NUR402 Test #2
Guiding Principles of CPSI Disclosure Guidelines - ANS -*Patient-centered healthcare:* An
environment of patient-centered healthcare fosters open, honest and ongoing communication
between healthcare providers and patients. Healthcare services should be respectful,
supportive and take into consideration the patient's expectations and needs at all times.
*Patient autonomy:* Patients have the right to know what has happened to them in order to
facilitate their active involvement and decision-making in their ongoing healthcare.
*Healthcare that is safe:* Patients should have access to safe healthcare services of the highest
possible quality. Lessons learned from patient safety incidents should be used to improve the
practices, processes and systems of healthcare delivery.
*Leadership support:* Leaders and decision makers in the healthcare environment must be
visible champions of disclosure as part of patient-centered healthcare.
Disclosure is the right thing to do: "Individuals involved at all levels of decision-making around
disclosure must ask themselves what they would expect in a similar situation1."
*Honesty and transparency:* When a harmful incident occurs, the patient should be told what
happened. Disclosure acknowledges and informs the patient, which is critical in maintaining the
patient's trust and confidence in the healthcare system.
CPSI (Canadian Patient Safety Institute) - Hand Hygiene Statistics - ANS -- 220,000 people are
afflicted with healthcare-associated infections in Canada every year.
- 8,000 to 12,000 of those individuals will die as a result of acquiring a healthcare-associated
infection.
One study found that:
- 80% of hospital staff who dressed wounds infected with methicillin-resistant Staphylococcus
aureus carried the organism on their hands for up to three hours.
- 60% of hospital staff in contact with patients with Clostridium difficile infection were
contaminated within half an hour without even touching the patient, merely from returning drug
charts to the ends of beds!
,- 40% of all patient-nurse interactions resulted in the same species of Klebsiella pneumoniae
being transmitted to healthcare workers' hands, even with contact as light as touching the
patient's shoulder.
- Meanwhile, simply washing with soap and water virtually eradicated these organisms.
CPSI (Canadian Patient Safety Institute)- Sepsis Introduction - ANS -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
Despite advances in understanding of the body and the disease the mortality rate continues to
increase
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).
CPSI (Canadian Patient Safety Institute)- Health Care Associate Infections - ANS -- are the
most frequent adverse event in healthcare delivery worldwide. Hundreds of millions of patients
are affected by healthcare-associated infections each year, leading to significant mortality and
financial losses for health systems (World Health Organization HAI Fact Sheet, 2014).
Each year, about 8,000 Canadians die from hospital-acquired infections; 220,000 others get
infected. Treatment is more costly than prevention; estimated costs for 2004 were $82 million.
Costs are estimated at $129 million for 2010. That's $12,216 per infected MRSA patient per
year due to:
- Prolonged hospitalization
,- Special control measures
- Expensive treatments
- Extensive surveillance
You can successfully reduce healthcare-associated infections with these five evidence-based
infection control strategies:
- Establish an aggressive hand hygiene program
- Clean and decontaminate the environment and equipment
- Implement contact precautions for any patient infected or colonized with a superbug
- Perform MRSA and VRE screening surveillance on admission and at other times
- Regularly report superbug infection rates to frontline and hospital leaders
CPSI (Canadian Patient Safety Institute)- Surgical Care Safety - ANS -Surgical care safety is
one of four priority areas of focus for CPSI.
The Canadian Adverse Events Study found a 7.5% incidence of adverse events in acute care
hospitals. Surgery was identified as the service most responsible for the care 51.4% of the time
in these adverse events. Improving safety in surgical care is multi-faceted and spans the period
before surgery, during the surgical procedure, and during care following surgery.
- Effective communication and teamwork are foundational to improving safety in surgical care.
- A tool specific to surgical care that is intended to strengthen communication and teamwork is
CPSI's Canadian Surgical Safety Checklist. Surgical teams can use the checklist to ensure that
key care information is communicated throughout the patient's surgical journey and to enhance
teamwork. Research has emphasized the impact of culture, communication, and teamwork on
the effectiveness of the checklist.
Several team training resources to improve patient safety are reviewed in CPSI's Canadian
Framework for Communication and Teamwork. Other programs that have gained strength for
surgical team training include the Comprehensive Unit-Based Safety Program (CUSP) and The
Productive Operating Theatre.
Implementing evidence-based guidelines is fundamental to improving safety in surgical care.
Ensuring that surgical practices follow these guidelines reduces the likelihood that a surgical
patient will experience a patient safety incident. There are three Safer Healthcare Now! Getting
Started Kits directly applicable to surgical care. These include guidelines to prevent surgical site
infections, reduce the likelihood of venous thromboembolism, and reduce medication incidents
with a medication reconciliation process.
Patients and CPSI - ANS -• Patients are involved in the analysis of harm incidents and the
development of guidelines for disclosure.
, Patients want to know:
- The facts about what happened.
- The steps that were and will be taken to minimize harm.
- That the HC org and/or provider is sorry for what happened.
- What will happen to prevent similar events in the future.
Changing Terminology - ANS -*Older Terminology*
*Adverse Event (AE):* "An event that results in unintended harm to the patient, and is related to
the care and/or services provided to the patient rather than to the patient's underlying medical
condition. (The Safety Competencies, CPSI, 2009, p. 41)
*Error:* New guidelines avoid using this term. Most incidents are 'a complex interplay of factors.'
**note that you will still see these terms used frequently!
New Terminology - ANS -- *Patient Safety Incident*: An event or circumstance that could result
in or did result in unnecessary harm to a patient.
*Harm Incident*: A patient safety incident that did result in harm to the patient. Replaces
'Adverse Event' or 'Sentinel Event'.
Near Harm Incident: A patient safety incident which reached the patient but no discernable harm
resulted.
Near Miss: A patient safety incident that did not reach the patient. Replaces 'Close Call'.
Systems Approach: involves analysis of multiple factors
Health Care
Associated Harm: Iatrogenic*
Patient Safety Incident - ANS -an event or circumstance which could have resulted, or did
result, in unnecessary harm to a patient.
Harmful incident: A patient safety incident that resulted in harm to the patient. Replaces
"adverse event." (Example: e wrong unit of blood was infused and patient died from a
haemolytic reaction.)
No harm incident: A patient safety incident which reached a patient but no discernable harm
resulted. (Example: e wrong unit of blood was infused, but was not incompatible.)
Near miss: A patient safety incident that did not reach the patient. Replaces "close call."
(Example: A unit of blood was being connected to the wrong patient's intravenous line, but this
was detected before the infusion started.)
Guiding Principles of CPSI Disclosure Guidelines - ANS -*Patient-centered healthcare:* An
environment of patient-centered healthcare fosters open, honest and ongoing communication
between healthcare providers and patients. Healthcare services should be respectful,
supportive and take into consideration the patient's expectations and needs at all times.
*Patient autonomy:* Patients have the right to know what has happened to them in order to
facilitate their active involvement and decision-making in their ongoing healthcare.
*Healthcare that is safe:* Patients should have access to safe healthcare services of the highest
possible quality. Lessons learned from patient safety incidents should be used to improve the
practices, processes and systems of healthcare delivery.
*Leadership support:* Leaders and decision makers in the healthcare environment must be
visible champions of disclosure as part of patient-centered healthcare.
Disclosure is the right thing to do: "Individuals involved at all levels of decision-making around
disclosure must ask themselves what they would expect in a similar situation1."
*Honesty and transparency:* When a harmful incident occurs, the patient should be told what
happened. Disclosure acknowledges and informs the patient, which is critical in maintaining the
patient's trust and confidence in the healthcare system.
CPSI (Canadian Patient Safety Institute) - Hand Hygiene Statistics - ANS -- 220,000 people are
afflicted with healthcare-associated infections in Canada every year.
- 8,000 to 12,000 of those individuals will die as a result of acquiring a healthcare-associated
infection.
One study found that:
- 80% of hospital staff who dressed wounds infected with methicillin-resistant Staphylococcus
aureus carried the organism on their hands for up to three hours.
- 60% of hospital staff in contact with patients with Clostridium difficile infection were
contaminated within half an hour without even touching the patient, merely from returning drug
charts to the ends of beds!
,- 40% of all patient-nurse interactions resulted in the same species of Klebsiella pneumoniae
being transmitted to healthcare workers' hands, even with contact as light as touching the
patient's shoulder.
- Meanwhile, simply washing with soap and water virtually eradicated these organisms.
CPSI (Canadian Patient Safety Institute)- Sepsis Introduction - ANS -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
Despite advances in understanding of the body and the disease the mortality rate continues to
increase
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).
CPSI (Canadian Patient Safety Institute)- Health Care Associate Infections - ANS -- are the
most frequent adverse event in healthcare delivery worldwide. Hundreds of millions of patients
are affected by healthcare-associated infections each year, leading to significant mortality and
financial losses for health systems (World Health Organization HAI Fact Sheet, 2014).
Each year, about 8,000 Canadians die from hospital-acquired infections; 220,000 others get
infected. Treatment is more costly than prevention; estimated costs for 2004 were $82 million.
Costs are estimated at $129 million for 2010. That's $12,216 per infected MRSA patient per
year due to:
- Prolonged hospitalization
,- Special control measures
- Expensive treatments
- Extensive surveillance
You can successfully reduce healthcare-associated infections with these five evidence-based
infection control strategies:
- Establish an aggressive hand hygiene program
- Clean and decontaminate the environment and equipment
- Implement contact precautions for any patient infected or colonized with a superbug
- Perform MRSA and VRE screening surveillance on admission and at other times
- Regularly report superbug infection rates to frontline and hospital leaders
CPSI (Canadian Patient Safety Institute)- Surgical Care Safety - ANS -Surgical care safety is
one of four priority areas of focus for CPSI.
The Canadian Adverse Events Study found a 7.5% incidence of adverse events in acute care
hospitals. Surgery was identified as the service most responsible for the care 51.4% of the time
in these adverse events. Improving safety in surgical care is multi-faceted and spans the period
before surgery, during the surgical procedure, and during care following surgery.
- Effective communication and teamwork are foundational to improving safety in surgical care.
- A tool specific to surgical care that is intended to strengthen communication and teamwork is
CPSI's Canadian Surgical Safety Checklist. Surgical teams can use the checklist to ensure that
key care information is communicated throughout the patient's surgical journey and to enhance
teamwork. Research has emphasized the impact of culture, communication, and teamwork on
the effectiveness of the checklist.
Several team training resources to improve patient safety are reviewed in CPSI's Canadian
Framework for Communication and Teamwork. Other programs that have gained strength for
surgical team training include the Comprehensive Unit-Based Safety Program (CUSP) and The
Productive Operating Theatre.
Implementing evidence-based guidelines is fundamental to improving safety in surgical care.
Ensuring that surgical practices follow these guidelines reduces the likelihood that a surgical
patient will experience a patient safety incident. There are three Safer Healthcare Now! Getting
Started Kits directly applicable to surgical care. These include guidelines to prevent surgical site
infections, reduce the likelihood of venous thromboembolism, and reduce medication incidents
with a medication reconciliation process.
Patients and CPSI - ANS -• Patients are involved in the analysis of harm incidents and the
development of guidelines for disclosure.
, Patients want to know:
- The facts about what happened.
- The steps that were and will be taken to minimize harm.
- That the HC org and/or provider is sorry for what happened.
- What will happen to prevent similar events in the future.
Changing Terminology - ANS -*Older Terminology*
*Adverse Event (AE):* "An event that results in unintended harm to the patient, and is related to
the care and/or services provided to the patient rather than to the patient's underlying medical
condition. (The Safety Competencies, CPSI, 2009, p. 41)
*Error:* New guidelines avoid using this term. Most incidents are 'a complex interplay of factors.'
**note that you will still see these terms used frequently!
New Terminology - ANS -- *Patient Safety Incident*: An event or circumstance that could result
in or did result in unnecessary harm to a patient.
*Harm Incident*: A patient safety incident that did result in harm to the patient. Replaces
'Adverse Event' or 'Sentinel Event'.
Near Harm Incident: A patient safety incident which reached the patient but no discernable harm
resulted.
Near Miss: A patient safety incident that did not reach the patient. Replaces 'Close Call'.
Systems Approach: involves analysis of multiple factors
Health Care
Associated Harm: Iatrogenic*
Patient Safety Incident - ANS -an event or circumstance which could have resulted, or did
result, in unnecessary harm to a patient.
Harmful incident: A patient safety incident that resulted in harm to the patient. Replaces
"adverse event." (Example: e wrong unit of blood was infused and patient died from a
haemolytic reaction.)
No harm incident: A patient safety incident which reached a patient but no discernable harm
resulted. (Example: e wrong unit of blood was infused, but was not incompatible.)
Near miss: A patient safety incident that did not reach the patient. Replaces "close call."
(Example: A unit of blood was being connected to the wrong patient's intravenous line, but this
was detected before the infusion started.)
