5d Safety in Health Care

Question 1

How many adults contract an infection in hospital?

Answer 1

One in ten adults contract infection in hospital.

Question 2

How many patients receive wrong medication or wrong dose?

Answer 2

One in ten patients receive wrong medication or wrong dose.

Question 3

What causes more deaths than breast cancer, motor vehicle accidents and HIV combined?

Answer 3

More deaths
after experiencing adverse events in hospital than deaths from breast cancer, motor vehicle accidents and HIV combined

Question 4

How much higher are adverse event rates in developing countries?

Answer 4

20 times higher

Question 5

What are some ways to limit the possibility of adverse events?

Answer 5

Communication/Teamwork

Teamwork and Familiarity

Question 6

What is considered more “dangerous” than fatigue? (Which highlights the importance of predictable patterns of behaviour)

Answer 6

Unfamiliarity

Question 7

What are some tools for improving patient safety through teamwork and communication?

Answer 7

SBAR

Executive Patient Safety Walkabouts

Question 8

What is SBAR?

Answer 8

SBAR technique provides a framework for communication between members of the health care team about a patient’s condition.
It is an easy, focused way to set expectations for what will be communicated and how between team members.

Question 9

What is SBAR useful for?

Answer 9

Useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. Develops teamwork and fosters a culture of patient safety.

Question 10

What activities to improve safety are part of “safer healthcare now”?

Answer 10

Improved care for Acute Myocardial Infarction
Prevention of Central Line-Associated Bloodstream Infection
Medication Reconciliation
Rapid Response Teams
Prevention of Surgical Site Infection
Prevention of Ventilator-Associated Pneumonia

Question 11

What is Hospital Standardized Mortality Ratio (HSMR)? What does it do?

Answer 11

HSMR (Hospital Standardized Mortality Ratio) tracks changes in hospital mortality rates in order to:

• Reduce avoidable deaths in hospitals
• Improve quality of care

Question 12

Who developed Hospital Standardized Mortality Ratip (HSMR), where, and when?

Answer 12

Developed in the UK in mid-1990s by Sir Brian Jarman of Imperial College

Question 13

Where is Hospital Standardized Mortality Ratio (HSMR) used?

Answer 13

Used in hospitals in several countries (i.e. Canada, UK, Sweden, Holland and USA)

Question 14

What are the four goals of Patients for Patient Safety Canada?

Answer 14

1. To realize full disclosure about all adverse events.
2. To incorporate the patient experience in patient safety research.
3. To involve patients and families in all care decisions.
4. To be continual learners and educators about patient safety.

Question 15

What are five principles of an organization that is highly reliable?

Answer 15

1. Attend to failures: Treat any and all failures (e.g. surprises) as a window on the health of the system.
2. Avoid simplifying interpretations: Socialize people to make fewer assumptions and to notice more.
3. Attend to operations: Develop an integrated big picture of ongoing operations.
4. Cultivate resilience: Anticipate AND develop the capacity to cope with surprises in the moment.
5. Defer to experts: Venerate expertise and experience over rank (fluid decision structures).

Question 16

What are some examples of situations that are worth looking into?

Answer 16

Adverse events/Incidents
Near misses
Hazardous situations
Deviations/Variations

Question 17

What are characteristics of “the pathological organization”?

Answer 17

Information is hidden
Messengers are "shot"
Responsibilities are shirked
Bridging is discouraged
Failure is covered up
New ideas are actively crushed

Question 18

What are characteristics of “the calculative organization”?

Answer 18

Information may be ignored
Messengers are tolerated
Responsibility is compartmentalized
Bridging is allowed but neglected
Organization is just and merciful
New ideas create problems

Question 19

What are characteristics of “the generative organization”?

Answer 19

Information is actively sought
Messengers are trained
Responsibilities are shared
Bridging is rewarded
Failure causes inquiry
New ideas are welcomed

Question 20

What are the dimensions of safety?

Answer 20

Overall commitment to quality
Priority given to patient safety
Perceptions of the cause of adverse events and their identification
Investigating adverse events and near misses
Organizational learning after an adverse event
Communication about safety issues
Personnel management and safety issues
Staff education and training about risk
Team working around risk management