361 / Prevention of decubitus ulcers through complex clinical protocols

HUNGARY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Decubitus ulcers
There is no specified text here There is no specified text here
Topic of the reported practice
Quality management system
Aim and the benefit of the Patient Safety Practice
 
With this practice we aim to develop an organisational culture which support learning from cases when complications, harm, deterioration of health, and by the lessons learnt we wish to improve patient safety. Our applied tools include root cause analysis in order to prevent harms during healthcare and avoidable mistakes.
...
Methods of operation:
- nurses lack of knowledge and cannot be accounted for their mistakes
- inadequate education of nurses
..
-poor protocol compliance
Description of the Patient Safety Practice
 
The main part of this practice is education. New colleagues are educated on quality of care during which they learn about our protocols and regulations and the structure and activity of the unit they will be working at. Nurses have to participate in professional trainings regularly, so they are able to learn new methods and trends of care. At each unit, there is an opportunity to discuss what they have learnt and analyse cases in order to improve nursing care.

Patient involvement is possible after taking nursing history and diagnosis and writing the personal nursing plan. At each patient admission we take the Norton scale to assess the risk of pressure ulcer. Patients in the highest risk level have the opportunity to talk with the caregivers. Talking about and understanding the preventive/ curative techniques which require the patient's participation will lead the patient to a higher level of adherence to therapy (e.g. importance of repositioning).

Evaluation:
Each unit reports indicator data monthly. These are analysed and evaluated annually and the results are presented to the hospital management. This process is working for 5 years now, so we were able to define our standards based on the data of the first 4 years. Difference from standard levels shows the points where there is a problem and intervention is necessary in order to maintain patient safety.
Analysing the reports, we have seen that while some units show constant improvement, the surgery units perform erratically. This revelation urges us to further analyse the causes of the problem.

Costs:
Our controlling system does not yet have the functions to define the exact amount of costs in case of need of extra care, neither does it allow us to assess the extra need of supplies.
It is also impossible to define the extra days of care, we do not know how many of them are due to the pressure ulcer, because in general the prolonged care is necessary because of the original illness, complications and comorbidities.
The cost of the new practice is a combination of the costs of creating the new protocol, education, implementation. These are all parts of the costs of the quality system, therefore it is not possible to define the exact amounts. The same stands for the costs of the supplies used for prevention, amortisation, etc.

Attachment of relevant written information and/or photos, as appropriate
443_WP4_PaSQ decubitus protokoll extract.docx
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Team level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Quantitative
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
443_WP4_Betegbiztonság_indikátor.docx
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
No
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient representative(s)
Point of time in which service user or their reprasentatives' involvement takes place
During evaluation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Yes
Short description of the service users' level of involvement
Not known
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
No
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Equipment was not enhanced or new
Lack of sharing of progress information among involved staff
No data feed back to involved staff
No motivation among staff
Not sufficient financial resources available
Not sufficient human resources available
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Not relevant
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Berényi Annamária
Country: HUNGARY
Organisation: Gottsegen György Országos Kardiológiai Intézet
E-mail: berenyi.annamaria@kardio.hu
Phone: +3612151220 / 228
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