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In this module, we will:
Advances in medicine have led to positive outcomes:
However, sponges are still found inside patients’ bodies after operations.
In the U.S. health care system:
Concentric circles show the layered system-level factors that affect patient safety: institutional factors, hospital factors, departmental factors, work environment factors, team factors, individual provider factors, and task factors all have an effect on patient safety.
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Examples of the Impact of System-Level Factors
System Factor | Effect |
---|---|
Daily rounds with an intensivist | When ICUs are staffed with a multidisciplinary team, including daily rounds with an intensivist, mortality is reduced |
Nurses responsible for more than two patients | When nurses are responsible for more than two patients, there is an increased risk of pulmonary complications in the ICU patient population |
Point-of-care pharmacist or pharmacist who participates in rounds | A point-of-care pharmacist or one who participates in rounds reduces prescribing errors |
Three principles of safe design are standardize, create independent checks, and learn from defects.
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Think about a recent safety issue in your unit and answer the four Learning from Defects questions:
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How do you see technical and adaptive work fitting in your unit?
Appreciate the wisdom of crowds
Provider A – Sender and Receiver
Messages
Provider B – Sender and Receiver
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Time Period | Median Catheter-Related Blood Stream Infection (CRBSI) Rate |
Incidence Rate Ratio |
---|---|---|
Baseline | 2.7 | 1 |
Pre-intervention | 1.6 | 0.76 |
0-3 months | 0 | 0.62 |
4-6 months | 0 | 0.56 |
7-9 months | 0 | 0.47 |
10-12 months | 0 | 0.42 |
13-15 months | 0 | 0.37 |
16-18 months | 0 | 0.34 |
*Please refer to the “Implement Teamwork and Communication” module for additional information*
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6. Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March 2009. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf (Plugin Software Help)
7. Klevens M, Edwards J, Richards C, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR. 2007;122:160-166.
8. Ending health care-associated infections, AHRQ, Rockville, MD, 2009. http://www.ahrq.gov/qual/haicusp.htm.
9. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–57.
10. Heifetz R. Leadership without easy answers, president and fellows of Harvard College. Cambridge, MA: Harvard University Press;1994.
11. Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007;33(1): 34-47.
12. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006;355(26):2725-32.
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Current as of August 2012
Internet Citation:
Understand the Science of Safety. Text Version of Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cusptoolkit/4scisafety/scisafetyslides.htm