Reconceptualizing Patient Safety Beyond Harm: Insights From a Mixed-Methods Qualitative Inquiry.

BACKGROUND: Although patients' and care partners' perspectives on patient safety can guide health care learning and improvements, this information remains underutilized. Efforts to leverage this valuable data require challenging the narrow focus of safety as the absence of harm. PURPOSE: The purpose of this study was to gain a broader insight into how patients and care partners perceive and experience safety. METHODS: We used a mixed-methods approach that included a literature review and interviews and focus groups with patients, care partners, and health care providers. An emergent coding schema was developed from triangulation of the 2 data sets. RESULTS: Two core themes-feeling unsafe and feeling safe-emerged that collectively represent a broader view of safety. CONCLUSION: Knowledge from patients and care partners about feeling unsafe and safe needs to inform efforts to mitigate harm and promote safety, well-being, and positive outcomes and experiences.

Homecare Safety Virtual Quality Improvement Collaboratives.

With Canada's aging population, innovations in technology and changes in patient preferences regarding where they receive care, there is a growing reliance on homecare services. Professionals in the homecare sector want to provide the best care possible for their clients, whereas homecare organizations look to foster a greater patient safety culture. The Canadian Patient Safety Institute and the Canadian Home Care Association conducted two learning collaboratives aimed at increasing quality improvement capability in homecare settings. Teams from across the country have increased their capacity and capability to engage patients and families, mitigate and prevent harm from homecare safety incidents such as falls and specifically address issues such as improving interprofessional collaboration, teamwork and communication.

Contributing causes to adverse events in home care and potential interventions to reduce their incidence.

The increasing complexity of home care services, pressures to discharge patients quicker, and the growing vulnerabilities of home care clients all contribute to adverse events in home care. In this article, home care staff in six programs analyzed 27 fall- and medication-related events. Classification of contributing causes indicates that patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as variations in home environments, are difficult to address. However, changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.

Contextualizing learning to improve care using collaborative communities of practices.

BACKGROUND: The use of interorganizational, collaborative approaches to build capacity in quality improvement (QI) in health care is showing promise as a useful model for scaling up and accelerating the implementation of interventions that bridge the "know-do" gap to improve clinical care and provider outcomes. Fundamental to a collaborative approach is interorganizational learning whereby organizations acquire, share, and combine knowledge with other organizations and have the opportunity to learn from their respective successes and challenges in improvement areas. This learning approach aims to create the conditions for collaborative, reflective, and innovative experiential systems that enable collective discussions regarding daily practice issues and finding solutions for improvement. METHODS: The concepts associated with interorganizational learning and deliberate learning activities within a collaborative 'Communities-of-practice'(CoP) approach formed the foundation of the of an interactive QI knowledge translation initiative entitled PERFORM KT. Nine teams participated including seven teams from two acute care hospitals, one from a long term care center, and one from a mental health sciences center. Six monthly CoP learning sessions were held and teams, with the support of an assigned mentor, implemented a QI project and monitored their results which were presented at an end of project symposium. 47 individuals participated in either a focus group or a personal interview. Interviews were transcribed and analyzed using an iterative content analysis. RESULTS: Four key themes emerged from the narrative dataset around experiences and perceptions associated with the PERFORM KT initiative: 1) being successful and taking it to other levels by being systematic, structured, and mentored; 2) taking it outside the comfort zone by being exposed to new concepts and learning together; 3) hearing feedback, exchanging stories, and getting new ideas; and 4) having a pragmatic and accommodating approach to apply new learnings in local contexts. CONCLUSIONS: Study findings offer insights into collaborative, inter-organizational CoP learning approaches to build QI capabilities amongst clinicians, staff, and managers. In particular, our study delineates the need to contextualize QI learning by using deliberate learning activities to balance systematic and structured approaches alongside pragmatic and accommodating approaches with expert mentors.

Enabling Role of Manager in Engaging Clinicians and Staff in Quality Improvement: Being Present and Flexible.

Managers are uniquely placed to facilitate quality improvement (QI), yet little empirical evidence exists about their influence in engaging clinicians in QI. To address this gap, a qualitative study was undertaken and revealed 2 themes: balancing being present with letting frontline staff lead their QI projects, and leveraging flexibility in scheduling with protected time. Efforts are needed to enable managers to engage clinicians and staff in local QI efforts.

Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial.

BACKGROUND: Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care. METHODS: Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents' physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed. RESULTS: We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents' sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents' somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule. INTERPRETATION: Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents' symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT00679809.

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative.

BACKGROUND: The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact. OBJECTIVE: We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada. METHODS: The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents. RESULTS: Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes. CONCLUSION: The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change.

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study.

BACKGROUND: Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada. METHODS: We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events. RESULTS: A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65-5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08-9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0-3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2-0.9). INTERPRETATION: More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.

What's behind the data: an examination of the processes and policies underlying the routine collection of clinical data in Ontario hospitals.

This article surveyed the processes and policies underlying the routine collection of clinical data in acute care hospitals in Ontario, Canada. Although there is evidence of a small shortfall in the availability of human resources, most health records departments employ experienced staff with health records certification. However, there is much more important variation in the documented and undocumented processes used to generate routinely collected clinical data. Current guidelines and coding schedules are helpful but insufficient to guide the production of good quality data. The variations in the processes used to produce clinical data have important implications for the management, reimbursement, and planning of healthcare. This is particularly critical at a time when hospitals and other stakeholders, such as governments, are relying more and more on accurate, reliable, and comparable data.

A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure.

BACKGROUND: Heart failure is the leading cause of hospitalization and readmission in many hospitals worldwide. We performed a meta-analysis to evaluate the effectiveness of multidisciplinary heart failure management programs on hospital admission rates. METHODS: We identified studies through an electronic search and mortality using 8 distinct methods. Eligible studies met the following criteria: (1) randomized controlled clinical trials of adult inpatients hospitalized for heart failure enrolled either at the time of discharge or within 1 week after discharge; (2) heart failure-specific patient education intervention coupled with a postdischarge follow-up assessment; and (3) unplanned readmission reported. Four reviewers independently assessed each study for eligibility and quality, achieving a weighted kappa of 0.73 for eligibility and 0.77 for quality. For each study we calculated the relative risk for readmissions and mortality for patients receiving enhanced education relative to patients receiving usual care. RESULTS: A total of 529 citation titles were identified, of which 8 randomized trials proved eligible. The pooled relative risk for hospital readmission rates using a random-effects model was 0.79 (95% confidence interval, 0.68-0.91; P<.001; heterogeneity P = .25). There was no apparent effect on mortality (relative risk, 0.98; 95% confidence interval, 0.72-1.34; P = .90; heterogeneity P = .20). Data were insufficient to meaningfully pool intervention effects on quality of life or compliance. CONCLUSION: This systematic review suggests that specific heart failure-targeted interventions significantly decrease hospital readmissions but do not affect mortality rates.

Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm.

OBJECTIVE: Accurate information about the magnitude and distribution of diabetes can inform policy and support health care evaluation. We linked physician service claims (PSCs) and hospital discharge abstracts (HDAs) to determine diabetes prevalence and incidence. RESEARCH DESIGN AND METHODS: A retrospective cohort was constructed using administrative data from the national HDA database, PSCs for Ontario (population 11 million), and registries carrying demographics and vital statistics. All HDAs and PSCs bearing a diagnosis of diabetes (ICD9-CM 250) were selected for 1991-1999. Two previously reported algorithms for identification of diabetes were applied as follows: "1-claim" (any HDA or PSC showing diabetes) and "2-claim" (one HDA or two PSCs within 2 years showing diabetes). Incident cases were defined as individuals who met the criteria for diabetes for the first time after at least 2 years of observation. For validation, diagnostic data abstracted from primary care charts (n=3,317) of 57 randomly selected physicians were linked to the administrative data cohort, and sensitivity and specificity were calculated. RESULTS: -In 1998, 696,938 individuals met the 1-claim criteria and 528,280 met the 2-claim criteria. Sensitivity for diabetes was 90 and 86%; for the 1- and 2-claim algorithms, specificity was 92 and 97%, respectively, and positive predictive values were 61 and 80%, respectively. Using the 2-claim algorithm, the all-age prevalence increased from 3.2% in 1993 to 4.5% in 1998 (6.1% in adults). Incidence remained stable. CONCLUSIONS: Administrative data can be used to establish population-based incidence and prevalence of diabetes. Diabetes prevalence is increasing in Ontario and is considerably higher than self-reported rates.

CCORT/CCS quality indicators for congestive heart failure care.

BACKGROUND: Quality indicators are measurement tools for assessing the structure, processes and outcomes of care. Although quality indicators have been developed in other countries, Canadian cardiovascular disease indicators do not exist. OBJECTIVE: To develop quality indicators for measuring and improving congestive heart failure (CHF) care in Canada. METHODS: An 11-member multidisciplinary national expert panel was selected from nominees from national medical organizations. Potential quality indicators were identified by a detailed search of published guidelines, randomized trials and outcomes studies. A two-step modified Delphi process was employed with an initial screening round of indicator ratings, followed by a national quality indicator panel meeting, where definitions of the indicators were developed using consensus methods. Indicators were designed to be measurable, using retrospective chart review and linking existing administrative databases. RESULTS: The case definition criterion was developed based on a discharge diagnosis of CHF (International Classification of Diseases, 9th revision [ICD-9] code 428.x), with diagnostic confirmation using clinical criteria. In total, 29 indicators and five test indicators were recommended. Process indicators included prescription for angiotensin-converting enzyme inhibitors, beta-blockers or warfarin (for atrial fibrillation) at hospital discharge. Nonpharmacological in hospital process indicators included evaluation of left ventricular function, weight measurement and selected patient education counselling instructions. Process indicators in the ambulatory setting included prescription and adherence to drug therapies and physician follow-up. Outcome indicators included mortality, readmissions and emergency visits. CONCLUSIONS: A set of Canadian quality indicators for CHF care encompassing organizational attributes, pharmacotherapy, investigations, counselling, continuity of care and disease outcomes has been developed. These quality indicators will serve as a foundation for future studies evaluating the quality of CHF care in Canada.

CCORT/CCS quality indicators for acute myocardial infarction care.

BACKGROUND: Although quality indicators for the care of acute myocardial infarction (AMI) patients have been described for other countries, there are none specifically designed for the Canadian health care system. The authors' goal was to develop a set of Canadian quality indicators for AMI care. METHODS: A literature review identified existing quality indicators for AMI care. A list of potential indicators was assessed by a nine-member panel of clinicians from a variety of disciplines using a modified-Delphi panel process. After an initial round of rating the potential indicators, a series of indicators was identified for a second round of discussion at a national meeting. Further refinement of indicators occurred following a teleconference and review by external reviewers. RESULTS: To identify an AMI cohort, case definition criteria were developed, using a hospital discharge diagnosis for AMI of International Classification of Diseases-Ninth revision (ICD-9) code 410.x. Thirty-seven indicators for AMI care were established. Pharmacological process of care indicators included administration of acetylsalicylic acid, beta-blockers, angiotensin-converting enzyme inhibitors, thrombolytics and statins. Mortality and readmissions for AMI, unstable angina and congestive heart failure were recommended as outcome indicators. Nonpharmacological indicators included median length of stay in the emergency department, and median waiting times for cardiac catheterization, percutaneous coronary intervention and/or coronary artery bypass graft surgery. INTERPRETATION: A set of Canadian quality indicators for the care of AMI patients has been established. It is anticipated that these indicators will be useful to clinicians and researchers who want to measure and improve the quality of AMI patient care in Canada.

Description of the development and validation of the Canadian Paediatric Trigger Tool.

OBJECTIVE: To describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT). METHODS: Five existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger. RESULTS: Nurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT. CONCLUSIONS: The CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.

Knowledge translation and patient safety: the Canadian Adverse Events Study.

The Canadian Adverse Events Study was the first national study of adverse events in Canadian hospitals. Learning from the controversy surrounding similar studies in other countries, the team engaged in extensive knowledge translation activities throughout the life of the project. Using meetings, Web-based communication and other tools, the team successfully prepared most Canadian stakeholders for the study's release, allowing them to develop anticipatory patient safety initiatives. However, upon publication of the study, the policy spotlight quickly shifted to other issues, and the long-term commitment needed to create safer healthcare is still uncertain.

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.

BACKGROUND: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. METHODS: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. RESULTS: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7- 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%-41.8%) and death in 20.8% (95% CI 7.8%-33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). INTERPRETATION: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.