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Near miss events

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https://www.readbyqxmd.com/read/28334586/processes-for-identifying-and-reviewing-adverse-events-and-near-misses-at-an-academic-medical-center
#1
William Martinez, Lisa Soleymani Lehmann, Yue-Yung Hu, Sonali Parekh Desai, Jo Shapiro
BACKGROUND: Conferences, processes, and/or meetings in which adverse events and near misses are reviewed within clinical programs at a single academic medical center were identified. METHODS: Leaders of conferences, processes, or meetings-"process leaders"-in which adverse events and near misses were reviewed were surveyed. RESULTS: On the basis of responses from all 45 process leaders, processes were classified into (1) Morbidity and Mortality Conferences (MMCs), (2) Quality Assurance (QA) Meetings, and (3) Educational Conferences...
January 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28299848/specimen-identification-errors-in-breast-biopsies-age-matters-report-of-two-near-miss-events-and-review-of-the-literature
#2
Gary Tozbikian, Mary L Gemignani, Edi Brogi
The consequences of patient identification errors due to specimen mislabeling can be deleterious. We describe two near-miss events involving mislabeled breast specimens from two patients who sought treatment at our institution. In both cases, microscopic review of the slides identified inconsistencies between the histologic findings and patient age, unveiling specimen identification errors. By correlating the clinical information with the microscopic findings, we identified mistakes that had occurred at the time of specimen accessioning at the original laboratories...
March 16, 2017: Breast Journal
https://www.readbyqxmd.com/read/28289254/mechanistic-movement-models-to-understand-epidemic-spread
#3
REVIEW
Abdou Moutalab Fofana, Amy Hurford
An overlooked aspect of disease ecology is considering how and why animals come into contact with one and other resulting in disease transmission. Mathematical models of disease spread frequently assume mass-action transmission, justified by stating that susceptible and infectious hosts mix readily, and foregoing any detailed description of host movement. Numerous recent studies have recorded, analysed and modelled animal movement. These movement models describe how animals move with respect to resources, conspecifics and previous movement directions and have been used to understand the conditions for the occurrence and the spread of infectious diseases when hosts perform a type of movement...
May 5, 2017: Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences
https://www.readbyqxmd.com/read/28248748/informing-the-design-of-a-new-pragmatic-registry-to-stimulate-near-miss-reporting-in-ambulatory-care
#4
Elizabeth R Pfoh, Lilly Engineer, Hardeep Singh, Laura Lee Hall, Ethan D Fried, Zackary Berger, Albert W Wu
OBJECTIVE: Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents...
February 28, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28236684/near-miss-experiences-of-transport-and-recreational-cyclists-in-new-south-wales-australia-findings-from-a-prospective-cohort-study
#5
R G Poulos, J Hatfield, C Rissel, L K Flack, L Shaw, R Grzebieta, A S McIntosh
This paper investigates events in which cyclists perceive a cycling crash is narrowly avoided (henceforth, a near miss). A cohort of 2038 adult transport and recreational cyclists from New South Wales (Australia) provided self-reported prospectively collected data from cycling diaries to allow the calculation of an exposure-based rate of near misses and investigation of near miss circumstances. During 25,971days of cycling, 3437 near misses were reported. For a given time cycling, cyclists who rode mainly for transport (compared with those who rode mainly for recreation), and cyclists with less experience (compared to those with more experience) were more likely to report a near miss; older cyclists (60+ years) were less likely to report a near miss than younger cyclists (25-59 years)...
February 22, 2017: Accident; Analysis and Prevention
https://www.readbyqxmd.com/read/28193186/afghan-migrants-face-more-suboptimal-care-than-natives-a-maternal-near-miss-audit-study-at-university-hospitals-in-tehran-iran
#6
Soheila Mohammadi, Soraya Saleh Gargari, Masoumeh Fallahian, Carina Källestål, Shirin Ziaei, Birgitta Essén
BACKGROUND: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. METHODS: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran...
February 13, 2017: BMC Pregnancy and Childbirth
https://www.readbyqxmd.com/read/28191498/a-prospective-study-of-patient-safety-incidents-in-gastrointestinal-endoscopy
#7
Manmeet Matharoo, Adam Haycock, Nick Sevdalis, Siwan Thomas-Gibson
Background and study aims Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included...
January 2017: Endoscopy International Open
https://www.readbyqxmd.com/read/28185075/paediatric-patient-safety-and-the-need-for-aviation-black-box-thinking-to-learn-from-and-prevent-medication-errors
#8
Chi Huynh, Ian C K Wong, Jo Correa-West, David Terry, Suzanne McCarthy
Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors...
April 2017: Paediatric Drugs
https://www.readbyqxmd.com/read/28178011/nursing-student-patient-safety-errors-in-the-practice-domain-a-scoping-review-protocol-of-the-quantitative-and-qualitative-evidence
#9
June Raymond, Christina M Godfrey, Jennifer M Medves, Amanda Ross-White
The objective of this scoping review is to identify the range of patient safety events that includes patient safety errors, harms or near misses that student nurses make while nursing in their clinical placements. The question that will guide this review is: what types of hazards, healthcare-associated harms, patient safety incidents, reportable circumstances, near misses, harmful incidents, no harm incidents and injuries to patients are being made and reported by nursing students during their practice in healthcare facilities?...
February 2017: JBI Database of Systematic Reviews and Implementation Reports
https://www.readbyqxmd.com/read/28164258/the-epidemiology-of-homicide-perpetration-by-children
#10
David Hemenway, Sara J Solnick
BACKGROUND: The United States has by far the highest rates of homicide perpetration among high-income countries. The perpetration of homicide by children is often newsworthy, but little is known about the incidence or the circumstances of child homicide perpetration. METHODS: We use data from the sixteen states reporting to the National Violent Death Reporting System (NVDRS) for all years 2005-2012. We read every violent death report that was classified a homicide with a child suspect (aged 0-14)...
December 2017: Injury Epidemiology
https://www.readbyqxmd.com/read/28152959/the-impact-of-a-just-culture-environment-on-the-reporting-of-medication-errors-near-misses
#11
Shani Michelle Weber
131 Background: UPMC CancerCenter is a large outpatient medical oncology network of 25 locations, located within a 200 mile radius of Pittsburgh, PA. The Cancer Center administers approximately 118,000 treatments and 38,000 injections per year by 200 oncology nurses. Staff members have been strongly encouraged for years to report not only medication errors but also near misses. Despite the continual encouragement it was suspected that the actual number of reported medication errors and near misses was frequently underreported...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28152762/ro-ils-radiation-oncology-incident-learning-system-data-trends-2014-2015
#12
Eric C Ford, Nadine L Eads, Ksenija Kapetanovic, Cindy Tomlinson
59 Background: Incident learning is one of the most effective ways to improve quality care. To facilitate patient safety improvement at a national level, American Society for Radiation Oncology (ASTRO) and American Association of Physicists in Medicine (AAPM) launched RO-ILS: Radiation Oncology Incident Learning System in June 2014. RO-ILS mission is to facilitate safer and higher quality care through a shared learning environment that is secure and non-punitive. METHODS: To ensure the security and protection of data, ASTRO contracted with Clarity PSO, a federally-certified patient safety organization that operates under the auspices of the Patient Safety and Quality Improvement Act of 2005...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28141696/the-relationship-between-safety-culture-and-voluntary-event-reporting-in-a-large-regional-ambulatory-care-group
#13
Nina Miller, Shelly Bhowmik, Margarete Ezinwa, Ting Yang, Susan Schrock, Daniel Bitzel, Maura Joyce McGuire
OBJECTIVES: The safety culture in the workplace may affect event reporting. We evaluated the relationship of safety culture and voluntary event reporting within a large network of ambulatory practices, most of which provided primary care. METHODS: This study was an observational, retrospective cohort study. Patient safety event reporting rates for 35 ambulatory practices were collected using a standard tool (UHC Patient Safety Net [PSN]) and normalized based on the number of patient visits in each practice...
January 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28104490/increasing-trainee-reporting-of-adverse-events-with-monthly-trainee-directed-review-of-adverse-events
#14
Alla Smith, Jonathan Hatoun, James Moses
OBJECTIVE: Underreporting of adverse events by physicians is a barrier to improving patient safety. In an effort to increase resident and medical student (hereafter "trainee") reporting of adverse events, trainees developed and led a monthly conference during which they reviewed adverse-event reports, identified system vulnerabilities and designed solutions to those vulnerabilities. METHODS: Monthly conferences over the 22-month study period were led by pediatric trainees, and attended by fellow trainees, departmental leadership, and members of the hospital's quality improvement team...
January 16, 2017: Academic Pediatrics
https://www.readbyqxmd.com/read/28090230/epidemiology-of-pregnancy-associated-icu-utilization-in-texas-2001-2010
#15
Lavi Oud
BACKGROUND: ICU admission is uncommon among obstetric patients. Nevertheless, the epidemiology of ICU utilization is considered to be a useful proxy for study of severe maternal morbidity and near-miss events. However, there is paucity of population-level studies in obstetric patients in the United States. METHODS: The Texas Inpatient Public Use Data File and state-based reports were used to identify pregnancy-associated hospitalizations and those involving admission to ICU (n = 158,410) for the years 2001 - 2010...
February 2017: Journal of Clinical Medicine Research
https://www.readbyqxmd.com/read/28011595/problems-with-health-information-technology-and-their-effects-on-care-delivery-and-patient-outcomes-a-systematic-review
#16
Mi Ok Kim, Enrico Coiera, Farah Magrabi
OBJECTIVE: To systematically review studies reporting problems with information technology (IT) in health care and their effects on care delivery and patient outcomes. MATERIALS AND METHODS: We searched bibliographic databases including Scopus, PubMed, and Science Citation Index Expanded from January 2004 to December 2015 for studies reporting problems with IT and their effects. A framework called the information value chain, which connects technology use to final outcome, was used to assess how IT problems affect user interaction, information receipt, decision-making, care processes, and patient outcomes...
December 23, 2016: Journal of the American Medical Informatics Association: JAMIA
https://www.readbyqxmd.com/read/28007750/parent-preferences-for-medical-error-disclosure-a-qualitative-study
#17
Maitreya Coffey, Sherry Espin, Tara Hahmann, Hayyah Clairman, Lisha Lo, Jeremy N Friedman, Anne Matlow
OBJECTIVE: According to disclosure guidelines, patients experiencing adverse events due to medical errors should be offered full disclosure, whereas disclosure of near misses is not traditionally expected. This may conflict with parental expectations; surveys reveal most parents expect full disclosure whether errors resulted in harm or not. Protocols regarding whether to include children in these discussions have not been established. This study explores parent preferences around disclosure and views on including children...
January 2017: Hospital Pediatrics
https://www.readbyqxmd.com/read/28003436/integrating-transcriptomic-and-proteomic-data-for-accurate-assembly-and-annotation-of-genomes
#18
T S Keshava Prasad, Ajeet Kumar Mohanty, Manish Kumar, Sreelakshmi K Sreenivasamurthy, Gourav Dey, Raja Sekhar Nirujogi, Sneha M Pinto, Anil K Madugundu, Arun H Patil, Jayshree Advani, Srikanth S Manda, Manoj Kumar Gupta, Sutopa B Dwivedi, Dhanashree S Kelkar, Brantley Hall, Xiaofang Jiang, Ashley Peery, Pavithra Rajagopalan, Soujanya D Yelamanchi, Hitendra S Solanki, Remya Raja, Gajanan J Sathe, Sandip Chavan, Renu Verma, Krishna M Patel, Ankit P Jain, Nazia Syed, Keshava K Datta, Aafaque Ahmed Khan, Manjunath Dammalli, Savita Jayaram, Aneesha Radhakrishnan, Christopher J Mitchell, Chan-Hyun Na, Nirbhay Kumar, Photini Sinnis, Igor V Sharakhov, Charles Wang, Harsha Gowda, Zhijian Tu, Ashwani Kumar, Akhilesh Pandey
Complementing genome sequence with deep transcriptome and proteome data could enable more accurate assembly and annotation of newly sequenced genomes. Here, we provide a proof-of-concept of an integrated approach for analysis of the genome and proteome of Anopheles stephensi, which is one of the most important vectors of the malaria parasite. To achieve broad coverage of genes, we carried out transcriptome sequencing and deep proteome profiling of multiple anatomically distinct sites. Based on transcriptomic data alone, we identified and corrected 535 events of incomplete genome assembly involving 1196 scaffolds and 868 protein-coding gene models...
January 2017: Genome Research
https://www.readbyqxmd.com/read/27995700/shot-conference-report-2016-serious-hazards-of%C3%A2-transfusion%C3%A2-%C3%A2-human-factors-continue-to-cause-most%C3%A2-transfusion-related-incidents
#19
P H B Bolton-Maggs
The Annual SHOT Report for incidents reported in 2015 was published on 7 July at the SHOT symposium. Once again, the majority of reports (77·7%) were associated with mistakes ('human factors'). Pressures and stress in the hospital environment contributed to several error reports. There were 26 deaths where transfusion played a part, one due to haemolysis from anti-Wr(a) (units issued electronically). The incidence of haemolysis due to this antibody has increased in recent years. Transfusion-associated circulatory overload is the most common contributor to death and major morbidity...
December 2016: Transfusion Medicine
https://www.readbyqxmd.com/read/27982407/a-study-of-cases-reported-as-incidents-in-a-public-hospital-from-2011-to-2014
#20
Leila Bernarda Donato Göttems, Maria do Livramento Gomes Dos Santos, Paloma Aparecida Carvalho, Fábio Ferreira Amorim
OBJECTIVE: Analyzing incidents reported in a public hospital in the Federal District, Brasilia, according to the characteristics and outcomes involving patients. METHOD: A descriptive and retrospective study of incidents reported between January 2011 and September 2014. RESULTS: 209 reported incidents were categorized as reportable occurrences (n = 22, 10.5%), near misses (n = 16, 7.7%); incident without injury (n = 4, 1.9%) and incident with injury (adverse events) (n = 167, 79...
September 2016: Revista da Escola de Enfermagem da U S P
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