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Patient safety, human error

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https://www.readbyqxmd.com/read/29122928/surgical-safety-checklist-training-a-national-study-of-undergraduate-medical-and-nursing-student-teaching-understanding-and-influencing-factors
#1
Caroline Laura Stephanie Kilduff, Thomas Oliver Leith, Thomas M Drake, J Edward F Fitzgerald
INTRODUCTION: Use of the WHO surgical safety checklist is consistently recognised to reduce harm caused by human error during the perioperative period. Inconsistent engagement is considered to contribute to persistence of surgical Never Events in the National Health Service. Most medical and nursing graduates will join teams responsible for the perioperative care of patients, therefore appropriate undergraduate surgical safety training is needed. AIMS: To investigate UK medical and nursing undergraduate experience of the surgical safety checklist training...
November 9, 2017: Postgraduate Medical Journal
https://www.readbyqxmd.com/read/29122210/strategies-to-increase-patient-safety-in-hemodialysis-application-of-the-modal-analysis-system-of-errors-and-effects-fema-system
#2
María Dolores Arenas Jiménez, Gabriel Ferre, Fernando Álvarez-Ude
BACKGROUND: Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement. OBJECTIVES: To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems])...
November 2017: Nefrología: Publicación Oficial de la Sociedad Española Nefrologia
https://www.readbyqxmd.com/read/29115074/adapter-based-safety-injection-system-for-prevention-of-wrong-route-and-wrong-patient-medication-errors
#3
Yong Chan Cho, Seung Ho Lee, Yang Hyun Cho, Young Bin Choy
Wrong-route or -patient medication errors due to human mistakes have been considered difficult to resolve in clinical settings. In this study, we suggest a safety injection system that can help to prevent an injection when a mismatch exists between the drug and route or patient. For this, we prepared two distinct adapters with key and keyhole patterns specifically assigned to a pair of drug and route or patient. When connected to a syringe tip and its counterpart, a catheter injection-port, respectively, the adapters allowed for a seamless connection only with their matching patterns...
December 2017: Journal of Korean Medical Science
https://www.readbyqxmd.com/read/29112030/nurses-views-highlight-a-need-for-the-systematic-development-of-patient-safety-culture-in-forensic-psychiatry-nursing
#4
Anssi Kuosmanen, Jari Tiihonen, Eila Repo-Tiihonen, Markku Eronen, Hannele Turunen
BACKGROUND: Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing. OBJECTIVES: The aim of this qualitative study was to describe nurses' views of patient safety culture in their working unit and daily hospital work in 2 forensic hospitals in Finland. METHODS: Data were collected over a period of 1 month by inviting nurses to answer an open-ended question in an anonymous Web-based questionnaire...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29101141/incidence-of-patient-safety-events-and-process-related-human-failures-during-intra-hospital-transportation-of-patients-retrospective-exploration-from-the-institutional-incident-reporting-system
#5
Shu-Hui Yang, Jih-Shuin Jerng, Li-Chin Chen, Yu-Tsu Li, Hsiao-Fang Huang, Chao-Ling Wu, Jing-Yuan Chan, Szu-Fen Huang, Huey-Wen Liang, Jui-Sheng Sun
BACKGROUND: Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. OBJECTIVE: To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. SETTING: A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan...
November 3, 2017: BMJ Open
https://www.readbyqxmd.com/read/29056227/intravenous-regional-anaesthesia-bier-s-block-for-pediatric-forearm-fractures-in-a-pediatric-emergency-department-experience-from-2003-to-2014
#6
Ivan S Y Chua, S L Chong, Gene Y K Ong
STUDY OBJECTIVES: To evaluate the efficacy (length of stay in the emergency department and failure rate of Bier's block) and safety profile (death and major complications) of Bier's block in its use for manipulation and reduction of paediatric forearm fractures. METHODS: This is a retrospective cohort study of pediatric patients in KKWomen's and Children's Hospital Children's Emergency Department with forearm fractures between Jan 2003 and Dec 2014 who underwent manipulation and reduction using Bier's block...
October 16, 2017: Injury
https://www.readbyqxmd.com/read/29028917/comparative-usability-of-modern-anaesthesia-ventilators-a-human-factors-study
#7
J Spaeth, T Schweizer, A Schmutz, H Buerkle, S Schumann
Background: The anaesthesia ventilator represents the key equipment for intraoperative respiratory care. Improper operation of this device may threaten a patient's health. A self-explanatory interface facilitates handling and decreases the risk of operating errors. This study systematically evaluates the usability of user interfaces in four modern anaesthesia ventilators. Methods: Twenty naïve operators were asked to execute 20 tasks on each of four different anaesthesia ventilators (Avance CS2™, GE Healthcare; Flow-i™, Maquet; and Perseus™ and Primus™, Dräger) in a randomized order...
November 1, 2017: British Journal of Anaesthesia
https://www.readbyqxmd.com/read/28970058/measuring-harm-in-hospitalized-children-via-a-trigger-tool
#8
Lya M Stroupe, Kamakshya P Patra, Zheng Dai, Jeffrey Lancaster, Anjum Ahmed, Emily Merti, Robert Riley, Jamie Whitehair
BACKGROUND: The 1999 report To Err Is Human published by the Institute of Medicine estimated that between 44,000 and 98,000 deaths occur each year in US hospitals due to medical errors. However, processes to detect medically induced harm remain inaccurate and inconsistent. Hospitalized pediatric patients are at high risk for adverse events, with published rates ranging between 1% and 11% of all hospitalizations. OBJECTIVE: The study aimed to use the Global Assessment of Pediatric Patient Safety (GAPPS) tool to detect adverse events in a pediatric inpatient setting of an academic medical center children's hospital and compare to internal incident reporting methods...
September 29, 2017: Journal of Pediatric Nursing
https://www.readbyqxmd.com/read/28958419/workplace-bullying-in-emergency-nursing-development-of-a-grounded-theory-using-situational-analysis
#9
Lisa A Wolf, Cydne Perhats, Paul R Clark, Michael D Moon, Kathleen Evanovich Zavotsky
BACKGROUND: The Institute of Medicine recognizes that the workplace environment is a crucial factor in the ability of nurses to provide safe and effective care, and thus interactions that affect the quality and safety of the work environment require exploration. OBJECTIVES: The purpose of this study was to use situational analysis to develop a grounded theory of workplace bullying as it manifests specifically in the emergency care setting. METHODS: This study used a grounded theory methodology called situational analysis...
September 22, 2017: International Emergency Nursing
https://www.readbyqxmd.com/read/28950188/strengths-and-limitations-of-early-warning-scores-a-systematic-review-and-narrative-synthesis
#10
REVIEW
C L Downey, W Tahir, R Randell, J M Brown, D G Jayne
BACKGROUND: Early warning scores are widely used to identify deteriorating patients. Whilst their ability to predict clinical outcomes has been extensively reviewed, there has been no attempt to summarise the overall strengths and limitations of these scores for patients, staff and systems. This review aims to address this gap in the literature to guide improvements for the optimization of patient safety. METHODS: A systematic review was conducted of MEDLINE(®), PubMed, CINAHL and The Cochrane Library in September 2016...
September 13, 2017: International Journal of Nursing Studies
https://www.readbyqxmd.com/read/28885221/the-establishment-of-the-drug-naming-committee-to-restrict-look-alike-medication-names-in-iran-a-qualitative-study
#11
Nazanin Abolhassani, Ali Akbari Sari, Arash Rashidian, Mansoor Rastegarpanah
BACKGROUND: Medication errors is a prominent issue on the health policy agenda due to its significant human and financial costs; confusing drug names are one of the most common causes of them. This issue necessitates the adoption of a mechanism to restrict such a confusion before approving drug names. OBJECTIVE: Following the establishment of a committee and developed relevant criteria as mechanisms to address the issue of drug names similarity Iran, there were problems in this process...
2017: International Journal of Risk & Safety in Medicine
https://www.readbyqxmd.com/read/28883183/cognitive-performance-of-users-is-affected-by-electronic-handovers-depending-on-role-task-and-human-factors
#12
Mareike Przysucha, Daniel Flemming, Georg Schulte, Ursula Hübner
Patient handovers are cognitively demanding, crucial for information continuity and patient safety, but error prone. This study investigated the effect of an electronic handover tool, i.e. the handoverEHR, on the memory and care planning performance of nurse students (n=32) in a randomised, controlled cross-over design with the factors handover task and handover role. On a descriptive level, handover recipients could improve their memory performance with electronic support, handover givers their performance of writing care plans...
2017: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/28841059/the-role-of-interpersonal-relations-in-healthcare-team-communication-and-patient-safety-a-proposed-model-of-interpersonal-process-in-teamwork
#13
Charlotte Tsz-Sum Lee, Diane Marie Doran
Patient safety is compromised by medical errors and adverse events related to miscommunications among healthcare providers. Communication among healthcare providers is affected by human factors, such as interpersonal relations. Yet, discussions of interpersonal relations and communication are lacking in healthcare team literature. This paper proposes a theoretical framework that explains how interpersonal relations among healthcare team members affect communication and team performance, such as patient safety...
June 2017: Canadian Journal of Nursing Research, Revue Canadienne de Recherche en Sciences Infirmières
https://www.readbyqxmd.com/read/28813898/robots-testing-robots-alan-arm-a-humanoid-arm-for-the-testing-of-robotic-rehabilitation-systems
#14
Jack Brookes, Maksims Kuznecovs, Menelaos Kanakis, Arturs Grigals, Mazvydas Narvidas, Justin Gallagher, Martin Levesley
Robotics is increasing in popularity as a method of providing rich, personalized and cost-effective physiotherapy to individuals with some degree of upper limb paralysis, such as those who have suffered a stroke. These robotic rehabilitation systems are often high powered, and exoskeletal systems can attach to the person in a restrictive manner. Therefore, ensuring the mechanical safety of these devices before they come in contact with individuals is a priority. Additionally, rehabilitation systems may use novel sensor systems to measure current arm position...
July 2017: IEEE ... International Conference on Rehabilitation Robotics: [proceedings]
https://www.readbyqxmd.com/read/28806225/preventing-retained-central-venous-catheter-guidewires-a-randomized-controlled-simulation-study-using-a-human-factors-approach
#15
RANDOMIZED CONTROLLED TRIAL
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...
October 2017: Anesthesiology
https://www.readbyqxmd.com/read/28770106/outcome-of-surgical-treatment-in-late-onset-capsular-block-syndrome
#16
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
#17
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
#18
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
#19
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
#20
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. Health care has learned from other high-risk organisations (HRO) such as 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
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