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Near miss events

Maurizio Macaluso, Lauren A Summerville, Meredith E Tabangin, Nancy M Daraiseh
Objectives Compared to other industries, healthcare has one of the highest rates of non-fatal occupational injury/illness. Evidence indicates these rates are underestimated, highlighting the need for improved injury surveillance. This study aims to demonstrate the feasibility of integrating active data collection in a passive injury surveillance system to improve detection of injuries in a healthcare establishment. Methods Using digital voice recorders (DVR), pediatric healthcare providers prospectively recorded events throughout their shift for two weeks...
May 7, 2018: Scandinavian Journal of Work, Environment & Health
Nimrah Baig, Jiangxia Wang, Shereef Elnahal, Todd McNutt, Jean Wright, Theodore DeWeese, Stephanie Terezakis
BACKGROUND AND PURPOSE: Factors contributing to safety- or quality-related incidents (e.g. variances) in children are unknown. We identified clinical and RT treatment variables associated with risk for variances in a pediatric cohort. MATERIALS AND METHODS: Using our institution's incident learning system, 81 patients age ≤21 years old who experienced variances were compared to 191 pediatric patients without variances. Clinical and RT treatment variables were evaluated as potential predictors for variances using univariate and multivariate analyses...
May 15, 2018: Radiotherapy and Oncology: Journal of the European Society for Therapeutic Radiology and Oncology
Christopher L Camp, Dean Wang, Alec S Sinatro, John D'Angelo, Struan H Coleman, Joshua S Dines, Stephen Fealy, Stan Conte
BACKGROUND: Although batters are frequently hit by pitch (HBP) in baseball, the effect of HBP injuries remains undefined in the literature. PURPOSE: To determine the effect of HBP injuries in terms of time out of play, injury patterns resulting in the greatest time out of play, and the value of protective gear such as helmets and elbow pads. STUDY DESIGN: Descriptive laboratory study. METHODS: Based on the Major League Baseball (MLB) Health and Injury Tracking System, all injuries to batters HBP during the 2011-2015 MLB and Minor League Baseball (MiLB) seasons were identified and analyzed...
May 1, 2018: American Journal of Sports Medicine
Stuart Greenham, Stephen Manley, Kirsty Turnbull, Matthew Hoffmann, Amara Fonseca, Justin Westhuyzen, Andrew Last, Noel J Aherne, Thomas P Shakespeare
Aim: To develop and apply a clinical incident taxonomy for radiation therapy. Background: Capturing clinical incident information that focuses on near-miss events is critical for achieving higher levels of safety and reliability. Methods and materials: A clinical incident taxonomy for radiation therapy was established; coding categories were prescription, consent, simulation, voluming, dosimetry, treatment, bolus, shielding, imaging, quality assurance and coordination of care...
May 2018: Reports of Practical Oncology and Radiotherapy
Jwan Kamla, Tony Parry, Andrew Dawson
In order to reduce accident risk, highway authorities prioritise maintenance budgets partly based upon previous accident history. However, as accident rates have continued to fall, this approach has become problematic as accident 'black spots' have been treated and the number of accidents at any individual site has fallen, making previous accident history a less reliable indicator of future accident risk. Another way of identifying sites of higher accident risk might be to identify near-miss accidents (where an accident nearly happened but was avoided)...
May 5, 2018: Accident; Analysis and Prevention
Julian Malicki, Ritva Bly, Mireille Bulot, Jean-Luc Godet, Andreas Jahnen, Marco Krengli, Philippe Maingon, Carlos Prieto Martin, Agnieszka Skrobala, Marc Valero, Hannu Jarvinen
The ACCIRAD project, commissioned by the European Commission (EC) to develop guidelines for risk analysis of accidental and unintended exposures in external beam radiotherapy (EBRT), was completed in the year 2014. In 2015, the "General guidelines on risk management in external beam radiotherapy" were published as EC report Radiation Protection (RP)-181. The present document is the third and final report of the findings from the ACCIRAD project. The main aim of this paper is to describe the key features of the risk management process and to provide general guidelines for radiotherapy departments and national authorities on risk assessment and analysis of adverse error-events and near misses...
May 2, 2018: Radiotherapy and Oncology: Journal of the European Society for Therapeutic Radiology and Oncology
Theresa Gropelli, Joyce A Shanty
BACKGROUND: The purpose of this study is to describe nursing students' perceptions of safety issues and communication in clinical settings. METHOD: A descriptive study of nursing students' perceptions of safety and communication in clinical settings was conducted at a state university in the northeastern United States. Study participants consisted of 196 junior- and senior-level undergraduate nursing students in a baccalaureate program. RESULTS: One third of the students reported thinking that mistakes are held against them...
May 1, 2018: Journal of Nursing Education
Yonathan Freund, Hélène Goulet, Judith Leblanc, Jérôme Bokobza, Patrick Ray, Maxime Maignan, Sabine Guinemer, Jennifer Truchot, Anne-Laure Féral-Pierssens, Youri Yordanov, Anne-Laure Philippon, Edwin Rouff, Ben Bloom, Marine Cachanado, Alexandra Rousseau, Tabassome Simon, Bruno Riou
Importance: Emergency departments (ED) are environments that are at high risk for medical errors. Previous studies suggested that the proportion of medical errors may decrease when more than 1 physician is involved. Objective: To reduce the proportion of medical errors by implementing systematic cross-checking between emergency physicians. Design, Setting, and Participants: This cluster randomized crossover trial includes a random sample of 14 adult patients (age ≥18 years) per day during two 10-day period in 6 EDs (n = 1680 patients) in France...
April 23, 2018: JAMA Internal Medicine
Bistra G Vlassakova, Sean M Sinnott, Nissa Askins, Matthew X Callahan, Izabela C Leahy, David Zurakowski, Paul R Hickey, Joseph P Cravero
BACKGROUND: During the past several decades, anesthesia has become increasingly safe. Truly major adverse events are rare, and anesthesia quality researchers have instituted programs to evaluate "near miss" or less critical adverse events to evaluate the safety of anesthesia delivery. In this study, we aimed to evaluate calls for emergency help in our institution as a surrogate for pending critical events. We hypothesized that calls would be more common in patients with high American Society of Anesthesiologists (ASA) physical status, history of prematurity, and children with recent respiratory illness compared to those without these characteristics...
April 17, 2018: Anesthesia and Analgesia
Hsiu-Chin Hsu, Mei-Hsiang Lin, Ning-Hung Chen, Wan Jing Ho
AIMS AND OBJECTIVE: To investigate the distribution and risk factors associated with undiagnosed Obstructive Sleep Apnea (OSA) among hypertensive patients. BACKGROUND: OSA has been deemed a cardinal risk factor affecting cardiovascular event, the condition is still frequently overlooked clinically. The lack of advanced diagnosis often causes hypertensive patients with OSA to miss opportunities for preventing chronic diseases. DESIGN: A cross-sectional design...
March 31, 2018: Journal of Clinical Nursing
Tara N Cohen, Sarah E Francis, Douglas A Wiegmann, Scott A Shappell, Bruce L Gewertz
The Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare) was used to classify surgical near miss events reported via a hospital's event reporting system over the course of 1 year. Two trained analysts identified causal factors within each event narrative and subsequently categorized the events using HFACS-Healthcare. Of 910 original events, 592 could be analyzed further using HFACS-Healthcare, resulting in the identification of 726 causal factors. Most issues (n = 436, 60.00%) involved preconditions for unsafe acts, followed by unsafe acts (n = 257, 35...
March 1, 2018: American Journal of Medical Quality: the Official Journal of the American College of Medical Quality
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 R 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...
May 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 coevolved, 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 pretreated with beta interferon (IFN-β), suggesting that one or more of the missing 17 open reading frames (ORFs) encode an antagonist of the IFN-induced antiviral state...
May 1, 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 remission in cancer patients, and chimeric antigen receptor (CAR)-engineered 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...
March 14, 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...
March 2018: Human Factors
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