Strategies for improving patient safety culture in hospitals: a systematic review

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The international journal of healthcare improvement Online First Current issue Archive About the journal Submit a paper Subscribe Help Online First Current issue Archive Supplements eLetters Topic collections RSS Home > Online First > Article BMJ Qual Saf doi:10.1136/bmjqs-2011-000582 Systematic review Strategies for improving patient safety culture in hospitals: a systematic review Renata Teresa Morello1, Judy A Lowthian1, Anna Lucia Barker1, Rosemary McGinnes1, David Dunt2, Caroline Brand1

1Centre of Research Excellence in Patient Safety, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia

2Centre for Health Policy, Programs and Economics, Melbourne School of Population Health, University of Melbourne, Victoria, Australia Correspondence to Renata Teresa Morello, Centre of Research Excellence in Patient Safety (CRE-PS), School of Public Health and Preventive Medicine, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; renata.morello{at}monash.edu Contributors RM: primary reviewer of included studies (data extraction and critical appraisal), drafting and finalisation of manuscript. JL: secondary reviewer of included studies (data extraction and critical appraisal) and revision of manuscript. AB: third reviewer and review of critical appraisal of studies, revision of the manuscript and finalisation of the discussion section of the manuscript. RMc: assisted with data extraction and critical appraisal of included studies and revision of the manuscript. DD: review and revision of the manuscript, in particular the introduction and methods sections. CB: overseeing the drafting and finalisation of the manuscript, with particular focus on the introduction and discussion sections.

Accepted 4 July 2012 Published Online First 31 July 2012 Abstract Purpose To determine the effectiveness of patient safety culture strategies to improve hospital patient safety climate.

Data sources Electronic search of the Cochrane Library, OVID Medline, Embase, CINAHL, proQuest and psychinfo databases, with manual searches of quality and safety websites, bibliographies of included articles and key journals.

Study selection English language studies published between January 1996 and April 2011 that measured the effectiveness of patient safety culture strategies using a quantitative measure of patient safety climate in a hospital setting. Studies included were randomised controlled trials (RCTs), non-RCTs, controlled before and after studies, interrupted time series and historically controlled studies.

Data extraction Data extraction and critical appraisal were conducted by two independent reviewers. Study design, intervention, level of application, setting, study participants, safety climate outcome measures and implementation lessons were extracted from each article.

Results of data synthesis Over 2000 articles were screened, with 21 studies meeting the inclusion criteria, one cluster RCT, seven controlled before and after studies, and 13 historically controlled studies. There was marked methodological heterogeneity amongst studies. Impacts of 11 different strategies were reported. There was some evidence to support that leadership walk rounds (p=0.02) and multi-faceted unit-based programmes (p? Conclusions Despite strong face validity for a variety of patient safety culture strategies, there is limited evidence to support definitive impacts on patient safety climate outcomes. Organisations are advised to consider robust evaluation designs when implementing these potentially resource intensive strategies.

Safety culture Patient safety Quality improvement Health services research Footnotes Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Data extraction and critical appraisal of included studies are available on request from the corresponding author.

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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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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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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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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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