Table 4 'Patients Informed about an Adverse Event by the Staff'

PSI 4: Patients Informed about and Adverse Event by the Staff
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Once a serious adverse event has happened it is important to identify it
and take adequately care of the patient and make adequate
improvements. A feature of a positive and highly developed safety
culture is awareness regarding unsafe act and procedures and openness.
Thus patient’s way of finding out about an adverse event is an
important measure of patient safety culture.
It is known facts among patient safety experts, that patient comprehend
adverse events as errors.
Aim of the PSI This PSI aims at surveillance how patients get to know about adverse
events.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This PSI is derived from the section on patient safety of the Danish
national patient survey: Patient’s experiences in hospital, question 19
(9;11).
Extent of Clinically
Testing
Attitudes and responses to adverse events have been investigated from
Danish patient’s and the staff’s point of view, using a questionnaire
survey. Patients were asked about their experiences with adverse
events and staffs handling of adverse events. Comparison of responses
to the same questions was made between the two groups. The
researchers concluded that healthcare staff should, to a larger extent,
inform openly about adverse events and their medical consequences.
Information should be communicated direct to the patient and their
relatives and written in the patient’s record (12).
This PSI has not been clinically applied.
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Institution-Wide PSI.
Data definitions Patients informed about the adverse event by the staff per 1000 patient
experienced adverse events.
Numerator Description Number of patients informed about the adverse event by the staff
Denominator Description Number of patients experiencing an adverse event during
hospitalisation.
Data Source Patient’s Experiences (Satisfaction) Survey.
Identifying the
institutional context
The impact of high quality incident management makes this PSI
important in cultural improvement policies.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
13
Care Setting The PSI applies for institution-wide quality incident management
especially relating to awareness, openness and communication.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific time standards given, but comparison every second year
has shown to be.
Scoring Scoring according to the manual of the Patient’s Experiences
(Satisfaction) Survey.