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Qual Saf Health Care 14:284-289 doi:10.1136/qshc.2004.012542
  • Original Article

Real time patient safety audits: improving safety every day

  1. R Ursprung1,
  2. J E Gray2,
  3. W H Edwards3,
  4. J D Horbar4,
  5. J Nickerson5,
  6. P Plsek6,
  7. P H Shiono7,
  8. G K Suresh8,
  9. D A Goldmann9
  1. 1Children’s Hospital Boston, Boston, MA; Harvard Medical School, Boston, MA; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  2. 2Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  3. 3Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Medical School, Lebanon, NH; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  4. 4University of Vermont College of Medicine, Burlington, VT; Vermont Oxford Network, Burlington, VT; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  5. 5Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  6. 6Paul E Plsek and Associates Inc, Atlanta, GA; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  7. 7Vermont Oxford Network, Burlington, VT; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  8. 8Medical University of South Carolina, Charleston, SC; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT, USA
  9. 9Children’s Hospital Boston, Boston, MA; Harvard Medical School, Boston, MA; Center for Patient Safety in Neonatal Intensive Care, Burlington, VT; Institute for Healthcare Improvement, Cambridge, MA, USA
  1. Correspondence to:
 Dr R Ursprung
 Pediatrix Medical Group, Department of Clinical Quality Improvement, Cook Children’s Medical Center, Department of Neonatology, Fort Worth, TX 76104, USA; Robert_ursprungpediatrix.com
  • Accepted 12 June 2005

Abstract

Background: Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety.

Objective: Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU).

Methods: A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003.

Results: A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected ⩾1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4).

Conclusions: Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free “culture of patient safety” involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

Footnotes

  • Funded in part by grants from The Agency for Healthcare Research and Quality (Center for Patient Safety in Neonatal Intensive Care, P20 HS11583), The Vermont Oxford Network and National Institutes of Health (NHLBI) K30 Grant No HL04095.

  • The authors declare no competing interests.

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