Aktuelt om pasientsikkerhet
Folkehelseinstituttet innhenter og videreformidler jevnlig aktuell informasjon som kan være nyttig for dem som er opptatt av pasientsikkerhet.
Referansene kommer fra to typer kilder: 1) bibliografiske databaser eller 2) nyhetsbrev fra fagmiljøer som arbeider med kvalitet og pasientsikkerhet i helsetjenesten.
For å kvalifisere til formidling skal innholdet være relevant og fortrinnsvis basert på oppsummert forskning. Vi vurderer ikke metodisk kvalitet på publikasjoner som videreformidles.
Les mer om søkekriteriene i Metodebeskrivelse - Aktuelt om pasientsikkerhet (pdf)
Avdeling for kvalitet og pasientsikkerhet i Folkehelseinstituttet videreformidler regelmessig publikasjoner om pasientsikkerhet. Blant de ni artiklene denne gangen er en om et nytt nettbasert hjelpemiddel i kommunikasjon med pasienter, pårørende og helsepersonell som har vært involvert i en pasientskade som følge av en uønsket hendelse.
Skal bedre kommunikasjonen etter pasientskade
Det amerikanske forskningsinstituttet Agency for Healthcare Research and Quality (AHRQ) lanserte for kort tid siden hjelpemiddelet CANDOR (Communication And Optimal Resolution). Målet med CANDOR er en åpen, rett fram og empatisk kommunikasjon med pasienter, pårørende og involvert helsepersonell så snart som mulig etter en uønsket hendelse med pasientskade.
Verktøyet har åtte moduler. Hver modul inneholder PowerPoint-presentasjoner og sjekklister eller videoinnslag om et relevant tema. For eksempel tar modul fem for seg kommunikasjon med pasienter og pårørende, mens modul seks handler om hvordan man kan vise omsorg og ivareta helsepersonellet som er involvert.
De åtte modulene utgjør et rammeverk som kan bedre helsetjenestens oppfølging av pasienter, pårørende og helsepersonell etter en uventet hendelse med en pasientskade. Det følger også med en veiledning om hvordan CANDOR-prosessen kan tas i bruk.
De andre publikasjonene
De andre publikasjonene som avdelingen videreformidler handler om:
- Forebyggbare uønskede hendelser – 19 sjekklister
- Feil i forskrivning av høyrisikolegemidler i sykehus
- Klassifikasjon av avvik funnet ved legemiddelsamstemming
- Forebygging av legemiddelfeil – barn på sykehus
- Preoperativ kirurgisk sjekkliste
- System for pårørendevarsling av forverring hos sykehuspasienter
- Varig forbedring av pasientsikkerhet – samlekompendium fra National Patient Safety Foundation
- Fallforebyggende design av helseinstitusjoner
Artiklene med omtale
Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality: Rockville, MD. [May 2016].
Communication and Optimal Resolution (CANDOR) is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. This AHRQ toolkit, based on the CANDOR process, is intended to assist hospitals in implementing communication and optimal resolution programs.
A traditional approach when unexpected harm occurs often follows a “deny-and-defend” strategy, providing limited information to patients and families, and avoiding admission of fault. In short, the CANDOR process is a more patient-centered approach that emphasized early disclosure of adverse events and a more proactive method to achieving an amicable and fair resolution for the patient/family and involved health care providers.
2. Eliminating harm checklists: Reduce all-cause preventable harm
American Hospital Association, Partnership for Patients, Health Research & Educational Trust Chicago, IL: Health Research & Educational Trust, 2016
Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.
The AHA/HRET HEN 2.0 team has worked with Hospitals in Pursuit of Excellence (HPOE) to produce a new resource as you approach harm reduction in your facility. The new compilation "Eliminating Harm Checklists" gathers evidence-based best practices, improvement strategies and action items along with checklists and resources that may be effective within your organization.
Alanazi MA, Tully MP, Lewis PJ J Clin Pharm Ther 2016
Prescribing errors are the most common type of error in the medication use process. However, there is a paucity of literature regarding the prevalence or incidence of prescribing errors in high-risk medicines (HRMs). HRMs bear a heightened risk of causing significant patient harm when they are used in error.
The aim of this research was to systematically investigate the literature regarding the prevalence and incidence of prescribing errors in HRMs in inpatient settings.
The prevalence of prescribing errors in HRMs in the inpatient setting has a very wide range that reflects the different data collection methods used within the included studies.
Almanasreh E, Moles R, Chen TF Br J Clin Pharmacol 2016
Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified.
We suggest that clear and consistent information on prevalence, types, causes and contributing factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.
Bannan DF, Tully MP J Clin Pharm Ther 2016;41(3):246-255
Bundle interventions are becoming increasingly used as patient safety interventions. The objective of this study was to describe and categorize which bundle interventions are used to reduce prescribing errors (PEs) and administration errors (AEs) in hospitalized children and to assess the quality of the published literature.
This novel analysis in a systematic review showed that bundle interventions delivering two or more intervention functions have been investigated but that the study quality was too poor to assess impact.
Biccard BM, Rodseth R, Cronje L, Agaba P, Chikumba E, Du Toit L, et al. S Afr Med J 2016;106(6):592-597
Meta-analyses of the implementation of a surgical safety checklist (SSC) in observational studies have shown a significant decrease in mortality and surgical complications. OBJECTIVE: To determine the efficacy of the SSC using data from randomised controlled trials (RCTs).
Four hundred and sixty-four citations revealed three eligible trials conducted in tertiary hospitals and a community hospital, with a total of 6 060 patients.
There is sufficient RCT evidence to suggest that SSCs decrease hospital mortality and surgical outcomes in tertiary and community hospitals.
Gill FJ, Leslie GD, Marshall AP Worldviews Evid Based Nurs 2016
Rapid response systems incorporate concepts of early recognition of patient deterioration, prompt reporting, and response which result in escalation of patient care. The ability to initiate escalation of care is now being extended to families of hospitalized patients.
Ten articles (all descriptive studies) reported implementation and evaluation of response systems for patients and families to trigger an alert for help.
A variety of practice models and calling criteria were reported to either directly activate an existing rapid response team or trigger a separate response to patient- or family-initiated calls. The broader calling criteria and more comprehensive implementation strategies were associated with more patient- and family-initiated escalation of care calls. There is no systematically researched evidence to assess the value of family-initiated calls for deteriorating patients.
National Patient Safety Foundation Boston, MA: National Patient Safety Foundation, 2016
Since 2010, the Lucian Leape Institute has explored five key areas to transform health care. This compendium combines the findings of five reports published between 2010 and 2015 to help foster leadership awareness of the changes needed to achieve lasting patient safety improvement.
The compendium consists of executive summaries, recommendations, and action checklists from reports on the following themes:
- Patient/consumer engagement
- Restoration of joy and meaning in work, including workforce safety
- Care integration
- Medical education reform
Taylor E, Hignett S Herd 2016
This systematic mixed studies review on hospital falls is aimed to facilitate proactive decision-making for patient safety during the healthcare facility design. The built environment can act as a barrier or enhancement to achieving the desired results in safety complexity that includes the organization, people, and environment.
Following full-text review, 27 papers were included and critically appraised using an evaluation matrix that included a mixed methods appraisal tool. Themes were coded by broad categories of factors for organization (policy/operations), people (caregivers/staff, patients), and the environment (healthcare facility design). Subcategories were developed to define the physical environment and consider the potential interventions in the context of relative stability.