Learning from Patient Safety Incidents

It is estimated that 1:10 patients in health care sustain harm that is potentially avoidable and which often highlight system errors that were not appreciated | Faculty of Intensive Care Medicine

Investigation results in the identification of these system errors and the generation of solutions to prevent future incidents. Sharing and implementing these lessons improves patient safety.

National Patient Safety Alerts relevant to intensive care

National alerts are produced in response to analysis of centrally reported patient safety incidents. Details of all alerts may be found on the Central Alerting System website (https://www.cas.dh.gov.uk/Home.aspx).

Lessons from adverse incidents

Lessons from local incidents may not be shared widely and to improve wider patient safety, the Joint Standards Committee of the Faculty and the Intensive Care Society has created this forum to allow lessons from local investigations into adverse incidents to be disseminated to the intensive care community.

We welcome you to share important safety lessons that have occurred in your own departments that may have general relevance. Please use the form below (or your local form if you would prefer) to submit an anonymised summary of the incident, the learning arising and any changes that have been implemented to prevent future a reoccurrence.

SAFETY MATTERS: Local Incident Lessons

Read the full overview here

Improving the catheter associated UTI rate in an intensive care unit

Galiczewski, J.M. & Shurpin, K.M. Intensive and Critical Care Nursing. Published online: 22 February 2017

Background: Healthcare associated infections from indwelling urinary catheters lead to increased patient morbidity and mortality.

Aim: The purpose of this study was to determine if direct observation of the urinary catheter insertion procedure, as compared to the standard process, decreased catheter utilization and urinary tract infection rates.

Conclusion: The findings from this study may promote changes in clinical practice guidelines leading to a reduction in urinary catheter utilization and infection rates and improved patient outcomes.

Read the full abstract here

Blood transfusion; NICE quality standard QS138 December 2016

This quality standard covers the general principles of blood transfusion in adults, young people and children over 1 year old. It describes high-quality care in priority areas for improvement. It does not cover specific conditions that blood transfusion is used for.  This quality standard is reviewed each year and updated if needed.

The four quality statements included in the latest review:

Statement 1  People with iron-deficiency anaemia who are having surgery are offered iron supplementation before and after surgery.

Statement 2  Adults who are having surgery and expected to have moderate blood loss are offered tranexamic acid.

Statement 3  People are clinically reassessed and have their haemoglobin levels checked after each unit of red blood cells they receive, unless they are bleeding or are on a chronic transfusion programme.

Statement 4  People who may need or who have had a transfusion are given verbal and written information about blood transfusion.

Use this link for more details about this quality standard.  Follow this link for a full list of NICE Guidance published in December 2016.

Newborn Individualized Developmental Care and Assessment Program Reduces Length of Stay

Moody, C. et al. Journal of Pediatric Nursing. Published online: 3 December 2016

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Infants born at ≤32 weeks gestation are at risk of developmental delays. Review of the literature indicates NIDCAP improves parental satisfaction, minimizes developmental delays, and decreases length of stay, thus reducing cost of hospitalization.

Highlights:

  • NIDCAP is a proven framework for providing developmentally supportive care in the NICU, and can mitigate risks of prematurity
  • Earlier initiation of NIDCAP led to discharge at a younger post-menstrual age
  • Quality improvement investigations are effective in addressing critical healthcare needs

Read the full abstract here

Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study

Scheer, S. et al. Critical Care Medicine. Published online: September 22 2016

Objective: To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated.

Design: Prospective observational before-after cohort study.

Setting: Tertiary university hospital in Germany.

Patients: All adult medical and surgical ICU patients with severe sepsis and septic shock.

Intervention: Implementation of a quality improvement program over 7.5 years.

Measurements: The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements.

Main Results: A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p < 0.001). Hospital length of stay decreased from 44 to 36 days (p < 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p < 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60-0.84; p < 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53-0.75; p < 0.001), 1-2 L crystalloids within the first 6 hours (hazard ratio 0.67-0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64-0.95; p = 0.012) as predictors for improved survival.

Conclusions: The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.

Read the abstract here

Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs.

Wysham, N. et al. Critical Care Medicine. Published online: 9 September 2016

https://www.flickr.com/photos/frenkieb/2321498281/

Image source: PROFrancis Bijl – Flickr // CC BY 2.0

Objective: Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment.

Design: Mixed-methods study.

Setting: Medical and surgical ICUs at three large academic hospitals.

Participants: Three hundred three nurses, intensivists, and advanced practice providers.

Measurements and Main Results: Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships.

Conclusions: Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.

Read the abstract here

Sepsis care bundles reduce mortality odds 40%

Compliance with sepsis care bundles can significantly reduce death in hospital. However compliance rates are generally low.

This study assessed how the Surviving Sepsis Campaign was implemented in various countries and the impact of implementing these care bundles for people with severe sepsis or septic shock. Data were analysed about 1,794 patients from 62 countries. Compliance with all the three-hour bundle metrics was 19%. Compliance was associated with lower hospital mortality. Compliance with all the six-hour bundle metrics was 36%. This was associated with lower hospital mortality. Overall, patients who received all aspects of the care bundles had a 40% reduction in the odds of dying in hospital with the three-hour bundle and a 36% reduction with the six-hour bundle.