Advancing Quality and Safety for All;

The International Society for Quality in Health Care 29 th International Conference Advancing Quality and Safety for All; Now and in the Future GENEVA 21 st - 24 th October 2012 Centre International de Conférences Genève (CICG) Abstract Book

Poster Displays 1067 Implementing a Falls-Prevention Programme in a Nursing Home in Singapore 1123 Patient-centered care: a case study on post stroke dysphagia elder 1136 Exploration related factors of oral cancer remove tumor during surgery and flap reconstruction of disturbed sleep 1142 Empowerment as a mediator of the influence of quality of life in community rehabilitation for chronic schizophrenia patients 1205 Intensive team care for diabetic foot increasing the limb s preserving rate 1238 Effectiveness of applying multimedia cd-rom and health manual in patients receiving carotid artery stenting 1242 In order to promote a sense of patient-centered service 1273 Cannulation of arteriovenous fistula using buttonhole cannulation method 1329 SMART group training effective or not? 1331 A nursing experience for a sepsis case based on Levine's conservation model and sepsis bundles 1349 Improving the accuracy and efficiency of prescription receipt and medication delivery for in-patient chemotherapy 1388 Determine the guideline for caring patient with multi-drug resistant pathogen infection by application of FMEA 1395 Home-care pharmaceutical service to elder patients 1455 What influences patient non-compliance with guidelines? 1528 The use of structured observation to embed improvements in nutritional care 1539 Reducing unplanned extubation in the neonatal intensive care unit 1541 Moving beyond biomedical markers implementation of psychological and erectile dysfunction screening tools in clinical practice in a diabetes unit 1584 Using the team resource management (TRM) to improve the care of critical trauma patients in emergency room 1597 Redefining in strict terms the most crucial indicator of report turnaround time in radiology; time clock converted to 24/7 (round the clock), resulting in improved communication and better patient satisfaction 1638 Incidence of placement of endotracheal tube in critically-ill patients causing skin tears and related factors

1646 Disclosure of medical errors to patients in Japan: physicians attitudes regarding the disclosure of medical errors 1662 Comparison of quality of life among patients with hemodialysis and peritoneal dialysis 1786 Reducing unscheduled 30 day readmissions for heart failure in National University Hospital (NUH), Singapore 1815 Testing a model for early detection of type 2 diabetes 1816 Using modern educational principles to improve self-care ability for patients with heart failure 1821 Survey of health clinic medical directors regarding futile treatments in home terminal care 1829 The utilization of integrated interdisciplinary medical team to reduce the preparation time of acute coronary syndrome treatment in the emergency room (ER) 1873 A pilot community-based pulmonary rehabilitation programme in Hong Kong East Cluster 1912 An evaluation of protocolised titration in sedation on enhancement of nursing engagement and autonomy in patient care 1984 Who cares for the sickest patients in America? 2009 Factors related to self-efficacy in patients with spinal cord injuries during rehabilitation stage 2030 Improving ability in home care of premature neonate caregivers 2042 A project to improve the quality of nutrition care performance in hospital 2108 Improving nursing staff on care of patients with nasogastric tube feeding food integrity 2119 Using systematic nursing instruction to help family members of infants and babies with respiratory disease to enhance the accuracy of chest physiotherapy performance 2124 Multidisciplianry care may improve outcomes for stage 5 chronic kidney disease patients who begin hemodialysis therapy 2185 The initiative to reduce pressure ulcer in a cardiovascular intensive care unit 2208 Understanding and improving the quality of care for patients with myeloma across the UK 2216 Investigating public interest in, and expectations of, patient experience information: a comparison between the Netherlands and England 2231 Comparison of the medication possession ratio in hypertensive patients according to the pattern of health care utilization

2264 Patient satisfaction survey in Hong Kong - both the means and the end for quality and patient engagement 2287 Standard assessment to improve compliance to ICU routines and nurse involvement in patient care 2293 Using bundle intervention to reduce the bloodstream infection rate in the oncology ward 2325 Recovery-oriented rehabilitation services for in-patients with severe mental illness in Castle Peak Hospital 2334 Using web-based collaborative care to improve the quality of glycaemic control in Type 2 diabetes 2348 A patient-centered clinical guideline enhances bloodless open-heart surgery 2364 Improvement of customer satisfaction through one shot instead of several intravenous (IV) injections 2372 Role of nurse managers in improving elderly patients knowledge about their medications and adherence in rural Vhembe district: South Africa 2395 Preventing increased intracranial pressure among traumatic brain-injured patients after brain surgeries 2396 Developing and psychometric testing of the nurse-perceived pain management competence scale (NPPMCS) 2448 Direct patients communication access in improving patient satisfaction 2463 To examine the efficiency and satisfaction of oral care practice in intensive care unit patients with oral endotracheal tube 2468 Application of crew resource management in handing over cardiac surgery patient from operating theater to ICU 2484 The improvement in constitution pattern after treatment of continuous positive airway pressure for patients with obstructive sleep apnea syndrome a preliminary report 2486 To improve antibiotic dosing by using medical informatics 2499 Application of multidisciplinary team to improve bloodstream infection density 2502 Respiratory care center s central venous catheter-related bloodstream infection rate 2604 An audit of intravenous fluid-prescribing practices and maintenance of fluid balance in St. Columcille's hospital in Dublin 2641 Acute coronary syndromes (ACS) and hemorrhagic complications: data analysis of patients managed by pre-hospital medical intensive care unit (MICU) of a university hospital from 2009 to 2010

2641 Acute coronary syndromes (ACS) and hemorrhagic complications: data analysis of patients managed by pre-hospital medical intensive care unit (MICU) of a university hospital from 2009 to 2010 2654 Patient-centered care to improve tuberculosis control in a high tuberculosis and multidrug-resistant tuberculosis incidence area in Lima, Peru 2656 Does the use of a multidisciplinary goal sheet improve the quality and safety of care in older medical inpatients? 2685 The effect of a teaching program with cartoon video on self-care behavior to prevent infective endocarditis among school-age children with congenital heart disease 1059 Assessment of patient-safety education in pre-registration adult nursing program 1131 Patient safety in the perception of the multidisciplinary team about the adverse events at a university hospital 1143 Exploring relationships sexual satisfaction, depressive symptoms and quality of life with COPD 1152 Increasing completion rates in nursing palliative care through multidisciplinary teamwork 1166 Increasing satisfaction with palliative care in bereaved caregivers through multidisciplinary teamwork 1227 A discussion of operating room personnel response to fire in the operating room 1255 The effect of multimedia-based nursing instruction on the improvement of drug use of COPD patients 1271 Using hands-on experience to improve empathy of nursing students in the operating theatre 1295 A diagnostic tool for the retrospective analysis of critical events (TRACE) 1310 Implementation of structured handover on a labour & delivery unit 1334 The use of physical restraint and its relationship to the belief of staff in different settings 1351 Multimodal hand hygiene improvement strategies to increase the hand hygiene compliance rate 1379 Multi-disciplinary collaboration in preventing patient falls 1396 Are our written and verbal signouts safe? Experiences of a community-based residency program 1436 Patient-safety knowledge covered in the undergraduate nursing curriculum and patientsafety competencies of graduating nursing students in Korea 1729 Fighting against workplace violence in the acute hospital setting

1794 Continuing education of healthcare assistants helped promoting quality patient care 1797 Strategies to enhance alliance of drug compliance in chronic psychiatric inpatients 1818 Public healthcare professionals views and experience of preparation and storage of reconstituted powdered milk: implications for microbiological safety and education 1848 Physicians perception of usefulness of quality-improvement tools: a contrasted picture 1852 An audit of antimicrobial prescribing habits among doctors in St. Columcilles Hospital, Loughlinstown 1903 Understanding elderly perception on advance care plan in rural southern Taiwan 1941 Nurses fall-prevention knowledge, attitudes, and practices: the effectiveness of an inservice education program in a regional teaching hospital in Taiwan 2006 Introducing competency-based training for high-risk ward-based procedures for junior doctors to enhance patient safety in National University Hospital, Singapore 2160 A novel institutional resident physician integration and training program in quality improvement 2181 Partnering with consumers to achieve quality outcomes in healthcare - a window into the Australian Council on Healthcare Standards Education Workshop 2261 The efficacy of continuous education for operative nurses in total knee replacement surgery 2332 Implementation experience of medication-safety education in southern Taiwan 2508 The use of process reengineering to improve discharge preparation and long-term care resources linked service operating 2536 The mask factors, negligent risky factors, and length of irreversible period among preventable malpractice mortalities and vegetations 2682 The effectiveness of smoking cessation programs in adults: systematic review 1145 Investment in quality initiatives to enhance business growth 1220 Evaluation of pay-for-performance quality incentive pilot programme: from lessons learnt to the way forward 1254 Mechanisms to monitor data quality for clinical documentation 1324 Getting knowledge into action to improve healthcare quality in NHSScotland 1378 An innovative approach to international healthcare involving multiple stakeholders 1403 It's good to talk: introducing a talking group approach in an intensive care unit team 1424 Error disclosure standards in Swiss hospitals

1663 Improving healthcare together: engaging clinicians in national quality-improvement activities 1861 Stop resistance, save antibiotics: a pathetic call for action of the world alliance against multi-resistant organisms (WAAMRO) 1863 Developing clinical leadership in the National Health Service in England 1869 Project LEAD: Dr Sharmila Gopisetti Dr Quen Mok Picu Great Ormond Street Children's Hospital 1915 The correlation study of career barriers and coping strategies among female nurses 1927 The future projection of cost-of-illness of stomach cancer in Japan 2063 Job uncertainty, professional commitment, personality hardiness and intention to leave of hospital registered nurses 2094 Using warehouse management to reduce the consumption cost of non-pricing of medical consumables 2109 Significant event management (POLICY) 2133 Management of priorities for resource allocation in a portfolio of projects 2189 Effecting the WHO'S HIGH5s correct site surgery SOP 2202 Voluntary peer review in German healthcare: a powerful tool focusing on sharing best practice and enabling individual and collaborative organizational learning 2217 The governance and the activities of the best : a project developing evidence-based practice in nursing and allied health professions 2218 Integration and impact of the senior charge nurse, senior charge midwife and team leader role 2322 Reducing the working load of the nurse service as the outpatient counsellor 2374 Designing the future: approaches to measuring patient experience 2379 A cross-sectional study of workload, support at work and intent to stay among hospital nurses in southern Taiwan 2382 A study of the relationship between personality trait, job satisfaction and turnover intention among hospital nurses 2513 Advancing the field of clinical governance research and practice 2535 Development of the guidelines and quality-evaluation tool for the management of outsourcing services 2556 Citizens participation in the creation of a national model for quality assessment and improvement of hospital service delivery

2620 Influence of public disclosure of healthcare quality information on artificial knee replacement and uterine myoma surgery under Taiwan s national health insurance system 2698 The effect of a provider feedback program on the change of medical care patterns 1084 Time out as a safety tool in chemotherapy infusion 1116 The report of the Dutch Healthcare Inspectorate s yearly assessment of the implementation of the obliged Safety Management System of hospitals in the Netherlands 1128 Clinical epidemiology of falls/slips based on incident reporting data at a teaching hospital in Japan: a retrospective case study 1163 Patient-safety climate and error reporting in laboratory medicine interruptions as a relevant cause of error 1183 Decreased risk of a surgical site infection with the implementation of a pre-incision standard of care for patients scheduled for an orthopaedic hip procedure (primary or revisions) 1195 A proposed plan to improve time out completion rates for patients undergoing surgery 1265 Creating a culture of safety in the intensive care unit 1307 The role of pharmacists in patient safety: a nationwide survey on patient-safety management systems 1322 CQI Project: to prevent hip fracture of high-risk elderly fallers by using hip protectors in a convalescent hospital 1353 Analysis of critical incident reports in an academic teaching hospital error categorisation of medication events 1358 Prioritizing quality measurement in hospital care: experts preferences and impact of non-medical factors 1362 Effectiveness of a bundle of measures implemented to prevent ventilator-associated pneumonia 1372 Electronic clinical handover in a hemodialysis unit: towards safer medical care 1392 Establishment and informed process of critical values 1397 Implementing a hospital-wide quality improvement and patient safety program for patient-safety cultural change - experience of a Taiwan metropolitan teaching hospital 1441 The initiative to reduce the incidence of unplanned self-extubation 1451 Optimizing patient safety through teamwork: case studies following team intervention in six hospitals 1460 A continuous improvement program on fall prevention in a palliative care setting in Hong Kong

1505 Learning from other high-risk industries: adapting proactive risk management methods for healthcare 1529 Improving injectable medicine patient safety with national recommendations for userapplied labelling of injectable medicines, fluids and lines 1564 Variation in safety-culture dimensions within and between us and Swiss hospital units: an exploratory study 1572 Physicians attitudes and perceived barriers towards reporting incidents, at Hamad Medical Corporation in the State of Qatar 1600 To assess the effectiveness of timely communication of panic results detected on ultrasound examinations to the primary physicians 1601 Using "Fall Risk Assessment Tool" to reduce the fall injury severity of patients 1623 Assessment of accidents in alpine skiing and definition of a preventive intervention 1644 Related factors for incidences of endotracheal tube in intensive care units at a specific medical center 1674 Potential drug interactions in multiple trauma patients in a Brazilian hospital 1682 The eye of the storm: emergency response to Hurricane Irene 1690 A new way to medication storage 1701 The effectiveness of the operating room pathological specimen example by a medical center in central Taiwan 1704 The improvement of nursing care on postoperative hypothermia patients in postoperative recovery room 1715 Opportunities for performance improvement in the management of patients with traumatic haemorrhage leading to death 1752 Reduction in the rate of in-ward, out-of-icu cardiopulmonary arrests by emphasizing vigilance on the emergence of early warning signs 1771 Reducing the management time of major trauma patients in emergency room through team resource management 1773 A hospital quality-improvement collaborative to reduce central venous catheter-related infections care bundle in the general medicine wards 1774 Development of hemostasis guidelines and its monitoring system to evaluate compliance with the protocol 1776 Building quality and safety checks in implementing new clinical services in National University Hospital (NUH), Singapore 1784 Improving endotracheal tube care through medical team communication and cooperation

1785 Development and computerization of a «controlled language» to write medical standard operating procedures: a new approach to improve healthcare quality and patients safety 1789 Reducing image retake for all patients undergoing general radiographic examinations, resulting in lesser radiation exposure in a tertiary care teaching hospital in the developing world 1814 Rationalizing the prescription of immuno-hematological examinations in thyroid surgery 1820 How to decrease the risk of Clostridium Difficile in a ward environment and help prevent the emergence of any new cases a Ninewells success story 1878 Reducing healthcare-associated infections by implementing enforcement of routine environmental cleaning measures in intensive care units 1887 Drug utilization of benzodiazepines in outpatients in a medical center of Taiwan 1895 Sorting out medical error leading to patient death: Japanese hospital and clinic administrators would recommend autopsy more than regular physicians 1901 Improvement of patient identification accuracy in the outpatient phlebotomy department by an advanced information system 1907 An exploratory study of the relationship between healthcare workers knowledge, attitude and behavior about patient safety in a Taipei hospital 1913 The Western Australian audit of surgical mortality: a 10 year evaluation 1962 Comparison between adverse events measured with global trigger tool in Norwegian healthcare and the target areas for the Norwegian Patient Safety Campaign 1963 Mapping taxonomies of adverse events in hospitals an initial analysis of classification systems in Norway 1964 A project to improve safety of the route: for patients who are under transfer 1992 Passing on the baton: from theatre for post-anaesthetic care unit 2004 Event analysis of accidents and injuries for emergency patients of a medical center in central Taiwan 2014 Empowering staff to improve safety 2016 Anticoagulation Safety Program 2017 The implementation of team resource management method to improve the quality of preoperative preparation 2040 Review of triage model for pregnant women attending the antenatal service and feedback at Tseung Kwan O Hospital 2083 Patients reports of adverse events to a primary care clinic through the practice website

2089 The "Resus:Station": Can design support the resuscitation trolley stock check? 2092 The level of quality in prophylactic antibiotics administration timing and period according to the experience of quality assessment for total knee replacement in Korea 2105 Identifying systems failures in hospital settings: the patient measure of organisational safety 2128 Quality improvement in knee-hip arthroplasty 2141 A review of adverse drug reaction in clinical trials for herbal medicine in Taiwan 2195 Improvement of families satisfaction with the childhood immunization process 2196 Barriers and facilitators in implementing a standard operating procedure for the prevention of wrong site surgery in the context of the international WHO High 5s Project 2197 Effectiveness of Years of Safety initiative in improving patient-safety climate 2222 The use of FMEA in the analysis of the processes of the cord blood bank of Verona Teaching Hospital, Italy: improvements and future challenges 2229 Adverse events and incidents in the intensive care unit 2230 The effect of the National Quality Improvement program on the prophylactic antibiotics for surgery in Korea 2234 Activities for reducing complications related to endoscopic procedure in a health checkup center 2254 A modified drug distribution system for enhanced patient safety in the emergency room 2259 Building patient-safety systems in African hospitals in Cameroon, Mali and Senegal: the power of a partnership-based approach 2283 Early awareness about scabies infection to institutional patients prevents outbreak a nursing staff monitoring project 2284 The correct use of chemotherapy and biological treatment in advanced non-small cell lung cancer, metastatic breast cancer, and metastatic colorectal cancer patients: an Italian experience 2285 Safe fixation policy in Imeldaziekenhuis 2304 The effect of systematic healthcare quality improvement and patient-safety training program 2345 To increase the value and utility of a resource, tap on the wisdom of stakeholders: the consultation process to revise the Canadian Root Cause Analysis Framework 2351 The improvement of the process to reduce errors in management of post-endoscopic specimen

2362 Multiple strategy application to improve the incidences of pressure ulcers in a specific medical center in Taiwan 2391 Project implementation of FMEA in a breast unit of the north east of Italy 2392 Performance of team resource management on reducing the risk of falls for inpatients in acute psychiatric ward in a general hospital 2408 Improvements in the care of in-patients with diabetes in NHS Lothian 2415 Patients as partner in standardization of providing an accurate medication overview at transitions in care 2438 Establishment of process for prevention of sedation patient-safety accident 2442 Lifting the filing rate of medical reports in orthopedics and surgery wards 2460 Drug-Related Problems (DRP): application of clinical pharmacy services to improve patient safety 2465 Quality promotion of handover across emergency and critical healthcare team 2490 Self-reported participation to wrong-site surgery among surgeons and anaesthetists: a cross-sectional survey at two annual meetings of surgery 2514 Designing an app to create home medication lists 2521 Smart Prescription in the medical department in a regional acute hospital 2588 Patients preference and satisfaction on hallway admission from an emergency department 2624 Hospital-Wide Fall Prevention Program with regular review to enhance patient safety 2660 Safe Surgery Checklist: how accurate are we at preventing surgical site infection? 2661 Assessing the perceptions of the patient-safety culture among healthcare workers in hospitals in the northeast of Libya 2669 Implementation of new heart failure assessment tool post cardiothoracic surgery and outcomes 2700 Implementation of a patient-safety learning system in a large academic health sciences centre 2705 The success of a post- office hours acute medical admission ward (AMAW) in a regional acute hospital during a medical manpower crisis 1024 A survey study on the satisfaction rate and opinions of medical review physicians from paper review to online professional review 1033 Measuring family experiences of care in two pediatric public hospitals in Argentina, based on HCAHPS Survey

1041 The effect of health promotion program in Taiwanese hypertensive people and hypercholesterolemia 1076 Reinforced Policy to implement the correct use of prophylactic antibiotics in the operating room 1134 Evidenced-based interventions for patient safety 1159 Endocrine therapy adherence and persistence and survival among women with breast cancer in Brazil 1165 A Psychologist for nurses and nurse-assistants in an intensive care unit: impact of burnout and anxiety on the caregivers 1173 Study of factors for unscheduled readmission to intensive care units in certain regional hospitals by retrospective analysis of medical records 1176 Evaluation of gastric extubation indicator in a home care program in a university hospital 1197 Ambulatory Care Sensitive Conditions (ACSC) admissions as an efficiency indicator for healthcare utilization 1228 The Time Effect of waiting for admission to intensive care unit on ventilator patients in emergency department 1267 Mapping adverse outcome screening to international classifications for diseases, tenth revision for using in Brazilian administrative database 1270 Improving final report turnaround time in all radiological modalities as an approach to patient-centered care and to measure and monitor service performance indicators 1275 Assessing Inpatient Mortality: a new review process that leverages information systems and engages frontline providers 1289 Reduction of average daily waiting time for drug collection after the implementation of multi-queue system in out-patient pharmacy 1337 Patient-Safety Indicators: reliability of hospital administrative data in comparison to retrospective chart review 1338 Improving the nursing instructions execution rate of nursing staff to epileptic patients in a pediatric intensive care unit 1354 Measure of the quality of stroke treatment by the HAS clinical practice indicators 1363 Implementation of surgical site infection prevention bundle- a tale of successes and challenges 1367 Evaluation for the effectiveness of peer pressure changing emergency physicians' disposition decisions and patient throughput 1425 To objectify the quality of care for breast cancer

1432 Obstacles to reliable collection of quality data: a survey of anesthesia staff 1435 Physician Performance in different health insurance systems 1459 Quality and costs of healthcare for acute stroke in Japan 1470 Prevention of adverse events in surgery: contents of time-out procedure 1480 Sources and potential impacts of hospital-level sampling bias in patient-safety assessment 1513 Development of standards for the conduct of a national clinical audit or qualityimprovement study 1537 Quality of healthcare delivery in US ambulatory surgical centers 1617 Advancing existing approaches to disease management evaluation: experiences from the Netherlands 1633 A project to improve 24 hours -continue digital EEG completeness in epilepsy patients 1679 Improve the ability of nurses in educating the postoperative care of patients receiving hair transplantation 1716 The development and validation of the nursing workplace stressors scale 1722 Nurses ratings of quality of care in small rural hospitals 1724 Case Finding as the best method for preventive medicine - are there non-attenders to primary care in Israel? 1745 The impact of Charlson Comorbidity Index to predict adverse outcome in patients revisiting emergency department within 72 hours and related admission 1748 A model for measuring safety performance: validation through patient perspectives as key stakeholders of safety in case management for long-term conditions 1763 A feasibility and pilot study of auricular acupressure to reduce chemotherapy-induced nausea and vomiting in children 1768 Implementation of a computerized antimicrobial stewardship program in adult patients admitted to intensive care units at a tertiary hospital in Taiwan 1772 Nursing instruction for self-care improvement in patients with permanent pacemaker 1831 Implementation of a continuing education program based on the process improvement methodology to guarantee the integration of technological innovations into a radiation oncology department 1838 What gets measured gets monitored... targeting parenteral nutrition over a 3-year period 1854 Patient Safety: violations of health standards and precepts

1856 Gaining insight into hospital-acquired adverse events in Portugal 1874 Evaluation of the effectiveness of assigning nurse manager for ambulatory cardiac rehabilitation program 1920 Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: a randomized controlled trial 1925 The impact of perceived nursing work environment on patient care quality 1933 Evaluation process of the general introduction of 32 priority guidelines on elective treatment in the Norwegian specialist health service 1967 Enhancing patient safety in cardiac surgery: assessment of an inter-professional teamwork approach 1995 Patient satisfaction with care and treatment services in two HIV clinics in Ebonyi State, Nigeria 2046 Quality-Improvement Activities: management of medical practitioners performance metrics 2059 Perception of patient-safety climate and nursing care quality 2081 Spectrum Analysis of drug utilization to facilitate hospital performance and management 2139 Can we improve the trial without catheter (TWOC) clinic referrals? A novel use of a new electronic referral system 2146 Impact of nosocomial infection on readmission: analysis of electronically-captured data 2156 Performance measurement in perioperative care: development of indicators and insight in current practice and patient safety 2169 A clinical pathway to improve the quality of outpatient care provided to patients with diabetes: preliminary results of a primary care assessment 2192 Analysis of palliative care inpatient services for Taoyuan Chang Gung Memorial Hospital in 2005-2009 2220 Quality indicators in multiple sclerosis 2232 The effect of the quality improvement through the assessment of long-term care hospitals service in Korea 2272 Triangulated findings of a concurrent multi-method case study of patient participation in symptom management in an acute oncology setting 2286 Evaluating the mental health services for elderly in Herefordshire and Birmingham through general practitioners' survey to measure the quality gap 2288 Relationship between structure and process indicators of quality of care: the case of pressure ulcers

2292 Developing indicators concerning hospital staff management: the French CLARTE Research Project 2310 Quality of medical care in Japanese acute care hospitals using patient discharge and administrative claims data 2367 Characteristics and quality of care to Swiss diabetic patients 2376 Quality indicators and multimorbidity: reaching process and outcome targets in multimorbid patients 2389 Promoting nursing students satisfaction with the internship program 2443 Evaluation of frozen section diagnosis accuracy for quality improvement in a medical center in Taiwan 2449 Use of 3D CT simulation for planning conventional palliative 2D cases: pros and cons - a sharing from Tuen Mun Hospital 2511 Using GRADE to develop an evidence-based benchmark for a patient-safety indicator: postoperative venous thromboembolism 2550 Application of Breakthrough Series Model to improve the handover quality of maternalnewborn care in caesarean section birth 2560 Structural characteristics of hospitals associated with patient-safety indicators 2596 SINAS Multidimensional healthcare quality assessment in Portugal 2605 Combining the fully functional service delivery system and performance-based contracting approaches to strengthen health systems in Uganda districts 2616 Surgical safety checklist usage and complications 2634 Ventilator-associated pneumonia in adult intensive care units: multidisciplinary team surveillance program 2643 Predictors of 30-day readmission rates after PCI in Estonia 2647 Delir Path Project: delirium management and monitoring of delirium incidence rates in a Swiss acute care hospital 2684 Do check that blood pressure: how clinical processes affect hypertension control rates 1408 The influence of global budget system on healthcare quality 2307 Methods for carbon emissions reduction in hospital 2428 Patient Empowerment approach in lifestyle modification for secondary coronary arteries disease prevention: a randomized controlled trial 2453 Wellness of the mind - dementia awareness project

1325 Improvement of intravenous cannulation for critically ill children with a near-infrared light device 1416 Unexpected clinical impact of implementing computer-based clinical decision support 1487 An attempt to improve automatic classification of incident reports using natural language processing 1542 Human Papillomavirus (HPV) testing in primary screening for cervical cancer 1606 Development of in-built, automated, paperless discount system in Radiology Information System (RIS) for strengthening financial controls and eliminating paper-based manual system 1608 Reporting of initial findings for all radiology requests received from emergency department (ED) 1611 Improving the print quality of archived images in general radiography as a pre-requisite for filmless environment eventually leading to cost rationalization 1628 Web-based implementation and dissemination of clinical practice guidelines in Japan: the role of MINDS 1654 A study of integrating adjustment mechanism and automated conversion for dispensing medicine in hospital 1671 Comparison of temporal artery thermometer with infrared ear thermometer: a rapid review of the literature 1673 Prospective risk analysis of the drug distribution process: impact of information technologies 1788 Apply SAS/EG to monitor ambulatory antibiotic prescribing and to improve the prescribing quality 1812 Using an Electronic Medical Record system to improve the patient referral process 1892 A proposal of tissue-saving-algorithm for small cell lung cancer biopsy sample in diagnostic and molecular study processes 1979 Assessing demand for health informatics education in Karachi, Pakistan 2188 Optimizing the QR-Code with Healthcare Failure Mode and Effects Analysis (HFMEA) for the outpatient pharmacy in Taiwan 2461 The effectiveness of innovative nursing case report technologies 2601 Education combined with information technology systems to increase the visiting rate of retinopathy of prematurity clinic 2699 Time Domain HRV with postural changes might be useful for the detection of symptomatic mitral valve prolapse syndrome in Taiwanese

1044 Application of Six Sigma quality tools and techniques: could it improve the quality of services and performance in El Hadara University Hospital? 1126 Retrospective assessment of nephrolithiasis's endourological surgery complications by the modified Clavien classification system in a single tertiary educational urology center in Uzbekistan 1250 Problematic Patient Handoffs: a survey of medical staff at private hospitals in Buenos Aires, Argentina 1264 Conceptual, item and semantic equivalence of the Brazilian Portuguese version of the Hospital Survey on Patient Safety Culture (HSOPSC) 1495 Process Improvement of medical record management systems 1593 A correlation study on violent inpatient behavior in an acute psychiatric ward 1683 HEALTHQUAL International: alternative data visualization methods to advance improvement data reporting 1687 Applying modern QI concepts to improve maternal care in low-resource settings 1726 Patient-safety insights from 12 African countries: a survey of relevant literature 1728 New ICU re-design reduces hospital-acquired infection - experience from a developing country 1750 A portrait of hospital accreditation in Brazil (2011) 1787 The improvement of the appropriate prophylactic use of antibiotics for surgery through 3-year-management at a national hospital of Korea 1857 The challenge of a new approach to informed consent: a cultural change 1882 A study on the improvement of the permanent specimen receipt process in the operating room 1937 Syntagmatic quality indicator management system: beyond the accreditation 1987 Building up the quality mindset in the Nigerian healthcare sector 2005 Developing Patient-Safety indicators for acute-care hospitals in Brazil 2036 Providing safe and quality care to NICU patients through achieving zero central line associated blood stream infection (CLABSI) rate for five months in a tertiary care hospital of a developing country 2149 Utilizing scientific principles of risk management to implement sustainable quality and safety in China healthcare reform 2201 Application of Failure Mode and Effects Analysis (FMEA) in risk prospection in the hospital care in Brazil 2384 Personal Approach in increasing physician involvement in quality care activities

2398 Translating regional patient-safety mandates into local action in African hospitals: the power of context-specific improvement resources 2462 Development and implementation of the critical pathway for day surgery on breast disease 2517 Competencies in self-care management with insulin-using Type 2 Diabetes Mellitus and occurrence of adverse events: prospective study in an ambulatory setting 2599 Safety Assessment of care to patients in hospitals accredited jointly by the Joint Commission International and the Consortium for Brazilian Accreditation 2608 Using a quality of care framework to develop, standardize, assess and improve the quality of health services for adolescents in low and middle-income countries 2611 Development of quality indicators for advanced pediatric emergency center 2651 Reduction of prolonged second-stage labor by using upright labor position 2693 The improvement in preventing suicide on medical/surgical units in a national hospital of Korea 1097 A system to improve documentation of policy, procedures and guidelines in a cluster of hospitals 1108 Prison Health Reform - achieving patient safety standards 1393 The role of medical clinicians working in the healthcare accreditation survey process: their motivations, the influences that affect them and the methods they employ to address those influences 1609 Advanced practice accreditation programme for nurses 1612 Mandatory quality management implementation in German medical practices - a 1:1 matched observational study 1795 The relationships among health-promoting behavior, work stress, and health status of employees at a medical center in northern Taiwan 1894 Economic Appraisal of health services accreditation: a fiendish problem desperately in need of a solution 2028 Health Service Accreditation Programs: are they becoming hybrids that satisfy no-one? 2064 Improving hospital care service quality through implementation of Korea healthcare accreditation standards 2207 Is healthcare accreditation dead? 2248 Staff Engagement- Doctors Day in Alice Ho Miu Ling Nethersole Hospital (AHNH) and Tai Po Hospital (TPH) 2282 Planetree Designation - a quality model for increasing patient satisfaction in a general and private hospital

2592 Exploring the relationships between the 'Visitatie' programme for multidisciplinary oncological care and the organisation and quality of cancer care in the Netherlands 2648 CRESAC contributions to the implementation of WHO-AFRO Stepwise Laboratory Quality Improvement Process towards Accreditation (SLIPTA) scheme in Cote d Ivoire 1813 Paradigm Shift from Traditional Nursing to shared nursing governance to enhance nursing practice, quality and education

1067 Implementing a Falls-Prevention Programme in a Nursing Home in Singapore B. H. Swee, M. Saravanan, H. H. Yong 1 Community Care Development Division, Agency for Integrated Care, 2 Sree Narayana Mission Home for The Aged Sick, 3 3Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore This quality improvement project focused on preventing falls and fall-related injuries in a Nursing Home (NH). It empowered the nursing/care staff of the NH to improve care for their residents by engaging an Aged Care Physician as a consultant and a facilitator from the Agency for Integrated Care (AIC) over a period of 13 months to train a core fall team/champions from the NH. The training created more staff awareness, increased their knowledge and skills and built up multi-disciplinary teamwork to prevent falls in the home.the Falls Prevention Programme aimed to: Reduce falls and fall-related injuries in the Nursing Home (NH) Equip nurses with the knowledge and skills to better identify residents at risk for falls and implement the appropriate intervention strategies Adopt a multidisciplinary approach towards falls prevention programme Collect and monitor falls-related data for continuous quality improvement Improve the quality of care for residents in the NH A multifaceted and multidisciplinary approach was adopted to prevent falls. Some of the measures included: 1. Training on fall-related topics (e.g. fall assessment, prevention measures,andfalls data) was conducted for nursing/care staff to increase their awarenesson falls prevention; 2. Reviewing the Standard Operating Procedures (SOP) on Falls Prevention and Falls Management - Steps to take when a resident falls in the NH; 3. Implementation of new clinical interventions: Fall Risk Assessment done by nurse and physiotherapist, Referral to the resident doctor to review the medications for residents at risk for fall; Use of Hip Protectors for residents at high risk for fall; 4. Implementation of new environmental interventions: The drain (uneven height) along the corridors of all floors was painted red to highlight caution; A steel gate was fixed at two staircases to discourage residents from using the stairs without assistance; 5. Reviewing the nursing manpower for closer supervision of residents during afternoon and night shift; 6. Collecting and monitoring of data on falls in the NH - the Fall Champion was taught data entry, data analysis and report writing /presentation by the facilitator from AIC. The outcomes of care were shown in the table below. Indicator Pre- training Training & Post-implementation Pre-implementation (Feb 2010-Aug 2010) (Sep 2010-Mar 2011) (Apr 2011 Oct 2011) Incidence of falls (rate) 0.46 0.29 0.17 Incidence of residents who sustained falls (average rate) No. of residents who sustained fall-related injuries 1.35 0.90 0.46 13 7 2 No. of unplanned admission to hospital due to falls-related injuries 1 2 0 The outcome indicators showed positive results i.e. a reduction of falls and injuries with implementation of the programme. Moving forward, the fall champions in the NH will continue with on-going training on falls prevention for all new staff and conduct a quarterly review of falls and injuries statistics. The NH will also consider organising a Fall Awareness Day and engage the physiotherapist more actively to introduce appropriate balance training for the residents. The challenge is to ensure that the improved processes in preventing falls eventually become adopted as a daily practice by all nursing/care staff in the NH.

1123 Patient-centered care: a case study on post stroke dysphagia elder Y.Y.Wong 1,* 1 Science and Technology, The Open university of Hong Kong, Hong Kong, Hong Kong, China From the literature search, persons with neurological diseases such as stroke, dementia and Parkinson s disease will under a high risk of having dysphagia. Nasogastric tube is commonly used to feed post stroke dysphagia elders, it is believed that it can prevent aspiration pneumonia and prolong their lives. However, such treatment sometimes violates their will. Whether tube feeding is beneficial for these elders is still being controversial. Mr. Wong was an 80 year-old Chinese, bedbound man with recurrent stroke who lived in a residential home. He was diagnosed with dysphagia by speech therapist and doctor suggested him to put on nasogastric tube feeding. However, Wong expressed his disagreement on that treatment by his body languages and un-cooperation such as frequently pulling out the tube or vigorous struggling during tube insertion. A multidisciplinary case conference was held to discuss the indication of tube feeding with Mr. Wong s son. Despite the clarification of the benefit on tube feeding and the risk of aspiration from professional view, he insisted to respect his father s wish by shouldering up the consequence and responsibility, and hence, oral feeding was resumed. Mr. Wong was able to grip the spoon and fed by himself. No dyspnea, abnormal breath sounds and desaturation happened during the feeding period. Restrainer was no longer needed. He tolerated it well and his quality of life was improved. Contrary to the common belief, there are a number of research findings stating that tube feeding does not yield a better outcome against aspiration pneumonia and cannot lower the mortality rate. Besides the non-oral feeding, there are several preventive measures that can be done on the patient who have feeding problems. For example modifying food and liquid consistencies, changing eating position, using stimulating sensory technique and swallowing maneuvers, all these can improve the physiology, decrease the risk of aspiration and they should be considered before the start of nonoral feeding. It is important to respect client and the relatives autonomy to choose whether they would take the risk of aspiration or to start tube feeding. They have the right to know the risk and benefits of non-oral feeding. Health professionals view, client s feeling and family s concern are not always in line. Patient centered care required the incorporation of knowledge of science and art in order to enhance their participation in treatment regime and provide better care towards them. References: Eisenstadt, HP. (2010) Dysphagia and aspiration pneumonia in older adults. Journal of the American Academy of Nurse Practitioners, 22(1), 17-22. Hinchey, JA, Shephard, T, Furie, K, Smith, D, Wang, D, & Tonn, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke,36, 1972-1976. Mamun, K, & Lim, J. (2005) Role of nasogastric tube in preventing aspiration pneumonia in patients with dysphagia. SingaporeMedical Journal, 46(11), 627-631. Metheny, NA. (2008) Preventing aspiration in older adults with dysphagia. American Journal of Nursing, 108(2), 45-46. Singh, S, & Hamdy, S. (2006) Dysphagia in stroke patients. British Medical Journal, 82(968), 383-391.

1136 Exploration related factors of oral cancer remove tumor during surgery and flap reconstruction of disturbed sleep H.-N. Chen 1,*, F.-M. Huang 2, M.-C. Tasi 3 1 12H ENT Ward, Chang Gung Medical Foundation, Taoyuan, 2 Education, National Chiayi University, Chiayi, 3 Nursing Department, Chang Gung Medical Foundation, Taoyuan, Taiwan Cancer patients experienced sleep problems in approximately 30% -50%, The sleep problems usually occur six months after the diagnosis of cancer. Oral cancer surgery results in not only damage to the facial appearance and function, but also mental disturbance, like pain, anxiety and depression. All of the above symptoms lead to the sleep problem obviously.to investigate the degree of pain, anxiety, depression and insomnia of oral cancer patients receiving tumor eradication and flap reconstruction operations. The data includes pre-operative, 2 weeks and 3 months post-operative period. We collect 120 oral cancer patients in the Linkuo Chang Gung Memorial Hospital from... to...the basic information includes patient characteristic, pain scale, hospital anxiety and depression scale, the amount of sleep problems. Statistics method is regression analysis of the impact on sleep-related factors. The regression analysis showed that the pain will affect the quality of sleep (Β = 0.259, t = 2.872). Preoperative depression (R = 0.239, p <0.01), anxiety (r = 0.311, p <0.01) also demonstrate great impact on sleep. The pain degree 2 weeks after surgery shows (r = 0.270, p <0.01), anxiety (r = 0.219, p <0.05) impact on sleep, Similarly, pain degree 3 months after surgery (r = 0.180, p <0.05) shows impact on sleep. However, tracheostomy and tumor size did not affect the degree of pain. Pre-operative depression and post-operative pain, anxiety and depression can affect the sleep quality of oral cancer patient receiving surgery. Early intervention by caregivers pre-operatively can reduce patients' depression and anxiety conditions and improve sleep quality. These results provide a practical reference for clinical use. References: Barsevick, A. M. (2007). The elusive concept of the symptom cluster. Oncology Nursing Forum,34(5).971-980. Campana, J.P.& Meyers, A.D. (2006). The surgical management of oral cancer. Otolaryngologic Clinics of North America, 39(2), 331-348. Chaudu, A., Smith, A. C. H., & Rogers, S. N.(2006).Health-related quality of life in oral cancer:a review.journal of Oral and Maxillofacial Surgery, 63(3),495-502. Hajjar, R. R. (2008). Sleep disturbance in palliative care.clinics in Geriatric Medicine, 24, 83-91. Kvale, E. A., & Shuster, J. L. (2006). Sleep disturbance in supportive care of cancer: A review. Journal of Palliative Medicine, 9, 437-450. Manber, R., Edinger, J. D., Gress, J. L., San Pedro-Salcedo,M. G., Kuo, T. F., & Kalista, T. (2008). Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep, 31, 489-495. Mystakidou, K., Parpa, E., Tsilika, E., Pathiaki, M., Patiraki,E., Galanos, A., et al. (2007). Sleep quality in advanced cancer patients. Journal of Psychosomatiic Research,62, 527-533. Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger,J. D., Espie, C. A., & Lichstein, K. L. (2006).Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004). Sleep, 29,1398-1414.Morin, C. M., & Espie

1142 Empowerment as a mediator of the influence of quality of life in community rehabilitation for chronic schizophrenia patients Y.-W. Shih 1,*, C.-J. Hsieh 2, T.-M. Hung 3, C.-Y. Wang 1 1 Taipei City Hospital Songde Campus, 2 National Taipei University of Nursing and Health Sciences, 3 PhD Students,Gradute Institute of Clinical Medical Sciences of Nursing, Chang Gung University, Taipei City Hospital Songde Campus, taipei, Taiwan To test more directly whether one aspect of empowerment perception mediates relations between psychiatric community rehabilitation and quality of life scale in patients with chronic schizophrenia. This study was conducted in ten community rehabilitation centers in northern Taiwan.The participants diagnosed with chronic schizophrenia by DSM-IV criteria(american Psychological Association, 1994) were included into this cross-section survey.we used probability proportional to size (PPS) random sampling. They were stratified random sampling from the institutes of psychiatric rehabilitation in community which in the halfway house and Community rehabilitation Center in the north of Taiwan. Instruments included the psychiatric symptoms scales (PSS), psychiatric community rehabilitation scale (PCRS), empowerment scale (ES), and the quality of life scale for Psychiatric patients (QLSP).SPSS 15.0 for windows and AMOS 7.0 were used to analyze this data. A total of 190 patients (95males, 95females) completed the entire questionnaires, with age of 44.9±11.6 years(range=20 to 85). A majority of patients presented negative symptom of chronic psychosis. The subjects had the highest score of self-esteem in empowerment perception, and score of righteous anger was the lowest. Structural equation modeling supported empowerment as a mediator of the influence of quality of life in community rehabilitation for chronic schizophrenia patients, Beyond descriptive statistics, correlation and structural equation models were computed. Findings showed that empowerment in chronic schizophrenia mediates quality of life, while psychosocial rehabilitation activities seem to increase empowerment, which may in turn increase quality of life. Psychotic symptoms seem to have a direct effect of decreasing quality of life that could not be mediated by empowerment. Empowerment had a significant effect on quality of life for chronic schizophrenia. We can understand the quality of life and empowerment perception in community rehabilitation for chronic schizophrenia patients. Empowerment had significant effects on quality of life for chronic schizophrenia. The findings of this study address the importance of empowerment and rehabilitation activities to promote quality of life for.chronic schizophrenia. It is also suggested that various rehabilitation programs and empowerment health education are needs to enhance quality of life for chronic schizophrenia in the community.the results of this study may guide the rehabilitation program of psychiatry and study in the future. References: American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorder, 4 th eds.american Psychiatric Association,Washington, D. C. Cheng, J. J., Ouyang, W. C., & Lee, S. F. C. (2006). Reliability and validity of the quality of life scale for psychiatric patient. Taiwanese Journal of Psychiatry, 20(1), 19-31. Hwu, H. G. (1994). Multidimensional psychopathological group research project on schizophrenia. Report of National Health Research Institute,Taiwan (DoH83, 84, 85-HR-306). Rogers, E. S., Chamberlin, J., Ellison, M. L., & Crean, T. (1997). A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatric Services, 48(8), 1042-1047.

1205 Intensive team care for diabetic foot increasing the limb s preserving rate C.-J. Hsieh 1, R.-T. Liu 1, J.-J. Sheu 2, C.-C. Chen 3,* 1 The Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital Kaohsiung, Taiwan, Kaohsiung City, 2 Cardiovascular and Thoracic Surgery, Kaohsiung Chang Gung Memorial Hospital, 3 Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan Diabetic patients have a 30-fold higher risk of lower-extremity amputation due to infection compared with patients without diabetes. In Taiwan, approximately 26.9% of the diabetic foot ulcers progressed to amputation. Amputations may be debilitating and can dramatically affect the patient s quality of life. In order to preserving the limbs of these patients, we set up diabetic foot care team to prompt identification of the infection, followed by appropriate antibiotic therapy and intensive blood glucose control in conjunction with good wound care and judicious use of aggressive surgical procedures when warranted, then followed by aggressive foot care education program. All type 2 diabetic patients with foot ulcer were admitted to the ward of Metabolism from emergency department. After admission, team discussion was hold within 24 hours. The intensive team car has been set up since 2005. The team included diabetic expert of Internal medicine, plasty surgeon, cardiovascular surgeon, orthopedic surgeon, dietician (option) and diabetic educator. According to Wager grade of foot ulcer and patient s condition, we decided the treatment method and clinical path-way. The diabetes doctor and plasty surgeon visited this patient every day. If condition got worse, case conference will be hold and further therapy would be concluded. After 5 years, we evaluated our outcome by another plasty expert not belonging to our team and compared the outcome between 2004 and 2010. The disease severity decreased due to successful education program for out-patients and post-ulcer patients. When comparing to the patients distribution of 2004, early hospitalization during low Wagner grade (G) status were found (G1. 21.6% vs. 5.4% p<0.001, G2: 9.7% vs. 6.0%, P= 0.05, G3: 35.8% vs. 25.5%, p<0.001, G4: 17.2% vs. 44.3, p<0.001, G5: 15.7% vs.18.8%, p= 0.07). The total amputation rates of below knee and above knee were reduced from 32.2% to 12.6%. Healed rate and improved rate were also increased after team-care program (healed rate: 45.6% vs. 54.5% p=0.001, improved rate: 18.8% vs. 43.3% p<0.001). Among the patients with high grade ulcer (G4 and G5), healed rate is also high in intensive team care group (65.9% vs.44.7, p<0.001). In 2010, we did more duppler sonography examination than expensive MRA. However, the successful rate of by-pass surgery increased significantly from 68% to 100%, p< 0.001. The average of hospital length of stay was not different (27.1 vs, 27.5 days), but increased in high grade group (G4 and G5: 31.0 vs. 24.6 days). Individualizing patient centered treatment is very important. Through team discussion, we can choose the correct direction and adequate clinical pathway for patient.

1238 Effectiveness of applying multimedia cd-rom and health manual in patients receiving carotid artery stenting L. H. Cheng 1,*, M. S. Tong 1, E. Y. Lin 1, F. Y. Li 1 1 Neurology, LINKOU CHANG GUNG MEMORIAL HOSPITAL, Taoyuan County, Taiwan Enhance satisfaction in health education instruction for patients receiving carotid artery stenting from 44.4% to 94% or more.and Enhancing integrity of nursing staff performance in health education guidance. Develop care guidelines for carotid artery stenting and content includes: preoperative evaluation, postoperative care and discharge care instructions are the basis of care and thereby to achieve care integrity. Formulate Carotid artery stenting health education instruction integrity checklist and place into special quality management monitoring program. Preparing and knowing carotid stenosis and stenting health education instruction manual. Due to the majority of patient consisting of elderly, the manual is designed with bolded text with font 16, which is supplemented by color photos to explain and enhance readability. Preparing the Acquaintance to carotid stenosis and stenting multimedia health education CD-ROM (in Mandarin and Taiwanese languages). Set up the central system broadcasting software by inquiring from professional computer software engineer with application of Media SDC to set up the automatic central broadcasting health education CD-ROM, in order to implement the periodic broadcasting and the reminder for broadcasting through marquee. Schedule the on-the-job education and training related to carotid artery stenting for nurses. Jointly discuss and develop various related courses with the radiologists through interdepartmental cooperation. The course content may include so-called carotid stenosis, diagnosis and evaluation, carotid artery stenting indications, contraindications, complications, and placement process, postoperative and discharge care instructions. The overall effectiveness of implementation for Health Education Instruction Satisfaction Survey for Patients of Strokes Receiving Carotid Artery Stenting was improved from 44.4% to 96.4%, indicating a progress rate of 117.11% and the achievement rate of 104.84%, meeting the target of this research. Moreover the integrity of nurses implementing carotid artery stenting health education instruction was also enhanced from 40.5% to 100%, where the nurse cognition to carotid artery stenting also improved from 45% to 93%. Due to the increasing number of people suffering strokes, the study revealed that carotid stenosis has high relevance with strokes, which thereby highlights more on the importance of carotid artery stenting. The integral health education instruction could demonstrate the unique and professional function of nurses, which can enhance the convenience for nurses in the implementation of health education through the auxiliary teaching materials, thereby to enhance the patient and caregiver satisfaction for carotid artery stenting health education instruction. Consequently, the nursing human resource and application of nursing hours can be saved to enhance the integrity of health education and thereby to enhance medical-seeking safety for patients and maintain excellent medical care quality. References: Burkhart, J. A. (2008). Training Nurses to Be Teachers. The Journal of Continuing Education in Nursing, 39(11), 503-510. Chaiurvech, S., & Yadav, J. (2006). The role of antiplatelet therapy in carotid stenting for ischemic stroke prevention. Stork, 37(2), 1572-1577. Lopez, A. C., & Roper, L. D. (2008). New techniques in carotid stenting. Nurse Practitioner, 33(4), 43-47. Otani, K., Waterman, B., Faulkner, K. M., & Boslaugh, S. (2009).Patient Satisfaction: Focusing on "Excellent". Journal of Healthcare Management,54(2), 93-104.

1242 In order to promote a sense of patient-centered service L. I-hsiu 1, S. Ching-Yun 1, H. Hsiao-Ping 1, W. Chin-Ling 1,* 1 Chang Gung Memorial Hospital of Kaohsiung, Kaohsiung, Taiwan Implementation of Patient centered care in order to maintain and provide our excellent quality of medical service and to provide touching service.we hope to achieve the goal of comforting both the patients and their relatives heart. In our ICU, we established a standardized pamphlet including possible questions(from patients and relatives) and answers that should be provided by our staff during the following situations: in-patient admission (reception),visiting hours,during hospitalization course.additional criteria which were included in our research are: (1) all medical staff must be equipped to provide the relatives with patient s current medical condition(2) provide elders or physical disabled relatives with chairs for them to sit(3) telephone visits for those relatives who are unable to come during visiting hours and provide them with the latest update concerning patient s current condition in order to alleviate their anxiety(4) Provide consultation from traditional Chinese medicine according to patient and relatives inquiries which might involve adjuvant therapy with Chinese(herbal) medicine and acupuncture in order to improve patients recovery.we provide professional service from our nursing staff, social workers, members of our referral group, dietician, clinical pharmacists and hospice palliative can also provide patients with different needs.before each patient s discharge, clinical nursing staff offer them online telephone service whenever they require additional medical assistance.for terminal patients, we will provide them with private space and flexible visiting hours for their relatives to accompany patients during their finale to compensate for the impending loss of the patient.after the patient expired, our nursing staff will also accompany patient s relative in corpse care and it is also during this scene when we try and encourage the relatives to bravely utter out their hidden secrets and at the same time empathize the relatives for their losses.each year, our hospital will arrange continuing education classes teaching medical treatment service quality.we will also teach newcomers our customarized telephone manners and the standardized response in answering alarm calls.this will provide a standardized and consistent medical service quality.each year our hospital arrange most outstanding medical service quality award contests for all medical staff, the winners of the contest will receive service rewards from the hospital.we also offer letters to the superintendent for patients and their family to express their deepest emotions.further rewards will be awarded to those medical staff who had been praised and recommended by family members.thus our hospital tries to promote the nursing staff in all ways in hope of providing patients with the most outstanding medical services. By continuous education classes for our nursing staff and positive reinforcement, our medical service satisfaction survey reached 95% which showed a 0.4% increment compared to last year's survey.our annual statistic revealed Thank you letters showthat high praise were given to our nursing staff for having professional nursing knowledge with a soft, understanding and caring heart in order to diminish relatives anxiety and frustration and at the same time bring heart warming effect for both the patient and their families. The main core value of nursing profession is care.when we bring a grateful and loving heart while performing our daily tasks, we will bring comfort and warmth to the patient and their relatives.for this is the final goal which we wish to achieve.

1273 Cannulation of arteriovenous fistula using buttonhole cannulation method Y. H. Chow 1,*, H. L. Tang 1, C. M. K. Tang 1, K. L. Tong 1 1 Renal Unit, Princess Margaret Hospital, Hospital Authority, Hong Kong, Hong Kong, China Traditional ropeladder cannulation of arteriovenous fistula (AVF) using sharp needle for haemodialysis inevitably causes cannulation pain and risk of vessel infiltration. Buttonhole cannulation is a newer method in our country using blunt needle for the procedure. The objectives of this project are to study whether buttonhole method could improve cannulation quality by reducing cannulation pain, to train nurses to perform buttonhole cannulation, and to implement this technique in our haemodialysis unit. A continuous quality improvement project was implemented in the haemodialysis unit of Princess Margaret Hospital from Feb to Oct 2011. Structured training was provided to nurses by a nurse trainer. AVF cannulation was changed from ropeladder to buttonhole method. Cannulation pain assessments were performed using an analogue visual scale, 0 indicating lack of pain and 10 indicating unbearable pain, in 3 different periods: 1) using sharp needle in ropeladder cannulation, 2) the first month of buttonhole blunt needle cannulation, and 3) the seventh month of buttonhole blunt needle cannulation. Patients feedback and interview, nurses comment and questionnaire, and cannulation-related complications were studied. Thirty-five nurses participated in the training. Fourteen chronic haemodialysis patients had buttonholes created. Pain score significantly decreased from 2.85±1.47 with ropeladder technique to 0.62±0.87 at the first month of buttonhole technique (p<0.001), and further decreased to 0.26±0.32 at the seventh month (p<0.05). No infection, aneurysm or vessel infiltration occurred at buttonhole sites. All patients observed shorter haemostasis time and some observed shrinkage of old aneurysm after using buttonhole method. All patients preferred buttonhole to ropeladder cannulation. After training, all nurses expressed confidence to educate patients on buttonhole care. 29/35(83%) nurses had confidence in buttonhole cannulation and 11/35(31%) nurses had confidence in buttonhole track formation. The nurses commented that the main advantages of buttonhole method were reduced patients cannulation pain and risk of vessel infiltration. Chronic haemodialysis requires AVF cannulation and buttonhole method using blunt needle improves the AVF cannulation quality by reducing cannulation pain. It is becoming the preferred cannulation method for both patients and nurses. With well-trained nurses, this technique can be implemented in haemodialysis units.

1329 SMART group training effective or not? C. K. Ip 1,*, M. Y. Lam 1, M. K. Wong 1, L. S. Yip 1 1 Department of Psychiatry, Hospital Authority - Shatin Hospital, New Territories, Hong Kong, China Psychiatric rehabilitation referred to the restoration of community functioning like daily living and vocational adaptation for well being who had psychiatric disability. SMART Group is a rehabilitation program of PDH established in 2003 aiming at enhancing clients self confidence and promoting social inclusion by assigning clients series of tasks in rehabilitation components and biweekly group evaluation. SMART is acronym for Stretch, Motivate, Augment, Rebuild, and Target. Those clients having deficits in living skills in area of household coping, social interaction and stress coping would be recruited in the group. Members generate the acquired skills to their living situation during the transition period to the community. Primary nurses would assess and measure clients life skills functioning by using Life Skill profile (LSP).This study aimed to evaluate the outcome of clients who have recruited into SMART group with other clients in PDH. All clients who have trained over 3 months and were discharged from PDH in the period of 5/2011 to 12/2011 were recruited to be the target clients in this study. A comparison of discharge outcome and differences of LSP between date of admission and date of discharge among SMART group clients and non-smart group clients were analyzed. Among 127 discharged clients, 37 clients were eligible to be analyzed (29.13%). 14 of them have been recruited into SMART group. 6 SMART group clients (42.86%) were discharged to daytime placement like ERB course, open or supported employment while just 5 non-smart group clients (21.7%) were discharged to the above-stated placement. Moreover, 1 SMART group client (7.14%) was re-admitted to psychiatric unit due to deterioration of mental states but 8 non-smart group clients (34.8%) were re-admitted to psychiatric unit. Also, there was a statistically significant improvement (p=0.034, Mann-Whitney U test) on the total score of LSP for SMART group clients. On the subscale of LSP, statistically significant results could be found on the nurturance (p=0.039, Mann-Whitney U test) and social contact (p=0.025, Mann-Whitney U test) among them. It can be concluded that clients who are under SMART group can be effectively improved not only on the discharge outcome but also the life skill functioning.

1331 A nursing experience for a sepsis case based on Levine's conservation model and sepsis bundles N.-Y. Chang 1,*, T.-Y. Lai 1, Y.-J. Liu 1, T.-Y. Huang 2 1 Department of Nursing, Chang Gung Medical Foundation Hospital, Kaohsiung, Taiwan., 2 Department of Nursing, Chang Gung University of Science and Technology, Kaohsiung, Taiwan Sepsis caused a systemic inflammation by infection; itprogresses dramatically fast and unexpected,which affects multiple systems functions and threatslife. An evidence-based medical sepsis bundles model has been used for sepsis care in clinic practice; therefore, it should emphasize the holistic nursing care for patients with sepsis. This report was a nursing experience case study over a patient with sepsis by using Levine s Conservation Model to assess and deliver nursing care. Data were collected during patient hospitalization from June 10,2011to June 21, 2011. By using physical assessment, medical chart review, communicating with patient by writing, and interviewing patient's family members and observation to collect the data. Nursing process is based on four perspectives; which are energy saving, structural integrity preservation, conservation and social integrity of the personal integrity. This case report can provide a useful nursing care experience for future care over sepsis patient. References: American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. (1992). Critical Care Medicine, 20(6), 864-874. Aitken, L. M., Williams, G., Harvey, M., Blot, S., Kleinpell, R., Labeau, S., et al. (2011). Nursing considerations to complement the Surviviing Sepsis Campaign guidelines. Critical Care Medicine, 39(7), 1800-1818. doi: 10.1097/CCM.0b013e31821867cc Dellinger, R. P., Levy, M. M., Carlet, J. M., Bion, J., Parker, M. M., Jaeschke, R., et al. (2008a). Surviving Sepsis Campaign: International g- uidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine, 36(1), 296-327. doi: 10.1097/01.CMM.000-0298158.12101.41 Dellinger, R. P., Levy, M. M., Carlet, J. M., Bion, J., Parker, M.M., Jaeschke, R., et al. (2008b). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Medicine, 34(1), 17-60. doi: 10.1007/s00134-007-09-34-2 De Miguel-Yanes, J. M., Munoz-Gonzalez, J., Andueza-Lillo, J. A., Moyano-Villaseca, B., Gonzalez-Ramallo, V. J., & Bustamante-Fermosel, A. (2009). Implementation of a bundle of actions to improve adherence to the Surviving Sepsis Campaign guidelines at the ED. The American Journal of Emergency Medicine, 27(6), 668-674. Levine, M. E. (1996). The conservation principles: a retrospective. Nursing Science Quarterly, 9(1), 38-41. Levine, M.E. (1973). Introduction to Clinical Nursing (2nd Ed). F.A. Davis Company: Philadelphia, PA.

1349 Improving the accuracy and efficiency of prescription receipt and medication delivery for in-patient chemotherapy H.-T. Sung 1, 2,*, P.-H. Hu 1, 2, Y.-Y. Chen 2, 3, 4 2, 3, 4, K.-M. Rau 1 Division of Clinical Pharmacy,Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, 2 Chang-Gung University, College of Medicine, 3 Division of Hematology-Oncology, Department of Internal Medicine, 4 Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan To improve the efficiency and safety of prescription through connecting the hospital's Barcode Information System with the enquiry of time-lag between receipt of prescription and delivery of medication for chemotherapy during hospitalization. Step 1. Establishment of a computerized barcode audit system for hospitalized patients to reduce slip of premedication in chemotherapy. Step 2.Use of the computerized barcode audit system in chemotherapy to reduce medication ineffectiveness due to drug expiration date overdue. Step 3.Cutback of telephone enquiries made by medical staff from ward station to reduce interference to the execution of chemotherapy prescription. Step 4. Main areas of improvement: 4-1 Proposed by the Department of Pharmacy and effective since March of 2011, a department will be established to deliver the in-patient chemotherapy prescription to the chemical analysis department. The computerized Barcode system will remind the chemotherapy medication department of the receiving time, prescription in process, and the prescription completion time to facilitate the tandem enquiry by medical staff. 4-2 The Information Department will assist in setting up an alert system using the hospitalization chemotherapy prescription barcode. 4-3 Analyzing and reporting abnormal prescription to the chemotherapy safety unit and then to the Oncology Committee for quality improvement. 1. In the period of January 2009 to February 2011 before implementation of the Barcode procedure management, there were 45 cases of premedication deficiency in hospitalization chemotherapy. In the period of March to December 2011 after implementation of the Barcode procedure management, the number of premedication deficiency decreased to zero. 2. Compared to the number in the period of January 2009 to February 2011, the number of cases with revised prescription due to malfunction of medication caused by time lag decreased from 3 to 0 after implementation of the Barcode procedure management. 3. Compared to the number in the period January 2009 to February 2011, the monthly number of enquiries made by the medical ward station decreased from 435 before implementation to 30 after implementation. Our hospital has adopted the hospital information system and Barcode procedure management to establish a real-time chemotherapy medication system. Pharmacists and medical staff have applied the procedures of the computerized hospitalization system to successfully reduce the time-lag between enquiry and medication prescription, the number of medication malfunction cases due to turn-around time overdue, the number of telephone enquiries, and minimize patients' waiting times.

1388 Determine the guideline for caring patient with multi-drug resistant pathogen infection by application of FMEA Y.-Y. Huang 1,*, Y.-L. Wu 1, Y.-H. Tang 1, F.-L. Teseng 1 and New Authors 1 chang-gung memorial hospital,kaohsiung, Kaohsiung City, Taiwan Trying to clarify the possible problems in contacting isolation by application of FMEA and set policy to improve problems. We wish to increase the sensitivity of risk-identifying and ability of problem-correction and then to shorten days of admission, decrease mortality rate, dimish wastes of medical resource, avoid disease spreading in community, and strengthen quality of medical care. We used cross-sectional research design with sampling 15 nurses who involved in infection ward in one of medical centers in south Taiwan and collecting data with some structural-questionnaire. We tested the participants for their knowledge about protection policies of caring patient infected by multidrug resistant pathogen with 20 questions. The more scores they got mean better knowledge. We also watch for the completeness of education in caring patient infected by multidrug resistant pathogen with special check list of 5 items. We scoring the achievement as 1 and nonachievement as 0 for each items. Also the more scores they got means more completeness. Finally, we use FMEA to evaluate the risk in daily caring-workers as three factors: occurrence rate, severity and detection rate. We defined the risk score between 1~10(1 as little, 2 as minimal, 4 as medium, 7 as high and 9 as extremely high.) The high scoring means the higher risks. The scoring of knowledge about protection policies of caring patient infected by multidrug resistant pathogen increased from 55 to 92.5. The completeness of education improved from 52.5% to 89.5%. The risk priority numbers declined from 1558 to 342 with improving ratio of 78%. In addition, there was no adverse events with colonization of multi-drug resistant pathogens. Prevention of out-spread of multi-drug resistant pathogen was one key point of infection-control in hospitials. We did define the risks occurring in daily works and set policy for correction by using "FMEA".We announced the importance of knowlegde of isolation principle, the accuracy of practice, continuous monitoring of risk of disease spreading in order to lower cross-infection, insure quality of medical care and prevent adverse events.

1395 Home-care pharmaceutical service to elder patients Y. P. Hsiang 1,*, C. L. Tai 1, P. Y. Lee 1, Y. D. Cheng 1 1 Department of Pharmacy, Medical Center, Kaohsiung, Taiwan Kaohsiung county is located in Southern Taiwan, more than 10% inhabitants are older than 65 years. In order to provide better health care, correct medication concept to them, and to diminish the government health insurance financial burden; Community Pharmacist supply home-care pharmaceutical service to elder patients who living alone or disability. Hospital clinical pharmacist assist in reviewing and checking if medication overlapping, un-indicated, interacted with food or drugs, adverse drug reaction, integrated medication, storage of medicine, etc. Disability or living alone Elderly resident inkaohsiung county, with poly-pharmacy and visited more than two hospitals, and asking for help frequently. If those patient and family members/caregiver needed or willing to meet the pharmaceutical service; then, the well-trained community pharmacist would visit patients and family members/caregiver to educate them and provide necessary assistant.the hospital clinical pharmacist would indicate and consult to review and check the medication. During this 6 months study, from May 2010 to October 2010, total 255 patients had accepted our pharmacist service. The majority of patients wereelder than 70 years old (70.2%); others 29.8%. Female were more than male (52.5% to 47.5%). The most important 5 items of inappropriate medication problems of home care patients were self-modulated dosage (24.4%), incorrect timing to take medication(18.3%), medication without prescription(15.9%), inappropriatemethods to take medication (14.6%) and terminate drug (13.4%) The most important 5 items of reasons of medication termination were unacquainted with the way to take medication(22.8%), better feeling without medication(17%), fear of organ damage by medication (13.6%), adverse drug reaction phobia (11.4%) and poor medication effectiveness(9.1%). Pharmacist, include community and hospital clinical pharmacist are specialist in pharmaceutical knowledge. Elderly patient lived along or disability especially needed home-care pharmacist service to integrate medication to avoid overlapping, interaction with food or drug, contraindication and so on. The outcome of this study demonstrated that homecarepharmaceutical service contributed a perfect and safe quality of medication service to elderly and disability patients. References: 1.Fick DM, Cooper JW, Wade WE, Waller JL, Beers MH. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Arch Intern Med 2003; 163:2716-24 2.Elda J, RajenderRA. Healthcare Outcomes Associated with Beers Criteria: A systemic Review. Ann Pharmacother2007; 41:438-48

1455 What influences patient non-compliance with guidelines? M. G. G. Justa 1, C. Meirelles 2, A. M. Malik 1,* and Programa Conxão Local - FGVEAESP 1 Gvsaude, FGVEAESP, São Paulo, 2 Health Department, Porto Feliz Municipality, Porto Feliz, Brazil Senior citizens with Diabetes and/or Hypertension are a priority in terms of primary healthcare programs at a municipality with less than 50.000 inhabitants. They are offered home visits, scheduled appointments at health facilities and free medication. The municipal Public Health Authority identified that these patients don t follow prescribed healthier habits or designed care pathways, and could not understand what was wrong in the system. Researchers defined the research question: what were the perceived problems leading to patient non compliance with the guidelines defined by the municipal system. Objectives were to find out what these problems were from the viewpoints of healthcare providers (with different levels of instruction), citizens included in the program and managers from the municipal health system. Researchers designed an exploratory qualitative study, with specific questionnaires for each of defined stakeholders (patients, two groups of professionals). For the managerial group, the Assessment of Chronic Illness Care- ACIC (part of Robert Wood Foundation ICIC) program was used. Community health agents were found to have insufficient knowledge about Hypertension and Diabetes (20% or more). They also consider the training they receive insufficient (more than 30%). Circa 50% consider patients follow guidelines for self care (and 50% consider they don t). Main complaints received from patients are related to delay for scheduling appointments (47%); absence of MDs at health care facility (17%); care provided by nurses (16%). 67% have received complaints about drug non availability. Healthcare professionals said patients don t know enough about the health program and about consequences of their illnesses (43%). According to 57% of them, main cause of non compliances is that patients have a very easy access to non-primary care health units, such as emergency services, where they don t have to wait for scheduled appointments. Those who complain of the care provided by nurses are perceived (by 43% of the professionals) as considering themselves neglected when there is no physician involved. 47% state that patients don t follow guidelines for self care. 64% have already heard complaints about the delay in care by patients, that want to be seen when they feel like it. Non compliant patients said that they found they had the medical condition after they had symptoms (52%). 59% confirmed that they only followed the guidelines related to drugs, not those related to life habits.73% said they usually come to scheduled routine appointments and 66% denied ever having been left without the prescribed medications. Managers answers to ACIC instrument, that allows for grades from 1 to 11, led to an average of 7, 35 (according to grading criteria, a reasonable support for the program). The highest grade was related to Organization of the Healthcare Delivery System (8,66), where system improvement is emphasized, as well as leadership issues. Integration of Chronic Care Model Components had the lowest grade (6, 33). This issue considers links between self care goals and information systems or local policies with therapeutic pathways for patients. Communication processes weak, leading to insufficient knowledge about the program by all stakeholders except managers, creating unfulfilled expectations. Managers have mistaken expectations about stakeholders. Education of patients and community agents seems ineffective. Assumptions about patient s interest in self care are unrealistic. Information systems don t show integration with policies to be assessed.

1528 The use of structured observation to embed improvements in nutritional care M. Miller 1,*, P. Bond 1 1 Healthcare Improvement Scotland, Glasgow, United Kingdom A Protected Meal Times Observation Tool has been developed and tested in collaboration with nutrition champions and colleagues from across Scotland as part Healthcare Improvement Scotland s Improving Nutritional Care Programme. The Tool is a 2-Part measuring instrument and is part of a range of resources that aim to support an improved mealtime experience for individuals. It has been designed to support observation and recording of meal times in a structured way that enables identification of good practice and areas for improvement, and allows improvements to be measured over time. Part 1 of the observation tool supports the recording of information about what happens during meal times. Specifically, observers check whether or not guidance concerning meal time processes is being followed. Part 2 supports the recording of information about how care is provided during meal times, focusing on the quality of interactions between staff and patients.nutrition improvement teams from NHS boards and care homes gathered baseline data with the use of the tools. Patient, staff and carer experience was also gathered. In order to prioritise areas for improvement around meal times, data was also examined from other sources including clinical quality indicators, datix incidents and complaints. Potential areas identified for improvement included: Patients identified as requiring assistance not getting help with eating and drinking Staff not always available to assist at meal times Medication rounds carried out during meal times Invasive clinical procedures, eg urinary catheterisation and IV cannulation carried out during mealtimes Individuals not having opportunity to wash hands before meals Cluttered bed tables Delay between meal trolleys arriving on the ward and meals being delivered to patients, resulting in the temperature of food being too cold. Using quality improvement methodologies including PDSA cycles a number of changes were tested in different areas resulting in improvements to mealtime processes including: - nutrition introduced as a key element of the safety brief - timing of medication rounds altered to avoid meal times - better compliance with completion of food charts - reduction in the time between the meal arriving on the ward and delivery to the patient - reduction in food wastage - mealtime gate-keeper to co-ordinate mealtimes and reduce unnecessary interruptions - increased opportunity for hand-washing before meals - clinical champion identified to lead on nutritional care - basket system for belongings to allow ease of access to meals on tray tables - real time feedback to team regarding good practice and areas for future improvement, and One particular resident would not sit through meal times, and after implementing these changes, this resident now sits through the entire meal time. (member of staff from care home) "Nutrition is now regarded as an important priority and staff are empowered to promote adherence to the protected meal time policy. (staff nurse) One of the highlights has been "approaching the dining room to observe and witnessing the staff carrying out this task (hand washing) without prompting for the first time Eureka! (care home manager) The use of the observation tool at mealtimes helped to build up a picture of individual's care and identify areas for improvement. Triangulating observation data alongside findings from other methods can help to provide a more complete picture of the care experiences of older people.

1539 Reducing unplanned extubation in the neonatal intensive care unit S.-W. Lin 1,*, W.-M. Shih 2, C.-F. Cheng 1, S.-Y. Su 1 1 Department of Pediatrics, Chang Gung Medical Foundation, Chang Gung Memorial Hospital, 2 School of Nursing, Chang Gung Institute of Technology, Kuei Shan Hsiang, Taiwan Unplanned extubation events are a serious hazard to patient safety and are important quality issues in current medical practice as it is a common occurrence in intensive care unit, especially in a neonatal intensive care unit, where reestablishing a secure airway can be difficult. The primary objective of this study was to assess the effectiveness of a continuous quality improvement program in reducing the incidence of unplanned extubation in a neonatal intensive care unit. This project was executed between July 1, 2011 and July 31, 2011. The implemented interventions were as follows: (1) held continuing education regarding endotracheal care and importance of prevention of unplanned extubation through literature review; (2) adjusted nurse and patient ratio to 1:2; (3) revised standard care of endotrachea and added pictures including fixation of endotrachea, suction, and patient posture; (4) increased mechanical ventilation tubing support points to decrease external forces involved. The evaluation period was held from August 1, 2011 to January 31, 2012. From a total of 114 patients who required 1812 intubated patient days, 3(2.6%) patients experienced 3 unplanned extubation events. The overall rate of unplanned extubation events for the study period was 0.17 unplanned extubation events per 100 intubated patient days, and this rate decreased from 0.65 to 0.17 which has obviously reached the goal. It is proved that through continuous quality improvement (CQI), the unplanned extubation events rate could be decreased in a NICU. Nurses should base on patient characteristics and course of disease to continue monitor related causes of endotracheal patient unplanned extubation events and intervene with prevention steps to avoid hurt of patient and provide better quality of care. References: Loughead, J. L., Brennan, R. A., DeJuilio, P., Camposeo, V., Wengert, J., & Cooke, D. (2008). Reducing accidental extubation in neonates. Joint Commission journal on quality and patient safety, 34(3), 164-170. Lucas da Silva, P. S., de Carvalho, W. B., (2010). Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations. Pediatr Crit Care Med, 11(2), 287-294. Sadowski, R., Dechert, R. E., Bandy, K. P., Juno, J., Bhatt-Mehta, V., & Custer, J. R., et al. (2004). Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit. Pediatrics, 114(3), 628-632. Veldman. A., Trautschold, T., Weiss, K., Fischer, D., & Bauer, K. (2006). Characteristics and outcome of unplanned extubation in ventilated preterm and term newborns on a neonatal intensive care unit. Paediatric anaesthesia, 16(9), 968-973.

1541 Moving beyond biomedical markers implementation of psychological and erectile dysfunction screening tools in clinical practice in a diabetes unit P. Harkin 1,* 1 Diabetes, St Vincents Private Hospital, Elm Park, Ireland In May 2011, Psychological and Erectile dysfunction screening tools were introduced into the care of our Diabetes Patients in St. Vincent s Private Hospital. - The DAWN study (Diabetes Attitudes Wishes and Needs Study 2001) and the Dawn MIND study with results published in 2011 highlight the psycho-social impact of diabetes. The global consensus highlights that Psychological assessments should be included as an ongoing part of the medical management of diabetes. Psychosocial issues impact the ability for diabetes self-management. It makes sense that addressing these issues can help to improve patient outcomes. Assessment should include general and diabetes-related quality of life. These assessments can help to screen for diabetes related distress, anxiety and depression The literature highlights the link with PAID scores and BMI and HbA1c. For physicians who like to focus on biomedical markers, psychological assessments can help to meet that goal. The aims were: - To conduct these assessments ensure that we are maintaining recommended standards of care. - To diagnose psychological issues as early as possible so that we can help to improve self-management. - To determine the extent of Erectile dysfunction and its severity as a marker for disease. - Patients can be referred and treatment initiated and records of referrals maintained. The WHO-5 Well-being Index, the PAID and the SHIM are self-administered questionnaires. Current Data 221 questionnaires completed since May 2011. 86 patients received Psychological assessments (50 men and 36 women). Of the 50 men 37 also received Erectile Dysfunction screening. 94 completed PAID questionnaires (56 men and 38 women) and 90 completed WHO-5 questionnaires (53 men and 37 women) Of the WHO-5 well-being index one woman scored <28% indicating likely depression but is a young Type 1 already attending regular Psychoanalysis. 8% scored <52% indicative of low mood. 13% Men scored <52% indicating low mood. 8%of the women scored >40% PAID indicative of high distress and 7% of men scored >40%. Shim results: Of the 37 patients, 10 had no ED and 27 had different degrees (7 had Type 1 and 20 Type 2). 24% Mild ED, 14% Mod-Mild ED; 5% Mod ED and 30% had Severe ED. Psychological and Erectile Dysfunction screening was found to be relatively straightforward to introduce into clinical care. They were not time consuming, patients had no objection to completing them and the results were conducive to discussion during the clinic visit. More importantly their introduction ensured recommended standards of care were being provided in the management of the diabetes patient group. The SHIM in particular allowed the sensitive issue of erectile dysfunction to be broached within the clinical setting

1584 Using the team resource management (TRM) to improve the care of critical trauma patients in emergency room C.-C. Liang 1,*, Y.-E. Hsu 2, H.-Y. Hsiao 1, C.-M. Yuen 1 1 Department of Emergency & Trauma Surgery, 2 DEPARTMENT OF EMERGENCY & TRAUMA SURGERY, KAOHSIUNG CHANG GUNG MEMORIAL HOSPITAL, CHANG GUNG UNIVERSITY COLLEGE OF MEDICINE, KAOHSIUNG, TAIWAN, Kaohsiung, Taiwan To improve the quality of managing critical trauma patient in the emergency room is the key to decease the associated high morbidity and mortality. When the patient arrives the emergency room with the presentation of either one devastating situation as Coma Glasgow Scale (CGS)<13, systolic blood pressure (SBP)<90mmHg, gun shot over the head, neck or trunk, a fall from more than 6 meter high, pelvic fracture or multiple trauma, the trauma patient in critical condition is coded as Trauma Blue. Once the kind of patient is identified, the nurse will call out Trauma Blue to all the involved staffs, alerting this case needs immediate first aide, timely management and intensive care. At first, from October 2010 to July 2011, we collected 2988 emergency patients, about 281 patients who were called out Trauma Blue and 204 patients who were indicated for calling out Trauma Blue. And the correct rate of calling out Trauma Blue was 64.40% and error rate of calling out Trauma Blue was 11.30%. To improve the quality, safety and efficiency of patient care, implement of training program, leadership, communicated skill, situation monitor and mutual support in response to the call of Trauma Blue is set up and organized by team resource management (TRM). Since its appliance from august to December 2011, we collected 1502 emergency patients, about 153 patients who were called out Trauma Blue and 136 patients who were indicated for calling out Trauma Blue. And the correct rate of calling out Trauma Blue was increased to 86.90% and error rate of calling out Trauma Blue was decreased to 2.20%. In summary, the TRM program can significantly improve the correct and error rate of calling out Trauma Blue and bear great potential in dealing with those critical trauma patients presented in the emergency room.

1597 Redefining in strict terms the most crucial indicator of report turnaround time in radiology; time clock converted to 24/7 (round the clock), resulting in improved communication and better patient satisfaction S. M. Sohail 1,*, N. F. Husain 1, I. Masroor 1, W. Siddiqui 1 1 Radiology, The Aga Khan University Hospital, Karachi, Pakistan The focus of this project was to align Radiology with the institutional patient-centered approach. We wanted to ensure that reporting of all radiological examinations is done timely, inclusive of studies done on public holidays and weekends resulting in improved patient communication and satisfaction. This Quality Improvement Project, with a focus on patient centered care, was undertaken by the department of Radiology, Aga Khan University Hospital, Karachi (Pakistan) in January 2011, using the PDCA methodology. The initial checks on report turnaround monitoring were related to working hours only; public holidays and weekends were excluded from the time bound, whereas the department operates 24/7. The previous practice did not reflect the actual report turnaround, due to improper time tags in the system. This delay was not being captured by the system; resulting unrealistically higher benchmarks/targets for this indicator. Hence, the rationale of the project was to redefine report turnaround time indicator, for all modalities in line with the department s operational timings. Being part of the healthcare industry the consequences foreseen could have had greater impact on patient care (realistic communication resulting in better patient satisfaction). These changes reflected the actual performance of the department in terms of timely reporting and provided us opportunities to identify areas of improvement. As facilitation tools, Failure Mode & Effect Analysis (FMEA), Check Sheet and Brainstorming were used. The baseline data of the report turnaround time indicator was taken from January June, 2011 with the previous time clock, excluding weekends and public holidays. The turnaround indicators in almost all the modalities showed performance over 90 %. The time clock was converted to 24/7 and retrospective data was collated which depicted that the report turnaround time indicator in all the modalities was actually much lower; CT dropped down from 97% to 60 %.; MRI from 97 % to 65 %; Nuclear Medicine from 98 % to 87 %; Special Procedures from 98 % to 72 %; Standard Procedures from 98 % to 76%; Ultrasound and VIR (Vascular & Interventional Radiology) almost remained at the same levels. As interventions: list of unsigned exam, unreported exams were daily circulated; residents, radiologist and staff members were sensitized; electronic, verbal and personal reminders sent to radiologists whose reports showed in either of the two lists. Correct portrayal of Radiology report turnaround times resulted in more accurate communication with patients, instilling confidence in them and resulting in improved patient satisfaction ratings. The weekends and/or public holidays are included in the calculation of turnaround time; calculations are done from the time of registration to the report finalization in the system. This initiative has lead to greater patient satisfaction and timely reporting of all Radiological exams. As a futuristic approach, based on the areas of improvement identified, we plan to monitor the following report turnaround time s indicators as well: All Stat/Urgent Requests (marked as Stat/Urgent on the Requisition slip) All Requests received from Critical Areas comprising of OR/ICU/NICU/CICU-CCU All Requests received from ER (Emergency Room)

1638 Incidence of placement of endotracheal tube in critically-ill patients causing skin tears and related factors T.-W. Liu 1,*, M.-Y. Peng 1 on behalf of Intensive Care Unit, Department of Internal Medicine, 1 Nurse Department, Far Eastern Memorial Hospital, New Taipei City, Taiwan Skin acts as a protection shield for humans. Pain and disfiguration is likely and infection is possible if not treated. The costs for care and length of hospitalization are increased. In clinical practice, skin tears caused by treatment needs, in particular surgical tapes, is often omitted from the literature. Previous research has indicated that skin tears mostly occur in the head and neck. Head and neck-induced skin tears accounts for 73% and above when excluding skin tears caused from medical dressings, most of which had a Level 3 injury level (complete tissue damage). The average time for wound healing was 10.29 days. The placement of endotracheal tubes in the patients of this unit was 86%~88%. We discuss incidence and related danger factors of skin tears caused by placing endotracheal tubes in hospitalized patients. Actual observation method was adopted to view patient skin and a self-designed checklist was used to gather the information. The facial skin of patients with endotracheal tube placement was checked every day at 07:00 from January to April 2011. It was discovered that the incidence of elastic adhesive tapes caused skin tears was 0.57% with the damage level was Level 2. Cause analysis: the average age of patients with facial skin tears was 78, HB average was 8.3 mg/dl, albumin average was 2.2 mg/dl, and belonged to the high-risk malnutrition group. The facial skin tears were caused by removal or replacement of endotracheal tube elastic adhesive tapes. Intervention: 1. immediately replace the elastic adhesive tape of endotracheal tube when patients are hospitalized and provide protection measures (artificial skin or breathable dressing); 2. hold in-service education on the skills required for remove elastic adhesive tapes, masking tapes, and breathable dressing; 3. use cotton yarn instead for patients with fragile, damage-prone skin, and those who currently have skin damage; and 4. hold monthly meetings to review the reasons of occurrence for skin tears. The incidence of endotracheal tube fastening that causes facial skin tears from June to December 2011 decreased to 0.05% After intervention and prevention measures were implemented with changes in method in care, the incidence of endotracheal tube fastening that caused facial skin tears decreased from 0.57% to 0.05%. Skin tears caused from treatments has shown positive effects in reducing incidences of skin tears from clinical intervention and prevention measures and by changing care methods. This can be used as a reference for skin tear prevention intervention in clinical practice. References: Anthony, D., Parboteeah, S., Saleh, M., & Papanikolau, P. (2008). Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. Journal of Clinical Nursing, 17(5), 646-53. Battersby, L. (2009). Exploring best practice in the management of skin tears in old people. Nursing Time, 105(16), 22-26. Beldon, P. (2008). Management options for patients with pretibial lacerations. Nursing Standard, 22(32), 53-60. Fore, J. (2006). A review of skin and the effects of aging on skin structure and function, Ostomy Wound Management, 52(9), 24-35. Vuolo, J. (2004). Current option for managing the problem of excess wound exudates. Professional Nurse, 19(9), 487-491.

1646 Disclosure of medical errors to patients in Japan: physicians attitudes regarding the disclosure of medical errors K. Kobayashi 1,*, S. Maeda 1 1 Graduate School of Health Management, Keio University, Kanagawa, Japan To investigate physicians attitudes regarding the disclosure of medical errors to patients in an acute care, teaching hospital in Japan. From September 12-30 th, 2011, anonymous questionnaires were distributed to all physicians in an acute care, teaching hospital with 400 beds in Kanagawa, Japan. The questionnaires included 4 hypothetical scenarios describing medical errors (serious error vs. minor error, more apparent vs. less apparent) to the patient. Responses to the questionnaires were measured on a 4-point Likert scale (from strongly disagree to strongly agree ). These responses were dichotomized at the midpoint (agree vs. disagree). We used Fisher s exact test to determine whether the responses differed based on whether the error was serious or minor, and whether the error was apparent or less apparent to the patient. We also examined what information would be disclosed by the physicians. Fifty-three (67.1%) physicians completed the questionnaire. All physicians agreed that medical errors should be open to the patients. However, some physicians would not disclose the error when the error is less apparent to the patient. All respondents would disclose the error when a patient knows what happened. However, 18.4% (serious error) and 28.0% (minor error) would not disclose the error when patients were unaware of that error. Of the respondents, almost all physicians (96.2%) would explain the aftermath due to that error and the follow-up treatment. Of the respondents, 28.3% said they would not apologize and 49.1% would not refer to the prevention of such an error in the future. Table1. Attitudes Regarding Scenarios Type of Error Patients Awareness of the Error Attitudes About Disclosure Disclose n. (%) Undisclosed n. (%) Serious Aware 50 (100.0) 0 (0.0) Unclear 47 (95.9) 2 (4.1) Unaware 40 (81.6) 9 (18.4) Minor Aware 50 (100.0) 0 (0.0) Unclear 48 (96.0) 2 (4.0) Unaware 36 (72.0) 14 (28.0) Physicians attitudes regarding disclosure of medical errors vary in the acute care, teaching hospital that responded to the questionnaire. A system to assist physicians in disclosing medical errors to patients and further education to enable physicians to do so needs to be established.

1662 Comparison of quality of life among patients with hemodialysis and peritoneal dialysis P. M. Chan 1,*, Y. S. Peng 2, H. E. Liu 3 1 Intensive Care Unit, National Cheng Kung University Hospital, Tainan, 2 Nephrology, Far Eastern Memorial Hospital, Taipei, 3 Nursing department, Chang Gung University, Taoyuan, Taiwan Quality of life was a important problem in chronic dialysis patients. This paper was designed to comparison of quality of life among patient with hemodialysis and peritoneal dialysis. We conducted this study by use questionnaires. A total of 245 patients(hd 209 V.S. PD 36) completed the questionnaires, and were enrolled into further analysis. The response rate was 58% & 69% (HD V.S. PD). Demographic data, biochemical and hematologic parameters were analyzed. All patients were asked to complete by themselves all three questionnaires(chinese version): (1)World Health Organization Quality of Life instrument (WHOQOL-BREF Taiwan version), (2)the Beck Depression Inventory-II(BDI-II) & (3)Charlson comorbidity index. Age, comorbidity index, depression and CRP level were associated with quality of life in hemodialysis. Comorbidity index and depression were negatively correlated with quality of life in peritoneal dialysis. Duration of dialysis and nutritional status (albumin concentration and hemoglobin) were not found to be correlated with the quality of life in hemodialysis and peritoneal dialysis patient. The hypoalbuminemia and hypercholesterolemia by patients on PD were more than those on HD. No difference was found in the quality of life scores between HD & PD. Table 1.Comparison of quality of life among patients with HD and PD Item HD (n=209) PD (n=36) mean(sd) mean(sd) U p valu e global 11.32(±2.7) 11.3(±2.8) 3685 0.84 physical 12.56(±2.7) 12.63(±3.4) 3574 0.63 psycholo gical Social.re lationshi p 12.17(±2.8) 11.79(±3.4) 3471 0.45 13.79(±2.5) 14.00(±2.2) 3657 0.78 environ 13.59(±2.1) 14.09(±2.0) 3181 0.13 mental * p < 0.05 Patients on chronic dialysis suffered from poor quality of life. Depression and comorbidity index were two major factors affecting the quality of life in this unique patient group. The comparison indicated no difference in quality of life between patients under hemodialysis and those under peritoneal dialysis. Key words: quality of life, hemodialysis, peritoneal dialysis References: Bohlke, M., Nunes, D.L., Marini, S.S., Kitamura, C., Andrade, M., & Von-gysel, M.P., (2008). Predictors of quality of life among patients on dialysis in southern Brazil. Sao Paulo Medical Journal, 126(5), 252-256. Merkus, M.P., Jager, K.J., Dekker, F.W., Boeschoten, E.W., Stevens, P., Krediet, R.T.,(1997). Quality of life in patients on chronic dialysis: self-assessment 3 months after the start of treatment. The Necosad Study Group. American Journal of Kidney Disease, 29(4), 584-592. Wasserfallen, J.B., Halabi, G., Saudan, P., Perneger, T., Feldman, H.I., Martin, P.Y., & Wauters, J.P., (2004). Quality of life on chronic dialysis: comparison between haemodialysis and peritoneal dialysis. Nephrology Dialysis Transplantation, 19(6), 1594-1599.

1786 Reducing unscheduled 30 day readmissions for heart failure in National University Hospital (NUH), Singapore R. Wong 1, S. C. Quek 2,*, W. X. Tan 3, T. C. Yeo 2 1 Medical Affairs, 2 Cardiac Department, 3 National University Health System, Singapore, Singapore To reduce unscheduled 30-day readmission for heart failure into Cardiac Department in NUH Unscheduled 30-day readmission contributes significantly to morbidity and mortality of heart failure (HF) patients, and strain tight healthcare resources. In NUH, it constitutes one of the commonest causes of 30-day readmission (18% in 2009; 13.2% in 2010) amongst all chronic diseases. According to Ministry of Health (MOH), cardiovascular disease including HF constitutes the largest portion of disability adjusted life years. Within Cardiac Department at NUH, 30-day readmissions contributed 17% of all HF hospitalizations. Data was systematically collected on unscheduled 30-day HF readmission between March 2010 to December 2011 and the average length of stay (ALOS) of HF patients admitted at Cardiac Department. CPIP methodology was used to study the factors affecting readmission rates. Unscheduled 30-day HF readmissions were used as measurement for change effects and ALOS was tracked to monitor a possible negative impact of the intervention. We identified two major factors contributing to increased readmission rates: comorbidities that were not fully addressed during admission; and suboptimal compliance by the patients or care-givers to medications and lifestyle modification. Using the PDSA cycle, we implemented targeted interventions that included devising a HF checklist to fine-tune discharge eligibility of all HF discharges within Cardiac Department addressing the more common comorbidities (renal-pulmonaryanemia) associated with heart failure. This is to assist ward physicians in evaluating appropriateness for discharge. Patients at high-risk for discharge failure patients were identified through a risk stratification method using modified 8P and GAP forms from Project BOOST. We set up Heart Failure Teaching Clinics for early review of HF patients at high risk for discharge failure. HF coordinators also provided additional counseling to caregivers and patients, appointed HF coordinators as discharge advocate, and redesigned HF brochures as education materials. NUH recorded 13.2% of 30-day HF readmission rates in 2010. In January 2011, it was >15%. The rates were tracked monthly after interventions were implemented. By June 2011, the readmission rate went down to 6.6 % with fluctuations noted in the subsequent months. December 2011 data showed the lowest rate at 6.0%. The ALOS increased from 4 to 5 days, probably as a result of additional observation day during hospitalization which was an effect of the enhanced predischarge care of these group of patients. By estimation, based on the actualized number of HF admissions, 32 patientdays were saved, translating to $8528 (B2 class) and $6456 (C class) in average costs of admissions. This change in hospitalization trend is dramatic, representing a system change that targets critical gaps in discharge planning. High risk discharge failures are pre-identified for aggressive treatment and early review. This CPIP on reduction of unscheduled 30-day readmission for heart failure had systematically and structurally identified the most critical problems in the inpatient management of heart failure, as well as discharge planning. We have successfully reduced the above mentioned rates significantly, and look set to sustain the process via systemic approach built into current care path.

1815 Testing a model for early detection of type 2 diabetes A. Blom 1,*, P. Qvist 1, B. R. Lindegaard 1 1 Center for Quality, Region of Southern Denmark, Middelfart, Denmark To study the applicability of a targeted effort to screen patients for undiagnosed type 2 diabetes In Denmark almost 300.000 persons are diagnosed with type 2 diabetes, and it is estimated that further 200.000 people are living with the condition undiagnosed. At the time of diagnosis almost 50 % of the patients have already developed one or more complications. This calls for an intensified effort to detect type 2 diabetes at an earlier stage. It is estimated that general practitioners (GP s) in Denmark are in contact with 90 % of the Danish population within a year. Therefore GP s have obvious opportunities to discover patients with diabetes. A total of 28 GP s in 16 medical practices agreed to participate in the project. In a period of 3 months they were asked to perform blood glucose tests in the following situations: Scheduled blood sample. All patients who had a scheduled time for a blood sample also had a blood glucose test. On the patients initiative. A poster and brochures were placed in the waiting room offering the patients the opportunity to be tested for type 2 diabetes right away. The risk group. The GP s were urged to be aware of patients at risk of having type 2 diabetes, and to offer blood glucose test in relevant cases. Persons below the age of 18 years were not included in the project. Follow up interviews were performed with representatives from the participating practices after the 3 month period. In the study period an abnormal blood glucose level was demonstrated in 262 cases. Further analyses with fasting blood glucose and HbA1c revealed that the diagnosis could only be confirmed for sure in 32 cases. In addition 28 persons were still under suspicion for developing type 2 diabetes by the end of the study period. 119 cases of abnormal blood glucose level were found by scheduled blood glucose test, 92 were discovered on the patients own request, and 45 were risk factor patients selected by the GP s. For six patients the reason for inclusion was not stated. Analyses of changes in the total number of blood glucose tests performed by the participating practices in the 3 month period showed an increase of 42% compared to the same period in the previous year. The follow up interviews revealed that most GP s found it possible to act proactively in terms of testing patients at risk of developing diabetes. The intensified effort proved to be feasible and not time consuming. Offering patients immediate blood glucose tests were generally positively received by people in the waiting room. Considering cost-benefit, some GP s expressed concerns in relation to inclusion of all patients with scheduled blood samples. This study shows that a short term intensified effort to detect patients with diabetes in general practice is feasible. Compared to the average detection rate of diabetics in general practise in Denmark, the detection rate in this study was less than expected. We conclude that additional approaches to solving the problem of undiagnosed diabetics in Denmark should be considered and tested.

1816 Using modern educational principles to improve self-care ability for patients with heart failure B. R. Lindegaard 1,*, I. Christensen 2, I. Svendsen 2, A. Blom 1 1 Center for Quality, Region of South Denmark, Middelfart, 2 Department of cardiology, Sygehus Sønderjylland, Åbenrå, Denmark To develop and test a group teaching model to improve self care ability for patients with heart failure. Empowering patients with chronic disease implies among other things - information and education to support self care. In this project experiences from earlier studies were supplemented by novel teaching principles to develop a heart failure education program. The program was subsequently tested and evaluated in a local hospital in the region of Southern Denmark. All patients with a diagnosed heart failure condition defined by an EF (Ejection Fraction) below 45% were offered inclusion in the project. Patients with severe concomitant diseases were excluded. The baseline knowledge and patient self care ability were assessed before and after entering the education program using a validated questionnaire. Patients were placed into classes of 7-10 people, and the educational activities consisted of 1½ hours weekly sessions during a six week period. The program was led and carried out by two dedicated nurses trained in modern teaching principles. These principles included the use of components like facilitation, translation, inspiration, involvement, acknowledgement and embracement. The possibilities for mutual exchange of experiences between participants were utilized as part of the program. In an eighteen month period from January 2011 to July 2012 forty nine patients (split up into six classes) were included in the program. Results from the before- and after assessment showed a significant increase in the participants knowledge about there diagnosis, including knowledge about prognosis, treatment, effects and side effects of medication and how to react on symptoms etc. Furthermore a significant increase in self confidence and belief in own resources were demonstrated. After completion of the program patients were given the possibility to comment on the teaching principles as part of the final questionnaire. This assessment revealed that the teachers had succeeded in creating a positive learning environment leading to fruitful discussions and meaningful dialog in each class. The patients generally felt more secure and confident about the future after having completed the program. They emphasized the importance of taking their personal situation into account and valued the possibility to meet similarly disposed patients in smaller groups. There were also suggestions for improvements for instance more knowledge about nutrition and multimedication and possibilities for evening or weekend education programmes. This study demonstrated that patients can improve their self care ability by participation in a six week education program using modern teaching principles in small groups of heart failure patients. The results might however be influenced by participation in other simultaneous activities, for instance hearth failure physical rehabilitation. Although economical assessment was not a part of this study, it is likely that expenditure on this low cost program will be equalized by savings caused by the increase of patients self care ability.

1821 Survey of health clinic medical directors regarding futile treatments in home terminal care E. Kamishiraki 1,*, S. Maeda 2, J. Starkey 3 1 University of Kochi, Kochi, 2 Graduate School of Health Management, Keio University, Kanagawa, Japan, 3 Dept. of Internal Medicine, University of California, San Diego, United States This study aims to clarify attitudes of clinic medical directors toward medically futile treatments in the terminal home care setting, and how family desires affects the decision to provide or withhold care. We present the case and ask respondents to decide if they would provide certain treatments, and also if they believed the treatments were medically futile. We conducted a survey of 1052 medical directors of Japanese health clinics selected at random from a population of 10520 institutions in total. A 9-item questionnaire was sent by mail July 30 - Aug 13, 2009. Statistical analysis was completed using JMP 8.0 software. Chi-squared analysis was used to compare group differences between respondents choosing each of three responses as outlined in Table1. Significance was set at an alpha less than 0.05. Case Presentation: A 60 year-old patient on terminal home care with end-stage pancreatic cancer refractory to treatment now has respiratory distress from widespread lung metastasis. The patient cannot tolerate orals, has decreased urine output, and is uremic. He is expected to live another 10 days. Of the 1052 eligible clinic medical directors, 401 (38.1%) responded. Respondents were asked to state if they would provide medically futile treatments as listed in Table1, given the above patient scenario. Table 1: Medically futile treatments Would not provide medically futile treatments (and explain why) n(%) Artificial hydration and nutrition Would provide medically futile treatments, regardless of family wishes n(%) Would provide medically futile, but only if requested by family n(%) 12 (40.3) 6 (1.9) 182 (57.8) 7 Vasopressors for hypotension 10 (39.2) 5 (1.9) 153 (58.9) 2 Antibiotics for pneumonia 33 (41.2) 0 (0.0) 47 (58.8) Chest compressions for cardiac arrest Artificial respiration for respiratory arrest Oxygen for shortness of breath Send to hospital for sudden status changes Analgesics for respiratory distress 12 (38.8) 6 (1.9) 191 (59.3) 5 12 (38.3) 5 (1.5) 203 (60.2) 9 12 (37.5) 1 (3.1) 19 (59.4) 75 (37.5) 3 (1.5) 122 (61.0) 9 (24.3) 0 (0.0) 28 (75.7) Narcotics for pain 2 (10.0) 0 (0.0) 18 (90.0) p=0.5425 Few medical directors indicated that they would provide medically futile care independent of family wishes. This may result from physicians fear of police intervention in Japan. There have been cases where police investigate withholding or withdrawal of care as a crime, even homicide. Further research is necessary about this. Many respondents indicated, on the other hand, that futile treatments would be conducted at the family s request that would have been otherwise withheld. In other words, the decision of providing medically futile care largely depends on the family s wishes. These results are intriguing, and further research is warranted. Comparative research with other countries is also important.

1829 The utilization of integrated interdisciplinary medical team to reduce the preparation time of acute coronary syndrome treatment in the emergency room (ER) T. H. Ling 1,*, L. Chuan Fang 1, T. WAN LAN 1 and 3 1 Department of Nursing, Chang Gung Medical Foundation. Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan Utilize the integrated interdisciplinary team care to improve the efficacy of cardiac catheterization therapy. Coordinating of interdisciplinary work of emergency medical department, cardiology department, and nursing department, to revise the cardiac catheterization protocol and nursing care, and thus shorten the preparation process at ER. 1.In aspect of doctor: To set up the Barcode for catheterization disposal, which includes the standard prescription, therapy item, and laboratory test. This can help doctors to shorten the duration of completing advice. 2.In aspect of nursing: (1) Set up the emergency triage area (2) Set up the registration sheet to monitor the effectiveness and timeliness of emergent cardiac catheterization for ST-segment elevation myocardial infarction at ER. (3) The responsible nurse is equipped a cell phone to coordinate the interdisciplinary business at any moment. 3.In aspect of standard operative protocol: (1)In order to modify the cardiac catheterization protocol, we divide the protocol period into two parts, one for the time spent in the preparation at ER (preparation time) and the other for times spent in the catheterization at the cardiac department (procedure time). We plan to shorten the time spent in the preparation at ER. (2)We apply the informative registry system to monitor and review the efficacy of treatment. (3)Use of the pictures and graphs in the poster to introduce the emergent intervention protocol of acute coronary syndrome with the patients and their family. (4)To set up the acute myocardial infarct (AMI) medication package, which includes NTG, Aspirin and etc.. in the ER pharmacy. We can retrieve these medication packages for the acute coronary syndrome protocol immediately from the Pharmacist. (5)To set up the cardiac package for emergent cardiac catheterization, containing of nasal cannula, informed consent, shaver, blood collection tubes, and inpatient cloths. 1.The preparation time (door to balloon) of patients with acute coronary syndrome are shortened from 101.8 minutes in year 2009, 61.7 minutes in year 2010, to 35 minutes in 2011. Total reduction of 66.86 minutes is achieved. 2.All EKG studies of patients with acute coronary syndrome were interpreted in 10 minutes after arrival to the ER. The immediate and appropriate treatment of acute coronary syndrome always challenge the ER work. In the first line, we shall put more emphasis on the care quality. The utilization of integrated interdisciplinary medical team is to simply the protocol, utilize the information registry system and set up the standard operative protocol. We surely improve the efficacy and timeliness. More, we connect this protocol with the outpatient department and the inpatient department. A safe, effective, patient-centered, timely, and efficient health care environment for patients with acute coronary syndrome is created. The satisfaction of this protocol from May 2010 to April 2011 is 94.8%.

1873 A pilot community-based pulmonary rehabilitation programme in Hong Kong East Cluster K. M. Wong 1, Y. P. Lam 1, L. So 1,*, L. Yam 1 1 Department of Medicine (Respiratory Team), Hospital Authority, Hong Kong, Hong Kong, China The Copd Out-patient-Non-government organization Community Engagement Rehabilitation Network (CONCERN) programme is an HKEC pilot utilizing a chronic disease management model. Following the success of the Phone CONCERN to support home COPD patients, CONCERN engages the Community Rehabilitation Network (CRN) to pilot the first community-based pulmonary rehabilitation programme (PRP) in Hong Kong. To empower COPD patients to cope with their illness utilizing a community-based PRP and to evaluate its safety and effectiveness in reducing healthcare utilization. PYNEH respiratory physicians and nurses invited CRN to co-organize a community-based PRP. Respiratory nurses supervised and provided training to CRN staff. A modified PRP was designed for CRN to conduct at its premises. Each of the 6-weekly PRP sessions consisted of 1- hour supervised gentle exercise followed by 1-hour education on essentials of COPD treatment, self-care, coping skills and stress management. Patients were recruited from PYNEH medical in-patients and out-patients with primary diagnosis of COPD after verbal informed consent. Inclusion criteria were ambulatory Stage 2 and 3 COPD patients (as per GOLD guidelines) who are willing to pay HK$60 to CRN. Home-bound patients and those with low motivation were excluded. Medical records of PRP completers were reviewed by respiratory nurses to compare the following healthcare utilization data six months pre- and six months post- PRP: Accident and Emergency Department (AED) attendance; hospital admission and length of stay, all adverse events during PRP and mortality Six PRP classes were held by CRN in Nov 2009-Dec 2011. Evaluation results available from the first 4 classes were: completion rate 86% (37/43 referred), average age 73.24 years (SD 8.50) among completers (97% male). Comparing preand post-prp, average AED attendance decreased from 0.78 to 0.46 time/person (-41%, p 0.05) and average admission from 0.46 to 0.32 time/person (-29%, p 0.05). Total hospital stay decreased from 91 to 57 days and average from 2.46 days to 1.54 days/person (-37%, p 0.05). Adverse reactions during PRP and patient mortality were not observed. Community-based PRP for stable GOLD Stage 2 and Stage 3 COPD patients in this pilot study was safe and was effective in reducing healthcare utilization.

1912 An evaluation of protocolised titration in sedation on enhancement of nursing engagement and autonomy in patient care H. M. Lee 1,*, K. H. Yip 1, C. K. Koo 1 1 Anaesthesia and Intensive Care Unit, Tuen Mun Hospital Hong Kong, Hong Kong, Hong Kong, China Management of sedation in ICU is a multi-disciplinary process that involves nurses and other health allies. Previously without protocol, Glasgow Coma Scale was used for patient assessment and doctors were informed if needed in our ICU. Therefore, doctor took a leadership role and nurses were mainly following orders. By using a valid and more practical assessment tool named RASS (Richmond Agitation Sedation Scale) and a designed nurse driven protocol in March 2011, ICU nurses might have considerable autonomy in handling sedation based on the set target, which can minimize the unnecessary variability and increase their engagement in patient care. 1. To assess the compliance of using the protocol by ICU nurses 2. To assess whether the protocol will increase the sense of engagement and autonomy of ICU nurses 3. To assess whether the nurse believe using the protocol can have a role to prevent unnecessary restraint All patients required mechanically ventilated for more than 24 hrs were recruited for the sedation protocol. Exclusion criteria included 1. Patients were substance abuser 2. Patients admitted to ICU because of status epilepticus 3. Patients were under neuromuscular blocker infusion. 4. Patients admitted to ICU because of neurosurgical problem including head trauma 5. Patients were successfully resuscitated after cardiac arrest or patients were undergoing end of life care. Two months nurse training included a video session on using RASS before the protocol was implemented. Records of ventilated patients with sedation protocol were retrospectively reviewed. ICU nurses were surveyed by questionnaire in January 2012 Return rate of the questionnaire was 85%. All the ICU nurses had used the protocol and most of them found the protocol was easy to use and assess when needed. More than 90% of nurses felt the protocol was useful in daily ICU patient care. Around 60 %of them believed using the sedation protocol can help to prevent unnecessary restraint on patients. Finally, over 80% of nurses found their engagement and autonomy in handling patient were much increased. Implementation of the nurse driven sedation protocol in ICU was an effective measurement to enhance their autonomy and engagement in patient care.

1984 Who cares for the sickest patients in America? K. E. Joynt 1,*, E. J. Orav 2, A. K. Jha 1 1 Health Policy and Management, 2 Biostatistics, Harvard School of Public Health, Boston, United States Hospitals vary widely in the severity of illness of their patient population, and the burden of caring for America s sickest patients falls on some hospitals over others. We know almost nothing about which hospitals care for the sickest patients. Further, given national policy efforts to reward (or punish) hospitals based on their performance on a series of metrics, understanding how these hospitals fare on those measures has implications for ensuring access and high quality care for the sickest patients. We used national Medicare data from 2008-2009 to create predicted mortality rates for all acute-care hospitals in the U.S. We classified hospitals based on their quartiles of predicted mortality. We examined the structural characteristics of the hospitals across these quartiles and identified how performance on patient experience metrics (measured by 2009 Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, data) varied across quartiles of predicted mortality. We also examined performance on objective process measures of quality as well as outcomes (30- day risk-adjusted readmissions) for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. We found, not surprisingly, that patients at the hospitals caring for the sickest patients were older, more often female and non-white, and had longer lengths of stay (5.4 versus 4.9 days). These patients were more often discharged to skilled nursing or rehabilitation facilities. Hospitals that cared for the sickest patients were larger and more often, non-profit teaching hospitals. In bivariate analyses, hospitals with the sickest patients had worse patient experience scores compared with hospitals with the least sick patients as measured by proportion of patients rating the hospital a 9 or 10 (62.6% versus 69.4%, p<0.001); these findings were consistent across all 8 patient experience metrics examined. In multivariable analyses, the differences in patient experience scores based on predicted mortality were much larger than those based on size, teaching status, location, or other covariates examined. Hospitals that cared for the sickest patients provided care that was of equal or higher process quality for AMI (97.6% versus 97.6%, p=0.84), CHF (93.9% versus 91.4%, p<0.001), and pneumonia (93.7% versus 92.7%, p<0.001) compared to hospitals caring for a less sick patient population. Finally, hospitals caring for the sickest patients had higher readmission rates for AMI (21.9% versus 19.7%, p<0.001), CHF (27.0% versus 25.4%, p<0.001), and pneumonia (20.8% versus 18.9%, p<0.001). Hospitals serving the sickest patients are generally larger, teaching hospitals. They tend to perform poorly on measures of patient experience and readmission rates, although their performance on process quality is generally comparable or better than other hospitals. As Medicare implements payment changes for hospitals, those that care for the sickest patients are at greater risk of being financially penalized, potentially creating disincentives for serving complex patients.

2009 Factors related to self-efficacy in patients with spinal cord injuries during rehabilitation stage W. Tzu-Jung 1,*, L. Chia-Chi 1, C. Shu-Ling 1, C. Hsiao-Yu 2 1 Nursing Department, Chung Shan Medical University Hospital, 2 Collage of Nursing, National Taichung University Sience and Technology, Taichung, Taiwan To identify factors associated with self-performance during rehabilitation for patients with spinal cord injury This was a cross-sectional study using purposive sampling to select eligible patients with spinal cord injury. A total of 54 patients admitted to the rehabilitation wards were enrolled in a medical center in central Taiwan. The survey instruments consisted of Demographic Data Form, The Self-efficacy Rating Scale, The Hope Scale and The Perceived Stress Scale were used to collect data. Statistical analysis was performed using SPSS for Windows 17.0 software package. The mean age of the patients was 47.44 ± 16.23 years and the average duration of injuries was about 14 months. Men were predominant, accounting for 61.1% of all patients. Car accidents were the major cause of injuries that accounted for 50%. There were 35.2% of patients with incomplete paraplegia in their extremities. The average self-performance score was 51.06 ± 13.65, indicating moderate confidence. For the patients with incomplete paralysis of lower body, their selfperformance was significantly better than those with the complete, incomplete paralysis in their extremities and those with complete paralysis of lower body (F = 2.87, p<0.05). Patients with higher levels of hope had better Self-efficacy (r=0.58, p<0.001). Results of stepwise regression analysis indicated that hope status was the best predictors of Self-efficacy (F = 25.64, p<0.001), accounting for 57.5% of the variance explained. The findings of this study suggest that the clinical staff can provide care to enhance the hope of these patients with spinal cord injuries in order to promote their Self-efficacy of daily activities during rehabilitation References: Bandura, A. (1997). Self-efficacy: Toward a unifying theory of bebavioral change. Psychological Review, 84, 191-215. Chen, H., & Boore, J. R. P. (2006). Considering the physiological and psychological consequences of spinal cord injury. British Journal of Neuroscience Nursing, 1(5), 225-32. Hampton, N, Z. (2000). Self-efficacy and quality of life in people with spinal cord injuries in China. Rehabilitation Counseling Bulletin, 43, 66-74. Hampton, N, Z. (2001). Disability status, perceived health, social support, self-efficacy, and quality of life among people with spinal cord injury in the People s Republic of China. International Journal of Rehabilitation Research, 24, 69-71. Middleton, J. W., Tate, R. l., & Geraghty, T. J. (2003). Self-efficacy and spinal cord injury : psychometric properties of a new scale. Rehabilitation Psychology, 48(4), 281-288.

2030 Improving ability in home care of premature neonate caregivers C. L. Hsu 1,*, C. M. Chen 1, S. C. Ho 1, S. W. Lin 1 1 Nursing Department, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan The survival rate of premature neonates is influence by the quality of medical service. But the family quality of life is impacted by the ability in home care of premature neonates caregivers when they return home. Traditional consulting program mostly decided by the medical team rather than the caregivers needs. Therefore, the aim to this study was to establish a comprehensive education and consultant program to various families for improving their ability in home care. Based on the weight and physical condition of the premature neonates, we modified the home care standardized procedure for premature neonates and made a booklet for nurses. All nurses were recommended for following this guideline and were checked up every month. We also have made a baby growing passport for encourage the attachment and interactions between neonates and their families. Based on the variety of caregiver needs, we provide individualized nursing consultation as well. After literature review and expertise opinion, we constructed a checklist for evaluating the completion of nursing discharge plan. The questionnaire of cognition was developed by the medical team for testing the cognition level of caregiver, it is a 25-item, Liker scale instrument, the higher the score means the better cognition level. And we also developed a instrument for evaluating the correction of techniques of caregivers. After this project, he completion of nursing discharge plan was increased from 74.2% to 100%. The caregiver satisfaction was increased from 78.2% to 90.7%. The caregivers cognition of knowledge was increased from 56 to 94, and the correction of technique was increased obviously from 20% to 96%. It is concluded that this program for improving the ability in home care is valid. For nurses, this program could promote the completion of nursing discharge plan. For caregivers, this program could increase the cognition level, correction of technique, and satisfaction as well. References: Discenza, D. (2009). NICU parents` top ten worries at discharge. Neonatal Network, 28(3), 202-203. Heermann, J. A., Wilson, M. E., & Wilhelm, P.A. (2005). Mothers in the NICU: Outsider to partner.pediatric Nursing, 31(3), 176-181. Jackson, K., Ternestedt, B. M., & Schol1in, J. (2003). From alienation to fami1iarity:experiences of mothers and fathers of preterm infants. Journal of Advanced Nursing, 43(2), 120-129. Sneath, N. (2009). Discharge teaching in the NICU: Are parents prepared? an integrative review of parents` perceptions. Neonatal Network, 28(4), 237-246. Trombini, E., Surcinelli, P., Piccioni, A., Alessandroni, R., & Faldella, G. (2008). Environmental factors associated with stress in mothers of preterm newborns. Acta Paediatrica, 97(7), 894-898. Turan, T.,Basbakkal, Z., & Ozbek, S. (2008). Effect of nursing intervention on stressors of parents of premature infants in neonatal intensive care unit. Journal of Clinical Nursing, 17(1), 2856-2866.

2042 A project to improve the quality of nutrition care performance in hospital E. M. Kim 1,*, J. H. Lee 1, K. Choi 1, S. Jung 1 1 Dietetic department, Kangbuk Samsung Hospital, Seoul, Korea, Republic Of It is well known that nutrition care is an important component of disease care and many of hospitalized patients are at nutritional risk. The importance of nutrition care for hospitalized patient has been emphasized and various nutritional interventions have been done for inpatients in hospitals. As a matter of fact, adequate nutrition care has been included in major hospital accreditation standards. To achieve the effective nutrition care, there are essential to establish correct direction and to perform adequately. However there were few trials to improve the quality of nutrition care in these aspects in Korea. Therefore we made an attempt to evaluate and to enhance the direction and performance of nutrition care be done. To evaluate the establishment of nutrition care direction, we reviewed the adequacy of nutrition diagnosis (PES - Problem/Etiology/Sign & symptom statement) and the concordance of nutrition diagnosis with initial nutritional intervention plan. Nutrition diagnosis is a critical step of nutrition care process (NCP) developed by American Dietetic Association. We also evaluated the adequacy of performance of actual nutrition care through treatment plan/acting note review. Review of the adequacy of treatment plan/acting note was carried out in 4 parts (problem selecting, goal setting, care planning, acting timing). The evaluation criteria were set through clinical dietitians consensus meeting. We collected those data from medical records of the in-patients who were provided nutrition care by clinical dietitians during hospitalization in Kangbuk Samsung Hospital. Data were collected once a month from March to December, 2011. Fifty medical records be selected randomly were reviewed monthly. Prior to perform the evaluation, we revised the computer program for easier recording of PES statement and treatment plan/acting note. The percentage of overall adequate PES had been gradually increased with lapse of time (March 85.4%, December 93.8%, yearly average 90.0%). Among components of nutrition diagnosis, the percentage of adequate description of sign/symptom was slightly lower compared with those of problem & etiology (problem 95.0%; etiology 94.8%; sign/symptom 92.6%). The concordance rate of nutrition diagnosis with initial nutrition intervention plan was 95.0% and this rate was gradually improved also (March 85.7%, December 98.0%). The adequacy rate of overall actual nutrition care performance was 90.2%. The adequacy rates of problem selecting, goal setting, care planning and acting timing were 96%, 98.1%, 97.4%, and 95.4% respectively. Monthly outcomes were informed to clinical dietitians and periodic meetings were held to improve the performance of nutrition care according to criteria. It is very difficult to evaluate the adequacy of performed nutrition care objectively and quantitatively. We applied the evaluation tool that introduced the concept of nutrition diagnosis. Although there were some limitations, it seemed that our activities were effective to improve the performance of nutritional care. It was expected that these activities might contribute to improve the overall quality of patient care. We think that management tool based on nutrition diagnosis is helpful to manage the quality of nutrition care for inpatients. Further studies and trials will be needed to evaluate & manage the quality of nutrition care performance.

2108 Improving nursing staff on care of patients with nasogastric tube feeding food integrity H.-S. Wu 1, 1,*, C.-L. Hsieh 1, C.-H. Chang 1, L.-C. Chen 1 1 ICU, Chang Gung Memoral Hospital, Taipei, Taiwan The nutritional status determines the disease-resistant ability of patients. Due to disease, the severe patients change the nutrient supply methods, and the most of them need to be fed by a nasogastric tube to provide adequate nutritional support. If the feeding skill is not complete, it is easy to cause diarrhea, indigestion, constipation, nausea, vomiting, abdominal distension, thereby affecting food intake decreased. Survey found that 41% of patients with nasogastric feeding 3-4 days after have the gastrointestinal complications. In order to provide the holistic care, implement the integrity of nasogastric tube feeding could reduce gastrointestinal complications, enhance enteral nutrition support, and also expected to provide comprehensive care for patients. In this case through the actual interviews and behavior observation 30 nursing staff, in connection with the nursing state of nasogastric tube feeding, collect the data to analysis the situation. As well refer the literature, the group proposed improvement together: (1) Hold conference for brewing various powder diet and establish the brewing process (2) Add water meter (3) Develop the control flow feeding bags (4) Set formulas (5) Amend tools cleaning standards. During the period of December 2010 to January 2011, investigate some patients who were provided with gastrointestinal nutrition by nasogastric tube feeding. In the hospital before, there are no symptoms of gastrointestinal discomfort. However, they were fed by nasogastric tube after 3 or 4 days, up to 41% patients began to appear gastrointestinal complications. The analysis demonstrated: the integrity of nasogastric tube feeding care only 61.2%. The improvement of nasogastric tube feeding after, the integrity of nursing care rises to 98.1%, and gastrointestinal complication rate dropped to 11.3%. Nasogastric tube feeding care is the most basic nursing activities, so the incomplete feeding skills will cause the burden on patient's stomach.therefore, it is necessary and very important to provide patients with appropriate nasogastric tube feeding care to maintain feeding safety.the good enteral-nutrition support could reduce complications, thereby reduce the mortality rate and reach a professional quality of care.

2119 Using systematic nursing instruction to help family members of infants and babies with respiratory disease to enhance the accuracy of chest physiotherapy performance H. Chia Wen 1,*, C. Shu Yuan 1, T. Ya Hui 1 1 CHANG GUNG MEDICAL FOUNDATION Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan Infants and babies, who suffer from respiratory tract infection; due to anatomy physiology coupled with increased physiology respiratory mucosal secretions,the sputum was accumulated and difficult to discharge, and frequently effected pulmonary infection to worsen. It caused prolonged hospital stays, and even life-threatening. In clinical, it needs hospital treatment by chest physiotherapy, using aerosol therapy and other methods, to discharge the mucus and maintain the airway. The investigation found that when nursing staff of Pediatric ward guided the physical therapy care to family members of Infants and babies with Respiratory disease; the implementation efficiency was 73.7%, the awareness of chest physical therapy by the family members only 56.5%, at the same time; the accuracy merely 57.2%. Therefore, we expect that using systematic nursing instruction to implement the correct chest physical therapy to the Infants and babies' family members; then they could deliver the correct chest physical therapy to the patients and improve patients symptoms and help them prompting a speedy recovery. The systematic nursing intervention had four steps: First, toorganize a pediatric physical therapy education and training once per week to provide physical therapy and health education pamphlets to family members, together with units own shot sputum formulas, DVD watching, and dummy demonstration. Afterwards, the family members repeat it as an exam, if they pass the test; they will get a certificate of "model family member of shoot sputum as a reward. Second, to develop a standard operations procedure for pediatric physical therapy care nursing guidance; to achieve the consistency when nurses implement health instruction practice, including a three-shift handover record to track the actual status of family members implementation after health education. The nurses fill the result into the form--the implementation of physical therapy care skills manual for pediatric family members--, to tracking the missing items and strengthen guidance, to reach the goal: the 90% accuracy before discharge. Third, to produce the physical therapy aids provided to family members: such as: the love shot sputum bracelet, creative oxygen hood, story books, the music CD of follow me singing/dancing with love pat and story-telling CD. According to the children ages and individual characteristics, to provide related support tools to assist family members to adapt a physical therapy for patients. Fourth, to establish the checklist for nurses when performing physical therapy care; and using it to audit nurse physical therapy care guiding rate of implementation. The results showed that nursing care and guide rate of the implementation increased to 94.7 %; recognition rate of the family members up to 90.8%, and the accuracy of implementation increased to 90.3%. It means that systematic nursing instruction could promote the accuracy of physical therapy, when family members performing it. It also provides relevant support tools to patients according to the assessment of all ages andindividualcharacteristics; and it indeed contributes to the adaptability of children and improve the quality of clinical care. 2124

Multidisciplianry care may improve outcomes for stage 5 chronic kidney disease patients who begin hemodialysis therapy C.-M. Lee 1,*, H.-Y. Chen 1, S.-C. Yang 1, Y.-S. Peng 1 1 Division of Nephrology, Department of internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan (R.O.C.), Taiwan Chronic kidney disease (CKD) is a major cause of death in Taiwan and a worldwide rapid-growing health problem. In previous investigations, consistent multidisciplinary care (MDC) for CKD patients may retard the CKD progression and improve quality of life. We intend to investigate the effectiveness of MDC for improvement of outcomes, such as hospitalization day and nutritional parameter, in stage 5 CKD patients who just initiating dialysis. This was a retrospective, observational study. We enrolled all incident hemodialysis (HD) patients in Far Eastern Memorial Hospital from Jan. 1, 2011 to Dec. 31, 2011 for outcome analysis. Hospitalization rate, hospitalization day, nutritional parameter and all cause mortality were selected outcomes. A total 275 patients were enrolled (144 woman and 131 man, aged 63 ± 28). 63 patients received MDC and 212 received regular medical care. Overall, 240 patients needed hospitalization to initiate HD due to any reason; 52 patients of them received MDC and 188 received regular care. The hospitalization rate were 82.5% and 88.6%; and the mean hospitalization day were 15 ±21 and 22 ±23 days (P=0.009) in patients who receiving MDC and regular care, respectively. Besides, patients received MDC had better hemoglobin (9.0 ± 1.5 v.s. 8.4 ± 4.8 g/dl, P=0.03) and albumin data (3.5 ± 0.4 v.s. 2.9 ± 0.5 mg/dl, P=0.002) while initiating HD. Two patients receiving MDC (3%) and 33 patients receiving regular care (15%) were dead during hospitalization for initiating HD. MDC shortens the hospitalization day and improves serum albumin and hemoglobin levels in stage 5 CKD patients who just initiating HD. MDC should be an important part of the medical care for pre-dialysis CKD patients.

2185 The initiative to reduce pressure ulcer in a cardiovascular intensive care unit L. Mo-Ying 1,*, C. M. Mei-Fang 1, S. M. Mei-Hua 1, H. H. Ho-Tsung 2 1 Department of nursing, 2 Cardiovascular Intensive Care Unit, Far Eastern Memorial Hospital, New Taipei City, Taiwan The appropriate management of pressure ulcer plays a vital role in the service of an intensive care unit, as any mistake will result in delayed healing of wound, further infection and probably severe sepsis and even death. The incidence of pressure ulcer is an important indicator of quality of nursing care. In our unit, there were 26 patients afflicted with 36 events of pressure ulcer in the period of 6 months in 2010. The incidence rate is 0.6%, which was lower than the average of other nationwide medical centers (0.89%). But it was higher than that of the peer unit in our institute (0.5%). Therefore, we have to tackle with this important problem. According to the Plato statistical analysis, pressure ulcers mostly develop over the coccyx and anus. In addition, the most frequent causes are long-term bedridden, malnutrition and diarrhea. Moreover, most of them suffered from circulatory insufficiency, which would result in poorer cutaneous perfusion, worse nutritional status and thus weaker skin barrier. The prescription of laxatives for patients with cardiovascular disorders might also contribute. The resulting soft stool or diarrhea made the skin over coccyx and anus more frequently immersed. By questionnaire, we interviewed 38 of our nursing staffs. We found out that the accuracy rate for nurses' changes of patients' positions was 15%. The investigation of reasons for this low accuracy rate included: (1) Lack of quality management and control of position changes. (2) Poor quality of pressure-reducing surfaces. (3) Shortage of pressure-reducing surfaces. (4) Inappropriate method of use of pressure-reducing surfaces. (5) Lack of training for position changing. By clarifying the aforementioned problems, we made a proposal to tackle them. Proposed strategy to correct the problems(since January, 2011):(1) Arrange promotional campaigns. (2) A program of in-office education was implemented. (3) We designed a water-containing cushion to reduce the pressure. (4) Add more pillows and water cushions. (5) Conduct case analysis when a patient develops a new pressure sore. (6) A follow-up program was launched to audit the improvement of the quality of care. After completion of this project, the accuracy rate for nurses' changes of patients' positions increased from 15% to 85%, and the incidence of pressure sores decreased from 0.64% to 0.49%. (between Jan, 2011 to May, 2011). The incidence dropped to 0.15%.In addition, the degree of pressure ulcer also declined. The result shows that accuracy of position change may affect the rate of pressure sore. We expect this project to serve as a reference in clinical practice for promotion of the quality of patient care. Keywords: pressure sore References: Pruitt,W. C., & Jacobs, M. (2003). Basics of oxygen therapy. Nursing, 33(10), 43-45. Levett-Jones, T. L. (2005). Continuing education for nurses: A necessity or a nicety? The Journal of Continuing Education in Nursing, 36(5), 229-233. Thompson, D. (2005). A critical review of the literature on pressure ulcer aetiology. Journal of Wound Care, 14(2), 87-90. Williams, L., & Inc, W. (2004). Did you know? Advance in Skin & Wound Care, 17(4), 160-162. Bouza, C., Saz, Z., Munoz, A., & Amate, J. M.(2005).Efficacy of advanced dressings in the treatment of pressure ulcers : a systematic review. Journal Wound Care,14(5),193-199. Kaya, A. Z., Turani, N., & Akyuz, M.(2005).The effectiveness of a hydrogel dressing compared with standard management of pressure ulcers. Journal of Wound Care,14(1),42-44.

2208 Understanding and improving the quality of care for patients with myeloma across the UK J. Pisko 1, T. Fellows 1,* 1 CHKS, London, United Kingdom Healthcare charities and other third sector organisations in the UK are increasingly driving the research and development of clinical services, and want assurance of the quality of care, regardless of the care setting. Myeloma UK invited CHKS to work with them to assess the quality of care provided by acute NHS trusts caring for patients with myeloma. Examples of areas of assessment were: - Do those trusts providing treatment meet current mandatory/best practice standards? - Do those trusts not providing treatment have appropriate referral systems in place? - Where and how can standards of care be improved? Starting with the initial standards proposed by Myeloma UK, through consultation we reviewed and developed detailed criteria for these. Standards were then fully developed and agreed. Examples of standard headings were: - Patient Centred care/treatment and care/patients' rights and respect - Supportive Care - Myeloma specific chemotherapy - End of Life Care To complement the standards, a set of indicators were derived from the mandatory, nationally-collected dataset in England (HES). Examples of the specified were: - Average length of stay for patients with primary diagnosis of myeloma - Mortality rates - Percentage of readmissions in 12 month period following admission with primary diagnosis of myeloma Assessment of care was based on peer review. Reviewers were selected, recruited, and trained to ensure that they were competent to undertake assessment against the standards. On-site surveys were undertaken. The outcome of the project is a programme of agreed standards which can be used to assess the quality of care provided for patients with myeloma which have been tested and applied to a range of health care providers. Indicators were used to assess changes in outcomes of care. Charities are now key stakeholders in the delivery of healthcare services in the UK. Their specialist interest, expertise and passion for improving quality of care are invaluable catalysts for driving improvements. They also provide an additional income stream to support improvement where central government funding is being cut, in real terms. Our study showed that quality of care in providers was improved following this process. This was shown by review of quantitative outcome measures and patient experience/satisfaction surveys.

2216 Investigating public interest in, and expectations of, patient experience information: a comparison between the Netherlands and England H. Atherton 1,* 1 Care Quality Commission, London, United Kingdom The number of websites containing comparative health care reports is rapidly growing worldwide. In the Netherlands, more emphasis is now being placed on transparency in healthcare, and information collected by the Dutch Consumer Quality Index surveys is starting to be disseminated to the Dutch general public. In England the coalition government is committed to increasing choice and to publishing more information about the quality of care provided by healthcare organisations. With increased accountability comes a need for reliable information that is easily available to the public and some of this information is collected and disseminated by the English national patient experience survey programme. The aim of this research was to investigate in both the Netherlands and England: - Whether there is public interest in information that arises from other patients about their hospitals or providers (patient experience information). - The type of patient experience information that the public are interested in - Reasons for the lack of usage of patient experience information. Semi structured interviews were carried out with stakeholders of the Dutch survey programme including the organisation that oversees the survey programme, commissioners of the surveys (insurance companies, healthcare providers, patient organisations) and the Government bodies; to find out more about the roles that the various stakeholders play in dissemination of the data to the public and their opinions on whether they believe the information aids patient choices. Semi- structured interviews were carried out with members of the public in the Netherlands and England (15 of each) and the topic guides for these interviews were designed using insight from the original interviews with the survey stakeholders; and concentrated on interest in and expectations of patient experience information. The results for the Dutch and English interviews were transcribed and coded manually into a number of key themes based on the structure of the questionnaire. The sets of interviews for each country were analysed separately and then brought together in the discussion. The research revealed that there is public interest in patient experience information both in England and the Netherlands, but in the Netherlands there is also a desire for clinical and financial information. Lack of awareness in the information, rather than lack of interest have led to it not being accessed. Expectations of what respondents thought the information should provide are generally reflective of what is available. Individuals can relate to the information as it derives from other patients, it covers aspects that are important to them personally and it allows public opinion on hospitals to be viewed rather than hidden. The type of organisation disseminating the information can influence whether it is trusted; if the organisation disseminating the information is not independent of the organisation collecting it, then it is less likely to be trusted. The respondents interviewed were sceptical about this type of information disseminated in the media. In addition, presentation can affect levels of trust; if explanations are not provided for missing data, then assumptions may be made about why it is missing, which are often incorrect. The presentation will describe how the findings are being put into practice.

2231 Comparison of the medication possession ratio in hypertensive patients according to the pattern of health care utilization E. Kim 1,*, H. J. Yoo 1, M. H. Kim 1, I. S. Shin 1 1 HEALTH INSURANCE REVIEW & ASSESSMENT SERVICE, SEOUL, Korea, Republic Of To identify the differences in the MPR (Medication Possession Ratio) of the hypertensive patients between two different groups in the pattern of the health care utilization using the result of the quality program. We used all data from the Korean National Health Insurance Claims Database. We selected 5,621,322 patients who received prescription of antihypertensive drugs for hypertension(korean Standard Classification of Disease[KCD] I10~I13) from January to June in 2011, in relation to the previous 6 months of prescribing the drugs. The subjects were divided into two groups by the pattern of health care utilization. Group A was prescribed antihypertensive drugs in a single medical institution, group B in several institutions. The MPR formula is as a follows: MPR = Total number of depressant prescription days / Total number of days in the research-targeted period 100 The average MPR of group A was higher than that of group B by 4.7%p and smaller deviation in group A than group B. That means that group A was prescribed 9days more than group B. In addition, the proportion of group A who were over 80% of MPR was significantly higher than group B by 8.2%(p<.0001). Table. MPR according to the health care utilization Parameter N Mean(%) 95% CI Mean(%) SD(%) p-value total 5,621,322 87.8 87.8 87.8 18.4 Group A 4,764,956 88.5 88.5 88.5 17.5 <.0001 Group B 856,366 83.8 83.8 83.9 22.2 In general, the level of MPR was high in Korea. Hypertenive patients who got the prescription in a single medical institution had higher adherence to therapy and higher MPR level. While continuous quality assessment is needed to improve the adherence to therapy for hypertensive patients, it is suggested to encourage visiting single clinic through the primary health care strengthening policy.

2264 Patient satisfaction survey in Hong Kong - both the means and the end for quality and patient engagement P. Wong 1,* 1 Patient Relations and Engagement Department, Hospital Authority, Hong Kong, Hong Kong, China Against the background of rising community expectation for transparency and accountability, Hong Kong Hospital Authority (HA) launched its first baseline Patient Satisfaction Survey (PSS) in 2010. The PSS was conducted by an independent body - the Chinese University of Hong Kong for more than 5,000 discharged patients in 25 public hospitals. This is the first survey of such scale in Hong Kong and in any Chinese community in Asia using a validated instrument adapted from the NHS PSS questionnaire by Picker Institute Europe. The 2010 baseline survey (Full Report available at www.ha.org.hk) reported to the public in June 2011 was generally well received by staff, patient groups, public and media. The overall result was encouraging with more than 87% of the patients indicating a high degree of trust for our doctors and nurses, and 80% rated that the treatment and care they received was good to excellent. Nonetheless, the benchmark PSS adopted a broad brush approach and was unable to address local issues specific to individual hospitals in details. There are also areas of low scores relating to patient engagement and communication about care, treatment or discharge planning. As the expectations from patients vs clinical team can be very different, and these aspects of hospital care are not the science of clinical care, but involves the understanding, acceptance, role modeling and operational arrangements at all levels of doctors and nurses, there appears a need to seek a deeper understanding of these important care aspects directly relevant to patient-centredness. To reinforce a culture of patient-centredness, the HA has decided to deepen the governance arrangement to set up a clear corporate policy, standards & protocols, monitoring, follow up & reporting on PSS. Individual public hospitals are encouraged and will be equipped with a standardized PSS tool to carry out small scale PSS locally and at regular intervals. Indepth study will be conducted in 2012 on (a) secondary data analysis of the 2010 PSS results; (b) patient engagement to gain a better understanding of the views of doctors and nurses on the enablers and barriers of patient engagement. A robust task group comprising front-line doctors and nurses was formed to develop and promote PSS and drive improvement actions at local levels. Through development of a short-version standardized questionnaire for regular PSS in individual hospitals, the hospitals will be able better monitor patient s views at the local level in a timely manner. This will allow meaningful benchmark and monitoring in the long term. The results of indepth study on (a) the 2010 PSS results (secondary data analysis); (b) patient engagement will be available by end of 2012. With these results, the management will be able to capture more indepth information for formulation of strategies to further enhance patient engagement and reinforce the patient-centred culture. Chinese people are generally perceived as less proactive than the western population in both the seeking and expressing of their opinions. Indeed, PSS itself is the means and the end of engaging patients and healthcare staff to reinforce the patient-centred culture. Through the PSS, patients are encouraged and more willing to express their views on the hospital services they received. Also, as evident from their active involvement and diligence in following up the 2010 PSS results particularly those areas with low scores, healthcare workers are embracing the PSS as a useful tool to enhance the experience and service quality from patient s perspectives.

2287 Standard assessment to improve compliance to ICU routines and nurse involvement in patient care K. H. Yip 1,*, H. M. Lee 1, C. K. Koo 1 1 Anaesthesia and Intensive Care, Tuen Mun Hospital, Hong Kong, Hong Kong, China (1) To ensure every patient in Tuen Mun Hospital were subjected to structured assessment everyday (2) To enhance compliance to standard ICU routines, namely, feeding, analgesia, sedation, thromboprophylaxis, glucose control and head elevation. (3) To strengthen the communication between ICU nurses and physician Structured computerized ICU assessment template which includes checklist for standard ICU routines was incorporated in the Clinical Information System in Jan 2011. ICU physician has been required to fill in these templates during patient assessment every morning. Compliance to standard ICU routines was checked by ICU Data Nurse before and after implementation of this template. Questionnaires were sent to Tuen Mun Hospital ICU nurses and ICU trainees to collection their opinion and satisfactory level toward this template. Compliance to all standard ICU routines was 63% before implementation of FAST HUG template. It has been increased to 100% after introduction of FAST HUG template. 95% of ICU nurses is using FAST HUG template in patient care. 97.5% of them find it helpful in reminding attending physician and themselves about necessary ICU routines. 92.5% of ICU nurses agree it is useful in patient care. ICU checklist was an effective tool helping ICU physician and nurses in providing comprehensive and structured assessment and management even in patients with complicated problems. ICU nurses also found it useful in communication with ICU physician.

2293 Using bundle intervention to reduce the bloodstream infection rate in the oncology ward C.-F. Hsieh 1,*, H. N. Liou 1, C. Y. Yuan 1 1 Far Eastern Memorial Hospital, New Taipei City, Taiwan Central venous catheters (CVCs) are essential for caring patients with malignancy. However, bloodstream infection (BSI) is a major drawback of central venous catheter use and causes significant mortality and morbidity. In an oncology ward (57 beds) of a tertiary medical center in Taiwan, 70% of the nosocomial infections are BSI. The overall rate of CVC use among patients is 88% in the ward. In 2010, the average BSI rate was 3.83 (2.90~5.45 ). The rate was 3.62 from January to April 2011, but it increased to 5.27 ~7.24 during June to September 2011, with an average rate of 6.52 (p<.000). For the increasing incidence of BSI, a bundle intervention program was implemented. We applied the evidence-based practice for prevention of catheter related BSI suggested by the CDC, Taiwan (2011). The bundle intervention includes (1) revising the standards of catheters` care, (2) replace swabs containing 10% iodine with 2% chlorhexidine in 70% isopropanol for disinfection, (3) use new sterile semipermeable dressing to cover the catheter site, (4) application of maximal sterile barrier precautions, and (5) hand washes. The average BSI rate was 3.76 (1.78 ~5.55 ) after implementation of bundle intervention (October 2011 to January 2012), which was 36% lower compared to May to September 2011 (p=0.022). The satisfaction rate of patients using new skin transparent dressings rose from 64% to 84%. Using bundle intervention at our unit decreased the BSI rate rapidly in a short period of time. A longer follow up period and strict enforcement of current care is warranted. References: Han, Z., Liang, S. Y., Marschall, J. (2010). Current strategies for the prevention and management of central lineassociated bloodstream infections. Infection and Drug Resistance, 2010(3), 147 163. doi: 10.2147/IDR.S10105 O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011) Guidelines for the prevention of intravascular catheter-related infections, 2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Pronovost, P., Needham, D., Needham, S., Sinopoli, D., Chu, H., Cosgrove, S., & Goeschel, C. (2006). An Intervention to Decrease Catheter- Related Bloodstream Infections in the ICU. The New England Journal of Medicine, 355(26), 2725-2732. Soothill, J. S., Bravery, K., Ho, A., Macqueen, S., Collins, J., Lock, P.(2009). A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: A pediatric single center before/after study on a hemopoietic stem cell transplant ward. American Journal Infection Control, 37(8), 626-630. doi:10.1016/j.ajic.2009.03.014 Worth, L. J., Slavin, M. A., Brown, G. V., Black, J. (2007). Catheter-related bloodstream infections in hematology: time for standardized surveillance? Cancer, 109(7), 1215-1226. doi: 10.1002/cncr.22527 Weber, D. J., Rutala, W. A. (2011). Central line-associated bloodstream infections: prevention and management. Infection Disease Clinical North American, 25, 77 102. doi:10.1016/j.idc.2010.11.012

2325 Recovery-oriented rehabilitation services for in-patients with severe mental illness in Castle Peak Hospital B. Siu 1,*, M. Poon 1, C. Lo 1 1 Psychiatry, Castle Peak Hospital, Hong Kong, Hong Kong, China Mental health recovery has been adopted as either the national policies or guiding principles of the mental health systems in different countries including America, Canada, England, Ireland, Australia and New Zealand. Patient empowerment and self-management are the central most important elements in the implementation of recovery in mental health services. Basing on the recovery model, the two rehabilitation wards of Castle Peak Hospital (CPH) provide a series of rehabilitation training for patients waiting for half-way house placement. Patients receive a multi-disciplinary assessment to determine their strengths and areas for improvement. An individualized care plan is drawn up, with active participation from the patient. In a culture of empowerment and optimism, patients join programs including mental health education, self-care training, money management, self-medication training, cooking skill training, community orientation, domestic skill training, sex education, social skill training, stress management, symptom management, road safety training, and vocational training, basing on their individual need. The care plan is regularly reviewed and is hand-overed to carers of the discharge destination to ensure continuity of care. The objectives of this study were to explore the demographics and assess the outcomes of patients having received the training programs basing on the recovery model in the rehabilitation wards. Patients in the two rehabilitation wards of CPH were assessed by the Brief Psychiatric Rating Scale (BPRS) and the Rehabilitation Scale (Rehab scale). They were asked to complete the Chinese version of Mental Health Recovery Measure (C-MHRM) and their clinical and sociodemographic characteristics were collected. Sixty-two patients in the rehabilitation wards were assessed and they all were under waitlist to half-way houses. Thirtyseven (59.7%) were males and 25 were females (40.3%). Their mean age was 36 years (SD= 11.8) and the majority of them (66.1%) were single. They all suffered from severe mental illness including schizophrenia (77.4%), schizoaffective disorder (8.1%), bipolar affective disorder (6.5%), and other psychotic disorders (8.1%) with an average length of stay in CPH of 599.4 days (SD= 1035.1 days). The mean BPRS score was 31.0 (SD= 6) and 24.2% of them had history of violence. There was a significant improvement in the Rehab scale score after training (50.1 vs 43.1, t= 6.367, p= 0.000) and the C-MHRM score rated by the patients was high (mean= 116.6, SD= 15.5). The rehabilitation wards of CPH have implemented a series of multi-disciplinary training programs to individualized patients with severe mental illness basing on the recovery model with emphasis on patient empowerment and selfmanagement. The significant improvement in Rehab scale score after training and the high score in C-MHRM supported the effectiveness of the training programs which were considered to be recovery-oriented by the patients.

2334 Using web-based collaborative care to improve the quality of glycaemic control in Type 2 diabetes S.-Y. Peng 1,*, H.-C. Ning 1 1 Laboratory Medicine, Chang Gung Medical Funndation, Linkou Chang Gung Memorial Hospital, Taoyun, Taiwan Using information technology to support patient-centered services offers a remarkable opportunity to improve outcomes for patients of diabetes. This study was designed to see if a web-based care management programme based on the electronic self-monitored blood glucose (SMBG) diaries can improve glycaemic control in type 2 diabetes. We conducted a trial of 119 adults with type 2 diabetes randomized to receive usual care plus web-based care management or usual care alone. Intervention patients (n=59) received 12 months of web-based care management and a regular comparing on glucose data between glucometer and laboratory analyzer. If the glucometer performance did not meet the quality goal based on the recommendation in the International Organization for Standardization s ISO 15197, the staff of phlebotomy department will make a replacement of glucometer. The doctors can access to this web-based care management programme, where diabetes electronic SMBG diaries and laboratory data could be viewed, graphed, educated, and discussed online. All patients were measured HbA1c every three month. HbA1c level declined by 1.15% (P<0.05) on average among intervention patients compared with usual care patients. There were 8% (5/59) glucometers of the intervention group did not achieve the quality goal and had been replaced. This relatively small randomized control trial demonstrated that web-based care management improved the results of HbA1c in those with access to the web intervention are impressive.

2348 A patient-centered clinical guideline enhances bloodless open-heart surgery F.-Y. Lee 1,*, C.-C. Wu 1, S.-T. Ho 2, C.-Y. Lin 3 1 Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, 2 Department of Anesthesiology, Tri-Service General Hospital, Taipei, Taiwan, 3 Department of Anesthesia and Critical Care, University of Chicago, Chicago, United States The safety of homologous blood transfusion has become a major concern for patients and physicians. Current transfusion practice is highly variable and may be associated with inappropriate blood use. In this study, we evaluated the feasibility of bloodless open-heart surgery. Perioperative clinical datawere retrospectively collected and analysed from two groups of patients undergoing open-heart surgery by one surgeon in the same season. Twenty consecutive patients underwent a bloodless approach and received isoflurane-based closed-circuit general anesthesia and 20 consecutive patients (comparison group) underwent fentanylbased anesthesia. A cell-saver was used for all patients to collect CPB(cardiopulmonary bypass) circuit blood for retransfusion. In the comparison group, conventional criteria were applied for blood transfusion and inotropic support and the goal was to keep hemoglobin > 10 g/dl and cardiac index > 2.2 L/min/m2. In the bloodless group, a patient-centered guideline for blood transfusion and inotropic support were used and included (1) low cardiac output syndrome, (2) impaired hemodynamic status and mixed venous oxygen saturation, (3) inadequate urine output, (4) metabolic acidosis, (5) ischemic signs on electrocardiography, and (6) patient s autonomy after being well informed of the benefits and risks of blood transfusion. In both groups, there was no in-hospital mortality and all patients were discharged in a stable condition. Eighteen of 20 (90%) patients did not receive blood transfusion, while inotropic support was not provided in 17 of 20 (85%) patients in the bloodless group; in contrast, blood transfusion and inotropic support were required for all patients in the comparison group (both: p < 0.01). All patients in the bloodless group, except one with severe chronic obstructive pulmonary disease (1- second forced expiratory volume of 0.9 L), accomplished earlier extubation (mean ± standard deviation, 1.2 ± 1.1 hours) and shorter intensive care unit stay (3.1 ± 2.1 days), as compared with patients in the comparison group (19.5 ± 2.5 hours and 5.1 ± 1.7 days, respectively; both: p < 0.01). With the aid of a cell-saver, closed-circuit anesthesia, and teamwork, a patient-centered clinically oriented guideline makes bloodless open-heart surgery feasible and safer in terms of postoperative recovery.

2364 Improvement of customer satisfaction through one shot instead of several intravenous (IV) injections Y. Hee Ja 1,*, Y. Gwang cheol 1, J. Yoon rye 1, P. ah young 1 1 Laboratory medicine, Seoul National University Bundang hospital, Seongnam-si, Gyeonggi-do, Korea, Republic Of The image of blood sampling occurred to most patients is a shot and a pain. If you get Computed Tomography(CT), Magnetic Resonance Imaging(MRI), Positron Emission Tomography(PET) and endoscopy as well as blood test all together, you will get a shot at least 3 or 4 times enduring the pain. Until now, you have been getting a shot each test. For example, CT, MRI, etc. To reduce the pain for intra-venous(iv) injections, we developed the new IV injection process. It has been possible to examine only one shot instead of several intra-venous(iv) injections. It is to meet the convenience of patients and improvement of customer satisfaction. First, electronic medical record (EMR) system was developed to easily recognize the patient for several IV injections. Second, a catheter inserted in a vein to draw the blood. And then, leave the catheter in a vein. Third, we enter the button Start IV injection through EMR system. The patient goes to other laboratories.for example, CT, MRI, etc. If the interval of drawing the blood and other test is longer than two hours, we don`t execute the IV injection to relieve pain for patients. If the patient is not willing to leave the catheter in a vein, we don`t execute the IV injection by respecting the patient`s opinion. In addition we developed the catheter remove program for the safety of patients. Because it is also important to remove the needle as much as execute the IV injection. We checked the intra-venous(iv) injection list at all time if the patient went home with not elimination of catheter after all test. For patients with poor vascular, we inputted the reason was not performed IV injection at EMR system. EMR system was constructed by sharing information other laboratories. Average daily numbers of IV injection patients were 94 in our hospital. If we had performed the previous sampling process, we would have been 81patients who got two shots, 13patients who got three shots, a patient who got four shots. Therefore we have been tried to improve patient satisfaction with the cooperation among laboratories. We performed one shot instead of several intra-venous(iv) injections to 19,497 patients of 20,079 patients. (June2011 ~ February2012) Implementation rate was 97.1%. The remaining 2.9% were excluded because of long term 2.0%(402 patients), poor vein 0.75%(150 patients), refusal or fail 0.15%(30 patients). Considering this, High implementation rate is manifest. This intra-venous injection process is being attempted domestically for the first time and we hope to spread widely to other hospitals. We will need to think about how it is return the benefit of saving time for the patients due to simple intra-venous injection process. To backup this intra-venous injection process from now on, we need to reduce the time less than 1 hour between intravenous injections. So, improvement activities will be needed enduringly to increase customer satisfaction.

2372 Role of nurse managers in improving elderly patients knowledge about their medications and adherence in rural Vhembe district: South Africa M. Mangena 1,* Mutshinyalo Mangena Ursula Dora Ramathuba 1 School of Health Sciences, University of Venda, Limpopo Province, South Africa The purpose of this study is to identify the specific barriers for each patient, adopting suitable techniques to improve medication adherence. As elderly population faced with ageing, mostly they become affected by chronic illnesses that challenge their abilities. Adherence to therapies is a primary determinant of treatment success. Failure to adherence is a serious problem which not only affects the patient but also the health care system. A non experimental method was done where there was no manipulation of the environment. A cluster random sample was done. A sample of 400 black elderly people living in Vhembe district of Limpopo province was interviewed. Data was collected through a structured interview. A questionnaire which was completed by ten research assistants who were all professional nurses, trained by the researcher on the instrument, communication skills and on how to complete the questionnaire. As many as 89% of the respondents were on medications. Of the respondents, (36%) received their medications from the traditional healers; while 32% reported that they buy from the shops. Only (21%) of the respondents reported to be Data show that as many as (76%) of the respondents do not adhere faithfully to their prescription- medication regimens. Patient medication non adherence is a major medical problem globally. It was evident that the respondents of this study were non-adherent to their medications. Non-adherence to medication regimens also affects the quality and length of life; for example References: Horne, R. 2006. Compliance, adherence, and concordance: implications for asthma treatment. 13(1)(Suppl):65-72. Agras WS. Understanding compliance with the medical regimen: the scope of the problem and a theoretical perspective. Arthritis Care Res 1989 Sep;2(3):S2-S7. Noble LM. Doctor patient communication and adherence to treatment. In: Myers LB, Midence K, eds. Adherence to treatment in medical conditions. Harwood Academic Publishers, 1998.p.51 82. Carr, A.J. 2001. Why doctors and patients disagree. Br J Rheumatol. 37(1):1-4..

2395 Preventing increased intracranial pressure among traumatic brain-injured patients after brain surgeries C.-C. Chiang 1,*, H.-C. Tsai 1, S.-C. Wang 1, K.-T. Huang 2 1 SICU, 2 Department of Neurosurgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan The mortality rate of the TBI patients was reported as 69% to 95%.With such a high incidence of raised ICP, it is important that healthcare professionals have adequate and accurate knowledge about how to prevent increased ICP and can safely perform interventions preventing increased ICP when providing care activities for traumatically brain-injured patients, particularly for those after brain surgeries. The aims of this project were to standardize the nursing interventions specifically for preventing increased ICP among traumatic brain-injured patients after brain surgery and develop useful devices to help nurses effectively prevent the occurrence of raised ICP among patients after brain surgeries. We evaluated18 ICU nurses skills performance of nursing interventions for patients after brain surgeries. We found that the nurses performed suction procedures accurately following recommendations for safe endotracheal suction. However, the error rate of positioning (including the failure to use 30 head elevation and maintain the head and neck in the midline position) was as high as 37.5%; the error rate of nursing with irritable patients was 25% (such as without providing proper devices to support and maintain patients in a proper position. To improve the care quality, several interventions were developed and implemented to reduce the incidence of raised ICP. First, elevation of the head to a 30 angle and maintaining the head and neck in the midline position have been routinized for nursing TBI patients after brain surgeries. Second, we standardized the procedure for patient positioning and regularly educated our nursing employees on preventing raised ICP. We also evaluated whether their skills performance following recommendations for preventing raised preventing increased ICP. Third, a specially designed pillow was used to keep patient s head in a midline position. Fourth, an anti-slippery seat mat was used to prevent a patient sliding forward and maintain a properposition. Fifth, keeping patients in the desired upright position can be difficult to achieve in practice. We thus made a bed angle indicatorwhich is a measuring device to ensure the patient is positioning at a 30 degree angle on each ICU bed. This indicator was made colorful to signal whether patient is positioning at 30 degree. The error rate of positioning (including the failure to use 30 head elevation and maintain the head and neck in the midline position) was reduced from 37.5% to 0%. The ICU nurses were able to correctly reposition and turn brain-surgery patients without increasing ICP. The error rate of nursing with irritable patients was decreased from 25% to 2.78%. With implementing these interventions, the average ICP was decreased from 20.37 to 10.56mmHg. The average length of hospital stay among these patients was reduced from 6.14 to 4.28 days. To prevent increased ICP among TBI patients after brain surgeries, our team members work together to provide safe care for the patients. We standardized the procedure for patient positioning and educated our nurses colleagues on how to preventing patients from increased ICP. We made a special pillow and an anti-slippery seat mat to keep our patients in a proper position. The skill performance evaluation was undertaken to ensure if our nurses followed recommendations for preventing increased ICP. Since nurses are on the front line to provide direct care for patients, it is important to ensure our nurse colleagues can perform nursing interventions accurately to prevent brain surgery patients from increased ICP.

2396 Developing and psychometric testing of the nurse-perceived pain management competence scale (NPPMCS) K. Jui-Ping 1,*, C. M. Weng 1, C. M. Chen 1 1 Surgical unit, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan Patients often suffer from pain before and/or after surgery. The incidence of patients who had undergone surgical procedures was reported from 41% to 91.2%, depending on the disease per se, operation site, and anesthesia type. With such high incidence of pain among postoperative patients, many studies demonstrate that postoperative pain continues to be under-treated and must be concerned. Some researchers suggested that a common reason for inadequate pain management is that health professionals such as nurses fail to systematically assess and evaluation pain and its assessment. Indeed, studies showed that nurses often underestimate or overestimated patients postoperative pain because nurses assessed patients pain by looking at the patients appearance, rather than asking the patients subjective feelings. Given that nurses work on the front lines of patient care, it is very important for nursing administrators and educators to use a reliable and valid instrument to efficiently assess surgical nurses pain management competence. After reviewing the current literature, we found that there is a lack of a psychometrically valid scale with good internal consistency to measure surgical nurses perceived pain management competence. The purpose of the study was to develop and evaluate the psychometric properties of the Nurse Perceived Pain Management Competence Scale (NPPMCS). A descriptive, cross-sectional survey was conducted at an acute care hospital in Southern Taiwan. We recruited 97 fulltime registered nurses who provided bedside care at the five surgical units at the hospital to join in the study by convenience sampling. The Nurses Perceived Pain Management Competency Scale was a self-developed tool including 17 items, which was developed specifically for measuring surgical nurses pain management competency. Five experts (three nursing faculty and two clinical experts) were invited to examine the content validity of this instrument. Content validity, construct validity, and reliability of the Nurse Perceived Pain Management Competence Scale (NPPMCS) were evaluated. Data entry and analyses were done using SPSS 14.0 (SPSS Inc., Taipei). Descriptive statistics such as mean and standard deviations were used to characterize the demographics of the participants, and the reliability of the total scale was shown by Cronbach s alpha coefficients. The content validity was CVI = 84% and the reliability of the total scale was r =.90. Factorial validity was supported using a two-factor model solution that accounted for 48.6 % of the total variance for nurses perceived pain management competence. Pain management had the highest explained variance (27.89%). The psychometric properties of the Nurse Perceived Pain Management Competence Scale were acceptable. Thus, the NPPMCS can be recommended for using as a tool to assess nurses perceived pain management competence. This tool can be used to assess nurses pain management competence so that nurse administrators can understand what nurses education needs in terms of managing surgical patients postoperative pain. By using this tool, we do expect that we are able to effectively relive the pain for those surgical patients and improve the quality of care that patients deserve.

2448 Direct patients communication access in improving patient satisfaction R. Setiawati 1,*, A. Tanjung 1 1 Siloam Hospital Kebon Jeruk, Jakarta, Indonesia The objective was to show that direct patients communication access to hospital management improved patients satisfaction. 1. We provided a special dedicated direct telephone number that was set up as short messages services (SMS). 2. We socialized to all our hospital management team that patients and public will have 24 hours direct and instant access to hospital management. 3. We also socialized this access intensively to patients and public via written announcement that were placed in several strategic public areas in our hospital. 4. We developed a flow process with clear protocol and procedures for follow up upon receiving SMS. 5. Pilot was conducted for almost 2 years. 1. There were average of 30 SMS were received every month. 2. Out of SMS received, 60% was related to patient's dissatisfaction, 30% was related to patient's suggestion to improve hospital's services, 8% was related to patient's compliment, and 2% was others. 3. Patient's dissatisfaction level had been decreased from 2.1% in year 2009 to 1.6% in year 2011. 1. The pilot reached the goal that was set out to be achieved. - Declining of patient dissatisfaction level to 1.6% had shown that the objective of this strategy to improve patient satisfaction had been obtained. 2. Direct patient communication access had improved patient's satisfaction as problem(s) could be detected early and solved rapidly and accurately.

2463 To examine the efficiency and satisfaction of oral care practice in intensive care unit patients with oral endotracheal tube M.-C. Chen 1,*, Y.-J. Liu 2, S.-C. Chang 3 1 Department of nursing, Chang Gung Medical Foundation. Kaohsiung Chang Gung Memorial Hospital, 2 Department of nursing, 3 Chang Gung Medical Foundation. Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan Oral care is a common nursing practice and effective oral care improves patient s comfort and prevents oral infection. Nonetheless, it is a challenging task for nursing staff to provide intubated patients with oral care. To examine the efficiency and satisfaction of oral care practice in intensive care unit patients with oral endotracheal tube and to enhance the quality of oral care of critically ill patients. This study used a descriptive, cross-sectional design. The data were collected by structured questionnaires and observational checklist from January to June 2011 at a medical center in southern Taiwan. The observational data were the oral care procedures performed by 27 ICU nurses for intubated 126 patients in ICU. The results showed that ICU nurses used defective oral care sewage tray devices for oral intubated patients making the implementation more difficult, and prolonging care hours. The accurate percentage of the nurses' skills of oral care has increased from 67.9% to 99.1%, the patients' satisfaction rate improved from 58.8% to 92.3%, and the patients' comfort improved from58.2% to90.9%. The results and instruments of this project could be used as an example for other departments caring for Oral Care Practice in Intensive Care Unit Patients with Oral Endotracheal Tube, to promote the quality of nursing care and to increase patients' and satisfaction and comfort. The strategies to resolve these issues including to set specialized oral care sewage tray devices, to teach nurses the knowledge of oral care of intubated patients and set criteria for the standardized execution procedures on oral nursing care. References: Feider, L.L. Mitchell P., &Bridges, E. (2010). Oral Care Practices for Orally Intubated Critically Ill Adults. Am J Crit Care,19(2),175-183. Abidia, R. F. (2007). Oral care in the intensive care unit: A review. The Journal of Contemporary Dental Practice, 8(1). Berry, A. M., & Davidson, P. M. (2006). Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit. Intensive & Critical Care Nursing, 22(6), 318-328. Coleman, P., & Watson, N. M. (2006). Oral care provided by certified nursing assistants in nursing homes. Journal of the American Geriatrics Society, 54(1), 138-143. Feider, L.L., &Mitchell, P.(2009). Validity and reliability of an oral care practice survey for the orally intubated adult critically ill patient. Nurs Res. 58(5),374 377 Lin, Y.S. Chang, J.C. Chang, T.H., &Lou, M.F.(2011)Critical care nurses' knowledge, attitudes and practices of oralcare for patients with oral endotracheal intubation: a questionnaire survey. Journal of Clinical Nursing. 20,3204 3214 Ross, A., & Crumpler, J. (2007). The impact of an evidencebased practice education program on the role of oral care in the prevention of ventilator-associated pneumonia. Intensive& Critical Care Nursing, 23(3), 132-136. Rello J, Koulenti D, Blot S, et al. Oral care practices in intensive care units: a survey of 59 European ICUs. Intensive Care Med. 2007; 33(6): 1066 1070. Schwartz, A. L., & Powell, S. (2009). Brush up on oral assessment and care. Nursing,39(3), 30-32. Thompson, P. (2008). Intervention: Oral hygiene. Retrieved August 6, 2009, from the Joanna Briggs Institute.

2468 Application of crew resource management in handing over cardiac surgery patient from operating theater to ICU C. H. Lee 1,*, T.-C. Chao 1, M.-L. Tsai 2, H.-C. Jao 3 1 Center For Quality Management, 2 Department of Anesthesiology, 3 Nursing Department, Linkou Chang Gung Memorial Hospital, TAOYUAN HSIEN, Taiwan The patients receiving cardiac surgery are generally among the sickest and at more advanced stages of disease. Immediate post-operative period is very critical and dangerous to the patient, especially on transferring the patient from operation theater (OR) to ICU. Crew resource management is applied to ensure that the patient is safely handed over to ICU. A team was built including cardiovascular surgeons, anesthesiologists, ICU physicians, surgical residents, anesthesia residents, surgical nurses, anesthesia nurses, respiratory therapist. The team initially reviewed patient transfer process and identify the vulnerable elements that might endanger the patient s safety. Solutions for the problems were generated which include: (1) The surgeon is the leader of the process. (2) Task work of ICU nurses in each shift is assigned to receive the patient. (3) Circulating nurse notifies the ICU at least half an hour before arrival, including patient s condition, equipments needed, medications, and others. (4) The receiving nurse confirms where the patient should be admitted and asks the ICU doctor and respiratory therapist to prepare for patient s arrival. (5) A step-by-step checklist including handover items is used. (6) Team members attend a training program which includes didactic instruction and simulation. (1) The required handover items checked at OR before and after the launch of program in 59% and 100%, respectively (2) The completion rate of handover items changed from 65.5% to 100%. (3) The time OR personnel spent at ICU for handover is 12.7 ± 9.7 minutes (mean ± SD). No accidents occurred after the launch of program. Teamwork is effective in handing the cardiac surgery patients over to ICU. Team members have things organized and patient safety is secured. Our results promote us to apply this model to hand over all surgical patients to ICU.

2484 The improvement in constitution pattern after treatment of continuous positive airway pressure for patients with obstructive sleep apnea syndrome a preliminary report Y.-L. Chen 1, 2, 3,*, H.-K. Wu 1, 2, K.-P. Lin 4 1, 2, 3, H.-H. Chang 1 Graduate Institute of Traditional Chinese Medicine, 2 School of Traditional Chinese Medicine, Chang Gung University, 3 Center for Traditional Chinese Medicine, Taoyuan Chang Gung Memorial Hospital of Chang Gung Medical Foundation, 4 Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan To evaluate the patients with obstructive sleep apnea syndrome (OSAS) before and after receiving treatment of continuous positive airway pressure (CPAP) in the aspects of constitution pattern, sympathetic activity and endothelial function. From May to December 2011, 8 patients with moderate to severe OSAS received CPAP were evaluated by Epworth Sleepiness Scale (ESS), Constitution in Chinese Medicine Questionnaire (CCMQ), heart rate variability (HRV) study, and traditional Chinese medicine pulse examination. Data including the baseline, the 4 th, 8 th and 12 th week of CPAP treatment were analyzed. There were significant change in ESS after treatment at the 4 th week (6.25 ± 4.95, mean ± SD, p=0.002), the 8 th week (6.38 ± 5.18, p=0.003) and the 12 th week (5.75 ± 2.66, p=0.003) compared with baseline (13.25 ± 3.45). As for CCMQ, there were significant changes in Gentleness type and Qi-deficiency type after treatment. In Gentleness type, there were significant increase at the 4 th week (66.41 ± 16.68, p=0.078), the 8 th week (69.14 ± 14.51, p=0.028) and the 12 th week (70.32 ± 14.08, p=0.034) compared with baseline (57.03 ± 10.53). In Qi-deficiency type, there were significant decrease at the 12 th week (35.16 ± 10.79, p=0.062) compared with baseline (45.70 ± 9.44). In HRV study, there were significant change in the difference between LF% (low frequency) and HF% (high frequency) at 8th week (24.50±4.85, p=0.042) compared with baseline (40.50 ± 4.90). Based on our limited data, CPAP significantly changed the ESS after treatment, Chinese medicine constitution pattern also improved in Gentleness type and Qi-deficiency type. For patients with OSAS, Chinese medicine constitution pattern also can help to evaluate the improvement of CPAP treatment. According to the previous study (J. Heitmann etc., 2007 and Craig L. Phillips etc., 2009), sympathetic tone of HRV and augmentation index had significant changes after CPAP treatment. We also found that our patients showed more balanced LF/HF at 8th week and pulse with high augmentation index, which may be associated to the string pulse in Chinese medicine. However, the preliminary finding needs more data and study in the future. (99-EC-17-A-19-S1-163)

2486 To improve antibiotic dosing by using medical informatics P.-P. Hung 1,*, R.-L. Ma 2 1 Medical Department, 2 Medical Informatic Department, Chia-Yi Christian Hospital, Taiwan (R.O.C.), Chia-Yi City, Taiwan In order to optimize the clinical efficiency of the antibiotics treatment in patients with infectious diseases, the choice of drug with proper indications, the adequate dosing of the drug, and the appropriate dosing adjustment for dynamic variation in renal function are all crucial in designing this program. We design the program by using the medical informatics. There are four parts within this program: First, patient-centered safety is the priority. Based on evidence-based medicine, the program has been embedded logics for elimination of improper drug use, such as tetracycline for children age under 8 years old, drugs belonged to pregnancy category C, D, and X for pregnant women, and drugs for the patients who are known to be allergic to the specific drugs etc. Secondly, we categorize the clinically antibiotics available in our hospital into various sites of the infections according to the approvals of the Food and Drug Administration (FDA). The third part is the central of our goal. It consists of the database which was built-up in view of the recommendation of the MicroMedex. We fulfill the database with the appropriate doses at any spectrum of creatinine clearance for every drug. Finally, to order to prompt the requirement of dosing adjustment immediately, we enable the system to recognize the difference in dosing according to the dynamic variation in renal function. When the informatics system works in the medical care, it acts as the assist role that recommends the proper drug indications by infection sites, adequate dosing of the selected drug, and prompting the real-time dosing adjustment. In the first part, the system successfully holds back the dangerous medical errors so long as the physicians complete the questionnaire in this program. In the second part, the performance couldn t be evaluated correctly because the physicians determine the infection sites subjectively. In the third part, the result of the proper drug dosing is impressive, as up to 92% of antibiotic orders adhere to the default (recommended) dosing of the selected antibiotics. In the fourth part, in spite of the minority of the physicians who do not pay attention to the clue of the dosing adjustment from the program, it does reduce the number of the patients to predispose the risk of drug overdose or underdose. The system actually ushers the new era of medical informatics in managing antibiotics in our hospital. The disadvantage of this program is: it is unable to recognize the proper site-specific indications for drug use.

2499 Application of multidisciplinary team to improve bloodstream infection density L. Fang-Ru 1,* 1 13pw Ward, National Taiwan University Hospital, Taipei City, Taiwan Nosocomial infection is an indicator for the quality of health care. The purpose of this study was to develop a bundles care program for clinic careand was to evaluate its effects in bloodstream infection density of reductionas well as to improve the medical care quality. The setting of this study is about a 24 beds pediatric oncology ward of NTUH from January in 2010 to February in 2011, according to the principles of the QC story. Our multidisciplinary team first developed instruments based on literatures review. The reliability and validity were taken. The main causes are inaccurate dressing changes for staff, imperfect environmental cleanness, both patients and caregivers lacked adequate skin care knowledge. The bloodstream infection density increased to 1.71 from January to July in 2011, we worked out those strategies: Five moments for hand hygiene and cross monitoring, standardization of dressing changesof port-a and Hickman s line, performing an irregular audit of dressing changes of port-a and Hickman s line, performing an irregular audit of port-a insertion techniques, performing audit of environmental cleannessby the month, performingnew fix body method of patient. The result showed the bloodstream infections densityfell from 1.71 (8/4582) pre-implementation to 0.65 (3/4645) post-implementation. The bloodstream infectioncan cause morbidity, mortality and high risk of interruption or delaying chemotherapy in cancer patients. Thus we concluded that this project not only provided an effectively decreased the bloodstream infection density, but also enhanced the quality of medicine. References: Engelhart, S., Glasmacher, A., Exner, M, & Kramer, M. H. (2002). Survelliance for Nosocomial Infections and Fever of Unknown Origin among adult Hematology-Oncology Patients. Infection Control and Hospital Epidemiology, 23(5), 244-248. Renaud, B., &Brun-buisson, C. (2001). Outcomes of Primary and Catheterrelated Bacteremia. American Journal of Respiratory and Critical Care Medicine, 163, 1584-1590. Urrea, M., Rives, S., Cruz, O., Navarro, A., Garcia, J. J., & Estella, Jesus. (2004). Nosocomial infections among pediatric hematology/oncology patients : Results of a prospective incidence study. American Journal of infection control, 32(4), 205-208.

2502 Respiratory care center s central venous catheter-related bloodstream infection rate H.-C. Chen 1,*, F. M. Cheng 1, K.-C. Hsieh 1 1 Landseed Hospital, Taoyuan, Taiwan It was found on September 1, 2010 that our central venous catheter-related bloodstream infection rate had soared to 26.7%, much higher than that of peer hospitals (13.2%). Therefore, the objective was to reduce the Respiratory Care Center s central venous catheter-related bloodstream infection rate to peer hospitals average, 13.2%. 1.The Respiratory Care Center has a total of 12 beds, and the patients we treat rely on a respirator and have transferred from the intensive care unit at our hospital or other hospitals. Their bodies are usually left with a central venous catheter, an endotracheal tube and a urinary catheter, retention rate of the three tubes standing at 80%. 2.The Center s average of hospitalization days stood at 38.6, and its bloodstream infection rate had been kept at a high level, so it was necessary to remove the central venous catheter as soon as possible (Chen, Chen, Dong, Su, Chen and Zheng, 2010). As a result, before entering the Center, from now on every patient has to receive a central venous catheter retention/removal assessment. If a patient needs to be treated with intravenous medicines, peripheral venous line insertion should be employed instead so that the he or she can continue to be treated with medicines without being affected. 3.Meanwhile, the nutrition consultant with the Center should conduct an assessment, and discussion with the nutrition consultant should be held to assess and confirm the patient s current nutritional state. Also, the patient s calories intake should be increased by raising the frequency of nasogastric tube feeding. 4.In accordance with the nutrition screening and assessment form as well as the patient s disease condition, the doctor should assess if the patient's central venous catheter needs to be removed within two days of his or her entering the Center (Marschall et al, 2008). The central venous catheter-related bloodstream infection rate decreased to 8.5% in January 2011 from 26.7% in 2010. A raft of factors is behind in-hospital bloodstream infection, and bedridden patients who suffer from chronic illnesses have weaker immunity, so they belong to an especially frail group, so to speak, in the hospital. When an illness is in an acute state, central venous catheter insertion serves as a necessary therapeutic means. However, if we could remove unnecessary tubes for patients as early as possible, we could boost protection from central venous catheter-related bloodstream infection by 50% (Harbarth, et al, 2003; Marschall et al, 2008). We suggest that group care and discussion be employed, and that nutrition assessment and opinions regarding patients nutritional needs be provided so as to allow patients to recover his or her physical strength and have their unnecessary catheters removed as early as possible. According to the findings from the execution of this project, exploring the necessity of retaining the central venous catheter and removing the catheter as early as possible can both help prevent in-hospital infection effectively. Some units believe that the central venous catheter should not be removed until the stipulated period ends so that medical personnel s workload and medical costs could be reduced. Nevertheless, this could instead increase patients in-hospital bloodstream infection rate, making things worse rather than better. Hopefully, beginning with this Respiratory Care Center, we could reduce the number of unnecessary catheter retention to decrease the in-hospital infection rate so as to maintain patients safety and enhance the quality of medical care.

2604 An audit of intravenous fluid-prescribing practices and maintenance of fluid balance in St. Columcille's hospital in Dublin E. Russell-Goldman 1, M. Redpath 1, T. Branigan 2,*, M. Sebastian 3 1 Medical Student, RCSI, 2 St. Columcille's Hospital, Dublin, Ireland, 3 General Surgery, St. Columcille's Hospital, Dublin, Ireland Preserving the correct fluid and electrolyte balance is essential to maintain normal physiological function. Hospital inpatients may be unable to eat and drink for a variety of reasons thus requiring intravenous fluid (IVF) therapy. It is essential that amount and type of fluid is appropriate for the patient to avoid the potential complications of fluid and electrolyte imbalance such as oedema, hypovolaemia and tachyarrythmias. This audit examined fluid management at St. Columcille's hospital to highlight areas where intervention could improve patient outcomes. A point prevalence study was done on all inpatients in the hospital on 7th February 2012, and in particular patients on intravenous fluid therapy, with the following items being recorded: medical or surgical patient, weight recorded on drug prescription booklet (Kardex), on IVF, the type of fluids, presence of a fluid balance sheet (FBS) in the chart, FBS completed or not, patient in positive or negative fluid balance. This information was collated and compared with the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) 2009. Of 96 patients in the hospital, 84 were admitted medically and 12 surgically. Of these, only 18 had their weight recorded in the kardex. A total of 20 patients were on IVF, with 55% on normal saline, 30% on 5% dextrose and 15% on hartmann's solution. Of the 20 patients on IVF, 15 (75%) had a FBS in their notes, with only 2 (12%) completed consistently with daily fluid balance summaries recorded. When compared to the GIFTASUP recommedations that every patient have their weight recorded and a daily completed fluid balance sheet maintained, only 1 patient of the 20 (5%) was compliant with the guidelines. Neither weight nor fluid balance is routinely calculated for patients on IVF therapy in St. Columcille's hospital. The healthcare staff are general all falling short of the requirements of best practice in IVF prescribing. This audit recommends that all patients have their weight recorded on admission and that the weight be written on the kardex and that all patients on IVF have a completed fulid balance sheet in their chart with daily calculated fluid balances. Where comorbidities affecting fluid status exist, such as congestive cardiac failure, renal failure, hypertension or liver failure, these should also be noted on the kardex to facilitate informed fluid prescribing. References: British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) 2009

2641 Acute coronary syndromes (ACS) and hemorrhagic complications: data analysis of patients managed by prehospital medical intensive care unit (MICU) of a university hospital from 2009 to 2010 F. Rouyer 1, 2, C. Massin 1,*, P. Goldstein 1, E. Wiel 1 1 CHRU Lille SAMU 59, Lille, 2 CH Seclin Intensive Care Unit, Seclin, France In patients with ACS, an increase of bleeding complications has been observed. (1)Bleeding increases mortality, length of in hospital stay and hospitalization cost. According to the use of new antiplatelet and anticoagulant agents such as Prasugrel or Bivalirudin, we wanted to know if STEMI patients who undergo either per cutaneous intervention (PCI) or thrombolysis or high risk NSTEMI patients presented more hemorrhagic complications. We retrospectively analyzed data from 161 patients managed by the pre-hospital MICU of our university hospital between 2009 and 2010 for a ST elevation myocardial infarction (STEMI) or a high risk non ST elevation myocardial infarction (NSTEMI). Many bleeding risk score exist and hemorrhagic risk was defined using TIMI and GUSTO criteria. Major bleedings were a decrease of more than 5 g/dl of hemoglobin, intracranial hemorrhage, hemorrhage with hemodynamic failure or death. Minor bleedings were defined with a decrease of hemoglobin between 3 and 5 g/dl or with blood transfusion needed without hemodynamic failure. Others bleedings with none of these criteria were also studied. 161 patients were included, 60 with high risk NSTEMI (group A) and 101 with STEMI (group B). In group A, 77% received aspirin, 51% a pre-hospital loading dose of clopidogrel, 58% sub-cutaneous enoxaparin and a few patients, fondaparinux or unfractioned heparin. In group B, 11% received prehospital thrombolysis, Aspirin was delivered in 95% patients, and 76% received a pre hospital loading dose of clopidogrel. Prasugrel has been introduced during 2010 and 8% of patients who undergo PCI received a pre hospital loading dose. 3% received bivalirudin. During PCI 47% received anti GP2b3a. 11% of patients (n=17) presented hemorrhagic complications, 12% in group A and 10% in group B and 2% were major bleedings, 2% were minor bleedings and 7% where others bleedings. Length of hospital stay was 5.4 versus 9.7 days (p<0.05) in the group with bleedings. According to registries such as FAST-MI, STEMI or high risk NSTEMI patients received treatments in the same range. Major bleedings rate are less important in our data than in GRACE registry or ACUITY where respectively 3.9% and 4.7% of major bleedings were reported. Pharmacological environment of ACS management is always in evolution. Molecules more efficient such as prasugrel, ticagrelor or bivalirudin are recommended according to the results of international multicenter randomized study but it still remains essential to be able to evaluate our daily strategy regarding complications such as bleedings. Professional practices evaluation allows us to evaluate benefit versus risk for our patients in the daily management of ACS. References: (1) STEMI patients--the more you bleed, the more you die: a comparison between classifications. Valente S, Lazzeri C, Chiostri M, Osmanagaj L, Giglioli C, Gensini GFin Clin Cardiol.2011 Feb:34(2):90-6.

2650 Febrile neutropenia in cancer patients managed at a single institution: a retrospective analysis of adherence to guidelines and outcome N. Pella 1,*, P. Ermacora 1, L. Foltran 1, K. Rihawi 1 1 Oncology, University Hospital Santa Maria della Misericordia Udine, Udine, Italy To measure the adherence to Guidelines (GL)-prescribed behaviours in early management of Febrile Neutropenia (FN) in Cancer Patient (Pts) Firstly five items as quality indicators for early FN management were selected from the Literature(1): a) circulatory and respiratory functions assessment b) assessment of indwelling i.v. catheter and of symptoms or signs suggesting an infection focus c) providing early investigations like blood cultures including cultures from indwelling i.v.catheter and, where clinically appropriated, other microbiology tests and chest X-Ray d) promptly prescribing empirical broad-spectrum antibiotic therapy e) risk assessment by the validated Multinational Association for Supportive Care (MASCC) scoring index in order to distinguish between Low-risk cases scoring >21 and High-risk cases <21 points. Thereafter medical records of 105 consecutive Pts admitted for FN to the Oncology Department of the University Hospital of Udine (Italy) between 2006 and 2011 were retrospectively reviewed. Pts mean age was 54 yrs (25-81); among these 59 had breast cancer, 9 sarcoma, 16 lung cancer, 8 colorectal cancer, 3 testicular cancer, 3 head and neck cancer, 7 other solid tumors. Only one of the Pts was treated with chemo-radiotherapy, the others were on adjuvant (36%) or neoadjuvant (11%) or first line (36%) chemotherapy (CT); 15% were on subsequent lines of CT for advanced disease. Early assessment of circulatory status permitted to treat 40% of the Pts with i.v.fluids, more intensive intervention was required in 4% of cases. Among the Pts 24% had an i.v. indwelling catheter and 34% had mild to severe symptom or signs of infection. Within 24 hours chest X-Ray was performed for only 31%, blood cultures were provided to 61% Pts and other microbiology tests to 40% Pts. Granulocytes Colony Stimulating Factors (GCSF) were administered subcutaneously to all Pts and broad spectrum antibiotic therapy was promptly prescribed as well. The antimicrobial agents used were quinolone combined with amoxicillin plus clavulanic acid (74%) monotherapy (quinolone or amoxicillin plus clavulanic acid) (10%); other antibiotics were prescribed in a minority of cases. 34 Pts (35%) received oral antibiotic therapy. Median duration of first line antibiotic therapy was 7days (1-14). Antifungal therapy was associated in 46% of cases. Nevertheless the antibiotic therapy was changed due to persistent fever over 48hours in 4% of Pts. MASCC Low versus High-risk Pts were 81 and 24 respectively. Median hospital stay was 4 days (1-22) and early discharge within 48 hours for apyrexial Pts was 18%. Time to recovery of Neutrophil count to >1,5x10^3/dl was less than 3 days for 79% of the Pts. In-hospital mortality was 6% (2% in low-risk Pts and 16% in high-risk Pts). FN is recognized as one of the most frightening treatment complications in Cancer Pts treated with standard chemotherapy regimens in terms of morbidity, mortality and use of healthcare resources. Comparing our results to five quality indicators for early FN management we observed an acceptable adherence to the known items. Due to retrospective nature of our study the validated MASCC scoring index was applied only in a post-hoc analysis. Nonetheless we can confirm that this predictive rule may explain the outcome we registered in term of mortality, length of hospitalization and recovery from fever and neutropenia. References: 1) de Naurois J. et al Management of febrile neutropenia: ESMO Clinical Practice Guidelines. Annals of Oncology 2010; 21 (Supplement 5): v252 v256.

2654 Patient-centered care to improve tuberculosis control in a high tuberculosis and multi-drug-resistant tuberculosis incidence area in Lima, Peru L. Fuentes-Tafur 1, W. Carpio 2, O. Cordon 3,*, E. Rumaldo 4 1 Deputy Director, Lima Ciudad Health Directorate, 2 Adjunt Director, General Directorate of Human Resources, MOH, 3 USAID CALIDAD EN SALUD, 4 Director, San Cosme Health Center, Lima, Peru Describe the benefit of successfully implementing a patient centered strategy for tuberculosis (TB) control in an area with a high rate of TB cases, including a significant proportion of multi drug resistant cases (MDR-TB) In 2009, the Lima Ciudad Health Directorate with assistance from USAID Peru began implementing the Plan TBCero program. This is a patient centric healthcare strategy, which focuses on strengthening capacity of community-level family health practitioners and promoters. The strategy aims to increase adherence to treatment, evaluate contacts, active case detection, and community uptake. Since March 2010, differentiated services are also offered to patients with negative sputum bacilloscopy at the La casa de alivio (the relief home) of San Cosme, a facility financed by the Municipality of La Victoria district. This facility provides comprehensive patient services, including psychological counseling and social services programs, as well as continuous follow-up with patients under treatment. The effectiveness of this intervention strategy was measured by monitoring identification of persons with respiratory symptoms (IPRS), defaulters to treatment (DtT), and cure rates The IPRS rate continuously increased from 5% in 2008 to 14.2% during 2011, while the DtT rate dropped from 20.4% in 2008 to 2.4% 2011. Simultaneously, the cure rate increased from 69.3% in 2008 to 90.5% in 2011 (See Table 1). Of the 148 patients who continued treatment through La casa de alivio, none defaulted on their treatment. Table 1: Tuberculosis operational indicators: Trends by year and by semester, San Cosme HC 2008-2011 Rates* 2008 2009 2010 2011 1st Sem 2nd Sem 1st Sem 2nd Sem 1st Sem 2nd Sem 1st Sem 2nd Sem IPRSr 5 6.8 7.8 14.2 DtTr 20.4 16.8 15.6 15.6 7.6 3.5 2.4 NA Cure rate 69.3 77.9 79.6 82.3 87.6 96.4 90.5 NA * Percentages NA= Not available Based on the operational indicators observed over a 3 year period, the TBCero intervention strategy was highly effective in improving performance of the San Cosme Health Care Facility s TB control program. This model should be replicated in areas with high incidence of TB Disclaimer: The authors views expressed in this abstract do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

2656 Does the use of a multidisciplinary goal sheet improve the quality and safety of care in older medical inpatients? S. Long 1,*, S. Brice 2, D. Ames 2, C. Vincent 1 1 Centre for Patient Safety and Service Quality, Imperial College London, 2 Medicine for the Elderly, Imperial College Healthcare NHS Trust, London, United Kingdom Effective, safe and patient centred care of frail, older inpatients requires the multidisciplinary team to be aware of a multitude of complex information, relating to pre-existing problems, acute illness, and the development of complications during the hospital stay. These often relate to complex geriatric syndromes (e.g. delirium, incontinence, functional and mobility decline). It is not surprising that it can be difficult for all members of the multidisciplinary team to keep track of the important issues for each patient. This study, inspired by Pronovost s daily goal sheets on the ICU (Pronovost, 2003), aimed to improve information sharing by testing a multidisciplinary goal sheet on a medicine for the elderly ward. The objectives of the study were to assess the effect of this intervention on staff goal understanding, and overall quality and safety of care as measured by COMPACT(a validated, reliable retrospective safety and quality measurement case record review tool designed for use in older medical patients, Long 2011). This prospective study was carried out on an acute Medicine for the Elderly ward. New admissions were cared for using a multidisciplinary goal sheet in addition to usual care. The goal sheet is a grid in which information relating to each of the geriatric syndromes is mapped out at each stage of the admission, with documentation of goals for the prevention or management of each. The sheet was completed at admission to the ward, then updated at weekly team meetings and ward rounds. The effects of the intervention were assessed with a COMPACT review before and after the study period, for the incidence of new adverse outcomes and scores for a wide range of process measures. As a continuous measure, staff were asked about their understanding of the goals of care for specific patients throughout. Staff questionnaires were used to assess perceptions of team working, acceptability and usefulness of the goal sheet. At the beginning of the study, only 42% of staff responded mostly or completely when asked about their understanding of goals of care for individual patients. This increased significantly (r =.683, p < 0.05) to 100% at 21 days and thereafter during the study period. Significant improvements were found in a wide range of process measure scores in the COMPACT review post-intervention compared with pre-intervention, but not in the incidence of new adverse outcomes. The majority of questionnaire respondents acknowledged problems with multidisciplinary information sharing and felt that the goal sheet was useful and not excessively burdensome. This study indicates that the use of a multidisciplinary goal sheet on a medicine for the elderly ward has significant benefits on staff understanding of goals of care for patients and significantly improves measures relating to processes of care, indicating improvements in overall quality of care. The study was too small to allow any consequent change in the incidence of adverse outcomes to be detected. However, staff felt that the goal sheet was useful and worth the extra time taken to complete it. A larger study is warranted to further investigate this novel approach to improving the care of frail older medical patients. References: Long, S. (2011) Measuring and Improving the Safety and Quality of Care in Older Medical Inpatients, PhD thesis, Imperial College London. Pronovost, P. et al (2003).Improving communication in the ICU using daily goals. Journal of Critical Care 18:(2), 71-75.

2685 The effect of a teaching program with cartoon video on self-care behavior to prevent infective endocarditis among school-age children with congenital heart disease R. Lekhawiphat 1,* 1 Sor Kor 6 Pediatric ward, King Chulalongkorn Memorial Hospital, Bangkok, Thailand To examine the effects of education by using cartoon video on self-care behavior for preventing infective endocarditis (IE) among school-age children with congenital heart disease This quasi-experimental research was classified into two groups, thirty samples were defined as control group, received normal instructions, and the other thirty for experimental group, received special intructions. The special intruction was developed from Social Cognitive Theory by Albert Bandura using cartoon video. The leading character in the video is "Anne" who has congenital heart disease and searching for "BAC" (Bacteria that cause IE) in the blood circulation by using a shrinkable spacecraft. The video takes 20 minutes. The data was obtained by using questionaires, "Self-care behavior for preventing IE". The score was analyzed by means, percentage and t-test. The experimental group demonstrated high score on self-care behaviors for preventing IE than the control group, statistically significant at 0.001 Cartoon video has helped to improve the self-care behavior for preventing IE and bring brighter smiles for children.

1059 Assessment of patient-safety education in pre-registration adult nursing program M. Mansour 1,* 1 Acute Care Department, Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, United Kingdom To examine the views of pre-registration adult nursing students and academic staff on the integration of World Health Organisation (WHO) patient safety curriculum guide in pre-registration adult nursing training. Small qualitative study was carried out, where 20 semi-structured interviews (with 10 academic staff and 10 final year pre registration adult nursing students) were conducted in one university in East of England in 2011. The interviews were guided by the 11 generic patient safety themes advocated by the new WHO Multi-Professional Patient Safety Curriculum Guide (2011). The results were analysed thematically. Ethical approval was sought and obtained prior to the start of data collection. Four main themes emerged from the participants views: 1) Not linked to patient safety; 2) A theory- practice mismatch; 3) The scope of the mentor role and 4) Impact of teaching approach and delivery. Almost all the participants emphasized the need to have an explicit strand for patient safety taught throughout the nursing program. On the other hand, the analysis of the participants views suggests that there were few issues, such as the ability to speak up concerns, which may be perceived as vital to complement patient safety training, but were not clearly addressed by the WHO patient safety curriculum guide. There are areas in current pre-registration/undergraduate nursing program which may need to be revised to accommodate modern patient safety agenda. The WHO patient safety curriculum guide represents an important step in integrating patient safety education in nursing training, but may need further considerations to accommodate wider aspects of patient safety into nursing training. The result of this exploratory research will help to inform future larger studies into the patient safety education in adult nursing training. References: House of Commons Health Committee (2009). Patient Safety: 6th Report of 9 session 2008-09. London, Stationery Office. Patey, R., Flin, R., Cuthbertson, B., MacDonald, L., Mearns, K., Cleland, J., Williams,D (2007). "Patient safety: helping medical students understand error in healthcare." Quality and Safety in Health Care 16(4): 256-259. World Alliance for Patient Safety. (2011). Patient Safety Curriculum Guide: Multi-professional Edition. from retrived http://whqlibdoc.who.int/publications/2011/9789241501958_eng.pdf. [accessed on 1st Febrary 2012].

1131 Patient safety in the perception of the multidisciplinary team about the adverse events at a university hospital M. M. Melleiro 1,*, R. Lima 1, D. Tronchin 1 1 Nursing School of University of São Paulo, São Paulo, Brazil The objectives of this study were to analyze the perception of the multidisciplinary team at a university hospital about factors involved in adverse events and to identify the factors involved in the occurrence of adverse events with the quality dimensions of Parasuraman, Berry and Zeilthaml. This is an exploratory-descriptive study, a quantitative approach, with prospective data collection. The population consisted of 98 professionals with bachelor's degree in health. The data collection was done during May-June 2010, with the permission of the Ethics Committee of the institution. In the characterization of the professionals it was found that the population consisted mostly of young adults, 74.5% were female and the level of education showed that 31.6% had graduate lato sensu. The perception of professionals about the factors involved in the occurrence of adverse events related to the dimensions of quality that stood out were: responsiveness to the user's right to refuse to undergo procedures, empathy with users' satisfaction and confidence regarding the statement of the institution. Among the participants, the professional classes were more expressed their perception analysts, pharmacists and nurses. The adverse events categories were most often cited by the pathological effects expected or unexpected off-label for medical treatment, medication errors and falls. Therefore, this research has helped understand the perception of the multidisciplinary team about the factors involved in the occurrence of adverse events, supporting the redesign of care processes and management focusing on risk management. References: Zeithaml V, Parasuraman A, Berry LL. Delivering service quality: balancing customer perceptions and expectations. New York: The Free Press; 1990. Parasuraman A, Zeithaml V, Berry LL. Refinement and reassessment of the SERVQUAL dimensions. Journal of Retailing 1991;67:420-50.

1143 Exploring relationships sexual satisfaction, depressive symptoms and quality of life with COPD M. L. Fang 1,*, H. W. Lee 1, L. C. Chen 1, S. C. Lan 1 1 Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan It is estimated that chronic obstructive pulmonary disease (COPD) could be the third of globally death by the year 2020. The deaths of COPD patients greatly increase year by year.near the end of life, patients with severe COPD have suffered from more distress, such a dyspnea, pain, sexual dysfunction, depression and anxiety. COPD affected patients no only physical but also psychosocial and quality of life. Comfortable care will be an important issue. We hope this study can provide insights about the strategy of caring COPD patients, which could be applied in nursing educational aims to help COPD patients understand concepts and gain competencies in holistic care. The goal of this study is to Exploring Relationships Sexual Satisfaction, Depressive symptoms and quality of life with chronic obstructive pulmonary disease. We select patients members of COPD patients in chest OPD clinics in New Taipei City. A structural form is used including the demographic information of male COPD patients, Sexual Satisfaction, Geriatric Depression and the Short Form 36 items Health Questionnaire. The Cronbach s Alpha value between factors is 0.9. The study period is from July 2011 to January 2012.When there was a suitable case the study team will be introduced to the case by the chief nurse of the unit. Informed consent will be obtained before enrolment, and the case has the right to decline the study at any time. All the information is collected anonymously and analyzed with spss13.0 for windows software. Sixty COPD patients were enrolled in our study during July 2011 to January 2012. The study showed significant findings:(1)a negative significant was found between sexual satisfaction and COPD duration; (2)Participants had longer duration of COPD,had more depression had worse of quality of life (3) A negative significant relationship was found between sexual satisfaction and depression symptoms of COPD male ; (4)Obviously,it also had more the depression symptoms domain of the COPD patients concems about the quality of life. Healthcare professionals may use these results to provide healthcare and enhance the quality of life of COPD patients. The findingsof this study suggest that nursing assessment include the issues of sexual needs. It will provide greater understanding of COPD patient s sexual needs. Transferring patients for consultation or giving advice to need ones may increase their sexual satisfaction and improving the depression status. Healthcare professionals may use these result to provide healthcare and enhance the quality of life of COPD patients. References: Bachmann, G, (2006). Female sexuality and sexual dysfunction: Are we stuck on the learning curve?journal of Sexual Medicine, 3(4), 639-645. Kara, M., & Mirici, A. (2004). Loneliness, depression, and social support of Turkish patients with chronic obstructive pulmonary disease and their spouses, Journal of Nursing Scholarship, 36(4), 331-336. Mannino, D, M., & Buist, A. S, (2007). Global burden of COPD: Risk factors, preva-lence, and future trends. Lancet, 370(9589), 765-773. Sonnenberg, C. M., Beekman, A, T., Deeg, D. J, & vantilburg, W(2002). Sex different in late-life depression. Acta Psychiatr Scand, 101(4), 286-292.

1152 Increasing completion rates in nursing palliative care through multidisciplinary teamwork M. H. Wang 1,*, M. L. Fang 1, Y. F. Huang 1, L. C. Chen 1 1 Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan Patients with end-stage chronic obstructive pulmonary disease (COPD) commonly suffer from dyspnea, mood swings, pain, or depression. A total of 82% of this patient population did not have improvements from these symptoms and they had greater suffering than end-stage cancer patients had and used more medical resources with a severe shortage of palliative care that was available to them. The nursing palliative care rate was 40% as surveyed in October 2010. The nursing palliative care satisfaction rate was 26.6% for end-stage COPD patients. The ultimate goal of medicine is to provide better service for quality life. We strive to provide complete palliative care by providing patients with COPD relief from respiratory symptoms and psychological support. The results from the questionnaires confirmed the following problems: the nursing instructions of palliative care for endstage COPD patients did not meet patient need; there was a lack of continuing education for palliative care, and lacking an audit system to monitor patient satisfaction for palliative care. We developed these measures for improvement: (1)create a nursing instruction manual for the palliative care of patients with end-stage COPD;(2)hold continuing education courses for palliative care;(3) hold workshops for rans-disciplinary support groups; and(4) establish an audit system to monitor patient satisfaction of palliative care. This study investigated the effectiveness of multidisciplinary teamwork to promote nursing palliative care.twenty endstage COPD patients were enrolled in our study duringoctober 2010 to April 2011. The study showed significant findings:the nursing palliative care rate was 81%. The palliative care satisfaction rate for end-stage COPD patients was 82%. Organized and integrated nursing instructions based on patient and family centered principles facilitated team participation in care processes, reaching consensus, understanding the experiences of caregivers, and understand their needs for emotional support. With the establishment of a unified palliative care plan for end-stage COPD patients, nursing care skills were improved and family members also received the chance to discuss and share experiences through support group activities. Most importantly, patients with end-stage COPD enjoyed wholistic care at the end stage of their lives. References: 沈 青 青 林 妙 怜 許 婷 秀 齊 珍 慈 (2008). 醫 護 人 員 及 家 屬 對 兒 童 安 寧 緩 和 照 護 需 求 滿 意 度 之 探 討. 榮 總 護 理,25(3),206-214 邱 雲 柯 王 英 偉 (2006). 共 同 照 護 - 以 醫 院 為 本 的 緩 和 醫 療 照 顧 團 隊. 慈 濟 醫 學,18(4),7-10 許 正 園 辛 幸 珍 (2011). 非 癌 疾 病 的 安 寧 療 護 : 談 COPD 末 期 照 護 倫 理. 台 灣 醫 學,15(2),180-186 張 惠 雯 (2010). 慢 性 阻 塞 性 肺 病 的 末 期 醫 療 照 護. 安 寧 療 護 雜 誌,15(1),81-93 趙 可 式 (2009). 台 灣 安 寧 療 護 的 發 展 與 前 瞻. 護 理 雜 誌,56(1),5-10 Curtis, J. R. (2008). Palliative and end-of-life care for patients with severe COPD. European Respiratory Journal, 32(3), 796-803. Freedman, Orit. C.,&Zimmermann, Camilla. (2009).The role of palliative care in the lung cancer patient: can we improve quality while limiting futile care?pulmonary Medicine, 15(4),321-326. Hall, Pamela.,&Morris, Mollie. (2010).Improving heart failure in home care with chronic disease management and telemonitoring. Home Healthcare Nurse, 28(10), 606-617. Helena, Elkington., Patrick, White., Julia, Addington-Hall., Roger, Higgs., &Polly, Edmonds. (2005). The healthcare needs of chronic obstructive pulmonary disease patients in the last year of life.palliative Medicine, 19(6), 485-491. Joyce, M., Schwartz, S., & Huhmann, M. (2008). Supportive care in lung cancer. Seminars in Oncology Nursing, 24(1), 57-67.

1166 Increasing satisfaction with palliative care in bereaved caregivers through multidisciplinary teamwork H. W. Lee 1,*, M. L. Fang 1, Y. F. Huang 1, L. C. Chen 1 1 Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan This study investigated the effectiveness of multidisciplinary teamwork to promote bereaved caregivers palliative care satisfaction. The deaths of COPD patients greatly increase year by year, near the end of life. Comfortable care will be an important.in our respiratory ward the patients were with the diagnosed with COPD. The bereaved caregivers had low satisfaction with palliative care.thus,this studyproject aimed at understanding the perception of good death of late-stage COPD patients by their bereaved caregivers and their level of satisfaction with the care give.this study strive to provide complete multidisciplinary teamwork increasing satisfaction palliative care in the bereaved caregivers. Convenient samples of late-stage COPD patients by bereaved caregiversthat needed palliative care and were hospitalized in respiratory departments in a medical center in Northern Taiwan from July 2010 to December 2010 were included in our study. Data were collected using structured questionnaires. It focused on the completion of nursing directive palliative care and thebereaved caregivers with palliative caresatisfaction. After analyzing the problems including:(1)short of completion instruction booklet forpalliative care;(2)lack of a standard procedure for giving nursing instruction;(3)lack of monitoring system (4) lack of nursing training and lack of continuing education.the four methods of used included:establish monitor tools for nursing palliative care, development standard nursing care procedures, and make the process of grup nursing instruction, and making an educational manual, and establish satisfaction scoring system palliative care. Thus,results show that the completion rate of nursing palliative care increased from 78.2%to 89.9%. The bereaved caregivers with palliative care satisfaction increased from 70.2% to 90.5%. The findings of this study suggested that nursing assessment include the issues of the theirbereaved caregivers with palliative care needsfor symptom control, emotional support, death certificate acquirement or very satisfaction service. It will provide greater understanding of late-stage COPD enjoyed wholistic care at the late stage of their lives. The health professionals should evaluate emotional distress of their bereaved caregivers in early stage, provide emotional support and consultation and apply empowerment strategy to promote their quality of life. References: Freedman, Orit C&Zimmermann, Camilla. (2009).The role of palliative care in the lung cancer patient: can we improve quality while limiting futile care?pulmonary Medicine, 15(4),321-326. Hall, Pamela&Morris, Mollie. (2010).Improving Heart Failure in Home Care with Chronic Disease Management and Telemonitoring. Home Healthcare Nurse, 28(10), 606-617. Varkey, Basil. (2010). Opioids for palliation of refractory dyspnea in chronic obstructive pulmonary disease patients. Pulmonary Medicine, 16(2),150-154.

1227 A discussion of operating room personnel response to fire in the operating room W. Chin-Chih 1,*, Y. Fen-Hui 1, H. Yi-Ling 1, H. Yu-Wen 1 1 CHANG GUNG MEDICAL FOUNDATION, TAIPEI, Taiwan Patient safety is one of the major objectives in healthcare. In 2010, Taiwan Joint Commission on Hospital Accreditation implemented a hospital-wide fire safety and emergency response system in a move to promote patient safety and healthcare quality. The operating room is a complex and unique environment. If a fire occur, a rapid and coordinated response by the operating room personnel is critical in minimizing harm. This paper aims to establish a fire prevention plan, conduct fire drills, formulating a workflow to follow in event of fire; plan escape routes, and assess the knowledge and competence of the personnel with regards to fire prevention in the operating room. This is a pre-poststudy which aims to establish a fire response plan, a fire prevention plan, conduct fire drills, formulating a workflow, design escape route, and assess the knowledge and competence of the personnel with regards to fire prevention in the operating room. We developed a checklist to assess the operating room personnel's preparedness of response to fire. This checklist was divided to three parts which assess the fire response cognition, completion of equipments, and the ability to operate these equipments. All staffs were taken pre-test before training program as a baseline. An operating room fire prevention plan was formulated after literature review and discussion with the heads of departments. All operating room personnel were required to read the plan and then sign to confirm that they have understood it. Besides that, some case-oriented scenarios by role play were conducted for advanced training. A yearly review of this plan was made compulsory as well. After the implementation of this plan, the fire response cognition levels showed improvement from 30.8% to 95.5%. The completion of equipments increased from 77% to 100%. And the ability of operating equipments raise from 65.9% to 98.6%. In order to improve the response of the operating room personnel should a fire occur, regular training with regards to the proper utilization of the various fire fighting equipment and fire safety and response workflow are necessary. The review of the workflow should also be performed in a timely manner. These measures will help to improve patient safety and ensure a better working environment in the operating room. A proper understanding of the various steps in fire safety and prevention workflow by every member of the operating room team will help to minimize harm, limit damage and prevent the loss of life.

1255 The effect of multimedia-based nursing instruction on the improvement of drug use of COPD patients H. Y. Tsai 1,*, M. L. Fang 1, J.-Y. Lin 1, L. C. Chen 1 1 Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan This study investigates the effect of multimedia-based nursing instruction on the improvement of drug use ofchronic obstructive pulmonary disease (COPD).In this digital era, integration of information technology and nursing instruction can be applied to enhance medical quality and patient s self-efficacy. It is found through an analysis that the content of onepage nursing instruction is not compliant with current situations, suggested process of using metered dose inhaler(mdi) has not been designed, and nursing instruction monitoring procedures are not available. The study extends from January 2009 to July 2011, and used convenience-sampling methods to select subjects for this study that were hospitalized patients with COPD from the Division of Respiratory Medicine from a specific medical center in northern Taiwan. A structured questionnaire including demographic information of COPD patients. Thus, solutions are proposed as follows: (1) Instruction manual on the use of MDI should be designed;(2) Nursing instruction video discs can be produced for patients to watch the videos on mobile computers in their sickrooms at any time; (3) Suggested drug use process should be set up;(4) Nursing instruction monitoring procedures should be designed and listed in the improvement programs. Through the implementation of the above measures, the completeness rate ofnursing instructions can reach 94%, and the correct use of MDI among COPD patients can also reach 96%.The results of this study suggest that drug use and nursing instruction monitoring programs should involve longitudinal follow-up use. The result indicates that the proposed program is significantly effective. It can not only help solve clinical problems but also serve as a basis of clinical care in the future. Furthermore, the results could be used as a reference in educational training of nurses,providing patients to high-quality nursing care. References: Barnett, M., (2007). Using a model in the assessment and management of COPD. Journal of Community Nurs, 21(11),4-10. Frace, M., (2007). Understanding chronic obstructive pulmonary disease. Journal of Community Nursing, 21(11), 8-11. Korniewicz,D.M.,& O, Brien,M.E.(1994).Evaluation of a home dialysis Patient education and support program.anna Journal,21 (1),33-38. Knowles,M.S.(1975).Self-directed learning-a guide for learners and Teachers. New York: Cambridge. Laviolette, L., Bernard, S., Lacasse, Y., Breton, M. J., & Maltais, F. (2008).Assessing the impacto fpulmonary rehabilitation on functional status in COPD. Thorax, 63, 115-121. Mazor,K.M.,&Billings-Gagliardi,S.(2003).Does reading about stroke increase stroke knowledge?the impact of different print materials. Patient Education&Counseling,51(3),207-215. Paz-Diaz, H., Montes de Oca, M., Lopez, J. M., & Celli, B. R. (2007). Pulmonary rehabilitation improves depression, anxiety, dyspnea and health status in patients with COPD. American Journal of Physical Medicine & Rehabilitation, 86(1), 30-36. Santavirta,N.,Lillquist,V.,Konttinnen,Y.T.,&Santavivta,S.(1994).Teaching of patients undergoing tatal hip replacrment surgery. International Journal of Nursing Studies,31(2),135-142.

1271 Using hands-on experience to improve empathy of nursing students in the operating theatre Y. Mei Yun 1,* 1 School of Nursing, Fooyin UNniversity, New Taipei City, Taiwan Empathy is a perceptual conception referring to the process and the way that one intuits the way an object or an event seeing from the inside, accurately and dispassionately understanding another person s (client s) point of view concerning his or her situation. Knowing how patients feel is an important component of caring in nursing, especially for professional education of novice in the operation room. Making nursing students keep reflexive diaries to understand their empathic thoughts in the operation room was helpful to develop empathic strategies toward nursing students. The objectives of this research were to explore the influence of empathic hands-on experience on nursing students who having clinical practice in operation room. Researchers adopted a narrative, qualitative research design. There were six nursing-student participants with internship experience in the operation room. They answered two questions after lying on operation table for 3 minutes: (a) what was the influence of this experience? (What did you think and behave when you lied on the operation table?); (b) what did you learn from this learning experience? (What will you do when you face a patient lying on the operation table in the future? Two of the six students had been operated on before. One was operated on once, and the other was operated on twice. However, neither of them remembers their operation experience. Most of participants felt unsafe, anxious, lonely, cold, fear and stressful when they lied on the operation table. When the table started to move by controllers, they wondered What will you do later? I was totally unfamiliar with the environment with low temperature, and was surrounded by machines, equipments and instruments. What a terrible look! If they are the operation nurses, they will have their own strategies to take care preoperative patients, including I will talk with them and tell them what will I do later to release their anxiety and unsafety. They might be fear and anxious. After this experience, I will be more concerned and care about patients feeling. Hope they can have their operations under a peaceful mood. Research findings may serve as a reference for nursing instructors to use hands-on strategies in nursing students clinical practicum.

1295 A diagnostic tool for the retrospective analysis of critical events (TRACE) A. F. Hannawa 1,*, D. L. Roter 2 1 Institute of Communication and Health, University of Lugano, Lugano, Switzerland, 2 The Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States This manuscript develops a diagnostic Tool for the Retrospective Analysis of Critical Events in Medicine (TRACE) that facilitates a comprehensive, theoretically grounded analysis of medical performance and the human factors that contribute to critical events. Conceptual integration of the existing patient safety literature Although communication is an important component of medical practice, existing literature has analyzed its role in error analysis and prevention in superficial and uncoordinated ways. These deficiencies in combination with vagaries of definition and terminology discourage effective critical incident analysis, particularly if an incident did not reflect a preventable adverse event. Indeed, the hierarchy of error reporting proposed by the Institute of Medicine (IOM) specifies mandatory reporting only for those adverse events deemed both serious and preventable. The IOM suggests that reporting of all other critical incidents, including those resulting in little or no harm be relegated to a voluntary reporting system developed in the future to serve as a tool for quality improvement purposes. It is in this arena that the proposed Tool for Retrospective Analysis of Critical Events (TRACE) may be seen. Recognizing the complex nature of critical incidents that arise during the practice of medicine, the TRACE is proposed as a practical tool to assist clinicians to more fully analyze and understand their medical practice and the role it has played in a critical incident, regardless of the occurrence of an adverse outcome. The matrix is grounded in medical practice through its reference to normative standards of care and the clinical functions within which errors occur, ranging from history taking to post-treatment care. Furthermore, it distinguishes error types on cognitive, behavioral and communicative dimensions, allowing for a differentiated analysis of critical incidents that conceptually integrates Reason s typology of knowledge- and rule-based mistakes and skill-based slips and lapses (Reason, 1990), Banja s (2005) criterion of reasonability, and Spitzberg and Cupach s (2002) theory of communication competence. The authors discuss how the TRACE may be used (1) as the means for a comprehensive, detailed analysis of human performance across the spectrum of five clinical practice contexts, (2) as an objective fact-check after the occurrence of a critical event, (3) as a heuristic tool to prevent critical incidents, (4) as a data-keeping system to enhance quality improvement, and (5) to assess the likelihood of rightful medical litigation. References: Reason, J. (1990). Human error. Cambridge, MA: Cambridge University Press. Banja, J. (2005). Medical errors and medical narcissism. Sudbury, MA: Jones and Bartlett Publishers, Inc. Spitzberg, B. H., & Cupach, W. R. (2002). Interpersonal skills. In M. L. Knapp & J. A. Daly (Eds.),Handbook of interpersonal communication (pp. 564-611). Thousand Oaks, CA: Sage.

1310 Implementation of structured handover on a labour & delivery unit E. Poot 1,*, M. de Bruijne 1, M. Wouters 2, C. Wagner 1 1 Public & Occupational Health, 2 Obstetrics & Gynaecology, VU University Medical Centre, Amsterdam, Netherlands To describe current shift-to-shift handover practice and initial strategies to structure handover with SBAR on a Labour & Delivery Unit in the Netherlands Communication and handover are susceptible for failure and form a leading cause of adverse events. Patient safety is a major concern in obstetrical care in the Netherlands, since perinatal mortality is relatively high compared to other West European countries. Recently, the first national audit on perinatal mortality called for improvement of communication and handover. Research suggests that structuring communication with SBAR (Situation, Background, Assessment, Recommendation) contributes to patient safety. Therefore, structured handover, based on SBAR, was implemented on a Labour & Delivery Unit in the Netherlands. The stepwise implementation strategy started with a focus group meeting to assess current problems in handover, observations to describe current shift-to-shift handover, and a Crew Resource Management (CRM) training to practice structured handover. In the focus group all relevant disciplines were represented. The items mentioned during the meeting were transcribed on a flip chart and directly verified by the participants. The meeting was audio taped for a final check. Direct observation of handovers (n=70) were carried out by a researcher, who assessed the structure (SBAR), duration, interruptions, leadership, eye contact and questions asked by staff members involved. Finally, a training based on Crew Resource Management (CRM) principles was offered to all staff members of the Labour & Delivery Unit. The 3-hour workshop focussed on communication, situational awareness and leadership during handover. The interactive training consisted of theory and two obstetrical scenarios with actors playing a labouring woman and her husband. Between the two scenarios SBAR was introduced. The training was evaluated in a 20-item questionnaire on a 5-point Likert scale (1=strongly disagree; 5=strongly agree). Descriptive statistics were used to analyze how CRM-training was received and current handover practice. Chi-square was used to detect significant difference between disciplines, interruptions, duration, questions and eye contact. The focus group meeting revealed that currently handovers were often inadequately structured, lacking preparation and a clear aim, and lacking attention and time of staff involved. Of seventy observed handovers 56% lasted <2 minutes and 53% were interrupted at least once. In 55% of handovers questions were asked, in 52% there was at least partly eye contact on a regular basis. Leadership was unclear in 92%. All elements of SBAR were handed over in 7%. In almost every handover Situation (99%) and Background (86%) were mentioned. In 97% of handovers Background was mentioned first and in 77% Situation second. Assessment and Recommendation were mentioned in 24% and 46% respectively. Information was seldom repeated back (3%). In 44% of handovers 3 elements of SBAR were mentioned. 76 % of all staff attended the training and rated the training very positive. Overall mean of all questions was 4.3 (std. dev. 0.41). Focus group meeting revealed that handover practice before the training was rather unstructured and incomplete and this was perceived as a problem by the professionals involved. Both Assessment and Recommendation are lacking frequently and Read Back almost always, thus leaving room for improvement by implementing SBAR. CRM-training on structured handover was positively evaluated. The training effects will be evaluated 6 months after the training.

1334 The use of physical restraint and its relationship to the belief of staff in different settings K. S. Tang 1,*, V. P. Y. Chan 2, H. W. Chui 1, O. C. M. Chan 1 1 Quality & Safety Division, NTWC, 2 Nursing Services Division, NTWC, Hospital Authority, Hong Kong, NT, Hong Kong, China To understand staff knowledge and belief towards physical restraint among nurses and healthcare assistants in an acute hospital in Hong Kong Topic about physical restraint has been growing concern in the past decade. It is, however, still commonly used in Hong Kong acute hospitals. The idea of carefully planning and evaluating before restraint used is suggested to be conveyed. Nurses and health care assistants play key role in initiating and implementing the issue. In order to develop a tailor-made education program, understanding why they insist to apply physical restraint become important. A total of 56 nurses from three different settings including ICU, medical and geriatric based were randomly interviewed using a structured questionnaire by trained staff. Individual interview was to last 20 minutes. Questions covered their attitude and knowledge on physical restraint used. Personal particulars including number of years in role were also collected. Patterns and the belief towards the physical restraint used were evaluated in different wards. Homogenous results were found in various settings. To avoid pulling out the central line and falling out of bed were the major documented reasons for the use of restraint. Knowledge gap was also identified. Over 80% nurses and healthcare assistants figured out safety vest might cause mortality whereas half of them indicated restraint could not cause serious morbidity at the same time. Such inconsistent mindset and behavior were showed. No significant perception difference was found between their perceptions toward restraint, years in role and environments. Concern over the inappropriate uses of physical restraint has been highlighted. Restraint use is a complex issue that should be well-planned, however, understanding the underlying reasons among different wards setting is an essential element. This study serves as an important step toward minimizing restraint and as a basis for designing a proper education program. More alternatives to restraints focused on prevention of falls and pulling out catheters/tubes should be introduced.

1351 Multimodal hand hygiene improvement strategies to increase the hand hygiene compliance rate M. J. Shin 1,*, H.-K. Seo 2, S. Kwon 2, H. B. Kim 2, 3 1 Hospital Infection Control Services, 2 Hospital Infection Control Services, 3 Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea, Republic Of Hand hygiene is the most important practice to prevent healthcare-associated infection (HCAI) in healthcare facilities. However, the hand hygiene compliance rate among healthcare workers (HCWs) is relatively low; mostly below 50% in many healthcare facilities. Therefore, Seoul National University Bundang Hospital (SNUBH) Infection Control Team commenced a series of activities to increase the hand hygiene compliance rate using 6 sigma method which is the key program used for quality improvement activities in various sections in SNUBH. SNUBH Hand Hygiene Improvement Team applied a series of activities to increase the hand hygiene compliance rate for eight months, then carrying out a post-management program for one year. In order to draw the key factors which could affect the hand hygiene compliance, we got close to HCWs in a few ways, including brainstorming, private interviews with HCWs, and observation on their practice. After then, we concluded that lack of time for hand hygiene, lack of knowledge of hand hygiene guideline, skin irritation or discomfort after using alcohol-based hand rubs, and mistrust about the effect of hand hygiene were the major factors to be overcome. Therefore, we designed the improvement plans suitable for SNUBH in consideration of those factors according to the Multimodal hand hygiene improvement strategy recommended by WHO. Our strategies were as follows; selection of target practice with the higher priority, regular monitoring and feedback, activities to increase satisfaction in using alcoholbased hand rub, reinforcement of education program, application of infection control leader system, a campaign for hand hygiene, promotion using various reminders, and participation in 2011 WHO Hand Hygiene Excellence Award. Hand hygiene compliance rate increased up to 82.0% after first quarter of post-management program from 65.8% before implementation of the program. Sigma level improved from 1.91 to 2.42. In addition, liters of alcohol based hand rub (ABHR) used per 1,000 in-patient days, which is known to be a performance indicator for hand hygiene, increased from 7.0 to 10.9 in general wards and from 27.7 to 36.2 in ICU, respectively. Multimodal hand hygiene improvement strategies modified according to the thorough assessment of current situation using 6 sigma method is effective to increase the compliance rate of hand hygiene practice. In order to prevent HCAI, which is the optimal goal of hand hygiene improvement, we continue to make the utmost efforts to vigilantly monitor the compliance rate of hand hygiene and analyze the HCAI data. References: 1. Eramus V., Brauwer W., Beeck E. F. et al. A qualitative exploration of reasons for poor hand hygiene among hospital workers: Lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infection Control of Hospital Epidemiology. 2009;30, 415-419. 2. Lee A., Chalfine A., Daikos G. et al. Hand hygiene practices and adherence determinants in surgical wards across europe and israel: A multicenter observational study. American Journal of Infection Control. 2011;33, 175-181. 3. Pittet D. The lowbury lecture: Behaviour in infection control. Journal of Hospital Infection. 2004; 58,1-13. 4. World Health Organization. WHO guidelines on hand hygiene in health care. 2009.

1379 Multi-disciplinary collaboration in preventing patient falls Y. T. P. Ko 1, G. H. Aboo 1, C. T. Sy 2,*, S. K. C. Leung 1 1 Nursing Services Division, 2 Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong East Cluster, Hong Kong Hospital Authority, Hong Kong, Hong Kong, China Patient falls contributed 70% of reported incidents. In recent years, a decrease in incidence of falls (i.e. 203 in 2010 and 157 in 2011) but increase in severity of fall injury (i.e. 4 in 2010 to 11 in 2011) such as patients sustained fracture after a fall, especially on patients who started ambulation is noted. Hence, fall prevention is not limit to reduce the incidence but prevent serious injury of fall. In December 2011, the Cluster Nursing Services Division (NSD) and Cluster Quality & Safety Office formed a multi-disciplinary working group. The working group firstly aims to increase the nurses knowledge and skills in fall assessment. Secondly, develops a cluster clinical protocol on fall prevention. Thirdly, to collaborate with different professionals to develop the system on nurse-initiated referral to allied health professionals for early assessment and mobilization for patients at risk to fall. Lastly, to evaluate the effectiveness of fall prevention program on care-related practice and environment-related issues in fall prevention. Cluster hospitals used different fall risk assessment scales (RAS) and NSD identified and aligned the use of one common valid and reliable RAS. Also, NSD reviewed the fall prevention records and the working group reviewed the fall prevention programs in cluster hospitals. In order to enhance the nurses knowledge in fall assessment, the working group organized train-the-trainers workshops with a particular focus on gait and fall assessments. Besides, nurses continued the monthly three-tiers nursing patient safety round on fall prevention, and the environmental safety check with an environment checklist before end of each shift. In 1Q12, NSD aligned cluster hospitals to use the Morse s Fall Scale (MFS) for assessment. Train-the-trainers workshops on MFS and fall prevention was or to be held 1Q-2Q12. Furthermore, NSD starts to identify the cut-off scores of MFS, one for acute and another one for non-acute hospitals. Besides, the working group is deriving the fall preventive measures for high, medium and low fall risk patients to be included in the fall prevention clinical protocol. Since, early and safe mobilization is important for patients in rehabilitation, a nurse-initiated referral to allied health professionals for early assessment and mobilization will be discussed. The effectiveness of the fall prevention program will then be evaluated in 2014. The occurrence of fall is to be prevented whenever possible. However, when fall prevention is not possible, then prevent serious injury of fall is one of the key elements in fall prevention. The success of fall prevention depends the concerted effort of different profession. Early assessment and safe mobilization are the strategies in fall prevention.

1396 Are our written and verbal signouts safe? Experiences of a community-based residency program N. K. Ali 1,*, S. Baksh 1, S. Thomas 1, N. Law 1 1 Medicine, Crozer Chester Medical Center, Upland, United States The duty-hour standards implemented by Accreditation Council on Graduate Medical Education in 2003 and 2010 have significantly increased the number of patient handoffs. Studies show that communication failures during handoffs lead to patient harm and delayed patient care. The objective of our study was to assess the accuracy and completeness of the process and content of verbal and written resident signouts. A transition task force consisting of interns, residents, chief resident and faculty mentor was formed to evaluate the content of the written and verbal signouts. The ANTICIPATE checklist proposed by Vidyarthi et al. was used as a framework to assess the accuracy and completeness of patient signouts. The checklist consisted of 28 variables in 9 categories: demographic data, admitting complaint and diagnosis, medications & allergies, assessment & plan, baseline vital signs and mental status, recent procedures and significant events, follow up plan, primary team contact information and organization of content. The adequacy of verbal signouts was assessed with a checklist created from the DRAW tool developed by Seton Family Hospital and best practices recommended by The Society of Hospital Medicine Healthcare Quality and Patient safety Committee for verbal exchange. The variables included in the checklist were Diagnosis, Recent changes, Anticipated changes, What to watch for, addressing questions or concerns, use of teach back technique, secure environment for patient information exchange and prioritizing ill patients. Fifty six written signouts were collected from 17 (77%) interns and 57 verbal signouts from 13 interns (59%) were tape recorded on randomly selected weekdays over a course of 4 weeks. The collected data was corroborated by crosschecking the patient charts. The chief resident obtained 6 process maps from the interns and residents to outline the steps involved in creation of signouts. Data was analyzed using descriptive statistics. The mean intern score for accurate and complete written signout was around 60% (16.77 ± 3.05 [SD] of 28 points). The categories which achieved mean completion scores of over 75% included organization of content (88% ± 1) and documentation of recent procedures and significant events (92% ± 1). The categories in which mean score was less than 50% included assessment and plan (21% ± 0) and baseline vital signs and mental status (2% ± 3). The mean intern score on the verbal checklist was 44% (4±3 of 9 points). The categories in which mean scores were over 75% included mention of diagnosis (92%±0.28), recent updates (92%±0.28) and tasks that need to be completed (78%±0.42). The weakest areas were use of the teach back technique (31%±0.46) and addressing questions or concerns (1.7%±0.13). The process mapping revealed that the process of preparing and delivering signouts was being carried out entirely by the interns with no direct involvement or input by the team resident or the attending physician. Substantial variability exists in the content and delivery of signouts. Multiple categories of critical significance are deficient indicating the need for standardization of signouts as well as provision of handoffs training to all interns and residents. This study provides an approach to evaluate the content and process of signouts for physicians in training. The next step for the transition task force is standardization of the written template as well as the handoffs process to ensure resident involvement and educating interns and residents about safe patient handoffs.

1436 Patient-safety knowledge covered in the undergraduate nursing curriculum and patient-safety competencies of graduating nursing students in Korea N.-J. Lee 1,*, C. S.-Y. Park 1, H.-N. Jang 1, 2 1 College of Nursing, Seoul National University, 2 Seoul National University Hospital, Seoul, Korea, Republic Of This is a descriptive study to assess the coverage of quality and safety competencies in nursing curriculum and nursing students self-reported level of patient safety competencies in Korea. 57 (100%) graduating nursing students of a nursing college participated. Quality and Safety Education for Nurses (QSEN)-the Student Evaluation Survey (SES) and Questionnaires to Measure Baccalaureate Nursing Students Patient Safety Competencies were used. The knowledge part of the QSEN-SES (Sullivan, et al., 2009) includes 19 knowledge objectives and a set of 5 answer options: classroom, course assignments/readings, clinical experiences, lab/simulations, and not covered. Students answered whether and which teaching methods of quality and safety related knowledge were taught during their 4 year curriculum. The 19 knowledge objectives are classified according to the 6 QSEN competencies: 4 Patient-centered Care, 5 Teamwork and Collaboration, 2 Evidence-based, 3 Quality and Improvement, 4 Safety, and 1 Informatics. The questionnaires to Measure Baccalaureate Nursing Students Patient Safety Competencies developed by the Research team (Lee & Jang, 2011) consist of 64 items including 18 attitude items of perceived importance of patient safety, 21 skills items of preparedness to perform patient safety skills, and 6 knowledge items of understanding patient safety concepts using a 5 point Likert scale and 19 multiple choice questions to test patient safety knowledge. After a systemic review of previous literature, selected patient safety measurement tools were translated into Korean, and then modified considering the Korean nursing education and practice. Modified questionnaires were tested for 1 st and 2 nd content validity by patient safety experts. Data analysis was conducted by descriptive statistic tests. - Patient Safety Knowledge Covered in the Undergraduate Nursing Curriculum Classroom was the most common learning method in covering QSEN competencies. Lab/simulation was the least venue of learning QSEN competencies. Patient-Centered care among QSEN competencies was mostly covered in Classroom, Clinical Experience, and Lab/simulation. The least covered QSEN competencies were Teamwork and Collaboration in Classroom and Lab/simulation, Informatics in Assignment, and Quality Improvement in Clinical Experience. Safety of QSEN competency was generally less covered than other competencies. - Patient Safety Competencies of Graduating Nursing Students The mean values of patient safety competencies in Knowledge, Attitude, and Skill were 2.63 (SD=.70), 4.13 (SD=.25), and 3.40 (SD=.47) respectively. More than 50% of Patient safety education contents are not covered in current nursing curriculum. Simulation or labs were barely used for Quality and Safety education. In order to integrate patient safety education contents into curriculum well, development of effective teaching strategies using simulation or lab activities are needed. Students' levels of perceived importance in the patient safety competencies were relatively higher than the self-reported preparedness and their understanding of patient safety concepts. Development of patient safety education program is needed to improve nursing students knowledge and skill. The research team is currently developing patient safety curriculum for the improvement of nursing students patient safety and plans to apply it. This study has been supported by National Research Foundation of Korea (810-20110011).

1729 Fighting against workplace violence in the acute hospital setting G. C. Wong 1,* 1 Chairman, Workplace Violence Committee, Queen Elizabeth Hospital, Hospital Authority, Hong Kong, Hong Kong, Hong Kong, China Workplace violence (WPV) is a worldwide problem in healthcare service. The figures of WPV in Queen Elizabeth Hospital (QEH) were increasing in the late 1990s. To tackle this problem, the QEH Workplace Violence Committee was setup in 2007. The committee approaches with 3 strategies, i.e. prevent, control and protect, as well as support. It is always desirable if WPV can be prevented at the first place. Anti-WPV bylaws, policy statements, pamphlets, posters and videos were available in eye-catching areas, Patient-friendly environment like lunch-time concert can nurture a harmonizing atmosphere. CCTV in strategic areas, 24-hours police post and security teams in Emergency Department have deterrent effect. Smart-card access to hospital wards restricts entrance of angry-prone visitors and during inappropriate times. Staff training on communication skills and staff resilience can be strengthened. Guidelines on workplace safety were designed and promulgated. WPV statistics are monitored and analyzed to identify WPV-prone areas and risky assailant to guide more effective strategies. Forums are held for sharing statistics and experience, and to show management commitment to gain confidence and trust from staff. Timely control of the aggressive situation are important to protect staff from injuries. Five-minutes response time of the security team and 24-hour police post in the Emergency Department provides necessary immediate support. Panic buttons and personal alarms in selected areas can alert other colleagues of the imminent danger for timely assistance. After the violence, the involved staff may be scared, frustrated and need immediate support and guidance. Flowchart for post-incident management is available and may include seeking medical care for physical and psychological trauma, incident reporting, preparation for prosecution and employee compensation. Psychological support is important to pacify the staff emotion. The Staff Active Support team (SAS), led by hospital managers, will coordinate the support, and issue concern card as a token of care and support. If required, referral to the Critical Incident Support Team ( 心 簷 ) may be made. Year 2005 2006 2007 2008 2009 2010 2011 AED 68 70 82 60 50 30 27 Other areas 70 73 71 72 44 39 63 Total no. of cases 138 143 153 132 94 69 90 Since the establishment of the QEH Workplace Violence Committee in Oct 2007, the incidence of WPV decreased dramatically (appendix). Analysis showed that the majority of the incidents occurred in the Accident & Emergency Department and the special ward where all the potentially violent patients with underlying mental disorder or under the effect of drugs and alcohol are admitted. It is not surprising to conceive that nurses were the major victim group. Ward access control has successfully limited the visitor-offenders in wards to only during the evening visiting hours this renders effective security measure more feasible at only certain times of the day. It is interesting to note that ¾ of the cases involved male offenders consistently over the years. However there was a rising trend of physical injuries in the past 2 years, and this was significantly contributed by the female offenders. The majority of these female offenders are patients who had abnormal mental state due to drugs, alcohol or underlying mental illnesses. The battle to fight against WPV is seemingly endless. We have just been able to bring down the number of incidences. The next practicable step is to maintain the case volume to a safe steady level. Afterall, the mismatch expectation, long waiting time, dissatisfied management and the aggressive mental status of the offenders can hardly be eradicated.

1794 Continuing education of healthcare assistants helped promoting quality patient care L. Y. W. Sum 1,* 1 Queen Elizabeth Hospital, Hospital Authority, Hong Kong, China Health Care Assistants play a vital role in the health care industry by helping patients with different aspects of daily functioning and management of ongoing medical conditions. To align with People First Culture advocated by HA, front line nursing manpower was relieved by the Health Care Assistants. In our hospital, most health care assistants work under the supervision of nurses. In Hong Kong, the training preparation of Health Care Assistants was done by various training organizations. Some of them were trained by the hospital itself while some were trained by some outsider training organizations. With the differences in training received, the attitude and work output by the Health Care Assistants were not consistent. Besides, after the basic training, they seldom receive continuing education which applies to nurses, doctors and other allied health professionals of the hospital. In order to keep up to standard the care provided to the patients by this group of staff, the Surgical and the Orthopedic & Private Ward Departments initiated a refresher training program for the Health Care Assistants in their departments. The program was co-organized by the Central Nursing Division, Queen Elizabeth Hospital. In January 2012, totally 3 half day training sessions were arranged for a total of 63 HCAs. Most of them were nominated to attend the program officially. The refresher program focused on the following essential patient care topics: Manual Handling Operation; Incontinence Pressure Ulcer Care; Prevention of Patient Fall & Use of Safety Device; Bed Bath & Hair Washing; Work Place Violence; Communication Skills & Customer Service and Infection Control. To follow up with the participants performances when they go back to their work place, a set of post-training follow up questionnaires were sent to their supervisors to review the effect of the training program. In the training, pre-test and post-test were done to assess the difference in knowledge and skills before and after the training. The results reviewed that there were marked improvements in the post-test. Most of the post-program follow up questionnaires were completed by the Ward Managers who would directly monitor the participants performances. The results showed that the Ward Managers generally agreed that the materials refreshed were relevant to the participants daily work and were very useful. They commonly agreed that after the training, the participants clinical knowledge and skills were enhanced. The percentage of improvements enhanced by the program ranged from 10% to 100%. Most of the essential skills refreshed were mostly applied on the job. By refreshing the essential care skills, the participants demonstrated enhanced confidence. There was learning culture built up in the work place as well and the results showed improvements of patient care and reduced complaints by patients. The common feedbacks showed that the program worth the investment because there showed an important benefit---enhanced staff morale, hospital image and staff/patients/relatives relationships. The Health Care Assistants appreciated joining the refresher training program, feeling that they were being recognized as one member of the hospital s multi-disciplinary team and were more willing and active in participating in the quality care delivery process. As a conclusion, the refresher program benefited all parties, including the hospital, ward, staff, patients and relatives and ultimately enhanced the patient care quality. References: Annual Report, 2011, Hospital Authority, Hong Kong

1797 Strategies to enhance alliance of drug compliance in chronic psychiatric inpatients Y.-H. Huang 1,*, Y.-J. Kao 2, S.-M. Tseng 2, T.-H. Huang 2 1 PSY, 2 Chang Gung Memorial Hospital, Taoyuan, Taiwan Studies suggest that as high as 40~50% of schizophrenic patients have poor drug compliance that results in frequent relapses, repeated admissions, and functional decline. While psychotropic medications play a major role in treating psychiatric patients, psychiatric nursing staff should be able to identify the subjective feelings and difficulties in patients taking these medications in order to enhance their willingness to comply actively with the prescriptions, and to avoid relapses and functional impairment. 80 chronic psychiatric inpatients were assessed for their medication compliance behavior by 2 self-developed questionnaires--"drug Compliance Training Observations" and "Questionnaire On Factors Affecting Active Compliance"-- throughout 2011/1/3-2011/2/14.We found that only 24% of participants were compliant actively.4 main factors impeding active compliance were identified, including:"i am always being medicated by others, and I will only take drugs when forced to," (n=44; 72.1%) "I don't know what I am taking, and thus I refuse to," (n=42; 68.9%) "I always expect adverse effects to surface and I don't know how to handle them, so I don't want to take medications," (n=38; 62.3%) "I often forget dosing times" (n=32; 52.5%).Other factors included not being informed about the importance of medications or about regimen adjustment. We have indeed found that many patients (70.7%) were not fully aware of their own medications, dosing time, dosing amount, indications of drugs, and related adverse effects. The main reasons are poor understandings of drugs and poorly integrated drug compliance training program. We have thus developed an intervention program based on what we found above and the related literature. The program includes: (1) developing drug compliance planning, (2) holding group therapy focusing on psychopharmacoeducation, (3) customizing individual drug compliance training card, and (4) establishing rewarding system. Under such intervention program, we have found: 1. Active compliance rate rose from 24% (n=19) to 65% (n=52). 2.Rate of poor drug understandings dropped from 70.7% to 35%. 3.Ipatients were encouraged to actively join their own treatment planning via understanding their own regimen, indications, adverse effects, and even manage their own medications under the instruction of individual drug compliance training cards. 4. Upon follow-up, 9 patients completed such program were able to be free from re-admissions due to regular drug compliance. Psychiatric nursing staff plays roles of both instructors and assessors on psychopharmacoeducation, monitoring drug responses, and enhancing drug compliance. By developing drug compliance planning program, holding group therapy focusing on psychopharmacoeducation, customizing individual drug compliance training card, and establishing rewarding system, we can enhance active drug compliance rate and raise the understanding of medications in chronic psychiatric inpatients. Our results suggest that such intervention program is effective. References: Davidson, L. (2005). Recovery, self-management and the expert patient- changing the culture of mental health from a UK perspective. Journal of Mental Health, 14(1), 25-35. Finkelman, A. W. (2000). Self-management for the psychiatric patient at home. Home Care Provider, 5(3), 95-103. Gillin M, Nuechterlein K, Subotnik KL (2001). Clinical outcome following neuroleptic discontinuation in patients with remitted recent-onset schizophrenia. Am J Psychiatry, 158, 1835-1842.

1818 Public healthcare professionals views and experience of preparation and storage of reconstituted powdered milk: implications for microbiological safety and education E. C. Redmond 1,*, C. Griffith 1 1 Cardiff School of Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom Methods used to prepare and store reconstituted powdered milk formula have important microbiological implications for safety and public health. Recommended procedures in the home and healthcare settings may be achieved by parents and caregivers equipped with adequate/correct knowledge, positive attitudes and motivation to implement behaviours that can minimise microbial risks. This study aims to understand public healthcare professionals beliefs, attitudes, practices and information provision relating to feeding with powdered milk formula. Sixteen focus groups (involving 152 participants) were conducted across the UK and included homogenous groups of public healthcare professionals (including hospital-nurses, midwives and health-visitors) and parents. The majority of respondents were unaware of specific microbiological risks associated with formula and considered current practices to be safe. Some parents reported storage of reconstituted formula at ambient temperature when away from the home; others reported to take water and powder separately and reconstitute immediately before use. Hospital nurses, midwives and health-visitors reported having limited information to distribute regarding formula feeding; many cited lack of time and conformity to the WHO Baby Friendly Initiative as reasons for not providing formula based advice or bottle demonstrations. Further discrepancies between professional healthcare caregiver groups have been identified, particularly regarding information provision. Information sources for parents and healthcare professionals are seen as limited; messages were perceived to be inconsistent and reportedly cause confusion at a parent and professional level. Findings will help to inform the development of informed, targeted information sources that address microbial risks of preparation and storage of powdered formula milk and improve public health.

1848 Physicians perception of usefulness of quality-improvement tools: a contrasted picture A.-S. Jannot 1,*, T. V. Perneger 1 1 Division of clinical epidemiology, University Hospitals of Geneva, Geneva, Switzerland Several quality improvement tools or mechanisms have been proposed to physicians. The doctors opinions about quality improvement tools likely influence their uptake and eventual impact on patient care. In particular, doctors may be skeptical of anything that they perceive as managerial interference in their work. Here we assessed physicians opinion on nine quality tools and identify associated characteristics to their opinion. We conducted a mail survey in 2007 among all doctors practicing patient care in canton Geneva, Switzerland. Briefly, all doctors were invited to participate, both hospital-based and in private practice. The survey assessed various topics related to health care policy and the role of the medical profession. The leading question on the utility of quality improvement tools was Several tools are currently proposed to improve healthcare quality either at hospital or at doctors offices. According to you, to what extent could the following tools be useful to improve healthcare quality in your work environment? The answers were rated from 1 (not at all useful) to 5 (enormously useful). Doctors characteristics were also recorded, such as age, sex, specialty, and practice setting. We report the distributions of perceived usefulness, overall and across subgroups of respondents. Of the 2745 eligible physicians, 1546 returned the questionnaire and 1530 completed the survey on quality improvement tools. Most respondents were men (61.5%) and in private practice (56.7%). Only 11.2% belonged to a managed care organization. Regular continuous education (rated as very or extremely useful by 74.6%), participation in quality circles with peers (60.4%) and mortality and morbidity conferences (64.8%) were seen as useful for a majority of practitioners. Compliance of medical practice with guidelines (36.1%), therapeutic objectives fulfillment assessment (40.6%) and patient satisfaction measurement (41.7%) were seen as useful by more than one third of doctors. Certification of office practices (8.4%), onsite evaluation visit with peer-review of medical records (11.5%) and periodic evaluation of doctors skills (14.5%) were not seen as useful tools for healthcare quality improvement. In general, hospital-based doctors held more positive opinions on quality improvement tools than doctors in private practice (for example 52.5% versus 22.7% for compliance of medical practice with guidelines utility). Also strong differences were observed for the different age classes with tools perceived as more useful by younger doctors: for instance, regular continuous education was perceived as useful for 90.8% of doctors below 35 years versus 62.7% of doctors above 50 years. Quality improvement tools that are seen as the most useful for physicians are regular continuous education, quality circles and mortality and morbidity conferences. Certification, on-site evaluation visit and periodic evaluation of doctors skills are not seen as effective. In conclusion, physicians trust the most non-judgmental and already widely implemented quality tools.

1852 An audit of antimicrobial prescribing habits among doctors in St. Columcilles Hospital, Loughlinstown J. Brennan 1, T. Branigan 1,*, C. O'Connor 2, S. Fitzgerald 3 1 General Surgery, 2 General Medicine, 3 Microbiology, St. Columcilles Hospital, Dublin, Ireland Point prevalence studies of antimicrobial use for the past two years in SCH have drawn the same conclusions and produced identical recommendations pertaining to prescribing habits, highlighting areas where doctors are not meeting the ideal standards of antimicrobial prescription (i.e. documentation of indication for antimicrobial treatment, documentation of stop/review date and compliance with antimicrobial prescribing guidelines). The aim of this study was to assess antimicrobial precribing habits from the doctors point of view, to compare this to the hard prescription data available and most importantly to raise awareness of the principles of prudent antimicrobial prescribing. A multiple choice questionnaire was used to examine the antimicrobial prescribing habits of doctors with regard to documentation of indication, documentation of a stop or review date, awareness of local empiric guidelines and other principles of prudent antimicrobial prescribing. 40 trainee and consultant doctors were surveyed. Of those questioned, just over a third claimed they always ensure that an indication for commencing antimicrobial treatment is documented in the patient s healthcare record, with 55.6% admitting to occasionally failing to do this. Only 55% always or mostly document a stop or review date when prescribing antimicrobials, while 69% indicated that they had failed to do this at least once in the preceding month. 20% of those surveyed sometimes or never consult local guidelines before prescribing. When switching patients from intravenous to oral therapy, 90% believed oral bioavailability to be an important factor, with only 10% citing a saving in nursing time as being relevant. It is apparent that this cohort of doctors fall short of best practice guidelines in prescribing antimicrobial drugs. We recommend formal and informal teaching for doctors in this area, with particular emphasis on prudent prescribing, coupled with improved availability of local empiric guidelines. Our survey identifies doctors self reporting of their deficits, allowing us to target the appropriate interventions to these deficits. It also identifies areas where awareness of diverted resources and safety issues could be used as the fulcrum for changing prescribing practices.

1903 Understanding elderly perception on advance care plan in rural southern Taiwan P. Huang 1, S.-C. Chen 2,*, W. Lee 2 1 General Affairs Department, 2 Social Service Department, Chia-Yi Christian Hospital, Chia-Yi, Taiwan As the mandate of Taiwan s Hospice and Palliative Care Act in 2000, many voluntary organizations including hospitals are vigorously pursing for promoting the concepts of hospice and palliative care. However it is commonly known that the elder people are afraid of facing the issue of death for the traditional belief in Taiwan. Elder people tend to hold a position of avoidance by no listening, no talking, no watching, and then death should leave you. The purpose of this project is to explore the perception on advance care planning among community elder people in the service area of Chia-Yi Christian Hospital. We designed an educational program providing elder people social activities and information about advance care plan (ACP) among 4 rural townships in Chia-Yi County. At the end of the session, we surveyed the participant s opinion using self developed structured questionnaire. There were 233 elder people responded to our survey. The results showed that only 8% of the participants had the experience of making terminal medical decision for their families. After the session, 66% of the participants were willing to think about or to have their ACP, 75% of the participants were willing to write down their own ACP. There were only 28% of the participants discussed their expectation on ACP. And after the session, there were 75% of them would like to discuss ACP with their families. We also found that there were 72% of respondents thought the information we provided were helpful. After the session, 80% said they would have a positive altitude toward illness and 61% would like to receive hospice care while needed in the future. The results showed that the elder people are not as afraid of facing the death issue as I believed. After the social and educational activities, most elder people changed their altitude to think about ACP. This finding encouraged us to advance our project in the future.

1941 Nurses fall-prevention knowledge, attitudes, and practices: the effectiveness of an in-service education program in a regional teaching hospital in Taiwan M.-J. Wu 1,*, M. L. Shyu 1 1 Nursing Department, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan Patient safety is regarded as an important indicator of nursing care quality. The aim of this investigation is to determine the effectiveness of a short-term in-service education program to enhance nurses knowledge, attitudes and practices to prevent patients falling during hospitalization The exploratory quantitative survey to examine current patient safety education for new nursing employee and to improve the knowledge, attitudes and practices to prevent patients falling during hospitalization A purposive sample of 304 new employee nurses was recruited at an in-service education program. The developed 90-minutes education program to new employee during monthly new employee training curriculum from July to December in 2011 The questionnaire included demographic data and three dimension (knowledge of the lead to fall factors, attitude of prevention high-risk patients and practice fall prevention used).the internal consistency of questionnaire was α<0.92 This score were used to measure when the monthly new employee training curriculum begin and one week after the curriculum All data analyses were done using SPSS version16.0 Frequency distribution, descriptive(mean, standard deviation) Pearson correlation Pair t-test statistics 298 nurses was recruited, six nurses was exclude because they were drop out of the curriculum. More than an half of nurses were bachelor degree and 37.6 % of new nursing employee none nursing working experience Approximately 56.3% of new employees were specialty in medical and surgical nursing The mean score of knowledge of the lead to fall factors improve from 7.18(SD±0.50) to 7.94(SD±0.91) after educational program The score was dramatically increase by 0.768(t=12.1, P < 0.01) Secondly, the attitude of prevention patients falls, the score prior of the program was 3.12(SD±0.36) and there was downward trend in the score of negative attitude(3.01, SD±0.30) Nevertheless, the new nursing employee significantly reduced practice fall prevention inadequate performance The mean score form 3.38(SD±0.37) to 2.92(SD±0.31), A significantly improvement in practice performance(t=-19.3, P < 0.01) However, there are significantly increase of three section after an in-service education program According to this survey, it pointed out that the high score of knowledge of nursing employee that the nurses toward the positive attitude(r=-1.37, P < 0.05) Furthermore, the new nursing employee s attitude variables were correlated with the practice performance of prevent high-risk patient fall (r=0.354, P< 0.01) Patient fall is the majority of the incidence report in hospital and lead up to increase the length of stay complication and high costs. There are various factors related to fall of inpatients. Base on the result,there are significantly enhancement in three dimension, such as the prevention inpatients falling knowledge positive attitude to prevent and performance adequate practice fall prevention after a short-term in-service program As the result, the direct healthcare providers not only provide high-quality nursing healthcare environment but also to upgrade the patient safety when patients during hospitalization References: Hunderfund, A. N., Sweeney, C. M., Mandrekar, J. N., Johnson, L. M., & Britton, J. W. (2011). Effect of a multidisciplinary fall risk assessment on fall among neurology inpatients. Mayo Clinic proceedings, 86(1), 19-24. Teri M.Chenot;lLarry G(2010).Frameworks for patient Safety in the nursingcurriculum.journal of nursing Education,49.P559-570

2006 Introducing competency-based training for high-risk ward-based procedures for junior doctors to enhance patient safety in National University Hospital, Singapore S. Hota 1, B. Mohankumar 1, D. Santos 1, S. Mujumdar 1,* 1 Medical Affairs, NATIONAL UNIVERSITY HOSPITAL, Singapore, Singapore To provide standardized competency based training for three high risk ward based procedures: central venous line placements, chest tube insertions and moderate sedation administration to junior doctors with an effort to improve patient safety A spate of adverse events, including one fatality involving central venous line (CVP), chest tube insertions and moderate sedation performed by junior doctors prompted the need to provide them with good quality training. Myriad practices across different specialties performing these high risk procedures were noted. Training for these procedures was prioritised based on their higher impact compared to other ward based procedures and available logistics support. A 2 pronged approach was adopted, 1 st was to build trainer capacity, through train the trainer workshops and 2 nd was to have sufficient number of workshops to capture the target group. The workshops were designed to impart a standardized set of skills, competencies and supervisory requirements. The curriculum was meticulously developed to consist of didactic modules, hands-on training and completion of a requisite number of supervised procedures. The didactic modules covers theory, familiarization with polices and the appropriate usage of checklists. In the hands-on module, participants practice newly acquired skills which require mandatory passing of a test to gauge post workshop knowledge. They then need to complete a requisite number of supervised procedures that are endorsed by the department head to be credentialed to practice independently. Workshops were planned for regular new intakes in May and November and additional ones for those that joined in between intakes. The first sets of workshops were initiated in May 2011. From May to November, 10, 11 and 16 workshops were held for central venous line insertion, moderate sedation and chest tube insertions respectively. The trainers evaluated their confidence level in teaching/training on a Likert scale of 1 to 5. a) 83.3% & 71.4% participants rated their level of knowledge and skills after training as Very Good/Excellent for chest tube & sedation workshops respectively b) 83.3% & 100% felt confident in conducting chest tube & sedation workshops respectively. The success of the implementation of the workshops was judged from feedback from the junior doctors: a) 92.2% highly commended the curriculum encompassed by the workshops b) The percentages of junior doctors rating the 3 workshops as Very Good/Excellent are as below: Improvement in knowledge/skills Confidence in performing procedure Overall Satisfaction with workshop CVP (n=79) 91.1% 81.0% 87.3% Chest tube (n=97) 92.8% 81.4% 91.8% Moderate Sedation (n=98) 91.9% 82.7% 93.0% All 3 Workshops 92% 82.0% 91% Though the overall satisfaction rate was high at 91%; only 82% were confident of performing the procedures independently. However 92% were certain that their knowledge and skills had markedly improved. c) Since the last 9 months from the commencement of these workshops, only one adverse event each has been noted for chest tube insertion and moderate sedation. The workshops have enabled imparting a higher level of competency-based knowledge, skills and confidence with the ability to inculcate safer practices amongst junior doctors. Encouraged by the success of these workshops, we plan to extend this training model to other high risk ward based procedures. However, before expanding into these areas we are trying to address our current constraints of limited administrative and logistics capacity.

2160 A novel institutional resident physician integration and training program in quality improvement N. J. Neufeld 1,* on behalf of Armstrong Institute for Patient Safety and Quality, P. G. Nagy 2, A. S. Evans 3, S. M. Berenholtz 3 on behalf of Johns Hopkins Housestaff Patient Safety and Quality Council Leadership Cabinet 1 Physical Medicine and Rehabilitation, 2 Radiology, 3 Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, United States Our objective is to demonstrate successful centralization of a novel multi-disciplinary resident physician training program in patient safety and quality improvement (PSQ). Our specific aim is to describe the implementation of this program designed to meet Accreditation Council of Graduate Medical Education (ACGME) core competencies and enhance PSQ education of all residency programs at an academic medical institution. In academic medicine resident physicians are on the front line of patient care and safety. As the future leaders of healthcare redesign, the ACGME recognizes the importance of training residents in quality and systems based practice. Our program enhances education and provides opportunity for residents with a specialized interest in PSQ where residencies are generally not adequately equipped to provide this specialized training. In order to centralize our efforts, we first established a hospital wide resident physician PSQ council utilizing individual resident quality officers from each respective training program. This created a deliberative body to promote resident physician voice on quality initiatives and provide a platform from which to leverage diverse residency participation and information dissemination. This group is collectively mentored and lead by resident physician leadership and multidisciplinary hospital champions to various institutional PSQ committees. The exposure on this council is a modeled monthly meeting of didactics on various aspects of PSQ tools with directed discussions on specific initiatives. For residents with additionally interest in PSQ, six residents are selected by application and interview process to be institutional resident fellows in PSQ. The fellows receive complementary individualized mentoring and additional training through weekly lectures and dedicated elective rotations. The fellows have increased exposure and are given additional responsibility in the resident physician PSQ council, departmentally, and within the hospital infrastructure of PSQ development. In the case of our institution, resident physicians have no central standardized education on quality improvement even though each departmental program has quality and systems based practice requirements by the ACGME. This program therefore meets the requirements of the ACGME and provides a centralized quality improvement training program. In being centralized we compliment the efforts of departmental basic training in systems based practice with a higher level of exposure and science of safety compitence beyond the requirements of the ACGME. The fellowship offers a more robust training for those interested in quality improvement as a component to their career development. Our complete data showing successful implementation of our resident physician PSQ training program will be ready to present by October 2012. Resident physicians gain insight into the process of improvement by being empowered to participate in PSQ improvement project innovation and implementation. As the specialty of PSQ continues to grow it is important to be training resident physicians in the most integrated, multidisciplinary, and multi-specialty environment possible. Supported by good science and mentors invested in promoting PSQ. This irreplaceable direct integration into institutional quality improvement initiatives benefits both the participant and the institution's need for clinician insight and involvement.

2181 Partnering with consumers to achieve quality outcomes in healthcare - a window into the Australian Council on Healthcare Standards Education Workshop S. Newell 1,*, J. Brumby 2 1 Educator, The Australian Council on Healthcare Standards, 2 Education Manager, Australian Council on Healthcare Standards, SYDNEY, Australia The Australian Council on Healthcare Standards (ACHS) "Partnering with Consumers to Achieve Quality Outcomes in Healthcare" workshop will be explored. Within the context of the Australian health care and health reform landscape, how the workshop s content supports health care workers and health care organisations to actively partner with health consumers to achieve quality improvement will be explained. Practical strategies for active engagement and effective partnering with health consumers will be discussed. The workshop methodology, strategies and action plans will be presented together with workshop participant action plan implementation measurement. In 2009, The Australian Council on Healthcare Standards (ACHS) partnered with the Australian Commission on Safety and Quality in Health Care to pilot a series of educational workshops on safety and quality in healthcare hot topics for ACHS members throughout Australia. As a result of the pilot and also as part of the increasing focus in Australia on health consumers being involved in every aspect of health care as partners the one day Partnering with Consumers to Achieve Quality Outcomes in Healthcare workshop commenced in 2010. The workshop methodology integrates interactive learning and group work to facilitate participants to develop practical strategies and action plans. Since 2010 the "Partnering with Consumers to Achieve Quality Outcomes in Healthcare" workshop has been delivered to a diverse range of Australian health care staff. Workshop participants have included frontline clinical health service staff, quality managers, patient safety managers, risk managers, executive directors and health service board members. In addition to the workshop being conducted at metropolitan, regional and rural locations throughout Australia, "on-site" workshops for specific health services and hospital staff have also been delivered. Increasingly health care worldwide is seeking effective ways to engage with health consumers and involve health consumers in areas of health care. Generally the focus has been on supporting health consumers to be more involved in their own health care. Initiatives for increasing health consumers' understanding about their condition or disease and their treatment and care have assisted health consumers' to actively participate in their own health care (Longtin et al, 2010). Active participation by health consumers is recognised as a key contributor to the overall experience of an individual s health care. In parallel, a growing body of evidence indicates that involving health consumers, that is both current and potential health service users, in the planning, design, delivery, monitoring and evaluation of health care delivery and services is vital to quality and care experience improvement (The Australian Commission on Safety and Quality in Health Care, 2011). The development and delivery of the "Partnering with Consumers to Achieve Quality Outcomes in Healthcare" workshops has been one key initiative in Australian Healthcare in assisting health service staff with "hands on" tools to create and advance active partnerships with health consumers to achieve quality improvement. References: Australian Commission on Safety and Quality in Health Care (2011), Windows into Safety and Quality in Health Care 2011, ACSQHC, Sydney 58-68. Longtin, Y., Sax, H., Leape, L. L., Sheridan, S. E., Donaldson, L., & Pittet, D. (2010). Patient Participation:Current Knowledge and Applicability to Patient Safety.Mayo Clinic Proceedings, 85(1), 53

2261 The efficacy of continuous education for operative nurses in total knee replacement surgery Y.-Y. Chen 1, C.-C. Wu 1,* 1 Nursing department, Chang Gung memorial hospital Taiwan, Taoyuan county, Taiwan Joint surgery is a very complex procedure that requires extensive operative techniques. In order to improve patients safety during total knee replacement surgery, Operative nurse must be able to identify every instrument used during surgery. Many nurses have difficulty learning to use the complex instrument.this study is promoting the continuous education of operative nurse, through the use of manuals and workshops that educate on all the elements and procedures involved in a total knee replacement surgery. This study aims to improve quality of care and safety of patients during surgery. This study employed a one group pretest-posttest quasi-experimental design method and purposive sampling. A total of 44 operative nurses were selected from the operating rooms.. The intervention is done though continuous education of operative nurse, which included manuals and workshops help them understand and practice the procedures during total knee replacement surgery. To evaluate the operative nurse learning performance on total knee replacement procedures, cognitive, affective, and skill.a questionnaires were employed before and after intervention to collect data. The data were analyzed using SPSS Version 17.0 for Windows. A total of 44 operative nurse were selected from the trauma operating rooms. That operative nurse were improved their knowledge on total knee replacement procedures and tools from 59% to 87% after intervention. Furthermore the workshop trainings lead to an improvement in their effectiveness from 44% to 88%. The greatest improvement was performance skill which went form a 70% to 93%. The finding demonstration that operative nurse had significantly higher scores in knowledge, affective, and skill performance.(p value <0.01). The result found the intervention not only increased the operative nurse knowledge, affective, and skill performance in total knee replacement procedures but it also raised professional confidence and competence for clinical practice. This helps in providing good quality of care and safety for patients, as well as, efficient and professional skill that promote team collaboration during surgery. References: Barbara,J. G.,& Fernsebner,B. (1995). Comprehensive Perioperative Nursing:Orthopedics. WHSmith.co:U.K. Brooks, P. (2009) Seven Cuts to the Perfect Total Knee. Orthopedics,32(9),22-23 Felson, D. T. (2006). Osteoarthritis of the knee. The New England Journal of Medicine, 354(8), 841 851. Felson, D. T., & Zhang, Y. (1998). An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis & Rheumatism, 41(8), 1343 1355.

2332 Implementation experience of medication-safety education in southern Taiwan H.-L. Pang 1,*, P.-Y. Lee 1, Y.-P. Hsiang 1, Y.-D. Cheng 1 1 Department of Pharmacy, Chang-Gung Memorial Hospital,Kaohsiung Medical Center, Kaohsiung, Taiwan This survey aims to know the current patients behavior about medication in Taiwan by questionnaire; and attempt to educate them to acquire the appropriate drug knowledge. Due to Department of Health raised a medication safety project and set up The Correct Medication Education Resource Center in Kaohsiung County;it combined with local resources to provide theright medication information and education activities for correct medication. It intends to promote the community pharmacy services, increase public knowledge of the correct medication, strengthen the public security division of labor and assist local health agencies or school educational activities to implement the correct medication. This was a sixmonths study, duration from 2010-05-01 to 2010-11-30; and 300 participants were recruited from Kaohsiung County inhabitants. During the implementation, in order to develop a creative education mode, amedication cognitive questionnaire was processed at health education seminars. It included the participants behavior and the attitudes about medication, and health education satisfaction. In the future, patient medication education advocacy and improvement will based on the analysisofthequestionnaire, and it will perform as an indicator with local feature. 293 copies of the drug cognitive questionnaires were collected with a 97%recovery rate. The results of this survey showed thefollowing facts:firstly, participants who took Western medicine, Chinese medicine or health care products over the last 6 months were 64.1%, 32.8%, 46.8% respectively; and those who took western medicine, Chinese medicine and health products together at the same time within one month were up to 32.1%.Secondly, participants threw away any leftover medicine due to drug expired, forget and /or unwilling to take medicine.thirdly, the most important medication information for participants in sequence were the purpose of drugs, the way to take drug, and drug effects. Fourthly, the sources of drug-related information participants got were from pharmacists, physicians, the description on the medicine bag or packaging, nurses, and relative and friend etc. Last, the propaganda activities satisfaction about this survey was 92.2 %.It showed that the expected target had achieved in terms of the useful content in the propaganda and the expression ability of the lecturer. Moreover, during the study, a variety of creative teaching and learning activities, singing and drama playing, were designed and through those real situation performances to emphasize and deliver the drug safety information to participants. During the study period, pharmacists were encouraged to develop diversified correct medication health education model. By the interaction between pharmacists and participants, participants will gain themedication safety information properly and continue self-monitoring medication knowledge. It will enhance medical quality and reduce unnecessary medication waste.

2508 The use of process reengineering to improve discharge preparation and long-term care resources linked service operating S. C. Chen 1,*, S. L. Yang 1, M. L. Kuo 1, S. Huang 1 1 Kaohsiung Chang gung Memorial hospital, Kaohsiung, Taiwan Looking to the dawn of the 21st century, the health care system will face more impact and challenges, "discharge planning" is a professional team of health care treatment, integrated health care resources to assist in case the safe and smooth return to the community or referral to appropriate medical institutions expect the use of process reengineering to improve discharge preparation and long term care resources link, making the case-cum-family members can be served a good resource services. The use of process reengineering to improve discharge preparation and long term care resources linked services program are as follows: First, build the structure, process and outcome of discharge planning service delivery model Discharge planning service center for hospitals to communicate the contact window, create a model of cooperation and long term care center, by a smooth pipeline of communication and contact, up to the timeliness and effectiveness of long term care resources. To establish a unit dedicated to nurse referral service systems and processes Nurses to perform high-risk factor screening in cases admitted to hospital within 8 hours, in the case of high-risk cases to HR (High risk) prompt to physician orders system, re-screened by a physician, the system at the same time link the note to discharge planning service centers dedicated referral nurse, completed to close the case and discharge needs assessment, integration of the medical team care case management model to develop a referral program, a complete record of the case referral tracking and assessment values. 100 annual service a total of 2389 people, 1032 people (43.2%) there is a long-term care, including referrals long-term care facility is 328 people, return home infirmary and home care services for 704 people. Provide discharge aids services and home rehabilitation 69 people 118 people referred to the long term care center, home of 80 people, 28 people, respite care and transportation of 36 passengers. By meets monthly referral case discussion will analyze and review. Through the discharge planning process reengineering to improve case management model to build long term care centers link cooperation to enhance the quality of life of the case-cum-family members to the Pacific case the individual needs of the continuity of service disease. References: Anderson, M. A., & Helms, L. B. (1994). Quality improvement in discharge planning: An evaluation of factors in communication between health care providers. Journal of Nursing care Quality, 8(2), 62-72. Cole, C. S., Williams, E. B., & Williams, R. D.(2006). Assessment and discharge planning for hospitalized older adults with delirium. Medsurg Nursing, 15(2), 71-75. O Connell, B., Baker, L., & Prosser, (2003). Theeducational needs of caregivers of stroke survivors in acute and community settings.journal of Neuroloscience Nursing, 35(1),21-29.

2536 The mask factors, negligent risky factors, and length of irreversible period among preventable malpractice mortalities and vegetations H.-H. Lee 1,*, W.-L. Liu 2 1 SURGERY, 2 ICU, LIOU YING CAMPUS, CHIMEI MEDICAL CENTER, TAINAN, Taiwan Identifying the neglected symptoms and signs among preventable malpractice mortalities and vegetations, the potential preventable period, and the factors from which the health providers make such errors is an important step in improving patient safety and reducing mortalities. This was a retrospective analysis of the mortalities and vegetations resulted from malpractice from the documented verdicts of the criminal court in Taiwan from year 2000 to 2010. Each case was analyzed to identify the neglected risky factors that contributed or caused the damage. The duration between the onset of the neglected symptoms or signs and the change to refractory shock or necessitating cardiac pulmonary resuscitation. Sixty-six mortalities and 3 vegetations were accused as guilty and should be preventable by the criminal court after the malpractice consultation committee, a official committee, which was made by 14 to 24 members, including 2/3 of the physicians, while the remains were the consumer representatives and the law professionals. The causes of mortalities were the following: 11 thoracic or abdominal internal bleeding, 8 sepsis, 8 air way problems, 5 intracranial lesions, 4 cardiac infarction, 1 tamponade, 5 neglected abdominal hollow organ s perforation, 4 fat or pulmonary embolism, 3 delayed diagnosis of malignancies, 2 surgeries died of preexisted pulmonary or thyroid disease, 15 miscellaneous. Forty one (62.1 %) received autopsy,25(37.9 %) without autopsy but having surgical procedures or very strong evidence of the diagnosis. One vegetation from slipped femoral artery cut edge bleeding, others from delayed treatment of cardiac tamponade or air way maintenance. The negligent risky factors such as : pre-shock symptoms and signs, e.g. oliguria, tachycardia, dyspnea, low blood pressure, or drowsy occurred in most patients; repeated symptoms under conservative management e.g. chest discomfort in cardiopulmonary disease; vomiting, consciousness change, neck pain, headache in intracranial hemorrhage; CT scan revealed increased posterior fossa pressure in pontine herniation, fever with abdominal irritation symptoms for intra-abdominal sepsis. The mask factors were: no profuse drainage in internal bleeding; no conscious change nor lateralizing sign in posterior fossa lesion; conscious disturbance after head injury with drinking in intracranial hemorrhage; upper respiratory tract irritation symptoms in myocarditis; minimal EKG change and initial normal cardiac enzyme in myocardium infarction; not high fever in sepsis. The length time of irreversible period were: 2.2±1 hours in procedure related arterial bleeding; 15 hrs after incomplete hemostasis, e.g. difficult laparoscopic cholecystectomy; 3± 1 hrs in progressive sepsis i.e. myocarditis or ARDS, 18±6 hrs in pneumonia or Fournier s gangrene ; 29 ±12 hrs in the intracranial hemorrhage, while 3.1 ± 1.3 hrs in the progressive course. The malpractice mortalities may be preventable through understanding the mechanism. The health careers must be aware of the mask factors, negligent risky factors and the length time of irreversible period, and perform immediately aggressive management to reduce malpractice mortalities or vegetations.

2682 The effectiveness of smoking cessation programs in adults: systematic review J. Hwang 1, S.-H. Park 2, Y.-K. Choi 3,*, C.-B. Kang 4 1 Department of Health Administration, Hanyang Cyber University, Seoul, 2 School of Nursing, Hanzhong University, Donghae, 3 Department of Nursing, Korea National Open University, 4 Policy Planning Team, Korea Health Promotion Foundation, Seoul, Korea, Republic Of The purpose of this study was to determine whether smoking cessation programs (SCP) are effective in adult without smoking related disease through systematic review in large randomized controlled trials (RCT). We established the PICO strategy, and reviewed 1,160 literatures from 8 domestic and foreign electronic databases, and finally selected 22 references based on selection and exclusion criteria. We evaluated the quality of references using the SIGN (Scottish Intercollegiate Guidelines Network) tool, and carried out meta-analysis focusing on the indicators of a smoking cessation program. - Population: Adults who current smoker without any smoking related disease and medical history (Participants is more than 300 people) - Intervention: SCP targeting adults - Comparators: placebo group or no treatment group - Outcomes: smoking status (self reported smoking status after 7 days, CO or cotinine level), whether or not trying to stop smoking Performed SCP is classified with anti-smoking medication (n=8, 36.4%), smoking counseling (n=5), non-smoking education (n=4), e-mail or mobile phone (n=2) and other SCP (n=3). The effects of smoking cessation counseling program as measured by the rate of smoking of 7 days at 12 months were no statistically significant, but physiologic indicators such as CO and urinary cotinine level were significant (OR=6.05, 95% CI 3.63-10.08). The effect of smoking education as measured by the rate of smoking on the 7 days was statistically significant (OR=1.57, 95% CI 1.34-1.84). The effect of anti-smoking drug such as nicotine patch was no significant effect, but CO level was significant (OR=1.47, 95% CI 1.31-1.65). When you provide a smoking cessation program for adult smokers, high strength of the evidence to be effective in RCT that provide the identified intervention strategies should be considered. Based on the findings, large RCT related to national smoking cessation programs development targeted at adult smokers is needed. In addition, adult smoking cessation programs and standardized guidelines for performance measurement development related to time and costeffectiveness analysis is advised.

1145 Investment in quality initiatives to enhance business growth A. A. Abd Rahman 1,*, N. Mohd Basir 1, N. Zahri 1 and Working group 1 Administration, KPJ Seremban Specialist Hospital, Seremban, Malaysia 1. To deliver quality healthcare services and be the preferred healthcare provider 2. To diversify business strategies for continuous growth 3. To increase the number of blooming thinking managers. 4. Promoting safety and best practices among healthcare workers through quality initiative programmes. All hospital activities complied to the principles of continuous quality improvement and the requirements of the quality frame work. All activities were planned and controlled within the frame work. The quality frame work and tools were used to define problems, measure and analyze them, and reach sustainable improvements in practice. Surveillances audit were conducted by internal and external auditors to ensure the conformity to the standards. The quality initiatives programs were continuously implemented in the organization since year 2006 till now. The impact of quality improvement initiatives can be seen through the growth of KPJ Seremban Specialist Hospital business. As a new hospital, we had generated profit in less than 3 years since it s operational. As at current, 38 objectives has been initiated and implemented. By improving the waiting time and quality healthcare services using the quality tools, hospital clinical incidents reduced by 28% in 2010 as compared to 2009. Through various initiatives, the number of inpatients and outpatients seeking treatments had increased by 3% and 8% respectively in 2010 compared to 2009. Occupancy rate and number of surgeries had increased by 4% and 2% respectively in 2010 compared to 2009. Profit before tax had increased by 60% in 2010 and revenue was higher by 15% in 2010 as compared to previous year. The quality initiatives really guide our employees to meet the standards in order to exceed patient s expectation so that the healthcare services provided are of world class quality. They become the marketing s foundation focusing on customers need and satisfaction, thus ensuring trust and building Confidence to every customers. References: 1. Annual report KPJ Seremban Specialist Hospital 2009 & 2010 2. KPJ Incident report 2009 & 2010 3. Qaulity improvement Activities report 2009 & 2010 4. Clinical Indicators report 2009 & 2010 5. Patient Safety Goals 6. KPJ Clinical Governance policies

1220 Evaluation of pay-for-performance quality incentive pilot programme: from lessons learnt to the way forward C. Choi 1, L. Wang 1, T. K. Yeung 1,* 1 Finance, Hong Kong Hospital Authority, Hong Kong, Hong Kong, China The Pay for Performance ( P4P ) Quality Incentive Pilot Programme ( QIP ) was piloted in 2010/11 to introduce financial incentives to quality improvement. After more than a year of implementation of QIP, a thorough evaluation of this programme was conducted. The objectives of the evaluation were to qualitatively collect and analyse the views of stakeholders on the effectiveness of QIP in achieving its objectives; the structure, process and outcome/impact of QIP on clusters and staff; and further development of this kind of programme within HA. 7 focus group discussions and 7 in-depth face-to-face interviews, based on a set of semi-structured, open-ended questions were conducted. Individual interviews were arranged by email invitation whereas the participants of the focus group discussions were recruited by snowball sampling method from Casemix Cluster Representatives. After implementation of QIP, improvements were observed among majority of the indicators. More clusters demonstrated improvement in performance in 9 out of 11 indicators. Notable improvement was also found in the 2010/11 on the management of chronic hypertension and diabetic patients. About 65% of HA s chronic hypertensive patients (vs. 58% in 2009) had been able to maintain their blood pressure below target level, whereas 16% more of the chronic diabetic patients have attained targeted control on their medical conditions as compared to 2009. The majority of participants agreed that an incentive programme had to be in place to reward the effort in improving quality and to raise the awareness of improving quality. However, it was perceived to be ineffective in driving behavioural change for quality improvement due to the inadequacy in definition of some quality indicators, relatively small amount of funding as the incentive and the indirect rewarding mechanism to the contributing departments/ teams. QIP is the first programme in HA that aligns financial payments to the level of achievement, as measured by the indicators. Evaluation helps shape the future direction for development of QIP framework for motivating quality improvement in HA. References: Beutow, S. Pay-for-performance in New Zealand primary health care. JHOM. 2008; 22(1): 36-47 Rosenthal, MB, Fernandopulle, R, Song, HR and Landon, B. Paying for Quality: Providers Incentives for Quality Improvement. Health Aff. 2004; 23(2): 127-41. Werner, RM, Kolstad TK, Stuart EA and Polsky D. The Effect of Pay-for-Performance in Hospitals: Lesson for Quality Improvement. Health Aff. 2011;30(4):690-98

1254 Mechanisms to monitor data quality for clinical documentation K. Fan 1, Y. S. Choi 1, L. Lau 1, T. K. Yeung 1,* 1 Finance, Hospital Authority, Hong Kong, Hong Kong, China With the introduction of Casemix based Pay for performance (P4P) internal resource allocation, the relevance of quality clinical documentation became apparent. While clinicians were encouraged to report clinically significant diagnoses and procedures for quality care of patients, the interpretation of such conditions may vary, causing inconsistency in the reported conditions between hospitals / clusters. This will affect the Casemix information for the purpose of performance measurement among clusters. To minimize the variations in clinicians reporting practices, a series of mechanisms were introduced to act as proxies to monitor data quality: - General trend analysis - Computerized edit checks - Unreporting analysis - Manual data quality review General trend analysis a broad trend analysis to monitor reported diagnosis and procedure activities amongst clusters Computerized edit check based upon established criterion of grouping standards, this is an automated process where secondary diagnoses (Sdx) codes are identified and removed from the DRG (Diagnosis Related Groups) grouping process. Trend analysis on the percentage of Sdx being removed was performed. Unreporting analysis also based upon established criterion of grouping standards, this is an automated process where secondary diagnoses codes are identified and trend analysis on the percentage of Sdx not being reported was performed. Manual data quality review a manual review is performed on paper and computerized medical records for the completeness of reported diagnoses and procedures. Results will be ready by the conference. This paper describes each mechanism and examines the implications of this multi-dimensional monitoring framework on data quality of reported diagnoses and procedures. The integrity of Casemix information highly relies on clinical significance of documentation based on clinician s judgment. Mechanisms to monitor data quality are important in ascertaining the accuracy and appropriateness of clinical documentation practices.

1324 Getting knowledge into action to improve healthcare quality in NHSScotland K. Ritchie 1,*, A. Wales 2, K. Rooney 3 1 Healthcare Improvement Scotland, 2 NHS Education for Scotland, Glasgow, 3 School of Health, Nursing and Midwifery, University of West of Scotland, Hamilton, United Kingdom The Knowledge into Action review, initiated in January 2011, was designed to define a new national system for knowledge management for the health service in Scotland. The objectives of this major review were to: help practitioners to apply knowledge to practice; integrate effective use of knowledge in quality improvement work; and, support practitioners to translate knowledge to deliver safe, effective, person-centred care. Several methods were used to collect data and information to inform the development of this new model of knowledge management.these included: commissioning a literature review of models of knowledge into action and effective knowledge implementation approaches in healthcare contexts; an analysis of current service provision and resourcing in health libraries; local nomination of test of change projects to assess what approaches identified in the review would be feasible and have greatest impact in the context of NHSScotland; and, extensive stakeholder engagement including the establishment of executive and clinical leads for knowledge into action in each NHS Board area. The review was managed by joint leadership from two special health boards in Scotland, NHS Education for Scotland and Healthcare Improvement Scotland and a national steering group was established with Scottish Government support. The literature review identified that that there are three types of approach that can improve knowledge into action: 1) specific knowledge interventions such as clinical pathways, online point of care reminders and audit and feedback; 2) developing and using networks such as communities of practice; 3) ensuring a receptive organisation environment/culture. The analysis of current service provision provided recommendations for optimal development of literature search and synthesis services and traditional library services such as document delivery. Seventeen test of change projects were established by local knowledge services teams, supported by quality improvement experts. Topics included development of point of care and decision support interventions to support integrated care pathways; production of specific knowledge assets to support clinical teams and patient safety collaborative projects; development of knowledge broker roles to support health improvement initiatives; and, initiatives to build organisational capacity for knowledge use. The findings of each of the elements of the review were used to derive a knowledge into action model, change package and implementation plan for NHSScotland to facilitate better integration of knowledge management with quality improvement and embed knowledge management in the national Quality Strategy. Knowledge services in Scotland have key role in improving the quality of health care. This review has defined a practical approach that will maximise the efficiency and effectiveness of the current knowledge management resource within the Scottish healthcare system, and integrate it with the existing quality improvement infrastructure, ultimately helping to bridge the knowledge-practice gap to deliver better patient care.

1378 An innovative approach to international healthcare involving multiple stakeholders J. Hendrie 1, A. Johnstone 1,* 1 CG&A, GSTT Germany, Bielefeld, Germany Guys and St Thomas (GSTT) NHS Foundation Trust have a contract with the UK Ministry of Defence (MOD) to provide hospital care to the British Forces community stationed in Germany. This care is provided through contracts with five German hospitals. The Governance & Assurance department of GSTT (Germany) and German provider hospital quality teams work closely together to develop a shared vision of quality and safe patient care. The contractual environment encompasses a variety of stakeholders (GSTT, Primary and Community Care, five German hospitals and the MOD chain of command), each with differing approaches, priorities and constraints. The challenge is to deal with the variations between the two distinct national healthcare systems to work towards the shared aim of providing safe and high quality care. A mutual understanding of the similarities and differences between each of the multiple stakeholders was paramount. The organisational, economic, socio-cultural and clinical factors needed careful consideration to ensure co-ordination of quality and safety initiatives and achieve the desired outcomes. The unique scenario of purchaser & providers working together to achieve mutual benefits to patients was developed despite the challenges of a contractual environment and commercially competitive German healthcare setting. Innovative cross organisational structures and systems were introduced to ensure input from all levels within all organisations. Jointly developed initiatives include: Integrated complaints management, joint incident reporting policies, shared patient feedback, peer review clinical assurance visits, sharing good practice, and a joint quality management strategy. Both observational methods and data analysis were used to assess the impact of the joint initiatives. Measures considered include length of stay, volume of complaints, incident reporting levels, patient feedback, clinical acceptance of peer review assurance visits, and an increased understanding by clinicians of the unique military population and their needs. A hierarchy of joint meetings was developed to enable all stakeholder staff groups from executive through to staff on the ward to be informed, involved and encouraged to share ideas. Comprehensive systems for data collection, analysis and reporting were developed and improved upon over time. The combination of the meeting structures and reporting framework gradually provided a strong foundation for the development of a joint quality management strategy. This is a reflective model, engendering organisational learning and long-term development and with a strong patient focus. Measurement of improvement: Analysis of patient experience via patient feedback Assurance of clinical services via peer review Analysis of complaints Analysis of incidents Analysis of length of stay data - It is important to gain a mutual understanding of each others situation - Creating a trusting work environment is essential - Working across seemingly insurmountable boundaries is possible - Information flow is key to success - Working in two languages requires timely and accurate translation - Systems to cascade meeting outcomes need to be explicit and not assumed - Careful planning and meeting preparation and briefing is essential - Time for gaining common understanding, persuasion and mutual gain should not be underestimated By building an environment of mutual trust and understanding in a respectful manner it is possible to align two distinct healthcare systems in developing safety solutions for the benefit of patients.

1403 It's good to talk: introducing a talking group approach in an intensive care unit team S. Delaloye 1, E. Durand-Steiner 1, F. Gigon 1, B. Ricou 1,* 1 Geneva University Hospitals, Geneva, Switzerland Increasing evidence indicates that psychosocial tensions and conflictual situations are common in intensive care units and impact negatively on team satisfaction and well-being at work 1,2. Providing opportunities to open discussions among caregivers improves effective and supporting communication and contributes to better unit performance and quality of care 3. However, few data are available on feasibility and effectiveness of a talking group approach in an intensive care unit team. The objectives of this study are first, to evaluate the feasibility of a talking group approach in intensive care unit and the caregivers satisfaction regarding this kind of approach and second to describe what are the main concerns and difficulties faced by intensive care unit caregivers. We used a qualitative and observational method. Two psychologists lead problem-based weekly sessions in small groups of caregivers with a systemic approach during 9 months. Attendance at groups was mandatory. Every participant was expected to attend at least 4 sessions. Psychologists wrote a report after each session. Feasibility and satisfaction were assessed by the attendance record and a questionnaire at the end of the intervention period. A content analysis was performed on group sessions reports to extract the most significant concerns discussed. Fifty nurses and nurse-assistants were randomly chosen among 170 caregivers of our intensive care unit and consented to participate to the talking group sessions. The participants were representative of the whole staff in terms of gender, age and occupational rate. Attendance:32 talking group sessions of 7-8 individuals on average were organized throughout the 9 months. Of the 50 participants, 35(70%) attended >=4 sessions. Satisfaction:38(76%) responded to the satisfaction questionnaire. The majority of participants 25(66%) were satisfied; the intervention has met fairly to completely the expectations of 25(66%). Main concerns:participants expressed suffering and discomfort at work consisting in a lack of support and communication, a sense of isolation and dehumanization. They also noted that the groups helped to develop a positive and constructive dynamics within the team. Under certain conditions (mandatory and regular attendance) a talking group approach was feasible and satisfying in our intensive care unit team. Such intervention may improve communication and support within the team and increase job satisfaction. Further investigation is needed to better evaluate the effect of long-term intervention on the whole team. References: 1 Merlani P, Am J Respir Crit Care Med 2011; 2 Maslach C, Annu Rev Psychol 2001; 3 Elpern EH & Silver MR, Current Opinion in Crit Care 2006

1424 Error disclosure standards in Swiss hospitals S. Mclennan 1,*, D. Schwappach 2, 3, B. Elger 1 1 Institute for Biomedical Ethics, Universität Basel, Basel, 2 Swiss Patient Safety Foundation, Zurich, 3 Institute for Social and Preventive Medicine, Universität Bern, Bern, Switzerland Error disclosure currently plays no significant role in Swiss health policy and there is currently no empirical data relating to actual practice or patients and practitioners attitudes and views. Given how important institutional support is to error disclosure, this study seeks to establish what stage Swiss hospitals are at in implementing an internal standard concerning communication with patients and families following an error that has resulted in harm. This will be compared with hospitals implementation of a complaint management system. Both error disclosure and complaint systems are two important mechanisms directed at patients and families when things go wrong. Swiss Hospitals were identified in August 2011 via the Swiss Hospital Association s website where hospital members are listed by cantons. An anonymous questionnaire was sent during September and October 2011 to 379 hospitals in German, French or Italian, depending on the language used in the hospital. Hospitals were asked to specify what type of hospital they are and the implementation status of an error disclosure standard and a complaints management system. The question concerning error disclosure was a slightly modified version of a question used in the University of Bonn s Institute for Patient Safety 2010 national survey concerning the implementation status of clinical risk management in German hospitals. 206 answered questionnaires were returned. 222 different hospitals types are listed due to 13 respondents reporting more than one hospital type. 204 responses were received regarding error disclosure, a 53.8% response rate. Overall, 95 (47%) respondents reported that they had an internal standard concerning error disclosure, 76 (37%) did not, and 33 (16%) did not but plan to implement one in the next 12 months. 206 responses were received regarding complaint management systems, a 54.3% response rate. Overall, 182 (88%) respondents reported that they had a complaints system, 11 (5.5%) did not, and 13 (6.5%) did not but plan to implement one in the next 12 months. Comparing the 204 responses to both questions, of note, 90 (44%) respondents reported that they had a complaints system and an error disclosure standard, 62 (30%) reported a complaints system but no error disclosure standard, and 29 (14%) reported a complaints system but no error disclosure standard though plan to implement one in the next 12 months. A lack of institutional support has been cited by practitioners internationally as a significant barrier to the disclosure of errors to patients and it appears that many Swiss hospitals still need to provide a more supportive and consistent framework for practitioners regarding such communication. It is positive that the majority of respondents reported having a complaint management system. However, it appears that many hospitals use a reactive strategy, waiting for patients to complain, rather than proactively encouraging the disclosure of errors to patients. International standards indicate that error disclosure is not only the right thing to do ethically it can prevent the need for disputes resolution in many instances.

1663 Improving healthcare together: engaging clinicians in national quality-improvement activities J. Graham 1,*, B. Robson 2 1 Programme Coordinator, 2 Executive Clinical Director, Healthcare Improvement Scotland, Glasgow, United Kingdom To develop a progressive and sustainable approach to clinical engagement for a national quality improvement organisation in Scotland Our strategy was developed using a 90 day process adapted by the Institute for Healthcare Improvement 1 and based on Proctor and Gamble s innovation method which is applied to stimulate new and innovative thinking when considering challenging issues. DAY 1 DAY 30: scan for evidence including interviews (28) and case study reviews to inform the detail of our strategy. DAY 31 DAY 60: focus considering what we have learned. Two focus groups sessions took place to further refine our thinking and provide a complete perspective. DAY 61 DAY 90: summarise our learning and create our strategy Most of the literature identified related to engaging with physicians or doctors. There was a lack of available evidence on the impact of clinical engagement in scrutiny. The evidence used to develop the strategy, in this area, was augmented with information from interviews and focus group sessions. There was wide variation in defining what clinical engagement looks like or how it is evaluated or measured. While clinicians were keen to get involved in our work, there were issues locally around freeing up clinicians time to contribute to national improvement activities. Further work is required to ensure that clinicians feel supported and valued when working with us and that benefits to clinicians are explored and articulated through the development of an attraction strategy and clinical advisers compact. We created a driver diagram which sets out a logical, structured approach to enable a sustainable, progressive approach to clinical engagement which may be of interest to other quality improvement organisations. Evidence suggests that clinical engagement is necessary and contributes to quality improvement and scrutiny. It was also highlighted that clinical engagement is not sufficient in itself as there are other factors which can make effective clinical involvement difficult to achieve. 2,3,4, Interviews and focus group sessions provided insight into opportunities for improvement and shaped five organisational priorities for action: - To ensure that clinicians view collaboration with Healthcare Improvement Scotland as necessary, valuable & worthwhile - To create and maintain a respectful partnership between Healthcare Improvement Scotland, the clinical community & key stakeholders - To develop and maintain a sustainable infrastructure - To develop an efficient & cost-effective approach - To continually review our approaches References: 1. Institute for Healthcare Improvement. 90-Day Research and Development Process. [online] 2009 [cited 2012 Feb 28]:http://qualityimprovementfaculty.pbworks.com/f/IHI+90+Day+Research+and+Development+ProcessApr09.pdf 2. NHS Institute for Innovation & Improvement & Academy of Medical Royal Colleges. Engaging doctors: what can we learn from trusts with high levels of medical engagement? [online] 2011 [cited 2011 Sep 27]: http://www.institute.nhs.uk/news/leadership/medical_leadership:_engaging_doctors_- _learning_from_trusts_with_high_levels_of_engagement.html 3. The Health Foundation. Evidence: How do you get clinicians involved with quality improvement? [online] 2011 [cited 2011 Sep 29]: http://www.health.org.uk/publications/how-do-you-get-clinicians-involved-in-quality-improvement/ 4. National Leadership & Innovation Agency for Healthcare. Engaging clinicians in a quality agenda. 2008 [cited 2011 Sep 27]: http://www.wales.nhs.uk/sitesplus/documents/829/engagingcliniciansinaqualityagendaapril08.pdf

1861 Stop resistance, save antibiotics: a pathetic call for action of the world alliance against multi-resistant organisms (WAAMRO) C. Pulcini 1, J. Carlet 2,* and the WAAMRO working group 1 CHU de Nice, Nice, 2 President of the World Alliance against Multi-resistant Bacteria, Paris, France Bacterial resistance has reached an alarming level worldwide. There is a worrying gap between the current worldwide spread of multiresistant bacteria and the lack of new antimicrobial drugs. Urgent measures are then needed in order to preserve the efficacy of antibiotics. In France, a national plan to decrease antibiotic use and curb bacterial resistance has been in place since 2001. As a result, antibiotic use has decreased by 16% in the outpatient setting between 1999 and 2009, but antibiotic use is slightly increasing again since 2005, especially in elderly people, and France is still one of the countries with the highest antibiotic use in Europe. Our aim was then to create an association in order to raise awareness and call for action to save antibiotics. We created in 2011 an international network, named the World Alliance Against Multi-Resistant Organisms (WAAMRO). It gathers health professionnals, veterinarians, environment specialists, economists and delegates of the public. This association is supported by 50 professional societies (40 French associations and 10 non-french associations, representing a total of 28 countries) and counts 350 members. We have met with government delegates, have communicated on the topic in the media and in the scientific literature. We have contacted the APUA (Alliance for the Prudent Use of Antibiotics), the BSAC (British Society of Antimicrobial Chemotherapy), the React initiative (Action on Antibiotic Resistance), and the WHO (World Health Organization) in order to participate in a common international call for action. Our next step in the coming months will be to suggest to goverment delegates to conduct a strong initiative showing that antibiotics are a very special class of drugs. Namely, we will suggest that doctors, including those in the outpatient setting, prescribe antibiotics on a dedicated form, mentioning the clinical indication and the duration of therapy. Moreover, a systematic re-evaluation of therapy around day 3 is of critical importance. We are planning to evaluate this strategy in a randomised controlled trial, assessing total antibiotic use as the main outcome. We believe that such global initiatives are urgently needed worldwide if antibiotics are to be saved. These precious drugs must be considered as "special" drugs, and actively protected (1). References: 1. Carlet J et al. Society's failure to protect a precious resource: antibiotics. Lancet. 2011 23;378(9788):369-71.

1863 Developing clinical leadership in the National Health Service in England I. E. Yardley 1,*, C. M. Rees 1 and Clinical Leadership Fellows, NHS Leadership Academy. 1 Clinical Leadership Fellows, National Leadership Academy, London, United Kingdom Recognition of the importance of well-prepared clinical leaders in improving quality in health care has been growing recently. High performing health systems typically have clinicians providing leadership at all levels. The National Health Service (NHS) in England has recently invested heavily in developing clinical leaders, particularly medical leaders. We describe a year-long program, the NHS Leadership Academy Clinical Leadership Fellows scheme, intended to develop a cadre of leaders from a broad range of clinical disciplines. In 2011, through open application and competition, the National Leadership Council (now the NHS Leadership Academy) recruited sixty clinicians to enter the fellowship. Candidates were drawn from a wide variety of clinical backgrounds including doctors, nurses, physical and psychological therapists, pharmacists and healthcare scientists amongst others. Selection was on the basis of leadership experience, potential to lead in the future and the quality of the service improvement project proposed by the candidate. The fellowship was funded centrally by the English Department of Health and comprised three elements: a personal leadership development program, a formal postgraduate qualification in leadership and service improvement and a quality improvement project within the fellow s own working environment. Each fellow was supported in their workplace by a designated sponsor and their progress was monitored by the NHS Leadership Academy. The personal development program encouraged self awareness and reflection and developed key skills such as presentation and strategic influencing. Fellows gained an understanding of leadership qualities and styles, and of how their personal qualities affected their leadership. They learned coaching skills and participated in action learning sets which encouraged personal and group development through critical reflection and active listening. The formal qualification provided a theoretical framework and an analytical approach to leadership and service development, drawing on contemporaneous real-life examples such as ongoing changes to the structure of the NHS and independent inquiries into failing hospitals. The engagement in an improvement project provided a practical means to apply the skills being taught and critically analyse the process of change management at the same time as directly improving the quality of services in each fellow s workplace. Each fellow developed in their own way, but through the fellowship program all were better able to work within teams, tackle complex problems and lead service development within their own area and potentially more widely in the health service in the future. Supporting clinicians who aspire to becoming clinical leaders and providing appropriate training for them can lead to rapid and significant improvements in their ability to lead change. The fellows will continue to provide leadership for quality improvement for the remainder of their careers and so the fellowship should be viewed as an investment in clinical leadership for the future.

1869 Project LEAD: Dr Sharmila Gopisetti Dr Quen Mok Picu Great Ormond Street Children's Hospital S. Gopisetti 1,* 1 Q. M. Picu, Great Ormond Street children's hospital, London, United Kingdom There is increased acknowledgement of vital role of clinical leadership in NHS and its implementation at every level. Leadership cannot be learnt purely by accumulating the knowledge; one needs to experience leadership responsibilities and learn from their experience. Attaining competence in leadership should be an integral part of every doctor s training and learning. At Paediatric Intensive care unit at Great Ormond street hospital, development of Leadership skills is perceived to be essential part of training and the trainees are given opportunities to exhibit and improve their skills. One such opportunity is the Fellow of the week. The Fellow role includes leading ward round, decision making, co-ordinate ward work, team work, delegation and ensuring task completion. The trainees are from different specialties at different stages of training. The confidence levels exhibited and perceived by the trainees was felt to be different. To ensure ongoing learning and improvement we aimed to review our experience systematically and introduce a structured feedback. The primary aim of Project LEAD is to improve the leadership skills of the trainees. This projectassesses the desire and confidence of trainees to become leaders and introduce a structured feedback to improve clinical leadership skills of the trainees ASelf assessment questionnaire containing 20 questions assessing various domains of leadership was distributed to the trainees and a feedback was obtained. Responses were scored on a scale of 1-5, 1 being a definite no and 5 being a definite yes. A score of fifty or higher indicates a desire to become a leader and a perceived ability to perform the tasks required of a leader. Questionnaires were numbered and distributed by the training coordinator and responses anonymised The response rate was 62.5% with 25 out of 40 trainees completing the questionnaires. Out of the total trainees who responded 23 of them were paediatric trainees and 2 anaesthetic trainees. Of them 13 were clinical fellows, 5- Post CCT fellows, 7- ST trainees. Three of them were grid trainees and 22 were non grid trainees. The questions like enjoy working with others and relating to others, planning, asking help had maximal responses of 4 and 5. However, questions relating to delegating work, writing memos, ability to resolve conflict had a maximal response of 3. Questions thrive for change and desire to become leader had majority responses 4 and 5. The overall score for all the trainees was greater than 50. 84% of trainees wanted formal leadership training incorporated in the curriculum This project helped to identify the perceived skills and abilities of the trainees, areas of improvement and the need for further training. Majority of the trainees are keen to improve their leadership skills and 84% preferred formal training incorporated in the curriculum. A structured feedback reviewing the activities will help improve these skills.key areas for development identified were delegation of work, handling complaints, writing memos, collection of data and ability to resolve conflict. Feedback form based on the NHS Leadership framework tailored to the requirements of the trainees was devised. Measurement of Improvement in the future: After the introduction of structured feedback a satisfaction survey from trainees will be conducted. A feedback will also be gained from the Consultants with regards to improvement of Leadership skills of the trainees. Further training needs identified will be addressed.

1915 The correlation study of career barriers and coping strategies among female nurses M.-H. Huang 1,*, C.-L. Kuo 2 1 Chiayi Chang Gung Memorial Hospital, Chiayi County, 2 College of Nursing,Fooyin University, Ksohsiung City, Taiwan Nursing is a traditional female occupation; however, the high itinerant rate of the nursing staff has been an important issue on nursing practice all the time. The present study adopts a cross-sectional correlational design with the cognitive view of the profession in order to explore the career barrier and coping strategy of female nurses, and to investigate the relationships between these two variables by a structured questionnaire. The research respondents were female nurses from two teaching hospitals in Chiayi and Pingtung county. A total of 516 efficient questionnaires were collected(67% retrieved). The major research findings are as follows: The career barriers of the female nursing staff belonged to moderate degree among which the pressure of multiple roles received the highest rating. It is the lowest that gender discrimination scored. Seeking assistance and support from others was employed most frequently. Personal background such as age, marital status, service seniority, professional duty, working department, specialized certificates count and in shifts or not, all had significant influence on career barrier and coping strategy. The positive coping strategies had negative correlation with career self barrier. The career barrier was related to coping strategies of delay-escape and negative adjustment. According to the findings, the researcher made some suggestions about nursing practice and further research. References: Benz, J. C. (1987). An analysis of the stress, strain and coping levels of public school teacher of serious emotionally disturbed students. Personality and Social Psychology, 46(4), 877-891. Ghiselli, E. E., Campbell, J. P., & Zedeck, S. (1981). Measurement theory for the behavioral sciences. San Francisco: Freeman. Lent, R. W., Brown, S. D., & Hackett, G. (1994). Toward a unifying social cognitive theory of career and academic interest, choice, and performance. Journal of Vocational Behavior, 45(1), 79-122. Leonard, C., & Corr, S. (1998). Sources of stress and coping strategies in basic grade occupational therapists. British Journal of Occupational Therapy, 61(2), 257-262. London, M. (1997). Overcoming career barriers: A model of cognitive and emotional processes for realistic appraisal and constructive coping. Journal of Career Development, 24(1), 26. Luzzo, D. A. (1993). Value of career-decision-making self-efficacy in predicting career-decision-making attitudes and skills. Journal of Counseling Psychology, 40(2), 194-199. Richard, G. V., & Krieshok, T. S. (1989). Occupational stress, strain and coping in university faculty. Journal of Vocational Behavior, 34(1), 117-132. Swanson, J. L., Daniels, K. K., & Tokar, D. M. (1996). Assessing perceptions of career-related barriers: The career barriers inventory. Journal of Career Assessment, 4(2), 219-244. Swanson, J. L., & Tokar, D. M. (1991). College students perceptions of barriers to career development. Journal of Vocational Behavior, 38(4), 92-106. Swanson, J. L., & Woitke, M. B. (1997). Theory into practice in career assessment for women: Assessment and interventions regarding perceived barriers. Journal of Career Assessment, 5(4), 443-462. Tipping, L., & Farmer, H. (1991). A home-career conflict measure:career counseling implications. Measurement and evaluation in Counseling and Development, 24(3), 111-118.

1927 The future projection of cost-of-illness of stomach cancer in Japan K. Matsumoto 1,*, K. Haga 1, T. Hasegawa 1 1 Social medicine, Toho University, Tokyo, Japan Stomach cancer was the leading cause of cancer death in Japan. Although the mortality rate of stomach cancer has been decreasing remarkably, it is still high compared to other cancers. The social burden of stomach cancer is still a serious problem for Japanese society. The purpose of this study is to investigate the future change of social influence of stomach cancer using the cost-of-illness (COI) method. Using Dorothy Rice s method we estimated the COI of stomach cancer (ICD10 code: C16) in Japan at 2008, 2014 and 2020. COI consists of the three parts; direct cost, morbidity cost and mortality cost. Direct cost is a health care cost of stomach cancer. Morbidity cost is an opportunity cost for inpatient care and outpatient care. Mortality cost is measured as the loss of human capital (human capital method). We calculated these costs at 2008 using Japanese official statistics. For future projection we adopted 2 types of method. One is a fixed method, which fixes health outcome indices (mortality rate, medical examination rate and average length of stay) of each age class at 2008 level, and the changes of population and age structure was taken into account (using official population projection). The other is a variable method, which estimates changes of health outcome indices in addition to population and age structure. Future health outcome indices are estimated using linear regression or logarithmic regression method. We adopted the regression which showed higher coefficient of determination. COI at 2008 amounted to 1,114 billion JPY. As for future projection, our 2 methods showed quite different results. Health outcome indices of stomach cancer have been improving since mid-1990s, that is, mortality rate, morbidity rate and average length of stay continue to decrease. If we ignore this health outcome change ( fixed method), COI is expected to increase. But if we take the health outcome change into account ( variable method), COI is expected to decrease remarkably. Estimation results are shown in following Table 1. Table 1: COI of stomach cancer in Japan billion JPY (80JPY=1US$) 2008 2014 2020 fixed method direct cost 254 288 315 morbidity cost 54 56 57 mortality cost 806 833 852 total COI 1,114 1,177 1,224 variable method direct cost 254 187 100 morbidity cost 54 37 20 mortality cost 806 557 358 total COI 1,114 781 479 The trend of COI is influenced by decease of mortality and morbidity rate. Since the recent decrease of mortality and morbidity rate is quite big, our fixed method may not reflect contemporary social conditions. Decreasing speed of mortality and morbidity rate is higher in elderly generation than in younger generation, and it is expected that total number of patients and deaths will not increase so much in spite of acceleration of aging. Hereafter rapid ageing increases the proportion of aged patients. This causes to reduce the value of human capital. As a result it is expected to reduce COI of stomach cancer in Japan.

2063 Job uncertainty, professional commitment, personality hardiness and intention to leave of hospital registered nurses H. M. Han 1,*, Y.-W. Wang 2, L.-C. Weng 2 1 Nursing, Chang-Gung Medical Foundation- Linkuo Medical Center, 2 Nursing, Chang-Gung University, Taoyuan, Taiwan A stable nursing staff directly affects the quality of patient care and it is the core issue underscores the importance of nursing education and clinical practice. However, few studies have investigated whether or not professional commitment and personality hardiness have negative influence on job uncertainty. A correlational research design was employed. Thecluster sampling methods and structured questionnaire (professional commitment, job uncertainty and personality hardiness) was used to collect data from 620 hospital nurses. The relationship of study variables was analyzed by logistic regression. 26.8% of those surveyed indicated an intention to leave. People who are older (exp (B) 0.92), junior in professional seniority (exp (B) 2.45), and those who had higher levels of professional commitment (exp (B) 0.96) and lower job uncertainty (exp (B) 1.08 for job natureand 1.09for job future) tended tostay; personality hardiness did not affect the tended to stay. Nursing staff turnover is still an issue that requires attentionand investigation. The results suggest that decreasing thelevel of job uncertainty and promoting the professional commitment of the nurse will lower the intention to leave. Relevance to clinical practice: A stable nursing staff was correlated withthe quality of nursing education and nurses contributions to hospital resources. Through sharing the staff s experiences and mentoring junior staff, a mutually beneficial social network can be formed that will reduce the leaving intention of the nursing staff. The nursing manager should set up a proper system to establish a good nursing work environment in order to improve the job uncertainty. References: Wu, Y.(2007). An exploratory study on job stress perception for clinical Nurses in Medical Center. Continuing medical education, 1 (22),17-41. Teng, C. I., Shyu, Y. I., & Chang, H. Y. (2007). Moderating effect of professional commitment on hospital nurse in Taiwan. Journal of Professional Nursing, 23 (1), 47-54. Lu, K. Y., Chang, L., C., & Wu, H. L. (2007). Relationships between professional commitment, job satisfaction and work stress in public health nurse in Taiwan. Journal of Professional Nursing, 23(2), 110-116.

2094 Using warehouse management to reduce the consumption cost of non-pricing of medical consumables S. C. Lin 1,*, X. H. Chen 2, C. W. Wen 3, X. F. Li 4 1 GSICU3, 2 8L, 3 NSICU1, 4 Nursing department, CHANG GUNG MEMORIAL HOSPITAL -LINKOU BRANCH, Taoyuan County, Taiwan According to National Health Insurance System in Taiwan, the payment is basic on global budget; as a result, cost control is the first priority projects to every hospital. Poor management can cause non-pricing medical material obsolete or expired. Also it will increase the operating costs of hospitals. Moreover, it will impact patients safety. Therefore, it is necessary to improve the management for non-pricing medical material. Setting a placement program and organize the non-pricing material. We innovated development of "the glide-landing box" for maintaining the validity of medical material to avoid the expiration of medical consumables. We set blood sugar machine standard plate for medical staff care get the material as soon as possible and used items to avoid waste. We also constructed a standard of the health material management. The development of the items set amount of basic standard formula of hypothesis quantity, to provide hospital setting standards. Besides that, the related training course were held for advanced discipline. We improved the non-pricing material consumer price and individual price difference.the non-pricing material consumer price and individual prizes are decreeing from 58% to 12%. Use warehouse management in non-pricing material checking correct rate is increasing from 41% to 91%. Also, the rate of the label and storage of the unit storeroom management is increasing from80% to 89%. Moreover, the high set unit rate is decreasing from64% to 0%. The spending of the storage unit is decreasing from 115,136 NT to 49,790 NT and total save 65,346 NT (56.8%). The nurses correct using non-pricing material behavior is improving from 61% to 100%. This assignment focuses on educated nurses to understand what non-pricing material management is and improved the incorrect behavior with using these materials. Also, save the cost of hospital material for the final purpose.

2109 Significant event management (POLICY) H. Walker 1,*, C. Paterson 1, A. Napier 1 1 Safety, Clinical Governance and Risk, NHS Tayside, DUNDEE, United Kingdom To conduct a root and branch review and redesign of existing Adverse Incident Management and Adverse Significant Clinical Incident Review processes within NHS Tayside. The aims were: - To further develop our incident management processes - To create and further develop an open and transparent, single, whole systems approach - Enhance clinical leadership throughout the process - Raise awareness of Executive Team in real time to incidents - To encompass partner organisations and relatives/families within the review process - To describe clear escalation processes to significant event management - To validate reviews through the use of recognised tools for facilitation - To improve the governance and assurance arrangements around reporting, monitoring and implementing changes that will lead to real improvements for patients and staff. - A retrospective review of International and National Evidence from the Institute of Healthcare Improvement and Healthcare Improvement Scotland. - A mapping exercise was undertaken of the current policies against the described best practice and similar policies from neighbouring Health Boards to identify similarities, gaps and opportunities for improvement. - Revised and updated Significant Event Management Policy - Redesigned systems and processes to support the Policy - Developed an Incident Reporting Measurement Plan - Developed a Significant Clinical Event Analysis Measurement Plan - Developed a Significant Event Management Implementation Plan - Linked to all levels of the Organisation's Governance structures from Local, Organisational to Strategic We believe we now have a robust system that will: - Inform the Nurse and Medical Director and Senior Executives of adverse events quickly - Provide a robust investigation process and follow up mechanism - Ensure recommendations from reviews are implemented, monitored and result in a more effective, safe and patient centred service for patients and staff. - Evidence timeframes identified in the Policy for reporting, reviewing and follow up of actions are being adhered to - Identify local champions to support the whole process within services - Allow faciliation and support to be provided to all staff The revised Significant Event Management Policy has been approved and accepted by our Clinical Quality Forum and Improvement and Quality Committee. As a result an implementation plan was developed to support staff with the changes and a measurement plan devised to track compliance with the Policy. Already more incident are being identified and investigated as a result of the Policy and resulting action plans are robust and monitored through the Organiastion's governance structures. References: Institute for Healthcare Improvement, 2010. Respectful Management of Serious Clinical Adverse Events http://www.ihi.org (accessed September 2011) NHS Education for Scotland, 2011. Significant Event Analysis Guidance for Primary Care Teams. Consequence, 2002. Six Steps to Root Cause Anlaysis. Healthcare Improvement Scotland, 2012. Suicide Reporting System. NHS Forth Valley, 2009. Critical Incident/Suicide Review (CIR) Guidance

2133 Management of priorities for resource allocation in a portfolio of projects A. Huchet 1,*, I. Peyrot-Perdrizet 1 1 Direction Projet Qualité, HUG, Geneva, Switzerland The strategic plan of the University Hospitals of Geneva has been translated into 52 projects. It was appropriate to define which projects needed to be considered as a priority for the allocation of available resources because of the large numbers of projects and of the economical restriction. Our proposition is to dispose of a structured methodological approach approved by direction committee members. In a first time, the 52 projects of the strategic plan of HUG have initially been divided into seven distinct action programs based on the domain to which they related. Each action program is overseen on the strategic aspects by sponsors who mostly belong to the direction committee, and also by program managers on the operational aspects. A project governance structure has been established to allow the coordination between the different actors and to consider the needs and the preoccupations of both project leaders, professionals in their field of expertise and members of the direction committee. In a second time: No bibliographic reference was found describing a method already tested or objective criteria to prioritize projects. That s why the Projects and Quality Direction has proposed a method of multi-criteria s analysis inspired by the FMECA. The proposition has been accepted by the direction committee members. This analysis was to retain two key criteria. To avoid a subjective evaluation, each criterion was defined with three sub-criteria more specific. For all the projects, a note on a 3-level scale was assigned to each sub criterion. The multiplication of these notes brings to define the priority of each project. The criteria selected by the sponsors and the managers in order to prioritize the projects vary with action program. All projects of the same program were analyzed with the same criteria by a rigorous method. This method has permitted to objectively define what kind of resources (human resources, equipments or financial resources) should be given in priority. Progressing state of the strategic plan is regularly verified at each meeting of direction committee. The methods used by the University Hospitals of Geneva for the allocation of available resources in the project portfolio of the strategic plan, has offered the possibility to objectively define priorities. This method can be applied to any kind of project in other sectors than health cares. With this exercise, the direction of the HUG has recognized the need to quickly provide some resources for critical projects so other projects considered as less urgent have seen their completion schedule changed and some actions shifted in time. For project managers, this approach allows them to have top management s support for the allocation of resources needed to success. It is also essential to consider that nothing is definitively acquired in project management. You must always take account the contextual changes and be able to offer this key process of prioritizing projects to all stakeholders and to top management. Because of the context of limited budget, it seems essential today to take systematically into account the criteria "ROI" or efficiency in the process of prioritizing projects, whatever the field of the project.

2189 Effecting the WHO'S HIGH5s correct site surgery SOP K. Soh 1,*, H. H. Theng 1, P. Lee 1, S. Koh 1 1 Ministry of Health, Singapore, Singapore The objective of implementing the SOP was to streamline the workflow of operating theatres and minimize risks of wrong site surgery. Champions from participating hospitals formed the High 5s Network with MOH to drive implementation. MOH also funded an executive in each institution to collect compliance data and close gaps. Initial baseline data showed poor compliance, especially for Time-Out. MOH worked closely with the executives, champions and OT nurse managers to improve compliance. Gap closures initiated include: revising surgical checklists, staff education and standardizing compliance data collection methods. Executives also performed cross review validation exercises to learn from each institution s workflow designs. Additionally, 2 hospitals wrote a Time-Out script for OT staff to read out prior to incision. They were noted to have marked improvement in compliance to the Time-Out section as staff could follow the step-by-step requirements of the Time-Out drill. Another two hospitals prepared video footage of actual time-outs being performed, which received positive feedback as staff could see it being performed on actual patients. Strategy for Change: Changes were implemented collaboratively by MOH, the champions and executives. The executives, though funded by MOH, report directly to hospital senior management. The champions were leaders in their professions such as head surgeons and anesthetists. As such, initiatives were better disseminated to the ground. The changes affected surgeons, anesthetists and nurses. After data collection methods were standardised, monthly compliance data were collected and reported back to OT staff and senior management. Based on the data, staff noted areas that needed improvement and gradually showed increased compliance to the SOP. Overall, it took a year to implement the SOP and reach steady state in data collection. The effects of the planned changes were measured by compliance data collected according to WHO s recommended indicators for benchmarking internationally. Analysis was through trending run charts to check compliance. By Jun 11, all institutions showed improvements of 8% to 22% in compliance to the Time-Out requirements with one institution achieving 100% compliance. Effects of change: The changes resulted in increased awareness of safety components built into the workflow in operating theatres. Problems encountered included resistance by surgeons to comply to site-mark and time-out drills; and nurses found it difficult to follow pre-operative verification components when there were variances in the process, such as language barriers to ascertain correct site of surgery. Lessons learnt: It was observed that the involvement of senior management personnel such as chairman surgical division and OT nurse managers were key in driving changes on the ground. Leaders of staff groups should be involved for better compliance. It was also noted that staff preferred scripts and visual aids to implement the SOP, such as through videos. MOH plans to develop more videos for staff to familiarise with the do s and don t s of the SOP.

2202 Voluntary peer review in German healthcare: a powerful tool focusing on sharing best practice and enabling individual and collaborative organizational learning G. Jonitz 1,* 1 Executive Board, Bundesärztekammer (German Medical Association), Berlin, Germany Improving quality and safety in health care through voluntary peer reviews based on open information exchange and mutual benefit. Peer Review is a form of external formative evaluation with the aim of supporting the reviewed health care organization to achieve substantial and sustainable improvements in the quality and safety of health care. The core element of this qualitative evaluation procedure is after the systematic self and external assessment - the on-site visit by an external team of experts, called Peers. Peers are independent and external but work in a similar environment and have specific professional expertise and knowledge of the evaluated field. The aim of the on-site visit is a systematic and critical reflection by the peers and the reviewed care providers on their own and colleague s performance in order to identify and mitigate hazards and to cross-share best practice. The reflection is based on the systematically collected and validated data of the previous self and external assessments. A fundamental precondition for the success of the dialogue at eye level is a solution-focused, blame-free and trusting atmosphere enabling an open information exchange and a willingness to learn from each other. The necessary approach of reflecting the whole treatment process also promotes integration and communication between the members of the different disciplines and professions and cooperative organizational learning. The evaluation of 15 pilot Peer Reviews in 2009 and 2010 by the German Medical Association and the initial experience of hospitals with voluntary peer reviews show the following key factors which led to the success of this process: 1. Quality and Accuracy of the Peer Review Procedure: - Systematic and structured assessment procedures - Multidisciplinary independent external peer teams - Voluntary participation - Freedom from sanction - Commitment to the principle of reciprocity: Learning from each other and cross-sharing best practices 2. Competence of the Peer Reviewers: - Professional expertise and experience, true peer - Methodical and personal evaluator skills Two Peer Review Procedures according to the described model above have been implemented in Germany between 2009 and 2011: 1. The peer review procedure of the Initiative Qualitätsmedizin (IQM), which voluntarily paired 210 hospitals in Germany and Austria (29.02.2012). Between 2009 and 2011, 63 of these hospitals had been reviewed. 2. The peer review procedure in intensive medicine which is organized by local networks of intensive care physicians. In 2011, 11 Intensive Care Units have voluntarily undergone a peer review. The results of the evaluation showed that there was a need for a theoretical introduction into the concept of peer review and for a qualification for peer reviewers. Consequently the German Medical Association met this need by publishing an appropriate Curriculum for Medical Peer Review in February 2011. By December 2011, 150 physicians have gained a peer review qualification covering this curriculum. Initial experience confirms that voluntary peer reviews offer a highly practical and relevant solution to improving health care with an immediately noticeable benefit provided by the rapid feedback inherent in the process. There are some other positive side effects reported such as increased professional autonomy and the acceleration of organizational changes. Health care professionals can be more integrated and motivated, especially because they perceive the process of development of quality as more self-determined.

2217 The governance and the activities of the best : a project developing evidence-based practice in nursing and allied health professions S. Ding 1,* on behalf of BEST: an affiliated center of the JBI, C. de Labrusse 1, E. Opsommer 1, N. Richli Meystre 1 1 BEST, HESAV, HEdS La Source, CHUV, Lausanne, Switzerland To develop and test the feasibility of an inter-institutional office, promoting Evidence-Based Practice (EBP) in nursing and allied health professions. Conscious of the importance and difficulties to implement research findings in clinical practice (i.e. EBP), two tertiary schools (HEdS-La Source and HESAV) of the University of Applied Sciences of Western Switzerland (HES-SO) and a University hospital (CHUV) collaborate to develop the BEST project (Bureau d Echange des Savoirs pour des pratiques exemplaires de soins). The purpose of the BEST is to facilitate and promote EBP in nursing and allied health professions: midwifery, physiotherapy, and radiography. A five-year project, launched in 2009, is conducted to define the organisation, roles and procedure, and to realise a pilot phase, which aims to test the feasibility of the proposed governance. A working group with broad representation from professions and experts in the field undertook the development of the BEST project using a four-phase approach. In the first phase, we conducted a thorough analysis of the needs, strengths and challenges of the three partner institutions and the health professionals.then (second phase), we identified and reviewed the international organisations promoting EBP and confronted these models with the local healthcare systems. The assessment of the existing models led,in the third phase, to agreement on a set ofobjectives and on the organisation and governance of the BEST. In the last phase, in process, we are conducting a pilot study to identify and answer several clinical questions. This presentation offers insight into the BEST project, including processes and obstacles, and sets out its activities: achievement of a systematic review and an adaptation of recommendations to answer clinical questions, the production of e-learning tools... The work of the group led to the enunciation of three strategic goals for the BEST: Produce high quality recommendations, in collaboration with health care services, Promote the use of research findings in clinical practice, Inform health professionals in EBP and support them in this approach. To meet these objectives, we became affiliated to the Joanna Briggs Institute (JBI), an international organisation promoting EBP. In addition to providing peer review and support, the JBI integrates us into an international network of health professionals involved in EBP. At the beginning of the pilot phase, health professionals from the CHUV provided 24 clinical questions for the BEST to consider. Among these questions, two were selected. For the first one, on the mechanic prevention of venous thromboembolism, a guideline from a credible source was retrieved, evaluated and recommendations adapted to the local setting. The second question concerned the effectiveness of patient therapeutic education in children with cancer and their family and has been treated through a JBI systematic review. The treatment of both questions has involved clinicians from the CHUV, which allows initiating them to the different steps of the EBP. Within the scope of this project, we also developed two e-learning tools, for structured, step-wise training to the use of Medline and Cinahl databases, for clinicians. The activities achieved led to caregivers satisfaction. The BEST contributes to the development of the nursing and allied health professionals, by positioning them as change agents, and to increase quality and safety of care.

2218 Integration and impact of the senior charge nurse, senior charge midwife and team leader role V. Thompson 1,*, D. Thomson 2 1 NHS Forth Valley / Scottish Government Health Directorate, 2 Performance & Assessment, Healthcare Improvement Scotland, Glasgow, United Kingdom To improve the effectiveness of care provision by developing an interactive diagrammatic resource of key initiatives and national programmes of work to promote a better understanding of how the integration of approaches enhances improved quality of care. By improving knowledge of integrated working encourages increased confidence from individuals and organisations to participate and contribute to quality and service improvements. Leading Better Care 1 with some of its key partners have developed a number of resources to support Senior Charge Nurses, Senior Charge Midwives and Team Leaders to understand the integration of work streams and programmes across NHS Scotland and also demonstrate the impact of their role. The first resource is an interactive live web resource www.nhsscotlandintegration.com. The resource supports access to relevant information such as reviews of related measurements, improvement activity and case studies. The second developed resource will support Senior Charge Nurses, Senior Charge Midwives and Team Leaders as well as organisations. This will include provision of a national overview reflecting on the impact that their roles have on patient care, quality of services and ability to achieve organisational targets. Through a scoping exercise it was identified that there is a deficit in knowledge and understanding of how programmes of work integrate and align to best effect. By hypothesising that improving such understanding increased the potential effectiveness of both care delivery and efficiency of systems and practice, we subsequently developed two interactive resources in the form of driver diagrams to reflect general and mental health inpatient care. The diagrams are aligned to the three quality ambitions (The Healthcare Quality Strategy for NHS Scotland) 2 The information set, also highlights change actions and supportive information in a single accessible resource. Further work is ongoing to include resources for midwifery and community care. The impact resource has been developed following the ongoing work of Leading Better Care 1 to support Senior Charge Nurses / Midwives (SCN/M s) and Team Leaders (TL s)by providing facilitation, support, development and educational opportunities to help them achieve high quality, person centered safe and efficient care for every patient first time and every time, This is achieved by ensuring there are better processes, effective ways of working, efficient and person centered care that result in more effective use of all resources. The impact resource will give clear results on the benefits of the role. It is envisaged that by using the resources to support the delivery of high quality care and to promote appropriate use of measures facilitates recognition and celebration of successes; this subsequently ensures continuous improvements and sustainability of established good practice. The impact resource will also be able to demonstrate the impact of the role in areas such as: - patients / clients / family and carers care and support - team working and development - their working environment - their organisational targets An integration and alignment of programmes that supports the delivery of high quality care to every patient every time and supports SCN/M s and TL s to demonstrate the key role they have to play in the delivery of high quality care. References: 1 Leading Better Care - www.leadingbettercare.scot.nhs.uk 2 The Healthcare Quality Strategy for NHSScotland - www.scotland.gov.uk/resource/doc/311667/0098354.pdf

2322 Reducing the working load of the nurse service as the outpatient counselor W. Hsiu Chuan 1,*, S. J. Lu 1, M. C. Tsai 1 1 Chang Gung Medical Foundation, Taoyuan, Taiwan The nurse service as the outpatient counselor large and diverse,expact accepting the non-professional advice. How to return nurse to professional, effective in reducing non-nursing professional workload, to reduce nurse workload-based project. Through the collection of information, The major promble of large work load is the scope of non-professional. The reasons including (1) With other administrative duties are not clearly defined (2) Hardware device is marked unclear and other administrative personnel duties are not clearly defined (3) The incorrectly referred form volunteer operator or the staff who approved price registered (4) No appropriate human resources support. Defined scope of services and responsibilities by the cross-sectoral coordination, telephone service standard language training, the operator, appropriate use of volunteers in accordance with the vesting of the shunt adapter Tel clerk to assist the non-nursing professional affairs, as well as hardware marked services and out-patient table to modify the advice line and other improvements. The scope of the non- professional telephone counseling decreased from 805 to 586, improving the effectiveness of 27.2%; site consulting services decreased from 3661 to 1732 to improve the effectiveness of 52.7%,reduces the working load of the nurse service as the outpatient counselor. Nurses to be given to the mission of servicing patients,and can not retuse. Therefore, the scope of the non- professional service volume can not be reduced to zero for this project restrictions. Recommendations in the nursing shortage of manpower and personel recruitment difficult circumstances, the processes of nursing job. To reduce non-essential work, decrease nurse,work load and improve retention rates, the unit heads should ponder and re-examine the processes of nursing job. References: Boyar, Scott. L.,Carl P Maertz, Jr, Pearson,A.w.,& Keough,S.( 2003).Work-family conflict:a model of linkages between work and family domain variables and turnover intentions.journal of Managerial Issues Pittsburg,15,175. Kotler P.(1984),Marketing Management: Analysis, Planning And Control, 5th ed,prentice-hall Inc. New Jersey. Sutherland, V. J., & Cooper, C. L. (1990) Understanding stress: A psychological perspective for health professionals. London: Chapman & Hall. Maslach,C.,& Goldberg, J. (1998) Prevention of burnout: New perspectives Applied & preventive Psychdogy.7(1),63-74 Murick,P.G.,Render,B.and Russel,R.S.(1990),Service Operation Management, Boston, Allyn & Bacon Corp.,pp.4

2374 Designing the future: approaches to measuring patient experience J. Cornwell 1,*, G. Robert 2, 1 The King's Fund, 2 Kings College, London, United Kingdom To explore the implications of research into what matters to patients for health policy in the National Health Service in England, and specifically to make recommendations with regard to the future design of approaches to measuring patient experience and improving the quality of care. We reviewed 24 publications which studied 'what matters' to patients and several other sources including secondary analyses of national surveys and the findings from previous field work to inform the design of these survey instruments. In addition, we conducted primary research in the form of - (a) 50 patient/carer narrative interviews (comprising 10 patients with one of five different conditions) - (b.) a survey of patient and voluntary organisations (n=36) - (c) secondary analyses of qualitative (1,000 postings) and quantitative (1,000 postings) data from two national patient feedback websites - (d) analysis of 2,600 rating questions used by hospitals in England as provided by one supplier of patient Experience Trackers (PETs) From 2012, the performance of the NHS in England will be assessed against a new Outcomes Framework (OF) that is designed to serve three purposes:accountability; transparency and improvement. The evidence from our literature review and other analyses suggest that current apporaches to measuring patient experience do not serve the three purposes of the OF well. Broadly, we conclude that: the criteria of timeliness, relevance and validity as commonly applied to measures of clinical quality and patient safety have not been applied to existing measures of patient experience; and there is a mismatch between what is measured now and what matters most to patients. The information patients need to inform decisions and choices has to be service specific, recent and relevant to be meaningful and useful; there is a need to evaluate experience of whole pathways of care; and there is a need to shift from a 'discovery' approach (which seeks to capture experiences without comparing them against what patients should expect) to an audit approach (which explores how patients' experience measure against standards). We propose that future national strategies for measurement of patient experience should be based on five fundamental principles. The approach should : simultaneously serve the three purposes of the OF; align with clinical services and outcomes (e.g. patient reported outcome measures PROMS); be evidence-based ; be simple and be embedded in quality standards.

2379 A cross-sectional study of workload, support at work and intent to stay among hospital nurses in southern Taiwan S.-Y. Lin 1,*, C.-H. Lin 1 1 Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan Many researchers have investigated nurses leaving intention or behaviours at organization and professional levels, but research into understanding workload, support at work and nurses intent to stay in their current employment have been rarely conducted so far. The study purpose was to explore the predictors of intent to stay in current employment for the next 12 months among hospital nurses in southern Taiwan. A cross-sectional questionnaire survey was conducted at a regional 1,000-bed teaching hospital in southern Taiwan. A voluntary sample without specific inclusion criteria was used. Questionnaires were distributed to 403 nurses employed full-time who provided direct patient care, and 370 nurses completed questionnaires. The validated response rate was 91.81%. Nurse administrators and part-time nurses not delivering direct patient care were excluded. Workload, support at work and intent to stay variables were measured using the Taiwan version of the Individual Workload Perception Scale- Revised (T-IWPS-R). The T-IWPS-R has been translated and validated for psychometric properties. Descriptive statistics, bivariate correlations and stepwise regression were performed. The regression model of intent to stay comprised only one predictor-workload, and it accounted 51.6% of the variance for intent to stay in current employment for the next 12 months. Workload has important influence on nurses intent to stay in current employments. The policy implications of the results include a consensus of mandatory staff-patient ratio in hospital care at the national level and a match of staffing plan with daily workload at the unit level. A national recognition program for excellent nursing work environment is recommended. Retention strategies targeting to reduce workload and enhancing nurse s support at work and professional development are imperative on nursing management. The implication to future study is to differentiate the predictors between intent to leave and intent to stay at organizational and professional levels.

2382 A study of the relationship between personality trait, job satisfaction and turnover intention among hospital nurses Y.-F. Hung 1,*, P.-E. Liu 2 1 Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, 2 Nursing, Hungkuang University, Taichung City, Taiwan There is an imbalance between supply and demand of nursing manpower in Taiwan. Although the supply of registered nurse appears risen in the past several years, the significantly increasing turnover rate leads to nursing shortage. The high turnover rate not only increases the cost in recruiting and training new nurses, but also increases nursing employees job stress and workload. These may leadto an overall declinein the qualityof patient care. To effectively retain sufficient nursing staffs, it is imperative to understand nurses job satisfaction and the turnover intention. The purpose of this study was to examine the relationship between personality traits, job satisfaction and turnover intention among hospital nurses. The study used a descriptive survey design in which data was collected using the questionnaires. Nurses working at a regional teaching hospital in South Taiwan were invited to participate in this study by convenient sampling. The research instruments included (1) demographic information, (2) the Big Five Personality Traits Test, (3) the job satisfaction scale, and (4) the intent to leave scale. Out of 510 distributed questionnaires, 507 were returned (return rate=99.4%) and 451 (88.4%) were valid. Statistical analyses including frequency, percentage, mean, standard deviation, t-test, one way ANOVA, and Pearson s correlation were performed by using SPSS 12.0 for Windows. There were significant differences between nurses job satisfaction and demographic variables such as age, marriage, number of children, in-service education, exercise habits, years of service, clinical ladder, day and night shifts, and divisions. Nurses intention to leave was different depending on nurses service of year, clinical ladder, and work unit. Nurses job satisfaction scores were significantly correlated with nurses personality traits. And there was a link between nurses personality traits and nurses intention to leave. Nurses job satisfaction was significantly related with their intention to leave. It is important for nurse administrators to understand nurses job satisfaction and intention to leave at the current employment. Based on the results of the study, nurse administrators are expected to develop useful strategies to retain and recruit nursing employees. Clinical implication in nursing retention and recruitment are also discussed.

2513 Advancing the field of clinical governance research and practice J. K. Johnson 1,*, J. Travaglia 2, R. Kwedza 3, J. Braithwaite 3 1 Centre for Clinical Governance Research, 2 School of Public Health and Community Medicine, 3 Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia It has been more than a decade since the Bristol Inquiry and clinical governance emerged as a framework to hold organizations accountable to monitor and improve the quality and safety of patient care. Since then health care organizations around the world have documented similar findings following major external inquiries and reviews which highlight failures in organizational structures and an overwhelming urgency to rectify the system. Clinical governance is seen as a strategy that offers a sustainable solution to improving safety and quality for patients. There is an opportunity to improve patient safety and quality through the implementation of an integrated and systematic clinical governance framework. The objective of this session will be to review the historical development of clinical governance, describe the critical features for an effective clinical governance framework, and to discuss strategies to advance clinical governance in different settings (e.g., primary care and allied health) as well in different countries. Drawing on our previous work examining the development, conceptualisation and application of clinical governance, we will review and extend the boundaries of clinical governance by engaging participants in an exploration of its current and future application in a variety of health related settings. In this interactive session we will review the origins of clinical governance and track the effect of government actions on health care governance. We will outline currently accepted governance strategies and review their changing patterns over time. Drawing on our own research and the literature, we will identify and discuss the importance of effective governance of health services by using an illustrative case study of governance arrangements in a large health care organization. Participants will then join small group discussions, which will be used to explore the applicability of clinical governance frameworks to different clinical settings. This will include resource-limited settings, multidisciplinary environments, transitional and developing countries as well as countries where the concept has not been embraced. This session will set the stage for advancing the field of clinical governance research and practice by engaging participants around the relevant drivers and important barriers to effective implementation. A better understanding of clinical governance will give participants the knowledge and skills to review their own clinical governance frameworks or reflect on the possibilities of introducing similar models within their organisations. The implications of an effective clinical governance framework for clinical practice are widely accepted and it has proved to be an effective mechanism for the integration and development of quality and safety improvement in hospital settings within developed countries. Advancing this field in both research and practice will have considerable implications for patient outcomes. The next challenge for this overarching framework will be to test its applicability to a variety of contexts, countries and emerging areas of concern. This workshop will provide an international forum within which to begin this review and development process.

2535 Development of the guidelines and quality-evaluation tool for the management of outsourcing services Y. Kim 1,*, M. Kim 1, E. Lee 1 1 Quality and Safety center, Seoul National University Hospital, Seoul, Korea, Republic Of Improve the quality of outsourcing services and customer satisfaction through the development and application of the guidelines and quality evaluation tool. Out hospital has 36 outsourcing service contracts in areas such as food, cleaning, mechanical and engineering controls, security, etc. We ve carried out this project in the above service areas from March, 2011 and the details are as follows. First of all, we ve formed a committee for quality management of outsourcing services with executives and the heads of relevant departments. Second, we ve established the guidelines for the management of outsourcing services, and received legal advice. Third, we ve developed the quality evaluation tool for the management of outsourcing services under agreements with outsourcing contractors. The tool includes common indicators and service specific indicators. Finally, the committee has approved the guidelines and quality evaluation tool, and we ve reflected them in our outsourcing contracts. Previously, outsourcing services of our hospital was not managed or integrated. Through the quality evaluation tool, we ve been able to monitor the level of service quality, key performance indicators, the result of improvement activities about the VOC (Voice Of Customer) and related problems. In addition to this, staffs of outsourcing contractors had to receive the education related to customer satisfaction, hospital infection, patient safety, etc, because we ve considered that staff training is important. In result of customer satisfaction survey, most outsourcing services have recorded 3 points or more on a scale from 1 to 5. But, food and parking service still have recorded low satisfaction. So we have made out more varied diet, expanded traffic signs and spaces with outsourcing contractors. Because assessment tool in some contracts will be applied from following agreements, the changed results of satisfaction survey and assessment scores will be ready by the conference. The guidelines and quality evaluation tool for the management of outsourcing services have been developed systematically and effectively. In order to meet the needs of patients, we ll keep going on these activities as part of our hospital s quality management and improvement program.

2556 Citizens participation in the creation of a national model for quality assessment and improvement of hospital service delivery G. Caracci 1, S. Carzaniga 1, V. Raho 1,*, B. Labella 1 and Lamanna, A- Tanese, A- Matastasio, R- Liberti, M- Cerilli, B- Di Stanislao, F 1 Quality and Accreditation, Agenas, Rome, Italy To test and validate shared methods and tools for monitoring quality of hospital care from the citizens perspective The National Agency for Regional Healthcare Services defined a system for monitoring quality of care aimed at the continuous quality and safety performance improvement. In developing the National system citizens point of view is taken into particular consideration for what concerns the ways to thwart inequalities and empowerment of citizens, as fundamental elements of health systems governance. For this purpose, Agenas has been promoting a project based on the widest possible involvement of stakeholders and aimed at defining a model for assessment and improvement of hospital responsiveness. Here follow the methodological steps: - Creation of a group of National experts in the field of service assessment from the point of views of professionals and citizens. - Involvement of all the Italian Regions and Autonomous Provinces (AP) through the representatives of the interregional working group on empowerment. - Definition and sharing with Regions and AP of a set of indicators for assessing quality of hospital care. - Testing of indicators and shared survey procedure - Validation of method and tools. Thanks to the collaboration of all the Italian Regions and AP and of the Civic Evaluation Agency- organization whose aims are the protection of citizens rights and the promotion of civic participation- the evaluation model has been defined. It is composed of 4 assessment factors (person-oriented organizational and care processes; physical accessibility, livability and comfort of care facilities; access to information, streamlining and transparency; taking care of the relationship with the patient/citizen), 12 sub-factors, 140 indicators. Survey procedure, regulatory sources and bibliographical references have been identified for each of the indicators. The testing activities, involving all the Italian Regions with more than thirty hospitals, are in progress and by the end of June 2012 the validation activities will be completed. The strategy based on the sharing of specific objectives, actions, critical issues and solutions has proved to be effective in fostering the widest possible participation of stakeholders. The merging between knowledge and experiences of professionals and citizens made an important contribution to the creation of a National model for monitoring quality of hospital care from the citizens perspective, based on the principles of empowerment for a shared governance of health systems.

2620 Influence of public disclosure of healthcare quality information on artificial knee replacement and uterine myoma surgery under Taiwan s national health insurance system P.-J. Wang 1,*, N. Huang 2, C.-H. Lee 1 1 Bureau of National Health Insurance, 2 Institute of Public Health & Department of Social Medicine, National Yang Ming University, Taipei, Taiwan Many experts and scholars call on relative health authorities to publish the quality information of medical care facilities with reasons including: (1) Publishing the medical care quality performances promotes competition among the medical care facilities, and further stimulates improvement of medical care quality, (2) Publishing the medical care quality performances would demand the medical care facilities to maintain a standard of medical care quality at the very least. For greater transparency of health insurance information, the Bureau of National Insurance in Taiwan has periodically published information on disease-specific medical care quality indicators for each related hospital since 2008, including re-hospitalizationrates of artificial knee replacement (AKR) and uterine myoma surgery (UMS). AKR serves as a reference for credibility of surgical quality. Uterine leiomyomata are among the most frequent entities encountered in the practice of gynecology. For the influences that this publication may bring, we aim to investigate whether the quality indicators get more improvement after the public disclosure of medical care quality information on AKR and UMS. Rates of re-hospitalization with related sickness within 30 and 14 days of dismissal are used to evaluate the outcome of artificial knee replacement and uteri myoma surgery, respectively. Hospitals which have 5-year claims file of these surgeries between 2006 and 2010 compose the study cohort. We use nationwide database to identify 160 and 131 hospitals for AKR and UMS, respectively. A longitudinal study by generalized estimating equation models with Poisson distribution were used to analyze the impact of public disclosure since 2008 on outcome indicators under controlling for other risk factors, such as hospital scale, location, number of surgeons, patient s average age, percentage of patient with catastrophic disease, and hospital-wide 14-day readmission rate. For AKR and MUS, the relative ratios of re-hospitalization rate between post-publication and pre-publication are 0.76 (pvalue=0.044) and 1.34 (p-value=0.043), respectively. Re-hospitalization rate for AKR significantly lessened 24% after public disclosure under controlling other risk factors. However, Re-hospitalization rate for MUS significantly increased 34% after public disclosure under controlling other risk factors. Public disclosure may not guarantee to improve or maintain medical quality. Multiple strategies to improve medical quality are needed. References: 1. The New Models for Public Disclosure of Health Information. Medical Dispute Review Report Series 34. NHI Dispute Mediation Committee, Department of Health, Executive Yuan, Taiwan 2008. 2. Publicly disclosed information about the quality of health care: response of the US public. Quality in Health Care 2001;10:96 103. E C Schneider, T Lieberman.

2698 The effect of a provider feedback program on the change of medical care patterns S. H., Y. J. Lee, Choi 1,*, H. J. Kang 1, J. C. Kim 1, J. S. Cho 1 1 Healthcare Fee Review planning division, Health Insurance Review &assessment service, seoul, Korea, Republic Of The purpose of this study is to make an analysis of the effect of the Voluntary Improvement System for Appropriate Healthcare Benefit (hereinafter "VISAHB") in Health Insurance Review and Assessment Service (hereinafter "HIRA"). The VISAHBis a smooth information exchange to make a change in medical care patterns by exchanging information and consulting between HIRA and healthcare institutions that locates in relatively highest than other health institutions. HIRA supplied the medical profiling information to 1,368 medical institutions and dental clinicsthat have extreme medical care pattern and consulted them by phone calling, sending an official document, and visiting etc. We analyzed out-patient medical pattern (medical cost and prescription rate per claim) of intervened clinic and others, comparing the effects between pre-visahb (the second half of 2009) and post-visahb (the second half of 2010). In the first half of 2010, medical cost per claim of feed-backed clinics increased 2.5%, but it of non-feed-backed clinics increased 4.0% even the extending policy on the health insurance benefit coverage, increases of insurance fee etc. In particular, there was significant decrease in intervention groups in regard to prescription rates of antibiotics for acute upper respiratory infection(u.r.i.), prescription rates of injections, and rates of prescription with more than 6 items decrease 10.8%p, 11.8%p and 11.5%p respectively. However, prescription rates of antibiotics for acute upper respiratory infection(u.r.i.), prescription rate of injections, and rate of prescription with more than 6 items among nonfeed-backed groups decreased only 0.5%p, 1.1%p and 0.8%p respectively. This study indicates that medical care pattern was changed after the feedback program to providers. This implies that prevention activities in medical care should be expanded for enhancing appropriate medical care and improving medical care quality.

1084 Time out as a safety tool in chemotherapy infusion M. L. D. C. C. Pavanello 1,*, P. M. Gollovitz 1, P. Nicolini 1 1 Oncology, Associação do Sanatório Sirio Hospital do Coração, São Paulo, Brazil According to Joint Commission International manual, high alert medications are those whose risks of errors may lead to significant adverse consequences. Medication errors, according to the National Coordinating Council for Medication Error Reporting and Prevention, are any preventable event that may cause damage to patient. The complexity of chemotherapy regimens, medication toxicity and clinical status of patients require efforts to minimize errors both in prescription and in administration, enhancing safety. Objectives Promote safety in processes involved in infusion of chemotherapic protocols, based on World Alliance for Patient Safety Guidelines of World Health Organization (WHO) and International Patient Safety of Joint Commission International. Design a form that comprises all steps, from checking chemotherapic agents upon their receiving at HCOR (Hospital do Coração) pharmacy to their final administration at the Oncology Unit. The initial checklist made by the Pharmacy encompasses 5 items of medication administration (right patient, right dose, right route, right medication and right time) and information about the chemotherapy agents (type of tube, traceability, photosensitivity, temperature and expiration date). In the Oncology Unit, the nurse makes a checklist of materials and equipment necessary for administration, documenting it in the form. Next, at the patient room, Time Out is performed by two members of the nursing team and chemotherapic infusion is started. The checkout is made after the chemotherapic infusion and the nurse will document in the checklist the conditions of the venous access, the notes made in the patient chart and the appropriate disposal of waste, signing and stamping the form. In the period between 2008 and 2011, there were 2,452 chemotherapy infusions administered. The use of Time Out led to the detection and interception of errors related with handling, such as labeling (14.81%), use of inappropriate infusion tubing (7.41%), inappropriate diluent (11.11%), detection of leaks (7.41%), foreign bodies in the solution (7.41%), and patient identification (7.41%). There has been 30% time reduction during the chemotherapy infusion procedure with the adoption of a checklist of materials and equipment used to infuse the chemotherapy agents, optimizing the time to provide care to the patients. The use of Time Out as a safety tool in chemotherapy infusion has provided: - Excellence in safety standards required in procedures involving chemotherapy infusion - Prevention of adverse event occurrences - Greater involvement of professionals in the process - Cost reduction References: - Joint Commission International Accreditation Standards for Hospitals 4 th Edition, 2010 - National Coordinating Council for Medication Error Reporting and Prevention, accessed on - World Health Organization (WHO) - World Alliance for Patient Safety

1116 The report of the Dutch Healthcare Inspectorate s yearly assessment of the implementation of the obliged Safety Management System of hospitals in the Netherlands J. Vesseur 1,* 1 Dutch Health Care Inspectorate, Zwolle, Netherlands The Dutch Health Care Inspectorate published in October 2011 the findings of its third assessment of the progress made by Dutch hospitals in implementing a Safety Management System (SMS). The Inspectorate is responsible for overseeing compliance with the agreements made with the sector organizations in June 2007, on the occasion of the launch of the Work safely, do no harm programme. Hospitals should reduce both avoidable adverse patient events and avoidable mortality by 50%, doing so through the introduction of a Safety Management System and measures which address ten specific high-risk areas. As in 2010, the Inspectorate noted that the improvements achieved further to prior risk assessments are not fully visible. Staff were unable to cite any such improvements. In a culture in which safety is high on the agenda, this is unacceptable. Now that reporting systems are in place in all hospitals, staff must be fully aware of the outcome of making a report and of the improvements which have been made further to the analysis of their reports. As in 2009 and 2010, the Inspectorate conducted the 2011 assessment among a representative sample of Dutch hospitals. On this occasion, the study involved 22 hospitals. It relied on the assessment framework applied in 2010, which is based on the priorities established by the SMS programme partners. These priorities, or spearheads, are intended to assist hospitals in the implementation of a Safety Management System which is able to meet all certification or accreditation requirements by the end of 2012. Hospitals which are accreditated by NIAZ were allowed to send the results of the NIAZ audit. The inspectorate used the audit results of NIAZ. The 22 hospitals visited appear to have devoted even greater attention to patient safety than in previous years. Nevertheless, there is still much to be done. Certain aspects of safety management, such as clearly identifying all potential risks, have yet to become standard practice in some hospitals. There are indeed some hospitals which have carefully scrutinized dozens of processes to assess where the potential risks to patient safety lie. However, the majority of hospitals have limited this undertaking to only a few processes of obvious high risk. Overall, the Inspectorate concludes that the successful implementation of a Safety Management System in hospitals has come a step closer, although it is not yet appropriate to speak of a mature system. Hospitals must prioritize risk management and the associated improvement processes. Given the current situation, the Inspectorate considers it unlikely that all hospitals will have a fully functional and mature Safety Management System by 2012. There are many which must now make a significant extra effort if they are to achieve this aim. In 2012 there will be an assessment of again more than 20 hospitals. Details of the assessment will be available in June 2012 and ready by the conference. References: Hélène Beaard, director NIAZ, the Netherlands

1128 Clinical epidemiology of falls/slips based on incident reporting data at a teaching hospital in Japan: a retrospective case study K. Egami 1,*, M. Hirose 2, J. Honda 3, H. Shima 4 1 Medical Care Quality Management Headquarters, St. Mary's Hospital, Kurume, 2 Center for Education on Hospital Medicine, Shimane University Hospital, Izumo, 3 Medical Care Quality Headquarters, 4 President, St. Mary's Hospital, Kurume, Japan This study aims to understand how Falls/Slips occurred at hospitals, the epidemiological aspects are explored by using incident reporting data. We analyzed 7,717 incident reports collected between 2007 and 2009 FY at a teaching hospital in Japan. Falls rate (FR) was 1.84/1000patient-days during target periods. Of 1,764 cases for Falls/Slips, the ratio of male to female is 973: 879, mean age ± SD (standard deviation) were 66.3 ±19.3 y.o. for male and 69.7±19.3 y.o. for female (p=0.554). FRs were 2.06 for male and 1.87 for female. FR in 70 s (555 cases) was 2.82 and the highest by age. FR at psychiatric service (68 cases) was 3.95 and the highest among clinical services, and FR at internal medical services were higher than those at surgical services. We assessed the highly positive association between length of hospital stay and FR (y=0.0405 x-0.9534;r=0.737, p<0.001). Furthermore, with respect to duration between admission and Falls/Slips, most frequent Falls/Slips took place on the second day after admission (129 cases), on the day of admission (100 cases), on the third day after admission (92 cases), and Falls/Slips decreasingly occurred day by day. The median of duration was 15.5 days. Since the characteristics of Slips/Falls are explored, patient safety managers and hospital directors are able to take appropriate and effective actions for securing patient safety and improving quality in health care. References: 1) Morgan VR, Mathison JH, Rice JC, et al, Hospital Falls: a persistent problem. American Journal of Public Health, 75,775-777, 1985 2) Sutton JC, Standen PJ, Wallace WA, Patient accidents in-hospital: incidence, documentation and significance, British Journal of Clinical Practice, 48,63-6,1994 3) Krauss MJ, Nguyen SL, Dunagan WC, et al, Circumstances of patient falls and injuries in 9 hospitals in a Midwestern Healthcare System, Infection Control and Hospital Epidemiology, 28(5),544-550,2007 4) Shaw R, Drever F, Hughes H, et al, Adverse events and near miss reporting in the NHS, Quality and Safety in Health Care, 14, 279-283, 2005 5) Healey F, Scobie S, Oliver D, et al, Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports, Quality and Safety in Health Care, 17, 424-430, 2008 6) Halfon P, Eggli P, Van Melle G, et al, Risk of Falls for Hospitalized Patients : A predictive Model Based on Routinely Available Data, Journal of Clinical Epidemiology, 54(12),1258-66,2001 7) Hitcho EB, Krauss MJ, Birge S, et al, Characteristics and circumstances of falls in a hospitalized setting. Journal of General Internal Medicine, 19,732-739,2004 8) Morse JM, Enhancing the safety of hospitalization by reducing patient falls, American Journal of Infection Control, 30(6),376-380, 2002 9) Shuto H, Imakyure O, Matsumoto J, et al, Medication use as a risk factor for inpatient falls in an acute hospital: a case-crossover study, British Journal of Clinical Pharmacy, 69(5), 535-542, 2010

1163 Patient-safety climate and error reporting in laboratory medicine interruptions as a relevant cause of error M. Meier 1,*, F. Giuliani 1, K. Bruni 2 1 Quality Management and Patient Safety, 2 Medical Diagnostic Department, University Hospital Zurich, Zürich, Switzerland The aim of this study was first to investigate the relationship between reporting of errors and the safety climate in a medical laboratory department at the time of introduction of an incident reporting system. Additional, possible causes of errors and critical incidents in this area were recorded. A cross-sectional study was conducted in the medical laboratory department of an 800-bed teaching hospital. Using a standardized questionnaire for medical laboratory areas according to Sorra et al. (2008) the dimensions safety climate, reasons errors happen and reasons errors are not reported were measured. The survey was administered to all clinical employees. The overall response rate was 41% (n=82). Linear associations between the dimensions were explored using Spearman correlation coefficient (SPSS). In testing if safety climate dimension predict reasons errors are not reported, linear regression analyses was applied. To obtain a better understanding of how errors are handled within the laboratory units a total of 7 guideline-based interviews were conducted with senior Biomedical Scientists (BMS). Following content analyzes were conducted to explicate process and establish comparability. The interviews with senior BMS show that all laboratory units follow a completely documented internal error reporting process. However, how this process of reporting error is implemented and applied points to relevant differences. A standardization of all laboratory units is planned. The survey revealed the following summarized results: Senior staff rated safety climate more positive than employees without management function. Working relationships with other clinical departments are perceived as needing improvement (lack of communication). Errors are often corrected immediately by employees but not reported. This prohibited learning from critical incidents. Safety climate seems to be a suitable predictor of behavioral patterns to report errors. Furthermore, errors could be caused by interruptions. As a result, employees try to work faster to cope with the ongoing workload. This compensational strategy has been well described in the literature (Westbrook et al., 2010). Because of this coping mechanism employees tend to perceive more stress and have the feeling to be not able to complete their tasks properly. Therefore several organizational development projects are launched for 2012. Main issue is to record which tasks in laboratory medicine are sensitive to interruptions and which workplace and human factor associated interventions are useful to protect them. This study shows that safety climate is a suitable predictor of behavioral patterns to report error. Moreover, in interruptdriven environments like laboratory medicine, employees reduce the time they spend on clinical tasks if they experience interruptions. This compensational strategy can increase the perception of stress. Workplace and human factor associated interventions are demanded to protect interruption-sensitive tasks. References: Sorra, J., Nieva, V., Fastman, BR., Kaplan, H., Schreiber, G. & King, M. (2008). Staff attitudes about event reporting and patient safety culture in hospital transfusion services.transfusion, Vol. 48, 1934-1942. Westbrook, J., Coiera, E., Dunsmuir, WTM., Brown, BM., Kelk, N., Paolini, P. & Tran, C. (2010). The impact of interruptions on clinical task completion. Qual Saf Health Care, Vol. 19, 284-289.

1183 Decreased risk of a surgical site infection with the implementation of a pre-incision standard of care for patients scheduled for an orthopaedic hip procedure (primary or revisions) D. Armellino 1,*, J. Mabie 2, G. Scluderi 2, Y. Dlugacz 3 1 Infection Prevention, 2 Orthopaedic, North Shore-Long Island Jewish Health System, Great Neck, 3 Krasnoff Quality Management Institute, North Shore-Long Island Jewish Health System, Lake Sucess, United States The objective of this initiative was to evaluate implementation of an evidence-based standard of care bundle for patients undergoing a hip procedure. The hypothesis test question: Is there a difference in the surgical site infection (SSI) rate for hip procedures after an evidence based standard of care bundle has been implemented? SSIs can occur following scheduled, non-emergent surgical hip procedures. In August 2011 leadership, orthopaedic surgeons and administrators, infection prevention staff, and peri-operative staff at eleven acute care hospitals planned and implemented five bundled pre-incision care elements to decrease a hip SSI. The bundle included five research based elements endorsed by the Institute for Healthcare Improvement (IHI). The implemented practice started in September 2011 and included: 1) Use of an alcohol-containing antiseptic agent for preoperative skin preparation; 2) Preoperative bathing or showering with 4% chlorhexidine gluconate (CHG) soap or 2% CHG impregnated wipes for at least 3 days prior to surgery; 3) Staphylococcus aureus screening and use of intranasal mupirocin for five days to decolonize Staphylococcus aureus carriers; 4) Appropriate use of prophylactic antibiotics; and 5) Appropriate hair removal. To monitor SSIs, registered nurses certified by the Certification Board for Infection Control reviewed all positive microbiology isolates following a surgical procedure, facility readmissions, and returns to the operating room. Each case was reviewed and categorized as an SSI based on the National Healthcare Safety Network definition. The SSI rate was calculated as the total number of SSIs following a hip procedure divided by the total number of procedures, multiplied by 100. Prevention efforts, the five bundle elements, were implemented at eleven hospitals in September 2011. Starting in November 2011 trained nurse abstractors retrospectivity collected and continue to collect compliance of each bundle element for patients discharge following a hip procedure. The January through August 2011 monthly aggregate SSI rate ranged from 0.44% to 2.20% for hip procedures. The implementation of the evidence based bundle elements during this time period were zero in aggregate. In November 2011, the assessed monthly rate of compliance with the bundle and hip SSI rate was started. Poisson regression adjusting for repeated measures will be used to calculate incidence rate ratios comparing the pre and post implementation periods and to evaluate the impact of bundle compliance. Post implementation assessment will be conducted monthly until August 2012. Orthopaedic hip procedures are commonly performed surgeries in the United States. Evidence supports the importance of five bundle elements for individuals scheduled for hip procedures. The hypothesis will be tested using Poisson regression.

1195 A proposed plan to improve time out completion rates for patients undergoing surgery P.-T. Huang 1,*, Y.-W. Huang 1, F.-H. Ye 1 1 Department of Nursing, Chang Gung Memorial Hospital (Linkou), Linkou County, Taiwan The quality of hospital healthcare is an important topic around the world. The goal of patient safety is to avoid unnecessary harm to the patient in the course of medical care. The 'Time Out' process performed before surgery is the last opportunity for any clarification by members of the surgical team. The operating room is a stressful and complex environment with a large number of staff. Hence, the accurate communication of patient information and standard operating protocols are important to ensure patient safety. This proposed protocol aims to ensure the proper indication of site of surgery, to enforce compliance to the 'Time Out' process, and to ensure its proper completion. Preliminary survey regarding the completion of the 'Time Out' process revealed a completion rate of 55.9% in the 3 months prior to the start of the study. The main points of concern were as follows : 1) not all 'Time Out' forms were fully completed 2) the site of surgery was not always indicated clearly 3) there was no standard method for the verification of the patient's identity and the Time Out process. A literature review was performed. This verified the importance of the pre-operative need for the 'Time Out' process, and the adverse consequences of not adhering to the process. We also looked at methods to improve communication between members of the surgical team. Steps to improve the 'Time Out' process were then proposed : 1) formulate a standard operating protocol to ensure patient verification and surgery site identification 2) conduct training workshops to ensure all staff understand the protocol 3) improve the computer software used for documentation, so as to eliminate the need for written forms which could be possibly misread 4) put up posters with photographs and slogans to remind staff about the 'Time Out' process 5) put in place an audit process. This proposed protocol was carried out from 1 June 2010 to 31 August 2010, and 60 randomly selected patients were involved in this study. The completion rates of the 'Time Out' process improved from 55.9% before the study to 100% after the implementation of this protocol. The main problem faced whilst implementing this new standard protocol was the compliance of the staff involved in the Time Out process. We overcame this obstacle firstly by conducting compulsory training workshops, where attendance was taken both at the beginning and end. Staff who did not attend were given reading materials to refer to. Secondly, the criteria for assessing the performance of staff was modified to include whether they were able to consistently and adequately complete the Time Out process. This was to encourage staff to adhere strictly to the protocol. Also, there was no fixed person who was responsible for ensuring the proper completion of the Time Out process previously. We addressed this by making the circulating nurse responsible for initiating the process. The surgeons were also not permitted to commence the surgery if the process had not been completed. The accurate communication between the various members of the healthcare team and the proper execution standardized protocols help to improve the safety of patients being treated in a hospital. All members of the healthcare team should aspire to adhere strictly to the various standard operating protocols. A good framework for communicating important patient information helps to minimize medical errors. Hence, explaining the operation to the patient before the operation, correctly marking the operative site and completing the 'Time Out' process help to enhance patient safety.

1265 Creating a culture of safety in the intensive care unit P. Merrifield 1,*, K. Goldrick 1, E. MarrisRogers 1 1 Critical Care, London Health Sciences Centre, London, Canada To create a culture change in the Intensive Care Unit by increasing compliance with Hand Hygiene to 100% in 100 days. Our project was modeled on the VitalSmarts Influencer training. To change behavior related to safety we needed to apply a scholarly, proven approach to exerting influence in order to change behaviours and thus culture. The focus was on changing a small number of high leverage actions that if routinely enacted would lead to the change in culture we wanted. Our ability to create change in our culture depended on having clear and measurable results. Three vital behaviours were identified. The first was to wash in when entering the patient environment and to wash out when leaving that environment. The second was to hold yourself and others accountable by speaking up when a missed opportunity to wash was noted. The third was to say thank you when you were reminded that you had missed an opportunity. Three types of forces influence motivation and ability: personal, social and structural. By overwhelming a problem using these forces on both ability and motivation, the probability of success in changing behaviour was increased. Staff identified multidisciplinary team members who were socially connected. These individuals were given training in having difficult conversations. They role modeled the 3 vital behaviours and were present to support other staff and physicians as they spoke up and held others accountable. Staff and others entering the ICU were asked to sign a written commitment to the three vital behaviours. Weekly audits were conducted by trained multidisciplinary auditors. The engagement of leadership and physicians who shared ownership of this project with the staff was vital to our success. Weekly audits were conducted and the data stream was posted openly in the ICU. Over the 100 days the compliance with the hand hygiene increased until the goal was reached. Setbacks occurred and the team analyzed and adjusted the work to ensure all 6 sources of influence were being used effectively. A sustainability plan was developed to ensure the change was permanent. Changing the behaviour of Hand Hygiene was an important step in creating a culture of accountability. This culture means that it is safe to speak up to others when patient safety is at risk. The staff and physicians know that when they speak up, this action will be met with respect and the understanding that our shared goal is patient safety.

1307 The role of pharmacists in patient safety: a nationwide survey on patient-safety management systems M. Hirose 1,*, Y. Imanaka 2, H. Fukuda 3, K. Hayashida 4 1 Center for Education on Hospital Medicine, Shoimane University Hospital, Izumo, 2 Department of Healthcare Economics and Health Policy, Kyoto University, School of Public Health, Kyoto, 3 Health Research Department, Institute for Health Economics and Policy, Tokyo, 4 Department of Medical Informatics, University of Occupational and Environmental Health, Kitakyushu, Japan This study aims to explore the role of pharmacist for patient safety activity within a hospital in Japan. We surveyed nationwide the situation of patient safety activities in hospitals allowed for additional costs on patient safety measures under the social insurance medical fee schedule using a questionnaire. We send the questionnaire including 14 fields and 93 items, to targeted 2,674 hospitals (all hospitals: 8,706 as of 1 st June) in Japan, 669 hospitals responded (response rate: 25.0%). In the assignment of risk manager, mean number of full-time risk manger as a physician was 0.04 ± 0.24. Likewise, mean number of full-time risk manager as a nurse and a pharmacist were 0.88 ± 0.96 and 0.07 ± 0.25. And, mean number of incident reports filed by physicians, nurses, and pharmacists were 17.7 ± 44.6, 510.0 ± 753.7, and 30.8 ± 112.5 in FY 2007, 17.7 ± 45.4, 579.9 ± 782.5, and 31.4 ± 86.6 in FY 2008, and 20.5 ± 57.0, 651.7 ± 946.4, and 39.3 ± 171.2 in FY 2009. Mean number of full-time risk manger as a pharmacist was higher than that as a physician, and mean number of incident reports from pharmacists was larger than that from physicians. The role of pharmacists is getting increasingly larger and pharmacists at hospitals are required to be much more involved in patient safety activity, as medication errors highly accounts for adverse events and Japan is suffering from a serious shortage of physicians. Instead this study is required to be statistically investigated with adjusting number of beds. References: 1) Fukuda H, Imanaka Y, Hirose M, Hayashida K: Economic evaluations of maintaining patient safety systems in teaching hospitals. Health Policy 88:381-91,2008. 2) Fukuda H, Imanaka Y, Hirose M, Hayashida K: Factors associated with system-level activities for patient safety and infection control. Health Policy 89:26-36,2009. 3) Fukuda H, Imanaka Y, Hirose M, Hayashida K: Impact of system-level activities and reporting design on the number of incident reports for patient safety. Quality & Safety in Health Care 19(2):122-127, 2010. 4) Hayashida K, Imanaka Y, Fukuda H: Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan. BMC Health Services Research 7:140; 2007. doi: 10.1186/1472-6963-7.140 5) Hirose M, Imanaka Y, Kaneko T, Fukuda H, et al.: Report of A study on current condition of patient safety system within hospitals in Japan. The Health Sciences Research Grants from the Ministry of Health, Labour and Welfare in Japan, 2010. (in Japanese)

1322 CQI Project: to prevent hip fracture of high-risk elderly fallers by using hip protectors in a convalescent hospital W. W. S. Lai 1,*, D. K. K. Lai 1, O. F. Chan 1, P. S. C. Lee 1 and the workgroup of this CQI program on the use of hip protector in Medical & Geriatric Department of Shatin Hospital 1 Medical & Geriatric, Shatin Hospital, Shatin, Hong Kong, China To promote the use of hip protectors as part of the fall prevention program in ward. This program was piloted in 2 wards staring in August 2011. A workgroup including ward nurses and occupational therapist (OT) was formed to explore factors contributing to the poor compliance of its use. Nursing and supporting staffs wore hip protectors on their own initiative to experience its feeling and make improvement strategies on the design of our current hip protectors. OT helped to redesign the product. Support from hospital management was sought to overcome the laundry facilities. During the study period till Jan 2012, 31.8% (177/557) patients were selected as high risk fallers. Overall compliance rate of using hip protectors was 85.4% (169/198) which was very encouraging as compared with the published data of similar care setting. 7 patients sustained falls, 5 of them wore hip protectors at the time of fall. The other two did not wear it because they were out of the selection criteria for using it before fall. None of these four patients suffered from fracture hips after fall. This project demonstrated high compliance rate of using hip protectors by the elderly patients was mainly affected by the healthcare workers in recognizing its benefit as part of fall prevention program to prevent injurious fall. On going review of the selection criteria on its use was necessary targeting all patients ware hip protectors at the time of fall.

1353 Analysis of critical incident reports in an academic teaching hospital error categorisation of medication events S. Huckels 1,*, U. Buschmann 1, T. Kaufmann 1, G. Schüpfer 2 1 Stab Medizin, Qualitäts- und Riskmanagement, 2 Stab Medizin, Luzerner Kantonsspital, Luzern, Switzerland Critical incident reports predominantly consist of medication errors. The aim was to identify which reported incidents reached the patient and which medication groups have been reported most frequently. All critical incident reports of 2011 were grouped according to the World Health Classification for Patient Safety methodology.[1] Medication errors were categorised using the Index NCC MERPO.[2] MERPO categories A-D differentiate incidents if reported events reached the patient or not. Category A include error-causing circumstances and category B cover recognised and prevented errors. Categories C-D subsume errors that reached the patient. Category C cause no patient harm whilst in category D was in addition the need for an intervention/monitoring. Categories E-I were not included because our set of critical incidents do not contain harm. An allocation to the main steps prescribing, preparation and administering of the medication use-process followed and every CIRS report was analysed concerning the defined medication group. A total of 804 incidents were reported including 343 (43 percent) medication errors. 91.2 percent reached the patient (categories C-D). 8.8 percent of the incidents were recognised before and averted (category B). 85.1 percent of the reports belong to category C and 6.1 percent to category D. The allocation to prescribing, preparation and administering showed that one report could included errors in all three phases. 126 errors (36,7 percent) happened in the prescribing node. Here 15.8 percent of errors were assigned to category B and 84.1 percent to categories C-D. 297 reports (86,6 percent) involved incorrect preparation and 295 reports (86,0 percent) a wrong administering technique. Only 5.4 percent in drug preparation and 2.4 percent in the administering node counted to category B, while more than 95 percent belonged to categories C-D. In category B, "wrong formulation presentation" with 58.8 percent and in categories C-D "Dosage mistake" with 40.7 percent were the most frequent errors. With 250 drug reports an allocation was made to various medication groups. The most frequent medication groups were antibiotics 12.4 percent, anticoagulants 11.2 percent and antithrombotics 10.4 percent, which appeared most often in connection with reports from category C. The results imply the impact of error chains in the medication process. Only few medication incidents were prevented before they reached the patient. The results are supported by international literature.[3] Therefore, existing security barriers need to be extended and new barriers must be established to interrupt error chains on time and to improve patient safety. Of particular importance is the awareness of employees to the appearance of error chains, potential security gaps and possible security barriers. Staff awareness will be enhanced by internal publication of CIRS cases and training on medication safety. Training may include the discussion of CIRS reports, sound-alike/look-alike or risk-afflicted medication groups or error analyses. In consequence, error categorisations of CIRS reports serve to recognise risks in medication management and develop measures to reduce risk. References: [1] WHO (2009): The Conceptual Framework for the International Classification for Patient Safety. [2] NCC MERP (2001): NCC MERP Index for Categorizing Medication Errors. [3] Hicks, Cousins, Williams (2004): Selected medication-error data from USP's MEDMARX program for 2002. Am J Health Syst Pharm. 2004; 61: 993-1000.

1358 Prioritizing quality measurement in hospital care: experts preferences and impact of non-medical factors U. Frick 1, 2,*, W. Wiedermann 1 1 Dept. Healthcare Management, Carinthia University of Applied Sciences, Feldkirchen, Austria, 2 Psychiatric University Hospital, University of Regensburg, Regensburg, Germany Measuring quality of inpatient care has produced a huge number of indicators, measurements and reporting systems. Indicators are usually seen as unconnected, reflecting very specific aspects of inpatient care. Attempts to integrate singular indicators into a coherent system of quality measurement are rare. This study aimed at empirically comparing medical doctors and other health professionals judgments on the relative importance of 14 existing quality indicators, which have been used in Switzerland. The stability of these judgments was tested by putting the indicators into short decision scenarios using a willingness-to-pay (WTP) framework. N = 104 Austrian and Swiss professional experts (physicians, nurses, quality managers) judged the relative importance of 14 different potential adverse events (AEs) in a ranking task. This list comprised errors for which either physicians or nurses could be held responsible (like instable hip replament or decubiti), or results that emerged from insufficient medical processes (like information deficits at the aftercare institution). Patient reported indicators as well as expert ratings were chosen. Respondents then answered for their 4 most dramatic and their 4 most lenient AEs, how much money they would be willing to spend in a decision situation, where they could halve the incidence of these AEs by improved quality management. Eight within-subjects scenarios were constructed such that high or low positive publicity for the fictitious hospital could be gained, the hospital faced high or low workload, and high or low time investments for the health professionals were necessary to halve AE incidence. Potential effects of presenting order and the potential impact of anchoring (expensive vs. cheap introductory example) were controlled as between-subjects factors. Nurses and physicians both judged AEs attributable to their own profession as more serious than AEs caused by others or insufficient process design. Patient reported outcomes or negative feedback from other institutions were judged as less important. There was considerable stability between WTP-judgments and the ranking task for all indicators based on expert ratings (Spearman correlations from 0.4 to 0.7), but there were virtually zero correlations for patient reported outcomes. Not to recognize a stroke during a hospital stay and delayed start of treatment was the most serious AE, which was (on average) worth for 1200 Euros (rsp. SFr) per case avoided. Neither country, nor profession (medical doctor vs. not), nor order of scenarios, nor positive publicity, nor existing work load, nor anchoring (62 vs. 200 Euros/SFr per AE avoided) could alter respondents decisions in a multilevel analysis. WTP for avoided AEs decreased by 156 Euros/SFr, if scenarios provided for 15 additional minutes of documentation (instead of 5 minutes) necessary to halve the existing incidence rate (p = 0.063). Patient reported outcomes do not seem to have a high impact on professionals perceived relative importance of adverse events during a hospital stay. A strict medical perspective on quality (at least for this sample) seems to prevail and to dominate potential economic considerations. Constructing a coherent system of quality indicators for a healthcare system as a whole would require a generic measure of (dis-)utility that could enable comparisons across medical specialties, diagnoses, and professional responsibilities.

1362 Effectiveness of a bundle of measures implemented to prevent ventilator-associated pneumonia V. E. Rodriguez 1,*, R. Durlach 1, C. Freuler 1 on behalf of Hospital Aleman Infection Control Team 1 Hospital Aleman, Buenos Aires, Argentina To assess the effectiveness of a bundle of measures implemented to increase the time free of ventilator associated pneumonia (VAP) in an intensive care unit of a general hospital in Buenos Aires This is a before-after study. Periods: first period from Jan 1 st 2007 to July 30 th 2008, second period from, August 1 st 2008 to 31 st Dic 2011. Intervention: 1) new sedation protocol, (2) daily oral care with chlorhexidine, (3) elevation of the head of the bed. New sedation protocol: daily assessment of ventilator need was done during ICU rounds and sedation was switched from fentanyl and midazolam to remifentanyl combined with others drugs, in order to keep the patient awake. Daily oral care with chlorhexidine: previous oral care was done only with benzydamine without teeth brushing. This procedure was changed to daily teeth brushing with chlorhexidine. Elevation of the head of the bed: patients were placed in semi recumbent position, between 30 and 45 degrees. The infection control nurse assessed the adherence to the intervention every day. The position was assured, initially, with an ad hoc protractor and after three months, a visual cue on the wall was used Surveillance: Healthcare associated infection surveillance was performed with the standardized NNISS method. An independent infection control practitioner validated the VAPs diagnosis during the second period. Mechanical ventilation: patients were ventilated with a Maquet ventilator Servo I model under subglotic aspiration circuits that were changed every seven days. Heat and moisture filters were changed every two days. Comparison: number of days without VAP in the adult ICU was compared between periods. Statistical analysis: Wilcoxon Rank Sum test was performed to compare the number of days without pneumonia cases between periods. Poisson regression was used to create an adjusted model. Intervention, ventilator days, length of stay and APACHE were considered for adjustment model. Nineteen VAPs were identified during the first period of 1920 ventilator days (19 months) and 8 VAPs, during the second period of 4843 ventilator days (41 month). A reduction in the mean of days without VAP of 72 days was found after the intervention (p: 0.03). Only the intervention was associated to reduction of VAP (IRR: 0.30, IC: 0.13-0.76; p: 0.01) under Poisson regression. Days without VAP Mean Median SD Comparison between periods(p) First Period 46 36 42 0.03 Second Period 174 108 213 The bundle composed of three of the five recommended measures to prevent VAP was effective to reduce the number of VAPs and increase the number of days without VAP. References: Hospital Aleman Infection Control Team: C. Ezcurra, M. Mayer Wolf, P. Montero, D. Torres

1372 Electronic clinical handover in a hemodialysis unit: towards safer medical care S.-C. Hsiang 1,*, J.-H. Chuang 1, H.-C. Wang 1, Y.-C. Liu 1 1 Council of Quality Health Care, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan Inadequate handover of patients becomes an important issue, resulting in discontinuous patient care and medical errors caused by information gaps, which eventually endangers patient safety. Most units or departments in our hospital still use written and verbal handover to transfer patient care from one unit to the other. Review of the process revealed a nonstandardized protocol, insufficient coverage of patient s clinical situation and incomplete documentation of all important findings or changes of condition, resulting in poor or incomplete handover and unsatisfied patient and the care team. An electronic handover system was developed in one of our hemodialysis units which covered 50-60 patients in the middle of 2011. A dataset was built in the electronic medical record system, which includes patients name, sex and age, location, prescriptions, record of hemodialysis, current condition, need for other consultation or investigation. The nurses and doctors were trained to be familiar with the system prior to execution of the system. Prior to establishment of the electronic handover system, incomplete handover occurred in an average of 28.4% of the patients over a six-month study period, which decreased to 9.5% after implementation of the system (P=0.01). 90.1% of the patients were satisfied with our service after adoption of the system, in contrast to 84.5% prior to conduction of the system. The documented handover incidents were 4 over the 6 months prior to using the system, which decreased to 2 in the 6 months following execution of the electronic handover system. An electronic handover system is a potential solution for complete or satisfactory handover, particularly in a unit for hemodialysis, where inter-specialty, intra-specialty or intra-unit transfer of patient care is frequent.

1392 Establishment and informed process of critical values C.-J. Wang 1,*, K.-H. liao 1, C.-C. Chen 1, S.-J. Huang 1 1 Landseed Hospital, Taoyuan, Taiwan Landseed Hospital is a community-based hospital in southern Taoyuan city.it is responsible for the health condition of the area.nursing staff collect samples after clinicians issued examination orders then medical technicians start examining when they have received samples. If medical technicians find laboratory data in the range of critical values, they have to warn the medical team immediately to observe patients situation.thus, the objective of this study is to establish an information delivery process of critical values. (I) Establish the item and range of critical values. Department of pathology and laboratory medicine in Landseed Hospital had set up critical values since hospital was established. The critical values are discussed annually by laboratory medicine and blood transfusion committee. (II) Establish informed system of critical values. Stage1. Inform nurses at nursing station by phone call. It may have some mistakes if nurses are too busy, causing delay or loss of information when warning medical team. Stage 2. Directly inform medical team staffs such as visiting staff, issued order doctor and nurse practitioner by phone call. Medical team staffs do not turn over their duty to the on duty staffs.the on duty staff cannot deal with patient s condition immediately. Stage 3. Inform on duty medical staffs by phone call. Medical technicians may spend more time to check medical affair shift table to communicate with on duty medical staffs. It will increase workload of medical technicians. Stage 4. Both inform visiting staff by short message and notice medical team staffs by phone call. Using this information delivery system,every data in the range of critical values will send to visiting staff s cellphone by short message immediately without missed. Stage 5. Inform visiting staff and nurse practitioner by short message, simultaneously nursing system of computer will get message too. (III) Establish receive critical values feedback system. Visiting staff can call back using cellphone or through computer hospital information system (HIS) page to confirm receiving message of critical values. Inform by phone call and recording the data manually resulted in information losses because medical technicians are often busy, forgetful, or unfamiliar with procedure. It was blow to 95% in 2008 May,and in this year the means rate monthly of inform is 98.3%. In 2010 August 12,department of medical affair canceled the informed process by phone call.this resulted in lower medical technicians workload, decrease the error and cost of phone call, and retrench human resources efficiently. Through information system, it can ensure that every data in the range critical values is informed medical team. The most department being informed is in internal medicine, second is department of emergency and critical care medicine. Department of surgery, on the other hand, has fewer informs. The most important thing of critical values informed system is timeliness. If medical team is informed in time, patients will get the most accurate diagnosis and optimum cure.

1397 Implementing a hospital-wide quality improvement and patient safety program for patient-safety cultural change - experience of a Taiwan metropolitan teaching hospital K.-S. Chu 1,*, C.-Y. Wang 1 1 Department of Medical Quality, Taipei Medical University - Shuang Ho Hospital, New Taipei City, Taiwan In order to verify effective patient safety programs that can improve hospital patient safety culture in 2010, we designed the study to compare the patient safety culture of hospital s employees between 2009 and 2010. We conducted a hospital-based study by using the data obtained from Safety Attitude Questionnaire (SAQ) sent out to healthcare employees of one hospital in Taiwan. This study had collected 647 and 900 questionnaires in 2009 and 2010 respectively, and the response rate was 56% and 62% respectively. The primary outcomes were the patient safety culture scores and positive percentage. The mean score and p-value were calculated by using t-test. Most of the respondents were nurses, followed by administrators, medical technologist, physician and pharmacist. The outcome of the analysis indicated that employees had more positive patient safety culture attitude in 2010 than 2009. The SAQ of the mean score including teamwork climate (p=0.0023), safety climate (p=0.0001) and stress recognition (p=0.0304), perception of management (p=0.0023) and working conditions (p=0.0022) were significantly difference between 2009 and 2010. Table: Healthcare employee s patient safety culture of 2009 and 2010 at a Taiwan metropolitan teaching hospital. Scale dimension Patient Safety Culture Pre-survey (2009) (N=642) Teamwork climate Safety climate Job satisfaction Stress recognition Perception of management Working conditions Mean score (Positive percentage) Mean score (Positive percentage) Mean score (Positive percentage) Mean score (Positive percentage) Mean score (Positive percentage) Mean score (Positive percentage) 67.8 (43.9) 64.7 (32.5) 64.4 (41.0) 67.6 (47.8) 62.7 (36.1) 62.3 (36.4) Post-survey (2010) (N=900) 70.0 (46.0) 67.9 (37.2) 66.4 (43.0) 69.9 (55.5) 65.9 (40.9) 66.8 (43.6) Statistically Significant 0.0023** 0.0001** 0.0766 0.0304* 0.0023** 0.0022** *< 0.05 **<0.01 #Positive percentage: Personal dimensions to answer "agree strongly" and "agree slightly", was regarded as positive attitudes toward this dimension which percentage of all respondents had positive attitudes toward same-oriented for the overall positive attitude (percentage). Positive patient safety culture of an organization to implement the core and foundation of patient safety, patient safety culture indicators and forward-looking, and with the original post to collect patient safety indicators, measured as a patient safety, not only can insight into the risk of opportunities for patient safety early in response to outside, persistent selfinvestigation of patient safety culture, but also help health care institutions to plan a perfect quality improvement and patient safety program. This study suggests that hospitals can use patient safety culture indicators (including teamwork climate, job satisfaction, perceptions of management, safety climate, working conditions and stress recognition) after implementing a quality improvement and patient safety program, and promote hospital s patient safety culture in the further, and can be used to investigate the association between culture promotion and patient safety improvement.

1441 The initiative to reduce the incidence of unplanned self-extubation M.-F. Chen 1,*, M.-H. Sun 1, W.-C. Chao 1 1 Nursing, Far Eastern Memorial Hospital, Taipei, Taiwan Unplanned self-extubation is known to increase morbidity and mortality. It also resulted in prolonged ventilator use and length of stay. In 2007, there were 30 events in our unit. The average incidence was 0.63%. Seventy-three percent of those who extricated themselves could experience successful ventilator-free course. Our analysis showed the major causes of self-extubation were: head-on-the-other-hand (33.3%), self-extubation without warning signs (26.7%) and constraint breakage (20%). Therefore, we launched a project to decrease the rate of self-extubation. We presented some features of our experience of unplanned sel-extubation: 1. The patients self-extubated themselves were 83.3% clearly conscious, 63.3% were male, and in their 60s (40%). They did not take any analgesics or sedatives (70%), and they had peaceful mood then (73%). Self-extubation mostly occurred at midnight (43.3%) 2. There was no standard operating protocol (SOP) regarding the discontinuation from ventilator. The chest physician (from Department of Pulmonogy) and the respiratory therapist visited and evaluated the intubated patients irregularly. The nurse played a passive role. The importance of intubation could not be clearly conveyed to the patient, even by auxiliary reminding card.. 1. We organized a project-oriented team, involving the attending physicians, nursing staff and the respiratory therapist. We also arranged weekly case conference and monthly doctor-nurse discussion in order to integrate the information and the treatment. 2. The unit recruited a dedicated chest physician and offered regular inspection of the intubated patients. A check list of weaning program was established, in cooperation with the therapist. 3. We also launched in-office education to increase the nurses knowledge about the discontinuation from ventilator and physical assessment. 4. An SOP of patient constraint was proposed. 5. We enriched the content and number of the reminding card. We adopted the Patient Safety Reporting System of Taiwan and Hospital Quality Assurance Report in our institute to collect data, including the rate of unplanned self-extubation and the factors contributing to successful unplanned extrication.some changes were observed after the intervention: (1)In 2008, the case number of unplanned self-extubation dwindled to 21 and the rate declined to 0.41%. (2)The rate of successful self-extubation after 24 hours dropped from 73.3% to 61.9%, which meant the unnecessary use of ventilator was reduced. (3)The patients that failed the weaning program and thus demanding transfer to respiratory care unit dwindled from 117 (in 2007) to 50 (in 2008). Through this project, we recognized that the patients could benefit from the integrated and team-wok based critical care. By establishing an SOP of ventilator discontinuation, enhancing the knowledge of the nurses and communicating with the patients with amended reminding card, we reduced the rate of unplanned self-extubation and of unnecessary ventilator usage. Unplanned self-extubation is frequently encountered in irritable patients without sedation and good communication. Our team work involving physicians, the nursing staff and the respiratory therapist offered an integral program to analyze and improve the patient care continuously.

1451 Optimizing patient safety through teamwork: case studies following team intervention in six hospitals C. Dekker - Van Doorn 1, L. Wauben 2,*, J. van Wijngaarden 1, R. Huijsman 1 1 Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, 2 Dept.of BioMechanical Engineering, Delft University of Technology, Delft, Netherlands To explore the effect at hospital system level, of the design and implementation of a Time Out Procedure (TOP) and Debriefing (plus) in operating rooms (OR) of 6 Dutch hospitals. The complexity of medical treatment increases the risk of errors, especially for patients hospitalized for surgical care. Errors are often due to poor communication and teamwork. To improve communication and teamwork among OR team members and reduce incidents, TOPplus was developed. TOPplus is a dialogue-based double check just before surgery to discuss critical aspects, involving all team members. To support adoption and compliance, adapting TOPplus to the local context was required. As implementation strategy two theories were combined: Participatory Design (PD) to structure the design process and Experiential Learning (EL) to support the learning process of OR team members. Therefore, it is expected that TOPplus also improves team learning across system levels. Study design: exploratory multi-case study. In each hospital (2 university, 2 teaching and 2 general hospitals) data were gathered via semi-structured interviews with OR team members and support staff. Information included: 1) actual use of TOPplus with the whole team present, 2) changes along the surgical pathway, and 3) facilitators and barriers for implementation. Interviews were recorded, transcribed and coded. Also general information about hospitals was gathered (e.g., size, structure, quality indicators, policies). The interview structure was based on the Clinical Micro Systems framework (CMS), and adapted to the surgical environment. In total 56 interviews were conducted. Early May all data will be analyzed, but preliminary results show positive effects at process and system level. Outcome - TOPplus was adopted as routine team procedure, with every surgical intervention in all 6 hospitals. TOPplus also led to structured handoffs between the clinical unit and OR, and in 3 cases to a checklist covering the whole surgical pathway. In all hospitals TOPplus was registered in patient records, sometimes in electronic records with sections for more details. In some hospitals results were discussed in team meetings. TOPplus also initiated team discussion in other disciplines like Obstetrics, Intervention Radiology and Intervention Cardiology. Implementation - In most hospitals patients received information (oral, website, brochure) on TOPplus. In 1 or 2 hospitals communication and teamwork were added to the job profile as non-technical skills, and sometimes integrated in clinical education. In all hospitals new employees received information or instruction on TOPplus. Few changes emerged in the leadership role. Managers encouraged participation, but active support at strategic level was lacking in most hospitals. Enablers: TOPplus poster in A1 format placed in every OR, the stepwise approach and detailed feedback, and engaging all team members. Sometimes a clinical champion was mentioned. Inhibitors: lack of a digital reporting system, lack of time, conflicting clinical procedures complicating team members presence, and resistance by some surgical disciplines. Introducing TOPplus as team procedure and allowing time and moments for learning and change improves adoption, supports team learning across system levels and is applicable in different hospital settings.

1460 A continuous improvement program on fall prevention in a palliative care setting in Hong Kong C. Y. Chuk 1,*, F. K. A. Lee 1, W. M. C. Kwan 1 on behalf of YPM Chui, GMN Shatin Hospital, Bradbury Hospice 1 Bradbury Hospice, Hospital Authority Hong Kong, Shatin, NT, Hong Kong, China It is well documented that the risk of falling is high among palliative and end of life patients (IshÃ,y & Steptoe 2011). Despite assessment and preventive measures have been used, number of all incidents were still high in our palliative unit. Interventions and suggestions were made to focus the improvement strategies to prevent patient falls as far as possible and to reduce serious injury resulting from falls. A work group was formed to analyze the fall incidents from 2009 to 2011. The data captured included the patient fall rate; the time of occurrence; gender and age distribution; restraint used before fall; Morse fall scale (MFS) before fall; possible contributory factors, severity index of each patient fall. Improvement strategies included enhance observation of patients, use of movement sensors, reinforced training of nurses on mobility assessment by physiotherapist. The Modified Functional Ambulatory Classification (MFAC) of patients mobility level was used. Information of the mobility level of patient would be placed at the head trunk of patient bed for communication on patient mobility capability. Physiotherapist would provide regular review. Patients with high risk of fall or their carers would be given education pamphlet during admission and upon discharge. An innovative design - ling long bell chains was introduced. Bells are connected with rubber bands in a chain and linked the gap of the side rail for the in-cooperative patients.. After introduction of these fall preventive measures, staffs were more alert on patients with high risk of fall. Staffs expressed acceptance to the improvement measures and preventing patient fall becomes a team work. Patient fall is a very common incident in the palliative ward and can cause harm to the patient. The whole clinical team should take much effort to prevent its happening. By reviewing the fall incidents and taking all possible measures, it is hoped that with these measures could reduce the fall rate. References: IshÃ,y, T. and Steptoe, P. (2011) A multicentre survey of falls among Danish hospice patients. International Journal of Palliative Nursing. 17(2): 75-79.

1505 Learning from other high-risk industries: adapting proactive risk management methods for healthcare S. Leyshon 1, E. Turk 1,*, T. A. Listyowardojo 1, M. Pytte 1 and DNV HRM project team 1 DNV Research and Innovation/ Healthcare, Høvik, Norway To adapt proactive risk management (PRM) methods from other high risk industries so that they are suitable for use within healthcare organisations. Everyday around the world thousands of patients are harmed by healthcare (Leape 2009; Hoffmann and Rohe 2010). Despite the efforts of clinicians, researchers and policy makers, there is evidence of patchy success in reducing this harm (Amalberti, Benhamou et al. 2011; Benning, Ghaleb et al. 2011). To date, greater emphasis has been placed on using reactive or retrospective approaches, such as analysis of patient safety incidents, to understand the causes of harm after they have happened. Limited use has been made of PRM methods that try to identify the potential for adverse events in healthcare before they happen and to introduce changes into systems pre-emptively to prevent harm (National Patient Safety Agency 2006). This presentation will describe attempts to adapt PRM methods from other high risk industries (such as oil, gas and maritime) for healthcare. A qualitative study combining a thematic literature review mapping the current use of PRM in healthcare with a multicentre study exploring users' perceptions of proactive risk assessment (as an exemplar of PRM). The latter will identify strengths and weaknesses of the use of proactive risk assessment as well as ways in which PRM methods from other high risk industries might be adapted to enhance the safety of healthcare. The study will run from January 2012 to December 2014. We will report the outcomes of the first phase of a three year, multicentre prospective study that will refine and evaluate PRM for healthcare: Mapping which PRM methods are currently in use in healthcare and other high risk industries Pilot workshops with PRM, patient safety, quality improvement practitioners and clinicians to explore and refine how PRM methods can be adapted from other high risk industries so that they enhance patient safety. We will report on the use of proactive risk assessment as an exemplar of PRM Focus groups with experts, clinicians and service managers to establish the face validity of the refined method for healthcare Increasing patient safety by reducing unacceptable risk and variation is the 'holy grail' of healthcare quality improvement. Like the quest for the grail, much effort has been expended but with limited results. This presentation highlights the potential for learning from other high risk industries and how that learning can be translated into useful ways of improving patient care. References: Amalberti, R., D. Benhamou, et al. (2011). "Adverse events in medicine: easy to count, complicated to understand, and complex to prevent." Journal of biomedical informatics 44(3): 390-394. Benning, A., M. Ghaleb, et al. (2011). "Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation." BMJ (Clinical research ed) 342: d195. Hoffmann, B. and J. Rohe (2010). "Patient safety and error management: what causes adverse events and how can they be prevented?" Dtsch Arztebl Int 107(6): 92-99. Leape, L. L. (2009). "Errors in medicine." Clin Chim Acta 404(1): 2-5. National Patient Safety Agency (2006). Risk assessment programme: Overview. London, NPSA.

1529 Improving injectable medicine patient safety with national recommendations for user-applied labelling of injectable medicines, fluids and lines D. Shipp 1,*, G. Bedford 1 1 The Australian Commission on Safety and Quality in Health Care, Darlinghurst, Australia To reduce harm from medication errors caused by unlabelled, or incompletely labelled, injectable medicines and fluids in Australian hospitals by developing and introducing nationally standardised user-applied labelling through National Recommendations for User-applied Labelling of Medicines, Fluids and Lines (the Labelling Recommendations). While implementation is ongoing, the standardised identification of medication removed from its original packaging through delivery to the patient is expected to improve patient safety. Approximately 25 per cent of hospital-based medication errors will involve injectable medicines, but nearly 60 per cent of medication errors that result in serious patient harm or death will involve injectable medicines. 1 Many of these are preventable. Australia, through the Australian Commission on Safety and Quality in Health Care (ACSQHC), has agreed and introduced nationally standardised user-applied labelling of injectable medicines and fluids to reduce the potential for error and risk of harm from unlabelled, or poorly labelled, injectable medicines.² Evaluation of current practice showed that labelling did not always comprehensively identify the right patient, the right medicine or the right route for injectable medicines removed from their original packaging. Draft Labelling Recommendations were nationally consulted, pilot tested and revaluated under the scrutiny of an expert advisory committee. A standard set of labels was established for identification of containers and conduits through standardising and building on existing processes. The Labelling Recommendations strengthen labelling practice and, for some health services, change practice with regard to line labelling and identification of medicines on the perioperative sterile field. Pilot testing identified the communications and resources necessary to implement the Labelling Recommendations. Implementation resources developed include explanatory notes, a slide presentation and posters, which can be tailored.²acsqhc provided information sessions for key implementation staff across Australia and provide ongoing assistance to health services. A standardisation maintenance and quality improvement process responds to implementation issues with outcomes reflected in an issues register and a set of frequently asked questions. Evidence suggests that trying harder to avoid medication errors is unlikely to be successful.³ However, identification in the context of a standardised process has the potential to make the system intrinsically safer. Baseline auditing by early adopters prior to implementation recognises that identification of injectable medicines was highly variable between users, clinical areas and health services. While evaluation of the nationally standardised userapplied labelling of injectable medicines is ongoing, initial uptake indicates that it addresses a recognised source of error and patient harm. References: 1. Patient Safety Observatory. Safety in doses: medication safety incidents in the NHS: National Patient Safety Agency, 2007. 2. Australian Commission on Safety and Quality in Health Care Web site. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/priorityprogram-06_ualimfl Accessed February 18, 2012 3. Merry AF, Shipp DH, Lowinger JS. The contribution of labelling to safe medication administration in anaesthetic practice. Best Pract Res Clin Anaesthesiol. 2011;25(2): 145-59

1564 Variation in safety-culture dimensions within and between us and Swiss hospital units: an exploratory study R. Schwendimann 1, 2,*, N. Zimmermann 3, K. Kueng 3, B. Sexton 4 1 Institute of Nursing Science, University of Basel, Basel, 2 School of Nursing, Duke University, Durham, 3 University hospital Bern, Bern, Switzerland, 4 Duke University Health System, Durham, United States The purpose of this study was to explore the variability in safety culture dimensions within and between Swiss and US clinical areas in hospitals. Cross sectional design. The Safety Attitudes Questionnaire (SAQ) was distributed to nurses and physicians involved in direct patient care in medical, surgical and mixed medical-surgical patient units of two Swiss and 10 US hospitals. With the 30-item SAQ Short version, six safety culture dimensions were evaluated in 2009. At the unit level, results were calculated as the percentage of respondents within a unit who reported positive perceptions. MANOVA and ANOVA s were used to test for differences between and within US and Swiss hospital units. In total, 1,370 health care workers from 54 hospital units responded, including 1,273 nurses (response rate=86%) and 97 physicians (response rate=64%). There was significant variability in each of the SAQ dimensions overall across the studied hospital units including significant differences between countries on half of the safety dimensions; safety climate, stress recognition and perceptions of unit management. Within countries significant differences were observed in all SAQ dimensions except stress recognition in the US units, and stress recognition and perceptions of unit management in the Swiss units. Despite some significant variability in safety culture dimensions between Swiss and US clinical areas, the overarching source of variability was not country. Rather, at the unit or clinical area level more variability was observed between units within countries than between countries. This highlights the empirical necessity of capturing health care worker assessments of patient safety norms and behaviours at the unit level.

1572 Physicians attitudes and perceived barriers towards reporting incidents, at Hamad Medical Corporation in the State of Qatar J. Alajmi 1,*, M. Alishaq 2 1 hamad med corporation, Doha, Qatar, 2 Quality, hamad med corporation, Doha, Qatar To examine the attitudes and perceived barriers of medical staff towards reporting incidents To encourage reporting incidents among physicians and create accountability rather than blaming of individuals It was a quantitative, non-experimental, cross sectional design for all physicians working at Hamad Medical Corporation HMC in the State of Qatar in order to obtain at least 600 subjects from the population. The study used Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture (HSPSC) which was modified previously for measuring nurses perceptions of patient safety at HMC in the State of Qatar. The survey was randomly distributed to all physicians working at HMC. Upon completion of data collection, statistical analyses was completed using the Statistical Package for the Social Sciences (SPSS) computer program to determine and measure frequencies and central tendencies. An appropriate statistical test was used to summarize and describe item interpretation and psychometric analyses of the modified instrument. 532 surveys were received from physicians who agreed to participate in the study from different departments, one hundred eighty five from medicine, one hundred fifty five from Obs/Gyne, and one hundred ninety two from surgical. In terms of Staff worry that mistakes they make are kept in their personnel file (77% agreed, negative response), Staff feel like their mistakes are held against them (75% agreed, negative response), and When an incident is reported, it feels like the person is being written up, not the problem (71% agreed, negative response). It was also found that two individual items received low positive response rates and indicated areas for improvement. The first item represented a near-miss situation and was worded When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported. This item received a positive response rate of 20%. The second item represented an actual error event and was worded When a mistake is made, which did not harm the patient, how often is this reported, and received a response rate of 20% (or high percentage of negative responses). Strategies to encourage incident reporting among physicians must address the awareness of no blame no shame culture through continuous staff education, provide a system that simplify process of reporting and getting the feedback in a timely manner.

1600 To assess the effectiveness of timely communication of panic results detected on ultrasound examinations to the primary physicians S. Sohail 1,*, N. F. Husain 1, M. Jabeen 1, W. Abid 1 1 Radiology, Aga Khan University Hospital Karachi Pakistan, Karachi, Pakistan To evaluate the impact on patient management by the Primary physician; after timely communication of panic alerts* This was a retrospective, random sampling study conducted from May 2010 to August 2011 in ultrasound section, Radiology department, Aga Khan University Hospital, Karachi, Pakistan. This was taken up as a quality project and a team was identified to study the JCIA requirements and come up with strategies to address the challenge of panic reporting and monitoring. The methodology used was PDCA. A list of exams that could result in life threatening emergencies was developed and it was emphasized that these results were supposed to be communicated to either the primary physician/team for in-patients. As Pakistan is a developing country with underdeveloped healthcare systems this is an exceptionally challenging task. A total of 100 inpatient cases were reported as Panic during the period specified. These were communicated immediately after the conclusion of the examination to the primary physicians/ team. Plan of management of the patient were retrieved from online database of Hospital Information System(HIS) to evaluate the changes in management after radiological diagnosis were communicated. The initiative of Panic Alert was established in light of the JCIA standard AOP 6.4 to improve effective communication of urgent and emergency reports; which mandates the requirement for timely communication, documentation and monitoring of the panic alerts so that continuity of patient care is not impaired. - Out of 100 patients; six (6%) Left Against Medical Advice (LAMA), in 10 cases (10%) no follow up was available. - In 12 patients despite panic results communication nothing was done. - In remaining 72 patients appropriate timely management was given to all patients (72%) either surgically or conservatively. Out of which 50 patients (69.44 %) underwent surgery and 22(30.55%) were treated conservatively. Due to timely management no major complication or death was recorded. Timely communication of panics detected on ultrasound is effective as it ensures provision of appropriate treatment at appropriate time. Panic communication policy should be strongly implemented in all radiology setups. References: *Panic Alerts: Reference AKUH, Radiology, protocol # 40 Panic is a life threatening emergency detected on ultrasound examinations that need to be timely communicated to the primary physician/ team to avoid catastrophic results. List of findings/diagnosis considered as life threatening at AKUH. (This is only a guideline; additional diagnosis may be communicated upon discretion of the Radiologists.) 1. Ectopic pregnancy 2. Ovarian / testicular torsion 3. Solid organ laceration 4. Intra uterine fetal demise 5. Intussusception 6. Deep venous thrombosis 7. Abruptio placenta 8. Grade 4 Intraventricular hemorrhage 9. Arterial occlusion leading to ischemia 10. Positive ultrasound FAST in cases of acute trauma

1601 Using "Fall Risk Assessment Tool" to reduce the fall injury severity of patients H. J. Jen 1,*, L.-H. Hsu 1, C.-L. Hsu 1 1 NURSE departement, NURSE, Taipei, Taiwan An aging society means falls are also on the rise in medical institutions and it has long been the second most frequently reported patient safety event in Taiwan. Severe fall injuries not only increase the length of hospital pay, cause complications. Patients may also feel unsafe, reducing their willingness to engage in everyday activity, lead to medical disputes or increased medical costs. Use "Fall Risk Assessment Tool" to carry out fall assessments as well inviting patients in the high fall risk group and their families to take part. Individual care guidance was provided in the hopes of reducing patient injury from falls and improving the quality of care. The fall-related factors for standard acute care patients at a certain medical center were subjected to regression data analysis. A total of 591 cases were accepted during the study period between January 1, 2009, and December 31, 2011. The suitability of the fall risk assessment tool of "High Fall Risk Assessment Form" (HFRAF) was examined with a review of relevant literature. Pharmacists and therapists were invited to take part in discussions based on the STRATIFY fall assessment form. Lower limb strength tests and use of multiple drugs were added to accurately assess groups with a high risk of falling in order provide a basis for fall prevention measures and performance assessment. In June, 2011, team members took part in a second discussion and testing session on fall cases. The consistency of the HFRAF was tested. Three training sessions were held on the new HFRAF clinical operating standards and achieved an attendance of 85%. Between June 18 ~ August 22, HFRAF was introduced in 4 wards with high fall risk groups (164 patients) and fall prevention assessment carried out. The program was gradually expanded and adopted hospital-wide in December. Nature of high fall risk patients indicated in nursing instructions, including: (1) Fall within the last 6 months. (2) Altered mental status or extreme irritability. (3) Unable to stand on one leg for more than 5 seconds. (4) Unable to leave the bed and use the toilet unassisted. (5) Must use walking aid. (6) Use of multiple drugs. Fall risk assessment was carried jointly by the nursing personnel and the patient or care giver then personalized fall prevention measures drawn up. Use of HFRAR increased the proportion of high fall risk cases from 68.2% to 79.3%. Further analysis revealed that the incidence of falls among patients was 0.7% between 2009 and 2011. The most common was minor injuries (swelling and bruising) and these increased from 17.8% to 27.2%. Moderate injuries however decreased from 7.6% to 5.5% while severe injuries decreased from 7.4% to 1.5%. While the number of minor injuries increased, there was a significant decline in moderate and severe injuries. Continued improvements will be made to the care of high fall risk patients to reduce the severity of fall injuries. The revised "Fall Risk Assessment Tool" also improved the care process by shortening the time required for nursing personnel to carry out HFRAF from 41.9 seconds to 19.71 seconds, a saving of 21.29 seconds. The implementation of fall prevention measures should be based on the patient's perspective and medical institutions must ensure that fall risk assessment & prevention are properly carried out. Only by improving the care environment, upgrading the quality of care and reducing the severity of fall injuries through the participation of the medical team can sustainable excellence achieved by the hospital.

1620 Measures to improve surgical safety - a multidisciplinary approach W. W. Y. Fong 1,*, Y. S. Chan 1, Y. K. Au 1, J. S. K. Wong 1 1 Operation Theatre, Hong Kong Baptist Hospital, Hong Kong SAR, China Surgery is an integral part of global health care. Our institution performs more than 25,000 surgeries annually. As the patient s advocate, the perioperative nurse has a duty to safeguard patient s health and welfare. The following policies have been implemented to improve surgical patient s safety: 1) Adopt Informed consent 2) Recommend Preoperative anaesthetic assessment 3) Adopt surgical Time-out 4) Develop Massive blood transfusion protocol 5) Implement surgical equipment and instrument maintenance program After implementation of the above measures, the following outcomes have been achieved: 1) Obtaining informed consent from the patient/guardian is an important prerequisite prior to performing the procedure. The Hospital introduced new consent forms allowing explanation of surgical procedures and anaesthesia procedures by attending clinician in August 2010. In order to ensure patients had sufficient understandings of the intended procedures, the Hospital also developed a number of information sheets and were available for download at the Hospital website. 2) To standardize the practice of pre-operative anaesthetic assessment, a list of conditions was developed in August 2010. The list stipulated the criteria the ASA classification and the type of surgery, for which the patient should be admitted earlier with adequate time before the surgery for stabilization. This policy was furthered reviewed and reinforced in December 2011. 3) In May 2010 surgical Time-out was implemented in the main theatre suite, as well as Endoscopy Unit, Specialist Centres and Radiological Department. Audit performed on Operating Room (OR) staff compliance carried out in April 2011 and data reviewed 100% staff compliance on the requirement of critical items and 96% of non-critical items. In August 2011, surgical Time-out was further extended to ward area s bedside procedures. 4) Massive blood transfusion protocol was implemented in April 2010. Measures included mandatory type and screen policy for all Obstetrics patients; storage of 5 units of un-matched O-positive in OR blood fridge; streamline workflow of urgent blood request. Cross-department drill with Blood Bank and Maternity Department were performed in April 2010 and November 2010 respectivelyto testify the compliance of 10 minutes service pledge and the result was encouraging. In October 2011, the scope of mandatory type and screen policy was broadened to include other major surgical procedures. 5) Working in collaboration with instrument suppliers to allow inspection of the physical status of endoscopic instruments at regular interval. A thorough inventory analysis was conducted in February 2012. OR medical equipment was under the care of the Hospital Medical Equipment Maintenance Unit (MEMU). In January 2012, the inventory list and preventive maintenance (PM) schedule could be accessed via Hospital intranet. The database would be updated on a monthly basis. For High Risk items (Class 3 & 4), PM was mandatory and the PM schedule would be followed and monitored closely, i.e. zero tolerance. PM service of High Risk items would be contracted out to suppliers. With the implementation of the above measures, the Hospital has gained much confidence and reputation from its surgical colleagues as evidenced by significant increase in the number of major complex surgical cases. The number of thoracic surgery has increased threefold from 65 in 2009 to 225 in 2011. Continuous quality improvement program is important to sustain surgical patient s safety.

1623 Assessment of accidents in alpine skiing and definition of a preventive intervention F. Marchiori 1,*, S. Tardivo 1, W. Mantovani 1, M. Migazzi 2 1 Public Health, University of Verona, Verona, 2 Prevention Department, Azienda per i Servizi Sanitari di Trento, Trento, Italy Alpine skiing is a sport practiced by about 2,3 million people in Italy every year with approximately 25,000 accidents reported. Several risk factors related to mountain environment and employed materials, together with the large amount of people involved, determine a high number of accidents and a relevant impact on health service. In order to improve prevention, it is therefore necessary to adopt a monitoring system. The present study aims at assessing the volume and typology of first aid intervention, with the purpose of defining a suitable preventive method for alpine skiing accidents in a specific area in the North-East of Italy The reports filled out after each emergency intervention at three ski slopes in Veneto Region and Autonomus Province of Trento have been collected and entered into a computer database. 325 identified actions out of 331 have been reviewed at Department of Public Health. The outcome of accidents were obtained by linkage with the database of the Emergency Relief (data not shown). Patients average age was 27 years, whereas the most affected group was between 11 and 20 years old. 186 Males (57%) were involved. The most used instrument linked to the accidents was ski (155 cases) followed by snowboard (66 cases). The most dangerous time slot was found to be in the middle of the day from 11 a.m. to 3 p.m. (63.5% of 325 interventions). The cumulative incidence of interventions ranges from 0.6*10000 accesses in the 2009/2010 to 0.57*10000 in the 2010/2011 (Risk Ratio 0.95; 95% CI 0.75 1.21). The 80.3% (261 cases) were orthopedic injuries, while 17.2% (56 cases) were lacerated contused injuries. Moreover, 10% (32 cases) of the studied population showed physical discomfort associated with different types of non traumatic problems. Lower limbs were involved in 43.5% of cases, upper limbs in 32.7% and the head/neck in 20.8%. In 236 cases (72.6%) at least one health measure was needed. In 165 subjects the affected area was immobilized. 18 cases (5.5%) required the application of cervical collar with spinal board for suspected cervical trauma. 30% of patients was medicated after major orthopedic injuries or lacerated contused wounds. In one case the Resuscitation was carried out. 37.5% of injured people has been transported downstream by akya (mountain stretcher), 7% by snowmobile and 10% by other means. In 3% of the cases it was necessary to resort to Rescue Helicopter Service while in 21.2% the patient was directly transported to hospital by ambulance. Moreover other variables were evaluated such as areas, times and days, weather conditions (data not shown) in order to improve the preventive measures to reduce the number of accidents. The analysis of the personal features of the subjects involved in accident, as the days and time span of occurrence, the places of greater occurrence and the type of accidents and first aid, have enable to draw up a guide for users that highlights major risk factors, safety rules and patterns of behavior in order to prevent and reduce the severity of accidents at the ski slopes in the Alpine Skiing investigated area. References: "Sistema Simon, Sorveglianza degli incidenti in montagna" Second Report. Istuto Superiore di Sanità. November 2005

1644 Related factors for incidences of endotracheal tube in intensive care units at a specific medical center S.-N. Wang 1,*, T.-W. Liu 2 1 Nurse Department, 2 Nurse Department medical intensive unit, Far Eastern Memorial Hospital, New Taipei City, Taiwan According to the Taiwan Patient-safety Reporting System in 2008, endotracheal intubation in tube incidences accounted for a maximum of 34.5% with a reintubation rate of 36.9% and Severity Assessment Code (SAC) showing medium or greater degrees of damage. Research has also indicated that 4-13% of patients with endotracheal intubation were not removed as planned. Reintubation of endotracheal significantly increased the prognosis, mortality, and medical costs with 2.8% patients fatality rate. The endotracheal intubation rate for patients from this unit reached 86-88%. The incidence of endotracheal tube incidents from September 2009 to August 2010 was 0.86%. We have discussed the related factors of endotracheal tube incidences. Our purpose is to discuss the effects of the intervention and related factors of endotracheal intubation incidences in intensive care units at a specific medical center. We reviewed 45 endotracheal intubation incidences from September 2009 to August 2010. We analyzed and deduced the incidents based on the reports and occurrences. We ensured that there were delays in tube removals, restricted methods, restricted time inappropriate evaluation, inappropriate fastening of endotracheal tubes and lack of communication channels to draft improvement measures. Intervention included: 1. Revised the endotracheal tube fastening method operating procedure; 2. formulated a standard operation procedure for ventilator weaning; 3. revised the content for communication cards and installed nurse calling systems at each bed; 4. created a multimedia teaching material regarding endotracheal tube fastening method and restricted nursing standard operation; and 5. hold monthly multidisciplinary discussions to review reasons for occurrence. Incidence of endotracheal tube incidents from 1 January to 31 December 2011 decreased to 0.08%. Patient safety is the primary goal for hospital management and medical organizations strive for. When patients are placed with endotracheal tubes during emergency admittances, they will often attempt to remove their endotracheal tube because of discomfort, as they are unable to express their needs verbally. To prevent patients from removing endotracheal tubes themselves, the fasting of tubes, restricted skills and methods, and breathing training are all concerns regarding this occurrence of endotracheal tube incidences. After intervention, the incidence of endotracheal tube incidents decreased from 0.86% to 0.08%. This enhanced patient safety, as well as shortened hospitalization length and reduces nursing workload and costs. References: Krayem, A., Butler, R., & Martin, C. (2006). Unplanned extubation in the ICU: Impact on outcome and nursing workload. Annals of Thoracic Medicine, 1(2), 71-75. Krinsley, J. S., & Barone, J. E. (2005). The drive to survive unplanned extubation in the ICU. Clinical lnvestigations in Critcal Care, 128 Silva, P. S. L., & Carvalho, W. B. (2010). Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations. Pediatric Critical Care Medicine, 11(2), 287-294.

1674 Potential drug interactions in multiple trauma patients in a Brazilian hospital L. Vieira 1,*, R. Oliveira 1, H. Capucho 1, S. Cassiani 1 1 University of São Paulo, College of Nursing, Ribeirão Preto, Ribeirão Preto, Brazil The present study aimed to determine the frequency of drug-drug interactions in prescriptions for multiple trauma patients hospitalized in intensive care units (ICUs), and analyze the related factors associated with pharmacotherapy and patient. Knowledge of the pharmacological mechanism and risk factors for drugs interactions (DIs) helps to increase the potential safety and effectiveness of treatment. The cross-sectional study was conducted in a large general hospital, located in Recife, Brazil. The potential DIs were identified on the requirements of the first day (24 hours) and the fifth days (120 hours) hospitalization using the software Thomson Healthcare s Micromedex. Data collection was conducted from July to September 2008 and the technique was document analysis, with retrospective chart review. The study was approved by the Ethics Committee of the Institution. Statistical analysis was performed using PROC FREQ of SAS 9.2 software. It was performed an exploratory analysis and calculated the Odss Ratio rough. Of the 58 patients studied, 47 (81.0%) were male. The average age was 34 years. Individuals aged less than 25 years accounted for 34.5% of the sample and 25 to 40 years 44.8%. These data show that most of those involved in this study were young adult males. The frequency of diagnosis, 40.9% of patients had a fracture of the skull and facial bones and 33.3% unspecified multiple traumas. The average length of hospital stay was 29 days. The average number of drugs prescribed per patient, with 24 hours of admission was 10.7 (SD 2.9) and with 120 hours, medications per patient was 11.9 (SD 2.2). Prescriptions in 24 hours, 77.6% of patients had potential drug interactions and the 120 hours that number was 77.2%. There was evidence of an association between number of prescribed medications and interactions in time 24 hours, but in time 120 hours there was no such evidence. Who used more than nine drugs had 29 times the chance of drug interactions compared to less than 9 who used drugs. In 120 hours, no variable showed evidence of association with drug interactions. Most DIs in relation to gravity, were classified as moderate or severe, reflecting that these interactions have clinical importance. The most frequent serious interaction in this study was fentanyl + midazolam. This interaction is classified by Micromedex as a pharmacodynamic interaction, based on pharmacological synergism - concomitant use of an opioid (fentanyl) and a benzodiazepine (midazolam) for sedation. This interaction is used in intensive care with a therapeutic purpose. Other potential interactions were identified: midazolam + phenytoin, phenytoin + ranitidine and fentanyl + phenytoin. The study contributed significantly to the profile of the DIs in ICUs, becoming an important tool for planning actions to improve patient safety in intensive care. To increase the safety of pharmacotherapy in the ICU, it is essential to implement strategies that help the health team to identify the interactions and implement preventive measures and monitoring of patients at risk of developing drugs interactions.

1682 The eye of the storm: emergency response to Hurricane Irene M. Solazzo 1, J. Romagnoli 1, M. Mahoney 2,*, G. Koster 3 and Emergency Operations Command 1 Administration, North Shore-LIJ, 2 North Shore-LIJ, Great Neck, United States, 3 Institute for Clinical Excellence and Quality, North Shore-LIJ, Great Neck, United States - Describe the steps that are necessary to ensure the safety of patients, employees and the community during multiple emergency hospital evacuations. - Discuss the role of the Emergency Command Center and the vital aspects of ongoing internal and external communication. - Describe results of a Quality Impact Evaluation that was conducted following the storm. In an extraordinary display of leadership, teamwork and advanced emergency preparedness, North Shore-LIJ Health System employees and physicians evacuated three hospitals (Staten Island University Hospital (North and South sites) and Southside Hospital in anticipation of Hurricane Irene that was expected to make landfall in the New York Area. A total of 947 patients were safely evacuated over the course of approximately 36 hours. During this first hurricane to hit the New York metropolitan region in 26 years, North Shore-LIJ established a safe haven for more than 1,300 patients, outside nursing home residents and others seeking shelter. Long before Hurricane Irene, North Shore-LIJ was honing its severe weather evacuation plan, as three of its 15 hospitals are situated in flood-prone areas. North Shore-LIJ Emergency Response to Hurricane Irene Number of Hospitals Evacuated 3 Number of Hospital Discharges 107 Total Number of Patients Evacuated 947 % Intensive Care Unit (ICU) Patients Evacuated - All ICU Types 20.3% Number of Evacuated Patients Accepted from Outside North Shore-LIJ 245 Number of Patients Transported by Ambulance 313 Number of Individuals from Shelters 32 Homeless Given Shelter 12 Number of Patients that Were Returned to Original Hospital/Nursing Home 284 Unexpected Mortalities During the Event 0 One of the most important lessons from Hurricane Irene is the need to have a functional emergency evacuation plan in place ahead of time-one that has been fully tested and refined by emergency management experts.a Quality Impact Evaluation that was conducted following the storm revealed the following as among the many best practices: - Communication with staff via hotline, mass texting and blast e-mails - Medical Staff who were cross credentialed at more than one North Shore-LIJ Facility - Medical personnel accompanying patients to the receiving facility and providing handoffs Lessons learned included: - Improve relief coverage in the Emergency Operations Center by mandating "rest-time" for incident command personnel and training back-up staff to man the command center and create a formal handoff process - Broaden the definition of staffing to include case management, security personnel and social workers. - Establish which services will remain open at evacuated facilities (i.e., cath lab), which staff will comprise the "Stay Team" at evacuated facilities and which staff will travel with patients to the receiving facility - Triage during transport when using buses to evacuate - Use security personnel to direct arrivals to appropriate areas based on the hospital plan - Supply hand sanitizers, or handwashing on buses and at the loading/unloading sites - Standardized policy to address medical record maintenance during emergencies - Central coordination of repatriation after the event

1690 A new way to medication storage M. P. S. Leung 1,*, S. Wong 1, C. LUK 1, Y. M. Chan 1 1 Accident & Emergency, Prince of Wales Hospital, Hospital Authority, HKSAR, Shatin, Hong Kong, China Traditional way of patient's medication storage in drug trolley is not feasible in an Accident & Emergency Department (A&E) with huge patients' load and access block. Different means were tried to identify the best way to medication storage. The objectives of this project are to find a way to store patient's medication safely and at the same time, to facilitate administration of medication. With the problem of access block in A&E, comprehensive medical treatment will start once patients are waiting for bed. Length of stay in A&E may be as long as one to two days. This creates a problem of medication storage since the traditional way of medication storage in a drug trolley cannot cope with the demand of high patients' volume and turnover rate. Different storage methods such as used of metal clips, plastic trays and plastic folders were used and to look for the best solution to the problem. With the funding support from department, a plastic folder is used to store medications returned from pharmacy. There are several advantages from this design. First of all, medications are stored together with patient s file, this creates a mean of safe storage since all the files are kept in a controlled area in nurses' station. Secondly, this reduced the unnecessary movement of nurses during administration of medication. Nurses do not have to move back and forth between the drug trolley and the patients. She can check and give the medication to patient at the same time and thus save time for other nursing procedures. Another added benefit is that patient s gum labels used to keep separately from the chart are now stored in the same plastic folder. This also reduced the chance of mixing up gum labels between patients. To evaluate the practicability of the system, all medical and nursing staffs involved in administration of medication and ward round are interviewed one month post implementation of the system. Two questions will be asked. The first is to check whether they are satisfied with this new drug storage system and second, whether this system is conducive to administration of medication. Concerned colleagues are asked to rate their feedback on a five point Likert scale. This evaluation is still underway and it is expected to complete by the end of March, 2012. Another observable outcome is that there is 100% compliance to the system by nurses. No single staff has breached this rule or to store medications by other means. In addition, there is no incident occurs as a result of mixing up patients' medications or gum labels. One limitation of this project is that it has only launched for one month, further monitoring and observation of this system is needed to identify possible undesirable outcomes and non-compliance to the system. In summary, storage of medications in a plastic folder is an alternative approach to safe medication storage. No adverse incident is observed after one month implementation of the system. Compliance to the system by nurses is 100% percent. Collection of feedback from both medical and nursing staff is still underway.

1701 The effectiveness of the operating room pathological specimen example by a medical center in central Taiwan C. H. Lee 1,*, F. M. Huang 1, S. C. Lin 1 1 department of nursing, Chung Shan Medical University Hospital, Taiwan, Taiwan Histopathology specimen provides a basis for diagnosis and treatment. Specimen lost or negligence in any part will affect patient diagnosis and treatment. Subjecting patient to repeated invasive inspection will also increase patient risk and cost. From June, 2009 to July, 2009, our department recorded a 13.33% incomplete submission of pathological specimen. In addition to returned specimen, cost for re-processing specimen is $8875 per month. The purpose of this project is to improve the quality in the process in order to reduce incomplete pathological specimen submission. Thereby reducing health care waste and costs, and improve the quality of medical care. With the use of TRM, our medical team analyzed possible causes and provides the following improvement strategies: set guidelines for the submission process; organize in-service education; implementation of audit systems; and setup barcode system. In addition, holding regular quality assessment meetings to review and analyze improvements. Our goal is for improved diagnosis and treatment for patients, and enhanced safety for surgical patients. Descriptive data analysis was performed by Microsoft Excel. Out of 2036 pathological specimens sent for inspection, there are 73 incomplete submissions, an incomplete rate of 3.59%. The incomplete submission rate reduced from 13.33% down to 3.59%. The monthly processing cost reduced from $8875 per month down to $2281.25 per month. Quality improvement was achieved. If there is a problem with specimen submission process, it will seriously affect the diagnostic results and treatment for the patient. If the specimen is lost, subjecting patient to repeated invasive inspection means increased risk for the patient and it will result in increased medical expenses and problems when requesting medical benefits coverage from the Bureau of National Health Insurance. Therefore, complete operating room pathological submission is very important. Through teamwork and continuous quality assessment, we can ensure the safety of surgical patients. References: Edson, D. C., Russell, D., & Massey, L. D. (2007). Proficiency testing: A guide to maintaining successful performance. Laboratory Medicine, 38(3), 184-186. Lippi, G., & Guidi, G. C. (2007). Risk management in the preanalytical phase of laboratory testing. Clinical Chemistry and Laboratory Medicine, 45(6), 720-727. Joint Commission on Accreditation of Healthcare Organization (2006). 2006 National Patient Safety Goals. Retrieved March 15, 2008, from http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/06_npsgs.htm Taiwan Joint Commission on Hospital Accreditation (2010) Patient Safety Retrieved May 15, 2011,from http: //www.tjcha.org.tw/ Upload/ 0BE90698-0510-4B30-AAB0-A73E35845801/1.%20 Watson, D. S., &Crum, B. S. (2005). Improving specimen practices to reduce errors. AORN Journal, 82(6), 1051-1054.

1704 The improvement of nursing care on postoperative hypothermia patients in postoperative recovery room W.-P. Lee 1,*, Y.-L. Lan 1, P.-Y. Wu 1, M.-Y. Lee 1 1 Chang Gung Memorial Hospital, Taoyuan, Taiwan The purpose of this study was to improve nursing care on postoperative hypothermia patients in postoperative recovery room. After implementation of revision of policy and procedure on postoperative hypothermia patient care, holding regular continuous education, regular auditing, adding reminding memo, and new design on warming sleeping robe, the nurses recognition rate on hypothermia management. The nurses recognition rate on hypothermia management increased from 84.3% to 100%; the execution rate based on policy and procedure on checking body temperature improved 67.4% to 100%. The major improvement of this study was the significant improvement on patient to recover to normal body temperature by putting on warming sleeping robe. The average time frame for patient to recover to normal body temperature reduced to 22.8 minutes from 51 minutes (improvement by 55.3%). The average time frame on staying in postoperative recovery room also reduced to 61 minutes from 89.2 minutes (improvement by 31.6%). It proved that warming sleeping robe could facilitate patient s body temperature back to normal more quickly. Another benefit from this study was the reduction on the amount of warm wrapper usage. The result of this study can increase patient s comfort as well as quality of care and reduction of cost.

1715 Opportunities for performance improvement in the management of patients with traumatic haemorrhage leading to death K. Mahendran 1,*, D. O'Reilly 1, N. Tai 1, M. Walsh 1 1 Trauma Clinical Academic Unit, Royal London Hospital, London, United Kingdom To establish the character of Opportunities for Performance Improvement (OPIs) identified by the Quality Improvement process specifically in patients dying from traumatic haemorrhage To ascertain whether the QI process has impacted on the number of deaths from traumatic haemorrhage in shocked patients An Opportunity for Performance Improvement (OPI) is a failure in the process of care. An effective quality improvement process must identify these errors and act to reduce their incidence. Our Quality Improvement process involves monthly Morbidity and Mortality meetings involving all disciplines involved in trauma care. Cases with OPIs are then referred to formal Peer review panel. Cause of death was determined by the investigators after reviewing case notes, M&M records and post mortem data. In patients for whom the primary cause of death was haemorrhage or for whom it was a significant secondary contributor, significant OPIs were extracted from M&M and Peer review notes. Data included active and latent failures, location at time of OPI and at death and departmental responsibility. There were 7511 patients admitted on the Trauma registry between 2006 and 2010. 423 patients died in this period. 112 deaths were identified as primarily due to haemorrhage with a further 15 where haemorrhage was a major contributor. 150 OPIs were identified in 84 of these 127 cases. The location of where OPIs occurred was heavily concentrated in the Emergency Department (57%). 38 OPIs related to delayed or inadequate resuscitation, particularly the giving of blood products. Changes in the nature of these failures and the standards considered acceptable by the M&M process were identified over the study period. 57% of OPIs involved problems in decision making by clinicians. Of 36 cases of missed, delayed or inappropriate surgery, only 8 involved a failure in diagnosis or the use of radiology. Actions taken in response to identified OPIs over the study period included new and altered treatment protocols, changes in staffing, new equipment, individual counselling, improved training and the introduction of novel treatments. There was a year-on-year improvement in mortality due to haemorrhage and all causes among patients presenting in shock over the study period. (Chi-square for trend, p<0.05). Deaths due to significant bleeding occur in severely injured patients after both blunt and penetrating trauma. These patients usually present to hospital with shock identifiable on baseline physiological observations, but this is not universal. Such deaths are often associated with active failures in management. These mostly arise in the ED, tend to involve poor decision making and often concern the choice between immediate surgery or angiography and further investigation. These failures are identifiable and remediable. A rigorous trauma QI process has been associated with the continual improvement in outcome for injured patients at risk of death due to bleeding.

1752 Reduction in the rate of in-ward, out-of-icu cardiopulmonary arrests by emphasizing vigilance on the emergence of early warning signs D. I. Suh 1, I. S. Son 1, M. S. Shim 1,*, J. D. Park 1 1 Seoul National University Children's Hospital, Seoul, Korea, Republic Of Detecting patients who show physiological instability leading to clinical deterioration which often ends up with cardiopulmonary arrest, and providing them with a prompt, appropriate intervention is the vital prerequisite for success in treating critically-ill patients. However, managing a specialized medical emergency team requires an extra cost of time and money. On the assumption that most in-ward respiratory and cardiopulmonary arrests may be predictable and preventable in children admitted outside intensive care unit, we made an effort to decrease the rate of cardiopulmonary arrests by means of encouraging an early detection and a prompt response from each medical personnel without introducing the specialized medical emergency team. Instead of making a separate medical emergency team, we tried to facilitate each medical personnel to do their inherent roles promptly. After having settled age-specific criteria on the early warning signs, on the assumption that they are indicative of an impending cardiopulmonary arrest, we made several rules as follows : 1. When the nurses observe any early warning sign on their regular ward rounds, they should alarm the assigned doctors promptly with a written fill-up sheet which specifies the violated criterion and a blank asking for the management plan. 2. When the doctors receive the fill-up sheet, they should immediately evaluate the patient and make their own plan to stabilize the patient. If necessary, they should contact the ICU staffs and get a second opinion. 3. If the assigned doctors are not available on the request, the nurses should immediately contact doctors who either supervise the assigned doctors or take charges of the ICU duty. 4. The ICU staffs re-evaluate all patients currently with any early warning sign during their daily rounds in the afternoon. We have introduced this early warning sign system to one general ward as a pilot program on the October, 2010 and gradually expanded to another wards, as a result, the whole wards adopted the early warning system on March, 2011. We compared the rate of in-ward, ouside-icu CPR before and after introducing the early warning sign system. There were from 13 to 66 episodes of positive pediatric early warning signs in children admitted in-ward out-of- ICU per month. Although most of warning signs were detected at department of pediatrics, all departments had at least 1 episode of the warning sign detection after the implementation of this early-warning system. The rate of in-ward, outside ICU CPR was decreased from 1.44 (before implementation) to 0.86 (after implementation) episode per month. The rate of in-ward, out-of-icu CPR can be reduced by means of enhancing vigilance on the emergence of early warning signs without the aid of a separate medical emergency team. References: Laurens NH, Dwyer TA. The effect of medical emergency teams on patient outcome: a review of the literature. Int J Nurs Pract 2010; 16: 533-44. Sarani B, Scott S. Rapid response systems: from implementation to evidence base. Jt Comm J Qual Patient Saf 2010; 36: 514-7. Brilli RJ, Gibson R, Lauria JW et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med 2007; 8:236-46.

1771 Reducing the management time of major trauma patients in emergency room through team resource management S. Lu 1,*, H.-Y. Lin 2, J.-T. Sun 3 1 Emergency medicine Department, Head Nurse, 2 Emergency medicine Department, Nurse, 3 Emergency medicine Department, MD, New Taipei city, Taiwan Deaths caused by trauma most likely happen within the 60 minutes after being injured, accounting for 45% of all mortality. The initial 60 minutes are therefore referred to as the Golden Hour. Since trauma medicine involves a high degree of complexity and uncertainty, it requires good teamwork during the treatment to prevent deaths caused by misdiagnosis and treatment delay. From January to July, 2010, the Hospital received 15,217 trauma patients; 75 patients were diagnosed as major trauma patients (Injury Severity Score, ISS 16), but only 15 of them were treated and diagnosed within 60 minutes after being received. In order to implement patient-centered holistic care, control possible damage, and reduce the management time, the Hospital implemented tools and techniques from Team Resource Management (TRM) to ensure major trauma patients received appropriate medical care within the Golden Hour, hence improving the quality of critical care.the purpose was to reduce the management time of major trauma patients in the emergency room from an average of 117 minutes down to 60 minutes. According to the trauma registration list, we retrospectively reviewed the charts of the trauma patients and found out from January to July, 2010, the Hospital received 75 major trauma patients, with average management time of 117 minutes. The reasons of such prolonged management time include the followings: (1)The emergency medical dispatcher center (EMDC) did not inform the Hospital of patients arrival in advance, leaving the emergency room unprepared.(2)the task assignment was not well-arranged in the team, resulting in the lack of team coordination.(3)trauma equipment was not placed and managed centrally.(4) The Division of Medical Imaging did not initiate emergent priority examination. The team members came up with the following solutions after considering their feasibility, urgency and importance thorough decision matrix analysis:(1)the EMDC should inform the Hospital in advance of the arrival of major trauma patients.(2)the tasks should be assigned properly according to the Leadership Module Training Techniques to improve team coordination.(3)a cabinet of trauma equipment should be prepared according to Situation Monitoring-STEP principles.(4)thedivision of Medical Imaging should initiate emergent priority examination for major trauma patients. Through continuous communication and cooperation, the medical team achieved the followings:(1)the Leadership Module Training improved the coordination and created a sense of belonging in the medical team.(2)the EMDC nurses would inform the Hospital of the arrival of major trauma patients in advance.(3)a cabinet of trauma equipment was prepared by nurses in the emergency room and ready to use in any emergent situation.(4)the Division of Medical Imaging started the priority examination for major trauma patients. After the intervention, the management time of major trauma patients in the emergency room was shortened to 46 minutes, down from 117 minutes. Our goal of treating within the Golden Hour was successfully achieved. TRM and its Leadership Module Training were implemented in the Hospital. Through continuous communication and cooperation, we built consensus and created the team rapport successfully. We hope through TRM, we continue to improve the quality of our medical care, reduce medical errors, and thus enhance patient safety.

1773 A hospital quality-improvement collaborative to reduce central venous catheter-related infections care bundle in the general medicine wards L. C. Chao 1,*, J. W. Liu 2 1 Committee of Hospital Infection Control, 2 Division of Infectious Diseases, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan Central venous catheters (CVCs) are being increasingly used in the inpatient and outpatient settings to provide long-term venous access. CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream (bacteremia) and hemodynamic changes and organ dysfunction (severe sepsis) may ensue possibly leading to death. Approximately 90 percent of the catheter-related bloodstream infections (CRBSIs) occur with CVCs. To prevent these infections, bundled interventions are increasingly recommended. Quality-improvement collaboratives (QICs) are frequently used to improve health care quality. Our general medicine wards were previously involved in a successful QIC to reduce the incidence of CVC related infections. We retrospectively reviewed the incidence of CVC related infectionfrom January to December, 2011. The collaborative approach included hospital-wide implementation of central-line insertion and maintenance bundles that proper hand hygiene, personal protective equipment, maximal barrier precautions and 2% chlorhexidine skin preparation during line insertion, daily discussion of catheter necessity, and meticulous site and tubing care. The 10 general medicine wards involved were the infections disease ward, the pulmonary medicine ward, the hematology and oncology ward, the gastroenterology ward, the cardiology ward, the nephrology ward, and the endocrinology and metabolism ward. Each individual ward was responsible for collecting unit-specific data and performing event-cause analysis within 48 hours of identifying a CRBSI. These results were shared with the other hospital wards. Compliance with the insertion and maintenance bundles was monitored and reported to each unit monthly. The bundles were deployed with qualityimprovement teaching and methods to support their adoption by teams at the participating wards. The rate of CVC related infectionsduring the intervention period (1 July 2011 to 31 December 2011) was compared with the average of the 6 months prior to implementation. The general medicine wards- CVC related infections rate decreased from a baseline of 0.3 to 0.1 (P <.001) after implementation of the QIC. Patients in the CVCcare bundleintervention arm were significantly less likely to acquire a primary BSI (14.6%vs 5.3%;P<0.01 [95% confidence interval, 2.7-6.2 ). For the combined outcome of CVC related infectionsand culture-positivesepsis, there were less occurrences in the CVCcare bundle arm, the difference was statistically significant (59%vs 23%; P <.001).There was no statistically significant difference in the incidence of infection among the insertion sites. Our hospital-cvccare bundle QIC resulted in a significant reduction in the incidence of CVC related infections at our general medicine wards. A collaborative model based on improvement science methodology is both feasible and effective in reducing the incidence of CRBSI. References: 1.Denis F,Cliivier M.Prevention of central venous catheter-related infection in the intensive care unit:crit Care Med.2010;14:212. 2.Ruesh S, Walder B,Tramer MR. Complication of central venous cathters:internal jugular versus subclavian access-a systemic review :Crit Care Med.2002;30:454-460. 3.Raad II,Hohn DC,Gilbreath BJ..Prevention of central venous catheter-related infection by using maximal sterile precaution during insertion :Crit Care Med.2010:R162. 1774

Development of hemostasis guidelines and its monitoring system to evaluate compliance with the protocol N. F. Husain 1, T. U. Haq 1,*, W. A. Mirza 1, R. Sayani 1 1 Radiology, The Aga Khan University Hospital, Karachi, Pakistan As an approach to ensure patient safety develop, implement and monitor compliance of the Hemostasis guideline in a radiological setup. This Quality Improvement Project was undertaken by the Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan in November 2010. It came into existence after a case of liver biopsy was declared as a sentinel event. When conducting the root cause analysis it was derived that the patient has several co-morbids that went unidentified; he wasn t labeled as a high risk patient and his labs were also noted to be deranged. On sight of such components missing in the patient care plan a focus group was formed to conduct intense analysis, brainstorm and literature review to come up with strategies so that such instances are not repeated in future. The suggestions of the Quality Improvement Team were that a Hemostasis Guidelines need to be developed, adhered to and then a compliance audit to be conducted. Based on the literature review of American College of Radiology and Royal college of Radiology the guidelines titled Ensuring Hemostasis following percutaneous interventions were developed and implemented in Q2, 2011. The objective of the protocol being: to ensure normal coagulation profile before invasive procedure done under imaging guidance. Following this a monitoring tool was developed in Q3, 2011 to capture data relevant to the requirement of patient care in Radiological intervention procedures; all patients who had deranged coagulation profile should be corrected before imaging guided invasive procedures. The fields deemed crucial for monitoring were PT, INR, APTT, Platelets, Creatinine (vascular intervention procedures only), Heparin status, Oral Antiplatelets status, Warfarin status, review of past scans and reports, time out carried out and consent taken. The acceptable ranges for labs were defined on the basis of less invasive and more invasive procedures. Informed consent was made mandatory for all intervention procedures. High risk consent was taken if the patient had several co-morbids and was also kept under observation in the Radiology recovery room. Since the implementation of the guidelines no sensitive incident or sentinel event has occurred. Implementation of this guideline ensured effectiveness in preventing unforeseen sentinel events and / or incidents related to interventional procedures. References: Thomas DA, Brian G, Timothy SL, J. WC, Brenda M. Ingalls H, and Mark DS Pancreas Transplants: Experience with 232 Percutaneous US-guided Biopsy Procedures in 88 Patients. Radiology 2004; 231: 845-849. Patrick CM, Clement JG, Sanjoy K, Debra AG et al Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in PercutaneousImage-guided Interventions J Vasc Interv Radiol 2009; 20: 240 249

1776 Building quality and safety checks in implementing new clinical services in National University Hospital (NUH), Singapore D. Santos 1, S. C. Quek 1, S. Mujumdar 1,* 1 Medical Affairs, National University Health System, Singapore, Singapore There was an identified need for management to have an oversight of all new clinial services in NUH. The existing evaluation process that included assessment of financial viability, potential returns and infrastructure support lacked an indepth analysis of the potential quality and safety impact to the patient, staff and institution. NUH took a proactive risk management approach by constituting an end-to-end process of implementing new services and by incorporating vital quality and safety checks in the process. 1. Pre-Implementation Assessment- The significant additions to the existing process are: (a) Procedure Workflowsteps on the approval process with reasonable timelines of completion for the service owner and the approving authority. (b) Clinical Requirements checklist: target population, evidence-based justifications, clinical guidelines/algorithms, equipment-related, staff to patient ratio, staff competency, clinical targets/outcome measures and environmental factors affecting patient safety. (c) Risk Assessment and Hazards Identification- a 2-tiered process: 1 st -conducted by department s clinician Patient Safety Officer and the service owner. 2 nd -conducted by the Safety Officer and Quality Assurance (QA) staff including inspection of the proposed location. (d) New Service Reviewing Team- QA staff, Patient Safety Officer and medical, operations and nursing representatives were tasked to evaluate all documents/previous assessments made prior to senior management s approval. (e) Operational Requirementschecklist: workflow/procedures, billing, IT and other infrastructure support, referral and appointments, coordination with internal/external partners and communication plan for effective information dissemination within and outside the institution. (f) Post-Implementation Review 6 months post-implementation check to optimise the delivery of the new service. 2. New Services Report Quarterly report from departments for new services implemented in the last quarter to countercheck if any service did not go through the review process; planned services in the next quarter; any adverse event arising from any new service. 3. A framework for new services (conceptualisation to post-implementation) was established to ensure its smooth and safe integration into the institution with clear delineation of roles and realistic timelines. A multi-disciplinary review team offered expert and unbiased evaluations. 4. Limitations/deficiencies found in new services applications were identified and tracked until resolved. Adverse event arising from an implemented service and services that did not go through the approval chain were tracked. Eight new services were reviewed since introducing the framework in 2010. We unearthed deficiencies related to staff competency (3), monitoring equipment (2), environmental safety (3) and infrastructure support (2). These issues were resolved before implementation. This can be translated to preventing risks that otherwise would have adversely impacted our patients. To date, neither an adverse event related to a new service nor a service that slipped through the approval process was noted. Senior management faces a challenging prospect in balancing the expectations of the stakeholders of the new service with the organizational needs. Moreover, quality and safety checks maybe overlooked. An end-to-end evaluation/approval/implementation process helped to align these goals. Engaging stakeholders in the process fosters ownership and deeper understanding of the new service.

1784 Improving endotracheal tube care through medical team communication and cooperation H.-C. Liu 1,*, R.-A. Shen 1, H.-J. Jen 1, C.-W. Chen 1 1 Nursing Department, Far Fastern Memorial Hospital, New Taipei City, Taiwan Intubation is one of the most common life-saving invasive procedures performed in emergency and intensive care units (Wu et al., 2010). For the patient however, the inability to speak and restricted movement becomes a major source o stress. When unplanned extubation occurs, reintubation is usually carried out as soon as possible. The patient may not only suffer secondary injury but also death or extended hospital stay (Chen, Hong & Wang, 2001). Medical team communication and cooperation was therefore employed to establish an evaluation process for planned extubation to improve the safety of endotracheal care, wean patients off the ventilator as soon as possible and shorten the length of hospital stay. The process would provide a reference for future care of ventilator patients. Retrospective data analysis was performed with the "Patient Safety Reporting Form" used to compile statistics on intubated patients in the surgical intensive care unit. The average self-extubation rate was found to be 0.36% while nonreintubation rate was 61.1%, 14.7% higher than other peers. Analysis indicated that in 83.3% of the cases, self-extubation occurred after the endotracheal tube was in place for 1 to 3 days and not reintubated. Analysis of the patients, medical team and process using the Causes & Effects Chart showed that the medical team lacked a suitable planned extubation evaluation plan and standard operating procedure. Medical team communication and cooperation was therefore used in this project to establish the "Endotracheal Tube Weaning Evaluation Process", the "Division of Responsibility for Physicians, Nursing Personnel and Respiratory Therapist", "Endotracheal Tube Weaning Evaluation Form" and "SBAR Structural Communication Model Endotracheal Tube Weaning Evaluation" definitions. Team communication and cooperation was practiced on a continuous basis and the PDCA cycle used to monitor the rate of unplanned extubation. After the project was implemented, unplanned extubation dropped from 0.36% in 2009 to 0.20% in 2010 and 0.16% in 2011. Statistics for successful weaning 1 ~ 3 days after intubation using the "Endotracheal Tube Weaning Evaluation Process" were kept. Between October and December 2010, 50 cases were successfully weaned with 43 cases (86.0%) successfully weaned 1 ~ 3 days of intubation. Between January and December 2011, 312 cases were successfully weaned with 170 cases (55.0%) successfully weaned 1 ~ 3 days after intubation. ICU bed turnover rate monthly 3.9 people in 2010, upgraded to 2011 4.3 people, Average days of hospitalization was shortened to 7.6 days in 2011 from 8.9 days in 2010. The results showed that evaluation for endotracheal tube weaning can be carried out even earlier to reduce the discomfort from intubation on the patient and ensure the safety of endotracheal tube care. Medical team communication and cooperation has become an international issue for promoting patient care. The implementation of the project showed that a well-defined standard operating procedure, a clear division of responsibility and comprehensive structured handoff for team communication and cooperation can help overcome difficulties and obstacles to team operation. Apart from realizing the goal of early extubation for intubated patients, it also improves the quality of clinical care and helps to promote a safe medical environment at the same time.

1785 Development and computerization of a «controlled language» to write medical standard operating procedures: a new approach to improve healthcare quality and patients safety D. A. Vuitton 1,*, I. THOMAS 2 on behalf of SENSUNIQUE, O. Blagosklonov 1 on behalf of SENSUNIQUE, E. Seillès 1 1 Research Federation 133, 2 Automated Linguistics Center L Tesnière, University of Franche-Comté, Besançon, France Quality procedures in health care have generated lots of written texts (especially standard operating procedures, SOP) to improve communication within a care unit, prevent accidents, and be used whenever legal issues are raised. However, quality of the texts is often questionable; health professionals feel SOP writing as a constraint; natural languages are full of ambiguities thus prone to misunderstanding; consensus on texts is difficult to obtain; and no applicable norms are available in the health field. A controlled language (CL), a special subclass of natural language, has restricted lexicon and grammar to make it more comprehensible and/or facilitate its translation; until now, such CLs have only been developed in big companies involved in high risk activities. Our aim was to develop and computerize a CL to improve SOP readability and understanding in the health domain. Through a multidisciplinary approach (linguists, health professionals and quality management specialists), we developed a linguistics-based methodology which allows us to create CLs adapted to the domain of activity, type of texts, level of emergency, target readers as well as to their use through computer-aided devices. Our research was based on the analysis of a wide corpus of texts available in hospitals, medical biology labs and public health communication. We applied our methodology to 3 domains in French: non-surgical interventions, medical biology, and hospital radionuclide waste management. We also developed original computer software to help health professionals and quality managers to use the CL for SOP writing. Analysis of the corpus revealed writing habits particular to medical writing which may severely impair proper understanding and generate unsuspected risks: use of passive voice for instructions, chronological inconsistencies, use of ambiguous words, or the bad management of exceptions to the rule may be cited as examples. Our software design combines non-linguist writer s needs (easy writing, adaptation to the field of interest) and CL s constraints (writing rules, allowed and forbidden words and structures), while allowing collaborative and standardized writing. It is composed of a back office platform for linguist engineers and a user-friendly interface since health professionals are not familiar with CL and cannot learn and memorize all CL rules. The back office platform is based on natural language processing techniques and permits the adaptation of a general CL by developing controlled lexicon and grammar related to each particular domain, professional need, type of texts and of readers, and various languages. The software automates a large part of linguistics rules and guides the user throughout the process of writing. Studies and tests performed with professional users, doctors, health personnel, lab technicians and quality management specialists confirm that such a tool is quite adapted and flexible, saves time and manpower, and might actually improve risk management in many fields relating to health care. In addition, controlling language also raises questions about professionals specific roles and health care organization, which leads far beyond the strict domain of linguistics and contributes to patient s safety.

1789 Reducing image retake for all patients undergoing general radiographic examinations, resulting in lesser radiation exposure in a tertiary care teaching hospital in the developing world A. H. Tasneem 1,*, M. Naqvi 1, W. Akhtar 1, A. Rajani 1 1 Radiology, The Aga Khan University Hospital, Karachi, Pakistan The key objective of this quality initiative is to ensure high quality radiology examination (general radiology procedures) with maximum patient safety. This is achieved by reducing the repetition of images in the CR (Computed Radiography) system resulting in reduction of radiation dose to the patients, improved throughput and reduced load on the equipment. This Quality Improvement Project was undertaken at the department of Radiology at the Aga Khan University Hospital in Karachi, Pakistan with a focus on establishing patient safety systems in our Radiology setup. Prior to the installation of PACS (Picture Archiving and Communication System), we used to have a quality indicator namely Film Reject Analysis, which was an indirect measure of unnecessary radiation dose exposure. This indicator became redundant after implementation of PACS; however, due to the newly installed CR (Computed Radiography) system, a more direct measure of unnecessary radiation exposure became available, which is Image Retake. The literature search also showed that this indicator became popular internationally with the installation of CR systems. The total numbers of the exposures per study, are recorded by the QC (Quality Control) Supervisor on CR system and the radiographer registers the repeat exposure along with the appropriate reasons for example Positioning error, Exposure error, Artifacts, Wrong Patients ID/Marker etc. Based on the specific information, the data was collected in 2010, which showed a very high retake rate of 8%. Our analysis revealed a number of factors contributing towards this very high percentage, which included improper positioning, improper marker placement, under or over exposure factors etc. After identification of the reasons, remedial journey was planned which included, didactic and practical teaching sessions for staff performing general radiography as well as efforts were made to associate junior radiographers with experienced radiographers in order to gain direct and under observation trainings. Radiography workshops on specific topics also contributed towards enhancement of understanding. In 2011, data was again gathered from January to December. The measures taken bore fruit. We noted a considerable reduction in retake rate which dropped down from 8% in 2010 to 4.98% by the end of 2011. While we all cherish this huge accomplishment, we also realize this is just the beginning of a long journey and we hope this will further reduce in the years to come. There are two important lessons learnt from this quality initiative. One is Quality is a journey and not the destination and all achievements are like milestones in this journey. The second lesson being the fact that with changing technology, new tools and methods should be explored to achieve objectives in a better way, which in our case was the movement from Film Reject Analysis indicator to Image Retake indicator; the former is an indirect measure of unnecessary radiation exposure, whereas, the latter is a direct measure of unnecessary radiation exposure.

1814 Rationalizing the prescription of immuno-hematological examinations in thyroid surgery L. Augey 1,*, J.-C. Lifante 2, A. Mialon 3, V. Piriou 4 And B Baffeleuf, L Maillard, M Roux, H Favre, Jl Peix 1 Hemovigilance, Hospices Civils de Lyon, PIERRE-BENITE, 2 chirurgie viscérale, Hospices Civils de Lyon, PIERRE- BENITE, 3 biologie, Hospices Civils de Lyon, PIERRE-BENITE, 4 anesthésie-réanimation, Hospices Civils de Lyon, PIERRE-BENITE, France To validate a methodology allowing the reduction of the number of blood grouping and researches of irregular antibodies before surgery, by adapting their prescription at the risk of transfusion. The thyroid surgery has been chosen because of an important volume of acts [1] (about 800 / year), a low transfusion risk (0.3%) with favoring factors identified [2] and a high potential for reducing prescription of immuno-hematological examinations. The risk of transfusion has been previously assessed by cartography [3] from 2006 to June 2011 by crossing databases concerning the surgery type and the rate of transfusion. The data concerning immuno-hematological examinations are collected manually. Recommendations were released starting in July 2010 and followed from July 2010 to December 2011. Two indicators were chosen : the relevance of the recommendations and their monitoring. The Fisher test has been used to calculate p. The percentage of transfused patients remained unchanged over time (0.3%) without a need for transfusion in a life threatening emergency. The execution of immuno-hematological examinations decreased from 52.8% to 13% (p < 0.05). The rate of relevance of the recommendations is 92% and the rate of monitoring of the recommendations is 89%. The transfusion risk in case of favoring factors is 2.2% and is 0.09% without. This approach resulted of 17 509 /year. Conclusiona: The rationalization of the prescription of immuno-hematological examinations by the transfusion risk cartography is innovative and effective. It involves a change in practice that may create concerns regarding the quality of patients care, therefore the local aspect is very important to convince and obtain the support of professionals [4]. It will be generalized to other types of surgeries in accordance with the recommendations of the French society of anesthesia reanimation ( Société Française d Anesthésie Réanimation ) on the preoperative assessment [5]. References: [1] Pieracci FM, Fahey TJ. Effect of hospital volume of thyroidectomies on outcomes following substernal thyroidectomy. World J Surg 2008;32:740-6 [2] Pieracci FM, Fahey TJ. Substernal thyroidectomy is associated with increased morbidity and mortality as compared with conventional cervical thyroidectomy. J Am Coll Surg. 2007; 205(1 ):1-7 [3] Puel C, Ducharne T, Mialon A, Augey L, Repellin L, Corond P, Magaud JP, Piriou V. Surgical risk of transfusion in a French Universitary Hospital examens immuno-hématologiques. Ann Fr Anesth Reanim 2012;31:132-40 [4] Bernard R, Benhamou D, Beloeil H. Preoperative testing : impact of implementation of local recommendations in a testing hospital. Ann Fr Anesth Reanim 2010;29:868-73 [5] Indication des examens préopératoires ANAES 1992 et 1998, ANAES / SFAR 2007

1820 How to decrease the risk of Clostridium Difficile in a ward environment and help prevent the emergence of any new cases a Ninewells success story S. Botros 1,*, D. Nathwani 2 1 Pharmacy, 2 Infectious Diseases, Ninewells Hospital - NHS Tayside, Dundee, United Kingdom Reduce the risk of Clostridium difficile in a surgical ward environment by promoting prudent antibiotic prescribing using a 3 day antibiotic bundle that improves compliance with local antibiotic policies and ensures the shortest and most optimum duration of intravenous antibiotics Design, test and implement the 3 day antibiotic bundle using the IHI improvement methodologies (including the Plan-Do- Study-Act cycle) Constantly audit antibiotic prescriptions on the ward for compliance with all aspects of the bundle and regularly share the updated results with all the relevant stakeholders in the form of Run-Charts demonstrating compliance with the bundle as a process Regularly review the compliance with the bundle and adjust practice accordingly with an aim to achieve good reliable compliance (80% average) with the bundle as a process Constantly monitor the number of new cases of C.Diff identified on the ward since the successful implementation of the bundle and regularly share the updated results with all the relevant stakeholders in the form of Run-Charts demonstrating number of days since last new C.Diff case identified on the ward During the course of this 9 months quality improvement project, we were able to successfully design, test and implement a 3 day antibiotic bundle using the IHI improvement methodologies. Ensuring that the 3 day antibiotic bundle was truly multidisciplinary in nature, where every member of the multidisciplinary team (Doctors, Nurses and Pharmacists) had a clear and specific role to play, we were able to achieve reliable 80% average compliance with the bundle as a process. This good and reliable compliance with the bundle as a process was translated as a significant reduction in the risk of C.diff on this surgical ward where we were able to achieve a remarkable 300 consecutive days with no new cases of C.Diff since the successful implementation of the 3 day antibiotic bundle Using the IHI methodologies for improvement, we were able to successfully design, test and implement a multidisciplinary 3 day antibiotic bundle that allowed us to achieve reliable good compliance with our local antibiotic policies that promote prudent antibiotic prescribing, which has helped us achieve our ultimate goal of reducing the risk of Hospital Acquired Infections and eliminate Clostridium difficile associated disease from our clinical environment

1878 Reducing healthcare-associated infections by implementing enforcement of routine environmental cleaning measures in intensive care units Y. W. Chang 1,*, J. W. Liu 2 1 Committee of Hospital Infection Control, 2 Division of Infectious Diseases, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung City, Taiwan Hospital cleaning services play a key part in minimizing the risk of healthcare-associated infections (HAIs), which have serious consequences for patients and lead to significant costs. With the ever increasing proliferation of superbugs, despite isolation precautions and enhanced hand hygiene product use, the transmission of healthcare-associated pathogens remains a major problem. We hypothesized that the environment cleaning policy of a hospital-wide quality improvement collaborative (QIC) would reduce the incidence of HAIs throughout our intensive care units. We performed a pre- and post intervention study in the 15 intensive care units at a 2754-bed academic medical center during the enhanced cleaning intervention (from March, 2008, through February, 2009) vs. baseline (from March, 2007, through February, 2008) periods. The intervention consisted of (1) different color coded cleaning instruments were used for cleaning different areas of the ward, depending on their contamination level,(2) a standard operating procedure (SOP) was established for guiding orderly environment cleaning practices,(3) an education program was arranged to increase the ward cleaners awareness of the SOPs and ensure its strict enforcement. This SOP was then applied to the cleaning of all ICUs in the hospital. An evidence-based intervention was used to reduce the incidence of HAIs, according to the guidelines of the National Nosocomial Infections Surveillance System. Patients were monitored for Multidrugresistant Acinetobacter baumannii (MDRAB) infection throughout the year-long study. Patient and environmental A. baumannii isolates were characterized using molecular methods in order to investigate temporal and colonial relationships. The environments in these ICUs were disinfected on a daily basis with household bleach (1:10 dilution of a 5% solution of sodium hypochlorite). MDRAB healthcare-associated infection rate was significantly reduced both in the ICU (0.4% vs. 0.9%, P < 0.001) and in the hospital as a whole (0.09% vs. 0.18%, P < 0.001). A. baumannii contaminated environmental sources included surfaces of bed rails, ventilator screen, sputum-suctioning device, shelves where urine containers were placed, and the sinks. Genotyping identified indistinguishable strains from both hand-touch sites and patients. Enhanced intensive care unit cleaning using the intervention methods may reduce MDRAB transmission. Molecular epidemiological methods supported the possibility that patients acquired A. baumannii from environmental sources. These findings suggest that additional research is warranted to further clarify the environmental, clinical and economic impact of enhanced hygienic cleaning as a component in the control of HAIs. References: 1. Dancer SJ. Hospital cleaning in the 21st century. Eur J Clin Microbiol Infect Dis. 2011 Dec; 30(12):1473-81. 2. Wilson AP, Smyth D, Moore G, et al: The impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: a randomized crossover study in critical care units in two hospitals. Crit Care Med. 2011 Apr; 39(4):651-8. 3. Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrug-resistant organisms from prior room occupants.

1887 Drug utilization of benzodiazepines in outpatients in a medical center of Taiwan C. F. Chen 1,*, H. W. Ting 2, 3, S. C. Wang 1, S. Y. Hung 4, 5 1 Department of Pharmacy, Mackay Memorial Hospital, Taipei, Taiwan, Taipei City, 2 Department of Neurosurgery, Taipei Hospital, Department of Health, New Taipei City, 3 Department of Information Management, Yuan Ze University, Tao- Yuan, 4 Department of Business Administration, National Taipei University, Taipei City, 5 Department of Strategy Planning, Taipei Hospital, Department of Health, New Taipei City, Taiwan To evaluate the medication use of benzodiazepines in outpatients in a medical center of Taiwan. The results can be a good indicator for medication usage. This study collected the demographic data and prescribed daily doses (PDD)/defined daily dose (DDD) ratio of adult patients who used benzodiazepines in a medical center from Mar. to Oct., 2011. According to anatomical-therapeuticalchemical (ATC) class, benzodiazepines usages were evaluated with hypnotics (N05CD, N05CF), anxiolytics (N05BA) and antiepileptics (N03AE). The overdoses were defined as PDD/DDD ratio > 1.5. This research collected 267949 cases (female/male=65.77%/34.23%). The most popular patients with benzodiazepines are 51 to 60 years old. There are zolpidem (17.6%), alprazolam (15.98%), fludiazepam (9.89%) and lorazepam (8.51%) in order to the amount of usages. Although department of psychiatry being higher PDD than other departments in different drugs, the mean PDD/DDD ratio of anxiolytics and antiepileptics were within normal limit (PDD/DDD ratio 0.08-1.09). Regarding to other hypnotics (PDD/DDD ratio 0.62-1.34), the mean PDD/DDD ratio of flunitrazepam were over 1.5. If considering the departments, the department of psychiatry (3.40) was higher than non-psychiatry departments (2.23). The dosages of benzodiazepines are lower than WHO suggestion in a medical center in Taiwan. But the dosages of flunitrazepam are higher than WHO suggestions. It may be attributed to the dosage form (2mg) of flunitrazepam in the medical center. The Pharmacy and Therapeutics Committee should construct the guideline of flunitrazepam and monitoring systems in hospitalsto improve quality of drug use. The standard forms and dosages also need further readjusted. References: Su TP, Cheng TJ, Hwang SJ, et al:utilization of psychotropic drugs in Taiwan: an overview of outpatient sector in 2000. Chinese Med J (Taipei). 2002;65:378-391. Petit N, Delporte JP, Ansseau M, Albert A, Jeusette F. Drug utilization review of oral forms of benzodiazepines in a Belgian 635-bed teaching hospital. Pharm World Sci. 1994; 16(4):181-6. Guideline for ATC classification and DDD assignment. WHO Collaborating Centre for Drug Statistics Methodology, Oslo, Norway. 2011.

1895 Sorting out medical error leading to patient death: Japanese hospital and clinic administrators would recommend autopsy more than regular physicians S. Maeda 1,*, E. Kamishiraki 2, J. Starkey 3 1 Graduate school of Health Management, Keio University, Fujisawa, 2 Department of Social Welfare, University of Kochi, kochi, Japan, 3 Department of Internal Medicine, University of california,san Diego, San Diego, United States Autopsy is indispensable in determining if medical error may have contributed to patient death, especially regarding ensuing prevention activities. The purpose of this study is to compare the attitudes of A) hospital and clinic administrators and B) physicians regarding autopsy when faced with a patient death and possible medical error. Our study was an observational, cross-sectional study. We used a structured, anonymous, self-administered questionnaire presenting scenarios of unexpected patient death with definite or possible medical error and asked if respondents believed autopsy was necessary and if they would recommend autopsy. Scenario 1 presented a case where medical care was definitely related to patient death but with uncertainty about medical error. Scenario 2 presented a case where medical error was definitely present but with uncertainty about the causal relationship to patient death. We sent questionnaires to 1654 administrators (2% of total 82612) and 1236 physicians (2% of total 61729) belonging to the Japanese Medical Association (JMA) on 10 February 2011. Of the eligible participants, 619 (37.5%) and 403 (32.9%) administrators and physicians responded, respectively. In scenario 1 where medical error was uncertain, of the 81.4% of administrators and 80.6% of physicians who thought an autopsy was necessary, 87.2 vs. 63.8% indicated they would actually recommend an autopsy. On the other hand, 5.4% and 11.3% of administrators and physicians, respectively, would recommend autopsy even if they thought it unnecessary. In scenario 2 where medical error was present but of uncertain significance, of the 80.5% of administrators and 80.7% of physicians who thought an autopsy was necessary, 92.4% vs. 73.1% indicated they would actually recommend an autopsy. On the other hand, 12.2% and 8.5% of administrators and physicians, respectively, would recommend autopsy even if they thought it unnecessary. Table 1: Physician attitudes about autopsy in case of patient death, administrators vs. physicians % of Administrators (n) % of Physicians (n) Scenario 1: Possible medical error Scenario 2: Definite error, but of unclear relation Belief of Autopsy Necessity Would Recommend Would NOT Recommend Woul Recom end Necessary 87.2 (407) 1 2. 9 Unnecessary 5.4 (6) 9 4. 6 Necessary 92.4 (426) 7. 6 Unnecessary 12.2 (13) 8 7. 9 For statistical analysis, the chi-square test was used; blank responses were excluded. P<0.05 Autopsy is important in determining cause of death when medical error may be present to better elucidate the relationship of that error to the patient s death. It is unacceptable that up to 20% of administrators and physicians may not think autopsy is necessary when a patient dies unexpectedly even when possible contribution of medical error is added to the scenario.

1901 Improvement of patient identification accuracy in the outpatient phlebotomy department by an advanced information system H.-C. Ning 1,* 1 Department of Laboratory Medicine, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan Accurate patient identification and specimen labeling during phlebotomy procedures are initial vital steps in the prevention of medical errors and thereby improvement of patient safety. For Chang Gung Memorial Hospital, Linkou, a large tertiary referral hospital in Taiwan with a daily outpatient phlebotomy service of more than 2000 cases, accurate patient identification is apparently much more critical and challenging. Patient identification through the wristband barcode system has long been used in the inpatient departments as a major part of the positive patient identification system, but the system is unfeasible for outpatient use. An automatic phlebotomy tube barcode labeling system has been implemented in our outpatient phlebotomy department since October 2009. An advanced information system comparing patient demographic information that incorporated on their respective healthcare insurance cards as well as those built-in in the automatic phlebotomy tube barcode labeling system was also established. The impact of the advanced informationsystem in the improvement of patient identificationaccuracy was evaluated in the present study. Before the implementation of the system, a total of 34 mislabeling events had been recorded since January 2008. In contrast, none were found in the subsequent period up to December 2011. The incidence of inappropriate specimen containers also fell from 0.03 before the implementation to 0.01 afterward (P <0.0001). Furthermore, the new system also improved the patient turnaround time, leading to the reduction of average waiting time from 4.5 to 2.5 min per patient. The advanced information system is apparently a very efficient patient identification system and has now been introduced and established in several other hospitals in Taiwan.

1907 An exploratory study of the relationship between healthcare workers knowledge, attitude and behavior about patient safety in a Taipei hospital C.-Y. Ho 1,*, C.-Y. Huang 1, J.-S. Lee 1, K.-P. Chung 2 1 Family Medicine, Taipei City Hospital, Yangming branch, Taipei, Taiwan, 2 Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan The healthcare systems of many countries try hard to improve patient safety. However, the existed studies about the knowledge, attitude, and behavior about patient safety are not comprehensive. The purposes of this study are to investigate how the personal and occupational characteristics of different healthcare workers can influence their knowledge, attitude, and behavior about patient safety; and to explore the relationship between their attitude, knowledge and behavior toward the national patient safety goal. The author wants to find the key factors to improve the most critical issues to improve the patient safety and the quality of healthcare systems. This cross-sectional study generally and anonymously surveyed 3904 healthcare workers of a Taipei Hospital from March 16th to April 15th, 2010. The questionnaires about patient safety knowledge and behavior were designed by the author. The questionnaires about patient safety attitude were derived from the Chinese version of Safety Attitudes Questionnaire, authorized by Dr. Bryan Sexton to the Taiwan Joint Commission on Hospital Accreditation and Quality Improvement. The author used descriptive analysis, independent-sample T test, one-way ANOVA, Spearman rank correlation, and multiple regression analysis to examine the collected data. The overall response rate was 56.99%(2,225 out of 3904 questionnaires). Males, high-educated healthcare workers, administration managers, and doctors have more patient safety knowledge. Low-educated, older or senior healthcare workers, nursing assistants, and administration managers have more positive patient safety attitude. Females, senior healthcare workers, administration managers, and the first-line people have better patient safety behavior. The doctors and nurses behave better than the technicians. The author finds that there are positive correlations between patient safety knowledge, attitude, and behaviors. Multiple regression analysis revealed incident reporting of the knowledge domain is important and influential factor of every attitude domain. Reducing infection, incident reporting, and team communication of the knowledge domain are the important and influential factors of every behavior domain. working conditions of the attitude domain is the important factors of every behavior domain. There are positive correlations between patient safety knowledge and attitude, patient safety knowledge and behavior, patient safety attitude and behavior, and patient safety knowledge, attitude and behavior. The incident reporting is the critical factors to patient safety. The healthcare policy-makers should give priority to encourage incident reporting and improve the effectiveness of communication among caregivers to further patient safety.

1913 The Western Australian audit of surgical mortality: a 10 year evaluation D. G. Azzam 1,*, A. C. L. Neo 1, F. E. Itotoh 1, R. J. Aitken 1 1 Western Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Perth, Australia The Western Australian Audit of Surgical Mortality (WAASM) is an independent, systematic, external peer-reviewed audit. An evaluation of the first 10 years 2002-2011 is reported. Hospitals report deaths occurring whilst under surgical care to WAASM, who send a standardised 23 question surgical case form (SCF) to the treating surgeon. Questions in the SCF include the patient s course to death, fluid balance, deep vein thrombosis (DVT) prophylaxis, and adverse events. The completed SCF is scrutinised by a first-line assessor, from which approximately 10% undergo a further detailed case review by a second-line assessor. The reviews are returned to the surgeon. Additional regular, detailed feedback is provided to all surgeons in the form of newsletters, a compilation of de-identified second line reviews, Annual Reports and multi-disciplinary symposia that address specific topics resulting from trends emanating from the annual reports. To evaluate the impact of WAASM on surgical practice, a survey was also sent out to participating surgeons. Data was analysed using Statistical Package for Social Science (SPSS). The number of deaths each year fell progressively from 692 to 586 (15%). When adjusted for population growth, the number of deaths fell from 35 to 27 per 100,000 population (23%). Specific changes in practice included an increase in DVT prophylaxis (12%), fewer fluid balance issues (11% to 7% of cases by 2011), increased use of High Dependency Beds and the specialisation of some complex, high risk operations. Some 138 (73%) surgeons participating in the audit acknowledged that WAASM had changed their practice. WAASM has demonstrated that an external peer review audit has changed surgical practice and reduced the number of deaths under the care of a surgeon. A mortality audit based on WAASM has now been established across the whole of Australia. A similar process for key post-operative events, such as return to theatre, should be considered.

1962 Comparison between adverse events measured with global trigger tool in Norwegian healthcare and the target areas for the Norwegian Patient Safety Campaign E. T. Deilkås 1,*, M. Haugen 2, E. Orskaug 2 1 Norwegian Knowledge Centre for Healthcare, Norwegian Unit for Patient Safety, 2 Norwegian Computing Centre, Oslo, Norway In order to measure adverse events (AE) in the national patient safety campaign, the Norwegian Health minister mandated that all healthcare trusts in the country should review randomly selected medical records according to the Global Trigger Tool procedure. To create a baseline it was done from March to December 2010. The campaign aims are to reduce harmful events to patients, establish competence and routines for patient safety and improve patient safety culture. Target areas have been chosen for clinical intervention. The aim of this paper is to compare the AE s identified with Global Trigger Tool, to the target areas chosen for the Norwegian patient safety campaign. Global Trigger Tool (GTT) was the chosen standard procedure for medical record review. Hospital trusts were required to establish at least one GTT team, consisting of two clinical nurses and one physician. Teams were trained according to the instructions in the manual and were required to review 10 randomly selected medical records twice a month. Teams categorized the identified AEs according to severity (E to I) and type (postoperative infection, bleeding, DVT, etc.). In addition to reporting AEs, the teams reported total number of admissions that the investigated had been randomly selected from. This was used for weighting team results. AEs disregarding types and severity were symmetrically distributed amongst the 39 teams. Estimates could therefore be made with t-confidence intervals. AEs according to type were not symmetrically distributed amongst the teams. These estimates had to be made with non parametric confidence intervals, using bootstrap. National results were compared to the target areas of the patient safety campaign: Safe surgery, with focus on postoperative sore infections, Medication reconciliation, Drug review, Stroke treatment, central line infection, Fall, Pressure ulcers, urinary tract infections. 18 of 19 trusts, and five private hospitals, submitted results. 39 GTT teams reviewed 7819 medical records. 16 % of the admissions included one or more AE (18 to 14, 95% CI). 7 % included an AE that led to prolonged hospital stay (8,6 to 5,7, 95% CI). 1% included an AE which led to permanent harm (1,4 to 0,8, 95% CI). 33 admissions (0, 66 % (0,8 to 0,5, 95% CI)) included an AE that led to death. Amongst admissions with one or more AEs, 14 % included urinary tract infection as an AE(17,7 to10,5, 95% CI), 12 % adverse drug event (17 to 8,95 % CI), 10% postoperative sore infections(13 to 8,6, 95% CI), 10% other surgical complications (13 to 7,5, 95% CI), 7% lower respiratory tract infections (4,8 to 10, 95 % CI), 5,7 % pressure ulcer (9 to 3, 95% CI), 3% fall injury (4,6 to 2, 95% CI), 3 % central line infections (4,5 to 1,7, 95% CI), 3% postoperative respiratory complications (4 to 2,4 95 % CI), 2% fractures (3 to 1,4, 95% CI). The baseline results reveal that a considerable number of AEs happen in Norwegian hospitals. The estimates show coherence between some target areas in the national patient safety campaign, and the most frequent types of AEs at the national level; urinary tract infections, followed by adverse drug events, and postoperative sore infections. Central line infections, falls and pressure ulcers occurred more seldom in the total sample but would be expected to happen more frequently in clinical subsamples. Interventions in the campaign for the less frequent occurring AEs may benefit from subsampling according to clinical speciality, to learn in which departments they occur the most.

1963 Mapping taxonomies of adverse events in hospitals an initial analysis of classification systems in Norway Å. Ringard 1,*, M. Brudvik 1, U. Krogstad 1, A. K. Lindahl 1 1 Norwegian Knowledge Centre for the Health Services, Oslo, Norway To map and analyse variation in existing taxonomies used to describe adverse events in Norwegian hospitals. The Norwegian Board of Health (NBH) has received reports on hospital adverse events since 1994. In total 2059 events were reported in 2009. Over the past few years, in line with international literature on the field, steps have been taken to separate the reporting system from the controlling and sanctioning authority (e.g. Vincent 2006). In June 2011 the Parliament decided to move the system from the NBH to the Norwegian Knowledge Center for the health services (NOKC) in order to emphasize the learning aspect of reporting adverse events. NOKC is the national HTA, Cochrane and quality improvement centre. The new system will start operating July 1st 2012. NOKC has launched an implementation project to create the national reporting and learning system (NRLS). The main objective is on systemic learning, and the system is based upon a causal model consisting of of i) causes; ii) the adverse event; iii) consequences (WHO 2009). The report of the adverse event will give data about causes, the event and consequences. The national system is that it is going to extract information about adverse events from hospitals electronical reporting systems. In addition, a web based service will be established for collecting data from hospitals without electronic reporting systems. Until now hospitals have, as in many European Countries, developed and used their own classifications /taxonomies for causes, adverse events, and consequenses (EuNetPas 2010). The NRLS will collect information on each hospital s taxonomy. In additon, members of the NRLS-team will code each adverse event in accordance with the the WHO s International Classification for Patient Safety (ICPS) (WHO 2009). Information from each hospital s electronical reporting system will be transfered to the NRLS. Data will contain information about how each hospital has classified causes, the adverse event, and consequences of the event. The information collected by the NRLS will provide the basis for the analyses in this paper. Data will, as the act comes into effect on 1 July 2012, be available and analyzed prior to the conference. The information will be used to i) to describe aspects of different taxonomies currently in use for the three analytical concepts presented in the model, and ii) to analyse how the taxonomies fare when compared to criteria for good classification systems, and iii) to provide (in the long run) guidance on how to improve and standardise classifications of adverse events in Norwegian hospitals. Previous analyses indicate that there presently are several different taxonomies used for classifying adverse events in Norway (Krogstad and Saunes 2009). When in operation the NRLS will provide useful information about the main causes, categories and consequences of adverse events in Norwegian hospitals. The mapping of taxonomies will, in the future, also be the basis for the development of a national taxonomy of adverse events. References: The European Network for Patient Safety (2010), Survey 2010 http://www.eunetpasrals.eu/index.php?option=com_content&view=article&id=138&itemid=103 (20.02.12) Krogstad U and Saunes IS (2009), Pasientsikkerhetsarbeid i norske sykehus, Rapport nr. 28-2009. Oslo: Nasjonalt kunnskapssenter for helsetjenesten Vincent C (2006), Patient Safety. Edinburgh: Churchill Livingstone Elsevier WHO (2009), Conceptual Framework for the International Classification for Patient Safety Version 1.1. Technical Report 2009. Geneva: World Health Organization

1964 A project to improve safety of the route: for patients who are under transfer Y.-H. Li 1,*, H.-M. Lin 1 1 CHANG GUNG MHOSPITAL EMORIAL, KAOHSIUNG, Taiwan Patients who required to undergo examination, therapy or operation would be transferred from units temporarily. During transferring, personal reason, professional and communication skill might affected its safety and urgent emergency measures. Patients who were under transferring frequently might have the higher probability to meet the security loophole of the route. Hence, our study aimed at 1) Improve the recognition of the transporter for the safety route, expected raising the percentage 59.7% to 85%. 2) Improve the precision of the enforcement of safety route, expected raising the percentage 40.3% to 91%. The solution after analysis: 1. Organize teaching lesson: introduce the common route and its function, the way of fixation and the management toward the route in slipping out, and also organize two teaching demonstration person by person. 2. Establish the step to manage the problem route: Make a flow chart and offer this flow chart every staff. 3. Make a standard procedure to manage the problem route: included the introduction of the common route, the way of route management toward the route in slipping out. 4. Establish the routine audit: Make a check list toward the management of problem route. After the assessment of the study, two training programs for safety route were organized. All staff participated the above training program, their recognition toward safety route had apparently increased from 59.7 to 85%. The precision for route checking, route condition while body transposing and the inspection of residual oxygen volume had obviously increased from 40.3% to 91%. Our study increased the recognition of the transporter toward safety route and its correct enforcement. After the study and through the participation of all staff, they truly understood the importance of safety route for patients who were under transfer. Otherwise, the care quality had apparently increased after this project.

1992 Passing on the baton: from theatre for post-anaesthetic care unit K. Ng 1,*, E. Fernandez 1, M. George 1 1 Anaesthetics, Great Ormond Street Hospital for Children, London, United Kingdom Anaesthesia is a dynamic, complex process. Effective handover of a patient s care in the post-anaesthetic care unit (PACU) is essential for the continuity, quality and safety of patient care. The study aims to establish the quality of handover in the PACU in a tertiary children s hospital, and to identify the barriers to good quality handover to improve current practice. The study was conducted in two parts: - A prospective audit of the information handed over from the anaesthetic team to the recovery team, measured against the standards published by the Royal College of Anaesthetists, London - The information includes: Patient and operation details, medical history, allergy history, anaesthetic course and post-operative plans - An observational study of the process of handover in the PACU, highlighting the behaviours of staff involved In the prospective audit, 71 handovers were audited. Consultants delivered 51% of the handovers and 49% were delivered by trainees. Of all the information studied, operation detail was the only information that was handed over in all cases. Other commonly handed over information included patient details (89%), medical history (85%), intra-operative analgesia and antiemetic (94% and 82%), and post-operative analgesic plan (80%). Patient s allergy history was not handed over in 70% of cases. In the second part of the study, 21 handovers were observed. In about 50% of cases, the handover process started prior to the patient being connected to the monitor. Full attention of the recovery nurses throughout the handover was only observed in 66% of the cases. Distractions during handovers included counting respiratory rates, bandaging cannula site, checking surgical site etc. In 4 cases, the anaesthetists were contacted after leaving the PACU for clarification or missing information. The study showed that the quality of handover, in terms of information handed over and the current practice of the handover process, is significantly substandard. Ultimately the process may compromise patient safety. The quality of handover is an indicator of quality patient care. As a result of this study, the department has invested in time and personnel to carry out a series of Plan-Do-Study-Act cycles, aiming to improve the quality of inter-professional handover in PACU.

2004 Event analysis of accidents and injuries for emergency patients of a medical center in central Taiwan H. Li Hua 1,*, L. Fei Yi 2 1 Nursing Department, 2 Nursing Department, Chung Shan Medical University Hospital, Taichun, Taiwan This study was conducted to analyze the events of accidents and injuries for emergency patients of a medical center in central Taiwan.Thus to understand the basic information of emergency patients, types of accident and injury events and to explore the associations between events and relevant factors, and eventually, to be used as a reference for health care workers to prevent emergency accidents. A total of 86 unusual events of emergency patients between 2007 and 2010 were collected from retrospective chart review. Statistical analysis was performed using SPSS for the windows (version17.0). The survey instruments, including Unusual Event Notification Form and Medical Chart, were used to collect the information of basic characteristics of patients, the procedures and main causes of unusual events, the impact on patient s health and the basic information of those who provided notices. The majority of emergency accidents occurred in male patients that accounted for 55.8%. The mean age was 54.3 ± 19.2 years, among whom 29.1% had an educational level of elementary school. Patients triaged level 2 were predominant, accounting for 43.0 %, followed by 32.6% of patients triaged level 3. Emergency accidents were predominant among patients in department of internal medicine, accounting for 82.6% (n=71) and most common during daytime shift (43.0%). There were 52.3% of the accidents encountered in the observation room. No witness to most of accidents (52.3%) while happening was observed. The majority of patients had no injury (45.3%) and mild injuries (30.2%) after accidents occurred. The SAC score of most accidents (77.9%) was 4. The primary care nurse practitioners with advanced N2 level were predominant (44.2%), followed by those with N level (38.4%). The majority accidents were fall events (43.0%), followed by adverse drug events (22.1%), intubation events (16.3%) and health care events (0.5%). The causes of accidents were as follows: The most common causes were associated with patients physiological and behavior problems (51.2%), followed by personal factors (40.7%), work process design related problems (23.3%), environmental factors (14.0%) and medication uses (9.3%). Furthermore, nurse practitioners with N1 and N2 levels showed significantly better ability to classify SAC scores (P<0.05). The Emergency medical staff should properly assess patients physical and psychological conditions in order to provide education and training for patient safety to the nurse practitioners with N2 level. The provision of immediate and appropriate procedures by medical team can prevent accidents from happening, reduce the extent of injuries, and promote patient safety as well as quality of care. References: Balas, M.C., Scott, L.D., & Rogers, A.E. (2004). The prevalence and nature of errors and near errors reported by hospital staffnurses. Appl Nurs Res, 17, 224-230. Chih, T. C., Cheng, T. H., & Jih, C. C. (2006). Medical Incidents in the Emergency Department. Journal of Emergency Medicine, Taiwan. 8(4). Wang, H.E., Fairbanks, R.J., Shah, M.N., Abo, B.N., & Yealy, D.M. (2008). Tort claims from adverse events in emergencymedicalservices. Ann Emerg Med,52(3), 256-262.

2014 Empowering staff to improve safety V. LoPachin 1,*, A. Restifo 1, M. Nicholson 1, P. Moleski 1 1 Administration/Quality, North Shore University Hospital, Manhasset, United States 1. To identify the components of a comprehensive good catch and hard stop program 2. To describe how to empower the staff to engage in speaking up for Safety in the perioperative setting 3. To implement web-based technology for staff to enter safety data for good catch or hard stop The Preoperative hard stop and good catch programs" were implemented using the Quality Management methodology, Plan, Do, Check, Act. A review of best practices in the literature reported senior leadership commitment, and development of a database necessary for enhancing effectiveness of reporting. A communication plan was developed for staff promoting Safety is everyone s job and that Good Catches /Hard Stops assists leadership in prioritizing efforts. Each month the performance improvement coordinator for the operating room prepared a report of good catches. At the interdisciplinary Perioperative committee consisting of senior administration, Perioperative leadership, anesthesia vice chair, chiefs of surgery and quality management reviewed each of the hard stops reported by the staff to identify safety concerns that were a risk to patients and /or, employees or the organization. In order to stream line the process a database was created that could enable the staff to enter good catch data right into a web based form that goes to a centralized database. Since the programs inception in 2005 there have been over 1237 (3%) good catches and 232 hard stops. A majority of the good catches are Site Verification (356) and Patient Identification (237). Patient Identification good catches has decreased from 27% to 9% in the past 4 years. Coincidentally, implementation of Team Stepps, The Joint Commission Universal Protocol, The WHO Surgical Safety Checklist, and Electronic Medical Record has contributed to a decrease in many of the good catches submitted at the start of the program. Trends in hard stops are incorrect surgical counts (65%) that require an escalation to management. The second trend is associated with equipment used in the OR that malfunctions. We developed a high risk equipment list for the OR that requires training and/or privileges before use. The Operating Room established a good catch program whereby they collected near miss events that did not reach the patient. Most of the catches were caught in the pre-surgery process. To further a culture of safety, Teamstepps training occurred. After a serious incident in the OR, a gap was identified in the training and actual processes; therefore, hard stops were implemented. When they occur the staff does not leave the patient they escalate. The good catch and hard stop programs were successful at North Shore University Hospital due to the leadership commitment, staff engagement, and dynamic database that enabled safety issues identified by all employees to be addressed. This program can be replicated at other organizations.

2016 Anticoagulation Safety Program A. Restifo 1,*, D. Rosenberg 2, R. Jamali 3, S. Ahmad 3 1 Administration/Quality, North Shore University Hospital, 2 Department of Medicine, Hofstra North Shore LIJ School of Medicine North Shore University Hospital, 3 Pharmacy, North Shore University Hospital, Manhasset, United States To identify the components of a comprehensive anticoagulation safety program and understand the issues within these components To implement a monitoring program for patients on anticoagulants allowing interventions for specific patients as well as changes in practice To recognize the structure needed for program effectiveness and communication An anticoagulation safety program was implemented at a large teaching hospital. A committee was charged to implement a risk assessment for anticoagulation prophylaxis and to decrease complications. An evidence-based Anticoagulation Safety Policy for management anticoagulants was developed. Prophylaxis was standardized, monitored and converted into CPOE. Pharmacy lead the interdisciplinary collaboration with nursing, nursing education, Quality, IT, laboratory, patient education and medical staff, which was essential to make this patient centered effort successful. Using the Plan, Do, Check, and Act methodology, the VTE team was able to promote the use of evidence based practice protocols, and minimize variability in care which resulted in improved hospital acquired conditions related to pulmonary embolism (PE) and deep vein thrombus (DVT). Pertinent data were supplied by Quality Management to support effective decision-making. Monthly meetings with the team created an opportunity to share best practices and other innovative initiatives, break down barriers, and measure overall progress. Communication throughout the organization was critical. The team presented their work in various forums including Performance Improvement Coordinating Group and the Medical Board. For patients who are prospectively monitored on anticoagulants, approximately 25 adverse drug events per month (300 annually) are prevented. In terms of near miss data, errors associated with anticoagulants have reduced from 13% to 7% as a result of continual monitoring of patients and building effective ordering processes with technology. With the implementation of several safety strategies, a downward trend was noted with the rate of anticoagulant associated medication errors from 2008 to 2011, 12.5% decrease. Clinical pharmacist monitor all patients with heparin induced thrombocytopenia (HIT) who are treated with argatroban. Approximately 37% reduction in drug utilization was seen from 2008 to 2011 (12 patients/month compared to 7.5 patients/month) as a result of recommendation by clinical pharmacist to discontinue Argatroban in unconfirmed HIT cases. In addition, the overall expenditure associated with argatroban purchases was also reduced by 53% (107 K in 2008 as compared to 51 K in 2011). The Pharmacy checking of INR before Warfarin administration remains at 100%. Positioning for healthcare reform requires a firm grasp of processes that effect hospital acquired conditions. After analyzing the results, the authors concluded that the Anticoagulation Initiative demonstrates how utilization of risk assessment and evidence-based practices improve quality and safety. Key implications include: Engaging and empowering local clinical experts and leaders, including lab and pharmacy Establishing hospital wide risk assessment and evidence based guidelines to improve clinical care Developing metrics to evaluate sustainability

2017 The implementation of team resource management method to improve the quality of preoperative preparation J. M. Weng 1,*, Y. T. Liu 1, M. L. Chen 1 1 Nursing, Taipei City Hospital, Taipei, Taiwan To report our preliminary experience in improvement the quality of preoperative preparation using team resource management methodology so as to prevent the potential medical errors in operating room. Total 220 operations requiring general anesthesia or spinal anesthesia were enrolled in this study. The safety checklist provided by World Health Organization were modified by surgeons, anesthesiologists and nursing staffs in our hospital and applied in our operating room. Staffs in our operating room examined the three steps regarding the operation, including sign in stage, time out stage and sign out stage. The data revealed that 23% incomplete rate were found in time out stage. Hence, the authors implemented check-back and brief-huddle-debrief technique adapted from team resource management methodology and tried to improve the completion rate of time out stage. The completion rate of time- out stage improved from 77.2% to 96.3% after the implementation of team resource management methodology. The implementation of team resource management methodology in time out stage of an operation could be an effective way to improve the communication between surgeons, anesthesiologists and nursing staffs so as to prevent the possible surgical medical errors in the operating room.

2040 Review of triage model for pregnant women attending the antenatal service and feedback at Tseung Kwan O Hospital W. W. Choi 1,*, C. C. Tam 1, T. C. Lo 1, Y. K. Fung 1 1 Physiotherapy Department, Tseung Kwan O Hospital, Hospital Authority, Hong Kong, Hong Kong, China Physical discomforts such as low back pain, wrist pain, leg cramp and anxiety are common due to mechanical, hormonal and vascular changes associate with pregnancy. Antenatal (AN) workshop with education on coping strategies and exercise has been conducted by physiotherapists for years to reduce symptoms and self-empowerment. However, exercise is strictly forbidden or need modification in complicated pregnancy. In order to have better risk control, the triage system for AN workshop was reviewed and a self administrated questionnaire as an adjunct to screen at risked women was adopted. 1) To evaluate the effectiveness of the triage model 2) To evaluate the feedback from the pregnant women It was a retrospective study based on the qualitative outcomes from questionnaires and surveys. All women attended AN services at Tseung Kwan O Hospital from April 2011 to February 2012 were reviewed. 3 levels triage model 1) Medical screening before workshop: Pregnant women with musculoskeletaldiscomfort were screened and referred by the obstetricians during their AN check up. 2) Counter screening: Referral was screened by the booking officer. Patients with gestation period between 16 to 32 weeks were grouped to AN class. Timely individual consultation in the Women Health Physiotherapy Clinic (WHPC) was offered for those with musculoskeletal pain (MSP). 3) On site screening:a questionnaire was filled and double checked by the physiotherapist in the workshop. The questionnaire was designed to rule out any contraindication or need special precaution for exercise based on the recommendation from American College of Obstetricians and Gynecologists 2002 and American College of Sports Medicine 2006. Based on the screening, they were categorized into 3 groups: Group 1) Uncomplicated pregnancy, suitable for group exercise. Group 2) Women with MSP would attend AN workshop and WHPC. Group 3) Complicated pregnancy, for learning general education, relaxation and breathing control only. Selective exercise was taught with modification. The contents of the workshop were 1. On site screening by questionnaire, consultation and education. 2. Practicum session and completion of survey. One hundred and twenty two pregnant women attended the workshop. 102(83.6%) were triaged as Group 1, 12(9.8%) Group 2 and 8(6.6%) Group 3. All Group 2 patients reported satisfactory pain relief. Among Group 3, one patient reported placenta previa after 26 weeks, one patient with double uterus and six patients needed exercise modification. No patient reportedanyadverse event. From the feedback, 64.3% reported very satisfied and 35.7% satisfied with the overall content and arrangement. The existing triage model was effective in screening women for safe, appropriate and timely treatment. For Group 1, they enjoyed group exercise and treasured the peer group sharing. For Group 2, additional sessions helped them to manage the pain. For Group 3, they appreciated the coping strategies they learnt. The present practice is cost effective and enhances better resource allocation. The high satisfactory feedback implied the AN workshop was effective to promote healthy pregnancy.

2083 Patients reports of adverse events to a primary care clinic through the practice website H. Moller 1,*, K. Hagild 1, H. H. Petersen 2, T. Eriksson 2 1 Primary Care Clinic, 2 KvEAP, Copenhagen, Denmark 1) To enable patients to report adverse events occurring in relation to the treatment in a primary care clinic through the practice website. 2) To make use of the information provided by patients to improve quality, safety and service in the clinic and thereby strengthen patient involvement. The project took place in a clinic with four GPs, five staff members on part time and a list size of 5,100 patients in the Copenhagen inner city district. On the clinic website an electronic reporting system was introduced in 2006 with the possibility of dialog between patient and GP. Patients and relatives may report eventsanonymously if they wish to. A GP is appointed responsible for patient safety and a work group formed within the practice involving GPs and staff. The group discuss reported adverse events reported by patients, appoints a responsible person for the communication with the reporter. Events are categorized according to the basic problem described, and when more uniform events occur, the group analyzes the events and initiates improvement work, using a simple plan, do, study and act approach. Since the start in 2006 patients reported in average 26 adverse events per year. The number of events has been slightly falling in the last two years. The majority of events concern contact and communication. The second and third most frequent subjects were accessibility and clinical treatments. Reporting of adverse events locally at a GP clinic provides possibility of learning internally and improves the collaboration and communication with patients. The collaboration between GPs and staff based on the reported events improves knowledge sharing and organizational learning within the clinic. All members of the practice team are involved in converting information from patient s reports into better solutions.

2089 The "Resus:Station": Can design support the resuscitation trolley stock check? S. Walker 1,*, V. Deelchand 1, C. Vincent 1 1 Centre for Patient Safety and Service Quality, Imperial College, London, London, United Kingdom Resuscitation attempts occur in a high-stress, time pressured environment with large ad hoc teams, who have probably never worked together before. All these factors increase the risk of error. The resuscitation team requires a fully stocked resuscitation trolley containing everything required to treat the patient in the first few minutes. However, in 2004/5, the National Patient Safety Agency (NPSA) had a total of 86 incidents reported to them involving resuscitation trolleys. Most of these related to poorly stocked trolleys. Of these, 13 led to patient harm, and 10 to patient death. The NPSA decided to sponsor a project to redesign the resuscitation trolley with the aim of improving the stocking process. This led to the production of the Resus:Station". The Resus:Station has been assessed from a number of perspectives, including assessing the impact on teamwork in resuscitation, and a clinical assessment in the ward environment. In this study we have looked at the impact of the ergonomic design on the trolley checking and stocking process. We specifically aimed to: 1. Assess attitudes, opinions and beliefs of participants regarding the new Resus:Station when compared with the standard resuscitation trolley. 2. Compare speed of the trolley check when using the Resus:Station compared with the standard resuscitation trolley. 3. Compare the accuracy of the trolley check when using the Resus:Station compared with the standard resuscitation trolley. A total of 60 participants were recruited to this comparison study assessing nursing staff using the standard and newly designed resuscitation trolley. Participants were asked to complete 2 trolley checks, as they would on the ward, with order of trolley use randomised. After each trolley check participants were asked to complete a questionnaire giving their opinions, on a Likert scale, to a series of statements about the trolley used. The speed with which participants completed the trolley check was timed using a stopwatch. Participants were unaware of this. Accuracy was assessed in terms of whether participants identified specific items that were missing, or had expired on both trolleys. These were consistent throughout all study sessions, and were selected as being of equal importance, although they were different on both trolleys. Attitudes and Views The overall user feedback results for all participants clearly indicate a strongly significant preference for the newly designed Resus:Station for all aspects. This includes the fact that it is very easy to find equipment on the trolley, the design makes checking the trolley easier, and that it is easy to see at a glance if items are missing from the trolley. Speed of checking Overall there is no statistically significant difference in the speed with which participants check both the trolleys (p = 0.86), although there is a trend towards being faster in nurses who are familiar with the new trolley from use on the wards. Accuracy of checking There is no significant difference in the accuracy of trolley check in terms of identifying missing or expired items on the Resus:Station or the standard resuscitation trolley. We have demonstrated highly significant results, in terms of user opinions, in favour of the Resus:Station. However, we have been unable to demonstrate any improvement in the accuracy of trolley check. There is a trend towards participants being faster at checking this ergonomically designed trolley when they are experienced in its use, but without an improvement in accuracy this would have no benefit in terms of patient safety.

2092 The level of quality in prophylactic antibiotics administration timing and period according to the experience of quality assessment for total knee replacement in Korea J. S. Lee 1,*, M. J. Lee 1, Y. A. Jeong 1 1 Health Insurance Review & Assessment Service, Seoul, Korea, Republic Of This study was conducted to examine if hospitals with repeated experience of prophylactic antibiotics use assessment had higher appropriateness of initial administration timing and shorter administration period than hospitals with initial assessment. The subject of the evaluation was 443 hospitals that had 10 or more surgeries and total 40,403 operation cases were selected with maximum 60 cases by each surgery randomly sampled from October to December in 2010. The subject surgery of the evaluation were gastrectomy, colon resection, laparoscopic cholecystectomy, hip replacement, total knee replacement, hysterectomy, Cesarean section, open heart surgery, craniotomy, prostatectomy and glaucoma surgery. Among these, this study examined the difference between 104 hospitals(5,285 cases) with one or more quality assessment experience and 63 hospitals(1,848 cases) that had first assessment in 2010 in order to compare the appropriate use of prophylactic antibiotics for total knee replacement, which had relatively large numbers of hospitals with initial assessment than other surgeries. The difference between the two groups was examined using t-test. The hospitals with previous assessment experience showed significant higher administration rate in initial prophylactic antibiotics received 1 hour prior to surgical incision than those with no previous experience by 34.5%p for total knee replacement(p<.0001). In addition, the administration period of the hospitals with repeated experience was also significantly shorter in the administration period by 5.9 days(p<.0001). sectio n A group B group Differences 104 hospitals 63 hospitals the two (5,285 cases) (1,848 cases) groups t-test p-value timing 85.1% 50.6% 34.5%p 6.393 <.0001 period 10.7days 16.6days 5.9days -5.159 <.0001 This study showed that the hospitals with previous assessment experience for total knee replacement had higher level of quality than those with no previous assessment. Therefore, constant assessment to improve the proper use of prophylactic antibiotics is needed.

2105 Identifying systems failures in hospital settings: the patient measure of organisational safety R. McEachan 1, J. Ward 1,*, R. Lawton 2, G. Armitage 1 on behalf of 'Improving safety through the involvement of patients' steering group and on behalf of the "Improving safety through the involvement of patients" steering group 1 Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, 2 Institute of Psychological Sciences, University of Leeds, Leeds, United Kingdom Patients are willing and able to report on contributory factors which may lead to patient safety incidents. We report the validation of the patient measure of organisational safety (PMOS), which can identify 12 domains of systems weaknesses at a ward level. Design: Cross-sectional survey. Participants: 282 patients/carers (54% male, 78% White-British, median age 52 years) recruited from 10 wards within a large English acute teaching hospital. Measures: patients completed the PMOS, and were asked to report patient safety incidents. Exploratory factor analyses revealed 9 domains including communication (patient and team), physical environment, delays, lines of responsibility and training. The 12 domain structure was not supported. Patient incident reports mapped onto low scoring domains, providing valuable feedback to ward staff. The revised PMOS will be used as a basis for a patient safety intervention, tested in a stepped wedge trial, across 5 NHS trusts in England.

2128 Quality improvement in knee-hip arthroplasty K. Rookkapan 1,* 1 VEJTHANI HOSPITAL, BANGKOK, Thailand Review quality improvement roadmap for hip and knee arthroplasy to ensure highest patient safety in the hospital 6 years (year 2006-2011) cases review at Vejthani TJR Center. A holistic care was given by care coordinators to ensure our effective program which includes: 1. pre-operative preparation: pre-operative patient instruction, pre-operative patient assessment and standardized plan of care 2. surgical site infection prevention methodology: SSI surveillance team, effective hand hygiene program, standardized wound care, prophylactic antibiotic, co-morbidity prevention and management 3. patient education program: patient instruction paper, VCD demonstration in Thai, English and Arabic languages to ensure patient understanding, telphone home call in all cases 4. effective rehabilitation program: post operative rehabilitation endorsed by surgeon and team, re-assessment on knee range of movement INDICATORS Target Results 2006 2007 2008 2009 2010 2011 Total cases: Knee Arthroplasty 112 110 121 119 131 145 Total case: Hip Arthroplasty 9 13 23 25 24 21 2. Infection Rate 2.1 SSI 2.2 Deep Infection <2 % 1.18% 0% 2.38% 0% 3.63% 0% 5.95% 0% 3. Mortality Rate (related to surgery 0% 0% 0% 0% 0% 0% 0% 4. Pulmonary Embolism Rate (for Hip surgery) 5. Hip Dislocation Rate from In hospital care 0% 0% 0% 0% 0% 4.3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% A comprehensive program to improve patient safety in knee and hip arthroplasty must be implemented in a center where there is the aging population and also in countries like Thailand where it is one of the most popular destination for medical tourism. A program must highlight from a patient centric approach by multidisciplinary team. An clear understanding of the progress of the disease, process of life, and whole process of care planned would enhance better healthcare outcomes and improve quality of life of our patients. 0% 0%

2141 A review of adverse drug reaction in clinical trials for herbal medicine in Taiwan H.-H. Chang 1, 2, 3,*, Y.-H. Chen 1, 2, R.-C. Yang 1, 3 1 Center for Traditional Chinese Medcine, Chang Gung Memorial Hospital at Taoyuan, Chang Gung Medical Foundation, 2 Graduate Institute of Traditional Chinese Medicine, 3 School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan In order to improve the quality of traditional Chinese Medicine, to provide scientific data, and to keep up with the global trend, Taiwan has been establishing the regulations of Chinese herbal medicine clinical trial for ensuring the quality of pilot implementation and the safety of subjects. Focusing on the last decade, this report adopts the information from the database of adverse drug reactions in clinical trials for herbal medicine in Taiwan with a view to discussing the security of the test medication (Concentrated preparations of Chinese medicine produced by GMP pharmaceutical factories in Taiwan). By investigating the record files of Taiwan Adverse Drug Reaction Reporting System from September 2001 to December 2011, we found 657 adverse reaction case reports in clinical trials. After excluding nine incomplete cases, there were 250 serious adverse event (SAE) cases (38.6%) and 398 non-sae cases (61.4%); 55% of the complete cases stand for men, and 45% for women. Moreover, most of the cases lie in the range from 31 to 60 years of age (58%). Medicines for clinical trials that have been reported for adverse reactions can be classed into four categories: single prescription (26 cases), complex formula (2 cases), single medicinals (4 cases) and non-traditional prescriptions (6 cases). We observed that only 31 cases of out of 250 SAE cases are drug-related. These 31 cases can be further divided into 3 groups on the grounds of severity: 16 severe cases, 13 moderate cases, and two mild cases. Then, using the Naranjo score to analysis these data, we found that no case was definitely caused by Chinese herbal medicine, with only one very possible case and 17 possible cases (6.8%) related to Chinese herbal medicine. In conclusion, no significant and definite adverse drug reaction in clinical trials for herbal medicine has been notified over the past decade. Nevertheless, we should maintain our concern for the safety of Chinese herbal medicine and promoting its modernization. (CCMP100-CT-002) (99-EC-17-A-19-S1-163)

2195 Improvement of families satisfaction with the childhood immunization process S.-H. Lo 1,*, H.-L. Feng 1, C.-H. Chan 1, L.-Y. Chien 1 1 Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan Vaccination is the most cost-effective approach to children s health. Providing a good quality vaccination service becomes a major concern in our Pediatric Clinic. However, we frequently observed anxious parents caused by crying baby, and repeated questions from family members in relation to the safety of the vaccine as well as about queuing order and waiting time. The objective of this project was to improve the care and satisfaction with immunization process. Several strategies were used to improve the care and family s satisfaction with immunization process, including (1) establishment of training program and backup team; (2) providing visual aids in the vaccine bulletin board; (3) reorganization of our queuing order system; (4) decoration of our waiting room; and (5) organization of appease skills inservice nurse education workshop and the design of own-pay vaccination information leaflet. After implementation of the strategies, a structured questionnaire was utilized to evaluate family members satisfaction level with care in relation to the immunization process. 1500 questionnaires were distributed with return rate of 69%. The result shows the family s satisfaction level with the immunization process was increased from 87.69% to 92.94%. It indicates that our strategies improved family s satisfaction with the immunization process. Providing a good quality vaccination service becomes a major concern in the Pediatric Clinic. A smooth process, friendly immunization environment and appropriate information aids during the immunization process would prevent the children s family from anxious and unnecessary waiting time; therefore improve their satisfaction with the process.

2196 Barriers and facilitators in implementing a standard operating procedure for the prevention of wrong site surgery in the context of the international WHO High 5s Project L. Fishman 1,*, C. Gunkel 1, D. Renner 1, C. Thomeczek 1 1 German Agency for Quality in Medicine, Berlin, Germany The objective of the WHO initiative Action on Patient Safety: High 5s [1] is to implement and evaluate evidence-based standardized operating procedures (SOPs) in a multi-national learning community in order to improve patient safety in hospitals. In the context of this project we evaluated the role of barriers and drivers in the introduction of the High 5s SOP Correct Site Surgery in the pre-operative hospital setting in Germany. This SOP consists of three complementary steps in the pre-operative preparation of each surgical patient: a comprehensive pre-operative verification process, surgical site marking, and the final verification Time Out immediately before starting the procedure. The SOP includes the use of a checklist for implementation and documentation purposes. We assessed implementation obstacles and enablers for this patient safety SOP in order to gain a better understanding for critical success factors of implementation processes and to develop future strategies for timely and effective implementation of similar protocols. We evaluated organisational and cultural barriers and drivers using a) a standardised online questionnaire comprising 57 questions covering the implementation process and components of the SOP and addressing specific barriers and drivers and b) semi-structured expert interviews to gain more detailed information about these factors, the required resources for implementation, and considerations for future sustainability. Both instruments were developed by the international High 5s working group and adapted for use in the German project hospitals. The questionnaire was administered from December 2011 to February 2012 to the project coordinators in all 16 project hospitals, while the interviews were conducted in March 2012 with project coordinators of three of the hospitals who answered the questionnaire. Project coordinators of 10 hospitals answered the questionnaire. Resistance to change, lack of resources and deficient communication were named as the most common challenges during the implementation process. These were coped with by leadership support, training and education, staff involvement and improved communication. Of the three steps of the SOP, introducing the time-out was associated with the most difficulties, some examples being a lack of seriousness, a perception that time was being wasted, and resistance to change. Training and individual pep talks were used to successfully surpass these barriers. For all three SOP steps additional important facilitators were an interdisciplinary and cross-hierarchical project team and standardization of the process across various units. The full study results, including the results of the interviews, will be presented at the conference. Our analysis confirms that relevant implementation barriers exist when introducing new practice in a hospital setting, but that these can be overcome with a targeted multifaceted intervention strategy encompassing locally successful drivers. Although local characteristics should equally be considered, our findings can be helpful for other hospitals in developing their implementation strategies when planning to introduce a correct site surgery protocol and checklist. References: [1] www.high5s.org

2197 Effectiveness of Years of Safety initiative in improving patient-safety climate C. T. Hung 1,*, G. Y. M. Cheng 1 1 Queen Elizabeth Hospital, Hong Kong, China Subsequent to the 2007 survey to review the Teamwork and Safety Climate in clinical areas of three hospitals (acute, rehabilitation and convalescent respectively), the Years of Safety program was launched covering different safety themes over 3 years. A follow-up survey was conducted in November 2011 to evaluate the effectiveness. The 2007 survey, using the self-completion questionnaire adapted from University of Texas Teamwork and Safety Climate Questionnaire, targeted at all medical, nursing and allied health staff. Eight statements were added totaling 35 statements for rating with a 5-point Likert scale from Strongly Disagree(1) to Strongly Agree(5). Implied consent was assumed upon return of questionnaire. Data analysis involved descriptive and inferential statistics, revealing issues with safety and teamwork climate. In response to the findings, the Years of Safety initiative was launched, namely Year of Patient Safety 08/09 ; Year of Staff Safety 09/10 and Year of Quality 10/11 to promote the safety culture. A series of activities were conducted throughout the theme years to engage staff in quality and safety such as strategic workshops, integrated quality and safety management structure, thematic conventions, promulgation of LEAN to streamline workflow, and the engagement in the ACHS hospital Accreditation. To evaluate the effectiveness of the improvement strategies, the survey was repeated in 2011 using the same methodology. In the 2011 survey, 4009 questionnaires were sent with a return rate of 23.4%, compared to 29% in 2007. The response rate per hospital varied from 21.6 to 52.8. Majority of the respondents were nurses (83.7%). Compared to 2007, improvement was observed in 30 factors out of 35 and more were found in the acute hospital which had attained full ACHS accreditation. In the teamwork climate, increased score was found for the statement on doctors and nurses working as coordinated team (3.39 to 3.61), and for the two negative statements difficulty in speaking up of a problem with patient care (2.71 to 2.52) and inability to express disagreement with doctor (2.99 to 2.79). Decline in scores were observed in the two highly rated factors in 2007 staff knowing names of workmates (4.31 to 3.99) and briefing before start of shift for patient safety (4.11 to 3.88). In the safety climate, improvement was noted for perceived level of staffing (2.36 to 2.63) and observed non-compliance to full checking procedures (3.37 to 3.16). Other improvements included discussion of errors, new staff orientation on teamwork and safety, feeling safe to have parents treated in this hospital, and spontaneous reporting of medical incident. Less favorable ratings were given on staff disregarding rules and regulation (2.61 to 2.72) and hospital management not compromising patient safety (2.80 to 2.69). Similar to previous findings, seniority of staff, discipline, age-group, years of professional experience and type of care-setting had varying significant effects on the scores for climate factors. Cultivating teamwork and safety climate in clinical settings takes time and requires determination of management and engagement of all staff. While each hospital has a prevailing teamwork and safety climate, the pace of staff engagement and application of strategies varies such that effect might not be fully observed after 3 years. The survey findings showed positive changes in safety and teamwork climate and signified the effectiveness of organizational strategies in improving the organizational culture in teamwork and safety. The sustainability of these changes would require a further study.

2222 The use of FMEA in the analysis of the processes of the cord blood bank of Verona Teaching Hospital, Italy: improvements and future challenges D. Pascu 1, A. Giuseppe 2, P. Bellini 2, T. Zerman 2,* and Vassanelli, A, Romano G, Tardivo S 1 Healthcare Trust 20, 2 Teaching Hospital, Verona, Italy Objective of the study is to examine the whole process, from the selection to the storage of cord, and identify in a systematic way the critical points. The donation is a highly complex process that involves women interacting with a multidisciplinary staff in different settings. The final aim is to ensure safety and quality for potential future users, enhancing, at the same time, the relationship with prospective donors. The Cord Blood Bank of Verona Teaching Hospital is an authorized national public service for the voluntary donation of cord blood. In 2011 the candidates were 552 (525 deliveries) of which 4,8% not eligible. The umbilical cords collected were 306 of which 44 (14,3%) consistent with the international register. The multidisciplinary team (physicians, head physician, technicians, obstetrics, and the clinical risk manager) analyzed the process using FMEA/FMECA. The working group selected 2 steps considered as core of the entire process : 1) Evaluation of the voluntary cord blood donor with 3 activities (1a. Pre-screening phone contact, 1.b Medical interview 1.c Lab examinations), and 2) Umbilical cord blood collection with 2 activities (2.a Collection at the time of childbirth 2.b Deliver for the cord blood storage in the Cord Blood Bank). A worksheet for analysis and synthesis of results was introduced in order to assess for each item the failure mode, based on Occurrence, Severity, Detection. A risk priority number (RPN) was calculated using the range score from 1 to 5 for each dimension. The activities 1.c (117 potential failures in 89 micro-activities) and 2.a (128 potential errors in 121 micro-activities) resulted most at risk with an overall RNP score >500, due to the high complexity. The third phase at risk was 1.b with a score of 327, whereas the one less at risk was 2.b (RNP < 300). The most critical points and the subsequent effects were: - RPN 27: - Wrong management of pre-screening call (step 1.a) with loss of the potential donor; - Lack of identification of donor and of informed consent and documentation (step 2.a) with lack of cord blood donation and delay; - Wrong labelling of the umbilical cord kit (step 2.a) with delay and adverse events; - RPN 18: - Incomplete anamnesis (step 1.b) with possibility of transmission of potential pathogens and pre-selection of inappropriate donors; - Misunderstanding of the anamnestic questions (step 1.b) with wrong information and pre-selection of inappropriate donors;wrong fill of Lab exam form and discordant labelling of the lab samples (step 1.c) with wrong exams, delay, adverse events, discomfort, increase of costs; - Delay in the storage of umbilical cord (step 2.b) with lack of material and loss of vitality of stem cells The complexity of management of cord blood bank is due to the number of steps. The crucial points are the prescreening, in order to enroll the potential donors, and the management in the delivery room. The FMEA allow to introduce improvements in order to enhance patient safety and reduce adverse events. Staff was educated to lead the prescreening in a friendly and polite way, to promote and emphasize the importance of the donation. Two checklists, in the anamnesis and in the delivery room, were introduced to guarantee safety in every step. The training of staff and the timely schedule are currently adopted as fundamental actions to ensure best practice and reduce every potential risk for mothers and potential users of stem cells.

2229 Adverse events and incidents in the intensive care unit L. A. Gonçalves 1,*, K. G. Padilha 2, R. Covello 1, C. C. Carramenha 1 1 IQG, 2 USP, São Paulo, Brazil To characterize adverse events and incidents in the Adult Intensive Care Unit An observational and prospective study with a quantitative approach, performed in four Intensive Care Units (ICUs) belonging to a tertiary University Hospital, in São Paulo, Brazil. The sample consisted of 86 patients. Data from this study were obtained from the daily analysis charts, the daily monitoring of medical visits and nursing shift change in two shifts (morning and evening) during the 40-day study. Adverse events were defined as unintentional injuries, which led to measurable lesions in affected patients and/or prolongation of hospitalization and/or death. Now as incidents it was considered failures resulting from health care that did not lead to measurable lesions or the prolongation of hospitalization. It was observed 1082 adverse events and incidents, being 865 (79.9%) incidents and 217 (20.1%) adverse events. From the incidents, most were related to failure in the systematization of the nursing assistance (36.2%), followed by medication errors (34.4%), occurrences arising from the interface with the clinical analysis laboratory (12.6%), failures to administer diets (11.9%) and the loss of therapeutic devices (4.9%). Regarding adverse events, hypoglycemia was represented by 32.2%, followed by ulcers by pressure (21.7%), loss of therapeutic devices (13.8%), nosocomial infection (12.0%), events related to medical procedures (10.1%), medication errors (9.7%) and phlebitis (0.5%). It is highlighted that from the 72 losses of the therapeutic artifacts during the period of study, 30 (41.7%) caused damage to the patient. In relation to damages resulting from medical procedures, it is noteworthy that the majority (54.5%) was associated with central venous catheter insertion. By checking the distribution of adverse events and incidents per patient a day it was observed in the ICU on the 4th floor an average of 1.3 (SD = 0.7), median of 1.3, a range between 0.2 and 3 0. Now in the 6th floor ICU, we found that adverse events and incidents per patient a day ranged from 0.9 to 5.8, with an average of 2.2 (SD = 0.9) and a median of 2, 2. These results provide important information about the lack of culture of safety in healthcare organizations, impacting on the care provided to patients and interferes in the guarantee of continuity of care. Given these data, strategies need to be defined for the structuring of the patient safety policy and its management, using protocols for prevention, with the involvement of the multidisciplinary team, to reduce the harm related to health.

2230 The effect of the National Quality Improvement program on the prophylactic antibiotics for surgery in Korea S. Y. Lee 1,*, J. S. Lee 1, M. J. Lee 1, Y. A. Jeong 1 1 HIRA (Health Insurance Review & Assessment Service), Seoul, Korea, Republic Of This study was performed to examine the effect of the National Quality Improvement (NQI) program on the prophylactic antibiotics for surgery in Korea. Assessment plan (performance measures, criteria, period of assessment) was announced in advance before the study started. The subject of the study was hospitals that had to operate over 10 cases each surgery from October to December in 2010. We chose maximum 60 cases each surgery through random sampling, thus total 40,403 operation cases in 443 hospitals were collected. The subject surgeries for the assessment were gastrectomy, colon resection, cholecystectomy, hip replacement, knee replacement, hysterectomy, Cesarean Section, open heart surgery, craniotomy, prostatectomy and glaucoma surgery. Five Measures were assessed including prophylactic antibiotics received one hour prior to surgical incision, antibiotics selection(aminoglycosides, 3rd Cephalosporins), antibiotics combination selection and average antibiotics prescription days after surgery. We compared the results of this study with those of the 2007 study. The rate of prophylactic antibiotics received one hour prior to surgical incision increased by 12.3%. The rates of Aminoglycosides selection, 3rd Cephalosporins and antibiotics combination decreased by 19.3%, 7.5%, and 28.6% respectively. In addition, average antibiotics prescription days after surgery decreased by 1.7 days. Table. The results of prophylactic antibiotics measures Measures 2007(1st) 2010(4th) 4th-1st Prophylactic antibiotics received 1 hour prior to surgical incision (%) Selection of Aminoglycosides(%) Selection of 3rd Cephalosporins(%) Selection of antibiotics combination (%) Antibiotics prescription days(days) 68.4 80.7 12.3 38.6 19.3 19.3 14.5 7.0 7.5 58.1 29.5 28.6 7.5 5.8 1.7 All the measures in the 2010(4th) study than those in 2007(1st) improved. This study showed that the NQI program influenced considerably on quality improvement in the prophylactic antibiotics usage for surgery in Korea.

2234 Activities for reducing complications related to endoscopic procedure in a health checkup center N. Y. Lee 1,*, H. R. Ryu 1, J. Y. Lee 1 1 Division of Endoscopy, Seoul National University Hospital Gangnam Center, Seoul, Korea, Republic Of Regular health checkups including gastroscopy and colonoscopy are common medical practices in Korea. Although its usefulness in early diagnosis in gastrointestinal disease is tremendous, endoscopic procedures accompany some complications from mild symptoms such as indigestion or pain to severe results such as perforation. The purpose of this study is to prevent and decrease complications and increase patient satisfactions related to endoscopic procedures. About 27,000 people annually receive gastroscopy or colonoscopy in Seoul National University Hospital Gangnam Center (one of the biggest health checkup centers in Korea). Most of them receive endoscopy under conscious sedation, and some of them revisit recovery room despite of finishing the endoscopy. We analyzed the frequencies and causes of revisiting recovery rooms from January to November 2010. On the basis of primary analysis, brainstorming was done by medical staffs including 11 gastroenterologists and 19 RNs engaged. The research on practice performance for managing complications proceeded. Common complications were categorized into insufficient recovery and dizziness after endoscopy under conscious sedation, mild abdominal complications such as abdominal discomfort, nausea, and vomiting after colonoscopy. Complications were managed using adequate prescription of flumazenil and intravenous fluids also had been applied to patients. From above analysis, standard practice protocol was developed with detailed guideline including medication instruction, complication management, and service guideline for the patients. From June 2011, this new standard protocol was practiced at Gangnam Center. In addition, the handover sheet was devised and used to record and share the information about medication, stages of sedation, and any remarks during the test preparation, procedure, and recovery. Furthermore, hot pack was applied to all patients who had colonoscopy test to prevent abdominal discomfort, the most common symptom after colonoscopy. Wall posters were placed in the waiting area to reinforce understanding possible mild complication after endoscopy under conscious sedation and colonoscopy. After activities of decreasing of endoscopic complications, mild complications were reduced from 1.03% to 0.94% after the practices. Frequencies of revisiting recovery rooms after endoscopy under conscious sedationwere reduced from 0.59% to 0.50% andonly 36 patients revisited the recovery room under insufficient recovery and dizziness. Incidence of common complications from colonoscopy was 0.97% (33 of 3383 patients), which was not significantly changed. Questionnaires for satisfaction in nurses in the endoscopy sector showedthat activities improved their taskscompetence and increased in satisfaction. Our activities to reducing complication related to endoscopic procedure was successful to decrease discomfort symptoms after endoscopy under conscious sedation. The ongoing survey about patients' satisfaction on complication management activities after colonoscopy will be needed so that our observation is in line with customer s satisfaction, and we will also continue monitoring incidence of complications from endoscopy.

2254 A modified drug distribution system for enhanced patient safety in the emergency room Y. M. Jeong 1,*, E. Lee 1, J. H. Lee 1 1 Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea, Republic Of At Seoul National University Bundang Hospital (SNUBH), hospitalized patients have been treated by the Unit Dose System (UDS) under the careful supervision of pharmacists. However, due to the nature of the facility, medication in the Emergency Room (ER) was usually distributed in a much more brusque manner, lacking the proper revision of pharmacists. A thorough revision of the preexisting system also showed that a pertinent process for dispensing was rather crude for discharge drugs given out in the ER since nurses, not pharmacists, delivered these medications to patients leaving the hospital. The potential threat of medical mistreatment caused by the absence of a competent system to resolve these issues caught the attention of several members of the staff, and therefore in 2010, modifications were made to the drug distribution system to reduce malpractice and ensure patient safety. The drug distribution system was modified to receive medication orders in real time, and medicine stocks in the ER were radically reduced for effective drug management. In this process, the amount of drugs returned to the hospital greatly increased because medication is usually dispensed with reference to a 24 hour time frame even though most ER patients only stay at the hospital a very short time. This created a significant workload for both the pharmacy department and the nurse station and also had other problems such as the possible misuse of these returned drugs during their reuse. Therefore, further modifications were made to the system so that nurses could directly request drugs from the pharmacy according to the hospitalization period of patients in the ER under the conditions where orders were already prescribed from doctors. Also, to provide sufficient education to the patients regarding their discharge medications and to step up their convenience, the preparation and administration of drugs is performed in outpatient pharmacy rather than the ER in the modified system. After the modified system went into effect, the portion of pharmacist supervised drug dispensed in the ER was increased from 75% to 100%, the cost to sustain the ER drug stock was reduced by 56%, and all patients discharged on weekdays could be provided with face-to-face education on their prescriptions. These improvements made in the drug distribution system of the ER are likely to minimize medication errors and ultimately lead to enhance the quality of patient safety at SNUBH.

2259 Building patient-safety systems in African hospitals in Cameroon, Mali and Senegal: the power of a partnershipbased approach S. Bagheri Nejad 1,*, S. B. Syed 1, J. Hightower 2, D. Pittet 1, 3 and International Working Group - APPS Partnerships between University of Geneva Hospitals and Cameroon, Mali and Senegal 1 Patient Safety Department, World Health Organization, Geneva, Switzerland, 2 Patient Safety Department, World Health Organization, Harare, Zimbabwe, 3 Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals, Geneva, Switzerland Patient safety (PS) is a serious global public health issue; the magnitude of the problem is expected to be higher in African countries. 3 hospitals in Cameroon, Senegal and Mali are partnered with Hôpitaux Universitaires de Genève (HUG) as part of WHO African Partnerships for Patient Safety (APPS). Key finding from implementing a 6-step partnership based PS improvement process over a 2-year period are presented, aiming to define crucial lessons. APPS utilizes a partnership model for PS improvement in African hospitals. Its approach builds on Africa-European partnerships between hospitals and has three main objectives: 1) to strengthen partnerships; 2) to improve PS; and 3) to facilitate the spread of PS improvements across each country. 12 PS action areas (endorsed by all 46 countries in the WHO African Region) form the focus of all APPS activity. A 6-step cyclical process was utilized to build PS systems in the 3 hospital partnerships. This involved partnership development, needs assessment, gap analysis, action planning, action and evaluation. In particular, a unique PS situational analysis tool (co-developed by the APPS network) was utilized at baseline and then repeated. Findings from each of the 6 steps were recorded, focused both on achievements as well as challenges. The PS situational analysis identified clear needs in relation to building PS systems in each of the 12 PS action areas. A gap analysis allowed prioritization of key areas. All partnerships conducted a range of activities related to strengthening infection prevention and control with an initial focus on hand hygiene (HH) improvement. Instruction on local production of alcohol-based handrub was provided across the three partnerships. HH training was conducted at HUG for all three partnerships on the WHO multimodal HH improvement strategy. Regular technical exchanges took place to ensure continued interchange of knowledge and experience and follow up to activities. Hospitals in Senegal and Mali worked on improving safe surgery. A partnership exchange visit at HUG allowed joint implementation planning for the WHO safe surgical checklist. Knowledge and learning, health care worker protection and health care waste management were also focused on. A simultaneous national APPS patient safety advocacy day took place in the 3 countries with the participation of a range of local and national stakeholders, focused on engaging the Ministry of Health. APPS utilizes an innovative model in order to improve patient safety in partnering hospitals; a range of lessons emerge through implementation. A good understanding of the local context and culture, and high-level institutional engagement are key factors for success. It is critical to simplify methods and locally adapt them to facilitate implementation. Adherence to a systematic improvement cycle can be the basis of building patient safety systems in African hospitals. To ensure sustainability, partnership activities need to be aligned with national and sub-national programmes focused on high quality health systems. References: 1. WHO AFRO Regional Director (2008). Patient Safety in African Health Services: Issues and Solutions. Brazzaville: World Health Organization. 2. Syed SB et al (2009). African partnerships for patient safety: a vehicle for enhancing patient safety across two continents. World Hospitals and Health Services, 24-7.

2283 Early awareness about scabies infection to institutional patients prevents outbreak a nursing staff monitoring project L. C. Chang 1,*, C.-C. TSAI 1, C.-H. Ho 1 1 Nursing Department, Kaohsiung Municipal Feng-Shan Hospital, Kaohsiung, Taiwan Over a period of 9 months (February 2010 October 2010), an outbreak of scabies affected 10 persons (including 2 staffs and 8 in-patients) in a community hospital. Failure to cure an epidemic may be because of a persistent, highly infectious patient or unrecognized contacts amongst patients and staff. Our project is to increase nursing staff the awareness of patient scabies infection and the accuracy of scabies management. We designed a cross sectional survey, utilizing convenience sampling to determine the accuracy of scabies recognition and management among all nursing staffs. The institute has 68 beds with nineteen 1-4 bed wards, includes some 10 longterm patients with ventilator dependence. The institute has no isolation rooms but some single bedrooms with washing and toilet facilities. One infection control nurse has responsibility for advice and assistance for the institute and a 210 patients hemodialysis center. The clinical diagnosis of scabies was confirmed by a Dermatologist. Patients with suspected scabies were isolated. The isolation procedure included use of gloves and hand washing, long-sleeved gowns and shoe cover, and isolated barometer. Patients were evaluated thoroughly the skin intact condition once admission to the ward. The institute designed a scabies infection prevention and protection passport for every single confirmed or suspected patient during staying the institute and discharged to home care center or other institute. All nursing staffs were monitored and audited for the scabies infection control. From January to November 2011 thirty high risk patients were evaluated, 5 among them were suspected scabies infection, and one was confirmed infection. Scabies infection care procedures were conducted definitely to all suspected cases. All 15 staffs were evaluated again the accuracy of scabies recognition and management the average score was significantly increased from 64 points to 90 points. Scabies is a common, but neglected, skin condition that is becoming increasingly prevalent globally. It caused distress and is frequently regarded as a stigmatizing condition of a health institute. Although is can affect anyone of any age or social class, understanding the epidemiology and life cycle of Sarcoptes scabiei and early think about scabies infection to high risk symptomatic patients is the key to effective prevention and control. References: Abdul B. Zafar.,& Sary O. Beidas.,&Linda K.Sylvester.(2002).Control of Transmission of Norwegian Scabies. Infection control and Hospital Epidermiology,23,278-279. Corazon R.Lafuente(2003).Is it Scabies?How to Tell.The Nurse Practitioner,6,57-59. David J.Gawkrodger(2002).Infestations.Dermatology(3th ed.,pp59).london,:churchill Livingstone. Michael, E. M., & Barbara, B.W.(2005).Scabies. Tom Hartman(Ed.),Principles and Practice of infection disease II (6th ed., pp3304-3305).u.s.a:frank. Obasanjo, olugbenga.o., & WU,Peggy., & Conlon,Martha., & Karanfil,Lynne.V., & Pryor,Patty., & Moler,Geraldine., & Anhalt,Grant., & Chaisson,Richard.E.,& Perl,Trish.M.(2001).An outbreak of Scabies in a teaching hospital:lessons Learned.Infection control Hospital Epidermilogy,22(1),13-18. http://www.tjcha.org.tw/safe/default.asp.htm http://www.derma.org.tw/doc/ok%ac%ce% BDH

2284 The correct use of chemotherapy and biological treatment in advanced non-small cell lung cancer, metastatic breast cancer, and metastatic colorectal cancer patients: an Italian experience N. Borciani 1,*, L. Scaltriti 2, S. Pergolizzi 1, D. Riccò 1 and MC Magnolo, D. Zoboli, A. Ferretti, R. Rodolfi, G. Sini, C. Busani, L. Paterlini, I. Manghi 1 Health Care Administration, 2 Oncological Committee, Azienda USL Reggio Emilia, Reggio Emilia, Italy To increase the correct use of chemotherapy and biological treatment as 1 st line treatment in advanced and metastatic non-small cell lung cancer (NSCLC) and metastatic breast cancer (MBC) and as 1 st, 2 nd, and 3 rd line treatment in metastatic colorectal cancer (mcrc). As requested by the Regional Drug Commission, the Emilia Romagna Regional Oncological Drug Group (GReFO) produced clinical recommendations for the correct use of oncological treatment based on the clinical indications of the European Medicines Agency and the Italian Drug Agency. In 2011, a multidisciplinary team of the Reggio Emilia Local Health Authority (one oncologist, one pharmacist, four medical officers) carried out a retrospective Audit in 5 hospitals on the year 2010 to verify whether those recommendations had been correctly applied. The selection of patients was performed through hospital discharge database using ICD-9-CM classification. To collect the data and calculate the clinical performance indicators, an electronic form was developed. Analysis focused on pathology, line of treatment, and target therapy. The multidisciplinary team evaluated the appropriateness of the use of Pemetrexed in NSCLC, Bevacizumab in NSCLC, mcrc and MBC, and Cetuximab in mcrc. Seventy-three clinical charts out of 776 examined were selected according to the Regional recommendation criteria: histological diagnosis, biological assessment, ctnm and ptnm, line treatment, patient age, and performance status by ECOG. The results in all 5 hospitals regarding pathology, line treatment, and target therapy were in line with the Regional standards except in two instances. The first concerned the use of Premetrexed in NSCLC (Adenocarcinoma) as 1 st line treatment; we found it was used in 63% of cases, which is higher than the Regional standard (30-50%). In our opinion, this finding could have been influenced by the low number of cases evaluated (n=8). The second critical area concerned the use of Bevacizumab and Fluoropirimidine, a combination not in line with Regional recommendations for 1 st line treatment in colorectal cancer. We found the combination used only once, however, in this group of patients (n= 17). Our findings show an appropriate use of chemotherapy and biological drugs in clinical cancer management in the Reggio Emilia hospitals, according to Regional recommendations. The multidisciplinary team deemed appropriate the management of the patient with mcrc who received Bevacizumab plus Fluoropirimidine in 1 st line treatment given his comorbidities and clinical conditions. Indeed, we observed that the criteria described in the GReFO recommendation does not take into consideration patient comorbidity and treatment toxicity, factors that should always inform decision-making in everyday clinical practice. Another important issue is the lack of international consensus on the definition of adjuvant or first-line therapies after surgical metastasectomies in either NSCLC or mcrc when the outcome is a pathological complete response (pcr) in rtnm. In fact, there is a substantial difference in the correct indication of biological plus chemotherapy combination based on evidence of residual positive disease or the lack thereof. Finally, although the GreFO recommendations are a good tool in clinical oncology practice, the management of cancer patients can be affected by several clinical characteristics.

2285 Safe fixation policy in Imeldaziekenhuis P. Van Daele 1,*, M. Gevels 1 and WG Vrijheidsbeperkende maatregelen Imeldaziekenhuis 1 IMELDAZIEKENHUIS, Bonheiden, Belgium Improving and monitoring the fixation policy in our hospital We started a 5-year project to improve our policy concerning fixation. At the start all available texts, SOP s (standard operating procedures), work instructions and materials were collected. On 12.12.2007 a baseline audit was performed during the night measuring: - The number of fixed patients; - To check which fixation devices were in use; - To ascertain whether the restraint is correctly used according to the available work instructions; - To verify that the nurse could show the SOP s concerning fixation; - To verify if fixation was correctly documented in the nursing file. In the beginning of 2008 a literature review and a benchmark was performed. A new directive 'restraints to protect patients' was made. New restraint material was selected by experienced nurses and for each device a SOP was developed. Everything was tested during 6 months within 2 wards. In October-November 2008 a the training program started with workshops on the proper use of restraining and positioning equipment. The legal and ethical framework was also treated.. The first sessions were mandatory for night nurses, head nurses and assistant head nurses. Who had to transfer their knowledge to their wards. During the ward meetings specialist lecturers could be invited. Each year a follow-up audit was performed. The audit was not announced and was held at 4 a.m. All patients were audited and all patient wards were visited. 12.12.2007 28.04.2011 p Nurse is able to show SOP fixation 78 % 14/18 94 % 17/18 >0.05 Total number of fixed patients 6.63% 30/452 5.95% 24/403 >0.05 Notes of reason for fixation present in file 59 % 18 100 % 24 >0.05 Notes of consultation with colleagues, family and / or partner in file 15 % 7 67 % 16 >0.05 Notes of daily evaluation in file 74 % 23 88 % 21 >0.05 Bel near patient 74 % 23 92 % 22 >0.05 Role fixation belt: correct fixation to bed 82 % 18 94 % 16 >0.05 Role fixation belt: tight (2 fingers) 41 % 9 100 % 17 >0.05 Role fixation belt: lateral straps tight 77 % 17 76 % 13 >0.05 less patients were fixed, which corresponds to the pursuit of a fixation poor policy; the knowledge, adherence and skills of fixation were improved.

2304 The effect of systematic healthcare quality improvement and patient-safety training program C.-T. Yang 1,*, W.-C. Fu 1 1 Landseed Hospital, Taoyuan, Taiwan The objective is to investigate the effect of systematic training program for healthcare quality improvement and patient safety on elevating hospital staff s attitude and recognition of healthcare quality. The Taiwan s patient safety goals were studied in 2003 and launched in 2004. We found that our staff s awareness on patient safety was lower than other-peers through the Safety Attitudes Questionnaire (SAQ).From 2008, we designed series course about healthcare quality improvement and patient safety to improvement staff s recognition of healthcare quality. The training programs comprised three main steps. It was promoted step by step, and the outcome of these training programs was evaluated. Step1: Course planning The content was focused on patient safety, differences among professional groups of the hospital staff, etc. The course plan can be divided into two parts: 1. Beginner course: This course was opened for everyone and given once every two months. The objective of this course was to increase staff' s awareness of patient safety and quality improvement. It consisted two categories: Healthcare quality improvement and Patient safety, including such as improving clinical care quality, etc. It also invited numerous experts from the outside to give lectures, and all the staff members had taken the course. 2. Advanced course: Given to seed-members form each department, this professional-specific training course enabled the seed-trainees to assist their department for improving patient safety and healthcare quality. Step2: Course implementation The implementation of the courses is briefly described below: The beginning course, it was given for eleven times about clinical care quality from 2008, and 3,436 staffs participated Patient safety-related course was held eighteen times during the same period, and 4,533 staffs had taken it. The Advanced course, total of four workshops were given, including RCA (Root Cause Analysis), SPC (Statistical Process Control), TRM (Team Resources Management), and the internal counselor training workshops. Total of 288 seedmembers were trained, and they all had effectively assisted their departments on improving their healthcare quality. Step 3: Course evaluation 1. Course evaluation survey was given at the end of each course and used to re-design the later course. 2. Our Hospital participates in the annual patient safety culture survey for comprehensive evaluation on hospital staff s attitude and recognition on patient safety. 1. The satisfaction rate of each course had increased from 71% to 85% or above. 2. All aspects had significant improvement according to the results from patient safety culture survey. Especially, the teamwork item had improved from 27% to 61.7% that surpasses the other peer-hospitals (55.0). 3. A total of 136 improvement cases and RCA analysis for sentinel events had completed. In these ongoing activities, the collaborative atmosphere among our medical teams has improved significantly. 4. Through these activities, the number of patient safety related cases reduced from 2008 s 789 cases per year to 2011 s 407 cases per year. This could significantly decrease any non-necessary expenditure, such as medical disputes and relevant administrative, about 70 million each year. This systematic and ongoing educational approach can effectively elevate hospital staffs understanding on healthcare quality as well as patient safety. This model will be continuously used for other types of educational training to firmly integrate the awareness of healthcare quality and patient safety into the daily routine of the hospital.

2345 To increase the value and utility of a resource, tap on the wisdom of stakeholders: the consultation process to revise the Canadian Root Cause Analysis Framework I. C. Popescu 1,*, P. Beard 2, S. Kossey 1 and Canadian Incident Analysis Working Group 1 Canadian Patient Safety Institute, 2 Alberta Health Services, Edmonton, Canada Since the original release of the Canadian Root Cause Analysis Framework (framework) in 2006, emerging evidence and leading practices incited the need to revise the framework. The expert working group leading the revision hypothesized that a comprehensive consultation process would increase the value and utility of the framework. Because the goal of the framework is to enhance the effectiveness of incident analysis and management in making care safer, an increased number of users who access and implement the resources included in the revised framework is desirable. The Canadian Patient Safety Institute (CPSI) in partnership with the Institute for Safe Medication Practices Canada, Saskatchewan Health, Groupe Vigilance, Patients for Patient Safety Canada, Paula Beard and Carolyn Hoffman (the working group - WG) designed a multi-step revision process that included evidence, expertise, and a multi-layer consultation process. A literature review that highlighted the latest evidence and trends in incident analysis together with learning from evaluations and surveys conducted over the years formed the foundation of the revision process. A roundtable with experts from around the world (March 2010) deepened the understanding of how analysis methods and processes can be enhanced to improve effectiveness, as well as helped generate ideas on the content and structure of the framework. To test and further refine the draft content of the framework (Versions 1-4) the WG conducted two focus groups and piloted some of the new tools and methods with a team of quality improvement consultants (June 2011). Their feedback was used to refine and build the next draft (Version 5). To align the document with the needs and priorities of Canadians, a consultation with representatives from provincial/territorial Ministries of Health, Health Quality Councils, and several professional regulatory bodies and association was conducted (October 2011), and the feedback received used to create the next draft (Version 6). This next version was at the center of the public consultation, which included information calls, access to the document, and a survey, conducted by a 3 rd party (December 2011). The survey findings shaped the content and structure of the final framework. The extensive consultation process, from the initial roundtable until the 3 rd party survey, proved to be a worthwhile investment. Almost 900 individuals downloaded the DRAFT document in one month for the purpose of the public consultation. 171 individuals completed the survey and provided very practical recommendations for improvement. See below two quotes from the 3 rd party report demonstrating the value of the document and intent to implement the resources included: Between 78% and 95% of participants agree or strongly agree with the statements on the Framework as a whole and most (81%) find that the framework will be useful or very useful to healthcare organizations and providers. For each tool and method described in the Framework, between 21% and 36% of participants reported that they plan on using it over the next 4 months. The Framework will be launched in the Spring of 2012, its quarterly uptake will be measured and included in the final presentation. Based on this WG s experience, a thorough consultation with key stakeholders and users can increase a framework s uptake, which can increase the effectiveness of incident analysis in reducing harm recurrence.

2351 The improvement of the process to reduce errors in management of post-endoscopic specimen J. S. Park 1,*, E. S. Han 1, J. H. Kim 1 1 Physiologic Diagnostic Laboratories, Seoul National University Bundang Hospital, Seong Nam, Korea, Republic Of An accurate endoscopic biopsy provides valuable diagnostic information for the therapeutic plan. At Seoul National University Bundang Hospital endoscopy unit, in average 930 cases of biopsies are processed every month. Errors related to specimens have occurred in about 15 of the cases, which deteriorate patient safety and laboratory quality. The aim of this study was to minimize errors by improving the process of specimen collection and delivery to the pathology laboratory. The key index is the number of specimen-related errors (errors). Errors are defined as the rejection from the pathology laboratory due to the discrepancies in the specimen, the specimen information on the container label, the request sheet for a pathology test and the biopsy order. The data was collected from specimens that have been judged as errors from November 2010 to March 2011. The causes of the errors were analyzed from five viewpoints, i.e. assistant, doctor, laboratory environment, laboratory system and EMR (Electronic Medical Record) system. Seven main causes of errors were found: 1) Absence of a double checking system before transfer to the pathology laboratory. 2) Incorrect biopsy orders and request sheets by new doctors. 3) The new staff not knowing how to correctly check the specimen information. 4) Discordance of the biopsy area between the doctor and assistant. 5) Miswritten specimen information on the container. 6) The usage of a different EMR system between the doctor and assistant makes it inconvenient to check specimen information. 7) A time-gap from doing a biopsy to typing an order. 13 solutions were presented after problem analysis: 1) A specimen management program should be set up in order to recheck specimens. 2) Update order-set on the EMR screen. 3) A link between the order and the interpretation screens. 4) Change the inscribed request sheet into the template to reduce input errors. 5) Make a standardized specimen checking manual for new staff. 6) Make plates which are designed to arrange specimens in order and to carry. 7) Keep specimens according to checking status. 8) During a procedure, the assistant repeats the name of biopsy area after the doctor. 9) Use printed labels of the specimen information on the container instead of hand written ones. 10) Make stickers to recognize the change of biopsy area instantly. 11) Install a spot light at the exam table in order to check small specimens. 12) Develop a program to check the request sheet and the order on the same screen. 13) Type the order immediately after the biopsy. A specimen management program was developed at the end of April, 2011, which made it possible to check the receipt, the biopsy order and the request sheet on the same EMR screen. Also, from that screen it is possible to print the specimen label. In addition, a secondary check-up process was established. There has been an increase of monthly biopsy specimen but the number of errors started to decrease from April, 2011. At the present, there have been no errors at all from November, 2011 (There were seven cases of errors in April, three in May, one in August and one in October, 2011.). Although specimen-related errors may cause serious problems involving patient safety and legal stability, those have occurred repeatedly due to complex processes and pressing duties. Accordingly, there was an urgent need to improve the process to minimize errors. The whole staff at the endoscopy unit made an effort in cooperation with other departments. As a result, errors reduced remarkably. The results are expected to improve patient safety and work efficiency.

2362 Multiple strategy application to improve the incidences of pressure ulcers in a specific medical center in Taiwan H.-L. Chen 1,*, H.-J. Jen 2, Y.-T. Chiang 3 1 surgical ward (11D), 2 nursing department, 3 medical ward (6D), Far Estern Memorial Hospital, new Taipei city, Taiwan The incidence of pressure ulcers is an important index for nursing quality. This hospital is a medical center in Taiwan that had a pressure ulcers incidence rate of 0.16% in 2008 and 0.12% in 2009, which was higher than the peer average of medical centers in Taiwan for two consecutive years (0.11%).We applied multi-strategic intervention to improve incidence rate at this hospital and to enhance nursing care quality. Cross-sectional design was adopted by the hospital. The data from patients hospitalized at a specific medical center in Taiwan were collected in 2010 using self-administered questionnaires. The cognition for pressure ulcers assessment for nursing personnel, continuous assessment of skin integrity for patients, nursing personnel turning patients every two hours was implemented. Starting from 2010, this hospital gradually carried out assessment forms for high-risk pressure ulcers groups, established pressure ulcer standards, and created turning clocks and inflatable pillows to assist patients in turning. We also revised nursing guidance form for pressureulcers to improve the pressure ulcer incidence rate of this hospital. The results showed that training on pressure ulcers cognition, the average score for nursing personnel on cognition of pressure ulcers assessment increased from 82.73 to 93.43, the accuracy rate of pressure ulcers cognition increased from 77% to 92.4%, and the accuracy rate of stage I pressure ulcers assessment increased from 67% to 100%. The continuous assessment of skin integrity for patients with an achievement rate increase from 70% to 91%. The achievement rate of nursing personnel turning patients every two hours increased from 33% to 90%. The incidence rate of pressure ulcers at the entire hospital reduced from 0.12% in 2010 to 0.10% in 2011 with the incidence further reduced to 0.08% in January 2012. Our research results showed that enhanced nursing personnel cognition for pressure ulcers and implementing assessment on high-risk pressure ulcers groups helped to diagnose pressure ulcers earlier to provide precautionary measures. By executing pressure ulcers in-service training, formulating documents on pressure ulcer standards, revising pressure ulcers guidance forms, and applying assistant turning tools, the convenience of nursing personnel to implement pressure reduction during clinical practice and efficiency for precautionary measures will further reduce the incidence rate of pressure ulcers at this hospital. References: Elizabeth,A.A.,& Barbara,B.(2001).How and why to do pressure ulcer risk assessment.advanced in Skin&Wound care,31(11),125-133. Eman,S.M.,Theo,D.,&Ruud,J.G.(2009).Pressure ulcer prevention in intensive care patients:guidelines and practice.journal of Evaluation in Clinical Practice, 15, 370-374. Katrien,V.,Michael,C.,Carol,D.,Lena,G.,&Tom,D.(2007).Pressure ulcer prevalence in Europe:a pilot study.journal of Evaluation in Clinical Practice,13,227-235. Narendra,B.,Amy,M.,Stephamie,D.,Julie,S.,Mellyn,J.,&Melissa,J.S.,et al.(2008).how our ICU decreased the rate of hospital-acquired pressure ulcers.journal of Nursing Care Quality,23(1),92-96. Shahin,E.S.,Dassen,T.,&Halfens,R.J.(2008).Pressure ulcer prevalence and incidence in intensive care patients: a literature review.nursing in Critical Care,13(2),71-79.

2391 Project implementation of FMEA in a breast unit of the north east of Italy S. Tardivo 1,*, F. Pellini 2, S. Mirandola 3, G. P. Pollini 4 1 Public Health, University of Verona, 2 Surgey, 3 Surgery, Azienda Ospedaliera Universitaria Integrata di Verona, 4 Surgery, University of Verona, Verona, Italy The aim of the study is to identify critical issues and possible errors that a patient affected by breast heteroplasia may experience during the process of care from the first contact to the discharge after surgery. The specific aims include: identifying all the steps of the process, analyzing all the potential failure modes and their classification according to their index of risk, defining corrective actions able to decrease the Priority Risk Index (PRI). The study was conducted at the Breast Surgery Department of Verona University Hospital Trust, from January to September 2011, by planning a field training called Giunone 3 ( Juno 3). A multidisciplinary team was formed, it consists ofbreast surgeon, nurse coordinator, coroner, anesthetist, manager of the quality management team, manager of the professional and innovation development, experts in Crew Resource Management and Human Factor. At first the whole process was divided into different steps. A specific analysis was performed on the following phases: definition of the process of care, post-operative phase, transfer and/or discharge. The 14 higher PRIs were analyzed. The highest PRI was 36 and the lowest was 3. The former is related to the communication of prescriptions to nurses during the transfer phase. This is a critical step in the post-operative period. Two different failures were identified: missing performance (PRI 27), partial performance (PRI 36). The effects are: incomplete or incorrect therapeutic treatment. The causes are haste/superficiality. The use of different procedures for therapy prescription in different wards (RPI 18) is due to the lack of shared protocols. The consequences can be that a correct prescription is not administered and/or a delayed therapy. In the vital parameters and surgical wound check, it was found out two failures out of six higher ranking errors/failures: missing, wrong, inadequate estimation of patients post-operative complications (PRI 27); failed control of drains and their functionality (PRI 24). Causes are lack of knowledge, inattention, superficiality, daily routine, haste, failed carefulness during diagnostic-therapeutic processes, high concentration of nurses activities in a short period of time. In the post-operative phase incomplete communication of information get a PRI of 24, it was caused by haste and high turnover of patients and staff. During the discharge phase it is pointed out a failed dialogue among the team (PRI 18) and failed mobilization of the upper arm (PRI 24), that can have functional impacts and lead to pain; these failures are caused by haste, inadequate training, lack of dialogue. These failures are more relevant in the day surgery service because of the short stay in the hospital and the possibility that the adverse event can manifest when patients are at home. FMECA pointed out critical aspects related with communication in different phases of the health care process. Thus, this area has to be improved with interventions and tools written above and with adequate trainings of all the professionals, all the stakeholders, especially patients and their relatives, should be involved. The path checklist has to be adapted looking at the needs of each department.

2392 Performance of team resource management on reducing the risk of falls for inpatients in acute psychiatric ward in a general hospital W. T. Chao 1,*, S. C. LI 2, T. L. HSU 2, S. L. Lin 2 1 Psychiatric department, 2 Taipei Hospital, Department of Health, Taiwan, NEW TAIPEI CITY, Taiwan The purpose of this study was to reduce the incidence of falling for inpatients staying in acute psychiatric ward. Our specific aims were to 1) characterize the issues about patients, prescriptions, and environment that should be closely monitored for patient s safety; and 2) assess the performance of interventions generated by inter-professional communication and cooperation on the prevention of falling for hospitalized patients in the acute psychiatric ward. According to the score monitoring system of Taiwan Quality Indicator Project( TQIP), which measuring and monitoring the medical quality by medical outcomes and clinical indices, the annual incidence rate of our inpatients in the acute psychiatric ward was as high as 0.41%. Thus, the program of falling prevention was conducted by the method of Team Resource Management, involving all the caring staff by inter- and intra- professional communication to generate a checklist for the administration of patient safety during hospitalization. The team members included nursing staff, caring assistants, occupational therapists, and psychiatrists. At the stage of implementation, we utilized the skills of leadership enhancement, well communication, situation monitoring, and mutual support. During the period of one year, the incidence rate of falling for inpatients in acute psychiatric ward dropped from 0.41% in 2010 (16,281 admissions in total) to 0.34% in 2011(17,180 admissions in total). Also, the average score of safety atmosphere satisfaction in the psychiatric team increased from 60 in 2010 to 92 in 2011 (score ranging from 0 to 100). Inter-professional communication revealed both good practices and those that contributed reducing the gaps in care. Prevention of falling for inpatients is one of the major issues of patient safety in acute psychiatric wards. Implementation of this program not only encouraged us for our team work in collaborations to reduce the risk of falling, but also enhanced the development of cooperation between inter- and intra-professional groups. Further studies based on the concepts, skills, and attitude developed by the application of Team Resource Management could be thus proposed in the future.

2408 Improvements in the care of in-patients with diabetes in NHS Lothian C. Swift 1,*, K. Adamson 1, J. Barclay 1 1 NHS Lothian, Scotland, Edinburgh, United Kingdom The provision of consistent, effective and proactive inpatient care for people with diabetes is still inadequate in the NHS with length of stay also being of great interest to all members of the multidisciplinary team involved in patient care (people with diabetes stay in hospital for up to 2.6 days longer in some specialities). Our objective was to increase patient satisfaction, reduce harm / errors, reduce length of stay and reduce inherent financial cost. Insulin is involved in one of the most reported incidents on our Incident Reporting System. A focus for improvement was therefore initiated with the Diabetic Specialist Team, a multidisciplinary clinical team and with the Scottish Patient Safety Programme in 2008 and have continued to test interventions using the Model For Improvement as advocated by the Institute for Healthcare Improvement. Tested and implemented: A Ward Insulin Guide to rationalise insulin held at ward level and available to the nursing staff for administration. There was a need to rationalise the complex range of insulin products available. The insulin s that are available to the nursing staff are insulin s that come in vial form and therefore nurses can only be able to withdraw the insulin from the vial using a syringe. This decision was made in light of some of the needle stick injuries having occurred as a result of the nursing staff withdrawing the insulin from cartridges and pre-filled pen devices. This decision supports the recommendations from the Royal College of Nursing (2007) that advocate that insulin should not be withdrawn from a cartridge by syringe. A hypoglycaemia algorithm (which was eventually adapted to incorporate NHS Scotland s algorithm) depicting the management of hypoglycaemia. Dose adjustment guidelines on the same document as the algorithm and insulin prescription chart. The introduction of hypo-boxes supplied by BBI Healthcare which contain the ingredients recommended in the algorithm easy to find and easy to use. New Blood Glucose reading monitors are being introduced which have information downloaded through the laboratories and presented on graphs on a Safe in our Hands poster to allow real-time feedback This information tells us numerous blood glucose readings. This system is being introduced with training sessions on each acute site. - 50% reduction in hypoglycaemia recordings in pilot ward - Increase from 50% to 75% compliance with effective dose adjustments using the guidelines - Increase to 80% using the hypo-boxes - Cost savings from one hospital s medical wards of 560 over 2 days, and 535 from non-medical wards (including surgery), from rationalising insulin stock - 34% reduction in the risk that errors will occur (using a Failure Modes and Effects Analysis [FMEA] as advocated by the Institute for Healthcare Improvement). Focusing on the quality of care, ensuring that processes are streamlined, ensuring that tools are readily available to assist clinicians, and real-time feedback will all impact on patient satisfaction, financial costs and length of stay for our in-patients with diabetes.

2415 Patients as partner in standardization of providing an accurate medication overview at transitions in care E. Van Der Schrieck-De Loos 1,*, A. Van Groenestijn 1 1 Patient safety, CBO (a TNO company), Dutch Institute for Healthcare Improvement, Utrecht, Netherlands Research and implementation advice across hospitals on the implementation of an international Standard Operating Procedure (SOP) for medication accuracy at transitions in care to reduce medication inaccuracies with 75% The main question of this 2-year study in 11 (non) teaching and academic Dutch hospitals was: how to improve patient safety with implementing an international SOP for medication accuracy at transitions in care? based on 3 sub questions: what interventions are most effective within the procedure of comparing accurate medication overviews to admission medication orders? How to identify and resolve medication inaccuracies within 24 hours? What factors influence implementation and how to expand the procedure hospital wide? The quantitative and qualitative study consists of: 4 baseline measurement indicators compared to monthly performance indicators. Structured demographic hospital profiles including interventions and biannual self reported implementation questionnaires (N=11). Yearly structured interviews and paper based culture surveys (response rate 47% before, 50% after implementation) (N=4). Results were discussed at 8 accredited meetings and disseminated by press release, publications and 13 national presentations (2010-2012). Hospitals achieved 75-90% reduction of medication inaccuracies within 1-5 months after implementation starting with patients 65 years admitted through emergency department (N=6). Compared to baseline measurements hospitals achieved 80% reduction of patients with at least one unintentional inaccuracy. And 90% of the mean number of unintentional inaccuracies per patient. Both engaging patients and interviewing patients, mostly by hospital pharmacy assistants about patients medica tion use, seems crucial. An open ended question interview is most effective. Patients reconciled <24 hours has been increased from 9,24% before to 40% after 6 months (N=11), >75% after 1 year (N=4) and >91-98% after 1,5 years (N=2) implementation. This is being optimized by interviewing patients to identify and resolve medication inaccuracies also during weekends. Hospital wide implementation is depending on hospital size, willingness to change and making staff available. This study confirms that patient safety is teamwork: patients must be engaged as partner in the SOP for medication accuracy at transitions in care to provide an accurate medication overview. As patients (and relatives) have a crucial role in preventing medication inaccuracies by providing accurate information about their current medication use. As part of the SOP hospitals intervened that well trained pharmacy assistants are most effective for identifying and resolving medication inaccuracies within 24 hours with 75%. To SOP or not to SOP is not the question after creating an internal spin off by SOP implementation step by step from a specific group of patients to all patients and transitions in care. Questions are when to start and how to create well trained staff within current resources for interviewing patients within 24 hours also during weekends. In the Netherlands the international procedure leads to improvement of patient safety and to medication accuracy at transitions in care guideline implementation. References: Van der Schrieck-de Loos, E. et al. 2011. SOP for Medication Reconciliation in hospitals in the Netherlands. MFM national pharmacological journal 1(2) & KIZ national quality and safety in healthcare journal 21(4) & The role of the client in patient safety. A necessity, not a desirability. 2009-2011. Study/press release/kiz publication/isbn paper.

2438 Establishment of process for prevention of sedation patient-safety accident S. K. You 1,*, S. H. Han 2, J. H. Lee 1 and Sedation team 1 Qulity Assurance, 2 Anesthesiology and Pain Medicine, Seoul national university Bundang Hospital, Seongnam-si, Korea, Republic Of The importance of sedation through the Healthcare Accreditation was highlighted, and it includes many targeted people of 3000 cases a month. However, the reasonable sedation performance rate was low. Moreover, the establishment of sedation process for the patient s negligent accident prevention, educations and promotion activities were urgent because the recognition of patients, patient of family and health care givers were low. This study proceeded improvement activities with techniques of DMAIC (define, measure, analyze, improve and control) through the six sigma for sedation process establishment. In the stage of Define, this technique confirmed problems of sedation within the current hospital. The problem is that each process without standardization was performed. Moreover, there was loss of work efficiency of health care givers due to diverse processes, and the health care givers satisfaction was very low. In the stage of Measure, this technique drew a goal through the key indicator. The processes of sedation could be confirmed through sedation chart. So, as a result of confirmation regarding the current level of sedation chart from December 2010 until February 2011, this technique selected completion rate of daily sedation chart as a key indicator, and it set a goal as 85% in order to reach more than 80%, which is evaluation the health care accreditation standard for the hospital. In the stage of Analyze, this technique drew key reasons for solving the problems. This was technique confirmed potential reasons through the technique of 5why. This technique selected an improvement direction through the key reasons drawn. In the stage of Improve, the improvement activities were progressed. This technique adjusted the existing sedation guide to the process by each department so that the sedation can be well settled by each department and then revised it. This technique produced introductions and sedation guide panel of patients and family of patient. Moreover, this technique changed a part of computer program and it built up the pediatric sedation protocol for smooth communications between departments. In the stage of Control, this technique confirmed once more the current level and the post-improvement activity level through the key indicator selected in the stage of Measure. This study confirmed the completion rate of sedation chart from September 01 until October 31, 2011, and the completion rate average of the sedation chart was improved into 89% from 65% by 24%. DPMO (defects per million opportunities) was improved into 88%, and the sigma level was also improved into 3.84sigma. This study organized actual and concrete guidelines and improved communications between departments. This study standardized the sedation process of the whole hospital, reorganized the sedation chart, and heightened the health care givers performance convenience. In addition, this study could heighten the recognition of patients, family of patient and health care givers through production of all sorts of educations and introductions. In the future, it is considered that the regular health care givers education and indicator management will be required for the steady management. References: 1. Ministry of Health and Welfare, Korea Institute for Healthcare Accreditation (2011), Healthcare Accreditation Standards for Hospital 2 th Edition 2. Joint Commission International (2011), Joint Commission International Accreditation Standards for Hospitals 4 th Edition 3. Seoul National University Bundang Hospital (2011) SNUBH Innovation teaching material(s) 3 th Edition

2442 Lifting the filing rate of medical reports in orthopedics and surgery wards T.-L. Hsu 1, H.-C. Wei 1, Y.-C. Lin 1, S.-L. Lin 1,* 1 Taipei Hospital, DOH, New Taipei City, Taiwan Medical records are used to record the judgments and treatments given by the professionals to the patients. With the patients consciousness in law and awareness of their own rights, medical records would be immediately requested, duplicated, or even taken by public prosecutor or judicial police into custody once the medical disputes occur. Legal issues in filing medical records are therefore highly attended. Use patient records sury we find in the wards of orthopedics and surgery, patients frequently visited and the filing rate of the medical records is averaged 99.5% from the quarterly reports of 2010. But it dropped to 95% in the first quarter of 2011, which called in question the filing procedure of the medical records among co-workers and affected the patients rights as well as related measures. The low filing rate was examined and imputed to: 1) the checking out procedure was not established, 2) the location of the old medical reports was not clearly specified and unified, and 3) the transfer of the old medical reports among units was not standardized. The filing rate of the medical reports in the wards was raised to 100% after the procedure of checking out medical reports was standardized, training sessions of the medical reports filing were conducted, and the stamps for labeling the old medical reports and numbering them were made. The effect was significantly noted, which does not only better the security of the patients visits, but also improves the overall medical quality.

2460 Drug-Related Problems (DRP): application of clinical pharmacy services to improve patient safety T. Sriwahyuni 1,*, Y. I. Sugiarto 1, H. Yuliani 1 1 Siloam Hospital Lippo Village, Jakarta, Indonesia The objective was to show that by finding the type and cause of DRP improved the effectiveness of pharmacists intervention in preventing and resolving medication errors enhancing patient safety. 1. We developed a DRP's software program based on the modified Pharmaceutical Care Network Europe (PCNE) ver. 6.2. tools. 2. We set up the inclusion criteria, i.e. adult patient with polypharmacy (more than 5 drugs), new patient with history of numerous drugs, patient with chronic and complicated diseases, intensive care patient, and elderly patient. 3. We also set up the exclusion criteria, i.e. DNR (Do Not Resuscitate) patient, pediatric patient, outpatient, and maternity patient. 4. We set up a flow process with clear protocol and procedures for follow up upon type and cause of DRP was detected. 5. The study was conducted over 1 year period. 1. The pharmaceutical care was done to approximately 30 patients per day. 2. There were overall of 282 cases were identified that contributes to 532 DRP. 3. The top 3 type of DRP were drug treatement more costly than necessary (35.34%), effect of drug treatment not optimal (18.23%), and unecessary drug treatment (16.92%). 4. The top 3 contributor to the cause of DRP were no indication for drug, inappropriate combination, and more costeffective drugs available. 5. Out of this top 3 type of DRP, 37% cases were interfered by pharmacists and were approved by the prescriber. 6. From all DRP, 68% cases were resolved. 1. The study reached the objective that was set out to be achieved. 2. By analyzing the type and the cause of DRP, the pharmaceutical care intervention by clinical pharmacist to prevent further DRP could be specific and thus, efficient in improving the safety of patients.

2465 Quality promotion of handover across emergency and critical healthcare team S. H. Yang 1,*, S. Y. Hung 2, 3, S. L. Lin 4 1 Department of Emergency Medicine, 2 Department of Strategy Planning, Taipei Hospital, Department of Health, Taiwan, New Taipei, 3 Department of Business Administration, National Taipei University, Taipei, 4 Department of Surgery, Taipei Hospital, Department of Health, Taiwan, New Taipei, Taiwan One of Taiwan patient safety annual goals around 2010-2011 is effective communication between medical staffs. Healthcare quality depends on accurately, rapidly and completely passing important medical messages in continuous healthcare. According to the data from Taiwan Patient-safety Report system (TPR) in 2011, 4.3% of medical adverse events are correlated with handover. Good communication during handover can help medical teams control key points effectively and pass messages accurately. However, because of overload working and being busy, information is easily omitted when handover across units. We want to set a handover procedure between emergency room (ER), intensive care unit (ICU) and operation room (OR). By setting a structural communication model, we hope more accurate handover and more effective communication between these units. The study was undertaken at a 500-bed public general hospital in New Taipei City. A special committee cross ER, ICU and OR was established. We surveyed procedures of healthcare in critical patients from ER and the standard operational procedure (SOP) was made. The handover documents from ER to ICU and ER through OR to ICU were integrated and revised. Since October 2011, every critical patient from ER was transferred following the revised SOP. Quality indicators including accuracy and completeness of handover were also audited according to 12 categories in the checklists from SOP. The results were analyzed statistically. The accuracy of handover could maintain averagely 95%. Errors mainly occurred in incomplete documents, especially in handover time and no or incorrect signout of physicians carrying on because the physician carrying on might not be the same and the handover unit was not informed in time. The indicator of inquiring for the patient s information by phone after handover was largely improved. After the project was executed, there was no inquiring by phone. The completeness of handover was elevated from 67% to 100%. Effective communication between emergency and critical healthcare units is important for medical quality. The study sets a standard operational procedure which is suited for emergency and critical units by a cross-unit committee. Not only the quality and efficiency of continuous healthcare could be improved, but also the atmosphere of cooperation between cross-sectoral and multi-disciplinary team would be raised. The culture of patient safety would be promoted; therefore, it is worthy to be popularized. Our standard operating procedure has entered the stage of informatization. By integration of information system, we hope not only to reduce workload of medical staffs but also prevent writing and verbal errors.

2490 Self-reported participation to wrong-site surgery among surgeons and anaesthetists: a cross-sectional survey at two annual meetings of surgery S. Cullati 1,* and Francis P, Degiorgi A, Hochreutener MA, Bezzola P, Courvoisier DS, Khabiri E, Licker MJ, Chopard P 1 University Hospitals of Geneva, Geneva, Switzerland To explore the number of self-reported wrong-site errors among surgeons and anaesthetists. Cross-sectional survey in 2010, with self-administered questionnaire, at two Annual Meetings (97th Annual Meeting of the Swiss Society of Surgery, Interlaken, and 45th Annual Meeting of the European Society for Surgical Research, Geneva). Main outcomes were number of self-reported participation in wrong-site surgery (site, side, procedure or patient error), no matter who was responsible (in the team s respondent) throughout the career and during the last three years. In the first meeting (Interlaken), 433 questionnaires were distributed and 152 returned (participation rate 35%). In the second meeting (Geneva), 400 questionnaires were distributed, 40 were returned, but only 38 were usable (participation rate 9.5%). Among the 190 total respondents, most were males (67.6%), surgeons (68.0%, Anaesthetists 26.9%, Others 5,1%), had a mean age of 44 years (SD 12 years), and a median number of interventions / procedures by year of 400 (Mean 707). Self-reported participation in surgical procedure in which an operating site error (wrong side, level, procedure, or patient) took place (no matter who were the persons responsible), during the entire career, was 35.6% (8.4% skipped the question). Among respondents who participated in wrong-site surgery, the mean number of wrong-site errors was 2.8 (Median 2.0, SD 3.1, Min 1, Max 16). During the last three years, 16.7% reported participation in wrong site surgery. By types of wrong-site surgery, wrong side was the most frequent, followed by wrong procedure, wrong patient and wrong level (respectively 28.2%, 12.6%, 11.5%, and 8.6%, during the entire career). Reporting participation in wrong-site surgery throughout the career was more frequent among older respondents (20-37y: 18.8%, 38-50y: 35.0%, 51y and older: 58.7%, p<0.0001), among anaesthetists (71.7%, surgeons 21.2%, others 33.3%, p<0.0001) and among doctors in private practice (76.2% versus employed doctor 29.8%, p<0.0001). Among the employed doctors, those in private hospital/clinic more often reported wrong-site surgery compared to those working in university hospitals or non-university public hospital (respectively 64.3%, 21.7%, 34.0%, p=0.011). Proportion of surgeons and anaesthetics reporting participation in surgical procedure in which an operating site error (wrong side, level, procedure, or patient) took place was not negligible. Anaesthetists and doctors in private practice tend to report more participations in wrong-site errors.

2514 Designing an app to create home medication lists V. Santana 1, M. Vazquez-Vazquez 1,*, P. Perez-Perez 1, H. Rodríguez-Contreras 1 1 Observatorio para la Seguridad del Paciente, Agencia de Calidad Sanitaria de Andalucía, Sevilla, Spain To design a mobile application (app) that enables the patients to create the most complete and accurate list possible of all medications they are currently taking (home medication list) To facilitate the medication reconciliation process through this app Requirements definition by a group composed by pharmacists (hospital and primary care), family doctors, nurses, patient safety experts, usability experts and software technology providers. Revision by the Institute for Safe Medication Practices (ISMP-Spain) Pilot test of the solution carried out by patients belonging to the Patient Safety Citiziens National Network and the Regional Patients School. Publication of the app on Android Market and App Store The app works with the most complete database provided by the Spanish Health Ministery, called "Integra". From this database, the patients can select those medications they are taking choosing by active pharmaceutical ingredient (API) or national code. They can also included the dose, frequency, route and timing, and attach a picture of the medication. Regarding the patient information, name, allergies, date of birth, and a photograph are the required fields, since the app allows managing home meditations lists for several patients. The use statistics and other results will be ready by the conference. The app helps the patient keep and maintain an accurate list of all medications, that should be updated and reviewed with the caregiver(s) at each care transition point. References: ISMP España. Errores en la conciliación de los tratamientos con medicamentos. Boletin ISMP España nº 34. Diciembre 2011.

2521 Smart Prescription in the medical department in a regional acute hospital B. S. C. Kwok 1, K. M. Chow 2, H. Y. SO 3,*, S. F. Lui 3 and Ms Ellen OL Wong, Dr Kong Chiu Wong, Ms Ching Yee Cheung, Ms Wing Han Liu 1 Quality & Safety, 2 Medicine & Therapeutics, Prince of Wales Hospital, 3 Quality & Safety, NTE Cluster, Hospital Authority, Hong Kong, Hong Kong, China Medication errors for hospital inpatients are common and their consequence can be serious or even fatal. From Jul 2009 - Jun 2011, medication incidents accounted for 13% of reported incidents and were ranked second highest in categorization. Prescribing, the beginning of the medication process, is vulnerable. Poor hand writing and ambiguous order can lead to misinterpretation and therefore wrong dispensing and administration or even transcribing whereas polypharmacy and inappropriate prescriptions increase workload and therefore dilutes staff awareness. This was a first attempt to understand the situation of prescribing in search of appropriate strategies. 1. A cross-sectional observational study of all medication administration orders (MAR) in medical department in the same morning. MARs were photocopied without any patient identity and clinical background. 2. Prescriptions were reviewed for polypharmacy and smart prescription options with clinicians inputs. Polypharmacy was defined as having more than 5 drugs for an individual. 3. Prescriptions were cross-reviewed for legibility by two panels, each made up of a medical intern, pharmacist intern and fresh nurse graduate of 2-3 months of working experience. Prescriptions were defined as illegible as found unidentifiable by 2 or more members of the panel. 2394 valid prescriptions of 306 in-patients in 10 medical wards were photocopied and reviewed. Prescriptions of regular and irregular frequencies and all administration routes were included. 1. Polypharmacy review: Patients were prescribed with 0-23 drug items, i.e. 8 items/individual averagely, and 68.6% of patients had > 5 drugs prescribed. It was difficult to conclude whether polypharmacy could be effectively reduced as the department gave quaternary services and patients clinical conditions were blinded. 2. Smart prescription option review: 82.2% of prescriptions were regular, non-infusion prescriptions i. Odd frequencies which could be simplified and lessened in interval were identified. ii. Unapproved abbreviations were noted and their meanings were not commonly understood. iii. Ambiguous preparation/ strength used led to problematic guessing. 3. Legibility review: 3066 valid and old medications and 174 allergy boxes were reviewed. 6% of medication orders and 3% of allergy boxes were defined illegible by the reviewing panels. It involved 36.8% of patients. Astonishingly, 0.2% was illegible to all members. Participating medical interns expressed their eagerness to learn more about how to prescribe smartly. Recommended strategies for medication safety are: 1. A systematic recommendation of smart prescription options and legible writing to doctors is important. 2. Support and train the younger generation of doctor to do smart prescription. 3. Promote writing in print and recognize and reward good performers. 4. Essential clinical information is required for a realistic understanding of polypharmacy.

2588 Patients preference and satisfaction on hallway admission from an emergency department D. K. Kim 1, D. Suh 1,*, H. Noh 2, J. H. Jeong 3 1 Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, 2 Department of Emergency Medicine, Myongji Hospital, 3 Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggido, Korea, Republic Of Hallway admission (HA) is a system that admits the patients in a boarding area of emergency department (ED) to the hallway of hospital wards. This system was developed to reduce ED overcrowding and to improve ED patients satisfaction. This study was conducted to know preference and satisfaction of ED patients on HA From 1 April to 31 August in 2011, HA was introduced to the four participating wards (1 general emergency ward, 1 orthopedic ward, and 2 pediatric wards) of Seoul National University Hospital, a tertiary referral hospital. A structured questionnaire was administered to the patients who stayed more than 6 hours in the ED of the hospital. We collected and analyzed demographic and administrative data, preference (before HA) and satisfaction (after HA) of the subjects on HA. During 5 month-long study period, a total of 1,319 patients were enrolled to the preference survey. Among these patients, 952 (72.2%) were adults (older than 19 years old), and the mean age was 39.7 (SD; ± 25.7). Total of 937 (71.0%) preferred HA, and more adults patients supported HA than children (73.5% vs. 64.3%, P=0.001). The multiple logistic regression analysis showed that not having a bed in ED, anticipation on rapid admission, privacy protection, and emotional comfort by HA were associated with favorable attitude toward HA. A total of 39 patients were admitted to the hallway during study period. Among these, 27 (69.3%) patients were satisfied, and 25 (64.1%) and 28 (71.8%) patients answered that they would recommend HA to others, and re-use HA, respectively. There was no mortality or transfer to intensive care unit among HA cases. A great majority of the patients who stayed longer than 6 hours in ED prefer HA, and satisfaction was high among patients who experienced HA.

2624 Hospital-Wide Fall Prevention Program with regular review to enhance patient safety S. M. Wong 1,*, H. Y. M. Li 1, C. L. M. Yau 1, S. Y. C. Chong 1 1 Nursing Department, Hong Kong Baptist Hospital, Hong Kong SAR, Hong Kong, China Patient falls are the leading cause of accidents and serious injuries in the hospital and also lead to extended length of stay, added diagnostic procedure and surgical litigation. Fall prevention to minimize the risk is essential. The objective of the program is to identify the risk factors and implement appropriate fall preventive measures for patients in a private hospital. Fall incidents in 19 wards and 14 centers were quarterly reviewed. Frontlines and managerial staff of wards, centers and various departments were invited to participate in the fall prevention program to ensure staff involvement and feasibility of intervention. Preventive strategy was revised and implemented with on-going evaluation. Analyzed result and outcome were disseminated to hospital staff regularly. Risk assessment tool was revised in Dec 2010. Fall preventive measures with concerted effort from multi-departments including physiotherapy, estate & facilities management, supporting services and security were enhanced. The key interventions accomplished were to gain the participation of patients and accompaniers after poster alert and the specific education were provided to raise their awareness. Fall assessment, environmental orientation, fall hazard signage display and assisted toileting schedules were implemented. Patients fall risk was emphasized during clinical handover of every shift. Besides, interdisciplinary environmental rounds for patient safety were implemented to reduce environmental hazards. After implementation of the fall prevention program in 2011, fall incident rate was decreased from 0.42 to 0.35 per 1000 patient-days, reduced by 12.6% when compared to 2010. Incidents related to communication breakdown between the frontlines and accompaniers were decreased from 22% to 6%; related to surgical procedure or after anesthesia were reduced from 24% to 21%; patient fell outside ward for smoking was decreased from 12% to 8% and 2% due to environmental problem in 2010 and 2011. Whereas 63% in 2011 was due to dizziness or lower limbs weakness of patients when compared to 40% in 2010. While other findings were more or less the same when compared with 2010. In 2011, 17% of patient falls took place in young-aged patients below 12, 46% in adult aged 12-60 and 37% patients were above the age of 60. Contributing factors of older patient included taking medication such as sleeping pills and diuretics, inappropriate footwear, past history of falls, slippery floor and over-confident of self ability. This result showed that regular periodic fall incident review was as important as the implementation of fall preventive measures. It could provide hospital the useful information for better resources allocation and patient safety.

2660 Safe Surgery Checklist: how accurate are we at preventing surgical site infection? S. Mhamdi 1,*, M. Letaief 1, Y. Cherif 1, H. Abdelaziz 2 1 Preventive Medicine, University of Monastir, 2 General Surgery, University hospital of Monastir, Monastir, Tunisia Antibiotic prophylaxis given within the last 60 minutes by operating team to prevent surgical site infection is a criterion of the World Health organization's surgical safety checklist. The aim of this study was to assess the accuracy of the operating team at preventing surgical site infection. A 6-months prospective study of all types of operations in the general surgery department at the university hospital of Monastir (Tunisia) was performed. Only interventions requiring a surgical antibiotic prophylaxis were included. We compared the trend of surgical site infections at the beginning and 6-months after checklist implementation using the correlation test of Spearman rank (r '). A total of 185 interventions were included. Among operated patients 13.51% developed surgical site infection. The rate of antibiotic prophylaxis rise significantly from 47.3 before the use of the safe surgery checklist to 64.8% after 6 moths of its use (p = 0.04). The rate of surgical site infection decreased significantly from 28.2% to 2.6% at the same period (p = 0.003). Implementation of the safe surgery checklist was associated with a significant reduction in the rates of surgical site infections among operated patients.

2661 Assessing the perceptions of the patient-safety culture among healthcare workers in hospitals in the northeast of Libya S. Rages 1,*, F. Irvine 2, T. Livsey 1 and Fiona Irvine, Livsey Trish and Christine wall 1 Health and social applied science, 2 Nursing, Liverpool John Moores University, Liverpool, United Kingdom To examine the perception of patient safety culture among health care workers in Libyan Hospitals The study followed a quantitative design, using the survey method to investigate the knowledge and behaviour of health care workers towards patient safety culture. The study used the survey of Hospital Patient Safety Culture (HSOPSC) which was developed by the US Agency for Health Care Research and Quality (AHRQ, 2004). Setting: The biggest three Libyan hospitals which were located in the Northeast of Libya were involved in the study. Participants: 446 health care workers who were working as Doctors, Nurses, Technicians, Pharmacists and Managers participated in the study. The survey measured twelve composites of Patient Safety Culture dimensions.ten of the patient safety culture dimension were very weak and they need to be improved. The study identified ten of twelve area related to patient safety culture in Libyan hospitals that were very weak and they need to be improved. The study identifies the current state of patient safety culture in Libya and it recommended the necessity for conducting a qualitative research to explore the main causes that were behind this weakness. References: Agency for Health Care Research and Quality (2009). Surveys on patient safety culture user network, Advancing Excellence in Health care, volume 1, issue 1.pp1-6. Alahmadi H A (2009). Assessment of patient safety culture in Saudi Arabian hospitals, British Medical Journal Volume 10, issue1136. Pp1-5. Abdullatif A A (2008). International hospitals perspective: Eastern Mediterranean, The patient safety friendly hospital initiative: An entry point to building a safer health system in the Eastern Mediterranean, Region International Hospital Federation, 18-21. Abbas H. A, Bassiuni N. A & Baddar F M (2008).Perception of Front-line Healthcare Providers Toward Patient Safety: A Preliminary Study in a university Hospital in Egypt, Advanced Practice Nursing Journl, 8(2)p 1-6. Al-shaq M A L (2008). Nursing perception of patient safety at Hamad Medical Corporation in the state of Qatar, School of Nursing, Purdue University Indianapolis, 8-9. Aneesh A Singla, Kitch B, Weissman J S & Campbel G. (2006). Assessing patient safety culture: A review and synthesis of the,measurement Tools, Journal of Patient Safety VoL 2, 105-115. Ajaj H & Pansalovich E (2005). How safe is anaesthesia in Libya?, The Internet Journal of Health, Volume 4 issue 1528-8315 pg2. Ashcroft D M, Moorcroft C, Parker D & Noyce P R (2005). Safety culture assessment in community pharmacy: Developments face validity and feasibility of the Manchester Patient Safety Assessment Framework, Quality and Safety Health Care, 14; 417-421. Agency of Healthcare Research and Quality (2004). Hospital survey on patient safety culture, user guide, 3(12) www.ahrq.gov. Report of the commission on Patient safety and Quality Assurance (2008) Building a culture of patient safety). Government of Ireland office, 01-02. Ben Inhuman E (2007). Libyan health care system to reform or to transform, That is the question? Jamahiriya Medical Journal, Board of Medical Vo1. 7 No.3.pg 162-163.

2669 Implementation of new heart failure assessment tool post cardiothoracic surgery and outcomes P. Punudom 1,* 1 CVT surgery, King Chulalongkorn Memorial Hospital, Bangkok, Thailand To early detect clinical of heart failure post cardio-thoracic surgery by implementing new assessment plan 1. Develop criterias for nursing assessment of clinical heart failure following post-operative CVTs patients by dividing them into three groups, specify green, yellow and red code which means low, medium and high risk accordingly 2. Develop clinical risk factors criterias for monitoring heart failure 3. Providing optimum nursing care for each group according to severity of risk factors 4. Improve follow-up phone call program for early detection of heart failure after discharged. 20 patients were recruited in the study. 15 of them were low risk and 5 were medium. None was high risk. After using the new assessment plan and care protocol, 16 were in low risk and 4 were in medium risk group. No clinical heart failure was detected. New clincal assessment program by using severity risk factors resulted in early detection and significantly reduce postoperative CVTs heart failure.

2700 Implementation of a patient-safety learning system in a large academic health sciences centre C. Backman 1,*, A. Forster 1, D. C. Rothwell 2 1 Performance Measurement, THE OTTAWA HOSPITAL, 2 Performance Measurement, THE OTTAWA HOSPITAL RESEARCH INSTITUTE, Ottawa, Canada The Ottawa Hospital s Patient Safety Learning System (PSLS) is a system consisting of people, processes and technologies, designed to systematically detect, analyze, and respond to adverse events with a goal of improving the safety of patient care. The purpose of this study is to describe the organization-wide implementation of the Patient Safety Learning System. Using the latest software from Datix Ltd as the core, TOH has built a unique Voluntary Reporting model that engages physicians in the validation of patient harm and engages risk management professionals in classifying events. In addition to a self-reporting capability, TOH has built a system that incorporates two proactive surveillance methods, namely the Clinical Observation module and the etrigger module. All three methods are integrated into a single user and computer system that unifies the results of all three event detection methodologies. In addition to the three detection modules, the TOH system is also leading-edge in the use of clinical reviewers (physicians) to determine whether the outcomes are due to medical error or the progression of the underlying illness; and the use of core reviewers (risk managers) to determine the severity of the incident and classify the event according to World Health Organization (WHO) standards. From January to December 2011, a total of 12,347 events were reported into the PSLS. Following the review by clinical reviewers, the reported events were classified as 14.7% (812) adverse events, 41.9% (5,179) potential adverse events and 42.4% (5226) non-events. Of these 14.7% adverse events, 940 (51.9%) were considered preventable and 872 (48.1%) non-preventable. Of the 51.9% preventable adverse events, the most common events were 40% clinical processes, 19% falls, 13% medication and 9% laboratory related. Of the 48.1% non-preventable adverse events, 80% were falls and 8% clinical process or procedure related. Of the 41.9% (5,179) potential adverse events, the most common events were 60% laboratory, 13% medication, 8% documentation and 7% clinical process or procedure related. These findings support the integration of the clinical reviewer and core reviewer functions into the PSLS. Continuous patient safety improvement can be further enabled by capturing and learning from adverse events and by measuring ongoing progress toward achieving a culture of safety.

2705 The success of a post- office hours acute medical admission ward (AMAW) in a regional acute hospital during a medical manpower crisis C. K. F. Mok 1,*, K. F. Chan 1, C. Lam 1, S. Y. Au 1 1 Medicine and Geriatrics, Hospital Authority, Hong Kong, Hong Kong, China Our hospital is the largest acute regional hospital in NTWC region of Hong Kong serving 1.1 million population with over 80% of the inpatients were emergency admissions (E-admission). Patients were admitted to various wards according to rota and specialty triage at Emergency Department. In 2011, there was severe frontline manpower shortage in M&G department. One of 10 acute Medicine & Geriatrics (M&G) wards was converted to a post- office hours acute medical admission ward (AMAW) as a contingency measure to enhance patient safety and improve admission efficiency. The running of AMAW was as follows: 1. Admit all M&G E-admission after office hour. ( > 60% of daily E-admission). 2. Senior staffs to conduct morning round of these patients for care-planning, subspecialty triage and early discharge. 3. All patients were either discharged or transferred to assigned M&G wards before afternoon. Evaluation of the AMAW includes its impact on the Average Length of Stay (ALOS), unplanned readmission rate (URR) and mortality rate (MR) of the department. The AMAW was successfully operated from January to August 2011. Data of 1st and 2nd Quarter 2011 were compared with 2010 and previous years. The efficiency was demonstrated by shorter ALOS: 4.75 days (2011) Vs 5.2 days (2010) despite similar E-admission. The effectiveness was demonstrated by similar URR: 22.6% Vs 22.0% and MR: 6.15% Vs 5.9% respectively. The advantages of AMAW logistics: 1. Strengthen the post-office hour E-admission process (the weakest link of M&G service). Since E-admissions were concentrated in AMAW after office-hours, all on-call manpower and resources could be deployed there synergistically. 2. Other M&G wards could focus on the caring of their inpatients and spared the admission pressure 3. Four case MO postings were spared during the period. The disadvantages were: 1. Difficult to sustain a strong nursing team for such intensive service (especially night time) in long term. 2. Increase in inter-ward transfer during day time. 3. Long term medical training and development needs of nurses were difficult to meet. With the gradual improvement of medical manpower, the need to cater for subspecialty bed requirement and the long term training needs of the nursing staffs, the AMAW was stopped in September 2011. AMAW is a workable model with good efficiency and effectiveness. This ensures good patient safety despite medical manpower crisis. Further exploration of this service model for M&G is worthwhile especially if additional resource is available.

1024 A survey study on the satisfaction rate and opinions of medical review physicians from paper review to online professional review W.-F. Tseng 1,*, M.-C. Lin 1, Y.-M. Chen 1 1 Medical Review and Pharmaceutical Benefits, Bureau of National Health Insurance, Taiwan, Taipei, Taiwan With an aim to develop an efficient, good-to-use online medical review system, a survey was conducted to all medical review physicians by the Bureau of National Health Insurance (BNHI) in Taiwan. This study investigated 3 main things: 1). the satisfaction rate and opinions of the reviewers on the current review procedure, 2). the status and satisfaction of using the existing PACS system to read electronic medical records, and 3). the willingness to use and opinions on an online medical review system which BNHI plans to install. The content of the questionnaire was designed centered on the various key aspects of empirical review practice so as to achieve the objectives stated above. The draft of the questionnaire was revised and finalized after discussions in several meetings with relevant personnel. To obtain the satisfaction rate and relevant opinions of all the reviewers, the questionnaires were sent out to all the 2,589 reviewer physicians. To raise the response rate, questionnaires were handed out to the reviewers by the branch staff when reviewers came to the branch offices to do the review. It took about two months to complete 1,242 questionnaires. The response rate was 47.97%. After manual key-in, a data base was constructed. Then statistical analysis and charts/graphs were done using SPSS version 14.0 and EXCEL. The results showed that among all NHI reviewers, 72.79% of them were satisfied with the current medical review procedure, 78.02% satisfied with the room space, 65.86% satisfied with the information provided, and 60.23% satisfied with the computer equipments. With regard to the medical records and related documents presented for review, while 56.44% of the reviewers indicated they were satisfied with the current way of using zerox copies, 56.69% agreed to change to using electronic medical record files. Moreover, 45.09% of reviewers indicated they have used the PACS system. Among them, 73.93% think it s convenient to use. For those who have never used the PACS system, 63.82% of them showed that they were willing to use it. Furthermore, 64.49% of the reviewers indicated they would be willing to use an online professional review system to do the review. If the BNHI establishes a new online professional review system in the future, 64.98% responded that they will require a training course for the new system; 62.64% will need a hand-writing tool to assist entering review opinions and denial related data; 63.20% request to build a checking mechanism to reduce errors in entering data; 64.41% need an automatic medical-order indexing system of the review regulations; 68.76% ask to upgrade computer equipments to speed up the review work. All these demanded-features and suggestions are worthy of consideration in constructing the new online review system. The overall survey revealed that review physicians expressed high satisfaction rate to the current review procedure, and the facilities or services provided by the BNHI in Taiwan for reviewers to do medical review, such as room space, the related document or information and computer equipments, etc. It also showed that large percentage of reviewers think the existing PACS system for reading electronic medical records is convenient to use. Most importantly, this survey collected very useful information and gave valuable insight for the BNHI to continue improving its current review procedure, to expand software/ hardware computer equipments, and even to construct a well-organized online professional review system.

1033 Measuring family experiences of care in two pediatric public hospitals in Argentina, based on HCAHPS Survey N. Dackiewicz 1,* on behalf of Hospital Garrahan, E. Garcia Elorrio 2 on behalf of IECS, S. Rodriguez 3 on behalf of Hospital Garrahan, C. Gonzalez 4 on behalf of Hospital Garrahan and Children s Hospital "R Gutierrez" 1 Quality and Safety Coordinator, Hospital de Pediatría "JP Garrahan"., 2 Quality and Safety Director, IECS, 3 Investigation Coordinator, 4 Assistant Physician, Hospital de Pediatría "JP Garrahan"., Buenos Aires, Argentina 1. To develop a survey for systematic and standardized assessment of quality of care and family experiences of pediatric inpatients, from the caregivers perspective during their children hospitalization, based on translation and cross-culturally adaptation of HCAHPS; 2.To measure validity and reliability of the survey in 2 Argentine pediatric hospitals Qualitative and quantitative cross-sectional study carried out in 2 reference pediatric hospitals in Argentina: Garrahan Hospital (GH) and R Gutierrez Hospital (RGH). Stages executed to adapt H-CAHPS survey: 1. Forward translation and backward translation of H CAHPS core survey; 2. Face validity; 3. Semistructured Interviews with health care members and focus groups with caregivers: to discuss opinions, values, and beliefs of key actors 4. Cognitive assessment of the preliminary version; 5. Validation: administration of adapted H-CAHPS to measure reliability and validity Study population: parents or caregivers of pediatric patients hospitalized for at least 24 hours in GH or RGH between november 2010 and august 2011. Exclusion criteria: Caregivers of patients discharged from ICU/ patients who died, or did not consent. Sample randomly selected. Surveys were administered by a health professional unrelated to patient s care inmediately before discharge. Study variables: a. Respondent s data(age, sex, relationship with patient, educational /socioeconomic level, place of residency) b. patient s data (age, sex, cause of admission, length of stay, transference between different areas or institutions, surgery, chronic disease).analysis: T Test or U Mann Whitney test /Fisher's exact test or Chi square Reliability: Cronbach s α score (> 0.7) Validity hypothesis 1. Modifications to original HCAHPS survey (based on face validity and qualitative phase) We excluded: Q10: Help with bathroom or bedpan; Q11: Frequency of help with bathroom or bedpan; About you Section (origin, race, language,etc) We added:q on security of belongings; Q on food quality; Q on paperwork 2. 1032 surveys were administrated, 630 (61%) at GH and 402 (39%) at RGH Caregivers: 85% was patient s mother (n=874) age: 33 ± 9. 4 yrs. Complete primary school: 282(27%). Incomplete secondary school: 61%(625). Families with unsatisfied basic needs: 35% (365), without health insurance: 51%(529). Patients: girls: 55% (564), age: 5.9 ± 5.3 yrs. Chronic illness: 62%. Surgical intervention: 35%. Transferred from another institution: 14%. Length of stay: 11±17 days. Validity hypotheses: The outcome variable,"good experience"(ge), was constructed from dichotomization of ranking scale as >9 /8 or <. GE was directly proportional to the question of opinion and educational level and inversely proportional to having health insurance Internal consistency (Cronbach α): Domain 1.Nurse care (q1q2q3) 0,78 2.Physician care (q5q6q7) 0.75 3.Hospital (H) setting (q8q9) 0.53 4.H Experience (e1e2e3) 0.39 5.Medication (q16q17) 0.85 6.Pain management (q13q14) 0.89 7. H discharge (q19q20) 0.44 The development of an instrument for evaluation of family experiences during their children hospitalizations was achieved. The survey, resulting from the adaptation of HCAHPS questionnaire, is reliable and valid for the evaluation of family perceptions of pediatric patients in Argentine hospitals. α

1041 The effect of health promotion program in Taiwanese hypertensive people and hypercholesterolemia M.-P. Wu 1,*, T.-C. Wang 2, M.-J. Kao 3, W. Yang 4 1 Department of Nursing, 2 Superintendent, 3 Department of Physical Medicine and Rehabilitation, 4 Department of Pediatrics, Taipei City Hospital, Taipei, Taiwan To evaluate the effectiveness of a health promotion program targeting people who suffer hypertension and hypercholesterolemia. A pre-experimental study was conducted. This study was conducted on residents living in the Shilin District of Taipei City, Taiwan. All of them were physically diagnosed suffering hypertension and hypercholesterolemia. Participants received a community-based health promotion program based on Bandura s concept of self-efficacy and behavior change. After assessing all the participant s needs, interventional programs, based on community mobilization, were implemented and measured. Participants completed assessments at the baseline and at a 6-month follow-up. Besides, a self-care booklet regarding hypertension and hypercholesterolemia was also given to participants. It contained real stories about people troubled by hypertension and hypercholesterolemia and how they managed their daily self-care activities.in addition, a 20- minute lecture, followed by a 20-minute exercise period and then a 40-minute efficacy-enhancing counseling session were provided by a facilitator. Sixty participants (mean age=65.83±9.32) were evaluated throughout a 6-month study period. The results indicated that there was no change in blood pressure and triglyceride. However, the waist (p=.03), HDL-cholesterol (p<.00), and efficacy expectations (p<.00) had significant improvement between the baseline and the 6-month follow-up. Systolic blood pressure Diastolic blood pressure Baseline Mean±SD 6-month follow-up Mean±SD 95% confidence interval t-value p-value 133.83±18.11 131.07±13.95-1.45~6.98 1.31 0.19 81.37±13.11 82.10±10.24-3.85~2.39-0.47 0.64 Triglyceride 130.12±86.17 123.60±86.01-8.41~21.44 0.87 0.39 Waist circumference 84.20±9.02 83.16±8.05 0.09~1.99 2.20 0.03 HDL-cholesterol 58.52±13.95 53.57±13.55 2.85~7.05 4.71 0.001 Efficacy expectation 110.58±32.84 137.47±18.13-36.03~-17.74-5.81 0.001 This study was the first using reliable instruments to measure the effectiveness of the health promotion program based on the self-efficacy theory on people with hypertension and hypercholesterolemia in Taiwan. The usage tended to have a positive effect on the participants self-confidence and helped them to maintain a higher level of both behavioral and physical health. Through promoting to the community, the program should have a good effect on common people but not constrained among chronic people or patients.

1076 Reinforced Policy to implement the correct use of prophylactic antibiotics in the operating room H.-C. Wang 1,*, J.-H. Chuang 2, C.-H. Huang 1, Y.-C. Liu 1 1 Department of Administration, 2 Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan Correct use of prophylactic antibiotics is known to decrease surgical site infection, shorten hospital stay of the patient and embrace cost-effectiveness for the hospital. According to a report from the Taiwan Patient Safety Reporting System (TPR) that was established in 2004, the number of medication without compliance to the scheduled time was 457 (5%) out of 9,148 medication error events in 2009 in Taiwan. The latter was listed as the number one events among a total of 29,803 reported to TPR. Accordingly, the Department of Health in Taiwan placed correct medication as the top priority in patient safety in 2010. As a medical center in southern Taiwan, we not only had to comply with the policy, we also adopted a strategy to implement the correct use of prophylactic antibiotics in the operating room (OR). Prior to reinforcement, the percentage of correct use of preoperative prophylactic antibiotics in OR was 84.23% in the first quarter in 2010. The correct use of second dose of antibiotics at 4 hours following operation when operating time is longer than 4 hours was only 13.83%. We adopted three strategies to improve it: 1, To give surgeons in every department or division a refreshment course to acknowledge the importance of correct use of prophylactic antibiotics; 2, To use timer for accurately alarming the nurses to give a second dose of prophylactic antibiotics at 4 hours following operation when operating time is longer than 4 hours in every OR; 3, To build up an electronic dashboard in our computer system to accurately monitor and record the time to give the antibiotics. Following the above strategies, the correct use of preoperative prophylactic antibiotics increased significantly from 84.23% to 91.9% (P=0.006). The correct use of second dose of antibiotics at 4 hours following operation improved dramatically from 13.83% to 81.33% (P=0.009) in the second quarter in 2010. The OR team accustomed to the policy and the percentage of correct use of prophylactic antibiotics continued to improve in the third quarter, which reached 96% and 95% respectively. Our results indicate that a reinforced policy including effective education, a timer to accurately monitor the operating time in order to give the second dose on time, as well as an electronic dashboard in our computer system to monitor the time to give the antibiotics is effective to improve the correct use of prophylactic antibiotics. References: [1] Alicia J. Mangram, MD; Teresa C. Horan, MPH, CIC; Michele L. Pearson, MD; Leah Christine Silver, BS; William R. Jarvis, MD;(1999)Guideline for Prevention of Surgical Site Infection, Infection Control and Hospital Epidemiology, 20(4)247-278. [2] Classen DC, Evans RS, Pestotnik SL, et al. (1992)The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. New Engl J Med, 326(5)281-286.

1134 Evidenced-based interventions for patient safety D. L. Cohen 1,* 1 Datix Ltd., London, United Kingdom Healthcare patient safety improvement efforts over the last decade have been inconsistent in application and success, while recent evidence suggests that the magnitude of harmful incidents is actually much greater than previously assumed. Whereas systematic reductions in the frequency of some kinds of adverse events have not been consistently demonstrated there have been notable successes, particularly in reductions of surgical morbidity and mortality and prevention of healthcare associated infections of several kinds. This presentation will summarize the basis for and results of implementation of strategies to reduce adverse events through utilization of standardized processes to prevent adverse events. Data demonstrating improved clinical outcomes and associated cost-savings/cost-avoidance will be emphasized. Strategies for extending the lessons learned from these experiences will be presented. 1. Define the incidence of hospital-based patient safety adverse events as identified by voluntary reporting or analysis by focused studies or trigger methodologies 2. Present examples of success in event avoidance 1. Catheter-Related bloodstream infections 2. Ventilator-Associated Pneumonia 3. Surgical Morbidity and Mortality 4. Medication Administration A systematic review of the patient safety medical literature was undertaken to identify relevant data portraying the incidence of hospital-based adverse events identified by voluntary reporting and focused studies and the outcomes of specific interventions designed to reduce adverse events of various kinds. Data demonstrating the merits of interventions in four targeted areas will be highlighted. 1. Between 25-30% of hospitalized patients experience adverse events during hospitalization and nearly half of these patients have prolonged hospital stays related to these events. 2. Voluntary reporting identifies only a small proportion of these events while focused studies identify a much larger proportion 3. Upwards of 65% of catheter-related bloodstream infections can be prevented with application of prevention guidelines and team training 4. As compliance with the IHI VAP bundle increases the rate of ventilator associated pneumonia dramatically decreases. 5. Utilization of the WHO Surgical Safety Checklist is associated with approximately 40% reductions in surgical morbidity and mortality. 6. Bar-coding can reduce the rate of potential adverse drug events by approximately 50% and medication timing administration errors by 25-30%. Transcription errors can be completely eliminated. 1. Focused-studies are more likely to define the magnitude of patient safety adverse events and are labor intensive 2. Significant reductions in serious events can be prevented by adoption of standardized processes for providing healthcare and utilization of bar-coding to prevent medication errors. References: de Vries, EN., et.al. Effect of a Comprehensive Surgical Safety Checklist on Patient Outcomes. NEJM 2010;363:1928 Pronovost P, et.al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. NEJM 2006;355:2725 Bird D, et.al. Adherence to Ventilator-Associated Pneumonia Bundle and Incidence of VAP in the Surgical Intensive Care Unit. Arch Surg 2010;145:465 Poon E, et.al. Effect of Bar-Code Technology on the Safety of Medication Administration. NEJM 2010;362:1698

1159 Endocrine therapy adherence and persistence and survival among women with breast cancer in Brazil C. Brito 1, M. C. Portela 2,*, M. T. L. Vasconcellos 3 1 department of administration, management and health planning, National School of Public Health/ Oswaldo Cruz Foundation, 2 department of administration, management and health planning, National School of Public Health/ Oswaldo Cruz Foundation and National Cancer Institute of Brazil, 3 National School of Statistical Sciences, Brazilian Institute of Geography and Statistics, Rio de Janeiro, Brazil This work was aimed at identifying explanatory variables of hormone therapy adherence and persistence in women withbreast cancer, and evaluating the effect of such variables in breast cancer survival rates. Retrospective longitudinal data from a cohort of5861 women with breast cancer, submitted to hormone therapy, was put together through linkage of the Brazilian National Cancer Institute (INCA)datasets, including the control of medicines delivered at its Pharmacy. A logistic regression model was applied to study adherence. Cox proportional hazard models were used to estimatepersistence and breast cancer survival. Assuming at least 80% adherence to treatment, the proportion of treatment adherent women was 75.3%. At the end of the first and the fifth year of treatment, respectively, overall persistence (without at least 60 day interruption) to treatment was79% and 31%, and survival was 94% and 71%. Similarly, better adherence and persistence to treatment, as well as breast cancer survival, were associated with higher education, having a partner, lower cancer stages, being submitted to surgery, having less inpatient care, making outpatient visits to a Mastologist and a Clinical Oncologist, and the need of less exams. Older women were more likely to adhere and to persist to treatment, but those aged 70 years old or more presented higher hazard of death. Alcoholism was associated with lower adherence and persistence, while tobacco use was associated with lower survival. Longer time between diagnosis and the beginning of hormone therapy and cancerfamily history were, respectively, a risk and a protective factor to treatment persistence and survival. Psychotherapy was protective for adherence and survival. Finally, treatment adherence was positively associated with breast cancer survival, being combined tamoxifen and aromatase inhibitor explicative of lower adherence, while only aromatase inhibitor use was associated with higher hazard of death. In this cohort, ¼ of the patients did not adhere, only 31% completed the 5-year hormone treatment without an interruptionof at least 60 days, and 71% were alive after five years. Socio-demographic, behavioral, clinical and health care aspects explained partially variations in these dependent variables.

1165 A Psychologist for nurses and nurse-assistants in an intensive care unit: impact of burnout and anxiety on the caregivers F. Gigon 1, 2, S. Delaloye 1, 2, P. Merlani 1, 2, B. Ricou 1, 2,* and the Psychologists in ICU Group 1 University of Geneva, 2 APSI, University Hospitals of Geneva, Geneva, Switzerland Caregivers of intensive care unit (ICU) are facing a demanding job with a high level of technology, a stressful environment and a high work load. They are at high risk of developing anxiety, depression and a burnout 1. These psychological distresses can impact on their welfare, performances and patients care 2. Burnout favours absenteeism and job-leave from ICU, whereas the shortage of ICU caregivers already started 3. Our objective was to evaluate the impact of the intervention of a psychologist on anxiety, depression and burnout of ICU nurses and nurse-assistants. Randomised, controlled, single blind study. The intervention group attended problem-based weekly sessions in small groups lead by 2 psychologists with a systemic approach during 9 months. Individual meetings with one of the psychologists were optional. Anxiety (HA)-depression (HD) and burnout were assessed by the Hospital Anxiety and Depression Scale (HADS) and the Maslach Burnout Inventory (MBI) respectively, before and after the intervention, and between the intervention (IG) and control (CG) groups. Out of 170 caregivers of a tertiary ICU of 36 beds, 99(58%) responded the questionnaires before and after the intervention: 77(78%) nurses; 22(22%) nurse-assistants. Men:24(24%); Age<40yo:72(73%); Occupational rate 100%:54(55); Intervention Group(IG):41(41%); Control Group(CG):58(59%). IG: Scores mean(sem):ha:before 7(17)/after 5(13); HD:0/2(5); MBI:-14.5(2.98)/-19.4(2.61)p<0.05; Exhaustion:16.3(1.83)/13.4(1.54); Depersonalisation:6.49(.87)/4.7(.65)p<0.01; Accomplishment:36.8(.98)/37.5(1.06). Proportions N(%) of severe Anxiety (HA>8):7(17)/5(13); Severe Depression(HD>8):3(5)/2(4); Severe burnout (MBI>- 9):15(27)/14(25). CG: Scores mean(sem):ha: before 6.5(.43)/after 6.7(.45); HD:4.2(.45)/3.8(.41); MBI:-15.8(2.33)/-18.5(2.07); Exhaustion:16.9(1.45)/15.1(1.35); Depersonalisation:5.3(.77)/5.0(.58); Accomplishment:38.1(.87)/38.7(.78). Proportions N(%) of severe Anxiety:7(13)/11(19); Severe Depression:0/2(5); Severe burnout:15(41)/9(22). HADS and MBI scores tended to decrease for the whole cohort of caregivers. The scores did not differ significantly between the groups at any moment. The scores of burnout decreased significantly after the intervention, whereas not in the control group. In parallel, the ICU activities during the 3 time periods of 3 months, before, during, after intervention were: Mortality(%): 8.8,8.3,13.0(p=0.009); Mean ICU admissions/month:272,242,173; Mean SAPS (severity of diseases of patients):39,37,37; Mean PRN (nurse work load):166,167,166, respectively. Up to 32% of ICU nurses and nurse-assistants showed high risk of burnout, and up to17/4% showed signs of anxiety/depression. After the intervention by psychologists, the scores of burnout decreased significantly whereas it was unchanged in the control group. Also, the anxiety-depression scores tended to decrease more in the IG, although there was no statistical significance. The presence of psychologists might help to care for the caregivers. Further investigation is needed for testing their usefulness for physicians. References: 1 Merlani P., Am J Respir Crit Care Med 2011; 2 Maslach C, Annu Rev Psychol 2001; 3 Steinbrook R. N Engl J Med 2002

1173 Study of factors for unscheduled readmission to intensive care units in certain regional hospitals by retrospective analysis of medical records M. Chen 1,*, T. Lin 1 1 Department of Nursing, Taipei City Hospital, Taipei, Taiwan 1. To study the diagnosis, length of day, and APACHE II variation of unanticipated return to intensive care unit cases; 2. To investigate the incidence of and related factors for unscheduled readmission to intensive care unit. The study design was based on the retrospection of medical records. The subjects of the present study were the adult patients transferred into the intensive care unit following transfer out of the all-purpose intensive care unit during hospitalization between January and December 2010. The diagnosis, APACHE II score, laboratory data, and return cause were collected. 1. The APACHE II score was significantly different (F=513.98; p=0.000 * ) when returning to the intensive care unit following the transfer in and out of it. 2. Hemochrome level and hemodynamics parameters could serve to elucidate the total explained variance of 33.9% (F(1,32)=8.220, p=0.001) when the patient returned to the intensive care unit. The identification of the cause, and diagnosis, of the return was beneficial to the assessment of the medical care quality. It was recommended that, prior to the transfer out of the intensive care unit, the hemochrome level be followed and rectified in order to sustain the hemodynamics parameters. References: Retrospective medical record study, unscheduled readmission, intensive care unit

1176 Evaluation of gastric extubation indicator in a home care program in a university hospital L. K. Naves 1,*, D. M. R. Tronchin 1, M. M. Melleiro 1, A. C. A. Garzin 1 1 Nursing School of University of São Paulo - Brazil, São Paulo, Brazil This study aimed to evaluate health care practice of gastrointestinal intubation for enteral feeding for users of the Home Care Program (HCP), at the University Hospital of the University of São Paulo. This is an exploratory-descriptive study, with a quantitative approach. The population consisted of 37 subjects enrolled in the HCP, with gastrointestinal intubation for enteral feeding. Data collection was performed by means of two forms and collected between April 15 to August 15, 2010. Data were analyzed according to descriptive and inferential statistics and statistical tests with significance of 5% were applied. In the characterization of users, 51.4% were female and 67.6% were aged 60 years. In relation to primary diagnosis, there was predominance of 67.6% of patients with neurological diseases and the mean stay in the HCP was 10.3 months (sd +12.2). Regarding caregivers, the majority (89.2%) was female, mean age of 50.6 years (sd +13.4), 97.3% had family ties with the user and 35.1% did not finish elementary school. Regarding the route of gastrointestinal intubation, 51.4% used the gastrostomy, the predominant type of diet was 51.4% semi-artisan. The gastrostomy feeding tube was replaced 29 times and the mean time of stay was 3.8 months. In the classification of extubations, considering 100 days, we obtained the overall incidence rate of 1.08, of which 0.26 of planned extubations and 0.82 of unplanned. The main circumstances involved in extubations were : in the planned, elective replacement of the tube; in the unplanned, balloon rupture of the gastrostomy tube, with a statistically significant difference (p = 0.009). When comparing the pediatric with the adult / elderly group, no statistical difference regarding stay in HCP and mean age of the caregiver (p = 0.00) were observed. The incidence rate of unplanned extubation in the pediatric group was 1.05 and in the adult / elderly group was 0.73, with no statistically significant difference (p = 0.28). The user s profile of HCP consisted mostly of elderly female patients, with an admission diagnosis of neurological diseases and gastrointestinal intubation via gastrostomy; the caregiver was a casual and family member represented by the female figure. Regarding gastrointestinal extubations measured through result indicators and by identifying the involved circumstances found that the findings helped to understand the reality of patients with gastrointestinal intubation for nutritional support in the program, providing subsidies to establish the assistance and managerial goals for the continuous improvement of quality and for the necessary changes in work processes in the home care practice. References: Cartolano F C, Caruso LC, Soriano FG. Terapia nutricional enteral: aplicação de indicadores de qualidade. Rev Bras Ter Intensiva. 2009;21(4):376-83. Cawsey SI, Soo J, Gramlich LM. Home enteral nutrition: outcomes relative to indication. Nutrition in Clinical Practice. 2010; 25 (3): 296-300 Donabedian A. Evalución de la calidad de la atención médica: In: White KL,Frank J org. Investigaciones sobre servicio de salud: uma antologia. Washington - (DC): OPAS; 1992. p.382-404.

1197 Ambulatory Care Sensitive Conditions (ACSC) admissions as an efficiency indicator for healthcare utilization E. Shin 1,*, K.-J. Jeong 2, J. Kim 3, H.-Y. Kang 4 1 Dept. of Preventive Medicine, The Catholic. University of Korea, 2 Dept. of Health Administration, Namseoul University, Seoul, 3 Dept. of Hospital Management, Konyang University, Daejon, 4 College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, InCheon, Korea, Republic Of To quantify ACSC admission rates and identify factors associated with variation among Korean hospitals to contemplate a potential problem of inefficient utilization of health care resources. Using the NHI claims data in 2004, mean ACSC admission rate of all hospitals with ACSC cases was computed. Regression analyses were conducted to assess the effect of hospital and regional characteristics on the ACSC admission rates. The average ACSC admission rate of 4,461 hospitals was 1.45%. Substantial variations were observed among small and medium-sized hospitals with a wide range of ACSC admission rates (0~87.9% and 0~99.6%, respectively) and high coefficient of variation (CV, 7.96 and 2.29, respectively), as compared to large hospitals (range: 0~19.1%, CV: 0.85). Regression analysis results showed that medium-sized hospitals compared to small-sized hospitals significantly increased the ACSC admission rates (b=0.986, p<0.05). Also, private corporate hospitals had significantly higher admission rates than public hospitals (b=0.271, p<0.05). Substantial variations in ACSC admission rates suggest the potential problem of unnecessary inpatient care. Since medium-sized and private corporate hospitals are likely to increase ACSC admission rates, future health policy on controlling health care use would need to focus on these types of hospitals. References: 1. Billings J, Zeitel L, Lukomnik J, et. al. Impact of socioeconomic status on hospital use in New York City. Health Aff (Milwood) 1993;12:162-173. 2. Niti M, Ng TP. Avoidable hospitalization rates in Singapore, 1991-1998: assessing trends and inequities of quality in primary care. J Epidemiol Community Health 2003;57:17-22. 3. Steiner JF, Braun PA, Melinkovich P, et al. Primary-care visits and hospitalizations for ambulatory-care-sensitive conditions in an inner-city health care system. Ambulatory Pediatrics 2003;3:324-328. 4. Kozak LJ, Hall MJ, Owings MF. Trends in avoidable hospitalizations, 1980-1998. Health Aff (Milwood) 2001;20:225-232. 5. Blustein J, Hanson K, Shea S. Preventable hospitalizations and socioeconomic status. Health Aff (Milwood) 1998;17:177-189. 6. Gill JM. Can hospitalizations be avoided by having a regular source of care? Fam Med 1997;29:166-171. 7. Shin SM, Kim MJ, Kim, ES, et. al. Medical Aid service overuse assessed by case managers in Korea. J Advanced Nursing 2010; 66(10): 2257-65. 8. Evans R. Supplier-induced demand: some empirical evidence and implications, in the economics of health and medical care. In Perlman K, ed. The Economics of Health and Medical Care. London:McMillan; 1974:162-73. 9. OECD Health Data, 2009. 10. Hwang JI. Characteristics of patient and healthcare service utilization associated with inappropriate hospitalization days. J Advanced Nursing 2007; 60(6): 654-62.

1228 The Time Effect of waiting for admission to intensive care unit on ventilator patients in emergency department S.-C. Hung 1,*, T.-C. Lee 2, C.-T. Kung 1, W.-H. Lee 1 1 Emergency Mdicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, 2 Department of Public Health, College of Health Science, Kaohsiung Medical University, Kaohsiung City, Taiwan The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, such studies have treated ICU waiting time in a dichotomous manner, and the definitions of delayed admission were not identical across studies. The current study explored the effect of waiting time on patients outcome, and proposed a model to define delayed admission. This was a retrospective cohort study. All non-traumatic adult patients on mechanical ventilation in the emergency department (ED) from July 2009 to June 2010 were included. The following data were collected and analyzed: demographics, triage result, length of time spent in ED, ICU waiting time, APACHE II score, early readmission after prior hospital discharge, days of ventilator use, length of stay in ICU and hospital, and patient s condition at discharge. The primary outcome measures were 21 ventilator-days mortality and prolonged hospital stay (over 30 days). Groups comparisons (survived vs. not survived) were analyzed using Chi-square, Student s t-test, and Wilcoxon s rank sum test. Models of Cox regression and logistic regression were used for multivariate analysis. The final analysis included 1242 non-traumatic adult patients. We subset the overall data by ICU waiting time and used the Cox regression method for iterative calculation to estimate the hazard ratio of ICU waiting hours on mortality in each subset. We found that if the waiting time less than 4 hours or over 10 hours, the hourly effect on mortality was not statistically significant, but statistical differences emerge for waiting time between 5 hours to 9 hours. Therefore, model of three stages of waiting time ( not delayed, delayed and too late ) was suggested. Logistic regression revealed that ICU waiting time affected the outcome of prolonged hospital stay at an odds ratio of 1.008 (95% confidence interval 1.002 1.014). The typical ED is not well equipped to act as a temporary ICU in caring for critically ill patients on ventilators. Such patients boarding in ED incurs adverse outcomes. A prolonged stay in the ED spent the opportunities of such patients, and may result in subsequent extra resource utilization. Further exploration of factors affecting the boarding in ED of critically ill patients, and the demarcation of waiting phases, is recommended. References: 1. Cowan RM, Trzeciak S. Clinical review: Emergency department overcrowding and the potential impact on the critically ill. Crit Care 2005;9(3):291-295. 2. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003;20(5):402-405. 3. Parkhe M, Myles PS, Leach DS, et al. Outcome of emergency department patients with delayed admission to an intensive care unit. Emerg Med (Fremantle) 2002;14(1):50-57. 4. Cardoso LT, Grion CM, Matsuo T, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care 2011;15(1):R28.

1267 Mapping adverse outcome screening to international classifications for diseases, tenth revision for using in Brazilian administrative database M. A. E. Dias 1, M. Martins 1,*, N. Navarro 2 1 Administração e Planejamento em saúde, Escola Nacional de Saúde Pública, 2 Escola Politécnica de Saúde Joaquim Venâncio, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil Patient safety has become a core subject on the international background, where the administrative database has been used to monitor the outcome of hospital care. Brazilian studies are scarce, but show the relevance of the problem. The aim of this study is to adapt adverse outcome screening for the International Classification of Diseases tenth revision (ICD-10) codes for its application in Brazilian administrative database. The 11 potential trackers were recoded by a professional expert, from the encoding available in the literature. Adults inpatients of the Systems Information Databases in Brazil in 2007 were selected for testing. Few cases were doubtful about the equivalent code in ICD-10. The percentage of trackers was 0.36%, 85.1% were in clinical medicine. The tool presented is applicable to Brazilian administrative database, and the recoding for ICD-10 makes possible the immediate use. But some efforts can improve this tool, including improving the quality of diagnostic information in hospital database. References: 1. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Eng J Med 2002; 346(22):1715-22. 2. Van Den Heede K, Sermeus W, Diya L, Lesaffre E, Vleugels A. Adverse outcomes in Belgian acute hospitals: retrospective analysis of the national hospital discharge dataset. Int J Qual Health Care 2006; 18(3):211-219. 3. Rozenfeld S. Agravos provocados por medicamentos em hospitais do Estado do Rio de Janeiro, Brasil. Rev Saúde Pública 2007; 41(1):108-15. 4. Noronha MF, Portela MC, Lebrão ML. Potenciais usos dos AP-DRG para discriminar o perfil da assistência de unidades hospitalares. Cad. Saúde Pública 2004; 20(suppl.2): S242-S255. 5. Grassi PR, Laurenti R. Implicações da introdução da 10ª revisão da classificação internacional de doenças em análise de tendência da mortalidade por causas. IESUS 1998; 7(3):43-7. 6. Dias MAE. Segurança do paciente: rastreamento de resultados adversos nas internações do Sistema Único de Saúde. Orientador: Martins MS. Dissertação (Mestrado) Escola Nacional de Saúde Pública Sergio Arouca, Rio de Janeiro, 2010; 75f. 7. Martins, M. Uso de medidas de comorbidades para predição de risco de óbito em pacientes brasileiros hospitalizados. Rev. Saúde Pública 2010; 44(3): 448-456. 8. Pepe VE. Sistemas de Informações hospitalares do Sistema Único de Saúde (SIH-SUS). Brasil. Ministério da Saúde. A experiência brasileira em sistemas de informação em saúde / Ministério da Saúde, Organização Pan-Americana da Saúde, Fundação Oswaldo Cruz. Brasília: Editora do Ministério da Saúde 2009; volume 2, pp: 65-85.

1270 Improving final report turnaround time in all radiological modalities as an approach to patient-centered care and to measure and monitor service performance indicators N. F. Husain 1, W. A. Mirza 1, M. Yusuf 1, W. Siddiqui 1,* 1 Radiology, The Aga Khan University Hospital, Karachi, Pakistan With an aspiration for better quality services and patient safety; being a healthcare institution in a developing country use existing resources to develop and execute strategies for improving the final report turnaround time and to bring about tangible improvements in the reporting mechanism. This Quality Improvement Project was undertaken by the department of Radiology, Aga Khan University Hospital, Karachi, Pakistan in the first quarter of 2011. A retrospective analysis was conducted to evaluate the performance indicator on report turnaround time in 2010. A simultaneous prospective study along with project interventions was done in 2011. The focus was on improving the standard of measuring departmental performance indicator of finalization of reports using e-signature by the credentialed radiologists. During data validation of 2010 it was identified that the time clock set for capturing this data excluded off hours and public holidays. The discrepancy of time clock was corrected and the time clock was converted to 24/7 providing coverage throughout the public holidays and weekends. After correction of the time checks a drastic decrease was observed in final report turnaround time with respect to the set targets and hence this project came in to existence. In order to improve e-signature, a team was constituted to brainstorm, do causal effect analysis and device strategies. After extensive workup it was decided that as an initiative of patient centered approach, monitoring of the performance indicators needed some interventions. REPORT TURNED AROUND INDICATOR 2010 2011 ANALYSIS Section Q1% Q2% Q3% Q4% Q1% Q2% Q3% Q4% CT 39.76 37.89 37.55 28.82 41.00 33.97 37.91 49.7 9 MRI 50.18 49.51 45.93 45.45 42.16 45.06 62.2 73.0 9 NM 80.29 86.71 89.4 81.13 85.47 88.13 89.21 90.3 8 Special 52.09 43.15 37.79 33.61 39.68 44.47 55.84 70.1 4 Standard 75.44 78.67 77.08 72.44 70.88 75.08 76.39 75.1 1 US 85.01 99.19 89.72 88.66 90.92 87.92 89.66 97.4 VIR 54.16 52.33 78.00 60.73 76.72 82.09 74.73 86.6 7 2010:Data clearly indicates a noncompliance of report turnaround time. 2011: Q1:Base line data with the new time checks in place. Q2: Intervention Strategies were planned and implemented. Hence a slight improvement is noted. Q3: Interventions were closely monitored and continuously reinforced. Q4- Post intervention improvement in comparison to the baseline data of Q1,2011: CT 9 % ; MRI 31%; NM 5%; Special 31%; Standard 5 %; Ultrasound 7%; VIR 10% The major interventions done are: time checks were modified to 24/7 in the system, staff assigned for daily follow-ups on unpicked exams and unsigned exams and email alerts generated to the reporting residents & radiologists. Lists circulated daily for close monitoring and follow-ups. Interventions were closely monitored and reinforced. Post intervention improvement in comparison to the baseline data shows improvement in CT 9 %; MRI 31%; NM 5%; Special 31%; Standard 5 %; Ultrasound 7% and VIR 10% respectively.

1275 Assessing Inpatient Mortality: a new review process that leverages information systems and engages frontline providers S. Rohan 1,*, A. Kachalia 1, A. Provenzano 1 1 Brigham and Women's Hospital, Boston, United States As hospitals explore strategies to reduce inpatient mortality, they face the limitations of existing mortality assessment methods. These can include: difficulty uncovering undocumented events, a time lapse between the death and the review, and a specialty-specific focus that misses system-level issues. We sought to address these shortcomings when creating a new method of reviewing all inpatient deaths that would identify system-level issues contributing to inpatient mortality. An initial survey of clinical departments on their mortality review processes revealed heterogeneous methods that did not reliably capture cross-departmental issues. In response, we collaborated with hospital leadership and frontline staff to develop key principles that we thought would be essential to the success of a house-wide review. Final consensus-based principles included that the review process should: cover all inpatient deaths, query frontline clinicians, and collect data efficiently and electronically. Accordingly, we developed a web-based review form with questions related to common causes of harm including: infections, complications, care delays, and communication breakdowns. The form also asks reviewers to provide a brief clinical summary and an opinion on the preventability of the death. The automated review process is designed to be user-friendly. Immediately after a patient expires, an email containing a personalized link to the review form is sent to the patient s attending and resident physicians. If a reviewer indicates possible preventability or a high-priority concern, a trigger alerts the quality and safety team. Additionally, the reviewer may use the form to request peer support or contact with quality and safety staff. All responses are stored in an electronic database that is readily accessible only to select members of the quality and safety staff. Aggregate data is shared periodically with quality and administrative leaders. Mortality review questionnaire completion rates and times (since launch in June 2011) are listed in Table 1. In approximately 23% of cases, a reviewer identified a contributing factor to death. Additionally, in 17% of cases, a reviewer indicated a suggestion for improvement or concern of a medical error or preventability. Providers also used the review form to request peer support and further contact with quality and safety. Table 1: Mortality Review Completion Data n=789 inpatient deaths Anticipated Observed % of reviews completed 70-80% 93% % of deaths with at least 1 review completed 75% 98% Median time required to complete 3-5 min <4 min Median time between notification and completion 48-72 hours 17 hours Addressing the systems issues driving preventable inpatient mortality is critical to improving patient care. We have found that it is possible to implement a program that can reliably and efficiently collect information on all inpatient deaths from frontline providers. Moreover, in this process, clinicians are willing to identify care quality issues and request follow-up. Next steps include using aggregate data to guide improvement efforts and expanding this review process to other team members. We are currently pilot testing an electronic nursing mortality review form. Additionally, with physician leaders in Anesthesia, Emergency Medicine, and Neonatal Care, we are creating review forms unique to their specialties.

1289 Reduction of average daily waiting time for drug collection after the implementation of multi-queue system in outpatient pharmacy A. H. Y. Tam 1,*, P. L. M. Chu 1, J. W. H. Wu 1 1 Hospital Authority, Hong Kong, Hong Kong, Hong Kong, China There are different factors that contribute existing long waiting time in Pharmacy. Average number of drug prescriptions daily = 1560. However, for this project we will concentrate on the improvement on the reduction on waiting time during drug collection process. With the existing single queue system, as patient presented the ticket number and pharmacy staff is required to walk to and from the issue counter to find the correct drug basket from the bulk trolley. Approximately, walking distance of 3,000m is being consumed by Pharmacy staff daily average. To increase out-put of multi-queue workflow balancing in-put diversion leveling of workload. The Multi-queue was chosen as a feasible solution. -3 pilot runs to test multi-queue setting in Out-patient Pharmacy and overall waiting time is saved by 16% and drug issue time is saved by 46.3% due to time saved in searching for drug basket before issuing could be done by Nov 2009. -Vision impact was improved by installation of extra of 5 sets of 23 LCD displays to drug issue counter in Apr 2010. The improvement enable patient to queue correctly to the designated issue counter for drug collection. - After the implementation in May 2010, the average daily waiting time for drug collection was reduced by 13.2%. - After one year of implementation, the result is still remained in reduction by 10%. After the implementation since 17 May 2010, average daily waiting time on drug collection had been reduced. An internal staff satisfaction survey will be performed after one year implementation. The staff feedbacks are encouraging and well received. Another measure was obtained to review if such modification of queue management could be sustained. The average waiting is still being reduced even though the workloads are similar. Moreover, internal workflow modification is required to enhance the accuracy and efficiency on the drug dispensing, checking and issuing process. References: Lean Management

1337 Patient-Safety Indicators: reliability of hospital administrative data in comparison to retrospective chart review C. Maass 1,* 1 Institute for Patient Safety, University of Bonn, Bonn, Germany Hospital administrative data is applied more and more to illustrate the quality and safety of patient care because of the low efforts of time and costs. Indicators are used, that count the adverse events during medical attendances in relation to a defined population at risk. Originally administrative data serve to manage accounting with health insurance funds so that the potential of this data to estimate patients safety is unclear. International literature doubts the ability of administrative data to detect all items with regard to adverse events. Valid investigations concerning this issue are missing. The presented study evaluates the reliability and validity of hospital administrative data to outline eight PSI. Frequencies of defined adverse events that are detectable in administrative data are compared with information out of an explicit retrospective chart review. Data of 3000 inpatient cases of the year 2010 with an increased prevalence of adverse events are used for measurement of eight PSI. Half of the study population consists of operative and other half of non-operative cases, further criteria for inand exclusion of the cases are defined for each PSI. Retrospective chart review with an expected reliability of 100 percent serves as gold standard. The experimental method constitutes the standardised measurement of hospital administrative data. Evaluated are eight PSI: PSI 1 Decubitus Ulcer, PSI 2 Selected Infections due to Medical Care, PSI 3 Postoperative Respiratory Failure, PSI 4 Postoperative deep Vein Thrombosis, PSI 5 Nosocomial Pneumonia, PSI 6 Nosocomial acute Kidney Failure, PSI 7 Acute Myocardial Infarction > 24 h after Hospital Admission and PSI 8 Postoperative Wound Infection. Reliability is calculated as Cohens Kappa for the correlation of both methods with 95%>confidence interval (CI), Validity is outlined in sensitivity, specificity and positive and negative predictive value (PPV, NPV). Analyses are made by SPSS. Kappa shows that reliability of administrative data varies a lot in relation to the PSI. Excellent reliability is given for PSI 2 Selected Infections due to Medical Care, PSI 4 Postoperative deep Vein Thrombosis and PSI 8 Postoperative Wound Infection, but with bad to low sensitivity. Bad Kappa show PSI 3 Postoperative Respiratory Failure and PSI 6 Nosocomial Acute Kidney Failure with sensitivity from excellent to low. Good and fair reliability obtain PSI 1 Decubitus Ulcer, PSI 5 Nosocomial Pneumonia and PSI 7 Acute Myocardial Infarction. Specificity is excellent for all PSI (0,99). PPV is varying for all PSI. PSI Cohen s Kappa 95% CI Sensitivity 1 0,63 0,59-0,67 0,67 2 0,86 0,84-0,88 0,06 3 0,25 0,21-0,29 >0,99 4 0,99 0,99-0,99 0,25 5 0,47 0,38-0,55 0,24 6 0,28 0,19-0,36 0,17 7 0,71 0,63-0,79 0,23 8 0,93 0,92-0,94 0,49 Results may be primary caused in different reasons for data collection. Administrative data are missing a lot of information that does not matter in context of hospital accounting. Present results imply administrative data as not useful to hint on patient safety problems because of bad reliability and sensitivity. But good PPV for some PSI permit conclusion that if the PSI reach high level in administrative data there might be a safety problem that should be explored. Presented investigation cannot answer the question of applicability of administrative data to generate PSI in total. Benefits of the administrative data to line out PSI are obvious, but to raise clinical information in detail draft upon an extensive database is essential.

1338 Improving the nursing instructions execution rate of nursing staff to epileptic patients in a pediatric intensive care unit H. Ya Fen 1, S. Ching-Yun 1, L. I Hsiu 1,* 1 Chang Gung Memorial Hospital of Kaohsiung, Kaohsiung, Taiwan Epilepsy is an abnormal, excessive or hypersynchronous neuronal discharge in the brain which will result in a stereotyped movement, unique sensation and behavioral changes in the patient. Each type of anticonvulsant / antiepileptic drug is tailored for the different types of epilepsy syndromes, in hope of effectively preventing seizure relapse and improving patient's quality of life.we wish to analyse the thoroughness of our nursing instructions towards epileptic patients regarding anticonvulsants in order to understand how much the main caretaker knows regarding the side effects and the main therapeutic effects of the antiepileptic drugs their children are ingesting. Our main purpose is to promote epileptic patients' life quality and to decrease the unplanned readmission rate. We invented a table with epilepsy drug care awareness in order evaluate how much our nursing staff understands regarding the anticonvulsant that our pediatric patients are ingesting. Expert validity was evaluated by five pediatric neurologists using Likert's 4 point scale. The result of our content validity index is 0.9, the average score obtained was 67.8%. Epilepsy medication guide checklist was used to inspect the thoroughness of nursing health education guidance. The result of our investigation revealed 23.4%. Thus two possible solutions were proposed:(1) Arrange continuing education classes for nursing staff periodically regarding antiepileptic medication guide in order to enhance and update our nursing staff s on the latest update regarding these areas of professional knowledge.(2) Create a formal PICU s Epilepsy medication guide checklist and set standardized protocols in order to accomplish a thorough health education guidance. The results of our two proposals revealed by that by arranging regular continuing education classes for nursing staff regarding antiepileptic medication guide can increase our nursing staff s professional knowledge regarding antiepileptic drugs from a score of 67.8 to 100.By creating a specialized PICU s Epilepsy medication guide checklist used to inspect the thoroughness of nursing health education guidance can increase our initial result of 23.4% to 94.4%. Various solutions were proposed in order to promote our nursing staff s professional knowledge such as arranging regular continuing education classes for nursing staff regarding antiepileptic medication guide in order to enhance and update our nursing staff s on the latest update regarding these areas of professional knowledge and we created a formal PICU s epilepsy medication guide checklist and set standardized protocols in order to accomplish a thorough health education guidance. Both of the above mentioned interventions showed promising results. Thus via special designed continuing education classes for our nursing staff and providing a formal PICU s Epilepsy medication guide checklist can improve the thoroughness of nursing instructions execution rate of nursing staff to epileptic patients in a pediatric intensive care unit. Eventually we hope that via enhancing the professional knowledge of our nursing staff will we be able to provide better quality of clinical care for our epileptic patients.

1354 Measure of the quality of stroke treatment by the HAS clinical practice indicators B. Bouamra 1,*, L. Vaconnet 1, E. Medeiros De Bustos 2, T. Moulin 2 1 Réseau RUN, 2 CHRU Service de Neurologie, BESANCON, France Driven by the French National Authority for Health (HAS), a national task force has established a list of indicators for stroke. These markers are intended to control the quality of patient management in different hospital structures in order to standardize different clinical practices in a population of patients. Neurovascular pathology lends itself particularly well to this type of health evaluation (long, non-centralized, complex treatment path, calling on different health professionals throughout the patient s journey). 27 indicators from the warning signs to acute phase management were calculated for 2010. The study population comprised patients from a region of France (Franche-Comté) with 1.17 million inhabitants. The indicators were calculated from a sample of patients discharged from hospital between 1 st March 2010 and 30 th April 2010 with a diagnosis of stroke. The data from 500 patients were thus analyzed using emergency department reports and discharge letters provided retrospectively by the 10 regional hospitals. 13,500 indicators were analyzed. We were able to obtain information on 65 % of the individual indicators, with a homogeneous distribution across the different hospitals studied. The study enabled us to highlight the heterogeneity of treatment in the hospitals and to rank them item-by-item according to regional averages. This quality control tool is relevant for the monitoring of medical practices. It also allows the effectiveness of different measures used to optimize patient management to be verified. In order to be effective, these markers need to be systematically and fully implemented. This can only happen if the tool is made available electronically. This work has enabled us to develop an appropriate piece of software that can be used by the entire region. References: Indicateurs de pratique clinique AVC, HAS Service Programmes pilotes Améliorer les pratiques Direction de l Amélioration de la Qualité et de la Sécurité des Soins, Juin 2010

1363 Implementation of surgical site infection prevention bundle- a tale of successes and challenges A. Khan 1,*, P. McKernan 1, V. Zellermyer 2 and SSI Prevention Task Force 1 Risk Management & Quality Improvement, 2 Perioperative Services, St Michael's Hospital, Toronto, Canada To evaluate and measure adherence rates to the perioperative best practices for colorectal surgery (CRS) patients and its effects on surgical site infection (SSI) rates. A multidisciplinary SSI Task Force was set up in 2007 to implement the following evidence based preventive measures to reduce SSIs: 1. Appropriate and timely antibiotic delivery and discontinuation of postoperative antibiotic within 24 hours (implemented in 2007) Pre-printed antibiotic order sets, Antibiotic delivery by anesthetist in the operating room (OR), Use of safety checklist to confirm antibiotic delivery, Education on standardized documentation in anaesthetic and OR records 2. The use of clippers for hair removal (implemented in 2007) and removal of razors from the operating rooms 3. Maintenance of perioperative normothermia (36-38 0 C) (implemented in 2008) Patient education in pre-op area, Preprinted order sets, Use of warm Bair Huggers, Use of fluid warmers in the OR, Increase ambient temperature of OR to 22 0 C, Education on documenting temperature in pre-op, intra-op and post-op area; 4. Skin antisepsis with 2% chlorhexidine with 70% alcohol (implemented in 2010) Staff education on safe and effective use with 3 minute drying time Prospective surveillance was conducted to measure adherence to these processes of care and SSI rates. There was improvement in compliance for all quality measures over time leading to a reduction in mean SSI rates (Table 1). The prophylactic antibiotic administration improved significantly over time (P=0.01 2006 vs 2011).The antibiotic discontinuation within 24 hours of surgery and the compliance with hair clipping was 100%. Normothermia also improved significantly. Patients with open surgery were more likely to be hypothermic compared to patients with laparoscopic surgery (Odds ratio=1.38, P=0.089). Mean adherence to use of chlorhexidine alcohol skin prep was 87.75 %. Table 1 Adherence rates of different best practices and SSI rates over time Measures 2006 N=158 Timely antibiotic adminstration Timely antibiotic discontinuation 2007 N=162 2008 N=177 2009 N=186 2010 N=172 2011 N=193 73.77% 86.12% 86.63% 92.14% 96.06% 96.10% - 100% 100% 100% 100% 100% Hair cliipping - 100% 100% 100% 100% 100% Normothermia in OR (operating room) Normothermia in PACU (postanaesthetic care unit) Chlorhexidine - alcohal pre-op skin prep 41.21% 39.94% 45.40% 42.25% 47% 70.42% 40.43% 43.65% 89.49% 64.88% 51.68% 56.77% - - - - 88.29% 86.68% Mean SSI rates 25.31% 18.12% 20.40% 21.81% 15.51% 18.67% Antibiotic delivery and hair clipping initiative implemented in 2007; Normothermia initiative implemented in 2008, 2%chlorhexidine-70%alcohal use implemented in 2010 Using systems-level protocol implementation strategy, we successfully implemented and improved our compliance with all evidence-based processes of care associated with a marked improvement in SSI rates. Achieving 100% adherence rate to best practices which involve multidisciplinary teams and multiple phases of care can be challenging. More directed efforts including practice audits may be required to understand and address the gaps in overlapping phases of care to further improve upon the Normothermia and the SSI rates.

1367 Evaluation for the effectiveness of peer pressure changing emergency physicians' disposition decisions and patient throughput K.-H. Wu 1,*, C.-W. Lee 2, C.-J. Li 1 1 Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, 2 Emergency Medicine, Graduate Institute of Medicine, Kaohsiung Medical university, Kaohsiung, Taiwan Prolonging emergency department(ed) observations, or even admitting patients under borderline criteria for in-patient care, have become common alternative practices for avoiding medico-legal liabilities in a busy ED. The strategy used in this study is to create a team norm for encouraging emergency physicians (EP) to discharge those patients that ought to be discharged. The objective of this study is to evaluate the patient throughput by discharge rate as well as length of stay (LOS) before and after intervention. In a tertiary academic medical center in southern Taiwan with over 120,000 annual emergency visits with 15 full time EP, all adult non-traumatic patients presenting to the ED between 7:30-11:30 in Wednesday to Sunday during the study period 2011-6-1 to 2012-1-15 was reviewed. We created team norm that imposed an unspoken peer-pressure effect by announcing the patient discharge rate of each EP via emails to each EP every month since 2010-10. We excluded from the study the Monday and Tuesday as well as period of Chinese New Year (January 18-29, 2011) because of the different EP scheduling. We compared the demographic factors, LOS, ED disposition at the 8 hour (i.e. the end of shift) and the final disposition of patients before (2010-6 to 2010-9) and after (2010-10 to 2011-1-15) intervention. The unscheduled 72- hour revisit rate was regarded as inappropriate discharge and analyzed. The independent variables were analyzed according to the Chi-Square test, Mann Whitney U test, and the student t-test. The statistical significance of the relationship between triage group of the discharge rate were analyzed using the logistic regression to obtain the odds ratio (OR) and 95% confidence interval (CI). During the study period, 3305 and 2945 patients were enrolled before and after intervention. There was no difference in age (59.5 ±18.39 vs. 58.6 ±17.83, p=.056), sex (male patient 48.32% vs. 48.28%, p=.978) and average visiting patient per shift (37.6 ± 6.34 vs. 38.3 ±8.79, p=.569). But we have different distribution of patient triage with more triage level 3 patients and less triage level 1,2,4,5 patients (p<.001) in the after intervention period. Discharge rate at the end of shift increased statistically significantly after intervention in overall patients (53.99% vs. 48.65%, p<.001) and triage level 3 (OR 1.3, CI 1.09~1.38) without difference in number of unscheduled 72 hours revisits (2.60% vs. 2.99%, p=.354). The disposition of patients differed significantly in the 8 hour disposition with more patients discharge and less patients who is under observation without effecting the final disposition of patient (Table II). Patients with the final disposition of discharge have shorter LOS (median 158.3 min vs. 140.4 min, p<.001) after intervention. Table I. Compare of the 8 hour and final disposition of patients before and after intervention 8-Hour Disposition Final Disposition Intervention Intervention Before After Total p before After Total p Discharge 1593 1577 3170 1978 1848 3826 Admission 373 293 666 1115 932 2047.003 AMA Discharge 71 47 118 121 86 207 Referral 43 37 28 70 55 125 Expired 12 9 21 21 24 45 Observation 1213 982 2195 N/A N/A N/A Total 3305 2945 6250 3305 2945 6250 Statistically significant difference if p<0.05 AMA: Against medical advice The intervention strategy that imposed a peer-pressure is to enhance patient flow and throughput. More patients were discharged at the end of shift overall and in triage level 3. The ED LOS of the discharged patients decreased statistical significantly..165

1425 To objectify the quality of care for breast cancer J. Hellings 1, 2, V. De Troyer 3,* 1 ICURO, Brussel, Belgium, 2 CEO, 3 Q&S STAFMEDEWERKER, ICURO, Brussel, Belgium - To define objective parameters to evaluate the quality of breast cancer care in Flemish hospitals - To adopt the Belgian legislation to include objective parameters in the recognition of specialized breast cancer programmes (next to structural and quantitative criteria). The Flemish hospital federation ICURO launched a call to establish a working group (involving 40 hospitals, the professional associations of gynaecologists and surgeons, the Belgian Health Care Knowledge Centre and the Belgian Cancer Registry with the intention to adapt the legislation by adding requirements (objective criteria) to recognize breast centres. Simultaneously, the Flemish government together with the Flemish association of Medical Directors (VVH) and the hospital federations ICURO and Zorgnet Vlaanderen took the initiative to define relevant indicators to objectify the quality of care delivered in hospitals. Due to the collaboration of all partners, a set of quality indicators was developed,based on (international) guidelines [1][2]. Eleven process and two outcome indicators are selected to provide public accountability was explicitly assumed by the professionals. In an advice to adapt the current legislation, requested by the federal Minister of Public Health, the intentions to use qualitative parameters to recognize breast cancer centers and defined indicators were integrated. Following 13 indicators (11 process and 2 outcome) were defined: Process indicators: proportion of women 1. in whom ER, PgR Status assessment 're performed before any systematic treatment with cytological and/or histological assessment before surgery with newly diagnosed cstage I-III who underwent two-view mammografie and breast sonography within 3 months prior to surgery discussed at the multidisciplinary team meeting who received radiotherapy after breast conserving surgery cstage I and II who undergo breastconserving surgery receiving adjuvant neoadjuvant hormonal therapy after breast surgery for invasive breast cancer receiving adjuvant neoadjuvant chemotherapy after breast surgery for invasive breast cancer who benefit from an annual mammography after a history of breast cancer with metas who receive systemic therapy as 1 st and / or 2 nd line treatment operabel ct2-t3 women who received neoadjuvant systemic therapy Outcome indicators Overall 5 year survival rate by stage Disease specific 5 year survival by stage (with relative survival as proxy) From 2012 onwards, hospitals will start with the registration of the data. In 2013, all the data from the different will be published anonymously. Hospitals will be encouraged to publish their results on the website of the hospitals. Data control will be guaranteed by the Flemish government. The advice of the NRZV is delivered to the federal minister of Health. - A thorough approach made it possible to compose a relevant indicator set with a professional willingness to provide public accountability about the quality of care. - These 13 indicators make it possible to objectify the quality of care and creates opportunities for internal PDCA-cycles and to give public accountability and will be published in 2013 on the internet site of each hospital. - A proposal to integrate objective quality standards in the federal legislation was formulated.

1432 Obstacles to reliable collection of quality data: a survey of anesthesia staff J. Wacker 1,*, T. Manser 2, J. Steurer 3, G. Mols 1 1 Institute of Anesthesiology and Intensive Care Medicine, Hirslanden Clinic, Zurich, 2 Department of Psychology, University of Fribourg, Fribourg, 3 Horten Center, University of Zurich, Zurich, Switzerland Reliable quality data are essential for documentation of quality of care, but gathering data is usually an additional task for busy health care professionals. At the study hospital, physician and nurse anesthetists enter intraoperative quality data into the anesthesia information management system (AIMS) at the end of each case. Results of a pilot study comparing recorded with actually reported intraoperative events indicated a poor reporting rate of only 11%. We wanted to identify perceived obstacles to accurate data collection by surveying anesthesia staff. After obtaining written informed consent, physician and nurse anesthetists of a major private hospital completed a 20- item, purpose defined, pilot tested questionnaire referring to assumed obstacles. A predefined selection of answers was given and comments in free text format were possible. Questionnaires were filled in in privacy, returned unnamed in neutral envelopes and opened only after all data had been collected to ensure anonymity. Data processing and basic statistical analysis was performed with Microsoft Excel for Apple Macintosh. Of the department's 68 staff, 12 were ineligible (study collaborator; quality data handling; no regular use of AIMS, newly employed, long term leave). One did not return the questionnaire. Thus, 55 completed the survey (92% of eligible and 81% of total staff: 25 physicians, 30 nurses). Professional experience was 13.8 (mean) + 7.5 (standard deviation) years; experience with the AIMS: 5.3 + 4.6 years. Answers to questions (% of all 55, in descending order): do not receive feedback on quality data: 94%; have other important duties during data entry: 87%; complete data entry before end of anesthetic: 85%; are unaware of management activities attempting to improve identified quality issues: 82%; do not know about use of collected data: 74.5%; indicate noise or interruptions usually interfering with entry: 65%; do no check record for events before entry: 51%; indicate a need to improve data collection: 49%; do not consider data useful for improvement of anesthesia quality: 47%; lack trust in anonymization: 42%; consider data collection (at institution) unreliable: 36%; regard definitions of events as unclear: 27%; consider data collection irrelevant for patient safety: 27%; indicate concern of easier prosecution because of data: 16%; have rarely or never enough time for data entry: 11%. The main obstacles reported by the surveyed staff refer to: 1. Knowledge or attitude (limited belief in benefit of data). 2. Quality data management in the institution (perceived lack of feedback, lacking knowledge of data use and anonymization). 3. Organisation and technique (premature data entry, competing duties, interfering noise and interruptions). Possible areas of improvement include therefore: 1. Educational activities (benefits of quality assessment). 2. Feedback (results) and instructions (purpose of data collection, anonymization). 3. Organizational (dedicated time slots for data entry) and technical improvements (clearer definitions, eventuality of delayed data entry). Repeated assessments of data quality and staff interviews should follow implementation. Given the common nature of the reported obstacles and their similarity to barriers to incident reporting 1, our data are presumably not specific for a single institution but highlight likewise common causes of unreliable routine quality data. References: 1. Pfeiffer Y., Manser T., Wehner T. Qual Saf Health Care 2010; 19:e60 ClinicalTrials.gov identifier of this study is NCT01524484

1435 Physician Performance in different health insurance systems I.-A. Huang 1,*, C.-T. Wu 1, S.-H. Hsia 1 1 Pediatrics, Chang Gung Children's Hospital, Taoyuan, Taiwan It is a rare opportunity to have the same physician practicing in the different health insurance systems to compare the performance. Chang Gung Memorial Hospital has several branch in China and Taiwan. They belong to different health insurance systems. The aim of this study is to evaluate the difference of the same pediatricians practicing in two different health insurance systems. To understand the impact on the physician performance. The medical records of 15 same pediatricians practicing in both China and Taiwan Branch during January 2009 to December 2010 were retrospectively reviewed. They are well-trained pediatricians in Taiwan Branch and take turns to Xiamen, China Branch for practicing. We collected nontruamatic visits to the pediatric emergency room (PER) by children less than 18 years. Each physician with over 100 practicing records in each branch during the study period was selected. We analyzed the demographics, the rate and type of laboratory and image surveys, the PER length of stay (LOS), the 72hour revisit rate and admission rate between Xiamen, China Branch and Keelung, Taiwan Branch. Total 14,761 and 11,765 medical records in Xiamen, China and Keelung, Taiwan Branch were included. Both hospitals are tertiary teaching hospitals located in the suburbs. Thay had the same annual PER volume of 15,000 visits. We found the rates of laboratory and image surveys were higher in Taiwan Branch, especially in clinical microbiology (19.2% vs 2.3%, P < 0.001), medical microscopy (20.1% vs 10.0%, P < 0.001), X rays (26.1% vs 10.3%, P < 0.001), and CT or MRI (0.53% vs 0%, P < 0.001). The admission rate to the intensive care unit (ICU) was also higher in Taiwan Branch (8.4% vs 0.9%, P < 0.001). Longer LOS (5.1hour vs 1.6hour, P < 0.001) and higher 72hour revisit rate (11.4% vs 7.0%, P < 0.001) are in China Branch. After we adjusted the age, the disease severity, and the most common diagnosis, the same differences were still significant. Different health insurance systems will impact the same physician making clinical decisions at PER, especially in the high price services. We found the medical resources of clinicical microbiology, medical microscopy, X rays, CT or MRI, and ICU care are arranged more in Taiwan Branch. The short-term outcoms of longer LOS, and higher 72hour revisit rate are noted in China Branch. The coverage of the high price services in the health insurance system is meaningful to the physician performance and quality of PER care. References: Chang YC, Ng CJ, Chen YC, Chen JC, Yen DH. Practice variation in the management for nontraumatic pediatric patients in the ED. Am J Emerg Med. 2010 Mar; 28(3): 275-83

1459 Quality and costs of healthcare for acute stroke in Japan J. Lee 1,*, T. Otsubo 1, Y. Imanaka 1 1 Department of Healthcare Economics and Quality Management, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan To investigate the association between health care costs and quality of care in ischemic stroke patients in Kyoto prefecture, Japan. We analyzed patients who were admitted to acute care hospitals in Kyoto prefecture due to ischemic stroke between February 2009 and March 2010 using hospital claims data provided by the Kyoto National Health Insurance Organizations, in a project conducted by the Kyoto Prefectural Government. The municipalities in Kyoto prefecture were categorized into quartiles according to age-sex adjusted health care costs (from a third-party payer s perspective) for ischemic stroke admissions, with municipalities with the lowest costs in Quartile 1 and municipalities with the highest costs in Quartile 4. Logistic regression models were used to analyze the association between costs and the quality of care. Quality of care was assessed using stroke process indicators including (1) Computed Tomography (CT) scans or Magnetic Resonance Imaging (MRI) scans conducted during hospitalization; (2) Tissue plasminogen activator (t-pa) administration during hospitalization; (3) Antithrombotics administered during hospitalization; (4) In-hospital rehabilitation services; (5) Early rehabilitation (within 30 days of admission); (6) Rehabilitation for dysphagia; and (7) Warfarin-administered to patients with Atrial Fibrillation (AF). Regression models were developed for each of the quality indicators, and the independent variables in these models included patient age upon admission, sex, comorbidities, as well as hospital characteristics such as teaching status and hospital size. Using Quartile 4 (municipalities with the highest costs) as the reference category, the lower three quartiles were included in the regression models as dummy variables in order to analyze if patients from municipalities with lower cost had poorer performance in the various quality indicators. Mean health care costs per patient ranged from US$9,749 to US$14,303 from the lowest to highest municipalities, indicating a difference of 47%. Municipalities in Quartile 1 were significantly associated with poorer performance in all of the process indicators except for CT or MRI scans. Patients in Quartile 1 presenting with AF were also less likely to be administered warfarin during admission.in Quartile 2, patients were significantly less likely to be provided with dysphagia rehabilitation and warfarin administration in AF patients when compared to patients in Quartile 4. Patients from Quartile 3 were significantly less likely to be provided with dysphagia rehabilitation and warfarin when presenting with AF. Regions with the lowest health care costs were significantly associated with poorer performance in all but one of the process indicators, even after adjusting for variations in patient and hospital characteristics. This may indicate an insufficient provision of resources and specialist expertise in the lower cost municipalities, leading to poorer performance in the quality indicators. Care must be taken during the implementation of cost-reducing measures in order to ensure that the quality of care provided is not detrimentally affected, and further efforts must be made to improve the quality of care in regions with lower health care costs in Japan.

1470 Prevention of adverse events in surgery: contents of time-out procedure C. De Blok 1,*, E. S. Koster 1, C. Wagner 1, 2 1 NIVEL, Utrecht, 2 EMGO+, VU University, Amsterdam, Netherlands To evaluate the extent to which Time-Out (TO) procedure guidelines are followed in the operating room. By focusing on the prevalence and the contents of the TO procedure we aim to deepen insights on the degree of implementation of a national patient safety program. In 2008, the Dutch Hospital Patient Safety Program was started to improve patient safety in hospitals in the Netherlands. Prevention of wrong patient, side, site, and intervention surgery was assigned as one of the improvement themes with the aim of reducing the number of incorrect events to 0. To this end, hospitals have to implement the TO procedure as the final check to prevent incorrect events in the operating room. Guidelines on the required contents of the TO procedure have been communicated by the program to all hospitals. To gain insight into the extent to which these guidelines are followed, an observational prospective study was conducted in 19 randomly selected Dutch hospitals. During 10 monthly visits, a trained research assistant observed the TO procedure. A checklist was used containing the items to be checked (patient, side, site, and intervention) during the TO procedure as well as other relevant information (disturbance of the time-out procedure, focus of operating team). Participating hospitals will receive their individual scores every quarter of the year. Data collection started in December 2010; currently data are available for the first three months. Data collection is still on-going. During the first months of the study, the number of operations we observed ranged between 93 for the first month and 89 for the second month. All hospitals in the study have implemented the TO procedure in some form. On average, during the first and second visit in hospitals 72% of the TO procedures was executed correctly according to the guidelines given by the National Patient Safety Program. Still, there was large variation among hospitals (T1: 0% - 100% and T2: 33%>100%). The check performed most often was patient identification (T1: 95% and T2: 97%), the intervention to be executed was checked least often (T1: 85% and T2: 88%). The complete operating team was focused on the TO for 62.5% of the TO procedures observed at T1 and for 55.8% at T2. The TO was not interrupted very often (T1: 6.3% en T2: 7.8%). The contents of the TO procedures varied among hospitals. Whereas 15% of the hospitals fulfilled the goal of complete and correct implementation and execution of each TO procedure, still 85% of the hospitals have not. Based on the data of the first two months of our study, these results underline the need for further improvement. First feedback has been sent to the participating hospitals which may trigger further improvement during the next months.

1480 Sources and potential impacts of hospital-level sampling bias in patient-safety assessment M. Counte 1,*, A. Schoen 1, V. Cheng 2, R. Shah 3 1 Health Management and Policy, Saint Louis University, Saint Louis, MO, 2 Kaiser Permanente, Modesto, CA, 3 BJC Healthcare, Saint Louis, MO, United States Describe variability in hospital-level reporting of organizational patient safety performance (CLABSI events) and sampling bias in a regional population of acute care hospitals. Secondary data regarding hospital attributes, local market activity, and patient safety performance were collected from WhyNotTheBest.org and other regional databases. The study sample was restricted to a single population of 116 adult, acute care hospitals within the United States (state of Missouri). The study focused initially on how many hospitals reported their patient safety performance ( a dichotomous measure based on reporting of CLABSI events). Then, bivariate analyses were performed to describe relationships between hospital patient safety reporting status, hospital attributes and local market factors. A majority of hospitals (N=68, 59%) did not voluntarily report their CLABSI event scores for the time period in question (2009) while N=48 (41%) did comply. Hospital attributes and local market factors were found to be consistently related to reporting status. Namely, those hospitals that did agree to provide their CLABSI event scores were: - from larger, urbanized markets (p<.01); - not under government ownership (p>.01) and - were located in local markets with higher education and per capita income (p<.01). There are very few published studies that focus on hospitals reporting patient safety data. The findings of this study show that within a large population of hospitals there is substantial variability in initial hospital patient safety reporting. Also, preliminary bivariate analyses found that both hospital and market/service area attributes are significantly related to variability in hospital patient safety reporting (sampling bias.) Non-responding hospitals were significantly more likely to be government-owned hospitals located in rural areas of the state. What is not known at this stage is what specific factors led to their non-responding (e.g., patient case-mix and levels of care, unwilling to report, unable to report adverse events?) As health care systems increase their attention to improved patient safety performance in hospital care, future studies will help to clarify these questions.

1513 Development of standards for the conduct of a national clinical audit or quality-improvement study N. Dixon 1,* 1 Healthcare Quality Quest, Romsey, United Kingdom National clinical audits, QI studies or quality indicator or performance monitoring have been carried out in several countries over the last two decades. Considerable funding is needed to support these activities. Guidance explicitly based on national or international evience related to best practice in the design and conduct of these activities has not been widely available. In the absence of agreement on best practice for this work, variation in the management and potential effectiveness of national audits or QI studies is inevitable. The objectives of this project were to: - identify and analyse international literature on explicit or implicit standards for the design and conduct of a national activity that involves measuring and facilitating the improvement of the quality of patient care - draft standards for the design and conduct of a national clinical audit or quality improvement (QI) study based on the analysis of the literature. Literature databases, key websites and reference lists were searched for publications that described standards, criteria, indicators or measures relating to the design and operation of a national or large-scale clinical audit, outcome study, quality or performance indicator monitoring, QI study, registry or equivalent activity. Publications were selected for abstracting if they defined aspects of good practice in the design or conduct of a national clinical audit or QI study. Thirty standards were derived from the analysis of the relevant literature. Standards related to structural aspects of a national clinical audit or QI study, processes through which an audit or study is carried out, and expected outcomes of an audit or study were identified. The structural standards relate to the following: ethical basis for the audit; governance; stakeholder involvement; resources allocated; and roles and responsibilities and project plan. The process standards are on the following subjects: recruitment; improvement-driven aims and objectives; population or sample; data collection strategy; quality-of-care measures; data elements and data sources; data collection and handling protocol and manual; protection of patient identity; identification and handling of ethics issues; training and support for data collectors; pilot testing; reliability testing; data linkages; data quality management, analysis and assurance; preliminary data and peer review; identification of good practice and shortcomings in quality of care; analysis of causes of shortcomings in quality; facilitation of improvements; reports; and communication. The outcome standards relate to the following: level of participation in the audit; reliability of data; timeliness of reports on preliminary findings; timeliness of complete reports; and evidence of improvements in quality of care. Detailed criteria were developed to enable the independent assessment of a proposed or actual clinical audit or equivalent activity. Thirty standards for best practice in the conduct of a national clinical audit or equivalent activity were identified from the literature. It is hoped that the standards developed will become a basis for debate and consensus among organizations undertaking national clinical audits or equivalent projects and for potential participating sites to make decisions about participation in such activities.

1537 Quality of healthcare delivery in US ambulatory surgical centers T. Hernandez-Boussard 1,*, C. Curtin 1, S. Pershing 2, K. M. McDonald 2 1 Surgery, 2 Stanford Health Policy, Stanford University, Stanford, United States Improving the quality and safety of health care is a national priority in the U.S. An important area in patient safety is understanding and preventing adverse events. Adverse events during healthcare treatment compromise patient safety, contribute to patients burden of disease, and increase total cost to the healthcare system. To date, the majority of studies examining adverse events focus on inpatient care. However, a large number of surgical procedures are now performed in the outpatient setting and ambulatory surgery has increased over 200% in the past decade, with over 6 million surgeries performed in an ambulatory surgical center (ASC) in the USA in 2009. ASC care is dominated by few specialties: ophthalmology, orthopedics, and general surgery. ASC are large providers of healthcare and their quality of care must be assessed. We performed a comprehensive, population based study to assess the quality of healthcare delivery in ASC, using standardized metrics that can be easily replicated. Our objectives were to measure adverse events in ASC, define quality indicators ideal for this setting, and identify risk factors and patterns of events associated with adverse outcomes in the ASC setting to inform initial steps of prevention and improvement of care. We used the Agency of Healthcare Research and Quality (AHRQ) statewide datasets for California, Florida, and New York between 2005-2009, which allow longitudinal follow-up. Three of the most common ambulatory procedures were selected for evaluation and identified using ICD-9 and CPT codes: distal radius fracture, cataract surgery, and colonoscopy. Quality indicators (QI) were developed based on literature review and other QI reports. Surgical complications were identified using ICD-9 diagnoses codes and varied by procedure. Statistical models identified predictors for 24-hour, 7-day, and 30-day unexpected hospitalizations and adverse events in the different surgical procedures, controlling for different patient and facility characteristics. A total of 1,776,044 cataract surgeries, 35,155 distal radius repairs, and 3,508,107 colonoscopy procedures were identified in adults. Thirty-day all-cause risk-adjusted readmissions were low for all procedures: cataracts, 1.2%; distal radius, 7.6%; and colonoscopy, 0.9%. Other adverse events based on procedure and diagnoses codes were similar for the three procedures: surgical complications: 3.1%; infections: 4.2; revision of procedure: 2.2; procedure-related adverse events: 5.2%, and adverse anesthesia events: 4.7%. Multivariate analyses revealed disparities in the quality of care delivered based on patient demographics, and facility technology and characteristics. Patient age, race, payor, and comorbidities were significantly associated with an increased odds of encountering an adverse event (p<.05). These data are the first to our knowledge to assess quality in the ambulatory setting at a population level. While adverse events were low, they were not uncommon and affected 5.6% of patients receiving outpatient surgery in the selected surgeries. Due to the volume of these procedures, further research is warranted to better understand these events and identify areas where quality improvement efforts can be focused. The measures we have developed to assessing quality of care in ASC should be validated in future work with clinically rich data. After validation, these QIs will be a first step to assess and evaluate quality healthcare delivery in the rapidly growing ambulatory sugery setting.

1617 Advancing existing approaches to disease management evaluation: experiences from the Netherlands A. Elissen 1,*, I. Duimel-Peeters 2, C. Spreeuwenberg 3, B. Vrijhoef 4 1 Department of Health Services Research, 2 Department of General Practice, 3 Maastricht University, Maastricht, 4 Scientific Center for Care and Welfare (TRANZO), Tilburg University, Tilburg, Netherlands As part of the European DISMEVAL-project ('Developing and Validating Disease Management Evaluation Methods for European Healthcare Systems'), this study aims to improve the methods used to evaluate the effects of complex population-based management programmes (DMPs) for chronic conditions. For this purpose, two advanced analytic techniques (i.e. meta-analysis and meta-regression) are applied to data from DMPs for type 2 diabetes in the Netherlands. These techniques allow for assessment of differential treatment effects and can improve insight into 'what works best for whom' in chronic care. Clinical data concerning a period of 20 to 24 months between January 2008 and December 2010 were collected from 18 Dutch care groups, i.e. primary care provider networks, which deliver diabetes DMPs in the Netherlands. For the patients enrolled in these groups (N=105,056), we compared the last measurements of four clinical outcomes during the first 8 to 12 months of the research period with the last measurements of those outcomes during the second year. Four clinical measures were included: glycated hemoglobin (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SBP), and body mass index (BMI). Meta-analysis and meta-regression techniques were used to investigate the heterogeneity (i.e. variation) in effect estimates across different care processes and patients. For this purpose, heterogeneous average results were stratified according to relevant covariates, such as age, disease duration, clinical measurement frequency, and length of follow-up. On average, no more than small to moderate improvements were attained in patients LDL, SBP and BMI over a mean follow-up of 11 to 12 months, whereas a slight deterioration occurred in HbA1c. However, clinically relevant improvements were achieved in patients with poor first-year values of these measures. Those with a first-year HbA1c >=75 mmol/mol, for instance, achieved a mean reduction of 16.8 mmol/mol during the research period. The positive effects of the DMPs on clinical outcomes were further shown to diminish with longer length of follow-up, yet improve with greater measurement frequency of those outcomes, especially in patients with uncontrolled diabetes. Compared to the grand means that currently inform many health care redesigns, the detailed insights gained from using meta-analysis and meta-regression methods can better support professionals and policymakers in their efforts to meet the complex care needs of the growing and inherently diverse population of chronically ill. The differential findings from this study plead for a move from standardized service delivery to a more tailored disease management approach, in which the characteristics of patients directly determine care processes. Frequent monitoring was shown to be especially useful for improving clinical values in poorly controlled diabetes patients. For those in relatively good health, a less physician-guided form of care that emphasizes self-management might be equally effective (and probably less costly) to maintain glycemic control.

1633 A project to improve 24 hours -continue digital EEG completeness in epilepsy patients C. C. Ching 1,*, N.-T. Chang 1 1 Nursing Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan The 24 hours -continue digital EEG can promote diagnostic rate, accurate orientation, and treatment decision on epilepsy. The smoothly procedure for examination not only promote nursing professional but also help care providers relationship among medical team. The aim of this research is to examine the completed rate of the epilepsy patients receiving 24 hours -continue digital EEG is up to 91%. (1) arranging staffs receive training; (2) developing 24hours -continue digital EEG examination standard guideline; (3) establishment standard order file in Hospital Information System (HIS); (4) moving e- consent permission; and (5) construct instruction compact disk. After the improvement project, the completeness of the 24hours -continue digital EEG has increased to 94%. Epilepsy patients can improve epilepsy diagnosis rate by 24 hours -continue digital EEG, locate the lesion of epileptic precisely, accept both traditional medicines and high-tech treatment of epilepsy nurses; Nursing plays a very important role to assist patients to complete the inspection, they provide appropriate care, make the completed checksuccessful, treat patients at the right time. This action not only to safeguard patients' rights, but also enhance the professional image of nursing. References: Huang, C. Y.,Lien, J. Y.,Liu, T. T.,& Lin, M. L.(2008).Improving family satisfaction in the ICU by offering courses on care skills.tzu Chi Nursing Journal, 8(3), 81-90 Chung, Y. U.,Tsai, C. C.,Hwang, H. L.,Lin, C. Y.,Hsu, Y. C.,& Chen, Y. J. (2007).The effect of giving health education via multimedia compact disc and written information to patients undergoing gastroscopy.tzu Chi Nursing Journal, 6(3), 71-81. Chien, H. S.,Chen, H. F.,& Huang, H. F. (2009).Improving the process of completing invasive procedures in the emergency department. VGH Nursing, 26(4), 357-366. Levett-Jones, T. L. (2005). Continuing education for nurses: A necessity or a nicety? The Journal of Continuing Education in Nursing, 36(5), 229-233.

1679 Improve the ability of nurses in educating the postoperative care of patients receiving hair transplantation H.-L. Lo 1,*, Y.-L. Chiang 1, H.-L. Lee 2, H.-J. Chan 1 1 Department of Aesthetic medical center, 2 Department of Nursing, Taipei Chang Gung Memorial Hospital Taiwan, Taipei, Taiwan Hair transplantation (HT) is the first choice among surgical interventions for androgenetic alopecia (AGA) which effectively improves the appearance of troubled patients. Studies have pointed out that prevalence of AGA is around 63% and accounts for 91% of males seeking medical advice for hair loss. The cost is relatively high and post-operation home care is complex and has direct impact on the survival of hair follicles. Patients receiving HT increased from 20 cases in 2010 to 36 cases in 2011. The growth rate is 55.5%. Therefore, patients are often required to return to clinics for wound care for three consecutive days after the surgery. It is crucial that nursing staffs provide complete and consistent guidance on post-operative care to reduce anxiety of the patients and to improve the outcome of HT. Data were collected using self-developed Post-HT wound care and home care guidance checklist and Post-HT wound care and home care guidance cognitive scale. The processes of wound dressing in the office, the content of wound care and home care instructions are analyzed to determine the main factors causing incomplete or inconsistent nursing instructions. Five solutions are provided accordingly: (1) Development of HT postoperative wound care standard operating specifications. (2) Development of HT postoperative home care instruction standard operating specifications. (3) Providing education brochure, manuals, videos on postoperative guide. (4) Development of recording sheets of nursing instructions. (5) Nursing staff in-service education. Before intervention, cognitive scale from nurses providing postoperative instructions was 72.1%, and completion rate of postoperative instruction was 67.2%. Five hours of in-service education and one-on-one feedback were provided for 14 nursing staffs. After intervention, cognitive scale improved from 72.1% to 91.5%, and completion rate improved from 67.2% to 98.9%. In a period of 5 months, standard operating specifications of HT postoperative care and instructions were made. The brochure, manuals and multimedia DVDs on postoperative care are manufactured to assist oral instructions. Recording sheet of nursing instruction is an effective supplement to provide a step-wise care instruction, and it also serves as a reminder to both instructors and patients. Consistency and completeness of postoperative care instruction are obviously improved, and self-care skills of patients are enhanced. Therefore, this project should continue to be promoted.

1716 The development and validation of the nursing workplace stressors scale J.-C. Chien 1,*, W.-C. Chao 2, H.-N. Liu 2, M.-H. Sun 2 1 the Department of Healthcare Administration, Oriental Institute of Technology, 2 the Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan The purpose of this study was to develop a Chinese version of the Nursing Workplace Stressors Scale (NWSS) and evaluate its validity and reliability. After reviewing the literature, the original items of the NWSS were generated by means of taking a semi-structured interview with 23 nurses for an in-depth understanding of their experiences of stress at work. After revisions by 6 experts in the content area, the 48 generated statements were categorized into 8 aspects: peer relationships, superior effectiveness, physician quality, interacting with patient/family, workload, patient s recovery, professional growth, and working environment. In addition, there were 2 items used for screening out nurses who were not truthful in their responses. A seven-point rating scale was used in the NWSS. The scale of answer was from 1 (strongly disagree) to 7 (strongly agree); a higher score indicated a higher degree of stress in nursing. After a pilot study (10 respondents), the scale was administered to a valid sample of 661 registered nurses on 28 units of a medical centre in Taiwan in July, 2011. The test-retest reliability of the NWSS was gathered in October, 2011 (n = 191). The data were analyzed using descriptive statistics, item analysis, exploratory factor analysis, internal consistency reliability, test-retest reliability, the Spearman correlation, etc. Item analyses resulted in the deletion of 12 items that did not correlate well with the total score. Two items were further deleted due to factor loadings less than.40. By means of principle component analysis (with orthogonal varimax rotation) on the remaining 34 items resulted in 7 factors labeled: peer relationships (5 items), superior effectiveness (6 items), physician quality (5 items), interacting with patient/family (5 items), workload (5 items), professional growth (4 items), and working environment (4 items). The KMO value was.88 and the total variance explained by the factor analysis was 60.15%. The internal consistency of the NWSS for an overall coefficient alpha was.89 and the values of coefficient alpha for the 7 subscales ranged from.73 to.91. The test-retest reliability for the total scale after 3 months was.69. The test-retest reliability coefficients for the 7 subscales ranged from.40 to.63. The criterion-related validity of the NWSS was tested with a Chinese version of Aiken and Patrician s Revised Nursing Work Index (NWI-R), the correlation was -.53 (p <.01). The result had demonstrated acceptable empirical validity. This study has developed a Chinese version of the NWSS and the results indicate that the NWSS is a scale with good reliability and validity for measuring workplace stressors in nursing. The NWSS is not only useful for nurses, but also provide important information to help improve healthcare quality in hospitals.

1722 Nurses ratings of quality of care in small rural hospitals M. Baernholdt 1,*, G. Yan 2, I. D. Hinton 3, J. Keim-Malpass 3 1 School of Nursing and Department of Public Health Sciences, 2 Department of Public Health Sciences, 3 School of Nursing, University of Virginia, Charlottesville, United States Recently, hospital and care providers have seen an increase in the development of quality measures used for payment and accreditation purposes. Criticism of these measures include that they have been developed and studied primarily in urban hospitals. Of the more than 5000 hospitals in the United States (US) about 2100 are rural. Two-thirds are small rural hospitals with about 100 beds or less. Rural hospitals and the environments in which they function are different from their urban counterparts, suggesting that quality measures might need to be somewhat different too. Guided by a conceptual model depicting organizational and structural components' relationship with outcomes, this study examined associations between characteristics of community, hospital, and nursing unit, the nurse work environment, and 3 quality measures in small rural hospitals. Surveys from 385 staff nurses in 15 small rural hospitals in two US states were collected and data from the US databases: provider of services file and Department of Agriculture were used. The 3 quality measures examined were nurses ratings of overall quality of care (QOC), overall perception of safety (OPS) and frequency of event reporting (FER). Predictor variables included: (a) Community characteristics such as state and poverty level, (b) Hospital characteristics (HC) including number of beds, ownership, accreditation, staffing, and hospital safety culture, (c) Nursing unit characteristics (NUC) using unit type, work complexity, availability of support services, and unit safety culture, and (d) the nurse work environment (NWE) using nurse education, experience, expertise, commitment to care, and professional practice. Regression analysis was performed to examine associations between each of the quality measures and the predictors. All 3 quality measures were associated with NUC and NWE. Two quality measures were also associated with HC. Higher ratings of QOC were associated with lower work complexity (a NUC), and higher commitment to care (part of NWE). Higher ratings of OPS were associated with better ratings of the 2 hospital safety culture variables: hospital management support for patient safety and handoffs and transitions (both HC), and the unit safety culture variable: feedback and communication about error (a NUC), lower scores on work complexity (a NUC), and higher professional practice scores (part of NWE). FEP was lower with higher ratings of the hospital safety culture variables: teamwork across hospital units (a HC) and the unit safety culture variables: feedback and communication about error and nonpunitive response to error (both NUC), and lower nurse educational level and higher nurse expertise (both part of NWE). For all 3 quality measures NUC and the NWE were important. Both are areas found to be important for quality in urban hospitals, but not reflected in mandatory hospital reporting requirements. The 2 quality measures OPS and FER were associated with the presence of a hospital safety culture. While a culture of safety is widely recognized as a first step to improve safety, it is not routinely included in mandatory quality reporting. Although more studies are warranted to explore the reported relationships and other quality measures, our findings support that nursing unit characteristic, the nurse work environment, and a culture of safety are also important for quality in rural hospitals.

1724 Case Finding as the best method for preventive medicine - are there non-attenders to primary care in Israel? S. Vinker 1, 2,*, D. Rosen 2, A. Cohen 1, S. Nakar 2 1 Chief Physician office, Clalit Health Services, 2 Family Medicine, Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel To assess the number of patients not attending primary care physicians (PCP) over a four year period and to describe the characteristics of patients with different visit patterns in order to improve preventive health care planning in Israel. The study population included 421,012 individuals that were born before 2007 and were members of Clalit HMO central district in the whole period of the years 2007-2011. Data retrieved for each individual included annual number of visits to PCP and to direct access consultants (DAC), chronic diseases and socio-demographic characteristics. The average number of visits to PCP in one year was 7.6-8.3 (9.5-10.2 including DAC). During the first year of the study 87.2% of the population visited a PCP, and 94.9% and 97.5% in two and three years respectively. In four consecutive years only 1.5% of the population did not visit a PCP. In all age groups women visited more than men. The highest visit frequency was in ages 0-4 and 65 years old and above. Individuals who belong to lower socioeconomic status or have more chronic diseases visited more. The proportion of non-attenders to PCP in Israel is very low in comparison to older data. With appropriate organization, it is possible to adopt the case finding method for implementing preventive health care

1745 The impact of Charlson Comorbidity Index to predict adverse outcome in patients revisiting emergency department within 72 hours and related admission H. T. Wang 1,*, K. H. Wu 1 1 Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan To identify the characteristics of patients who return to emergency department within 72 hours after an initial visit and admit to hospital due to the same diagnosis. And to use Charlson Comorbidity index to predict the possibility of major complication. An exploratory quantitative descriptive study was conducted to identify characteristics of non-trauma patients aged above 17 years old with unscheduled 72 hr ED returns. The sample consisted of all patients with 72 hr ED return visits since 1 st January to 31th December of 2011. Data were collected from electronic patient records in an urban teaching hospital. Demographic data, the examination in each visiting, Charlson comorbidity index, and the complication during hospitalization were reviewed. Admitted revisit patients accounts for 1.5% (1103/72185) of patient encounters in a teaching hospital with 7 days of mean ward waiting. 62.5% of those patients admitted due to the same diagnosis as the first ED visit were enrolled in our study. The average age is 56.3 ± 17.7 years. The top three disease classifications of ED revisits are infectious, gastroenterological, and neurological diseases. The etiology of return visit includes complication related to the disease (15.7%), recurrence of symptoms (72%), miss-diagnosis (4.6%), and difficulty in diagnosis (7.5%). Sixty percent were discharged directly in the first visit, 7.8% discharged after symptom relief during ED observation, and 32% were arranged admission initially but discharged after treatment in ER due to prolonged ward waiting. The mean Charlson cormobidity index(cci) is 2.02. The value of mean CCIs in each group compatible with the complication rates. There is a total fifty patients (7.2%) with higher CCIs expired among 690 admitted revisit patients (CCIs 4.43 v.s. 1.83, p<0.001). Those patients discharged directly had lowest CCIs and lowest in-hospital mortality rate. However, patients discharged after temporary observation (no requirement of admission by physicians judgment) had significant higher complication than those be decided to admission(p< 0.05). In a busy urban teaching hospital, the determination of patient s admission by only physician s subjective decision is not reliable and might lead to higher complication during admisison. The objective evaluation tool such as Charlson cormobidity index provides more effective means of judgment and better patient care quality. References: 1. Kuan W S, M. M. (2009). "Emergency unscheduled returns: can we do better?" Singapore Med J 50(11): 1068. 2. Minnee, D. and J. Wilkinson (2011). "Return visits to the emergency department and related hospital admissions by people aged 65 and over." N Z Med J 124(1331): 67-74. 3. Wang, H.-Y. C., Ghee. Kung, Chia-Te. Chung, Kun-Jung. Lee, Wen-Huei. (2007). "The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours.." Chang Gung Medical Journal 30(5): 437-444. 4. White D, K. L., Eddy L. (2011). "Characteristics of patients who return to the emergency department within 72 hours in one community hospital." Adv Emerg Nurs J. 5. Wu, C. L., F. T. Wang, et al. (2010). "Unplanned emergency department revisits within 72 hours to a secondary teaching referral hospital in Taiwan." J Emerg Med 38(4): 512-517.

1748 A model for measuring safety performance: validation through patient perspectives as key stakeholders of safety in case management for long-term conditions S. Jones 1,* 1 WMG, University of Warwick, Coventry, United Kingdom Research on patient perspectives of safety is limited to experience of harm, their ability to report and estimations of their rate of error. This study is part of a larger project which aims to understand safety from the perspective of key stakeholders, in order to propose a proactive method for measuring safety. This study has developed a model that identifies key stakeholders in community care for patients with long term conditions; the relationships between them and categories of performance measures. Furthermore a key stakeholder group has been engaged to provide empirical evidence of its validity in the context of case management. An extensive literature review has been conducted covering three main topic areas; Department of Health (DoH) publications pertaining to the care of patients with long term conditions and/or safety; scholarly articles on the implementation of DoH guidance and performance measurement and safety in general and in healthcare. Furthermore, validation of the model was achieved through semi-structured interviews with the newly identified stakeholders: patients. Patients who met the selection criteria were recruited from the case management population at three Primary Care Trusts via delivery of a recruitment pack from their community matron. In order to reduce hospital admissions, case management seeks to provide on-going care for patients with complex needs in their home. This has resulted in a role change for patients; they now have greater if not full control over the environment, medication and care plan. They are expected to engage with self-management in the absence of a healthcare professional. The 'Integrated Safety Measurement Model' introduced the concept of patient responsiblity and accountability for safety and health outcomes, becoming a key stakeholder. Domains for measurement were derived from the work laid out by Donabedian in 1969 which have since been widely used for quality improvement, utilising the structure, process and outcomes themes. In the model presented here, structure and prcoess influence each other and are presented cyclically to ultimately impact upon two types of outcome: clinical and patient reported. Patients agreed that they had a role to play and felt they were now responsible for their safety and health outcomes. Patients also identified another key stakeholder that they felt were missing from the model who made an enormous contribution to their safety: informal carers. This has been reflected by alterations to the model which will be presented here. Patients have become a key stakeholder in their own safety; they provide the environment in which the care is delivered, have full control over medication and influence the care plan and how it is achieved through self care. Patients themselves agree and in doing so validated the key stakeholder relationships in An Integrated Safety Measurement Model. The use of patient perspectives to validate the model contributes to reinforcing patient-centred care. Understanding the role patients have to play in this particular care pathway and developing a method to measure this could contribute to improving health outcomes for this patient group.

1763 A feasibility and pilot study of auricular acupressure to reduce chemotherapy-induced nausea and vomiting in children S. W. Lin 1,*, C. H. Yeh 2 1 Pediatrics, Chang Gung Memorial Hospital, Linkou, Taoyuan county, Taiwan, 2 Department of Health Promotion, University of Pittsburgh, School of Nursing, Pittsburgh, United States Over 40% of children with cancer have reported that chemotherapy-induced nausea and vomiting (CINV) are the two most distressing side effects of treatment even when antiemetic drugs have been used.the purpose of this paper is to report the findings from our feasibility and pilot study using Auricular Acupressure (AA) for CINV in a small group of children in Taiwan. This was a cross-over randomized design study. CINV symptoms were assessed on ten patients just prior to and for 7 days following each of three rounds of chemotherapy drugs (CTX). They received standard care (UC) and were not entered into a test treatment group until they completed the baseline assessment, which was conducted during their first round of chemotherapy after entering the study. The enrollment rate for this study was 77% of the children invited to participate and of those, 88% provided completed data sets for all three treatment conditions. Patients in the AA group reported significantly lower occurrence and severity of nausea and vomiting than patients in the UC group (p <.05). There were no significant differences of nausea and vomiting for patients between the AA and AP groups. All of the patients took antiemetic medication on the day they received CTX and 80% of patients reported that the antiemetics did not help to treat CINV. These preliminary findings did show evidence that AA is acceptable to the children and their parents to prevent/treat CINV. However, there were no statistically significant differences between the AA and AP groups in the prevention/treatment of CINV. There were clinical trend differences between the groups, which may due to the small sample size. References: 1. Herrstedt J. Antiemetics: an update and the MASCC guidelines applied in clinical practice. Nat Clin Pract Oncol. 2008;5:32-43. 2. National Comprehensive Cancer Networks(NCCN). NCCN Clinical Practice Guidelines in Oncology: Antiemesis. v.4. updated December 28 2009. Available from: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. 3. Yeh CH, Wang CH, Chiang YC, et al. Assessment of symptoms reported by 10- to 18-year-old cancer patients in Taiwan. J Pain Symptom Manage. 2009;38:738-746. 4. Baggott C, Dodd M, Kennedy C, et al. Multiple symptoms in pediatric oncology patients: A systematic review. J Pediatr Oncol Nurs. 2009;26:325-339. 5. Gottschling S, Reindl TK, Meyer S, et al. Acupuncture to alleviate chemotherapy-induced nausea and vomiting in pediatric oncology - a randomized multicenter crossover pilot trial. Klin Padiatr. 2008;220:365-370. 6. Dean-Clower E, Doherty-Gilman AM, Keshaviah A, et al. Acupuncture as palliative therapy for physical symptoms and quality of life for advanced cancer patients. Integr Cancer Ther. 2010;9:158-167. 7. Chen CH, Chen HH, Yeh ML, et al. Effects of ear acupressure in improving visual health in children. Am J Chin Med. 2010;38:431-439. 8. Yeh ML, Chen CH, Chen HH, et al. An intervention of acupressure and interactive multimedia to improve visual health among Taiwanese schoolchildren. Public Health Nurs. 2008;25:10-17. 9. Jones E, Isom S, Kemper KJ, et al. Acupressure for chemotherapy-associated nausea and vomiting in children. J Soc Integr Oncol. 2008;6:141-145. 10. SAS Institute Inc.SAS OnlineDoc 9.2, 2009. 11. Yeh CH, Chiang YC, Lin L, et al. Clinical factors associated with fatigue over time in paediatric oncology patients receiving chemotherapy. Br J Cancer. 2008;99:23-29.

1768 Implementation of a computerized antimicrobial stewardship program in adult patients admitted to intensive care units at a tertiary hospital in Taiwan I. L. Chen 1,*, C. H. Lee 2, J. W. Liu 2 1 Pharmacy, 2 Infection Disease, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Kaohsiung, Taiwan Increasing bacterial resistance with few new antibiotics has led many institutions worldwide to attempt preservation of susceptibilities with antibiotic stewardship. We developed a computerized antimicrobial stewardship program (CASP) to guide the use of antimicrobial agents in late 2004 in a 2500-bed medical centre in southern Taiwan. The objective of this study was to evaluate the impacts of CASP on the intensive care units (ICUs). Kaohsiung Chang Gung memorial hospital with 43 wards and 18 ICUs contain 9 medical and 6 surgical ICUs for adults. This retrospective study observed clinical outcome in adult patients admitted to ICUs andimplementation of CASP from 2007-2009. Susceptibility data was obtained from hospital antibiograms and antibiotic usage was reported in doses dispensed/1000 patient days. The percentage of the pharmacy budget dedicated to antibiotics was documented. The following resistant organisms were evaluated: ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species). The days of ICU stay, total consumption of antibiotics and percentage of antibiotics prescription in ICU patients was no significant change. The age and severity of ICU patients were increasing. However, the duration of antibiotics treatment as well as cost of antibiotics and ICU crude mortality were decreasing statistically. The trends in the proportion of antimicrobial resistance in Gram-negative bacteriawere stable except increasing susceptibility in aminoglycosides, piperacillin and cefepime. The trends in antimicrobial resistance in ESKAPE pathogenswere stable except increasing K. pneumoniaeisolates resistant to ceftriaxone. TABLE: Clinical outcomes of computerized antimicrobial stewardship program in ICU adult patients Time 2007Q1 2007Q2 2007Q3 2007Q4 2008Q1 2008Q2 2008Q3 2008Q4 2009Q1 2009Q2 2009Q3 2009Q4 Age, years 65.4±18.0 65.3±19.1 65.2±18.8 65.4±18.2 66.8±18.4 64.7±18.4 64.6±18.2 65.5±18.1 65.9±16.7 66.7±16.7 64.2±16.5 64.8±17.0 ICU stay days 5.0±11.5 5.0±12.3 5.0±10.2 5.0±12.2 5.0±12.8 5.0±13.5 5.0±11.0 5.0±10.4 5.0±13.3 5.0±10.1 5.0±11.9 5.0±9.7 Patients with antibiotics prescription s(%) 1103(65) 971 (60.4) 990 (61.6) 989 (60.5) 974(60.9) 1062 (63) 1240 (74) 1269 (74) 923 (58.3) 955 (56.5) 988 (58.2) 986 (63.0) Duration of antibiotics treatment 5.0±9.3 5.0±7.9 5.0±7.0 5.0±9.3 5.0±8.4 4.0±7.2 4.0±7.4 4.0±6.6 4.0±6.2 4.0±7.6 4.0±7.5 4.0±6.4 Antibiotics cost ($) per person a 395±4046 357±4599 394±4228 350±9142 328±4703 299±6548 263±3226 262±3821 174±3261 174±5689 158±3002 188±2948 Patients with severity(%) b 994(70.7) 938(66.2) 1069(74.1) 995 (69.2) 1007(66.0) 1088(74.2) 1007(70.0) 972 (66.6) 1022(76.5) 1083(77.8) 1051(79.3) 1055(79.3) Patients with crude mortality( %) 237 (14.0) 233 (14.5) 280 (17.4) 217 (13.3) 228 (14.3) 176 (10.5) 216 (12.9) 198 (11.5) 161 (10.2) 221 (13.1) 206 (12.2) 193 (12.3) P value 0.046 NS NS <0.001 <0.01 <0.001 <0.001 NOTE. Data are number or median ± standard deviation. ICU: intensive care unit, Q: quarter, NS: not significant change a All costs are expressed in 2012 constant dollars. b Severity: if patients with APACH II score >15 or coma score <9. CASP is a sustainable system for providing antibiotic stewardship and exerts a positive impact on the ICUs by reducing duration of antimicrobial therapy and expenditure whilst improving healthcare quality.

1772 Nursing instruction for self-care improvement in patients with permanent pacemaker L.-Y. Huang 1,*, T.-Y. Huang 2, T.-C. Chao 1 1 Linkou Chang Gung Memorial Hospital, 2 Chang Gung University of Science and Technology, Taoyuan, Taiwan Permanent pacemaker (PPM) implantation is necessary and important treatment for patients with brad- arrhythmias. Patients can survive by getting alone with the device permanently. It is crucial to have sufficient competency in self care of PPM. The purpose of this study is to investigate the effectiveness of a comprehensive nursing education improving self care knowledge, attitudes, and behavior in patients with permanent pacemaker. Quasi-experimental with two-group pre- & post- test design was used for the current study. Pre-test was conducted before PPM implantation operation, and post-test was examined at the first visit patients came back, usually scheduled one to two weeks after discharge. Patients were assigned into experimental and control group purposively. Patients in the control group received routine ward postoperative nursing care, those who in the experiment group received comprehensive nursing education developed by researcher. Instruments for measuring subjects knowledge (12 items, α=.44-.66), attitudes (9 items, α=.70-.75), and behavior (8 items, α=.36-.62) were developed for this study. Satisfied psychometric properties were confirmed by experts (CVI=.91-.98). Comprehensive patient education for patients with PPM consists of integrated education module adopted by experts of cardiology and one-by-one individualized program, including in-patient education and telephone reinforcement 72 hours after discharged. Paired t-test was used to examine and compare the effect between two groups. Seventy-two patients were recruited, 35 patients were assigned into control group and 37 patients were assigned into experiment group respectively. Demographic characteristics were 49% male, 78% elderly (older than 65 years old), and there were no significant differences between experimental and control group. Compared with pre-test of knowledge, attitude, and behaviour scores, post-test scores were significantly improved in both groups. However, only self care knowledge score improvement reached group difference significantly (t=3.45, p<.001; t=3.09, p<.005, power=.99). Both comprehensive and routine patient education can improve self care knowledge, attitude, and behaviour of patients with PPM. Comprehensive patient education builds up patients knowledge more effectively. New-developed patient education module of the current study can be applied in the clinical setting to improve patients self care post PPM surgery.

1831 Implementation of a continuing education program based on the process improvement methodology to guarantee the integration of technological innovations into a radiation oncology department E. G. Lenaerts 1,*, M. Delgaudine 1, P. Coucke 1 1 Radiation oncology, University Hospital of Liege, Liege, Belgium To create a specific program of continuing staff training to cope with technological innovations in high quality image guided radiotherapy We used the process improvement methodology to describe processes in our organization in order to optimize high quality care.processes were defined taking into account the multi disciplinary environment of radiation oncology (medical, nursing, radiation physics, quality management and administrative). We mapped macro-processes, processes, activities and tasks necessary to run our department. We focused on the process "Managing Human Resources" and the subprocess "Managing skills" of employees especially on the profiles «Therapist» and «Dosimetrist» for which no specialized academic training is available in Belgium.We gathered data from the radiation treatment process analysis, the skill profiles managed by the institutional HR department and the «Repository of Expertise» built and managed by the department describing the mandatory skills to perform daily tasks in radiotherapy as well as to implement technological innovations.where differences were found, an adequate training program was implemented. The «Process approach» provided a better visibility of daily practices and was informative about relationships between staff and patients.it allowed to identify areas at risk in the treatment process and to anticipate disregarding of rules and standards, with a focus on profiles of both «Therapist» and «Dosimetrist». Based on the department experience in the analysis of Precursor Events (PE) reported by the staff - 3195 records were reported over a period of 37 months (December 2008-December 2011) - we know that any precursor events due to a gap in professional skills can potentially have a serious impact on treatment and patient safety. Our analysis determined that the tasks of the two profiles are involved in 14.4% of PE. The first training program started in october 2011 with the direct involvement of several employees. More than 40 people have responded positively to this call wich spontaneously generated a spirit of solidarity and mutual aid among all professional groups of the department. The training program covers 22 subjects for a total of 41 sessions and employees working on peripheral sites could attend via video conference. The implementation of this project was made public outside of the department itself and many declared interest to take part in this training program. The assessment of this first year is still ongoing, but the initial evaluations indicate that sessions are very well received. The «Process approach» allowed a better understanding of the activities and tasks performed daily for radiation treatments. The goal of this project was to provide a strong training program highly oriented to the specific tasks in radiotherapy in order to make employees more comfortable with technological innovations. This specific training in radiation therapy for profiles «Therapist» and «Dosimetrist» meets a substantial need in Belgium and is currently being recognized through a university certificate at the University of Liege.

1838 What gets measured gets monitored... targeting parenteral nutrition over a 3-year period S. Matthews 1,* 1 Nurition and Dietetics, St. Vincent's Private Hospital, Dublin, Ireland We examined the incidence of line infections, patterns of use and appropriate use of Parenteral Nutrition (PN) in a large private hospital against the National Institute of Health and Clinical excellence guidelines (NICE, 2006). Parenteral Nutrition data of three consecutive years from 2009 to 2011 were reviewed. All parameters including rationale, compliance, appropriateness, route of administration, types of PN regimens used, complications affecting receipt of PN, wastage of PN regimens, line infections and primary outcomes of PN were audited. The incidence of central line infections in 2009 was 3%, increased to 7% in 2010, and fell again to 3% in 2011. The inappropriate use of PN continues to decrease year on year from 6% to 3% in 2011. Examples of inappropriate use that was ceased included patients with high output ileostomies, reversal of an ileostomy and pre-operative feeding. Three quarters of total PN used, was for surgical patients. Wastage of PN bags remains <1%, but the quantity has increased from 2 PN bags in 2009, 5 PN bags in 2010 to 6 PN bags in 2011. An increase was noted for complications affecting receipt of PN. In 2009 and 2010, 4% and 7% of patients were affected, but in 2011 there was a dramatic increase with 13% of patients having complications affecting PN receipt which resulted in 31 days of no PN nutrition. As part of the audit process we measured the level of adherence with our hospital policies. In 2009 there was 96% compliance and in 2011 this had increased to 100%. The NICE guidelines stipulate defined criteria for the initiation of PN, in 2009, 96% of patients referred for PN met with these criteria, in 2010 this improved to 98% and in 2011 there was a further increase to 99%. The reduction in line infections from the spike in 2010 is attributed to the implementation of a central venous catheter and PICC maintenance care bundle form which is completed on a daily basis by nursing staff. Ongoing education of nursing staff seems to be a significant factor in reducing the inappropriate use of PN. Discussion with consultants regarding the most suitable form of nutritional support other than Parenteral Nutrition, acts as an informal type of education for the medical staff and that 98% of all PN is commenced within dietitian supervision. Wastage is attributed to the premature removal of PICC lines. The dramatic increase in the complications affecting receipt of PN could be associated with a move to a new 265 bedded hospital in December 2010. This resulted in the need for new systems to be implemented as systems used previously in the smaller hospital were ineffective in the new larger capacity hospital. An Enhanced Recovery After Surgery (ERAS) programme will be implemented in 2012, and should have some impact on the use of PN. Overall, education and audit have played a significant role in minimising the negative factors associated with Parenteral Nutrition.

1854 Patient Safety: violations of health standards and precepts N. B. Nascimento 1, C. Travassos 2,* 1 Escola Nacional Saúde Pública Sergio Arouca - ENSP, 2 Instituto de Comunicação e Informação Científica e Tecnológica em Saúde - Icict, Fundação Oswaldo Cruz - Fiocruz, Rio de Janeiro, Brazil National and international organizations stress the need to develop devices and strategies for reducing unnecessary healthcare-associated patient harm to a minimum. A growing number of actions and studies have been performed over the last decade. In addition to the new technologies and the technical knowledge acquired during this period, behavioral aspects related to the complexity and specificity of health care began to be taken into consideration. In order to better understand violation behavior, which is a part of the process leading to medical errors, this study focused on the procedures for hand hygiene (HH) and the difficult task of getting health professionals to adhere to such procedures. The explanatory models used in this study to understand this phenomenon were those proposed by James Reason, an English cognitive psychologist, and Christophe Dejours, a French psychoanalyst, occupational physician and ergonomist. Concepts introduced by Bill Runciman and colleagues on violations in health care were also used. The study used qualitative methods and was based on the development of a grounded theory aimed at understanding violation behavior during hand hygiene initiatives in medical practice. The method involved collecting data and simultaneously developing ideas within a logical and systematic explanatory system. Data were collected using various techniques interviews, participant observation, and document review in order to obtain multiple viewpoints on the same object. The study was conducted in adult and pediatric intensive care units (ICUs) in two hospitals in southeastern Brazil. The criteria for choosing the study's hospitals were: (1) having implemented a HH initiative as recommended by national and international agencies, (2) being an accredited hospital, and (3) being a teaching and research institution. Our analysis showed that intensive-care physicians in adult ICUs adhere less frequently to HH procedures than pediatricians in pediatric ICUs. The former seem to believe that, when dealing with complex clinical cases, the effectiveness of a technical act is strictly related to the use of more advanced techniques and technologies. That would lead to an undervaluation of simple and routine HH procedures. Pediatricians, on the other hand, have shown a different understanding of the effectiveness of technical acts, encompassing both physical and emotional aspects. The way these professionals perceive the practice of medicine helps to promote cooperation and engagement by other professionals in the team. This establishes a hierarchy based on the specificity of technical knowledge without creating vertical distancing. Such a posture gives pediatricians the role of guardians of adherence to good standards and procedures, and therefore to HH procedures. The study also noted the importance of the implementation stage of HH initiatives in preventing healthcare-associated infections. In general, a more advanced stage leads to increased adherence by professionals. Reason suggests that, in order to understand adherence behavior, both personal and systemic factors must be taken into account. In moderately successful organizations, whose procedures and behaviors are adjusted over the years, the safety and quality of work increases, as adherence to standards and procedures is more psychologically rewarding than non-adherence.

1856 Gaining insight into hospital-acquired adverse events in Portugal F. M. Baptista 1,*, F. Costa 1, J. Pontes 2, J. Sequeira 1 1 Healthcare, Siemens S.A., Amadora, 2 Grupo da Qualidade e Segurança do Doente, Centro Hospitalar do Alto Ave, EPE, Guimaraes, Portugal The objective of this study was to evaluate the feasibility of using administrative hospital data to estimate the rate of adverse hospital-acquired events in the Portuguese Healthcare setting. The difference between adjusted and unadjusted rates (per 1,000 discharges at risk) was estimated. The potential association between the occurrence of adverse hospitalacquired events and different factors, such as age, gender and length of hospital stay were evaluated. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) were used for identifying adverse hospital-acquired events in Portuguese hospitals, using ICD-9-CM coded and administrative data. Due to lack of information on admission diagnosis, days from admission to procedure, admission type and major procedure, the original algorithms were modified and implemented using Microsoft SQL Server Integration Services. AHRQ risk adjustment covariates and coefficients were used to estimate PSI adjusted rates. Provider-specific odds ratios were estimated using maximum-likelihood techniques. Odds ratio confidence intervals were obtained via likelihood-ratio tests. Statistical analyses were performed in R (v. 2.12.1). The study population consisted of one-year discharge data. Logistic regression analysis was used to assess the association between the occurrence of adverse hospital-acquired events and the distribution of patient s age, gender and length of hospital stay. Despite original data structure limitations, it was possible to estimate PSI rates and no major difficulties were found regarding the identification of the numerator, denominator and excluded cases. Death in low-mortality diagnosis related groups was found to be positively associated with patient age (P<0.001). Age and length of stay were significantly associated with the occurrence of pressure ulcer (P<0.05).Postoperative wound dehiscence and accidental puncture or laceration were significantly associated with increased length of stay (P<0.01). Therefore, the occurrence of adverse events is likely to be associated with increased hospital costs. No association was found between hospital-acquired adverse events and gender (P>0.05). Even thought Portuguese hospitals use DRGs for hospital reimbursement, data registration and coding practices vary among hospitals and present room for improvement. Accidental puncture or laceration observed rate was significantly lower than the expected rate, suggesting data registration and/or coding practices limitations. Problems related with systematic screening/diagnosis and reliability of registration/coding were suspected regarding central venous catheterrelated blood stream infections. Postoperative wound dehiscence observed rate was significantly higher than the expected rate, thus suggesting room for improvement at clinical practice level. Pressure ulcer observed rate was significantly lower than the expected rate, but at the same level as the average of international hospital performance, suggesting a good hospital performance. Assessment of patient safety using routinely collected administrative data can be used as an effective tool to identify potential patient safety issues in the Portuguese hospital setting, but its sensitivity depends on the PSI. This approach represents a cost-effective monitoring approach which might be applied at a national-level. Study results provided valuable information to identify strategies to reduce hospital-acquired events and highlighted a potential association between the occurrence of adverse events and increased hospital stay.

1874 Evaluation of the effectiveness of assigning nurse manager for ambulatory cardiac rehabilitation program M. C. Chung 1,*, M. Y. Au 1 1 Rehabilitation, Tuen Mun Hospital, Hong Kong, Hong Kong, China To evaluate the effectiveness of cardiac rehabilitation program with a designated nurse as case manager This was a retrospective study with pre- and post intervention group. Convenient samples were recruited for this study. The target population was cardiac patients joining the program from January 2009 to December 2010 and have attended follow-up clinic. The clinical records of all these patients were reviewed. There were 98 patients completed the CRP during the period. Male patients contributed the majority of the subjects (n=74, 75.5%). The mean age of the subjects was 60.2 years (range from 34 to 83). The overall attendance rate the entire program was 93.3%. 35 subjects (35.7%) had a diagnosis of non-st elevated myocardial infarction (NSTEMI). Patients with ischemic heart disease (IHD) ranked the second major group and constituted 34.7% of the subjects (n=34). The majority of the subjects (n=68, 69.4%) had undergone percutaneous coronary intervention (PCI) before joining CRP. Among the risk factors, most subjects had hyperlipidemia (n=91, 92.9%). After the completion of the program, remarkable outcomes were seen. The functional capacity of the patients increased from 5.3 METS to 6.6 METS (t=-9.456, P<0.0001). The mean time spent in moderate intensity exercise increased from 89.0 min/week to 312.8 min/week (t=-10.841, P<0.0001). The mean body weight was reduced statistically from 66.3 kg to 65.2 kg (t=4.333, P<0.0001). Likewise, the mean waist circumference reduced significantly (pre: 89.4 cm, post: 88.2 cm; (t=3.342, P<0.005). There were also positive outcomes in mean total cholesterol level (4.34 mmol/l to 3.97 mmol/l; t=5.443, P<0.0001) and LDL levels (2.37 mmol/l to 2.1 mmol/l; t=5.689, P<0.0001). The blood pressure demonstrated significant improvement with mean systolic blood pressure reduced from 127.3±19.4mmHg to 119.5±11.0mmHg (t=3.866, P<0.0001) and diastolic blood pressure from 75.3±12.7mmHg to 71.9±9.9mmHg (t=2.798, P<0.0001). Besides, almost all patients (n=96, 98%) had developed a habit of home BP monitoring (X 2 =34.028, P<0.0001). The psychosocial well-being of the patients also significantly improved as reflected by an improvement in total HADS scores (z=-4.722, P<0.0001). Whilst, the anxiety subscore (z=-3.238, P<0.005) and depression sub-scores (z=-4.285, P<0.0001) also demonstrated marked improvement (z=-2.07, P<0.05). The results of the study demonstrated that the program was successful with significant improvement in metabolic outcomes and cardiovascular risk factor control. The high attendance rate and improvement in the HADS score reflected that the marked improvement of psychosocial well-being of patients and their active participation. At the same time, almost all patients committed to engage in a healthy lifestyle with regular exercise and home blood pressure monitoring. Support for developing similar program is encouraged.

1920 Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: a randomized controlled trial N. Junod Perron 1,*, J.-P. Humair 1, D. Haller 1, J.-M. Gaspoz 1 1 Department of community medicine, primary care and emergencies, Geneva University Hospitals, Geneva, Switzerland Telephone or text-message reminders have been shown to significantly reduce the rate of missed appointments in different medical settings. Since text-messaging is less resource-demanding, our aim was to test the hypothesis that textmessage reminders would be as effective as telephone reminders in an academic primary care clinic. This randomised non inferiority trial was conducted in the academic primary care clinic of Geneva University Hospitals between November 2010 and April 2011. Patients registered for an appointment at the clinic, and for which a cell phone number was available, were randomly selected to receive a reminder via text-message or via a telephone call 24 hours before the planned appointment. Patients were eligible to be included each time they had an appointment. The outcome of interest was the rate of unexplained missed appointments. Appointments that were cancelled or re-scheduled before the planned appointments were not considered as missed. We defined non-inferiority as less than 2% difference in the rate of missed appointments and powered the study accordingly. 5076 patients were included (2563 in the text-message group and 2515 in the telephone group). The rate of missed appointments was 10.2% (95%CI: 9.0-11.3) in the text-message group and 8.5% (95%CI: 7.4-9.6) in the telephone group. This small difference was statistically in favour of telephone reminders (p=0.041). Yet both methods led to considerably lower rates of missed appointments than usually encountered in our clinic (14%). In the satisfaction survey conducted among a random sample of 288 patients, none of them was disturbed by the reminder, whatever its nature. More than 80% of them recommended its regular implementation in the clinic. Text-message reminders are slightly less effective than telephone reminders in reducing the proportion of missed appointments in our academic primary care clinic but are less resource-demanding. Both types of reminders are well accepted by patients.

1925 The impact of perceived nursing work environment on patient care quality W.-C. Chao 1,*, C.-Y. Yuan 1 1 Department of nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan This study aimed to examine the impact of perceived nursing work environment on patient care quality. A cross-sectional survey was conducted for collecting data from 830 nurses employed over 3 months in a medical center located in northern Taiwan. Total of 784 questionnaires were completed and response rate was 94%.Two measurements adapting from Chinese version of Aiken and Patrician s Revised Nursing Work Index (NWI-R) and quality of care were used. Seven factors were extracted and accounted for 45.2% variance of nursing work environment by factor analysis with an orthogonal rotation, such as professional practice, professional development, professional standard, staffing and resource adequacy, nurse-physician collaboration, supportive nurse manager, and nursing competence. Nurses perceived staffing and resource adequacy and nurse-physician collaboration remarkably lower than supportive nurse manager. After adjusting for demographic characteristics, results from multiple regression indicated that staffing and resource adequacy (β=.18, p=.000), nurse-physician collaboration (β=.18, p=.034) and supportive nurse manager (β=.29, p=.001) accounted for 30.2% variance of nursing carequality. Our findings suggest that greater investments in improving the nurse practice environment, the adequacy of nurse staffing, and maximizing nurse-physician collaboration would result in better care outcomes. References: Spence, L., Heather, K., & Leiter, M.(2006). The impact of nursing work environments on patient safety outcomes: the mediating role of burnout engagement, Journal of Nursing Administration, 36(5), 259-267. Schubert, M., Glass, T. R., Clarke, S. P., Aiken, L. H., Schaffert-Witvliet, B., Sloane, D. M., & De Geest, S. (2008). Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study. International Journal for Quality in Health Care, 20, 227 237. Van Bogaert, P., Clarke S., Vermeyen, K., Meulemans, H., & Van de Heyning, P. (2009). Practice environments and their associations with nurse-reported outcomes in Belgian hospitals: development and preliminary validation of a Dutch adaptation of the Revised Nursing Work Index. International Journal of Nursing Studies,46(2), 55 65. Friese, C.R., Lake, E.T., Aiken, L.H., Silber, J.H. & Sochalski, J. (2008). Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research, 43,1145 1163.

1933 Evaluation process of the general introduction of 32 priority guidelines on elective treatment in the Norwegian specialist health service L. Lund Håheim 1,*, A. Schou Lindman 1 1 Norwegian Knowledge Centre for the Health Service, Oslo, Norway The Norwegian Directorate for Health directed a consensus process to develop revised priority guidelines for access to elective hospital treatment. In all 32 priority guidelines were developed by groups of clinicians in the relevant fields. The guidelines were introduced at different time points after authorization by the Directorate for Health during the time period 2008-2009. The aim of the study is to evaluate this intervention by using statistical analyses of hospital data before and after the implementation. Individual clinical data from the Norwegian Patient Registry for all persons hospitalized were linked with data from Statistics Norway on mortality, education, and marital status after receiving permits form the Norwegian Data Inspectorate and the Regional Ethical Committee for Medical Research. Included in the project is a validation study by patient journal revision to assess the referral diagnosis and the hospital diagnosis as reason for giving priority. Two disease conditions from each of eleven selected priority guidelines were selected for journal review. The study is ongoing research. The overall analysis will investigate data by different methods primarily on the change in waiting time in compliance with the new priority limits and the hazard rate of extended waiting time. The ICD10-codes were defined with the assistance of clinicians for each guideline. These codes had to be defined in order to analyse the data from the Norwegian Patient Registry as the priority scheme was established for conditions in a combination of diagnosis and procedures. Through a consensus process among three researchers eleven guidelines were selected for detailed analyses. The inclusion criteria were: 1) sufficient power reflected by assessed number of inpatients in a year, 2) reflect a range of medical fields and their related disease groups for prevalence and degree of severity, 3) reflect a range in the population in terms of age and gender. The study outlines methods for before and after analyses of the effect on waiting time for elective treatments introduced by the full scale implementation of 32 priority guidelines, an intervention in the specialist health service of Norway.

1967 Enhancing patient safety in cardiac surgery: assessment of an inter-professional teamwork approach K. Graves 1,*, O. Dzemali 1, M. Genoni 1 1 Cardiac Surgery, City Hospital Triemli Zurich, Zürich, Switzerland Changes in surgical practice regarding accountability and evolving employment strategies have added importance to assessing and influencing improvements in safer and more efficient teamwork in high-risk work settings. A database registry (Dendrite Clinical Systems) for the Safe Surgery Saves Lives (SSSL) procedure in our cardiac surgery clinic was constructed to enable an ongoing quantitative and qualitative evaluation of inter-professional teamwork. Functioning as a work-based assessment tool, the database focuses collected information on four interventional targets of the SSSL procedure: 1) inputs (preoperative checklists from participating units (ward, anesthesiology) and preoperative de-briefing of team members); 2) processes (changes in interactions among team members); 3) outcomes (changed, or improved communication, altered strategies); and 4) impact (to what extent the SSSL intervention has led to improvements in teamwork and patient safety). Interviews with various team-members enabled a qualitative assessment in regards to inadequate team-work and identified barriers to implementation of interventions aimed at improving communication between professionals. Fully successful usage of preoperative checklists (inputs, teamwork) is achieved in only 42% of all cases, although improvements resulted from additional team training. Errors in pre-operative checklists (unsigned, checked but not done, etc.) were discovered in 13.1%. Debriefing information and detection of unforeseen patient morphology (inputs and outcomes) through transesophageal echocardiography (TEE) prior to surgical incision altered surgical strategy in 28 (8.2%) of the 340 patients, thereby reducing the incidence of undiscovered or inadequately corrected valve dysfunction or manipulation of the atherosclerotic aorta prior to incision, events that are known risk factors for increased postoperative morbidity and mortality. Critical incident reports due to communication or procedure errors occurred in 25 procedures (7.4%). A barrier to the sustainability of the SSSL procedure was a lack of acceptance and commitment of all team members to its intended goal (interviews), the momentum of the intervention being provided by only a few individuals. The database registry enables a quantitative assessment of the effects of the SSSL procedure and, to a lesser extent, a qualitative evaluation of non-technical skills of the personnel of the cardiac surgery theatre. While detection of error through de-briefing was clearly demonstrated, error related to inadequate checklist usage (teamwork) proved in most cases to be case-hardened. However, one ward showed good improvement following additional team-training. Qualitative assessment revealed misunderstandings and aided in addressing programme deficiencies. It could not be shown that increased teamwork contributed to satisfaction with regards to working conditions or enthusiasm for the SSSL procedure. Regarding enhanced qualitative analysis, a more organised approach to non-technical skills assessment will have to be adopted in the future.

1995 Patient satisfaction with care and treatment services in two HIV clinics in Ebonyi State, Nigeria B. N. Azuogu 1, 2,*, C. Alo 2, L. U. Ogbonnaya 2 1 Community Medicine, Ebonyi State University Teaching Hospital, 2 Community Medicine, Ebonyi State University, Abakaliki, Nigeria To assess the quality of care in the HIV clinic as perceived by the HIV patients To assess the perception of HIV patients about their state of health To evaluate the attitude of Doctors/Nurses to the patients during and after clinic periods This was a descriptive study involving two HIV clinics in Ebonyi State: Ebonyi State University Teaching Hospital (EBSUTH) which is a tertiary hospital in Abakaliki and Mater Misericordiea Hospital (MMH) which is a faith-based hospital in Afikpo offering both primary and secondary care. Each of the hospitals runs an HIV clinic which is sponsored by AIDSRelief in partnership with the Institute of Human Virology University of Maryland, United States. This survey was carried out between September 2011 and November 2011. Structured questionnaire was used to collect information from 149 randomly selected patients enrolled for HIV treatment and care on their demographic characteristic, ease of accessing care, perception of their health status, waiting time, clients relationship with care-givers, and clients willingness to continue accessing care in the clinics. Five-point Likert scale of strongly agree, agree, undecided, disagree and strongly disagree was used during data collection but was later simplified to three point scale of agree, disagree and undecided during analysis. Analysis was done using Microsoft Excel. The mean age of the respondents was 25.8 in EBSUTH and 27.1 in MMH. Overall satisfaction was 57.2% in EBSUTH and 60.7% in MMH. Both facilities were rated high (EBSUTH 71.4% and MMH 77%) in terms of friendliness of care givers. But 67.4% of patients in EBSUTH and 35% of patients in MMH rated their state of health as poor. Poor self-rated health is associated with higher morbidity and mortality, as well as lower patient satisfaction and trust in the healthcare system. Satisfaction in this study was relatively high but it did not completely translate to better state of health. It is, therefore, important to add quality to painstaking services given to patients in order to improve their health status.

2046 Quality-Improvement Activities: management of medical practitioners performance metrics T.-Y. Kim 1, C.-W. Park 1,*, Y. Rho 2, J.-H. Lee 3 1 Quality Improvement, 2 Strategy & Planning HQ, 3 Neurosurgery, Wooridul Spine Hospital, Seoul, Korea, Republic Of Recently, the Korean government has announced medical tourism as one of next-generation growth engines. As a response to government s new policy, each hospital is seeking to attract foreign patients to their hospital by supplying trust to the foreign patients as credited by Joint Commissions International (JCI) certification, which as an internal standards for patient safety systems. Even though our institution is the only hospital as accredited by JCI certification among the spine-specialized hospitals in Korea, objective medical practitioner s performance indicators to provide the selection parameters of an internal physician from the foreign patients have not been prepared yet. Therefore this research was carried out to establish annual performance metrics of each spine surgeon through analysis of the correlations between physician s performance and the patient satisfaction and to provide its result as a critical rationale in selection of a surgeon to the foreign patients. This study was conducted between the period of January 1 st, 2010 and December 31 st, 2011 under the assumption of foreign patients selection parameters of medical practitioner might be similar with that of domestic patients. A total 3,470 patients, 20% of which comprises between the ages of 18 and 75 as an impartial research, (1,690 out of total 8,448 patients in 2010, and 1,780 of 8,898 patients in 2011) who underwent spine surgery from 16 different surgeons in our institution were included in this study to investigate the patients satisfaction degree and compliance. All patients survey was compiled by telephone survey using modified and combined questionnaire based on standard form of Hospital Consumer Assessment of Healthcare Providers and Systems by trained researcher. Medical record from every case was also reviewed to assess each spine doctor's performance. The investigated performance indices are; unplanned reoperation ratio, unexpected re-admission ratio, surgery cancellation ratio, and wound infection. The unplanned reoperation ratio was decreased from 3.65% to 1.93%, unexpected re-admission ratio was decreased from 2.38% to 1.89%, surgery cancellation ratio was decreased 15.84% to 6.64%, and wound infection ratio was decreased 0.99 to 0.80%, respectively. In a correspondence with the improvement of doctor s performance indices, the overall patients satisfactions degree were also increased to 81.1 point in 2011 in operating phase from 72.8 point in 2010 pre-operating phases and compliance of patients was increased to 8.6 point in 2011 from 7.8 point in 2010. The objective performance index of medical practitioners can be used as indication for the patient's selection of primary care physician as well as management indication of the hospitality quality improvement. Hospitals could improve medical services quality through establish performance metrics and disclosure of medical practitioners performance index to patients. Authors are considered that an improvement of medical practitioners performance was resulted from implied reconsideration under monitoring activities through objective index of performance.

2059 Perception of patient-safety climate and nursing care quality C.-Y. Yuan 1,*, W.-C. Chao 1 1 Department of nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan This study aimed to examine the impact of perceived patient Safety Climat on nursing care quality. Data was obtained by administrating a structured- questionnaire survey consisting two part. The main part of the survey was made up of Safety Climat and nursing care quality questions. The items were rated on a four-point scale (1=strongly disagree; 4= strongly agree). The last part inquired demographic questions about the nurses. A cross-sectional survey was conducted among nurses employed over 3 months in a medical center located in northern Taiwan, during 2010. Total of 784 questionnaires were completed and response rate was 94% (784/830). Statistical analysis by means of descriptive statistics, Pearson s correlation, and multiple regression was performed based on the data obtained. The overall safety climate mean score was 2.81 (SD= 0.33). The item the culture of this clinical area makes it easy to learn from the mistakes of others had the highest mean score (2.93, SD=0.46). The correlation was.56 (p <.000) between patient safety climateand nursing carequality. After adjusting for demographic characteristics, results from multiple regression indicated that patient safety climate (β=.85, p=.000) accounted for 30% variance of nursing carequality. This research provides managers a reference to create a safe treatment environment and to enhance care quality with the promotion of patient safety culture. References: Raftopoulos, V., Savva, N., & Papadopoulou, M.(2011). Safety culture in the maternity units: a census survey using the Safety Attitudes Questionnaire. BMC Health Services Research, 11(238), 1-10. Halligan, M., Zecevic, A.(2011). Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ Quality & Safety, 20(4), 338-343. Hughes, L. C., Chang,Y., & Mark, B. A.(2009). Quality and strength of patient safety climate on medical-surgical units. Health Care Management Review, 34(1), 19-28. Hartmann, C. W., Rosen, A. K., Meterko, M., Shokeen, P., Zhao, S., & Singer, S., et al.(2008). An overview of patient safety climate in the VA. Health Services Research, 43(4), 1263-1284.

2081 Spectrum Analysis of drug utilization to facilitate hospital performance and management G. Lam 1, C. Cheng 1, T. K. Yeung 1,* 1 Finance, Hospital Authority Hong Kong, Hong Kong, China Drugs play an important role for patients in treating various conditions. In Hong Kong, drug consumption is about 10% of the total resource utilization in the public healthcare system. Drug utilization monitoring becomes a potential tool to be used in the evaluation of hospital performance. The purpose of the study is to describe a new indicator Relative Drug Index ( RDI ) for acute inpatients and to assess its implication. Drug utilization data in 2010/11 were gleaned from the Pharmacy Management System ("PMS") in the Hong Kong Hospital Authority ( HA ). The RDI was defined as the ratio of observed (actual) drug consumption to the expected drug consumption (based on HA overall for 2010/11), adjusted for casemix. The RDI is based on a model that includes acute inpatient drug consumptions per day and length of stay. An RDI greater than 1 indicates the drug spent is more than what would be expected. An RDI less than 1 indicates that the drug consumption is less than what would be expected. The RDI was calculated at various levels, such as hospital, department and Diagnosis Related Groups ( DRGS ). The variations in drug utilization performance among different levels in RDI were analyzed. The RDI is the first drug indicator in HA in measuring drug utilization related to consumption to facilitate hospital performance; however, other studies related to prescribing, dispensing or its associated events could also be considered. The study offers guidance for development of drug management information to facilitate Hong Kong public hospitals management and planning.

2139 Can we improve the trial without catheter (TWOC) clinic referrals? A novel use of a new electronic referral system J. Jelski 1, 1, F. McMeekin 1, J. Scott 1,*, N. Burns-Cox 1 1 Urology, Musgrove Park Hospital, Taunton, United Kingdom All referrals to TWOC clinics should include sufficient information to enable successful patient management. This includes details of the catheterisation, relevant comorbidities and drug history, pertinent examination and investigation results, and a plan for future management. Appropriate management of urinary retention with alpha- blockers has been shown to improve TWOC success rates [1]. This in conjunction with adequate history and examination should lead to an improved service and better patient outcomes. Referrals for all patients attending TWOC clinics between 25/11/2011 and 23/01/2012 were included. Referral forms (paper) were assessed for the provision of basic patient information, details of catheterization, relevant medical history, and pertinent examination and investigation results. Data was collected prospectively by two nurses in charge of the TWOC clinics, and entered in a yes/no/not applicable format. The patients were then categorised into successful and unsuccessful TWOCs. Failure to pass urine following catheter removal, inappropriate clinic referral and the need for a delayed TWOC were all categorised as unsuccessful referrals. The success of TWOC was correlated with three variables. 1. Firstly the adequacy of referral, assessed on the study proforma. 2. Prescription of an Alpha-blocker prior to TWOC 3. PSA level. 27 patients attended TWOC clinics in the period studied. 93% of referrals for these patients included their identification details, and 74% the name of the referring Consultant. The date of catheter insertion was included in 78% of referrals and the indication in 74%; only 56% specified whether the patient had had previous catheterisations. 54% of forms detailed whether the patient was receiving a 5a-reductase inhibitor or alpha-adrenergic antagonist. The findings on digital rectal examination were included on 41% of forms; the prostate size specifically mentioned in 37%. Relevant investigation results were detailed in 52% of referrals; 6 mentioned the PSA value. The results of the TWOC were available on the Hospital discharge system for 22 patients. 15 patients were successfully TWOC d, with mean number of correctly filled data boxes 9.3 (range 4-17). Of the 7 patients who experienced unsuccessful outcomes, the mean number of boxes filled was 4.6 (range 0-10). Of these unsuccessful patients only 14% had been started on an alpha-blocker prior to clinic attendance, in comparison with 80% of those with a successful result. Successful TWOCs were associated with a lower average PSA (Accounting for prostatic volume) reading than in unsuccessful patients. This data however based on low numbers and therefore cannot be interpreted with any confidence. This pilot study highlights both the improvement in outcome with an appropriate referral and the need for a more proficient way of referring patients. We are currently introducing a novel new eletronic referral system [2] which will only allow referrals to be made should all required information be inputed. We should therefore see better outcomes for our patients as has been shown in this study. References: [1] McNeill SA, Hargreave TB, Roehrborn CG, Alfaur study group. Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study. Urology. 2005;65(1):83 9 [2] Davies T. et al Faxing is so 90s Introducing an electronic system for consultant-to-consultant referral in a District General Hospital. (unpublished) presented UKFPO 10/02/2012

2146 Impact of nosocomial infection on readmission: analysis of electronically-captured data Y. P. Tabak 1,*, X. Sun 2, R. S. Johannes 3, 4 1 Clinical Research, CareFusion, Weston, 2 Clinical Research, CareFusion, Lincoln, 3 Clinical Research, CareFusion, Newton, 4 Medicine, Harvard Medical School, Boston, United States Patients with hospital-onset infections may be at higher risk for readmission after discharge. We sought to investigate the prevalence and impact of nosocomial infections on readmissions within 30 days. We analyzed electronic clinical and administrative data between 10/1/2008 and 8/30/2009 from 20 US hospitals. We identified hospital-onset infections using previously validated Nosocomial Infection Marker (NIM). The NIM is an algorithm-based system that accounts for timing of specimen collection in relation to patient admission and location. It excludes common contaminations. We estimated the impact of NIM on readmission within 30 days using multivariable regression, controlling for age and principal diagnosis based clinical conditions in the seeding admission. Among 277,545 seeding discharges (220,015 unique patients) during the study period, 11,859 NIM cases were identified (43 NIM cases per 1,000 discharges). The 30-day readmission rates for patients with NIM by source in the live seeding discharges were: stool (50.5%), wound (48.0%), blood (45.4%), multiple sources (44.2%), other (43.3%), urine (38.1%), and respirate (36.4). The corresponding risk adjusted odds ratios and (95% CI) were 5.38 (4.80-6.04, stool), 6.47 (5.87-7.13, wound), 4.58 (3.99-5.26, blood), 4.65 (4.20-5.15, multiple), 5.91 (5.04-6.94, other), 3.47 (3.25-3.70, urine), and 3.41 (3.04-3.82, respirate), respectively, compared with patients without NIM in the seeding admissions (all P<0.0001). Compared with cases without NIMs, cases with NIMs have up to more than 6-fold increase of odds of readmission within 30 days after an index discharge, adjusting for the age and clinical conditions.

2156 Performance measurement in perioperative care: development of indicators and insight in current practice and patient safety H. Calsbeek 1,*, Y. Emond 1, J. Stienen 1, A. Wolff 2 1 Scientific Institute for Quality of Healthcare (IQ healthcare), 2 Anaesthesiology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands Evidence-based pre-, per-, and postoperative safety guidelines with accompanying quality indicators have been developed in the Netherlands. To implement the guidelines, insight into current clinical practice is necessary. With the newly developed quality indicators we aim to assess current perioperative care. A set of 11 quality indicators has been developed, based on a systematic RAND-modified Delphi procedure (Table 1: nr 1-11). These indicators are currently being tested in 6 surgical settings to assess their measurability (availability of data), applicability (applicable to most patients), and room for improvement (indicator score<90%, or not meeting underlying items of a structure indicator). A first subset of 8 indicators (Table 1: 1-8), only covering pre- and peroperative care, has already been tested in a small sample of 56 elective surgery patients in 3 surgical settings.the total set of quality indicators will then be applied in a multicenter study to assess current practice in perioperative care.in this study, aimed at the implementation of the perioperative safety guidelines, 9 representative Dutch hospitals participate in a stepped wedge cluster randomized trial design. This includes a sequential roll-out of an implementation strategy to all hospitals over a number of time periods, and 4 additional outcomes regarding perioperative patient safety will be applied (Table1:nr12-15). Indicator 1 STOP-bundle (7 individual check moments in the perioperative care pathway) 2 Protocol on antibiotics 3 Timely administration of antibiotic prophylaxes 4 Protocol on anticoagulants 5 Protocol on tasks and responsibilities regarding maintenance medical equipment 6 Protocol on prospective risk analysis of medical equipment 7 OR-regulations on hygiene 8 Surveillance system for postoperative wound infections 9 Postoperative wound infections 10 Registration system of complications and mortality 11 Postoperative mortality 12 Perioperative morbidity 13 Unplanned reoperation 14 Unplanned admission to intensive care (ICU) 15 Extended length of hospital stay (LoS) Type of indicator Process Structure Process Structure Structure Structure Structure Structure Outcome Structure Outcome Outcome Outcome Outcome Outcome Measurability Applicability Improvement potential moderate good poor good good good good good good good good good moderate good good/moderate good good/moderate poor unknown poor poor good moderate good/moderate The first practice test of 8 indicators showed good applicability, but the measurability appeared to be difficult for two individual check moments in the STOP-bundle, timely administration of antibiotic prophylaxes, and OR-regulations on hygiene (indicators 1,3,7 in Table 1). Four indicators showed sufficient room for improvement. Some individual check moments in the STOP-bundle and the presence of three protocols (indicators 2,4,5)showed little room for improvement, but were maintained in the set for reasons of content validity. Results of the more extensive practice test of the total indicator set, as well as results on current clinical practice and patient safety, will be presented. Based on the guidelines and a systematic consensus procedure, a valid set of quality indicators for perioperative care has been developed. Preliminary results indicate moderate to good feasibility with sufficient improvement potential. More results on feasibility, improvement potential, and variation in current clinical practice and patient safety will be presented.

2169 A clinical pathway to improve the quality of outpatient care provided to patients with diabetes: preliminary results of a primary care assessment A. Slama-Chaudhry 1,*, A. Ourahmoune 2, N. Junod Perron 1, J.-M. Theler 1 1 Community Medicine, Primary Care and Emergency, 2 Quality of Care Service, Medical Directorate, Geneva University Hospitals, Geneva, Switzerland - To retrospectively assess the quality of outpatient care provided to patients with diabetes by an interdisciplinary team of primary care professionals (a primary care doctor, a nurse and a dietician) in the Geneva University Hospitals, Switzerland. - To develop and implement a local institutional care pathway for patients with diabetes. The first step of the project aimed at building a comprehensive registry of patients with diabetes. Patients eligible for inclusion in the quality care pathway program were patients having i) at least 3 medical visits over a one year-period (1.08.2010 to 01.08.2011, and ii) a medical records. A data entry grid was developed and the following variables were collected: 1) socio-demographic characteristics 2) cardiovascular risk factors 3) general information about patient s health 4) measure of process of care and outcomes (HbA1c, BP, lipid profile, number of eye and foot examination ) 5) Care givers and patients perceptions (through a self-administered questionnaire). The initial assessment identified 437 patients. 294 (67.3%) of those patients were eligible and their medical record reviewed. A total of 294 (49% women) subjects were included. The mean follow-up time in the outpatient care was 5.7 yrs and the mean diabetes evolution time was 9.3 years. The overall mean age was 59 yrs. Hypertension was reported in 82% (13.3% missing values), overweight (BMI>25 kg/m2) in 82%, and obesity (BMI>30 kg/m2) in 56 % (26% missing values). 28% were current smokers. 95% of the patients were treated for diabetes by oral (62%), insulin (16%) or combined (21%) treatment. Most of patients suffering from diabetes were tested for HbA1c at least once per year (88%) and 35% were tested twice. The median level of HbA1c was 7.44% (min 5.1 and max 13.5). 36% had their eye fundus checked annually (35.4% missing values). This study describes an assessment of the quality of outpatient care provided to patients with diabetes in a Swiss outpatient care setting. The next step is to develop and implement a care pathway for diabetes patients, thus organizing the care delivered by a multi-disciplinary team including a primary care physician, a nurse, a dietician, an endocrinologist and a specialist in therapeutic education. The pathway will integrate care objectives in line with the international guidelines for diabetic patients care. This step is currently underway with the development of a pilot-pathway to be introduced on April 1st, 2012, for a 6 months period. After conducting the evaluation of this pilot, the pathway will be generalized to the whole practice on December 1 st, 2012 and a further assessment will be planned after a one year trial.

2192 Analysis of palliative care inpatient services for Taoyuan Chang Gung Memorial Hospital in 2005-2009 H.-Y. Y. Betty 1,*, J.-L. J. Lee 1, T.-H. T. Huang 1 1 Department of Nursing, Chang Gung Medical Foundation, Chang Gung Memorial Hospital at Taoyuan, Gueishan, Taiwan To investigate source of patient referee, patients from different medical departments, disease diagnosis, length of hospital stay, symptoms, prognosis, discharge, and end of patient follow up in hospice and palliative ward of Taoyuan Chang- Gung Hospital from 2005 to 2009. A retrospective study and investigations during the period from Jan 2005 to Dec 2009. Total hospitalized patients were 1143. We enrolled 1023 patients information. All data were analyzed using SPSS 12.0 statistical software. The subjects of this study included 1023 hospitalized patients with male patient in predominance of 55.5%. The mean (SD) age was 64.4 years. Age above 65 years old was 58%. Patients admitted once were 91.3%. Median length of stay was 13 days. Mean survival time of subject groups was 11.8 days. The source of patient referee is as followings: hospitalized patients from different medical departments 57% and patients from emergency departments 24.3%. With regard to the primary cancer origins in the subject group, lung cancer patients was the largest group (15.7%), followed by colorectal cancer patients (15.7%), and liver cancer patients (14.9%). Regarding symptoms encountered by hospitalized patients, dry mouth is most common (83.7%), followed by anorexia (79.6%), and general malaise (78.4%). Among total hospitalized patients, death in hospice accounts for 82.5%; stable discharged with home care and others were 17.5%. Total hospitalized patients were 1143. 1023 (98.2%) patients were referred within the institute of Chang-Gung Memorial Hospital. 14 days of hospitalization of the subject group was 60%. 7 days of hospitalization of terminal ill patients was 46.2%. Among death of 942 patients, patients discharged with terminal status accounted for 38.3%. This phenomenon reflected the cultural difference of Taiwan with the Westerns. By analyzing hospitalized condition of cancer terminal patients, we hope to assist in medical services that emphasized in appropriate intervention to those patients at proper timing. The database will be kept and continuously collected as a reference for improvement of hospice care quality and aim in future development. References: Ida E, Miyachi M, Uemura M, et al. Current status of hospice cancer deaths both in-unit and at home (1995e2000), and prospects of home care services in Japan. Palliat Med 2002;16:179-184. Connor SR, Tecca M, LundPerson J, et al. Measuring hospice care: the National Hospice and Palliative Care Organization national hospice data set.j Pain Symptom Manage 004;28:316-328. Hospice Information. Hospice and palliative care facts and figures 2005. Available from. www. hospiceinformation.info/uploads /documents/ hospice_&_palliative_care_facts_&_figures_2005. pdf. Accessed on July 4, 2006. Hunt RW, Fazekas BS, Luke CG, et al. The coverage of cancer patients by designated palliative services: a populationbased study, South Australia, 1999. Palliat Med 2002;16:403-409.

2220 Quality indicators in multiple sclerosis D. Veillard 1,*, A. Muret 1, K. Chauvin 1, V. Deburhgraeve 2 1 Department of Epidemiology and Public Health - Rennes University Hospitaln, France, 2 Neurology, University Hospital, Rennes, France To develop quality indicators for the care of patients with multiple sclerosis (MS) Quality indicators development based on the perspectives of health professionals and of patients living with multiple sclerosis. To define indicators from the health professionals perspective, we used the RAND/UCLA appropriateness method (RAM) in a 2 stages process: -First stage with 15 MS providers (neurologists, physical and rehabilitation practitioners, MS nurses, physiotherapists) who identified relevant care domains to define quality of the practices and proposed a list of quality indicators based on a literature review and on their professional experience. -Second stage with another group of 24 experts in MS to rate each indicator in a two-round modified Delphi process. They first rated appropriateness of the indicators individually, using a nine-point response Likert scale to classified each indicator as appropriate, uncertain or inappropriate. The 2 nd round included a meeting of the panellists to discuss their ratings and focusing on areas of disagreement. After the discussion they re-rated these indicators individually. Classification of the indicators into 3 levels of appropriateness used the following definitions[1]: -Appropriate: panel median of 7-9 without disagreement -Uncertain: panel median of 4-6 or any median with disagreement -Inappropriate: panel median of 1-3 without disagreement The Interpercentile Range Adjusted for Symmetry was used to measure disagreement: IPRAS = IPRr + (AI * CFA), where IPRr is the Interpercentile Range Adjusted for symmetry required for disagreement when perfect symmetry exists, AS the Asymmetry Index and CFA the Correction Factor for Asymmetry. To define the final list of indicators, the 2 nd group of experts and the research team considered also the frequency with which an indicator was supposed to be applicable, its evidence-based level and the accessibility to the information. To define indicators from persons with MS perspective, we developed a questionnaire using a standardized multistep method combining qualitative and quantitative approach. Item generation step was based on literature review and MS patients focus groups (6 FGs including 36 patients). The tapes of the FGs were transcribed and item analysis carried out on the material, producing items for the first draft of the questionnaire. The content validity was tested through interviews of other patients with MS, producing the second version of the questionnaire. It reliability and construct validity is being tested. From the professionals perspective, the final list includes 48 indicators in 6 main domains : diagnosis, management of exacerbations, treatment by disease-modifying agents, management of radiological following, management of rehabilitation following. From the patients perspective, the 2 nd version of the questionnaire includes 35 questions in 5 main domains: information regarding the disease and involvement in decisions, accessibility and continuity of care, personal and family daily life, professional life, social and financial support. Next steps of the study are to explore the link between performance of medical processes (based on quality indicators) and improved patients outcomes (Expanded Disability Status Scale and quality of life) and to consider the caregivers perspective for quality indicators. References: [1] Fitch, K, Bernstein SJ, Aguilar MS and al. The RAND/UCLA Appropriateness Method User's Manual. Santa Monica, CA: RAND Corporation, 2001.

2232 The effect of the quality improvement through the assessment of long-term care hospitals service in Korea S. J. Yang 1,*, E. G. Do 1, D. I. Bae 1, J. G. Jeon 1 1 Health Insurance Review & Assessment Service Agency, Seoul, Korea, Republic Of In January 2008 in Korea, a new form of care facility was introduced for patients who needed long-term care, such as subacute and rehabilitation care. A flat rate per day was applied for payment system. Health Insurance Review & Assessment Service (HIRA) initiated an annual assessment of the quality of medical services, if it provided adequately. In this study, we try to measure the quality-improvement effect during a quality assessment of long-term care hospitals. Two dimensional data were used; seven structural area indicators comprising basic and security facilities and equipment collected through web from long-term care hospitals(571 in 2009, 718 in 2010, and 782 in 2011). Two medical process indicators including percentage of patients with indwelling urinary catheter divided into high-risk and low-risk group collected via patient assessment charts along with medical fee payment claims over 3 years from 2008 to 2010. The descriptive analysis such as percentage and frequency for each indicator were used to examine the effect of assessment. The study shows that the multi-bed wards percentage decreased by 1.1% from 49.6% in 2009 to 48.5% in 2011 and the four safety-related facilities installation rates increased considerably. The medical equipment area indicators like the number of EKG monitor and pulse oximeter per 100 beds increased slightly. In addition, the medical process indicators such as the percentage of high-risk patients with indwelling urinary catheter and that of low risk group decreased gradually, respectively by 1.4%, by 1.1%(table). Table: Assessment results of structure and medical process indicators for long-term care hospitals (unit: %, No.) Classification Indicator '08 Total mean '10 Total mean variation from 08 Basic facilities Safety facilities Medical equipment Medical process Percentage of the multibed wards(with seven or more beds) Rate of the emergency call systems installed(in wards, bathrooms and toilets) Rate of non-slip floors installed(in toilets) Rate of non-slip floors installed(in bathrooms) Rate of thresholds or bumps removed(from wards) No. of EKG monitor per 100 beds No. of pulse oximeter per 100 beds Percentage of high-risk patients with indwelling urinary catheter 49.6 48.5 decrease of 1.1 7.0 53.6 increase of 46.6 50.1 84.0 increase of 33.9 59.9 88.2 increase of 28.7 78.6 86.6 increase of 8.0 2.6 2.9 increase of 0.3 3.5 4.2 increase of 0.7 24.1 22.7 decrease of 1.4 Percentage of low-risk 4.0 2.9 decrease of 1.1 patients with indwelling urinary catheter This study showed an overall improvement in service quality of long-term care hospitals over 3years. However, while rapid improvement was noted in the structural process area, quality improvement in the medical process area was relatively slow. Therefore, additional quality control seems to be required to bring about behavior change in medical staff in charge of treatment of patients.

2272 Triangulated findings of a concurrent multi-method case study of patient participation in symptom management in an acute oncology setting E. Cohen 1,*, M. Botti 2 1 Deakin University, Melbourne, Australia, 2 Epworth/Deakin Centre for Clinical Nursing Reseach, Deakin University, Melbourne, Australia The complexity of symptom presentation and experience in the acute oncology setting requires collaboration between patients and clinicians if optimal symptom management is to be achieved. The overall aim of this research program was to uncover the role of the patient in symptom management practices in an acute oncology setting. More specifically, the objective was to gain a deeper understanding of the processes of care related to incorporating patients as participants in the management of their symptoms in acute care and in optimising symptom outcomes. Three overarching questions guided this work: 1) How is patient participation in symptom management enacted in the acute oncology setting? 2) What is patients preference for participation in symptom management in the acute oncology setting? 3) What are the processes of care that facilitate or impede patients participating in symptom management at their preferred level in the acute oncology setting? A single institution case study, concurrent multi-method, observational design was used. The context of data collection was an acute oncology setting. Methods included: patient survey, focus group interviews of nurses, medical record audit (documentation and symptom management medications) and naturalistic observation. 171 patients were surveyed and their medical records audited, 3 focus group interviews with nurses and 15, 2-hour observations of practice were conducted. Integration of the mixed methods-derived data led to two major conclusions. The first was the variable processes for symptom management in acute cancer care. Symptom assessment processes tended to be ad hoc and were influenced by clinicians expectations and knowledge of individual symptom treatment. Symptom documentation in medical records was incomplete and symptom management prescription and administration practices were inconsistent. High frequency, low duration interactions resulted in limited time available for multiple symptom assessment. The second conclusion was the ambivalence expressed and demonstrated by patients and nurses about patient participation in symptom management. There was a mismatch in clinician perceptions of the role of patients in symptom management and patients actual role. Patient reported behaviours and preferences for participation were not commensurate with observed behaviours. Processes of care and clinician behaviours may not be conducive to patient participation in this context. The findings suggested that the culture of care in the acute care environment was not wholly conducive to incorporating patients as participants. Small windows of opportunity for patients to participate coupled with a lack of systematic assessment and ambiguity in both patient and clinician understanding of patient participation may explain the limited evidence of patient participation in clinical practice. The findings have informed three key aspects fundamental to the integration of patient participation in symptom management in acute health care: patient-related factors associated with participation in health care; processes of care related to clinical assessment and management of symptoms, and, to some extent, system issues in facilitating patient participation.

2286 Evaluating the mental health services for elderly in Herefordshire and Birmingham through general practitioners' survey to measure the quality gap A. K. Rana 1,*, C. Vassilas 2, R. Eggar 3, P. Jacques 3 1 Old Age Psychiatry, Devon Partnership NHS Trust, Paignton, 2 Old Age Psychiatry, BSMHFT, Birmingham, 3 Old Age Psychiatry, 2gether NHS Foundation Trust, Hereford, United Kingdom To evaluate General Practitioners (GPs) satisfaction and expectation of the current mental health services for older adult in Herefordshire (a rural county) and Birmingham (an urban county). To measure the quality of service provided and expected to measure the Quality Gap and to explore GPs expectation of service reforms as future commissioners. The recent white paper on National- Health Service (NHS) in United Kingdom Equity and Excellence: Liberating the NHS has proposed some fundamental changes in NHS to excel in service delivery in a more economical way. This includes proposed changes in the commissioning of health services by devolving power and responsibility for commissioning services to clinical commissioning groups run by GP consortia and other frontline staff. The Lead/Interested GP for mental health in all the surgeries were asked to complete a survey either online or paper based version looking at their satisfaction and expectation of Mental Health services for older adults in their respective areas. The study also consisted of qualitative data by identifying GPs subjective perception of services and thus identifying the Quality Gap in the services Gap through qualitative measurement by thematic framework analysis. The study surveyed Lead GPs from 24 GP practices in Herefordshire and 30 Lead GPs from South Birmingham with a response rate of 71% in Herefordshire and variable rate in Birmingham. Most GPs were satisfied with the services in both counties but a significant proportion doesn t think that the Quality of service meet their expectation. Overall Herefordshire GPs are more satisfied than Birmingham GPS. Specific areas like access to Psychology service are rated as poor while waiting time, quicker access to CPN, better response to referral, access to social services are the other mainly identified areas of gaps. The services seems to be overloaded and therefore GPs suggested services reforms by reducing complexity, easy and single referral system, leaning the service provision by moving some services to primary care like CPN access and single access to health and social services. The study suggests that higher demand on service due to ageing population, higher service standards and early interventions, the service need to be transformed to maintain high standards of service with more focus on satisfaction of service users, carers, purchasers, commissioners and referrers. The study has explored various options through various frameworks of quality management and change management to make recommendations for consideration for service redesigning. This may need further exploration of service users and carers satisfaction and expectations to complete this study to achieve the desired outcomes. References: 1. Crosby PB (1984); Quality without tears ; New York; McGraw-Hill. 2. DoH White paper: Equity and Excellence: liberating the NHS http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_117353 3. Garvin D (1984). What does product quality mean? Sloan Management review; p25. 4. Parasuraman A et al (1985). A conceptual model of service quality and its implication for future research. Journal of marketing 49; p 41-50. 2288

Relationship between structure and process indicators of quality of care: the case of pressure ulcers M. Ferrua 1,*, M. Couralet 1, S. Morin Planche 2, H. Leleu 1 1 Projet COMPAQ-HPST, Inserm, Villejuif, 2 Haute Autorité de Santé, Saint Denis, France The objective of this study is to assess the relationship between a structure indicator (SI) and process indicator (PI) of quality of care using the example of pressure ulcers. Two indicators were developed in France in order to assess the quality of care for pressure ulcers. Those indicators are based on clinical practice guidelines, and were validated for their content by national medical associations and for their metrological qualities by the COMPAQ-HPST project The SI measures the features of the rehabilitations hospital that are related to high quality of pressure ulcers care as a 100-point score. The features include having a specific location in the patient medical record to record risk factors for pressure ulcers. Data collection for the SI is based on a hospital-level questionnaire. The PI measures the percentage of patient for whom the risk factors for pressure ulcers were assessed within 7 days after admission. It is based on a retrospective review of 80 patients randomly selected medical records. Both PI and SI were assessed in 41 rehabilitations hospitals in 2010. We calculated Pearson correlation between the results of both indicators adjusted on the average patient s age in each hospital. SI and PI results: Quality indicators Min Max Mean [std] Structure indicator 9.5 91.5 60.2 [19.9] Process indicator 0 100 51.8 [34.4] Results show a positive but moderate correlation between the results of the two indicators in the participating hospitals (Pearsoncoefficient s = 0.39). Adjusting on the average patient s age improved the correlation (Pearsoncoefficient s = 0.48). Although, reassuringly process and structure indicators assessing the quality of pressure ulcers care are related, their correlation is not strong enough to substitute one with the other. We postulate that having the essentials features for pressure ulcer care in place does not guaranty that they are applied in practice. Thus, both indicators need to be measured, the PI assessing how, through a medical records extraction, SI is implemented in the hospitals. The improved correlation after adjustment on age suggests that the implementation of the SI differs with the population hospitalized in each hospital. Hospitals with older patients assess more systematically the risk factors for pressure ulcers at admission than hospitals with younger patients (i.e. higher level of PI). even when essential features are in place (i.e. at high SI implementation level). Thus, the results of the PI are not only influenced by the SI but also by characteristics that could include the safety culture within the hospital. It would be interesting to confront the results to those of an outcome indicator, however it is much more delicate to design and implement on a national scale in the absence of an adequate information system.

2292 Developing indicators concerning hospital staff management: the French CLARTE Research Project C. Paille-Ricolleau 1,*, E. Anthoine 1, P. Lombrail 2, L. Moret 1 and CLARTE consortium 1 Medical Evaluation Unit, CHU Nantes, NANTES Cedex, 2 Bobigny University, Bobigny, France The CLARTE project (Consortium Loire-Atlantique Aquitaine Rhône-Alpes pour la production d indicateurs en santé), financed by the French Ministry of Health, aims to develop and validate several quality indicators, as well as indicators concerning safety in hospital care. Two of these indicators concern hospital staff management: absenteeism (Abs) and turn-over (TO) of non-medical staff. Such a focus is essential to the completion of the care quality indicators previously generalized. The founding principles of CLARTE are to develop simple indicators which are useful for hospitals, comprehensible and easy to collect from hospital databases. Abs indicators of nursing staff were tested two times in several volunteer French hospitals, as a part of the WHO-PATH project launched in 2003. The CLARTE team analyzed the results of the evaluations and then supplemented their findings with information from the literature. A working group composed of university experts, human resources managers and head nurses was set up at the beginning of 2011 in order to think about indicator definitions and elaborate the corresponding descriptive sheets. These proposals were then presented to the human resources steering committee. The CLARTE hospital panel is composed of French public and private hospitals throughout the country. A test of data collection methods was planned before launching the data collection process. Four meetings led to the following indicator proposals, which were then validated by the steering committee in June 2011: - Absenteeism: overall Abs (all grounds for absenteeism taken into account, distinguishing foreseeable Abs from unexpected Abs) and short-term Abs for medical grounds - Turn-over: overall TO and voluntary redundancies Each indicator had to be collected, in a retrospective way, not only for all the non-medical hospital staff, but also for five specific professional groups directly involved in patient care, including nurses. The test, which was conducted in October 2011, included a representative sample of seven hospitals and led to the improvement of all the documents for data collection. Moreover, it showed that the selected indicators were appropriate and useful for hospital management. The data collection was launched within the CLARTE panel in November; it took 3 months. 123 hospitals volunteered to test Abs indicators and 120 to test TO indicators. Hospitals were provided with data collection guides and were asked to collect and enter their own data on the CLARTE website. They were all asked to complete an additional third grid, which included interpretation variables and questions for a better understanding of each hospital s organization, human resource databases and obligations. A hotline was set up to help them during the data collection period. In the end, six hospitals abandoned the project, whereas 89 filled in the Abs grid and, 91, the TO grid. The data is currently being analyzed. In order to support the project dynamics, workshops are to be organized within the CLARTE panel. These workshops will initiate benchmarking practices and allow participating hospitals to share results, management processes and improvement plans. The definitions and descriptive sheets need to be improved before the second data collection, planned at the end of 2012, so as to take into account the difficulties encountered by the hospitals. The CLARTE project recommendations, in favour of generalization and possible use for accountability of these indicators (or not), are expected in 2013.

2310 Quality of medical care in Japanese acute care hospitals using patient discharge and administrative claims data S. Ikeda 1,*, M. Kobayashi 2, S. Matsuda 3, K. Fushimi 4 1 School of Pharmacy, International University of Health and Welfare, Ohtawara-city, 2 Graduate School of Nursing, Chiba University, Chiba, 3 Department of Public Health, University of Occupational and Environmental Health, Kita-kyushu, 4 Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan The objective of this study was to assess the quality of medical care in Japanese acute care hospitals using the DPC (Diagnosis Procedure Combination) database, which contains patient discharge and administrative claims data. DPC data, which was collected by the DPC Research Group and funded by the Japanese Ministry of Health, Labor, and Welfare, provided by acute care hospitals from July 1 to December 31 in 2010 were analyzed. Nine clinical indicators developed by the National Hospital Organization (NHO) were assessed to measure clinical performance in acute care hospitals. Hospitals eligible for inclusion in this study were assumed to have more than 10 discharged patients for denominator data. In order to determine the effect of patient volume, relation between the size of the target population and the performance rate for each indicator was examined on the hypothesis that larger-volume hospitals tend to perform better. In 270 hospitals (n = 7,272), 80.7% of patients with acute cerebral infarction started rehabilitation within 4 days after total knee replacement. The number of acute myocardial infarction patients in each hospital was weakly correlated with the performance rate (r = 0.23). Of the patients with hemorrhagic gastric or duodenal ulcer (n = 13,058), 69.7% received endoscopic hemostatic therapy. The number of patients with hemorrhagic gastric or duodenal ulcer in each hospital (n = 463) was weakly correlated with the performance rate (r = 0.20). Of the patients with acute cerebral infarction (n = 46,081), a brain scan (computed tomography or magnetic resonance imaging) was performed within 2 days of admission in 96.2%. The number of patients with acute cerebral infarction in each hospital (n = 725) was slightly correlated with the performance rate (r = 0.19). In 900 hospitals (n = 28,726), 92.7% of patients with acute myocardial infarction received prescriptions for aspirin and clopidogrel sulfate upon discharge (95% CI, 92.23 93.13). In 270 hospitals (n = 7,272), 83.5% of acute cerebral infarction patients started rehabilitation within 4 days after total knee replacement. In 474 hospitals (n = 20,483), prophylactic antibiotics were discontinued within 72 h after total knee replacement or bipolar hip arthroplasty in 65.8% of patients. In 270 hospitals (n = 6,501), 75.1% of breast cancer patients (stage I) underwent breast-conserving surgery. For the three clinical indicators, no correlations were observed between the number of patients and performance rate in each hospital. Pulmonary embolism was prevented in 93.9% of surgical patients at risk for venous thromboembolism. The incidence of pulmonary embolism in all patients at risk was 0.21%. Although a significant association was observed between the prevention and incidence of pulmonary embolism (p < 0.001), hospitals with low rates of prevention also had low incidence of pulmonary embolism. Statistically significant correlations were found between the number of patients and clinical performance in early rehabilitation for acute cerebral infarction and endoscopic hemostatic therapy for hemorrhagic gastric or duodenal ulcer. In hospitals that treat more patients within the target population, structures for provision of medical care may be better prepared than in hospitals with fewer patients. The negative association between prevention and incidence of pulmonary embolism may be caused by underreporting of the incidence of pulmonary embolism.

2367 Characteristics and quality of care to Swiss diabetic patients I. Peytremann-Bridevaux 1,*, J. Bordet 1, B. Burnand 1 1 Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland Within the framework of the development of a Swiss chronic disease management program, we aimed at collecting baseline data 1) to describe the population of residing diabetic patients, and 2) to assess the quality of their care. A cross-sectional study was conducted in the fall of 2011 in the canton of Vaud. Out of 140 randomly selected community pharmacies registered in the canton, 56 accepted to participate in patients recruitment. Non-institutionalized adult diabetic patients (disease duration > 12 months) visiting a pharmacy with a prescription for oral anti-diabetic drugs, insulin, glycemic strips or glucose meter were eligible. Patients not residing in the canton of Vaud, not speaking and understanding French well enough, presenting obvious cognitive impairment, and women with gestational diabetes, were excluded. Using a self-administered questionnaire, data were collected on patients characteristics and diabetes and on various process (e.g. recommended annual screenings) and outcome quality of care indicators (HbA1C, blood pressure levels, quality-of-life measures). Descriptive analyses were performed and confidence intervals were calculated considering the hierarchical structure of the data. A total of 406 patients with diabetes participated. Mean age was 64 years, 41% were women and 63% were married. Patients reported type 1, 2 and unknown types of diabetes in 14%, 73% and 13% of the cases, respectively. Overweight and obesity was found in 36% and 46% of the patients, and 16% were current smokers. Patients were treated with oral anti-diabetic drugs (50%), insulin (23%) or both (27%), and almost half suffered from diabetes since more than 10 years. While 48.5% of the patients did not report any diabetes-related complication, 34% and 23% reported macrovascular or microvascular complications, respectively. During the past 12 months, 97% and 94% reported at least one blood pressure and weight measure, 94% reported having had a cholesterol check, 74%, 69% and 64% had eyes, feet and urine screening respectively. 62% of the patients had been immunized against influenza. At least 76% of the patients had a minimum of 5 of the 7 previously described process indicators performed during the past 12 months. 82% of the patients self-monitored glucose levels at home. Of those who were aware of HbA1C (n=218), 98% reported at least one HbA1C control during the last 12 months. Among patients who knew about HbA1C, mean HbA1C was 7.4% (n=145; 95%CI 7.2-7.6). Mean systolic and diastolic blood pressure were 133.3 (95%CI: 131.5-135.0) and 77.5 (95%CI: 76.2-78.9), and mean physical and mental SF-12 summary scores were 42.8 (95%CI: 41.7-43.9) and 47.8 (95%CI: 46.4-48.9), respectively. Care satisfaction was described as excellent or very good by 67.5% of the patients. This study targeting community-based diabetic patients shows that while routine clinical and laboratory tests were annually performed in the vast majority of patients, feet and urine screening, as well as influenza immunization, were less often reported by patients. The proportion of patients with diabetes having had at least 5 out of the 7 annual screenings performed was nevertheless high, as were outcomes quality of care indicators such as mean HbA1C and blood pressure levels.

2376 Quality indicators and multimorbidity: reaching process and outcome targets in multimorbid patients R. Balicer 1,*, E. Shadmi 2, H. Bitterman 3, O. Jacobson 4 1 Clalit Research Institute, Clalit Health Services, Tel Aviv, 2 Nursing in the Faculty of Social Welfare and Health Sciences, University of Haifa, 3 Faculty of Medicine, Technion Israel Institute of Technology, Haifa, 4 Community Division, Clalit Health Services, Tel Aviv, Israel Research shows that multimorbidity presents a challenge for reaching quality of care targets. We examine the association between multimorbidity and attainment of process and outcome quality measures. The study population was a representative sample of 1 in 10 enrollees of Clalit Health Services, a non-for-profit insurer and provider of 53% of the Israeli population, during the year 2010. Multimorbidity was measured using the Adjusted Clinical Groups (ACG) System. We used Aggregate Diagnostic Groups (ADGs) (a core morbidity measure of the ACG system) to classify persons into morbidity levels. ADGs represent the entire spectrum of health conditions a person has during a predetermined period (usually a year) based on diagnostic information (ICD codes). We used Electronic Medical Record (EMR) diagnostic information from all medical encounters (hospital and community visits) during 2010. Morbidity levels were classified as: low (0-4 ADGs), medium (5-8 ADGs), or high (>8 ADGs). The degree to which multimorbidity was associated with the attainment of quality process and outcome measures was tested for the following outcomes: diabetes control (HbA1c <9mgdl) and blood pressure control (below 160/100 mg/dl), as a percent of all diabetics/hypertensive patients registered in Clalit's chronic disease registries. We used high thresholds to abide by target levels acceptable for multimorbid individuals. Performance rates of the following preventive measures were tested mammography, fecal occult blood tests, and influenza immunizations in defined target populations. Logistic regressions were used to test the association between multimorbidity and the attainment of each quality measure (separately) controlling for age, gender, socioeconomic status, and number of primary care and specialist visits. For each outcome the sample included between 26,498 (target population for mammography screening) 98,798 (target population for receipt of flu vaccines) persons. High multimorbidity levels (8+ ADG's - types of conditions), versus low multimorbidity (0-4 types of conditions), was not statistically significantly associated with either diabetes or blood pressure control (Adjusted Odds Ratio [AOR]: 1.05, 95% Confidence Interval [CI]: 0.93-1.19, and AOR: 0.86, 95%CI: 0.73-1.02, respectively). For all process measures there was a significant positive association between high multimorbidity levels and performance of each preventive measure (AOR: 1.39, 95%CI: 1.33-1.46; AOR: 1.23, 95%CI: 1.13-1.34; AOR: 1.13, 95%CI: 1.06-1.21 for performance of influenza immunization, mammography, or occult blood tests, respectively). In this study multimorbidity was found to be associated with attainment of processes but not with outcomes of care. The lack of differences in outcomes may reflect the ongoing quality improvement initiatives for diabetics and hypertensive patients at Clalit. Performance of preventive measures was more prevalent in patients with high multimorbidity, after controlling for demographic characteristics as well as number of visits to community physicians. These findings may indicate that patients and/or physicians of patients with high morbidity are more attentive to meeting preventive care requirements than their counterparts with lower morbidity.

2389 Promoting nursing students satisfaction with the internship program M.-Y. Lin 1,*, S.-Y. Huang 1 1 Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan Clinical practice is a requirement for nursing students to complete nursing professional courses. It is also an important opportunity to guide nursing students to develop a positive professional identity. Effectively reducing stress resulting from clinical practice by providing a good learning environment may enhance nursing students satisfaction and willingness to engage in nursing profession in the near future. The purpose of this project was to explore the issues related to nursing students clinical learning and identify the sources of students stress, such as learning within an unsatisfied environment, experiencing poor interactions with other staffs, etc. The reviewed literature suggests that many factors are associated with nursing students unsatisfaction. Several interventions were planned and implemented based on the literature and the nursing students needs. To meet students needs, a nursing cart designed for teaching purpose, a location designed for nursing students personal belongings. In clinical teaching, we adequately arranged the curriculum for classes and bedside teachings, provided a teacher with expertise in a specialty of clinical area, and established a clear communication channel between students and teachers. By doing so, the students satisfaction with teaching equipment has been improved by 11.03%, and the satisfaction with teacher-student interaction has been increased to 15.2%. By providing the guidance for clinical teachers and the nurses about how to effectively guide nursing students in their clinical practice, the nursing students were able to have a better understanding about clinical nursing practice, apply what they learned in nursing school to the clinical setting, and reinforces their identification with the nursing profession, and increase their satisfaction with this learning experience in the clinical setting. Based on the literature and students needs, providing nursing students a positive learning environment during their clinical practice courses is important for us to encourage as many good nurses as possible to join in clinical practice in the future.

2443 Evaluation of frozen section diagnosis accuracy for quality improvement in a medical center in Taiwan E. Gonzalez 1, J.-W. Lin 1, S. Lopez Valdes 2 1, 3,*, C.-C. Huang 1 Department of Pathology, 2 Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 3 Department of Pathology, Chang Gung University College of Medicine, Kaohsiung, Taiwan Frozen section is an important communication tool between surgeons and pathologists, contributing to the success of surgical treatment of the patients. This study is aimed to evaluate the accuracy of frozen section diagnosis at the Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, a laboratory accredited by the College of American Pathologists (CAP) since 2008. A quality improvement program for frozen section has been executed since 2007 at this hospital. This study retrospectively analyzed the data of the quality improvement program from 2007 to 2011, which reviewed and compared all the frozen section slides with the permanent section slides prepared from either the frozen section block(s) or the rest tissue block(s) after formalin fixation. The causes of discordant diagnoses were classified into 3 categories according to the reason of discordance by CAP Q-probes. Category A was defined as misinterpretation of the original frozen section; category B as frozen section negative, but permanent sections from the frozen section block positive; and category C as gross sampling error. In addition, the clinical impact of the discordant diagnosis was classified as major or minor error clinical severity as that proposed by Raab et al. A major error was defined as a disagreement that potentially affected clinical care (eg. a change in diagnosis from benign to malignant), and a minor error was defined as that presumably did not affect patient care. The discordant rates of frozen section diagnoses were compared between the periods before CAP (2007) and CAP accredited (2008-2011) by Mann-Whitney U test. There were 12,256 cases of frozen section consultation evaluated during the five-year period at the hospital. The total cases with discordant diagnoses were 149 (1.22%). The majority of the discordant diagnoses occurred because of misinterpretation of the original frozen section (94 cases, 63.1%), followed by frozen section negative, but permanent section from the frozen section block positive (30 cases, 20.1%) and gross sampling error (25 cases, 16.8%). For the classification of the clinical impact of the discordant diagnosis, 93 cases (62.4%) were classified as major errors, and 56 (37.6%) cases as minor errors. There were 41 out of 2,432 cases (1.69%) with discordant frozen section diagnoses in 2007, and 108 out of 9,824 cases (1.10%) with discordant frozen section diagnoses from 2008 to 2011. The discordant rate of frozen section diagnoses in the period with CAP accreditation (2008-2011) was significantly lower than that before CAP (2007) by the analysis with Mann-Whitney U test (p = 0.018). Frozen section diagnosis is a reliable intraoperative procedure at our hospital, with a low discordant rate comparing to the documented average discordant rate of frozen diagnoses (1.36% ~ 3.5%). Furthermore, the quality improvement program for frozen section executed since 2007 may contribute to the significant lower rate of discordant frozen section diagnoses in the period with CAP accreditation comparing to that before CAP accreditation at this hospital.

2449 Use of 3D CT simulation for planning conventional palliative 2D cases: pros and cons - a sharing from Tuen Mun Hospital C. K. Ng 1,*, S. M. Wong 1 1 Department of Clinical Oncology, Hosptial Authority, Hong Kong, Hong Kong, China To compare the use of 3D CT simulation with traditional 2D simulation in terms of time consumption of patients, radiation therapists and oncologists in treatment site localization for patients for palliative radiotherapy. One oncologist and six radiation therapists with relevant experiences in the treatment site localization process were interviewed with questionnaire survey for data collection. Pros: 3D CT simulation is a time saving process for patients and oncologists. Patients can leave just after CT acquisition. Complaints from patients due to long waiting time for oncologists in simulation decreased. Replan without the presence of patient is possible in case oncologists would like to change the initial treatment plan by just using the original 3D data set. Volumetric 3D images provided more valuable information for oncologist. It saved the time spent on online localization in simulator by oncologist(s) with increased accuracy for treatment planning since each slice of images can be reviewed. Cons: Resistant to change among staff. Adaptations among oncologists and radiation therapists are required for the workflow of a new system. The introduction of 3D CT simulation planning can foster a positive change in the localization simulation process for radiotherapy of palliative patients. It is an effective and seamless process leading to a reduction of patient waiting time and overall complaints by patients. Furthermore, there is some saving of the total time spent by oncologists per case. Although workload and pressures may be induced to radiation therapists, those problems would likely be faded out as time lapses when staff are familiar to the new system when a new standard of practice or guideline is drafted up for the change.

2511 Using GRADE to develop an evidence-based benchmark for a patient-safety indicator: postoperative venous thromboembolism B. Burnand 1,*, J.-M. Januel 1 and IMECCHI 1 Institute of social and preventive medicine, Lausanne University Hospital, Lausanne, Switzerland Evidence-based benchmarks may help appraise the actual value of a quality indicator in a given setting. The GRADE system may assist grading the quality of evidence for such benchmarks 1. However, GRADE is tailored to examine the type and quality of evidence in comparative designs. Our goal was to adapt the GRADE methodology for a rate or a proportion in the framework of a systematic review aimed at developing a benchmark for in-hospital symptomatic venous thromboembolism (VTE) in patients who had a surgical total or partial hip or knee arthroplasty (TPHA, TPKA) under recommended VTE prophylaxis 2. We evaluated each component of GRADE to assess its suitability to appraise the evidence base of a rate. In our case study, we included randomized clinical trials (RCT) testing efficacious VTE prophylaxis regimens and observational studies of patients receiving VTE prophylaxis, which reported confirmed post-operative symptomatic VTE that occurred before hospital discharge following TPHA and/or TPKA in adult inpatients, in a systematic review. BB and JMJ commented independently each GRADE item. The comparison, discussion and reconciliation in one list allowed its use in our systematic review. We developed ad hoc criteria to rate inconsistency and imprecision of pooled estimates. We synthesized GRADE evaluations according to type of VTE prophylaxis: low molecular weight heparin, oral direct and indirect factor Xa/IIa inhibitors. We considered GRADE elements about study design, outcome assessment, and sources of potentials biases. We included allocation concealment, blinding, sparse data, attrition bias, indirectness (external validity), potential measurement bias, and potential conflict of interest at study level. At group level, we included risk of bias, imprecision, inconsistency, indirectness, and publication bias. We summarized the quality assessment of the included studies in five categories: consistency, imprecision, generalisability to population of interest, publication bias and other limitations (allocation concealment, blinding, potential measurement bias). In our case study, we included 47 studies, mostly RCT (41). The individual sub-group and pooled estimates showed consistency, but large confidence intervals indicated lack of precision, indeed 95% CI estimates ranged widely for all RCT and observational studies. A potential measurement bias was present in less than 13% of RCT, whereas it ranged between 67% and 75% of observational studies. Indirectness of evidence varied largely between subgroups (0-93%). We have adapted and used the GRADE system to assess the quality of published evidence to establish the expected rate of symptomatic VTE in TPHA and TPKA patients under recommended VTE prophylaxis, as a benchmark for the corresponding patient safety indicator. Our adaptation was influenced by the type of evidence available, mostly RCT in this case, what may not always be the case when developing evidence-based benchmarks for quality indicators. This tentative approach should be further developed and assessed by the GRADE working group. References: 1. GRADE working group. www.gradeworkinggroup.org. 2. Januel JM, Chen G, Ruffieux C, Quan H, Douketis JD, Crowther MA, Colin C, Ghali WA, Burnand B, for the IMECCHI Group. Symptomatic In-Hospital Deep Vein Thrombosis and Pulmonary Embolism Following Hip and Knee Arthroplasty Among Patients Receiving Recommended Prophylaxis: A Systematic Review. JAMA 2012; 307: 294-303.

2550 Application of Breakthrough Series Model to improve the handover quality of maternal-newborn care in caesarean section birth Y.-L. Hung 1,*, L.-C. Chen 2, S.-H. Hung 3 1 Pediatrics, 2 Obstetric and Gynecology, 3 Quality Control Center, Cathay General Hospital, Taipei, Taiwan The safety of pregnant women and newborns delivered via caesarean section needs more attention on handover between obstetrics, anesthesiologists and pediatric team, especially in women of high risk pregnancy. This study aims to improve the quality of care in mothers and newborns delivered via Caesarean section by application of the Breakthrough Series Model. After analysis of the process of maternal and newborn care in caesarean section from August 2011 to November 2011, the transfer of patient care within the same unit was generally appropriate, but the accuracy and integrity in inter-speciality handover (eg. obstetric ward vs. postoperative recovery room) was only 74.2% and 91.8%, respectively. Besides, the implementation rate of Briefing before high risk pregnancy caecerian section by the obstetricians was 51%. A survey of satisfaction degree of staff members on inter-specialty handover was only 52.6%. Three major models for improvement were implemented: 1.Re-designed the Kardex which were the same as the items listed in the standard procedure for handover in all related unit, such as obstetric ward, operating room, postoperative recovery room, baby room and neonate intensive care unit. 2. Advocacy the importance of the performing Briefing in high risk pregnancy caesarian section to all obstetricians. 3. Set up the standard item for handover in pediatric consultation or high risk neonate delivery standby (e.g. basic clinical condition of mother; instrument needs for delivery standby). The improvement models were applied using Plan, Do, Study, Act cycles until a method of implementation was identified that maximized compliance. From December 2011 to February 2012, there were 126 pregnant women receiving Caesarean section in our hospital. Among them, 30 belonged to the high risk pregnancy. The accuracy and integrity in inter-specialty handover was 83.1% and 100%, respectively, and the handover incident rate was zero. The implementation rate of Briefing before high risk pregnancy caesarean section by the obstetrician was 90%. The satisfaction degree of staff members on inter-specialty handover increased to 80.6%. Implementation of the Breakthrough Series Model significantly improved the interdisciplinary handover quality of maternal and newborn care in caesarean section birth.

2560 Structural characteristics of hospitals associated with patient-safety indicators C. R. Tvedt 1, 2,*, I. S. Sjetne 3, J. Helgeland 1, G. Bukholm 4 1 Quality Measurement Unit, The Norwegian Knowledge Centre for the Health Services, 2 University of Oslo, 3 User Surveys Unit, The Norwegian Knowledge Centre for the Health Services, Oslo, 4 Østfold Hospital Trust, Fredrikstad, Norway Variation in patient safety outcomes between hospitals might be explained by differences in structural characteristics. Findings on this field are not consistent, but give reason to assume that features like hospital volume, nurse to patient ratio and teaching status are associated with patient safety indicators. In qualitative studies it is suggested that characteristics like size, complexity and financial status should be controlled for when patient safety interventions are evaluated. Structural equation modelling was used to test a hypothesized model of associations between characteristics of hospitals and two different outcome measures: 1) nurse-reported patient safety 2) 30-days survival after acute myocardial infarction (AMI) Hospital characteristics available from official statistics were used in the analyses (nurse to patient-ratio, physician to patient ratio, number of beds, university status, mean occupancy and index for patient mix). The nurse reported ratings of patient safety were collected through an international cross-sectional study conducted in 2009 (RN4CAST). From 35 Norwegian hospitals with 90 beds or more 5455 nurses gave their workplace a general grade on patient safety (total response rate 57%). The Norwegian Knowledge Centre for Health Services published results from a study assessing 30 days survival after admission for AMI, stroke and hip fracture in Norwegian hospitals. Patient administrative data were retrieved from all Norwegian hospitals for patients discharged in the period 1.1.1996-30.12.2009 by means of in-house developed software. Records for AMI were identified according to the International Classification of Diseases (ICD-10). Risk adjustments were made for sex, age, number of admissions the last two years and Charlsons comorbidity index. Preliminary analyses show that higher index for patient mix was associated with higher 30 days survival after AMI. Nursereported patient safety scores were associated with nurse-patient ratio (positively) and number of beds (negatively). Some of the structural characteristics were internally associated. Testing the model we found associations between structural characteristics and patient safety indicators. Our results imply that different types of patient safety indicators have different associations with structural characteristics. However, the associations between index for patient mix, university hospital, nurse-patient and nurse-physician ratios are strong. This observation might be interpreted as an indication that the more specialized the hospital is (higher nurse -patient ratio and higher index for patient mix), the better it scores on both patient safety indicators. Our study involved only 35 hospitals, and this should be taken into account when interpreting the results. The inconsistency in our findings confirms the need to better understand the complexity of the hospital organisation.

2596 SINAS Multidimensional healthcare quality assessment in Portugal V. Pinheiro 1,*, E. C. Alves 1 and ERS Board of Direction 1 ERS - Entidade Reguladora da Saúde, Porto, Portugal SINAS[1] the National System of Health Quality Assessment is the first project set up for assessing healthcare in several quality dimensions in Portugal. In order to deliver clear and useful information on the quality of healthcare services, ERS[2] the Portuguese Health Regulation Authority created SINAS based upon three major values: accuracy, transparency and objectivity. The assessment results are periodically published by ERS on a dedicated website, allowing healthcare providers to continuously improve their services quality levels, enabling benchmarking between peer institutions and offering patients and general public decoded and useful information. [1] SINAS Sistema Nacional de Avaliação em Saúde (National System of Health Quality Assessment) [2] ERS Entidade Reguladora da Saúde (Health Regulation Authority) SINAS is designed to assess healthcare providers according to the specific type of care rendered. There are two modules currently implemented: SINAS @ Hospitals, dedicated to institutions with inpatient treatment, and SINAS @ Oral.Care, dedicated to dental care providers. Five dimensions of quality were selected to be included on each of the modules: Quality dimensions assessed within SINAS @ Hospitals - Clinical Excellence, Patient Focus, Adequacy and Comfort of Facilities, Patient Safety and Patient Satisfaction. Quality dimensions assessed within SINAS @ Oral.Care - Registration and Licensing, Organization and Procedures, Adequacy and Comfort of Facilities, Patient Safety and Patient Satisfaction. The SINAS framework considers a two-step classification system. First step - quality stars. For each dimension assessed, providers evidencing compliance with minimum quality criteria are given a star; these requirements are set out by a panel of experts on the different areas. Second step - rating. Providers who received the quality star are positioned on a rating scale composed by three quality levels. Ratings computing is based on information mainly provided by the institutions being assessed; ERS periodically audits random groups of institutions, in order to confirm the accuracy of the provided data. SINAS uses structure, process and outcome quality indicators, selected according to their adequacy to the areas being assessed and the availability of the data. The data collection and the statistical analysis methods are chosen to meet the specific requirements of the quality dimension being analysed. All assessment parameters are carefully chosen, discussed and consensually approved by experts and professionals. SINAS@Hospitals first results were published in 2010. The 73 hospitals currently involved (on a voluntary basis) in this module are being assessed in four dimensions: Clinical Excellence (procedures and outcomes in orthopedics surgery, gynecological surgery, ambulatory surgery, obstetrics, pediatrics, acute myocardial infarction and stroke), Patient Focus, Adequacy and Comfort of Facilities and Patient Safety (safety practices and adverse events). The first data collection for the SINAS@Oral.Care assessment began in January 2012. The 4.869 Portuguese registered providers of dental care are being assessed in four quality dimensions: Registration and Licensing, Organization and Procedures, Adequacy and Comfort of Facilities and Patient Safety. Complete results are not ready yet, but will be available by the time of the conference. Consulting SINAS results will enable institutions, patients and public to access clear, pertinent and solid information on several dimensions of quality present on the Portuguese healthcare providers.

2605 Combining the fully functional service delivery system and performance-based contracting approaches to strengthen health systems in Uganda districts A. Burua 1,*, P. Hamilton 1, F. Castano 2 1 STRIDES for Family Health, Management Sciences for Health, Kampala, Uganda, 2 Center for Health Services, Management Sciences for Health, Arlington, United States Demonstrate the impact on health service delivery of a broad health systems strengthening approach combining the fully functional service delivery systems (FFSDS) and performance-based contracting (PBC) strategies, working with both the public and private sectors. STRIDES for Family Health (STRIDES) works in 15 districts in Uganda to reduce fertility and maternal and child morbidity and mortality. It strengthens the capacity of district health systems, comprising both the public and private sectors, to make them fully functional and able to provide quality services. One of project s key strategies is the FFSDS approach, a systems approach that requires the presence of national and international quality standards and components for service delivery at the facility and community levels. Another key project strategy is PBC, used by STRIDES to engage the public sector by way of a Memorandum of Understanding (MoU), and the private sector by means of contracts. Both agreement types incorporate performance-based principles, albeit with significantly more weight in the case of the contracts. PBC promotes improved self accountability and motivation among contractors, leading to improved performance in quality of services delivered. A facility-based assessment of the FFSDS standards and components conducted in December 2009 found substantial inadequacies, causing poor utilization of services. To address these concerns, STRIDES started with implementing components of the FFSDS in the public sector facilities and at community level, as a system cannot be fully-functional without the involvement of the community in both service delivery and in the monitoring of services. Late 2010, STRIDES added its PBC program with the private sector, new for Uganda on this large scale. Using performance-based agreements with both sectors provides for a powerful mechanism to foster public-private sector partnerships (PPPs), which help expand and strengthen functional health systems. As components of the FFSDS standards were introduced at facility level within the district public sector, limited impact was noted. However, with the gradual expansion of private sector services, the involvement of Village Health Teams at community level, and the linking of private sector partners with the districts health system using PBC, improvements in health indicators became evident. The use of outreach to provide services closer to where people live, using public and private providers, also contributes to improved health impact. STRIDES for Family Health s engagement with the broadest range of health service delivery actors at district level, using the FFSDS approach in combination with PBC, renders the district health system fully functional and able to deliver improved quality and affordable services for maternal, child, reproductive health, family planning, and other health needs. Through STRIDES systems-based approach, the benefits extend beyond service provision alone and lead to the formation of genuine public-private partnerships with the potential to sustain and expand improved health outcomes.

2616 Surgical safety checklist usage and complications S. Rout 1, S. Russ 1,*, K. Moorthy 1, A. Darzi 1 and E K Mayer, J Caris, N Sevdalis, R Davies, J Mansell. & C Vincent 1 Department of Surgery and Cancer, Imperial College, London, United Kingdom An international pilot study of the WHO surgical safety checklist demonstrated improvements in morbidity and mortality rates with checklist usage [1]. The pilot study was however limited by only around half its patients being in developed healthcare systems and lack of case-mix adjustment. This current study aimed to evaluate checklist usage with case-mix adjusted clinical outcomes within a single developed healthcare system during mandatory national implementation. Information from 6772 elective and emergency operative cases was prospectively collected between March 2010 and June 2011 across five NHS Trusts in England. The information included self-report data regarding checklist usage and operative and patient metrics. Post-operative outcome data was gathered prospectively from Trust databases. Subsequently this data was entered onto dedicated software that performed case-mix adjustment using POSSUM criteria. Of 6772 cases, 2686 were general surgery, 2989 were orthopaedics and 1082 were urology. The Checklist was not used at all in 3% of cases overall (n= 213); 3.5% in general surgery, 2.5% in orthopaedics and 3.9% in urology. There was no significant difference in the case-mix of patients when grouped according to when the checklist was and was not used (p = 0.29). Complication rates were significantly higher when the checklist was not used (17% vs. 11%, p = 0.028); there was no significant difference in mortality rates (1.4% vs. 0.8%, p = 0.72). During the period of the study, overall surgical safety Checklist usage was high at 97%. Although numbers of patients for which the checklist was not used were low, there was a statistically significant greater case-mix adjusted complication rate. This confirms the findings of the international pilot study and validates the efficacy of the Checklist in lowering postoperative complications in the NHS setting. References: 1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009;360(5):491-9.

2634 Ventilator-associated pneumonia in adult intensive care units: multidisciplinary team surveillance program W.-L. Liu 1, 2,*, P.-C. Chang 3, W.-L. Chen 4, Y.-H. Lin 5 1 Center for Quality Management, 2 Intensive Care Medicine, 3 Internal Medicine, 4 Respiratory Therapy, 5 Infection Control Committee, Chi Mei Medical Center, Liouying, Tainan, Taiwan Ventilator-associated pneumonia (VAP) is the most common and fatal nosocomial infection of intensive care units (ICU) and requires having a surveillance program which allows detection and implementation of preventive strategies. This study was conducted in the 63-bed adult ICU including the medical, surgical, and coronary care units at Chi Mei Medical Center, Liouying branch, an 800 bed hospital providing primary care in southern Taiwan since 2005. Incidence surveillance for VAP was performed through multidisciplinary team work, including ICU chest physicians, infection specialists, infection control unit, and respiratory therapists. We use Centers for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance criteria as a surveillance protocol. In this preinterventional and postinterventional study, we compared the rates of VAP, on a monthly basis, from January 2009 to March 2010, for a 15- months period before the initiation of multidisciplinary team VAP surveillance program. This rate was compared with the VAP rates after intervention from April 2010 to October 2010 (a 7-month period). The implementation of the multidisciplinary team VAP surveillance resulted in the VAP rates from a mean of 0.68 cases/1000 ventilator days in the preintervention period to 11.05 cases/1000 ventilator days in the postintervention period (p<.0001)(table 1). Statistical process control charts showed that the monthly incidence of VAP increased dramatically and was sustained during the postintervention period. Table 1: The ventilator-associated pneumonia incidence in ICU * Time Period Preintervention 2009/01-2010/03 Postintervention 2010/04-2010/10 Preintervention Postintervention p-value mean SD mean SD 0.68 0.71 11.05 5.78 <.0001 SD: standard deviation * Incidence: events/1000 ventilator-days The real incidence of ventilator-associated pneumonia in adult ICU only can be revealed by multidisciplinary team work with CDC surveillance protocol.

2643 Predictors of 30-day readmission rates after PCI in Estonia G. Paat-Ahi 1, 2,*, R. A. Kiivet 1 1 Department of Public Health, University of Tartu, Tartu, 2 Health Policy, PRAXIS Centre for Policy Studies, Tallinn, Estonia 30 days readmission after PCI (Percutaneus coronary intervention) is a frequently used indicator for measuring the quality of treatment. Estonia (population 1.3 million) has three central hospitals performing PCI and until now the outcome of PCI has not been measured using international standards. This study aimed to identify factors associated with 30-days readmission after primary PCI, using administrative databases, and concentrating on the impact of co-morbidities. Using data from the Estonian Health Insurance, we identified all 1966 PCI procedures conducted in 2008 in Estonia on patients, who had not been revascularized during the previous 3 years. Demographic characteristics studied included age and gender, clinical variables included all primary and concomitant diagnosesand procedural characteristics includedthe number of stents and length of hospital stay. We used multivariate logistic regression models to estimate the risk factors that contribute to the 30-day readmission. In addition, the association between 30-day readmission and 1-year mortality was analyzed by applying Cox proportional hazards models with readmission as a time-dependent covariate and by using landmark analysis. The main outcome measures were all cause 30-day readmission to any heart disease hospitalization following PCI and 1-year mortality. The share of 30-day readmitted patients was 8.9% (n = 175) with one year mortality of 3.51% (n = 69). The multivariate analysis indicated that the major risk factors for the 30-day readmission were myocardial infarction (OR = 3.29), peptic ulcer disease (OR = 2.59), chronic pulmonary disease (OR = 2.16) and age over 65 years (OR = 1.45). Although the average length of stay was significantly different across the two groups, only the length of stay less than 3 days was found to be a risk factor for subsequent readmission. 30-day readmission was also associated with the higher risk of 1-year mortality (OR=3.60; 95% CI, 2.03-6.37; P=.000) it was 4% higher than among patients not readmitted. Table 1: Patients Characteristics Demographic Characteristics No 30-day readmission n=1791 30-day readmission n=175 P-value Age, mean (SD), y 64,8(10,8) 68,1 (11,4) 0.0003 Male sex 1188(66,3) 102 (58,2) 0.0325 Clinical Characteristics Nr of comorbidities, mean (SD) 3,3(1,5) 3,7(1,7) 0.0020 Procedural Characteristics Stents, mean (SD) 1,6(1,0) 1,6(1,0) 0.6148 Re-revascularization in 1 year 221(12,3) 19(10,9) 0.5676 Length of stay in days, mean (SD) 5,6(5,1) 7,5(4,7) 0.0001 The analysis showed that in addition to advanced age, co-morbidities have major impacts on readmission rate in PCI patients. In comparison to studies carried out elsewhere, the current study revealed a significantly higher mortality among patients not readmitted to hospital. Moreover, the myocardial infarction was found to a very important contributing risk factor. At the same time, the length of stay over 3 days and sex was not found to be a contributing risk factor to readmission.

2647 Delir Path Project: delirium management and monitoring of delirium incidence rates in a Swiss acute care hospital M. Schubert 1,*, R. Spirig 1 on behalf of Delir Path and Project group Delir Path: Josi Bühlmann, RN; Jacqueline Barmet, RN; Helena Braun, RN; Esther Liem, RN; Seven Lorenz, MNS; Margrit Müller, MNS; Marcellina Haeberlin, MD; David Garcia MD; Urs Schwarz, MD; Maria Schubert, PhD, RN 1 Centre of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland In response to the observed burdens of hospital acquired deliriums and their effects on patient outcomes place on healthcare professionals, hospitals and entire healthcare systems, a pilot study was launched in 2011/2012 in a tertiarycare university based hospital. Its purpose was to develop and implement a multiprofessional, multicomponent delirium management protocol and a monitoring system for the prevention and treatment of hospital acquired deliriums in acute care patients. This ongoing prospective pilot cohort study included six general surgical/medical units, one intermediate care unit and two surgical intensive care units of a Swiss university-based tertiary-care hospital. A multiprofessional research team developed an evidence-based multicomponent delirium management protocol and an implementation and evaluation strategy. In order to monitor and evaluate the protocol's implementation a baseline assessment, followed by intermediate and final evaluations were conducted. The implementation of the protocol was evaluated with regard to adherence to the protocol, delirium incidence rates and other data. In this evaluation, data of approximately 900 patient were included. The developed delirium management protocol includes the following components: (1) Delirium prevention through identification and management of risk factors, along with individualized nursing and medical treatment measures; (2) Early detection and diagnosis of delirium by screening non-icu patients with the delirium observation scale (DOS) [1] and ICU patients the Intensive Care Delirium Screening Checklist (ICDSC) [2, 3]. In non-icu patients with DOS score scores 3 the Mental Status Questionnaire (MSQ) [4] and Confusion Assessment Method (CAM) [5] were also used to approve a diagnosis of delirium; (3) Identification and management of each delirium's etiology in inpatients with an indicated delirium (positive CAM score or ICDSC scores 4); (4) Confirmation of the diagnosis, including documentation of the diagnosis in the medical records by the responsible physician and nurse, and a neurologist or psychiatrist if required; (5) Pharmacological treatment with Haldol, Dipiperon, Midazolam and / or Temesta in inpatients with confirmed delirium. In preparation for the implementation roughly 260 nurses and 200 physicians working in the pilot units were trained regarding the program components. The preliminary data of the baseline assessment indicate delirium incidence rates similar to those internationally reported. Further results will be presented at the conference following the evaluation, which will be completed by the end of August 2012. The continuing evaluation shows that with the multiprofessional, multicomponent delirium management protocol, the detection, prevention and treatment of hospital acquired deliriums, particularly those of mixed and hypoactive motor subtypes, can be improved.

2684 Do check that blood pressure: how clinical processes affect hypertension control rates O. W. Odunukan 1, S. Taler 1, J. M. Naessens 2, M. A. Nyman 1,* 1 Department of Internal Medicine, 2 Health Sciences Research, Mayo Clinic, Rochester, United States Hypertension control rate is an important clinical quality measure. Quality measures for meaningful use of electronic medical records (EMR) in the United States require the measurement of blood pressure and assessment of control rates in hypertension. However assessments of hypertension control in this manner is not devoid of challenges. Notably, control rates cannot be accurately determined when blood pressure (BP) measurements from electronic records of index hypertension visits are unavailable. Our objective was to use the EMR to assess the delivery of hypertension care among provider groups using measurement of blood pressure as a surrogate. Cross sectional study involving adults with hypertension having 2 or more office visits in 2008 and 2009 with at least one visit in 2009 seen by primary or specialist providers at a large medical group practice. We measured the proportion of all visits for these hypertension patients with a properly documented blood pressure measurement. We compared rates of BP measurements and BP control across primary and specialist groups. Of the 72,823 documented visits for 19,686 patients, 85% had a properly documented blood pressure. Measurement rates varied considerably among the 6 provider groups studied - Family medicine 96%, Primary Care Internal Medicine 89%, Cardiology 85%, Nephrology 73%, Preventive Medicine 73%, and General (referral) Internal Medicine 76%. Provider groups with high measurement rates had commensurately high control rates (proportion of patients with BP <140/90 at their last office visit for hypertension) - Family medicine 79%, Primary Care Internal Medicine 74% as compared to the other provider groups Cardiology 65%, Nephrology 51%, Preventive Medicine 59%, and General (referral) Internal Medicine 55%. Control rates were however similar across provider groups when patients with unavailable BP were excluded: Family medicine 79%, Primary care 76%, Cardiology 78%, Nephrology 78%, Preventive Medicine 83%, and General (referral) Internal Medicine 78%. Process measures in combination with intermediate outcome measures like control rates provide a more comprehensive picture of the quality of hypertension care. Including measurement and documentation of BP in the standard clinical processes at all hypertension patient visits may help to eliminate differences in hypertension control rates among different provider groups.

1408 The influence of global budget system on healthcare quality H.-L. Hung 1,*, H.-M. Liu 1, H.-C. Chiu 2, Y.-H. Chung 1 1 Respiratory, 2 Medical center, Kaohsiung, Taiwan The Integrated Delivery System (IDS) integrates different levels of respiratory care and consists of intensive care units, respiratory care centers, respiratory care wards, and home care, which has been implemented for 10 years in Taiwan. During the 10 years, the Bureau of National Health Insurance (BNHI) made some revisions to the IDS, among which the most influential one is believed to be the Global Budget System (GBS) which was implemented on July 1, 2002. This retrospective study aimed to investigate the affect of GBS on the medical resource utilization of IDS for ventilatordependent patients ( 21 days) by comparing the difference between the Group A:IDS (Integrated Delivery Services)implementation,Group B:IDS with GBS(Global Budget System) implementation for one to two years and Group C:IDS with GBS implementation for three to four years.the study subjects were patients selected from the BNHI from January 2001 to December 2008.A multiple logistic regression analysis were utilized to investigate whether the healthcare quality (lung collapse,infection with pneumonia, critical condition that led to in-hospital mortality)for IDS patients was affected by the implementation of GBS. (1). The predicted result showed that healthcare quality for patients (lung collapse) was not affected by the implementation of GBS (P=0.273). (2). According to the predicted result, no significant difference was observed for the implementation of GBS and healthcare quality for patients (infection with pneumonia) (P=0.440). (3). The findings did not show any significant difference for the implementation of GBS and healthcare quality for patients (critical condition that led to in-hospital mortality) (P=0.139). It was observed that the accessibility to medical care for insured patients was unaffected by the implementation of hospital s GBS in the three groups. In addition, the healthcare quality was also shielded from the influence imposed by the intervention of GBS which was demonstrated by the well-maintained healthcare quality across hospitals. It was particularly commendable that healthcare professionals managed to ensure the level of healthcare quality under the strict cost control imposed by the GBS.

2307 Methods for carbon emissions reduction in hospital C. Kun Chih 1,*, C. Y. Ting 2 1 affairs depeartment, Kaohsiung Chang Gung Memorial Hospital, Niaosong Dist,Kaohsiung City, 2 affairs depeartment, E- DA HOSPITAL, Jiaosu Village, Yanchao District, Kaohsiung City, Taiwan Kaohsiung Chang Gung Memorial hospital accounted for to 18 hectares, there are 2,362 beds for anxious and chronic disease, average monthly outpatient number up 150,000 people, emergency case about 10,000 people,inpatient about 58,000 people, staff number more up 5,000 people, statistics annual medical waste produced volume up 650,000 kg (produced carbon emissions volume 1.34 million kg), General waste produced volume up 2.17 million kg(produced carbon emissions volume 4.48 million kg). The hospital would like to fulfill our corporate social responsibility (CSR), provide better medical environment, to improve the practices from the reduction of the reuse of waste separation and recovery measures and the implementation of greening and tree planting to achieve carbon reduction targets This project has two types of carbon reduction practices. First class "reuse of waste separation and recovery", including medical waste recycling (soft bags, plastic medicine bottles in plastic syringes, IV) a total of 3; waste recycling (waste paper, scrap metal material, plastic bins, waste PVC tube, fluorescent tubes, cans, ink cartridges) a total of 7.Second class "planting" method: adopt land growing tree category tree, deformed o use landscaping (recycling, waste classification): 2011 medical waste recycling-total 140,000 kg, General waste recycling-total 649,000 kg total of 789,000 kg, 1.625 million kg of carbon emissions reduction. (Second, the planting): newly adopted land to 5,288, tree planting 1,493 class and grass planting-planting area of 11,458m2, can reduce carbon emissions by a total of 2, 30,000 kg. The hospital through the classification of waste recycling and planting practices, effective in reducing total: 1.648 million kg of carbon emissions. Improving practices sustainable and provide references to other hospitals, enables hospitals to fulfill our corporate social responsibilities, provide better medical environment.

2428 Patient Empowerment approach in lifestyle modification for secondary coronary arteries disease prevention: a randomized controlled trial K. F. V. Mok 1,*, W. H. J. Sit 2, J. Law 1, H. W. Luk 1 1 Medical Specialty, Hospital Authority Queen Elizabeth Hospital, 2 The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China The aims of this study were to examine the effectiveness of a cardiac patient empowerment approach in reducing behavioral and cardiovascular risks for secondary prevention. This was a randomized controlled trial. Patients with recent diagnosis of coronary heart disease, medically stable and with borderline dyslipidaemia were recruited from medical and cardiac units. They were randomly assigned either to control group (CG) receiving usual cardiac rehabilitation or intervention group (IG) which aimed to empower patients to take responsibility and actions for lifestyle modification after hospital discharge. This patient empowerment programme began at in-patient stage and extended to 8 weeks post hospital discharge stage. Data were collected at three time points: pretest, 1-week post test and 12-week post test. Data collection format included self-report questionnaire (eating and exercise habit), anthropometric assessment (BP and BMI) and blood tests (blood lipid profile and blood sugar). Intentionto-treat analysis was performed. Of 82 recruited subjects, 65 (30 in CG and 35 in IG) completed the study. Drop-out rate was 26.8% (CG) and 14.6% (IG) respectively. Results on group-by-time effect showed that IG had a greater reduction in saturated fat intake and salted food intake (p<0.001) and increase in heart healthy food intake (vegetable, fruit, nuts and whole grain food) (p<0.001). Regarding CAD risk factors, significant decrease in SBP (p<0.001) and DBP (p=0.002) were found in IG. No significant between-group different was found in blood lipid, exercise behaviour, BMI and BSL. However, within group comparison over the 3 time points in IG showed an increase in HDL (p=0.001) while a reverse pattern was observed in the CG. Significant decrease of LDL was also found in IG at 1-week post test but was unable to maintain at 3-month post test. Dietary modification has been emphasized as an integral component for secondary prevention in cardiac rehabilitation. The findings of this study add to the current evidence that patients receiving nurse follow-up on dietary intervention perform better in heart-healthy dietary habits over a period of 5 months. Patient-nurse partnerships is particularly important in dietary intervention by giving post MI patients socioeconomic/culturally relevant choices and problem-solving skills thereby enabling them to actively participate in secondary prevention by self-management. Improved and sustained heart-healthy dietary behavior can be achieved when patients are motivated to take control in participating self-health management. Telephone follow-up should be considered because of its convenience and accessibility for post-hospital monitoring, counseling and empowerment. References: 1. Hospital Authority, Hong Kong. HA Statistical Report 2008-2009. Retrieved 2 Feb 2011 from http://www.ha.org.hk/upload/publication_15/281.pdf 2. Centre for Health Protection, Hong Kong. Death rates by leading causes of death, 2011-2010. Retrieved 2 Feb 2011 from http://www.chp.gov.hk/en/data/4/10/27/117.html 3. Zhao D. Cardiovascular risk factors and their control in China. Journal of Hong Kong College of Cardiology. 2001;9:23-26. 4. Chinese Health Ministry. Chinese Annual Health Statistics 2008 Update. Retrieved Nov 1, 2008 from http://www.moh.gov.cn 5. Wu XG. An epidemiological status and trends of coronary heart disease in Chinese population. Chinese Journal of Prevention and Control of Chronic Non-communicable Disease. 2003;11(4):190-191.

2453 Wellness of the mind - dementia awareness project N. D. D. Ranasinghe 1,* and Loretta Gillespie, Bridget Robinson, Robyn Saunders, John Gillespie 1 Quality, DRs TQM Pty. Ltd, Mt. Waverley, Australia This Australian Government funded initiative was to develop a project to raise awareness of dementia in the Sri Lankan community in Victoria. Delivery information about dementia via media release and personal contact to ethnic radio and newspaper; Organised bi-monthly breakfast meetings and other social gatherings to present Mind your Mind program; Communication of weekly information in Sri Lankan web directories; Creation and distribution of a poster to Sri Lankan Community Groups; and Provide the Sri Lankan elderly community with relevant information regarding dementia, and different types of dementia: o Use Alzheimer s Australia Mind your Mind Program and the Information and Fact Sheets and translate some into Sinhalese and Tamil; o Liaise with the Sri Lankan Alzheimer s association to access and provide relevant language specific material and resources. Provide processes for managing medication use in dementia; Educate family members who live with an elderly family member/s suffering with a diagnosis of dementia on strategies how to manage the various behaviours that may present as a result of the dementia; Raise awareness of the Sri Lankan community to understand how high blood pressure, high cholesterol, diabetes and obesity can increase the risk of dementia; Raise awareness and understanding of the importance of early intervention; Provide Sri Lanakn elderly community with relevant information regarding the Dementia Risk Reduction Program: Screening and detection; and Introduce Dementia Risk Reduction program Seven Health Tips or Signposts for dementia. Tools and activities we used throughout project Conducted health checks - blood glucose levels, and blood pressure, and weighing of attendee these proved popular. Developed a power point display about dementia and about the seven steps on how to reduce the risk of developing the disease. Use of 3 minute U -tube video relating to physiology of Dementia was popular Pre and post awareness survey questionnaire used to evaluate the project. Results are as follows. Pre & post Information questions Total% Before Do you know what dementia is? 62 95 Are you aware that there are several different types of dementia Are you aware of some of the early warning signs of dementia? Can you list 5 factors that might increase your chance of developing dementia? 21 91 20 90 10 87 Do you know where to obtain help and information if 13 82 you are concerned about your (or a family member's) memory? At the completion of the project there was significant increase in the knowledge and understanding of the five questions posed. This project met the objective of the Australian Government Initiative to increase awareness of dementia in the Sri Lankan community in Victoria. After

1325 Improvement of intravenous cannulation for critically ill children with a near-infrared light device L. Yi-Yu 1,*, S. C.-Y. Ching-Yun 1, L. I.-H. I-Hsiu 1, W. Chin-Ling 1 1 Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung, Taiwan Vascular access is frequently required for patients admitted to the pediatric intensive care unit as it provides a quick accessfor emergent fluid supplementation and medication prescription. The purpose of our study is to evaluate the effectivenessof a vein-viewing device (VeinViewer) on various outcome variable between those using VeinViewer(VeinViewer group) and those without using VeinViewer (control group) performed by 5 experienced nursing staff in a pediatric intensive care unit. This randomized controlled trial examined pediatric inpatients from the age of 3 months old to 17 years requiringvascular access at a medical center in southern Taiwan. The mean time required to find the first available vessel(seconds), first attempt success rate, mean number of attempts per patient and total time of attempt per patient (seconds) were recorded for both the Veinview group and the control group. When comparing the two groups, the mean time required to find the first available vessel decreased from 383.61 seconds (control group) to 126.37 seconds(veinviewer group), the mean number of attempts per patient decreased from 3.48 (control group) to 1.77(VeinViewer group), and the total time of attempt per patient decreased from 497.23 seconds (control group) to 186.16 (VeinViewer group). Results were statistically significant for the above mentioned outcome variables beveen the two groups. Vein Viewer (vein viewer, Luminetx corporation, Memphis,Tenn) with the assistance of Near-infrared light illuminating over patient s skin which is called vein viewer prototype (V-V-P) produced promising effects. When comparing the effect of V- V-P and ultrasound guided visualization of veins before phlebotomy, V-V-P showed greater sensitivity when detecting veins and can also help in determining the direction of venous flux or reflux by projecting the image of refilling after compression of the telangiectasis. By applying vein viewer into clinical practice we can assist the patients at pediatric emergency departments(ed), pediatric inpatient hospitalizations, vein viewer can also assist in treating patients with varicose veins and telangiectasias. In contrast to Perry et. al. s study which revealed that vein viewer did not reach statistical significance in pediatric ED patients, our results showed clinical significance probably due to longer hours of training session( 2 hrs vs. 1 hr ) designed and conducted by the device manufacturer and the fact that our patients populations are recruited from pediatric intensive care unit(vs. pediatric ED). IN short, use of a vein-viewing device significantly decreased the mean time required to find the first available vessel, decreased the mean number of attempts per patient, and decrease the total time of attempt per patient. The device was well received by patients, families, and staff.

1416 Unexpected clinical impact of implementing computer-based clinical decision support M. B. VanSuch 1, P. J. Caraballo 1, J. M. Naessens 1,* 1 Mayo Clinic, Rochester, United States Assess the effect of implementing a clinical decision support (CDS) rule in the electronic medical record (EMR) to increase compliance with the Joint Commission Heart Failure (HF) core measure of prescribing ACEI/ARB at discharge for patients with low ejection fraction (EF) This retrospective study included all hospital inpatients (n=15,663) discharged from Mayo Clinic Rochester from 2004 through 2010 with last measured EF<40%. Ejections fractions were based on echocardiogram results. A pharmacistbased reminder system (P-Care) was implemented in 2006 and replaced with a provider-based CDS rule in the EMR (Blaze rule) in 2009. To assess effects, three time frames were evaluated: baseline (3Q04-1Q06), P-Care (2Q06-1Q09), and Blaze rule (2Q09-2Q10).Within each time frame, patients were classified based on HF ICD-9-CM diagnosis codes from administrative data: principal diagnosis of HF, secondary diagnosis of HF, no diagnosis of HF. Compliance with the HF core measure increased from 80% at baseline to 95% during P-Care and to 98-100% during the Blaze rule implementation among patients with a principal diagnosis of HF. Meanwhile, the prescription of ACEI/ARB at discharge significantly decreased for patients among this group in each time frame: baseline 83.2% (614/738), P-Care 75.8 % ( 847/1117), Blaze rule 64.1% (426/665) (p = 0.0001). Similar significant decreases in ACEI/ARB prescriptions were also seen for patients with a secondary diagnosis of HF and those with no HF diagnoses. Interestingly, about a third of the patients with low EF in each time frame did not have a diagnosis of HF. During P-Care, 5 % (60/1176) of stays with a HF principal diagnosis were flagged with the reminder while during Blaze rule 3.5% (24/867) were flagged (p = 0.0001). 43.3%(26/60) accepted the intervention in P-care with 73%(19/26) being prescribed an ACEI/ARB; during Blaze rule 62.5% (15/24) accepted interventions with a 66.7%(10/15) prescription rate for ACEI/ARB; differences between intervention acceptance and prescribing rates between the periods were not significant. For stays with HF as a secondary diagnosis results were similar:7.4%(257/3452) were flagged with a reminder in P-Care and 4.1%(75/1822) of stays flagged during Blaze rule; intervention acceptance rates and prescribing rates were 39.3%(101/257)and 82.6%(76/92) in P-Care and 36%(27/75) and 96.3%(26/27) respectively during Blaze rule. However for stays without a HF diagnosis where the intervention was accepted, prescribing ACEI/ARB was greater during Blaze rule than P-Care: 92.3%(24/26 ), vs. 69.9%(58/83) (p = 0.02) Using the computer based tools, P-Care and Blaze rule, improved adherence to ACEI/ARB guideline for patients with HF principal diagnosis and EF<40%. However, the prescription of ACEI/ARB unexpectedly decreased with the implementation of these systems. Possible reasons for this decrease include improved documentation of allergies and other contraindications to ACEI/ARB, higher prevalence of contraindications over time, other changes in patient severity of illness/comorbidities or change in inpatient admitting practices. Computer-based clinical decision support can be an effective tool to increase compliance with quality measures. Because the reminders are incorporated in the EMR, they become part of the normal work flow and may be less disruptive and more effective than other types of effort to improve compliance. However, the resulting clinical effects may not always be as expected.

1487 An attempt to improve automatic classification of incident reports using natural language processing K. Okamoto 1, M. Hirose 2,*, T. Tsuruoka 1, H. Yoshihara 1 1 Department of Medical Informatics, Kyoto University Hospital, Kyoto, 2 Center for Education on Hospital Medicine, Shimane University Hospital, Shimane, Japan The authors attempted to improve automatic classification of incident reports using natural language processing (NLP), i.e., Japanese morphologic analysis and machine learning. The authors conducted a multicenter study using incident reports of Kyoto University Hospital, Shimane University Hospital and St. Mary s Hospital. In this study, we dealt with the class Falls and made a binary classification of incident reports using NLP. We gave the class Falls a positive value and the other classes a negative value. 4,025 incident reports were filed at Shimane University Hospital between Apr. 2006 and Aug. 2009, and the number of incident reports under the class Falls was 1,097. 8,306 incident reports were filed at Kyoto University Hospital between Apr. 2002 and Aug. 2005, and the number of incident reports under the class Falls was 1,077. 8,300 incident reports were filed at St. Mary s Hospital between Apr. 2006 and Aug. 2009, and the number of incident reports under the class Falls was 2,092. The incident reports were separated into two sets: a training set and a test set. We put incident reports from two of the hospitals into the training set, and those from the third hospital into the test set, and we had three scenarios one where the incident reports of Kyoto University Hospital formed the test set, another where those of Shimane University Hospital formed the test set, and a third case where the reports from St. Mary s Hospital formed the test set. A Japanese morphological analyzer, MeCab, identified word segmentations of all the incident reports, including both training and test set reports. A machine learning method, the support vector machine (SVM) method, made a classification model using the identified words of the training set. The test set was classified based on the classification model. To evaluate the automatic classification, we used two measures, precision and recall. Precision was defined as the number of true positives divided by the total number of reports labeled as belonging to the positive class (i.e. the sum of true positives and false positives), recall was defined as the number of true positives divided by the total number of reports truly belonging to the positive (i.e. the sum of true positive and true negative). To improve the automatic classification, we revised the classification of the incident reports of the three hospitals. The revision was made based on the automatic classification results. Accordingly, based on the revised classification, the SVM method restructured the classification model and classified incident reports to improve precision and recall. The following table shows the result of the automatic classification of the SVM method using unrevised and revised incident reports, respectively. In the table, Shimane University Hospital, Kyoto University Hospital and St. Mary s Hospital are abbreviated as KUH, SUH and SMH, respectively. Table: Precision and recall of the SVM method automatic classification using unrevised and revised incident reports Before revision After revision Precisi on (%) Recall (%) Precision (%) Recall (%) KUH 85.6 93.9 88.1 96.0 SUH 94.2 97.0 96.8 98.4 SMH 96.4 84.9 96.7 95.1 The results demonstrate that automatic classification was improved by revising the classification of the incident reports manually.

1542 Human Papillomavirus (HPV) testing in primary screening for cervical cancer J. Abbotts 1,* 1 Healthcare Improvement Scotland, Glasgow, United Kingdom Persistent infection with high-risk subtypes of human papillomavirus (HPV) (particularly 16 and 18) can lead to cervical cancer. Many countries have introduced HPV vaccination programmes targeting adolescent girls. This is expected to change the epidemiology of cervical cancer over the next few decades. National cervical screening programmes, where these exist, differ in age range, screening interval, test and protocol. The objective of this study was to assess the clinical and cost effectiveness of HPV testing, followed by liquid-based cytology (LBC) triage of positive results, in primary screening for cervical cancer; in order to inform decision-making within the Scottish Cervical Screening Programme. A rapid literature review was undertaken. No direct evidence was found on whether HPV testing, followed by LBC triage of positive results, is clinically effective in primary screening for cervical cancer compared with current Scottish practice of inviting women aged 20 60 for screening using LBC every 3 years. Results are reported on the closest-matching alternative intervention and comparator screening protocols. This evidence shows that HPV testing using Hybrid Capture II (HC2) (QIAGENE, Gaithersburg, MD), followed by conventional cytology triage of positive results, is highly sensitive and highly specific in primary screening for cervical cancer. HPV testing triaged by conventional cytology is more sensitive than conventional cytology alone. In women older than 35 years, HPV testing triaged by conventional cytology is more specific than conventional cytology alone. There is a lack of evidence on specificity of HPV testing triaged by cytology applicable to women aged 20 35 years. Primary HPV testing allows the screening interval to be safely extended to at least 6 years. A 5-year screening interval for HPV testing triaged by cytology may be cost effective compared with 3-yearly conventional cytology. Evidence generalised from studies using conventional cytology as a comparator suggests that HPV primary testing, followed by LBC triage of positive results, would be clinically and cost effective in cervical cancer screening. Any proposal to introduce HPV primary testing in the Scottish Cervical Screening Programme may require different management strategies to be identified for cohorts defined by vaccination status and age.

1606 Development of in-built, automated, paperless discount system in Radiology Information System (RIS) for strengthening financial controls and eliminating paper-based manual system S. M. Sohail 1,*, R. Baig 1, A. H. Tasneem 1, Z. Jamil 1 1 Radiology, The Aga Khan University Hospital, Karachi, Pakistan Since the inception of discount system for outpatient population (more than 7 years ago), the discount offering and approval system in Radiology department was a paper-based manual system. The objective of this quality project was to develop an IT system based discount system in RIS for strengthening financial controls, time saving and continuous review/monitoring eliminating manual work and record keeping. Pakistan is one of those third world countries where access to quality health care for an ordinary person is very difficult due to high prices. The Aga Khan University Hospital, Karachi Pakistan realizes this problem and therefore offers various financial assistance programs including welfare support and discounting on prices of diagnostic procedures in Radiology. This manual discount process, since its inception, was very time consuming, shaky in terms of financial controls and requiring many man hours and efforts to complete the process. To address the afore-mentioned problems, a team including representatives from Radiology and IT was constituted to convert the manual discount process into user friendly IT based system. We used PDCA (Plan, DO, Check, Act) methodology and related quality tools of Brainstorming, Flow Charts and Pareto analysis. The discount process was analyzed in terms of time taken for various steps in the process before & after implementation of new discount process. The outcome of the analysis is shown in a table appended below under "Results" section. We realized highly encouraging quantitative and qualitative results. The quantitative achievements are summarized in the table below: Time Savings in minutes/day Description Discount Process (Manual) Discount Process (IT BASED) Recording of Discount 90 10 Verification of Discount 60 5 Retrieval of discount 30 0 Calculation of discount 60 15 Review & Sign by Manager 15 5 Total Time 255 35 There is a marked time savings in almost all of the discount process steps including recording, verification, retrieval, calculation and review and approval. The total time consumed per day dropped from 255 minutes to 35 minutes. This is almost process re-engineering as the entire process got revamped. Additionally, the possibility of any error (in discount offer) was completely eliminated and a system based financial control was established resulting in a paperless system. New In-built discount system in Radiology Information Systems enabled us to significantly reduce human time & efforts which led to utilization of human resource in other patient care areas. In addition to that new system proves to be an automated and efficient system. It is user friendly eliminating any possible error in offering discount and offers strong financial controls in the discount management system.

1608 Reporting of initial findings for all radiology requests received from emergency department (ED) M. Yusuf 1,*, T.-U. Haq 1, S. M. Sohail 1, A. Adenwala 2 1 Radiology, 2 Information Technology, Aga Khan University, Karachi, Pakistan To record initial findings of any Radiology examination requested from the Emergency Department (ED) within short time duration so that physicians managing critical patients in ED can base their decisions on this information until the final report becomes available. Diagnostic services have a significant impact on patient care within a healthcare environment. The effectiveness of these services can be perceived in many ways. One important parameter is the identification and communication of critical findings to the respective persons/groups so that appropriate and urgent action may be taken in time. In this quality project we focused on the radiology requests received from Emergency Department. However, the scope of examinations was not only restricted to critical findings; rather, it included both Normal and Critical findings. The total volume of examinations requested from ED in 2011 was 38,574. Prior to this quality initiative, there was no such mechanism (Manual or System based) to report initial findings of any radiological examination. Various platforms were evaluated where such information can be posted. The logical place is the PACS (Picture Archiving and Communication System) system where a radiologist can view the patient images and quickly enter the initial findings without extended navigation. The authorized physician can then view the initial findings as soon as the relevant study is accessed. Features in the PACS were utilized to store such information as part of the patient image record. One important feature is that more than one comment can be added to one study and all comments are accessible when the respective study is opened up. This feature is based on IHE (Integrating the Healthcare Enterprise) standards (Key Image Notes). The available options within the PACS were successfully configured to allow radiologists to enter the initial findings. The workflows were appropriately modified to support the functionality. The project was completed within time without any additional budget overhead. Now, we have a system of recording initial findings of all radiological examinations requested from any service. Initially, we intend to restrict it to ED only, due to resource limitation; however, it can be applied to all radiological examinations without any system change. The feature to record initial comments in a short span of time will prove beneficial for increased quality in patient care, especially for the critical ones. It enhances the compliance as per the international standards and benefits the physicians for planning the treatment.

1611 Improving the print quality of archived images in general radiography as a pre-requisite for filmless environment eventually leading to cost rationalization S. M. Naqvi 1,*, A. Rajani 1, A. H. Tasneem 1, M. Yusuf 1 1 Radiology, The Aga Khan University Hospital, Karachi, Pakistan In order to embark upon a filmless environment, after PACS implementation, it is necessary that quality of film printing is same before and after archiving a study in PACS. The objective of this quality project is to improve the print quality of archived images, in general radiography, in order to move towards filmless environment and achieve cost rationalization. Today filmless and paperless environment is envisioned by all who implement PACS. In early 2011, while striving to establish a similar environment at the department of Radiology, The Aga Khan University Hospital, Karachi, Pakistan, we encountered a problem related to the quality of printed radiographs of the archived images. It was noted that the prints from the archived images, of General Radiography, were not of sufficient quality which could give optimum clinical information. This was because of lower optical densities and smaller image sizes which could lead to misdiagnosis and wrong reporting. A team comprising of the Physician, Medical Physicist, Radiographers, Information Technology and Picture Archiving & Communication System (PACS) experts was established to address the issue. The image quality parameters including Contrast, Resolution, Magnification and Distortion were compared for the prints before and after archiving of the radiological exams and it was noted that all prints made from the archived data were found unacceptable. In order to get to the core of issue, Bio-Medical Engineers along with relevant manufacturer were involved in the diagnostic journey and entire process was checked including Computed Radiography (CR) system, the dry printer and PACS. The root causes were identified with the coding of the printer s Look Up Tables which translate the DICOM data for the printer and with the improper configuration of PACS printing options. Secondly a reference scale was also set which appear on each radiograph and that scale helps in estimating the right size of the printed objects. The radiographic prints after these interventions were shared with the Radiologists and were found to be of desired clinical quality. All components of the imaging system including CR, Printer and PACS are now synchronized and thus producing images of diagnostically acceptable quality from archived images. This project has set the stage in moving forward on the institutional goal of having a filmless environment resulting in cost rationalization. The following table clearly shows the impact of cost rationalization and potential savings that would occur when the institution moves towards a filmless environment. Section Annual film Usage Annual Cost (USD) Monthly Cost (USD) General 159,000 238,949 19,912 Mammography 18,000 16,552 1,379 Clifton Medical Services 78,000 88,914 7,409 Total 255,000 344,414 44,082 Inpatient (40%) 102,000 137,766 17,633 Outpatient (40%) 102,000 137,766 17,633 To establish a filmless environment in any health care setup, the image quality before and after the archiving should be compared and all components of the imaging system should be properly integrated to produce images of diagnostically acceptable quality.

1628 Web-based implementation and dissemination of clinical practice guidelines in Japan: the role of MINDS N. Yamaguchi 1,*, M. Yoshida 1, N. Takahashi 1, A. Okumura 1 and MINDS Group 1 MINDS Center, Japan Council for Quality Health Care, Tokyo, Japan The Japan Council for Quality Health Care, public interest incorporated foundation, is providing a web-based information service, MINDS. MINDS publishes clinical practice guidelines (CPGs) and other related information for health professionals as well as patients and public. This study presents the procedures from search and evaluation of CPGs and other information to the implementation and dissemination through the MINDS web site. CPGs are usually published as books, journal articles and other media. The first step of MINDS editorial process is therefore to search systematically such published CPGs. The quality of identified CPGs is then evaluated by a formal procedure, and CPGs approved by the evaluation process are posted on the MINDS web site. Among the CPGs published in 2011 in Japan, 120 CPGs were selected for the evaluation procedure, and approximately 80% of selected CPGs were approved by evaluation committee. The guideline summary on the MINDS web site provides the overview of approved CPG. The full content of CPG is posted if the CPG developer accepts to publish its CPG on our web site. MINDS also provides additional supplementary contents for patients and public by explaining the contents of CPG by plain language. CPGs are important information source to ensure high quality of health care. The number of CPGs is increasing steadily in Japan as well as in other countries, but CPGs published as books or journal articles are not easily accessible in daily clinical settings. The present study shows a web-based information service, which is becoming more and more popular in a whole variety of clinical practice, is promising to provide CPGs to be referred to during clinical activities.

1654 A study of integrating adjustment mechanism and automated conversion for dispensing medicine in hospital H.-O. Lin 1,*, Y.-L. Tseng 2, C.-T. Lee 3, J.-S. Liu 2 and the Medical Record Management Committee 1 Sector of Medical Record, 2 Department of Neurology, 3 Department of Nephrology, Kaohsiung Chang Gung Memorial Hospital, Kaousiung, Taiwan The study aims to improve the function of the prescription that a doctor orders medicines for a patient to take several times a day or different doses in a week (e.g. Insulin, Warfarin). Before dispensing liquid medicine doses, doctors need to calculate the total amount, and then convert it into the correct number of bottles that a patient needs in a certain period. On the other hand, once the medicine has two different packings, doctors should choose the most suitable packing, such as Lactulose 500ml/bot or 60ml/bot. To avoid errors and wasting, it is important to set up an automated conversion table for medicine prescription so as to provide better coverage which may reduce the patient s round-trip visit to hospital. First, all of the Insulin items are listed on the Conversion Table for Irregular Doses and Different Packings (CTIDDP) in order system. Physicians can type the demand units in the four columns, which are morning, noon, evening and before bed during a day, and the system will show the exact number of bottles automatically. Second, the doctors may revise the number of prescribed bottles according to the patient s stockpile. As for Warfarin, we divide it into seven columns for one week. In the case of Lactulose, the system will suggest the optimal combination with two packings. Through CTIDDP, the medicine order will be printed on medicine bags for providing all dispensing information. For example, the Insulin dose may show 8 units before breakfast and 12 units before dinner, instead of total 20 units a day or attention: variable dose each time. This may offer safety guarantee for the patients and to reduce care givers perplex. In emergent situation, the medicine bags may provide important and quick information for medical staff. To provide user-friendly milieu, we also use color columns to alert users once prescription changes. As for Lactulose, the optimal combination in packings will be suggested for an efficient way in the medical resources. User s satisfaction was over 97% after the study. In conclusion, the project revises the operating system in the medical order to make convenient calculation and unit alteration through CTIDDP. We also apply colored background to altered columns to emphasize medical revision which may enhance the patients safety on taking medicine. The medicine bags note clearly when and how much the patients should take the medicine. For a better doctor-patient relationship, the operation system can actively integrate the patients need after changing medication instead of passively waiting for patients responses. This project may enhance the accuracy of medication and improve efficiency in dispensing medical resources.

1671 Comparison of temporal artery thermometer with infrared ear thermometer: a rapid review of the literature L. Thompson 1, K. Macpherson 2,*, S. Myles 2 1 SIGN, Healthcare Improvement Scotland, Edinburgh, 2 Healthcare Improvement Scotland, Glasgow, United Kingdom The temporal artery thermometer (TAT) is a hand held, battery operated device which uses infra-red detection technology to calculate skin temperature over the temporal artery area(forehead), as a proxy for measuring core temperature. The device repeatedly samples the skin temperature of the forehead and the ambient temperature and uses equations of heat loss to arrive at an estimate. Measurement of core body temperature to detect or monitor fever or hypothermia is vital to guide patient assessment and management. Important patient groups include neonates, immune compromised patients and those receiving postoperative care. Specific clinical scenarios will present different temperature ranges over which accuracy is required and patient groups will have a range of needs with respect to how appropriate or acceptable invasive techniques may be. When assessing any new diagnostic test, measurement against a standard is required. Measurement of pulmonary artery (PA) temperature using a thermistor within a catheter is regarded as the gold standard to which other methods of temperature assessment should be compared. Studies in infants and children commonly report measurement of rectal temperature as a standard for assessment of new technologies. The following questions were scoped: 1. What is the published evidence base for the clinical effectiveness of TAT in adults and in infants and children when compared with an appropriate standard? 2. What is the published evidence base for the clinical effectiveness of TAT in adults and in infants and children when compared with rectal temperature measurement? 3. What is the published evidence base for the clinical effectiveness, cost effectiveness and utility (including safety, ease of use and patient acceptability) of TATs compared with infra-red ear thermometers (IRETs) for temperature assessment in routine clinical practice? A limited search of the published literature was undertaken using electronic databases and websites to identify clinical and economic evidence. Registers of ongoing studies were consulted. Where they addressed the key questions, hard copies of the studies were obtained and the conclusions summarised. Evidence from a range of adult and paediatric patient groups suggests that TAT is insufficiently accurate for clinical use in inpatient settings when compared with an appropriate gold standard. Most studies where comparison was made with rectal temperature concluded that TAT was not sufficiently accurate for detection of rectal fever. Six studies comparing both TAT and IRET with various reference standards in various patient groups have reported inconsistent results, with four studies favouring TAT. An initial examination of the published literature on the relative benefits and costs of TAT compared with IRET highlighted heterogeneity in the reference standards and patient groups studied and identified a lack of information on safety and cost effectiveness. Issues for consideration in future work This brief examination of the published literature indicates the complexity of comparisons for non-invasive assessment of core temperature. Extrapolation of the findings from one clinical setting to another is not straightforward. In particular, the accuracy and utility of a device in normothermic patients cannot be translated into clinical situations where hyperthermia or hypothermia is likely to be encountered. Non-contact infra-red devices should be examined in any future work.

1673 Prospective risk analysis of the drug distribution process: impact of information technologies L. Cingria 1,*, P. Bonnabry 1, L. Carrez 1 1 Pharmacie, Hôpitaux Universitaires de Genève, Genève 14, Switzerland Each step of the medication process can be a potential source of errors. In the global distribution process, a 1% error rate is observed when this task is carried out manually. The introduction of information technologies is an option to improve the reliability and the efficiency. Within our institution, we decided to implement two complementary methodologies: 1) a robot, to distribute the majority of references and, for items that cannot integrate the robot, 2) a scanning system for the storage and the distribution steps. Our objective was to evaluate the evolution of the risk of errors in the drug distribution process, before and after the introduction of information technologies, by a prospective risk analysis Following the FMECA (Failure Modes, Effects and Criticality analysis) methodology, failure modes (FM) were defined by an interdisciplinary working group and their criticality indexes (CIs) were calculated according to their estimated occurrence, potential severity for patients and probability of detection. The manual process was compared to a mode of organization assisted by scanning and robotization. CIs were discussed and the acceptability of residual risks was determined. A pharmacoeconomic evaluation was finally achieved, by combining the expected safety improvements with the financial investments necessary to implement the technologies. Thirty-three FM were determined at different stages of the process: reception (9), storage (4), distribution (11), transportation (4) and returns (5). The sum of CI was 1733 for manual distribution, 1110 (-36%) for scanning and 861 (- 50%) for the robot. The number of FM with a CI higher than 100 was 8, 2 and 0, respectively. Scanning reduced the criticality of 18 FM, while the robot impacted on 6 additional FM. With the scanning the highest residual CIs were the error in the quantity distributed (120) and the mixing of products for several wards (112). With the robot, highest CIs were the mistake in relabeling packaging without barcode (84) and the non-detection of a wrong quantity received (80). The total investments necessary to implement the scanning and the robot were about 60 000 CHF and 600 000 CHF, respectively. The costs to reduce the CI by one point were about 95 CHF for the scanning and 690 CHF for the robot in comparison with the manual distribution. The introduction of information technologies can significantly reduce the criticality of the process of drugs storage and global distribution in hospital pharmacies. The robot provides an additional increase of safety compared to scanning, but at the cost of a sizeable financial investment. This should be offset by a significant improvement in efficiency that permits to reduce the number of collaborators working in drug distribution and leading to a return on the investment in a few years. In the future, a measurement of objective error rates with information technologies will be performed and the results will be compared to the predictions from this FMECA analysis.

1788 Apply SAS/EG to monitor ambulatory antibiotic prescribing and to improve the prescribing quality I. L. Chen 1,*, C. H. Lee 2, J. W. Liu 2,.. SAS Working Group 3 1 Pharmacy, 2 Infection disease, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Kaohsiung, 3 Management Information System, Chang Gung Foundation, Taoyuan, Taiwan Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We used SAS Enterprise Guide (SAS/EG) software to perform a review of ambulatory antibiotic prescribing and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce inappropriate antibiotics prescription. Quantity data from the ambulatory care sector were obtained fromambulatory care expenditures by visits and details of ambulatory care orders. The above data were collected from January 2009 through January 2012. The Anatomical Therapeutic Chemical (ATC) classification and Defined Daily Dose (DDD) measurement units were assigned to analyze the data. The number of DDDs /per 1,000 inhabitants (DID) were used to calculate the consumption of antibiotics, and percentage of antibiotics prescription in ambulatory carepatientsaccording to antibiotic classes. The linear regression mode was used to establish the trend for DID change, and Chi-Square test was used to analyze the prescriptive behaviors of physicians for broad-spectrum antibiotic prescription. The physicians of departments with higher DID and DDD were audited. We establish the screening model with SAS/EG for the ambulatory antibiotics prescribing. During this study period, the overall DID and percentage of antibiotics prescribing in ambulatory care patients was stable, but the prescribing rate of broad spectrum antibiotics was increasing (P <0.001). The department with highest DID and DDD was urology department, and following as general surgery, ear-nose-throat, dermatology, and infectious diseases department. Then, we made a feedback for urologists for the indication of broad spectrum antibiotics treatment, and duration of antibiotics treatment. After feedback, the DID and prescribing rate of broad-spectrum antibiotics of ambulatory care patients in urology department was significant decreasing (P <0.0001). The mean of DID of fluoroquinolone were dropped from 10.6 in pre-feedback period to 7.4 in post-feedback period( since September 2010). Used SAS-EG to monitor ambulatory antibiotics prescription is convenient and easy. We can get the data to audit and to improve the antibiotics prescribing quality.

1812 Using an Electronic Medical Record system to improve the patient referral process I. Chang 1,*, W. W. Chen 1, I.-C. Chiiu 1, Y.-T. Wang 1 1 National Cheng-Kung University Medical Center, Tainan, Taiwan In order to improve the efficiency of the patient referral process, through the national image exchange center, we established a hospital electronic medical record (EMR) system to exchange the referral medical image and report with other hospitals. A multidisciplinary team of quality circle project was organized in January 2011. An electronic transmission of medical image and report were designed for the referral patient to replace the traditional paper-based records. An EMR system of medical image and report was developed which follows the national standard of medial record and image format. In order to enhance the use of EMR system for improving the referral process, the PDCA method of quality circle was adopted to monitor the frequencies of EMR exchange between IEC and the hospital. Data collection included group discussion, monthly meeting, and statistics of IEC use. The data were analyzed periodically and systematically. Four improvement plans were identified and proposed: (1) reducing transmission errors of the EMR exchange, (2) designing an EMR standard process for the referral patient, (3) increasing the user training hours, (4) providing incentives to encourage the use of EMR. After a six-month implementation period, the frequencies of EMR exchange increased from 1,771 to 2,829 records monthly. The number of EMR users increased from 39 to 99 persons monthly. The improvement rate of using EMR for referral patients achieved up to 20.4%. Through the image exchange center, we established an automated EMR exchange mechanism among hospitals. Based on the improvement outcome of our quality circle project, the EMR system coupled with exchange functions proved to be effective in improving the patient referral process.

1892 A proposal of tissue-saving-algorithm for small cell lung cancer biopsy sample in diagnostic and molecular study processes T.-J. Kim 1,*, C. K. Park 2, E. J. Lee 1, C. S. Kang 1 1 Hospital Pathology, 2 Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea, Seoul, Korea, Republic Of Small biopsy has increased the demand for biologic information for target therapy as well as histologic confirmation for patients with lung cancer. We aimed to develop tissue-saving-algorithm in treating small lung cancer biopsy samples during diagnostic process in patholgy lab. With participants of pathologists, technicians in pthology labs and physicians of pulmonary division of internal medicine, we developed new process algorithm including process synchronization and simplification, individually allocation of tissue fragments on gross examination, rearrangement of process order, quality improvement methodology involving data collection, evaluation, feedback and education were undertaken to improve tissue dissipation rate. Educational interventions included technical detailing and group feedback presentations. Retrospective baseline assessment of tissue dissipation rate revealed 29.4% (15/51) by reviewing electronic medical record. During 12 months after process improvement, 63 biopsies including 13 brochoscopic biopsies and 50 percutaneous transthoracic needle biopsies were undertaken. Mean number of immunohistochemical staining and molecular study was seven and three, respectively. Zero samples (0/63) displayed tissue dissipation during diagnostic and molecular study process. Mean volume of remaining tissue after end of all process was 45%. Markedly decreased tissue dissipation was documented with new tissue-saving-algorithm

1979 Assessing demand for health informatics education in Karachi, Pakistan S. Habib 1,*, A. Khamisani 2 1 Professional Services, 2 Health Information Management Services, Aga Khan University Hospital, Karachi, Pakistan To determine the demand for health informatics education in Pakistan The need for health informatics education is recognized by many countries who are now engaged in introducing technology to healthcare. Universities are slow in response. Entry level and generic courses in health informatics are being developed in order to get a head start. Awareness of this intriguing field is on the rise and health informatics programs are being initiated in some developing countries. To meet this demand there is need for educated and trained individuals in health informatics who should be able to grasp the concepts and transform ideas into action, thereby performing health informatics related tasks and activities in order to benefit the health of communities. The focus of their work should be on producing effective leaders in health informatics through professional health education, engaging in best practices and developing self sustaining models of healthcare delivery while at the same time enriching the health information management system. Particular attention should be given to innovative and successful approaches to training in order to equip students with critical thinking and problem solving skills so as to enable them to address the challenges facing their own communities and societies. The study adopted a qualitative design utilizing face-to-face interviews with subjects. Snowball sampling methodology, which is a non probability type of sampling, was utilized to identify the subjects. By obtaining perception about health informatics, the need for health informatics education to meet the demand of healthcare institutions of Karachi was identified and confirmed. There are many educational gaps as well as hugely depleted resources which need to be addressed in order to fulfill the demand for health informatics education in healthcare institutions. Modalities to rejuvenate education of health informatics were discussed and competencies required for Health Informaticians were established for prospective employers and educators. After reviewing details and results from the approaches that were disseminated, the leadership of the institution were able to make a decision based on the results of the study. The approach adopted blended in with the culture of the target population. There is massive need to specifically design and develop high quality standards and convenient capacity building educational programs corresponding to the demands and behavior of target market and stakeholders in the healthcare industry. The Informaticians who graduate from the program should be sensitized to the economic reality, the society, and assume responsibility for, and become accountable to, the population they serve. This will be a colossal contribution towards enhancing the approach of training professionals in the field of Health Informatics. It is often the case that the citizens of the Third World travel to the developed world to acquire higher education, which is extremely scarce in one s own country and at times nonexistent. This enables them to return to their homeland with unique skills and in turn train native people to aspire to a level of competency that gels in with the universally accepted methodologies of the developed world.

2188 Optimizing the QR-Code with Healthcare Failure Mode and Effects Analysis (HFMEA) for the outpatient pharmacy in Taiwan Y. Lu 1, C. C. Chen 1, L. C. Liu 1, S. L. Lin 2,* 1 Department of Pharmacy, 2 Department of Surgery, Taipei Hospital, Department of Health, Hsin-Chuang District, New Taipei City, Taiwan The medication error is very important for patient safety. Researches used Healthcare Failure Mode and Effects Analysis (HFMEA) to improve the processes of drugs dispensing and decreased the medication error. Some hospitals also used information technologies for the same issues. But the failure modes will change after induction of information technologies. The previous research change dispensing procedure with QR code for the medication errors rate decreasing. The actual dispensing process became more complete and the number of warnings during dispensing was increased. Unfortunately, the new fail modes were found. The new research used the HFMEA to readjust the new fail mode and improved the dispensing procedure. This research found that the procedure still have18 failure modes and 57 potential causes for fail modes after QR code induction. The hazard scores for 11 failure modes were reduced to less than 8 and the 6 failure modes were reduced to less than 4 after readjusted the HFMEA. The total medication errors decrease after HFMEA and QR codes induction. This research found that the procedure significantly changed and new fail modes occurred after information technologies induction. The usage of dynamic HFMEA will discover new fail modes and readjust new procedure. This research combined QR code and dynamic HFMEA decreased medications error effectively.

2461 The effectiveness of innovative nursing case report technologies H.-N. Liu 1,*, M.-H. Sun 1, H.-L. Chou 1 1 Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan The study explores the effects of nursing personnel attitude towards learning concept mapping and effects of writing case reports by applying concept mapping teaching strategies. Research design combines qualitative and quantitative methodology. A total of 48 case report instructors and 25 report writing students were selected using purposive sampling from April to December 2010. Seven sessions for 15 hours of concept mapping curriculum and guidance application were conducted on the case report instructors. The research tools used were concept mapping attitude scale and assessment questionnaire on accepting case report guidance.data analysis has revealed sample characteristics using descriptive statistics. The data was gained from the result of repetitive measurements using five dimensions on the concept mapping attitude scale. A paired-t test was conducted to examine differences of the scores before and after implementing teaching strategy. Content analysis was implemented on the assessment questionnaire on accepting case report guidance using qualitative method. The research results have shown that the pre- and post-test scores regarding the five dimensions of concept mapping attitude scale had a significant change (p <.05) on identification of concept mapping teaching (p =.004), the difficulty of establishing concept mapping (p =.017), and the overall score (p =.022). All post-test scores were higher than pre-test scores. This indicates that after implementation of concept mapping teaching, instructors identified with the application of concept mapping teaching better and believed that constructing concept mapping became easier, as well as having a more positive learning attitude towards concept mapping.the assessment content analysis of students after guidance and submission revealed positive and joyful emotion and recognition and appreciation towards the instructors as well as willingness to share and encourage others. The results of this study provide a reference for staff guidance and case report writing strategies, as well as offer an innovative application of technologies for clinical care planning. References: Akinsanya, C., & Williams, M. (2004). Concept mapping for meaningful learning. Nurse Education Today, 24(1), 41-46. All, A. C., Huycke, L. I., & Fisher, M. J. (2003). Instructional tools for nursing education. Nursing Education Perspective, 24(6), 311-320. Hill, C. M. (2006). Integrating clinical experiences into the concept mapping process. Nurse Educator, 31(1), 36-39. Lin, M. C., & Chen, C. H. (2004). An investigation on the nursing competence of southern Taiwan nurses who have passed N3 case report accreditation. Journal of Nursing Research, 12(3), 203-212.

2601 Education combined with information technology systems to increase the visiting rate of retinopathy of prematurity clinic A.-L. Yen 1, Y.-C. Chang 2,*, T.-P. Chu 2 1 PICU, 2 Department of Nursing, Chiayi Chang Gung Memorial Hospital of the Chang Gung Medical Foundation, Chiayi County., Taiwan Retinopathy of prematurity would endanger vision, for very low birth weight infants is still a great threat, especially retinopathy of prematurity was cause of the development countries child leading blindness. Through the survey found, which preterm infants hospitalized due to insufficient awareness of the family members to disease, nursing education content inconsistencies, to ignore the importance of retinopathy of prematurity back to the clinic is low. Hope combined with the information system through health education, network, and the popularity of mobile phones and intimate sense of service to import patient relationship management, and thus enhance the visiting rate of retinopathy of prematurity clinic. To hold the in-service education of nurses for retinopathy of prematurity, to amend the health education leaflets and production of health education CD-ROM, a unified nursing and health instruction content and tracking of telephone interview measures, combined with information technology systems and networks, one week before the return visiting remind the families of preterm infants back to the clinic date. After the implementation of the program, the enhance nurses in retinopathy of the preterm infants knowledge correct rate from 73% to 98.2%, the families in this disease knowledge of the correct rate from 52.3% increase to 88.3%, the visiting rate of retinopathy of prematurity clinic from 66.7% increased to 92.6%. Retinopathy in preterm infants after by active treatment may not be able to solve all the problems of the eyes, fundus examination after treatment still continue to avoid high myopia, flash, strabismus and other complications. Expect more by inter-departmental medical integration, to develop a more comprehensive in preterm infants professional medical care models are worthy of further exploration level. References: Rajvardhan, A., Parijat, C., Sourabh, D. P. & Aparna, G. (2010). Profile of asymmetrical retinopathy of prematurity in twins. Indian Journal of Ophthalmology, 58(3), 209-211. Misra, A., Heckford, E., Curley, A. and Allen, L. (2008). Do current retinopathy of prematurity screening guidelines miss the early development of pre-threshold type 1 ROP in small for gestational age neonates? Eye, 22, 825 829. Murat, Ö. and Sedat, K. (2009). Ocular Growth and Morbidity in Preterm Children Without Retinopathy of Prematurity. Jpn J Ophthalmol, 53, 623 628. CL Funnell and TR Dabbs. (2007). Assisted conception and retinopathy of prematurity: 8-year follow-up study. Eye, 21, 383 386.

2699 Time Domain HRV with postural changes might be useful for the detection of symptomatic mitral valve prolapse syndrome in Taiwanese L. W. Tsai 1,*, S. -.-F. Tsai 1, C.-Y. Chan 1 1 Medical Education and Research, Taipei Medical University Hospital, Taipei, Taiwan Short term HRVs were claimed to be similar to 24 hour HRVs. MVPS has been reported to be associated with significant ANS dysfunction. The aim of the study is to evaluate if HRV parameters with postural changes can be used to differentiate between symptomatic MVPS patients and normal controls. A total of 72 symptomatic patients (4 males and 68 females) had been echocardiographically diagnosed as having MVPS from the cardiology clinic and 101 healthy university students (51 males and 50 females) were recruited as normal controls for the present study. A locally developed HRV system with one modified lead II ECG was used to record the tracing. All the records were taken during the daytime to avoid the influence of diurnal changes. The subjects were asked to rest at least 5 minutes before taking the records and the postural alterations (lying, sitting and standing). Time domain Parameters between MVPS and Normal Group was statistically significantly different in lying and sitting positions (P< 0.05) (Vide infra Table 1); Whereas, Frequency domain Parameters with postural changes were shown to have no significant differences in all postures. 1. For time domain, HRV symptomatic MVP group is statistically significant different to normal control in lying and sitting positions. 2. Lying and sitting female MVP Time domain parameters were statistically significant different to normal; whereas male only lying RMSSD and NN50 were significantly different. 3. For frequency domain, HRV can not significantly differentiate symptomatic MVP group from normal control.

1044 Application of Six Sigma quality tools and techniques: could it improve the quality of services and performance in El Hadara University Hospital? A. E. Siam 1, 2,*, O. Mossallam 3 1 El Hadara University Hospital, Alexandria University, Alexandria, Egypt, 2 Spinal Surgery and Paraplegiology, Zentralklinik Bad Berka, Bad Berka, Germany, 3 American University in Cairo, Cairo, Egypt A pilot study to apply the tools and techniques of Six Sigma in the field of healthcare management in a developing country 1- Historical and demographic backgrounds of El Hadara University Hospital. (Public non-for-profit university teaching hospital built in 1886 serving a population of 15 millions, specialised in orthopaedic surgery and traumatology) 2- Assessment of the managerial system and hierarchy 3- Statistics of workers and departments 4- Statistics of patients 5- SWOT analysis 6- DMAIC, D: Definition of customers and requierements Critical To Quality s 7- Employee survey (Internal customers) 8- Patients survey (External customers) 9- M: Measurement of the main problems (waiting times as an example) 10- A: Analysis (why patients wait too long? and where?) 11- I: Improvement (pathways, procedures) 12- C: Control (is this alternative better?) This pilot study concluded that the application of Six Sigma tools and technique is highly effective in directing the limited resources of the healthcare organisations in the developing countries to the continuous improvement processes with putting the customer in the first place. The results of the surveys showed: 1- Unexpectedly, the satisfaction of patients is more than the satisfaction of the employees, although the employees should have more awareness of the huge services that are being delivered to the public. This means that employees should know the information that clarifies the magnitude of these services. Numbers of patients in hundred thousands and a budget of several millions of Egyptian pounds yearly being spent on the poor should mean to the simple employees that they are doing something great, as well as very beneficial to the society. 2- High patient satisfaction rate does not give a reliable indicator of the situation and does not mean that the hospital is reaching its potential. This very high satisfaction rate comes from a number of facts: Patients come from a low socioeconomic standard and do not have expectations higher than those being produced. Patients surveyed were mainly women and they are always less aggressive and do not care much about long duration of time being spent in the hospital, unlike men who have a strong feeling of stress being unable to work for a long time. Patients do not pay anything to the hospital and they receive a very efficient service, they appreciate this from being a free hospital for the public. In-patients get 3 meals daily also for free and this is also appreciated whatever the quality of food served. 3- High patient satisfaction rate means also that approaching a Six Sigma quality is not impossible, and needs less fund and effort than expected. 4- The main problems of the hospital: shortage of nursing staff, shortage of labour, overcrowding and long waiting times, improper behaviours among employees, little wages in relation to increasing life costs, managers: uncoordinated decisions and injustice among employees, dirtiness of the wards, very long visiting times, absence of security. Based on our study we could confirm that application of six sigma tools and techniques could be suited to healthcare providing organizations. This type of quality improvement systems is highly needed in the healthcare field for continuous self assessment, customer satisfaction measures and continuous processes of improvement of services and products.

1126 Retrospective assessment of nephrolithiasis's endourological surgery complications by the modified Clavien classification system in a single tertiary educational urology center in Uzbekistan N. Muratova 1,*, F. A. Akilov 1, S. I. Giyasov 1 and Mukhtarov S.I., Mirkhamidov D.K., Nasirov F.R. 1 Urology, Uzbekistan Republican Specialized Urology Centre, Tashkent, Uzbekistan The objective is to review retrospectively our experience with endourological interventions (PCNL and URS) to grade perioperative complications according to the modified Clavien classification. The medical records of 1027 patients who underwent endourological interventions (percutaneous nephrolithotomy (PCNL) or\and ureterorenoscopy (URS)) between January 2008 and December 2010 were reviewed retrospectively. The subjects were divided into two groups: a simple calculi group (single calculus in different localizations) and a complex calculi group, including staghorn and multiple stones. The gender and age distribution, duration of anesthesia, American Society of Anesthesiologists Physical Status Classification Score, number of surgical percutaneous access, presence of initial complications and co-existing diseases, including initial urinary tract infections, surgical procedure type, duration of surgical procedure were compared between two groups. Using these multiple factors, as well the work experience of surgeons, we retrospectively reviewed and analyzed all patients for complication rates classified by the modified Clavien grading system. Statistical analysis was performed using STATA software. From 1027 cases, intra-operational serious complications (injuries of kidney pyelocaliceal system and ureter, severe bleeding over 500 ml) were in 14 (1.4%) patients. A totally 250 post-operative complications were documented in 180 (17.5%) patients. The additional surgical interventions in patients with residual stones from simple calculi group were considered as complications as well. According to the modified Clavien classification, grade I, II, IIIa, IIIb, IVa, IVb, and V complications were observed in 64 (6.2%), 111 (10.8%), 33 (3.2%), 39 (3.8%), 2 (0.2%), 1 (0.1%), and 0 (0%) patients, respectively. The most common complication were fever in 135 (13.1%) patients, among them with urine tract infectious complications - 115 (11.2%) patients, required further additional antibiotic and infusion therapy, hematuria 49 (4.9%), but only 7 (0,7%) patients needed in transfusion. In complex calculi group patients grade I, II, IIIb, and IVa complications were significantly more common, and all grade IVb complications occurred in patients from complex calculi group. Grade V was not registered in our center. In 85.6% cases, stones were eliminated totally. In 148 (14.4%) patients were diagnosed with residual stones. In 42 (4.1%) patients with residual stones were undergone further percutaneous nephrolithotomy and ureterorenoscopy (URS), and in 40 (3.9%) patients underwent extracorporeal shock-wave lithotripsy (SWL). The others were not clinically significant and required additional interventions. The advantages of this standardized grading system are more accurate and precise PCNL and URS specific complications. A shorter operation time and qualification of surgeon were significant for less bleeding and intrasurgical complications. Previous stone-related fever and staghorn stones were significant contributing factors for developing postoperative symptomatic infectious complications. In our opinion additional PNCL, URS and extracorporeal SWL in patients with residual stones in complex calculi group were not complications, but the next stage of the same surgical treatment. But all residual stones in simple calculi group and additional surgical interventions have to be considered as complications, and should be classified according to the type of the additional surgical intervention.

1250 Problematic Patient Handoffs: a survey of medical staff at private hospitals in Buenos Aires, Argentina G. Fuller 1, 2, E. Garcia Elorrio 2,* and Sanatorio Otamendi; Medicus; Instituto Argentino de Diagnostico y Tratamiento 1 Harvard Medical School, Boston, United States, 2 Quality and Patient Safety, IECS, Buenos Aires, Argentina To survey medical staff at three private hospitals in Buenos Aires, Argentina about their perception of: 1. The logistics and content of current patient handoff practices and 2. The frequency and consequences of problematic patient handoffs A survey of nurses, physicians, and residents at three private hospitals in Buenos Aires, Argentina INSTRUMENT: The study instrument was adapted from the 2008 Kitch et al. survey used to assess handoff practices among house staff at Massachusetts General Hospital in the United States. Forward and backward language translation between Spanish and English was completed by bilingual study staff. The survey uses a 5-point Likert scale and includes questions about: Demographics; Handoff logistics; Handoff content; Problematic handoffs (handoffs with missing, inaccurate, or misleading information); and Consequences of problematic handoffs (management uncertainty; minor or major patient harm). METHODOLOGY: The study was approved by a local review board and informed consent was obtained from participants. A pilot survey and cognitive interviews were conducted to ensure comprehensibility and cultural appropriateness. In total, the survey was deployed to 155 medical personnel at three private hospitals. A secretarial coordinator with access to both nursing and physician staff at each hospital was responsible for survey distribution and collection. Paper surveys were distributed to a stratified convenience sample of medical staff in a variety of departments (emergency, intensive care, general medicine) and work-shifts (day and night) between November 2011 and February 2012. Surveys were returned to the respective coordinators. Descriptive data analysis was performed. Participants included physicians (31.2%), residents (10.4%), and nurses (58.4%). Over half (56.8%) of the medical staff reported that one or more patients had been harmed during the past three months as a result of problematic handoff, and 19.4% reported that at least one patient had experienced major harm. Over one-third (39.5%) of staff rated the overall quality of handoffs they received as poor or fair. Over two-thirds (68.0%) of staff reported that handoffs never or rarely took place in quiet, private setting. One-quarter (25.0%) reported that there was never or rarely an opportunity to ask questions. Problematic handoffs are widely recognized as a patient safety hazard in developed countries, but have not been studied in developing countries. This study, the first analysis of patient handoff communication in Argentina, demonstrates that handoffs with incomplete, missing, or inaccurate information are common in a group of private hospitals in Argentina and present a clear danger to patient safety. Furthermore, current best practice techniques are not consistently practiced. While further investigation on problematic patient handoffs and the specific factors that lead to patient safety concerns is needed in developing countries, our results indicate that hospitals in developing regions are important targets of interventional approaches to improve patient handoffs. The results of our study may serve as a baseline from which to assess progress in handoff safety and effectiveness. References: Kitch B, et al. Handoffs causing patient harm: A survey of medical and surgical house staff. Joint Commission Journal of Quality and Patient Safety, 2008;34(10):563-70.

1264 Conceptual, item and semantic equivalence of the Brazilian Portuguese version of the Hospital Survey on Patient Safety Culture (HSOPSC) C. Reis 1,*, J. Laguardia 2, M. Martins 1 1 National School of Public Health, 2 Institute of Communication and Scientific and Technological Information in Health, Laboratory of Health Information, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil Developing a patient safety culture was one of the recommendations by the Institute of Medicine to assist hospitals at improving patient safety. Patient safety culture assessment,required by international accreditation organizations, allows hospitals to identify and prospectively manage safety-relevant issues in routine works and work conditions in order to monitor changes and safety outcomes. This approach has permitted healthcare organizations to obtain a clear view of the patient safety aspects requiring urgent attention, and also to identify the weaknesses and strengths of their safety culture. In Brazil, patient safety culture is a relatively new field and few studies have been published on this topic. Our objective is to describe the initial steps of the cross-cultural adaptation of the Hospital Survey on Patient Safety Culture (HSOPSC) into Brazilian Portuguese. A universalist approach was adopted to assess conceptual, item and semantic equivalence. The methodology included a literature review and participation of both experts and target population. Conceptual and item equivalence was established with participation of experts and target population. Semantic equivalence was analyzed in the following four stages: (1) two translations of the questionnaire into Portuguese performed independently; (2) two back-translations into English performed independently as well,and both were evaluated by a third researcher from the public health field which showed good referential and connotative similarity to the original; (3) specialist panel to assess verbal understanding and to prepare a draft version; (4) pilot test to assess verbal understanding of the draft version done through asample of 30 individuals of the target population. The questionnaire was translated into Portuguese, and the scale final version included 42 items, as in the original. Both the experts and target population members assessed most of the items as easy to understand. Pilot testing showed that question comprehension was scored by respondents between 4,10 and 5, with average value of 4,74 (maximum value = 5). In order to improve the understanding, some concepts were introduced in the items since their averages reached lower values. The questionnaire has now been translated and adapted into Portuguese, with evidence of clear understanding. However, it is still necessary to assess its internal consistency, measurement equivalence, external validity and reproducibility.

1495 Process Improvement of medical record management systems A. Khamisani 1,* 1 Health Information Management Services, Aga Khan University Hospital, Karachi, Pakistan To enhance the quality of care provided in a safe and secure environment by ensuring that medical record folders are available at the point of care by reviewing the overall process of MRMS system. HIMS at AKUH-K is the pioneer in introducing the concept of information management in the healthcare industry in Pakistan. The service commenced in 1984 with the aim of establishing a quality based entity at par with international standards in addition foreign consultants were on hand to nurse the department in its nascent phase. Since then the department has grown steadily through the years evolving from Rolodex cards to the terminal digit order filing system progressing forward by providing competent technical expertise via established units. To date 2.3 million medical record numbers have been issued with 1,100,000 medical record folders in circulation, currently being stored at multiple storage locations. As part of the aftermath of a sentinel event, Medical Record Management System (MRMS) Review was conducted under the leadership of Senior Management with a multifunctional team comprising of twelve members representing Nursing, Information Technology, Management Engineering, Clinic Management and Health Information Management Services. The team initiated its deliberations on July 20, 2011 and accomplished the task by submitting the final report in September, 2011. Organizational Continuous Quality Improvement model of Plan-Do-Study-Act (PDSA), as defined in the AKUH Quality Improvement and Patient Safety program 1) Informed decision making leading to improved customer satisfaction. 2) Confidentiality issues addressed with checks and balances through a bar code solution. 3) Reduction in loss of folders by providing locked storage at consulting clinics. 4) Established formal method for delivery, receipt and issuance of medical record folders to increase accountability and introduced batch delivery. 5) More robust process was introduced for appointment scheduling and cancellation in consulting clinics so as to keep an audit trail of system users. 6) Reduced number of temporary folders with strengthened checking in/out system linked with Medical Record Indexing. 7) Acquired centralized adequate storage space leading to minimized loss/misplacement of records. 8) Managed uncontrollable factors e.g. frequent change of hands in handling medical record folders. 9) Procured covered trolleys led to safe and secure folder transportation system. 10) Specialized training was given to staff to increase awareness of providing safe and quality care. Implemented measures led to improvement in the current medical records management system across AKUH which resulted in increased accountability and enhanced circulation control mechanism. This action promoted enhancement of quality care e by providing easy access to the information which facilitated safe / informed decision making. The major learning has been that key stakeholders should be correctly identified and made to sit with each other in a team format.this method results in exceptionally high quality discussions and mutually acceptable solutions.all of us were inspired to commit to improvement. Accelerated efforts are underway to move towards establishment of Electronic Health Record so as to transform the department into a state of the art facility through use of cutting edge technology coinciding with the customer s demanding needs.

1593 A correlation study on violent inpatient behavior in an acute psychiatric ward C.-L. Hsu 1,*, C.-Y. Yuan 2, C.-L. Chen 1 1 Department of Psychiatry, 2 Department of Nursing, Far-Eastern Memorial Hospital, Taipei, Taiwan Psychiatric patients often have violent behavior that leads to frequent physical and psychological harm on clinical nursing staffs. The objectives of this study are: 1. understanding the violence occurrence rate, its basic characteristics, the type of violence, and clinical management status; 2. investigation of a correlation between the violent behavior of patients with violence history, inpatient stay lengths, diagnoses, and substance abuse history. A cross-sectional descriptive correlational research design was adopted with natural observation. Subjects were recruited using convenience sampling from a acute psychiatric ward at a specific medical center in New Taipei City. The research tools used for recruitment were basic information of patients and the overt aggression scale. First, the scale was translated into Chinese. The pilot study was conducted on 1 April 2011 with five clinical nursing personnel serving as recruiters. For consistency, the result of Kendall s W test analysis was 100%. The research was officially conducted from 2 April to 31 June 2011 with 52 subjects recruited. Data were statistically analyzed using SPSS 17.0 software. For descriptive statistics, average value, percentage, and frequency table analysis were implemented using basic attributes, type of violent behavior, time attributes, incidence, and clinical management as variables. For inferential statistics, nonparametric Mann-Whitney U was used to analyze correlations between the number of days patients were hospitalized, psychiatric disease diagnosis, history of violence, history of substance abuse, and violence. The average age of patients with violent behavior is 38.5 years old and most of them were female (58.1 %). The highest education level attained was high school/vocational high school (54.8 %). Most patients were clinically diagnosed with schizophrenia (41.9 %). In terms of history of violence, most patients had occasional violent behavior in the past (61.3%), while average inpatient length of stay was 22.9 days. The violence occurrence rate was 14.7 % with most incidences occurring during daytime shifts (52.3 %). The major type of violence was destruction of objects (44.1 %).The study results show that violence history for patients, inpatient stay lengths were not significantly correlated to violent behavior (p>0.05). The study used current clinical inpatient violence to improve occupational environmental standards. It is recommended that a violence assessment scale must be employed as a regular monitoring tool. The earlier patient violence is detected, the earlier medication management and intervention will be utilized to prevent harm. Prevention of violent behavior must start with nursing education. Courses on violence prevention and handling must be scheduled for new nursing staff. This will increase the knowledge and skills of staff for violent behavior and will further enhance the sensitivity and alertness during clinical working hours by providing a safe working environment. References: Chen,K.P.,Yang,H.F.,Chen,H.L.&Yang,M.S.(2010).Workplace Violence(WPV): Emotional Reactions and Coping Among Hospital Nurses.Journal of Nursing and Healthcare Research, 6(3),163-171. Yudofsky,S.C.,Silver,J.M.,Jackson,W.,Endicott,J.,Williams,D.(1986).The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry,143,35-9. Silver,J.M,&Yudofsky,S.C.(1991).The Overt Aggression Scale:Overview And Guiding Principles.Journal Neuropsychiatry Clin Neurosci,3( 2).S22-S29.

1683 HEALTHQUAL International: alternative data visualization methods to advance improvement data reporting B. Agins 1,*, A. Wei 1, J. Bardfield 1, R. Birchard 1 1 HEALTHQUAL International, New York, United States HEALTHQUAL International (HQI) is a model to build capacity within national ministries of health, funded through PEPFAR, to create sustainable local quality management (QM) programs. Innovation in data reporting for quality improvement (QI) is in its infancy. Reporting of national performance data associated with QI activities is critical to communicating national- and clinic-level progress and essential to building evidence supporting the science of improvement. Visualization of data is essential for deriving meaning and understanding of performance data by providers, patients and donors for decision- making and prioritization of areas for improvement, and equally important for understanding the association with specific QI activities. HQI has transitioned from complex cross-sectional country- or performance indicator-based comparisons and streamlined a visualization strategy to highlight longitudinal improvement trends by indicator and successive groups of providers integrated at varying intervals, while retaining a format suitable for benchmarking. Using a combination of tables and line charts, HQI presents mean clinic scores for each clinic group over time. To communicate drop-outs and fluctuations in patient populations, HQI supplements line charts with descriptive tables containing relevant values and other descriptive statistics medians, percentiles, minimums and maximums to illuminate context. Since QI occurs at the clinic level and since aggregating clinic performance scores often leads to loss of information, HQI adds additional granular methods such as sparklines and heat maps to describe data without compromising a view of macro-level patterns. Innovation in data reporting for QI has revealed data trends and patterns often masked or overlooked by more traditional data reporting methods. This increase in the resolution of the data not only reveals clinic level improvement but also improves graphic integrity in communication of performance results. Consideration of alternative data visualization methods is key to linking data and QI, plays a pivotal role in reinforcing the science of improvement, and may prove to advance QI activities in resource limited settings.

1687 Applying modern QI concepts to improve maternal care in low-resource settings Y. Tawfik 1,*, A. Clark 1 1 University Research Co., Bethesda, United States To explain the basic concepts of modern quality improvement and the need to adapt them for application in low resource settings based on experience from improving maternal care in Kenya and Uganda. We applied the improvement collaborative (IC) approach that is based on modern quality improvement concepts that emphasize teamwork among staff, process analysis and change to obtain better health outcome, testing impact, and monitoring of results. The IC approach adds the features of multiple teams working on common objectives, shared learning, and peer-to-peer learning. Our team used the IC approach to close the performance quality gap in different aspects of maternal health services in selected districts in Kenya and Uganda. In each setting, a specific quality improvement program was designed using the Model for Improvement that prompts quality improvement teams to answer three questions: What are we trying to accomplish? How will we know that a change is an improvement? and What changes can we make that will result in improvement? By answering these questions, the quality improvement teams specify the specific aim/objective of the IC effort, develop clear indicators to measure improvement, and create innovative ideas for changing the process of service delivery to achieve better maternal health outcome. Quality improvement teams were formed at the health facilities and communities. Teams included staff members at primary care facilities, community health workers, and community support committees. The teams received support from quality improvement coaches at the district level. In Kwale District, Kenya, the quality of antenatal care services dramatically improved. The proportion of pregnant women who had their blood pressure measured increased from 32 to 99%, had their hemoglobin level checked increased from 34 64%, received three months supply of Iron tablet increased from 23-83%, and three month supply of Folate tablets increased from 49-81%. In Luwero and Masaka districts, Uganda, the proportion of women who received correct active management of third stage of labor to reduce postpartum hemorrhage at the health facility level increased from 1-81%. Important adaptations to the methodology had to be made to adjust to the lack of basic resources at the implementation sites: training of staff in the target clinical areas had to be added to compensate for the lack of basic skills; training of members of quality improvement teams was added to allow them to measure and monitor changes in the selected indicators, special efforts were made to coordinate with national and district level authorities to assure the availability of essential drugs and supplies, and special efforts were made to simplify the tools for collecting data, particularly for the staff at the community level. Modern quality improvement concepts focus on understanding the processes of service delivery and changing them to obtain better health outcomes. Such concepts are suitable for application to improve basic health care, such as maternal care, in resource limited settings. However, significant adaptations are needed to compensate for the lack of basic clinical skills among service providers and the chronic shortages of medications and supplies. References: - Institute for Healthcare Improvement (IHI). 2003. The Breakthrough Series: IHI s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series White Paper. Cambridge, MA: IHI. -Langley G, Nolan KM, Norman CL, Provost LP, Nolan TW. 2009. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2 nd edition. San Francisco: Jossey-Bass.

1726 Patient-safety insights from 12 African countries: a survey of relevant literature A. Malik 1, 2,*, R. Roy 1, 3, S. B. Syed 4 1 Chief Medical Officer's Clinical Advisor Scheme, 2 Moorfields Eye Hospital, 3 Andover Medical Centre, London, United Kingdom, 4 African Partnerships for Patient Safety, WHO Patient Safety, Geneva, Switzerland African Partnerships for Patient Safety (APPS) is focused on improving patient safety in African hospitals through working in partnership with European hospitals; patient safety insights emerging from African countries are critical to consider. This study concentrates on reviewing available literature on patient safety insights emerging from the African region, particularly in twelve African countries closely related to APPS activities (Cameroon, Ethiopia, Ghana, Kenya, Malawi, Mali, Mozambique, Rwanda, Senegal, Tanzania, Uganda and Zambia). A range of electronic databases (PubMed, Embase, Cochrane, African Index Medicus) were searched using standardized relevant search terms between January1995 and February 2011. All types of patient safety insights (burden, awareness, interventions, outcomes and policy) were included in a deliberate attempt to capture a broad range of perspectives. The search focused on twelve countries. Reference lists of included studies were also screened for further publications. Websites of major international, regional and national development and funding organisations were also examined to identify relevant grey literature. Two authors assessed and selected relevant titles based on the findings of the search; subsequently, each author independently extracted relevant information from the selected titles. Findings were categorized into broad patient safety themes. 729 papers were identified in the initial search. Title and abstract review led to the final inclusion of 38 relevant peerreviewed papers providing insights from across the African Region. A further 23 non-peer reviewed but relevant documents related to patient safety were identified. Insights emerged in a number of key areas including: health worker awareness of patient safety issues; patient safety monitoring and reporting systems; prevention and control of hospital transmission of communicable disease; unsafe injection and blood transfusion practice; and medication safety. Six crosscutting findings emerged. First, many papers focused on reporting burden of disease associated with patient safety issues; only some considered interventions. Second medication errors, poor infection control and unsafe injection practice were most frequently cited as patient safety challenges. Third, WHO policies and strategies are key drivers for implementation of patient safety interventions. Fourth, African healthcare workers value patient safety interventions; however, common staff practice is often not in accordance with guidance and monitoring systems are weak. Fifth, intrainstitutional communication is critical for embedding patient safety interventions; these are often delivered patchily. Finally, no papers were identified on insights from patients themselves. Insights are emerging on multiple dimensions of patient safety in African settings; priorities are beginning to become clearer. However, the published literature on evidence based patient safety interventions in the African context still lags far behind high-income countries. Furthermore, many published studies are not based on standardized patient safety taxonomy. Patient safety issues and solutions from high income settings cannot be simply applied to African countries and there is a need to understand insights emerging from the front line in African countries. This study lays the foundation for the development of a pool of knowledge across Africa on important patient safety insights.

1728 New ICU re-design reduces hospital-acquired infection - experience from a developing country P. Kietdumrongwong 1, A. Chuansumrit 2,*, S. Ruangkanchanasetr 2, R. Tulawipak 3 1 Queen Sirikit Medical Center, 2 Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 3 Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand To measure the effectiveness of intensive care unit re-design to reduce hospital acquired infection in low income university hospital. The new intensive care unit design was initiated in order to tackle the infection that cost millions Thai Baht annually. Each separate single room was small due to lack of space but provide minimal functionality. Each room has washing basin to remind staff and patient's relatives about hand hygiene even it located farer in the room. The hospital acquired infection rates (namely Ventilator Associated Pneumonia, Catheter Associated Urinary Tract Infection, and Catheter Related Bloodstream Infection) were measured prior and after re-design and renovation of 8 beds university hospital intensive care unit. The Infection Rate Infection rate Prior to Project After Project p value VAP 6.5 1.1 0.029 CAUTI 7.8 5.9 0.200 CRBSI 7.0 2.1 0.200 Total 21.1 9.1 0.057 Even the new design intensive care unit can not fit into recommendation standard, though the infection rate has been reduced significantly. From our observation, VAP has been reduced remarkably while as not in CAUTI and CRBSI. The indwelling catheter is still the key source of infection. But this new design has proved the concept of infection control by environment control. The cost of redesign is 3,834,162 THB (109,547 US ) comparing 1,658,880 US saved from HAI prevented. On economic perspective, the redesign can save not only cost but also lives.

1750 A portrait of hospital accreditation in Brazil (2011) B. Caldas 1,*, H. Oliveira 2, L. Carap 2 1 Instituto Nacional de Cardiologia, 2 FGV Projetos, Rio de Janeiro, Brazil To identify the percentage of accredited hospitals in Brazil and make a brief characterization of this group of hospitals by region, by the adopted methodology and by nature Accreditation status on the country is relevant information once that it has been the main mechanism to introduce issues related to quality inside healthcare organisations in Brazil. This is a cross-sectional descriptive study concerning only the hospital accreditation programs in Brazil. The total number of hospitals was collected from the National Register of Healthcare Facilities website (Cadastro Nacional de Estabelecimentos de Saúde - CNES) held by the Ministry of Health. This website was also used to characterize the accredited hospitals in terms of their nature (public or private). The list of accredited hospitals was obtained from the websites of the 3 accreditors in Brazil, a national one (Organização Nacional de Acreditação - ONA) and two internationals (Joint Commission International - JCI represented exclusively by Consórcio Brasileiro de Acreditação - CBA and Accreditation Canada - AC represented exclusively by Instituto Qualisa de Gestão - IQG). The consultations to the websites were done during the month of august 2011. According to CNES, Brazil has 6,348 hospitals distributed all over its 5 regions (table). Data collected on the website of the 3 accreditors revealed a total of 163 accredited hospitals. Regarding national data, 2.6% of the brazilian hospitals have any kind of accreditation certificate. Region Public Accredited % Private Accredited % Total Accredited % North 226 1 0.4% 249 1 0.4% 475 2 0.4% Northeast 834 1 0.1% 923 12 1.3% 1757 13 0.7% Southeast 487 22 4.5% 1761 96 5.5% 2248 118 5.2% South 245 1 0.4% 839 22 2.6% 1084 23 2.1% Center- West 280 0 0.0% 504 7 1.4% 784 7 0.9% Total 2,072 25 1.2% 4,276 138 3.2% 6,348 163 2.6% Regions with the lowest percentages of accredited hospitals are those with higher human and technological resources deficit. Among all states, São Paulo (southeast region) is the one that shows the best performance: 8.7% of its hospitals are accredited. If we consider just the private organisations this rate rises to 9.8%. From the group of 163 accredited hospitals, 136 (83.4%) were accredited exclusively by the national methodology (ONA), taking in account different levels of standards requirement, 48 (29.4%) hospitals at level 1, 40 (24.6%) at level 2 e 48 (29.4%) at level 3. Sixteen hospitals were accredited exclusively by international methodologies, 15 (9.2%) by JCI/CBA and 1 (0.6%) by AC/IQG. Eleven hospitals (6.8%) were accredited simultaneously by ONA (level 3) and by AC/IQG. This finding is probably related to the fact that IQG certificates both methodologies. Regarding the nature of the accredited hospitals, 83% (135) are private and 15% (24) are public. Four (2%) of the 163 hospitals couldn t be characterized because their registers were not found at the CNES website. The difference found between private and public hospitals shows the unequal access to quality and safe healthcare among social classes. All 3 accreditation methodologies were found at public and private hospitals. Brazil counts with 2.6% of all its hospitals accredited. Most of them are located in the southeast region of the country. Private organisations represent the biggest portion of accredited hospitals. The national accreditation methodology is the most widespread. Stimulus to adherence to accreditation programs should be part of health policies once that accreditation is an important instrument to introduce issues related to quality inside healthcare organisations in Brazil.

1787 The improvement of the appropriate prophylactic use of antibiotics for surgery through 3-year-management at a national hospital of Korea J. Yang 1,*, H. M. Jang 1, M. S. Kim 1, Y. J. Kim 1 1 Seoul National University Hospital, Seoul, Korea, Republic Of The appropriate use of prophylactic antibiotics is very important to prevent the surgical site infection (David, et al., 1992; Kim, et al., 2010; Sagong, et al., 2007). The objective of this study is to examine the effect of management system for the appropriate prophylactic use of antibiotics for surgery at a national university hospital of Korea from 2007 to 2010. We collected clinical data of three different surgical procedures (colectomy, heart surgery, hysterectomy) for three months of 2007 and 2010. The number of total cases was 245(137, 54, 54) in 2007, 240(133, 42, 65) in 2010. Performance measures were the rate of use of inappropriate prophylactic antibiotics (Aminoglycosides, 3 rd or 4 th Cephalosporin, Combination of antibiotics, Prescription of antibiotics for discharge), administration within 1 hour prior to the incision and the antibiotics prescription days after surgery. To evaluate the effectiveness of the management system, the results of the two groups (Group1=2007, Group2=2010) were compared by t-test, Chi-square test or Fisher s exact test. The rate of use of Aminoglycoside decreased drastically from 11.4% to 0.8% (p<.001). The selection of 3 rd /4 th Cephalosporin dropped from 11.8% to 5.8% (p=.020). The combination of antibiotics decreased from 27.8% to 11.7% (p<.001). The antibiotic prescription rate for discharge declined from 11.8% to 2.5% (p<.001) and the number of antibiotics prescription days after surgery was shortened from 4.2 days to 2.3 days (p<.001). The rate of administration within 1 hour didn t have any significant statistical difference between two groups. Through 3-year-management, 5 out of 6 measures improved significantly in statistics (except the administration within 1 hour). The rate of surgical site infection decreased from 2.4% to 1.3% (p=.504). Table: The result of prophylactic antibiotics measure Administration of inappropriate prophylactic antibiotics Variable 2007 (Group 1) 2010 (Group 2) p-value Aminoglycosides 28(11.4) 2(0.8) <.001 3 rd / 4 th Cephalosporin 29(11.8) 14(5.8).020 Combination of antibiotics 68(27.8) 28(11.7) <.001 Prescription of antibiotics for discharge 29(11.8) 6(2.5) <.001 antibiotics prescription days 4.2±4.9(97.1) 2.3±2.0(95.8) <.001 The result demonstrates that the management system made an impact on enhancing the quality of prophylactic use of antibiotics for surgery with decrease of the rate of surgical site infection during 3 years. We will keep trying to improve the quality of the prophylactic antibiotic use and to lower the rate of surgical site infection with this management system. References: 1. David, C. C., R. Scott, E., Stanley, L. P., Susan, D. H., Ronald, L. M., & John, P. B. (1992). The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. The New England Journal of Medicine, 326, 281-286. 2. Kim, K. H., Park, C. S., Chang, J. H., Kim, N. S., Lee, J. S., Choi, B. R., Lee, B. R. et al. (2010). Association Between Prophylactic Antibiotic Use and Surgical Site Infection Based on Quality Assessment Data in Korea, Journal of Preventive Medicine and Public Health, 43(3), 235-244. 3. Sagong, P. (2007). Association between Pattern of Prophylactic Antibiotic Use and Rate of Surgical Site Infection. (Master's dissertation, Seoul National University of Medicine, 2007).

1857 The challenge of a new approach to informed consent: a cultural change M. D. O. Tania 1, C. Behr 2,*, C. Garcia 1, C. Sardenberg 3 1 Patient safety and Risk management, 2 Quality, 3 Medical Practice, Albert Einstein Hospital, São Paulo, Brazil Modify the informed consent process in a general and private hospital in order to improve quality and safety to the patients, increasing the credibility of the institution. For many years the informed consent process at Albert Einstein Hospital in Sao Paulo has been very generalist. As an institution with an open medical staff, the challenge was to cause a major change in culture for physicians and patients, improving transparency, accuracy focusing on humanization and patient-centered care. When analyzing serious adverse events, the risk management group found that, in most of times, the informed consent was not specific about risks and benefits of a surgical procedure, decreasing the patient's satisfaction as well as the credibility of the institution. Since 2011 a multidisciplinary team has been set including the best of each medical specialty chosen with the purpose of studying the procedures which should be initially focused. They decided to consider firstly the surgeries where there were more adverse events and those ones indicated by IHI improvement map. The study group decided to standardize the information on the procedures chosen by providing documents which included worldwide statistics of the most common complications and mortality rates, in order to give the patient an opportunity to make an assertive choice. The study has allowed a cultural change of the medical team, which has standardized the information of informed consent specific to 10 new different types of procedures in a first time. References: IHI Improvement Map

1882 A study on the improvement of the permanent specimen receipt process in the operating room H. Kim 1, Y. Kim 1,*, C. Choe 2, B. Park 2 1 QA team, 2 Seoul National Universty Hospital, Seoul, Korea, Republic Of It aims to maintain the permanent specimen receipt process in the operating room(or) and introduce the bar-coding receipt system in order to prevent permanent specimen loss and receipt error in the OR, manage the specimen receipt process by computer, and thereby improve patient safety in the OR. In the process of a doctor delivering the specimen and goes through the receipt process, he or she may lose it or make receipt error of some kind. In order to prevent this problem, the permanent specimens are collected at the entrance of the OR and the pathology department receives them in a lump. This is the current process. By maintaining the procedures to transfer them to the inspecting room, the receipt divides into the OR s receipt(the primary receipt) and the inspecting room s receipt(the secondary receipt). The process has been changed as the pathologic inspection request that written by hand has been computerized. There have been some problems in the manual work such as uncertain specimen information for the incomplete inspection request or the omission of request items, delayed inspection from it, and inaccurate inspection resulted from various mistakes. At the receipt of specimens collected in the OR, the pathologic inspection request is computerized. Also, it sets up five necessary items: collecting room, specimen number, collecting region, operation name, clinical diagnosis. The computerized program sets up that the specimen receipt is impossible when the inspection request is unwritten or any of the necessary items are omitted. By developing a permanent specimen receipt program, the permanent specimens that have been received by the book written by hand can now be received by computer. If the user logs on and reads the barcode of the specimen label, he or she can check the specimen information of the pathologic inspection request written by computer. After such step, the primary receipt is completed. With this specimen receipt program, he or she can check the specimen information, and can correct it when there is any problem. Then the inspecting room receives the specimen, the clerk who has received the specimen checks the accordance of the inspection request and the actual specimen. After that, he or she writes his or her name on the program. On EMR, it realizes an additional page for the inquiry about the progress of pathologic inspection. With all the specimens collected from the OR, the medical teams can check them in terms of the specimen s location or the progress of inspection. After the improvement of the permanent specimen receipt process, small problems such as unwritten requests or written errors have reduced about 51% than before. And serious errors such as specimen loss or specimen tissue s discordance have been reduced to approximately 55%. The cases of error occurrences are reduced to approximately 53% from 10.7 to 5 in terms of monthly average. By computerizing the pathologic inspection request preparation and specimen receipt that have been done manually and maintaining the specimen receipt process, errors related with permanent specimens could be reduced. This has led to the prevention of inspection delay and accurate performance of the inspection, so it has greatly contributed to improving patient safety in the OR. In order to solve problems occurring in the receipt process afterwards, when the specimen is not received properly after the completion of the operation within a fixed time, development of SMS program to solve the problems promptly through SMS notification to the proper doctor is being planned.

1937 Syntagmatic quality indicator management system: beyond the accreditation H. Im 1,*, Y. Kim 1, M. Kim 1, E. Lee 1 1 QA team, Seoul National University Hospital, Seoul, Korea, Republic Of The purpose of this project is to enable integrated management of the quality indicators in EMR based tertiary teaching hospital. If you cannot measure it, you cannot manage it. Almost every hospital manages their own quality indicators under a variety of necessity reasons, but indicators from diverse fields are not integrated so that they just have passive accreditation or to meet simple evaluation criteria. Our hospital has been developing variable indicators but the measurement and monitoring process has been done manually so that not only workers are exhausted but also the reliability and the validity of the calculated results were not fully guaranteed. To rectify those problems, we have been developing the OPTIMUS program-the integrative computerized quality indicator management program- and steps are as follows. At first, the revision of the quality indicators had been done. Unnecessary or out of date indicators had been removed and new and improved indicators were added. Total of 279 indicators enrolled in multidisciplinary approach and they had flexibility to add and delete each indicator which is unnecessary. We decided to call our quality indicator management system OPTIMUS. All OPTIMUS indicators are divided to five domains (patient safety, clinical outcome, patient care, administration and facilities, patient satisfaction), 37 categories (e.g., mortality, infection rate, staff education etc.). Second, we appointed the person in charge on every indicator to emphasize the responsibility, encourage the voluntary indicator management and quality improvement activities. Third, the Indicator Specifications were written in the unified format. Every Indicator Specification explains what the indicator means, and how the indicator s calculates etc. Fourth, the computerization process was initiated. We have been using CDW (Clinical Data Warehouse) program already for some indicators. But it has some limitations on the electronic data mining of doctor s medical records. Therefore, collaboration of the electronic engineers and experts to build the high-dimensional OPTIMUS program initiated. Fifth, we collected monitored results from all quality indicators every quarter or half a year, which means on regular base. Trend of the results are monitored and indicators which is below the reference had been inspected for the cause, and the improvement action was taken simultaneously. The collected results of the indicators are reported to the heads of the hospital, and the Quality Assurance Committee opened every other month and shared the relative information with designated departments. About 280 quality indicators for our hospital were selected according to order of importance. Computerization process to improve the indicators is ongoing project at present. Our CDW program is very useful for monitoring the indicators but with limitations on the electronic data mining of doctor s medical records, brand new OPTIMUS program can help us monitor, manage and improve those indicators in syntagmatic, objective ways. We established multidisciplinary syntagmatic quality indicator monitoring system which called OPTIMUS. Indicator Specification completion, the person in charge appointment, regular monitoring and reporting process were done and now we are working to computerize all indicators. We aim to finish this computerization work at the end of this year. Then our indicator management system will be more powerful, efficient and flawless.

1987 Building up the quality mindset in the Nigerian healthcare sector N. N. C. Ndili 1, E. A. Elebute 1, F. Laoye 1,*, N. F. Onyia 1 1 Society for Quality in Healthcare in Nigeria, Lagos, Nigeria To showcase the Society as a model for driving a culture of change in health care quality To propose matrices for assessment of the impact of the Society Provision of Healthcare in Nigeria is the constitutional responsibility of ALL tiers of government but quality remains poor due to the ill-structured regulatory environment. SQHN was incorporated in 2006 to bring about a wider understanding and acceptance of quality towards improved patient outcomes. Since 2009, SQHN has organized events to help build capacity, promote quality improvement practices & establish support networks, & foster alliance with national & International bodies by: - Promoting the principles & practice of quality improvement - Introducing the concept of accreditation as a tool for improving healthcare quality - Emphasizing the importance of patient safety & measurement of clinical outcomes - Encouraging sharing knowledge among members on quality improvement The concept of Accreditation: Accreditation is perceived to be difficult to achieve in resource constrained setting where basic healthcare standards is a challenge. However, founding members, Lagoon Hospitals (the first hospital network in Sub-Saharan Africa to attain JCI accreditation) and SHELL (recently accredited by COHSASA), are now part of the collaboration between JCI, COHSASA & PharmAccess to form Safe Care, an accreditation platform for small & medium sized healthcare providers in resource poor settings. Safe Care has been introduced to 5 clinics in Nigeria in the last 6 months to commence the accreditation process. Patient Safety: SQHN advocates an integrated national approach to patient safety to reduce mortality, revenue wastages and morbidity associated with poor quality healthcare delivery and unsafe medical practices. It remains high on the SQHN agenda with emphasis on: - Use of Checklists - Introduction of Patient safety culture - Role of governance & leadership to promote patient safety Infection Prevention and Control: SQHN has heightened the awareness by: - Papers delivered at conferences on Hand washing promotion & Infection Prevention and Control (IPAC) and reducing individual disease programs to handle vertical infection control activities and the integration of IPAC on policy management and service levels. Quality Improvement: SQHN workshops emphasis practical application advocating that: Standards are realistic and operational Progress is measureable Achievement is recognized and rewarded 1. Membership Increase: Awareness of SQHN has steadily improved with 286 members including 9 Corporates, 15 hospitals, 229 individuals & 33 students. 2. Event Variety: 3 annual international conferences, 2 seminars & 1 workshop with over 1100 attendees since inception, & the attendance continues to increase. 3. Increased Government Participation: We have achieved active participation from government (always represented) at all levels with strong endorsement from the Minster of Health. SQHN is building up the Quality Mindset of in the Nigerian Healthcare sector by: 1. Raising awareness through increased membership drive and organizing events for providers and beneficiaries of healthcare in Nigeria. 2.Engaging stakeholders to: a) Conduct periodic assessments; b) Build internal capacity; c) Be accountable; e) Measure results against expected outcomes; d) Embark on continuous improvement processes

2005 Developing Patient-Safety indicators for acute-care hospitals in Brazil C. Gouvêa 1,*, C. Travassos 2 1 Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, 2 Instituto de Comunicação e Informação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil The aim of this study was to develop patient safety indicators related to infection control and medication use for acutecare hospitals in Brazil. The indicators were initially selected through a systematic review of the literature (Gouvêa & Travassos, 2010). A tworound Delphi method was used to choose and adapt the indicators to the Brazilian context. The study participants were healthcare professionals, researchers and administrators from the five regions of the country. The process was based on three criteria: face validity, relevance, and viability. A Web application was developed to implement the Delphi method online. Experts received information about the study, the systematic review, the indicators descriptions (indicators definitions, and the scientific evidence supporting its implementation), a glossary of terms, and a questionnaire with closed and open questions. Thirty-five indicators related to infection control, classified into 8 subgroups, and 57 indicators related to medication use, classified into 5 subgroups, were evaluated. Eighty-seven experts participated in the study (32 in the infection control groups, and 55 in the medication use groups), with a response rate of 27% in the first round and 90% in the second. Forty-seven indicators were selected: 23 on infection control and 24 on medication use (Table 1). Table 1: Patient safety indicators selected. Area Subgroup Number of indicators Infection control 1. Central line-associated bloodstream infection: Adult Intensive Care Unit (ICU), Paediatric ICU, Neonatal ICU, Hematology Unit, and Oncology Unit 2. Ventilator Pneumonia 1 3. Surgical Site Infection (SSI): caesarean section, hysterectomy, knee prosthesis procedures, coronary artery bypass graft (CABG), femoro-popliteal bypass, open abdominal aortic aneurysm 4. Neonatal infection 2 Medication use 1. Medication orders/ prescriptions 6 2. Management of High-Alert Medications 6 3. Antibiotic therapy 4 4. Care continuum (discharge information; medication reconciliation) 5. Blood transfusion 2 Implementing the Delphi method on the Web was essential to bring together experts from the five regions of the country, guaranteeing the free expression of opinions by professionals with different backgrounds and positions within the health system. However, using the Internet did not increase the low response rate in the first round, which is common in studies like this. The selected indicators are an important step for building a set of indicators in the areas of infection control and medication use. However, it is necessary to eliminate redundancies and unnecessary duplication. Also, the specifications of indicators can be refined, with the inclusion and exclusion of variables and risk adjustment. That could be done by a panel of experts, which could meet face to face or using audiovisual technology such as teleconferencing after the application of the Delphi method and before performing a pilot study. 6 14 6

2036 Providing safe and quality care to NICU patients through achieving zero central line associated blood stream infection (CLABSI) rate for five months in a tertiary care hospital of a developing country N. K. A. Lalani 1, A. Bardai 2, S. Demas 1,*, R. Ali 3 1 Women and Child Health Area, 2 NICU, 3 Pediatric, The Aga Khan University Hospital, Karachi, Pakistan To reduce the rate of Central Line Associated infections in a Neonatal Intensive care unit in a tertiary care hospitals. The unit faced an outbreak of the CLABSI in the third quarter for year 2010 and the rate was noticed as high as 32.37 Separate Kidney Dishes, Hexi sprays and disinfection sprays. So interventional methodology was used and measures were taken with the input of NICU team of physician and nurses along with the recommendations from infection control team including provisions like separate weighing scale; Intubation trollies; Intravenous cannulation trollies to each room of NICU in comparison to the former practice where one trolley was shared in all 4 rooms. This was also causing sharing equipment between the infected and Non-infected cases. Moreover Separate Kidney Dishes, Hexi sprays, disinfection sprays, and latex glove boxes were made available for individual patients; using of plastic glove for diaper change was reformed to practice of latex glove usage. To add on; Practice of covering Hubs of central lines with gauze dressings were introduced along with usage of surgical gloves instead of latex for the central line handling. Staff awareness and involvement had also played a significant role in implementation of the interventions. CLABSI rates were reduced to Zero from 32.37 which was preceded by rates of 13.1 and 24.4. with implementation of the above mentioned strategies for five months and that has ultimately improved clinical outcomes of critically ill neonates. Clinical outcome of the critically ill neonates can be significantly improved by improving on the CLABSI rates through implementing proper barriers precautions and enhanced staff involvement in the care protocols.

2149 Utilizing scientific principles of risk management to implement sustainable quality and safety in China healthcare reform K. Timmons 1,*, J. S. Gao 2 1 Healthcare, DNV, Oslo, Norway, 2 DNV Sustainability Centre Healthcare, DNV, Beijing, China As the world s fasting growing economy, with a population of over 1.3 billion people, China is mobilising a new paradigm for delivering a sustainable healthcare platform. China s goals are ambitious; to establish a healthcare system that can provide safe, effective, and low-cost services for all of its 1.3 billion citizens by 2020. This presentation will focus on the China National Health Development Research Centre s (CNHDRC) efforts to minimize and mitigate the challenges of health reform through proactive risk management. The presentation will demonstrate how the application of multi-criteria and risk-based tools including gap analysis, project execution, change management, cost-effectiveness and mitigation, can assist in the formulation and execution of health reform that is sustainable. Lessons from the past and other industries will be emphasized to demonstrate how CNHDRC is applying scientific concepts of sustainable development in healthcare reform. The presentation will highlight the goals of CNHDRC in developing a scientific framework, risk management principles and methodologies that will be applied to the formulation of healthcare reform, while building capacity for quality and safety. China is mobilizing a new paradigm for healthcare, with massive change at unparalleled scale. The use of proactive risk identification, assessment, and management will positively implement sustainable, transformational change.

2201 Application of Failure Mode and Effects Analysis (FMEA) in risk prospection in the hospital care in Brazil F. Caixeiro 1,*, M. Martins 2 1 Departamento de Planejamento, Instituto de Mediciana Social - IMS/ UERJ, 2 Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúsde Pública Sergio Arouca - ENSP/ FIOCRUZ, Rio de Janeiro, Brazil The study aimed to describe the use of FMEA in Brazilian hospitals for prospecting risk in the provision of services and help in establishing measures to prevent the occurrence of adverse events. We sought to compare this usage with international experience to explore possible peculiarities of the Brazilian reality and thus help to overcome them and to improve quality and patient safety in the provision of health services in the country. The study is defined as exploratory and descriptive. The target population consisted of all hospitals accredited, or in preparation to achieve accreditation, based on the standards of the Joint Commission International Accreditation for Hospitals. We used a semi-structured questionnaire using Word program, developed specifically for this study based on literature review. The questions were grouped into categories that represent the range of requirements for successful implementation of FMEA: leadership, focus and commitment to safety, continuous improvement strategy, effective management of information, and qualified and well trained. A five-point Likert scale was used and the results were analyzed using descriptive statistics. In addition, we analyzed the Middle Ranking (MR) of the set of questions in each category, assuming a cutoff value 3. Thus, if the MR of category was higher than 3 it is considered a positive factor regarding the condition, i.e., successful application of FMEA. The data collection period was from December 2010 to March 2011. Invitations were sent to 49 hospitals, of which 16 are accredited and 33 are in Accreditation process. Of these, 27 (55.1%) responded and 22 (44.9%) did not respond to the invitation. Of the hospitals that responded to the invitation only 13 used FMEA. Among them, two hospitals that share the same management, and apply FMEA for ordinary processes, consolidated their information in one questionnaire. Thirtyfour analyzes were conducted by 12 hospitals since 2005, and represent a reasonable number, considering the costs of applying the method and the fact that its implementation was not mandatory before 2008. FMEA has been used in the prospecting risk and to establish measures to prevent the occurrence of adverse events in most of the hospitals surveyed, although its application still prevails in response to sentinel events and other specific incidents. All hospitals surveyed reported that they develop a program or a process of quality improvement. Some research results denote that these programs or processes are at different levels of maturity, such as the report of the fickleness of the strategic objectives and resource allocation; some observations on the low involvement of professionals and lack of awareness of the value added with the application of the method; no simulations, pilot testing and monitoring of tests; and any non-application of the conclusions of the analysis. The main problems observed in applying the method does not diverge from international experience, such as the time and dedication of the remaining team members and their training; the lack of a culture of prevention; and omission of some steps in its implementation. The number of experiments still small, but meaningful according to the time that these hospitals began to use FMEA, it is an important feature of our reality. Other aspects are the lack of provision of training outside the area of engineering and over-regulation of health care, limiting the options for the redesign of processes.

2384 Personal Approach in increasing physician involvement in quality care activities D. Widjaja 1,* 1 Siloam Hospital Lippo Cikarang, Jakarta, Indonesia The objective was to show that personal approach improved physicians willingness to involve in quality care activities enhancing patient safety. 1. We developed six Clinical Quality Indicators (CQI) based on regular physician's activities to monitor the output, i.e. outpatient doctor attendance, completed outpatient notes, completed informed consent, in-patient doctors visit, in-patient doctors assessment, and completed discharged forms. 2. We approached our physicians individually to communicate and persuade their view and their support on quality care activities. 3. We also developed other forms of regular communication approached, such as communication meeting among the physicians for each specialties and communication meeting between medical staffs and our management team. 4. As initial part, we focused only on 2 indicators, i.e. physicians compliance in completing informed consent and discharged forms. 5. The pilot was conducted for 3 months. 1. The percentage of physician compliance in completing informed consent increased from 93.45% in month one to 94.02% in month three. 2. The percentage of physician compliance in completing discharged forms increased significantly from 72.98% in month one to 95.12% in month three. 3. The overall percentage of physician compliance in all six CQI increased from 85.17% in month one to 89.12% in month three. 1. The pilot reached the target that was set out to be achieved. 2. Personal approach was far more being appreciated by physicians and hence, better relationship and understanding between physicians and management were developed. 3. Given the outcome of this pilot, we planned to expand the focus of the personal approach to the remaining 4 indicators.

2398 Translating regional patient-safety mandates into local action in African hospitals: the power of context-specific improvement resources J. Storr 1,*, E. Kelley 2, J. Hightower 3, S. B. Syed 4 1 Patient Safety, WHO, London, United Kingdom, 2 WHO, Geneva, Switzerland, 3 WHO, Harare, Zimbabwe, 4 Patient Safety, WHO, Geneva, Switzerland At the 58 th WHO African Regional Committee (RC-58) all 46 countries endorsed a Technical Paper on patient safety that called for action in twelve areas. This acted as a catalyst for kinetic action that is now translating a regional mandate into positive changes to hospital safety and quality across Africa. The objective of this paper is to outline the development and utility of a triad of patient safety improvement resources for African hospitals. A partnership approach to patient safety improvement has driven the development of simple, bespoke improvement resources informed by the current literature on quality improvement, implementation and sustainability science. Resource development was aligned with the regional mandate, framed around 12 patient safety action areas. Local contexts across Africa were incorporated through APPS partnership hospitals. Three key resources were co-developed, each framed around 12 patient safety action areas. First, a situational analysis tool enables establishment of the state of patient safety within a healthcare facility. Second, an improvement framework outlines potential first steps in improving patient safety. Third, a resource map informs improvement and assists with implementation and sustainability (developed in response to direct requests from partnerships). The Situational Analysis is a needs assessment tool that allows rapid collection of information (both strengths and weaknesses) utilizing a yes/no approach, as well as a more qualitative open approach. The findings serve as a robust data foundation for patient safety action planning at the hospital and assists with impact evaluation. Improving Patient Safety First Steps, outlines an improvement approach structured around the 12 action areas, with spread as a central aim. It lists key considerations for improvers at the start of their journey. The resources listed within the APPS Resource Map are diverse and span guidance, policies, publications, templates and toolkits. The Map is arranged across three levels. Each level builds on the former, culminating in a set of case studies. The triad of core improvement resources allows any health care facility to identify gaps, agree critical areas for action and locate necessary resources for sustainable improvement. This triad is the first of a kind package for patient safety improvement in the African Region. Lessons learned from early implementers demonstrate the utility of the triad in initiating small-scale, simple change with potential to result in more wide scale system-wide and in-country improvement. Alignment of patient safety improvement resources with policy has been central to creating impetus for and actual action on patient safety across partnership hospitals across 14 African countries, and significantly strengthens the translation of mandate to action. A unique feature has been direct involvement of front line healthcare workers in shaping improvement resources. The approach illustrates the impact that global thought leadership can have when it interacts with front line workers to develop context specific resources for action. Simplicity is the key ingredient when bringing implementers and policy makers together to make a difference to patients receiving healthcare in Africa.

2462 Development and implementation of the critical pathway for day surgery on breast disease H. Jang 1, M. Kim 1, S. Ahn 1, J. Yang 1,* 1 Seoul national university hospital, Seoul, Korea, Republic Of The goal of this study is to determine the impact of a standardized critical pathway (CP) and giving integrated education program for patients in order to increase the efficiency of managing a Day-surgery operating room. The Day-surgery on Breast disease CP was developed from April to June of 2009 and standardized critical pathway (CP) has been implemented from June 2009 until now in Seoul National University Hospital. We organized multidisciplinary teams for Day-surgery on Breast disease CP. These teams consisted of general surgeons, anaesthesiologists, head nurses, radiological exam staff, administration office staffs, and staffs in division of quality improvement. It determined the criteria for application, drop, exclusion and the team discussed standardized protocols for Day-surgery on Breast disease CP. The patients who suffers from breast disease need to get general anaesthesia, without other conditions were applied in the Day-surgery CP, while the old age patients, with other conditions were excluded. We developed the Day-surgery procedure on Breast disease CP. This CP programs included 1) standardized protocols based in EMR, 2) the integrated education programs provided by doctors and nurses to patients and their family members. Standardized protocols based in EMR that consists of 3 structures; Set registration program, user program for doctor and user program for nurse. 1) With the Set registration program, following items are in place prior to the procedure; goal, monitoring, treatment, medication, activity, diet, test, consultation, education, evaluation, medical/nursing medical record and permission. 2) The User program for doctors/nurses is comprised of patient information and has same items as the set registration program. We informed and trained the related people (doctors, nurses, and other professionals) of the Day-surgery on Breast CP. So they provided patients care according to the Day-surgery on Breast CP. In the Day-surgery on Breast CP, the number of Day-surgery increased in 2010(202) compared with 2009(28). In Intraepithelial carcinoma surgery, the average length of hospitalization decreased in the groups applied CP (1 days) compared with the groups unapplied CP (7.0 days). The average hospital cost per day was higher in the groups (1,274 USD) applied CP than the groups did not apply CP (547 USD). The benign breast disease patients who were inconvenienced for lack of patient s rooms and operating rooms were satisfied this process, because of reducing waiting period for admission and operation. Our standardized critical pathways and integrated education programs for the patients who undergo breast disease had a positive effect on increasing efficiency of managing Day-surgery operation room and patient s satisfaction.

2517 Competencies in self-care management with insulin-using Type 2 Diabetes Mellitus and occurrence of adverse events: prospective study in an ambulatory setting B. Sirikamonsathian 1,*, J. Sriratanaban 1, N. Hiransuthikul 1, S. Lertmaharit 1 1 Chulalongkorn University, Bangkok, Thailand To examine the relationship between competencies in self- care management and occurrence of adverse events in patients with insulin-using in Type 2 Diabetes mellitus[t2dm]. A prospective 15 month between April 2010 and July 2011, repeated measure 4 times of 310 patients with insulin- using in type 2 diabetes mellitus were performed to interview a competencies in self care managements and frequency, injury, treatment, characteristics of adverse events. Generalized estimating equations (GEEs) were calculated. The competencies in self care management scores were associated with increase risk of adverse events. [Adjusted OR=4.83,95%CI=2.29-10.15] Overall of the incidence rate of occurrences of adverse events in poor group were 2.12 episodes per 100 person month and the incidence rate of occurrence of adverse events in well group were 0.44 episodes per 100 person month.a total of occurrences of adverse events were 47 episodes: 36[76.59%] occurred at home. 63 episodes injured at head, extremity, had abrasion, contusion, dislocation, bone fracture, injured of other person, thing destroyed, and marked did not clear. Cause of adverse events were 88 episodes: miss meal, forgot insulin injection, altered a time of insulin injection, altered dose of insulin, after exercise. Adverse events got diagnosis hypoglycemia, severe hypoglycemia, and diabetic ketoacidosis (DKA). Table Incidence rate (IR, per 100 person-month) of adverse events and competencies in each group CSCM* Month 3 Month 6 Month 9 Month 12 Case/ personmonth IR Case/ personmonth IR Case/ person-month IR Case/ person-month Well group 11/471 2.33 8/936 0.85 11/1395 0.78 9/1842 0.48 Poor group 1/459 0.22 2/918 0.21 3/1377 0.22 2/1827 0.11 Total 12/930 1.29 10/1854 0.54 14/2772 0.50 11/3669 0.29 IR *CSCM = competencies in self care management Competencies in self care managements were strong associated with adverse events (AEs) among insulin using in type 2 diabetes mellitus Thai patients. It is particularly common in patients who have poor competencies self care managements. To develop a quality of life and make a potential of health promotion, Patients roles must be empowerment by competencies of themselves.

2599 Safety Assessment of care to patients in hospitals accredited jointly by the Joint Commission International and the Consortium for Brazilian Accreditation H. Costa Junior 1,*, J. L. V. Filho 2, M. M. P. Santos 3, S. N. Cozer 1 1 Consulting and Education Services, 2 Health Plans Accreditation, 3 Superintendence, Consortium for Brazilian Accreditation, Rio de Janeiro, Brazil The study aimed to compare the compliance of 7 Brazilians Hospitals jontly accredited by Joint Commission International JCI and Consortium for Brazilian Accreditation CBA with the International Patient Safety Goals IPSG during the period these Hospitals where in preparation for renewal of accreditation award. To compare institutions with each other, authors verified arithmetic mean, mode and median of the results from external evaluations in two different opportunities. Also standard deviation, coefficient of variation and asymmetry where calculated. A significant difference among the Hospitals compliance with the IPSG was observed except for the IPSG 5. The results indicated that the consultation and education processes are important to prepare the organiations for accreditation programs. Once all 7 Hospitals later got their re-accreditation grant, authors concluded that the assessments performed before the evaluations by JCI for renewal of accreditation grant are very useful, for the resumption of the safety standards of services provided by health institutions. References: Joint Commission International Standards for Hospitals Accreditation - 3ª edition - 2008, Chicago - USA

2608 Using a quality of care framework to develop, standardize, assess and improve the quality of health services for adolescents in low and middle-income countries K. Bose 1, L. Ogbaselassie 1, V. Chandramouli 1,* 1 WHO, Geneva, Switzerland To support countries in formulating national quality standards for health services for adolescents and assessing and improving the quality of health services for adolescents 1. Using WHO s Guidebook on developing quality standards for Adolescent Friendly Health Services (AFHS), 18 countries were supported between 2001 and 2011 to develop national quality standards based on five dimensions of quality - accessibility, acceptability, equity, appropriateness and effectiveness. 2. Ten of these countries were also supported to adapt WHO's Quality Assessment Guidebook for health services to adolescents. National tools were developed to assess the quality of health service provision to adolescents, comprising tools for interviewing: a) the health facility manager; b) health-care providers; c) support staff; d) adolescent clients In addition, an observation checklist was also developed. The results from four countries, one each from four of WHO s six regions, are presented below. Country Sites assessed Results at different levels of the Quality assessed Utilisation health system Haryana, India Moldova Mongolia Tanzania 11 intervention & 10 control facilites & adolescent clients HCPs** Health Care Providers ASRH*** Adolescent Sexual & reproductive Health 12 existing YFHS**** facilites & adolescent clients YFHS ****Youth friendly Health Services 53 intervention & 29 control facilites & adolescent clients 90 facilities randomly chosen Intervention vs. control sites scored higher on: -facilities providing specified package of services, having trained HCPs**, maintaining privacy & cleanliness, having educational materials; -facilities maintaining supervision & monitoring (45% vs. 13%); -HCPs communicating with adolescents; -HCPs being respectful & non-judgemental( 44% vs. 1%); -adolescents being aware of & satisfied with services -communities supporting ASRH*** services Facility compliance with STAN* (Standards) -maintained privacy, confidentiality, equity; mobilised community support; -but only 41% provided effective health services -youth knew YFHS facilities and found them accessible and acceptable Intervention vs. control sites scored higher on: -facilities displaying services available, maintaining educational materials, ensuring privacy; -providers feeling competent on ASRH and counseling; -youth knowing about YFHS, reporting respectful treatment, trusting that confidentiality will be maintained; satisfaction with services Facility compliance with STAN* (Standards) -increased availability of guidelines; maintained safety, privacy, cleanliness; provided supportive supervision; interacted with communities; -40% of HCPs** trained on ASRH; -40-50% of facilities had relevant educational materials; essential equipment & supplies; age & sex data on clients; -performed poorly on knowledge of ASRH rights; information display of available services; opening after-school hours increased utilisation increased utilisation increased utilisation not assessed With WHO's support more countries are developing quality standards for health service provision to adolescents.

2611 Development of quality indicators for advanced pediatric emergency center J. H. Lee 1, J. H. Jeong 2,*, D. K. Kim 3, D. Suh 3 1 Department of Emergency Medicine, Seoul Natioal University College of Medicine, Bundang, 2 Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggido, 3 Emergency Medicine, Seoul National University, Seoul, Korea, Republic Of The Government of Korea designated six Advanced Pediatric Emergency Centers (APECs) to improve emergency medical service for children since 2010. However, the measurement of quality and performance of APECs, such as facility, equipment, personnel, and function has not been appropriately conducted due to the lack of standards in performance measures. The purpose this study was to develop the measurable quality indicators for APECs. First, we set principles in selecting quality indicators, which were as follows; excellence to lead other pediatric emergency departments (PED), objectivity to assess clearly, and basic indicators to achieve the aim of the early phase of APECs. Based on these principles, candidates for the quality indicators were searched by (1) survey of peer-reviewed literature, (2) consensus meetings of 10 pediatric emergency medicine specialists, and (3) a public hearing with directors and faculties of the 6 APECs. Through the 9 month-long process, we selected three structural and seven qualitative measures. The three structural measures include; (1) separate facility from adult ED, (2) list of suitable equipments for each age of children, (3) minimum requirements for the workforce of health care providers based on annual census. The seven qualitative measures are as follows; (1) specialized protocols for pediatric patients, (2) immediacy (< 1 hour) of seeing a specialist, (3) effectiveness of asthma treatment, (4) safety of trauma patients, (5) safety of patients undergoing procedural sedation and analgesia (PSA), (6) safety of patients with acute abdominal pain, (7) explanation of discharge plan by a specialist. We suggest the structural and qualitative measures to assess quality and performance of APECs in Korea.

2651 Reduction of prolonged second-stage labor by using upright labor position K. Maneepum 1,* 1 Obstetrics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand To reduce the incidence of prolonged second stage by changing labor position from supine to upright All pregnant patients presented in the second stage of labor without exclusion criteria were recruited in this study. We then changed the patients' position from supine to upright. Triangular pillow was used to support patients' back in sitting position during delivery. Their knees and feet were widely opened and heels were placed on the trestle. We encouraged the labor force simultaneously with the rhythm of patients' uterine contraction. When the babies were head down near vagina, we subsequently changed mothers' position to prone and delivery. Time of delivery, prolonged 2nd stage cases and patients' satisfaction during labor were collected. 19 pregnant patients were recruited in the study. Average time in second stage were 1 hour 6 minutes in 1st pregnancy and 39 minutes in the 2nd pregnancy. Rate of prolonged 2nd stage was reduced from 2 to 0 percents. All patients were satisfied without any complaint with the new labor position. No complication was detected during the study. Changing labor position from supine to upright can significantly reduce labor time in the second stage. The position was comfortable and safe.

2693 The improvement in preventing suicide on medical/surgical units in a national hospital of Korea M. Kim 1, S. Park 1, Y. Kim 1,*, E. Lee 1 1 Quality Assurance Center, Seoul National University Hospital, Seoul, Korea, Republic Of Suicide has ranked in the top five most frequently reported events to the Joint Commission since 1995. Compared to the psychiatric hospitals and units, the general hospital inpatient units are not designed to assess suicide risk and do not have adequate staffs with specialized training to deal with suicidal individuals. The objective of this study is to assure that patients outside of psychiatric units are appropriately screened and cared for. We collected the suicide data during last five years. The data was analyzed using root cause analysis. Contributing to overall risk are risk factors contained within the health care environment. Common environmental risk factors included potential anchor points of hanging, material that can be used for self-injury, and problems of maintaining a secure environment. The methods of self-inflicted harm most frequently used in health care environments including hanging, jumping correspond to these common environmental risk factors. Some specific means that are easily available in general hospitals inpatient units and that have been used for completing suicide include: elastic tubing and elastic stocking. In addition to physical environmental risk factors, systemic care shortcomings contribute to suicide include: inadequate screening and assessment, care planning and observation; insufficient staff orientation and training; poor staff communication; inadequate staffing; and lack of information about suicide prevention and referral resources. In order to effectively reduce the risk of suicide in the medical/surgical settings, we identify patients with risk for suicide and then intervene to prevent suicide with those patients who are identified as at risk. We used these risk reduction strategies. 1) Using self-check tools for screening and assessment of suicide risk in EMR (electronic medical record), the patients identified as at risk are provided with a psychological consultation to assess immediate risk of individuals. 2) Behavioral observation, mental status, or conditions that may indicate a risk of imminent suicide: acute signs of depression, anxiety and chronic pain or other debilitating problems, including chronic illness and terminal cancer, we provide person-centered care, which engages the person at risk in care planning and decision-making. 3) Strengthening the orientation and training of staffs and communicating with patients and family or other relative party, we could offer the patient the opportunity to be visited by family members who can offer peer support and alert to any warning signs that may indicate imminent action linked to suicide. 4) Improving hospitals safety facility could prevent any unexpected accidents. Decrepit facilities have been renovated and security guards would be patrolling around the hospital helping patients stay in a safer environment. Self-check tools for screening and assessment of suicide risk in EMR (electronic medical record) have been used and the patients at risk of suicide were sent to psychiatrists in timely manner. Education also cover finding environmental risk factors, achieving a better understanding of behavioral health in general, screening and referral of patients at risk for suicide. EMR has been used to assess the patients at risk for suicide using self-check tools within it and use variety of methods to intervene to prevent suicide in those patients identified as at risk.

1097 A system to improve documentation of policy, procedures and guidelines in a cluster of hospitals H. Y. So 1,*, C. S. W. Choi 2, W. W. M. Chan 1, S. F. Lui 1 and NTEC Task Force on Documentation 1 Quality & Safety, 2 Information Technology, NTE Cluster, Shatin, Hong Kong, China Policy, procedures and guidelines are important documents to ensure consistency in service delivery, to preserve knowledge of healthcare organizations, and to facilitate continuous quality improvement. Before 2009, there was no system in the 7 hospitals of the New Territories East Cluster (NTEC) in Hong Kong which serves a population of 1.3 million. A movement was started in 2009 to ensure that these documents are properly written, regularly updated, and the most updated version must be easily accessible when required. 1. Establishment of governance body and policy A task force was formed to look into improvement of documentation. The task force reports through the Cluster Committee on Quality and Safety to top management of the Cluster. A Document Control Policy, which defines the types of documents, roles and responsibilities of different staff in each stage of the document life cycle, as well as minimal requirements in the format of the document was written and endorsed by top management. 2. Establishment of electronic document control system An electronic platform intec- was established on the intranet system. It was written using Microsoft Sharepoint, and staff can manage their own website after basic training. There are 2 subsystems: the ihospital and icommittee designed, amongst other functions, for document control for each department and each committee respectively. Each department and committees within the cluster were provided their own website. The design of the website combines standard elements and flexibility and because of the standardized template can be produced rapidly. A search engine (igateway) facilitates retrieval of document. 3. Training of webmasters Webmasters from all the departments and committees were appointed and trained. 4. Training workshops for document writing and document control The 4 sessions in these half-day workshops included: processes and document, how to write documents, principles of document control, and use of the electronic platform (ihospital) for document control. Participants had to submit a practicing document within one month after the workshop for correction by trainers. Improvements based on evaluation after each workshop were made. From 2009 to 2011, websites for 218 departments and 178 committees were set up and 731 webmasters were trained. 14 Documentation workshops with held, with 769 staff trained. An audit performed in October 2011 showed that 2,123 policies, procedures or guidelines were uploaded. Within a period of less than 2 years, a framework which allows each department to write and upload their own documents into a website is established. The system allowed easy retrieval of relevant documents as well as facilitate learning and sharing amongst different departments. The success of the movement depends on effective leadership and staff engagement, as well as appropriate choice of information technology.

1108 Prison Health Reform - achieving patient safety standards T. P. Dezen 1,* 1 SA Health, South Australian Prison Health Service, Prospect East, Australia To reduce the number of serious patient incidents, implement patient and staff safety programs and increase compliance to budget allocation, hence preparedness for accreditation certification. The South Australian Prison Health system was identified as unsafe, non compliant to contemporary clinical practices and had a high serious incident rate for patient safety. The service was immobilised by internal staff industrial relation issues and was unable to consistently meet budget allocation. There were insufficient systems to monitor patient and safety and therefore independent accreditation certification could not be achieved. Perform internal review of current systems and benchmark activities with like organisations. Conduct an independent external review of service models and staffing levels compared to interstate and national standards. Engage key stake holders from within South Australian Health, Department of Correctional Services, South Australian Police and Court systems to strategize for a more effective system. Implement a high level planning group at Chief Executive level to review recommendations and seek endorsement of a model of care and budget allocation for the future. A new model of care developed for nursing and medical services aligned to contemporary practices including the introduction of the nurse practitioner and local general practice clinics in country location managing the prisoner from a population health perspective. Introduction of a patient safety systems including pre packaged medication and patient/prisoner held medication at some sites. Introduction of clinical pathway procedures and standing orders for nursing staff and implementation of health promotion, chronic disease management and satellite clinics. The development of a robust corporate support systems and the introduction of key performance indicators to monitor and manage patient and staff safety. Implementation of corporate systems including patient safety, accreditation and risk management which has resulted in reduced patient incident rates. South Australian Prison Health Service was deemed an unsafe work environment by the nurses union which created the impetus for reform. New management positions were created with a mandate to reform the service and introduce models of care aligned to nursing and medical enterprise agreements. Addressing these issues has resulted in robust systems development, compliance to enterprise agreements and improved patient and staff safety systems. This has achieved budget compliance and will ensure future accreditation certification. References: PricewaterhouseCoopers external review report Australian Council on Healthcare Standards- Accreditation Standards Australian National Safety and Quality Standards South Australian Health policy and procedures South Australian Prison Health Services procedures

1393 The role of medical clinicians working in the healthcare accreditation survey process: their motivations, the influences that affect them and the methods they employ to address those influences L. Low 1,*, J. Braithwaite 2, B. Johnston 3, D. Greenfield 2 1 Executive Director, The Australian Council on Healthcare Standards, 2 Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, 3 Chief Executive, The Australian Council on Healthcare Standards, Sydney, Australia The Australian Council on Health Care Standards (ACHS), which offers accreditation programs to private and public sector health care organisations throughout Australia, conducts a collaborative peer review process involving teams of surveyors from multiple disciplines including nursing, allied health, administration and medicine. Surveyors, mainly volunteers, perform on-site reviews of the quality and safety aspects of the health care organisations against a set of prescribed standards. This study is an evidence-based examination of medical clinician (MC) surveyors, and more specifically, investigating: 1. The motivations for medical clinicians becoming surveyors 2. The issues and influences that affect MC surveyors during the survey process and the inter-rater reliability of their judgements. 3. The methods MC surveyors employ to deal with these influences. There is limited research and empirical evidence as to the benefits of accreditation and improved service quality, despite the significance of accreditation for hospitals and the resources expended on it. Medical clinicians form the largest group of professionals involved in accreditation, they have the most influential role but they can view accreditation with cynicism and suspicion; they therefore form an interesting and important group to study. The research consisted of three distinct stages. The diagram shows the research design: 1. A questionnaire provided to 49 medical clinician surveyors 2. In-depth interviews of eight medical clinicians 3. Six case studies for which 298 responses were received from surveyors working in teams designed to replicate a real-life survey process The large amount of data was analysed utilising a range of social science methods. The study employed an action research methodology. The research identified several factors that motivated MC surveyors to participate in accreditation. These are summarised as follows: - Improvement of quality in the health system and within their own organisation - Facilitation of benchmarking and comparison of health care organisations - Provision of an external perspective, sharing of ideas and increased networking - Assistance to their professional development - Gaining of prestige, respect and increase in their influence - Enjoyment. Demotivating factors, although mentioned less frequently, included adverse staff reaction towards them, hospital politics and the challenging or stressful nature of some surveys. The research identified fourteen interrelated factors that influence the survey process and potentially, the accreditation outcome. It found that MC surveyors were acutely aware of the need to be objective in their surveying and furthermore, were conscious of the difficulty in attaining objectivity. They reported that they had available to them a range of solutions which they could draw upon to deal with the variety of issues that an individual survey might present. This research has provided evidence supporting medical clinicians involvement in the accreditation process. It reports a positive view of accreditation, highlighting the characteristics of the accreditation process that MC surveyors consider benefits health care as well as leading to a more objective accreditation outcome.

1609 Advanced practice accreditation programme for nurses A. Rojas-de-Mora-Figueroa 1, A. Almuedo-Paz 1, P. Brea-Rivero 1, A. Torres-Olivera 1,* 1 Andalusian Agency for Healthcare Quality, Seville, Spain To describe the launch of the Advanced Practice Accreditation Programme for Nurses in the Public Health System in Andalusia (SSPA), Spain. The Regional Ministry of Health in Andalusia is promoting the incorporation and consolidation of an Advanced Nursing Practice Model which increases their scope and gives a closer, warmer and more humane view for citizen s specifics needs. Nurse s interventions related to SSPA pharmaceutical care are defined in the 307/2009 Decree. The 4 th article specifically states that accredited nurses will be able to cooperate in certain protocolized and individualized drug treatments, established by previous indication and medical or dental prescription. In 2011, to comply with this strategy, the Andalusian Agency for Healthcare Quality, with help from Experts Committees set up by nurses, doctors and pharmacists, has developed two portfolio programmes through which professionals review their own practices, demonstrating their skill in the advanced pharmaceutical care practice. The accreditation processes has 3 phases: Application, Self-assessment, Recognition and Certification. The developed accreditation programmes are: Protocolized monitoring in diabetes Protocolized monitoring of the individualized drug treatment in patients with oral anticoagulation medicine To access these programmes, nurses must have previously achieved an accreditation level in the Professional Skill Accreditation Programme of the Andalusian Agency for Healthcare Quality (Advanced, Expert or Excellent). Up to now (February 2012), eight professionals are in the Application phase of the Protocolized monitoring in diabetes Accreditation Programme, four professionals in the Self-assesment phase and one professional has achieved the accreditation which means that she is nowable to cooperate in the protocolized monitoring of the treatments with Metformin, Sulfonylurea and Basal Insulin. Regarding to the protocolized monitoring of the individualized drug treatment in patients with oral anticoagulation medicine, four professionals are in the Application phase, two professionals in the Self-assessment phase and five professionals have achieved the accreditation which means that they are able to cooperate in the protocolized monitoring of treatments with Acenocoumarol or Warfarin. Furthermore, we are developing the following: Protocolized monitoring of the individualized drug treatment in patients with palliative sedation Protocolized monitoring of the individualized drug treatment in patients with antihypertensives The launch of the Advance Practice Accreditation Programme for Nurses is pioneer, enabling nurses to participate in new activity areas and is an essential element for their professional development. Nurses who join this advanced practice model are professionals with a high level of experience assessing complex situations and with a high level of clinical skill. Furthermore, they carry out a wide range of practical and theoretical activities based on scientific evidence and their interventions are characterized by a high level autonomy and a high degree of responsibility.

1612 Mandatory quality management implementation in German medical practices - a 1:1 matched observational study S. Auras 1,*, W. de Cruppé 1, F. Diel 2, M. Geraedts 1 1 Institute for Health Systems Research, Witten/Herdecke University, Witten, 2 National Association of Statutory Health Insurance Physicians, Berlin, Germany Since 2004 physicians contracted to treat patients under national health service provision ( Statutory Health Insurance (SHI) physicians ) in Germany are obliged to introduce quality management (QM) in their practices. The Federal Joint Committee (G-BA), the supreme organ of self-government in the German healthcare system, has to evaluate the introduction, effectiveness and usefulness of QM. Against this background we studied whether medical practices which are at an advanced stage of implementation of QM (documented by voluntary QEP accreditation, a QM system (QMS) for medical practices that complies with all legal requirements) meet quality requirements better than medical practices without any certificate. The organisational and treatment processes, job satisfaction of doctors, patient satisfaction and clinical outcomes were investigated. In a cross-sectional observational study accredited general practitioners, internists and gynaecologists were compared with non-accredited doctors matched 1:1 using 7 medical practice characteristics. A self-developed doctor questionnaire gathered data from the practices about organisational and treatment processes (quality of structures and processes) and job satisfaction of physicians. One-sided tests were carried out using 3 sum scores (sign test with Bonferroni correction). Using data from patient satisfaction questionnaires (validated questionnaire of the Hanover Medical School, Germany) and Disease Management Programme (DMP) feedback reports, hypothesis-generating statements were derived regarding the quality of medical outcomes (sign test and McNemar test without Bonferroni correction). 74 of 180 accredited and 74 of 460 non-accredited medical practices participated in the study (41% and 16%). 73 medical practice pairs were evaluated which delivered 73x2 doctor questionnaires, 21x2 patient surveys and 16x2 DMP feedback reports. Accredited medical practices implemented important quality requirements significantly more often than non-accredited practices (p<.001, sign test). This particularly involved standardisation, structuring and documentation of treatment and practice processes, controlled handling of errors, sophisticated complaint management and dedicated employee orientation. The job satisfaction rate of doctors did not differ (p=.121, sign test). Reliable statements about the outcome quality (patient satisfaction, DMP feedback reports) were not possible due to low participation. A fully implemented QMS in medical practices is associated with improved organisational and treatment processes. The job satisfaction of doctors with and without fully implemented QMS does not differ.

1795 The relationships among health-promoting behavior, work stress, and health status of employees at a medical center in northern Taiwan S.-C. Wu 1, C.-C. Ho 2, C.-E. Chang 1, H.-L. Lee 3,* 1 Chang Gung Memorial Hospital, Linkou, 2 Chang Gung University of Science and Technology, Guishan Township, 3 Chang Gung Memorial Hospital, Taipei, Taipei, Taiwan The health promotion and health status have gathered great importance in recent years. Over the last decades, we have seen mounting evidence of the usefulness of workers health-promoting strategies into their acquisition process. A review of the literature indicates that work-related stress and health-promoting behavior are related to the health status. However, research which has empirically documented the link between work stress, health-promoting behavior and health status among employees who work at a medical center in Taiwan is scant. The study may lead to a better understanding of the relationships among health-promoting behavior, work stress, and health status of employees at a medical center in northern Taiwan. Of the 231 employees were enrolled in this study. Follow the routine annual employees physical examination, subjects were interviewed and asked to fill out questionnaires. Approximately 65% of the participants were female, 26% were nurses, and 34% need shift work. The average age was 40±7 years old, and the mean of body mass index (BMI) were 24±3. Four instruments were used in this study. 1. the demographic data sheet; 2. the Chinese version of job content questionnaire, which contain working load and social support; 3. the Chen s modified health promoting life style profile for assessing the health promoting behavior; 3. the Chinese version of psychological general well-being index (PGWBI) for evaluating employees health status. All the instruments had acceptable validity and reliability. The work-related stress, health-promoting behavior and health status have been shown to be positively correlated with each other (r =.476**,.270**, and.357**, respectively). We hypothesized that age, BMI, shift work, stress and healthpromoting behavior could contribute to a model that might predict health status that was tested using multiple regressions. The model was found to be significant (F=14.09, p<0.001), account for 31% of the variance. Shift work, work stress and health-promoting behavior influence to health status. Age and BMI were not related to health status. Statistical power in this study is.99. The health status is influenced by shift work, work stress and health-promoting behavior among employees who work at a medical center in Taiwan. The factors studies here may be of importance in explaining the phenomenon and the article concludes with implications for theory, research, and practice.

1894 Economic Appraisal of health services accreditation: a fiendish problem desperately in need of a solution V. Mumford 1, D. Greenfield 1,*, K. Forde 2, J. Braithwaite 1 1 Centre for Clinical Governance Research, Australian Institute of Health Innovation, UNSW, 2 School of Public Health and Community Medicine, UNSW, Sydney, Australia To assess the use of economic appraisal in health services accreditation and to review the costs and benefits of health services accreditation. We systematically searched and synthesised relevant literature on this topic between June and December 2011, employing three strategies. First, health economic databases (NHS Economic Evaluation Database, Evidence for Policy and Practice Information Centre, National Bureau of Economic Research & EconLit) were examined for economic evaluations of accreditation. Second, a targeted search was carried out in SCOPUS and CINAHL for studies on the costs and benefits of health services accreditation. Third, we collected grey literature by searching health department websites, and contacting international accreditation agencies and key researchers in the field. We applied four assessment criteria to the benefit studies: 1) studies were divided into pre- and post- the United States Institute of Medicine 2000 seminal report, To Err is Human; 2) scalability, that is, whether studies covered more than 5% of available facilities; 3) level of independence, that is, whether or not outcomes were related to the accreditation process and independently assessed; and, 4) level of claim, whereby studies did or did not demonstrate that accreditation was related to improved patient safety and quality of care. No formal economic appraisal of health services accreditation has been carried out to date. The costs and benefits of accreditation were examined in six and fifteen studies, respectively. The costs studies were mainly from single hospital studies, and estimated the incremental costs of complying with accreditation as ranging between 0.2% and 1.7% of total costs per annum, averaged over the accreditation cycle. Opportunity and remedial costs were rarely mentioned and not estimated. The pre-2000 benefit studies (see Table 1) show a consistently low level of claim but the post-2000 studies reflect a more variable outcome with the majority of studies showing a link between accreditation and patient safety and quality of care. Table 1: Summary assessment of benefit studies Study assessment criteria H=High, M=Medium, L=Low Pre-2000 studies (N=6) Post-2000 studies (N=9) Total studies (N=15) Scalability Yes 3 5 8 No 3 4 7 Independence H 3 4 7 M 2 3 5 L 1 2 3 Level of claim H 0 1 1 M 0 5 5 L 6 3 9 The review shows a lack of economic appraisal of health services accreditation, despite substantial world-wide investments in this process. The lack of a clear relationship between accreditation and the outcomes measured in the benefit studies makes it difficult to design and conduct such appraisals without a more robust and explicit understanding of the costs and benefits involved. The more mixed picture in later studies could be due to an increase in the number of standards addressing the safety and quality of care and the availability of data on independent clinical outcome measures (mainly reflecting compliance with care pathways). This is a significant and thorny problem requiring urgent research attention. Further work is needed to identify indicators and measure improvements in patient safety and quality of care and in separating out the effects of accreditation from other safety and quality programmes.

2028 Health Service Accreditation Programs: are they becoming hybrids that satisfy no-one? D. Greenfield 1,*, R. Hinchcliff 1, M. Moldovan 1, J. Braithwaite 1 1 Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia To investigate the understandings and concerns of stakeholders regarding healthcare accreditation programs. Stakeholder representatives from accreditation programs operated by the Aged Care Standards and Accreditation Agency, Australian General Practice Accreditation Limited, and the Australian Council on Healthcare Standards participated in group and individual interviews. In addition to healthcare consumers, participants included: staff, managers and executives from accredited health services; professional advocacy groups; health department delegates; and accreditation agency representatives. There were 46 research activities, conducted between August 2011 and February 2012, involving 259 participants. Interviews lasted, on average, one hour, and were digitally recorded and transcribed. Transcriptions were analysed using textual referencing software. Analysis identified four significant issues of concern for stakeholders. First, participants viewed the underlying philosophy of an accreditation program as a critical influence on the participation, motivation and behaviours of health professionals. Three models were noted: regulatory compliance, continuous improvement, and a hybrid model incorporating the main elements of the other two. Respondents debated the compatibility or incommensurability of the first two models, and the extent to which clinicians, managers, policy officers and consumers react differently to their philosophies. The second and closely related issue to philosophy raised by stakeholders was the aim of a program. Participants discussions centred upon three aspects to this, that is, are programs striving to: improve organisational performance, clinical performance or both; enforce a minimum standard or promote innovation or both; and, address structure, process or outcomes. Third, the implementation and outcomes of the different models frustrated or affirmed respondents. Participation in a program was reportedly experienced as ranging on a continuum from malicious compliance to performance audits to quality improvement journeys. Experiences were reportedly shaped by: the requirement to participate (voluntary or enforced); extent of engagement in accreditation activities; program flexibility; and the conduct of surveys and related reliability issues. Wider contextual factors were noted as the fourth issue shaping understandings of respondents. In particular, political and community expectations, and associated media reporting, were considered significant influences on the evolution and operations of programs. Participants discussed the increasing external expectation that accreditation programs will ensure high quality and safe services in time pressured, high intensity, organisationally and interprofessionally bounded, resource limited environments. Respondents reflected upon how external forces were, at times, promoting changes that needed greater consideration. This is a unique study, eliciting the views of diverse healthcare accreditation stakeholders, from primary, acute and aged care sectors within one country. The acceptance and credibility of accreditation programs has been, in part, founded upon engagement with and consistent understandings across healthcare stakeholders. Accreditation programs were described as embodying multiple expectations of differing stakeholders that gives rise to tensions and conflicts. While accreditation programs will continue to be shaped by internal and external forces, the management of this evolution will determine the quality and safety of health services into the future.

2064 Improving hospital care service quality through implementation of Korea healthcare accreditation standards H. Woo 1,*, Y. Kim 1, M. Kim 1, E. Lee 1 1 Quality & Safety Center, Seoul National University Hospital, Seoul, Korea, Republic Of The purpose of this project is to improve patient s care services through implementation of Korea healthcare accreditation standards and to identify effect of it. Hospital evaluation system converted to the accreditation system in 2010, Korea. Our goal is to receive excellent result, improve and continue quality health care service. Therefore, we proceeded with this project from January, 2010 and details as follows. First of all, we redesigned several systems and revised 107 policies with organizing multidisciplinary teams. We trained all staffs working in our hospital, checked compliance frequently, and rewarded individual based on results. We updated EMR (electronic medical record) forms and all sorts of informed consents based on our healthcare policies, and kept control on filling out the forms. Second, we interviewed some of our staffs-subcontractors on accreditation-related experience. The aim is to identify the effects of preparing hospital accreditation in November, 2010. Third, since acquiring accreditation, we developed 102 quality indicators with accreditation standards and built monitoring systems. We defined indicators, specified person in charge for each item, frequency and target, then measured and analysed as scheduled with making best use of our existing electronic systems such as EMR system, MIS (medical information system), CDW (clinical data warehouse), examination system, cyber education system, etc. Finally, we informed the related people (doctors, nurses, managers, and administrators) of the monitoring results every month and performed activities for quality improvement such as revision of EMR program, revision of guidebooks, change in examination process, etc. Interviews with some staff members and subcontractors about their accreditation related experience in November, 2010, they reported that trying to meet accreditation requirements helped on obedience to principles, standardization of care process, improvement of communication, safety for patients and staff, etc. With monitoring results of major indicators which were based on Korea healthcare accreditation requirements, handwashing, use of verbal or telephone order were partially improved, but did not meet our goal in total. Other indicators (for example, cancellation rate of routine operation, replying time for consultation, arrest to cardiopulmonary resuscitation time, waste rate in blood product, the incidence of bedsore, etc) were in satisfactory rate, but there were no meaningful change after accreditation. Patient satisfaction continues to increase, but it wasn t linked to hospital accreditation. So we plan to strengthen monitoring system, our activity implementation for quality improvement, and to keep training staff members. Healthcare accreditation in short term has positive effects and helps to keep remaining levels as standards. It is possible to check up major indicators regularly with our monitoring system and to use activities for quality improvement. In the future, we are going to exceed standards for all indicators.

2207 Is healthcare accreditation dead? M. Amess 1, T. Fellows 1,* 1 CHKS, London, United Kingdom CHKS has been working with NHS acute trusts for almost 25 years. In that time, we have seen a significant reduction in the number of NHS trusts across the UK undertaking accreditation. We wanted to understand why this internationally tried and tested methodology should have fallen out favour. We designed a simple survey to get feedback from a range of stakeholders in NHS trusts, from governance and patient safety managers to directors of nursing and chief executives. The results revealed that: - organisation-wide accreditation is seen as unwieldy and difficult to manage in large, multi-site organisations. The establishment of a healthcare quality regulator in England in 1999, now called the Care Quality Commission (CQC), introduced a mandatory assessment and inspection process - the whole-organisation approach does not target specific areas where problems exist - the NHS Operating and Outcomes Frameworks have moved the focus from systems and processes to patient outcomes - the whole-organisation approach requires a significant amount of investment, especially in terms of staff time commitment We have used these results to redevelop our standards-based assessment for NHS trusts. We now identify problems in specific specialties or service streams using quantitative indicators, such as complication rates, length of stay and excess mortality rates, and benchmark against similar organisations. This identifies the areas that trusts need to investigate further. Standards are now developed as modules supporting service or specialty areas of care such as maternity or oncology, or risk and patient safety. These incorporate national guidance and best practice, to assess their own compliance and use them as a framework to make improvements. Peer reviewers provide an external assessment and performance indicators are again reviewed to assess improvement in patient outcomes. Accreditation is still a valuable and powerful tool for supporting healthcare improvement. Being innovative in the way that it is packaged and delivered is the key to its success.

2248 Staff Engagement- Doctors Day in Alice Ho Miu Ling Nethersole Hospital (AHNH) and Tai Po Hospital (TPH) S. S. Ho 1,*, C. Y. Chan 2, J. Sung 2, R. Yeung 2 1 Member of Patient Relation & Engagement Committee, NTEC, Hospital Authority, Hong Kong, 2 Doctors' Association, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China March 30 th has been proclaimed as National Doctors' Day since 1991 in the United States of America. The first Doctors Day observance was March 30, 1933, in Winder, Ga. In recognition of the contributions of hard-working doctors under serious shortage of manpower within the hospital authority, AHNH Doctors Association has designated the same day as the Doctors Day to mark its annual celebration. National Doctor's Day is commonly celebrated in healthcare organizations as a day to recognize the contributions of doctors to individual lives and communities. In collaboration with the administrative staff in AHNH, the Doctors Association of AHNH had launched a pilot program entitled Doctors Day as a token of appreciation for numerous efforts the doctors have made at AHNH and Tai Po Hospital. The theme of our program is We care, we serve and we appreciate, our doctors are being cared by our hospital management so that they can serve our public and being appreciated by all medical staff and our patients. The event was widely promoted to gain staff participation and to facilitate communications, care and concern among healthcare professionals. The event was concluded with a ceremony, conducting a series of activities including the presentation of awards to most popular doctors nominated by each clinical department and patients. To strengthen the team spirit among the frontline staff, the hospital choir team led all participants to sing the theme song, which was jointly composed by a doctor and a chaplain to commemorate this special event. The event was widely supported by the frontline staff, having a total of 120 doctors (~70% doctors in TPH/AHNH) attended the ceremony. The Cluster Chief Executive of NTEC was planning to embark on a cluster-wide celebration with the participation of all staff including Allied Health, Administration and Support in NTEC. Various staff engagement programs have been launched previously but the attendance rate was not satisfactory. The Doctor s day program is efficacious both in terms of staff engagement and boosting staff moral. The event has reinforced synergy among all participating staff in promoting a happy, harmonious and rewarding work environment.

2282 Planetree Designation - a quality model for increasing patient satisfaction in a general and private hospital C. Behr 1,*, R. Grotto 2, M. Dornaus 3, C. Barros 1 1 Quality, 2 Customer Services, 3 Neonatal ICU, Albert Einstein Hospital, São Paulo, Brazil Demonstrate that after implementation of the Planetree quality model was improvement in care processes and patient satisfaction indicators. The Planetree model of quality is recognized by the International Joint Commission as a tool for improving care processes with a focus on humanization and patient-centered care. The Planetree is a model that favors the recovery of patients on the physical, mental, emotional, social and spiritual. The model is based on a holistic approach, focusing on human dimensions, environmental, educational and social. It consists of 10 pillars: 1. Human Interactions 2. Patient Education, Family and Employees 3. Family Support 4. Nutritional Aspects 5. Architecture and Design 6. Art, Music and Entertainment 7. Spirituality 8. Complementary Therapies 9. Human Touch 10. Communities We receivedthe official designation of the Planetree in December 21, 2011 and this year many actions were undertaken with a focus on patient-centered care, such as campaign of silence, recreation for children in the waiting area of examinations, training group counters of histories for patients, magic in waiting areas for outpatients, formation of the advisory board of patients, actions of spirituality, better conditions in the workplace for employees, internal activities to improve the atmosphere between the staff, availability of family in 24 hours areas of Neo-ICU and ICU adult patients, individualized menus, activities of complementary therapies, cancer patients. We used the methodology of evaluation of customer satisfaction indicators HCAHPS. This study was conducted from November 2011 to January 2012, 6,000 questionnaires were sent via the Internet with a response rate of 7%, totaling 435 respondents (95% confidence). The approachof the satisfaction questionnaire was based on aspects related to the Medical Staff Services, Nursing and General Aspects.Regarding the question about "Respect and understanding of my condition during the treatment" for both medical and nursing teams to score was 94 points, four points higher than the 2010 Survey. As for "courtesy and attention with my doubts and anxieties" the result was 93 points, three points higher than the year of 2010. General questions as quiet environment received 84 points and hygiene and cleaning the bathrooms 94 points. We conclude thatthe Planetree model improves patient care especially in matters relating to care focused on their needs. The results obtained through HCAHPS indicators were satisfactory, which demonstrates that a program that helps care practice in maintaining quality standards adopted by the institution, with an increase in the humanization of patient care. Actions focused on improving the quality of the work environment imply a more satisfied employee who has a better performance in his hospital. References: www.planetree.org www.pickerinstitute.org www.hcahpsonline.org

2592 Exploring the relationships between the 'Visitatie' programme for multidisciplinary oncological care and the organisation and quality of cancer care in the Netherlands M. Kilsdonk 1, 2,*, S. Siesling 1, 2, R. Otter 1, W. van Harten 2, 3 1 Comprehensive Cancer Centre The Netherlands, Utrecht, 2 Department of Health Technology and Services Research, MB-HTSR, University of Twente, Enschede, 3 The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI- AVL), Amsterdam, Netherlands To evaluate the impact of the visitatie programme for multidisciplinary oncological care on the organisation, processes and clinical outcomes of care Visitatie is the dominant external quality assessment method in the Netherlands that shares common grounds with accreditation. Data from 27 hospitals from different regions in the Netherlands was analysed. The first visitatie was performed in the North of the Netherlands 1993 and the program gradually spread to the rest of the country. To include data prior to participating in the programme the study period was chosen from 1990 to 2010. Visitatie was performed in intervals of 3-5 years. Data concerning three rounds of the visitatie programme could be used of 13 hospitals, two rounds of 11 hospitals and a control group without visitatie was created consisting of 3 hospitals. The hospitals were grouped by their performance on implementing the recommendations that were given by the programme. We gathered data from the Netherlands Cancer Registry on tumour characteristics-, treatment data and survival from newly diagnosed patients with a number of tumour types such as, breast- and coloncarcinoma. Information on participation in other quality improvement programmes was collected. Results will be available for presentation at the conference. Relative survival rates, treatment figures and time periods from diagnosis till treatment will be compared between the groups of hospitals with adjustment for sex, age and tumour stadium. The question whether the visitatie programme has influenced the organisation and quality of cancer care will be addressed.

2648 CRESAC contributions to the implementation of WHO-AFRO Stepwise Laboratory Quality Improvement Process towards Accreditation (SLIPTA) scheme in Cote d Ivoire S. Essiagne Daniel 1,*, T. Gnomblessons GEORGES 1, L. E. Esmel Claude 1, S. Aly 1 1 CRESAC, ABIDJAN, Côte d'ivoire Improve capacities of PHLs using SPLITA scheme toward to accreditation Selection of the 25 PHLs Training of 12 national assessors (for the assessment and coaching of laboratories) Elaboration of a national guide for the use of the WHO-AFRO check-list Baseline assessment of the 25 laboratories 2 steps of training and one step of assessment Baseline assessment of the 25 laboratories 3 Stars: 1 laboratory, 1 Star: 4 laboratories, 0 Stars: 20 laboratories. Assessment after one year concerning evolution of theses items: Documents and Records: 54% Management Reviews: 38% Process Control and Internal & External Quality Assessment: 65% Facilities & Safety: 73% Our goal is to have the 25 labs at 5 stars in two years WHO-AFRO SLIPTA emerged as a result of critical country political commitments to strengthen the capacity of PHLs in the African Region to improve disease prevention and control. It is an ambitious and, important project relevant and useful in the area of improvement of patient health care and security. References: ISO 15189:2007 ISO/CEI 17025:2009 ISO 9001:2008 GBEA: 1999

1813 Paradigm Shift from Traditional Nursing to shared nursing governance to enhance nursing practice, quality and education E. Joseph 1, S. Chourochen 1, P. Rindani 1, E. Brown 2,* and Pat Folcarelli (PHMI) 1 WOCKHARDT HOSPITALS LTD., Mumbai, India, 2 Partners Harvard Medical International, Boston, United States To improve patient and nursing outcomes through a nursing leadership development program & Shared Nursing Governance Model to engage and align staff & leaders in nursing practice, quality & education goals, initiatives and resources across an 8 hospital system in India India has an acute nursing shortage with one of the lowest nurse per population rates in the world (0.8/1000). Contributing factors of note are poor image of nursing, insufficient nurses entering nursing & migration of nurses out of India to more developed countries. Subsequently, hospitals are struggling with shortages of skilled nurses. The Wockhardt Hospital System (WHL) response has been to systematically develop a multi-level infrastructure in collaboration with colleagues from the United States to improve nursing & patient outcomes. First, a robust competency-based nursing leadership development program (NLP) was designed & delivered by multidisciplinary faculty to build leadership competencies, such as managing performance, leading teams, communicating effectively & building collaborative relationship. Second, a transformative model in shared nursing governance was designed & implemented. This model is a bottom up & a top down approach, which empowers nurses with decision-making in relation to creation & implementation of policies, setting & monitoring standards of practice, creating educational programs to support quality & practice needs and monitoring unitbased quality. WHL is the first hospital system in India to adopt this type of governance model. The development of the Shared Nursing Governance Council Model (SNG) was driven by participants & leaders of the NLP with staff nurses input & depicts four prima verticals, briefly described below: Coordinating Council: Develops administrative policies for nursing services & coordinates councilor work Quality Council: Reviews quality data, such as National Patient safety goals & core process and outcome measures; makes recommendations to promote & maintain best practices in patient safety & quality Practice Council: Provides forum for shared decision making in nursing best practice initiatives across organization; reviews patient care policies & nursing practice guidelines; ensures conformance to standards Educational Council: Develops, reviews & implements training modules based on needs in alignment with other Councils The SNG model is implemented across all 8 WHL engaging all levels of nursing in quality, education & practice initiatives such as: 1. Nursing quality dashboards across all hospitals monitoring nursing sensitive indicators & patient safety goals 2. Standardizing guidelines for infusion pumps & medications compatible through peripheral lines 3. Patient education & staff training initiative for usage of anticoagulants 4. We Care initiative with implementation of pocket size reference book of commonly used phrases in multiple languages to improve communication 5. 24 hour audit for all Code Blue cases to evaluate need for Rapid Response Teams 6. Specific nursing feedback form 7. Interdisciplinary team to improve door to balloon time Preliminary outcomes: 1. Improvement in Nursing Patient Satisfaction Index from 4.06 to 4.20 (scale 1-5) 2. Reduction in nursing attrition from 3.6% to 2.8% 3. Increased engagement of staff & improved succession planning 4. Improvement in compliance to ventilator associated pneumonia bundle 5. Improvement in hand hygiene Implementing a Nursing Leadership Program & a Shared Nursing Governance Model are supporting structures to improve nursing & patient outcomes.