Patient safety quality care improvement case study

Analyze multiple dimensions of patient centered care: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

Patient safety quality care improvement case study

Medical error Greek physician treating a patient, c.

Effective Governance for Quality and Patient Safety Program

Greek healers in the 4th century BC drafted the Hippocratic Oath and pledged to "prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

However, despite an increasing emphasis on the scientific basis of medical practice in Europe and the United States in the late 19th Century, data on adverse outcomes were hard to come by and the various studies commissioned collected mostly anecdotal events.

Presenting accounts of anesthetic accidents, the producers stated that, every year, 6, Americans die or suffer brain damage related to these mishaps. The APSF marked the first use of the term "patient safety" in the name of professional reviewing organization. Both organizations were soon expanded as the magnitude of the medical error crisis became known.

To Err is Human[ edit ] In the United States, the full magnitude and impact of errors in health care was not appreciated until the s, when several reports brought attention to this issue. Building a Safer Health System. The majority of media attention, however, focused on the staggering statistics: Within 2 weeks of the report's release, Congress began hearings and President Clinton ordered a government-wide study of the feasibility of implementing the report's recommendations.

However, subsequent reports emphasized the striking prevalence and consequences of medical error. The experience has been similar in other countries. On average forty incidents a year contribute to patient deaths in each NHS institution.

Communicating starts with the provisioning of available information on any operational site especially in mobile professional services. Communicating continues with the reduction of administrative burden, releasing the operating staff and easing the operational demand by model driven orders, thus enabling adherence to a well executable procedure finalised with a qualified minimum of required feedback.

Patient safety quality care improvement case study

Effective and ineffective communication[ edit ] Nurse and patient non-verbal communication The use of effective communication among patients and healthcare professionals is critical for achieving a patient's optimal health outcome.

However, according to the Canadian Patient Safety Instituteineffective communication has the opposite effect as it can lead to patient harm. Use of effective communication can aid in the prevention of adverse events, whereas ineffective communication can contribute to these incidences.

If ineffective communication contributes to an adverse event, then better and more effective communication skills must be applied in response to achieve optimal outcomes for the patient's safety.

There are different modes in which healthcare professionals can work to optimize the safety of patients which include both verbal and nonverbal communication, as well as the effective use of appropriate communication technologies.

Case Studies in Patient Safety

Some channels are more likely to result in communication errors than others, such as communicating through telephone or email missing nonverbal messages which are an important element of understanding the situation.

It is also the responsibility of the provider to know the advantages and limitations of using electronic health recordsas they do not convey all information necessary to understanding patient needs.

If a health care professional is not practicing these skills, they are not being an effective communicator which may affect patient outcome. Practice of effective communication plays a large role in promoting and protecting patient safety. There are several techniques, tools, and strategies used to improve communication.

Any team should have a clear purpose and each member should be aware of their role and be involved accordingly. Strategies such as briefings allow the team to be set on their purpose and ensure that members not only share the goal but also the process they will follow to achieve it.

Healthcare providers meet to discuss a situation, record what they learned and discuss how it might be better handled.

Closed loop communication is another important technique used to ensure that the message that was sent is received and interpreted by the receiver. SBAR is a structured system designed to help team members communicate about the patient in the most convenient form possible.

Safety culture As is the case in other industries, when there is a mistake or error made people look for someone to blame.

How we use information submitted to the NRLS

This may seem natural, but it creates a blame culture where who is more important than why or how. A just culture, also sometimes known as no blame or no fault, seeks to understand the root causes of an incident rather than just who was involved.

When assessing and analyzing an incident, individuals involved are much more likely to be forthcoming with their own mistakes if they know that their job is not at risk. From there, root cause analysis can occur.

There are often multiple causative factors involved in an adverse or near miss event. Disclosure of an incident[ edit ] After an adverse event occurs, each country has its own way of dealing with the incident.

In Canada, a quality improvement review is primarily used. A quality improvement review is an evaluation that is completed after an adverse event occurs with the intention to both fix the problem, as well as preventing it from happening again.

Healthcare providers have an obligation to disclose any adverse event to their patients because of ethical and professional guidelines. The disclosure of adverse events is important in maintaining trust in the relationship between healthcare provider and patient.

It is also important in learning how to avoid these mistakes in the future by conducting quality improvement reviews, or clinical peer review.Organizations around the world are using Lean to redesign care and improve processes in a way that achieves and sustains meaningful results for patients, staff, physicians, and health systems.

Case Studies

A BMJ Quality & Safety article reviews five areas of health care that are essential to improving patient safety, which the IHI/NPSF Lucian Leape Institute (LLI) first identified in Learn more about the work of LLI members and other thought leaders at the annual LLI Forum and Keynote Dinner in September.

QUALITY IMPROVEMENT (QI) Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

Knowledge Skills Attitudes; Describe strategies for improving outcomes of care in the setting in which one is engaged in clinical practiceAnalyze the impact of context (such as. Until then, selected better practices have been noted, with the potential to contribute to pragmatic efforts to improve patient care quality and safety in hospitals.


From a research tradition in which nurse staffing factors were primarily background variables, the study of nurse staffing and patient outcomes has emerged as a legitimate and. Improvement Opportunity: Cleveland Clinic began working with the Patient Safety Indicators (PSIs) in because patient safety is the “right thing to do” and because Federal payment programs and private payers use these quality indicators in their reimbursement programs.

A small percentage of patients die during hospitalization or shortly thereafter, and it is widely believed that more or better nursing care could prevent some of these deaths.

Canadian Patient Safety Institute