4 ms·

CL procedure auditing: The work I did was as an oversight tool internal to UHN -- we implemented a handheld tool to allow roaming nurses to audit practice adher

CL procedure auditing: The work I did was as an oversight tool internal to UHN -- we implemented a handheld tool to allow roaming nurses to audit practice adherence for many high infection risk procedures, including those related to central line insertion and maintenance. Our work was based on the guidelines set by http://www.saferhealthcarenow.ca/EN/Interventions/CLI/Pages/default.aspx http://www.saferhealthcarenow.ca/EN/Interventions/CLI/Pages/... . I left the group while the intervention was in progress, so I'm not aware of any specific publications. Hand washing: I didn't work in this area directly -- many of my colleagues did, however. The principal output of their work was the Human Factors Hand Hygiene Toolkit at http://www.handhygiene.ca/English/Tools/Pages/Human-Factors-Toolkit.aspx http://www.handhygiene.ca/English/Tools/Pages/Human-Factors-... Positive patient ID: The PPID work that I've been exposed to was targeted at in-hospital evaluations of various vendor systems; I'm not aware of it having been published externally. If you're interested I can follow up with members of the team who worked on this to see if anything public came out of it. Medication errors: Lots of work here. Presented link-list style: http://www.hubmed.org/display.cgi?uids=20724398 http://www.hubmed.org/display.cgi?uids=20724398 http://www.hubmed.org/display.cgi?uids=22103759 http://www.hubmed.org/display.cgi?uids=22103759 http://www.hubmed.org/display.cgi?uids=20427310 http://www.hubmed.org/display.cgi?uids=20427310 http://www.patientsafetyinstitute.ca/English/research/cpsiResearchCompetitions/2007/Documents/Easty/Report/Easty%20Full%20Report.pdf http://www.patientsafetyinstitute.ca/English/research/cpsiRe...

Ihavenoname 14y ago
The key is to find root cause wile and not turn off the thinking process. It is easy to overrely on standardized tools. It is also easy to game oversimplified evaluations. Too many central infections can make a Physician avoid placement even when it is medically nessary. When PPI and the new recommended antibiotic treatment protocol compliance went up C-diff when through the roof. There was an enormous amount of effort placed on hand washing compliance which was already high instead of fixing evaluating the problem and fixing it. Larger than needed PPI and certan antibiotics can each separately massively increases risk. You can't make compliance over 100% at some point you have to attack the rook cause not the low lying fruit.
drx 14y ago
Thanks.

Ihavenoname 14y ago

The key is to find root cause wile and not turn off the thinking process. It is easy to overrely on standardized tools. It is also easy to game oversimplified evaluations. Too many central infections can make a Physician avoid placement even when it is medically nessary. When PPI and the new recommended antibiotic treatment protocol compliance went up C-diff when through the roof. There was an enormous amount of effort placed on hand washing compliance which was already high instead of fixing evaluating the problem and fixing it. Larger than needed PPI and certan antibiotics can each separately massively increases risk. You can't make compliance over 100% at some point you have to attack the rook cause not the low lying fruit.

drx 14y ago

Thanks.