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Patient safety, human error

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https://www.readbyqxmd.com/read/28643113/-safety-culture-in-orthopedics-and-trauma-surgery-course-concept-interpersonal-competence-by-the-german-society-for-orthopaedics-and-trauma-dgou-and-lufthansa-aviation-training
#1
REVIEW
A-K Doepfer, R Seemann, D Merschin, R Stange, M Egerth, M Münzberg, M Mutschler, B Bouillon, R Hoffmann
Patient safety has become a central and measurable key factor in the routine daily medical practice. The human factor plays a decisive role in safety culture and has moved into focus regarding the reduction of treatment errors and undesired critical incidents. Nonetheless, the systematic training in communication and interpersonal competences has so far only played a minor role. The German Society of Orthopaedics and Trauma (DGOU) in cooperation with the Lufthansa Aviation Training initiated a course system for interpersonal competence...
June 22, 2017: Der Ophthalmologe: Zeitschrift der Deutschen Ophthalmologischen Gesellschaft
https://www.readbyqxmd.com/read/28594533/implementation-of-teamstepps-in-orthopaedic-surgery
#2
Harpal S Khanuja, Zan A Naseer, Lynne C Jones, James R Ficke, Dwight W Burney Iii
An Institute of Medicine report published in 2000 brought attention to the devastating consequences of medical errors. The report estimated that 98,000 deaths occurred in US hospitals each year as a result of medical errors and spawned investigations into factors that are associated with medical errors as well as strategies to avoid them. Taking cues from high-reliability organizations, such as the airline industry, evidence-based tools were developed to minimize human risk factors and foster teamwork, communication, and other skills that are essential to patient safety and quality...
February 15, 2017: Instructional Course Lectures
https://www.readbyqxmd.com/read/28570333/response-to-medical-errors
#3
Adam Webb
Despite improvements in patient safety science over the past 15 years since the Institute of Medicine's publication of To Err Is Human, medical errors remain a major contributor to adverse patient outcomes and mortality. In the aftermath of a harmful medical error, providers often face dilemmas regarding how to best report and disclose errors.
June 2017: Continuum: Lifelong Learning in Neurology
https://www.readbyqxmd.com/read/28549789/systematic-approaches-to-adverse-events-in-obstetrics-part-i-event-identification-and-classification
#4
Christian M Pettker
Despite our best intentions to improve health when a patient presents for care, adverse events are ubiquitous in medical practice today. Known complications related to the course of a patient's illness or condition or to the characteristics of the treatment have been an openly stated part of taking care of patients for centuries. However, it is only in the past decade that preventable adverse events, instances of harm related to error and deviations in accepted practice have become a primary part of these conversations...
April 2017: Seminars in Perinatology
https://www.readbyqxmd.com/read/28549772/codon-optimized-rpgr-improves-stability-and-efficacy-of-aav8-gene-therapy-in-two-mouse-models-of-x-linked-retinitis-pigmentosa
#5
M Dominik Fischer, Michelle E McClements, Cristina Martinez-Fernandez de la Camara, Julia-Sophia Bellingrath, Daniyar Dauletbekov, Simon C Ramsden, Doron G Hickey, Alun R Barnard, Robert E MacLaren
X-linked retinitis pigmentosa (XLRP) is generally a severe form of retinitis pigmentosa, a neurodegenerative, blinding disorder of the retina. 70% of XLRP cases are due to mutations in the retina-specific isoform of the gene encoding retinitis pigmentosa GTPase regulator (RPGR(ORF15)). Despite successful RPGR(ORF15) gene replacement with adeno-associated viral (AAV) vectors being established in a number of animal models of XLRP, progression to human trials has not yet been possible. The inherent sequence instability in the purine-rich region of RPGR(ORF15) (which contains highly repetitive nucleotide sequences) leads to unpredictable recombination errors during viral vector cloning...
May 24, 2017: Molecular Therapy: the Journal of the American Society of Gene Therapy
https://www.readbyqxmd.com/read/28540465/technology-induced-errors-associated-with-computerized-provider-order-entry-software-for-older-patients
#6
Manuel Vélez-Díaz-Pallarés, Ana María Álvarez Díaz, Teresa Gramage Caro, Noelia Vicente Oliveros, Eva Delgado-Silveira, María Muñoz García, Alfonso José Cruz-Jentoft, Teresa Bermejo-Vicedo
Background The introduction of new technologies in the prescribing process has seen the emergence of new types of medication errors. Objective To determine the prevalence and consequences of technology-induced prescription errors associated with a computerized provider order entry (CPOE) system in hospitalized older patients. Setting Patients 65 years or older admitted to the Departments of Internal Medicine, General Surgery, and Vascular Surgery of a tertiary hospital. Method Prospective observational 6-month study...
May 24, 2017: International Journal of Clinical Pharmacy
https://www.readbyqxmd.com/read/28530330/-the-sherlock-system-clinical-and-logistic-pharmaceutical-services
#7
Roni Leibowitz, Shahar Aflalo, Ornit Cohen, Ahuva Lustig
BACKGROUND: The drug inventory in the hospital consumes a large part of the hospital's budget. Classic drug management is based on weekly visits of the pharmacist in the departments, writing an order and dispensing it. This method is wasteful in terms of sending a bulk of drugs that will not necessarily be utilized, and it is also inefficient in terms of human resources. The unit-dose method, which is more advanced, is based on filling out individual prescriptions for each of the inpatients in the department...
August 2016: Harefuah
https://www.readbyqxmd.com/read/28520711/inhalational-chlorine-injuries-at-public-aquatic-venues-california-2008-2015
#8
Jason A Wilken, Michele DiMaggio, Matthew Kaufmann, Kevin O'Connor, Svetlana Smorodinsky, Christina Armatas, Tracy Barreau, Richard Kreutzer, Lino Ancheta
In June 2015, personnel from California's Contra Costa Health Services Environmental Health and Hazardous Materials (hazmat) divisions were alerted to a possible chemical release at a swimming pool in an outdoor municipal water park. Approximately 50 bathers were in the pool when symptoms began; 34 (68%) experienced vomiting, coughing, or eye irritation. Among these persons, 17 (50%) were treated at the scene by Contra Costa's Emergency Medical Services (EMS) and released, and 17 (50%) were transported to local emergency departments; five patients also were evaluated later at an emergency department or by a primary medical provider...
May 19, 2017: MMWR. Morbidity and Mortality Weekly Report
https://www.readbyqxmd.com/read/28470132/value-based-hr-practices-i-deals-and-clinical-error-control-with-csr-as-a-moderator
#9
Tuan Luu, Chris Rowley, Sununta Siengthai, Vo Thanh Thao
Purpose Notwithstanding the rising magnitude of system factors in patient safety improvement, "human factors" such as idiosyncratic deals (i-deals) which also contribute to the adjustment of system deficiencies should not be neglected. The purpose of this paper is to investigate the role of value-based HR practices in catalyzing i-deals, which then influence clinical error control. The research further examines the moderating role of corporate social responsibility (CSR) on the effect of value-based HR practices on i-deals...
May 8, 2017: International Journal of Health Care Quality Assurance
https://www.readbyqxmd.com/read/28437161/randomized-phase-iii-trial-of-trastuzumab-plus-capecitabine-with-or-without-pertuzumab-in-patients-with-human-epidermal-growth-factor-receptor-2-positive-metastatic-breast-cancer-who-experienced-disease-progression-during-or-after-trastuzumab-based-therapy
#10
Ander Urruticoechea, Mohammed Rizwanullah, Seock-Ah Im, Antonio Carlos Sánchez Ruiz, István Láng, Gianluca Tomasello, Hannah Douthwaite, Tanja Badovinac Crnjevic, Sarah Heeson, Jennifer Eng-Wong, Montserrat Muñoz
Purpose To assess the efficacy and safety of trastuzumab plus capecitabine with or without pertuzumab in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer who experienced disease progression during or after trastuzumab-based therapy and received a prior taxane. Patients and Methods Patients were randomly assigned to arm A: trastuzumab 8 mg/kg → 6 mg/kg once every 3 weeks plus capecitabine 1,250 mg/m(2) twice a day (2 weeks on, 1 week off, every 3 weeks); or arm B: pertuzumab 840 mg → 420 mg once every 3 weeks plus trastuzumab at the same dose and schedule as arm A plus capecitabine 1,000 mg/m(2) on the same schedule as arm A...
April 24, 2017: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28418101/effect-of-an-electronic-medication-administration-record-application-on-patient-safety
#11
Noelia Vicente Oliveros, Teresa Gramage Caro, Covadonga Pérez Menendez-Conde, Ana María Álvarez-Díaz, Sagrario Martín-Aragón Álvarez, Teresa Bermejo Vicedo, Eva Delgado Silveira
RATIONALE, AIMS, AND OBJECTIVES: To evaluate the effect of an electronic medication administration record (eMAR) application on the rate of medication errors in medication administration recording (ME-MAR). METHODS: A before-and-after, quasiexperimental study was conducted in a university hospital that implemented the eMAR application in March 2014. Data collection was conducted in April 2012 (pre-) and June 2014 (post-) by two pharmacists. The ME-MARs were analysed by the staff involved to identify their cause...
April 18, 2017: Journal of Evaluation in Clinical Practice
https://www.readbyqxmd.com/read/28417303/paediatric-in-patient-prescribing-errors-in-malaysia-a-cross-sectional-multicentre-study
#12
Teik Beng Khoo, Jing Wen Tan, Hoong Phak Ng, Chong Ming Choo, Intan Nor Chahaya Bt Abdul Shukor, Siao Hean Teh
Background There is a lack of large comprehensive studies in developing countries on paediatric in-patient prescribing errors in different settings. Objectives To determine the characteristics of in-patient prescribing errors among paediatric patients. Setting General paediatric wards, neonatal intensive care units and paediatric intensive care units in government hospitals in Malaysia. Methods This is a cross-sectional multicentre study involving 17 participating hospitals. Drug charts were reviewed in each ward to identify the prescribing errors...
April 17, 2017: International Journal of Clinical Pharmacy
https://www.readbyqxmd.com/read/28410711/failure-modes-and-effects-analysis-of-bilateral-same-day-cataract-surgery
#13
Neal H Shorstein, Carol Lucido, James Carolan, Liyan Liu, Geraldine Slean, Lisa J Herrinton
PURPOSE: To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING: Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN: Retrospective cohort study. METHODS: Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry...
March 2017: Journal of Cataract and Refractive Surgery
https://www.readbyqxmd.com/read/28394204/medication-adherence-staying-within-the-boundaries-of-safety
#14
Robin Sue Mickelson, Richard J Holden
An important domain of patient safety is the management of medications in home and community settings by patients and their caregiving network. This study applied human factors/ergonomics theories and methods to data about medication adherence collected from 61 patients with heart failure accompanied by 31 informal caregivers living in the US. Seventy non-adherence events were identified, described, and analysed for performance shaping factors. Half were classified as errors and half as violations. Performance shaping factors included elements of the person or team (e...
April 10, 2017: Ergonomics
https://www.readbyqxmd.com/read/28364581/self-reported-confidence-in-patient-safety-knowledge-among-australian-undergraduate-nursing-students-a-multi-site-cross-sectional-survey-study
#15
Kim Usher, Cindy Woods, Glenda Parmenter, Marie Hutchinson, Judy Mannix, Tamara Power, Wendy Chaboyer, Sharon Latimer, Jane Mills, Lesley Siegloff, Debra Jackson
BACKGROUND: Patient safety is critical to the provision of quality health care and thus is an essential component of nurse education. OBJECTIVE: To describe first, second and third year Australian undergraduate nursing students' confidence in patient safety knowledge acquired in the classroom and clinical settings across the three years of the undergraduate nursing program. DESIGN: A cross-sectional online survey conducted in 2015. SETTING: Seven Australian universities with campuses across three states (Queensland, New South Wales, South Australia)...
June 2017: International Journal of Nursing Studies
https://www.readbyqxmd.com/read/28338437/contralateral-peripheral-neurotization-for-a-hemiplegic-hindlimb-after-central-neurological-injury
#16
Mou-Xiong Zheng, Xu-Yun Hua, Su Jiang, Yan-Qun Qiu, Yun-Dong Shen, Wen-Dong Xu
OBJECTIVE Contralateral peripheral neurotization surgery has been successfully applied to rescue motor function of the hemiplegic upper extremity in patients with central neurological injury (CNI). It may contribute to strengthened neural pathways between the contralesional cortex and paretic limbs. However, the effect of this surgery in the lower extremities remains unknown. In the present study the authors explored the effectiveness and safety of contralateral peripheral neurotization in treating a hemiplegic lower extremity following CNI in adult rats...
March 24, 2017: Journal of Neurosurgery
https://www.readbyqxmd.com/read/28325209/-to-err-is-human-but-to-not-put-processes-in-place-to-avoid-errors-from-becoming-fatal-is-inhumane-5th-international-summit-of-the-patient-safety-movement-psm-california-usa-2017
#17
https://www.readbyqxmd.com/read/28257288/root-cause-analyses-of-reported-adverse-events-occurring-during-gastrointestinal-scope-and-tube-placement-procedures-in-the-veterans-health-association
#18
Christina Soncrant, Peter D Mills, Julia Neily, Douglas E Paull, Robin R Hemphill
OBJECTIVE: This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur. METHODS: This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database...
March 3, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28248749/medication-safety-in-two-intensive-care-units-of-a-community-teaching-hospital-after-electronic-health-record-implementation-sociotechnical-and-human-factors-engineering-considerations
#19
Pascale Carayon, Tosha B Wetterneck, Randi Cartmill, Mary Ann Blosky, Roger Brown, Peter Hoonakker, Robert Kim, Sandeep Kukreja, Mark Johnson, Bonnie L Paris, Kenneth E Wood, James M Walker
OBJECTIVE: The aim of the study was to assess the impact of Electronic Health Record (EHR) implementation on medication safety in two intensive care units (ICUs). METHODS: Using a prospective pre-post design, we assessed 1254 consecutive admissions to two ICUs before and after an EHR implementation. Each medication event was evaluated with regard to medication error (error type, medication-management stage) and impact on patient (severity of potential or actual harm)...
February 28, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28219432/personalized-heterogeneous-deformable-model-for-fast-volumetric-registration
#20
Weixin Si, Xiangyun Liao, Qiong Wang, Pheng Ann Heng
BACKGROUND: Biomechanical deformable volumetric registration can help improve safety of surgical interventions by ensuring the operations are extremely precise. However, this technique has been limited by the accuracy and the computational efficiency of patient-specific modeling. METHODS: This study presents a tissue-tissue coupling strategy based on penalty method to model the heterogeneous behavior of deformable body, and estimate the personalized tissue-tissue coupling parameters in a data-driven way...
February 20, 2017: Biomedical Engineering Online
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