Yes / Evidence suggests that patients can meaningfully feed back to healthcare providers about the safety of their care. The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect feedback from patients to support service improvement. The intervention is being implemented in acute care settings with patient feedback collected by hospital volunteers for the first time. To undertake a formative evaluation which explores the feasibility and acceptability of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders. Design: A qualitative evaluation design was adopted across two acute NHS Trusts in the UK between July 2014 and November 2015. We conducted five focus groups with hospital volunteers (n = 15), voluntary services and patient experience staff (n = 3) and semistructured interviews with ward staff (n = 5). Data were interpreted using framework analysis. Results: All stakeholders were positive about the PRASE intervention as a way to support service improvement, and the benefits of involving volunteers. Volunteers felt adequate training and support would be essential for retention. Staff concentrated on the infrastructure needed for implementation and raised concerns around sustainability. Findings were fed back to the implementation team to support revisions to the intervention moving into the subsequent summative evaluation phase. Conclusion: Although there are concerns regarding sustainability in practice, the PRASE intervention delivered in collaboration with hospital volunteers is a promising approach to collect patient feedback for service improvement. / The Health Foundation (Closing the Gap in Patient Safety Programme).

Yes / Although the risks associated with iodinated contrast administration are acknowledged to be very low, screening of kidney function prior to administration is still standard practice in many hospitals. This study has evaluated the feasibility of implementing a screening form in conjunction with point of care (PoC) creatinine testing as a method to manage the risks of post contrast acute kidney injury (PC-AKI) within the CT imaging pathway. Method: Over an eight-week period 300 adult outpatients attending a UK CT department for contrast-enhanced scans were approached. Participants completed a screening questionnaire for co-morbidities linked to kidney dysfunction and consented to have a PoC and laboratory creatinine tests. Comparison was made against with previous baseline blood tests obtained within the preceding 3 months, as required by the study site. Participants were also invited to attend for follow up PoC and laboratory bloods tests at 48–72 h. Results: 14 patients (4.7%) had a scan-day eGFR below 45mL/min/1.73m2, all identified through screening. The majority of patients (n=281/300; 93.7%) fell in the same risk category based on previous and scan-day blood results. Six PoC test failures were recorded on the scan day. The constant error between the Abbott i-STAT PoC scan-day measurements and the laboratory scan-day measurements was -3.71 (95% CI: -6.41 to -0.50). Five patients had an elevated creatinine (≥25% from baseline) post contrast administration, but no instances of PC-AKI (≥50% from baseline) were identified. Conclusion: PoC creatinine testing is a practical method of ensuring renal function and is feasible in the radiology environment. / National Cancer Diagnostics Capacity Fund, NHS England. Andrew Lewington, Bethany Shinkins and Michael Messenger are currently supported by the NIHR MIC- Leeds In Vitro Diagnostics Co-operative (was previously NIHR Leeds Diagnostic Evidence Co-operative)

No / Rational, aim, and objectives: A positive patient safety culture in maternity units is linked to higher quality of care and better outcomes for mothers. However, safety culture varies across maternity units. Analyses of variation in safety culture using statistical process control (SPC) methods may help provider units to learn from each other's performance. This study aims to measure patient safety culture across maternity units in Oman using SPC methods. Methods: The 36-item Safety Attitude Questionnaire (SAQ) was distributed to all doctors, nurses, and midwifes working in ten maternity care units in Oman's hospitals and analysed using SPC methods. The SAQ considers six domains: job satisfaction, perception of management, safety climate, stress recognition, teamwork, and work condition. Results: Of the 892 targeted participants, 735 (82%) questionnaires were returned. The overall percentage of positive safety responses in all hospitals ranged from 53% to 66%, but no hospital had the targeted response of above 75%. Job satisfaction had the highest safety score (4.10) while stress recognition was the lowest (3.17). SPC charts showed that the overall percentage of positive responses in three maternity units (H1, H7, and H10) was above and one (H4) was below the control limits that represent special cause variation that merits further investigation. Conclusion: Generally, the safety culture in maternity units in Oman is below target and suggests that considerable work is required to enhance safety culture. Several maternity units showed evidence of high/low special cause variation that may offer a useful starting point for understanding and enhancing safety culture.

Yes / Patient safety culture/climate in maternity units has been linked to better safety outcomes. Nurses have a crucial role in patient safety and represent the majority of staff in maternity units. In many countries, nurses are recruited from abroad, bringing their own perceptions of patient safety culture. Nonetheless, little is known about the relationship between perceptions of patient safety culture and nurses’ nationality. Understanding this relationship will assist stakeholders in designing a responsive programme to improve patient safety culture. Aims: To investigate the association between nurses’ nationality and their perceptions about patient safety culture in maternity units in Ministry of Health hospitals in Oman. Methods: In 2017, the Safety Attitude Questionnaire (SAQ) was distributed to all staff (892 distributed, 735 returned) in 10 maternity units. Results: About three-quarters (74%, 541/735) of the returned SAQs were completed by nurses, of whom 34% were non-Omani, 21.8% were Omani and 44.7% did not report their nationality (missing). Overall, the mean safety score for non-Omani nurses was significantly higher than for the Omani nurses: 3.9 (SD 1.3) vs 3.6 (SD 1.2) (P < 0.001). The mean safety score for stress recognition was significantly lower for non-Omani nurses: 2.8 (SD 1.5) vs 3.2 (SD 1.3) (P < 0.001). Conclusion: Non-Omani nurses have a more positive perception of patient safety culture than Omani nurses except in respect of stress recognition. Decision-makers, directors, and clinicians should consider these differences when designing interventions to improve patient safety culture. / This study is part of a PhD study that was funded by the Ministry of Health in Oman

Yes / The Patient Safety Huddle (PSH) is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. Despite growing interest and application of huddles as a mechanism for improving safety, evidence of their impact remains limited. There is also variation in how huddles are conceived and implemented with insufficient focus on their fidelity (the extent to which delivered as planned) and potential ways in which they might influence outcomes. The Huddle Up for Safer Healthcare (HUSH) project attempted to scale up the implementation of patient safety huddles (PSHs) in five hospitals - 92 wards - across three UK NHS Trusts. This paper aims to assess their fidelity, time to embed, and impact on teamwork and safety culture. A multi-method Developmental Evaluation was conducted. The Stages of Implementation Checklist (SIC) was used to determine time taken to embed PSHs. Observations were used to check embedded status and fidelity of PSH. A Teamwork and Safety Climate survey (TSC) was administered at two time-points: pre- and post-embedding. Changes in TSC scores were calculated for Trusts, job role and clinical speciality. Observations confirmed PSHs were embedded in 64 wards. Mean fidelity score was 4.9/9. PSHs frequently demonstrated a 'fear free' space while Statistical Process Control charts and historical harms were routinely omitted. Analysis showed a positive change for the majority (26/27) of TSC questions and the overall safety grade of the ward. PSHs are feasible and effective for improving teamwork and safety culture, especially for nurses. PSH fidelity criteria may need adjusting to include factors deemed most useful by frontline staff. Future work should examine inter-disciplinary and role-based differences in TSC outcomes. / The Health Foundation’s Scaling Up Improvement Programme: Round One (2015)

Yes / Despite many benefits offered by Health Information Technology (HIT) systems, new technology brings new and unforeseen risks to healthcare quality and patient safety if they're not properly planned, designed, implemented, and managed. This study examined health information technology-related (HIT) incidents to identify patient details-related issues, their association with contributing factors, and outcomes. Sources of information comprised retrospectively collected incident reports (n = 95) using two sampling methods, i.e., purposive and snowball sampling. The incident reports were analyzed using both the inductive method (thematic analysis) and the deductive approach using an existing framework, i.e., the International Classification for Patient Safety. The studies identified 90 incidents with 120 patient details-related issues-categorized as either information-related (48%) or documentation-related (52%) problems; around two-thirds of the 120 issues were characterized by human factors. Of the total sample, 87 contributing factors were identified, of which "medical device/system" (45%) and "documentation" (20%) were the most common contributing factors. Of 90 incidents, more than half (59%) comprised patient-related outcomes-patient inconvenience (47%) and patient harm (12%) and the remaining 41% (n = 37) included staff or organization-related outcomes. More than half of the incidents resulted in patient-related outcomes, namely patient inconvenience and patient harm, including disease risks, severe health deterioration, injury, and even patient death. Incidents associated with patient details can cause deleterious effects; therefore, characterizing them should be a routine part of clinical practice to improve the constantly changing healthcare system. / A publishing grant has been received from Linnaeus University as a part of the University Library’s research support.

The impact of Computerized Physician Order Entry (CPOE) on the dependent variables of medication-order compliance and time to first dose of antibiotic was investigated in this quasi-experimental study of a naturally-occurring CPOE intervention. The impact of CPOE on compliance and time to first dose was assessed by comparing measures of these variables from the intervention site and a non-equivalent control before and during intervention phases. Medication orders placed using CPOE were significantly more compliant than paper-based medication orders (p<.001), and first doses of antibiotic ordered using CPOE were delivered significantly faster than antibiotic orders placed using the paper-based system (p<.001). Findings support previous research indicating the positive impact of CPOE on patient safety as well as justify and enable future interventions to increase CPOE adoption and use among physicians. Additionally, data collected in this study will be used to provide behavior-based feedback to physicians as part of CPOE adoption and use intervention strategies to be explored in the forthcoming research. / Master of Science

Patient safety has progressed in 15 years from being a relatively insignificant issue to a position high on the agenda for health care providers, managers and policymakers as well as the general public. Sweden has seen increased national, regional and local patient safety efforts since 2011 when a new patient safety law was introduced and a four-year financial incentive plan was launched to encourage county councils to carry out specified measures and meet certain patient safety related criteria. However, little is known about what structures and processes contribute to improved patient safety outcomes and how the context influences the results. The overall aim of this thesis was to generate knowledge for improved understanding and explanation of influences on patient safety in the county councils in Sweden. To address this issue, five studies were con-ducted: interviews with nurses and infection control practitioners, surveys to patient safety officers and a document analysis of patient safety reports. Patient safety officers are healthcare professionals who hold key positions in their county council’s patient safety work. The findings from the studies were structured through a framework based on Donabedian’s triad (with a contextual element added) and applying a learning perspective, highlight areas that are potentially important to improve the patient safety in Swe-dish county councils. Study I showed that the conditions for the county councils’ patient safety work could be improved. Conducting root-cause analysis and attaining an organizational culture that encourages reporting and avoids blame were perceived to be of importance for improving patient safety. Study II showed that nurses perceived facilitators and barriers for improved pa-tient safety at several system levels. Study III revealed many different types of obstacles to effective surveillance of health care-associated infec-tions (HAIs), the majority belonging to the early stages of the surveillance process. Many of the obstacles described by the infection control practi-tioners restricted the use of results in efforts to reduce HAIs. Study IV of the Patient Safety Reports identified 14 different structure elements of patient safety work, 31 process elements and 23 outcome elements. These reports were perceived by patient safety officers to be useful for providing a structure for patient safety work in the county councils, for enhancing the focus on patient safety issues and for learning from the patient safety work that is undertaken. In Study V the patient safety officers rated efforts to reduce the use of antibiotics and improved communication be-tween health care practitioners and patients as most important for attaining current and future levels of patient safety in their county council. The patient safety officers also perceived that the most successful county councils regarding patient safety have good leadership support, a long-term commitment and a functional work organisation for patient safety work. Taken together, the five studies of this thesis demonstrate that patient safety is a multifaceted problem that requires multifaceted solutions. The findings point to an insufficient transition of assembled data and information into action and learning for improved patient safety.

A identificação do paciente tem sido reconhecida como um componente essencial e crucial na segurança do paciente e a ausência de processo padronizado de identificação nos serviços de saúde pode contribuir para a ocorrência de falhas. O estudo teve como objetivo investigar a temática de identificação dos pacientes em serviços de saúde. Para alcançar os objetivos propostos, a pesquisa foi conduzida em três fases: a elaboração da revisão integrativa (RI) e a condução de dois estudos descritivos. A busca dos estudos primários para inclusão na RI foi realizada nas bases de dados: PubMed, CINHAL, LILACS, SciELO, Scopus e Embase. A amostra da revisão integrativa foi composta por 17 estudos primários, agrupados em seis categorias temáticas. A estratégia do uso da pulseira de identificação de forma individualizada e que atenda às necessidades tanto das instituições quanto dos pacientes têm sido apontada pelos autores. O estudo descritivo da fase dois foi conduzido em 17 instituições de saúde sendo 12 hospitais e 5 unidades de pronto atendimento selecionados com a participação dos 17 enfermeiros responsáveis técnicos (RT). Para coleta de dados foi elaborado um instrumento submetido à validação aparente e de conteúdo por cinco juízes. Os enfermeiros RT responderam sobre as estratégias utilizadas pelos serviços de saúde para identificação dos pacientes.Todos os hospitais (100%) identificam seus pacientes internados, destacando-se o uso de pulseira e nenhum pronto atendimento independente utiliza essa estratégia. A admissão do paciente representa a etapa do atendimento em que as pulseiras de identificação são colocadas. Em 75% das instituições pesquisadas foi apontado como problema a falta de padronização na utilização das pulseiras, assim como a adoção de modelos não padronizados, destacada a variedade de cores, para identificar determinadas informações sobre o paciente. Em 33,3% dos hospitais mais de uma pulseira é colocada no mesmo paciente. Para a identificação de alergias, 50% dos hospitais usam pulseira vermelha. O nome completo, sobrenome, registro hospitalar e data de nascimento são dados que devem constar na pulseira de identificação do paciente. A pulseira de identificação tem sido reconhecida como a melhor forma de identificação do paciente nas instituições de saúde, mas além do uso desta metodologia é importante que todos, ao prestar um cuidado realizem a checagem da identificação confirmando neste momento os identificadores preconizados. O estudo descritivo da fase três foi conduzido em uma instituição hospitalar selecionada com vistas a analisar a influência da identificação do paciente na ocorrência de eventos adversos (EA) quanto às causas, locais das ocorrências, frequência, se a identificação foi uma barreira, danos causados, consequências, medidas corretivas e preventivas. No período analisado, de agosto de 2012 a agosto de 2014, foi notificado um total de 1673 ocorrências no sistema de notificação, sendo que dessas, 38 estavam relacionadas à identificação do paciente, representando 2,3% do total das ocorrências. A identificação do paciente atuou como barreira para identificar uma falha no processo relacionada ao EA em 45% das notificações. A quebra de protocolo foi responsável por 86% das causas que levou a ocorrência de EA, relacionadas à identificação do paciente. A existência de protocolos e procedimentos escritos por si só não garantem que falhas aconteçam, principalmente em relaçao à identificação do paciente, sendo necessário a implementação de medidas de avaliação do cumprimento dos mesmos. Isso possibilitará o aprimoramento desse processo e, com isso, garantirá qualidade e segurança / Patient identification has been acknowledged as a crucial an essential component in patients\' safety and the absence of a standard identification process in healthcare services can contribute to failures. This study aimed to investigate the theme around patient identification in healthcare services. To reach such objectives, research was conducted in three phases: elaboration of an integrative review and the conduction of two descriptive studies. Search for primary studies to be included in the integrative review was done on the following databases: PubMed, CINHAL, LILACS, SciELO, Scopus and Embase. The integrative review\'s sample concerned of 17 primary studies in six categories: identification in the healthcare teams\' and patients\' (or the patients\' tutors\') perspective (eis); identification in newborn and pediatric patients; identification in administration of chemotherapy and medication; identification in blood transfusion and sample collecting; identification in surgical patients and implementation of patient identification policies. The identification wristband strategy in an individualized manner with regards to both the patients\' and the institutions\' needs has been acclaimed by authors. Phase 2\'s descriptive study was conducted in 17 healthcare institutions, 12 hospitals and 5 emergency care units, selected with participation of 17 tech-nurses in charge. For data collection, an instrument that underwent apparent and content validation by five judges was created. Nurses answered about strategies used by healthcare services for patient identification. Every hospital reported having identification protocols; and while wristbands usage stands out in hospitals, no independent emergency care unit uses that strategy. Patient admission represents the stage during which wristbands are placed. In 75% of the researched institutions, lack of standardization in wristband use was pointed out as an issue as well as adoption of non-standardized methods; variety in color for the sake of categorization of patients sticks out in this matter. In 33% of the hospitals, more than one wristband is placed on a single patient. For identification of allergies, 50% of the hospitals use red wristbands. A patient wristband must contain a patient\'s full name, hospital record and date of birth. The identification wristband has been acknowledged as the best form of identification for patients in healthcare facilities, but apart from this method, it is important that all who are carrying out patient care check the identification, confirming the preconized identification. Phase 3\'s descriptive study was conducted in a selected hospital facility for this investigation aimed to analyze the influence of patient identification on adverse events (EA) as to causes, locale, frequency, if identification was a barrier, damage caused, consequences, and corrective and preventive measures. In the time period from August 2012 and August 2014, a total of 1673 occurrences in the institution\'s identification system was notified; among those, 38 concerned patient identification, representing 2,3% of the total. Patient identification acted as a barrier to identify a failure in an EA-related process in 45% of institutions. Protocol breach was behind 86% of the cause of EA occurrences that were connected to patient identification. Existence of protocols and procedures written alone does not guarantee failures occur, especially when it comes down to patient identification; which brings out the need for implementation of measures of evaluation that assure that these protocols are being followed by the staff. This will allow the enhancement of this process and with it a betterment in quality and safety in patient care

A busca da qualidade do sistema de serviços de saúde é uma exigência cada vez mais presente na sociedade moderna e um dever do próprio sistema. No ambiente hospitalar, esta exigência torna fundamental a criação de normas e mecanismos de avaliação e controle da qualidade assistencial. Neste cenário, a qualidade é definida a partir das necessidades e do interesse dos clientes, que desejam adquirir produtos e serviços com excelência em todos os aspectos. Com base na premissa de que a segurança do paciente é parte integrante da prestação de cuidados de qualidade, os locais de atendimento à saúde devem estabelecer programas abrangentes voltados para a melhoria continua da segurança do paciente. A adesão das iniciativas da Aliança Mundial para Segurança do Paciente da Organização Mundial de Saúde (OMS), promovidas pelo Ministério da Saúde e a Agência Nacional de Vigilância Sanitária (ANVISA) por parte dos serviços é baixa, justamente por não terem uma cultura institucional voltada para a segurança do paciente. O reflexo disso está na alta ocorrência de eventos adversos (EA) evitáveis em hospitais brasileiros, que corresponde a cerca de 67% de todos os EA. A segurança do paciente é enfoque central das discussões na área da saúde em quase todo o mundo. O tema é para o campo da avaliação em saúde, um dos atributos da qualidade proposto por Donabedian. No Brasil, em 2013, foi editada a Portaria n. 529, de 01 de abril que instituiu a Política Nacional de Segurança do Paciente, definindo ações e metas. No mesmo ano, foi criada a Resolução da Diretoria Colegiada n. 36, de 25 de julho de 2013 que estabeleceu a obrigatoriedade de implantação de um Núcleo de Segurança do Paciente (NSP) nos hospitais, visando reduzir a ocorrência de danos e eventos adversos na assistência aos pacientes, melhorar a qualidade dos serviços prestados, promover o registro e aprimorar a sua qualidade. Certo que resoluções não são suficientes para modificar práticas, este estudo teve como objetivo analisar a implementação de Núcleos de Segurança do Paciente em serviços hospitalares. Trata-se de pesquisa quantitativa, transversal do tipo Survey, por meio da aplicação de questionário estruturado. Para o desenvolvimento da pesquisa, as seguintes etapas foram percorridas: elaboração do questionário, validação de face e conteúdo do mesmo e coleta de dados nos hospitais selecionados utilizando o questionário, composto por 20 itens relacionados ao processo de criação, formação e atuação do NSP nos serviços hospitalares. A pesquisa foi desenvolvida em 11 hospitais de um município do interior do Estado de São Paulo e demonstrou que a maioria dos hospitais 81% (n=9) participam de programa de melhoria da qualidade. Todos os respondentes informaram uma composição multiprofissional do NSP. Quanto ao Plano de Segurança do Paciente (PSP), a maioria dos respondentes indicou a existência (91%; n = 10) e o único hospital que não tem um PSP justificou que não conseguiu elaborar. Todos os hospitais notificam e comunicam os incidentes e eventos adversos, sendo esse procedimento feito tanto na forma eletrônica (82%) como na forma manual (73%) e os dados são analisados, na maioria das vezes, pelo NSP (63,6%) e pelo escritório da qualidade (54,5%). Os respondentes indicaram que 64% dos hospitais informam os pacientes e familiares sobre o acontecimento da ocorrência do EA. Aproximadamente 27% dos hospitais reportaram que não envia à ANVISA a ocorrência de EA. Todos os hospitais realizam a abordagem e devolutiva sobre o EA com o colaborador e adotam os protocolos do Ministério da Saúde referentes ao Programa Nacional de Segurança do Paciente. A dificuldade de aceitação das equipes, a falta de envolvimento dos profissionais das diversas áreas, a falta de adesão dos setores envolvidos apareceu permeando a dificuldades de implantação do NSP. Percebe-se que há NSP atuantes nos serviços hospitalares, bem como um fluxo bem estabelecido para a notificação dos EA, porém, faz-se necessário expandir estas informações coletadas no processo de notificação. Diante do exposto, acredita-se que os resultados encontrados possam oferecer subsídios e acrescentar evidências que contribuam para as reformulações que se fizerem necessárias no processo de formação e implantação dos NSP / The search for the quality of the health service system is a requirement increasingly present in modern society and a duty of the system. In the hospital environment, this requirement makes the creation of care quality evaluation and control standards and mechanisms of fundamental importance. In that context, quality is defined based on the clients\' needs and interest, who want to purchase products and services of excellence in all aspects. Based on the premise that patient safety is a part of quality service provision, the healthcare establishments should establish comprehensive programs for the continuous improvement of patient safety. The services\' compliance rates with the initiatives of the World Health Organization\'s (WHO) Global Patient Safety Alliance, promoted by the Brazilian Health Department and the Brazilian National Health Surveillance Agency (ANVISA) is low, exactly because they do not have an institutional patient safety culture. That is reflected in the high rates of avoidable adverse events (AE) in Brazilian hospitals, corresponding to about 67% of all AE. Patient safety is the main focus of discussions in health almost everywhere in the world. In the field of health assessment, the theme is one of the quality attributes proposed by Donabedian. In Brazil, Decree 529 was enacted on April 1st, 2013, which established the National Patient Safety Policy, setting actions and targets B. In the same year, the Collegiate Directorate Resolution 36 was created on July 25th, 2013, which established the compulsory implementation of a Patient Safety Center (PSC) in hospitals, aiming to reduce the occurrence of damage and adverse events in patient care, to improve the quality of the service provided, to promote the registration and improve its quality. As resolutions are insufficient to modify practices, the objective of this study Analyze the implementation of Patient Safety Centers in hospital services. A quantitative and cross-sectional survey was undertaken through the application of a structured questionnaire. To develop the research, the following steps were executed: elaboration of the question, face and content validation and data collection at the selected hospitals using the questionnaire, which consisted of 20 items related to the creation, constitution and activity process of the NSP in the hospital services. The research was developed in 11 hospitals from an interior city in the State of São Paulo and demonstrated that most of the hospitals, 81% (n=9), participate in a quality improvement program. All of the respondents informed that the PSC consists of multiple professions. As regards the Patient Safety Plan (PSP), most respondents indicated that such a plan exists (91%; n = 10) and the only hospital that does not have a PSP justified that it did not manage to elaborate one. All hospitals report and inform about the incidents and adverse events. This procedure takes place electronically (82%) and/or manually (73%) and, in most cases, the data are analyzed by the PSC (63.6%) and the quality service (54.5%). The respondents indicated that 64% of the hospitals inform the patients and relatives about the occurrence of the AE. Approximately 27% of the hospitals reported that they do not forward the AE report to ANVISA. All hospitals discuss and give feedback to the collaborator about the AE and adopt the Health Department\'s protocols of the National Patient Safety Program. The teams\' acceptance difficulties, the lack of involvement among professionals from different areas and the lack of compliance of the sectors involved permeated difficulties to implement the PSC. As noticed, Patient Safety Centers are active in the hospital services, with a well-established flow for the reporting of AE. Nevertheless, this information collected during the reporting process needs further expansion. In view of the above, we believe that the results found can offer support and add evidence that contributes to any reformulations needed in the development and implementation process of the PSC