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https://www.readbyqxmd.com/read/28099046/death-notification-someone-needs-to-call-the-family
#1
Rachel Ombres, Lauren Montemorano, Daniel Becker
BACKGROUND: The death notification process can affect family grief and bereavement. It can also affect the well-being of involved physicians. There is no standardized process for making death notification phone calls. We assumed that residents are likely to be unprepared before and troubled after. OBJECTIVE: We investigated current death notification practices to develop an evidence-based template for standardizing this process. DESIGN: We used results of a literature review and open-ended interviews with faculty, residents, and widows to develop a survey regarding resident training and experience in death notification by phone...
January 18, 2017: Journal of Palliative Medicine
https://www.readbyqxmd.com/read/28098743/analysis-of-incident-and-accident-reports-and-risk-management-in-spine-surgery
#2
Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Tetsuro Hida, Kenyu Ito, Mikito Tsushima, Yoshimoto Ishikawa, Akiyuki Matsumoto, Masayoshi Morozumi, Yoshihiro Nishida, Yoshimasa Nagao, Naoki Ishiguro
STUDY DESIGN: A review of accident and incident reports. OBJECTIVE: To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery. SUMMARY OF BACKGROUND DATA: In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. All reports are analyzed by a medical safety management group...
January 16, 2017: Spine
https://www.readbyqxmd.com/read/28096015/association-of-medication-errors-with-drug-classifications-clinical-units-and-consequence-of-errors-are-they-related
#3
Maki Muroi, Jay J Shen, Alona Angosta
Registered nurses (RNs) play an important role in safe medication administration and patient safety. This study examined a total of 1276 medication error (ME) incident reports made by RNs in hospital inpatient settings in the southwestern region of the United States. The most common drug class associated with MEs was cardiovascular drugs (24.7%). Among this class, anticoagulants had the most errors (11.3%). The antimicrobials was the second most common drug class associated with errors (19.1%) and vancomycin was the most common antimicrobial that caused errors in this category (6...
February 2017: Applied Nursing Research: ANR
https://www.readbyqxmd.com/read/28093118/surgical-fires-and-operative-burns-lessons-learned-from-a-33-year-review-of-medical-litigation
#4
Asad J Choudhry, Nadeem N Haddad, Mohammad A Khasawneh, Daniel C Cullinane, Martin D Zielinski
OBJECTIVE: We aimed to understand the setting and litigation outcomes of surgical fires and operative burns. METHODS: Westlaw, an online legal research data-set, was utilized. Data were collected on patient, procedure, and case characteristics. RESULTS: One hundred thirty-nine cases were identified; 114 (82%) operative burns and 25 (18%) surgical fires. Median plaintiff (patient) age was 46 (IQR:28-59). Most common site of operative burn was the face (26% [n = 36])...
December 12, 2016: American Journal of Surgery
https://www.readbyqxmd.com/read/28088527/navigation-in-the-electronic-health-record-a-review-of-the-safety-and-usability-literature
#5
REVIEW
Lisette C Roman, Jessica S Ancker, Stephen B Johnson, Yalini Senathirajah
OBJECTIVE: Inefficient navigation in electronic health records has been shown to increase users' cognitive load, which may increase potential for errors, reduce efficiency, and increase fatigue. However, navigation has received insufficient recognition and attention in the electronic health record (EHR) literature as an independent construct and contributor to overall usability. Our aims in this literature review were to (1) assess the prevalence of navigation-related topics within the EHR usability and safety research literature, (2) categorize types of navigation actions within the EHR, (3) capture relationships between these navigation actions and usability principles, and (4) collect terms and concepts related to EHR navigation...
January 11, 2017: Journal of Biomedical Informatics
https://www.readbyqxmd.com/read/28087554/how-prepared-are-uk-medical-graduates-for-practice-a-rapid-review-of-the-literature-2009-2014
#6
Lynn V Monrouxe, Lisa Grundy, Mala Mann, Zoe John, Eleni Panagoulas, Alison Bullock, Karen Mattick
OBJECTIVE: To understand how prepared UK medical graduates are for practice and the effectiveness of workplace transition interventions. DESIGN: A rapid review of the literature (registration #CRD42013005305). DATA SOURCES: Nine major databases (and key websites) were searched in two timeframes (July-September 2013; updated May-June 2014): CINAHL, Embase, Educational Resources Information Centre, Health Management Information Consortium, MEDLINE, MEDLINE in Process, PsycINFO, Scopus and Web of Knowledge...
January 13, 2017: BMJ Open
https://www.readbyqxmd.com/read/28079581/assessing-the-impact-of-the-anesthesia-medication-template-on-medication-errors-during-anesthesia-a-prospective-study
#7
Eliot B Grigg, Lizabeth D Martin, Faith J Ross, Axel Roesler, Sally E Rampersad, Charles Haberkern, Daniel K W Low, Kristen Carlin, Lynn D Martin
BACKGROUND: Medication errors continue to be a significant source of patient harm in the operating room with few concrete countermeasures. The organization and identification of medication syringes may have an impact on the commission of medication errors in anesthesia, so a team of physicians and designers at the University of Washington created the Anesthesia Medication Template (AMT) to define a formal way of organizing the anesthesia workspace. The purpose of this study is to assess the ability of the AMT to reduce perioperative medication errors by anesthesia providers...
January 11, 2017: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/28079561/-single-checked-patient-group-directions-during-initial-nurse-assessment-within-paediatric-emergency-departments-of-the-uk-and-ireland
#8
Chris K Bird, Anthony G Sinclair, Stuart Hartshorn
OBJECTIVE: Double checking medications at initial assessment within paediatric emergency departments (EDs) has the potential to delay patient flow, and doubt has been cast on the efficacy of double checking in all but high-risk medications. We aimed to benchmark current practice for the use of Patient Group Direction (PGD) medications at initial assessment in EDs within the Paediatric Emergency Research UK and Ireland (PERUKI) network, with a focus on the use of 'single-checker' PGDs...
January 10, 2017: European Journal of Emergency Medicine: Official Journal of the European Society for Emergency Medicine
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
#9
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/28072938/welfare-of-anaesthesia-trainees-survey
#10
G B Downey, J M McDonald, R G Downey
This study was designed to investigate levels of stress, anxiety or depression and to identify factors compounding or relieving stress in anaesthesia trainees within the Australian and New Zealand College of Anaesthetists (ANZCA) training scheme. An electronic survey was sent to 999 randomly selected trainees and 428 responses were received. In addition to demographics, psychological wellbeing was assessed using the Kessler Psychological Distress Scale (K10) and questions were asked about depression and anxiety, exacerbating factors, personal healthcare and strategies used to manage stress...
January 2017: Anaesthesia and Intensive Care
https://www.readbyqxmd.com/read/28069680/medication-errors-associated-with-transition-from-insulin-pens-to-insulin-vials
#11
Adam N Trimble, Bryan Bishop, Nancy Rampe
PURPOSE: Three insulin administration errors that occurred after a hospital's transition from insulin pens to vials are described, and process improvement initiatives implemented to prevent future errors are reviewed. SUMMARY: In response to numerous reports and warnings related to the risk of insulin pen sharing, a 450-bed community hospital made a transition from insulin pens to insulin vials. Shortly after this transition, three major medication errors involving insulin occurred...
January 15, 2017: American Journal of Health-system Pharmacy: AJHP
https://www.readbyqxmd.com/read/28067682/utilizing-a-human-factors-nursing-worksystem-improvement-framework-to-increase-nurses-time-at-the-bedside-and-enhance-safety
#12
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...
January 7, 2017: Journal of Nursing Administration
https://www.readbyqxmd.com/read/28064289/views-of-faculty-members-in-a-medical-school-with-regards-to-error-disclosure-and-reporting-to-parents-and-or-higher-authorities
#13
C H Wong, A C L Phuah, N S Y Naik, W S Choo, H S Y Ting, S M L Kuan, C L Teng, N Sivalingam
BACKGROUND: Little is known about the views of faculty members who train medical students concerning open disclosure. OBJECTIVES: The objectives of this study were to determine the views of faculty in a medical school on: 1 what constitutes a medical error and the severity of such an error in relation to medication use or diagnosis; 2 information giving following such an adverse event, based on severity; and 3 acknowledgement of responsibility, remedial action, compensation, disciplinary action, legal action, and reporting to a higher body in relation to such adverse event...
October 2016: Medical Journal of Malaysia
https://www.readbyqxmd.com/read/28063462/going-digital-a-narrative-overview-of-the-clinical-and-organisational-impacts-of-ehealth-technologies-in-hospital-practice
#14
Justin Keasberry, Ian A Scott, Clair Sullivan, Andrew Staib, Richard Ashby
Objective The aim of the present study was to determine the effects of hospital-based eHealth technologies on quality, safety and efficiency of care and clinical outcomes.Methods Systematic reviews and reviews of systematic reviews of eHealth technologies published in PubMed/Medline/Cochrane Library between January 2010 and October 2015 were evaluated. Reviews of implementation issues, non-hospital settings or remote care or patient-focused technologies were excluded from analysis. Methodological quality was assessed using a validated appraisal tool...
January 9, 2017: Australian Health Review: a Publication of the Australian Hospital Association
https://www.readbyqxmd.com/read/28061829/patterns-of-gestational-diabetes-diagnosis-inside-and-outside-of-clinical-guidelines
#15
Jacinda M Nicklas, Chloe A Zera, Janet Lui, Ellen W Seely
BACKGROUND: Hospital discharge codes are often used to determine the incidence of gestational diabetes mellitus (GDM) at state and national levels. Previous studies demonstrate substantial variability in the accuracy of GDM reporting, and rarely report how the GDM was diagnosed. Our aim was to identify deliveries coded as gestational diabetes, and then to determine how the diagnosis was assigned and whether the diagnosis followed established guidelines. METHODS: We identified which deliveries were coded at discharge as complicated by GDM at the Brigham and Women's Hospital in Boston, MA for the year 2010...
January 6, 2017: BMC Pregnancy and Childbirth
https://www.readbyqxmd.com/read/28060982/-ethical-dilemmas-about-disclosure-of-errors-in-medicine
#16
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/28057945/ismp-medication-error-report-analysis-aggrastat-argatroban-mix-ups-don-t-expect-radiofrequency-identification-stock-systems-to-be-perfect-paralyzed-by-mistakes-reassess-the-safety-of-neuromuscular-blockers-in-your-facility
#17
Michael R Cohen, Judy L Smetzer
These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program...
December 2016: Hospital Pharmacy
https://www.readbyqxmd.com/read/28048700/tu-d-bra-00-treatment-planning-system-commissioning-and-qa
#18
Greg Salomons
INTRODUCTION: Treatment planning systems (TPS) are a cornerstone of modern radiation therapy. Errors in their commissioning or use can have a devastating impact on many patients. To support safe and high quality care, medical physicists must conduct efficient and proper commissioning, good clinical integration, and ongoing quality assurance (QA) of the TPS. AAPM Task Group 53 and related publications have served as seminal benchmarks for TPS commissioning and QA over the past two decades...
June 2016: Medical Physics
https://www.readbyqxmd.com/read/28048509/th-a-brc-03-aapm-tg218-measurement-methods-and-tolerance-levels-for-patient-specific-imrt-verification-qa
#19
M Miften
: AAPM TG-135U1 QA for Robotic Radiosurgery - Sonja Dieterich Since the publication of AAPM TG-135 in 2011, the technology of robotic radiosurgery has rapidly developed. AAPM TG-135U1 will provide recommendations on the clinical practice for using the IRIS collimator, fiducial-less real-time motion tracking, and Monte Carlo based treatment planning. In addition, it will summarize currently available literature about uncertainties. LEARNING OBJECTIVES: 1. Understand the progression of technology since the first TG publication 2...
June 2016: Medical Physics
https://www.readbyqxmd.com/read/28048199/su-g-brc-15-the-potential-clinical-significance-of-dose-mapping-error-for-intra-fraction-dose-mapping-for-lung-cancer-patients
#20
N Sayah, E Weiss, W Watkins, J Siebers
PURPOSE: To evaluate the dose-mapping error (DME) inherent to conventional dose-mapping algorithms as a function of dose-matrix resolution. METHODS: As DME has been reported to be greatest where dose-gradients overlap tissue-density gradients, non-clinical 66 Gy IMRT plans were generated for 11 lung patients with the target edge defined as the maximum 3D density gradient on the 0% (end of inhale) breathing phase. Post-optimization, Beams were copied to 9 breathing phases...
June 2016: Medical Physics
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