Pneumothorax: Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of hospital associated Pneumothorax, clinical and system reviews should be conducted to identify latent causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resources Introduction.
If your review reveals that your cases of Pneumothorax are linked to specific processes or procedures, you may find these resources helpful:
- Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov
- Agency for Healthcare Research and Quality. Selected best practices and suggestions for improvement PSI 6: Iatrogenic pneumothorax. QI Toolkit Roadmap. Published 2014. Accessed March 2021. http://www.ahrq.gov/professionals/systems/hospital/qitoolkit/d4e-pneumothorax-bestpractices.pdf
- Journal of Hospital Medicine https://www.journalofhospitalmedicine.com
- Shieh L, Go M, Gessner D, Chen JH, Hopkins J, Maggio P. Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach. Journal of hospital medicine. 2015;10(9):599-607. doi: 10.1002/jhm.2388
- Seminars in Respiratory and Critical Care Medicine https://www.thieme.in/seminars-in-respiratory-and-critical-care-medicine
- Hallifax R, Janssen JP. Pneumothorax - time for new guidelines? Semin Respir Crit Care Med. 2019;40(3):314-322. doi:10.1055/s-0039-1693499
- Thorax www.thorax.bmj.com
- Johnston SL (Ed.). BTS Pleural Disease Guideline 2010. Thorax. August 2010; 65(Suppl 2). https://thorax.bmj.com/content/65/Suppl_2
Pneumothorax
