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Patient Trauma: Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of complications from patient trauma, 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:

  1. Measure and monitor the types and frequency of these occurrences.
  2. Use appropriate analytical methods to understand the contributing factors.
  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
  4. ÌýHave 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 forÌýconducting chart auditsÌý²¹²Ô»åÌýanalysis methodsÌýare included in theÌýHospital Harm Improvement Resources Introduction.

If your review reveals that your patient trauma related events are linked to specific processes or procedures, you may find these resources helpful:

  • Agency for Healthcare Research and Quality (AHRQ).Ìý
    • Preventing falls in hospitals: a toolkit for improving quality of care. 2013.
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  • ECRI InstituteÌý
    • . 2016.
  • Healthcare Insurance Reciprocal of Canada (HIROC).Ìý
    • Risk Reference Sheets. Healthcare Acquired Burns. 2020.Ìý
    • Appendix A: Iatrogenic Burns
    • Appendix B: Healthcare Associated Asphyxia, Entrapment & Entanglement
  • National Institute for Health and Care Excellence.Ìý
    • Falls in older people: Assessing risk and prevention. NICE guidelines. 2013.
  • NHS Institute for Innovation and Improvement. https://www.nhs.uk
    • Stepwise falls guide. How to reduce harm (inpatient falls), improve quality and save costs: A practical step-by-step guide for ward staff and frontline healthcare teams. 2013.Ìý
  • Registered Nurses' Association of Ontario (RNAO).Ìý
    • Preventing Falls and Reducing Injury from Falls, Fourth Edition. 2017.
    • Promoting Safety: Alternative Approaches to the Use of Restraints. 2012.
    • Sustainability and the Prevention of Falls and Fall Injuries in the Older Adult. 2014.
  • Royal College of Physicians (UK)l.Ìý
    • Ìý
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Patient Trauma

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Patient Trauma

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