Patients expect hospital care to be safe, and for most people it
is. However, a recent study showed that patients experienced potentially
preventable harm in more than 138,000 hospitalizations or about 1 in 18
hospitalizations (this does not include hospitalizations in Quebec).
Key findings from the Measuring
Patient Harm in Canadian Hospitals report, which was released by the
Canadian Institute for Health Information (CIHI) and the Canadian Patient
Safety Institute (CPSI), showed that the five most common types of harm, making
up 51 per cent of all harmful events, were electrolyte and fluid imbalance,
urinary tract infections, delirium, anaemia-haemorrhage, and pneumonia.
was estimated that patients who experienced harm spent a total of more than half
a million additional days in hospital – that is more than 1,600 beds each day,
or the equivalent of approximately four large hospitals occupied over a year.
The associated hospital cost (excluding physician fees, follow-up care, and readmission)
was about $685 million.
The Hospital Harm measure identifies acute care hospitalizations
with at least one occurrence of unintended harm (during the hospital stay) that
could have potentially been prevented by implementing known evidence-informed
practices. The measure is comprised of 31 clinical groups that fall under four
The Hospital Harm measure complements other patient safety
information available to hospitals, including patient safety incident reports,
patient experience surveys, chart reviews or audits, infection control data,
global trigger tools, and clinical quality improvement process measures.
Combined, this information can inform and optimize improvement initiatives.
Harm Improvement Resource was developed by the Canadian Patient Safety
Institute to complement the CIHI Hospital Harm measure. It links measurement
and improvement by providing evidence-informed practices that support patient
safety improvement efforts.
The online Improvement Resource is a compilation of
evidence-informed practices linked to each of the 31 clinical groups within the
Hospital Harm measure to help drive changes that will make care safer. Through
extensive research and consultation with clinicians, experts and leaders in
quality improvement (QI) and patient safety, the Improvement Resource is
intended to make information on improving patient safety easily available, so
teams spend less time researching and more time optimizing patient care.
The Improvement Resource includes a summary of evidence-informed
practices that reduce the likelihood of harm, and suggested measures for
outcomes and processes. For example, evidence-informed practices for Delirium
include: developing a standardized protocol for preventing or managing
delirium, including identifying and treating underlying causes; implementing
non-drug strategies such as early mobility; implementing environmental
strategies such as visible daylight; and reassessing sedation daily. For
Medication events the evidence includes: conducting an organizational Medication Safety Self-Assessment;
implementing medication reconciliation and high-alert medication safety
processes; and improving core processes for ordering, dispensing and
administering medications. Also included in the resource are patient
stories, success stories, standards and required organizational practices
associated with each clinical group.
The Improvement Resource is a dynamic tool that the Canadian
Patient Safety Institute will continue to update as new tools and approaches
are developed and more evidence-informed practices emerge.
The hospital harm project aims to provide health system leaders
with better information on patient safety and support patient safety
improvement efforts. Armed with evidence-informed practices compiled through
continued research efforts and united through collaboration, clinicians,
hospital staff and patients can all play a role in improving safety in Canadian
For more information, visit www.cihi.ca or www.patientsafetyinstitute.ca