Patient safety - what works? 4 th  June 2009 See safety folder on web site  http://homepage.mac.com/johnovr/FileSharing2.h...
. <ul><li>. </li></ul>08/03/09 Once upon a time… In a parallel universe… Not so far from here…..
<ul><li>Dr Anna Johansson,  </li></ul><ul><ul><li>Director of Internal Medicine, Shockholm sjukhus. </li></ul></ul><ul><li...
Don’t complicate things – what works …? Proven safety solutions recommended or mandated by authoritative bodies  <ul><li>(...
Clinical safety practices: changes for common problems <ul><li>Two of 11 AHRQ 2001 “just do its” (others in the 680p repor...
Katolinska Sjukhus toilets – quick/low cost  video cams & poster 08/03/09
Katolinska Sjukhus 08/03/09
Good cost/effectiveness – direct communication with patients 08/03/09
We will do these 2 because these are a problem for us <ul><li>1 Infection rates: Antibiotic prophylaxis </li></ul><ul><li>...
How do you know these work? <ul><li>Evidence: see Øvretveit, 2004, 2007, 2009 reviews of research for WHO and SKL </li></u...
<ul><li>You have not convinced me, but to sell to my colleagues: </li></ul><ul><li>Would it work here?  </li></ul><ul><li>...
Sven Angstrom: the Dr Darth Viking of Shockholm sjukus & the Local Context King <ul><li>Look at this research Dr Darth…. <...
Can you grow pineapples in Shockholm? 08/03/09 Seed Gardener/planting & nurture Climate / soil The point is, choose plants...
Say again Jon? <ul><li>Environment + Evidence +Implementation  =  Quality </li></ul><ul><li>Supportive infrastructure  </l...
Later… back at the Katolinska Research Centre …Jon calls together the research group 08/03/09
Jon enthuses the research team  - we can make a difference… <ul><li>Fantastic opportunity – no research on this: </li></ul...
Other points about safety – post modernist writer in residence <ul><li>Intervention is not separate from context </li></ul...
Research points - 2 <ul><li>Theory informed evaluation – models of intervention in context: next is one example  </li></ul...
08/03/09 1994  1995  1996 1997 1998  1999  2000  2001  2002  2003  2004  2005  2006  2007  2008  2009 Theory informed eval...
Hindrances for us researchers: <ul><li>More silos than in health organisations </li></ul><ul><li>Academic departments, dis...
Johns safety research wish list <ul><li>Incidence and solutions to AEs outside of hospitals </li></ul><ul><ul><li>PHC, Nur...
Other points about safety research – 3  – address the 4 challenges <ul><li>Data validity </li></ul><ul><li>Attribution </l...
Summary <ul><li>What works  to reduce AEs – rigorous research in one setting </li></ul><ul><li>Where works best ? </li></u...
What works? <ul><li>High certainty: </li></ul><ul><ul><li>If implemented fully, will reduce Aes in most situations </li></...
What does not work? 08/03/09 “ be more careful”
Patient safety - what works? <ul><li>Evidence from elsewhere  about  </li></ul><ul><ul><li>Efficacy in rigorous study situ...
Researchers may need guidance … 08/03/09
Questions to you  … <ul><li>1) How to collaborate to make the needed research practical </li></ul><ul><ul><ul><ul><li>and ...
. <ul><li>. </li></ul>08/03/09
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Ovret Sdo Patientsafety4 June09

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  • Goal: Identify Patients Correctly � Requirement 1: Use at least two (2) ways to identify a patient when giving medicines, blood or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. The patient&apos;s room number cannot be used to identify the patient. Goal: Improve Effective Communication � Requirement 2: Implement a process/procedure for taking verbal or telephone orders, or for the reporting of critical test results that requires a verification &amp;quot;read-back&amp;quot; of the complete order or test result by the person receiving the information. NOTE: Not all countries permit verbal or telephone orders. Goal: Improve the Safety of High-alert Medications Requirement 3: Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride &gt;0.9%) from patient care units. Goal: Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery Requirement 4: Use a checklist, including a &amp;quot;time-out&amp;quot; just before starting a surgical procedure, to ensure the correct patient, procedure and body part. Requirement 5: Develop a process or checklist to verify that all documents and equipment needed for surgery are on hand and correct and functioning properly before surgery begins. Requirement 6: Mark the precise site where the surgery will be performed. Use a clearly understood mark and involve the patient in doing this. Goal: Reduce the Risk of Health Care � acquired Infections Requirement 7: Comply with current published and generally accepted hand hygiene guidelines. NOTE: This should recognize that not all countries have a CDC (Centers for Disease Control and Prevention) or may not recognize the US CDC. Goal: Reduce the Risk of Patient Harm Resulting from Falls Requirement 8: Assess and periodically reassess each patient&apos;s risk for falling, including the potential risk associated with the patient&apos;s medication regimen, and take action to decrease or eliminate any identified risks.
  • K eep it simple, Sven believes in green leadership
  • I ts one thing in hot house study conditions, another out in the wild
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  • Ovret Sdo Patientsafety4 June09

    1. 1. Patient safety - what works? 4 th June 2009 See safety folder on web site http://homepage.mac.com/johnovr/FileSharing2.html <ul><li>John Øvretveit, </li></ul><ul><li>Director of Research, Professor of health innovation and implementation, Karolinska Medical Management Centre Sweden and Professor of Health Management, Faculty of Medicine, Bergen University </li></ul>08/03/09
    2. 2. . <ul><li>. </li></ul>08/03/09 Once upon a time… In a parallel universe… Not so far from here…..
    3. 3. <ul><li>Dr Anna Johansson, </li></ul><ul><ul><li>Director of Internal Medicine, Shockholm sjukhus. </li></ul></ul><ul><li>Unusually, </li></ul><ul><li>called Jon Tviet over </li></ul><ul><ul><li>Director of research, Katolinksa Medical School. </li></ul></ul><ul><ul><ul><li>(You know that look when…) </li></ul></ul></ul><ul><li>Wanted to know, “We’ve got to improve patient safety… </li></ul><ul><li>– quickly, cheaply, saving the most suffering, and costs” </li></ul>08/03/09
    4. 4. Don’t complicate things – what works …? Proven safety solutions recommended or mandated by authoritative bodies <ul><li>(See SDO safety folder on web site) </li></ul><ul><li>Do you use any of these? </li></ul><ul><li>AHRQ 2001 – The first 11 “Nike no-brainers” – just do it! </li></ul><ul><li>NQF top 30 </li></ul><ul><li>IHI 100k and 5m lives solutions (& country versions) </li></ul><ul><li>WHO list </li></ul><ul><li>Joint commission safety goals </li></ul><ul><li>ACHS etc & … You pays your money…t </li></ul>
    5. 5. Clinical safety practices: changes for common problems <ul><li>Two of 11 AHRQ 2001 “just do its” (others in the 680p report) </li></ul><ul><li>Antibiotic-impregnated central venous catheters to prevent infection </li></ul><ul><li>Pressure relieving bedding materials to prevent pressure ulcers. </li></ul><ul><li>Inappropriate prescribing for people over 65 </li></ul><ul><li>Information on medications for patient transfers (NCH (2000)) </li></ul><ul><li>Every patient, every time, every place as appropriate? </li></ul><ul><li>What’s the cheapest? </li></ul>
    6. 6. Katolinska Sjukhus toilets – quick/low cost video cams & poster 08/03/09
    7. 7. Katolinska Sjukhus 08/03/09
    8. 8. Good cost/effectiveness – direct communication with patients 08/03/09
    9. 9. We will do these 2 because these are a problem for us <ul><li>1 Infection rates: Antibiotic prophylaxis </li></ul><ul><li>2 Failure to rescue (arrests, emergency admit to ICU): critical care outreach team </li></ul>08/03/09
    10. 10. How do you know these work? <ul><li>Evidence: see Øvretveit, 2004, 2007, 2009 reviews of research for WHO and SKL </li></ul><ul><li>Antibiotic prophylaxis </li></ul><ul><ul><li>Clinical trial standardised full implementation and excluded other explanations : intervention to physiology – “mechanical” causal pathways </li></ul></ul><ul><li>Critical care outreach team </li></ul><ul><ul><li>Less sure: social intervention to social system – people are unpredictable, especially when together… </li></ul></ul><ul><ul><ul><ul><li>Not fully implemented, long pathway, but makes sense! </li></ul></ul></ul></ul>08/03/09
    11. 11. <ul><li>You have not convinced me, but to sell to my colleagues: </li></ul><ul><li>Would it work here? </li></ul><ul><li>How much would it cost? </li></ul><ul><li>and what’s effective for implementation? </li></ul><ul><li>Little research on this </li></ul><ul><li>Effective implementation to get the changes? </li></ul><ul><li>Which contexts necessary or help and hinder? </li></ul><ul><li>Probable that supportive context more important than you or implementation strategy </li></ul><ul><li>Come with me to see the CEO, to get this… </li></ul><ul><li>But keep it simple… </li></ul>
    12. 12. Sven Angstrom: the Dr Darth Viking of Shockholm sjukus & the Local Context King <ul><li>Look at this research Dr Darth…. </li></ul><ul><li>Jon, do you have a cat… </li></ul>
    13. 13. Can you grow pineapples in Shockholm? 08/03/09 Seed Gardener/planting & nurture Climate / soil The point is, choose plants you see growing in similar environments – and change which aspects of climate you can Can Darth change the micro or macro climate? Anna, supported by Darth
    14. 14. Say again Jon? <ul><li>Environment + Evidence +Implementation = Quality </li></ul><ul><li>Supportive infrastructure </li></ul><ul><li>+ Proven change </li></ul><ul><li>+ Effective implementation </li></ul><ul><li>= Higher quality </li></ul><ul><li>Anna needs help with the context bit…that’s Darth’s department… </li></ul>
    15. 15. Later… back at the Katolinska Research Centre …Jon calls together the research group 08/03/09
    16. 16. Jon enthuses the research team - we can make a difference… <ul><li>Fantastic opportunity – no research on this: </li></ul><ul><li>1)Before/After complex changes: effective? </li></ul><ul><li>2)Implementation strategies: effective for getting the before/after change? </li></ul><ul><li>3)Supportive contexts: group, departmental, organisational, external - what is necessary to help the implementation? </li></ul><ul><li>4) Also, not just evaluation & implementation research </li></ul><ul><ul><li>Eg patients view about how to involve them in improving safety </li></ul></ul><ul><ul><li>(choose 2 – quickest and lowest cost?) </li></ul></ul>08/03/09
    17. 17. Other points about safety – post modernist writer in residence <ul><li>Intervention is not separate from context </li></ul><ul><li>Many influences on result variables you study </li></ul><ul><li>Intervention is one, and it interacts with context </li></ul><ul><li>Research “draws a boundary” between the intervention and context </li></ul><ul><ul><li>To assess how influential intervention is on outcomes vs other influences </li></ul></ul><ul><ul><li>Don’t confuse your model with reality </li></ul></ul>08/03/09
    18. 18. Research points - 2 <ul><li>Theory informed evaluation – models of intervention in context: next is one example </li></ul>08/03/09
    19. 19. 08/03/09 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Theory informed evaluation – safety interventions evolve in context Actions: planning and preparations Result: agreed care goals, three shared centres and joint management Planning Innovation Further development actions Established Actions to develop coordinated client/patient care planning system & other systems & procedures >>>>>>>>>>>> Context factors help and hinder implementation at different times Government policy helps planning Intermediate results : coordination structures and changes in personnel behaviour 1996 2000 2004 2008 Results : Consequences for personnel Results: Consequences for clients
    20. 20. Hindrances for us researchers: <ul><li>More silos than in health organisations </li></ul><ul><li>Academic departments, disciplines </li></ul><ul><li>Ownership and branding wars confuse terminology </li></ul><ul><ul><li>Makes communication between disciples for MD and MM research more difficult </li></ul></ul>08/03/09
    21. 21. Johns safety research wish list <ul><li>Incidence and solutions to AEs outside of hospitals </li></ul><ul><ul><li>PHC, Nursing homes </li></ul></ul><ul><li>The “in-betweens” – transitions and entire episode of care </li></ul><ul><li>Costs of adverse event, Cost of 50% solution, Saving </li></ul><ul><ul><li>(MMC “saving suffering campaign” ) </li></ul></ul><ul><li>Second victim impact and costs </li></ul>08/03/09
    22. 22. Other points about safety research – 3 – address the 4 challenges <ul><li>Data validity </li></ul><ul><li>Attribution </li></ul><ul><li>Generalisation </li></ul><ul><li>Use and ultility </li></ul>08/03/09
    23. 23. Summary <ul><li>What works to reduce AEs – rigorous research in one setting </li></ul><ul><li>Where works best ? </li></ul><ul><ul><li>Which implementation and context; context insensitive/ robust? </li></ul></ul><ul><li>Why it works? </li></ul><ul><ul><li>explain pathways of influence & intermediate and ultimate effects </li></ul></ul><ul><ul><li>Helps others decide if and how to implement – will it work in my service? </li></ul></ul><ul><li>How strong evidence needs to be before acting? </li></ul><ul><ul><li>Proportionate to cost and ease of implementation and risk of harm compared to alternatives (eg no action) </li></ul></ul><ul><li>. </li></ul><ul><ul><li>. </li></ul></ul>08/03/09
    24. 24. What works? <ul><li>High certainty: </li></ul><ul><ul><li>If implemented fully, will reduce Aes in most situations </li></ul></ul><ul><ul><li>Don’t know costs or how best to implement in different situations </li></ul></ul><ul><li>Probable </li></ul><ul><ul><li>In some situations </li></ul></ul><ul><li>Possible/promising </li></ul><ul><ul><li>No research, little testing experience </li></ul></ul><ul><li>Does not work </li></ul><ul><ul><li>Research high certainty in some situations, probably, possibly </li></ul></ul>08/03/09
    25. 25. What does not work? 08/03/09 “ be more careful”
    26. 26. Patient safety - what works? <ul><li>Evidence from elsewhere about </li></ul><ul><ul><li>Efficacy in rigorous study situation </li></ul></ul><ul><ul><li>Effectiveness of implementation actions, in a context </li></ul></ul><ul><li>Find and adapt this evidence to your service </li></ul><ul><li>Look for implementation research into similar changes </li></ul><ul><ul><li>To find which context factors help and hinder </li></ul></ul><ul><li>Use iterative testing with feedback on small scale to develop the intervention locally and spread </li></ul><ul><li>More at http://homepage.mac.com/johnovr/FileSharing2.html </li></ul><ul><ul><li>. </li></ul></ul><ul><li>. </li></ul><ul><ul><li>. </li></ul></ul>
    27. 27. Researchers may need guidance … 08/03/09
    28. 28. Questions to you … <ul><li>1) How to collaborate to make the needed research practical </li></ul><ul><ul><ul><ul><li>and the practical research needed? </li></ul></ul></ul></ul><ul><li>2) This was new or surprising, for me… </li></ul><ul><li>Reviews of research download from safety folder on web site http://homepage.mac.com/johnovr/FileSharing2.html </li></ul>08/03/09
    29. 29. . <ul><li>. </li></ul>08/03/09
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