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Classification of the PSP |
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Type of Patient Safety Practice
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Potentially Safe
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Clinical Risk Management Practice (CRMP)
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Related practices from PaSQ database
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| "Best fit" category of the reported practice |
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Identification of risk and harm
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| Topic of the reported practice |
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Clinical risk management
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Aim and the benefit of the Patient Safety Practice
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The objective is to obtain a useful tool for a General and Digestive Surgery Department in order to detect adverse events in an efficient way through some situations (“triggers”) closely related to adverse events. It´s important to detect the triggers in a short time. If we find a trigger we proceed to review the clinical record to look for an adverse event. Then, you categorize it regarding severity and preventability and proceed accordingly.
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Description of the Patient Safety Practice
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We´ve chosen a trigger-tool panel, considering some of the IHI (Institute for Healthcare Improvement) triggers and others collected from a bibliographic review and experts' opinion.
After studying sensitivity and specificity for adverse events' detection and having applied logistic regression, we can offer a selection of few triggers that can detect many of adverse events.
• Methodology: in 2012 we studied a representative sample of 350 patients treated in 3 General and Digestive Surgery departments in Hospital 12 de Octubre (Madrid), using the following triggers:
I. Care Triggers
• Transfusion or use of blood products*
• Code/arrest/rapid response team*
• Positive blood culture*
• X-ray or Doppler studies for emboli or DVT (Deep Vein Thrombosis)*
• Readmission within 30 days*
• Transfer to higher level of care*
II.Surgical Triggers
• Return to surgery*
• Change in procedure*
• Admission to intensive care post-op*
• Intubation/reintubation/BiPap in Post*
• Intra-op or post-op death*
• Mechanical ventilation greater than 24 hours post-op*.
• Injury, repair, or removal of organ*
*Triggers collected from IHI proposal.
III.Triggers collected from literature and experts´ opinion.
• Pathology report not related to the original diagnosis.
• Increased stay in post-op recovery unit.
• Admissions in Emergency department within 30 days after discharge.
• Invasive procedures
• No planned radiology
• Broad spectrum antibiotherapy
• Parenteral nutrition.
After reviewing references about the trigger-tool we´ve selected a panel easy to find using only electronic information. We intended to analyze all triggers for every patient in less than 5 minutes and to get a high sensitivity and specificity.
• Results and Proposal of Trigger Panel:
We found positive triggers in 125 cases (35,71%) and 165 adverse events were detected using the triggers. In summary:
Sensitivity: 86%
Specificity: 93,6%
Predictive positive value: 86%
Predictive negative value: 93%
Finally, we propose to use a panel of only 8 triggers, that can predict 98% of adverse events:
1. Intra-op or post-op death.
2. Readmission within 30 days.
3. Admission to intensive care post-op.
4. Increased stay in post-op recovery unit.
5. Return to surgery.
6. No planned radiology.
7. Positive blood culture.
8. Parenteral nutrition.
Study team:
Ana Isabel Pérez Zapata
María Gutiérrez Samaniego
Elías Rodríguez Cuélla
Agustín Gómez de la Cámara
Pedro Ruiz López
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| Attachment of relevant written information and/or photos, as appropriate |
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Effectiveness of the Patient Safety Practice
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| Degree of implementation of reported practice |
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Yes, partly
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| Level of implementation of reported practice |
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Unit or ward level
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| Specific and measurable outcome for the reported practice were defined |
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Not known
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| A baseline measurement before implementation of the reported practice was obtained |
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Yes
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| A measurement after full implementation of the reported practice was obtained |
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No
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| Evaluation of a "positive" effect of the reported practice on Patient Safety |
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Effect not known or the intervention has not yet been evaluated
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| Type of before-and after evaluation |
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Quantitative
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| Enclosure of a reference or attachment in case of published evaluation's results |
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Health care context where the Patient Safety Practices was implemented
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Hospital
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Transferability
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| Successful implementation of this Patient Safety Practice in other health care settings than above stated |
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No
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| Specification of implementation in another health care setting(s) |
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| Successful implementation's level of this Patient Safety Practice across settings |
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Involved health care staff
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Physicians
Nurses
Pharmacists
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Patient Involvement
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| Direct service user's involvement as integral part of this Patient Safety Practice |
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No
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| Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice |
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| Point of time in which service user or their reprasentatives' involvement takes place |
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| Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice |
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| Short description of the service users' level of involvement |
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| Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users |
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No
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| List of sources where public information is accessible |
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Implementation of the Patient Safety Practice
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| Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice |
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No
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| Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc. |
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No
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| List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice |
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| List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice |
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Motivated staff
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| Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice |
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No
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| Description of used incentives, if any. |
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| Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice |
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No
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Costs of the Patient Safety Practices
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| Completion of cost calculation related to this Patient Safety Practice |
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No
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| Total number of person days required to implement this Patient Safety Practice |
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
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| Total number of person days required for training as preparation for implementation of this Patient Safety Practice |
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
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| Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice |
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| Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice |
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Contact information
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Name: Pedro Ruiz-López
Country: SPAIN
Organisation: Hospital Universitario 12 de Octubre
E-mail: pruizl@salud.madrid.org
Phone: 34913908164
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