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12. Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD. Measurement
Learning activities of quality and assurance of safety in the critically ill. Clin Chest Med 2009;
30: 169–79.
13. Wilson RM, Van Der Weyden MB. The safety of Australian healthcare: 10
● Using each domain of quality and safety as headings (i.e. years after QAHS. Med J Aust [editorial] 2005; 182: 260–61.
structure, process, culture, outcome), list some of the key 14. Speroff TP, O’Connor GT. Study designs for PDSA quality improvement
considerations for a quality improvement project targeting research. Qual Manage Health Care 2004; 13(1): 17–32.
pressure ulcer prevention in your unit. 15. Curtis JR, Cook DJ, Wall RJ, Angus DC, Bion J et al. Intensive care unit quality
● Examine the patterns of incidence for a high-frequency improvement: a ‘how-to’ guide for the interdisciplinary team. Crit Care Med
2006; 34: 211–18.
adverse event (e.g. medication error) in your unit over the 16. Ehsani JP, Jackson T, Duckett SJ. The incidence and cost of adverse events in
past 12 months. What were the causes of incidents? What Victorian hospitals 2003–04. Med J Aust 2006; 184(11): 551–5.
targeted strategies could be used to reduce the incidence 17. Runciman WB, Roughead EE, Semple SJ, Adams RJ. Adverse drug events and
medication errors in Australia. Int J Qual Health Care 2003; 15: i49–59.
of these adverse events? 18. Needham DM, Thompson DA, Holzmueller C, Dorman T, Lubomski LH
● Identify and provide a rationale for an aspect of care that et al. A system factors analysis of airway events from the Intensive Care Unit
might benefit from the use of a checklist in your unit. Safety Reporting System (ICUSRS). Crit Care Med 2004; 32(11): 2227–31.
Develop some specific checklist items that you think should 19. Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents
be included. relating to the intra-hospital transfer of critically ill patients: an analysis of
● Describe how technology is used in your unit to improve the reports submitted to the Australian Incident Monitoring Study in Inten-
sive Care. Intens Care Med 2004; 30(8): 1579–85.
care delivered to patients. Using the information outlined 20. Capuzzo M, Nawfal I, Campi M, Valpondi V, Verri M, Alvisi R. Reporting of
in the section on information and communication tech- unintended events in an intensive care unit: comparison between staff and
nologies, identify where there is potential to use technol- observer. BMC Emerg Med 2005; 5(1): 1–7.
ogy to improve care delivery further. Use examples specific 21. Wolff AM, Bourke J, Campbell IA, Leembruggen DW. Detecting and reducing
hospital adverse events: outcomes of the Wimmera clinical risk management
to your unit. program. Med J Aust 2001; 174: 621–5.
22. Beckmann U, West L, Groombridge GJ, Baldwin I, Hart GK et al. The Aus-
tralian Incident Monitoring study in Intensive Care: AIMS-ICU. The develop-
ment and evaluation of an incident reporting system in intensive care. Anaesth
Intens Care 1996; 24(3): 314–19.
ONLINE RESOURCES 23. Baldwin I, Beckmann U, Shaw L, Morrison A. Australian incident monitoring
study in intensive care: local unit review meetings and report management.
Anaesth Intens Care 1998; 26: 294–7.
Agency for Healthcare Research and Quality, http://www.ahrq.gov 24. Classen DC, Metzger J. Improving medication safety: the measurement
Australian Commission on Safety and Quality in Health Care (ACSQHC), http:// conundrum and where to start. Int J Qual Health Care 2003; 15: i41–47.
www.safetyandquality.gov.au 25. Koppel R. What do we know about medication errors via a CPOE system
Australian Council on Healthcare Standards (ACHS), http://www.achs.org.au/ versus those made via handwritten orders? Crit Care 2005; 9: R516–17.
Intensive Care Coordination and Monitoring Unit (ICCMU), New South Wales 26. Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Pronovost
Health, http://intensivecare.hsnet.nsw.gov.au PJ. Evaluation of two methods for quality improvement in intensive care:
Institute for Healthcare Improvement (IHI), USA, http://www.ihi.org/ihi facilitated incident monitoring and retrospective medical chart review. Crit
The Joint Commission (USA), http://www.jointcommission.org/ Care Med 2003; 31(4): 1006–11.
National E-Health Transition Authority, http://www.nehta.gov.au/ 27. Taxis K, Barber N. Ethnographic study of incidence and severity of intrave-
National Health and Medical Research Council, http://www.nhmrc.gov.au/ nous drug errors. BMJ 2003; 326: 684–7.
National Quality Forum, http://www.qualityforum.org/ 28. Malashock CM, Shull SS, Gould DA. Effect of smart infusion pumps on
World Health Organization Patient Safety, http://www.who.int/patientsafety/en medication errors related to infusion device programming. Hosp Pharm
2004; 39: 460–69.
REFERENCES 29. Rothschild J, Landrigan CP, Cronin JW, Kaushal R, Lockley SW et al. The
Critical Care Safety Study: the incidence and nature of adverse events and
1. Valentin A, Capuzzo M, Guidet B, Moreno R, Dolanski L et al. Patient safety serious medical errors in intensive care. Crit Care Med 2005; 33(8):
in intensive care: results from the multinational Sentinel Events Evaluation 1694–1700.
(SEE) study. Intens Care Med 2006; 32: 1591–8. 30. Apkon M, Leonard J, Probst L, DeLizio L, Vitale R. Design of a safer approach
2. Lohr K, Schroeder S. A strategy for quality assurance in medicine. New Engl to intravenous drug infusions: failure mode effects analysis. Qual Saf Health
J Med 1990; 322: 1161–71. Care 2003; 13: 265–71.
3. Rogers AE, Dean GE, Hwang WT, Scott LD. Role of registered nurses in error 31. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of
prevention, discovery and correction. Qual Safe Health Care 2008; 17: interruptions with an increased risk and severity of medication administra-
117–21. tion errors. Arch Intern Med 2010; 170(8): 683–90.
4. Cullum N, Cilicska D, Haynes RB, Marks S. Evidence-based nursing: an intro- 32. Kliger J. Giving medication administration the respect it is due: comment
duction. Oxford, UK: Blackwell Publishing; 2008. on “association of interruptions with an increased risk and severity of medi-
5. National Health and Medical Research Council. How to use the evidence: cation administration errors”. Arch Intern Med [Invited Commentary] 2010;
assessment and application of scientific evidence. Canberra: Commonwealth of 170(8): 690–92.
Australia; 2000. 33. Australian and New Zealand Intensive Care Society, Australian Council on
6. Jennings BM, Loan LA. Misconceptions aming nurses about evidence-based Healthcare Standards. Intensive care indicators. Sydney: ACHS; 2011.
practice. J Nurs Scholarsh 2001; 33(2): 121–7. 34. Esmail R, Kirby A, Inkson T, Boiteau P. Quality improvement in the ICU: a
7. Grol R, Grimshaw J. From best evidence to best practice: effective implemen- Canadian perspective. J Crit Care 2005; 20: 74–8.
tation of change in patients’ care. Lancet 2003; 362: 1225–30. 35. Ilan R, Fowler R. Brief history of patient safety culture and science. J Crit Care
8. Ilott I, Rick J, Patterson M, Turgoose C, Lacey A. What is protocol-based care? 2005; 20: 2–5.
A concept analysis. J Nurs Manag 2006; 14: 544–52. 36. Pronovost PJ, Rinke ML, Emery K, Dennison C, Blackledge C, Berenholtz S.
9. Miller M, Kearney N. Guidelines for clinical practice: development, dissemi- Interventions to reduce mortality among patients treated in intensive care
nation and implementation. Int J Nurs Stud 2004; 41: 813–21. units. J Crit Care 2004; 19(3): 158–64.
10. Intensive Care Coordination and Monitoring Unit. New South Wales 37. Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.
Department of Health; 2010 [Cited March 2011]. Available from: http:// Improving communication in the ICU using daily goals. J Crit Care 2003;
intensivecare.hsnet.nsw.gov.au/state-wide-guidelines. 18(2): 71–5.
11. Donabedian A. Evaluating the Quality of Medical Care. Milbank Q 2005; 38. Pronovost PJ, Holzmueller C. Partnering for quality. J Crit Care 2004; 19(3):
44(3): 691–729. 121–9.