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

Abstract

ObjectivesThis study aimed to describe how a Patient Safety Organization, to which healthcare organizations submit patient safety event data for both protections and analysis, used a learning system approach to analyze and interpret trends in member data. The data analysis informed evidence-based practice recommendations for improvement of patient outcomes for patients receiving prone-position ventilation.MethodsPatient safety analysts with critical care nursing backgrounds identified a need for increased support of Patient Safety Organization members who were proning patients during the COVID-19 pandemic. Patient safety events from member organizations across the United States were analyzed and aggregated. Primary and secondary taxonomies for safety events experienced by patients receiving prone-position ventilation were created, which provided insight into harm trends in this patient population.ResultsAnalysis of 392 patient safety events resulted in the identification of gaps in the care of these fragile patients, including but not limited to medical device–related pressure injuries, concerns with care delivery, staffing and acuity issues, and medical device dislodgement. Event themes in prone-position ventilation safety events informed a literature search from which an evidence-based action plan was developed and disseminated to Patient Safety Organization members for use in harm reduction efforts.ConclusionsUsing a learning system approach, patient safety event data related to prone-position ventilation or any other type of patient safety event can be aggregated and analyzed to identify key areas of safety concerns and gaps in practice, allowing organizations to affect improvement efforts.