Read by QxMD icon Read

Near miss events

Patrick B Murphy, Kelly N Vogt, Brandyn D Lau, Jonathan Aboagye, Neil G Parry, Michael B Streiff, Elliott R Haut
Importance: Venous thromboembolism (VTE) is the most preventable cause of morbidity and mortality in US hospitals, and approximately 2.5% of emergency general surgery (EGS) patients will be diagnosed with a VTE event. Emergency general surgery patients are at increased risk of morbidity and mortality because of the nature of acute surgical conditions and the challenges related to prophylaxis. Observations: MEDLINE, Embase, and the Cochrane Database of Collected Reviews were searched from January 1, 1990, through December 31, 2015...
March 14, 2018: JAMA Surgery
R P Reena, K R Radha
Severe life-threatening situations leading to a "near-miss" event may arise unexpectedly in pregnancy. Delay in seeking help, delayed access to care, and poor quality of emergency obstetric services can lead to undesirable outcomes. Women meeting the WHO "near-miss" criteria were assessed using a cross-sectional study design. These women were interviewed to evaluate the circumstances leading to a near-miss event. Reasons for delays in getting proper care were studied using the "3 delays' model...
January 2018: Indian Journal of Public Health
Joshua N Sampson, Allan Hildesheim, Rolando Herrero, Paula Gonzalez, Aimee Kreimer, Mitchell H Gail
Cervical cancer is a leading cause of cancer mortality in women worldwide. Human papillomavirus (HPV) types 16 and 18 cause about 70% of all cervical cancers. Clinical trials have demonstrated that three doses of either commercially available HPV vaccine, Cervarix or Gardasil, prevent most new HPV 16/18 infections and associated precancerous lesions. Based on evidence of immunological non-inferiority, 2-dose regimens have been licensed for adolescents in the United States, European Union, and elsewhere. However, if a single dose were effective, vaccine costs would be reduced substantially and the logistics of vaccination would be greatly simplified, enabling vaccination programs in developing countries...
February 20, 2018: Contemporary Clinical Trials
Alexander Thiele, Mark A Bellgrove
Attention is critical to high-level cognition and attention deficits are a hallmark of neurologic and neuropsychiatric disorders. Although years of research indicates that distinct neuromodulators influence attentional control, a mechanistic account that traverses levels of analysis (cells, circuits, behavior) is missing. However, such an account is critical to guide the development of next-generation pharmacotherapies aimed at forestalling or remediating the global burden associated with disorders of attention...
February 21, 2018: Neuron
Lori R Kogan, Mark Rishniw, Peter W Hellyer, Regina M Schoenfeld-Tacher
OBJECTIVE To assess the prevalence of medical errors (specifically, near misses [NMs] and adverse events [AEs]) and their personal and professional impact on veterinarians. DESIGN Cross-sectional study. SAMPLE Members of the Veterinary Information Network (n = 46,481). PROCEDURES An electronic survey regarding veterinarians' experiences with NMs and AEs was distributed via email to an online veterinary community between September 24 and October 21, 2015. Responses were summarized and compared between genders by means of the χ2 test...
March 1, 2018: Journal of the American Veterinary Medical Association
Ruikang Liu, Bernard Moss
Type I interferons (IFNs) induce expression of more than 300 cellular genes that provide protection against viruses and other pathogens. For survival, viruses evolved defenses to prevent the IFN response or counteract the IFN-induced antiviral state. However, because viruses and cells co-evolved, the dynamic relationship between virus and host is difficult to discern. In the present study, we demonstrated that vaccinia virus with a large deletion near the left end of the genome had a diminished ability to replicate in cells that had been pre-treated with IFNβ, suggesting that one or more of the missing 17 open reading frames (ORFs) encodes an antagonist of the IFN-induced antiviral state...
February 14, 2018: Journal of Virology
Sean L Berry, Kevin P Tierney, Sharif Elguindi, James G Mechalakos
INTRODUCTION: An electronic checklist has been designed with the intention of reducing errors while minimizing user effort in completing the checklist. We analyze the clinical use and evolution of the checklist over the past 5 years and review data in an incident learning system (ILS) to investigate whether it has contributed to an improvement in patient safety. METHODS AND MATERIALS: The checklist is written as a standalone HTML application using VBScript. User selection of pertinent demographic details limits the display of checklist items only to those necessary for the particular clinical scenario...
December 24, 2017: Practical Radiation Oncology
Elizabeth Louise Siegler, Pin Wang
Cancer immunotherapy has enormous potential in inducing long-term remissions in cancer patients, and chimeric antigen receptor-engineered T (CAR-T) cells have been largely successful in treating hematological malignancies in the clinic. CAR-T therapy has not been as effective in treating solid tumors, in part due to the immunosuppressive tumor microenvironment. Additionally, CAR-T therapy can cause dangerous side effects, including off-tumor toxicity, cytokine release syndrome, and neurotoxicity. Animal models of CAR-T therapy often fail to predict such adverse events and frequently overestimate the efficacy of the treatment...
February 1, 2018: Human Gene Therapy
Karl E Bridges, Paul M Corballis, Erik Hollnagel
Objective The objective was to develop an understanding, using the Functional Resonance Analysis Method (FRAM), of the factors that could cause a deer hunter to misidentify their intended target. Background Hunting is a popular activity in many communities. However, hunters vary considerably based on training, experience, and expertise. Surprisingly, safety in hunting has not received much attention, especially failure-to-identify hunting incidents. These are incidents in which the hunter, after spotting and targeting their quarry, discharge their firearm only to discover they have been spotting and targeting another human, an inanimate object, or flora by mistake...
January 1, 2018: Human Factors
Yun Yu, Kaiying Zhang, Ling Zhang, Huantao Zong, Lingzhong Meng, Ruquan Han
BACKGROUND: Various techniques have been employed for the early detection of perioperative cerebral ischaemia and hypoxia. Cerebral near-infrared spectroscopy (NIRS) is increasingly used in this clinical scenario to monitor brain oxygenation. However, it is unknown whether perioperative cerebral NIRS monitoring and the subsequent treatment strategies are of benefit to patients. OBJECTIVES: To assess the effects of perioperative cerebral NIRS monitoring and corresponding treatment strategies in adults and children, compared with blinded or no cerebral oxygenation monitoring, or cerebral oxygenation monitoring based on non-NIRS technologies, on the detection of cerebral oxygen desaturation events (CDEs), neurological outcomes, non-neurological outcomes and socioeconomic impact (including cost of hospitalization and length of hospital stay)...
January 17, 2018: Cochrane Database of Systematic Reviews
Charles Vincent, Jane Carthey, Carl Macrae, Rene Amalberti
BACKGROUND: Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today...
December 28, 2017: Implementation Science: IS
Emma C Hamilton, Dean H Pham, Andrew N Minzenmayer, Mary T Austin, Kevin P Lally, KuoJen Tsao, Akemi L Kawaguchi
BACKGROUND: Electronic hospital variance reporting systems used to report near misses and adverse events are plagued by underreporting. The purpose of this study is to prospectively evaluate directly observed variances that occur in our pediatric operating room and to correlate these with the two established variance reporting systems in our hospital. MATERIALS AND METHODS: Trained individuals directly observed pediatric perioperative patient care for 6 wk to identify near misses and adverse events...
January 2018: Journal of Surgical Research
Harry A Seifert, Raleigh E Malik, Mondira Bhattacharya, Kevin R Campbell, Sally Okun, Carrie Pierce, Jeffrey Terkowitz, J Rick Turner, Mitchell W Krucoff, Gregory E Powell
This white paper provides a summary of the presentations and discussions from a think tank on "Enabling Social Listening for Cardiac Safety Monitoring" trials that was cosponsored by the Drug Information Association and the Cardiac Safety Research Consortium, and held at the White Oak headquarters of the US Food and Drug Administration on June 3, 2016. The meeting's goals were to explore current methods of collecting and evaluating social listening data and to consider their applicability to cardiac safety surveillance...
December 2017: American Heart Journal
Shravya Tallapureddy, Revathi Velagaleti, Himabindu Palutla, Chaitanya Venkata Satti
Obstetric near-miss or severe acute maternal morbidity is gaining interest internationally as a new indicator of the quality of obstetric care. This is a retrospective study conducted using "The WHO Near-Miss Approach" to provide insight into obstetric emergencies, near-miss cases, and maternal deaths in our hospital. The maternal near-miss ratio was 8.4/1000 live births, maternal near-miss to mortality ratio was 5.3:1. Hemorrhage was the leading cause (43.7%) of morbidity in near-miss cases while hypertensive disorders were the leading cause in maternal deaths (66...
October 2017: Indian Journal of Public Health
S Tahmina, Mary Daniel, Preetha Gunasegaran
Introduction: Emergency Peripartum Hysterectomy (EPH), although relatively infrequent in present day obstetrics, is a life-saving procedure in the event of a massive postpartum haemorrhage. Aim: To assess incidence, risk factors, indications and complications of peripartum hysterectomies at a tertiary care teaching hospital in India. Materials and Methods: A retrospective study was conducted at 650-bedded tertiary care medical teaching hospital in Southern India...
September 2017: Journal of Clinical and Diagnostic Research: JCDR
Hanan H Edrees, Mohd Nasir Mohd Ismail, Bernadette Kelly, Christine A Goeschel, Sean M Berenholtz, Peter J Pronovost, Ali Abdul Kareem Al Obaidli, Sallie J Weaver
Objective: Assess perceived barriers to speaking up and to provide recommendations for reducing barriers to reporting adverse events and near misses. Design, setting, participants, intervention: A six-item survey was administered to critical care providers in 19 Intensive Care Units in Abu Dhabi as part of an organizational safety and quality improvement effort. Main outcome measures: Questions elicited perspectives about influences on reporting, perceived barriers and recommendations for conveying patient safety as an organizational priority...
November 1, 2017: International Journal for Quality in Health Care
Madeleine de Gruijter, Claire Nee, Christianne J de Poot
Crime scenes can always be explained in multiple ways. Traces alone do not provide enough information to infer a whole series of events that has taken place; they only provide clues for these inferences. CSIs need additional information to be able to interpret observed traces. In the near future, a new source of information that could help to interpret a crime scene and testing hypotheses will become available with the advent of rapid identification techniques. A previous study with CSIs demonstrated that this information had an influence on the interpretation of the crime scene, yet it is still unknown what exact information was used for this interpretation and for the construction of their scenario...
November 2017: Science & Justice: Journal of the Forensic Science Society
Katie Lean, Bethan F Page, Charles Vincent
OBJECTIVE: To reduce the incidence of retained vaginal swabs and near misses. STUDY DESIGN: A review of previous retained swab incidents and near misses in a large maternity unit identified handovers and transfers as a key point of vulnerability. Interventions were introduced to improve communication at handover from the delivery suite to theatre and from theatre to the high dependency unit. Process data was collected to monitor compliance. The outcome measures were the incidence of retained swab never events and the incidence of near misses...
January 2018: European Journal of Obstetrics, Gynecology, and Reproductive Biology
Jinshu Cui, Heather Rosoff, Richard S John
Many studies have investigated public reactions to nuclear accidents. However, few studies focused on more common events when a serious accident could have happened but did not. This study evaluated public response (emotional, cognitive, and behavioral) over three phases of a near-miss nuclear accident. Simulating a loss-of-coolant accident (LOCA) scenario, we manipulated (1) attribution for the initial cause of the incident (software failure vs. cyber terrorist attack vs. earthquake), (2) attribution for halting the incident (fail-safe system design vs...
November 24, 2017: Risk Analysis: An Official Publication of the Society for Risk Analysis
Gina L Tonn, Seth D Guikema
Although individual behavior plays a major role in community flood risk, traditional flood risk models generally do not capture information on how community policies and individual decisions impact the evolution of flood risk over time. The purpose of this study is to improve the understanding of the temporal aspects of flood risk through a combined analysis of the behavioral, engineering, and physical hazard aspects of flood risk. Additionally, the study aims to develop a new modeling approach for integrating behavior, policy, flood hazards, and engineering interventions...
November 17, 2017: Risk Analysis: An Official Publication of the Society for Risk Analysis
Fetch more papers »
Fetching more papers... Fetching...
Read by QxMD. Sign in or create an account to discover new knowledge that matter to you.
Remove bar
Read by QxMD icon Read

Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"