In this section :
- Hospital harm is everyone’s concern
-
Hospital Harm Improvement Resource
- How to Use the Hospital Harm Measure for Improvement
- Learning from Harm
- General Patient Safety Quality Improvement and Measurement Resources
- Hypoglycemia: Introduction
- Aspiration Pneumonia: Introduction
- Delirium: Introduction
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Infusion, Transfusion and Injection Complications: Introduction
- Infusion, Transfusion and Injection Complications: Discharge Abstract Database
- Infusion, Transfusion and Injection Complications: Importance to Patients and Families
- Infusion, Transfusion and Injection Complications: Clinical and System Reviews, Incident Analyses
- Infusion, Transfusion and Injection Complications: Measures
- Infusion, Transfusion and Injection Complications: Success Stories
- Infusion, Transfusion and Injection Complications: References
- Medication Incidents: Introduction
- Obstetric Hemorrhage: Introduction
- Patient Trauma: Introduction
- Pneumonia: Introduction
- Pneumothorax: Introduction
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Post Procedural Infections: Introduction
- Post Procedural Infections: Discharge Abstract Database
- Post Procedural Infections: Importance to Patients and Families
- Post Procedural Infections: Clinical and Systems Reviews, Incident Analyses
- Post Procedural Infections: Measures
- Post Procedural Infections: Success Stories
- Post Procedural Infections: References
- Pressure Ulcer: Introduction
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Sepsis: Introduction
- Sepsis: Discharge Abstract Database
- Sepsis: Importance to Patients and Families
- Sepsis: Clinical and System Reviews, Incident Analyses
- Sepsis: Measures
- Sepsis: Success Stories
- Sepsis: References
- UTI: Introduction
- Venous Thromboembolism: Introduction
- Wound Disruption: Introduction
- Obstetric Trauma: Introduction
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Procedure-Associated Shock: Introduction
- Procedure-Associated Shock: Discharge Abstract Database
- Procedure-Associated Shock: Importance to Patients and Families
- Procedure-Associated Shock: Clinical and System Review, Incident Analysis
- Procedure-Associated Shock: Measures
- Procedure-Associated Shock: Success Stories
- Procedure-Associated Shock: References
- Selected Serious Events: Introduction
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Electrolyte and Fluid Imbalance: Introduction
- Electrolyte and Fluid Imbalance: Discharge Abstract Database
- Electrolyte and Fluid Imbalance: Importance to Patients and Families
- Electrolyte and Fluid Imbalance: Clinical and System Reviews, Incident Analyses
- Electrolyte and Fluid Imbalance: Measures
- Electrolyte and Fluid Imbalance: Success Stories
- Electrolyte and Fluid Imbalance: References
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Anemia – Hemorrhage (Health Care / Medication Associated Condition): Introduction
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Discharge Abstract Database
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Importance to Patients and Families
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Measures
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Success Stories
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): References
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Anemia – Hemorrhage (Procedure-Associated Conditions): Introduction
- Anemia – Hemorrhage (Procedure-Associated Conditions): Discharge Abstract Database
- Anemia – Hemorrhage (Procedure-Associated Conditions): Importance to Patients and Families
- Anemia – Hemorrhage (Procedure-Associated Conditions): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Procedure-Associated Conditions): Measures
- Anemia – Hemorrhage (Procedure-Associated Conditions): Success Stories
- Anemia – Hemorrhage (Procedure-Associated Conditions): References
- Birth Trauma: Introduction
- Device Failure: Introduction
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Infections due to Clostridium difficile, MRSA or VRE: Introduction
- Infections due to Clostridium difficile, MRSA or VRE: Discharge Abstract Database
- Infections due to Clostridium difficile, MRSA or VRE: Importance to Patients and Families
- Infections due to Clostridium difficile, MRSA or VRE: Surveillance, Outbreak Management
- Infections due to Clostridium difficile, MRSA or VRE: Clinical and System Reviews, Incident Analyses
- Infections due to Clostridium difficile, MRSA or VRE: Measures
- Infections due to Clostridium difficile, MRSA or VRE: Success Stories
- Infections due to Clostridium difficile, MRSA or VRE: References
- Laceration: Introduction
- Retained Foreign Body: Introduction
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Viral Gastroenteritis: Introduction
- Viral Gastroenteritis: Discharge Abstract Database
- Viral Gastroenteritis: Importance to Patients and Families
- Viral Gastroenteritis: Surveillance, Outbreak Management
- Viral Gastroenteritis: Clinical and System Reviews, Incident Analyses
- Viral Gastroenteritis: Measures
- Viral Gastroenteritis: Success Stories
- Viral Gastroenteritis: References
Sepsis: Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of hospital associated Sepsis, 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 Sepsis are linked to specific processes or procedures, you may find these resources helpful:
- BC Patient Safety and Quality Council https://bcpsqc.ca/
- BC Patient Safety & Quality Council. BC Sepsis Network. BC Patient Safety & Quality Council. https://bcpsqc.ca/improve-care/bc-sepsis-network/
- Canadian Patient Safety Institute (CPSI) https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Improvement-Resources/Pages/default.aspx
- Hospital Harm Improvement Resource – Infections due to C.diff, MRSA, VRE
- Hospital Harm Improvement Resource – Pneumonia
- Hospital Harm Improvement Resource – Post-Procedure Infections
- Hospital Harm Improvement Resource – UTI.
- Centers for Disease Control and Prevention www.cdc.gov
- Centers for Disease Control and Prevention. Sepsis: Clinical Information. Clinical Resources. Published December 7, 2020. Accessed March 2021. https://www.cdc.gov/sepsis/clinicaltools/index.html
- Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control Hospital Epidemiology. 2010;31(4):319-326. http://www.cdc.gov/hicpac/pdf/cauti/cautiguideline2009final.pdf
- Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention. Morbidity and Mortality Weekly Report. 2016;65(33):864-869. http://dx.doi.org/10.15585/mmwr.mm6533e1
- Tumpey A. Empowering Nurses for Early Sepsis Recognition; 2016. Accessed March 2021. https://www.youtube.com/watch?v=s687VMj6iwo
- Tumpey A. Sepsis Standard Work: Improving Compliance with Early Recognition and Management of Perinatal Sepsis; 2017. https://www.youtube.com/watch?v=BUuFfwsj1W4
- Tumpey A. Advances in Sepsis: Protecting Patients Throughout the Lifespan; 2016. Accessed March 23, 2021. https://www.youtube.com/watch?v=EASYi4-_bv4
- Global Sepsis Alliance www.global-sepsis-alliance.org
- Infection Prevention and Control Canada www.ipac-canada.org
- Society of Critical Care Medicine https://www.sccm.org
- Surviving Sepsis Campaign https://www.sccm.org/SurvivingSepsisCampaign/Home
- Guidelines and Bundles
- Covid-19 Guideline https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/COVID-19
- Adult Patients https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients
- Pediatric Patients https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Pediatric-Patients
Sepsis
