Wilson Mary-Agnes, Sinno Maya, Hacker Teper Matthew, Courtney Karoline, Nuseir Deema, Schonewille Aidan, Rauchwerger David, Taher Ahmed
From the Mackenzie Health.
Temerty Faculty of Medicine.
J Patient Saf. 2022 Oct 1;18(7):680-685. doi: 10.1097/PTS.0000000000000978. Epub 2022 Feb 14.
In response to an organizational survey revealing low safety culture scores, we implemented a "zero harm" approach to eliminate preventable harm across a wide variety of clinical areas. We aimed to achieve this objective within 3 years.
We developed a 5-part strategy for cultural and process redesign that included (1) engaging leadership; (2) developing an organization-specific patient safety framework; (3) monitoring specific quality aims based on high-risk, high-volume, high-cost, and problem-prone areas; (4) standardizing a 3-part review process that includes a root cause analysis for moderate and critical patient safety incidents; and (5) communicating progress to staff in real time via unit-specific electronic dashboards.
In less than 1 year, we increased patient safety incident reporting by 37% while simultaneously decreasing falls with injury by 39%, pressure injury rates by 37%, and central line-associated blood stream infections by 34%. We also improved medication reconciliation rate by 3.3% and decreased our irretrievable specimen rate to 0. Finally, we noted increased awareness around patient safety within clinical teams, with open discussions about patient safety becoming a routine part of patient care.
This study describes an initiative that sought to introduce system-wide changes to practice and patient safety culture in a rapid time frame. Results suggest that our 5-step approach to transformation may confer substantial gains in patient safety for peer institutions. Next steps include continuing to expand and monitor quality aims as we progress through our journey to eliminating preventable patient harm in our healthcare system.
为应对一项组织调查显示的安全文化得分较低的情况，我们实施了一种“零伤害”方法，以消除广泛临床领域内的可预防伤害。我们旨在3年内实现这一目标。
我们制定了一项包含五个部分的文化和流程重新设计策略，其中包括：（1）让领导层参与进来；（2）制定一个针对本组织的患者安全框架；（3）根据高风险、高工作量、高成本和易出现问题的领域监测特定质量目标；（4）规范一个包含对中度和严重患者安全事件进行根本原因分析的三部分审查流程；（5）通过特定科室的电子仪表盘向员工实时通报进展情况。
在不到1年的时间里，我们将患者安全事件报告率提高了37%，同时将受伤跌倒率降低了39%，压疮发生率降低了37%，中心静脉导管相关血流感染率降低了34%。我们还将用药核对率提高了3.3%，并将无法找回的标本率降至零。最后，我们注意到临床团队对患者安全的认识有所提高，关于患者安全的公开讨论成为患者护理的常规组成部分。
本研究描述了一项旨在在短时间内对实践和患者安全文化进行全系统变革的举措。结果表明，我们的五步转型方法可能会为同行机构在患者安全方面带来显著收益。下一步包括在我们朝着消除医疗系统中可预防的患者伤害迈进的过程中，继续扩大并监测质量目标。
