11

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

2

Presentation of results

<insert your name, title and affiliation>

3

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]

4

Retrospective record review

5

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

6

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]

7

Record review of current in-patients

88

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

99

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]

10

Staff interviews on current in-patients

1111

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

1212

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]

13

Nominal group meeting

1414

What has been done?

Meetings: [insert number and duration of meetings held]

Participants: [insert total number of participants]

Meeting content:1. identified solutions2. scored appropriateness of each

solution 3. agreed on most important

solutions4. established roles,

responsibilities and time plan to implement solutions

5. selected general actions to improve patient safety

1515

Results of the meeting(s)

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

16

Direct observation and related interviews

1717

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

1818

Results of the observation and interviews

present and discuss the results tables explain identified improvement measures

1919

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

2020

Thank you for participating!

Questions? Comments?

21

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/