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1.
Medicine (Baltimore) ; 98(41): e17569, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593143

RESUMO

Near misses and unsafe conditions have become more serious for patients in emergency departments (EDs). We aimed to search the near misses and unsafe conditions that occurred in an ED to improve patient safety.This was a retrospective analysis of a 10-year observational period from January 1, 2007 to December 31, 2016. We gained access to the adverse event notification forms (AENFs) sent to the hospital quality department from the ED. Patient age, sex, and date of presentation were recorded. The near misses and unsafe conditions were classified into 7 types: medication errors, falls, management errors, penetrative-sharp tool injuries, incidents due to institution security, incidents due to medical equipment, and forensic events. The outcome of these events was recorded.A total of 220 AENF were reported from 294,673 ED visits. The median age of the 166 patients was 60 (21-95) years. Of these, 57.1% of the patients were females and 47.9% were males. The most commonly reported events were medication errors (32.7%) and management errors (27.3%). The median age of falling patients was 67.5 years. The nurse-patient ratio between 2007 to 2011 and 2011 to 2016 were 1/10 and 1/7, respectively. We found that when this ratio increased, the adverse events results were less significant (P < .003).This was the 1st study investigating the adverse events in ED in Turkey. The reporting ratio of 0.07% for the total ED visits was too low. This showed that adverse events were under-reported.


Assuntos
Serviço Hospitalar de Emergência/normas , Erros de Medicação/estatística & dados numéricos , Segurança do Paciente/normas , Acidentes por Quedas/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Erros Médicos/classificação , Erros Médicos/estatística & dados numéricos , Erros de Medicação/classificação , Pessoa de Meia-Idade , Ferimentos Penetrantes Produzidos por Agulha/classificação , Segurança do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Medidas de Segurança/classificação , Turquia/epidemiologia
3.
Clin Orthop Relat Res ; 477(1): 130-133, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30794236

RESUMO

BACKGROUND: Implant selection in the operating room is a manual process. This manual process combined with complex compatibility rules and inconsistent implant labeling may lead to implant-selection errors. These might be reduced using an automated process; however, little is known about the efficacy of available automated error-reduction systems in the operating room. QUESTIONS/PURPOSES: (1) How often do implant-selection errors occur at a high-volume institution? (2) What types of implant-selection errors are most common? METHODS: We retrospectively evaluated our implant log database of 22,847 primary THAs and TKAs to identify selection errors. There were 10,689 THAs and 12,167 TKAs included during the study period from 2012 to 2017; there were no exclusions and we had no missing data in this study. The system provided an output of errors identified, and these errors were then manually confirmed by reviewing implant logs for each case found in the medical records. Only those errors that were identified by the system were manually confirmed. During this time period all errors for all procedures were captured and presented as a proportion. Errors identified by the software were manually confirmed. We then categorized each mismatch to further delineate the nature of these events. RESULTS: One hundred sixty-nine errors were identified by the software system just before implantation, representing 0.74 of the 22,847 procedures performed. In 15 procedures, the wrong side was selected. Twenty-five procedures had a femoral head selected that did not match the acetabular liner. In one procedure, the femoral head taper differed from the femoral stem taper. There were 46 procedures in which there was a size mismatch between the acetabular shell and the liner. The most common error in TKA that occurred in 46 procedures was a mismatch between the tibia polyethylene insert and the tibial tray. There were 13 procedures in which the tibial insert was not matched to the femoral component according to the manufacturer's guidelines. Selection errors were identified before implantation in all procedures. CONCLUSIONS: Despite an automated verification process, 0.74% of the arthroplasties performed had an implant-selection error that was identified by the software verification. The prevalence of incorrect/mismatched hip and knee prostheses is unknown but almost certainly underreported. Future studies should investigate the prevalence of these errors in a multicenter evaluation with varying volumes across the involved sites. Based on our results, institutions and management should consider an automated verification process rather than a manual process to help decrease implant-selection errors in the operating room. LEVEL OF EVIDENCE: Level IV, therapeutic study.


Assuntos
Artroplastia de Quadril/instrumentação , Artroplastia do Joelho/instrumentação , Comportamento de Escolha , Tomada de Decisão Clínica , Sistemas de Apoio a Decisões Clínicas , Técnicas de Apoio para a Decisão , Prótese de Quadril , Prótese do Joelho , Erros Médicos/prevenção & controle , Automação , Hospitais com Alto Volume de Atendimentos , Humanos , Erros Médicos/classificação , Salas Cirúrgicas , Rotulagem de Produtos , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Desenho de Programas de Computador
4.
J Am Coll Radiol ; 16(3): 282-288, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30528933

RESUMO

PURPOSE: The aim of this study was to measure diagnostic imaging safety events reported to an electronic safety reporting system and assess steps at which they occurred within the diagnostic imaging workflow and contributing sociotechnical factors. METHODS: The authors evaluated all electronic safety reporting system reports related to diagnostic imaging during calendar year 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and 680,000 diagnostic imaging studies annually. Each report was assigned a harm score ranging from 0 to 4 by the reporter; scores of 2 (minor harm) to 4 (death) were classified as "potential harm." Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and sociotechnical factors per the Systems Engineering Initiative for Patient Safety framework. The κ coefficient was used to measure interreviewer agreement on 10% of reports. The percentage of reports that could cause "potential harm" was compared for each step and sociotechnical factor using χ2 analysis. RESULTS: Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was imaging procedure (54% of reports), potential harm occurred more in result communication (odds ratio, 2.36; P = .05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to tasks compared with person factors (odds ratio, 5.03; P < .0001). The κ coefficient was 0.79. CONCLUSIONS: Safety events were related to diagnostic imaging in 7% of reported events. Potential harm occurred primarily during imaging procedure and result communication. Safety events were attributed to multifactorial sociotechnical factors. Further work is necessary to decrease safety events related to diagnostic imaging.


Assuntos
Diagnóstico por Imagem/efeitos adversos , Erros Médicos/classificação , Segurança do Paciente , Centros Médicos Acadêmicos/estatística & dados numéricos , Coleta de Dados , Humanos , Erros Médicos/estatística & dados numéricos , Serviço Hospitalar de Radiologia/estatística & dados numéricos , Fluxo de Trabalho
5.
J Evid Based Med ; 12(2): 91-97, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30511516

RESUMO

OBJECTIVES: The purpose of this study was to describe the level, preventability and categories of adverse events (AEs) in Chinese geriatric patients identified by medical record review using the Global Trigger Tool. The applicability of the GTT was also assessed to explore possible modifications for trigger tools. METHODS: The study was conducted at a 4300-bed tertiary teaching hospital. Twenty randomly-selected medical records for patients over 60 were reviewed every 2 weeks from January 1 2015 to December 31st, 2015. We studied 480 medical records in total. Two trained specialists reviewed the presence of AEs using 43 triggers, and a physician reviewed and validated the findings. The outcome measures included the number of AEs per 1000 patient days, AEs per 100 admissions, the percentage of entries with at least 1 AE and AE categorisation. Also, we carried out a descriptive analysis of the suspected factors of AEs, such as age, gender, length of stay, surgery. RESULTS: A total of 610 AEs were detected in the 480 medical records reviewed, corresponding to 127 injuries per 100 admissions. The number of AEs per 1000 patient days was 22.43. AEs occurred at least once in 329 (68.54%) patients. The rate of care harms ranked highest of all AEs, followed by the rate of medication harms and surgical harms. Patients with a more extended hospital stay or surgery was more likely to experience AEs. However, there was a negative correlation between age and the rate of AEs. CONCLUSION: The Global Trigger Tool was a useful method for detecting the characteristics of AEs in geriatric patients in a Chinese tertiary teaching hospital. To improve patients' safety, this tool should be incorporated into routine screening systems.


Assuntos
Hospitais Universitários/estatística & dados numéricos , Auditoria Médica/métodos , Erros Médicos/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , China , Feminino , Hospitais Universitários/normas , Humanos , Tempo de Internação , Masculino , Erros Médicos/classificação , Erros de Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Segurança do Paciente , Estudos Retrospectivos
6.
Angiol Sosud Khir ; 24(4): 11-17, 2018.
Artigo em Russo | MEDLINE | ID: mdl-30531764

RESUMO

The article deals with the analysis of retrospective and prospective studies dedicated to examining patient safety regarding epidemiology, frequency and severity of adverse events associated with rendering medical care. Electronic retrieval was carried out over the period from 1990 to 2017 using the following databases: MEDLINE, Cochrane Collaboration, EMBASE, SCOPUS, ISI Web of Science. The carried out meta-analysis made it possible to determine that cases of doing harm (adverse events) while rendering medical care are registered in 10.6% of patients. More than 80% of adverse events occur in hospital, with more than half of them revealed in the operating room and about third in a patient ward. While rendering medical care outside hospital, more often cases of doing harm are observed due to medical errors made in the physician's office and due to the patient's behaviour at home. The majority of adverse events appeared to be associated with performing an operation, manipulation, carrying out drug therapy, late or inappropriate treatment and diagnosis. Unexpected death secondary to unfavourable events is observed in 5.3% of patients. In the structure of in-hospital mortality, the proportion of deaths associated with rendering medical care accounts for 24.9% and in the structure of overall population mortality - for 9.7%, ranking third amongst all causes.


Assuntos
Erros Médicos , Administração dos Cuidados ao Paciente , Segurança do Paciente , Humanos , Erros Médicos/classificação , Erros Médicos/mortalidade , Erros Médicos/prevenção & controle , Mortalidade , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Gestão de Riscos
7.
Int J Health Care Qual Assur ; 31(8): 1014-1029, 2018 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-30415623

RESUMO

PURPOSE: The purpose of this paper is to present a review of health information system (HIS)-induced errors and its management. This paper concludes that the occurrence of errors is inevitable but it can be minimised with preventive measures. The review of classifications can be used to evaluate medical errors related to HISs using a socio-technical approach. The evaluation could provide an understanding of errors as a learning process in managing medical errors. DESIGN/METHODOLOGY/APPROACH: A literature review was performed on issues, sources, management and approaches to HISs-induced errors. A critical review of selected models was performed in order to identify medical error dimensions and elements based on human, process, technology and organisation factors. FINDINGS: Various error classifications have resulted in the difficulty to understand the overall error incidents. Most classifications are based on clinical processes and settings. Medical errors are attributed to human, process, technology and organisation factors that influenced and need to be aligned with each other. Although most medical errors are caused by humans, they also originate from other latent factors such as poor system design and training. Existing evaluation models emphasise different aspects of medical errors and could be combined into a comprehensive evaluation model. RESEARCH LIMITATIONS/IMPLICATIONS: Overview of the issues and discourses in HIS-induced errors could divulge its complexity and enable its causal analysis. PRACTICAL IMPLICATIONS: This paper helps in understanding various types of HIS-induced errors and promising prevention and management approaches that call for further studies and improvement leading to good practices that help prevent medical errors. ORIGINALITY/VALUE: Classification of HIS-induced errors and its management, which incorporates a socio-technical and multi-disciplinary approach, could guide researchers and practitioners to conduct a holistic and systematic evaluation.


Assuntos
Sistemas de Informação em Saúde/organização & administração , Erros Médicos/classificação , Erros Médicos/estatística & dados numéricos , Protocolos Clínicos/normas , Técnicas e Procedimentos Diagnósticos/normas , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Meio Ambiente , Sistemas de Informação em Saúde/normas , Humanos , Erros Médicos/prevenção & controle , Erros de Medicação/classificação , Erros de Medicação/estatística & dados numéricos , Modelos Organizacionais , Alta do Paciente/normas , Alta do Paciente/estatística & dados numéricos , Carga de Trabalho
8.
Br Dent J ; 225(4): 291-292, 2018 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-30117499

RESUMO

NHS England has set out plans for combatting the rise in never events in the realm of dentistry. This Opinion article investigates the root cause of never events, whether a wrong site surgery should be deemed a never event, and whether the approaches adopted to reduce risk exposure, such as local safety standards for invasive procedures (LocSSIPS), are helping or hindering safe medical care.


Assuntos
Erros Médicos/classificação , Medicina Estatal , Extração Dentária , Humanos , Reino Unido
9.
Nurse Educ Today ; 70: 34-39, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30145532

RESUMO

OBJECTIVE: This study was to investigate the differences in the types, frequency, and perspectives of self-reported adverse events reported following simulation encounters between students enrolled in two Bachelor of Science in Nursing (BSN) programs: accelerated option (AO-BSN) or traditional (T-BSN) and by role (participant or observer) during simulation. METHODS: This study analyzed 6994 adverse event reports entered by students through the simulated adverse event reporting system. RESULTS: The AO-BSN students reported a higher percentage of adverse events coded as errors. In contrast the T-BSN students reported more near misses and sentinel events. Further, the T-BSN students significantly reported more fall related errors, while AO-BSN students reported more confidentiality breach errors. Participants reported more medication errors, whereas observers reported more airway and fall categorized errors. CONCLUSION: The vantage from which adverse events are viewed and educational track appear to alter slightly the perceptions of the precipitating factors leading to committed or observed adverse events.


Assuntos
Erros Médicos/estatística & dados numéricos , Treinamento por Simulação/métodos , Estudantes de Enfermagem/estatística & dados numéricos , Atitude do Pessoal de Saúde , Bacharelado em Enfermagem , Humanos , Erros Médicos/classificação
10.
BMC Fam Pract ; 19(1): 121, 2018 07 19.
Artigo em Inglês | MEDLINE | ID: mdl-30025528

RESUMO

BACKGROUND: Patient safety incidents (PSIs) frequently occur in primary care and are often considered to be preventable. Better knowledge of factors contributing to PSIs is required to build safer care. The aim of this work was to describe the underlying factors, specifically the human factors, that are associated with PSIs in primary care using CADYA ("CAtégorisation des DYsfonctionnements en Ambulatoire" or "Categorization of Errors in Primary Care"). METHODS: We followed a mixed method with content analysis and coding in CADYA of PSIs reported in the ESPRIT study, a French cross-sectional survey of primary care. For each incident, a main contributing factor (MD) and, if applicable, a secondary contributing factor (SD) were identified. Several descriptive keywords from an incremental glossary have been suggested to describe each identified human factor (attitudes or behaviours). A descriptive statistical analysis was then conducted. RESULTS: Among the 482 PSIs reported in the ESPRIT study, from 13,438 acts reported by 127 participating general practitioners (GPs), we identified 590 contributing factors (482 MDs and 178 SDs). Overall, 35% were related to the care process, 30% to human factors, 22% to the healthcare environment and 13% to technical factors. The contributing factors, in decreasing order of frequency, were communication errors (13.7%), human factors related to healthcare providers (12.9%) and human factors related to patients (12.9%). The human factors were mainly related to 'lack of attention', 'stress', 'anger' and 'fatigue'. CONCLUSIONS: Our results tend to prove that human factors are often involved in PSIs in primary care, with GPs and patients being equally responsible. Beyond the identification of communication errors, often found in other international research, we have described the attitudes and behaviours contributing to unsafe care. Further research exploring the links between working conditions and human factors is required.


Assuntos
Erros Médicos/classificação , Segurança do Paciente , Atenção Primária à Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos Transversais , Feminino , França , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Fatores de Risco , Adulto Jovem
11.
J Eval Clin Pract ; 24(4): 752-757, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29947085

RESUMO

RATIONALE, AIMS, AND OBJECTIVES: Patient safety is recognized as a key indicator of quality of medical care. International experience has shown that all efforts should focus on the delivery of a safer work environment and health care system as a whole in order to reduce or mitigate medical errors and their impact on society. The aim of this study is to investigate and classify the most common incidents regarding patient safety as well as their contributory factors, based on personal real-life experiences and situations in medical care reported by health care professionals. METHODS: A mixed-methods study design was used. Sixty-five respondents participated (aged from 23 to 58 y). Reported cases of undesirable events (UE), medical errors (ME), and near misses (NM) were collected, processed, and analysed based on our original conceptual framework. A qualitative content analysis and descriptive statistics were conducted on the narratives in all 34 reported valid case files. Intercoder reliability was measured through the kappa statistics (κ = .69). The overall agreement of judgments on all codes was excellent (95%). RESULTS: A total of 29 MEs in 34 cases were reported. In 85% of them, an average of 1.83 contributory factors were identified. The most common contributory factors were "Incompetence," "Neglect," "Severe work overload," and "Shortage of staff." DISCUSSION: Important steps to prevent medical errors are their identification and reporting. CONCLUSION: Health care professionals appear able to report UEs, MEs, and NMs occurring in medical care practice. They seem more willing to report and distinguish incidents related to MEs than to UEs and NMs.


Assuntos
Assistência à Saúde/normas , Erros Médicos/prevenção & controle , Segurança do Paciente , Adulto , Bulgária , Feminino , Humanos , Masculino , Erros Médicos/classificação , Pessoa de Meia-Idade , Segurança do Paciente/normas , Segurança do Paciente/estatística & dados numéricos , Melhoria de Qualidade , Projetos de Pesquisa , Gestão de Riscos/organização & administração , Gestão de Riscos/normas
12.
Jt Comm J Qual Patient Saf ; 44(4): 212-218, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29579446

RESUMO

BACKGROUND: More than half of the 50 states (27) and the District of Columbia require reporting of Serous Reportable Events (SREs). The goal is to hold providers accountable and improve patient safety, but there is little information about the administrative cost of this reporting requirement. This study was conducted to identify costs associated with investigating and reporting SREs. METHODS: This qualitative study used case study methods that included interviewing staff and review of data and documents to investigate each SRE occurring at one academic medical center during fiscal year 2013. A framework of tasks and a model to categorize costs was created. Time was summarized and costs were estimated for each SRE. RESULTS: The administrative cost to process 44 SREs was estimated at $353,291, an average cost of $8,029 per SRE, ranging $6,653 for an environmental-related SRE to $21,276 for a device-related SRE. Care management SREs occurred most frequently, costing an average $7,201 per SRE. Surgical SREs, the most expensive on average, cost $9,123 per SRE. Investigation of events accounted for 64.5% of total cost; public reporting, 17.2%; internal reporting, 10.2%; finance and administration, 6.0%; and 2.1%, other. Even with 26 states mandating reporting, the 17.2% incremental cost of public reporting is substantial. CONCLUSION: Policy makers should consider the opportunity costs of these resources, averaging $8,029 per SRE, when mandating reporting. The benefits of public reporting should be collectively reviewed to ensure that the incremental costs in this resource-constrained environment continue to improve patient safety and that trade-offs are acknowledged.


Assuntos
Documentação/economia , Erros Médicos/estatística & dados numéricos , Humanos , Entrevistas como Assunto , Joint Commission on Accreditation of Healthcare Organizations , Erros Médicos/classificação , Modelos Econômicos , Pesquisa Qualitativa , Fatores de Tempo , Estados Unidos
13.
AORN J ; 107(2): 225-235, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29385247

RESUMO

Medical errors involve different health care professionals, are multifaceted, and can occur at the individual practitioner or system level. The conditions for errors vary in the health care environment; some practice areas may be more vulnerable to errors than others. Limited research exists that explores perioperative nursing errors. The purpose of this study was to describe and interpret the experiences of perioperative nurses related to intraoperative errors. We used the hermeneutic phenomenological method. Ten perioperative RNs participated in focus group interviews that we audio-recorded and transcribed. We analyzed data using thematic analysis, and three themes emerged that represent the essence of the experience of nurses involved in intraoperative errors: environment, being human, and moving forward. The findings support efforts to improve quality care and foster a culture of safety in the OR through strategies such as perioperative staff training, interprofessional team building, and controlling environmental factors that are distracting.


Assuntos
Erros Médicos/psicologia , Enfermeiras e Enfermeiros/psicologia , Adulto , Feminino , Grupos Focais/métodos , Humanos , Masculino , Erros Médicos/classificação , Erros Médicos/enfermagem , Pessoa de Meia-Idade , Enfermagem Perioperatória/métodos , Pesquisa Qualitativa
15.
Nurs Inq ; 25(2): e12225, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28980365

RESUMO

In recent decades, debate on the quality and safety of healthcare has been dominated by a measure and manage administrative rationality. More recently, this rationality has been overlaid by ideas from human factors, ergonomics and systems engineering. Little critical attention has been given in the nursing literature to how risk of harm is understood and actioned, or how patients can be subjectified and marginalised through these discourses. The problem of assuring safety for particular patient groups, and the dominance of technical forms of rationality, has seen the word 'unavoidable' used in connection with intractable forms of patient harm. Employing pressure injury policy as an exemplar, and critically reviewing notions of risk and unavoidable harm, we problematise the concept of unavoidable patient harm, highlighting how this dominant safety rationality risks perverse and taken-for-granted assumptions about patients, care processes and the nature of risk and harm. In this orthodoxy, those who specify or measure risk are positioned as having more insight into the nature of risk, compared to those who simply experience risk. Driven almost exclusively as a technical and administrative pursuit, the patient safety agenda risks decentring the focus from patients and patient care.


Assuntos
Erros Médicos/classificação , Indicadores de Qualidade em Assistência à Saúde/tendências , Gestão de Riscos/normas , Disparidades em Assistência à Saúde/classificação , Humanos , Dano ao Paciente/classificação , Dano ao Paciente/prevenção & controle , Gestão de Riscos/métodos , Populações Vulneráveis
16.
J Healthc Qual ; 40(2): 89-96, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28671897

RESUMO

INTRODUCTION: This article examines the reliability of the Human Factors Analysis and Classification System (HFACS) for classifying observational human factors data collected prospectively in a trauma resuscitation center. METHODS: Three trained human factors analysts individually categorized 1,137 workflow disruptions identified in a previously collected data set involving 65 observed trauma care cases using the HFACS framework. RESULTS: Results revealed that the framework was substantially reliable overall (κ = 0.680); agreement increased when only the preconditions for unsafe acts were investigated (κ = 0.757). Findings of the analysis also revealed that the preconditions for unsafe acts category was most highly populated (91.95%), consisting mainly of failures involving communication, coordination, and planning. CONCLUSION: This study helps validate the use of HFACS as a tool for classifying observational data in a variety of medical domains. By identifying preconditions for unsafe acts, health care professionals may be able to construct a more robust safety management system that may provide a better understanding of the types of threats that can impact patient safety.


Assuntos
Cuidados Críticos/normas , Erros Médicos/classificação , Erros Médicos/estatística & dados numéricos , Segurança do Paciente/normas , Gestão da Segurança/normas , Centros de Traumatologia/normas , Adulto , Cuidados Críticos/estatística & dados numéricos , Análise Fatorial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente/estatística & dados numéricos , Reprodutibilidade dos Testes , Gestão da Segurança/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos
17.
Emerg Med Australas ; 30(1): 55-60, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28816011

RESUMO

OBJECTIVE: To review incident reports relating to problems encountered during the ED management of patients with 'airway or breathing' problems, with the aim of finding and highlighting common themes within these rare events, and making recommendations to further improve patient safety in the areas in which deficiencies have been identified. METHODS: Thematic analysis of 36 incidents reported from Australasian EDs, which were related to problems with airway and breathing. RESULTS: In all, 51 problems were identified among the 36 incidents related to airway and/or breathing. Fourteen involved clinical decision-making, 11 equipment, nine communication, seven intubation, five surgical access and five pneumothorax. Eight incidents involved children and there were nine deaths within hours or days. CONCLUSIONS: Recommendations for improving preparedness of ED staff and facilities have been made for each of the problem areas identified with respect to clinical practice, equipment, communication and clinical process. Analysis of incidents from the Australasian Emergency Medicine Events Register allows clusters of like-events to be identified and characterised, providing the possibility of getting a better idea of how problems present and progress, with some information about contributing factors, characteristics and context. This will pave the way for earlier and better detection of life-threatening problems and the development and reinforcement of preventive and corrective strategies.


Assuntos
Manuseio das Vias Aéreas/normas , Manuseio das Vias Aéreas/tendências , Erros Médicos/classificação , Australásia , Tomada de Decisão Clínica/métodos , Comunicação , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Falha de Equipamento/estatística & dados numéricos , Humanos , Erros Médicos/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Gestão de Riscos
18.
JAMA Netw Open ; 1(7): e185147, 2018 11 02.
Artigo em Inglês | MEDLINE | ID: mdl-30646381

RESUMO

Importance: Reducing wrong-site surgery is fundamental to safe, high-quality care. This is a follow-up study examining 8 years of reported surgical adverse events and root causes in the nation's largest integrated health care system. Objectives: To provide a follow-up description of incorrect surgical procedures reported from 2010 to 2017 from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events. Design, Setting, and Participants: This quality improvement study describes patient safety adverse events and close calls reported from 86 VHA medical centers from the approximately 130 VHA facilities with a surgical program. The surgical procedures and programs vary in size and complexity from small rural centers to large, complex urban facilities. Procedures occurring between January 1, 2010, and December 31, 2017, were included. Data analysis took place in 2018. Main Outcomes and Measures: The categories of incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room, adverse events or close calls, surgical specialty, and harm. These results were compared with the previous studies of VHA-reported wrong-site surgery (2001-2006 and 2006-2009). Results: Our review produced 483 reports (277 adverse events and 206 close calls). The rate of in-operating room (in-OR) reported adverse events with harm has continued to trend downward from 1.74 to 0.47 reported adverse events with harm per 100 000 procedures between 2000 and 2017 based on 6 591 986 in-OR procedures. When in-OR events were examined by discipline as a rate, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10 000 cases. The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10 000 procedures based on 3 234 514 in-OR procedures. The most common root cause for adverse events was related to issues in performing a comprehensive time-out (28.4%). In these cases, the time-out either was conducted incorrectly or was incomplete in some way. Conclusions and Relevance: Over the period studied, the VHA identified a decrease in the rate of reported adverse events in the OR associated with harm and continued reporting of adverse event close calls. Organizational efforts continue to examine root cause analysis reports, promulgate lessons learned, and enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences.


Assuntos
Erros Médicos , Saúde dos Veteranos/estatística & dados numéricos , Seguimentos , Humanos , Erros Médicos/classificação , Erros Médicos/prevenção & controle , Erros Médicos/estatística & dados numéricos , Segurança do Paciente , Qualidade da Assistência à Saúde , Estados Unidos , United States Department of Veterans Affairs
19.
Aten Primaria ; 50(8): 486-492, 2018 10.
Artigo em Espanhol | MEDLINE | ID: mdl-29183678

RESUMO

OBJECTIVE: To assess the extent of healthcare related adverse events (AEs), their effect on patients, and their seriousness. To analyse the factors leading to the development of AEs, their relationship with the damage caused, and their degree of preventability. DESIGN: Retrospective descriptive study. LOCATION: Porriño, Pontevedra, Spain, Primary Care Service, from January-2014 to April-2016. PARTICIPANTS AND/OR CONTEXT: Reported AEs were entered into the Patient Safety Reporting and Learning System (SiNASP). METHOD: The variables measured were: Near Incident (NI) an occurrence with no effect or harm on the patient; Adverse Event (AE) an occurrence that affects or harms a patient. The level of harm is classified as minimal, minor, moderate, critical, and catastrophic. Preventability was classified as little evidence of being preventable, 50% preventable, and sound evidence of being preventable. DATA ANALYSIS: percentages and Chi-squared test for qualitative variables; P<.05 with SPSS.15. DATA SOURCE: SiNASP. Ethical considerations: approved by the Research Ethics Committee (2016/344). RESULTS: There were 166 recorded AEs (50.6% in males, and 46.4% in women. The mean age was 60.80years). Almost two-thirds 62.7% of AEs affected the patient, with 45.8% causing minimal damage, while 2.4% caused critical damages. Healthcare professionals were a contributing factor in 71.7% of the AEs, with the trend showing that poor communication and lack of protocols were related to the damage caused. Degree of preventability: 96.4%. CONCLUSIONS: Most AEs affected the patient, and were related to medication, diagnostic tests, and laboratory errors. The level of harm was related to communication problems, lack of, or deficient, protocols and a poor safety culture.


Assuntos
Erros Médicos/efeitos adversos , Segurança do Paciente , Comunicação , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/complicações , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Masculino , Erros Médicos/classificação , Erros Médicos/prevenção & controle , Erros Médicos/estatística & dados numéricos , Pessoa de Meia-Idade , Atenção Primária à Saúde , Estudos Retrospectivos , Fatores de Risco , Espanha
20.
Pract Radiat Oncol ; 7(5): 346-353, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28865683

RESUMO

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. The reports were split into 3 groups of 100 events each: low-risk institutional, high-risk institutional, and SAFRON. Three raters retrospectively analyzed each event for contributing factors using the American Association of Physicists in Medicine taxonomy. RESULTS: No events were described by a single causal factor (median, 7). The causal factor taxonomy was found to be applicable for all events, but 4 causal factors were not described in the taxonomy: linear accelerator failure (n = 3), hardware/equipment failure (n = 2), failure to follow through with a quality improvement intervention (n = 1), and workflow documentation was misleading (n = 1). The most common causal factor categories contributing to events were similar in all event types. The most common specific causal factor to contribute to events was a "slip causing physical error." Poor human factors engineering was the only causal factor found to contribute more frequently to high-risk institutional versus low-risk institutional events. CONCLUSIONS: The taxonomy in the study was found to be applicable for all events and may be useful in root cause analyses and future studies. Communication and human behaviors were the most common errors affecting all types of events. Poor human factors engineering was found to specifically contribute to high-risk more than low-risk institutional events, and may represent a strategy for reducing errors in all types of events.


Assuntos
Falha de Equipamento/estatística & dados numéricos , Erros Médicos/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Melhoria de Qualidade , Radioterapia (Especialidade)/organização & administração , Radioterapia/efeitos adversos , Humanos , Erros Médicos/classificação , Erros Médicos/prevenção & controle , Radioterapia/instrumentação , Radioterapia/estatística & dados numéricos , Gestão de Riscos/métodos , Fluxo de Trabalho
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