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User instructions. This presentation is provided to assist with presenting the results of the study to health care facility stakeholders Always present the results to key stakeholders as soon as results are available

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User instructions

User instructions

  • This presentation is provided to assist with presenting the results of the study to health care facility stakeholders

  • Always present the results to key stakeholders as soon as results are available

  • The slides can either be used to animate a face-to-face meeting (projected with a beamer or used as talking points), serve as talking points for a telephone conversation or, less ideally, be sent by email or distributed in hard-copy

  • Study and adapt the slides before the presentation (delete the slides on the methods you did not conduct, insert details of the study and its results as highlighted)

  • Prepare

  • Be receptive to feedback for improvement

  • Provide further information if necessary


Presentation of results

Presentation of results

<insert your name, title and affiliation>


Reminder of the context

Reminder of the context

  • We have previously agreed to conduct [insert method used] at your health care facility

  • The objective was to [delete objectives that do not apply]: count harmful incidents and/or identify causes of harmful incidents and/or develop an action plan and/or monitor & improve patient safety achievements

  • We have now completed our study and would like to present our results and discuss these with you

[delete those of the following slides that do not apply]


Retrospective record review

Retrospective record review


What has been done

What has been done?

Scope: [insert number] randomly selected patient records from [insert selected wards/units]

Subjects of study: all patients who were hospitalized last year [insert year studied]

Duration: [insert number of hours/days needed]

Process:

screened all records to determine presence of harmful incidents reviewed positively screened cases for more information

for monitoring and improvement only: discussed results with doctor to compare the results to those of the last study


Results of the record review

Results of the record review

incidence of harmful incidents: [insert incidence]

outcome of harmful incidents [insert incidence per type of harmful incidents]: patient death, severe disability, moderate disability, minor or no disability, prolonged hospitalization, and new hospitalization

preventability: [insert estimated preventability]

types of harmful incidents : [insert types of harmful incidents in decreasing order of frequency]

contributing factors: [insert contributing factors in decreasing order of frequency]

for monitoring and improvement only:

[insert by how much the incidence of harmful incidents has decreased/increased]

[insert by how much preventable harmful incidents have decreased/increased]

[explain how causes have differed]

[recommend further improvement measures]

[recommend when and how to next assess the situation]


Record review of current in patients

Record review of current in-patients


What has been done1

What has been done?

  • Scope: x patients from [insert selected wards/units]

  • Subjects of study: all in-patients on [insert day of data collection]

  • Duration: [insert number of hours/days needed]

  • Process:

    • screened all records and interviewed nurse to determine presence of harmful incidents

    • reviewed positively screened cases and interviewed doctor in charge for more information

    • for monitoring and improvement only: discussed results with doctor to compare the results to those of the last study


Results of the record review1

Results of the record review

  • prevalence of harmful incidents: [insert prevalence]

  • outcome of harmful incidents [insert prevalence per type of harmful incidents]: patient death, severe disability, moderate disability, minor or no disability, prolonged hospitalization, and new hospitalization

  • preventability: [insert estimated preventability]

  • types of harmful incidents : [insert types of harmful incidents in decreasing order of frequency]

  • contributing factors: [insert contributing factors in decreasing order of frequency]

  • for monitoring and improvement only:

    • [insert by how much the prevalence of harmful incidents has decreased/increased]

    • [insert by how much preventable harmful incidents have decreased/increased]

    • [explain how causes have differed]

    • [recommend further improvement measures]

    • [recommend when and how to next assess the situation]


Staff interviews on current in patients

Staff interviews on current in-patients


What has been done2

What has been done?

  • Scope: x patients from [insert selected wards/units]

  • Subjects of study: all in-patients on [insert day of data collection]

  • Duration: [insert number of hours/days needed]

  • Process:

    • interviewed nurse to determine presence of harmful incidents

    • interviewed doctor in charge to receive more information

    • for monitoring and improvement only: discussed results with doctor to compare the results to those of the last study


Results of the record review2

Results of the record review

prevalence of harmful incidents: [insert prevalence]

outcome of harmful incidents [insert prevalence per type of harmful incidents]: patient death, severe disability, moderate disability, minor or no disability, prolonged hospitalization, and new hospitalization

preventability: [insert estimated preventability]

types of harmful incidents : [insert types of harmful incidents in decreasing order of frequency]

contributing factors: [insert contributing factors in decreasing order of frequency]

for monitoring and improvement only:

[insert by how much the prevalence of harmful incidents has decreased/increased]

[insert by how much preventable harmful incidents have decreased/increased]

[explain how causes have differed]

[recommend further improvement measures]

[recommend when and how to next assess the situation]


Nominal group meeting

Nominal group meeting


What has been done3

What has been done?

  • Meetings: [insert number and duration of meetings held]

  • Participants: [insert total number of participants]

  • Meeting content:

    • identified solutions

    • scored appropriateness of each solution

    • agreed on most important solutions

    • established roles, responsibilities and time plan to implement solutions

    • selected general actions to improve patient safety


Results of the meeting s

Results of the meeting(s)

  • present the final ranking of identified causes in order of decreasing importance


Direct observation and related interviews

Direct observation and related interviews


What has been done4

What has been done?

  • observation of facilities and stock in [insert number and names of observed] wards/units

  • observation of [insert number] injections

  • conducted interviews with [insert number] injection providers

  • conducted interviews with [insert number] department supervisors


Results of the observation and interviews

Results of the observation and interviews

  • present and discuss the results tables

  • explain identified improvement measures


Next steps

Next steps

[Delete those that do not apply]

This study was conducted to count harmful incidents and/or understand their causes and a next step could be to:

  • use the findings to raise awareness of harmful incidents, and/or

  • develop an action plan aimed at tackling harmful incidents, and/or

  • count harmful incidents (if only a nominal group meeting or direct observation has been conducted)

    This study was conducted to monitor and improve patient safety

    achievements

  • the next step would be to re-assess the situation at a later stage


Thank you for participating questions comments

Thank you for participating!Questions? Comments?


Further information

Further information

  • For further information, questions or comments contact

    <insert your name and telephone number or email>

  • Visit the Patient Safety Programme (Research) website at: http://www.who.int/patientsafety/research/en/


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