"New Look" reflects changing style of patient safety enhancement

Hand hygiene in hospitals: an observational study in hospitals from two southern states of India

BACKGROUND

Hand hygiene is a simple and low-cost measure to reduce healthcare associated infection yet it has always been a concern in low as well as high resource settings across the globe. Poor hand hygiene during intra-partum and newborn care may result in sepsis, which is a major cause of death among newborns and puts a financial burden on already strained health systems.

METHODS

We conducted non-participatory observations in newborn care units and labour rooms from secondary and tertiary level, public and private hospitals, as part of a baseline evaluation of a quality improvement collaborative across two southern states of India. We assessed hand hygiene compliance during examinations and common procedures, using tools adapted from internationally recommended checklists and World Health Organization's concept of five moments of hand hygiene. We assessed differences in compliance by type (public/private), level (secondary/tertiary) and case load (low/intermediate/high). Analysis was adjusted for clustering and weighted as appropriate.

RESULTS

We included 49 newborn care units (19 private, 30 public) and 35 labour rooms (5 private, 30 public) that granted permission. We observed 3661 contacts with newborns and their environment, 242 per-vaginal examinations and 235 deliveries. For the newborns, a greater proportion of contacts in private newborn units than public complied with all steps of hand hygiene (44% vs 12%, p < 0.001), and similarly in tertiary than secondary units (33% vs 12%, p < 0.001) but there was no evidence of a difference by case load of the facility (low load-28%; intermediate load-14%; high load- 24%, p = 0.246). The component with lowest compliance was glove usage where indicated (20%). For deliveries, hand hygiene compliance before delivery was universal in private facilities but seen in only about one-quarter of observations in public facilities (100% vs 27%, p = 0.012). Average overall compliance for hand-hygiene during per-vaginal examinations was 35% and we found no evidence of differences by type of facility.

CONCLUSION

Observed compliance with hand hygiene was low overall, although better in private than public facilities in both newborn units and labour rooms. Glove usage was a particular problem in newborn care units.

TRIAL REGISTRATION

Retrospectively registered with Clinical Trials Registry- India ( CTRI/2018/04/013014 ).

A survey of attitude of frontline clinicians and nurses towards adverse events

BACKGROUND

It is often said that doctors are only human. However, technological wonders, apparent precision of diagnostic tests and scientific innovation have created an expectation of perfection from medical science. Patient safety and prevalence of adverse events on the hospital floor have become issues of serious concern for the healthcare environment.

METHOD

The study had cross-sectional design, done over a period of one year at a teaching medical college and its affiliated hospitals. The study instrument was an anonymous, voluntary 5-point Likert scaled questionnaire and study sample was selected by simple random sampling into two groups of front-line clinicians (n = 175) and nurses (n = 60). The questionnaire was analysed for its reliability, construct and content validity. Subsequently, the data was entered into an Excel Spreadsheet and further analysed by statistical software SPSS version 16.

RESULTS

Total of 175 front-line clinicians and 60 nurses completed the survey for response rate of 96%. The study instrument was suitably validated for its psychometric properties. Statistically significant differences were observed between the two study samples across certain attitudinal statements, the important ones being responsibility for reporting and comfort level towards disclosing adverse events. Surgical site infections, Medication errors and Patient Falls were the commonly observed adverse events and lack of communication among team members was identified as a major factor leading to adverse events.

CONCLUSION

Effective attitude-based interventions need to be developed, where the attitude and culture of front-line healthcare workers can be explicitly targeted for inducing desirable behavioural changes towards improved patient safety.

Educating for safety in the pharmacy curriculum

This overview of the Educating for Safety supplement issue explores the context and urgency of the problem of unsafe care, what we have learned about improving both safety and quality in health care, and the implications of this for educators. This supplement issue is a response to the charge of the AACP Council of Deans (COD) and the Council of Faculties (COF) Medication Safety Task Force to address the role of colleges and schools of pharmacy in responding to the national patient safety agenda. The articles included are intended to serve as a nexus for pharmacy education in developing curricula and promoting best practices as they relate to the importance of medication safety.

The epidemiology of medical errors: a review of the literature

BACKGROUND

Medical errors are one of the most important quality problems in health care today. The best insight into the incidences and characteristics of medical errors is through studies on adverse events (AEs) since a considerable fraction of AEs are results of errors and as such preventable. Even though prevention is where effort should be directed to, only a few studies report on the preventability of AEs. Our aim is to give an overview of the literature reporting on AEs and their preventability.

METHODS

We systematically searched Medline and Embase for literature published between 1980 and June 2002. All articles reporting primary data on incidences of AEs and their preventability were included.

RESULTS

The 8 articles retrieved were divided into two categories. 1) Four large scale retrospective studies: They reported incidences of AEs between 2.9% and 16.6% of all hospitalizations that were judged as preventable in 48.0-69.6% and negligent in up to 32.3%. 2) Four prospective studies: The reported rates of AEs vary remarkably (0.0037-39.0%) because of different detection methods used, different definitions applied and different health care settings studied. One prospective observational study identified AEs in 39.0% of hospitalized patients with a preventability of 18.0%. Two other studies, using process oriented incidence reporting detected rather low rates of AEs (4.2-5.4%) which were preventable in up to 62.5%. One prospective study in the outpatient setting, using voluntary incidence reporting detected only about 3.7 events per 100,000 clinic visits of which a high fraction was judged to be preventable (83.0%).

IMPLICATIONS

Incidence, medical outcome and costs of AEs warrant this issue to be high on any countries health care agenda. The U.S., Australia and Britain have adopted this challenge by creating a centre for quality improvement and patient safety within the health service and by enacting new laws. But real improvement of patient safety will need a fundamental change in medicine from a culture of individual blame and guilt to a culture of learning, system thinking and executive responsibility.

Effective communication of drug safety information to patients and the public: a new look

Recent parallel developments in the fields of medicine and the social sciences are providing us with new insights and resources that have the potential for improving the effectiveness of drug safety communication and decision-making. These developments include medicine's new look at patient safety with its emphasis on complex adaptive systems, education's new appreciation for learning as an internal change process and risk communication's evolving recognition that relevant knowledge may not be the exclusive property of 'experts'. Eight principles are drawn from this analysis: there cannot be a safer drug until there is a safer system;all stakeholders are equal partners and have an equal voice in all deliberations;paternalism must be eliminated;the expertise for determining acceptable benefit and risk is dispersed throughout society;patients and all stakeholders serve as both teachers and learners;all stakeholders are involved in the identification of their learning needs, processes and evaluation of outcomes;in a complex adaptive system all individual actions are interconnected and;patients must be involved in the continuous feedback and redesign of the evolving drug safety information system. The conclusion is that we are not asking the right questions; 'what information should we communicate?' and 'how do we communicate more effectively?' should be reframed to ask 'how do we provide an equal voice for patients with the other stakeholders in the determination and communication of benefit-risk information?' Some patients are not waiting. The International Alliance of Patient Organizations (IAPO), the Database of Individual Patient Experience (Dipex) and the Self-Help Group Clearinghouse are examples of international patient driven efforts to actively participate in their own care. The author suggests that the emerging discipline of inter-active management can contribute methodologies for creating citizenship models to generate the collective wisdom and translate it into action. A future research agenda calls for creating new models of public accountability that support these evolving systems of engaging the entire community in benefit-risk determination, communication and management.

An organizational climate intervention associated with increased handwashing and decreased nosocomial infections

Handwashing practices are persistently suboptimal among healthcare professionals and are also stubbornly resistant to change. The purpose of this quasi-experimental intervention trial was to assess the impact of an intervention to change organizational culture on frequency of staff handwashing (as measured by counting devices inserted into soap dispensers on four critical care units) and nosocomial infections associated with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). All staff in one of two hospitals in the mid-Atlantic region received an intervention with multiple components designed to change organizational culture; the second hospital served as a comparison. Over a period of 8 months, 860,567 soap dispensings were recorded, with significant improvements in the study hospital after 6 months of follow-up. Rates of MRSA were not significantly different between the two hospitals, but rates of VRE were significantly reduced in the intervention hospital during implementation.

Improving adherence to hand hygiene practice: a multidisciplinary approach

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol- based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene.

Promoting patient safety and preventing medical error in emergency departments

An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.