Alison Cracknell

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

Objective To evaluate the performance of a routine incident reporting system in identifying patient safety incidents. Design Two stage retrospective review of patients case notes and analysis of data submitted to the routine incident reporting system on the same patients. Setting A large NHS hospital in England. Population 1006 hospital admissions between January and May 2004: surgery (n=311), general medicine (n=251), elderly care (n=184), orthopaedics (n=131), urology (n=61), and three other specialties (n=68). Main outcome measures Proportion of admissions with at least one patient safety incident; proportion and type of patient safety incidents missed by routine incident reporting and case note review methods. Results 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% confidence interval 20.3% to 25.5%). 270 (83%) patient safety incidents were identified by case note review only, 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. 110 admissions (10.9%; 9.0% to 12.8%) had at least one patient safety incident resulting in patient harm, all of which were detected by the case note review and six (5%) by the reporting system. Conclusion The routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in harm. Structured case note review may have a useful role in surveillance of routine incident reporting and associated quality improvement programmes.

Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital

Objectives: To estimate the extent, nature and consequences of adverse events in a large National Health Service (NHS) hospital, and to evaluate the reliability of a two-stage casenote review method in identifying adverse events. Design: A two-stage structured retrospective patient casenote review. Setting: A large NHS hospital in England. Population: A random sample of 1006 hospital admissions between January and May 2004: surgery (nu200a=u200a311), general medicine (nu200a=u200a251), elderly (nu200a=u200a184), orthopaedics (nu200a=u200a131), urology (nu200a=u200a61) and three other specialties (nu200a=u200a68). Main outcome measures: Proportion of admissions with adverse events, the proportion of preventable adverse events, and the types and consequences of adverse events. Results: 8.7% (nu200a=u200a87) of the 1006 admissions had at least one adverse event (95% CI 7.0% to 10.4%), of which 31% (nu200a=u200a27) were preventable. 15% of adverse events led to impairment or disability which lasted more than 6 months and another 10% contributed to patient death. Adverse events led to a mean increased length of stay of 8 days (95% CI 6.5 to 9). The sensitivity of the screening criteria in identifying adverse events was 92% (95% CI 87% to 96%) and the specificity was 62% (95% CI 53% to 71%). Inter-rater reliability for determination of adverse events was good (κu200a=u200a0.64), but for the assessment of preventability it was only moderate (κu200a=u200a0.44). Conclusion: This study confirms that adverse events are common, serious and potentially preventable source of harm to patients in NHS hospitals. The accuracy and reliability of a structured two-stage casenote review in identifying adverse events in the UK was confirmed.

Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review.

OBJECTIVESnto estimate the extent, preventability and consequences of adverse clinical events in elderly and non-elderly patients.nnnDESIGNna two-stage structured, retrospective, patient case-note review.nnnSETTINGna large NHS hospital in England.nnnPOPULATIONna random sample of 1,006 non-psychiatric patients.nnnMAIN OUTCOME MEASURESnproportion of patients with adverse events, the proportion of preventable adverse events and the types and consequences of adverse events in patients >or=75 and under 75 years old.nnnRESULTSnforty five [13.5%; 95% confidence interval (CI) 10-17] of 332 patients >or=75 years and 42 (6.2%; 95% CI 4-8) of 674 patients <75 years had at least one adverse event. There was a significantly raised risk of experiencing an adverse event with increasing age [odds ratio (OR) = 1.03 adverse events per year of life, P < 0.001]. There was no statistically significant difference in preventability of adverse events and also in experiencing disability or death as a result of an adverse event by age after adjustment for potential confounders.nnnCONCLUSIONnadverse events are significantly more common in non-psychiatric elderly inpatients than younger patients. There is little evidence that adverse events in older patients are more preventable and lead to disability or death more frequently.

Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine

Patient safety is a major priority for health services. It is a multi-disciplinary problem and requires a multi-disciplinary solution; any education should therefore be a multi-disciplinary endeavour, from conception to implementation. The starting point should be at undergraduate level and medical education should not be an exception. It is apparent that current educational provision in patient safety lacks a systematic approach, is not linked to formal assessment and is detached from the reality of practice. If patient safety education is to be fit for purpose, it should link theory and the reality of practice; a human factors approach offers a framework to create this linkage. Learning outcomes should be competency based and generic content explicitly linked to specific patient safety content. Students should ultimately be able to demonstrate the impact of what they learn in improving their clinical performance. It is essential that the patient safety curriculum spans the entire undergraduate programme; we argue here for a spiral model incorporating innovative, multi-method assessment which examines knowledge, skills, attitudes and values. Students are increasingly learning from patient experiences, we advocate learning directly from patients wherever possible. Undergraduate provision should provide a platform for continuing education in patient safety, all of which should be subject to periodic evaluation with a particular emphasis on practice impact.

The role of emotion in patient safety: Are we brave enough to scratch beneath the surface?

Healthcare professionals work in emotionally charged settings; yet, little is known about the role of emotion in ensuring safe patient care. This article presents current knowledge in this field, drawing upon psychological approaches and evidence from clinical settings. We explore the emotions that health professionals experience in relation to making a medical error and describe the impact on healthcare professionals and on their professional and patient relationships. We also explore how positive and negative emotions can contribute to clinical decision making and affect responses to clinical situations. Evidence to date suggests that emotion plays an integral role in patient safety. Implications for training, practice and research are discussed in addition to strategies to facilitate health services to understand and respond to the influence of emotion in clinical practice.

Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline

BackgroundClinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals – but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes.MethodsThe TDFI approach was used in a pre-post study in three NHS hospitals with a fourth acting as a control (with usual care and no TDFI). The target behavior identified for change was to increase the use of pH testing as the first line method for checking the position of a nasogastric tube. Repeat audits were undertaken in each hospital following intervention implementation. We used Zou’s modified Poisson regression approach with robust standard errors to estimate risk ratios for the use of pH testing. The projected return on investment (ROI) was also calculated.ResultsFollowing intervention implementation, the use of pH first line increased significantly across intervention hospitals [risk ratio (95% CI) ranged from 3.1 (1.14 to8.43) pu2009<u2009.05, to 8.14 (3.06 to21.67) pu2009<u2009.001] compared to the control hospital, which remained unchanged [risk ratio (CI)u2009=u2009.77 (.47-1.26) pu2009=u2009.296]. The estimated savings and costs in the first year were £2.56 million and £1.41 respectively, giving an ROI of 82%, and this was projected to increase to 270% over five years.ConclusionThe TDFI approach improved the uptake of a patient safety guideline across three hospitals. The TDFI approach is clinically and cost effective in comparison to the usual practice.

Huddle up for safer healthcare: how frontline teams can work together to improve patient safety

This project aimed to: nnUsing quality improvement methodology, safety huddles were tested with four front-line teams in one large acute hospital trust. The wards focused on a harm area to improve; this was determined by the teams and was initially …

Partners at Care Transitions: exploring healthcare professionals’ perspectives of excellence at care transitions for older people

Introduction Hospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs. Previous research has predominantly focused on the errors and harms that occur during transitions of care. In contrast, this study adopts an asset-based approach to learn from factors that facilitate safe outcomes. It seeks to explore how staff within high-performing (‘positively deviant’) teams successfully support transitions from hospital to home for older people. Methods and analysis Six high-performing general practices and six hospital specialties that demonstrate exceptionally low or reducing 30-day emergency hospital readmission rates will be invited to participate in the study. Healthcare staff from these clinical teams will be recruited to take part in focus groups, individual interviews and/or observations of staff meetings. Data collection will explore the ways in which teams successfully deliver exceptionally safe transitional care and how they overcome the challenges faced in their everyday clinical work. Data will be thematically analysed using a pen portrait approach to identify the manifest (explicit) and latent (abstract) factors that facilitate success. Ethics and dissemination Ethical approval was obtained from the University of Leeds. The study will help develop our understanding of how multidisciplinary staff within different healthcare settings successfully support care transitions for older people. Findings will be disseminated to academic and clinical audiences through peer-reviewed articles, conferences and workshops. Findings will also inform the development of an intervention to improve the safety and experience of older people during transitions from hospital to home.

46 Using a quality improvement approach to improve treatment escalation plans and reduce cardiac arrests at a large acute nhs trust

Background Cardiopulmonary resuscitation (CPR) is effective for a minority of patients, with survival to discharge of less than 20%. A recent UK review of in-hospital CPR attempts identified failure to recognise patients at risk of cardiac arrest, discuss treatment escalation plans (TEPs) including CPR, and make do not attempt CPR decisions. Methods In 2014, Leeds Teaching Hospitals NHS Trust (LTHT) established a quality improvement (QI) collaborative to improve the care of patients at risk of clinical deterioration and reduce avoidable deterioration or inappropriate CPR. It consisted of 14 pilot wards across specialty areas, supported by a multi-disciplinary faculty including Palliative Care. Three key drivers for change were identified, including a work-stream focussed on timely TEPs for patients nearing the end of life. Over 12 months, pilot wards developed and tested improvement ideas. In June 2015, a bundle of five key interventions, including a TEP sticker and decision prompts, safety huddles and post-CPR debrief, was tested successfully across the 14 wards. A staggered trust-wide roll out of the bundle started in March 2016. Results Statistical process control charts have shown a sustained and significant 25% reduction in cardiac arrest calls across LTHT, and a 32% reduction at the Saint James’s University Hospital Site. This equates to 87 fewer cardiac arrests annually across the Trust than in 2015. On pilot wards the proportion of patients with a treatment escalation plan and a CPR decision increased by 125% and 72%, respectively. The Trust incidence of cardiac arrests per 1000 admissions at SJUH is now 25% lower than the national average. Conclusion A QI collaborative approach, empowering ward level innovation, with expert faculty support, can improve recognition of patients at risk of cardiac arrest, change behaviours and increase the number of patients with TEPs including CPR decisions; leading to a statistically significant reduction in cardiac arrests.

116 Measuring the impact of end of life care quality improvement (qi) projects

Aim To demonstrate the application of QI methodology to improving end of life care (EOLC), using improvement data (run charts/statistical process control charts (SPC)) to measure the impact of interventions. Background QI methods are applied widely across healthcare. SPC and run charts are employed to demonstrate if interventions can lead to sustained and significant improvements. Identifying variables that suit themselves to measurement by repeated data points is more of a challenge for interpersonal aspects of care (such as palliative and EOLC) than for technical interventions (Conry M, 2012). Methods QI methodology and measures were employed in two QI EOLC initiatives in a large acute NHS trust. The first was a multidisciplinary collaborative to improve the care of patients at risk of clinical deterioration, to reduce avoidable deterioration and/or inappropriate cardiopulmonary resuscitation. The second was an intervention led by the Palliative Care Team to improve the assessment and management of terminal agitation on designated wards. SPC and run charts were created for these initiatives, with baseline data pre-intervention and on-going data collection during the testing, implementation and sustainability phases. Both initiatives were developed following identification of local need; were led by frontline teams and empowered ward level innovation. Results In the first initiative SPC charts demonstrated sustained, significant 25% reductions in cardiac arrest calls across the trust, and on 14 pilot wards a 125% increase in patients with a treatment escalation plan and 75% increase in documented CPR decisions. In the second initiative, run charts demonstrated statistically significant improvements in the rate of assessment, reassessment and evaluation of terminal agitation (p<0.05). Routine review and dissemination of data with the frontline teams in these initiatives enhanced collaborative engagement, motivation and success. Conclusion SPC and run charts can be used to measure the impact of interventions, and contribute to improvements in EOLC.