Given the broad range of potential causes of complications from patient trauma, clinical and system reviews should be conducted to identify latent causes and determine appropriate recommendations
Occurrences of harm are often complex with many contributing factors. Organizations need to:
Measure and monitor the types and frequency of these occurrences.
Use appropriate analytical methods to understand the contributing factors.
Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resources Introduction.If your review reveals that your patient trauma related events are linked to specific processes or procedures, you may find these resources helpful:
Agency for Healthcare Research and Quality (AHRQ). https://www.ahrq.gov
Preventing falls in hospitals: a toolkit for improving quality of care. 2013. http://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf
Canadian Patient Safety Institute https://www.patientsafetyinstitute.ca
Patient Safety and Incident Management Toolkit. http://www.patientsafetyinstitute.ca/English/toolsResources/PatientSafetyIncidentManagementToolkit/Pages/default.aspx
Safer Healthcare Now! Getting Started Kit
Reducing Falls and Injury from Falls https://www.patientsafetyinstitute.ca/en/Topic/Pages/Falls.aspx
Falls Prevention GSK Evidence Update! New for 2018 https://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/Falls%20Evidence%20update%202018-01.PDF
ECRI Institute www.ecri.org
Surgical Fire Prevention. 2016. https://www.ecri.org/Accident_Investigation/Pages/Surgical-Fire-Prevention.aspx
Healthcare Insurance Reciprocal of Canada (HIROC). https://www.hiroc.com
Risk Reference Sheets. Healthcare Acquired Burns. 2020. https://www.hiroc.com/resources/risk-reference-sheets/healthcare-acquired-burns
Appendix A: Iatrogenic Burns
Appendix B: Healthcare Associated Asphyxia, Entrapment & Entanglement
National Institute for Health and Care Excellence. www.Nice.org.uk
Falls in older people: Assessing risk and prevention. NICE guidelines. 2013. http://www.nice.org.uk/guidance/cg161/chapter/1-recommendations
NHS Institute for Innovation and Improvement. https://www.nhs.uk
Stepwise falls guide. How to reduce harm (inpatient falls), improve quality and save costs: A practical step-by-step guide for ward staff and frontline healthcare teams. 2013. http://www.institute.nhs.uk/safer_care/safer_care/stepwise.html
Registered Nurses' Association of Ontario (RNAO). https://rnao.ca
Preventing Falls and Reducing Injury from Falls, Fourth Edition. 2017. https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries
Promoting Safety: Alternative Approaches to the Use of Restraints. 2012. https://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints
Sustainability and the Prevention of Falls and Fall Injuries in the Older Adult. 2014. https://rnao.ca/bpg/get-involved/acpf/executive-summaries/giselle-talledo-hastie
Royal College of Physicians (UK)l. https://www.rcplondon.ac.uk/
FallSafe Resources https://www.rcplondon.ac.uk/search?keys=fallsafe&sort_by=search_api_relevance