Safe practices indicators project: background, summary of ... › resources › ... ·...

1

Safe practices indicators project: background, summary of methods and measurement strategies

REPORTS, STUDIES AND RESEARCH 2008 MINISTRY OF HEALTH AND SOCIAL POLICY

THIS STUDY IS THE PROPERTY OF: Agencia de Calidad del SNS Ministerio de Sanidad y Consumo Paseo del Prado, 18-20 28071 Madrid PROJECT COORDINATOR Pedro J. Saturno. University of Murcia. Preventive Medicine and Public Health Department. COORDINATING COMMITTEE Pedro J. Saturno. University of Murcia. Preventive Medicine and Public Health Department. Enrique Terol García. Spanish NHS Quality Agency. Ministry of Health and Consumer Affairs. Madrid. Yolanda Agra Varela. Spanish NHS Quality Agency. Ministry of Health and Consumer Affairs. Madrid. Mª del Mar Fernández Maillo. Spanish NHS Quality Agency. Ministry of Health and Consumer Affairs. Madrid. TECHNICAL COMMITTEE Development of indicators Carmen Castillo M.ª José López Teresa Ramón Andrés Carrillo M.ª Dolores Iranzo Víctor Soria Pedro Parra Rafael Gomis Juan José Gascón Field work for the pilot José Martínez Carmen Arellano Trabajo de campo en hospitales del SNS: Zenewton A. Da Silva Gama Silvana L. De Oliveira Adriana C. De Souza Yadira Fonseca Marta Sobral This document is to be cited as: Analysis of the patient safety culture in the Spanish National Health System hospital environment. Madrid: Ministry of Health and Social Policy; 2009.

2

3

Safe practices indicators project: background, summary of methods and measurement strategies

(Pending review)

4

Contents Background ..................................................................................................................... 7 Methods ........................................................................................................................... 9 Measurement strategies ............................................................................................... 11 Field test and baseline measurement .......................................................................... 13 Annex 1 .......................................................................................................................... 15 Annex 2. Indicators ...................................................................................................... 23

5

6

Background

One of the components of any strategy to control safety in health care is the development and monitoring of indicators to identify safety problems, compare institutions, and measure the effect of interventions. However, most of the existing initiatives on building and measuring safety indicators1,2 focus on outcomes, including mortality and other adverse events. Outcome indicators need appropriate adjustments to be correctly used and interpreted, they are not easy to measure, and may lack validity regarding their usefulness to point out what processes should be targeted for improvement. An alternative, or at least complementary, approach is to focus on evidence-based structural and process elements, known to be related with safety problems. These type of indicators may be easier to measure and interpret, and more readily useful to identify specific safety problems and to design interventions to improve. The NQF’s document “Safe Practices for Better Health Care”3,4 is a good starting point for this approach. The document proposes 30 practices with high priority to be implemented, on the basis of existing evidence and their potential for generalization. The main objectives of our project, under a contract with the Spanish Ministry of Health, were (i) to identify structure and process indicators to measure to what extent NQF recommendations are implemented in hospitals; (ii) to assess the indicators reliability and usefulness in identifying safety problems; and (iii) to field test measurement strategies; and (iv) to perform a baseline study in a representative sample of hospitals. 1 Agency for Healthcare Research and Quality. Guide to patient safety indicators. Version 3.0 (May 2006). Washington: AHRQ; 2003. Available at: http://www.qualityindicators.ahrq.gov. [accessed 14 Enero 2008].: 2 Kelley E, Hurst J. Health Care Quality Indicators Project: conceptual framework paper. Paris: OECD; 2006. OECD Health Working Papers Nº 23. Available at: http://www.oecd.org/els/health/workingpapers. [accessed 14 Enero 2008]. 3 The National Quality Forum (NQF). Safe Practices for Better Healthcare: a consensus report. Washington: The National Quality Forum: 2003. 4 The National Quality Forum (NQF). Safe Practices for Better Healthcare 2006 update. Washington: The National Quality Forum, 2007.

7

http://www.qualityindicators.ahrq.gov/

http://www.oecd.org/els/health/workingpapers

Methods

A multi-disciplinary team was formed to analyze NQF recommendations and their supporting evidence, and to convert them into indicators. The guidelines for this process were the following:

• Indicators should translate into measurable elements NQF’s recommendations. • They should be structure and process indicators, reflecting what hospitals

should have or do to prevent the safety problems addressed by the NQF’s recommendations.

• Indicators should be evidence-based. • Try to achieve parsimony. • Take into account feasibility of measurement.

The team included experienced health professionals from all concerned services (intensive care, surgery, medicine, pharmacy), and quality management experts. To review evidence and to formulate/propose indicators, NQF’s 30 Safe Practices were assigned to team members according to their area of expertise. Proposed indicators were presented and discussed in team meetings, to assure compliance with the project’s (above stated) general guidelines. After several discussion rounds, a total of 69 indicators were proposed and pilot tested for reliability and feasibility in three hospitals, representing the three types of hospitals in which the eventual national sample was to be stratified. The main features of the resulting set of indicators are the following: - 5 of the 30 Safe Practices could not be converted into indicators, for two principal reasons:

• 2 of them (information on adverse outcome risk differences among facilities, specific training in critical care for physicians working in intensive care units) did not apply to our Health System, where facilities are regionalized, and where it is compulsory for physicians to have specialized training in intensive care for working in intensive care units.

• For 3 of them (computerized prescriptions system, prophylactic treatment with beta-blockers for elective surgery, prevention of risk of aspiration), evidence was found to be insufficient, contradictory, or with too many specifications for measurement.

- 40 of the 69 indicators are structural (including culture of safety as one of them), and 29 are process indicators (including 10 composite measures). Most structure indicators refer to the existence and assessment of appropriate norms and protocols to prevent specific safety problems. -Average number of indicators per Safe Practice is 3, ranging from 1 to 9. The one Safe Practice with 9 indicators is the standardization of methods for labeling, packaging and storing medications.

9

- Measurement methods include clinical records review, inspection, observation, and survey questions (a total of 10) added to the Culture of Safety instrument (an adaptation of the AHRQ’s instrument)5,6. - To assure uniform data gathering, appropriate instruments for data abstraction have been devised for most indicators. 5Patient Safety Culture Survey. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/qual/hospculture/ (accessed 02-12-2008) 6 Adapted version for Spain: Cuestionario sobre seguridad de los pacientes. Madrid: Agencia de Calidad, MSC; 2005. Available at: http://www.msc.es/organizacion/sns/planCalidadSNS/docs/CuestionarioSeguridadPacientes1.pdf (accessed 02-12-2008)

10

http://www.ahrq.gov/qual/hospculture/

http://www.msc.es/organizacion/sns/planCalidadSNS/docs/CuestionarioSeguridadPacientes1.pdf

Measurement strategies

To facilitate measurement and the use of indicators as problem identification tools within a single institution, several strategies were devised, including:

• Using LQAS for the indicators measured with data abstracted from clinical records and other registered data sources.

• Constructing composite indicators for particularly relevant Safe Practices (such as prevention of surgical site infection, central venous catheter-associated infections, use of standardized abbreviations and dose designations, etc.) so that their several aspects could be summarized in a single measure.

• Selecting for inspection at different sites (hospital pharmacy, wards, emergency room, and operating theatre) those drugs that conspicuously represent main possible failures in labeling, packaging and storing medication.

• Combining, whenever possible, structure and process indicators for the same Safe Practice.

• Focusing on high risk patients to select LQAS samples (i.e. >65 y.o. for prevention of pressure ulcers, specific surgical procedures for prophylaxis of infection, intensive care patients for prevention of malnutrition, etc).

Overall, apart from the Culture of Safety survey, the whole set of indicators can be measured in three days of work by a team of three health professionals.

11

Field test and baseline measurement

After pilot testing, the set of indicators (see Table 1 attached) has been measured in a random sample of 21 Spanish hospitals, stratified by hospital size. The main objective has been to field test the feasibility of measurement in the various settings representing real life situations in the context of the Spanish Health Care System, and to have baseline data to foster and compare future improvements. The methodological report (in Spanish) can be downloaded from: http://www.msc.es/organizacion/sns/planCalidadSNS/docs/construccionValidacionIndicadoresSeguridadPaciente.pdf Pedro J. Saturno, October 2008 Universidad de Murcia Tel: +34 968 363948 Fax: +34 968 363947 <[email protected]>

13

http://www.msc.es/organizacion/sns/planCalidadSNS/docs/construccionValidacionIndicadoresSeguridadPaciente.pdf

http://www.msc.es/organizacion/sns/planCalidadSNS/docs/construccionValidacionIndicadoresSeguridadPaciente.pdf

14

Annex 1

Table 1: List of Indicators Based on NQF recommended Safe Practices1

NQF RECOMMENDATIONS INDICATORS

GROUP

RECOMMENDATION No.

DESCRIPTION

MEASUREMENT METHOD

1. Create a healthcare culture of safety

1 / Create a healthcare culture of safety

1.1. Safety Culture survey* Survey

2 / For designated high-risk, elective surgical procedures or other specified care, patients should be clearly informed of the likely reduced risk of an adverse outcome at treatment facilities that have demonstrated superior outcomes and should be referred to such facilities in accordance with the patient’s stated preference.

-----------------

----------------

3 / Specify an explicit protocol to be used to ensure an adequate level of nursing based on the institution’s usual patient mix and the experience and training of its nursing staff.

3.1.The hospital has a document with explicit norms for the staffing of nurses 3.2. The hospital Units/Services have measured nursing workloads according to patient-mix

Inspection

Inspection

4 / All patients in intensive care units (both adults and pediatric) should be managed by physicians having specific training and certification in critical care medicine.

---------------

--------------

2.Matching healthcare needs with service delivery capability

5 / Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.

5.1. Pharmacists are available (in-service or on call) 24 hours –a-day 5.2. The hospital has a protocol for detecting, recording and communicating prescription errors, involving the hospital Pharmacy Service (PhS). 5.3. PhS reviews and validates medication orders before dispensing them, including:

• Formulas. • Cytostatics. • Nutrition • IV mixtures. • All other drugs prescriptions

Inspection/Interview

Inspection

Inspection/Interview

15

/…… Table 1 (cont.)

6 / Verbal orders should be recorded whenever possible and immediately read back to the prescriber- i.e., a healthcare provider receiving a verbal order should read or repeat back the information that the prescriber conveys in order to verify the accuracy of what was heard .

6.1. The hospital has explicit norms about verbal orders 6.2. Frequency with which verbal orders are repeated back by providers receiving them. 6.3. Frequency with which verbal orders are recorded. 6.4. Do not give verbal orders regarding chemotherapy.

Inspection.

Survey.

Survey.

Survey.

7 / Use only standardized abbreviations and dose designations.

7.1. The hospital has a list of abbreviations, symbols and dose designations that could cause medication errors. 7.2. Frequency of use of abbreviations, symbols and dose designations that could cause medication errors. *

Inspection.

Medical records review.

8 / Patient care summaries or other similar records should not be prepared from memory.

8.1. Frequency with which patient care summaries and other similar records are prepared total or partially from memory.

Survey.

3. Facilitating information transfer and clear communication

9 / Ensure that care information, especially changes in orders and new diagnostic information, is transmitted in a timely and clearly understandable form to all of the patient’s current healthcare providers who need that information to provide care.

9.1. Frequency of prescribing without reviewing/reconciling all the medication the patient is taking 9.2 Frequency with which the changes in medication are communicated clearly and timely to all healthcare professionals involved in the patient’s care. 9.3. Frequency with which any new information regarding the patient’s diagnosis is transmitted in a clear and timely form to all the healthcare professionals involved in the patient’s care

Survey.

Survey.

Survey.

16

/….. Table 1. (cont.)

10 / Ask each patient or legal surrogate to recount what he or

she has been told during the informed consent discussion.

10.1. Frequency with which the healthcare professionals make sure that their patients understand the potential risks and complications of prescribed healthcare interventions before the patient signs the informed consent.

Survey.

11 / Ensure that written documentation of the patient’s preference for life-sustaining

treatments is prominently displayed in his/her chart.

11.1. The hospital has explicit norms or protocols about patient preferences for life-sustaining treatments. 11.2. Frequency with which patient preferences for life-sustaining treatments are known by healthcare providers.

Inspection.

Survey.

12 / Implement a computerized prescribing order system.

---------------------------

---------------------

13 / Implement a standardized protocol to prevent the mislabeling

of radiographs.

13.1. The hospital has explicit norms or protocol to prevent the mislabeling of radiographs. 13.2. % of errors in labeling radiographs. *

Inspection.

Review of radiographs documents.

14 / Implement standardized protocols to prevent the occurrence of wrong-site

procedures or wrong-patient procedures

14.1. The hospital has explicit norms or protocol to prevent wrong-site or wrong-patient procedures

Inspection.

15 / Evaluate each patient undergoing elective surgery for

risk of an acute ischemic cardiac event during surgery, and provide prophylactic treatment of high-risk

patients with beta-blockers.

-------------------------------

-------------------

4. Adopting safe practices in specific

clinical care settings or for

specific processes of care.

16 /Evaluate each patient upon admission, and regularly thereafter, for the risk of

developing pressure ulcers. This evaluation should be repeated at

regular intervals during care. Clinically appropriate preventive methods should be implemented

consequent to the evaluation.

16.1. The hospital has explicit norms or protocol for prevention of pressure ulcers. 16.2. % of patients assessed for risk of pressure ulcers within the first 48 hours after admission. 16.3. Regular changes in the position of an immobile patient is performed according to the patient’s risk of pressure ulcers.

Inspection.



17

/……. Table 1. (cont.)

17 / Evaluate each patient upon admission, and regularly thereafter, for the risk of

developing deep vein thrombosis (DVT)/venous thromboembolism

(VTE). Utilize clinically appropriate methods to prevent DVT/VTE.

17.1. The hospital explicit norms or protocol for the prevention of DVT and VTE. 17.2. % of patients with documented evaluation for risk of developing DVT/VTE.

Inspection.


18 /Utilize dedicated anti-thrombotic (anti-coagulation)

services that facilitate coordinated care management.

18.1 The hospital explicit norms or protocol for anti-coagulation management, including the patient’s involvement. 18.2. The hospital a protocol for prescription of heparin using a nomogram. 18.3. Evaluation of the patient (weight and renal function) before prescribing heparin. *

Inspection

Inspection.


19 / Upon admission, and regularly thereafter, evaluate each patient

for the risk of aspiration.

--------------------------

-------------------

20 /Adhere to effective methods of preventing central venous catheter

(CVC)-associated blood stream infections.

20.1. The hospital has explicit norms or protocol for the prevention of CVC-associated blood stream infections. 20.2. Evaluation of compliance, at the time of CVC insertion, with recommended measures (barriers) to prevent infection. * 20.3. Failures in continuous care of CVC to prevent infection. *

Inspection.

Observation.

Observation.

18


21 / Evaluate each pre-operative patient in light of his or her

planned surgical procedure for the risk of surgical site infection, and implement appropriate antibiotic prophylaxis and other preventive

measures based on that evaluation.

21.1. The hospital has a protocol for antibiotic prophylaxis for surgical procedures. 21.2. .The hospital has a protocol for nursing care of surgical wounds. 21.3. The hospital has a protocol for the preparation of skin and mucosa for surgical procedures. 21.4. Compliance with the antibiotic prophylaxis protocol for surgical procedures. * 21.5. Measures taken to maintain normotermia in patients undergoing major surgical procedures (>2 hours). 21.6. Administration of O2 (FiO2≥80%), during and after the intervention, to patients undergoing major surgical procedures (>2 hours). *

Inspection.

Inspection.

Inspection


Interview


22 / Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal

failure, and utilize a clinically appropriate method for reducing risk of renal injury based on the

patient kidney function evaluation.

22.1. The hospital has a protocol to prevent contrast-media induced renal failure. 22.2. % of patients undergoing contrast media tests, with documented assessment for contrast media-induced renal failure, prior to the tests. 22.3. % of patients at risk for contrast media-induced renal failure with documented prevention plan.

Inspection.



19


23 / Evaluate each patient upon admission, and regularly

thereafter, for risk of malnutrition. Employ clinically appropriate

strategies to prevent malnutrition.

23.1. The hospital has explicit norms or protocol to assess the risk of and to prevent malnutrition. 23.2. % of patients assessed for risk of malnutrition within the first 24 hours after admission. 23.3. % of patients with artificial nutrition explicitly adjusted to their calories and proteins needs.*

Inspection.



24 / Whenever a pneumatic

tourniquet is used, evaluate the patient for the risk of an ischemic and/or thrombotic complication,

and utilize appropriate prophylactic measures

24.1. The hospital has explicit norms or protocol to control the use of a pneumatic tourniquet in surgical procedures, and the care of the patient thereafter. 24.2. Time and pressure are controlled and recorded when using a pneumatic tourniquet in surgical procedures. *

Inspection.


25 / Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap

prior to and after direct contact with the patient or objects immediately

around the patient.

25.1. The hospital has explicit norms or protocol about hand washing and decontamination for healthcare personnel. 25.2. In the previous 12 months, the hospital had educational activities on hand washing and decontamination for health personnel. 25.3. The hospital has adequate infrastructure (including washbasins, disinfectant soap, hydro-alcoholic solution and single use towels). 25.4. Compliance with the hand washing and decontamination protocol. *

Inspection.

Inspection.

Inspection.

Observation.

20

/….. Table 1. (cont.)

26 / vaccinate healthcare workers against influenza to protect both them and patients from influenza.

26.1. The hospital has explicit norms or protocol to implement influenza vaccination for healthcare personnel. 26.2. Prevalence of influenza vaccination in the hospital healthcare personnel.

Inspection.

Survey.

27 / Keep workspaces where medications are prepared clean, orderly,

well lit, and free of clutter, distraction, and noise.

27.1. All workspaces where medications are prepared are clean, orderly, well lit, and free of clutter, distraction and noise. *

Inspection 5. Increase safe medication use

28 / Standardize the methods for labeling,

packaging, and storing medication.

28.1. The hospital has explicit norms or protocol for labeling, packaging, storing and replacing drugs in wards repositories. 28.2. The hospital has explicit norms or protocol for labeling, packaging, storing and replacing drugs in the hospital pharmacy. 28.3. The hospital pharmacy has explicit norms or protocol for labeling and preparing unit-dose medications. 28.4. The hospital has explicit norms or protocol for the maintenance of arrest carts. 28.5. The hospital pharmacy has a list of antidotes specifying:

Place where they are stored. Minimum stocks that should

be available. Expiration date control

28.6. Failures in labeling, packaging and storing drugs in wards repositories. * 28.7. Arrest carts correctly maintained. *

Inspection

Inspection

Inspection

Inspection.

Inspection.

Inspection.

Inspection

21

/…… Table 1.(cont.)

28.8. Failures in labeling, packaging and storing drugs in the hospital pharmacy. * 28.9. Correct labeling of medications prepared en the hospital pharmacy*, including:

• Formulas • Parenteral Nutrition • I.V. mixtures. • Cytostatics.

Inspection

Review of medication labels

29 / Identify all “high alert” drugs (e.g., intravenous adrenergic agonists and

antagonists, chemotherapy agents,

anticoagulants and anti-thrombotics, concentrated

parenteral electrolytes, general anesthetics,

neuromuscular blockers, insulin and oral

hypoglycemics, narcotics and opiates) .

29.1. The hospital has a list of “high alert” drugs. 29.2. The hospital has explicit norms or protocol for the administration of “high alert” drugs, including maximum doses, duration, via and double check for doses calculation. 29.3. The hospital has explicit norms for the labeling and storage of “high alert” drugs . 29.4. The hospital has automatic (pre-printed) prescriptions for Cytostatics.

Inspection

Inspection

Inspection

Inspection

30 /Dispense medications in unit-dose or, when

appropriate, unit-of-use form, whenever possible.

30.1. % of beds with drugs dispensed in unit-dose:

- Monday to Friday. - Everyday (including week-ends and holidays).

Interview/Inspection.

1: The National Quality Forum (NQF). Safe Practices for Better Healthcare: a consensus report. Washington: The National Quality Forum: 2003. *: Composite indicator.

22

Annex 2. Indicators

23

Existence of well-founded rules on nurse staffing levels

TITLE Existence of well-founded rules on nurse staffing levels.

RATIONALE

Main aim of indicator: to ensure that the level of nurse staffing is appropriate to facilitate correct patient care. The existence of rules on nurse staffing levels demonstrates the hospital’s endeavors to adjust nurse staffing levels to its needs. The level of nurse staffing in a healthcare institution is strongly associated with the risk of adverse events encountered by patients. Specifically, lower staffing rates are associated with increased risk of adverse events.

DESCRIPTION This indicator is used to determine whether or not the hospital has specific rules on nurse staffing levels.

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure.

DOMAIN Structure.

DATA SOURCE Provider data

DOCUMENTATION OF EVIDENCE

• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43, AHRQ Publication No 01-E058. Rockville, MD: Agency for Healthcare Research and Quality. July 2001.

• The National Quality Forum (NQF). Safe Practices for Better Healthcare: a consensus report. Washington: The National Quality Forum: 2003.

• Seago J. The California experiment: alternatives for minimum nurse-to-patient ratios. JONA, 2002; 32(1): 48-58.

• Aiken LH, Clarke SP, Sloane DM et al. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care 2002; 14 (1): 5-13.

• Committee on the Work Environment for Nurses and Patient Safety and Ann Page. Keeping Patients Safe. Transforming the work environment of Nurses. Washington DC: National Academy Press; 2004.

• Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nurse-patient ratios: a systematic review of the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm. 2004 Jul-Aug; 34 (7-8): 326-37.

COMMENT Request copy of document.

24

Existence of well-founded rules on nurse staffing levels

TITLE Existence of a nursing staff workload study.

RATIONALE

Main aim of indicator: to ensure that the level of nurse staffing is appropriate to facilitate correct patient care. The fact that workload is measured reflects the hospital’s endeavors to adjust nurse staffing levels to its needs. The level of nurse staffing in a healthcare institution is strongly associated with the risk of adverse events encountered by patients. Specifically, lower staffing rates are associated with increased risk of adverse events.

DESCRIPTION This indicator is used to determine whether or not the hospital assesses nursing staff workload.

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure.

DATA SOURCE Provider data.




• Aiken LH, Clarke SP, Sloane DM et al. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care 2002; 14 (1): 5-13

• Needleman J, Buerhaus O, Matke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002; 346 (2): 1715-1766.

• Kane RL, Shamliyan T, Mueller C et al. Nurse Staffing and Quality of Patient Care. Evidence Report/Technology Assessment No. 151, AHRQ Publication No 07-E005. Rockville. MD: Agency for Healthcare Research and Quality. March 2007. http://www.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf (last retrieved: 14 January 2008).


25

http://www.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf

http://www.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf

Involvement of pharmacist in prescription, dispensation and

administration of drugs TITLE Availability of pharmacist (on site or on call) 24 hours a

day.

RATIONALE

Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications and administration and monitoring of medications.

DESCRIPTION This indicator is used to determine whether or not the hospital has pharmacists available 24 hours a day, distinguishing between weekdays and weekends/public holidays.

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure DATA SOURCE Pharmacy data.


• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report / Technology Assessment No. 43, AHRQ Publication No 01-E058. Rockville. MD: Agency for Healthcare Research and Quality. July 2001.


• Botha JH, Tyrannes I, Miller R et al: Pharmacokimetic consultation program in a pediatric asthma clinic. Am J Hosp Pharm, 1992; 49 (8): 1936-40.

• Krska J, Cromarty JA, Arris F et al. Pharmacist-led medication review in patients over 65: a randomized controlled trial in primary care. Age Aging. 2001; 30 (3): 205-211.

COMMENT

26

Involvement of pharmacist in prescription, dispensation and administration of drugs

TITLE Existence of a protocol for detection, recording and reporting of medication errors that involves the pharmacy service.

RATIONALE

Main aim of indicator: to reduce the incidence of medication-related adverse events. The existence of a protocol for detection, recording and reporting of medication errors demonstrates the pharmacy service’s endeavors to prevent these errors. Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications and administration and monitoring of medications. This indicator is used to determine whether or not the hospital has a protocol for detection, recording and reporting of medication errors that involves the pharmacy service.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure. DATA SOURCE Pharmacy data


• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report / Technology Assessment No. 43, AHRQ Publication No 01-E058. Rockville, MD: Agency for Healthcare Research and Quality. July 2001.


• Leape LL Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. JAMA.1995; 274 (1): 35-43.

• Wong SW, Gray ES. Clinical Pharmacy services in oncology clinics. J Oncol Pharm Pract. 1999; 5 (1): 49-54.


27

Involvement of pharmacist in prescription, dispensation and administration of drugs

TITLE Validation of medication orders by pharmacy service before

dispensation. Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications and administration and monitoring of medications.

RATIONALE

This indicator is used to determine the percentage of prescriptions that are validated before dispensation, distinguishing between magistral formulas, parenteral nutrition, intravenous mixtures, cytostatic drugs and all other medication orders.

DESCRIPTION

NUMERATOR Number of prescriptions validated in last year x 100. DENOMINATOR Total number of prescriptions issued in last year. DOMAIN Process. DATA SOURCE Registry data.


• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43, AHRQ Publication No 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001.


• Leape LL Bates DW, Cullen DJ et al: Systems analysis of adverse drug events. JAMA 1995; 274 (1): 35-43.

• Krska J, Cromarty JA, Arris F et al: Pharmacist-led medication review in patients over 65: a randomized controlled trial in primary care. Age Aging 2001; 30 (3): 205-211.

COMMENT The percentage of medication orders validated before dispensation is also requested. The tool designed for structured data collection is included below.

HOSPITAL

28

DATA COLLECTION TABLE (PHARMACY SERVICE SURVEY)

1: VALIDATION PROCESS DESCRIPTION

Do all prescriptions come to the PS for validation before being dispensed?*

Night-time

prescriptions

Weekend

prescriptions

- Formulas

- Cytostatic drugs

- Parenteral nutrition

- Intravenous mixtures

- Other prescriptions for hospital patients

- Emergency dept.

- Medical day hospital

- Surgical day hospital

- Outpatient clinics

* Answer: yes, no or in part.

2: ESTIMATED PERCENTAGE OF PRESCRIPTIONS VALIDATED BEFORE DISPENSATION

- Estimated percentage (total): - Note data source and form of calculation of percentage.

29

Ensure that verbal orders have been understood

TITLE Existence in hospital of explicit rules on verbal orders.

RATIONALE

Safe and effective healthcare delivery depends to a large extent on accurate and timely communication among care-givers. The need for clear, unambiguous communication of orders cannot be overstated; a lapse in communication at any step can result in an error that can cause serious illness or injury, long-term disability or death. The existence of explicit rules on verbal orders demonstrates the hospital’s endeavors to prevent these problems. This indicator is used to determine whether or not the hospital has rules or a protocol on how to deal with verbal orders.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure. DATA SOURCE Provider data.


• Chassin MR, Becher EC. The wrong patient. Ann Intern Med, 2002; 136(11): 826-833.


• Cardosi KM. Runway Safety: It’s Everyone’s Business. US Department of Transportation: Federal Aviation Administration; 2001. http://www.faa.gov/runwaysafety/pdf/handbook.pdf (last retrieved: 14 January 2008).

• Gadenius M, Rudenäs N. Cleared to land? An overview of the problem Runway Incursions. 2003. http://www.tfhs.se/docs/student/enskilda%20arbeten/Clear%20to%20Land.pdf (last retrieved: 14 January 2008).

• Health Care Association of New Jersey (HCANJ). Medication management guideline. Hamilton (NJ): Health Care Association of New Jersey (HCANJ); 2006 Apr. 33 p.

• Kelly, Kate. (2005, May). Cell Phones and Telephone Orders. Pharmacy Times Magazine, ISMP Medication Safety Alert article, Pg. 16.


30

http://www.faa.gov/runwaysafety/pdf/handbook.pdf

http://www.tfhs.se/docs/student/enskilda%20arbeten/Clear%20to%20Land.pdf

http://www.tfhs.se/docs/student/enskilda%20arbeten/Clear%20to%20Land.pdf

Ensure that verbal orders have been understood TITLE Percentage of healthcare workers who affirm that verbal

orders are always repeated out loud in their unit or area.

RATIONALE

Safe and effective healthcare delivery depends to a large extent on accurate and timely communication among care-givers. The need for clear, unambiguous communication of orders cannot be overstated; a lapse in communication at any step can result in an error that can cause serious illness or injury, long-term disability or death. Main aim of indicator: to increase patient safety by ensuring that verbal orders are always repeated out loud. This rate should increase over time. This indicator is used to determine the percentage of healthcare workers who affirm that verbal orders are always repeated out loud in their unit or area.

DESCRIPTION

NUMERATOR Replies indicating “always” x 100. Total number of healthcare workers replying to this item in

the survey. DENOMINATOR DOMAIN Process. DATA SOURCE Clinician Survey







COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: When verbal orders are received on treatment or care to be given or procedures to be followed, staff repeat the order received out loud to the person issuing the order, to ensure that it has been correctly understood. Possible replies: never / almost never / sometimes / almost always / always.

31



TITLE Percentage of healthcare workers who affirm that in their unit or area orders received verbally are always written down.

RATIONALE

Safe and effective healthcare delivery depends to a large extent on accurate and timely communication among care-givers. The need for clear, unambiguous communication of orders cannot be overstated; a lapse in communication at any step can result in an error that can cause serious illness or injury, long-term disability, or death. Main aim of indicator: to increase patient safety by always writing down orders received verbally. This rate should increase over time. This indicator is used to determine the percentage of healthcare workers who affirm that in their unit or area orders received verbally are always written down.

DESCRIPTION

NUMERATOR Replies indicating “always” x 100. Total number of healthcare workers replying to this item in

the survey. DENOMINATOR DOMAIN Process. DATA SOURCE Clinician Survey. DOCUMENTATION OF EVIDENCE






COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: When orders on treatment or care to be given or procedures to be followed are received verbally, they are noted down by staff in the corresponding clinical document. Possible replies: never / almost never / sometimes / almost always / always.

32



TITLE Percentage of healthcare workers who affirm that in their unit or area orders relating to chemotherapy are never issued verbally.

RATIONALE

Safe and effective healthcare delivery depends to a large extent on accurate and timely communication among care-givers. The need for clear, unambiguous communication of orders cannot be overstated; a lapse in communication at any step can result in an error that can cause serious illness or injury, long-term disability or death. Main aim of indicator: to increase patient safety by never giving orders relating to chemotherapy verbally. This rate should increase over time. This indicator is used to determine the percentage of healthcare workers who affirm that in their unit or area orders relating to chemotherapy are never issued verbally.

DESCRIPTION

NUMERATOR Replies indicating “never” x 100. Total number of healthcare workers replying to this item in

the survey. DENOMINATOR DOMAIN Process. DATA SOURCE Clinician Survey.



• Chassin MR, Becher EC. The wrong patient. Ann Intern Med 2002; 136(11): 826-833.



• Kelly, Kate (2005, May). Cell Phones and Telephone Orders. Pharmacy Times Magazine, ISMP Medication Safety Alert article, Pg. 16.

COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: If you handle chemotherapy treatment, orders relating to chemotherapy are issued verbally. (Reply only if you handle chemotherapy treatment in your area). Possible replies: never / almost never / sometimes / almost always / always.

33


Limited and regulated use of abbreviations and dose designations TITLE Existence of a list of abbreviations, symbols and dose

designations connected with medication errors.

RATIONALE

Experiential data show that using standardized abbreviations and symbols and standardized phraseology reduces medication errors. Main aim of indicator: to enhance patient safety by controlling the symbols and abbreviations used in prescriptions. The existence of a list of abbreviations reflects the hospital’s endeavors to control medication errors. This indicator is used to determine whether or not a hospital has a list, rules or guidelines on abbreviations, symbols and dose designations connected with medication errors.

DESCRIPTION



• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report / Technology Assessment No. 43, AHRQ Publication No 01-E058. Rockville, MD: Agency for Healthcare Research and Quality. July 2001


• Cohen MR, Davis NM. Avoid dangerous Rx abbreviations. Am Pharm. 1992; NS32 (2): 20-21.

• Sentinel Event Alert: Medication errors related to potentially dangerous abbreviations. Joint Commission 2001; 23:1-4.

• Institute for Safe Medication Practices. ISMP list of error-prone abbreviations, symbols, and dose designations. ISMP Medication Safety Alert! 2003; 8 (24): 27 Nov

• Seguridad de Medicamentos. Abreviaturas, símbolos y expresiones de dosis asociados a errores de medicación. Farm Hosp 2004; 28 (2): 141-144


34

Limited and regulated use of abbreviations and dose designations

TITLE Percentage of medical prescriptions free of non-standard abbreviations, symbols or dose designations.

RATIONALE

Experiential data show that using standardized abbreviations and symbols and standardized phraseology reduces medication errors. Main aim of indicator: to enhance patient safety by reducing the number of prescriptions containing abbreviations connected with medication errors. This indicator is used to determine the percentage of medical prescriptions that are free of non-standard abbreviations, symbols or dose designations, based on the first and last (discharge report) prescription of each patient.

DESCRIPTION

NUMERATOR Number of prescriptions without errors x 100. DENOMINATOR Number of prescriptions studied.

DOMAIN Process.

DATA SOURCE Administrative data. Medical record.


• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report / Technology Assessment No. 43, AHRQ Publication No 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001.




• Institute for Safe Medication Practices. ISMP list of error-prone abbreviations, symbols, and dose designations. ISMP Medication Safety Alert! 2003; 8 (24): 27 Nov.

• Seguridad de Medicamentos. Abreviaturas, símbolos y expresiones de dosis asociados a errores de medicación. Farm Hosp 2004; 28 (2): 141-144.

COMMENT

The aspects studied are connected with: • Abbreviations and symbols not recommended for use

to indicate dose, form and frequency of administration.

• Dose designations, use of decimals and zeros. • Initials of chemical formulas and pharmaceutical

products. • Abbreviations and initials of drugs. The tool designed for data collection, with all the expressions studied, is included below.

35

HOSPITAL Abbreviations and symbols not recommended for use to indicate dose, form and frequency of administration

17

16

15

14

13

12

11

10

9 8 7 6 5 4 3 2 1

µg

cc

U/u

d

IN

SC

cap

comp

+

X

</>

36

HOSPITAL Dose designations, use of decimals and zeros

17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1

´0

Nam

e and dose

Dose &

m

easurement

Num

ber w

ithout units

106

37

HOSPITAL Initials of chemical formulas and pharmaceutical products

17

16

15

14

13

12

11

10

9 8 7 6 5 4 3 2 1

ClN

a

ClK

HC

O3

R(retard)

F(forte)

38

HOSPITAL Abbreviations and initials of drugs

17

16

15

14

13

12

11

10

9 8 7 6 5 4 3 2 1

AZT

HC

T

MTX

VM

-26

MM

F

FK-506

IVIS

FTC

3TC

T-20

ddC

ddI

d4T

39

Limited and regulated use of abbreviations and dose designations

TITLE Average number of non-recommended abbreviations, symbols or dose designations used in medical prescriptions.

RATIONALE

Experiential data show that using standardized abbreviations and symbols and standardized phraseology reduces medication errors. Main aim of indicator: to enhance patient safety by reducing the use of abbreviations, symbols or dose designations connected with medication errors. The average should decrease over time. This indicator is used to determine the average number of forbidden abbreviations, symbols or dose designations used in medical prescriptions, based on the first and last (discharge report) prescription of each patient.

DESCRIPTION

NUMERATOR Number of non-recommended expressions d d Total number of prescriptions (first prescription and

discharge report prescription) x number of patients studied

DENOMINATOR

DOMAIN Process.



• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report / Technology Assessment No. 43, AHRQ Publication No 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001.




• Institute for Safe Medication Practices. ISMP list of error-prone abbreviations, symbols, and dose designations. ISMP Medication Safety Alert! 2003; 8 (24): 27 Nov.

• Seguridad de Medicamentos. Abreviaturas, símbolos y expresiones de dosis asociados a errores de medicación. Farm Hosp 2004; 28 (2): 141-144.

COMMENT

The aspects studied are connected with: • Abbreviations and symbols not recommended for use

to indicate dose, form and frequency of administration.

• Dose designations, use of decimals and zeros. • Initials of chemical formulas and pharmaceutical

products. • Abbreviations and initials of drugs. The average number of non-standard expressions, stratified by first prescription and last (discharge report) prescription, is also calculated. The tool designed for data collection, with all the expressions studied, is included below.

40

HOSPITAL Abbreviations and symbols not recommended for use to indicate dose, form and frequency of administration

17

16

15

14

13

12

11

10

9 8 7 6 5 4 3 2 1

µg

cc

U/u

d

IN

SC

cap

comp

+

X

</>

41

HOSPITAL Dose designations, use of decimals and zeros

17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1

´0

Nam

e and dose

Dose and

measurem

ent

Num

ber w

ithout units

106

42

HOSPITAL Initials of chemical formulas and pharmaceutical products

17

16

15

14

13

12

11

10

9 8 7 6 5 4 3 2 1

ClN

a

ClK

HC

O3

R(retard)

F(forte)

43

HOSPITAL Abbreviations and initials of drugs

17

16

15

14

13

12

11

10

9 8 7 6 5 4 3 2 1

AZT

HC

T

MTX

VM

-26

MM

F

FK-506

IVIS

FTC

3TC

T-20

ddC

ddI

d4T

44

Prepare summaries and reports on the basis of data, not from memory

TITLE Percentage of healthcare workers who affirm that in their unit or area clinical reports and summaries are never written without having all the necessary data to hand.

RATIONALE

When relying on memory to transcribe medical records, natural human limitations, often exacerbated by environmental circumstances, can result in errors of recall, increasing the risk of error and of an adverse event. Main aim of indicator: to enhance patient safety by reducing to a minimum the number of clinical reports and summaries written without having all the necessary data to hand. The rate should increase over time. This indicator is used to determine the percentage of healthcare workers who affirm that in their unit or area clinical reports and summaries are never written without having all the necessary data to hand.

DESCRIPTION

NUMERATOR Replies indicating “never” x 100. Total number of healthcare workers replying to this item in

the survey. DENOMINATOR DOMAIN Process. DATA SOURCE Clinician survey.



• Cohen MR. Medication errors: check the name on the medication administration record before transcribing a drug order. Nursing 1981; 11 (4): 34.

• Thomas EJ, Lipsitz SR, Studdert DM, Brennan TA. The reliability of medical record review for estimating adverse event rates. Ann Intern Med 2002; 136 (11): 812-816.

COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: Medical record or summary reports are written from memory, without having all the appropriate documentation to hand (test results, radiological reports, medication administered, etc). Possible replies: never / almost never / sometimes / almost always / always.

45

Clear and timely communication of changes in patient care

TITLE Percentage of healthcare providers who affirm that in their unit or area prescriptions are always prepared revising all the medication being taken by each patient.

RATIONALE

Changes in medications that occur during one care setting are often not communicated to healthcare providers in other care settings. As a result, professionals often lack important information when making treatment decisions. This lack of information is a frequent cause of medication prescribing errors. Main aim of indicator: to enhance patient safety by increasing the percentage of cases in which prescriptions are prepared revising all the medication being taken by each patient. This indicator is used to determine the percentage of healthcare providers who affirm that in their unit or area prescriptions are always prepared revising all the medication being taken by each patient. This rate should increase over time.

DESCRIPTION

NUMERATOR Replies indicating “always” x 100. Total number of healthcare providers replying to this item

in the survey. DENOMINATOR DOMAIN Process DATA SOURCE Clinician Survey




• Leape LL, Bates DW Cullen DJ et al. Systems analysis of adverse drug events. JAMA 1995; 274 (1): 35-43.

• Warholak-Juarez T, Rupp MT, Salazar TA, Foster S. Effect of patient information on the quality of pharmacists’ drug use review decisions. J Am Pharm Assoc 2000; 40 (4): 500-508.

COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: Before a new prescription is made, the list of medication being taken by the patient is revised. Possible replies: never / almost never / sometimes / almost always / always.

46


TITLE Percentage of healthcare providers who affirm that in their unit or area changes in medications are always communicated clearly and rapidly to all professionals involved in patient care.

RATIONALE

Changes in medications that occur during one care setting are often not communicated to healthcare providers in other care settings. As a result, professionals often lack important information when making treatment decisions. This lack of information is a frequent cause of medication prescribing errors. Main aim of indicator: to enhance patient safety by improving communication between health professionals.

DESCRIPTION

This indicator is used to determine the percentage of healthcare providers who affirm that in their unit or area changes in medications are always communicated clearly and rapidly to all professionals involved in patient care. To improve patient safety, this rate should increase over time.






• Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. JAMA 1995; 274 (1): 35-43.


COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: All changes in medications are communicated clearly and rapidly to all professionals involved in patient care. Possible replies: never / almost never / sometimes / almost always / always.

47


TITLE Percentage of healthcare providers who affirm that in their unit or area information affecting a patient’s diagnosis is always communicated clearly and rapidly to all professionals involved in patient care.

RATIONALE

Main aim of indicator: to increase patient safety by improving communication between health professionals. Changes in medications that occur during one care setting are often not communicated to healthcare providers in other care settings. As a result, professionals often lack important information when making treatment decisions. This lack of information is a frequent cause of medication prescribing errors. This indicator is used to determine the percentage of healthcare providers who affirm that in their unit or area information affecting a patient’s diagnosis is always communicated clearly and rapidly to all professionals involved in patient care.

DESCRIPTION


in the survey. DENOMINATOR DOMAIN Process

DATA SOURCE Clinician Survey




• Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. JAMA 1995; 274 (1): 35-43.


COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: Information affecting a patient’s diagnosis is communicated clearly and rapidly to all professionals involved in the patient’s care. Possible replies: never / almost never / sometimes / almost always / always.

48

Ensure that informed consent has been understood

TITLE Percentage of healthcare providers who affirm that in their unit or area steps are always taken to ensure that patients have understood the risks and complications before they sign the informed consent form.

RATIONALE

Informed consent should be viewed as an interactive process between healthcare providers and patients, not merely a form for which a signature must be obtained. Main aim of indicator: to increase patient safety by improving communication between health professionals and patients. The rate should increase over time. This indicator is used to determine the percentage of healthcare providers who affirm that in their unit or area steps are always taken to ensure that patients have understood the risks and complications before they sign the informed consent form.

DESCRIPTION







• Paasche-Orlow MK, Taylor HA, Brancati FL. Readability standards for informed-consent forms as compared with actual readability. N Engl J Med 2003; 348 (8): 721-726.

COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: Before signing the informed consent form, patients or their representatives are asked to repeat their understanding of the explanations received regarding possible risks and complications of the intervention, exploration or treatment concerned. Possible replies: never / almost never / sometimes / almost always / always.

49

Ensure that patient preferences regarding end-of-life care are known

Existence in the hospital of rules or protocols on terminal patients’ preferences and advance directives. TITLE The provision of unwanted end-of-life care is an adverse event that can be avoided by the implementation of effective patient communication. Written documentation about patient preferences indicates that they have given thought to this important issue and have stated preferences in the form of a written advance directive.

RATIONALE

This indicator is used to determine whether or not the hospital has rules or protocols on terminal patients’ preferences and advance directives.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure DATA SOURCE Provider data.




• Ditto PH, Danks JH, Smucker WD, et al. Advance directives as acts of communication: a randomized controlled trial. Arch Intern Med 2001; 161 (3): 421-430.

• Teno JM, Stevens M, Spernak S et al. Role of written advance directives in decision making: insights from qualitative and quantitative data. JGIM 1998; 13 (7): 439-446.


50

TITLE Percentage of healthcare providers who affirm that in their unit or area enquiries are always made about terminal patients’ preferences regarding life-support procedures and treatment.

RATIONALE

The provision of unwanted end-of-life care is an adverse event that can be avoided by the implementation of effective patient communication. Written documentation about patient preferences indicates that the patient and his or her family have given thought to this important issue and have stated preferences in the form of a written advance directive. Main aim of indicator: to improve healthcare quality by always enquiring about terminal patients’ preferences. The rate should increase over time.

DESCRIPTION This indicator is used to determine the percentage of healthcare providers who affirm that in their unit or area enquiries are always made about terminal patients’ preferences regarding life-support procedures and treatment.

NUMERATOR Replies indicating “always” x 100. DENOMINATOR Total number of healthcare providers replying to this item in

the survey. DOMAIN Process DATA SOURCE Clinician Survey




• Ditto PH, Danks JH, Smucker WD, et al. Advance directives as acts of communication: a randomized controlled trial. Arch Intern Med 2001; 161 (3): 421-430.

• Teno JM, Stevens M, Spernak S et al. Role of written advance directives in decision making: insights from qualitative and quantitative data. JGIM 1998; 13 (7): 439-446.

COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: In the case of probably terminal patients, enquiries are made in advance about their preferences regarding life-support procedures and treatment. (Reply only if you care for probably terminal patients in your area). Possible replies: never / almost never / sometimes / almost always / always.

Ensure that patient preferences regarding end-of-life care are known

51

Reduce misinterpretation of radiographs resulting from miscommunication of critical information TITLE Existence of protocol for prevention of erroneous labeling

of radiographs.

RATIONALE

In both inpatient and outpatient settings, the potential exists for radiographs to be mislabeled, or not completely labeled, and consequently misinterpreted. The existence of a protocol for labeling of radiographs reflects the hospital’s endeavors to prevent misinterpretation. This indicator is used to determine whether or not the hospital has a protocol for prevention of erroneous labeling of radiographs.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure DATA SOURCE Provider data




• Fitzgerald R. Error in Radiology. Clin Radiol 2001; 56 (12): 938-946.

• Sociedad Española de Radiología Médica (SERAM: Spanish Medical Radiology Society). Guía de Gestión de la SERAM http://www.seram.es/docs/formacion/ guiadegestion.pdf (last retrieved: 14 January 2008).


52

http://www.seram.es/docs/formacion/%20guiadegestion.pdf


Reduce misinterpretation of radiographs resulting from miscommunication of critical information TITLE Percentage of simple radiographs correctly identified.

RATIONALE

In both inpatient and outpatient settings, the potential exists for radiographs to be mislabeled, or not completely labeled, and consequently misinterpreted. Main aim of indicator: to enhance patient safety by increasing the percentage of radiographs that are correctly identified. This percentage should increase over time. The indicator is used to determine the percentage of simple radiographs that are correctly identified. Correct identification requires that the same two identifying features (eg. patient name and medical record number) appear on the radiograph and the envelope containing the radiograph.

DESCRIPTION

NUMERATOR Number of radiographs without errors x 100. DENOMINATOR Number of radiographs studied.

DOMAIN Process. DATA SOURCE Special or unique data (radiological documents).





• Sociedad Española de Radiología Médica (SERAM: Spanish Medical Radiology Society). Guía de Gestión de la SERAM. http://www.seram.es/docs/formacion/ guiadegestion.pdf (last retrieved: 14 January 2008).

COMMENT The tool designed for data collection is included below.

53



HOSPITAL Radiology Department Correct

Name on X-ray

MR num. and/or SS num. on X-ray

Name on envelope

MR num. and/or SS num. on envelope

Names coincide

MR or SS numbers coincide

Yes

No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 TOTAL

MR: medical record. SS: Social Security. X-ray: simple radiographs. Indicator calculation:

1. Correct (no errors): LQAS (85.55; 0.05, 0.1); minimum 12. 2. % error: number of errors detected / number of possible errors x 100.

3. Describe type of error.

54

Reduce misinterpretation of radiographs resulting from miscommunication of critical information TITLE Percentage of errors in identification of simple radiographs.

RATIONALE In both inpatient and outpatient settings, the potential exists for radiographs to be mislabeled, or not completely labeled, and consequently misinterpreted.

DESCRIPTION

The indicator is used to determine the percentage of errors in identification of simple radiographs. Correct identification requires that the same two identifying features (eg. patient name and medical record number) appear on the radiograph and on the envelope containing the radiograph. Main aim of indicator: to enhance patient safety by increasing the percentage of radiographs that are correctly identified. The percentage of errors detected should decrease over time.

NUMERATOR Number of errors detected x 100. DENOMINATOR Number of possible errors assessed.

DOMAIN Process DATA SOURCE Medical record





• Sociedad Española de Radiología Médica (SERAM: Spanish Medical Radiology Society). Guía de Gestión de la SERAM. http://www.seram.es/docs/formacion/ guiadegestion.pdf (last retrieved: 14 January 2008).

The tool designed for structured data collection is included below COMMENT

55



HOSPITAL Radiology Department Correct Name

on X-ray

MR num. and/ or SS num. on X-ray

Name on envelope

MR num. and/ or SS num. on envelope

Names coincide

MR or SS numbers coincide

Yes

No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 TOTAL

MR: medical record. SS: Social Security. X-ray: simple radiographs. Indicator calculation:

4. Correct (no errors): LQAS (85.55; 0.05, 0.1); minimum 12. 5. % error: number of errors detected / number of possible errors x 100.


56

Apply protocol for prevention of wrong-site and wrong-patient surgery TITLE Existence of a protocol for prevention of wrong-site or

wrong-patient surgery.

RATIONALE

Similarity of patient names and other characteristics and symmetry between the two sides of the body present many opportunities for wrong-site errors or wrong-patient errors. These errors often result in significant adverse events, events that are now believed to be far more common than previously recognized. The existence of a protocol in this respect reflects the hospital’s endeavors to reduce adverse events related to wrong-site or wrong-patient surgery. The indicator is used to determine whether or not the hospital has a protocol for prevention of wrong-site or wrong-patient surgery.

DESCRIPTION






• Joint Commission on Accreditation of Healthcare Organizations. A follow-up review of wrong site surgery. Sentinel Event Alert, Issue 24 - December 5, 2001. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_24.htm (last retrieved: 14 January 2008).

• American Academy of Orthopaedic Surgeons, available. Advisory Statement: Wrong-Site Surgery. Document Number 1015; October 2003. http://www.aaos.org/about/papers/advistmt/1015.asp (last retrieved: 14 January 2008).

COMMENT

Request copy of document and assess whether or not it includes: • Wrong site. • Wrong patient. • Determine whether or not the protocol is in use in all

surgical units.

57

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_24.htm

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_24.htm

http://www.aaos.org/about/papers/advistmt/1015.asp

Assessment and prevention of decubitus ulcers

TITLE Prevention of pressure ulcers: existence of rules approved by hospital on measures to be taken for prevention of pressure ulcers.

RATIONALE

All patients are at the risk of developing pressure ulcers when seriously ill, immobile for a prolonged period or unable to respond to pressure discomforts. However, prevention is the key to reducing the prevalence of pressure ulcers. Appropriate prevention methods are known and widely available, although substantially underused. The existence of a protocol in this respect reflects the hospital’s endeavors to reduce the incidence of pressure ulcers. The indicator is used to determine whether or not the hospital has rules for prevention of pressure ulcers. DESCRIPTION

NUMERATOR Does not apply to this measure. Does not apply to this measure. DENOMINATOR Structure. DOMAIN





• Brandeis GH, Berlowitz DR, Katz P. Are Pressure Ulcers preventable? A survey of experts. Adv Skin Wound Care 2001; 14 (5): 244-48.

• Lyder CH. Pressure ulcer and management. JAMA 2003; 289 (2): 223-226.

• García Fernández FP, Carrascosa García MI, Bellido Valejo JC et al. Guía para el manejo de: Riesgo de deterioro de la integridad cutánez, deterioro de la integridad cutánea. Deterioro de la integridad tisular, relacionado con las úlceras por presión. Marco conceptual enfermero. Evidentia 2005 sept; 2 (supl). [ISSn: 1697-638X] http://www.index-f.com/evidentia/ 2005supl/guia_upp.pdf (last retrieved: 14 January 2008).

COMMENT

Request copy of document and assess whether or not protocol includes: • Assessment scale. • Frequency of assessment. • Reassessment. • Mobility care. • Nutrition care.

58

http://www.index-f.com/evidentia/%202005supl/guia_upp.pdf

http://www.index-f.com/evidentia/%202005supl/guia_upp.pdf


TITLE Prevention of pressure ulcers: percentage of patients over 64 years of age who are assessed within 48 hours of admission to hospital for the risk of developing pressure ulcers.

RATIONALE

All patients are at the risk of developing pressure ulcers when seriously ill, immobile for a prolonged period or unable to respond to pressure discomforts. However, prevention is the key to reducing the prevalence of pressure ulcers. Appropriate prevention methods are known and widely available, although substantially underused. The evidence shows that risk assessment for pressure ulcers is not performed in a consistent or predictable manner. Main aim of indicator: to increase the percentage of elderly hospital patients (65 years or over) who are assessed within 48 hours of admission to hospital for the risk of developing pressure ulcers. This indicator is used to determine the percentage of patients over 64 years of age who are assessed within 48 hours of admission to hospital for the risk of developing pressure ulcers.

DESCRIPTION

NUMERATOR Number of patients over 64 years of age who have been in hospital at least two days and who, according to documentary evidence, were assessed within 48 hours of admission for the risk of developing pressure ulcers x 100.

Total number of patients studied over 64 years of age who have been in hospital at least two days. DENOMINATOR

DOMAIN Process.





• Bergstrom N, Braden B, Kemp M et al. Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnosis and prescription of preventive interventions. J AM Geriatr Soc 1996;44(1):22-30.

• Allman RM Goode Patrick MM, et al. Pressure ulcer risk factors among hospitalised patients with activity limitation. JAMA 1995; 273 (11).

• Grupo Nacional para el Estudio y Asesoramiento en Ulceras por Presión y Heridas Crónicas (GNEAUPP). Clasificación-Estadiaje de las Úlceras por Presión. Logroño. 2003. Retrieved 2008, from http://www.gneaupp.org/documentos/gneaupp/estadiaje.pdf.

• García Fernández FP, Carrascosa García MI, Bellido Valejo JC et al. Guía para el manejo de: Riesgo de deterioro de la integridad cutánea, deterioro de la integridad cutánea. Deterioro de la integridad tisular, relacionado con las úlceras por presión. Marco conceptual enfermero. Evidentia 2005; 2 (supl). Retrieved 2008, from http://www.index-f.com/evidentia/2005supl/ guia_upp.pdf.


59

http://www.gneaupp.org/documentos/gneaupp/estadiaje.pdf

http://www.index-f.com/evidentia/2005supl/%20guia_upp.pdf

http://www.index-f.com/evidentia/2005supl/%20guia_upp.pdf


TITLE Prevention of pressure ulcers: percentage of patients over 64 years of age who receive appropriate posture changes according to their risk of developing pressure ulcers.

RATIONALE

All patients are at the risk of developing pressure ulcers when seriously ill, immobile for a prolonged period or unable to respond to pressure discomforts. However, prevention is the key to reducing the prevalence of pressure ulcers. Appropriate prevention methods are known and widely available, although substantially underused. Main aim of indicator: to raise the level of compliance with recommendations for posture changes in elderly patients at risk of developing pressure ulcers. This indicator is used to determine the percentage of patients over 64 years of age who receive the appropriate posture changes according to their risk (medium or high) of developing pressure ulcers.

DESCRIPTION

NUMERATOR Number of days of correct posture changes in each medium- or high-risk patient.

DENOMINATOR Number of patients studied multiplied by number of days at risk. DOMAIN Process.





• Bergstrom N, Braden B, Kemp M et al. Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnosis and prescription of preventive interventions. J Am Geriatr Soc 1996; 44 (1): 22-30

• Allman RM Goode Patrick MM, et al. Pressure ulcer risk factors among hospitalised patients with activity limitation. JAMA 1995; 273 (11)

• García Fernández FP, Carrascosa García MI, Bellido Valejo JC et al. Guía para el manejo de: Riesgo de deterioro de la integridad cutánez, deterioro de la integridad cutánea. Deterioro de la integridad tisular, relacionado con las úlceras por presión. Marco conceptual enfermero. Evidentia 2005 sept; 2 (supl). [ISSN: 1697-638X] http://www.index-f. com/evidentia/2005supl/guia_upp.pdf (last retrieved: 14 January 2008).


60

HOSPITAL Assessment in first 24 hours after admission of risk of developing pressure ulcers and compliance with protocol for posture change.

RISK ASSESSMENT SCALE RISK

CASE NORTON EMINA BRADEN High Medium Some posture change

Correct posture changes * Observations

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

TOTAL

* Each day of stay with risk to be assessed as one unit of study

61

Assessment and prevention of venous thromboembolism (VTE) TITLE Existence in hospital of protocol for prevention of venous

thromboembolism.

RATIONALE

Several clinical interventions are known to effectively prevent venous thromboembolism. The most appropriate specific intervention will depend on the thrombotic risk, the clinical setting and other factors. The existence of a protocol approved by the hospital demonstrates the endeavors being made to prevent these adverse events. This indicator is used to determine whether or not the hospital has a protocol for prevention of venous thromboembolism.

DESCRIPTION





• Agnelli G, Sonaglia F. Prevention of venous thromboembolism. Thromb Res 2000; 97 (1): V49-V62

• Hyers TM. Management of venous thromboembolism. Arch Intern Med 2003; 163: 759-768.

• Stratton MA, Anderson FA, Bussey HI, Caprini J, et al. Prevention of venous thromboembolism: adherence to the 1995 American Collage of Chest Physicians Consensus Guidelines for Surgical Patients. Arch Intern Med 2000; 160 (3): 334-340.

• Clagett GP, Anderson FAJ, Levine MN, Wheeler HB. Prevention of venous thromboembolism. Chest 1995; 108 (suppl): 312S-334S.


62

63

Assessment and prevention of venous thromboembolism (VTE)

TITLE Percentage of patients over 64 years of age assessed in the first 24 hours after admission to hospital for the risk of developing venous thromboembolism.

RATIONALE

Despite widespread education about the need for preventive intervention and the publication of clinical guidelines for venous thromboembolism prevention, appropriate prophylaxis continues to be substantially underused, especially in patients at low or moderate risk of venous thrombosis. Main aim of indicator: to increase the percentage of hospital patients over 64 years of age who are assessed in the first 24 hours after admission for the risk of developing venous thromboembolism.

DESCRIPTION This indicator is used to determine the percentage of patients over 64 years of age who are assessed, with documentary evidence, in the first 24 hours after admission to hospital, for the risk of developing venous thromboembolism.

NUMERATOR Number of patients over 64 years of age who are assessed, with the corresponding entry in their medical record, in the first 24 hours after admission, for the risk of developing venous thromboembolism x 100.

DENOMINATOR Total number of patients studied over 64 years of age who have been in hospital at least two days.

DOMAIN Process.





• Agnelli G, Sonaglia F. Prevention of venous thromboembolism. Thromb Res 2000; 97 (1): V49-V62

• Hyers TM. Management of venous thromboembolism. Arch Intern Med 2003; 163: 759-768.

• Spyropoulos AC. Emerging Strategies in the Prevention of Venous Thromboembolism in Hospitalized Medical Patients. Chest 2005; 128: 958–969.

• Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Antithrombotic and Thrombolytic Therapy Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 338S–400S

COMMENT

Specific handling of anticoagulants

TITLE Existence of protocol for handling of oral anticoagulants by patients, for patients who receive anticoagulants from outpatient clinics or health centers.

RATIONALE

Anticoagulants are considered high-alert medications due to the relative frequency of adverse events they may cause when doses are not properly adjusted to patients’ needs: sub-optimal doses may cause thromboembolism; overdoses may cause hemorrhage. The existence in the hospital of a protocol for handling of oral anticoagulants by patients demonstrates the hospital’s endeavors to prevent adverse events related to these medications. This indicator is used to determine whether or not the hospital has a protocol for handling of oral anticoagulants by patients.

DESCRIPTION





• Knowton CH, Thomas OV, Williamson A, et al.: Establishing community pharmacy–based anticoagulation education and monitoring programs. J Am Pharm Assoc 1999; 39 (3): 368-74.

• Bungard TJ, Ackman ML, Ho G. et al. Adequacy of anticoagulation in patients with atrial fibrillation coming to a hospital. Pharmacotherapy 2000; 20 (9): 1060-5.

• Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The Pharmacology and Management of the Vitamin K Antagonists. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3_suppl):204S–233S.


64


TITLE Existence of protocol approved by hospital for correct heparin administration via nomogram.

RATIONALE

Anticoagulants are considered high-alert medications due to the relative frequency of adverse events they may cause when doses are not properly adjusted to patients’ needs: sub-optimal doses may cause thromboembolism, overdoses may cause hemorrhage. The existence in the hospital of a protocol for heparin administration via nomogram demonstrates the hospital’s endeavors to prevent adverse events related to these medications. This indicator is used to determine whether or not the hospital has rules for heparin administration via nomogram.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure.





• Knowton CH, Thomas OV, Williamson A, et al. Establishing community pharmacy–based anticoagulation education and monitoring programs. J Am Pharm Assoc 1999; 39 (3): 368-74.

• Bungard TJ, Ackman ML, Ho G. et al. Adequacy of anticoagulation in patients with atrial fibrillation coming to a hospital. Pharmacotherapy. 2000; 20 (9): 1060-5.

• Hirsh J, Raschke R Heparin and Low-Molecular-Weight Heparin. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 188S–203S

COMMENT

Request copy of document and assess whether or not it includes the following minimum criteria: • Initial dose. • Corresponding blood tests. • Modification of dose in light of results of blood tests.

65


TITLE Percentage of patients assessed for weight and renal function before starting anticoagulant therapy with heparin.

RATIONALE

Anticoagulants are considered high-alert medications due to the relative frequency of adverse events they may cause when doses are not properly adjusted to patients’ needs: sub-optimal doses may cause thromboembolism, overdoses may cause hemorrhage. Main aim of indicator: to increase the percentage of patients in whom precautions are taken prior to administration of heparin, with adjustment of dose according to patient weight and renal function. This indicator is used to determine the percentage of patients whose renal function (creatinine, low molecular weight heparin) and weight (both types of heparin) are assessed prior to administration of heparin. Accordingly, patients’ medical records should reflect their weight 24 hours before starting therapy and their creatinine levels 48 hours before starting therapy.

DESCRIPTION

NUMERATOR Number of patients receiving heparin treatment whose weight and, where appropriate, renal function is reflected in their medical records x 100.

DENOMINATOR Total number of patients receiving heparin.

DOMAIN Process.





• Knowton CH, Thomas OV, Williamson A, et al. Establishing community pharmacy–based anticoagulation education and monitoring programs. J Am Pharm Assoc 1999; 39 (3): 368-74.

• Bungard TJ, Ackman ML, Ho G. et al. Adequacy of anticoagulation in patients with atrial fibrillation coming to a hospital. Pharmacotherapy 2000; 20 (9): 1060-5.

• Hirsh J, Raschke R. Heparin and Low-Molecular-Weight Heparin. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 188S–203S.


66

HOSPITAL

Assessment of patient (weight and renal function) before starting anticoagulant therapy with unfractionated heparin (weight) or low molecular weight heparin (weight and renal function)

WEIGHT CREATININE* COMPLIANCE

CASE Type of heparin YES YES NO YES NO Observations

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

TOTAL

* Not applicable in the case of unfractionated heparin. Compliance with indicator, LQAS (85.55; 0.05; 0.1): minimum 12.

67

Prevention of central venous catheter (CVC)-related infections TITLE Existence in hospital of rules for prevention of central venous

catheter (CVC)-related infections.

RATIONALE

Vascular catheter-related infections are the leading cause of hospital-acquired bloodstream infections and are associated with significant morbidity in critically ill patients. Most central venous catheter-related infections are considered preventable. The existence in the hospital of rules for prevention of CVC-related infections demonstrates its endeavors to prevent these adverse events.

DESCRIPTION

This indicator is used to determine whether or not the hospital has rules for prevention of CVC-related infections. These rules should include:

• Measures to be taken when inserting CVCs. • Measures to be taken for maintenance of CVCs.





• O’ Grady NP, Alexander M, Raad II et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002; 51 (RR-10): 1-29.

• O’Grady NP. Applying the science to the prevention of catheter-related infections. J Crit Care 2002; 17 (2): 114-121.

• Higuera F, Rosenthal VD, Duarte P, Ruiz J, Franco G, Safdar N. The effect of process control on the incidence of central venous catheter–associated bloodstream infections and mortality in intensive care units in Mexico. Crit Care Med 2005; 33 (9): 2022–2027.

• Guideline for Hand Hygiene in Healthcare settings. Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Hand Hygiene Task Force, Society for Healthcare Epidemiology of America (SHEA); Association for Professionals in Infection Control and Epidemiology (APIC), Infectious Diseases Society of America (IDSA). J Am Coll Surg 2004; 198 (1): 121-127.


68

Prevention of central venous catheter (CVC)-related infections

TITLE Percentage of errors by healthcare providers relating to recommendations on full barrier precautions to be taken when inserting central venous catheters (CVCs).

RATIONALE

Main aim of indicator: to reduce the number of errors connected with full barrier precautions when inserting CVCs. Vascular catheter-related infections are the leading cause of hospital-acquired bloodstream infections and are associated with significant morbidity in critically ill patients. Most central venous catheter-related infections are considered preventable. This indicator is used to determine the percentage of errors by healthcare providers relating to recommendations on full barrier precautions to be taken when inserting central venous catheters (CVCs). Barrier precautions consist of: sterile gloves, long-sleeved sterile gowns, sterile field drapes, mask and headwear.

DESCRIPTION

NUMERATOR Number of errors in each sterile barrier component x 100. Total number of cases of CVC insertion studied x 5 possible

errors. DENOMINATOR DOMAIN Process. DATA SOURCE Study of CVC insertions.




• O’ Grady N9, Alexander M, Raad II et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002; 51 (RR-10): 1-29.

• O’Grady NP. Applying the science to the prevention of catheter-related infections. J Crit Care 2002; 17 (2): 114-121.

• Guideline for Hand Hygiene in Healthcare settings. Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Hand Hygiene Task Force, Society for Healthcare Epidemiology of America (SHEA); Association for Professionals in Infection Control and epidemiology (APIC), Infectious Diseases Society of America (IDSA). J Am Coll Surg 2004; 198 (1): 121-127.


69

BARRIER PRECAUTIONS IN CENTRAL VENOUS CATHETER INSERTION ASSESSMENT SHEET

CRITERIA PATIENTS

HEADWEAR MASK STERILE GOWN

STERILE DRAPES

STERILE GLOVES TYPE

□ Jugular □ Subclavian □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

□ Drum □ Jugular □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Subclavian □ Drum □ Jugular □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Subclavian □ Drum □ Jugular □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Subclavian □ Drum □ Jugular □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Subclavian □ Drum □ Jugular □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Subclavian □ Drum □ Jugular □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Subclavian □ Drum

□ Jugular

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Subclavian

□ Drum

□ Jugular


□ Drum

□ Jugular


□ Drum

Calculation of indicator: % error: number of errors detected / number of possible errors x 100. Specify type of error

70


TITLE Percentage of central venous catheters (CVCs) in use that are correctly maintained.

RATIONALE

Main aim of indicator: to increase the number of CVCs that are correctly maintained. Vascular catheter-related infections are the leading cause of hospital-acquired blood stream infections and are associated with significant morbidity in critically ill patients. Most central venous catheter-related infections are considered preventable.

DESCRIPTION

This indicator is used to determine the percentage of CVCs in use that are correctly maintained. Maintenance is understood to be correct if the following criteria are met: • Use of sterile gauze or transparent sterile dressing to cover

catheter insertion point. • Caps on lumens not in use. • Clamps on lumens not in use.

NUMERATOR Number of CVCs in use that are correctly maintained x 100. DENOMINATOR Total number of central venous catheters studied. DOMAIN Process. DATA SOURCE Direct observation.





• Raad II, Hanna HA. Intravascular catheter-related infections: new horizons and recent advances. Arch Intern Med 2002; 162: 871-878.

• Ross VM, Orr PA. Prevention of infections related to central venous catheters. Crit Care Nurse Q 1997; 20 (3):79-88.


71

HOSPITAL

Errors in central venous catheter care

DATA COLLECTION AND COMBINED INDICATOR CALCULATION TABLE

Enter the following data for each patient with a CVC: Dressing Cap Clamp Catheter Lumens 1 Lumens 2

. . .

. . .

. . . Lumens n

• Dressings assessed in all CVCs studied. • Caps and clamps assessed in CVCs with lumens that are not in use.

Total number of CVCs without errors

• Indicator: -------------------------------------------------------- x 100 Total number of CVCs studied

72


TITLE Percentage of maintenance errors in central venous catheters (CVCs)

in use.

RATIONALE

Main aim of indicator: to reduce the number of CVCs that are incorrectly maintained. Vascular catheter-related infections are the leading cause of hospital-acquired bloodstream infections and are associated with significant morbidity in critically ill patients. Most central venous catheter-related infections are considered preventable.

DESCRIPTION

This indicator is used to determine the percentage of maintenance errors in CVCs in use. Maintenance is understood to be correct if the following criteria are met: • Use of sterile gauze or transparent sterile dressing to cover

catheter insertion point. • Caps on lumens not in use. • Clamps on lumens not in use.

NUMERATOR Number of errors in care of each CVC in use x 100. Total number of central venous catheters studied x lumens not in use x

possible errors assessed. DENOMINATOR DOMAIN Process. DATA SOURCE Direct observation.





• Raad II, Hanna HA. Intravascular catheter-related infections: new horizons and recent advances. Arch Intern Med 2002; 162: 871-878.

• Ross VM, Orr PA. Prevention of infections related to central venous catheters. Crit Care Nurse Q 1997; 20 (3):79-88.


73

HOSPITAL

Errors in central venous catheter care


Enter the following data for each patient with a CVC: Dressing Cap Clamp Catheter Lumens 1 Lumens 2

. . .

. . .

. . . Lumens n Total number of errors detected

• Combined indicator: -------------------------------------------------------- x 100 Total number of possible errors assessed

The denominator varies according to the number of catheters and lumens assessed, as

possible cap and clamp errors are only assessed in CVCs that have lumens that are not in use.

74

Prevention of surgical infection TITLE Existence of protocol approved by hospital for antibiotic

prophylaxis.

RATIONALE

Many surgical procedures have shown a reduction in surgical site infections through the use of prophylactic antibiotics that are given prior to surgery in order to establish tissue levels at the time of incision and that are maintained throughout the operation. The medical literature regularly publishes recommendations and updates for prophylactic antibiotics for various surgical procedures. The existence of a protocol approved by the hospital for antibiotic prophylaxis demonstrates its endeavors to prevent post-surgical infections. This indicator is used to determine whether or not the hospital has an approved protocol for antibiotic prophylaxis.

DESCRIPTION





• Mangran AJ, Horan TC. Pearson ML, et al. Guidelines for prevention of surgical site infection. Infect Control 1999; 20 (4): 247-80.

• Nichols RL. Preventing surgical site infections: a surgeon’s perspective. Emerg Inf Disease 2001; 7 (2): 220-24.

• Dobrzanski S, Lawley DI, McDermott I, Selby M, Ausobsky JR. The impact of guidelines on peri-operative antibiotic administration. J Clin Pharm Ther 1991; 16:19-24.


75

Prevention of surgical infection

TITLE Existence of protocol approved by hospital for specific

nursing practices for post-operative wound care.

RATIONALE

The essential foundation of infection control for patients undergoing surgery includes operating room (OR) practices for preparing and maintaining an aseptic surgical field within a controlled environment that minimizes contamination; proper sterilization of surgical instruments, attire and surgical scrub of the OR team; meticulous surgical technique; and careful post-operative wound care. The effectiveness of these practices has been demonstrated over time. The existence of a protocol for specific nursing practices for post-operative wound care demonstrates the hospital’s endeavors to prevent post-surgical infections. This indicator is used to determine whether or not the hospital has an approved protocol for specific nursing practices for post-operative wound care.

DESCRIPTION





• Blake, GJ. Administering prophylactic antibiotics before surgery. Nursing 1994; 24 (12): 18.



76


TITLE Existence of protocol for nursing practices for surgical

preparation of skin and mucous.

RATIONALE

The essential foundation of infection control for patients undergoing surgery includes operating room (OR) practices for preparing and maintaining an aseptic surgical field within a controlled environment that minimizes contamination; proper sterilization of surgical instruments, attire and surgical scrub of the OR team; meticulous surgical technique; and careful post-operative wound care. The effectiveness of these practices has been demonstrated over time. The existence of a protocol for nursing practices for surgical preparation of skin and mucous demonstrates the hospital’s endeavors to prevent post-surgical infections. This indicator is used to determine whether or not the hospital has a protocol for nursing practices for surgical preparation of skin and mucous.

DESCRIPTION






• Blake GJ. Administering prophylactic antibiotics before surgery. Nursing. 1994; 24 (12): 18.

COMMENT Request copy of document and assess whether or not it includes:

• Electric shaving.

77


TITLE Percentage of surgical procedures that meet recommendations on antibiotic prophylaxis.

RATIONALE

Many surgical procedures have shown a reduction in surgical site infections through the use of prophylactic antibiotics that are given prior to surgery in order to establish tissue levels at the time of incision and that are maintained throughout the operation. The medical literature regularly publishes recommendations and updates for prophylactic antibiotics for various surgical procedures. Main aim of indicator: to increase compliance with recommendations on use of antibiotic prophylaxis in surgical procedures.

DESCRIPTION

This indicator is used to determine the percentage of surgical procedures that meet the recommendations on antibiotic prophylaxis. The following aspects are assessed: • Use of antibiotic in surgery in which prophylaxis is indicated • Correct antibiotic • Correct dose • Timely administration • Correct duration of prophylaxis

NUMERATOR Patients receiving correct prophylactic treatment in all aspects x 100. DENOMINATOR Patients undergoing surgery in which prophylaxis is indicated. DOMAIN Process.







• Gilbert DN, Mouldering RC, Eliopoulos GM, Sande MA. The Sanford Guide to antimicrobial therapy 2007. Antimicrobial Therapy Inc., Sperryville 2007.

• McKibben L, Horan T, Tokars JI et al. Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control 2005; 33: 217-26.


78

HOSPITAL

Compliance with protocol for antibiotic prophylaxis

CASE

Surgery in which prophylaxis is

indicated (Yes/No)

Correct antibiotic (Yes/No)

Correct dose

(Yes/No)

Correct time

(Yes/No)

Correct duration (Yes/No)

Observations*

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 TOTAL

*: •: If prophylaxis is not indicated in the surgical procedure or the antibiotic is incorrect, none of the other aspects will be studied.

• If the hospital has no approved protocol, the assessment will be made based on the guidelines laid down by Gilbert AN, Moellering RC, Eliopoulos, GM, Samde, MA, The Sanford guide to antimicrobial therapy 2007, 37 ed., Antimicrobial Therapy. Inc., Sperryville, 2007.

Calculation and description of indicator:

1. No errors: LQAS (85.55); minimum 12 cases with no errors. Alternatively, if more than 30 cases have been assessed: % of cases with no errors + confidence interval of 95%, excluding from the denominator all cases in which chemoprophylaxis is not indicated (clean surgery).

79


TITLE Percentage of errors connected with recommendations on antibiotic prophylaxis in surgical procedures.

RATIONALE

Many surgical procedures have shown a reduction in surgical site infections through the use of prophylactic antibiotics that are given prior to surgery in order to establish tissue levels at the time of incision and that are maintained throughout the operation. The medical literature regularly publishes recommendations and updates for prophylactic antibiotics for various surgical procedures. Main aim of indicator: to reduce the number of errors connected with recommendations on antibiotic prophylaxis in surgical procedures.

DESCRIPTION

This indicator is used to determine the percentage of errors connected with recommendations on antibiotic prophylaxis in surgical procedures. The following are considered errors: • Lack of use of antibiotic in surgery in which prophylaxis is indicated • Incorrect antibiotic • Incorrect dose • Untimely administration • Incorrect duration of prophylaxis

NUMERATOR Errors in compliance with protocol for antibiotic prophylaxis DENOMINATOR Number of surgical procedures reviewed x possible errors assessed. DOMAIN Process.





• Mangran AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection. Infect Control 1999; 20 (4): 247-80.


• Gilbert DN, Mouldering RC, Eliopoulos GM, Sande MA. The Sanford Guide to antimicrobial therapy 2007. Antimicrobial Therapy Inc., Sperryville 2007.

• McKibben L, Horan T, Tokars JI et al. Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control 2005; 33: 217-26.


80

HOSPITAL

Compliance with protocol for antibiotic prophylaxis

CASE Surgery in which

prophylaxis is indicated (Yes/No)

Correct antibiotic (Yes/No)

Correct dose

(Yes/No)

Correct time

(Yes/No)

Correct duration (Yes/No)

Observations*

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 TOTAL

* •: If prophylaxis is not indicated in the surgical procedure or the antibiotic is incorrect, none of the other aspects will be studied. • If the hospital has no approved protocol, the assessment will be made based on the guidelines laid down by Gilbert AN, Moellering RC, Eliopoulos, GM, Samde, MA, The Sanford guide to antimicrobial therapy 2007, 37 ed., Antimicrobial Therapy. Inc., Sperryville, 2007.

Calculation and description of indicator:

1. % error: number of errors detected / number of possible errors x 100.

2. Specify number of errors detected of each possible type.

81

Prevention of surgical infection TITLE Existence of practices for monitoring and control of normothermia

in major surgery (procedures lasting more than two hours).

RATIONALE

The essential foundation of infection control for patients undergoing surgery includes operating room (OR) practices for preparing and maintaining an aseptic surgical field within a controlled environment that minimizes contamination; proper sterilization of surgical instruments, attire and surgical scrub of the OR team; meticulous surgical technique; and careful post-operative wound care. The effectiveness of these practices has been demonstrated over time. The existence of practices for monitoring and control of normothermia in surgical procedures lasting more than two hours reflects endeavors on the part of the surgical unit to prevent surgical site infections. This indicator is used to determine whether or not steps are taken for monitoring and control of normothermia in major surgery (procedures lasting more than two hours). These practices must include monitoring of temperature and use of at least one of the following: warm saline solution, thermal blankets or forced warm air.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Process. DATA SOURCE Clinician survey.





• Nichols RL. Preventing surgical site infections: a surgeon’s perspective. Emerg Inf Disease 2001; 7 (2): 220-24

• Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334: 1209-1215.

COMMENT The tool designed for structured data collection is included below.

82

HOSPITAL Practices for maintaining normothermia in major surgery (procedures > 2 h Data collection table: Note which of the following are routine practices (interview with Anesthesia Unit): - Monitoring of temperature: Yes / No. If Yes:

• How?

• How often?

- Thermal blankets: Yes / No

- Warm saline solution: Yes / No

- Forced warm air: Yes / No

- Start and Finish (time) of these practices.

83


TITLE Percentage of patients who receive an inspired oxygen fraction greater than or equal to 80% in major surgery (procedures lasting more than two hours) with general anesthetic.

RATIONALE

The essential foundation of infection control for patients undergoing surgery includes operating room (OR) practices for preparing and maintaining an aseptic surgical field within a controlled environment that minimizes contamination; proper sterilization of surgical instruments, attire and surgical scrub of the OR team; meticulous surgical technique; and careful post-operative wound care. The effectiveness of these practices has been demonstrated over time. Main aim of indicator: to increase the use of supplemental oxygen with FiO2 > 80% in major surgery (procedures lasting > 2 hours) with general anesthetic, as its use is connected with the prevention of surgical wound infection. This indicator is used to determine the percentage of patients who receive an inspired oxygen fraction greater than or equal to 80% in major surgery (procedures lasting > 2 hours) with general anesthetic. This supplement should last throughout the surgical procedure and up to two hours after the procedure.

DESCRIPTION

Number of patients undergoing major surgery (procedures lasting > 2 hours) with general anesthetic who receive supplemental oxygen (FNUMERATOR Oi 2: 80%) during and up to two hours after surgery x 100.

DENOMINATOR Number of patients undergoing major surgery. DOMAIN Process.







• Belda FJ, Aguilera L, Garcia de la Asuncion J, Alberti J, Vicente R, Ferrandiz L, Rodriguez R, Company R, Sessler DI, Aguilar G, Botello SG, Orti R; Spanish Reducción de la Tasa de Infección Quirúrgica Group. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA 2005; 294: 2035-2042

• Dellinger E. Increasing inspired oxygen to decrease surgical site infection. JAMA 2005; 294: 2091-2092.

• Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med 2000 Jan 20; 342 (3): 161-7.


84

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Belda+FJ%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Aguilera+L%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Garcia+de+la+Asuncion+J%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Alberti+J%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Vicente+R%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Ferrandiz+L%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Rodriguez+R%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Company+R%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Sessler+DI%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Sessler+DI%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Aguilar+G%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Botello+SG%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Orti+R%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Spanish+Reduccion+de+la+Tasa+de+Infeccion+Quirurgica+Group%22%5BCorporate+Author%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Spanish+Reduccion+de+la+Tasa+de+Infeccion+Quirurgica+Group%22%5BCorporate+Author%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10639541&query_hl=31&itool=pubmed_docsum

HOSPITAL

Intraoperative supplemental oxygen (FiO2: 80%) in major surgery (procedures lasting more than two hours) with general anesthetic

DURING SURGERY

AFTER SURGERY (2 hours)

DURING & AFTER SURGERY

YES / NO FiO2 YES / NO FiO2 Observations 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 TOTAL

CALCULATION OF INDICATOR:

1. Compliance (no errors) LQAS (85.55; 0.05, 0.1): minimum of 12.

2. Type of error: specify number of “during” and “after” errors separately.

85

Use of protocols to prevent contrast-induced renal damage

TITLE Existence of protocol approved by hospital for prevention of acute nephropathy caused by exposure to iodine-containing contrast media.

RATIONALE

Adverse events resulting from the intravenous administration of contrast dye include allergic reactions, anaphylaxis and kidney damage. Contrast media-induced renal failure rarely occurs in patients with normal kidney function, but patients with pre-existing renal insufficiency or other conditions (eg. diabetic nephropathy, dehydration, congestive heart failure or concurrent administration of nephrotoxic drugs) are at risk of renal failure when given iodine-containing contrast media. The existence of a protocol for prevention of contrast-induced nephropathy reflects the hospital’s concern to prevent adverse events of this kind. This indicator is used to determine whether or not the hospital has a protocol for prevention of acute nephropathy caused by exposure to iodine-containing contrast media.

DESCRIPTION





• Mangran AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection. Infect Control 1999; 20 (4): 247-80.


• Dobrzanski S, Lawley DI, McDermott I, Selby M, Ausobsky JR. The impact of guidelines on peri-operative antibiotic administration. J Clin Pharm Ther 1991; 16: 19-24.


86


TITLE Percentage of patients whose renal function (creatinine level) is assessed in the 24 hours prior to undergoing tests with iodine-containing contrast media.

RATIONALE

Main aim of indicator: to increase the percentage of patients whose renal function is assessed prior to undergoing tests with iodine-containing contrast media. Adverse events resulting from the intravenous administration of contrast dye include allergic reactions, anaphylaxis and kidney damage. Contrast media-induced renal failure rarely occurs in patients with normal kidney function, but patients with pre-existing renal insufficiency or other conditions (eg. diabetic nephropathy, dehydration, congestive heart failure or concurrent administration of nephrotoxic drugs) are at risk for renal failure when given iodine-containing contrast media.

This indicator is used to determine the percentage of patients whose renal function (creatinine level) is assessed in the 24 hours prior to undergoing tests with iodine-containing contrast media.

DESCRIPTION

NUMERATOR Number of patients whose medical record indicates that they have been assessed for renal function (creatinine level) in the 24 hours prior to undergoing tests using contrast dye x 100. Total number of patients studied undergoing tests using iodine-containing contrast media. DENOMINATOR

DOMAIN Process.





• Ahuja TS, Niaz N, Agra harker N. Contrast-induced nephrotoxicity in renal allograft recipients. Clin Nephrol 2000; 54 (1): 11-14.

• Olsen JC, Salomón B. Utility of the creatinine prior to intravenous contrast studies in the emergency department. J Emerg Med 1997; 15 (5): 726-27.

COMMENT

87


TITLE Percentage of patients at risk of developing acute nephropathy to whom a prevention program is applied prior to tests with iodine-containing contrast media.

RATIONALE

Main aim of indicator: to increase prevention of acute nephropathy resulting from administration of iodine-containing contrast media. Adverse events resulting from the intravenous administration of contrast dye include allergic reactions, anaphylaxis and kidney damage. Contrast media-induced renal failure rarely occurs in patients with normal kidney function, but patients with pre-existing renal insufficiency or other conditions (eg. diabetic nephropathy, dehydration, congestive heart failure or concurrent administration of nephrotoxic drugs) are at risk for renal failure when given iodine-containing contrast media.

DESCRIPTION

This indicator is used to determine the percentage of patients at risk of developing acute nephropathy (plasma creatinine > 1.5 mg/dl) to whom a prevention program is applied prior to tests with iodine-containing contrast media. Fluid therapy via two protocols is considered a prevention measure: 1) 1 ml/kg/hour of crystalloids (saline or hyposaline solution or glucose water), starting 12 hours previous to the diagnostic test and continuing up to 12 hours after the test. 2) 1,000 ml of water taken orally in the ten hours previous, followed by saline solution administered intravenously at a rate of 300 ml/hour during 30-60 minutes and continued for the next six hours. The following therapeutic regime must also have been prescribed and administered: 600 mg N-acetylcysteine, taken orally, twice a day one day before and one day after the procedure. In the case of patients allergic to N- acetylcysteine, treatment with theophylline could be considered.

NUMERATOR Number of patients to whom a contrast-induced acute nephropathy prevention program is applied.

Total number of patients at risk of developing contrast-induced nephropathy (plasma creatinine > 1.5 mg/dl), excluding patients undergoing extrarenal cleansing techniques.

DENOMINATOR

DOMAIN Process.





• Ahuja TS, Niaz N, Agra harker N. Contrast-induced nephrotoxicity in renal allograft recipients. Clin Nephrol 2000; 54 (1): 11-14.

• Mueller C, Buerkle G, Buettner HJ et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med 2002; 162 (3): 329-36.

• Nallamothu BJ, Shojania KG, Hofer TP, Humes HD, Moscucci M, Bates ER. Is Acetylcysteine Effective in Preventing Contrast-Related Nephropathy? A Meta-analysis. Am J Med 2004; 117 (12): 938-947.

• Bagshaw SM, Ghali WA. Theophylline for Prevention of Contrast-Induced Nephropathy. A Systematic Review and Meta-analysis. Arch Intern Med 2005; 165 (10): 1087-1093.

COMMENT

88

Assessment of risk and prevention of malnutrition TITLE Existence in hospital of rules for prevention of malnutrition.

RATIONALE

Malnourished patients experience increased morbidity and mortality and prolonged hospital stays. Malnutrition in hospitalized patients is frequently not recognized. Providing nutritional support to patients who are either malnourished or at risk of malnutrition can result in improved clinical outcomes and fewer adverse events. The existence of rules for prevention of malnutrition reflects the hospital’s endeavors to prevent this problem. This indicator is used to determine whether or not the hospital has rules for prevention of malnutrition. DESCRIPTION





• Klein S, Kimmey J, Jeejeeboy K et al. Nutritional support in clinical practice: review of the published data and recommendation for future research directions. J Parenter Enteral Nut 1997; 21 (3): 133-56.

• Mullen JL. Consequences of malnutrition in the surgical patient. Surg Cln North Am 1981; 61 (3): 465-87.

• Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P and Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN 2003; 27 (5): 355-373.

• Charney P. Nutrition assessment in the 1990s, where are we now. Nutr Clin Pract 1995; 10 (4): 131-139.

• Planas M, Bonet A, Farré M. Valoración nutricional. Influencia de la malnutrición sobre las funciones fisiológicas. In: García de Lorenzo A (ed). Soporte Nutricional en el paciente grave. Medicina Critica Práctica. Barcelona: EdikaMed; 2002.


89

Assessment of risk and prevention of malnutrition

TITLE Percentage of Intensive Care Unit (ICU) patients who are assessed for risk of malnutrition in first 24 hours after admission.

RATIONALE

Main aim of indicator: to increase the percentage of ICU patients who are assessed for the risk of malnutrition in the first 24 hours after admission. Malnourished patients experience increased morbidity and mortality and prolonged hospital stays. Malnutrition in hospitalized patients is frequently not recognized. Providing nutritional support to patients who are either malnourished or at risk of malnutrition can result in improved clinical outcomes and fewer adverse events.

DESCRIPTION

This indicator is used to determine the percentage of patients admitted to the ICU for at least two days who are assessed for the risk of malnutrition in the first 24 hours after admission. The explicit assessment may be based on specific indexes such as the SGA or CONUT scales, or on the following symptoms:

* Cachexia * Weight loss in the last three months of > 10% * Serum albumin < 30 gr/l * Artificial nutrition * Inadequate oral feeding during > 1 week

NUMERATOR Number of patients assessed for risk of malnutrition in first 24 hours after admission to ICU x 100.

DENOMINATOR Number of patients admitted to ICU for more than 48 hours. DOMAIN Process.






• Mullen JL. Consequences of malnutrition in the surgical patient. Surg Cln North Am 1981; 61 (3): 465-87.


• Charney P. Nutrition assessment in the 1990s, where are we now. Nutr Clin Pract 1995; 10 (4): 131-139.

The tool designed for data collection is included below. COMMENT

90

HOSPITAL

Assessment of risk of malnutrition in first 24 hours after admission to ICU

CASE SGA scale CONUT scale Cachexia ↓weight>10%

in 3 months Albumin <30g/l Artificial nutrition

Inadequate feeding

Assessment (Yes/No)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

TOTAL

Compliance with indicator LQAS (85.55; 0.05; 0.1): minimum 12.

91

Assessment of risk and prevention of malnutrition

TITLE Percentage of Intensive Care Unit (ICU) patients receiving artificial nutrition whose calorific-protein requirement is calculated on a regular basis.

RATIONALE

Main aim of indicator: to increase the percentage of critical ICU patients whose calorific-protein requirement is controlled on a regular basis. Malnourished patients experience increased morbidity and mortality and prolonged hospital stays. Malnutrition in hospitalized patients is frequently not recognized. Providing nutritional support to patients who are either malnourished or at risk of malnutrition can result in improved clinical outcomes and fewer adverse events.

DESCRIPTION

This indicator is used to determine the percentage of ICU patients receiving artificial nutrition whose calorific-protein requirement is calculated on a regular basis. The calculation should be made every four days, using one of the following methods: a) Harris Benedict Equation or similar formula. b) Open circuit indirect calorimetry. c) Modification of degree of aggression.

NUMERATOR Number whose calorific-protein requirement is calculated on a regular basis.

DENOMINATOR ICU patients receiving artificial nutrition. DOMAIN Process.



• Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43, AHRQ Publication No 01-E058 Rockville, MD: Agency for Healthcare Research and Quality. July 2001.



• Braga M, Biamottil, Nespoli L, et al. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg 2002; 137 (2): 174-80. http://archsurg.ama-assn.org/cgi/reprint/137/2/174.pdf (last retrieved: 14 January 2008).


COMMENT

92

http://archsurg.ama-assn.org/cgi/reprint/137/2/174.pdf

Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with tourniquet cuffs

TITLE Existence of protocol for nursing practices for controlled ischemia prior to surgical procedures and postoperative care.

RATIONALE

Ischemic neuromuscular injury may occur if the pneumatic tourniquet remains inflated too long. Direct pressure injury to nerves may also occur. Additionally, tourniquet inflation and deflation may depress the cardiorespiratory function in the perioperative period, including causing “showers” of embolic debris to the heart, which may in turn cause pulmonary embolism. The existence of a protocol for nursing practices for controlled ischemia in surgical procedures reflects the hospital’s endeavors to prevent these adverse events. This indicator is used to determine whether or not the hospital has a protocol for nursing practices for controlled ischemia prior to surgical procedures and postoperative care.

DESCRIPTION



• Tetro AM, Rudan JF. The effects of the pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg 2001; 44 (1): 33-38.


• Recommended practices for the use of the pneumatic tourniquet. AORN Journal 2002: 75 (2): 379-386.

COMMENT Request copy of document and assess whether or not it includes: • Control of duration of ischemia. • Control of pressure.

93

Assessment and prevention of thrombotic and ischemic complications in

patients undergoing procedures with tourniquet cuffs

TITLE Percentage of surgical procedures in which pneumatic tourniquet cuff pressure and time of inflation are recorded.

RATIONALE

Ischemic neuromuscular injury may occur if the pneumatic tourniquet remains inflated too long. Direct pressure injury to nerves may also occur. Additionally, tourniquet inflation and deflation may depress the cardiorespiratory function in the perioperative period, including causing “showers” of embolic debris to the heart, which may in turn cause pulmonary embolism. Main aim of indicator: to increase the percentage of surgical procedures in which pneumatic tourniquet cuff pressure and time of inflation are controlled. This indicator is used to determine the percentage of surgical procedures in which pneumatic tourniquet cuff pressure and time of inflation are recorded.

DESCRIPTION

NUMERATOR Number of procedures in which pneumatic cuff time and pressure are recorded x 100. Number of patients undergoing surgical procedures with tourniquet cuffs. DENOMINATOR

DOMAIN Process.




• Wakai A, Winter DC, Street JT, et al. Pneumatic tourniquet in extremity surgery. J Am Acad Orthop Surg 2001; 9 (5): 345-351.




94

HOSPITAL

Monitoring of pressure and time of inflation of pneumatic tourniquet cuffs

TIME PRESSURE NO ERRORS Observations

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

TOTAL

Calculation of indicator:

1. No errors: LQAS (85.55; 0.05; 0.1); minimum 12.

95

Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with tourniquet cuffs

TITLE Percentage of errors in recording of ischemia time and

pressure in surgical procedures.

RATIONALE

Ischemic neuromuscular injury may occur if the pneumatic tourniquet remains inflated too long. Direct pressure injury to nerves may also occur. Additionally, tourniquet inflation and deflation may depress the cardiorespiratory function in the perioperative period, including causing “showers” of embolic debris to the heart, which may in turn cause pulmonary embolism. Main aim of indicator: to improve control of ischemia in surgical procedures. This indicator is used to determine the percentage of errors in monitoring of ischemia time and pressure in surgical procedures

DESCRIPTION

NUMERATOR Number of errors in recording of time and pressure of pneumatic tourniquet x 100. Number of surgical procedures conducted with pneumatic tourniquet. DENOMINATOR

DOMAIN Process.




• Wakai A, Winter DC, Street JT, et al. Pneumatic tourniquet in extremity surgery. J Am Acad Orthop Surg 2001; 9 (5): 345-351.




96

HOSPITAL

Monitoring of pressure and time of inflation of pneumatic tourniquet cuffs

TIME PRESSURE NO ERRORS Observations

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

TOTAL

Calculation of indicator:

1. % error: number of errors detected / number of possible errors x 100.


97

Hand washing before and after direct contact with patients or patient environment

TITLE Existence in hospital of protocol for hand washing by

healthcare providers

RATIONALE

Although hand washing has been shown to be highly effective in preventing the transmission of pathogens within a hospital, studies have repeatedly shown that hand washing compliance rates are generally less than 50 percent. The existence of a protocol for hand washing reflects the hospital’s endeavors to comply with this good patient safety practice. This indicator is used to determine whether or not the hospital has a protocol for hand washing by healthcare providers.

DESCRIPTION





• Bonten MJ. Infection in the intensive care unit: prevention strategies. Curr Opin Infect Dis 2002; 15 (n): 401-405.

• Guideline for hand hygiene in healthcare settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51: 1-56

• Guideline for hand hygiene in healthcare settings. Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Hand Hygiene Task Force, Society for Healthcare Epidemiology of America (SHEA); Association for Professionals in Infection Control and Epidemiology (APIC), Infectious Diseases Society of America (IDSA). J Am Coll Surg 2004; 198 (1): 121-127.


98

Hand washing before and after direct contact with patients or

patient environment TITLE Existence of continued training courses in hand washing

within the last year’s training activities.

RATIONALE

Although hand washing has been shown to be highly effective in preventing the transmission of pathogens within a hospital, studies have repeatedly shown that hand washing compliance rates are generally less than 50 percent. The existence in the hospital of training courses in hand washing reflects its endeavors to comply with this good patient safety practice. This indicator is used to determine whether or not the hospital has conducted courses in hand washing within the last year’s training activities.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure. DATA SOURCE Administrative data.




• Bonten MJ. Infection in the intensive care unit: prevention strategies. Carr opin Infect Dis 2002; 15 (n): 401-405.

• Guideline for hand hygiene in healthcare settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51: 1-56.

• Naikoba S; Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers a systematic review. J Hosp Infect 2001; h 7 (3): 3-181.


COMMENT Request copy of document evidencing that the course was conducted.

99

Hand washing before and after direct contact with patients or

patient environment

TITLE Existence of washbasins provided with soap and antiseptic solution / alcohol gel hand cleaners (dispensing units or single-use handrubs) easily accessible to healthcare providers.

RATIONALE

Although hand washing has been shown to be highly effective in preventing the transmission of pathogens within a hospital, studies have repeatedly shown that hand washing compliance rates are generally less than 50 percent. The existence of washbasins provided with soap and antiseptic solution / alcohol gel hand cleaners indicates that the hospital complies with this fundamental quality criterion that facilitates hand washing. This indicator is used to determine whether or not the hospital has appropriate infrastructure for hand washing (washbasins, supplies of soap / alcohol gel hand cleaners) in all units of the hospital in which patient care is administered.

DESCRIPTION

NUMERATOR Does not apply to this measure. DENOMINATOR Does not apply to this measure. DOMAIN Structure. DATA SOURCE Observational data.




• Bonten MJ. Infection in the intensive care unit: prevention strategies. Cyrr Opin Infect Dis 2002; 15 (n): 401-405.

• Guideline for hand hygiene in healthcare settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51: 1-56.

• Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers - a systematic review. J Hosp Infect 2001; 47 (3): 173-181.

• Kesavan S. Hand washing: handwashing facilities are inadequate. BMJ 1999; 319 (7208): 518-19.


COMMENT

The following are considered appropriate infrastructure: • one washbasin with soap and antiseptic solution per ICU patient; • one washroom area per operating room; • at least one washbasin per nursing area in conventional wards. Different areas of hospital to be assessed: • ICU • A ward at random • An operating room at random. The tool designed for data collection is included below.

100

HOSPITAL

Hand washing infrastructure Alcohol gel hand cleaners

or antiseptic solution

Washing facilities*

Soap Dispensing unit

Single- use

Disposable towel

Sample / Universe

Operating room

1 of….

Random ward

1 of…

ICU 1 of… * : • Operating room: one washroom area per theatre.

• Ward: one washroom area per nursing area. • ICU: one washbasin per patient.

101

Hand washing before and after direct contact with patients or patient environment

TITLE Percentage of healthcare providers who comply with rules on hand

washing.

RATIONALE

Main aim of indicator: to increase the percentage of healthcare providers who comply with rules on hand washing. Although hand washing has been shown to be highly effective in preventing the transmission of pathogens within a hospital, studies have repeatedly shown that hand washing compliance rates are generally less than 50 percent. This indicator is used to determine the percentage of healthcare providers who comply with rules on hand washing, distinguishing between Intensive Care Unit (ICU) staff and ward staff. Hand washing must be done before and after procedures and using the correct technique.

DESCRIPTION

NUMERATOR Number of errors in hand washing technique and timing in contacts with patient or patient environment x 100.

DENOMINATOR Total number of contacts studied x 7 possible errors in each. DOMAIN Process. DATA SOURCE Observational data.




• Bonten MJ. Infection in the intensive care unit: prevention strategies. Cyrr Opin Infect Dis 2002; 15 (n): 401-405.

• Guideline for hand hygiene in healthcare settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51: 1-56

• Naikoba S; Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers - a systematic review. J Hosp Infect 2001; h 7 (3): 3-181.


COMMENT

Points to be assessed: whether or not hands are washed before and after: a) direct contact with patients; b) insertion of vascular catheters; c) insertion of urethral catheters; and d) dressing of wounds. In addition, the correct 5-step technique must be used: 1) apply soap from dispenser; 2) rub palm against palm; 3) rub palm to palm with fingers interlaced; 4) rub with fingers closed over palms; 5) dry with disposable towel. The tool designed for data collection on hand washing assessment is included below.

102

TECHNICAL ASSESSMENT AND INDICATION OF HAND WASHING SHEET

INDICATOR UNIT OF STUDY PERIOD OF STUDY

Assessment of compliance by healthcare providers with hand washing protocol

Healthcare providers. Hospital:

ICU: Ward:

CRITERION: INDICATION OF HAND WASHING CRITERION: CORRECT HAND WASHING PROCEDURE

CASE Direct patient contact Insertion vascular

catheter Insertion urethral

catheter Dressing of wounds Apply soap

from dispenser

Rub palm against palm

Rub palm to palm, fingers

interlaced

Rub, fingers closed over

palms

Dry with disposable

towel

Before Yes □ No □ Before Yes □ No □ Before Yes □ No □ Before Yes □ No □

After Yes □ No □ After Yes □ No □ After Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □

Yes □ No □ After Yes □ No □

























103

Influenza vaccination for all hospital workers TITLE Existence in hospital of explicit rules on influenza

vaccinations for staff.

RATIONALE

Vaccination of healthcare workers can prevent worker infection and worker-mediated transmission of disease among patients, but evidence shows that only about one-third of hospital workers have current vaccinations against influenza. The existence in the hospital of explicit rules on influenza vaccinations for staff reflects the hospital’s endeavors to control this problem. This indicator is used to determine whether or not the hospital has rules or protocols on influenza vaccinations for its staff.

DESCRIPTION





• Bolyard EA, Tablan OC, Williams WW, et al. Guidelines for infection control in health care personnel. Infect Control Hosp Epidemiol 1998; 19 (6): 407-463.

• Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000; 355 (9198): 93-97.


104

Influenza vaccination for all hospital workers TITLE Percentage of healthcare workers with influenza

vaccinations in past year.

RATIONALE

Main aim of indicator: to increase the percentage of healthcare workers who have vaccinations against influenza every year. Vaccination of healthcare workers can prevent worker infection and worker-mediated transmission of disease among patients, but evidence shows that only about one-third of hospital workers have current vaccinations against influenza. This indicator is used to determine the percentage of healthcare workers who have had influenza vaccinations in the past year.

DESCRIPTION

NUMERATOR Replies indicating “Yes” x 100. Total number of healthcare workers replying to this item in

the survey. DENOMINATOR DOMAIN Process. DATA SOURCE Health personal survey.




• Bolyard EA, Tablan OC, Williams WW, et al. Guidelines for infection control in health care personnel. Infect Control Hosp Epidemiol 1998; 19 (6): 407-463.

• Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000; 355 (9198): 93-97.

• Pachucki CT, Pappas SA, Fuller GF, Krayse SL, Lentino JR, Schaaf OM. Influenza A among hospital personnel and patients: implications for recognition, prevention and control. Arch Intern Med 1989; 149 (1): 77-80

COMMENT

May be added to the “Safety Culture” survey instrument. The item would be: Have you been vaccinated against influenza in the last year? Possible replies: No / Yes

105

Appropriate conditions in medication dispensing areas TITLE

Clean, well-organized, quiet and well-lit medication dispensing areas.

RATIONALE

A number of environmental factors in the medication dispensing area itself are known to increase the occurrence of errors, including heavy workload and cluttered workspace, whereas well-lit workspace has been shown to both decrease error and increase efficiency. Clean and well-organized medication dispensing areas reflect endeavors on the part of the pharmacy service to prevent errors.

DESCRIPTION

This indicator is used to determine whether or not the medication dispensing areas are clean and well-organized. All dispensing areas should be:

• Clean • Well organized (uncluttered) • Quiet • Clear of breakages • Well-lit • With nothing on floors

NUMERATOR Does not to apply to this measure. DENOMINATOR Does not to apply to this measure. DOMAIN Structure.

DATA SOURCE Observational data.



• Buchaman TL, Barker KN, Gibson JT, Jiamg BC, Pearson RE. Illumination and errors in dispensing. Am J Hosp Pharm 1991; 48: 2137-45.

• Flymn EA, Barker KN, Gibson JT, et al. Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. Am J Heath Syst Pharm 1999; 56: 1319-25.

• Aramburu I, Vázquez S. Guía para la auto-implantación de la metodología 5S en organizaciones sanitarias. Osakidetza/Servicio Vasco de Salud (Basque Regional Health Authority). September 2003.

COMMENT

Medication dispensing areas are considered to be areas in which: a) Medications are repackaged. b) Sterile preparations are prepared (parenteral

nutrition, intravenous mixtures, cytostatic drug doses and magistral and sterile standardized formulas).

c) Magistral and standardized formulas are made up.

106

Standardized methods for labeling, packaging and storing medications

TITLE Existence in hospital of rules or protocols on correct storage, conservation and restocking of medications in nurse station dispensaries.

RATIONALE

Improper labeling and packaging of medications are well-known causes of serious medication errors. The evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. The existence of rules on correct storage, conservation and restocking of medications in nurse station dispensaries reflects the hospital’s endeavors to prevent medication errors. This indicator is used to determine whether or not the hospital has rules or protocols on storage, conservation and restocking of medications in nurse station dispensaries.

DESCRIPTION




• Enright SM, Smith KE, Abel SR, Ramirez RA, Alsaggabbi AH. Preventing medication errors. US Pharm 2000; 25: HS41-52.

• Cohen MR. Medication errors: violating protocol; failing to label syringes. Nursing 1987; 17: 26

COMMENT

Request copy of document and assess whether or not it includes: • Stock levels of medications. • Cardiac arrest trolley. • Narcotics and psychotropic drugs. • Conservation and temperature records for thermo-

labile medications. • Conservation of photosensitive medications. • Use-by date control system. • Restocking system.

107


TITLE Existence in hospital of rules or protocols on correct storage, conservation and restocking of medications in pharmacy service.

RATIONALE

Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. The existence of rules on correct storage, conservation and restocking of medications in the pharmacy service reflects the hospital’s endeavors to prevent medication errors. This indicator is used to determine whether or not the hospital has rules or protocols on storage, conservation and restocking of medications in the pharmacy service.

DESCRIPTION





• Cohen MR. Medication errors: always prepare an I.V. admixture before labelling the container. Nursing 1984; 14 (3): 23.

COMMENT

Request copy of document and assess whether or not it includes: • Storage. • Conservation. • Restocking.

108


TITLE Existence in hospital of rules or protocols on labeling and repackaging of medications in unit doses. Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. RATIONALE The existence of rules on labeling and repackaging of medications in unit doses reflects the hospital’s endeavors to prevent medication-related errors.

DESCRIPTION This indicator is used to determine whether or not the hospital has rules or protocols on labeling and repackaging of medications in unit doses.






• American Society of Hospital Pharmacists. ASHP statement on unit dose drug distribution. Am J Hosp Pharm 1989; 46: 2346.

COMMENT

Request copy of document and assess whether or not the labels include: • Brand name. • Active principle. • Pharmaceutical form. • Dose. • Excipients subject to mandatory labeling. • Use-by date. • Batch number.

109

Standardized methods for labeling, packaging and storing medications TITLE Existence of rules approved by hospital on maintenance

of cardiac arrest trolleys.

RATIONALE

Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. The existence of rules on maintenance of cardiac arrest trolleys reflects the hospital’s endeavors to prevent medication-related errors. This indicator is used to determine whether or not the hospital has approved rules or procedures for maintenance of cardiac arrest trolleys.

DESCRIPTION







110


TITLE Existence, in pharmacy service, of list of antidotes including indication of location and minimum stocks and use-by date control system.

RATIONALE

Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. The existence of a list of antidotes, including indication of location and minimum stocks and use-by date control system, reflects the hospital’s endeavors to prevent medication-related errors. This indicator is used to determine whether or not the hospital pharmacy service has a list of antidotes, including indication of their location and minimum stocks and use-by date control system.

DESCRIPTION




• Aranda A, Tobaruela M, Iranzo MD et al. Guía de administración de antídotos. 2ª ed. Murcia; Hospital J Mª Morales Meseguer; 2005.

• Nogué S. Intoxicaciones Agudas. Protocolos de tratamiento. Barcelona; Hospital Clínic de Barcelona: 2004.

• Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS. Toxicologic emergencies. New York; McGraw-Hill: 2002.

COMMENT

Request copy of document and assess whether or not it includes: • Location of antidotes. • Minimum stocks. • Control of use-by dates.

111

Standardized methods for labeling, packaging and storing medications TITLE Percentage of errors in conservation and storage of

medications in nurse station dispensaries.

RATIONALE

Main aim of indicator: to reduce the number of errors connected with conservation and storage of medications in nurse station dispensaries. Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. This indicator is used to determine the percentage of errors in conservation and storage of medications in operating room, medical ward and emergency department dispensaries.

DESCRIPTION

NUMERATOR Number of errors detected x 100. Total number of possible errors assessed in three dispensaries (operating room, medical ward and emergency department) selected at random.

DENOMINATOR

DOMAIN Process. DATA SOURCE Observational data.




• Cohen MR. Medication errors: violating protocol; failing to label syringes. Nursing 1987; 17: 26.

COMMENT

A set of medications has been selected for assessment of the following aspects: use-by date; separation of concentrates; caution warning in high-alert medications; safekeeping under lock and key; refrigeration; protection from light; complete labeling (name or active principle, concentration and pharmaceutical form). The tool designed for data collection and calculation of the indicator is included below.

112

HOSPITAL

Errors in conservation and storage of medications in dispensaries


Complete labeling

Warning Use-by

Name or active

principle

Separation concentrates

Under lock

& key

Concentration

Form Refrigeration Protection

from light

OPERATING ROOM

Lidocaine

Morphine

ClK

MEDICAL WARD

Insulin

Heparin

ClK

EMERGENCY DEPARTMENT

Bicarbonate soda

Largactil

ClK

Total type of error

3 9 9 9 9 9 1 1 1

• Calculation of combined indicator = % error: errors detected/possible errors x 100. Total denominator: 51 Total errors possible: 51

Denominator Operating room: 17 Denominator Medical ward: 17 Denominator Emergency department: 17

• Specify type of error.

113


TITLE Percentage of errors connected with use-by dates, stocks and location of medications and equipment available on cardiac arrest trolleys.

RATIONALE

Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. Main aim of indicator: to reduce the number of errors connected with use-by dates, stocks and location of medications and equipment available on cardiac arrest trolleys. This indicator is used to determine the percentage of errors connected with use-by dates, stocks and easy location of medications and equipment available on cardiac arrest trolleys.

DESCRIPTION

NUMERATOR Number of errors detected x 100. Total number of errors possible on a cardiac arrest trolley

selected at random. DENOMINATOR DOMAIN Process. DATA SOURCE Observational data.





COMMENT

Considering that cardiac arrest trolleys should: a) have a set list of stocks and medications included; b) contain only the set medications and quantities; c) not contain any medications past their use-by date; d) have all contents easily located. The hospital list will be used to determine these aspects, meaning that it will not be possible to determine any aspects that are missing from the list, eg. stocks.

114

Standardized methods for labeling, packaging and storing medications TITLE Percentage of errors in conservation and storage of

medications in pharmacy service.

RATIONALE

Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. Main aim of indicator: to reduce the percentage of errors connected with conservation and storage of medications in the pharmacy service. This indicator is used to determine the percentage of errors in conservation and storage of medications in the pharmacy service. Aspects assessed: use-by date; separation of concentrates; safekeeping under lock and key; refrigeration and protection from light. In the case of antidotes the following will also be assessed: the existence of a list of available antidotes, located separately from other drugs, with indication of use-by dates, stocks and easy location of a selection of these.

DESCRIPTION

NUMERATOR Number of errors detected x 100. DENOMINATOR Total number of possible errors assessed. DOMAIN Process. DATA SOURCE Observational data.





The tool designed for data collection and calculation of the indicator is included below. COMMENT

115

HOSPITAL


Use-by

date Separation

concentrates Lock & key

Refrigerated Protection from light

Listed Located separately

Stocks Easily located

Lidocaine

Morphine

Insulin Sodium heparin

Bicarbonate of soda Chlorpromazine

Antidotes (global) Mineral oil

Methylene blue BAL (Dimercaprol)

Activated carbon

Absolute ethanol

Glucagon

Ipecacuanha syrup

Fuller’s earth N-Acetylcysteine

Naloxone D-Penicillamine (Cupripen)

Potassium permanganate Protamine

Magnesium sulfate Sodium thiosulfate

21 5 1 5 1 1 1

15 15 Denominator for combined indicator: 65

% error: number of errors detected / number of possible errors x 100. Specify type of error

116


TITLE Percentage of errors in labeling of medications prepared

in hospital pharmacy service.

RATIONALE

Improper labeling and packaging of medications are well-known causes of serious medication errors. However, the evidence shows that there are effective methods for simplifying pharmacy dispensing by standardizing the labeling of medication containers and drawn-up syringes and the packaging of medications. Main aim of indicator: to reduce the percentage of errors in labeling of medications prepared in the hospital. This indicator is used to determine the percentage of errors in labeling of medications prepared in the hospital pharmacy service, distinguishing between magistral formulas, parenteral nutrition, intravenous mixtures and cytostatic drugs.

DESCRIPTION

NUMERATOR Number of errors detected x 100. Total number of possible errors assessed in labels

studied. DENOMINATOR DOMAIN Process. DATA SOURCE Pharmacy data.




• Cohen MR. Medication errors: always prepare on I.V. admixture before labelling the container. Nursing 1984; 14 (3):23.

The tool designed for data collection, specifying the labeling requisites for each individual medication, is included below.

COMMENT

117

HOSPITAL

LABELING REQUISITES

Magistral formula

Cytostatic drugs

Parenteral nutrition IV mixtures

Yes / No Yes / No Yes / No Yes / No Total errorsMedical record number* Full name* Unit / Area* Bed (hospital patients)* Composition Form of administration Batch number Date of preparation Use-by date Special conservation requirements† Magistral formula name Pharmaceutical form

Total volume

* May be included: on the same label, on an additional label or in the information leaflet accompanying the magistral formula. † Special conservation requirements (keep away from light, keep refrigerated, etc.). Clarifications: • Details may appear on the same label or on additional labels. • Magistral formulas are those prepared individually for specific patients (eg. eye drops). • Pharmaceutical preparations are not prepared per patient but for stock (eg. iodine dye). • A label is required for each medication. Calculation of Indicator • Labels with no errors: (specify which medications). • Labels with errors: (specify which medications). • Specify type of error. • Record annual or monthly total of medications labeled in pharmacy service.

118

Specific identification of high-alert medications TITLE Existence in hospital of list of high-alert medications.

RATIONALE

Certain classes of medications have been repeatedly shown to cause adverse drug events and should be viewed as particularly serious threats to patient safety. The existence in the hospital of a list of high-alert medications reflects its endeavors to prevent adverse events connected with these medications. This indicator is used to determine whether or not the hospital has a list of high-alert medications. DESCRIPTION




• Cohen MR, Anderson RW, Atilio RM, et al. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm. 1996; 53: 737-746.

• Joint Commission Ids five high-alert meds. ED Manag 2000; 12 (2): 21-22.

• Institute for Safe Medication Practices. ISMP’s list of high-alert medications. Huntingdon Valley (PA): ISMP: 2003 http://www.ismp.org/Tools/highalertmedications.pdf (last retrieved: 14 January 2008).

• Seguridad de medicamentos. Prevención de errores de medicación. Farm Hosp 2002; 26 (4): 250-254.

Request copy of document and verify when last updated (the list should be updated annually). COMMENT

119

http://www.ismp.org/Tools/highalertmedications.pdf

Specific identification of high-alert medications TITLE Existence of rules approved by hospital on administration

of high-alert medications.

RATIONALE

Certain classes of medications have been repeatedly shown to cause adverse drug events and should be viewed as particularly serious threats to patient safety. The existence in the hospital of rules on administration of high-alert medications reflects its endeavors to prevent adverse events connected with these medications. This indicator is used to determine whether or not the hospital has rules on administration of high-alert medications (maximum dose, duration, form of administration, double check of calculation of dose).

DESCRIPTION




• Cohen MR, Anderson RW, Atilio RM, et al. Preventing medication errors in cancer chemotherapy. M J Health Syst Pharm. 1996; 53: 737-746.

• Hadaway LC. How to safeguard delivers of high alert. I.V. drugs. Nursing 2001; 31: 36-41.


• Otero MJ, Martín R. Seguridad de medicamentos. Prevención de errores de medicación. Farm Hosp 2002; 26 (4): 250-254.

• Cohen, Michael R. and Kilo, Charles M. "High-Alert Medications: Safeguarding Against Errors". In Medication Errors, edited by Michael R. Cohen, 5.1-5.40. Washington, D.C.: American Pharmaceutical Association, 1999.

COMMENT

Request copy of document and assess whether or not it includes: • Maximum dose. • Duration. • Form of administration. • Double check of calculation of dose.

120


Specific identification of high-alert medications

TITLE Existence in hospital of rules on special labeling and storage of high-alert medications.

RATIONALE

Certain classes of medications have been repeatedly shown to cause adverse drug events and should be viewed as particularly serious threats to patient safety. The existence in the hospital of rules on special labeling and storage of high-alert medications reflects its endeavors to prevent adverse events connected with these medications. This indicator is used to determine whether or not the hospital has rules on special labeling and storage of high-alert medications.

DESCRIPTION




• “High-alert” medications and patient safety. International Journal for Quality in Health care 2001; 13 (4): 339-340.l


• Joint Commission IDs five high-alert meds. ED Manag 2000; 12 (2): 21-22.



• Seguridad de Medicamentos. Importancia del proceso de selección de medicamentos en la prevención de los errores de medicación. Farm Hosp 2003; 27 (4): 264-270. http://www.ismp-espana.org/ficheros/ Fichero14.pdf (last retrieved: 14 January 2008).

COMMENT Request copy of document and assess whether or not it includes: • Labeling. • Storage.

121


http://www.ismp-espana.org/ficheros/%20Fichero14.pdf

http://www.ismp-espana.org/ficheros/%20Fichero14.pdf

Specific identification of high-alert medications

TITLE Existence in hospital of pre-printed prescriptions for cytostatic

drugs.

RATIONALE

Certain classes of medications have been repeatedly shown to cause adverse drug events and should be viewed as particularly serious threats to patient safety. The existence in the hospital of pre-printed prescriptions for cytostatic drugs reflects its endeavors to prevent adverse events connected with high-alert medications. Existence in hospital of pre-printed prescriptions for cytostatic drugs. DESCRIPTION





• Joint Commission IDs five high-alert meds. ED Manag 2000; 12 (2): 21-22.



Audit: check existence of pre-printed or automated forms for prescriptions for these high-alert medications. COMMENT

122


Unit-dose dispensation TITLE Percentage of hospital beds with unit-dose dispensation.

RATIONALE

The evidence shows that unit-dose packaging reduces the number of medication errors and appears to be widely used in most general medical and surgical wards. However, it is not used as much as it could be in other locations such as intensive care units, operating rooms and emergency departments. Main aim of indicator: to increase the percentage of hospital beds with unit-dose dispensation. This indicator is used to determine the percentage of beds with unit-dose dispensation, distinguishing between weekdays and weekends/public holidays and between conventional wards and intensive care units.

DESCRIPTION

NUMERATOR Number of beds with unit-dose dispensation.

DENOMINATOR Total number of beds in hospital. DOMAIN Process. DATA SOURCE Pharmacy data.




• Schultz SM, White SJ, Latiolais CJ. Medication errors reduced by unit-dose. Hospitals 1973; 47: 107-112.

• Black HJ, Tester WW, Decentralized pharmacy operations utilizing the unit-dose concept. Ann J Hosp Pharm 1967; 24 (3): 120-129.

• American Society of Hospital Pharmacists. ASHP statement on unit dose drug distribution. Am J Hosp Pharm 1989; 46: 2346.

Specify whether or not it includes intensive care. The tool designed for data collection is included below. COMMENT

123

HOSPITAL Percentage of beds with unit-dose dispensation

% of unit doses* Includes ICU

(Yes / No) Weekdays (Mon to Fri)

Weekends & public holidays

* Record data source (register)

124

125

126

Date post:	28-Jun-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

Safe practices indicators project: background, summary of ... › resources › ... ·...

Documents