2021_Book_TextbookOfPatientSafetyAndClin

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194 15.4.4 Measuring Quality of Performance (Quality Indicators) However, institutions need to adapt appropriate quality indicators, and the following quality indicators can represent the quality of emergency departments: • Door-to-triage time • Door-to-doctor time • Door-to-needle time in stroke thrombolysis • Pain score assessment • Investigation return time • Nurse/patient ratio • Patient satisfaction level • Time taken for discharge • Mortality (Adjusted) • Length of stay • Left without been seen by a doctor • Pain assessment/reassessment • Safety—patient falls, medication error, failed intubation rate • Incident reporting and RCA • Infections—hand-hygiene compliance • Door-to-triage time –– Description: Time interval of patient arrival to nurse triage –– Type of parameter: Outcome –– Formula: Time from patient arrival to time when triage is completed for a particular category of patients –– Benchmark: Does not exist –– Action plan: Ensures quality in design, conformance • Door-to-doctor time –– Description: In case of emergency the time shall begin from the time the patient’s arrival at the emergency till the time that the initial assessment is completed –– Type of parameter: Outcome –– Formula: Sum of the time taken for assessment/total number of patients in emergency –– Benchmark: Does not exist –– Action plan: Ensures quality in design, conformance R. Pini et al. • Door-to-needle time in stroke thrombolysis –– Description: In case of acute onset ischemic stroke in window period –– Type of parameter: Morbidity in stroke –– Formula: Number of stroke patients thrombolyzed/number of eligible stroke patients for thrombolysis –– Benchmark: Does not exist –– Action plan: Ensures quality in design, conformance • Mortality parameter –– Description: Standardized mortality rate (SMR) –– Type of parameter: Outcome –– Formula: Number of deaths/number of discharges and deaths × 100 –– Benchmark: None –– Action plan: Ensures quality in design and conformance • Patient satisfaction (effective communication) –– Description: Efficacy of communication –– Type of parameter: Process –– Formula: Quarterly average score/Max score possible × 100 –– Benchmark: Not known –– Action plan: Through patient satisfaction • Patient fall rates –– Description: Patient fall rate –– Type of parameter: Safety; morbidity –– Formula: Number of falls/number of bed days –– Benchmark: 8.46/1000 bed days –– Action plan: Ensures quality in design (beds) and conformance (sedation) • Medication errors –– Description: Medication error –– Type of parameter: Safety –– Formula: (Number of errors/number of bed days) × 1000 –– Benchmark: 1.2 to 947/1000 bed days (reported) –– Action plan: Clinical pharmacists; process (2-people check) • Compliance to hand-hygiene protocols –– Description: Compliance to hand hygiene –– Type of parameter: Infection; outcome; safety
15 Emergency Department Clinical Risk –– Formula: (Number adhered/total number of procedures) × 100 –– Benchmark: 90% adherence –– Action plan: Surveillance; health education • Investigation return time –– Description: Radiology CT investigation report –– Type of parameter: Adherence to protocol –– Formula: Time of order to time of reporting –– Benchmark: 60 min –– Action plan: Clinical audit • Length of stay in ER –– Description: Average length of stay –– Type of parameter: Adherence to protocol, safety –– Formula: Total length of stay of all patients in hours/total number of patients –– Benchmark: 240 min –– Action plan: Audit • Nurse patient ration in ER –– Description: Nurse per bed per shift –– Type of parameter: Safety, mortality, morbidity –– Formula: Number of nurse/number of beds in each shift –– Benchmark: Does not exists –– Action plan: Audit • Pain management in ER –– Description: Proportion of patients presenting with pain in whom validated pain score is documented –– Type of parameter: Key performance indicator –– Formula: Patients with pain assessment using validated score/total number of patients presented with pain × 100 –– Benchmark: Does not exists –– Action plan: Audit • Time taken for discharge –– Description: Discharge is the process by which a patient is shifted out from the ED with all concerned medical summaries after ensuring stability –– Type of parameter: Safety –– Formula: Sum of time taken for discharge/ number of patients discharged 195 –– Benchmark: Does not exists –– Action plan: Audit • Left against medical advice –– Description: Percent of patients who leave the ED before examination –– Type of parameter: Safety –– Formula: Total number of patients who leave ER before seen by doctor/total number presented to ER during the time of study × 100 –– Benchmark: Does not exists –– Action plan: Audit • Non-conformance control and management –– Any non-conformance observed should be properly reported through incident reporting system which will be reviewed by a multidisciplinary committee and quality department of the hospital. –– The non-conformances could be (a) Near-miss (b) Medical error (c) Sentinel event • Configuration control and management under quality of design –– Any process change in hospital flow system or physical layout or functions related to assignment pattern of doctors/staff need to be reported and discussed in the leadership team meet of the institution along with the justification of such a change and approval. 15.4.5 Sharing Best Practices A “Best Practice” can be defined as a technique or methodology that has proven reliably to lead to a desired result. At a minimum, a best practice should: • Demonstrate evidence of success • Affect something important (e.g., safety, wait time) • Have the potential to be replicated to other settings • Evidence-based protocols/guidelines must be incorporated to deliver care
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Textbook of Patient Safety and Clin
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Liam Donaldson • Walter Ricciardi
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Foreword As a member of the 17th le
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Preface Despite the extensive atten
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Acknowledgements The volume editors
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xii Contents 11 Adverse Event Inves
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Part I Introduction
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4 explain how to prepare and update
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6 considered preventable) [11]. Fur
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8 W. Ricciardi and F. Cascini the l
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10 W. Ricciardi and F. Cascini inte
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12 maximized or perhaps even realiz
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14 steps in obtaining, managing, an
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16 quality improvement methodologie
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18 99. Morciano C, et al. Policies
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20 Reason travelled the world makin
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22 For each hospital unit, other do
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24 As head of clinical risk managem
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26 R. Tartaglia Table 2.1 Differenc
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28 R. Tartaglia Open Access This ch
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30 otherwise efficient brains lead
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32 • A routine violation is basic
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34 Table 3.1 Framework of contribut
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36 H. Higham and C. Vincent The con
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38 H. Higham and C. Vincent recogni
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40 H. Higham and C. Vincent Table 3
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42 assessment and prevention was no
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44 of human error, 2nd: 1983: Bella
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46 ment of theories on how to deliv
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48 all times, not only when there i
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50 healthcare, pursued by enthusias
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52 15. National Academies of Scienc
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54 In this chapter, I will reflect
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56 hospital, there may be 50 indivi
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58 medicals, these are part of the
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60 facility and could therefore bec
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62 health. It is hoped that the Che
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64 Medication Without Harm, invites
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66 21. World Alliance for Patient S
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68 death of my late husband, Pat, f
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70 S. Sheridan et al. test. A separ
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72 enced some kind of harm due to h
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74 S. Sheridan et al. member of The
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76 6.7.1 Example: Canada 6.7.1.1 Wo
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78 All stakeholders must accept, va
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Human Factors and Ergonomics in Hea
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7 Human Factors and Ergonomics in H
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Patient Safety in the World Neelam
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8 Patient Safety in the World 95 8.
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8 Patient Safety in the World adopt
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Infection Prevention and Control An
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9 Infection Prevention and Control
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The Patient Journey Elena Beleffi,
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10 The Patient Journey 119 End of e
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10 The Patient Journey 121 Fig. 10.
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10 The Patient Journey advocates) i
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10 The Patient Journey Table 10.2 T
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10 The Patient Journey 7. Internati
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130 from these interactions that pe
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132 Data integration is certainly t
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134 organizational processes, such
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136 Table 11.3 Scheme of contributo
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138 tocol requires one or more exte
Page 147 and 148: 140 system failure. Quantification
Page 149 and 150: 142 8. Carayon P, editor. Handbook
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Page 153 and 154: 146 (2002) argue is a more effectiv
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Page 157 and 158: 150 hospital in Kenya with focus on
Page 159 and 160: 152 Haines et al. (2002) proposed a
Page 161 and 162: 154 G. Dagliana et al. Fast Track -
Page 163 and 164: 156 G. Dagliana et al. 11. Jha AK,
Page 165 and 166: Part III Patient Safety in the Main
Page 167 and 168: 162 development of new receptor ant
Page 169 and 170: 164 Physician burnout and the psych
Page 171 and 172: 166 S. Damiani et al. Fig. 13.1 In
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Page 175 and 176: 170 ing to patient safety and share
Page 177 and 178: 172 ability to cope with the workin
Page 179 and 180: 174 2. Vlayen A, Verelst S, Bekkeri
Page 181 and 182: Safe Surgery Saves Lives Francesco
Page 183 and 184: 14 Safe Surgery Saves Lives manner
Page 185 and 186: 14 Safe Surgery Saves Lives not yet
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Page 189 and 190: 14 Safe Surgery Saves Lives 14.15.1
Page 191 and 192: 14 Safe Surgery Saves Lives • Tea
Page 193 and 194: Emergency Department Clinical Risk
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Page 209 and 210: 206 • Pragmatic: in a healthcare
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Page 213 and 214: 210 Table 16.1 Common and Recurrent
Page 215 and 216: 212 improved clinical surveillance
Page 217 and 218: 214 (only IM wards or all medical w
Page 219 and 220: 216 M. L. Regina et al. Table 17.1
Page 221 and 222: 218 Table 17.2 Types and preventabi
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Page 227 and 228: 224 Table 17.6 “Debiasing questio
Page 229 and 230: 226 in care. At a minimum, medicati
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Page 233 and 234: 230 well-structured, concise, focus
Page 235 and 236: 232 M. L. Regina et al. Fig. 17.3 W
Page 239 and 240: 236 Table 17.14 Risk factors for as
Page 241 and 242: 238 Table 17.16 Common risk factors
Page 243 and 244: 240 In patients with kidney disease
Page 245 and 246: 242 Table 17.19 Clinical response t
Page 247 and 248: 244 stones. Giordano’s test posit
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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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268 and breast cancer) and can be r
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270 happened during the first three
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272 40. World Health Organization (
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Patient Safety in Orthopedics and T
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19 Patient Safety in Orthopedics an
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Patient Safety and Risk Management
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20 Patient Safety and Risk Manageme
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Patient Safety in Pediatrics Sara A
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21 Patient Safety in Pediatrics eve
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21 Patient Safety in Pediatrics of
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21 Patient Safety in Pediatrics Cri
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21 Patient Safety in Pediatrics of
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Patient Safety in Radiology Mahdieh
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22 Patient Safety in Radiology The
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22 Patient Safety in Radiology indu
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22 Patient Safety in Radiology CA a
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22 Patient Safety in Radiology Refe
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Organ Donor Risk Stratification in
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23 Organ Donor Risk Stratification
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23 Organ Donor Risk Stratification
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326 M. Plebani et al. Fig. 24.1 The
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328 ical laboratory and the definit
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330 • Findings of external accred
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332 M. Plebani et al. Fig. 24.2 Mod
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334 laboratory medicine professiona
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336 (WHO) website on the incidence
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338 54. Magnezi R, Hemi A, Hemi R.
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340 In 2010 this condition represen
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342 which should be slightly smalle
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344 needed by the pulse waveform to
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346 washed properly prior to steril
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348 ocular reaction without infecti
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350 large retrospective cohort stud
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352 • Lack of appropriate skills.
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354 scription [126]. Furthermore, a
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356 time and knowledge to young doc
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358 48. Barry P, Gettinby G, Lees F
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360 implant versus intravitreal ant
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Part IV Healthcare Organization
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366 causes of safety incidents and
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368 • Human factors such as teamw
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370 access to the Emergency Room. F
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372 that many doctors simply choose
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374 E. Alti and A. Mereu Open Acces
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376 components (people, technology,
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378 J. Braithwaite et al. Hence, cl
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380 stakeholders to figure out how
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382 J. Braithwaite et al. Clinician
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384 27.5.3 Social Networks in a War
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386 J. Braithwaite et al. Fig. 27.9
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388 representations the essential l
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390 21. Pomare C, Churruca K, Ellis
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Measuring Clinical Workflow to Impr
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28 Measuring Clinical Workflow to I
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Shiftwork Organization Giovanni Cos
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29 Shiftwork Organization influenci
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29 Shiftwork Organization Many epid
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29 Shiftwork Organization quences o
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29 Shiftwork Organization in shift
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Non-technical Skills in Healthcare
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30 Non-technical Skills in Healthca
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Medication Safety Hooi Cheng Soon,
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31 Medication Safety • Be familia
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31 Medication Safety 439 Table 31.1
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31 Medication Safety to be made bet
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31 Medication Safety medication reg
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31 Medication Safety and contexts,
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31 Medication Safety quently when m
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31 Medication Safety 31.5 Final Rec
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31 Medication Safety 451 ity and im
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31 Medication Safety 453 Open Acces
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456 studies in recent years have hi
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458 F. Ranzani and O. Parlangeli in
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460 Any difficulty encountered by t
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462 32.4.2 The Usability Assessment
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464 23. Parlangeli O, Mengoni G, Gu
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466 S. Ushiro et al. No-fault compe
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468 33.2 The Meaning of “No-Fault
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470 S. Ushiro et al. figure of 2.3
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472 S. Ushiro et al. Childbirth fac
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474 • When cerebral palsy is caus
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476 (c) (d) (e) (f) (g) (h) (i) (j)
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478 115 bpm to 80 bpm and complete
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480 • It is desirable that system
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482 cific monitoring procedures (1)
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484 Res. 2019;45(3):493-513. https:
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486 19. In the most severe cases, t
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488 Phases 3 and 4, strong emphasis
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490 Phases 5 and 6 focus is on the
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492 during a pandemic to promote tr
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494 M. Tanzini et al. the mother, p
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496 All four abilities are necessar
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