Vignettes in Patient Safety - Volume 3最新文献

Transfusion Error in the Gynecology Patient: A Case Review with Analysis 妇科患者输血错误一例回顾与分析

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.79184

C. Hornis, R. Vigh, J. Zabo, E. Dierking

引用次数: 2

Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense 在手术室避免火灾:预防和常识的交集

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.76210

M. Saeed, M. Swaroop, Franz S. Yanagawa, A. Buono, S. Stawicki

{"title":"Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense","authors":"M. Saeed, M. Swaroop, Franz S. Yanagawa, A. Buono, S. Stawicki","doi":"10.5772/INTECHOPEN.76210","DOIUrl":"https://doi.org/10.5772/INTECHOPEN.76210","url":null,"abstract":"The operating room (OR) is a complex environment that involves large teams and multiple competing priorities, dynamically interacting throughout the entire course of a surgical procedure. The simultaneous presence of flammable substances, volatile gases, and the frequent use of electrical current results in a potentially dangerous combination. Operating room fire (ORF) is a rare but potentially devastating occurrence. To prevent this “never event”, it is critical for institutions to establish and follow proper fire safety protocols. Adherence to proven prevention strategies and awareness of associated risk factors will help reduce the incidence of this dreaded safety event. When ORF does occur despite strict adherence to established safety protocols, the entire OR team should know the steps required to contain and extinguish the fire as well as essential measures to minimize or avoid thermal injury. If injury does occur, it is important to recognize and treat it promptly. Appropriate and honest disclosure to all injured persons and their families should be made without delay. As with all serious patient safety events, regulatory reporting and root cause determinations must take place in accordance with applicable laws and regulations. The goal of patient safety champions at each institution should be the attainment of zero incidence of ORF.","PeriodicalId":222529,"journal":{"name":"Vignettes in Patient Safety - Volume 3","volume":"12 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121690149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1

Fact versus Conjecture: Exploring Levels of Evidence in the Context of Patient Safety and Care Quality 事实与猜想:探索患者安全和护理质量背景下的证据水平

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.76778

M. Saeed, M. Swaroop, D. Ackerman, Diana Tarone, J. Rowbotham, S. Stawicki

{"title":"Fact versus Conjecture: Exploring Levels of Evidence in the Context of Patient Safety and Care Quality","authors":"M. Saeed, M. Swaroop, D. Ackerman, Diana Tarone, J. Rowbotham, S. Stawicki","doi":"10.5772/INTECHOPEN.76778","DOIUrl":"https://doi.org/10.5772/INTECHOPEN.76778","url":null,"abstract":"Evidence-based medicine (EBM) can be defined as the integration of optimized clinical judgment, patient values, and available evidence. It is a philosophical approach to making the best possible clinical decisions for individual patients. Based on objective evaluation and categorization of methodological design and data quality, all existing literature can be organized according to a hierarchy of “ evidence quality ” that helps determine the applicability and value of scientific findings in terms of clinical implementation and the poten- tial to change existing patterns of practice. In terms of general categorization of scientific impact, randomized controlled trials (RCTs) are placed on top of the hierarchy, followed by systematic reviews of randomized controlled trials (RCTs), quasi-randomized designs, observational studies including retrospective case series, and finally case reports and expert opinion. Each study design is susceptible to certain limitations and biases, highlighting the importance of both clinical and scientific acumen of the interpreting provider. Such approach is critical to determining the value and the applicability of study recommendations in everyday practice. Evidence-based practice (EBP) has become one of the fundamental components of modern medicine and plays an indispensible role in the development (and improvement) of patient care and safety worldwide. Furthermore, organizations that create guidelines and policies for the management of specific conditions, often base the content and strength of their recommendations on the quality of evidence available to expert decision-makers. Therefore, understanding the “ state of the science ” upon which those recommendations are based will help guide the medical practitioner on “ if,","PeriodicalId":222529,"journal":{"name":"Vignettes in Patient Safety - Volume 3","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133919616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 7

Patient Safety Issues in Pathology: From Mislabeled Specimens to Interpretation Errors 病理学中的患者安全问题:从错误标记的标本到解释错误

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.79634

D. Tang, Peter A. Dowbeus, M. Firstenberg, T. Papadimos

{"title":"Patient Safety Issues in Pathology: From Mislabeled Specimens to Interpretation Errors","authors":"D. Tang, Peter A. Dowbeus, M. Firstenberg, T. Papadimos","doi":"10.5772/INTECHOPEN.79634","DOIUrl":"https://doi.org/10.5772/INTECHOPEN.79634","url":null,"abstract":"Catastrophic breaches in patient safety often involve point-of-care settings such as the operating theater or intensive care unit, quite frequently without due consideration given to the elements leading up to such errors. Among such occurrences, wrong site procedures (WSPs) and diagnostic discrepancies continue to result in significant morbidity and mor tality among patients. Addressing adverse events is difficult for all stakeholders involved. Furthermore, clinician familiarity with the workflow specific to particular disciplines or procedures may be poor, amplifying communication lapses that precede patient safety occurrences. The patient care paradigm has become increasingly multidisciplinary, and it is important to discuss, improve, and be more cognizant of measures required to achieve “zero defect” performance. Despite the rarity of “never events,” their consequences may damage patient and community trust, provider morale, and institutional reputation. This chapter aims to assess current preventive measures and risks in the context of errors involving surgical pathology in the setting of the operating theater utilizing the framework of clinical vignettes. The discussion below will further center on the practical and inter pretative errors that occur in the pathological workflow, and the potential for compound - ing of such errors in the operating theater. Definitions concerning WSP and diagnostic discrepancies will be outlined to characterize potential outcomes of communication errors.","PeriodicalId":222529,"journal":{"name":"Vignettes in Patient Safety - Volume 3","volume":"365 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131056053","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Introductory Chapter: Medical Error and Associated Harm - The The Critical Role of Team Communication and Coordination 导论章:医疗差错和相关伤害——团队沟通和协调的关键作用

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.78014

Alyssa M. Green, S. Stawicki, M. Firstenberg

引用次数: 5

Adverse Events in Hospitals: “Swiss Cheese” Versus the “Hierarchal Referral Model of Care and Clinical Futile Cycles” 医院不良事件:“瑞士奶酪”与“分级转诊模式与临床无效循环”

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.75380

M. Buist

{"title":"Adverse Events in Hospitals: “Swiss Cheese” Versus the “Hierarchal Referral Model of Care and Clinical Futile Cycles”","authors":"M. Buist","doi":"10.5772/INTECHOPEN.75380","DOIUrl":"https://doi.org/10.5772/INTECHOPEN.75380","url":null,"abstract":"The James Reason ‘Swiss Cheese’ model of adverse event causation has been the predom- inant principle in the determination and prevention of health-care-associated adverse events for the last 20 years. This model was developed to understand the causation of large-scale organisational and industrial accidents. In principle, it looks for holes in the defence layers of a large organisation that are largely administrative and not the fault of individuals that may be directly involved with the accident. This model has limitations when applied to health care, where most of the errors or accidents are individual technical or competency deficiencies within a background of an ever-changing micro socio-cultural environment. As such, using ‘Swiss Cheese’ methodology, there has been an over reliance on looking for system issues in health care that has led to a decreased focus on the individual performance of the health-care professional and avoidance of difficult cultural workplace issues. Clinical futile cycles (CFCs) are a model of adverse event causation that primarily focuses on the interaction between the immediate health- care professionals and patients and between health-care professionals. This focus allows for interventions that address issues such as clinical competency and the culture of the health-care environment. later found widespread bowel and hepatic ischaemia, and Mrs. M died the next day of multi-organ failure (Day-6).","PeriodicalId":222529,"journal":{"name":"Vignettes in Patient Safety - Volume 3","volume":"19 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133062583","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1

Adverse Events during Intrahospital Transfers: Focus on Patient Safety 院内转院期间的不良事件:关注患者安全

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.76777

J. Tolentino, Jennifer Schadt, B. Bird, Franz S. Yanagawa, T. Zanders, S. Stawicki

{"title":"Adverse Events during Intrahospital Transfers: Focus on Patient Safety","authors":"J. Tolentino, Jennifer Schadt, B. Bird, Franz S. Yanagawa, T. Zanders, S. Stawicki","doi":"10.5772/INTECHOPEN.76777","DOIUrl":"https://doi.org/10.5772/INTECHOPEN.76777","url":null,"abstract":"Additional information available at the end of the chapter Abstract Intrahospital transport of patients constitutes an integral part of care delivery in the complex environment of modern hospitals. In general, the more complicated and acute the patient ’ s condition is, the more likely he or she will require both scheduled and unscheduled trips. The purpose of this chapter is to highlight the potential adverse events associated with intrahospital transfers (IHTs), to discuss the interdepartmental handoff process when patients travel within the walls of a single institution, and finally to provide strategies to prevent adverse events from occurring during the IHT process. A comprehensive literature review, covering some of the most recent developments in this area, has been included in this manuscript. Aspects unique to this presentation include sections dedicated to risk assessment, commonly seen patterns of transfers and complications, as well as the inclusion of family communication as a core component of the process. The overall goal of providers and patient safety champions should be the achievement of “ zero incidence ” rate of IHT-related events. We hope that this chapter provides a small, but significant, step in the right direction.","PeriodicalId":222529,"journal":{"name":"Vignettes in Patient Safety - Volume 3","volume":"36 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116136978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 7

Learning of Patient Safety in Health Professions Education 卫生专业教育中的患者安全学习

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.75973

Shimaa Elaraby, Rabab Abdel Ra'oof, Rania Alkhadragy

引用次数: 4

Patient Safety Culture in Tunisia: Defining Challenges and Opportunities 突尼斯的患者安全文化:确定挑战和机遇

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-09-05 DOI: 10.5772/INTECHOPEN.73155

M. Mallouli, W. Aouicha, Mohamed Ayoub Tlili, M. B. Dhiab

{"title":"Patient Safety Culture in Tunisia: Defining Challenges and Opportunities","authors":"M. Mallouli, W. Aouicha, Mohamed Ayoub Tlili, M. B. Dhiab","doi":"10.5772/INTECHOPEN.73155","DOIUrl":"https://doi.org/10.5772/INTECHOPEN.73155","url":null,"abstract":"Background: Although adverse events in health care have been a center of attention recently, patient safety culture in primary care is relatively neglected. This study aimed to provide a baseline assessment of patient safety culture in the primary healthcare centers and explore its associated factors. Methods: This is a multicenter cross-sectional descriptive study. It was conducted in the center of Tunisia over a period of 4 months. It surveyed 30 primary healthcare centers, thus 251 staff members. It used the French-validated version of the Hospital Survey on Patient Safety Culture questionnaire. Results: The total number of respondents was 214 participants with a response rate of 85%. The dimension of “teamwork within units” had the highest score (71.47%). Though, three safety dimensions had very low scores, which are “frequency of event reporting,” “on-punitive response to errors,” and “staffing” with the following percentages 31.43, 35.36, and 38.43%, respectively. As for associated factors, the dimension of “Frequency of reported events” was significantly higher among professionals involved in risk management committees (p = 0.01). Conclusion: This study demonstrated that the level of the patient safety culture needs to be improved in primary healthcare centers in Tunisia. As well, the results obtained highlight the necessity of the implementation of quality management system in primary healthcare centers.","PeriodicalId":222529,"journal":{"name":"Vignettes in Patient Safety - Volume 3","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129121755","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 2

Defining Adverse Events and Determinants of Medical Errors in Healthcare 定义医疗保健中医疗差错的不良事件和决定因素

Vignettes in Patient Safety - Volume 3 Pub Date : 2018-04-04 DOI: 10.5772/INTECHOPEN.75616

V. Kapaki, K. Souliotis

{"title":"Defining Adverse Events and Determinants of Medical Errors in Healthcare","authors":"V. Kapaki, K. Souliotis","doi":"10.5772/INTECHOPEN.75616","DOIUrl":"https://doi.org/10.5772/INTECHOPEN.75616","url":null,"abstract":"The concept of error typically regards an action, not its outcome, and its meaning becomes clear when separated into categories (medical error, nurse perceptions of (medication) error, diagnostic error). One wrong action may or may not lead to an adverse event either because the abovementioned action did not cause any serious damage to patients’ health condition or because it was promptly detected and corrected. The concept of error, on the contrary, which is used alternatively in the study, refers to the adverse outcome of an action. The responsibility for the emergence of errors in healthcare systems is shared among the nature of the healthcare system that is governed by organizational and functional complexity, the multifaceted and uncertain nature of medical science, and the imperfections of human nature. Medical errors should be examined as errors of the healthcare system, in order to identify their root causes and develop preventive mea- sures. The main aims of this chapter are the following: (1) to understand medical errors and adverse events and define the terms that describe them; and (2) the most excellent way to comprehend how medical errors and adverse events occur and how to prevent them. Moreover it makes clear their classification and their determinants.","PeriodicalId":222529,"journal":{"name":"Vignettes in Patient Safety - Volume 3","volume":"58 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-04-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126738873","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 4