Canada: Keeping Patients Safe: Interventions Based On Efficacy

In recent years, there has been a significant shift in the culture of health care, with the focus of this shift falling squarely on the design and delivery safe patient care.

While it has become a core issue and the central driving force in health care expenditures, uptake in patient safety has been riddled with challenges, such as shifting priorities, limited access to capital/resources, and the complicated process of deciding which intervention to implement. This Marsh Insights highlights the key challenges when implementing patient safety initiatives, which practices best improve patient safety, and assess the economic implications on the health care system, and on society as a whole.

Various U.S. studies have identified that "approximately 3-4% of hospitalized patients suffer a serious adverse event... a substantial proportion (between 30-50%) are preventable." ^{1, 2} Recent Canadian literature has demonstrated that the rate of adverse events in Canada is 7.5% of all hospital admissions ³.

To better understand this issue from a global perspective, the World Health Organization (WHO) Patient Safety team conducted a global study on patient safety issues. Despite discrepancies among the different countries based on their economic status (developed/ high income, transitional/medium income, and developing/low income) 23 major safety issues were identified ⁴, further subdivided into three categories: structure, process and outcomes ⁵.

• Structural Issues – Issues surrounding staffing, complexity of patients, patient volume, and pressure to improve on throughput, have all contributed to an environment that fosters/ contributes to unsafe patient care. These environments have also created challenges with communication — a key culprit in patient adverse events.
• Process Related Issues – In developed countries — despite the most sophisticated technologies – misdiagnoses or wrong diagnoses continue to create significant adverse outcomes for patients. Other process-related issues include missed critical lab values, lack of coordination within the circle of care, and communication breakdowns. In transitional and developing countries, these processes are further complicated by substandard medications, unsafe injection practices, and poor quality control.
• Outcomes Related Issues – Medication-related adverse events continue to plague health care systems around the world. According to the WHO, between 7.5% and 10.4% of inpatients experience adverse outcomes as a result of medication errors. In the U.S. alone, adverse drug events lead to 140,000 deaths annually. It is believed that an upward of 56% of those deaths are avoidable ⁶. Another major patient safety issue is nosocomial (hospital acquired) infections. A national study in Canada revealed that approximately 220,000 cases of nosocomial infections have resulted in the death of approximately 8,000 patients ⁷. The European Prevalence of Infection in Intensive Care (EPIC) study revealed a prevalence of 20.8% of nosocomial infections resulting in a 2.5% increase in hospital length of stay ⁸.

Getting To The Root Of The Problem

Of the many studies that have been conducted both nationally and internationally, the pivotal focus is on patient safety as a systems-related issue,⁹ meaning actions directed at patient safety must be undertaken simultaneously by ALL stakeholders, both internal and external. While "the success of efforts to improve patient safety is a function of how well safety is built into the fabric of the system itself," ¹⁰ a bottom-up approach will allow for greater involvement by front-line staff and greater engagement results in greater uptake of changes in processes and policies. The end result is a culture that is focused on patient safety. This achievement requires the synergy of:

1. Identifying what works (efficacy).
2. Ensuring that the patient receives it (appropriate use).
3. Flawless, error-free delivery ¹¹ that involves engagement from frontline staff, compliance that is earned (rather than forced), and best interventions implemented ¹².

Making Tough Decisions

In the past, patient safety interventions have been the result of evidence-based practice. In 2008, Shojania and Ranji published a study of all of the interventions that contribute to improved patient safety outcomes, and found that "evidence on more clinical interventions over more explicitly safety-oriented interventions... reduce complications of care and ...gain greater acceptance" ¹³. Similarly, The Institute for Healthcare Improvement "100,000 Lives" campaign promoted the implementation of evidence-based interventions as opposed to general approaches that focus on patient safety ¹⁴. Shonajia et al (2001) developed a framework for selecting which safety interventions to implement based on the following criteria:

• Scope of the problem: Considers prevalence and severity of the safety problem.
• Effectiveness: Determines the strength of the evidence that supports the intervention.
• Need for Vigilance: The need for monitoring for possible of unintended outcomes or consequences.
• Implementation Issues: Cost and complexity of the intervention.
• Momentum and Synergy with Other Interventions: Some interventions have the potential to create momentum within the organization, aligned with the organization's strategic direction.

Source: Shojania. K.G., Duncan, B.W., McDonald, K.M. et al. Making healthcare safer: a critical analysis of patient safety practices. AHRQ Publication No. 01-E058; July 2001. Available at: http://www.ahrq.gov/clinic/ptsafety. Accessed: June 11, 2014.

Once the intervention has been determined based on the aforementioned criteria, another factor to consider is the Patient Safety intervention hierarchy. Below are lists of interventions that have strong evidence to support their efficacy.

Strongly Encouraged Patient Safety Practices

• Preoperative checklists and anaesthesia checklists to prevent adverse events associated with surgery
• Checklists to prevent central line infections
• Implementation of stop orders or reminders for reduction in urinary catheter use
• Interventions aimed at reducing Ventilator Associated Pneumonia such as head of bed elevation, oral care with chlorhexadine, and subglottic suctioning
• Hand hygiene
• "Do Not Use" list for hazardous abbreviations
• Interventions designed for the reduction of pressure ulcers
• Precautions to reduce health care acquired infections
• Use of real-time ultrasound for placement of central lines
• Prophylaxis interventions for venous thromboembolism

Source: Agency for Healthcare Research and Quality Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices http://www.ahrq.gov/research/findings/evidence-based-reports/services/ quality/ptsafetysum.pdf

Encouraged Patient Safety Practices

• Interventions to reduce falls
• Use of clinical pharmacists to reduce adverse drug events
• Documentation of advance directives with respect to life sustaining treatments
• Informed consent with emphasis on greater patient understanding of potential risks associated with treatments and procedures
• Team training
• Medication reconciliation
• Implementation of Surgical Outcomes measurements
• Rapid response systems/teams
• Complimentary methods of for detecting adverse events
• Computerized provider order entry system
• Use of simulation exercises in patient safety interventions

Source: Agency for Healthcare Research and Quality Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices http://www.ahrq.gov/research/findings/evidence-based-reports/services/ quality/ptsafetysum.pdf

The National Centre for Patient Safety at the US Department of Veterans Affairs believes that actions focused on systemic changes and not on individual memory are more effective and has identified the patient safety hierarchy, below:

Conclusion

For as much as evidence-based safety interventions are emphasized within this paper, it is also imperative to note that many patient safety interventions will be based on judgement and experience combined with the best available evidence.

For intervention implementations to be successful, essential elements -- such as fostering and sustaining a culture of patient safety, understanding the problem, involving key stakeholders, and continuous monitoring of performance and key metrics — need to exist. By improving patient safety within the health care system, greater opportunities to provide increased services, reduce costs and improve efficiencies and utilization of resources will exist.

Consultants in the Marsh Risk Consulting (MRC) Clinical Risk Practice can help provide guidance and program development expertise to health care clients that will help reduce adverse events and help improve quality of care.

Footnotes

^{1 Jha, A, ed. Summary of the evidence on patient safety: Implications for research. Geneva World Health Organization 2008.}

^{2 Jha, A.K., Praposa-Plazier, N., Larizgitia,I. et al. Patient Safety Research: an overview of the global evidence. Qual Saf Health Care 2010 19:42-47.}

^{3 Baker, G.R., Norton, P.G., Fintoft, V. et al: The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004: 170:1678-86.}

^{4 Based on World Bank 2006 classification}

^{5 Leape, L.L., Berwick, D.M., & Bates, D.W. What Practices will most improve Safety? Evidence Based Medicine Meets Patient Safety JAMA 2002;288(4)501-7}

^{6 Jha, A, ed. Summary of the evidence on patient safety: Implications for research. Geneva World Health Organization 2008.}

^{7 Khoury,L. & Iokheles, M. Factual Causation and Health Care –Associated. Infections. Health Law Journal 2009: 17:195-228.}

^{8 Khoury,L. & Iokheles, M. Factual Causation and Health Care –Associated. Infections. Health Law Journal 2009: 17:195-228.}

^{9 Leape, L.L., Berwick, D.M., & Bates, D.W. What Practices will most improve Safety? Evidence Based Medicine Meets Patient Safety JAMA 2002;288(4)501-7}

^{10 Buchan, H. Different Countries, different cultures: convergent or divergent evolution for health care quality? Qual Health Care 1998:7; 62-67.}

^{11 Leape, L.L., Berwick, D.M., & Bates, D.W. What Practices will most improve Safety? Evidence Based Medicine Meets Patient Safety JAMA 2002;288(4)501-7}

^{12 Lewis, R.Q., & Fletcher, M. Implementing a national strategy for patient safety: lessons from the National Health Service in England Qual Saf Health Care 2005; 14: 135-39.}

^{13 Ranji, S.R. & Shojania, K.G. Implementing Patient Safety Interventions in Your Hospital: What to Try and What to Avoid. Med Clin N Am 92 (2008: 275-93.)}

^{14 Ibid}

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.