Bakgrund: Lex Maria infördes på 1930-talet efter att personal på ett sjukhus i Stockholm råkade förväxla ett läkemedel med ett rengöringsmedel vilket resulterade i att många patienter dog. Genom att känna till vilka misstag som görs och varför ökar, yrkeskompetensen och på så sätt höjs patientsäkerheten inom vården. Syfte: Syftet med studien var att jämföra vad som anmälts enligt Lex Maria på sjukhus i Region Skåne under år 2000 och år 2010. Metod: En empirisk studie med kvantitativ ansats. Lex Maria anmälningar hämtades från Socialstyrelsens regionala tillsynsmyndighet syd. Därefter gjordes en innehållsanalys för att skapa variabler. Resultat: Resultatet innehåller 228 anmälningar från båda åren tillsammans. Resultatet presenteras i form av tabeller och diagram för att det överskådligt ska kunna jämföras. Diskussion: De fyra viktigaste fynden relaterat till sjuksköterskans yrke var: ”Fördröjd vård”, ”Misstag i allmänna vården”, ”Misstag i läkemedelshanteringen” samt ”Misstag i omvårdnaden”. Fynden jämförs och orsaker om varför felen uppstår diskuteras. Slutsats: Fel enligt Lex Maria uppstår i många fall på grund av stress, okunskap, dålig kontinuitet och brist i rutiner. Sjuksköterskors skyldighet är att vara medvetna om lagar och författningar som styr dem i sitt arbete och studien kan vara ett hjälpmedel i deras arbetsliv. / Background: Lex Maria was founded in 1930 after staff at a hospital in Stockholm happened to confuse one drug with a detergent with the result that many patients died. By knowing which mistakes are made and why, the professional skills will increase, thereby increasing the patient safety in healthcare. Purpose: The purpose of this study was to compare what is reported according to Lex Maria in hospitals in Region Skåne year 2000 and year 2010. Method: An empirical study with a quantitatively approach. Lex Maria reports were taken from the Board's regional supervisor South. Then a content analysis was made to create variables. Results: The results include 228 notifications from both years together. The results are presented in tables and diagrams to clearly be compared. Discussion: The four most important discoveries related to the nurse's profession was: “Delayed care”, “Mistakes in public care”, “Mistakes in drug dealing” and “Mistakes in nursing”. The findings are compared and reasons why errors occur are discussed. Conclusion: Errors according to Lex Maria are in many cases caused by stress, ignorance, lack of continuity and lack of procedures. Nurses' obligation is to be aware of laws and regulations that govern them in their work and the study may work as an aid in their work.

This dissertation study presents a conceptual framework for implementing and assessing patient safety systems in healthcare institutions. The conceptual framework consists of critical processes and performance measures identified in the context of the 2003 Malcolm Baldrige National Quality Award (MBNQA) Health Care Criteria for Performance Excellence. Methodology: The Delphi technique for gaining consensus from a group of experts and forecasting significant issues in the field of the Delphi panel expertise was used. Data collection included a series of questionnaires where the first round questionnaire was based on literature review and the MBNQA criteria for excellence in healthcare, and tested by an instrument review panel of experts. Twenty-three experts (MBNQA healthcare reviewers and senior healthcare administrators from quality award winning institutions) representing 18 states participated in the survey rounds. The study answered three research questions: (1) What are the critical processes that should be included in healthcare patient safety systems? (2) What are the performance measures that can serve as indicators of quality for the processes critical for ensuring patient safety? (3) What processes will be critical for patient safety in the future? The identified patient safety framework was further transformed into a patient safety tool with three levels: basic, intermediate, and advanced. Additionally, the panel of experts identified the major barriers to the implementation of patient safety systems in healthcare institutions. The identified "top seven" barriers were directly related to critical processes and performance measures identified as "important" or "very important" for patient safety systems in the present and in the future. This dissertation study is significant because the results are expected to assist healthcare institutions seeking to develop high quality patient safety programs, processes and services. The identified critical processes and performance measures can serve as a means of evaluating existing patient safety initiatives and guiding the strategic planning of new safety processes. The framework for patient safety systems utilizes a systems approach and will support healthcare senior administrators in achieving and sustaining improvement results. The identified patient safety framework will also assist healthcare institutions in using the MBNQA Health Care Criteria for Performance Excellence for self-assessment and quality improvement.

Background: Surgical site infections are commonly occuring within healthcare, especially in Africa. Good hygiene is the most effective way in which to reduce and prevent infection, compliance however is often low or insufficient. Aim: The Aim of the study was to observe intraoperative compliance to basic hand hygiene in the operating theatre, the secondary aim was to investigate the surgical teams views on patient safety by using a survey on patient safety culture. Method: The design is a quantitative observational study. Through participant observation information was gathered on compliance to basic intraoperative hygiene routines in operating theatres in Mozambique. Operating personnel were then asked to complete a survey on patient safety culture. Result: None of the work elements were performed in complete compliance to WHO’s guidelines at all times. The operating theatre personnel’s views on Patient Safety Culture showed the highest percentage of positive responses was the dimensions “Teamwork Within Hospital Units” and “Organisational Learning- Continous improvement”. The dimensions with the least positive response was “Nonpunitive Response To Error” and “Staffing”. When comparing compliance to basic hygiene and the results of the patient safety culture survey a medium relation was found, where the staff who gave the most positive response to the survey also complied better to the WHO’s hygiene guidelines. Conclusions: Compliance to basic hygiene during the intraoperative phase in the operating theatre in Mozambique, Maputo was often insufficient. There was a medium strong relation between the staffs views on patient safety and their compliance to basic hygiene. This implies that working with the staff’s attitudes concerning patient safety could improve hygiene compliance resulting in reduced number of surgical site infections.

INTRODUCTION: Older people are a vulnerable population for falls and the risk may be increased by unfamiliar hospital environments. Using a mixed method ergonomic approach to acknowledge the complexity of contemporary hospital environments, this thesis aims to explore the associations between patient characteristics and environmental causal factors of in-patient falls for older people. METHODS: A series of three exploratory pilot studies were carried out, followed by two large scale research projects using nationally collected data from patient incident reports and overnight bedrail audits. The mixed method approach included; secondary data analysis, interviews, surveys, and audits. MAIN FINDINGS: 1. Patients in care of older people wards have different characteristics compared to same age peers in other wards, with higher levels of frailty and confusion. 2. Bedrail use was found to rise with increasing level of confusion which is against general guidance. Staff rationales for bedrail use suggested an underlying intent to restrain confused patients. 3. Up to 92% of patients falls were reported to be un-witnessed. This may be explained by only 24% of patient beds being visible from nursing stations. 4. There were significant differences found in the fall locations between patients who were described as frail and those who were described as confused. CONCLUSION: Patients in care of older people wards have a different set of characteristics compared to same age peers in other wards. This suggests that they will have different requirements for fall prevention in terms of layout, visibility, equipment use and facilitating independence. Further research should focus on designing wards for care of older people patients which improve visibility, layout and way-finding to toilets and investigate whether these design improvements will facilitate independent movement and prevent patient falls.

Background: Opioid-induced respiratory depression (OIRD) is a life-threatening complication of opioid analgesia. Failure to recognize and respond to OIRD may result in respiratory arrest, anoxic brain injury, and death. Measuring end-tidal carbon dioxide through the use of capnography has been shown to detect early signs of OIRD. Early detection of OIRD facilitates the timely rescue of patients on medical-surgical units where critical patient events are less likely to be witnessed. Purpose: The goal of this quality improvement project was to enhance patient safety by decreasing the incidence of OIRD. The aim was to design, implement, and evaluate a multifaceted intervention to improve patient monitoring for OIRD on medical-surgical units through the use of capnography. The intervention included an updated nursing protocol, an electronic order trigger, improved access to capnography monitors, and education to nurses about OIRD and the use of capnography. Methods: The project was conducted over twelve months on ten medical-surgical units at a 489-bed academic medical center in Southern Arizona. Outcomes were measured using pre- and post-intervention point prevalence surveys. Indicators included the number of patients being monitored with capnography and the number of cases of OIRD. A survey of medical-surgical RNs was also conducted to gather their perceptions on the ease of use and effectiveness of capnography. Results: Twelve months after introducing the intervention, there was a statistically significant increase in monitoring frequency, with 2.56 times more patients at high risk for OIRD being monitored with capnography than at baseline (p = .006). Of the 167 RNs surveyed during this project, 99% perceived the portable capnography monitors as easy to use and interpret. However, 71% reported systems issues in obtaining the monitoring equipment, and 65% reported problems with patient adherence. Preliminary data suggest that the incidence of OIRD decreased after one year, although not by a statistically significant amount (p = .876). Implications for Practice: The intervention succeeded in increasing the number of high-risk patients being monitored with capnography, though the increased monitoring did not improve patient outcomes. The RN survey highlighted areas in need of further improvement, such as the supply of monitors and patient education.

Bakgrund: Inom vården sker en stor genomströmning av information. Därför är tydlig kommunikation mellan vårdpersonal viktig eftersom patientsäkerheten annars äventyras. Ett exempel på en kommunikationsmodell är SBAR som står för ”situation”, ”bakgrund”, aktuell status” och ”rekommendationer”. Syfte: Att undersöka i vilken utsträckning sjuksköterskor använder sig av SBAR på fem avdelningar på ett universitetssjukhus i Mellansverige och om det finns samband mellan antal yrkesverksamma år och inställning till SBAR, samt i vilka situationer som sjuksköterskor anser att SBAR är bäst tillämpbart. Metod: Deskriptiv stvärsnittsstudie med kvantitativ ansats. 103 enkäter delades ut till sjuksköterskor på vårdavdelningar respektive akutvårdsavdelningar. Resultat: Oavsett avdelning ansåg totalt 56 procent av sjuksköterskorna (n=33) att SBAR var ett verktyg som var bäst tillämpbart vid rapport till akutteam. Trettiosex procent av sjuksköterskorna (n=26) på akutvårdsavdelningarna använde SBAR dagligen jämfört med vårdavdelningar där elva procent av sjuksköterskorna (n=8) använde SBAR dagligen. Inget samband kunde påvisas mellan antalet yrkesverksamma år och inställning till SBAR. Slutsats: Nittio procent (n=66) av de tillfrågade sjuksköterskorna i studien använde SBAR ibland och 46 procent (n=34) använde SBAR dagligen. De flesta ansåg att SBAR var ett verktyg som var tillämpbart vid rapportering till läkare eller till akutteam. Forskning stödjer att SBAR med fördel kan tillämpas vid icke akuta situationer. Trots det visar resultatet att sjuksköterskor inte använder SBAR i sådana lägen i den utsträckning som är möjlig. Kontinuerlig utbildning krävs för att SBAR ska inarbetas ytterligare i det dagliga arbetet. / Background: Within health care there is a constant flow of information regarding patients. To have a good communication system between hospital staff is important since patient safety always is at risk. One example of a communication model is SBAR, which stands for “situation”, “background”, “assessment” and “recommendations”. Aim To investigate to what extent nurses use SBAR at five wards at a university hospital in Sweden and to see if there is a correlation between numbers of years in the profession and attitude towards SBAR and to see in what situations nurses think SBAR is most useful. Method: Empirical descriptive cross-sectional study with a quantitative approach. 103 questionnaires were handed out to nurses at wards and at intensive care units at a hospital in Sweden. Results: Regardless of ward-type, a total of 56 percent of the nurses (n=33) thought that SBAR was most useful when reporting to emergency teams. Thirty-six percent of the nurses (n=26) at intensive care units used SBAR on a daily basis, compared to nurses at regular wards where 11 percent of the nurses (n=8) used SBAR daily. No correlation was found between number of years in the profession and attitude towards SBAR. Conclusion: Ninety percent of the participants used SBAR occasionally. Forty-six percent used SBAR on a daily basis. Most nurses thought that SBAR was most useful when reporting to emergency teams followed by reporting to doctors. Resarch supports the fact that SBAR is useful in non-acute situations. Despite that, the result showed that nurses don’t use SBAR on such occasions to the extent, which is possible. Continuous training is demanded for SBAR to be used more.

Previous research has established a consensus that in-hospital adverse events are ubiquitous, cause significant harm to patients, and have important financial consequences. However, information on the extent, consequences and costs of adverse events in Canada is limited. For example, there is, as yet, no published study that has investigated the costs of adverse events in a Canadian context. This dissertation aims to redress this situation by providing Ontario-based estimates of the impact of eleven nursing sensitive adverse events on cost, death, readmission, and ambulatory care use within 90 days after hospitalization. This dissertation also aims to contribute more broadly to the patient safety literature by quantifying the impact of diagnostic coding error in administrative data on estimates of the excess costs attributable to adverse events. Given the increasing importance of these estimates in Canada and elsewhere for hospital payment policy and for assessments of the business case for patient safety, this is an important gap in the literature. Each of the adverse events was associated with positive excess costs, ranging from $29,501 (metabolic derangement) to $66,412 (pressure ulcers). Extrapolation from the study hospitals yielded a provincial estimate of $481 million in annual excess costs attributable to the adverse events, which represents 2.8 percent of Ontario’s total hospital expenditures. Several of the adverse events were also associated with significant excess rates of death, readmission, and ambulatory care use. These results suggest that there are economic as well as ethical reasons to improve patient safety in Ontario hospitals. Estimates of adverse event costs were highly sensitive to coding error. The excess cost of adverse events is likely to be significantly underestimated if the error is ignored. This finding, coupled with the observation that the likelihood of error is ignored in most studies, suggests that previous assessments of the business case for patient safety may have been biased against the cost effectiveness of patient safety improvements. Furthermore, the observed extent of institutional level variation in adverse event coding indicates that administrative data are an inadequate basis for adverse event payment policies or for public reporting of adverse event rates.

Background Number of patients treated with medicine that has an anticoagulation character is constantly increasing. Chronic atrial fibrillation is the most common diagnosis being treated, but other diagnoses such as venous thrombosis), pulmonary embolism, stroke, coronary stent thrombosis and arterial thrombosis treated. There are a variety of anticoagulant drugs. In Sweden Warfarin is used as standard medicine for oral anticoagulation therapy. Purpose The purpose of this study is to examine and reflect nurses' experiences of working on anticoagulation clinic, and if he / she claims to have access to the necessary skills and resources to carry out a safe care. Design The study has a qualitative design with semi-structured interviews which were analyzed with an inductive approach. The interviews included six respondents. Findings The results showed that nurses who worked at anticoagulation Clinics had no specific training to operate these clinics. Respondents felt that they had obtained their knowledge through practical experience. However, previous research and Welfare guidelines emphasize the importance of continuous training. Even The National Board of Health and Welfare in Sweden requires that nurses should have significant skills to be able to provide good and safe care with high quality. Conclusion From these results it was concluded that the nurses who worked in anticoagulation clinics felt that they were able to do their work even though they had no specific training. However they considered that a basic theoretical knowledge could contribute to a more secure feeling regarding patient safety. Keywords Wafarinmonitoring, patient safety, Warfarin, Nurse

The purpose of this research was to examine physical layout and organization of equipment as it pertained to patient care in rotor-wing air ambulances. The qualitative approach included observations, interviews, surveys and incident report reviews; and involved paramedics, educators, engineers and physicians affiliated with Ornge Transport Medicine. Findings showed that there is inconsistent placement of equipment within and between bases. A standardized approach to storing equipment, including labelling, could improve readiness for a call by assisting paramedics in ensuring equipment is properly stocked. It was also found that the layout of the patient care compartment was not optimal for some tasks, such as intubation and documentation, due to lack of space. Future helicopters should have seating, both behind the head and at the side of the patient that accommodates safe postures and allows paramedic’s access to the supplies necessary for the full spectrum of patient care expected in this environment.

The purpose of this research was to examine physical layout and organization of equipment as it pertained to patient care in rotor-wing air ambulances. The qualitative approach included observations, interviews, surveys and incident report reviews; and involved paramedics, educators, engineers and physicians affiliated with Ornge Transport Medicine. Findings showed that there is inconsistent placement of equipment within and between bases. A standardized approach to storing equipment, including labelling, could improve readiness for a call by assisting paramedics in ensuring equipment is properly stocked. It was also found that the layout of the patient care compartment was not optimal for some tasks, such as intubation and documentation, due to lack of space. Future helicopters should have seating, both behind the head and at the side of the patient that accommodates safe postures and allows paramedic’s access to the supplies necessary for the full spectrum of patient care expected in this environment.