Table of Contents

1. Cognitive Errors and Logistical Breakdowns Contributing to Missed and Delayed Diagnoses of Breast and Colorectal Cancers: A Process Analysis of Closed Malpractice Claims
2. A Collaborative, Systems-Level Approach to Eliminating Healthcare-Associated MRSA, Central-Line–Associated Bloodstream Infections, Ventilator-Associated Pneumonia, and Respiratory Virus Infections
3. Diagnostic Errors and Flaws in Clinical Reasoning: Mechanisms and Prevention in Practice
4. Error Reporting in Transfusion Medicine at a Tertiary Care Centre: A Patient Safety Initiative
5. Errors and Near Misses in Digestive Endoscopy Units
6. The Feedback Intervention Trial (FIT)—Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial
7. Impact of Automated Alerts on Follow-Up of Post-Discharge Microbiology Results: A Cluster Randomized Controlled Trial
8. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
9. Interruption Handling Strategies during Paediatric Medication Administration
10. Intravascular Retained Surgical Items: A Multicenter Study of Risk Factors
11. Medication Problems Are Frequent and Often Serious in a Danish Emergency Department and May Be Discovered by Clinical Pharmacists
12. Non-Technical Skills Training to Enhance Patient Safety: A Systematic Review
13. Partnering with Family Members to Improve the Intensive Care Unit Experience
14. Patterns in Neurosurgical Adverse Events and Proposed Strategies for Reduction
15. Preventing Wrong-Site Surgery in Minnesota: A 5-Year Journey
16. Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for System Changes
17. Safety Climate and Medical Errors in 62 US Emergency Departments
18. Sharing Lessons Learned to Prevent Incorrect Surgery
19. Surgical Debriefing: A Reliable Roadmap to Completing the Patient Safety Cycle
20. Ultrasound to Reduce Cognitive Errors in the ED

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Frequently Asked Questions

The Universal Patient Compact™ is a statement of principles established by NPSF that define the elements of true and effective partnering between patients and providers. It helps health care organizations by providing a framework to shape an organization’s efforts toward integrating patients and families into care teams. The Compact describes principles that are essential to providing care that is truly patient-and-family-centered and that respects the rights of patients.

Patients, too, have responsibilities as part of their own care teams. For them, the Universal Patient Compact offers specific ways that they can work with their health care providers to improve the safety of their care.

Q. What are the principles of the Compact?

A. The Compact sets forth principles of the relationship between patients and providers that NPSF considers fundamental to the delivery of safe and high quality care. NPSF considers the principles representative of effective partnerships between patients and providers. The compact helps to inform and support hospitals and other organizations in their efforts to incorporate these principles into organizational policy and practice. It also serves as a guideline and reminder for patients, to help them become more involved in their care.

Q. How were these principles developed?

A. The initiative for The Universal Patient Compact™ was the outcome of a roundtable discussion during the 2007 McKesson Nursing Leadership Congress. It was introduced as part of the 2009 Patient Safety Awareness Week activities. The principles of the Compact, guided by elements of health literacy, were carefully developed through a multistakeholder approach. The document was created with input from the Patient and Family Advisory Committee at NPSF and affiliated patient advocacy groups, NPSF Board members, Stand Up for Patient Safety member organizations, and a variety of other patient and provider representatives.

Q. How is the Compact different from the Consumer Bill of Rights?

A. The Compact expands on principles contained in the Consumer Bill of Rights to describe a mutual covenant between health care providers and their patients. While the Bill of Rights focuses on the patient perspective, the Compact focuses on the relationship between the patient and the patient’s health care partners by creating an understanding between the parties about how they will work together.

Q. Is the Compact a legally binding document?

A. No, the Compact is not a legal instrument and is not meant to function as a binding contract between the patient and the care provider, nor to replace any form of document that hospitals or organizations may already use for this purpose. For this reason, NPSF encourages each organization to consider its own policies and needs when deciding how best to employ and disseminate the Compact.

Q. How do health care organization use the Compact?

A. The Compact is not a legally binding document. Health care organizations may display it in areas with wide visibility, such as office reception areas, waiting and exam rooms, or cafeterias. Some health care organizations share the compact with their patients or with Patient and Family Advisory Councils. Some may take it further by actually using the Compact as the foundation for a program built around the principles.

Other organizations may use the Compact to begin discussions among staff and the organization’s leadership. Such discussions help to gauge an organization’s adherence to the principles. If gaps are identified, the Compact can serve as a basis for creating goals to focus on the principles.

To make sure that patients and staff have an equal understanding of the Compact, health care organizations may choose to include it in patient education packets, as well as in staff or member orientation handbooks and training manuals.

Read more about the NPSF Universal Patient Compact Survey tool.

Q. Will the principles of the Compact ever be revised?

A. Yes. As the role of patients and providers evolves, the principles will be updated. NPSF seeks feedback on the principles continually so that it may be reaffirmed annually. Health care organizations can help us by asking a staff member and a patient representative to complete the respective two parts of an online survey.

The survey can also help organizations measure how closely their practices already match the principles of the compact. Part 1 is designed to be completed by the organization. It includes questions from the providers’ point of view. Part 2 is to be completed by patients, but it asks similar questions. When comparing responses from health care staff to those of patients, the gaps that appear may help organizations identify areas to improve and opportunities for dialogue.

Read more about the NPSF Universal Patient Compact survey.

Assessing Hospitals’ Use of Mandatory Error Reports for Quality Improvement and Error Reduction

Joel C. Cantor, ScD, CSHP, Kimberley S. Fox, MPA; Denise A. Davis, Dr.PH, MPA; Cara L. Cuite, MA; David M. Frankford, JD; Albert L. Siu, MD, MSPH; and, Andrea I. Kabcenell, RN, MPH

State-mandated medical error reporting in hospitals and other health care facilities has become common since the release of the Institute of Medicine’s report To Err is Human in 2000. In 2002, Rutgers Center for State Health Policy conducted an exploratory study funded by the National Patient Safety Foundation to assess hospitals’ use of mandatory medical error and adverse event reports in New York State. This system, called New York Patient Occurrence Reporting and Tracking System (NYPORTS), is one of the oldest and largest state-mandated hospital reporting systems in the country. Based on semi-structured telephone interviews with over 100 administrative and clinical leaders from a stratified random sample of 20 hospitals throughout New York State, the study investigated hospital leaders’ awareness and perceived purpose of the reporting system, the process by which hospitals collect and use this data, the barriers to use, and perceived value by hospital leaders and its impact on patient safety. The study also sought to identify key factors that either facilitated or limited the use of data from the mandatory reporting system within New York State hospitals.

This study, the first of its kind, found that state-mandated hospital adverse event reporting in New York was successful in raising awareness of patient safety among hospital leadership and promoting investigative processes of serious medical errors that hospitals have found to be useful. However, during the early years of the reporting system, hospitals did not appear to have been utilizing much of NYPORTS adverse event data because of insufficient comparative data feedback and lack of confidence in event reporting across hospitals. We generally did not observe variations in patterns of use across hospital types. Our primary findings instead demonstrate the influence that one’s position in a hospital’s administrative and leadership structure has for perceptions of this adverse event reporting system. This study suggests that well-designed, state-mandated reporting systems can have positive impacts in raising awareness and accountability within hospitals, but also points to some barriers and burdens that designers of next-generation error reporting systems should address.

Remote Analysis of the Surgical Environment: Measuring the Effect of Debriefing Attendings on Surgical Safety Factors

Reid B. Adams, MD, J. Forrest Calland, MD; Stephanie Guerlain, PhD; Bruce Schirmer, MD; R. Scott Jones, MD; Keith Littlewood, MD; and, Carl Lynch, MD

The investigators of this study utilized an institutionally developed, integrated, multi-media audio-visual and sensor data collection system (RATE, for Remote Analysis of Team Environments). Debriefing sessions, which followed evaluation of baseline team performance and Crew Resource Management (CRM)* training sessions, were held with the attending surgeon and his team after the surgical procedure and included discussion and critique using video clips of the operative case.

Preoperative briefing elements and optimal intra-operative communication practices increased in frequency after implementation of CRM training and debriefing sessions, and this effect was sustained over subsequent study cases for each surgical team. Case specific participant knowledge and awareness, evaluated from post case questionnaires, also improved after debriefing sessions.

This study demonstrated that debriefing sessions are an effective technique to positively influence surgical safety factors of attending surgeons and their team members.

Impact of Computerized Alerts and Reminders on Implementation of a Weight-Based Unfractionated Heparin Dosing Protocol

Anne Marie Greco, PharmD, NYPH; Michael I. Oppenheim, MD; Ferdinand Velasco, MD; Rudina Odeh-Ramadan, PharmD; and, Josephine Sollano, MPH

At New York-Presbyterian Hospital (NYPH), we have implemented, and are in the process of evaluating, an IT-based project to improve the management of patients receiving heparin therapy. The project is designed to assure that care at NYPH is compliant with nationally accepted weight-based heparin dosing guidelines.

NYPH is a 2400-bed multi-campus academic health center. NYPH has an Eclipsys Computerized Provider Order Entry (CPOE) system implemented throughout the hospital. For this project, we are taking advantage of the clinical decision support features available in Eclipsys.

Data about heparin orders, administrations and other medications will be extracted from Eclipsys. PTT and creatinine results to assess exclusion criteria will be extracted from the lab system. Information about co-morbid conditions and adverse outcomes will come from chart review and the administrative data warehouse.

We have completed designing the experimental and analytic plan. We have also completed several interventions and designed measurement system analysis to evaluate and ensure data integrity. We are currently moving forward with the data collection using these refined automated and manual data collection methodologies.

Improving Patient Safety in Cardiac Surgery via Prospective Use of the Cumulative Sum (CUSUM) Failure Method

Investigators: Richard J. Novick, MD (PI), Douglas Bloyd, MD, John Lee, MD, Mckenzie Quantz, MD

Using a statistical methodology known as CUSUM, this two-year study analyzed the learning curves of new surgical consultants and surgeons engaged in minimally invasive cardiac surgery. The investigators anticipated that the CUSUM method would enable prospective analysis of the learning curves of new surgical consultants and of surgeons engaging in innovative, minimally invasive procedures. The goal of this study was to incorporate the CUSUM technique into standard methods of surgical audit to improve patient safety and outcomes after
cardiac surgery.

The results of this study illustrate that prospective use of the CUSUM method can alert surgeons to suboptimal results and the need for prompt remedial action in advance of standard comparative analyses.

In a highly innovative field such as cardiac surgery where techniques are changing weekly, an “online” sequential probability assessment of patient outcomes is obligatory. The researchers have already noted significant interest in CUSUM analysis among the cardiac surgical community in North America and
Europe and believe that it will have a significant impact on future outcome assessment in cardiac surgery.

Pediatric Sedation: a Safety and Efficacy Problem for Children Requiring Diagnostic and Therapeutic Procedures in the Hospital Setting; A Human Factors Opportunity for Improvement

George T. Blike, MD (PI), Joseph Cravero, MD, Gene Nelson, PhD, Kate Whalen, RN

This research involved extensive video observation of pediatric procedural sedation in the hospital setting. The study sought to shift how medical practitioners viewed the concepts of safety and efficacy to all aspects of the sociotechnical system that impacts outcome. Specifically, this research aimed to characterize performance in a state-feedback control model that would allow critical factors affecting control to be identified and then utilized for system redesign.

The results of this research have led to a shift in our understanding regarding the undertreatment of pain and anxiety. Undertreatment errors should be viewed as a safety failure and are related to control failures in managing overdose events.
Practitioners with unreliable systems for managing overdose states in patients routinely tolerate underdose states to create a margin of safety. These data fostered subsequent research focused on rescue systems and distributed teams. The initial study funded by NPSF was pivotal in allowing our research team to secure funding from the National Institute of Child Health and Human Development to use simulation to identify latent conditions preventing optimal rescue and control of rare but potentially lethal overdose events.

Ultimately, this project impacted the provision of sedation to pediatric patients at our hospital, resulting in improved safety and reliability for children who require painful and/or stressful procedures. We have implemented a sedation program that has now been in place for over eight years that was designed to optimize control.

Error Detection and Recovery: Fixation vs. Adaptability

Investigators: William R. Torbert, PhD, Jenny Rudolph, PhD, John S. Carroll, PhD, Daniel Ramer, PhD

The goal of this project was to help medical trainees understand and transcend their internal barriers in identifying, discussing, and recovering from error. The study focused on the debriefing of trainees who have been challenged with responding to critical events during training sessions in a realistic simulator. Study aim was to better understand the process of fixation error, revise the debriefing sessions to reduce fixation and improve hypothesis generation, and then retest performance in a subsequent event to assess the efficacy of the intervention.

Serious Medication Errors: Evaluation of Prevention Strategies in Pediatrics

Donald Goldmann, MD, Rainu Kaushal, MD, David W. Bates, MD, Margaret D. Clapp, MS

The team of this project is studying the effectiveness of two interventions, pharmacist involvement on inpatient pediatric wards plus CQI teams and a physician order system, on the rate of serious medication errors at two academic pediatric institutions. This project follows a study that has been examining adverse events and medications errors in a fashion similar to that of studies in adult populations. While these interventions have been studied in adult populations, the investigators have identified unique qualities of errors and sequelae in children that justify examination in this setting.