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Patient safety, human error

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https://www.readbyqxmd.com/read/28806225/preventing-retained-central-venous-catheter-guidewires-a-randomized-controlled-simulation-study-using-a-human-factors-approach
#1
Maryanne Z A Mariyaselvam, Ken R Catchpole, David K Menon, Arun K Gupta, Peter J Young
BACKGROUND: Retained central venous catheter guidewires are never events. Currently, preventative techniques rely on clinicians remembering to remove the guidewire. However, solutions solely relying upon humans to prevent error inevitably fail. A novel locked procedure pack was designed to contain the equipment required for completing the procedure after the guidewire should have been removed: suture, suture holder, and antimicrobial dressings. The guidewire is used as a key to unlock the pack and to access the contents; thereby, the clinician must remove the guidewire from the patient to complete the procedure...
August 11, 2017: Anesthesiology
https://www.readbyqxmd.com/read/28770106/outcome-of-surgical-treatment-in-late-onset-capsular-block-syndrome
#2
Yang Huang, Zi Ye, Hang Li, Zhaohui Li
PURPOSE: To further investigate the pathogenesis of late-onset capsular block syndrome (CBS) and to evaluate the safety of surgical treatment. METHODS: Seven patients diagnosed with late-onset CBS were retrospectively analyzed. Anterior chamber depth (ACD), intraocular pressure (IOP), refractive diopter, and best-corrected visual acuity (BCVA) before and after surgery were recorded. The opaque substance was tested with Western blot, and a flow cytometer multiple array assay system was utilized to evaluate the levels of inflammatory cytokines from opaque substance and aqueous humor, respectively...
2017: Journal of Ophthalmology
https://www.readbyqxmd.com/read/28739242/helicopter-emergency-medical-service-simulation-training-in-the-extreme-simulation-based-training-in-a-mountain-weather-chamber
#3
Urs Pietsch, Ludwig Ney, Oliver Kreuzer, Armin Berner, Volker Lischke
Mountain rescue operations often confront crews with extreme weather conditions. Extremely cold temperatures make standard treatment sometimes difficult or even impossible. It is well-known that most manual tasks, including those involved in mountain rescue operations, are slowed by extremely cold weather. To lessen and improve the decrement in performance of emergency medical treatment caused by cold-induced manual impairment and inadequate medical equipment and supplies, simulation training in a weather chamber, which can produce wind and temperatures up to -22°C, was developed...
July 2017: Air Medical Journal
https://www.readbyqxmd.com/read/28735373/systematic-heuristic-evaluation-of-computerized-consultation-order-templates-clinicians-and-human-factors-engineers-perspectives
#4
April Savoy, Himalaya Patel, Mindy E Flanagan, Michael Weiner, Alissa L Russ
We assessed the usability of consultation order templates and identified problems to prioritize in design efforts for improving referral communication. With a sample of 26 consultation order templates, three evaluators performed a usability heuristic evaluation. The evaluation used 14 domain-independent heuristics and the following three supplemental references: 1 new domain-specific heuristic, 6 usability goals, and coded clinicians' statements regarding ease of use for 10 sampled templates. Evaluators found 201 violations, a mean of 7...
August 2017: Journal of Medical Systems
https://www.readbyqxmd.com/read/28700023/patient-safety-in-the-understanding-of-health-care-students
#5
Graziela Maria Rosa Cauduro, Tânia Solange Bosi de Souza Magnago, Rafaela Andolhe, Taís Carpes Lanes, Juliana Dal Ongaro
Objective: To verify the understanding of graduate health care students on patient safety. Method: Descriptive cross study, held in 2015 with 638 students at the Health Sciences Center of the Federal University of Santa Maria, State of Rio Grande do Sul, Brazil. The study used a questionnaire with variables related to the characterization of students, the conceptual and attitudinal aspects of human error and patient safety, made available online in the Student Portal...
July 6, 2017: Revista Gaúcha de Enfermagem
https://www.readbyqxmd.com/read/28691756/surgical-specimen-handover-from-the-operating-theatre-to-laboratory-can-we-improve-patient-safety-by-learning-from-aviation-and-other-high-risk-organisations
#6
Peter A Brennan, Marieke T Brands, Lucy Caldwell, Felipe Paiva Fonseca, Nic Turley, Susie Foley, Siavash Rahimi
Essential communication between healthcare staff is considered one of the key requirements for both safety and quality care when patients are handed over from one clinical area to other. This is particularly important in environments such as the operating theatre and intensive care where mistakes can be devastating. Healthcare has learned from other high-risk organisations (HRO) such aviation where the use of checklists and human factors awareness has virtually eliminated human error and mistakes. To our knowledge, little has been published around ways to improve pathology specimen handover following surgery, with pathology request forms often conveying the bare minimum of information to assist the laboratory staff...
July 10, 2017: Journal of Oral Pathology & Medicine
https://www.readbyqxmd.com/read/28679898/pharmacovigilance-mobile-tool-design-in-the-field-of-arhroplasty
#7
Hanne Åserød, Ankica Babic
Pharmacovigilance is an important part of the patient safety and it has a great appeal to physicians. It is concerned with the safety of medical devices and treatments in the light of understanding the risks and dangers based on the already reported safety issues. Internet resources such as the Manufacturer And User Facility Device Experience (MAUDE) web-site are often retrieved due to the lack of internal, local safety databases. The research looked at how Human Computer Interaction could improve user experience...
2017: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/28678068/anesthesia-adverse-events-voluntarily-reported-in-the-veterans-health-administration-and-lessons-learned
#8
Julia Neily, Elda S Silla, Sam John T Sum-Ping, Roberta Reedy, Douglas E Paull, Lisa Mazzia, Peter D Mills, Robin R Hemphill
BACKGROUND: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions...
July 1, 2017: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/28675553/a-combined-intervention-to-reduce-interruptions-during-medication-preparation-and-double-checking-a-pilot-study-evaluating-the-impact-of-staff-training-and-safety-vests
#9
Saskia Huckels-Baumgart, Milena Niederberger, Tanja Manser, Christoph R Meier, Carla Meyer-Massetti
AIM: The aim was to evaluate the impact of staff training and wearing safety vests as a combined intervention on interruptions during medication preparation and double-checking. BACKGROUND: Interruptions and errors during the medication process are common and an important issue for patient safety in the hospital setting. METHODS: We performed a pre- and post-intervention pilot-study using direct structured observation of 26 nurses preparing and double-checking 431 medication doses (225 pre-intervention and 206 post-intervention) for 36 patients (21 pre-intervention and 15 post-intervention)...
July 3, 2017: Journal of Nursing Management
https://www.readbyqxmd.com/read/28668911/recognizing-the-ordinary-as-extraordinary-insight-into-the-way-we-work-to-improve-patient-safety-outcomes
#10
Elizabeth A Henneman
The Institute of Medicine (now National Academy of Medicine) reports "To Err is Human" and "Crossing the Chasm" made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the "near miss" process and as the final safety net for the patient is of paramount importance...
July 2017: American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses
https://www.readbyqxmd.com/read/28665833/why-an-open-disclosure-procedure-is-and-is-not-followed-after-an-avoidable-adverse-event
#11
Irene Carrillo, José Joaquín Mira, Mercedes Guilabert, Susana Lorenzo
OBJECTIVE: The aim of the study was to analyze the relationships between factors that contribute to healthcare professionals informing and apologizing to a patient after an avoidable adverse event (AAE). METHODS: A secondary study based on the analysis of data collected in a cross-sectional study conducted in 2014 in Spain was performed. Health professionals from hospitals and primary care completed an online survey. RESULTS: The responses from 1087 front-line healthcare professionals were analyzed...
June 29, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28662196/a-feasible-low-cost-reproducible-lamb-s-head-model-for-endoscopic-sinus-surgery-training
#12
Henrique Fernandes de Oliveira, Valdes Roberto Bollela, Wilma Terezinha Anselmo-Lima, Carlos Augusto Pires de Oliveira Costa, Márcio Nakanishi
OBJECTIVE: To describe and standardize a reproducible, viable, low-cost lamb's head model for endoscopic sinus surgery training. METHODS: Otorhinolaryngology residents performed the following three endoscopic sinus surgeries using the lamb's head model: inferior turbinectomy, bullectomy, and maxillary antrostomy. Each student dissected 10 specimens before training these procedures on human patients, and the benefit of the animal model training was evaluated. RESULTS: Nineteen resident physicians of comparable academic level participated in training...
2017: PloS One
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
#13
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
#14
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
#15
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
#16
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
#17
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...
August 2, 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
#18
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...
August 2017: International Journal of Clinical Pharmacy
https://www.readbyqxmd.com/read/28530330/-the-sherlock-system-clinical-and-logistic-pharmaceutical-services
#19
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
#20
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
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