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The Canadian Human Factors in Healthcare Network2455Research;Guide9/12/2017 2:58:38 PM The Canadian Patient Safety Institute (CPSI), through the SHIFT to Safety program, has teamed up with the Canadian Human Factors in Healthcare Network to provide human factors information to healthcare organizations and the professionals who work there to add to their existing knowledge base related to quality and patient safety. Many healthcare professionals in Canada have, by now, heard about human factors engineering and psychology from other patient safety activities or venues, including the WHO human factors module and CPSI modules and presentations on human factors. The network's intent is to provide up to date information about human factors research and trends in Canada and around the world that go beyond the basics. As technology evolves and changes the way we do work, human factors specialists and researchers can help determine ways to improve the safety of the new ways of working. Use the links on the right hand side of the page to learn more about the Canadian Human Factors in Healthcare Network, its members and upcoming learning opportunities. SHIFT to Safety brings you the latest in advancements in human factors in healthcare. Shift your focus to what you do best — improving your practices for the benefit of your patients. The Canadian Human Factors in Healthcare Network is currently supported by the CPSI and in-kind funding by the member organizations. Objective of the Network Provide human factors expertise to healthcare organizations through consultation, knowledge transfer and exchange activities. Promote partnerships between healthcare organizations, industry, and academic institutions to promote the delivery of safer, more effective care to patients. If you have any questions for the members of the Healthcare Human Factors Network, please email The Canadian Human Factors in Healthcare Network The Canadian Patient Safety Institute (CPSI), through the SHIFT to Safety program, has teamed up with the Canadian Human Factors in Healthcare4/25/2018 7:36:44 PM115
Enhanced Recovery After Surgery2458Video7/13/2016 2:57:58 AM What is Enhanced Recovery After Surgery? Enhanced Recovery After Surgery - ERAS is a program highlighting surgical best practices and consists of a number of evidence-based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. As part of CPSI's Integrated Patient Safety Action Plan for Surgical Care Safety and with support from 24 partner organizations from across the country, Enhanced Recovery Canada is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles. A number of Canadian surgical care teams have already embraced the ERAS principles Alberta Health Services, Eastern Health, McGill University Health Centre, University of Toronto's Best Practices in Surgery, the Winnipeg Regional Health Authority as well as BC's Patient Safety & Quality Council and the Doctors of British Columbia. Additional Information Position Statement Video Series We trust this 6 part interview with international ERAS expert Dr. Henrik Kehlet will whet your appetite. Stay tuned for additional information regarding Enhanced Recovery Canada. Use the YouTube playlist below to play all, or any of the six videos in the series. Where can you learn more about ERAS in the interim? BC's ERAS Collaborative has developed a website providing a variety of resources to support the implementation of Enhanced Surgical Recovery programs. See Enhanced Recovery BC The McGill University Health Center has developed a number of ERAS related Surgery Patient Guides you may find helpful as well. Connect with an experienced ERAS coordinatorIndustry Partners Gold Level Silver Level Bronze Level For more information, contact us at Recovery CanadaWhat is Enhanced Recovery After Surgery ? Enhanced Recovery After Surgery - ERAS is a program highlighting surgical best practices and consists of a4/10/2018 8:23:58 PM661
Deteriorating Patient Condition2427Toolkits3/30/2017 5:19:46 PM Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical inpatient events are preceded by warning signs that occur approximately six-and-a-half hours in advance. In this section, you'll find information, tools and resources to not only help you recognize deteriorating patient condition, but what you can do to act on it as a member of the public, a healthcare provider or leader. Click any of the icons below to get started! Deteriorating Patient ConditionEarly warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical4/10/2018 3:45:44 PM145
Safety at Home: A Pan-Canadian Home Care Study5895Research7/1/2015 2:02:05 AM ​​One out of every six seniors receives home care services in Canada. As the aging population continues to grow there is a greater need to ensure the delivery of Home Care in Canada is safe. The release of The Safety at Home A Pan- Canadian Home Care Study is the first of its kind that examines adverse events in the home and includes recommendations on how to make care safer. Dr. Diane Doran, professor at the Faculty of Nursing at the University of Toronto, co-lead Dr. Régis Blais, professor at the Department of Health Administration at the University of Montreal, and their team spent the last two years examining administrative databases and reviewing charts across the country which showed the rate of adverse events in Canadian Home Care clients was 10 -13 per cent, over a period of one year. Extrapolating to the over one million home care recipients, that is up to 130,000 Canadians, who have experienced an adverse event, with half being deemed to be preventable. The Canadian Patient Safety Institute partnered with other sponsoring organizations for the study including, the Canadian Institutes of Health Research (CIHR), Institutes of Health Services and Policy Research (IHSPR), The Change Foundation, and the Canadian Foundation for Healthcare Improvement (CFHI). The study examined the reasons for harmful incidents, determined the impact on families and clients and made suggestions on how to make home care safer. The research team in collaboration with CPSI and national partners such as Canadian Home Care Association, Accreditation Canada, and Victoria Order of Nurses will be developing tools and resources for various audiences including clients, caregivers, Home Care organizations, and policy makers. Watch for the launch of these tools on the CPSI website. Download Journal article Assessing adverse events among home care clients in three Canadian provinces using chart review Click here to access the News Release.Safety at Home: A Pan-Canadian Home Care Study One out of every six seniors receives home care services in Canada.   As the aging population continues to grow there is a greater need to11/9/2016 4:52:19 PM308
A Framework for Establishing a Patient Safety Culture2439Framework2/14/2018 4:54:19 PMPatient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety culture necessitates interventions that simultaneously enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardization/alignment. Download a one-pager of the Patient Safety Culture Bundle for CEOs/Senior Leaders Why was this Bundle created? A patient safety culture is difficult to operationalize. Improving safety requires an organizational culture that enables and prioritizes patient safety. The importance of culture change needs to be brought to the forefront, rather than taking a backseat to other safety activities. The National Patient Safety Consortium Education Working Group verified the critical role senior leadership plays in ensuring patient safety is an organizational priority. A Working group of partners, led by the Canadian Patient Safety Institute, Canadian College of Health Leaders (CCHL), HealthCareCAN and the Healthcare Insurance Reciprocal of Canada (HIROC) were brought together to establish a framework and advance this work. How can I use the Patient Safety Culture Bundle? The key components required for a Patient Safety Culture are identified under three pillars ENABLING ENACTING LEARNING Within each pillar you will find links to valuable tools and resources to help your efforts in establishing and sustaining a patient safety culture.Are you looking to establish and sustain a culture of safety? We are committed to providing a robust framework to advance a safety culture. The Bundle is a dynamic tool that will be continually updated. We invite you to check back often for more links and resources. We also need your participation and input to ensure the Bundle is current and relevant. Please forward any links or comments to info@cpsi-icsp.caTestimonials "Patient safety and healthcare quality are advanced when boards and senior leaders are committed to it and are able to show evidence of that commitment. Missing until now is a concise "how to" guide. The Patient Safety bundle for Leaders fills that gap." Catherine Gaulton, CEO, HIROC "Leadership is critical to developing a patient safety culture and building leadership capacity requires a vision of the knowledge, skills and behaviours necessary to achieve this. The Patient Safety Leadership Bundle provides this and will be a practical tool for health leaders across the healthcare continuum to assess their personal capabilities. It will also provide both organizations and the system, as a whole, a checklist for what's missing from our collective leadership education toolkits so that we can strategically respond to these needs. HealthCareCAN is committed to the spread of this tool across the country as part of a cultural shift to safety and a drive towards high-reliability culture." Dale Schierbeck, Vice-President, Learning & Development, HealthCareCAN and Co-Chair, Patient Safety Education for Leaders Working A Framework for Establishing a Patient Safety CulturePatient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety5/4/2018 7:40:08 PM969
Canadian Disclosure Guidelines2445Guide;Publication4/18/2011 4:05:57 PM ​​​​​​​​​​​​The Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare providers, inter-professional teams, organizations, and regulators. These guidelines symbolize a commitment to patients’ right to be informed if they are involved in a patient safety incident by promoting a clear and consistent approach to disclosure, emphasizing the importance of inter-professional teamwork, and supporting learning from patient safety incidents. The development of the Canadian Disclosure Guidelines is a significant achievement in healthcare in Canada.​ Download Canadian Disclosure Guidelines (November 2011) Backgrounder Development of the Canadian Disclosure Guidelines (2006) The Impact of Disclosure on Litigation (2007)​Canadian Disclosure Guidelines: Being open with patients and familiesThe Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare6/20/2016 8:35:25 PM1008
Patient Stories24497/27/2015 12:39:48 PM ​​​​​​​​​​​​​​​​​​​​​​​​​​​Patient Stories5/19/2016 4:22:33 AM1066
STOP! Clean Your Hands Day2363Events6/3/2015 4:46:05 PM​​​​​​ Clean your hands the bug stops here! #thebugstopshere #thebugstopshere This year's theme is Clean your hands THE BUG STOPS HERE! Cleaning your hands is one of the best ways to prevent infection. We want the bug to stop here. Join us this year as we ask everyone to STOP! Clean Your Hands to stop bugs in their tracks. Whether you're a patient, provider or work in a healthcare setting – if you're involved in the healthcare system, take the time to have a conversation with yourself and ask what you can change today to improve for tomorrow. Here's a run down of what we've got planned for STOP! Clean Your Hands Day 2018#thebugstopshere quiz Put your hand hygiene prowess to the test Take the quiz #thebugstopshere webcast Date May 4th, 2018 10amMT/ 12pm ET Want to Improve Hand Hygiene Compliance? Join us May 4th to gain a fresh perspective on your hand hygiene program! #thebugstopshere Learn More #thebugstopshere photo contest On May 4th we want you to #STOPCleanYourHands to help save lives. Download and print our photo contest poster below; then use it when you Tweet photos of you cleaning your hands. Use the hashtag #thebugstopshere. Encourage friends, family and colleagues to join the fight against the spread of infection. Prizes to be won. Download If you do not have a Twitter account, you may complete the form to enter Enter Sponsored by ​Partners STOP! Clean Your Hands Day Clean your hands: the bug stops here! #thebugstopshere #thebugstopshere This year's theme is Clean your hands: THE BUG5/11/2018 2:39:18 PM16723
Incident Analysis2434Framework;Publication4/19/2011 9:12:41 PM ​​​​​​​​​​​​​​Analyze, manage, and learn from patient safety incidents in any healthcare setting with the Canadian Incident Analysis Framework. Incident analysis is a structured process for identifying what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It is an integral activity in the incident management continuum, which represents the activities and processes that surround a patient safety incident. The framework was developed collaboratively by CPSI, the Institute for Safe Medication Practices Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn Hoffman, and Micheline Ste-Marie and is based on the 2006 Canadian Root Cause Analysis Framework. Download To learn more about the framework and the resources available, you can click here to watch the information webinars recorded. The following resources have been carefully selected to support you in implementing the Canadian Incident Analysis Framework. To contribute a resource or to provide feedback, please email To learn more about the framework and the learning opportunities available click here. Incident AnalysisRoot Cause Analysis (RCA)6/20/2016 3:47:55 PM1088
The Measurement and Monitoring of Safety2435Metrics;Report;Framework7/12/2016 5:25:21 PM Rewiring your thinking on measuring and monitoring of patient safety. To improve your organization's patient safety, you need reliable, up-to-date qualitative and quantitative information to help guide your delivery of safe healthcare. The Measurement and Monitoring Safety Framework, created by Professor Charles Vincent and colleagues from the Health Foundation, consists of five dimensions that organizations, units, or individuals including leaders, providers, patients and families can use to understand, guide and improve patient safety. This new approach assesses and evaluates safety from "ward to board" by providing a comprehensive and accurate real-time view of patient safety. The Framework helps users move from “assurance” to “inquiry” by shifting away from a focus on past cases of harm towards current performance, future risks and organizational resiliency. Download Armed with a series of valuable questions, you can make better decisions about the safety of the care you provide. The primary questions are Has patient care been safe in the past? Are our clinical systems and processes reliable? Is our care safe now? Will our care be safe in the future? Are we responding and improving? The Framework will be foundational to CPSI's new measurement coaching services offered by its Central Measurement Team. Stay tuned for additional details on how to access these coaching services. For more information, contact us at "The Framework helps us think differently, and have different conversations at different levels, whether it be at ward level through safety huddles and safety briefs in the morning, the hospital safety brief, or through other scheduled meetings. By doing this we can ensure everything we do every day for our patients and for our staff is focused on the same thing. We consider different components to determine if it's affected by system, process, or human factor and determine what we should do differently." -- Charlie Sinclair, Associate Director, Nursing NHS BordersThe Measurement and Monitoring of SafetyRewiring your thinking on measuring and monitoring of patient safety. To improve your organization's patient safety, you need reliable, up-to-date5/2/2018 7:15:51 PM204
The Safety Competencies Framework2419Publication;Framework4/14/2009 11:53:32 PM ​​​Achieve safe patient care by incorporating our framework The Safety Competencies into your healthcare organization’s educational programs and professional development activities. Patient safety, defined as the reduction and mitigation of unsafe acts within the healthcare system, and the use of best practices shown to lead to optimal patient outcomes, is a critical aspect of quality healthcare. Download Flyer Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is critical to creating one of the safest health systems in the world. The Safety Competencies is a highly relevant, clear, and practical framework designed for all healthcare professionals. Created by the Canadian Patient Safety Institute (CPSI), The Safety Competencies has six core competency domains Domain 1 Contribute to a Culture of Patient Safety – A commitment to applying core patient safety knowledge, skills, and attitudes to everyday work. Domain 2 Work in Teams for Patient Safety – Working within interprofessional teams to optimize patient safety and quality of care.. Domain 3 Communicate Effectively for Patient Safety – Promoting patient safety through effective healthcare communication.. Domain 4 Manage Safety Risks – Anticipating, recognizing, and managing situations that place patients at risk.. Domain 5 Optimize Human and Environmental Factors – Managing the relationship between individual and environmental characteristics in order to optimize patient safety.. Domain 6 Recognize, Respond to, and Disclose Adverse Events – Recognizing the occurrence of an adverse event or close call and responding effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence.. This valuable framework includes 20 key competencies, 140 enabling competencies, 37 knowledge elements, 34 practical skills, and 23 essential attitudes that can lead to safer patient care and quality improvement. CPSI encourages its stakeholders, national, provincial, and territorial health organizations, associations, and governments; and universities and colleges to play a role in engaging stakeholders and spreading the word about this program so that healthcare professionals recognize the knowledge, skills, and attitudes needed to enhance patient safety across the spectrum of care. For further information, please email Safety CompetenciesThe Safety Competencies: Message from the CEO9/12/2017 8:43:40 PM945
Venous Thromboembolism Prevention (VTE): Getting Started Kit Components2444Getting Started Kit;Toolkits2/9/2017 6:41:38 PM Venous thromboembolism comprises both deep vein thrombosis (DVT) and pulmonary embolism (PE) and is one of the most common and preventable complications of hospitalization.1 Many risk factors for developing VTE have been identified (see Table 1), but the most common risk factor in hospitalized patients is reduced mobility. Almost every hospitalized patient has at least one of these risk factors for VTE and most have multiple risk factors.2 The VTE Getting Started Kit provides you with evidence-based resources to assist you in increasing the use of appropriate thromboprophylaxis in acute care hospitalized patients and aligns with Accreditation Canada's Required Organizational Practices on VTE prevention. This free resource contains clinical information, information on the science of improvement, and everything you need to know to optimize the appropriate use of thromboprophylaxis. Getting Started Kit The Venous Thromboembolism Prevention Getting Started Kit is divided into eight sections Section 1 Rationale for VTE Prophylaxis Section 2 Evidence-Based Appropriate VTE Prophylaxis Section 3 Adherence to VTE Prophylaxis Section 4 A Formal Process to VTE Prophylaxis Quality Improvement The 10 Steps Section 5 VTE Prophylaxis Improvement Guide Section 6 Measurement and the VTE Improvement Program Section 7 Measurement - Technical Descriptions and Worksheets Section 8 Appendices Want to learn more? Download the complete Venous Thromboembolism Prevention Getting Started Kit Download This document was updated in January 2017 For more information, email or call 1-866-421-6933Venous Thromboembolism Prevention (VTE): Getting Started Kit Components Venous thromboembolism comprises both deep vein thrombosis (DVT) and pulmonary embolism (PE) and is one of the most common and2/10/2017 9:01:24 PM219
Healthcare Provider Stories245310/19/2015 4:42:11 PM​​ Healthcare Provider Stories10/26/2015 3:41:32 PM191
Venous Thromboembolism: Introduction5626Guide4/14/2015 5:50:41 PM​​​Overvie​w​ Venous thromboembolism (VTE) comprises both deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT occurs when an abnormal blood clot forms inside a vein deep in the leg. DVT may cause leg pain and/or swelling but is often clinically silent. PE occurs when all or part of a DVT breaks away from its site in a vein and travels through the venous system to lodge in the lungs. PE may cause chest pain, shortness of breath, tachycardia, hemoptysis, or pre-syncope but is often clinically silent. In pregnancy, due to hormonal influences on vascular tone and compressive effects on veins by the enlarging uterus, DVT in pregnancy generally presents in the lower extremities, with a predisposition for the left leg (70 to 80 per cent). In contrast to their presentation in non-pregnant patients, DVTs are often isolated to the iliac and/or femoral vein during pregnancy (61 per cent) (Chan et al., 2014).The first and second trimesters of pregnancy convey similar risks for DVT, with a higher risk in the third trimester and the first three weeks postpartum. PE occurs more commonly postpartum, decreasing in incidence after the first six weeks (Chan et al., 2014).Implications VTE is one of the most common and preventable complications of hospitalization. The rate of asymptomatic hospital-acquired DVT, if thromboprophylaxis is not used, is 10 to 40 per cent after general surgery and 40 to 60 per cent after hip surgery. The rate of symptomatic VTE is up to five per cent (or more) of medical and surgical patients if thromboprophylaxis is not used (Geerts et al., 2008). VTE remains an important cause of maternal morbidity and mortality in Canada with an overall incidence of DVT and PE of 12.1 per 10,000 and 5.4 per 10, 000 pregnancies, respectively (Chan et al., 2014). VTE occurs at a rate of 5.4 per 10,000 antepartum, 7.2 per 10,000 peripartum, and 4.3 per 10,000 pregnancies postpartum. Postpartum PE is a leading cause of maternal mortality in Canada, with up to 17 maternal deaths each year (Chan et al., 2014).Goal To prevent VTE in hospitalized adult and obstetrical patients by implementing strategies which increase the use of evidence-based thromboprophylaxis. ​Back to Hospital Harm Indicator Home Page DownloadVenous Thromboembolism: IntroductionOverview Venous thromboembolism (VTE) comprises both deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT occurs when an abnormal blood clot10/20/2016 2:39:59 PM18
Medication Incidents: Introduction5618Guide9/2/2016 4:55:37 PMGoal To prevent medication-related events involving incorrect administration or dosage of medications during a hospital stay.Overview and Implications Medication incidents are defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communication, product labeling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use" (ISMP Canada, Definitions, 2016). Medication safety is a shared responsibility among the healthcare team members, staff, and organizational leadership. In the Canadian Adverse Events Study, drug- and fluid-related events were the second-most common type of adverse event (Baker et al., 2004). The Institute of Medicine (IOM) Committee on Identifying and Preventing Medication Errors estimated that at least 1.5 million preventable adverse drug events (ADEs) occur each year in the United States (Aspden et al., 2006). The Institute of Medicine report, To Err is Human Building a Safer Health System, identified medication events as the most common type of adverse event in healthcare and highlighted that in the U.S., preventable medication events resulted in up to 7,000 deaths per year in hospitals and tens of thousands more in outpatient facilities. A study by Lucian Leape and colleagues identified the frequency of occurrence of error at each stage of the hospital medication use process prescribing 39 per cent, order processing and transcription 12 per cent, dispensing 11 per cent and administration 38 per cent. Nearly half of the prescribing errors were intercepted by nurses and pharmacists and about one third of transcription errors were identified and corrected prior to administration. However, only two per cent of errors occurring at the administration stage were intercepted (Leape et al., 1995). Several more recent studies have assessed the prevalence of medication incidents and cost to the health care system (Bell et al., 2011; Bishop et al., 2015; Scales et al., 2016; Lee et al., 2010). High Alert Medications High-alert (or high-hazard) medications are medications that bear a heightened risk of causing significant patient harm when they are used in error. The Institute for Safe Medication Practices (ISMP) reports that, although mistakes may not be more common in the use of these medications, when errors do occur, the impact on the patient can be significant (ISMP, 2011). Examples of high-alert medications include anticoagulants, hypoglycemic agents, opioids, concentrated electrolytes, cancer chemotherapy and paralyzing agents. For a complete list, see ISMP High-Alert Medications in Acute Care Settings. Known safe practices can reduce the potential for harm as listed below under Evidence-Informed Practices "Implement High Alert Medication Safety Processes" (IHI, 2012).Medication Reconciliation Communicating effectively about medications is a critical component of delivering safe care. By identifying and resolving medication discrepancies, the likelihood of adverse events occurring within health care organizations across the continuum of care will be reduced (Accreditation Canada et al., 2012). Medication reconciliation is a three-step process in which healthcare providers work together with patients, families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care (Safer Healthcare Now! 2011). Medication reconciliation requires a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully evaluated. It is an essential component of medication management and will inform and enable prescribers to make the most appropriate prescribing decisions for the patient. The literature regarding the potential impact of medication reconciliation continues to expand. The reconciling process has been demonstrated to be a powerful strategy to reduce ADEs as patients move from one level of care to another (Alex et al., 2016; Boockvar et al., 2011; Eggnik et al., 2010; Vira et al., 2006; Whittington, Cohen, 2004; Rozich et al., 2004; Mekonned et al., 2016; Michels, Meisel, 2003).Never Events (Canadian Patient Safety Institute, 2015) A Never Events Report for Hospital Care in Canada includes Five Pharmaceutical Never Events that result in serious patient harm or death, and that can be prevented by using organizational checks and balances Wrong-route administration of chemotherapy agents, such as vincristine administered intrathecally (injected into the spinal canal). Intravenous administration of a concentrated potassium solution. Inadvertent injection of epinephrine intended for topical use. Overdose of hydromorphone by administration of a higher-concentration solution than intended (e.g., 10 times the dosage by drawing from a 10 mg/mL solution instead of a 1 mg/mL solution, or not accounting for needed dilution/ dosage adjustment). Neuromuscular blockade without sedation, airway control and ventilation capability. Capturing information about the incidence of never events and sharing the learning from reviews of incidents will be key to following system safety progress over time. Back to Hospital Harm Measure DownloadMedication Incidents: IntroductionGoal To prevent medication-related events involving incorrect administration or dosage of medications during a hospital stay. Overview and10/20/2016 2:41:46 PM20
Infusion, Transfusion and Injection Complications: Introduction56204/10/2017 4:01:08 PMAir embolism following infusion, transfusion and therapeutic injection An air embolism is a bubble that becomes trapped in a blood vessel and blocks the vessel. It is a rare but potentially fatal event. The seriousness of the blockage depends on which part of the body the affected blood vessel supplies blood to, and the size of the air bubble. For example, an air embolism in the arteries leading to the brain may cause a decreased level of consciousness, dizziness, slurred speech, seizures, and/or a stroke. An air embolism that travels to the coronary arteries may cause a myocardial infarction or an arrhythmia. An air embolism that travels to the lungs may cause a pulmonary embolism (Gordy & Rowell, 2013; National Health Service, 2015).Vascular complications following infusion, transfusion and therapeutic injection Phlebitis refers to inflammation of the vein and it may be a complication of peripheral cannulation. Phlebitis may be painful, and it compromises future venous access. Other symptoms include warmth, tenderness, erythema or palpable venous cord. If it is bacterial and untreated, it may lead to a bloodstream infection. Phlebitis may be localized to the insertion site or travel along the vein. It may occur during catheterization or up to 48 hours after cannula removal (Ray-Burruel et al., 2014).ABO incompatibility reaction Acute hemolytic transfusion reaction is a possible complication of a blood transfusion. It may be associated with ABO-incompatibility, other blood group incompatibilities (there are 29 blood group systems, in addition to ABO, that may cause incompatibility), and with rare cases when group O platelets with high titers of anti-A and/or anti-B are transfused to a non-group O recipient (Callum et al., 2016; Fung et al., 2007). ABO-incompatibility is the most common cause of morbidity from RBC transfusion. The reaction is often due to a clerical error, or an error in patient identification. Half of all errors are due to administering properly labelled blood to the wrong patient, while other errors are the result of improper labelling of samples or testing errors. One in 38,000 red cell transfusions are ABO-incompatible due to transfusing the wrong blood to a patient, and less than 10 per cent of ABO-incompatible transfusions result in a fatal outcome. The risk of death correlates with the amount of incompatible blood transfused (Callum et al., 2016). Symptoms of hemolytic reaction include back pain, bloody urine, chills, fainting or dizziness, fever, flank pain and flushing of the skin (National Heart Lung and Blood Institute, 2011, Transfusion reaction, 2016).Rh incompatibility reaction Rh is known as the D antigen. Less than 15 per cent of the population do not have this antigen expressed on their red blood cells and are typed as D negative, more commonly known as Rh negative. If an Rh negative person is exposed to Rh positive blood, either by a blood transfusion or their fetus during pregnancy, a small percentage will form an antibody to the D antigen (Anti-D). If the patient does develop anti-D, subsequent exposures to Rh positive blood products can produce a hemolytic reaction (Ontario Regional Blood Coordinating Network, 2016). In the case of pregnancy, if an Rh negative mother develops Anti-D during her first pregnancy with an Rh positive baby, her second or subsequent babies could suffer devastating effects as the anti-D in her plasma may attack the D-antigen on the surface of the baby's red cells causing hemolysis. This is a known cause of hemolytic disease of the fetus and newborn (HDFN). An infant with HDFN may show signs of anemia, jaundice, hypotonia, lethargy, or in some cases, brain damage or even death can occur. The administration of Rh Immune globulin (Rhogam) during prenatal care can reduce the likelihood of developing Anti-D, which would affect future pregnancies (Ontario Regional Blood Coordinating Network, 2016).Anaphylaxis to serum Anaphylactic shock can result from a blood transfusion. It is the most severe form of allergic reaction and accounts for approximately three per cent of transfusion associated fatalities (Food and Drug Administration, 2009). The occurrence rate for anaphylaxis is rare at one in 40,000. The vast majority of anaphylactic reactions are unexplained (Callum et al., 2016). Anaphylactic/anaphylactoid reactions usually begins within one to 45 minutes of the start of the infusion and are associated with cutaneous reactions (urticaria), hypotension, hypoxia, hoarseness, stridor, wheezing, chest pain, dyspnea, anxiety, feelings of impending doom, gastrointestinal symptoms (nausea, vomiting) and rarely death (Callum et al., 2016).Other serum reactions Urticaria may present as one lesion or be widespread lesions. Urticaria may be associated with pruritus, erythema, flushing or mild upper respiratory symptoms (cough, wheezing), nausea, vomiting, abdominal cramps or diarrhea (Callum et al., 2016). Minor allergic reactions affecting the skin with occurrence of hives, rash, and urticaria are far more common occurring at a rate of one in 100 blood products transfused (Callum et al., 2016).Goal Reduce the incidence of complications following infusion, transfusion and therapeutic injection. Back to Hospital Harm Measure DownloadInfusion, Transfusion and Injection Complications: IntroductionAir embolism following infusion, transfusion and therapeutic injection An air embolism is a bubble that becomes trapped in a blood vessel and4/12/2017 3:29:07 PM22
Aspiration Pneumonia: Introduction56289/30/2016 7:53:42 PMOverview Nosocomial pneumonia can be classified into various subtypes, the most common of which is aspiration pneumonia (Marik, 2011). Aspiration is defined as the misdirection of oropharyngeal or gastric contents into the larynx and lower respiratory tract. Aspiration pneumonia then results when orogastric secretions colonized with bacteria produce an infectious response in the lungs. Aspiration of sterile contents causes chemical inflammation or aspiration pneumonitis (Marik, 2011). There are three causes for aspirations that lead to aspiration pneumonia 1. Orogastric secretions in patients with marked disturbance of consciousness. For example, acute neurological insult including stroke or head trauma. 2. Misdirected orally ingested liquids and/or foods due to swallowing difficulties secondary to a medical condition or intervention. For example, progressive neurological illnesses including Parkinson’s disease, ALS as well as tumours of the head and neck or iatrogenic causes such as head and neck cancer treatments such as surgical ablation, chemoradiation therapy and damage to the laryngeal area following prolonged endotracheal intubation. 3. Misdirected orally ingested liquids and/or foods due to aging process. Pneumonitis is best defined as acute lung injury following the aspiration of regurgitated gastric contents. This syndrome occurs in patients with a marked disturbance of consciousness, such as drug overdose, seizures, and anesthesia. Drug overdose is a common cause of aspiration pneumonitis, occurring in approximately 10 per cent of patients hospitalized following a drug overdose. The risk of aspiration increases with the degree of unconsciousness (as measured by the Glasgow Coma Scale). Historically, the syndrome most commonly associated with aspiration pneumonitis is Mendelson’s syndrome (Marik, 2011). Aspiration pneumonia occurs when regurgitated gastric contents or oropharyngeal secretions or food are inadvertently directed into the trachea and subsequently into the lungs. As the bacteria and other microorganisms become part of an infiltrate within the lung tissue, the resulting effect is an infection in the lung (Pace & McCullough, 2010). Approximately half of all healthy adults aspirate small amounts of oropharyngeal secretions during sleep. However, if the mechanical, humoral, or cellular mechanisms are impaired or if the aspirated inoculum is large enough, pneumonia may follow. Any condition that increases the volume and/or bacterial burden of oropharyngeal secretions when the host defense mechanism is impaired may lead to aspiration pneumonia (Marik, 2011). Healthy people commonly aspirate small amounts of oral secretions, but normal defense mechanisms usually clear the inoculum without sequelae. Aspiration of larger amounts, or aspiration in a patient with impaired pulmonary defenses, often causes pneumonia and/or abscess. Elderly patients tend to aspirate because of conditions associated with aging that alter the level of consciousness, sedative use, neurologic disorders, weakness and other disorders. Empyema also occasionally complicates aspiration (Sethi, 2014). Paediatric populations have different causes of dysphagia than in adult populations. These causes include cerebral palsy; acquired/traumatic brain injury; other neuromuscular disorders; craniofacial malformations; airway malformations; congenital cardiac disease; gastrointestinal disease; ingestional injuries; and preterm birth (Dodrill & Gosa, 2015; Lefton-Greif & Arvedson, 2007). Risk factors for aspiration pneumonia and pneumonitis (DiBardino, 2015; Marik, 2011, American Association of Neuroscience Nurses, 2006) 1. Dysphagia/swallowing 2. Altered mental status or decreased alertness and attention span 3. Esophageal motility disorders/vomiting 4. Enteral (tube) feeding 5. Poor oral hygiene, decrease in salivary clearance 6. Increased impulsiveness or agitation 7. Use of medications such as psychotropic, neuroleptic, antidepressants, anticholinergic, or phenothiazine drugs 8. Hyperextended neck or contractures 9. Facial or neck reconstruction, cancers and their treatments 10. Long-term intubation 11. Advancing age due to decreased muscle mass reducing pharyngeal contraction and bolus drive 12. Supine position Paediatric risk factors for aspiration pneumonia (Weir et al, 2007) 1. Trisomy 21 2. Asthma 3. Gastroesophageal reflux disease (GERD) 4. Lower respiratory tract infection 5. Moist cough 6. Multisystem diagnoses Implications Aspiration pneumonia represents five per cent to 15 per cent of pneumonias in the hospitalized population (DiBardino, 2015). It has been suggested that dysphagia carries a seven-fold increase risk of aspiration pneumonia and is an independent predictor of mortality (Metheny, 2011). Critically ill patients have an increased risk for aspirating oropharyngeal secretions and regurgitated gastric contents. For those who are tube-fed, aspiration of gastric contents is of greater concern. While witnessed large-volume aspirations occur occasionally, small-volume clinically silent aspirations are far more common. Because no bedside tests are currently available to detect microaspirations, efforts to prevent or minimize aspiration take on added importance (American Association of Critical-Care Nurses, 2016). Silent aspiration is frequent in the pediatric population (Lefton-Grief et al, 2006; Arvedson et al, 1994). Aspiration pneumonia generally occurs in elderly, debilitated patients with dysphagia (Marik, 2011). Epidemiological studies have demonstrated that the incidence of pneumonia increases with aging, with the risk being almost six times higher in those over the age of 75, compared to those less than 60 years of age (Marik, 2011). Aspiration pneumonia is the major cause of death in patients with dysphagia resulting from neurological disorders including cerebrovascular accidents, Parkinson’s disease, and dementia (Marik, 2011).Goal To prevent aspiration pneumonia and aspiration pneumonitis in hospitalized patients by implementing strategies known to reduce the incidence of aspiration pneumonia and pneumonitis. Back to Hospital Harm Measure DownloadAspiration Pneumonia: IntroductionOverview Nosocomial pneumonia can be classified into various subtypes, the most common of which is aspiration pneumonia (Marik, 2011). Aspiration4/5/2017 7:30:41 PM31
Sepsis: Introduction5617Guide9/29/2016 2:33:58 PMOverview Recently, sepsis has been redefined as “life-threatening organ dysfunction caused by dysregulated host response to infection” (Singer, 2016). It affects neonatal, pediatric, and adult patients worldwide. Differentiated from an uncomplicated infection by virtue of the dysregulated host response and acute organ dysfunction, sepsis can present as or progress to septic shock, recently redefined as “a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.” (Singer, 2016) For patient identification, organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score (Vincent, 1996) of two points or more, which is associated with an in-hospital mortality greater than 10 per cent. Patients with septic shock can be identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater AND serum lactate level greater than 2 mmol/L in the absence of hypovolemia (i.e. after adequate fluid resuscitation). This combination is associated with hospital mortality rates greater than 40 per cent (Singer, 2016). These recent modifications were made in order to better integrate the definitions with evolving concepts of this syndrome. Pending future reports, the definitions and diagnostic criteria for pediatric and neonatal sepsis should be considered similar to adult definitions, inclusive of age-specific cut-off values (Goldstein, 2005; Dellinger, 2013). Maternal sepsis refers to sepsis occurring during pregnancy, childbirth and the puerperium. It encompasses a complicated clinical scenario due to the presence of an additional patient (the fetus) and significant pregnancy-related alterations in cardiorespiratory, immunological and metabolic functions.Implications Sepsis is a growing health concern in Canada as well as in the rest of the world (CIHI, 2009; Adhikari, 2010). In Western countries, the incidence of sepsis in adults and children continues to rise despite a significantly decreased, but still unacceptably high, mortality rate of 20 to 30 per cent (Annane, 2003; Dombrovskiy, 2007; Angus. 2001, 2013; Friedman, 1998; Stevenson, 2014; Lagu, 2012; Kaukonen, 2015). Despite advances in the understanding of the pathophysiology of sepsis, of provider training, better surveillance, monitoring and prompt initiation of therapy, there is still much room for improvement as sepsis remains one of the most deadly emergency department arrival or hospital-acquired conditions (Donald, 2015). Similar to other time-sensitive disorders such as polytrauma, acute myocardial infarction, or stroke, the speed and appropriateness of therapy administered in the initial hours after sepsis develops are likely to influence outcome. These features suggest the opportunity for earlier recognition and management of sepsis in improving the outcomes of these patients (Liu, 2014), which, unfortunately, is often not the case. Indeed, in two studies, timely initiation and completion of adequate sepsis management were only between 40 to 58 per cent and 10 to 43 per cent respectively (Mikkelsen, 2010; Ferrer, 2008). Similar observations have been made for pediatric and maternal sepsis (Safer Healthcare Now! Sepsis, 2015). Sepsis can be prevented in two ways 1. Treating infections early and appropriately before they develop into sepsis. 2. Identifying, mitigating or preventing risk factors related either to the patient or as a result of care delivered to them. Examples of risk factors are · Age (higher risk in infants and elderly persons than in other age groups). · Chronic diseases with/without severe organ dysfunction. · Immunodeficiency. · Immunosuppressive agents. · Inappropriate use of antibiotics. · The presence of implanted medical devices (intravascular or other). · Prematurity. · Infection is more likely to occur when the normal anatomy is altered by a process – benign or malignant - that either obstructs a normal passage (e.g. calculous cholecystitis, prostatitis) or breaks and enters a previously sterile system (e.g. skin breakdown by trauma, dermatological conditions). · Patients unable to communicate their symptoms often present later in their illness (i.e. often with sepsis). Risk factors for the development of maternal sepsis also include factors affecting the pregnancy itself (home birth in unhygienic conditions, low socioeconomic status, history of pelvic infection or of group B streptococcal infection, poor nutrition, diabetes, anemia, primiparity, prolonged rupture of membranes, prolonged labor), multiple pregnancy, pregnancy-related genital manipulation/procedures, multiple (>5) vaginal examinations in labor, cervical cerclage, amniocentesis, artificial reproductive techniques, obstetrical manoeuvres, unassisted vaginal delivery, caesarean section, preeclampsia and postpartum hemorrhage. Healthcare-associated infections (HAIs) can lead to sepsis and its deleterious outcomes (Riley 2012). HAIs represent the most common complication affecting hospitalized patients today, with currently five to 10 per cent of patients in acute care hospitals acquiring one or more infections. Catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), surgical site infections (SSI), and ventilator-associated pneumonia (VAP) account for the vast majority of all HAIs. Each year about 8,000 Canadians die from hospital-acquired infections; and 220,000 others get infected (Zoutman, 2003). Failure to comply with evidence-based infection preventive practices for HAIs increases the incidence of hospital-acquired sepsis. Goal To decrease the morbidity and mortality from sepsis and to prevent nosocomial sepsis in the hospitalized pediatric and adult population. Back to Hospital Harm Measure Home Page Download Sepsis: IntroductionOverview Recently, sepsis has been redefined as: “life-threatening organ dysfunction caused by dysregulated host response to infection”10/20/2016 2:44:14 PM86
Hypoglycemia: Introduction562311/23/2016 4:22:39 PM Hypoglycemia is defined as any blood glucose less than 4.0 mmol/L. When blood glucose decreases to 2.8 mmol/L, cognitive impairment ensues (CDA, Clayton, Woo, Yale, 2013). Hypoglycemia is a widely recognized cause of acute, potentially fatal events. Patients with or without diabetes may experience hypoglycemia in the hospital due to co-morbidities such as heart failure, renal or liver disease, malignancy, infection or sepsis or in association with an altered nutritional state. Additional triggering events include sudden reduction of corticosteroid dose, altered ability of the patient to report symptoms, reduced oral intake, emesis, new "nothing by mouth" (NPO) status, inappropriate timing of short- or rapid-acting insulin in relation to meals, and unexpected interruption of enteral feedings or parenteral nutrition (ADA, 2015; CDA, Houlden, Capes, Clement, Miller, 2013; Rubin & Golden, 2013). Patients with diabetes are at a higher risk of hypoglycemia than other patients due to the added risk of medication errors involving insulin (Rubin & Golden, 2013). Hypoglycemia is associated with increased length of stay and inpatient mortality (Nirantharakumar et al., 2012). In patients with type 2 diabetes and established cardiovascular disease (or very high risk for cardiovascular disease), symptomatic hypoglycemia (<2.8 mmol/L) is associated with increased mortality (CDA, Clayton, Woo, Yale, 2013). Symptoms of hypoglycemia are sweating, shakiness, tachycardia, anxiety, hunger, weakness, fatigue, dizziness, difficulty concentrating, confusion and blurred vision. In extreme cases, hypoglycemia may lead to coma and death (Desimone & Weinstock, 2016). The Canadian Diabetes Association (CDA, Clayton, Woo, Yale, 2013) lists the symptoms of hypoglycemia according to neurogenic (autonomic) and neuroglycopenic symptoms (see Table 1 below). Table 1 Symptoms of hypoglycemiaNeurogenic (autonomic)NeuroglycopenicTremblingPalpitationsSweatingAnxietyHungerNauseaTinglingDifficulty concentratingConfusionWeaknessDrowsinessVision changesDifficulty speakingHeadacheDizzinessHypoglycemia with diabetes mellitus, type 1 or type 2 Insulin is the most appropriate agent for effectively controlling glycemia in-hospital (CDA, Houlden, Capes, Clement, Miller, 2013). However, insulin causes the most harm and severe adverse events of the high alert medications (CDA, Houlden, Capes, Clement, Miller, 2013; ISMP, 2016). Mild hypoglycemic events are common in medical and surgical patients with type 2 diabetes who are receiving subcutaneous insulin therapy. Increasing age, impaired renal function, daily insulin dose, and insulin regimen (basal/bolus versus SSI) are important predictors of hypoglycemia in patients with type 2 diabetes mellitus who are on insulin therapy (Farrokhi et al., 2012).Nondiabetic hypoglycemic coma and drug-induced hypoglycemia without coma Hypoglycemia is uncommon in patients who do not have diabetes. Drugs are the most common cause of nondiabetic hypoglycemia. Other causes are malnutrition and alcohol use. Hypoglycemia may also follow bariatric surgery. Drugs that may lead to hypoglycemia include Bactrim (sulfamethoxazole and trimethoprim), beta-blockers, haloperidol, MAO (monoamine oxidase) inhibitors, pentamidine, quinidine, quinine, ACE (angiotensin-converting enzyme) inhibitors, lithium and second generation antipsychotic agents as well as medications used in the treatment of diabetes, such as insulin or oral medications used for management of type 2 diabetes (Cryer, 2011; Desimone & Weinstock, 2016; Murad et al., 2009; Suzuki et al., 2009). Hypoglycemia secondary to these drugs is higher in elderly patients and in patients with sepsis, and renal or hepatic disease (Murad et al., 2009).Goal Reduce the incidence of hypoglycemia in diabetic and non-diabetic patients during a hospital stay. Back to Hospital Harm Measure DownloadHypoglycemia: IntroductionHypoglycemia is defined as any blood glucose less than 4.0 mmol/L. When blood glucose decreases to 2.8 mmol/L, cognitive impairment ensues (CDA,8/15/2017 8:25:41 PM50
Obstetric Hemorrhage: Introduction5627Guide10/7/2016 8:15:54 PMOverview Primary Postpartum Hemorrhage (PPH) is defined as excessive bleeding that occurs within the first 24 hours after delivery. Traditionally the definition of PPH has been blood loss in excess of 500 mL after vaginal delivery and in excess of 1000 mL after abdominal delivery. For clinical purposes, any blood loss that has the potential to produce hemodynamic instability should be considered PPH. The amount of blood loss required to cause hemodynamic instability will depend on the pre-existing condition of the woman. Hemodynamic compromise is more likely to occur when conditions such as anemia (e.g., iron deficiency, thalassemia) or volume-contracted states (e.g., dehydration, gestational hypertension with proteinuria) (Leduc et al., 2009) are present. Blood loss is difficult to estimate, and is frequently underestimated (Lyndon et al., 2015). Healthy women can compensate for significant blood loss before exhibiting marked signs and symptoms. This underscores the importance of clinical vigilance to manage patients who experience PPH and to ensure the development and implementation of protocols and practices to actively manage the third stage of labour (the period following the completed delivery of the newborn until the completed delivery of the placenta) to prevent PPH (WHO, 2012; Lyndon et al., 2015). PPH is one of the few obstetric complications with an effective preventive intervention and it is generally assumed that by preventing and treating PPH, most PPH-associated deaths could be avoided (Mathai et al, 2007; WHO, 2012). There are several possible reasons for severe bleeding during and after the third stage of labour, often referred to as the four T's Tone or uterine atony abnormalities of uterine contraction; Tissue retained placenta, products of conception; Trauma of the genital tract lacerations of the cervix, vagina or perineum; uterine rupture; uterine inversion; and Thrombin abnormalities of coagulation due to pre-existing states such as haemophilia A and von Willebrand's Disease, or acquired in pregnancy such as Immune Thrombocytopenic Purpura (ITP) or Disseminated Intravascular Coagulation (DIC) (Leduc, et al., 2009). Tone or "uterine atony" is the leading cause of immediate PPH (75 to 90 per cent) (Koh et al., 2009). Secondary PPH is defined as excessive vaginal bleeding from 24 hours after delivery, to up to six weeks postpartum. Most cases of delayed PPH are due to retained products of conception, choriocarcinoma, infection, and subinvolution of the placental implantation site. Other causes include, lower genital tract lacerations/hematoma, surgical injury, dehiscence of Caesarean section scar, fibroids and arteriovenous malformation and coagulopathies (Alexander, Thoas, Sanghera, 2002; ACOG, 2006; Aiken, Mehasseb, Prentice, 2012). Instrumentation and C-Section Some obstetrical interventions are found to consistently be associated with higher rates of blood loss at the time of delivery thus predisposing patients to developing PPH. Included interventions are instrumental deliveries, episiotomy and Caesarean sections, with emergency Caesarean sections associated with higher rates of blood loss. It is important to note that more recent studies suggest that some obstetrical interventions increase the likelihood of PPH in a subsequent pregnancy, and that the recent increase in PPH in developed countries, which cannot seem to be wholly explained by factors related to the current pregnancy and delivery, may be due to more distal contributory factors (Roberts et al., 2009; Briley et al., 2014).Risk Factors for PPH Table 3 of the SOGC Clinical Practice Guideline "Active Management of the Third Stage of Labour Prevention and Treatment of Postpartum Hemorrhage" (Leduc et al., 2009) lists multiple risk factors associated postpartum hemorrhage (PPH). The California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrha ge Toolkit (Lyndon et al., 2015), offers guidance on assessing for risk factors on admission as well as during labour and postpartum (see details of risk factors listed below). Table 1 Pregnancy/Admission Risk Factors (Lyndon et al., 2015) Low Medium High No previous uterine incisionPrior Caesarean birth(s) or uterine surgeryPlacenta previa, low lying placentaSingleton pregnancyMultiple gestationSuspected placenta accreta, percreta, increta≤ 4 previous vaginal births> 4 previous vaginal birthsHematocrit < 30 AND other risk factorsNo known bleeding disorderChorioamnionitisPlatelets < 100,000No history of postpartum hemorrhageHistory of previous postpartum hemorrhageActive bleeding Large uterine fibroidsKnown coagulopathy Additional risk factors that may develop in labour include Prolonged second stage. Prolonged oxytocin use. Active bleeding. Chorioamnionitis. Magnesium Sulfate treatment. Additional third stage/postpartum risk factors for hemorrhage stemming from the birth process include Vacuum- or forceps-assisted birth. Caesarean birth (especially urgent/emergent Caesarean). Retained placenta.Implications Postpartum hemorrhage is the leading cause of maternal death worldwide, with an estimated mortality rate of 140 000 per year, or one maternal death every four minutes. PPH occurs in five per cent of all deliveries and is responsible for a major part of maternal mortality. The majority of these deaths occur within four hours of delivery, which indicates that they are a consequence of the third stage of labour. Nonfatal PPH results in further interventions, such as uterine exploration, evacuation or surgical procedures. Other implications include iron deficiency anemia, exposure to blood products, coagulopathy, and organ damage with associated hypotension and shock which has the potential to jeopardize future fertility (Leduc, et. al, 2009). Despite the use of uterotonics and active management of third stage of labour to prevent PPH, increases in PPH rates have been reported from high income countries, including Canada, the United States, the United Kingdom and Australia. Rates of severe PPH and of transfusion for treatment also appear to be rising. Rates of postpartum hemorrhage and severe postpartum hemorrhage continued to increase in Canada between 2003 and 2010 [from 3.9 per cent in 2003 to 5.0 per cent in 2010] and occurred in most provinces and territories. The increase could not be explained by maternal, fetal, or obstetric factors. Routine audits of severe postpartum hemorrhage are recommended for ensuring optimal management and patient safety (Mehrabadi et al., 2014).Goal To prevent obstetrical hemorrhage from the pelvic area, genital tract, or perineum following vaginal delivery and from surgical incision after an instrument-assisted delivery or Caesarean section. Back to Hospital Harm Measure DownloadObstetric Hemorrhage: IntroductionOverview Primary Postpartum Hemorrhage (PPH) is defined as excessive bleeding that occurs within the first 24 hours after delivery.10/20/2016 2:42:19 PM69
Delirium: Introduction5622Guide8/31/2016 5:30:00 PM​​Overview Delirium (acute confusional state) is a common condition in older people, affecting up to 30 per cent of all older patients admitted to hospital. Delirium is often not recognized by clinicians. However, early recognition allows more effective non-pharmacological intervention. Delirium may be prevented in up to one-third of older patients (Safer Healthcare Now! 2013), making its detection an important benchmark for a quality initiative. Furthermore, Delirium is an under-recognized, but surprisingly common problem in hospitalized ICU patients. Up to 80 per cent of critically ill patients from various ICU populations can be identified as having Delirium or sub-syndromal Delirium according to validated screening criteria (Ouimet, Kavanagh, et al., 2007; Ouimet, Riker, et al., 2007). The most important step in Delirium management is early prevention.Implications Patients who develop Delirium have high mortality, institutionalization and complication rates, and have longer lengths of stay than non-delirious patients (Safer Healthcare Now! 2013). Delirium is also believed to be associated with increased ventilator days, and self-removal of important devices (endotracheal tubes, central venous catheters) (Safer Healthcare Now! 2013).G​oal To improve the early detection and reduce the incidence of Delirium in at risk hospitalized patients in intensive and general care units through implementation of standardized Delirium screening and prevention strategies. ​Back to Hospital Harm Indicator Home Page DownloadDelirium: IntroductionOverview Delirium (acute confusional state) is a common condition in older people, affecting up to 30 per cent of all older patients admitted to10/20/2016 2:40:57 PM62
Pneumothorax: Introduction5619Guide9/27/2016 9:48:18 PM​​Overview ​A pneumothorax is present when there is air in the pleural space. Pneumothoraces are classified as spontaneous, which develop without preceding trauma or other obvious cause, and traumatic, which develop as a result of direct or indirect trauma to the chest. Traumatic pneumothoraces can be either iatrogenic or non-iatrogenic. Iatrogenic pneumothoraces (IP) occur as a result of certain diagnostic or therapeutic procedures and constitute the current indicator (Light RW, 2016). A tension pneumothorax is present when the air accumulates in the pleural space to a point where the increasing pressure in the pleural space impedes normal cardiovascular function. Tension pneumothorax can occur with any of the types of pneumothorax but occur more commonly - although not exclusively - to patients receiving positive pressure ventilation or CPR. It can lead - often quite suddenly - to life-threatening hypotension and shock, making it a medical emergency (Light RW, 2016).Implications Iatrogenic pneumothoraces is a potentially life-threatening complication seen in three per cent of ICU patients (Chen, 2002; Anzueto, 2004; De Lassence, 2006). It has been associated with an increase in ICU and hospital length of stay and resource utilization (Amato, 1998; Anzueto, 2004; De Lassence, 2006; Zhan, 2006) as well as an increase in the risk of death (Gattinoni 1994, Schnapp 1995, Esteban 2002). Despite doubt cast by a retrospective review (Weg, 1998), this increase was recently quantified as twice that of ICU patients without iatrogenic pneumothorax and similar to the risk of death associated with ventilator-related barotrauma or post-procedural pneumothorax (De Lassence, 2006). In addition to tension pneumothorax, systemic air embolism is a rarer but potentially lethal complication of ventilator-related pneumothorax (Azad, 2011; Ibrahim, 1999). IP is largely preventable (De Lassence, 2006). In the ICU setting, the currently low three per cent incidence of IP in ICU patients was around eight per cent in the 1980s (De Lassence, 2006). This decrease is believed to be due to improved equipment, techniques and safer practices both for mechanical ventilation- and procedure- related pneumothorax (Celik, 2009) The significant decrease in pneumothorax related to mechanical ventilation over the last decades coincides with the implementation of improved "lung-protective" ventilation strategies (The ARDS Network, 2000; Miller, 2008). However, recent case series demonstrate no relationship between the incidence of barotrauma and ventilatory settings (Weg, 1998; Briel, 2010; Hsu, 2014). It may be that more factors were involved in this decrease than simply protective lung strategies, such as improved ventilators, overall ventilator care and treatment of the underlying disease processes. One example is the reduction of pneumothorax in ventilated patients with ARDS when administered neuromuscular blocking agents in the first two days of ventilation (Papazian, 2010). The incidence of procedure-related pneumothorax has also been reduced by improved equipment (e.g. ultrasound), and education and training; these improvements have equally been noted in the non-ICU and pediatric settings (Duncan, 2009; Gordon, 2010; Havelock, 2010; Lenchus, 2010; Cavanna, 2010; Troianos, 2012).Goal To prevent iatrogenic pneumothorax in hospitalized adult patients by implementing best practices for risk reduction. ​Procedures Associated with Iatrogenic Pneumothorax Dry needling (Health Quality Council of Alberta, 2014) this term refers to interventional techniques (diagnostic or therapeutic) that use a solid filament needle to puncture the skin. A non-exhaustive list pertaining to iatrogenic pneumothorax includes central venous catheterization (subclavian or internal jugular), thoracentesis (greater if indication is therapeutic vs diagnostic) (Gordon, 2010), transthoracic needle aspiration and percutaneous biopsy of the lung (Cox, 1999; Choi, 2004), pleura or liver, radiofrequency ablation of lung tumors, intercostal nerve block, acupuncture, and brachial plexus block (supra- or infraclavicular approaches). Airway-related endotracheal tube insertion (intubation) or misplacement (neonates), inadequate clearance of trapped secretions, positive airway pressure devices (Carron, 2007; Chebel, 2010; Hegde, 2013; Milési, 2014) including mechanical ventilation, transbronchial lung biopsy, inadvertent endobronchial placement of small nasogastric/feeding tubes, bronchoscopy (rigid, fiberoptic (diagnostic or interventional) – more frequent in children. Surgical tracheostomy, thoracotomy, mediastinoscopy, cardiac surgery, insertion/revision/replacement/removal of cardiac pacemaker or cardioverter/defibrillator, breast augmentation, rarely abdominal cavity operations. Other cardiopulmonary resuscitation (CPR). In these series (most enumerate patient risk factors, see below), central venous catheterization, thoracentesis and mechanical ventilation are the most commonly reported procedures in adults and Pediatric case series (Johnson, 2010). For central venous insertion and thoracentesis, additional risk factors are the need to do two to three, or more needle passes and staff inexperience (Bailey, 2000; Molgaard, 2004; Gordon, 2010). Risk factors have also been described with specific procedures (e.g. transthoracic needle aspiration or biopsy (Haynes, 2010)). ​In most healthcare institutions, healthcare professionals are authorized to practice these interventions by the institution’s Medical Director based on professional accreditation and clinical competency.Patient Risk Factors​ ​Patient factors that increase the risk of pneumothorax in the setting of an intervention include Age Low body weight Poor healing ability (chronic corticosteroid use, malnutrition) Severity of acute illness Acute or chronic pulmonary or pleural ​disease Agitation AIDS ​ Back to Hospital Harm Measure Home Page Download​Pneumothorax: IntroductionOverview A pneumothorax is present when there is air in the pleural space. Pneumothoraces are classified as spontaneous, which develop without4/12/2017 3:33:04 PM14
Post Procedural Infections: Introduction5631Guide9/28/2016 3:55:36 PMOverview and Implications A Post Procedure infection is associated with a medical or surgical procedure and results from colonization with a bacterial load greater than the capability of the immune system to manage. These infections can significantly increase cost, morbidity and even mortality. Surgical Site infections are most commonly caused by Staphylococcus, Streptococcus, and Pseudomonas bacteria. Any surgery that causes a break in the skin or mucosa can lead to a postoperative infection. Surgical site infections are a frequent cause of morbidity following surgical procedures. Surgical site infections have also been shown to increase mortality, readmission rates, length of stay, and costs for patients who incur them. In the United States, the rate of surgical site infection averages between two to three per cent for clean cases (Class I/Clean as defined by CDC), and an estimated 40 to 60 per cent of these infections are preventable. Surgical site infection is the most common healthcare associated infection among surgical patients, with 77 per cent of patient deaths reported to be related to infection (Cataife et al., 2014). In Western countries, between two to five per cent of patients undergoing clean surgical procedures and up to 20 per cent of patients having intra-abdominal surgical procedures will develop a surgical site infection (Auerbach, 2011). Infected surgical patients are twice as likely to die, spend 60 per cent more time in the intensive care unit, and are five times more likely to be readmitted to hospital after initial discharge (Kirkland et al., 1999). Such infections result in 3.7 million extra hospital days and U.S. $1.6-3 billion in excess hospital costs per year (Kirkland et al., 1999 and Martone et al., 2001). Knee and hip replacements are two of the most commonly performed surgeries in the United States, with more than 1.1 million combined cases performed annually. It is estimated that between 6,000 and 20,000 surgical site infections (SSIs) develop each year in the U.S. after knee and hip replacements, and these numbers are expected to rise (Hussaini, Martin, 2013). Infective endocarditis (IE) is an infection of the endocardium, particularly affecting the heart valves, caused mainly by bacteria but occasionally by other infectious agents. IE can be caused by several different organisms, many of which could be transferred into the blood during an interventional procedure (Centre for Clinical Practice at NICE, 2008). IE often affects older patients who often develop IE as the result of healthcare-associated procedures. It can occur in patients with no previously known valve disease or in patients with prosthetic valves (Habib et al., 2009). Endocarditis is a rare condition, with an annual incidence of fewer than 10 per 100,000 cases in the general population. Despite advances in diagnosis and treatment, IE remains a life-threatening disease with significant mortality (approximately 20 per cent) and morbidity (Centre for Clinical Practice at NICE, 2008). Central Line-Associated Bloodstream Infections (CLABSIs) Central venous catheters (CVCs) are increasingly being used in both in- and out-patient settings to provide long-term venous access. CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. This infection may spread to the bloodstream and cause hemodynamic changes and organ dysfunction (severe sepsis) to occur and, possibly lead to death. Approximately 90 per cent of the CLABSIs occur with CVCs. BSI may also occur in association with arterial catheters (Safer Healthcare Now! 2012). Forty-eight per cent of intensive care unit (ICU) patients in the U.S. have central venous catheters, accounting for 15 million central-venous-catheter-days per year in U.S.-based ICUs. Studies of catheter-related bloodstream infections that control for the underlying severity of illness suggest that mortality attributable to these infections is between four per cent and 20 per cent. Thus, it is estimated that 500 to 4,000 US patients die annually due to bloodstream infections. Nosocomial bloodstream infections prolong hospitalization by a mean of seven days. Estimates of attributable cost per bloodstream infection are between U.S. $3,700 and $29,000. There are no equivalent Canadian figures for burden of illness (Safer Healthcare Now! 2012).Goal To prevent Post Procedural infections and deaths in hospitalized patients by reliably implementing evidence-based procedural care for all patients undergoing invasive procedures. Back to Hospital Harm Measure Home Page Download Post Procedural Infections: IntroductionOverview and Implications A Post Procedure infection is associated with a medical or surgical procedure and results from colonization with a10/20/2016 2:43:55 PM64
2016 - 2017 CPSI Research Competition57494/21/2016 5:02:35 PM Announcing the successful applicant of the 2016 research competition The Canadian Patient Safety Institute, Accreditation Canada, the Canadian Home Care Association, Patients for Patient Safety Canada and the Registered Nurses' Association of Ontario are pleased to announce that Dr. Chantal Backman of the University of Ottawa and her research team have been awarded $50,000 for the 2016-2017 Research Competition for their study entitled "Safe and effective person-and-family-centered care practices during transitions between hospital-based care and home care – A mixed method study." The five partners came together to help develop knowledge in, and to support innovative solutions to patient safety. Using person-and family centred approaches to care, this research aims to explore how patient safety is operationalized and monitored during transitions in care. Transitions, when patients are moved from hospital-based care to home care, have been identified as potentially high risk for harm. The call for commissioned research, launched in January 2016, sought projects that would help reduce the harm that can occur during transitions in care. Dr. Backman's project promises to yield much needed information about patient safety that can help reduce harm and improve patient safety during transitions. The objectives of the study from Dr. Chantal Backman and team are Describe patients and families' perceptions of key factors that would improve safety and facilitate person- and family-centered care during transitions from hospital-based care to home care; Identify the indicators (structural, process and outcome) that best reflect safe person- and family-centered care transitions; Identify how organizations monitor inter-organization transitions to ensure that they are safe and person- and family-centered; Describe best practices for safe person- and family-centered care transitions and identify high performing organizations that have successfully implemented and monitored these practices; and Develop recommendations for how Canadian healthcare organizations at both regional and local levels can implement and monitor safe person-and-family-centered care transitions from hospital to home care. The final report will be available on our website in the fall of 2017.Team Principal Investigator Dr. Chantal Backman Assistant Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa; Affiliate Investigator, Clinical Epidemiology Program, The Ottawa Hospital Research Institute; Associate Investigator, Nursing Best Practice Research Centre, University of Ottawa Co-investigators Dr. Wendy Gifford, Assistant Professor, School of Nursing, Faculty of Health Sciences Dr. Nelly D. Oelke, Assistant Professor, School of Nursing, Faculty of Health and Social Development Dr. Julie Chartrand, Assistant Professor, School of Nursing, Faculty of Health Sciences Dr. Sharon Johnston, Associate Professor, Department of Family Medicine Dr. Alan J. Forster, Senior Scientist, Clinical Epidemiology Program This project was made possible through the support of Canadian Patient Safety Institute Accreditation Canada Canadian Home Care Association Patients for Patient Safety Canada​ Registered Nurses' Association of Ontario Congratulations to Dr. Chantal Backman and her research team! 2016 – 2017 CPSI Research CompetitionAnnouncing the successful applicant of the 2016 research competition The Canadian Patient Safety Institute, Accreditation Canada , the 4/25/2016 7:03:07 PM52
Pneumonia: Introduction5624Guide9/27/2016 5:00:16 PM ​Overview​​​ Pneumonia, an acute illness, is defined by the Centers for Disease Control and Prevention (2014) as “an infection of the lungs that can cause mild to severe illness in people of all ages.” Pneumonia can be caused by viruses, bacteria, and fungi (Centers for Disease Control, 2015). By consensus, pneumonia that develops at least 48 hours after hospital admission, (excluding those which were incubating at the time of admission) is considered to be hospital-acquired pneumonia (HAP). The most common pathogens are gram-negative bacilli and Staphylococcus aureus; drug-resistant organisms are an important concern. Symptoms and signs are the same as those for community-acquired pneumonia. Diagnosis is suspected on the basis of sepsis criteria together with chest x-ray changes and cough (productive with bacterial pneumonia). Nasopharyngeal swabs for viral testing can confirm the diagnosis in cases of influenza and other respiratory viruses. Sputum cultures for bacteria should be obtained but have poor sensitivity and specificity. Cultures obtained by bronchoalveolar lavage may have better specificity but lower sensitivity. They do not alter outcomes and therefore it is recommended to not perform this procedure routinely (Muscedere, Dodek, et al, 2008). Blood cultures should be obtained but have very low sensitivity. Treatment is with antibiotics. Overall prognosis is poor, due in part to comorbidities. HAP, ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) remain important causes of morbidity and mortality despite advances in antimicrobial therapy, better supportive care modalities, and the use of a wide-range of preventive measures. HAP may be managed in a hospital ward or in the intensive care unit (ICU) when the illness is more severe. VAP refers to pneumonia that arises more than 48 hours after endotracheal intubation. Although not included in this definition, some patients may require intubation after developing severe HAP and should be managed similar to patients with VAP. HCAP includes any non-hospitalized patient with pneumonia who was hospitalized in an acute care hospital for two or more days within the past 90 days; resided in a nursing home or long-term care facility; received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days; or attended a hospital or hemodialysis clinic within the past 30 days of the infection. Although this document focuses more on HAP and VAP, most of the principles overlap with HCAP. Because most of the current data have been collected from patients with VAP, and microbiologic data from non-intubated patients may be less accurate, most of our information is derived from those with VAP, but by extrapolation can be applied to all patients with HAP, emphasizing risk factors for infection with specific pathogens (American Thoracic Society and Infectious Diseases Society of America, 2005). Based on 2002 data, nearly 80 per cent of all hospital-acquired infections are caused by four types of infections. Urinary tract infections (UTIs) comprise the highest percentage (34 per cent of all hospital-acquired infections), followed by surgical-site infections (17 per cent), bloodstream infections (14 per cent), and pneumonia (13 per cent) (Klevens et al., 2007). “In non-intubated patients, risk factors include previous antibiotic treatment, high gastric pH (due to stress ulcer prophylaxis or therapy), and coexisting cardiac, pulmonary, hepatic, or renal insufficiency. Major risk factors for postoperative pneumonia are age > 70, abdominal or thoracic surgery, and dependent functional status,” (Sethi, 2014). Implications According to the Centers for Disease Control and Prevention (Centers for Disease Control, 2014), hospital-associated pneumonia “has accounted for approximately 15 per cent of all hospital-associated infections.” (Tablan et al., 2003) Hospital-acquired pneumonia, and notably ventilator-associated pneumonia, developing as a consequence of lung bacterial colonization, alters clinically important outcomes, including duration of mechanical ventilation, length of stay in the intensive care unit (ICU), and mortality rates (Roquilly et al., 2015). For the Canadian healthcare system, the incidence of VAP is 10.6 cases per 1000 ventilator days. Using conservative assumptions, we determined that VAP costs approximately $11,500 per case, is responsible for approximately 230 deaths per year (5.8 per cent), and accounts for approximately 17,000 additional ICU days per year -- around two per cent of all ICU days in Canada. This represents the equivalent of three to four ICUs completely occupied for the whole year solely to treat patients with VAP. Finally, the cost to the healthcare system is [estimated to be] CAN $46 million per year (Muscedere, Martin, et al, 2008). Non-ventilator hospital-acquired pneumonia (NV-HAP) is an underreported and understudied disease, with potential for measurable outcomes, fiscal savings, and improvement in quality of life (Quinn et al., 2014). Many Canadian hospitals monitor ventilator-associated pneumonia; however, there is only limited monitoring and reporting of NV-HAP. The limited studies available indicate that NV-HAP is an emerging factor in prolonged hospital stays and significant patient morbidity and mortality. HAP​​​​ a. Adds an estimated additional $40,000 to $65,000 to the cost of care for each affected patient in the U.S. b. Adds seven to nine days to the length of hospital stay. c. Significantly increases discharge to skilled nursing facilities instead of returning home. d. Has an attributable mortality rate as high as 50 per cent. e. Is associated with half of patients not being discharged back to their homes. ​​ While HAP has received significant attention from healthcare quality review boards, their focus has been on intensive care unit (ICU)-level of care and ventilated patients who acquire pneumonia (Quinn et al., 2014). Several factors may contribute to increased risks for HAP, including older patients with a low body mass index and signs of malnourishment; altered mental status; low albumin; dependent for activities of daily living; receiving central nervous system depressants or acid blocking medications; and presence of chronic or inadequately managed pain (Quinn et al., 2014). Modifiable risk factors for HAP and VAP are crucial targets for prevention that can reduce patient mortality and morbidity, and also promote the cost-effective use of healthcare resources. Effective prevention strategies include the use of strict infection control, hand hygiene, microbiological surveillance with availability of data on local drug resistant pathogens, monitoring and early removal of invasive devices, and programs to reduce or alter antibiotic prescribing practices (Rotstein, 2008). Goal To prevent hospital-associated pneumonia in hospitalized adult patients by implementing proven interventions. Back to Hospital Harm Measure Home Page DownloadPneumonia: IntroductionOverview Pneumonia, an acute illness, is defined by the Centers for Disease Control and Prevention (2014) as: “an infection of the lungs10/20/2016 2:43:17 PM31
UTI: Introduction5621Guide9/29/2016 7:52:22 PMOverview and Implications Urinary Tract Infection (UTI) UTIs can be divided into upper tract infections, which involve the kidneys (pyelonephritis), and lower tract infections, which involve the bladder (cystitis), urethra (urethritis), and prostate (prostatitis). Infection may spread from one site to the other. Although urethritis and prostatitis are infections that involve the urinary tract, the term UTI usually refers to pyelonephritis and cystitis (Imam 2013). Most cases of cystitis and pyelonephritis are caused by bacteria. The most common nonbacterial pathogens are fungi (usually candidal species), and, less commonly, mycobacteria, viruses, and parasites. Nonbacterial pathogens usually affect patients who are immunocompromised; have diabetes, urinary tract obstruction, or structural abnormalities; or have had recent urinary tract instrumentation. Urethritis is usually caused by sexually transmitted infections (STI). Prostatitis is usually caused by bacteria and sometimes STIs (Imam 2013). Healthcare-Associated UTI Healthcare-associated UTI is the fourth leading cause of healthcare associated infections after pneumonia, surgical site infections and intra-abdominal infection (Magill et al, 2014). Approximately 80 per cent of healthcare associated UTIs are attributable to indwelling urethral catheters (IHI 2012). Catheter-Associated Urinary Tract Infection (CAUTI) CAUTI is the presence of symptoms of infection along with a positive catheter or midstream urine specimen in a patient who was previously catheterized within 48 hours (Hooton et al, 2010). A urinary catheter provides a portal of entry into the urinary tract. The source of bacteria causing CAUTI is usually endogenous—typically via meatal, rectal, or vaginal colonization—but rarely may be exogenous, from equipment or contaminated hands of healthcare personnel (APIC 2014). The most important risk factor for development of CAUTI is the duration of catheterization. Daily risk of acquisition of bacteriuria with urinary catheters is around seven per cent and among those with catheter-associated bacteriuria, symptomatic CAUTI will develop in 24 per cent (95 per cent CI, 16-32 per cent) and bacteremia will develop in 3.6 per cent (95 per cent CI, 3.4-3.8 per cent) (Saint, 2000). Other factors predispose CAUTI including patient-related factors such as diabetes, fecal incontinence, incomplete emptying of the bladder, dehydration etc.; care provider related factors such as poor hand hygiene practices, poor insertion technique, etc.; and hospital, equipment, and/or environmental systems (APIC 2014). The CDC reports that the most frequent pathogens associated with CAUTI in hospitals between 2006 and 2007 were Escherichia coli (21.4 per cent) and Candida spp (21 per cent), followed by Enterococcus spp (14.9 per cent), Pseudomonas aeruginosa (10 per cent), Klebsiella pneumoniae (7.7 per cent), and Enterobacter spp (4.1 per cent). A smaller proportion was caused by other gram-negative bacteria and Staphylococcus spp (APIC, 2014). CAUTIs account for the majority of healthcare-associated UTIs and have been associated with increased morbidity, mortality, hospital cost, and length of stay (APIC 2014). It is well established that the duration of catheterization is directly related to risk for developing a UTI. With a catheter in place, the daily risk of developing a UTI ranges from 3 to 7 per cent (IHI, 2012). During hospitalization, from 12 to 16 per cent of patients may receive short-term indwelling urinary catheters. The average rate of CAUTI is higher in ICU patients than in non-ICU patients (APIC 2014). An estimated 17 to 69 per cent of CAUTIs may be preventable with implementation of evidence-based practices. Although there has been modest improvement in CAUTI rates, progress has been much slower than other device-associated infections (APIC 2014). Post-partum UTI Post-partum UTI may begin as asymptomatic bacteriuria during pregnancy and is sometimes associated with bladder catheterization to relieve urinary distention during or after labor (Imam 2013). Physiological changes in the bladder occur during pregnancy and predispose women to develop post-partum urinary retention (PUR) during the first hours to days after birth which can lead to UTI (Leach 2011). PUR after vaginal birth is a relatively common event, with the reported incidence ranging from 1.7 to 17.9 per cent (Leach 2011). The risk is higher among instrument-assisted births and use of regional analgesia. Other common risk factors include primiparity, prolonged first and second stage perineal tearing and oxytocin use. Unrecognized PUR may lead to upper urinary tract damage and permanent voiding difficulties (Leach 2011). Pyelonephritis may occur postpartum if bacteria ascend from the bladder. The infection may begin as asymptomatic bacteriuria during pregnancy and is sometimes precipitated by peripartum urinary retention and/or bladder catheterization during or after labor (Imam 2013). UTIs Among Neonates The characteristics of UTI in neonates differ from UTIs in infants and children. Its prevalence is much higher, male sex is affected predominantly non-Escherichia coli infections are more frequent, and there is a higher risk of urosepsis than in older age groups. UTI in neonates may be the first indicator of underlying abnormalities of kidneys and the urinary tract (Beetz 2012). Some 35 to 50 per cent of term and preterm neonates with UTI have abnormal urinary tract ultrasounds (Bonadio et al, 2014, Ismaili et al, 2011, Goldman et al, 2000, Sastre et al, 2007). The prevalence of UTIs among full-term neonates has been reported to be up to 1.1 per cent, increasing up to seven per cent among those with fever. Evidence indicates that up to approximately 15 per cent of febrile neonates have positive urine culture (Bonadio et al, 2014, Ismaili et al, 2011) and most UTI in neonates is related to pyelonephritis as compared to cystitis in older children. The presence of UTI is significantly higher in uncircumcised vs circumcised boys (Beetz 2012). Goal Prevention of urinary tract infection by implementing recommended components of care. Back to Hospital Harm Measure Home Page DownloadUTI: IntroductionOverview and Implications Urinary Tract Infection (UTI) UTIs can be divided into upper tract infections, which involve the kidneys10/20/2016 2:44:36 PM106
Pressure Ulcer: Introduction5629Guide11/16/2015 8:44:18 PMOverview A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (National Pressure Ulcer Advisory Panel et al, 2014). Pressure ulcers cause considerable harm to patients, hindering functional recovery, frequently causing pain and the development of serious infections. Pressure ulcers have also been associated with an extended length of stay, sepsis, and mortality (IHI, Pressure Ulcers). Accreditation Canada recognizes the importance of effective prevention strategies in the reduction of pressure ulcers and has identified pressure ulcer prevention as a Required Organizational Practices (ROP) (Accreditation Canada).Implications Pressure ulcers continue to be a significant health concern as the population ages and the complexity of care increases across all care settings (RNAO, 2011). A literature review done in Canada in 2004 found that the overall prevalence of pressure ulcers across all institutions studied was 26 per cent. Although 50 per cent of these were Stage 1 ulcers, this data is still disturbing (Woodbury & Houghton, 2004). Pressure ulcer incidence rates vary considerably by clinical setting — ranging in the Unites States from 0.4 per cent to 38 per cent in acute care, from 2.2 per cent to 23.9 per cent in long-term care, and from 0 per cent to 17 per cent in home care. It is estimated that pressure ulcer prevalence (the percentage of patients with pressure ulcers at any one point in time) in acute care is 15 per cent, while incidence (the rate at which new cases occur in a population over a given time period) in acute care is seven per cent. It is estimated that 2.5 million patients are treated for pressure ulcers in U.S. acute healthcare facilities each year. The estimated cost of managing a single full thickness pressure ulcer is as high as $70,000, and the total cost for treatment of pressure ulcers in the U.S. is estimated at $11 billion per year (IHI, 2011).Goal To reduce the incidence of pressure ulcers. ​Back to Hospital Harm Home Page Download Pressure Ulcer: IntroductionOverview A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure, or10/20/2016 2:39:09 PM24
201557507/1/2015 2:13:32 AM​​​​​Announcing the successful applicant of the 2015 research competition The Canadian Patient Safety Institute, Accreditation Canada, HealthCareCAN and the Canadian Home Care Association are pleased to announce the results of a unique research competition that brought the four partners together to help improve the transitions of care between hospital and home for the frail elderly population. Dr. Andrew Costa, assistant professor and holder of the Schlegel Chair in Clinical Epidemiology and Aging at McMaster University, and his research team have been awarded $50,000 for the 2015-2016 Research Competition for their study entitled “The transition from the emergency department into home care (Trans-ED-HC) project A mixed methods study of patterns of patient safety events and transition processes.” The four partners came together to support a project that would help improve the safety for complex frail elderly patients transitioning from the hospital to their own home, and recommend innovative strategies and/or tools to help the patient, their family caregiver(s), and health care team work together. The call for proposals was launched last November, and 13 applications were submitted. The proposals were reviewed by expert reviewers external to the four partner organizations. While each proposal brought interesting and important ideas to the forefront, Dr. Costa’s proposal combined an elegant research design with the potential for results with national applicability. Dr. Costa’s project promises to yield much needed information about the issues for frail elderly patients being discharged from hospital emergency rooms. The objectives of the study are To describe the key challenges in the ED to home care transition process among relevant providers as well as patients and their informal caregivers. To examine the incidence of patient safety and other adverse health events among ED patients who recently transitioned to home care from the ED. To quantify the influence of poor referral processes (delays in assessment, delays in admission, etc.) on the incidence of patient safety and other adverse health events among ED patients who recently transitioned to home care from the ED. To quantify the influence of patient safety and other adverse health events on negative health outcomes (death, LTC admission, ED re-admission, and hospitalization) among ED patients who recently transitioned to home care from the ED. To identify and prioritize potential process improvements in ED to home care transitions that are likely to improve patient outcomes. Dr. Costa’s study includes a capstone component that will allow the researchers to explore their findings with other experts nationally. The final report will be available on each partners’ website after March 31, 2016. Team Lead Dr. Andrew Costa, McMaster University Co-lead Veronique Boscart, R.N., M.Sc.N., M.Ed., Ph.D. George Heckman, M.D., M. Sc. Martin Farrugia, BSW This project was made possible through the support of Accreditation Canada HealthCareCAN Canadian Home Care Association Canadian Patient Safety Institute Congratulations to Dr. Andrew Costa and his research team! Thank you to all teams that put forward a submission and to the external reviewers. 2015-2016 CPSI Research Competition: The transition from the emergency department into home care (Trans-ED-HC) project: A mixed methods study of patterns of patient safety events and transition processesAnnouncing the successful applicant of the 2015 research competition The Canadian Patient Safety Institute, Accreditation Canada, HealthCare CAN 8/4/2015 8:15:20 AM198
Safety in Long-Term Care Settings5896Research7/1/2015 2:02:50 AM ​​How can we improve patient safety in long-term care? While there is a growing body of literature on patient safety, there has been less emphasis on the long-term care (LTC) setting than the acute care sector. Recognizing the gap in our understanding of patient/resident safety issues in LTC, the Canadian Patient Safety Institute, Capital Health (Edmonton), and CapitalCare (Edmonton) collaborated to create a research and action agenda for improving safety in the LTC setting. Download Research Results Safety in Long-Term Care SettingsSafety in Long-Term Care Settings11/9/2016 4:35:33 PM319
Wound Disruption: Introduction5630Guide10/19/2016 2:52:57 PM​​Overview Wound healing is a critical outcome in surgery, and postoperative wound disruption or separation of the layers of a surgical wound with disruption of the fascia is a serious complication. Surgical incisions are acute wounds that activate the healing process. The healing process has four identified stages, namely coagulation, inflammation, proliferative phase/granulation tissue formation and the remodelling phase, in reality it is a complex, continuous process (Demidova-Rice et al., 2012). Despite improvements in contemporary preoperative care and suture materials, the rate of surgical wound disruption has not decreased in recent years; estimated around six per cent after elective surgery and 16 per cent after emergency surgery (Sorensen et al., 2005). This may be attributable to the increasing incidence of risk factors within the patient population outweighing the benefits of technical achievements. Overall, surgical site infection (SSI) is the strongest predictor of wound disruption (Moghadamyeghaneh et al., 2015). Abdominal wound disruption typically occurs at 10 +/- 6.5 days (median eight days) after surgery (Kenig et al., 2014). A better understanding of which patients are at risk of such complications will help identify targets for preventative actions, patient satisfaction, and an equitable use of financial resources. Post-partum perineal wound dehiscence remains a rare complication of vaginal delivery. Although infections rates in episiotomy wounds are surprisingly low, they are responsible for up to 80 per cent of wound dehiscence (Kamel & Khaled, 2014). The majority of perineal wound infections occur within the first three weeks postoperatively, after hospital discharge. Risk Factors Disruption of the vascular supply, thrombosis of blood vessels, and tissue hypoxia is common for all tissues subjected to surgery. When the blood supply is restored a number of factors may complicate healing with the most important being the proliferation of bacteria in the wound thus increasing the risk of infection (Sorensen et al., 2006). Malnutrition is a common problem that adversely affects outcomes in surgical patients. Albumin is the most commonly used and reliable indicator of nutritional status, with preoperative hypoalbuminemia being an independent risk factor for the development of SSI (Hennessey et al., 2010). Diabetic patients have a higher level of wound complications following general surgery and pregestational diabetes is associated with a 2.5 – fold increase in wound complications after Caesarean delivery (Takoudes et al., 2004). Obese patients have increased rates of diabetes mellitus as well as atherosclerosis vascular disease, both of which are associated with poor wound healing. In addition, thickness of subcutaneous fat is predictive of SSI. Finally, occult immune dysfunction is known to exist in the obese and one theory suggests that impairment of monocyte and macrophage function has the potential to be contributory (Winfield et al., 2016). Smoking is also a risk factor for wound healing complications after different types of surgeries; plastic, abdominal, orthopedic, breast cancer and Caesarean delivery (Avila et al., 2012). Acute, high-dose systemic corticosteroid use likely has no clinically effect on wound healing, whereas chronic systemic steroids may impair wound healing in susceptible individuals (Wang et al., 2013). Psychological stress impairs the inflammatory response and matrix degradation processes in the wound immediately following surgery and these findings suggest that pre-operative interventions to reduce the patient's psychological stress level may improve wound repair and recovery (Broadbent et al., 2003). In children risk factors for wound disruption include patient age younger than one year, wound infection, median incision, and emergency surgery (van Ramshorst et al., 2009). Operative vaginal delivery, third and fourth degree perineal laceration and meconium contamination, are the most significant factors leading to perineal wound infection (Williams, 2006). Implications Wound disruption still remains a major cause of morbidity in surgical patients (Hahler, 2006). Wound disruption can be divided into two types; those requiring immediate surgical intervention due to bowel protrusion and those that can be managed using a more conservative approach. Hospital stay is significantly longer for patients with wound disruption, with a median of 36 days, compared to 16 days in a control group (van Ramshorst et al., 2010). Wound complications are a burden for patients, their families, and the health care system. Accurately estimating the cost associated with wound complications is difficult due to the use of different care products and their varying costs, frequency of interventions and costs associated with staff time and resources, but it is believed that wound care has a significant impact on healthcare expenditure (Butcher & White, 2014). A post discharge wound complication costs, on average, an additional $3,000 (Marrs et al., 2014). Perineal wound dehiscence, may lead to major physical, psychological and social problems if left untreated. It can be associated with persistent pain and discomfort at the perineal wound site, urinary retention, defecation problems, dyspareunia, psychosexual issues from embarrassment and altered body image (Williams & Chames, 2006).Goal Reduce the incidence of wound disruption in surgical and obstetrical patients by assessing risk, implementing risk factor modifications prior to surgery and instituting good wound care management. Back to Hospital Harm Measure Download Wound Disruption: IntroductionOverview Wound healing is a critical outcome in surgery, and postoperative wound disruption or separation of the layers of a surgical wound with10/24/2016 5:08:33 PM24