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RESEARCH

How to cite this article:

Rivas-Espinosa JG, Verde-Flota EEJ, Ramírez-Villegas RM, Guerra-Escamilla LM, Ramírez-Espinosa L. Rev Enferm Inst Mex Seguro Soc. 2015;23(3):135-42

Compliance with international patient safety goals

Juan Gabriel Rivas-Espinosa,¹ Elsy Elizabeth de Jesús Verde-Flota,¹ Raquel María Ramírez-Villegas,¹ Laura Margarita Guerra-Escamilla,² Leticia Ramírez-Espinosa²

¹Licenciatura en Enfermería, ²Pasante de Licenciatura en Enfermería. Universidad Autónoma Metropolitana, Xochimilco, Distrito Federal, México

Correspondence: Juan Gabriel Rivas Espinosa

Email: gabrielrivas50@yahoo.com.mx

Received: March 13^th 2014

Judged: May 21^st 2014

Accepted: August 20^th 2014

Abstract

Introduction: The international patient safety goals (IPSG) are important guidelines at the international level to promote specific improvements in the process of providing safe and high-quality patient care.

Objective: To measure the level of compliance of the IPSG that is carried out by nursing staff in a tertiary care level hospital.

Methodology: Descriptive study. We designed an instrument with three choices: “Yes”, “No” and “Not applicable” (NA). Then, we applied the Kuder Richardson 20 (Kr-20), with a result of 0.89. We surveyed a total of 97 nurses. Once we obtained scores, we established a four-item color code, according to the level of compliance: green (82-100 %), yellow (71-80 %), red (60-70 %) and black, whose value was < 59 %. Then, the average implementation time was obtained.

Results: The level of compliance was 72.6 % and the yellow color was assigned, according to the color scheme established. The overall rating of NA was 2.9 %. The average time was 20 minutes with a minimum of 13 and a maximum of 50 minutes, with a standard deviation of 7.93.

Conclusions: This instrument is efficient to measure the way the IPSG are applied. Shift change is the ideal time to apply the measurement. According to the color code, the overall level of compliance is in yellow, so it is necessary to reinforce training in order to improve the application of these goals and provide high-quality care to patients.

Keywords: Patient safety; Healt care quality assurance

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Introduction

Patient safety is defined as a "set of organizational structures and processes that reduce the probability of adverse events resulting from exposure to the healthcare system during the course of diseases and procedures".¹ For Santacruz et al. patient safety is the result of the safety of the health system, hospital safety and clinical safety and not only doctor or health personnel performance.² As such, it is a complex activity, since it combines aspects inherent to healthcare and human actions. The International Joint Commission states that the safety of healthcare is a process that focuses on knowledge of the risks of adverse effects, eliminating unnecessary risks, and preventing events that are avoidable using interventions based in scientific evidence with demonstrated effectiveness.³

Based on this, Castro et al. mention that various international organizations, such as the World Health Organization (WHO) and the same Joint Commission International, have developed initiatives to support national and international strategies that contribute to improving patient safety.⁴ In this context in 2004 WHO launched the World Alliance for Patient Safety, and the Joint Commission International published the international patient safety goals (IPSG), in September 2006, based on proposals from WHO; the IPSG are defined as "specific strategies to improve the safety of the person receiving care within hospital units", ⁵ and they are important lines of worldwide application to promote specific improvements in the process of safe and high quality patient care, based on scientific evidence and created by expert knowledge.

Specifically, the IPSG instructs:

1. Identify patients correctly.
2. Improve effective communication.
3. Improve the safety of high-alert medications.
4. Ensure correct-site, correct-procedure, correct-patient surgery.
5. Reduce the risk of health care-associated infections.
6. Reduce the risk of patient harm resulting from falls.

The IPSG is a full component of quality in healthcare, which the WHO says is to "ensure that each patient receives the most appropriate set of diagnoses and therapies for optimal healthcare service, taking into account all factors and knowledge of the patient and the medical service, and to achieve the best results with minimum risk of iatrogenic effects and high patient satisfaction with the process".⁶ For Castellanos et al., quality is the degree to which services increase the rate of optimal results that are consistent with current medical knowledge.⁷

Quality of care ensures the prevention of adverse events, which are a serious public health problem with varying degrees of damage to the patient and their family, and which increase the cost of the care process and hospital stay.⁸ Adverse events are a major cause for concern about the unfavorable effects of varying degrees that can result from medical care, so it is important to incorporate and innovate strategies to prevent them and perform ongoing evaluation to monitor smooth operation, with the result of an improvement in quality of the patient care process. The Joint Commission International mentioned that errors and adverse events can result from several factors at different levels within healthcare, such as the degree of care, either by structures or processes, or at the point of intervention between patients and professionals. Hence, solutions will be sought to promote an environment and systems of support that minimize the risk.

Studies of the frequency and type of adverse events indicate that 17.6% cause hospital readmission, and 23.9% cause serious harm to the patient, including death. An estimated 10 out of every 100 hospitalized patients have had adverse effects sometime during hospitalization and the rate is expected to increase to 20 if the number of days of hospitalization doubles. In the Estudio Iberoamericano de Efectos Adversos (IBEAS), the estimated prevalence of adverse effects was 10% and it was found that over 28% of the adverse effects triggered disability and 6% death.⁹

In Mexico, resulting from the IBEAS study, it is known that the prevalence rate of adverse events in national hospitals was 7.7%.¹⁰ For improved patient safety, identification, prevention, and eradication of adverse events are essential in strengthening policies and developing strategic models.

Importantly, the IPSG are incorporated into international standards and patient-centered standards and are oriented towards management for the certification of hospitals; as background, in our country the Comisión Permanente de Enfermería implemented quality indicators with the aim that nursing care should be provided opportunely, in a safe, efficient, and humane environment throughout the national health system.¹¹ Delgado states that subsequently the Secretaría de Salud (SSA), the Instituto Mexicano del Seguro Social (IMSS) and the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) had independently developed and implemented evaluation procedures from several indicators consistent with the programs of work of each institution, such as the application of the instrument "Perception about the grouping of international patient safety goals" in a general hospital in Mexico City, Mexico. Therefore the implementation of standards in the process of hospital certification ensures quality care and efficiency.¹⁰

In 2006, SSA was linked to the World Alliance for Patient Safety through the then Subsecretaría de Innovación y Calidad. In September 2007 the SSA signed with WHO-PAHO and other countries in the region, the "Joint Declaration in support of the initiative of the first global challenge for patient safety: Clean Care is Safer Care". On September 6, 2008 by instruction 133/2008, the Patient Safety initiative was attached to the Sistema Integral de Calidad en Salud (SICALIDAD), which was renamed Programa Nacional de Seguridad del Paciente.¹² This comprehensive strategy, SICALIDAD, promotes various actions and programs from the perspective of perceived quality, technical quality, patient safety, and institutionalization of quality. One of its specific objectives is to develop patient safety indicators to assess progress and propose ajustments.¹³

Another objective that has been determined by the WHO and in which Mexico participates is "Safe Surgery Saves Lives". It began in October 2008 in Washington DC, and in December 2009 in Mexico; "Bacteremia Zero" began in Spain and the UK in 2010 and in our country in July 2011; these challenges are framed in each IPSG.¹⁴

It should be noted, as Arreola8 mentions, that currently the quality of healthcare and patient safety is a national priority, common purpose, and shared responsibility highlighted in the Plan Nacional de Desarrollo 2013-2018.

Based on the above, the purpose of this study was to measure the level of compliance with international patient safety goals (IPSG) that nurses conducted in inpatient of a tertiary care hospital.

The overall objective was to measure the level of IPSG compliance that nurses performed in inpatient services, emergency, recovery, intensive care, intermediate care, in the morning, evening, and night shifts in a tertiary hospital in Mexico City.

The specific objectives were to quantify the average time of implementation of the instrument based on the IPSG and to establish a traffic light based on the level of IPSG compliance in four areas: green (82-100%), yellow (71-80%), red (60-70%) and black, which represent less than 59%.

Methodology

It is a non-experimental, descriptive study. It involved all the nurses who worked in inpatient services, emergency, recovery, respiratory intensive care unit, respiratory intermediate care unit, including morning, evening, and night shifts of a tertiary care hospital in Mexico City. Nurses from all three shifts, regardless of their category and schooling level were included. Incomplete surveys were removed. A convenience sample was taken and, based on the total population of 97 nurses, a sample calculation was performed using the formula of finite populations, and evenly balanced in services and designated shifts; however, it was possible to include the total population (N = 97).

Procedure

An assessment tool was designed based on another entitled "Perceptions about grouping international patient safety goals," by author Rivas et al. The scale was modified with the following options "Yes", "No" and "Not applicable" (NA). The wording of the items was to comply with the standards of the institution. The original instrument was of 37 items and after modification it had a total of 39; later, it underwent the consensus of experts from the departments of Quality and of Enseñanza e Investigación en Enfermería at the hospital where the study was conducted. It was applied to a total of 97 nurses in different services and shifts; shift change was chosen as the time to apply the survey using the shadowing technique. To score the items, they were assigned a scale based on the maximum and minimum sum to establish a traffic light by a simple division into four categories: green (82-100%), yellow (71-80%), red (60- 70%) and black, equivalent to less than 59%. A Kuder Richardson 20 test (Kr-20) was also carried out for their reliability, which was reported at 0.89.

A statistical analysis was performed for frequency, percentage, mean, and for the allocation of the items proposed in the traffic light. After obtaining the results by shift, the average application time and standard deviation were obtained according to the level of general compliance evaluated; also, the overall average number of items that could not be verified by shift was obtained.

Ethical considerations

The principles of the Code of Ethics for nurses in Mexico were considered, which are: the principle of beneficence and non-maleficence, justice, autonomy, fundamental value of human life, and privacy. It also took into account the provisions of the Declaration of Helsinki World Medical Association (52nd General Assembly, Edinburgh, Scotland, October 2000), in particular in Articles 2, 5, 8, 9, where the ethical standards are stipulated to promote respect for all human beings and protect their health and individual rights; and Articles 10, 11, 14, 19, 20, 21, 22, 23, which state that we must protect the life, health, privacy and dignity of the human being.

The study was approved by the Bioethics Committee of the hospital and was examined and approved for implementation.

Results

Compliance and applicability was expressed by "Yes", non-compliance or non-applicability with a "No," and when it could not be verified at the time of the audit, the value NA was assigned, meaning "does not apply.”

Compliance and applicability of international goals for nurses was higher in the morning shift with 80% for patient identification (goal 1); 50% and 44% of staff establish effective communication (goal 2); in the three shifts staff carries out safety measures for high-risk medications (goal 3) in 96, 94 and 89%, respectively; only 72 and 44% of the staff of the morning and night shift and 84% of the evening shift  ensure surgery on the correct site, procedure, and patient (goal 4); 67% of staff on the night shift does practices to reduce the risk of infections associated with healthcare (goal 5); and 98% of staff in the three shifts reduces the risk of harm to patients from falls (goal 6) (Figure 1).

The overall percentage of instrument items that could not be verified at the time the application was 8.8%, and it was observed that in all three shifts the highest percentage with NA were goal 2 and goal 4; in the morning shift goal 2 had 27.9% and goal 4 had 14.5%; in the evening shift goal 2 had 29.6% and goal 4 had 8.3%, and in the night shift in goal 2 had 37% and goal 4 had 20.8%.

In accordance with established traffic lights, shift results obtained from each IPSG were: Goal 1 in the morning shift was yellow with 78%, the evening shift red with 62%, and the night shift yellow with 73%. Goal 2 in the three shifts was black, as the morning shift had 50%, and the evening and night shifts had 44% compliance and applicability. For goal 3 all three shifts had green, because the morning shift had 96%, the evening shift 94%, and the night shift 89%. Goal 4 in the morning shift obtained 72% (yellow), the evening shift 84% (green) and the night shift 44% (black). For goal 5, the morning shift was red with 65%, the evening shift black with 50%, and the night shift red with 67%. Finally, for goal 6 the morning shift got 98%, the evening shift 98%, and night shift 97%, so the three shifts all got green (Figure 2).

The average time of application was an average of 20.7, with a standard deviation of 7.93, a minimum of 13 and maximum of 50; the level of IPSG compliance by nurses in inpatient services in three shifts was 72.6%, so they were designated yellow.

Discussion

Patient safety contributes to improving the quality of care and a measure to accomplish this is to conduct and verify IPSG implementation.

According to Castro et al, 55% of staff knows goal 1 and through verification, they found patients without identification sheet and bracelet; also they observed neonates with illegible identification bracelets. Similarly, Dackiewicz et al. reported that the health team is aware of the use and benefits of correctly identifying patients.¹⁵ In a similar study by Moris de Tassa et al., entitled "Unambiguous identification of patients in hospitals of the Sistema Nacional de Salud", it is mentioned that in Catalonia a cross-sectional descriptive study was conducted in public and private hospitals; their results found that of the 75 centers surveyed, 90.7% said that they used some form of patient identification. Only 26.7% of the centers had identification systems in all inpatient services.¹⁶

Regarding goal 2, Enhance effective communication, the three shifts obtained < 59% level of compliance. This result shows similarity with the investigation of Castro et al., as only 30 nurses (53%) know the goal, which could increase the possibility of errors by verbal or telephone prompts. In an article by Ramirez et al. the importance of effective communication for safety in healthcare is mentioned, as the authors state that appropriate communication allows doctors, nurses, paramedics, and patients to follow the same guidelines that will enable appropriate medical care. The communication will be written, oral, or electronic, and most of this will be reflected in the clinical record; therefore, it is imperative that everything be written legibly, abbreviations avoided and the data accurate and reliable.¹⁷

For goal 3, Improving the safety of high-risk medications, the three shifts obtained between 82 and 100% compliance level unlike those found by Castro et al., in whose study only 50% of nurses knew that goal. Vitolo mentions that interruptions during administration is correlated with a greater likelihood of medication errors,¹⁸ which is consistent with an observational study by Trbovich et al. In this study the authors found that nurses were interrupted about 22% of the time and many of these interruptions occurred while administering high-risk medications.¹⁹

For objective 4, Ensure correct-site, correct-procedure, correct-patient surgery, the morning shift obtained between 71 and 81%, the evening shift between 82 and 100% and the night shift less than 59% of the level of compliance; unlike research by Nava and Espinoza (2011), held at the Instituto Nacional de Neurología y Neurocirugía, who conclude that this goal is accomplished and that they also recognize the importance of correctly filling the verification list.²⁰

Under goal 5, To reduce the risk of healthcare-associated infections, the morning shift obtained between 60 and 70%, the evening shift less than 59%, and the night shift from 60 to 70% level of compliance, which is similar to the results obtained in the study by Castro et al, in which 57% of the nurses know this goal; however 50% did not wash their hands before attending to a patient. Although the technique of hand washing is a basic technique of care, it is still not practiced with the due regularity.

Another study by Lalane et al. aimed to assess the process of hand washing in the nursing team and found that the technique was correct on average 9.5% of the time; they also found that 20.5% of people who fail in one washing step it did because of an error in the technique.²¹

Finally, goal 6, Reduce the risk of patient harm resulting from falls, the morning, evening, and night shifts scored between 82 and 100% compliance level, compared with a study by Molina Robles et al. (2008) in the Unidad de Hemodiálisis in a Hospital General in Barcelona. This research found the prevalence of falls from a sample of 14 patients, that 10 of them (71.43%) had one fall and four (28.57%) had more than one fall (one suffered three falls). According to fall history, only four patients (28.6%) had not previously suffered any fall, and the rest had suffered these accidents.²²

Another study by López (2010) showed the absence of a systematic registration and investigation of these events in the public institution and that 60% of falls occurred in men and 54.7% in patients over 60 years. 64.5% of falls caused no physical damage to the patient.²³

Conclusions

The level of IPSG compliance and general applicability in the three shifts in the tertiary care hospital where the study was conducted was 72.6%, which was found in yellow in accordance with the established traffic light. Ongoing training is suggested in each of the goals for nursing professionals, so that these may be implemented in inpatient services as a patient-centered standard. The average time of application of the instrument was an average of 20.7, with a standard deviation of 7.93 minutes, a minimum of 13 and maximum of 50 minutes.

Patient safety is a priority at national and international levels to ensure quality care and decrease the possibility of adverse events, so it is concluded that the application of the instrument in secondary and tertiary care hospitals is effective and efficient to maintain an improvement in hospital care.

It is suggested to apply the instrument to measure IPSG compliance by the nursing staff at shift change at first, because it was seen that indicators above 91% can be audited. It is also necessary to verify the relevance of goal 2, on effective communication, because if it is addressed only to medical advice by telephone, it will have no impact on public sector hospitals.

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