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Best practice error prevention

Andrew Y-Z Ou, Yu Jiang, Po-Liang Wu, Lui Sha, Richard B Berlin
In a medical environment such as Intensive Care Unit, there are many possible reasons to cause errors, and one important reason is the effect of human intellectual tasks. When designing an interactive healthcare system such as medical Cyber-Physical-Human Systems (CPHSystems), it is important to consider whether the system design can mitigate the errors caused by these tasks or not. In this paper, we first introduce five categories of generic intellectual tasks of humans, where tasks among each category may lead to potential medical errors...
January 2017: Journal of Medical Systems
Massimo Farina, Gianni De Paoli, Monica Canciani
PURPOSE: Raccomandazione 14 (Recommendation 14), issued by the Italian Ministry of Health, is aimed at providing requirements for preventing medication errors with antineoplastic drugs. Raccomandazione 14 covers all steps of the process, from supply to administration of therapies with specific conclusive guidance on tools and methods to be adopted for the assessment and management of clinical risk. METHODS: A form and a score system were designed and provided to healthcare professionals for self-assessment of adherence to Raccomandazione 14...
August 29, 2016: Tumori
Luciana Garbayo, James Stahl
Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued...
August 6, 2016: Medicine, Health Care, and Philosophy
Kyoko Shida, Toshiyasu Suzuki, Kazuhiro Sugahara, Kazuya Sobue
BACKGROUND: In the case of medication errors which are among the more frequent adverse events that occur in the hospital, there is a need for effective measures to prevent incidence. According to the Japan Society of Anesthesiologists study "Drug incident investigation 2005-2007 years", "Error of a syringe at the selection stage" was the most frequent (44.2%). The status of current measures and best practices implemented in Japanese hospitals was the focus of a subsequent investigation...
May 2016: Masui. the Japanese Journal of Anesthesiology
Peter J Franks, Judith Barker, Mark Collier, Georgina Gethin, Emily Haesler, Arkadiusz Jawien, Severin Laeuchli, Giovanni Mosti, Sebastian Probst, Carolina Weller
Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities...
June 2016: Journal of Wound Care
Aishwarya Navalpakam, Mohammed Dany, Inaya Hajj Hussein
Human Papillomavirus (HPV) vaccination decreases the risk for cervical cancer. However, the uptake of HPV vaccine remains low when compared with other recommended vaccines. This study evaluates the knowledge and attitudes towards HPV infection and vaccination, and the readiness for the uptake of HPV vaccine amongst female students attending Oakland University (OU) in Michigan, United States. This is a cross-sectional study targeting a randomized sample of a 1000 female OU students using an online questionnaire...
2016: PloS One
Rodolphe Charles, Josette Vallée, Claire Tissot, Frédéric Lucht, Elisabeth Botelho-Nevers
BACKGROUND: Vaccination is a common act in general practice in which, as in all procedures in medicine, errors may occur. To our best knowledge, in this area, few tools exist to prevent them. OBJECTIVE: To create a checklist that could be used in general practice in order to avoid the main errors. METHODS: From April to July 2013, we systematically searched for vaccination errors using three sources: a review of literature, individual interviews with 25 health care workers and supervised peer review groups meeting at the Medicine school of Saint-Etienne (France)...
August 2016: Family Practice
Michael E Hopkins, Robert V MacKenzie-Ross
BACKGROUND: Symptoms of theophylline toxicity and factors that augment the risk of developing it are well documented in the literature. However these appear to be poorly considered in clinical practice. This case underlines the challenges in recognising and managing theophylline toxicity; moreover the requirement for improved application of knowledge of its pharmacokinetics to our practice. CASE PRESENTATION: In this case we observe how theophylline toxicity can be overlooked due to the presence of non-specific symptoms and lack of a structured system to mitigate error in detection, in both hospital medicine and general practice...
2016: BMC Pharmacology & Toxicology
V D Mendelevich, K Yu Zalmunin
BACKGROUND: For many years, clinical protocols for treatment of drug abuse patients and treatment standards in Russian Federation were not grounded on the principles of evidence-based medicine [1]. Recommendations for use of certain drugs were not accompanied by any indication of the level of credibility of the evidence supporting it. The appearance in 2014 of such indications in clinical recommendations can be considered a significant step forward for the science of addiction medicine [2]...
2015: International Journal of Risk & Safety in Medicine
Jennifer L Cruz, Jamie N Brown
OBJECTIVES: Rigorous practices for safe dispensing of investigational drugs are not standardized. This investigation sought to identify error-prevention processes utilized in the provision of investigational drug services (IDS) and to characterize pharmacists' perceptions about safety risks posed by investigational drugs. METHODS: An electronic questionnaire was distributed to an audience of IDS pharmacists within the Veteran Affairs Health System. Multiple facets were examined including demographics, perceptions of medication safety, and standard processes used to support investigational drug protocols...
June 2015: Therapeutic Advances in Drug Safety
Michael J Robertson, Julian Tirado-Rives, William L Jorgensen
The development and validation of new peptide dihedral parameters are reported for the OPLS-AA force field. High accuracy quantum chemical methods were used to scan φ, ψ, χ1, and χ2 potential energy surfaces for blocked dipeptides. New Fourier coefficients for the dihedral angle terms of the OPLS-AA force field were fit to these surfaces, utilizing a Boltzmann-weighted error function and systematically examining the effects of weighting temperature. To prevent overfitting to the available data, a minimal number of new residue-specific and peptide-specific torsion terms were developed...
July 14, 2015: Journal of Chemical Theory and Computation
Samuel Pannick, Iain Beveridge, Hutan Ashrafian, Susannah J Long, Thanos Athanasiou, Nick Sevdalis
INTRODUCTION: The majority of preventable deaths in healthcare are due to errors on general wards. Staff perceptions of safety correlate with patient survival, but effectively translating ward teams' concerns into tangibly improved care remains problematic. The Hospital Event Analysis Describing Significant Unanticipated Problems (HEADS-UP) trial evaluates a structured, multidisciplinary team briefing, capturing safety threats and adverse events, with rapid feedback to clinicians and service managers...
2015: BMJ Open
Ayako Okochi, Etsuko Tadaka
OBJECTIVES: Self-management is essential for individuals with chronic cervical spinal cord injury, but some cases of self-neglect have been reported. The objective of this study was to examine the establishment of self-management in order to help inform community care practice. METHODS: This was a qualitative study applying a grounded theory approach with semi-structured home interviews. We interviewed 29 individuals with cervical spinal cord injuries (aged 26-77 years) who were members of each of the three branches of the nationwide self-help group, or the clients of a home-visit nursing care station...
2015: [Nihon Kōshū Eisei Zasshi] Japanese Journal of Public Health
Anne Lyren, Richard Brilli, Michael Bird, Nicholas Lashutka, Stephen Muething
OBJECTIVES: Building upon their previous collective success and a clinical imperative for rapid improvement, the eight tertiary pediatric referral centers in Ohio sought to dramatically decrease the most serious types of harm that occur to hospitalized children by collectively employing high reliability methods focused on safety culture. METHODS: With the support of the hospitals' executives, the Ohio collaborative obtained legal protection and built will by clearly identifying types and frequency of harm events that occur in each participating hospital and across the state...
July 2016: Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality
Sharon A Van Wicklin
Specific actions for handling various types of specimens may differ; however, the management process is essentially the same. Accurate specimen management requires effective multidisciplinary communication, minimal distractions, and awareness of the opportunities for error. When advocating for patients and working with members of the health care team to provide a safe perioperative environment, perioperative nurses should adhere to best practices for specimen management and strive to prevent specimen-related errors that may lead to inaccurate or incomplete diagnoses, the need for additional procedures, and perhaps most importantly, physical and psychological injury to patients...
May 2015: AORN Journal
Gregor Cevc
Partition coefficient, P, is the preferred descriptor of molecular lipo- or hydrophilicity, and thus of relationships between a solute (S, e.g., a drug), a polar medium (W, e.g., an aqueous buffer), and an essentially apolar, organic, medium or a drug carrier (O). The coefficient is commonly identified with the linear ratio of solute quantities in the two media, P=nSO/nSW, even to characterise solute association with or binding to a surface (e.g., of a HPLC column or a drug carrier). To check the latter practice correctness-and credibility of the prevailing P definition-this paper compares an ideal solute distribution between two separate homogeneous fluid media (i...
May 2015: European Journal of Pharmaceutics and Biopharmaceutics
Michael Schivo, Chinh Phan, Samuel Louie, Richart W Harper
Critical asthma syndrome represents the most severe subset of asthma exacerbations, and the critical asthma syndrome is an umbrella term for life-threatening asthma, status asthmaticus, and near-fatal asthma. According to the 2007 National Asthma Education and Prevention Program guidelines, a life-threatening asthma exacerbation is marked by an inability to speak, a reduced peak expiratory flow rate of <25 % of a patient's personal best, and a failed response to frequent bronchodilator administration and intravenous steroids...
February 2015: Clinical Reviews in Allergy & Immunology
James K H Luk, T Y Chan, Daniel K Y Chan
Falls are a common problem in the elderly. A common error in their management is that injury from the fall is treated, without finding its cause. Thus a proactive approach is important to screen for the likelihood of fall in the elderly. Fall assessment usually includes a focused history and a targeted examination. Timed up-and-go test can be performed quickly and is able to predict the likelihood of fall. Evidence-based fall prevention interventions include multi-component group or home-based exercises, participation in Tai Chi, environmental modifications, medication review, management of foot and footwear problems, vitamin D supplementation, and management of cardiovascular problems...
April 2015: Hong Kong Medical Journal, Xianggang Yi Xue za Zhi
Susan A Cotter, Lynn A Cyert, Joseph M Miller, Graham E Quinn
PURPOSE: This article provides recommendations for screening children aged 36 to younger than 72 months for eye and visual system disorders. The recommendations were developed by the National Expert Panel to the National Center for Children's Vision and Eye Health, sponsored by Prevent Blindness, and funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration, United States Department of Health and Human Services. The recommendations describe both best and acceptable practice standards...
January 2015: Optometry and Vision Science: Official Publication of the American Academy of Optometry
Giuseppe Lippi, Giuseppe Banfi, Stephen Church, Michael Cornes, Gabriella De Carli, Kjell Grankvist, Gunn B Kristensen, Mercedes Ibarz, Mauro Panteghini, Mario Plebani, Mads Nybo, Stuart Smellie, Martina Zaninotto, Ana-Maria Simundic
Laboratory diagnostics develop through different phases that span from test ordering (pre-preanalytical phase), collection of diagnostic specimens (preanalytical phase), sample analysis (analytical phase), results reporting (postanalytical phase) and interpretation (post-postanalytical phase). Although laboratory medicine seems less vulnerable than other clinical and diagnostic areas, the chance of errors is not negligible and may adversely impact on quality of testing and patient safety. This article, which continues a biennial tradition of collective papers on preanalytical quality improvement, is aimed to provide further contributions for pursuing quality and harmony in the preanalytical phase, and is a synopsis of lectures of the third European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)-Becton Dickinson (BD) European Conference on Preanalytical Phase meeting entitled 'Preanalytical quality improvement...
February 2015: Clinical Chemistry and Laboratory Medicine: CCLM
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