QUALITY & SAFETY: strategies

الثلاثاء، 11 سبتمبر 2012

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

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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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الأحد، 29 يوليو 2012

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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