User instructions

1. 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

2. Presentation of results <insert your name, title and affiliation>

3. 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]

4. Retrospective record review

5. 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

6. 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]

7. Record review of current in-patients

8. 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

9. 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]

10. Staff interviews on current in-patients

11. 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

12. 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]

13. Nominal group meeting

14. What has been done? • Meetings: [insert number and duration of meetings held] • Participants: [insert total number of participants] • Meeting content: • identified solutions • scored appropriateness of each solution • agreed on most important solutions • established roles, responsibilities and time plan to implement solutions • selected general actions to improve patient safety

15. Results of the meeting(s) • present the final ranking of identified causes in order of decreasing importance

16. Direct observation and related interviews

17. 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

18. Results of the observation and interviews • present and discuss the results tables • explain identified improvement measures

19. 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

20. Thank you for participating!Questions? Comments?

21. 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/