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https://www.readbyqxmd.com/read/29282080/safety-analysis-over-time-seven-major-changes-to-adverse-event-investigation
#1
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
https://www.readbyqxmd.com/read/29229148/are-we-missing-the-near-misses-in-the-or-underreporting-of-safety-incidents-in-pediatric-surgery
#2
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
https://www.readbyqxmd.com/read/29223428/enabling-social-listening-for-cardiac-safety-monitoring-proceedings-from-a-drug-information-association-cardiac-safety-research-consortium-cosponsored-think-tank
#3
REVIEW
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
https://www.readbyqxmd.com/read/29219140/-near-miss-obstetric-events-and-maternal-mortality-in-a-tertiary-care-hospital
#4
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
https://www.readbyqxmd.com/read/29207784/emergency-peripartum-hysterectomy-a-14-year-experience-at-a-tertiary-care-centre-in-india
#5
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
https://www.readbyqxmd.com/read/29186417/examining-influences-on-speaking-up-among-critical-care-healthcare-providers-in-the-united-arab-emirates
#6
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 23, 2017: International Journal for Quality in Health Care
https://www.readbyqxmd.com/read/29173455/rapid-identification-information-and-its-influence-on-the-perceived-clues-at-a-crime-scene-an-experimental-study
#7
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
https://www.readbyqxmd.com/read/29172067/improving-communication-at-handover-and-transfer-reduces-retained-swabs-in-maternity-services
#8
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
https://www.readbyqxmd.com/read/29171903/public-response-to-a-near-miss-nuclear-accident-scenario-varying-in-causal-attributions-and-outcome-uncertainty
#9
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
https://www.readbyqxmd.com/read/29148087/an-agent-based-model-of-evolving-community-flood-risk
#10
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
https://www.readbyqxmd.com/read/29120292/survival-and-negotiation-narratives-of-severe-near-miss-neonatal-complications-of-syrian-women-in-lebanon
#11
Livia Wick
The World Health Organization has elaborated a maternal and neonatal near-miss reporting, audit and feedback system designed to improve the quality of care during and after childbirth. As part of a four-hospital comparative study in the Middle East, this article discusses the experiences of mothers whose newborns suffered from severe complications at birth in the Rafik Hariri University Hospital, the only public hospital in Beirut. Based on in-depth home interviews several weeks after childbirth, it aims to explore the experience of neonatal near-miss events through the mothers' birth narratives...
October 2017: Reproductive Health Matters
https://www.readbyqxmd.com/read/29091463/falls-from-agricultural-machinery-risk-factors-related-to-work-experience-worked-hours-and-operators-behavior
#12
Federica Caffaro, Michele Roccato, Margherita Micheletti Cremasco, Eugenio Cavallo
Objective We investigated the risk factors for falls when egressing from agricultural tractors, analyzing the role played by worked hours, work experience, operators' behavior, and near misses. Background Many accidents occur within the agricultural sector each year. Among them, falls while dismounting the tractor represent a major source of injuries. Previous studies pointed out frequent hazardous movements and incorrect behaviors adopted by operators to exit the tractor cab. However, less is known about the determinants of such behaviors...
November 1, 2017: Human Factors
https://www.readbyqxmd.com/read/29076855/creating-a-fair-and-just-culture-in-schools-of-nursing
#13
Jane Barnsteiner, Joanne Disch
: In recent years, health care organizations have been moving away from a culture that responds to errors and near misses with "shame and blame" and toward a fair and just culture. Such a culture encourages and rewards people for speaking up about safety-related concerns, thus allowing the information to be used for system improvement. In part 1 of this series, we reported on findings from a study that examined how nursing schools handled student errors and near misses. We found that few nursing schools had a policy or a reporting tool concerning these events; and that when policies did exist, the majority did not reflect the principles of a fair and just culture...
November 2017: American Journal of Nursing
https://www.readbyqxmd.com/read/29048467/identification-of-copy-number-variations-and-translocations-in-cancer-cells-from-hi-c-data
#14
Abhijit Chakraborty, Ferhat Ay
Motivation: Eukaryotic chromosomes adapt a complex and highly dynamic three-dimensional (3D) structure, which profoundly affects different cellular functions and outcomes including changes in epigenetic landscape and in gene expression. Making the scenario even more complex, cancer cells harbor chromosomal abnormalities (e.g., copy number variations (CNVs) and translocations) altering their genomes both at the sequence level and at the level of 3D organization. High-throughput chromosome conformation capture techniques (e...
October 18, 2017: Bioinformatics
https://www.readbyqxmd.com/read/29028690/adverse-event-reporting-harnessing-residents-to-improve-patient-safety
#15
Sarah E Tevis, Ryan K Schmocker, Tosha B Wetterneck
OBJECTIVES: Reporting of adverse and near miss events are essential to identify system level targets to improve patient safety. Resident physicians historically report few events despite their role as front-line patient care providers. We sought to evaluate barriers to adverse event reporting in an effort to improve reporting. Our main outcomes were as follows: resident attitudes about event reporting and the frequency of event reporting before and after interventions to address reporting barriers...
October 13, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29023218/out-of-hospital-pediatric-patient-safety-events-results-of-the-csi-chart-review
#16
Garth Meckler, Matthew Hansen, William Lambert, Kerth O'Brien, Caitlin Dickinson, Kathryn Dickinson, Joshua Van Otterloo, Jeanne-Marie Guise
OBJECTIVE: Studies of adult hospital patients have identified medical errors as a significant cause of morbidity and mortality. Little is known about the frequency and nature of pediatric patient safety events in the out-of-hospital setting. We sought to quantify pediatric patient safety events in EMS and identify patient, call, and care characteristics associated with potentially severe events. METHODS: As part of the Children's Safety Initiative -EMS, expert panels independently reviewed charts of pediatric critical ambulance transports in a metropolitan area over a three-year period...
October 12, 2017: Prehospital Emergency Care
https://www.readbyqxmd.com/read/28969656/inadequate-programming-insufficient-communication-and-non-compliance-with-the-basic-principles-of-maternal-death-audits-in-health-districts-in-burkina-faso-a-qualitative-study
#17
Boukaré Congo, Djénéba Sanon, Tieba Millogo, Charlemagne Marie Ouedraogo, Wambi Maurice E Yaméogo, Ziemlé Clement Meda, Seni Kouanda
BACKGROUND: Implementation of quality maternal death audits requires good programming, good communication and compliance with core principles. Studies on compliance with core principles in the conduct of maternal death audits (MDAs) exist but were conducted in urban areas, at the 2nd or 3rd level of the healthcare system, in experimental situations, or in a context of skills-building projects or technical platforms with an emphasis on the review of "near miss". This study aims to fill the gap of evidence on the implementation of MDAs in rural settings, at the first level of care and in the routine care situation in Burkina Faso...
September 29, 2017: Reproductive Health
https://www.readbyqxmd.com/read/28885381/characteristics-of-medical-adverse-events-near-misses-associated-with-laparoscopic-thoracoscopic-surgery-a-retrospective-study-based-on-the-japanese-national-database-of-medical-adverse-events
#18
Takashige Abe, Sachiyo Murai, Yasuyuki Nasuhara, Nobuo Shinohara
OBJECTIVES: The aim of this study was to clarify the characteristics of adverse events/near misses during laparoscopic/thoracoscopic surgery. METHODS: Using relevant key words for minimally invasive surgeries, 540 records were identified in the database of the Japan Council for Quality Health Care. After data review and the classification of adverse events, 746 events associated with laparoscopic (laparo group) and/or thoracoscopic (thoraco group) surgery were identified...
September 6, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28879688/building-a-learning-culture-and-prevention-of-error-to-near-miss-or-not
#19
EDITORIAL
Anthony Arnold
This editorial provides an insight into learning and prevention of error through near miss event reporting.
September 2017: Journal of Medical Radiation Sciences
https://www.readbyqxmd.com/read/28878928/evaluation-of-a-guided-continuous-quality-improvement-program-in-community-pharmacies
#20
Chanadda Chinthammit, Michael T Rupp, Edward P Armstrong, Tara Modisett, Rebecca P Snead, Terri L Warholak
BACKGROUND: The importance of creating and sustaining a strong culture of patient safety has been recognized as a critical component of safe medication use. This study aims to assess changes in attitudes toward patient safety culture and frequency of quality-related event (QRE) reporting after guided implementation of a continuous quality improvement (CQI) program in a panel of community pharmacies in the United States (U.S.). METHODS: Twenty-one community pharmacies volunteered to participate in the project and were randomly assigned to intervention or control groups...
2017: Journal of Pharmaceutical Policy and Practice
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