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1.
Appl Immunohistochem Mol Morphol ; 30(7): 477-485, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35876743

RESUMO

Assessment of automated immunohistochemical staining platform performance is largely limited to the visual evaluation of individual slides by trained personnel. Quantitative assessment of stain intensity is not typically performed. Here we describe our experience with 2 quantitative strategies that were instrumental in root cause investigations performed to identify the sources of suboptimal staining quality (decreased stain intensity and increased variability). In addition, these tools were utilized as adjuncts in validation of a new immunohistochemical staining instrument. The novel methods utilized in the investigation include quantitative assessment of whole slide images (WSI) and commercially available quantitative calibrators. Over the course of ~13 months, these methods helped to identify and verify correction of 2 sources of suboptimal staining. One root cause of suboptimal staining was insufficient/variable power delivery from our building's electrical circuit. This led us to use uninterruptible power managers for all automated immunostainer instruments, which restored expected stain intensity and consistency. Later, we encountered one instrument that, despite passing all vendor quality control checks and not showing error alerts was suspected of yielding suboptimal stain quality. WSI analysis and quantitative calibrators provided a clear evidence that proved critical in confirming the pathologists' visual impressions. This led to the replacement of the instrument, which was then validated using a combination of standard validation metrics supplemented by WSI analysis and quantitative calibrators. These root cause analyses document 2 variables that are critical in producing optimal immunohistochemical stain results and also provide real-world examples of how the application of quantitative tools to measure automated immunohistochemical stain output can provide a greater objectivity when assessing immunohistochemical stain quality.


Assuntos
Diagnóstico por Imagem , Análise de Causa Fundamental , Corantes , Diagnóstico por Imagem/métodos , Humanos , Processamento de Imagem Assistida por Computador/métodos , Controle de Qualidade , Coloração e Rotulagem
2.
J Grad Med Educ ; 14(3): 304-310, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35754621

RESUMO

Background: The Accreditation Council for Graduate Medical Education Common Program Requirements require residents to participate in real or simulated interprofessional patient safety activities. Root cause analysis (RCA) is widely used to respond to patient safety events; however, residents may lack knowledge about the process. Objective: To improve clinicians' knowledge of the tools used to conduct an RCA and the science behind them, and to describe this course and discuss outcomes and feasibility. Methods: A flipped classroom approach was used. Participants completed 5 hours of pre-course work then attended an 8.5-hour program including didactic sessions and small group, facilitator-led RCA simulations. Pre- and post-surveys, as well as a 10-month follow-up on knowledge of and comfort with the RCA process were compared. Statistical significance was evaluated for matched pairs using a repeated measures analysis of variance. Results: Of 162 participants trained, 59 were residents/fellows from 23 graduate medical education programs. Response rates were 96.9% (157 of 162) for pre-course, 92.6% (150 of 162) for post-course, and 81.5% (132 of 162) for 10-month follow-up survey. Most participants had never participated in an RCA (57%, 89 of 157) and had no prior training (87%, 136 of 157). Following the course, participants reported improved confidence in their ability to interview and participate in an RCA (P<.001, 95% CI 4.4-4.6). This persisted 10 months later (P<.001, 95% CI 4.2-4.4), most prominently among residents/fellows who had the highest rate (38.9%, 23 of 59) of participation in real-world RCAs following the training. Conclusions: The course led to a sustained improvement in confidence participating in RCAs, especially among residents and fellows.


Assuntos
Internato e Residência , Análise de Causa Fundamental , Acreditação , Educação de Pós-Graduação em Medicina , Humanos , Segurança do Paciente
3.
Jt Comm J Qual Patient Saf ; 48(6-7): 326-334, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35577696

RESUMO

BACKGROUND: Reactive risk assessments (RRAs) such as incident reporting and root cause analysis (RCA), as well as proactive risk assessments (PRAs) such as failure mode and effects analysis, are generally conducted independently in health care. Literature promotes combining risk assessment techniques. This concept builds on previous methodologies and presents an innovative, scalable, and generalizable risk assessment methodology. METHODS: A Combined Proactive Risk Assessment (CPRA) technique entails combining incident reports (RRAs), combining proactive risk assessments (PRAs), and merging components of PRA and RRA. Using specific keywords, this technique aligns patient safety reporting data with process steps and failure modes to assess risk within any of the process steps. This technique was tested by using PRAs from several Veterans Health Administration (VHA) facilities and national patient safety data from the VHA National Center for Patient Safety's database. Reported events and RCAs related to the outpatient blood draw process were used for this illustration. Repeatability was determined by independently applying the technique to two years of data and auditing results. RESULTS: Aggregating PRAs from multiple facilities identified 220% more failure modes; and integrating incident reports into PRA identified 310% more failure modes than the single facility average. Overlaying safety reports onto a comprehensive process flow diagram revealed that 85.8% of events occurred in three of seven process steps. Accuracy of this technique was generally above 85%. CONCLUSION: This technique is promising for identifying vulnerable points in health care processes or to compliment a traditional PRA. Single PRAs are less likely to identify all potential failures or focus on the most hazardous process steps. This technique may aid in assessing key health care processes at an enterprise level.


Assuntos
Segurança do Paciente , Análise de Causa Fundamental , Atenção à Saúde , Instalações de Saúde , Humanos , Medição de Risco
4.
Appl Ergon ; 103: 103771, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-35523017

RESUMO

The current study analyzed the root causes of 22 helicopter accidents/incidents that took place between 1998 and 2019. Each root cause was coded using three commonly used classification models in aviation HFACS, ATSB, and IATA to identify recurring factors for better targeting of future prevention strategies. The frequency analysis revealed that not following procedure (22 observations), training inadequate or unavailable (17), inadequate regulatory oversight (17), inadequate procedure guidance (16), company management absent or deficient (10) and incorrect manuals/charts/checklists (9) were the most frequent contributing factors. Since none of the existing models could summarize the root causes of 22 occurrences effectively, a scenario-based human-machine-environment-procedure (HMEP) classification scheme was proposed to use organizational influences, people management, technical failure, procedure and document, and environment as the first-layer subcategories. The HMEP scheme was additionally applied to the analysis and coding of 4 helicopter accidents in the USA published by the NTSB. The HMEP scheme revealed that NTSB had identified a significantly greater number of root causes in the manufacturer design, manufacturing & documentation. Overall, HMEP can be used to guide the data collection during accident investigation and subsequently to aggregate aviation accidents to derive recurring factors and compare accident patterns in an efficient manner.


Assuntos
Acidentes Aeronáuticos , Aviação , Acidentes , Acidentes Aeronáuticos/prevenção & controle , Acidentes de Trabalho , Aeronaves , Humanos , Análise de Causa Fundamental
5.
Medicine (Baltimore) ; 101(11)2022 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-35356952

RESUMO

ABSTRACT: In allogeneic hematopoietic stem cell transplantation (AHSCT), falls can lead to immediate and late consequences and in some cases to death. We analyzed risks and causes of falls with root cause analysis (RCA) based on which improvement interventions were implemented.A retrospective observational study was conducted to analyze with RCA data of incidence reports and medical records of patients admitted; an expert panel identified actions to prevent falls, which were collected in a checklist.Between December 2017 and November 2019, 214 patients were admitted to ordinary hospital stays for AHSCT or AHSCTrelated complications. In this period, 15 falls, involving 11 patients, occurred resulting in a 2.32 d/patient incidence. In 66.67% of cases minor head trauma occurred. Diuretic drugs (93.33%), induced hyper-diuresis in nonbladder catheter patients (93.33%) and antihypertensive drugs (93.33%) were reported as most common cause in our incident reports. The most frequent fall time slot was between 10 PM and 7 AM (60%). We determined with RCA diuretics and consequent induced hyper-diuresis (80%), self-insufficiency (40%), antihypertensive (33.3%) and noncompliance (33.3%) as the most common cause of falls. Finally, 16 actions, collected in a "safe comfort" checklist, were identified to prevent falls.Diuretic drugs inducing hyper-diuresis, self-insufficiency, poor patient compliance, orthostatic hypotension, fever, night-time and obstacles within inpatient units are the most common contributing factors. Therefore, administration of diuretic and antihypertensive drugs should be rescheduled and a multidimensional risk assessment scale integrated with a preventive action plan, such as the safe comfort checklist, should be implemented to reduce falls.


Assuntos
Transplante de Células-Tronco Hematopoéticas , Análise de Causa Fundamental , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Transplante de Células-Tronco
6.
Cancer Cytopathol ; 130(8): 609-619, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35298098

RESUMO

BACKGROUND: Fine-needle aspiration (FNA) results classified as the nondiagnostic category of the Milan system for reporting salivary gland cytopathology (MSRSGC) may be infrequently encountered in children. Clinical management may be challenging due to lack of data regarding outcomes and underlying causes. METHODS: We retrospectively analyzed 106 consecutive pediatric salivary gland FNAs (2000-2020; 45% performed under image guidance). The outcomes of patients with nondiagnostic results were analyzed. Clinical parameters, FNA procedural parameters, and histopathologic parameters were compared between diagnostic and nondiagnostic cases. A root cause analysis was performed using the fishbone diagram and the 5 Whys method. RESULTS: A total of 103 initial FNAs were identified. The nondiagnostic rates for initial and repeat biopsy were 16% (16/103) and 67% (2/3), respectively. Initial nondiagnostic FNAs were most frequently managed by clinical/radiologic follow-up only (56%, 9/16), followed by direct surgery (19%, 3/16) and repeat FNA (19%, 3/16). By histologic and clinical/radiologic follow-up, the risk of malignancy for nondiagnostic cases was zero. Palpation guidance (P < .05), inadequate sampling determined by rapid on-site evaluation (P < .01), and lesions with cystic, vascular, or diffuse nature (P < .05) were significantly associated with nondiagnostic results. By root cause analysis, proceduralist sampling error and lack of ultrasound guidance were the most common primary and secondary causes, respectively. CONCLUSIONS: Pediatric salivary gland lesions of the nondiagnostic MSRSGC category have minimal risk of malignancy and may be successfully managed by clinical/radiologic follow-up. The root causes for nondiagnostic results were often multifactorial and primarily related to proceduralist sampling, characteristics of the lesions, and lack of ultrasound guidance.


Assuntos
Cistos , Neoplasias das Glândulas Salivares , Biópsia por Agulha Fina , Criança , Cistos/patologia , Humanos , Estudos Retrospectivos , Análise de Causa Fundamental , Neoplasias das Glândulas Salivares/diagnóstico , Neoplasias das Glândulas Salivares/patologia , Glândulas Salivares/patologia
7.
Bioresour Technol ; 349: 126895, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35217160

RESUMO

The cultivation of anaerobic ammonia oxidizing bacteria (anammox) has gained enormous awareness over the last few decades. Although numerous studies focus massively on successfully growing these anammox to different enrichment environments, in reality, the failure rates are somewhat comparable to the reported success rates. This study combines a variety of measurement techniques to observe and monitor the sequence of a bioreactor performance decline following elevated influent substrate concentration. After attaining stable substrate removal throughout a nitrogen loading rate (NLR) range of 0.691 to 1.669 kg-N·m-3·d-1, the performance of the lab-scale anammox-sequencing batch reactor (SBR) abruptly broke down as the NLR reached 2.01 kg-N·m-3·d-1. The gathered information showed that the increased NLR firstly caused a significant and unfavorable change in the free ammonia (FA) and free nitrous acid (FNA) concentration in the bioreactor. A subsequent drop in N2 production and a decline from a peak high of 0.381 to a low of 0.012 kg-N·kg-VSS-3·d-1 of the specific nitrogen removal rate (SNRR) led to an 82% absurd decline in microbial cellular energy production. Prior to these anammox switching to survival mode and secreting larger quantities (32% higher) of extracellular polymeric substances (EPS), the activity of syntrophic decomposers increased substantially leading to the internal production of excess CO2 in the bioreactor and thereby diverging the bioreactor pH to lower levels. The purposes of this study are to understand the reason an anammox process shows different signals during a decline phase and to enable immediate response to performance deterioration.


Assuntos
Análise de Causa Fundamental , Amônia , Reatores Biológicos/microbiologia , Nitrogênio/química , Oxirredução , Esgotos/microbiologia
8.
Home Healthc Now ; 40(1): 40-48, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-34994719

RESUMO

Falls are a significant health problem in community-dwelling older adults, resulting in injuries, deaths, and increased healthcare costs. Falls were a quality concern for a Northeastern home care agency and this project aimed to evaluate the falls prevention process for older adults receiving home care services by determining potential root causes of falls and to identify a practice change. This quality improvement project used a root cause analysis methodology with a retrospective matched case-control design. Records of patients with falls were assessed for falls prevention process fidelity and compared with patients without a fall matched on the Missouri Alliance for Home Care-10 (MAHC-10) assessment, examining plan of care accuracy and patient fall risk factors. Findings indicated fidelity concerns in the fall prevention process, with gaps in care planning aligned with identified risk factors. Interventions to mitigate identified MAHC-10 risk factors on care plans were present less than 50% of the time for four of the six factors. Polypharmacy (7.46%) and pain affecting function (9.21%) were most frequently unaddressed risk factors in the care plan. Recommendations included implementation of a falls prevention pathway, including standardized falls risk assessment, universal falls precautions in the care plan with tailored interventions based on risk factors, and referral initiation when necessary.


Assuntos
Acidentes por Quedas , Serviços de Assistência Domiciliar , Acidentes por Quedas/prevenção & controle , Idoso , Humanos , Vida Independente , Estudos Retrospectivos , Análise de Causa Fundamental
9.
Radiology ; 302(3): 613-619, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34812668

RESUMO

Background Emotional harm incidents in health care may result in lost trust and adverse outcomes. However, investigations of emotional harm in radiology departments remain lacking. Purpose To better understand contributors and clinical scenarios in which emotional harm can occur in radiology, to document incidences, and to develop preventative countermeasures. Materials and Methods A large tertiary hospital adverse event reporting system was retrospectively searched for submissions under the category of dignity and respect in radiology between December 2014 and December 2020. Submissions were assigned to one of 14 categories per a previously developed classification system. Root-cause analysis of events was performed with a focus on countermeasures for future prevention. The person experiencing emotional harm (patient or staff) was noted. Results Of all radiology-related submissions, 37 of 3032 (1.2%) identified 43 dignity and respect incidents: failure to be patient centered (n = 23; 54%), disrespectful communication (n = 16; 37%), privacy violation (n = 2; 5%), minimization of patient concerns (n = 1; 2%), and loss of property (n = 1; 2%). Failure to be patient centered (n = 23) was subcategorized into disregard for patient preference (12 of 23; 52%), delay in care (eight of 23; 35%), and ineffective communication (three of 23; 13%). Of the 43 incidents, 32 involved patients (74%) and 11 involved staff (26%). Emotional harm in staff was because of disrespectful communication from other staff (eight of 11; 73%). Seventy-three countermeasures were identified: staff communication training (n = 32; 44%), individual feedback (n = 18; 25%), system innovation (n = 16; 22%), improvement of existing communication processes (n = 3; 4%), process reminders (n = 3; 4%), and unclear (n = 1; 1%). Individual feedback and staff communication training that focused on active listening, asking for the patient's preferences, and closed-loop communication addressed 34 of the 43 incidents (79%). Conclusion Most emotional harm incidents were from disrespectful communication and failure to be patient centered. Providing training focused on active listening, asking for patient's preferences, and closed-loop communication would potentially prevent most of these incidents. © RSNA, 2021 See also the editorial by Bruno in this issue.


Assuntos
Emoções , Relações Interprofissionais , Segurança do Paciente , Relações Profissional-Paciente , Serviço Hospitalar de Radiologia , Respeito , Feminino , Humanos , Masculino , Erros Médicos/prevenção & controle , Privacidade , Estudos Retrospectivos , Fatores de Risco , Análise de Causa Fundamental , Roubo
10.
J Patient Saf ; 18(4): 342-350, 2022 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34850624

RESUMO

OBJECTIVES: Unintended events (UEs) are prevalent in healthcare facilities, and learning from them is key to improve patient safety. The Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method is a root cause analysis method used in healthcare facilities. The aims of this systematic review are to map the use of the PRISMA-method in healthcare facilities worldwide, to assess the insights that the PRISMA-method offers, and to propose recommendations to increase its usability in healthcare facilities. METHODS: PubMed, EMBASE.com, CINAHL, and The Cochrane Library were systematically searched from inception to February 26, 2020. Studies were included if the PRISMA-method for analyzing UEs was applied in healthcare facilities. A quality appraisal was performed, and relevant data based on an appraisal checklist were extracted. RESULTS: The search provided 2773 references, of which 25 articles reporting 10,816 UEs met our inclusion criteria. The most frequently identified root causes were human-related, followed by organizational factors. Most studies took place in the Netherlands (n = 20), and the sample size ranged from 1 to 2028 UEs. The study setting and collected data used for PRISMA varied widely. The PRISMA-method performed by multiple persons resulted in more root causes per event. CONCLUSIONS: To better understand UEs in healthcare facilities and formulate optimal countermeasures, our recommendations to further improve the PRISMA-method mainly focus on combining information from patient files and reports with interviews, including multiple PRISMA-trained researchers in an analysis, and modify the Eindhoven Classification Model if needed.


Assuntos
Segurança do Paciente , Análise de Causa Fundamental , Lista de Checagem , Atenção à Saúde , Humanos , Sistemas de Informação
11.
Simul Healthc ; 17(1): e51-e58, 2022 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-34137738

RESUMO

INTRODUCTION: Pediatric inpatients are at high risk of adverse events (AE). Traditionally, root cause analysis was used to analyze AEs and identify recommendations for change. Simulation-based event analysis (SBEA) is a protocol that systematically reviews AEs by recreating them using in situ simulated patients, to understand clinician decision making, improve error discovery, and, through guided sequential debriefing, recommend interventions for error prevention. Studies suggest that these interventions are rarely tested before dissemination. This study investigates the use of simulation to optimize recommendations generated from SBEA before implementation. METHODS: Recommendations and interventions developed through SBEA of 2 hospital-based AEs (event A: error of commission; event B: error of detection) were tested using in situ simulation. Each scenario was repeated 8 times. Interventions were modified based on participant feedback until the error stopped occurring and data saturation was reached. RESULTS: Data saturation was reached after 6 simulations for both scenarios. For scenario A, a critical error was repeated during the first 2 scenarios using the initial interventions. After modifications, errors were corrected or mitigated in the remaining 6 scenarios. For scenario B, 1 intervention, the nursing checklist, had the highest impact, decreasing average time to error detection to 6 minutes. Based on feedback from participants, changes were made to all but one of the original proposed interventions. CONCLUSIONS: Even interventions developed through improved analysis techniques, like SBEA, require testing and modification. Simulation optimizes interventions and provides opportunity to assess efficacy in real-life settings with clinicians before widespread implementation.


Assuntos
Lista de Checagem , Análise de Causa Fundamental , Criança , Simulação por Computador , Humanos , Revisões Sistemáticas como Assunto
12.
J Patient Saf ; 18(2): e503-e507, 2022 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-34009869

RESUMO

INTRODUCTION: Falls in persons with dementia are associated with increased mortality. Occupational therapy (OT) is a rehabilitation discipline, which has, among its goals, the promotion of safety and fall prevention in older adults and those with dementia. The purpose of this study was to evaluate root cause analysis (RCA) data to identify causes of falls with adverse events in patients with dementia who were referred to or receiving OT services within the Veterans Health Administration (VHA). METHODS: This study used retrospective review of RCAs within the National Center for Patient Safety database for the VHA. The RCA database was searched using these terms: falls with adverse events, dementia, and OT. Descriptive statistical analysis of demographic information, location, occurrence of orthopedic fracture, and mortality was used. All root causes were qualitatively categorized using thematic analysis of determined causes. RESULTS: Eighty RCAs were included in analysis. Mean age of veterans included was 80 years; 96% were male; 76% resulted in hip fracture; and 20% died as a result of the fall. Occupational therapy evaluations occurred within 7 days of admission to VHA and falls most frequently occurred within 4 days of OT evaluation. Most common causes included inappropriate or lack of equipment (21%), need for falls/rehabilitation assessment (20%), compliance/training to fall protocol of all staff (19%), and behavior/medical status (17%). CONCLUSIONS: Earlier identification for OT evaluation need may improve access to services, and use of proper equipment to decrease frequency of falls may improve patient safety for older adults with dementia.


Assuntos
Demência , Terapia Ocupacional , Veteranos , Idoso , Idoso de 80 Anos ou mais , Demência/complicações , Humanos , Masculino , Estudos Retrospectivos , Análise de Causa Fundamental , Estados Unidos , United States Department of Veterans Affairs
13.
Am J Surg ; 223(1): 176-181, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34465448

RESUMO

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.


Assuntos
Redução de Custos/estatística & dados numéricos , Eficiência Organizacional/economia , Informática Médica , Salas Cirúrgicas/organização & administração , Procedimentos Cirúrgicos Vasculares/organização & administração , Centros Médicos Acadêmicos/economia , Centros Médicos Acadêmicos/organização & administração , Centros Médicos Acadêmicos/estatística & dados numéricos , Eficiência Organizacional/normas , Eficiência Organizacional/estatística & dados numéricos , Implementação de Plano de Saúde/organização & administração , Implementação de Plano de Saúde/estatística & dados numéricos , Humanos , Salas Cirúrgicas/economia , Salas Cirúrgicas/normas , Salas Cirúrgicas/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Estudos Retrospectivos , Análise de Causa Fundamental/estatística & dados numéricos , Procedimentos Cirúrgicos Vasculares/economia , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , Fluxo de Trabalho
14.
J Patient Saf ; 18(2): 119-123, 2022 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33852542

RESUMO

ABSTRACT: This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese model has become well known in most safety circles, there are several aspects of its underlying theory that are often misunderstood. Some authors have dismissed the Swiss cheese model as an oversimplification of how accidents occur, whereas others have attempted to modify the model to make it better equipped to deal with the complexity of human error in health care. This narrative review aims to provide readers with a better understanding and greater appreciation of the Theory of Active and Latent Failures upon which the Swiss cheese model is based. The goal is to help patient safety professionals fully leverage the model and its associated tools when performing a root cause analysis as well as other patient safety activities.


Assuntos
Segurança do Paciente , Análise de Causa Fundamental , Atenção à Saúde , Humanos
15.
J Patient Saf ; 18(1): 33-39, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33273398

RESUMO

OBJECTIVES: Few studies have analyzed suicide deaths and attempts occurring outside inpatient units on other hospital locations. We aimed to quantify and analyze suicide deaths and attempts occurring on Department of Veterans Affairs medical center outpatient clinic areas, common areas, and hospital grounds including parking lots to determine whether a relationship with access to mental health care exists and to elucidate potential mitigation strategies. METHODS: We conducted a retrospective review of patient safety report (n = 3,186), root cause analysis (n = 234), and issue brief (n = 2,064) national databases between January 1, 2015, and December 31, 2018, to identify occurrences of suicides and attempts. Correlation between mental health access times and hospital-specific rates of suicides and attempts was assessed. Qualitative analyses of root causes and mitigation strategies were conducted. RESULTS: Of 192 reports meeting our location criteria, 42 suicides or attempts occurred in outpatient clinic areas, 39 in common spaces, and 111 on outdoor facility areas. Forty-four reports (23%) pertained to suicides, and 148 (77%) pertained to attempts. The predominate methods were death by firearms (64%) and attempt by drug overdose (38%). We identified a weak yet significant relationship between mental health access times for established patients and rates of on-campus suicides and attempts (r = 0.279, P = 0.0013). CONCLUSIONS: Clinical changes including environmental assessments and interventions, staff training on identifying suicide risk characteristics, policy changes toward improving contraband search techniques, and medications risk assessment, as well as timely access to care may be effective mitigation strategies toward preventing suicides of this nature.


Assuntos
Tentativa de Suicídio , Veteranos , Instituições de Assistência Ambulatorial , Hospitais , Humanos , Análise de Causa Fundamental , Tentativa de Suicídio/prevenção & controle , Veteranos/psicologia
16.
J Patient Saf ; 18(1): 64-70, 2022 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33044255

RESUMO

OBJECTIVES: Applying high-reliability organization (HRO) principles to health care is complex. No consensus exists as to an effective framework for HRO implementation or the direct impact of adoption. METHODS: The Veterans Health Administration (VHA) National Center for Patient Safety established the high-reliability hospital (HRH) model for HRO adoption and piloted HRH in collaboration with the Truman VA Medical Center (Truman) during a 3-year intervention period (January 1, 2016-December 31, 2018). High-reliability hospital components are as follows: annual patient safety (PS) assessment, annual PS culture survey, annual root cause analysis training, daily leadership walk-arounds, monthly PS forum, annual processes standardization review, Just Culture training, unit-based Clinical Team Training, unit-based continuous improvement projects, and annual Clinical Team Training simulation education. The impact of HRH was examined using a PS Culture Survey, PS event reporting, and quality outcomes of standardized mortality rate and complication rate. RESULTS: Truman internally improved PS culture and PS event reporting rates resulting in outcomes better than all VHA facilities (All VHA; P < 0.001 and P < 0.001, respectively). Low-harm PS event reporting increased (P < 0.001); however, serious safety event rate remained unchanged versus All VHA. Significant improvement in Truman standardized mortality rate and complication rate versus All VHA occurred immediately and were sustained through intervention (slopes, P < 0.001 and P < 0.020; respectively). CONCLUSIONS: High-reliability hospital is an effective framework for HRO implementation and will be applied to 18 additional VHA sites. Based on these results, the expected outcome will be improved PS culture and overall PS event reporting. The impact of HRH on serious safety event rate and quality measures requires further study.


Assuntos
Segurança do Paciente , Gestão da Segurança , Atenção à Saúde , Humanos , Reprodutibilidade dos Testes , Análise de Causa Fundamental
17.
J Healthc Qual ; 44(3): 169-177, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-34617929

RESUMO

ABSTRACT: Mobile integrated health and community paramedicine (MIH-CP) programs are gaining popularity in the United States as a strategy to address the barriers to healthcare access and appropriate utilization. After one year of operation, leadership of Baltimore City's MIH-CP program was interested in understanding the circumstances surrounding readmission for enrolled patients and to incorporate quality improvement tools to direct program development. Retrospective chart review was performed to determine preventable versus unpreventable readmissions with a hypothesis that deficits in social determinants of health would play a more significant role in preventable readmissions. In the studied population, at least one root cause that can be considered a social determinant of health was present in 75.8% of preventable readmissions versus only 15.2% of unpreventable readmissions. Root Cause Analysis highlighted health literacy, functional status, and behavioral health issues among the root causes that most heavily influence preventable readmissions. Common Cause Analysis results suggest our MIH-CP program should focus its resources on mitigating poor health literacy and functional status. This project's findings successfully directed leadership of the city's MIH-CP program to modify program processes and advocate for the use of these quality improvement tools for other MIH-CP programs.


Assuntos
Readmissão do Paciente , Cuidado Transicional , Humanos , Melhoria de Qualidade , Estudos Retrospectivos , Análise de Causa Fundamental , Estados Unidos
18.
J Patient Saf ; 18(3): e620-e625, 2022 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-34569993

RESUMO

OBJECTIVES: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy. METHODS: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff. RESULTS: Of the 281 bleeding events reviewed, 188 (67%) were unwitnessed and 54 (19%) were associated with an alteration in mental status. Most deaths (n = 11; 79%) were associated with central venous catheter access. Root cause analyses reported 83 root causes, of which 33% identified physical barriers to direct observation or an equipment issue.Action plans addressed policy/procedures (30%), training/education (20%), and changes to environment/equipment (19%). Patient Safety Advisory publication was associated with a significant increase in low-harm PS reports, from 9 to 18 per year (P = 0.001). CONCLUSIONS: Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting.


Assuntos
Segurança do Paciente , Análise de Causa Fundamental , Humanos , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Saúde dos Veteranos
19.
J Patient Saf ; 18(1): e163-e171, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-32467445

RESUMO

OBJECTIVES: Safety-net health care systems, serving vulnerable populations, see longer delays to timely colonoscopy after a positive fecal occult blood test (FOBT), which may contribute to existing disparities. We sought to identify root causes of colonoscopy delay after positive FOBT result in the primary care safety net. METHODS: We conducted a multisite root cause analysis of cases of delayed colonoscopy, identifying cases where there was a delay of greater than 6 months in completing or scheduling a follow-up colonoscopy after a positive FOBT. We identified cases across 5 California health systems serving low-income, vulnerable populations. We developed a semistructured interview guide based on precedent work. We conducted telephone individual interviews with primary care providers (PCPs) and patients. We then performed qualitative content analysis of the interviews, using an integrated inductive-deductive analytic approach, to identify themes related to recurrent root causes of colonoscopy delay. RESULTS: We identified 12 unique cases, comprising 5 patient and 11 PCP interviews. Eight patients completed colonoscopy; median time to colonoscopy was 11.0 months (interquartile range, 6.3 months). Three patients had advanced adenomatous findings. Primary care providers highlighted system-level root causes, including inability to track referrals between primary care and gastroenterology, lack of protocols to follow up with patients, lack of electronic medical record interoperability, and lack of time or staffing resources, compelling tremendous additional effort by staff. In contrast, patients' highlighted individual-level root causes included comorbidities, social needs, and misunderstanding the importance of the FOBT. There was a little overlap between PCP and patient-elicited root causes. CONCLUSIONS: Current protocols do not accommodate communication between primary care and gastroenterology. Interventions to address specific barriers identified include improved interoperability between PCP and gastroenterology scheduling systems, protocols to follow-up on incomplete colonoscopies, accommodation for support and transport needs, and patient-friendly education. Interviewing both patients and PCPs leads to richer analysis of the root causes leading to delayed diagnosis of colorectal cancer.


Assuntos
Neoplasias Colorretais , Análise de Causa Fundamental , California , Colonoscopia , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/métodos , Humanos
20.
Indian J Ophthalmol ; 70(1): 164-170, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34937230

RESUMO

PURPOSE: To present varied clinical presentations, surveillance reports, and final visual outcomes of a rare outbreak of cluster endophthalmitis caused by gram-negative, opportunistic bacilli, Burkholderia cepacia complex (Bcc). METHODS: Details of five patients who developed postoperative cluster endophthalmitis were collected. For each patient, an undiluted vitreous sample was collected during vitreous tap. Bacterial culture from the vitreous sample in each case had grown Bcc. Surveillance investigations for root cause analysis (RCA) were performed in the operating room (OR), admission, and day-care wards to localize the source. RESULTS: Four patients had undergone phacoemulsification surgery, and one patient had undergone penetrating keratoplasty. Each patient received an initial dose of empiric intravitreal ceftazidime and vancomycin. The organism isolated in each case was sensitive to ceftazidime, cotrimoxazole, and meropenem and resistant to other antibiotics. Core vitrectomy was done after 48-60 hours in four patients along with intravitreal imipenem injection. One patient did not provide consent for core vitrectomy and subsequently developed phthisis bulbi. Three patients had subsequent recurrences. Two patients had a final BCVA of 20/60, two had BCVA better than 20/200, while one patient had no perception of light. None of the surveillance samples from the OR complex could isolate Burkholderia. CONCLUSION: Extensive OR surveillance should be done to identify the potential source of infection. However, the source may not be identifiable in few instances like in our case. Longer follow-up is recommended in cases of Bcc endophthalmitis due to the persistent nature of the infection.


Assuntos
Complexo Burkholderia cepacia , Endoftalmite , Infecções Oculares Bacterianas , Antibacterianos/uso terapêutico , Endoftalmite/diagnóstico , Endoftalmite/tratamento farmacológico , Infecções Oculares Bacterianas/diagnóstico , Infecções Oculares Bacterianas/tratamento farmacológico , Humanos , Estudos Retrospectivos , Análise de Causa Fundamental , Vitrectomia
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