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Patient safety, human error

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https://www.readbyqxmd.com/read/28219432/personalized-heterogeneous-deformable-model-for-fast-volumetric-registration
#1
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
https://www.readbyqxmd.com/read/28196568/human-milk-management-redesign-improving-quality-and-safety-and-reducing-neonatal-intensive-care-unit-nurse-stress
#2
Margaret Doyle Settle, Amanda Bulette Coakley, Christine Donahue Annese
Human milk provides superior nutritional value for infants in the neonatal intensive care unit and is the enteral feeding of choice. Our hospital used the system engineering initiative for patient safety model to evaluate the human milk management system in our neonatal intensive care unit. Nurses described the previous process in a negative way, fraught with opportunities for error, increased stress for nurses, and the need to be away from the bedside and their patients. The redesigned process improved the quality and safety of human milk management and created time for the nurses to spend with their patients...
February 1, 2017: Creative Nursing
https://www.readbyqxmd.com/read/28193619/improving-specialist-drug-prescribing-in-primary-care-using-task-and-error-analysis-an-observational-study
#3
Narinder Chana, Talya Porat, Cate Whittlesea, Brendan Delaney
BACKGROUND: Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs. AIM: To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS. DESIGN AND SETTING: Semi-structured interviews with key informants followed by an observational study involving GPs in the UK...
February 13, 2017: British Journal of General Practice: the Journal of the Royal College of General Practitioners
https://www.readbyqxmd.com/read/28192533/improving-medication-safety-development-and-impact-of-a-multivariate-model-based-strategy-to-target-high-risk-patients
#4
Tri-Long Nguyen, Géraldine Leguelinel-Blache, Jean-Marie Kinowski, Clarisse Roux-Marson, Marion Rougier, Jessica Spence, Yannick Le Manach, Paul Landais
BACKGROUND: Preventive strategies to reduce clinically significant medication errors (MEs), such as medication review, are often limited by human resources. Identifying high-risk patients to allow for appropriate resource allocation is of the utmost importance. To this end, we developed a predictive model to identify high-risk patients and assessed its impact on clinical decision-making. METHODS: From March 1st to April 31st 2014, we conducted a prospective cohort study on adult inpatients of a 1,644-bed University Hospital Centre...
2017: PloS One
https://www.readbyqxmd.com/read/28186187/factors-associated-with-aberrant-imprint-methylation-and-oligozoospermia
#5
Norio Kobayashi, Naoko Miyauchi, Nozomi Tatsuta, Akane Kitamura, Hiroaki Okae, Hitoshi Hiura, Akiko Sato, Takafumi Utsunomiya, Nobuo Yaegashi, Kunihiko Nakai, Takahiro Arima
Disturbingly, the number of patients with oligozoospermia (low sperm count) has been gradually increasing in industrialized countries. Epigenetic alterations are believed to be involved in this condition. Recent studies have clarified that intrinsic and extrinsic factors can induce epigenetic transgenerational phenotypes through apparent reprogramming of the male germ line. Here we examined DNA methylation levels of 22 human imprinted loci in a total of 221 purified sperm samples from infertile couples and found methylation alterations in 24...
February 10, 2017: Scientific Reports
https://www.readbyqxmd.com/read/28185075/paediatric-patient-safety-and-the-need-for-aviation-black-box-thinking-to-learn-from-and-prevent-medication-errors
#6
Chi Huynh, Ian C K Wong, Jo Correa-West, David Terry, Suzanne McCarthy
Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors...
February 10, 2017: Paediatric Drugs
https://www.readbyqxmd.com/read/28179154/managing-the-patient-identification-crisis-in-healthcare-and-laboratory-medicine
#7
REVIEW
Giuseppe Lippi, Camilla Mattiuzzi, Chiara Bovo, Emmanuel J Favaloro
Identification errors have emerged as a critical issue in health care, as testified by the ample scientific literature on this argument. Despite available evidence suggesting that the frequency of misidentification in vitro laboratory diagnostic testing may be relatively low compared to that of other laboratory errors (i.e., usually comprised between 0.01 and 0.1% of all specimens received), the potential adverse consequences remain particularly worrying, wherein 10-20% of these errors not only would translate into serious harm for the patient, but may also erode considerable human and economic resources, so that the entire healthcare system should be re-engineered to act proactively and limiting the burden of this important problem...
February 5, 2017: Clinical Biochemistry
https://www.readbyqxmd.com/read/28099286/multicenter-study-validating-accuracy-of-a-continuous-respiratory-rate-measurement-derived-from-pulse-oximetry-a-comparison-with-capnography
#8
Sergio D Bergese, Michael L Mestek, Scott D Kelley, Robert McIntyre, Alberto A Uribe, Rakesh Sethi, James N Watson, Paul S Addison
BACKGROUND: Intermittent measurement of respiratory rate via observation is routine in many patient care settings. This approach has several inherent limitations that diminish the clinical utility of these measurements because it is intermittent, susceptible to human error, and requires clinical resources. As an alternative, a software application that derives continuous respiratory rate measurement from a standard pulse oximeter has been developed. We sought to determine the performance characteristics of this new technology by comparison with clinician-reviewed capnography waveforms in both healthy subjects and hospitalized patients in a low-acuity care setting...
January 17, 2017: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/28092200/the-challenges-surrounding-preclinical-testing-in-transcatheter-device-development-and-the-implications-on-the-clinic
#9
Ralf Holzer, Jake Goble, Ziyad Hijazi
Transcatheter devices have contributed significantly to the advances achieved in treating many cardiovascular conditions over the last few decades. Sophisticated and detailed preclinical testing is not only a regulatory requirement to support an investigational device exemption (IDE) application, but more crucially its success and accuracy is needed to safeguard patients during the subsequent clinical testing stages. Areas covered: This article covers the regulatory background as well as specific considerations related to pre-clinical testing of transcatheter devices...
January 31, 2017: Expert Review of Medical Devices
https://www.readbyqxmd.com/read/28079584/the-development-and-implementation-of-cognitive-aids-for-critical-events-in-pediatric-anesthesia-the-society-for-pediatric-anesthesia-critical-events-checklists
#10
Anna Clebone, Barbara K Burian, Scott C Watkins, Jorge A Gálvez, Justin L Lockman, Eugenie S Heitmiller
Cognitive aids such as checklists are commonly used in modern operating rooms for routine processes, and the use of such aids may be even more important during critical events. The Quality and Safety Committee of the Society for Pediatric Anesthesia (SPA) has developed a set of critical-event checklists and cognitive aids designed for 3 purposes: (1) as a repository of the latest evidence-based and expert opinion-based information to guide response and management of critical events, (2) as a source of just-in-time information during critical events, and (3) as a method to facilitate a shared understanding of required actions among team members during a critical event...
March 2017: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/28076342/knowledge-beliefs-and-attitudes-report-on-patient-care-and-safety-in-undergraduate-students-validating-the-modified-apsq-iii-questionnaire
#11
Ezequiel García Elorrio, Dolores Macchiavello, Viviana Rodriguez, Yael Catalano, Giuliana Corna, Josefina Dahinten, Marina Ontivero
INTRODUCTION: Patient safety aims to achieve healthcare free of damage. The World Health Organization indicates that this objective is achieved through communication, analysis, and prevention of adverse events in patients. Organizational culture has been identified as one of the main factors for interventions aimed to reduce medical errors; and an essential component of safety culture is the attitude of health professionals towards medical error. Attitudes can be improved through appropriate education in biomedical careers but its inclusion in Argentina is scarce...
December 20, 2016: Medwave
https://www.readbyqxmd.com/read/28070607/-human-factors-in-medicine
#12
M Lazarovici, H Trentzsch, S Prückner
The concept of human factors is commonly used in the context of patient safety and medical errors, all too often ambiguously. In actual fact, the term comprises a wide range of meanings from human-machine interfaces through human performance and limitations up to the point of working process design; however, human factors prevail as a substantial cause of error in complex systems. This article presents the full range of the term human factors from the (emergency) medical perspective. Based on the so-called Swiss cheese model by Reason, we explain the different types of error, what promotes their emergence and on which level of the model error prevention can be initiated...
January 2017: Der Anaesthesist
https://www.readbyqxmd.com/read/28067682/utilizing-a-human-factors-nursing-worksystem-improvement-framework-to-increase-nurses-time-at-the-bedside-and-enhance-safety
#13
C Adam Probst, Megan Carter, Caton Cadigan, Cortney Dalcour, Cindy Cassity, Penny Quinn, Tiana Williams, Donna Cook Montgomery, Claudia Wilder, Yan Xiao
OBJECTIVE: The aim of this study is to increase nurses' time for direct patient care and improve safety via a novel human factors framework for nursing worksystem improvement. BACKGROUND: Time available for direct patient care influences outcomes, yet worksystem barriers prevent nurses adequate time at the bedside. METHODS: A novel human factors framework was developed for worksystem improvement in 3 units at 2 facilities. Objectives included improving nurse efficiency as measured by time-and-motion studies, reducing missing medications and subsequent trips to medication rooms and improving medication safety...
February 2017: Journal of Nursing Administration
https://www.readbyqxmd.com/read/28060982/-ethical-dilemmas-about-disclosure-of-errors-in-medicine
#14
Sebastián Lavanderos, Juan Pedraza, Moisés Russo N, Sofía P Salas
Since the publication of the Institute of Medicine’s report “To Err is Human: Building a Safer Health System” awareness of the importance of medical errors has increased. These are a major cause of morbidity and mortality and recent studies suggest that they can be the third leading cause of death in the United States. Difficulties have been identified by health personnel to prevent, detect and disclose to patients the occurrence of a medical error, an also to report them to the appropriate authorities. Although human error cannot be eliminated, it is possible to design safety systems to mitigate their frequency and consequences...
September 2016: Revista Médica de Chile
https://www.readbyqxmd.com/read/28058456/-human-factors-in-medicine
#15
M Lazarovici, H Trentzsch, S Prückner
The concept of human factors is commonly used in the context of patient safety and medical errors, all too often ambiguously. In actual fact, the term comprises a wide range of meanings from human-machine interfaces through human performance and limitations up to the point of working process design; however, human factors prevail as a substantial cause of error in complex systems. This article presents the full range of the term human factors from the (emergency) medical perspective. Based on the so-called Swiss cheese model by Reason, we explain the different types of error, what promotes their emergence and on which level of the model error prevention can be initiated...
January 2017: Der Urologe. Ausg. A
https://www.readbyqxmd.com/read/28047931/su-f-t-249-application-of-human-factors-methods-usability-testing-in-the-radiation-oncology-environment
#16
H Warkentin, K Bubric, H Giovannetti, G Graham, C Clay
PURPOSE: As a quality improvement measure, we undertook this work to incorporate usability testing into the implementation procedures for new electronic documents and forms used by four affiliated radiation therapy centers. METHODS: A human factors specialist provided training in usability testing for a team of medical physicists, radiation therapists, and radiation oncologists from four radiotherapy centers. A usability testing plan was then developed that included controlled scenarios and standardized forms for qualitative and quantitative feedback from participants, including patients...
June 2016: Medical Physics
https://www.readbyqxmd.com/read/28039240/medication-safety-in-the-operating-room-literature-and-expert-based-recommendations
#17
J A Wahr, J H Abernathy, E H Lazarra, J R Keebler, M H Wall, I Lynch, R Wolfe, R L Cooper
Human error poses significant risk for hospitalized patients causing an estimated 100,000 to 400,000 deaths in the USA annually. Medication errors contribute, with error occurring in 5.3% of medication administrations during surgery. In this study 70.3% of medication errors were deemed preventable. Given the paucity of randomized controlled studies, we undertook a rigorous review of the literature to identify recommendations supported by expert opinions. An extensive literature search pertaining to medication error, medication safety, operating room, and anaesthesia was performed...
January 2017: British Journal of Anaesthesia
https://www.readbyqxmd.com/read/28026210/interpretive-error-in-radiology
#18
Stephen Waite, Jinel Scott, Brian Gale, Travis Fuchs, Srinivas Kolla, Deborah Reede
OBJECTIVE: Although imaging technology has advanced significantly since the work of Garland in 1949, interpretive error rates remain unchanged. In addition to patient harm, interpretive errors are a major cause of litigation and distress to radiologists. In this article, we discuss the mechanics involved in searching an image, categorize omission errors, and discuss factors influencing diagnostic accuracy. Potential individual- and system-based solutions to mitigate or eliminate errors are also discussed...
December 27, 2016: AJR. American Journal of Roentgenology
https://www.readbyqxmd.com/read/27957697/benefit-of-slit-and-scit-for-allergic-rhinitis-and-asthma
#19
REVIEW
Giovanni Passalacqua, Giorgio Walter Canonica, Diego Bagnasco
Allergen immunotherapy (AIT) has been in use since more than one century, when Leonard Noon experimentally proved its efficacy in hayfever (Noon, in Lancet 1:1572-3, 1911). Since then, AIT was administered only as subcutaneous injections (SCIT) until the sublingual route (SLIT) was proposed in 1986. The use of SLIT was proposed following several surveys from the USA and UK that repeatedly reported fatalities due to SCIT (Lockey et al. in J Allergy Clin Immunol 75(1): 166, 1985; Lockey et al. in J Allergy Clin Immunol 660-77, 1985; Committee on the safety of medicines...
November 2016: Current Allergy and Asthma Reports
https://www.readbyqxmd.com/read/27907031/in-vitro-pre-clinical-validation-of-suicide-gene-modified-anti-cd33-redirected-chimeric-antigen-receptor-t-cells-for-acute-myeloid-leukemia
#20
Kentaro Minagawa, Muhammad O Jamil, Mustafa Al-Obaidi, Larisa Pereboeva, Donna Salzman, Harry P Erba, Lawrence S Lamb, Ravi Bhatia, Shin Mineishi, Antonio Di Stasi
BACKGROUND: Approximately fifty percent of patients with acute myeloid leukemia can be cured with current therapeutic strategies which include, standard dose chemotherapy for patients at standard risk of relapse as assessed by cytogenetic and molecular analysis, or high-dose chemotherapy with allogeneic hematopoietic stem cell transplant for high-risk patients. Despite allogeneic hematopoietic stem cell transplant about 25% of patients still succumb to disease relapse, therefore, novel strategies are needed to improve the outcome of patients with acute myeloid leukemia...
2016: PloS One
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