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
1
Presentation of results
<insert your name, title and affiliation>
2
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]
3
Retrospective record review
4
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
5
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]
6
Record review of current in-patients
7
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
8
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]
9
Staff interviews on current in-patients
10
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
11
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]
12
Nominal group meeting
13
What has been done?
 Meetings: [insert number and
duration of meetings held]
 Participants: [insert total number of
participants]
 Meeting content:
1. identified solutions
2. scored appropriateness of each
solution
3. agreed on most important
solutions
4. established roles,
responsibilities and time plan to
implement solutions
5. selected general actions to
improve patient safety
14
Results of the meeting(s)
 present the final ranking of identified causes in order of
decreasing importance
15
Direct observation and related interviews
16
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
17
Results of the observation and interviews
 present and discuss the results tables
 explain identified improvement measures
18
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
19
Thank you for participating!
Questions? Comments?
20
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/
21