keyword
MENU ▼
Read by QxMD icon Read
search

Near miss events

keyword
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
#1
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
#2
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
#3
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
https://www.readbyqxmd.com/read/28875548/bacterial-contamination-of-platelet-components-not-detected-by-bact-alert%C3%A2
#4
M A Abela, S Fenning, K A Maguire, K G Morris
OBJECTIVES: To investigate the possible causes for false negative results in BacT/ALERT® 3D Signature System despite bacterial contamination of platelet units. BACKGROUND: The Northern Ireland Blood Transfusion Service (NIBTS) routinely extends platelet component shelf life to 7 days. Components are sampled and screened for bacterial contamination using an automated microbial detection system, the BacT/ALERT® 3D Signature System. We report on three platelet components with confirmed bacterial contamination, which represent false negative BacT/ALERT® results and near-miss serious adverse events...
September 5, 2017: Transfusion Medicine
https://www.readbyqxmd.com/read/28865683/evaluation-of-near-miss-and-adverse-events-in-radiation-oncology-using-a-comprehensive-causal-factor-taxonomy
#5
Matthew B Spraker, Robert Fain, Olga Gopan, Jing Zeng, Matthew Nyflot, Loucille Jordan, Gabrielle Kane, Eric Ford
PURPOSE: Incident learning systems (ILSs) are a popular strategy for improving safety in radiation oncology (RO) clinics, but few reports focus on the causes of errors in RO. The goal of this study was to test a causal factor taxonomy developed in 2012 by the American Association of Physicists in Medicine and adopted for use in the RO: Incident Learning System (RO-ILS). METHODS AND MATERIALS: Three hundred event reports were randomly selected from an institutional ILS database and Safety in Radiation Oncology (SAFRON), an international ILS...
September 2017: Practical Radiation Oncology
https://www.readbyqxmd.com/read/28851308/patterns-and-determinants-of-pathways-to-reach-comprehensive-emergency-obstetric-and-neonatal-care-cemonc-in-south-sudan-qualitative-diagrammatic-pathway-analysis
#6
Khalifa Elmusharaf, Elaine Byrne, Ayat AbuAgla, Amal AbdelRahim, Mary Manandhar, Egbert Sondorp, Diarmuid O'Donovan
BACKGROUND: Maternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility...
August 29, 2017: BMC Pregnancy and Childbirth
https://www.readbyqxmd.com/read/28843757/changing-operating-room-culture-implementation-of-a-post-operative-debrief-and-improved-safety-culture
#7
Stephen T Magill, Doris D Wang, W Caleb Rutledge, Darryl Lau, Mitchel S Berger, Sujatha Sankaran, Catherine Y Lau, Sarah G Imershein
BACKGROUND: Patient safety is foundational to neurosurgical care. Post-procedural "debrief" checklists have been proposed to improve patient safety, but there is limited data about their use in neurosurgery. Here, we implemented an initiative to routinely perform post-operative debriefs and evaluated the impact of debriefing on operating room (OR) safety culture. METHODS: A 10-question safety attitude questionnaire (SAQ) was sent to neurosurgical operating room staff at a major academic medical center before and 18-months after implementation of a post-operative debriefing initiative...
August 23, 2017: World Neurosurgery
https://www.readbyqxmd.com/read/28842446/a-natural-history-study-of-x-linked-myotubular-myopathy
#8
Kimberly Amburgey, Etsuko Tsuchiya, Sabine de Chastonay, Michael Glueck, Rachel Alverez, Cam-Tu Nguyen, Anne Rutkowski, Joseph Hornyak, Alan H Beggs, James J Dowling
OBJECTIVE: To define the natural history of X-linked myotubular myopathy (MTM). METHODS: We performed a cross-sectional study that included an online survey (n = 35) and a prospective, 1-year longitudinal investigation using a phone survey (n = 33). RESULTS: We ascertained data from 50 male patients with MTM and performed longitudinal assessments on 33 affected individuals. Consistent with existing knowledge, we found that MTM is a disorder associated with extensive morbidities, including wheelchair (86...
August 25, 2017: Neurology
https://www.readbyqxmd.com/read/28799352/free-energy-landscape-and-molecular-pathways-of-gas-hydrate-nucleation
#9
Yuanfei Bi, Anna Porras, Tianshu Li
Despite the significance of gas hydrates in diverse areas, a quantitative knowledge of hydrate formation at a molecular level is missing. The impediment to acquiring this understanding is primarily attributed to the stochastic nature and ultra-fine scales of nucleation events, posing a great challenge for both experiment and simulation to explore hydrate nucleation. Here we employ advanced molecular simulation methods, including forward flux sampling (FFS), pB histogram analysis, and backward flux sampling, to overcome the limit of direct molecular simulation for exploring both the free energy landscape and molecular pathways of hydrate nucleation...
December 7, 2016: Journal of Chemical Physics
https://www.readbyqxmd.com/read/28768045/examining-factors-that-influence-the-existence-of-heinrich-s-safety-triangle-using-site-specific-h-s-data-from-more-than-25-000-establishments
#10
Patrick L Yorio, Susan M Moore
In the 1930s, Heinrich established one of the most prominent and enduring accident prevention theories when he concluded that high severity occupational safety and health (OSH) incidents are preceded by numerous lower severity incidents and near misses. Seventy-five years of theory expansion/interpretation includes two fundamental tenets: (1) the ratio of lower to higher severity incidents exists in the form of a "safety-triangle" and (2) similar causes underlie both high and low severity events. Although used extensively to inform public policy and establishment-level health and safety priorities, recent research challenges the validity of the two tenets...
August 2, 2017: Risk Analysis: An Official Publication of the Society for Risk Analysis
https://www.readbyqxmd.com/read/28757402/brachytherapy-patient-safety-events-in-an-academic-radiation-medicine%C3%A2-program
#11
Shira Felder, Lyndon Morley, Elizabeth Ng, Kitty Chan, Heather Ballantyne, Anne Di Tomasso, Jette Borg, Jean-Pierre Bissonnette, Stephen Breen, John Waldron, Alexandra Rink, Michael Milosevic
PURPOSE: To describe the incidence and type of brachytherapy patient safety events over 10 years in an academic brachytherapy program. METHODS AND MATERIALS: Brachytherapy patient safety events reported between January 2007 and August 2016 were retrieved from the incident reporting system and reclassified using the recently developed National System for Incident Reporting in Radiation Treatment taxonomy. A multi-incident analysis was conducted to identify common themes and key learning points...
July 27, 2017: Brachytherapy
https://www.readbyqxmd.com/read/28754161/a-cross-sectional-study-of-maternal-near-miss-and-mortality-at-a-rural-tertiary-centre-in-southern-nigeria
#12
Ikechukwu Innocent Mbachu, Chukwuemeka Ezeama, Kelechi Osuagwu, Osita Samuel Umeononihu, Chibuzor Obiannika, Nkeiru Ezeama
BACKGROUND: The study evaluated the pattern of severe maternal outcome, near miss indicators and associated patient and healthcare factors at a private referral hospital in rural Nigeria. METHODS: This was a cross sectional study conducted from September 2014 to August 2015 in Madonna University Teaching Hospital Elele, Rivers State, Nigeria. Pregnant and postpartum women were recruited for the study using Nigeria near miss network proforma which was adopted from the WHO near miss proforma...
July 28, 2017: BMC Pregnancy and Childbirth
https://www.readbyqxmd.com/read/28688909/are-we-making-an-impact-with-incident-learning-systems-analysis-of-quality-improvement-interventions-using-total-body-irradiation-as-a-model-system
#13
Aileen Kim, Eric Ford, Matthew Spraker, Jing Zeng, Ralph Ermoian, Loucille Jordan, Gabrielle Kane, Matthew Nyflot
PURPOSE: Despite increasing interest in incident learning systems (ILS) to improve safety and quality in radiation oncology, little is known about interventions developed in response to safety data. We used total body irradiation (TBI) as a model system to study the effectiveness of interventions from our institutional ILS. METHODS AND MATERIALS: Near-miss event reports specific to TBI were identified from a departmental ILS from March 2012 to December 2015. The near-miss risk index was rated at multidisciplinary review from 0 (no potential harm) to 4 (critical potential harm)...
June 6, 2017: Practical Radiation Oncology
https://www.readbyqxmd.com/read/28668911/recognizing-the-ordinary-as-extraordinary-insight-into-the-way-we-work-to-improve-patient-safety-outcomes
#14
Elizabeth A Henneman
The Institute of Medicine (now National Academy of Medicine) reports "To Err is Human" and "Crossing the Chasm" made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the "near miss" process and as the final safety net for the patient is of paramount importance...
July 2017: American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses
https://www.readbyqxmd.com/read/28662794/lessons-learnt-from-past-incidents-and-accidents-in-radiation-oncology
#15
T Knöös
The purpose of this report is to review and compile what have been and can be learnt from incidents and accidents in radiation oncology, especially in external beam and brachytherapy. Some major accidents from the last 20 years will be discussed. The relationship between major events and minor or so-called near misses is mentioned, leading to the next topic of exploring the knowledge hidden among them. The main lessons learnt from the discussion here and elsewhere are that a well-functioning and safe radiotherapy department should help staff to work with awareness and alertness and that documentation and procedures should be in place and known by everyone...
June 26, 2017: Clinical Oncology: a Journal of the Royal College of Radiologists
https://www.readbyqxmd.com/read/28662440/review-of-serious-events-in-cases-of-suspected-child-abuse-and-or-neglect-a-rose-by-any-other-name
#16
Shanti Raman, Michelle Maiese, Viviana Vasquez, Paola Gordon, Jennifer M Jones
Child abuse and neglect (CAN) cases presenting to health-services may be complex; when things go seriously wrong such as a child death or near miss, cases are reviewed and health-services and professionals subject to intense scrutiny. While there are a variety of mechanisms to review critical incidents in health-services no formal process for the review of cases where child protection is the primary concern exists in Australia. We aimed to develop a systematic process to review serious events in cases of suspected CAN across two health districts in Sydney, so that shared learnings could fuel system change...
June 26, 2017: Child Abuse & Neglect
https://www.readbyqxmd.com/read/28661998/description-and-yield-of-current-quality-and-safety-review-in-selected-us-academic-emergency-departments
#17
Richard Thomas Griffey, Ryan M Schneider, Brian R Sharp, Jeffrey J Pothof, Sheridan Hodkins, Roberta Capp, Jennifer L Wiler, Neil Sreshta, John E Sather, Christopher S Sampson, Jonathan T Powell, Kathryn Y Groner, Lee M Adler
OBJECTIVES: Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement...
June 29, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28652332/theory-of-long-binding-events-in-single-molecule-controlled-rotation-experiments-on-f1-atpase
#18
Sándor Volkán-Kacsó, Rudolph A Marcus
The theory of elastic group transfer for the binding and release rate constants for nucleotides in F1-ATPase as a function of the rotor angle is further extended in several respects. (i) A method is described for predicting the experimentally observed lifetime distribution of long binding events in the controlled rotation experiments by taking into account the hydrolysis and synthesis reactions occurring during these events. (ii) A method is also given for treating the long binding events in the experiments and obtaining the rate constants for the hydrolysis and synthesis reactions occurring during these events...
July 11, 2017: Proceedings of the National Academy of Sciences of the United States of America
https://www.readbyqxmd.com/read/28650384/incident-reporting-in-emergency-medicine-a-thematic-analysis-of-events
#19
Emily Loving Aaronson, David Brown, Theodore Benzer, Shaw Natsui, Elizabeth Mort
BACKGROUND: Incident reporting is a recognized tool for healthcare quality improvement. These systems, which aim to capture near-misses and harm events, enable organizations to gather critical information about failure modes and design mitigation strategies. Although many hospitals have employed these systems, little is known about safety themes in emergency medicine incident reporting. Our objective was to systematically analyze and thematically code 1 year of incident reports. METHODS: A mixed-methods analysis was performed on 1 year of safety reporting data from a large, urban tertiary-care emergency department using a modified grounded theory approach...
June 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28645018/take-over-performance-in-evasive-manoeuvres
#20
Riender Happee, Christian Gold, Jonas Radlmayr, Sebastian Hergeth, Klaus Bengler
We investigated after effects of automation in take-over scenarios in a high-end moving-base driving simulator. Drivers performed evasive manoeuvres encountering a blocked lane in highway driving. We compared the performance of drivers 1) during manual driving, 2) after automated driving with eyes on the road while performing the cognitively demanding n-back task, and 3) after automated driving with eyes off the road performing the visually demanding SuRT task. Both minimum time to collision (TTC) and minimum clearance towards the obstacle disclosed a substantial number of near miss events and are regarded as valuable surrogate safety metrics in evasive manoeuvres...
June 20, 2017: Accident; Analysis and Prevention
keyword
keyword
61214
1
2
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"