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Patient safety, human error

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https://www.readbyqxmd.com/read/29734279/patient-safety-climate-a-study-of-southern-california-healthcare-organizations
#1
Andre S Avramchuk, Stephen J J McGuire
Human error remains the most important factor in unnecessary deaths and suffering in U.S. hospitals. Human error results from healthcare providers' attitudes and behaviors toward patients in different settings. Therefore, taking periodic snapshots of the attitudes and behaviors prevalent in an organization and manifested in its patient safety climate (PSC) is essential.We developed and tested a short survey instrument intended as an organization-level measure of PSC with good psychometric properties that can be used in hospitals, clinics, or other healthcare provider settings...
May 2018: Journal of Healthcare Management / American College of Healthcare Executives
https://www.readbyqxmd.com/read/29724440/intravenous-smart-pumps-usability-issues-intravenous-medication-administration-error-and-patient-safety
#2
REVIEW
Karen K Giuliano
With an estimated 90% of all hospitalized patients receiving intravenous medications via infusion pumps, intravenous infusion pump systems are among the most frequently used technologies in health care. This article reviews important issues regarding clinical usability, intravenous medication administration error, and patient safety related to the use of intravenous smart pumps. Although it is possible to address some of the issues with changes in clinical processes, the most fundamental challenges need to be addressed through innovation and the development of new technologies using a human factors approach...
June 2018: Critical Care Nursing Clinics of North America
https://www.readbyqxmd.com/read/29697505/device-related-error-in-patient-controlled-analgesia-analysis-of-82-698-patients-in-a-tertiary-hospital
#3
Hyo-Jung Son, Sung-Hoon Kim, Jeong-Ok Ryu, Mi-Ra Kang, Myeong-Hee Kim, Jeong-Hun Suh, Jai-Hyun Hwang
BACKGROUND: Patient-controlled analgesia (PCA) is one of the most popular and effective methods for managing postoperative pain. Various types of continuous infusion pumps are available for the safe and accurate administration of analgesic drugs. Here we report the causes and clinical outcomes of device-related errors in PCA. METHODS: Clinical records from January 1, 2011 to December 31, 2014 were collected by acute pain service team nurses in a 2715-bed tertiary hospital...
April 23, 2018: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/29676947/intravenous-chemotherapy-compounding-errors-in-a-follow-up-pan-canadian-observational-study
#4
Rachel E Gilbert, Melissa C Kozak, Roxanne B Dobish, Venetia C Bourrier, Paul M Koke, Vishal Kukreti, Heather A Logan, Anthony C Easty, Patricia L Trbovich
PURPOSE: Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable...
April 20, 2018: Journal of Oncology Practice
https://www.readbyqxmd.com/read/29660827/patient-blood-management-and-the-importance-of-the-transfusion-practitioner-role-to-embed-this-into-practice
#5
REVIEW
L Bielby, R L Moss
Patient blood management (PBM) is a widely established international initiative, with a multidisciplinary approach to reduce transfusion. The Transfusion Practitioner (TP) role is well embedded in the United Kingdom (UK) and Australia. The value of the TP in changing both culture and practice to implement an all-inclusive PBM approach to care will be discussed. The TP role was born from both a safety and haemovigilance culture, where the greatest identified risk to the patient undergoing a transfusion was human error...
April 16, 2018: Transfusion Medicine
https://www.readbyqxmd.com/read/29656504/efficacy-and-safety-of-myl-1501d-vs-insulin-glargine-in-patients-with-type-1-diabetes-after-52-weeks-results-of-the-instride-1-phase-iii-study
#6
Thomas C Blevins, Abhijit Barve, Bin Sun, Michael Ankersen
AIM: To test the safety and efficacy of MYL-1501D, a proposed insulin glargine biosimilar, in patients with type 1 diabetes mellitus (T1DM). METHODS: The safety and efficacy of MYL-1501D and reference insulin glargine were evaluated in INSTRIDE 1, a 52-week, open-label, randomized, phase III study in patients with T1DM. The primary objective was to determine whether once-daily MYL-1501D was non-inferior to once-daily insulin glargine when administered in combination with mealtime insulin lispro based on change in glycated haemoglobin (HbA1c) from baseline to week 24...
April 15, 2018: Diabetes, Obesity & Metabolism
https://www.readbyqxmd.com/read/29643628/pediatric-critical-incidents-reported-over-15-years-at-a-tertiary-care-teaching-hospital-of-a-developing-country
#7
Shemila Abbasi, Fauzia Anis Khan, Sobia Khan
Background and Aims: The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Material and Methods: Incidents related to pediatric population from neonatal period till the age of 12 years were selected...
January 2018: Journal of Anaesthesiology, Clinical Pharmacology
https://www.readbyqxmd.com/read/29623864/-clinical-drug-profiles-an-instrument-to-improve-shared-decision-making
#8
P J Jongen
Doctors and patients are increasingly choosing treatment options by means of the shared decision-making process. However, human decisions are subject to cognitive bias, i.e. systematic and predictable errors in probability estimation and information synthesis. Decision-making may also be hampered by incomplete information. Clinical Drug Profiles (CDPs) aim to provide up-to-date, evidence-based and independent information about drug characteristics that are relevant to doctors and patients alike in the context of shared decision-making...
2018: Nederlands Tijdschrift Voor Geneeskunde
https://www.readbyqxmd.com/read/29601529/assessing-the-health-care-risk-the-clinical-var-a-key-indicator-for-sound-management
#9
Enrique Jiménez-Rodríguez, José Manuel Feria-Domínguez, Alonso Sebastián-Lacave
Clinical risk includes any undesirable situation or operational factor that may have negative consequences for patient safety or capable of causing an adverse event (AE). The AE, intentional or unintentionally, may be related to the human factor, that is, medical errors (MEs). Therefore, the importance of the health-care risk management is a current and relevant issue on the agenda of many public and private institutions. The objective of the management has been evolving from the identification of AE to the assessment of cost-effective and efficient measures that improve the quality control through monitoring...
March 30, 2018: International Journal of Environmental Research and Public Health
https://www.readbyqxmd.com/read/29601462/incident-reporting-to-improve-patient-safety-the-effects-of-process-variance-on-pediatric-patient-safety-in-the-emergency-department
#10
Karen J OʼConnell, Kathy N Shaw, Richard M Ruddy, Prashant V Mahajan, Richard Lichenstein, Cody S Olsen, Tomohiko Funai, Stephen Blumberg, James M Chamberlain
OBJECTIVE: Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care. SETTING/PARTICIPANTS: We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events...
April 2018: Pediatric Emergency Care
https://www.readbyqxmd.com/read/29595399/functionality-of-a-novel-follitropin-alfa-pen-injector-results-from-human-factor-interactions-by-patients-and-nurses
#11
Helen Saunders, Laura de la Fuente Bitaine, Chriss Eftekhar, Colin M Howles, Johanna Glaser, Tina Hoja, Pablo Arriagada
OBJECTIVE: The main objective of this user experience testing study was to evaluate the impact of human factors on the use of a disposable pen containing follitropin alfa by patients and nurses with special focus on the convenience, safety and ease of use, in different types of stimulation protocols. METHODS: Infertile women trying to conceive, and specialist nurses were recruited across 6 European countries. In total 18 patients and 19 nurses took part in the testing, which included both nurse-patient pairings and in-depth interviews...
March 29, 2018: Expert Opinion on Drug Delivery
https://www.readbyqxmd.com/read/29556886/intravenous-lipid-emulsion-overdose-in-infancy-a-case-report-and-overview-of-opportunities-challenges-and-prevention
#12
REVIEW
Wasim Khasawneh, Salar Bani Hani
Medication errors remain among the major problems seen in hospitals. Such errors can relate to the prescription, dispensation, or administration of drugs. Human factors account for most of these mistakes, but other factors such as infusion pump programming defects should always be considered. Worldwide, medication errors have been reported to affect 2-30% of patients, depending on the institution. Intravenous lipid emulsion (ILE) infusion is frequently used as part of total parenteral nutrition in patients of all ages with feeding and gastrointestinal issues...
March 19, 2018: Drug Safety—Case Reports
https://www.readbyqxmd.com/read/29494584/tegumentary-leishmaniasis-and-coinfections-other-than-hiv
#13
REVIEW
Dalila Y Martínez, Kristien Verdonck, Paul M Kaye, Vanessa Adaui, Katja Polman, Alejandro Llanos-Cuentas, Jean-Claude Dujardin, Marleen Boelaert
BACKGROUND: Tegumentary leishmaniasis (TL) is a disease of skin and/or mucosal tissues caused by Leishmania parasites. TL patients may concurrently carry other pathogens, which may influence the clinical outcome of TL. METHODOLOGY AND PRINCIPAL FINDINGS: This review focuses on the frequency of TL coinfections in human populations, interactions between Leishmania and other pathogens in animal models and human subjects, and implications of TL coinfections for clinical practice...
March 2018: PLoS Neglected Tropical Diseases
https://www.readbyqxmd.com/read/29473297/promoting-collaboration-in-emergency-medicine
#14
Shobhana Nagraj, Juliet Harrison, Lawrence Hill, Lesley Bowker, Susanne Lindqvist
BACKGROUND: Collaborative practice between paramedics and medical staff is essential for ensuring the safe handover of patients. Handover of care is a critical time in the patient journey, when effective communication and collaborative practice are central to promoting patient safety and to avoiding medical error. To encourage effective collaboration between paramedic and medical students, an innovative, practice-based simulation exercise, known as interprofessional clinical skills (ICS) was developed at the University of East Anglia, UK...
February 23, 2018: Clinical Teacher
https://www.readbyqxmd.com/read/29443720/retained-guidewires-in-the-veterans-health-administration-getting-to-the-root-of-the-problem
#15
Leila Cherara, Gary L Sculli, Douglas E Paull, Lisa Mazzia, Julia Neily, Peter D Mills
OBJECTIVES: The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS: The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken...
February 13, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29425599/use-of-simulation-in-performance-improvement
#16
REVIEW
Amanda Burden, Erin White Pukenas
Human error and system failures continue to play a substantial role in preventable errors that lead to adverse patient outcomes or death. Many of these deaths are not the result of inadequate medical knowledge and skill, but occur because of problems involving communication and team management. Anesthesiologists pioneered the use of simulation for medical education in an effort to improve physician performance and patient safety. This article explores the use of simulation for performance improvement. Educational theories that underlie effective simulation programs are described as driving forces behind the advancement of simulation in performance improvement...
March 2018: Anesthesiology Clinics
https://www.readbyqxmd.com/read/29346222/-to-err-is-human-but-disclosure-must-be-taught-a-simulation-based-assessment-study
#17
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...
April 2018: Simulation in Healthcare: Journal of the Society for Simulation in Healthcare
https://www.readbyqxmd.com/read/29340732/-electronic-decision-support-to-promote-medication-safety
#18
REVIEW
Walter E Haefeli, Hanna M Seidling
Because of its inherent complexity, it is a considerable challenge to tailor drug treatment to a prevalent disease and its subgroups, which are increasingly defined by genomic variability (personalized medicine) and require consideration of context information such as co-morbidity, co-medication, patient preferences, and the specific characteristics of the healthcare sector. Thus, optimum treatment decisions might not be taken intuitively any longer, because decisions must be made both rapidly and increasingly based on analyses of complex relations of numerous variables that exceed the processing performance of a human brain...
March 2018: Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz
https://www.readbyqxmd.com/read/29239662/the-effect-of-electronic-health-records-on-patient-safety-a-qualitative-exploratory-study
#19
Ahmad Tubaishat
BACKGROUND: Electronic health records (EHRs) are increasingly used in healthcare settings and it is believed that they have brought benefits to patients and healthcare services alike. Few previous studies, however, have explored the impact of these records on patient safety. AIM: The overall purpose of this study was to explore the effect of EHRs on patient safety, as perceived by nurses. METHODS: This qualitative exploratory study was conducted using semi-structured interviews with staff nurses working in hospitals that employed the same EHR system in Jordan...
December 14, 2017: Informatics for Health & Social Care
https://www.readbyqxmd.com/read/29214031/parp-inhibitors-as-potential-therapeutic-agents-for-various-cancers-focus-on-niraparib-and-its-first-global-approval-for-maintenance-therapy-of-gynecologic-cancers
#20
REVIEW
Mekonnen Sisay, Dumessa Edessa
Poly (ADP-ribose) polymerases (PARPs) are an important family of nucleoproteins highly implicated in DNA damage repair. Among the PARP families, the most studied are PARP1, PARP2 and PARP 3. PARP1 is found to be the most abundant nuclear enzyme under the PARP series. These enzymes are primarily involved in base excision repair as one of the major single strand break (SSB) repair mechanisms. Being double stranded, DNA engages itself in reparation of a sub-lethal SSB with the aid of PARP. Moreover, by having a sister chromatid, DNA can also repair double strand breaks with either error-free homologous recombination or error-prone non-homologous end-joining...
2017: Gynecologic Oncology Research and Practice
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