Read by QxMD icon Read

Near miss events

M J J Kunst, M Van de Wiel
The current study investigated whether mental health practitioners are influenced by the narrative fallacy when assessing the psychological injuries of trauma victims. The narrative fallacy is associated with our tendency to establish logical links between different facts. In psychodiagnostic assessments, this tendency may result in overdiagnosis of mental disorders when psychological symptoms can be attributed to a traumatic event. Consequently, legal decision makers may be at risk of awarding compensation for psychological injuries which are not severe enough to justify financial reimbursement...
2016: Psychological Injury and Law
Pál Czobor, Brigitta Kakuszi, Kornél Németh, Livia Balogh, Szilvia Papp, László Tombor, István Bitter
Deficits in error-processing are postulated in core symptoms of ADHD. Our goal was to investigate the neurophysiological basis of abnormal error-processing and adaptive adjustments in ADHD, and examine whether error-related alterations extend beyond traditional Regions of Interest (ROIs), particularly to those involved in adaptive adjustments, such as the Salience Network system. We obtained event-related potentials (ERPs) during a Go/NoGo task from 22 adult-ADHD patients and 29 matched healthy controls using a high-density 256-electrode array...
October 17, 2016: Brain Imaging and Behavior
Jonathan P Riley, Andrew B Boucher, Denise S Kim, Daniel L Barrow, Matthew R Reynolds
BACKGROUND: Transorbital intracranial penetrating trauma (TIPT) with a retained intracranial foreign body is a rare event lacking a widely-accepted diagnostic and therapeutic algorithm. Intraoperative catheter angiography (IOA) has been advocated by some authorities to rule out cerebrovascular injury prior and/or subsequent to removal of the object, but no standard of care currently exists. CASE DESCRIPTION: A 19-year-old male was involved in a construction site accident whereby a framing nail penetrated the left globe, traversed the lateral bony orbit, and terminated in the mid-temporal lobe...
September 28, 2016: World Neurosurgery
N Baig, S M Elnahal, T R McNutt, J L Wright, T L DeWeese, S A Terezakis
No abstract text is available yet for this article.
October 1, 2016: International Journal of Radiation Oncology, Biology, Physics
Steven Hawken, Beth K Potter, Julian Little, Eric I Benchimol, Salah Mahmud, Robin Ducharme, Kumanan Wilson
BACKGROUND: The self-controlled case series (SCCS) is a useful design for investigating associations between outcomes and transient exposures. The SCCS design controls for all fixed covariates, but effect modification can still occur. This can be evaluated by including interaction terms in the model which, when exponentiated, can be interpreted as a relative incidence ratio (RIR): the change in relative incidence (RI) for a unit change in an effect modifier. METHODS: We conducted a scoping review to investigate the use of RIRs in published primary SCCS studies, and conducted a case-study in one of our own primary SCCS studies to illustrate the use of RIRs within an SCCS analysis to investigate subgroup effects in the context of comparing whole cell (wcp) and acellular (acp) pertussis vaccines...
2016: BMC Medical Research Methodology
Gabriel Loor, Sara J Shumway, Kenneth R McCurry, Suresh Keshavamurthy, Syed Hussain, Garry D Weide, John R Spratt, Mazin Al Salihi, Colleen G Koch
BACKGROUND: Donor organs are often procured by junior staff in stressful, unfamiliar environments where a single adverse event can be catastrophic. A formalized checklist focused on preprocedural processes related to thoracic donor organ procurement could improve detection and prevention of near miss events. METHODS: A checklist was developed centered on patient identifiers, organ compatibility and quality, and team readiness. It went through five cycles of feedback and revision using a panel of expert procurement surgeons...
September 19, 2016: Annals of Thoracic Surgery
Niyati T Parmar, Ajay G Parmar, Vihang S Mazumdar
BACKGROUND: Constant decline in maternal mortality ratio has given rise to the need of a new indicator. This search has motivated investigation of severe maternal morbidity-"maternal near-miss" (MNM) event. World Health Organization (WHO) defines MNM as "a woman who, being close to death, survives a complication that occurred during pregnancy, delivery or up to 42 days after the end of her pregnancy". METHODOLOGY: A hospital-based cross-sectional study was carried out at Sir Sayajirao General Hospital (SSGH), a tertiary care referral hospital in Vadodara, Central Gujarat, from May to September 2012...
October 2016: Journal of Obstetrics and Gynaecology of India
Singh Abha, Shrivastava Chandrashekhar, Dube Sonal
BACKGROUND: MMR has always been recognized as an important indicator of quality of health services. The MMR in India has so far not reached up to the required MDG 2015. If we look into this matter with the eagle's eye view, then there are certain gray areas which need attention. For this, it is not the maternal mortality but the maternal near miss which has to be focused. OBJECTIVES: To audit the maternal near miss in our institution and to review the pathways that lead to severe maternal morbidity and death...
October 2016: Journal of Obstetrics and Gynaecology of India
Bradley M Wertheim, Andrew J Aguirre, Roby P Bhattacharyya, John Chorba, Ashutosh P Jadhav, Vanessa B Kerry, Eric A Macklin, Gabriela Motyckova, Shveta Raju, Kent Lewandrowski, Daniel P Hunt, Douglas E Wright
BACKGROUND: Overutilization of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily-implemented intervention to promote rational laboratory utilization without compromising resident education or patient care. METHODS: The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring lab orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering...
September 9, 2016: American Journal of Medicine
Junya Zhu, Liping Li, Zehui Zhou, Qingqing Lou, Albert W Wu
OBJECTIVES: Patient safety climate is associated with patient outcomes in hospitals around the world. A better understanding of how safety climate varies within and across hospitals will help identify improvement opportunities. We examined variations in safety climate by work area and job category in Chinese hospitals. METHODS: We administered the Chinese Hospital Survey on Patient Safety Climate in 2011 to workers in 6 hospitals in China, with completed surveys from 1464 (86% response)...
September 9, 2016: Journal of Patient Safety
Victoria M Steelman, Tamara L Williams, Marilyn K Szekendi, Amy L Halverson, Suzanne M Dintzis, Stephen Pavkovic
Context .- Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm. Objectives .- To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events. Design .- A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013)...
September 9, 2016: Archives of Pathology & Laboratory Medicine
Jessica Påfs, Aimable Musafili, Pauline Binder-Finnema, Marie Klingberg-Allvin, Stephen Rulisa, Birgitta Essén
BACKGROUND: Rwanda has made remarkable progress in decreasing the number of maternal deaths, yet women still face morbidities and mortalities during pregnancy. We explored care-seeking and experiences of maternity care among women who suffered a near-miss event during either the early or late stage of pregnancy, and identified potential health system limitations or barriers to maternal survival in this setting. METHODS: A framework of Naturalistic Inquiry guided the study design and analysis, and the 'three delays' model facilitated data sorting...
2016: BMC Pregnancy and Childbirth
Olga Gopan, Jing Zeng, Avrey Novak, Matthew Nyflot, Eric Ford
PURPOSE: The pretreatment physics plan review is a standard tool for ensuring treatment quality. Studies have shown that the majority of errors in radiation oncology originate in treatment planning, which underscores the importance of the pretreatment physics plan review. This quality assurance measure is fundamentally important and central to the safety of patients and the quality of care that they receive. However, little is known about its effectiveness. The purpose of this study was to analyze reported incidents to quantify the effectiveness of the pretreatment physics plan review with the goal of improving it...
September 2016: Medical Physics
Å Wahlberg, M Andreen Sachs, K Johannesson, G Hallberg, M Jonsson, A Skoog Svanberg, U Högberg
OBJECTIVE: To examine post-traumatic stress reactions among obstetricians and midwives, experiences of support and professional consequences after severe events in the labour ward. DESIGN: Cross-sectional online survey from January 7 to March 10, 2014. POPULATION: Members of the Swedish Society of Obstetrics and Gynaecology and the Swedish Association of Midwives. METHODS: Potentially traumatic events were defined as: the child died or was severely injured during delivery; maternal near-miss; maternal mortality; and other events such as violence or threat...
August 26, 2016: BJOG: An International Journal of Obstetrics and Gynaecology
Russell K McAllister, Robert T Booth, Timothy M Bittenbinder
Operating room surgical table failure is a rare event but can lead to a dangerous situation when it does occur. The dangers can be compounded in the presence of obesity, especially in the anesthetized or sedated patient. We present a case of a near-miss fall of a morbidly obese patient while turning the patient in preparation to transfer from the operating room table to the hospital bed when 2 fractured bolts in the tilt cylinder mechanism led to an operating room table failure.
September 2016: Journal of Clinical Anesthesia
Andreas Oldag, Jens Neumann, Michael Goertler, Hermann Hinrichs, Hans-Jochen Heinze, Andreas Kupsch, Catherine M Sweeney-Reed, Klaus Kopitzki
The measurement of autoregulatory delay by near-infrared spectroscopy (NIRS) has been proposed as an alternative technique to assess cerebral autoregulation, which is routinely assessed via transcranial Doppler sonography (TCD) in most centers. Comparitive studies of NIRS and TCD, however, are largely missing. We investigated whether cerebrovascular reserve (CVR), as assessed via TCD, correlates with the delay of the autoregulatory response to changes in arterial blood pressure (ABP) as assessed by NIRS, i...
November 2016: Journal of Neurology
Takeshi Otowa, Yoshiya Kawamura, Akizumi Tsutsumi, Norito Kawakami, Chiemi Kan, Takafumi Shimada, Tadashi Umekage, Kiyoto Kasai, Katsushi Tokunaga, Tsukasa Sasaki
Stressful events have been identified as a risk factor for depression. Although gene-environment (G × E) interaction in a limited number of candidate genes has been explored, no genome-wide search has been reported. The aim of the present study is to identify genes that influence the association of stressful events with depression. Therefore, we performed a genome-wide G × E interaction analysis in the Japanese population. A genome-wide screen with 320 subjects was performed using the Affymetrix Genome-Wide Human Array 6...
2016: PloS One
Dov Zohar, Jin Lee
The study was designed to test a multilevel path model whose variables exert opposing effects on school bus drivers' performance. Whereas departmental safety climate was expected to improve driving safety, the opposite was true for in-vehicle disruptive children behavior. The driving safety path in this model consists of increasing risk-taking practices starting with safety shortcuts leading to rule violations and to near-miss events. The study used a sample of 474 school bus drivers in rural areas, driving children to school and school-related activities...
October 2016: Accident; Analysis and Prevention
David Jones, Matt Hansen, Josh Van Otterloo, Caitlin Dickinson, Jeanne-Marie Guise
OBJECTIVE: Emergency medical services providers may be called to a variety of sites to transport pediatric patients, whether it be a scene call for initial evaluation and care, a clinic for transportation of a patient who has been assessed by medical providers, or a hospital where assessment and stabilization have already begun. We hypothesize that there may be a direct relationship between adverse event rates and adverse event severity in transports from less medically stabilizing origins...
July 12, 2016: Pediatric Emergency Care
Jennifer Brook, Marilia Amaro Calcia
Handover is a high risk point for errors in clinical care, in many cases leading to adverse events or near misses. The timely transfer of accurate and useful information between professionals is vital to ensure quality and safety, and to ensure the transfer of accountability for care. In this project standards were developed for quality handover between doctors in a liaison psychiatry department. The aim of these were to ensure adequate identification of patients, clear communication of tasks to be completed and relevant risk issues, as well as a guide to the priority of jobs...
2016: BMJ Quality Improvement Reports
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"