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https://www.readbyqxmd.com/read/29419944/incident-learning-in-radiation-oncology-a-review
#1
REVIEW
Eric C Ford, Suzanne Evans
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well-established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over forty publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including: history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root-cause analysis, and national and international ILS for shared learning...
February 8, 2018: Medical Physics
https://www.readbyqxmd.com/read/29383083/preparing-emergency-medicine-residents-to-disclose-medical-error-using-standardized-patients
#2
Carmen N Spalding, Sherri L Rudinsky
Introduction: Emergency Medicine (EM) is a unique clinical learning environment. The American College of Graduate Medical Education Clinical Learning Environment Review Pathways to Excellence calls for "hands-on training" of disclosure of medical error (DME) during residency. Training and practicing key elements of DME using standardized patients (SP) may enhance preparedness among EM residents in performing this crucial skill in a clinical setting. Methods: This training was developed to improve resident preparedness in DME in the clinical setting...
January 2018: Western Journal of Emergency Medicine
https://www.readbyqxmd.com/read/29356714/disclosure-of-harmful-medical-error-to-patients-a-review-with-recommendations-for-pathologists
#3
Yael K Heher, Suzanne M Dintzis
Harmful error is an infrequent but serious challenge in the pathology laboratory. Regulatory bodies and advocacy groups have mandated and encouraged disclosure of error to patients. Many pathologists are interested in participating in disclosure of harmful error but are ill-equipped to do so. This review of the literature with recommendations examines the current state of the patient safety movement and error disclosure as it pertains to pathology and provides a practical and explicit guide for pathologists for who, when, and how to disclose harmful pathology error to patients...
January 19, 2018: Advances in Anatomic Pathology
https://www.readbyqxmd.com/read/29346222/-to-err-is-human-but-disclosure-must-be-taught-a-simulation-based-assessment-study
#4
Ashley C Crimmins, Ambrose H Wong, James W Bonz, Alina Tsyrulnik, Karen Jubanyik, James D Dziura, Kelly L Dodge, Leigh V Evans
INTRODUCTION: Although error disclosure is critical in promoting safety and patient-centered care, physicians are inconsistently trained in its practice, and few objective methods to assess competence exist. We used an immersive simulation scenario to determine whether providers with varying levels of clinical experience adhere to the disclosure safe practice guidelines when exposed to a serious adverse event simulation scenario. METHODS: This was a prospective cohort study with medical students, junior emergency medicine (EM) residents (PGY 1-2), senior EM residents (PGY 3-4), and attending EM physicians participating in a simulated case in which a scripted medication overdose resulted in an adverse event...
January 17, 2018: Simulation in Healthcare: Journal of the Society for Simulation in Healthcare
https://www.readbyqxmd.com/read/29240330/regulating-black-box-medicine
#5
W Nicholson Price
Data drive modern medicine. And our tools to analyze those data are growing ever more powerful. As health data are collected in greater and greater amounts, sophisticated algorithms based on those data can drive medical innovation, improve the process of care, and increase efficiency. Those algorithms, however, vary widely in quality. Some are accurate and powerful, while others may be riddled with errors or based on faulty science. When an opaque algorithm recommends an insulin dose to a diabetic patient, how do we know that dose is correct? Patients, providers, and insurers face substantial difficulties in identifying high-quality algorithms; they lack both expertise and proprietary information...
2017: Michigan Law Review
https://www.readbyqxmd.com/read/29227430/continuing-education-meets-the-learning-organization-the-challenge-of-a-systems-approach-to-patient-safety
#6
John M Eisenberg
Since the release of the report of the Institute of Medicine on medical errors and patient safety in November 1999, health policy makers and health care leaders in several nations have sought solutions that will improve the safety of health care. This attention to patient safety has highlighted the importance of a learning approach and a systems approach to quality measurement and improvement. Balanced with the need for public disclosure of performance, confidential reporting with feedback is one of the prime ways that nations such as the United States, Canada, the United Kingdom, and Australia have approached this challenge...
October 2017: Journal of Continuing Education in the Health Professions
https://www.readbyqxmd.com/read/29189647/the-use-of-simulation-in-physician-assistant-programs-a-national-survey
#7
Donald Coerver, Nina Multak, Ashley Marquardt, Eric H Larson
PURPOSE: The purpose of this study was to develop a national-level description of the current use of simulation activities in physician assistant (PA) education and to assess the degree to which the use of simulation varies by PA program size and institutional type. METHODS: An electronic survey on medical simulation was sent to 177 PA program directors or to a designated simulation activities coordinator, using the directory on the Physician Assistant Education Association website...
December 2017: Journal of Physician Assistant Education
https://www.readbyqxmd.com/read/29142538/patient-safety-awareness-among-postgraduate-students-and-nurses-in-a-tertiary-health-care-facility
#8
Attia Bari, Uzma Jabeen, Iqbal Bano, Ahsan Waheed Rathore
Objective: To determine the knowledge of patient safety among postgraduate residents (PGR) and nurses in a tertiary care hospital. Methods: This casual comparative study was conducted among the postgraduate residents and nurses working at The Children's Hospital Lahore in the month of July, August 2017. Both PGR and nurses were asked to complete APSQ-IV questionnaire about patient safety on 7 point Likert scale. Data was analyzed using SPSS version 20 and t-test was used to compare the mean score between two groups...
September 2017: Pakistan Journal of Medical Sciences Quarterly
https://www.readbyqxmd.com/read/29075381/a-checklist-to-help-faculty-assess-acgme-milestones-in-a-video-recorded-osce
#9
L Jane Easdown, Marsha L Wakefield, Matthew S Shotwell, Michael R Sandison
BACKGROUND : Faculty members need to assess resident performance using the Accreditation Council for Graduate Medical Education Milestones. OBJECTIVE : In this randomized study we used an objective structured clinical examination (OSCE) around the disclosure of an adverse event to determine whether use of a checklist improved the quality of milestone assessments by faculty. METHODS : In 2013, a total of 20 anesthesiology faculty members from 3 institutions were randomized to 2 groups to assess 5 videos of trainees demonstrating advancing levels of competency on the OSCE...
October 2017: Journal of Graduate Medical Education
https://www.readbyqxmd.com/read/29052704/patients-experiences-with-communication-and-resolution-programs-after-medical-injury
#10
MULTICENTER STUDY
Jennifer Moore, Marie Bismark, Michelle M Mello
Importance: Dissatisfaction with medical malpractice litigation has stimulated interest by health care organizations in developing alternatives to meet patients' needs after medical injury. In communication-and-resolution programs (CRPs), hospitals and liability insurers communicate with patients about adverse events, use investigation findings to improve patient safety, and offer compensation when substandard care caused harm. Despite increasing interest in this approach, little is known about patients' and family members' experiences with CRPs...
November 1, 2017: JAMA Internal Medicine
https://www.readbyqxmd.com/read/28904910/complications-acknowledging-managing-and-coping-with-human-error
#11
REVIEW
Sevann Helo, Carol-Anne E Moulton
Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication...
August 2017: Translational Andrology and Urology
https://www.readbyqxmd.com/read/28863125/ethical-considerations-on-disclosure-when-medical-error-is-discovered-during-medicolegal-death-investigation
#12
Dwayne A Wolf, Stacy A Drake, Francine K Snow
In the course of fulfilling their statutory role, physicians performing medicolegal investigations may recognize clinical colleagues' medical errors. If the error is found to have led directly to the patient's death (missed diagnosis or incorrect diagnosis, for example), then the forensic pathologist has a professional responsibility to include the information in the autopsy report and make sure that the family is appropriately informed. When the error is significant but did not lead directly to the patient's demise, ethical questions may arise regarding the obligations of the medical examiner to disclose the error to the clinicians or to the family...
December 2017: American Journal of Forensic Medicine and Pathology
https://www.readbyqxmd.com/read/28829995/factors-affecting-nursing-students-intention-to-report-medication-errors-an-application-of-the-theory-of-planned-behavior
#13
Merav Ben Natan, Ira Sharon, Marlen Mahajna, Sara Mahajna
BACKGROUND: Medication errors are common among nursing students. Nonetheless, these errors are often underreported. OBJECTIVES: To examine factors related to nursing students' intention to report medication errors, using the Theory of Planned Behavior, and to examine whether the theory is useful in predicting students' intention to report errors. DESIGN: This study has a descriptive cross-sectional design. SETTINGS: Study population was recruited in a university and a large nursing school in central and northern Israel...
August 15, 2017: Nurse Education Today
https://www.readbyqxmd.com/read/28816851/clinical-practice-guideline-safe-medication-use-in-the-icu
#14
Sandra L Kane-Gill, Joseph F Dasta, Mitchell S Buckley, Sandeep Devabhakthuni, Michael Liu, Henry Cohen, Elisabeth L George, Anne S Pohlman, Swati Agarwal, Elizabeth A Henneman, Sharon M Bejian, Sean M Berenholtz, Jodie L Pepin, Mathew C Scanlon, Brian S Smith
OBJECTIVE: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system...
September 2017: Critical Care Medicine
https://www.readbyqxmd.com/read/28759586/apology-in-cases-of-medical-error-disclosure-thoughts-based-on-a-preliminary-study
#15
Sonia Dahan, Dominique Ducard, Laurence Caeymaex
BACKGROUND: Disclosing medical errors is considered necessary by patients, ethicists, and health care professionals. Literature insists on the framing of this disclosure and describes the apology as appropriate and necessary. However, this policy seems difficult to put into practice. Few works have explored the function and meaning of the apology. OBJECTIVE: The aim of this study was to explore the role ascribed to apology in communication between healthcare professionals and patients when disclosing a medical error, and to discuss these findings using a linguistic and philosophical perspective...
2017: PloS One
https://www.readbyqxmd.com/read/28756146/two-year-experience-implementing-a-curriculum-to-improve-residents-patient-centered-communication-skills
#16
Amber W Trickey, Anna B Newcomb, Melissa Porrey, Franco Piscitani, Jeffrey Wright, Paula Graling, Jonathan Dort
OBJECTIVES: Surgery milestones from The Accreditation Council for Graduate Medical Education have encouraged a focus on training and assessment of residents' nontechnical skills, including communication. We describe our 2-year experience implementing a simulation-based curriculum, results of annual communication performance assessments, and resident evaluations. DESIGN: Eight quarterly modules were conducted on various communication topics. Former patient volunteers served as simulation participants (SP) who completed annual assessments using the Communication Assessment Tool (CAT)...
November 2017: Journal of Surgical Education
https://www.readbyqxmd.com/read/28742712/specialist-physicians-attitudes-and-practice-patterns-regarding-disclosure-of-pre-referral-medical-errors
#17
Lesly A Dossett, Rondi M Kauffmann, Jay S Lee, Harkamal Singh, M Catherine Lee, Arden M Morris, Reshma Jagsi, Gwendolyn P Quinn, Justin B Dimick
OBJECTIVE: Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors. SUMMARY BACKGROUND DATA: Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. METHODS: We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers...
July 24, 2017: Annals of Surgery
https://www.readbyqxmd.com/read/28671908/development-of-the-barriers-to-error-disclosure-assessment-tool
#18
Darlene Welsh, Dominique Zephyr, Andrea L Pfeifle, Douglas E Carr, Joseph L Fink, Mandy Jones
OBJECTIVES: An interprofessional group of health colleges' faculty created and piloted the Barriers to Error Disclosure Assessment tool as an instrument to measure barriers to medical error disclosure among health care providers. METHODS: A review of the literature guided the creation of items describing influences on the decision to disclose a medical error. Local and national experts in error disclosure used a modified Delphi process to gain consensus on the items included in the pilot...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671905/the-impact-of-incident-disclosure-behaviors-on-medical-malpractice-claims
#19
Priscila Giraldo, Luke Sato, Xavier Castells
OBJECTIVES: To provide preliminary estimates of incident disclosure behaviors on medical malpractice claims. METHODS: We conducted a descriptive analysis of data on medical malpractice claims obtained from the Controlled Risk Insurance Company and Risk Management Foundation of Harvard Medical Institutions (Cambridge, Massachusetts) between 2012 and 2013 (n = 434). The characteristics of disclosure and apology after medical errors were analyzed. RESULTS: Of 434 medical malpractice claims, 4...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28645408/disclosure-of-medical-errors
#20
EDITORIAL
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No abstract text is available yet for this article.
July 2017: Annals of Emergency Medicine
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