The moral imperative of designating patient safety and quality care as a national nursing research priority

Since the early 1990s, research studies conducted respectively in the USA, UK and Australia have found that between 4 and 16.6 per cent of patients suffer from some kind of harm (including permanent disability and death) as a result of human errors and adverse events while in hospital. It has been further estimated that approximately 50 per cent of these human errors/adverse events resulting in harm could have been prevented. In response to the significant financial, social, and political implications of these figures, a range of processes have been put in place in an attempt to improve patient safety and quality care in Australia. Nonetheless, it is evident that more can be done to improve the status quo. One process that warrants consideration is that of peak health professional groups and organisations providing active leadership in the promotion of patient safety, such as by making a visible and recognisable commitment to patient safety as a strategic research priority area. In this paper it is contended that, given the moral importance of patient safety and quality care in nursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focussed public attention to patient safety and quality care as a national research priority.

Evidence for the safety and quality issues associated with the care of patients with cognitive impairment in acute care settings : a rapid review

The Australian Commission on Safety and Quality in Health Care commissioned this rapid review to identify recent evidence in relation to three key questions: 1. What is the current evidence of quality and safety issues regarding the hospital experience of people with cognitive impairment (dementia/delirium)? 2. What are the existing evidence-based pathways, best practice or guidelines for cognitive impairment in hospitals? 3. What are the key components of an ideal patient journey for a person with dementia and/or delirium? The purpose of this review is to identify best practice in caring for patients with cognitive impairment (CI) in acute hospital settings. CI refers to patients with dementia and delirium but can include other conditions. For the purposes of this report, ‘Hospitals’ is defined as acute care settings and includes care provided by acute care institutions in other settings (e.g. Multipurpose Services and Hospital in the Home). It does not include residential aged care settings nor palliative care services that are not part of a service provided by an acute care institution. Method Both peer-reviewed publications and the grey literature were comprehensively searched for recent (primarily post 2010) publications, reports and guidelines that addressed the three key questions. The literature was evaluated and graded according to the National Health and Medical Research Council (NHMRC) levels of criteria (see Evidence Summary – Appendix B). Results Thirty-one recent publications were retrieved in relation to quality and safety issues faced by people with CI in acute hospitals. The results indicate that CI is a common problem in hospitals (upwards of 30% - the rate increases with increasing patient age), although this is likely to be an underestimate, in part, due to numbers of patients without a formal dementia diagnosis. There is a large body of evidence showing that patients with CI have worse outcomes than patients without CI following hospitalisation including increased mortality, more complications, longer hospital stays, increased system costs as well as functional and cognitive decline. 4 To improve the care of patients with CI in hospital, best practice guidelines have been developed, of which sixteen recent guidelines/position statements/standards were identified in this review (Table 2). Four guidelines described standards or quality indicators for providing optimal care for the older person with CI in hospital, in general, while three focused on delirium diagnosis, prevention and management. The remaining guidelines/statements focused on specific issues in relation to the care of patients with CI in acute hospitals including hydration, nutrition, wandering and care in the Emergency Department (ED). A key message in several of the guidelines was that older patients should be assessed for CI at admission and this is particularly important in the case of delirium, which can indicate an emergency, in order to implement treatment. A second clear mess...

Patient safety, ethics and whistleblowing : a nursing response to the events at the Campbelltown and Camden Hospitals

In November 2002, in what stands as one of the most significant whistleblowing cases in the history of the Australian health care system, four nurses went public with concerns they had about the management of clinical incidents and patient safety at two hospitals in Sydney, New South Wales. The handling of this case and its aftermath raises important moral questions concerning the nature of whistleblowing in health care domains and the possible implications for the patient safety and quality of care movement in Australia. This paper presents an overview of the case, the moral risks associated with whistleblowing, and some lessons learned.

Culture, language, and patient safety : making the link

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a ‘resident pathogen’ within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture–language–patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

Clinical risk management and patient safety education for nurses : a critique

Nurses have a pivotal role to play in clinical risk management (CRM) and promoting patient safety in health care domains. Accordingly, nurses need to be prepared educationally to manage clinical risk effectively when delivering patient care. Just what form the CRM and safety education of nurses should take, however, remains an open question. A recent search of the literature has revealed a surprising lack of evidence substantiating models of effective CRM and safety education for nurses. In this paper, a critical discussion is advanced on the question of CRM and safety education for nurses and the need for nurse education in this area to be reviewed and systematically researched as a strategic priority, nationally and internationally. It is a key contention of this paper that without ‘good’ safety education research it will not be possible to ensure that the educational programs that are being offered to nurses in this area are evidence-based and designed in a manner that will enable nurses to develop the capabilities they need to respond effectively to the multifaceted and complex demands that are inherent in their ethical and professional responsibilities to promote and protect patient safety and quality care in health care domains.

The National Safety and Quality Health Service Standards requirements for orientation and induction within Australian healthcare: a review of the literature

Introduction: A workplace orientation program is a core requirement of the National Safety and Quality Health Service (NSQHS) Standards in Australia. This is particularly important within healthcare as patient safety and the patient experience are at risk if the healthcare workforce is not supported with an effective orientation and induction program. Aim: This study aimed to review the literature and map the requirements of the NSQHS Standards in relation to orientation and induction. Method: This study utilised online databases to search for literature pertaining to orientation and induction within healthcare. Inclusion criteria included relevance to research questions, and originating in a country with a comparative health system to Australia. Results: The search identified a total of 202 articles of potential relevance with 42 articles meeting the inclusion criteria. Articles were ranked according to hierarchy of evidence criteria for both qualitative and quantitative studies. The importance of using orientation to detail safety and quality roles, the organisations' risk management system, governance structure, operational processes and procedures was highlighted. Patient-centred care, antimicrobial stewardship, clinical handover and mechanisms for escalation of care and emergency assistance should also be covered within the orientation process. Conclusion: There is a dearth of studies in relation to orientation and induction in the healthcare literature. Orientation content is now clearly prescribed, what is lacking within healthcare is a standardised framework. Concept mapping, educational theory and adult learning methods have been shown to enhance workforce problem solving and engagement with orientation, however further research is needed to enhance practice

Why has the safety and quality movement been slow to improve care?

Buist and Middleton lament that the safety and quality 'agenda' has failed to fundamentally alter the safety of healthcare systems, in part because of the disengagement of doctors from their responsibilities for patient safety . While there have been discernable improvements in the efficiency and effectiveness of care in some settings, patients still experience unacceptable harm and often struggle to have their voices heard; processes are not as efficient as they could be; and costs continue to rise at alarming rates while quality issues remain . Perhaps of most concern, recent public reports into health system failures continue to document a widespread lack of attentiveness to patient concerns, a culture of denial and widespread lack of professionalism . Alarmingly, clinician discontentment, cynicism and burn-out are reflected in antagonistic language by clinicians about the healthcare system and their patients. Taken together with the many dissatisfied and now more vocal patient groups, all point to an unprecedented crisis of faith in our healthcare systems which has been getting worse over past decade . This personal perspective aims to address the fundamental tensions that are keeping much of healthcare reform efforts from successfully transforming the culture and outcomes except at the margins.

Patient safety and the RCA: A document analysis

This research examined the function of Queensland Health's Root Cause Analysis (RCA) to improve patient safety through an investigation of patient harm events where permanent harm and preventable death, Severity Assessment Code 1, were the outcome of healthcare. Unedited and highly legislated RCAs from across Queensland Health public hospitals from 2009, 2010 and 2011 comprised the data. A document analysis revealed the RCAs opposed organisational policy and dominant theoretical directives. If we accept the prevailing assumption that patient harm is a systemic issue, then the RCA is failing to address harm events in healthcare.

Patient safety and communication: A new assessment for doctors trained in countries where language differs from that of the host country: Results of a pilot using a domain-based assessment

Objective

Global migration of healthcare workers places responsibility on employers to comply with legal employment rights whilst ensuring patient safety remains the central goal. We describe the pilot of a communication assessment designed for doctors who trained and communicated with patients and colleagues in a different language from that of the host country. It is unique in assessing clinical communication without assessing knowledge.

A 14-station OSCE was developed using a domain-based marking scheme, covering professional communication and English language skills (speaking, listening, reading and writing) in routine, acute and emotionally challenging contexts, with patients, carers and healthcare teams. Candidates (n = 43), non-UK trained volunteers applying to the UK Foundation Programme, were provided with relevant station information prior to the exam.

The criteria for passing the test included achieving the pass score and passing 10 or more of the 14 stations. Of the 43 candidates, nine failed on the station criteria. Two failed the pass score and also the station criteria. The Cronbach's alpha coefficient was 0.866.

This pilot tested ‘proof of concept’ of a new domain-based communication assessment for non-UK trained doctors.

The test would enable employers and regulators to verify communication competence and safety in clinical contexts, independent of clinical knowledge, for doctors who trained in a language different from that of the host country.

Patient safety and beyond: what should we expect from microneedle arrays in the transdermal delivery arena?

Research based upon microneedle (MN) arrays has intensified recently. While the initial focus was on biomolecules, the field has expanded to include delivery of conventional small-molecule drugs whose water solubility currently precludes transdermal administration. Much success has been achieved, with peptides, proteins, vaccines, antibodies and even particulates delivered by MN in therapeutic/prophylactic doses. Recent innovations have focused on enhanced formulation design, scalable manufacture and extension of exploitation to minimally invasive patient monitoring, ocular delivery and enhanced administration of cosmeceuticals. Only two MN-based drug/vaccine delivery products are currently marketed, partially due to limitations with older MN designs based upon silicon and metal. Even the more promising polymeric MN have raised a number of regulatory and manufacturability queries that the field must address. MN arrays have tremendous potential to yield real benefits for patients and industry and, through diligence, innovation and collaboration, this will begin to be realised over the next 3-5 years.

Development of Safety and Quality Management System in Shrimp Farming

Shrimp Aquaculture has provided tremendous opportunity for the economic and social upliftment of rural communities in the coastal areas of our country Over a hundred thousand farmers, of whom about 90% belong to the small and marginal category, are engaged in shrimp farming. Penaeus monodon is the most predominant cultured species in India which is mainly exported to highly sophisticated, quality and safety conscious world markets. Food safety has been of concem to humankind since the dawn of history and the concern about food safety resulted in the evolution of a cost effective, food safety assurance method, the Hazard Analysis Critical Control Point (HACCP). Considering the major contribution of cultured Penaeus monodon to the total shrimp production and the economic losses encountered due to disease outbreak and also because traditional methods of quality control and end point inspection cannot guarantee the safety of our cultured seafood products, it is essential that science based preventive approaches like HACCP and Pre requisite Programmes (PRP) be implemented in our shrimp farming operations. PRP is considered as a support system which provides a solid foundation for HACCP. The safety of postlarvae (PL) supplied for brackish water shrimp farming has also become an issue of concern over the past few years. The quality and safety of hatchery produced seeds have been deteriorating and disease outbreaks have become very common in hatcheries. It is in this context that the necessity for following strict quarantine measures with standards and code of practices becomes significant. Though there were a lot of hue and cry on the need for extending the focus of seafood safety assurance from processing and exporting to the pre-harvest and hatchery rearing phases, an experimental move in this direction has been rare or nil. An integrated management system only can assure the effective control of the quality, hygiene and safety related issues. This study therefore aims at designing a safety and quality management system model for implementation in shrimp farming and hatchery operations by linking the concepts of HACCP and PRP.

Safety and quality and stage of distribution

Let 0 denote the level of quality inherent in a food product that is delivered to some terminal market. In this paper, I characterize allocations over 0 and provide an economic rationale for regulating safety and quality standards in the food system. Zusman and Bockstael investigate the theoretical foundations for imposing standards and stress the importance of providing a tractable conceptual foundation. Despite a wealth of contributions that are mainly empirical (for reviews of these works see, respectively, Caswell and Antle), there have been relatively few attempts to model formally the linkages between farm and food markets when food quality and consumer safety are at issue. Here, I attempt to provide such a framework, building on key contributions in the theoretical literature and linking them in a simple model of quality determination in a vertically related marketing channel. The food-marketing model is due to Gardner. Spence provides a foundation for Pareto-improving intervention in a deterministic model of quality provision, and Leland, building on the classic paper by Akerlof, investigates licensing and minimum standards when the information structure is incomplete. Linking these ideas in a satisfactory model of the food markets is the main objective of the paper.