed all drafts of the research article. NM contributed to the concept and design of the study and was one of the principle writers of the research article. All authors approved the final version of the research article.

Accepted 4 January 2012 Published Online First 22 April 2012 Background The objective was to systematically review comparative economic analyses of patient safety improvements in the acute care setting.

Methods A systematic review of 15 patient safety target conditions and six improvement strategies was conducted. The authors searched the published literature through Medline (2000–November 2011) using the following search terms for costs: ‘costs and cost analysis’, ‘cost-effectiveness’, ‘cost’ and ‘financial management, hospital’. The methodological quality of potentially relevant studies was appraised using Cochrane rules of evidence for clinical effectiveness in quality improvement, and standard economic methods.

Results The authors screened 2151 abstracts, reviewed 212 potentially eligible studies, and identified five comparative economic analyses that reported a total of seven comparisons based on at least one clinical effectiveness study of adequate methodological quality. Pharmacist-led medication reconciliation to prevent potential adverse drug events dominated (lower costs, better safety) a strategy of no reconciliation. Chlorhexidine for vascular catheter site care to prevent catheter-related bloodstream infections dominated a strategy of povidone-iodine for catheter site care. The Keystone ICU initiative to prevent central line-associated bloodstream infections was economically dominant over usual care. Detecting surgical foreign bodies using standard counting compared with a strategy of no counting had an incremental cost of US$1500 (CAN$1676) for each surgical foreign body detected. Several safety improvement strategies were less economically attractive, such as bar-coded sponges for reducing retained surgical sponges compared with standard surgical counting, and giving erythropoietin to reduce transfusion requirements in critically ill patients to avoid one transfusion-related adverse event.

Conclusions Five comparative economic analyses were found that reported a total of seven comparisons based on at least one effectiveness study of adequate methodological quality. On the basis of these limited studies, pharmacist-led medication reconciliation, the Keystone ICU intervention for central line-associated bloodstream infections, chlorhexidine for vascular catheter site care, and standard surgical sponge counts were economically attractive strategies for improving patient safety. More comparative economic analyses of such strategies are needed.

Funding Unrestricted grant from the Canadian Patient Safety Institute.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement This research article is a literature review. All data presented in this article have been previously published.

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Transforming healthcare: a safety imperative

The international journal of healthcare improvement Qual Saf Health Care 2009;18:424-428 doi:10.1136/qshc.2009.036954 L Leape1, D Berwick1,2, C Clancy3, J Conway2, P Gluck4, J Guest5, D Lawrence6, J Morath7, D O’Leary8, P O’Neill9, D Pinakiewicz4, T Isaac10

1

Harvard School of Public Health, Boston, Massachusetts, USA

2

Institute for Healthcare Improvement, Cambridge, Massachusetts, USA

3

Agency for Healthcare Research and Quality, Bethesda, Maryland, USA

4

National Patient Safety Foundation, Boston, Massachusetts, USA

5

Consumers Union, Yonkers, New York, USA

6

Kaiser Foundation Health Plan (retired), Oakland, California, USA

7

Vanderbilt University Medical Center, Nashville, Tennessee, USA

8

The Joint Commission (retired), USA

9

Alcoa (retired), Pittsburgh, Pennsylvania, USA

10

Dana-Farber Cancer Institute, Boston, Massachusetts, USATen years ago, the Institute of Medicine reported alarming data on the scope and impact of medical errors in the US and called for national efforts to address this problem. While efforts to improve patient safety have proliferated during the past decade, progress toward improvement has been frustratingly slow. Some of this lack of progress may be attributable to the persistence of a medical ethos, institutionalized in the hierarchical structure of academic medicine and healthcare organizations, that discourages teamwork and transparency and undermines the establishment of clear systems of accountability for safe care. The Lucian Leape Institute, established by the US National Patient Safety Foundation to provide vision and strategic direction for the patient safety work, has identified five concepts as fundamental to the endeavor of achieving meaningful improvement in healthcare system safety. These five concepts are transparency, care integration, patient/consumer engagement, restoration of joy and meaning in work, and medical education reform. This paper introduces the five concepts and illustrates the meaning and implications of each as a component of a vision for healthcare safety improvement. In future roundtable sessions, the Institute will further elaborate on the meaning of each concept, identify the challenges to implementation, and issue recommendations for policy makers, organizations, and healthcare professionals.

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The human factor: the critical importance of effective teamwork and communication in providing safe care

The international journal of healthcare improvement Qual Saf Health Care 2004;13:i85-i90 doi:10.1136/qshc.2004.010033 M Leonard1, S Graham2, D Bonacum3

1Colorado Permanente Medical Group, Denver, Colorado, OH, USA

2California Kaiser Permanente, Oakland, CA, USA

3Kaiser Permanente, Oakland, CA, USA Correspondence to:? Dr M Leonard? Physician Leader for Patient Safety, Patient Safety, One Kaiser Plaza, 22nd Floor, Oakland, CA 94612, USA; mmleonardatt.netEffective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common “critical language” to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.

Competing interests: none declared

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Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?

The international journal of healthcare improvement BMJ Qual Saf 2012;21:576-585 doi:10.1136/bmjqs-2011-000603 OPEN ACCESS Juliet Higginson, Rhiannon Walters, Naomi Fulop

NIHR King's Patient Safety and Service Quality Research Centre, King's College London, London, UKCorrespondence to Professor Naomi Fulop, Department of Applied Health Research, University College London, 1-19 Torrington Place, London WC1E 7HB, UK; n.fulop{at}ucl.ac.ukContributors JH was involved in the conception and study design; data collection, analysis and interpretation; and was the main author. RW contributed to the analysis and interpretation of the data and drafting the paper. NF was involved in the conception and the study design, and contributed to the data analysis and drafting the paper.

Accepted 27 March 2012 Published Online First 3 May 2012 Introduction National Health Service hospitals and government agencies are increasingly using mortality rates to monitor the quality of inpatient care. Mortality and Morbidity (M&M) meetings, established to review deaths as part of professional learning, have the potential to provide hospital boards with the assurance that patients are not dying as a consequence of unsafe clinical practices. This paper examines whether and how these meetings can contribute to the governance of patient safety.

Methods To understand the arrangement and role of M&M meetings in an English hospital, non-participant observations of meetings (n=9) and semistructured interviews with meeting chairs (n=19) were carried out. Following this, a structured mortality review process was codesigned and introduced into three clinical specialties over 12 months. A qualitative approach of observations (n=30) and interviews (n=40) was used to examine the impact on meetings and on frontline clinicians, managers and board members.

Findings The initial study of M&M meetings showed a considerable variation in the way deaths were reviewed and a lack of integration of these meetings into the hospital's governance framework. The introduction of the standardised mortality review process strengthened these processes. Clinicians supported its inclusion into M&M meetings and managers and board members saw that a standardised trust-wide process offered greater levels of assurance.

Conclusion M&M meetings already exist in many healthcare organisations and provide a governance resource that is underutilised. They can improve accountability of mortality data and support quality improvement without compromising professional learning, especially when facilitated by a standardised mortality review process.

Funding The NIHR King's Patient Safety and Service Quality Research Centre (King's PSSQ) is part of the National Institute for Health Research (NIHR) and is funded by the Department of Health.

Disclaimer This report presents independent research commissioned by the NIHR. The views expressed in this report are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Competing interests All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; and no other relationships or activities that could appear to have influenced the submitted work.

Ethics approval NHS Ethical Approval Granted (REC ref 09/H0807/74).

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Data are available on request from the corresponding author.

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What is "quality improvement" and how can it transform healthcare?

The international journal of healthcare improvement Qual Saf Health Care 2007;16:2-3 doi:10.1136/qshc.2006.022046 Paul B Batalden1, Frank Davidoff2

1Center for Evaluative Sciences, Dartmouth Medical School, Hanover, New Hampshire, USA

2Institute for Healthcare Improvement, Cambridge, Massachusetts, USA Correspondence to:? Dr P B Batalden? Center for Evaluative Sciences, Dartmouth Medical School, Hanover, NH 03755, USA Transformation of healthcare—quality improvement

Many in healthcare today are interested in defining “quality improvement”. We propose defining it as the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning; fig 1). This definition arises from our conviction that healthcare will not realise its full potential unless change making becomes an intrinsic part of everyone’s job, every day, in all parts of the system. Defined in this way, improvement involves a substantial shift in our idea of the work of healthcare, a challenging task that can benefit from the use of a wide variety of tools and methods (table 1).

Table 1 Illustrative tools and methods in improvement

Figure 1 Linked aims of improvement.

Although all improvement involves change, not all changes are improvement. If healthcare is going to benefit fully from the science of disease biology, we need to be sure that the changes we make …

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Formal consensus: the development of a national clinical guideline

The international journal of healthcare improvement Qual Health Care 2001;10:238-244 doi:10.1136/qhc.0100238.. J Rycroft-Malone, research & development fellow

Quality Improvement Programme, RCN Institute, Radcliffe Infirmary, Oxford OX2 6HE, UKMs J Rycroft-Malone joanne.rycroft-malone{at}rcn.org.ukBackground—There is currently a political enthusiasm for the development and use of clinical guidelines despite, paradoxically, there being relatively few healthcare issues that have a sound research evidence base. As decisions have to be made even where there is an undetermined evidence base and that limiting recommendations to where evidence exists may reduce the scope of guidelines, thus limiting their value to practitioners, guideline developers have to rely on various different sources of evidence and adapt their methods accordingly. This paper outlines a method for guideline development which incorporates a consensus process devised to tackle the challenges of a variable research evidence base for the development of a national clinical guideline on risk assessment and prevention of pressure ulcers.

Method—To inform the recommendations of the guideline a formal consensus process based on a nominal group technique was used to incorporate three strands of evidence: research, clinical expertise, and patient experience.

Results—The recommendations for this guideline were derived directly from the statements agreed in the formal consensus process and from key evidence-based findings from the systematic reviews. The existing format of the statements that participants had rated allowed a straightforward revision to “active” recommendations, thus reducing further risk of subjectivity entering into the process.

Conclusions—The method outlined proved to be a practical and systematic way of integrating a number of different evidence sources. The resultant guideline is a mixture of research based and consensus based recommendations. Given the lack of available guidance on how to mix research with expert opinion and patient experiences, the method used for the development of this guideline has been outlined so that other guideline developers may use, adapt, and test it further.

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A multi-faceted approach to the physiologically unstable patient

The international journal of healthcare improvement Qual Saf Health Care 2010;19:1-6 doi:10.1136/qshc.2008.031807 Gillian Robb1,2, Mary Seddon2

1Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand

2Quality Improvement Unit/Te Pai Huanga, Counties Manukau District Health Board, Manukau, Auckland, New Zealand Correspondence to Ms Gillian Robb, Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand; g.robb{at}auckland.ac.nzAccepted 31 August 2009 Published Online First 29 July 2010 Background Patients on general hospital wards who deteriorate clinically are often not recognised as needing an escalation in care, and effective interventions are delayed. This study reviews a multifaceted approach to the identification and management of these patients in a large metropolitan hospital in Auckland, New Zealand.

Strategies for change Four interventions were combined into the Physiologically Unstable Patient (PUP) programme. These were: (1) redesign of the vital sign observation chart; (2) introduction of an early warning scoring system; (3) deployment of a nurse-led rapid response team; and (4) a comprehensive ward-based education programme.

Key measures for improvement Completeness and accuracy of routine observations; actions taken in accordance with the algorithm; impact on medical emergency team callouts, cardiac arrest calls and unplanned intensive care unit admissions.

Effects of change The PUP programme was implemented in 16 wards over 15 months. Vital sign recording improved, and the PUP score became a recognised metric for prioritising patients for review. Consistent with others' experience, there was a reluctance to call for help. Raised PUP scores prompted action around 30% of the time on average. Medical emergency team calls increased significantly from a median of 27.5 calls per month to 70.5. There was no significant change in unplanned transfers to intensive care unit or in cardiac arrest calls.

Lessons learnt A multifaceted programme to identify physiologically unstable patients on general wards can be introduced and can improve the recognition of such patients, but there are still barriers to ensuring that these patients receive the extra care that they require. These systemic failings need to be investigated and addressed for real change to occur.

Funding Counties Manukau District Health Board.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

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