Using a Learning System Approach to Improve Safety for Prone-Position Ventilation Patients

Area of Science:

• Healthcare quality improvement
• Patient safety research
• Clinical data analysis

Background:

• Critical care nurses identified a need for enhanced support for prone positioning during the COVID-19 pandemic.
• Patient Safety Organizations (PSOs) collect and analyze safety event data from member healthcare organizations.
• Prone-position ventilation is a critical care intervention with associated patient safety risks.

Purpose of the Study:

• To describe how a Patient Safety Organization utilized a learning system approach to analyze patient safety event data.
• To identify trends and gaps in care for patients receiving prone-position ventilation.
• To develop evidence-based recommendations for improving patient outcomes and reducing harm.

Main Methods:

• A learning system approach was employed to aggregate and analyze patient safety events submitted by member organizations.
• Patient safety analysts developed primary and secondary taxonomies to categorize safety events related to prone-position ventilation.
• A literature search informed the development of an evidence-based action plan based on identified event themes.

Main Results:

• Analysis of 392 patient safety events revealed significant gaps in care for patients in prone position.
• Identified issues included medical device-related pressure injuries, care delivery concerns, staffing challenges, and device dislodgement.
• An evidence-based action plan was developed and disseminated to PSOs for harm reduction.

Conclusions:

• A learning system approach enables the analysis of patient safety event data to identify critical safety concerns and practice gaps.
• This systematic approach allows healthcare organizations to implement targeted improvement efforts.
• The findings support the use of aggregated safety data for proactive harm reduction strategies in critical care settings.