Preface

Chapter 8 **Comprehensive and Live Air Purification as a Key**

**Prospective Evaluation 137**

**VI** Contents

**Environmental, Clinical, and Patient Safety Factor: A**

Beverly Snyder, Sherrine Eid and Kathryn C. Worrilow

Stanislaw P. Stawicki, Chad Brisendine, Lee Levicoff, Frank Ford,

This book represents the fourth—and the last—volume of *Vignettes in Patient Safety*. Since 2017, the year of the initial publication of Volume 1, we noted significant and sustained inter‐ est in the content published in the subsequent second and third volumes. In total, the first three volumes were downloaded more than 12,000 times, with more than 50 attributable scholarly citations. This tremendous success—and validation of our efforts to promote patient safety—compelled us to embark on the current installment.

The interest in patient safety continues to grow across the world, as evidenced by the emer‐ gence of various advocacy movements and the sustained focus on improving treatment out‐ comes while eliminating any and all potentially preventable complications. Once again, we are very proud to play a small part in raising awareness of this critically important—and rapidly developing—area of clinical expertise. As we emphasize all of the "positives" we must remain humble and focused because much more work remains ahead of us.

When assessing the first three volumes of the *Vignettes* for any potential content gaps, we iden‐ tified a number of topics that often become overlooked when it comes to general patient safety discourse. For example, the current volume contains chapters focusing on radiation monitor‐ ing and safety; primary care considerations; alarm fatigue; complications of peripheral intra‐ venous catheters; as well as the importance of air purification systems to improving patient outcomes (and safety) through reducing the risk of healthcare associated infections. With the goal of "zero incidence" for many of the so-called "never events" there continues to be more room for improvement. As the reader will find throughout this final volume of *Vignettes in Patient Safety*, the need to develop, encourage, and support safer healthcare systems is at the core of building better hospitals and clinics of tomorrow.

Similar to the first three volumes, we utilized a case-based approach, focusing on practical as‐ pects of identification and remediation of medical errors, including their root causes and pre‐ ventive strategies. We found that by providing our readers with realistic, case-based scenarios, we empower the audience to better incorporate the educational content in their daily patient care activities. Through the use of hypothetical scenarios that are based on typical "patterns of errors," each chapter highlights its own set of unique circumstances leading to "patient harm" events. At the same time, we are able to more effectively focus the reader's attention on oppor‐ tunities for improvement in bedside care delivery, clinical team interactions, regulatory con‐ siderations, and pertinent system-based processes. We hope that our audience, once equipped with this important knowledge, will be better positioned to continually reduce the everpresent risk of medical error in their clinical practices.

Another important component of the case-based approach to patient safety is the realization that as healthcare providers we do not—and should not—function in silos. Rather, we operate in an increasingly complex regulatory and clinical environment, characterized by a rapidly evolv‐ ing set of expectations and competing priorities. Thus, the impact of the smallest of "adverse occurrences" within such an intricate system—despite being seemingly "insignificant" at firstcan result in both substantial and unpredictable impacts on downstream patient outcomes. Yet despite numerous challenges and opportunities, we remain optimistic that the current systemwide efforts to provide safer patient care are beginning to demonstrate tangible results.

As noted throughout this entire series, the process of assessing and evaluating patient safety events has evolved beyond "placing blame" and is now firmly focused on identifying "how and why" a specific set of events took place. Within this broader context, the overall emphasis has shifted toward proactively and constructively identifying various opportunities for im‐ provement, instituting appropriate remedies, as well as investing in education and patient safety advocacy.

The editors of *Vignettes in Patient Safety* would like to acknowledge the tremendous efforts of all of the people involved in bringing this entire book cycle to fruition. We want to thank our friends and family who unconditionally supported this important endeavor. We must also for‐ mally acknowledge and express our appreciation to all of the authors who contributed their valuable time, experience, and effort to the *Vignettes*. Their efforts, especially in the context of an open source publication model in which the authors support the expenses of a publication, clearly reflect true dedication to the primary objectives of this book series—and willingness to share and promote this work's noble message.

The institutional development of a culture and climate focused on patient safety can be very difficult to achieve and can be frustrating to those who are truly committed to such efforts. Yet the growing number of healthcare safety champions, whose vision is to continually improve patient outcomes through individual and institutional culture change, continue unimpeded on their quest to achieving better and safer clinics, hospitals, and pharmacies around the world. One form of such championship is the willingness to share experiences and knowledge through authoring scholarly works in the form of articles and chapters. Finally, we must rec‐ ognize the important role of various departments and institutions in this publication effort, both through their support of faculty time and effort, as well as through generous contribu‐ tions to the open access publication process. It is only through such collaborative undertakings that we will be able to fulfill our shared goal of promoting patient safety efforts worldwide.

As we complete this final volume of *Vignettes in Patient Safety*, we hope that the collective ef‐ forts of more than 60 authors, spanning more than three years, and resulting in 40 unique vi‐ gnette-based chapters, will provide our readers with important and actionable knowledge that will remain relevant for years to come. As in earlier volumes, we would like to emphasize once more that sharing one's knowledge and experiences, with the goal of helping others and making a difference, constitutes the highest form of giving. On behalf of our entire team of patient safety champions and experts, we would like to thank you!

**Stanislaw P. Stawicki, MD, MBA, FACS, FAIM**

Department of Research of Innovation St. Luke's University Health Network Bethlehem, Pennsylvania, USA **Chapter 1**

**Provisional chapter**

**Introductory Chapter: Patient Safety is the Cornerstone**

**Introductory Chapter: Patient Safety is the Cornerstone** 

Patient safety (PS) is inextricably linked to quality of care. In the value-driven paradigm of modern health-care systems, focus on these critical elements is required for institutions wishing to stay relevant and competitive [1–5]. This is the fourth and final volume of the **Vignettes in Patient Safety**. The previous three volumes featured a total of 31 chapters, covering a multitude of topics in PS and related fields. Discussed among a variety of concepts were PS education, institutional culture, application of evidence-based practices, handoff communication, disruptive behaviors, fatigue and burnout, team collaboration, and a plethora of discipline-specific topics [5–7]. The current book adds eight additional chapters, including in-depth discussions on communication, medication errors, patient safety culture, alarm fatigue, radiation safety, complications of intravenous therapy, as well as health-care policy

What has become clear over the course of the four volumes of the **Vignettes in Patient Safety** is that, despite continuous long-term efforts by health-care systems to enhance PS, numerous opportunities for improvement remain. In fact, we are all too often faced with the reality that our still limited knowledge of various gaps in safety, including any associated errors and consequences, can affect patient quality of life, the overall trust in our health-care systems, as well as health-care expenses overall [5, 8, 9]. Slowly and methodically, our understanding of how individuals, teams, and systems can more effectively prevent errors continues to evolve. With the advent of electronic medical records, the ability to capture critical events and their timing made it possible to construct root cause analyses more effectively and accurately,

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.83842

**of Modern Health-Care Delivery Systems**

**of Modern Health-Care Delivery Systems**

Stanislaw P. Stawicki, Alyssa M. Green, Gary G. Lu,

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Gregory Domer, Timothy Oskin and

Stanislaw P. Stawicki, Alyssa M. Green, Gary G. Lu, Gregory Domer, Timothy Oskin

http://dx.doi.org/10.5772/intechopen.83842

Michael S. Firstenberg

**1. Introduction**

and operations.

and Michael S. Firstenberg

**Michael S. Firstenberg, MD, FACC, FAIM** The Medical Center of Aurora Colorado, USA

#### **Introductory Chapter: Patient Safety is the Cornerstone of Modern Health-Care Delivery Systems Introductory Chapter: Patient Safety is the Cornerstone of Modern Health-Care Delivery Systems**

DOI: 10.5772/intechopen.83842

Stanislaw P. Stawicki, Alyssa M. Green, Gary G. Lu, Gregory Domer, Timothy Oskin and Michael S. Firstenberg Stanislaw P. Stawicki, Alyssa M. Green, Gary G. Lu, Gregory Domer, Timothy Oskin and Michael S. Firstenberg

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.83842

#### **1. Introduction**

can result in both substantial and unpredictable impacts on downstream patient outcomes. Yet despite numerous challenges and opportunities, we remain optimistic that the current system-

As noted throughout this entire series, the process of assessing and evaluating patient safety events has evolved beyond "placing blame" and is now firmly focused on identifying "how and why" a specific set of events took place. Within this broader context, the overall emphasis has shifted toward proactively and constructively identifying various opportunities for im‐ provement, instituting appropriate remedies, as well as investing in education and patient

The editors of *Vignettes in Patient Safety* would like to acknowledge the tremendous efforts of all of the people involved in bringing this entire book cycle to fruition. We want to thank our friends and family who unconditionally supported this important endeavor. We must also for‐ mally acknowledge and express our appreciation to all of the authors who contributed their valuable time, experience, and effort to the *Vignettes*. Their efforts, especially in the context of an open source publication model in which the authors support the expenses of a publication, clearly reflect true dedication to the primary objectives of this book series—and willingness to

The institutional development of a culture and climate focused on patient safety can be very difficult to achieve and can be frustrating to those who are truly committed to such efforts. Yet the growing number of healthcare safety champions, whose vision is to continually improve patient outcomes through individual and institutional culture change, continue unimpeded on their quest to achieving better and safer clinics, hospitals, and pharmacies around the world. One form of such championship is the willingness to share experiences and knowledge through authoring scholarly works in the form of articles and chapters. Finally, we must rec‐ ognize the important role of various departments and institutions in this publication effort, both through their support of faculty time and effort, as well as through generous contribu‐ tions to the open access publication process. It is only through such collaborative undertakings that we will be able to fulfill our shared goal of promoting patient safety efforts worldwide. As we complete this final volume of *Vignettes in Patient Safety*, we hope that the collective ef‐ forts of more than 60 authors, spanning more than three years, and resulting in 40 unique vi‐ gnette-based chapters, will provide our readers with important and actionable knowledge that will remain relevant for years to come. As in earlier volumes, we would like to emphasize once more that sharing one's knowledge and experiences, with the goal of helping others and making a difference, constitutes the highest form of giving. On behalf of our entire team of

**Stanislaw P. Stawicki, MD, MBA, FACS, FAIM**

Department of Research of Innovation St. Luke's University Health Network Bethlehem, Pennsylvania, USA

The Medical Center of Aurora

Colorado, USA

**Michael S. Firstenberg, MD, FACC, FAIM**

wide efforts to provide safer patient care are beginning to demonstrate tangible results.

safety advocacy.

VIII Preface

share and promote this work's noble message.

patient safety champions and experts, we would like to thank you!

Patient safety (PS) is inextricably linked to quality of care. In the value-driven paradigm of modern health-care systems, focus on these critical elements is required for institutions wishing to stay relevant and competitive [1–5]. This is the fourth and final volume of the **Vignettes in Patient Safety**. The previous three volumes featured a total of 31 chapters, covering a multitude of topics in PS and related fields. Discussed among a variety of concepts were PS education, institutional culture, application of evidence-based practices, handoff communication, disruptive behaviors, fatigue and burnout, team collaboration, and a plethora of discipline-specific topics [5–7]. The current book adds eight additional chapters, including in-depth discussions on communication, medication errors, patient safety culture, alarm fatigue, radiation safety, complications of intravenous therapy, as well as health-care policy and operations.

What has become clear over the course of the four volumes of the **Vignettes in Patient Safety** is that, despite continuous long-term efforts by health-care systems to enhance PS, numerous opportunities for improvement remain. In fact, we are all too often faced with the reality that our still limited knowledge of various gaps in safety, including any associated errors and consequences, can affect patient quality of life, the overall trust in our health-care systems, as well as health-care expenses overall [5, 8, 9]. Slowly and methodically, our understanding of how individuals, teams, and systems can more effectively prevent errors continues to evolve. With the advent of electronic medical records, the ability to capture critical events and their timing made it possible to construct root cause analyses more effectively and accurately,

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

further accelerating our understanding of various "gaps in safety" and corresponding "failure modes" [10–12]. It is hoped that these incremental steps will collectively help reduce both the frequency and impact of medical errors and hopefully lead to better mitigation strategies and the ultimate attainment of the elusive "zero incidence" goal [13]. Some examples of early successes include the growing evidence that adverse outcomes are becoming less common across different areas of care, likely due to a combination of better training and more effective processes and procedures becoming integrated into existing safety systems [11, 14–16]. Concepts such as "failure to rescue" and "never-events" serve to focus teams on minimizing relatively infrequent, but often catastrophic events (e.g., hospital acquired infections; delays in therapy for critical diagnoses such as stroke, sepsis, acute respiratory failure, or acute myocardial infarction) [17–20]. Again, the ultimate goal is to simultaneously achieve 100% readiness and 0% incidence for any such occurrences.

into the fabric of health-care operations, both clinical and nonclinical [33]. To paraphrase, there should be a constant emphasis on ensuring that dedicated institutional processes are focused on making it easy to "do the right thing" and harder to "do the wrong thing." The use of checklists helps facilitate just that. Standardization of the process by incorporating all critical steps into an easy-to-follow framework provides a potent fail-safe measure to prevent

Introductory Chapter: Patient Safety is the Cornerstone of Modern Health-Care Delivery Systems

http://dx.doi.org/10.5772/intechopen.83842

3

Of importance, continuous real-time review of patient safety and quality processes must be performed to ensure that all active implementations are being monitored for proper functioning, as well as any unintended consequences or down-stream problems, for either the patient or the health-care system [29, 36, 37]. This can be accomplished through conducting regular performance improvement initiatives, hiring dedicated staff to track and report on different quality measures, and building robust systems to ensure not only that safety and quality are being upheld but also to resolve any issues as they arise [7, 38]. For example, there are numerous initiatives to reduce the incidence of deep vein thrombosis and pulmonary embolisms [39–41]. Clearly, such initiatives are intended to address a substantial and highly complex set of PS issues. Yet, it is critical for clinicians to avoid "blindly" following protocols and guidelines that rely solely on "guaranteeing" that every patient is receiving "standard of care" anticoagulation prophylaxis while failing to consider the potential impact of anticoagulation on bleeding and related complications. Similarly, patients who are fully ambulatory are much less likely to benefit from antithrombotic prophylaxis than patients who are tethered to their beds and unlikely to ambulate for three or more days. Finally, clinicians must always be sensitive to the impact of therapeutic anticoagulation under circumstances where risks outweigh benefits of such intervention [42]. Use of clinical judgment is imperative in such situations in order to determine the necessity, applicability, and appropriateness of any evidence-based

Patient safety culture depends heavily on institutional ability to create an environment that welcomes honest disclosure and constructive, nonjudgmental feedback [43]. It has been shown that more positive PS culture correlates with fewer adverse health-care events [44]. A change in culture is no easy feat, but it is instrumental in the development of an environment that does not penalize human error (**Figure 1**). It has been suggested that although humans certainly contribute to adverse events, faulty organizational systems are more likely to be at the root of many of these errors [45]. This suggests that a more fundamental change is needed to affect the safety and quality of care delivered within the health-care system. It has been pointed out that institutions fully committed to a culture of patient safety have seen reductions in medical errors [45]. This involves integration of "error management strategies" to analyze the causes of error and instituting mechanisms of prevention [46]. Buy-in from administration as well as other leadership is integral to the process of adoption of a patient safety culture. Without engagement from leadership, it will be difficult to transform existing organizational "patterns and habits". Hospital leadership must set PS as a priority, even

both human and systemic errors [34, 35].

protocol or guideline.

**3. Gradual and sustainable culture change**

The evolving role of public reporting of quality and safety data, including various clinical metrics and outcomes, will provide a powerful stimulus for developing processes and systems that will make patient care both safer and more efficient [21, 22]. However, without proper organizational and individual context, exclusive attention to such metrics will not inherently result in better or safer care [23–25]. For example, a study looking at 28 strategies to improve "door-to-balloon time" (a commonly utilized quality metric in cardiovascular medicine) across 365 hospitals demonstrated that despite several strategies being associated with substantial reductions in "door-to-balloon time," only a minority of institutions was actually utilizing these proven approaches [26]. It is therefore critically important to evaluate PS systems in a comprehensive and multifactorial fashion, maintaining open and constructive stance on exploring "what is going right", "what has gone wrong", and "what might go wrong."
