2021_Book_TextbookOfPatientSafetyAndClin

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96 First of all, it is important to promote transparency around events that have led to harm and open disclosure with the patient, their family, caregivers, and other support persons. At the same time, it is necessary to encourage public awareness of the measures taken by healthcare organizations for the prevention of adverse events. This need is underlined by the result of a Eurobarometer survey that found that European citizens perceive the risk of being harmed during care to be higher than in reality, both in hospitals and in non-acute settings—in fact more than half of the respondents believed that they could be harmed while receiving care. The model of patient care should switch from a “patientcentered” approach to a “patient-as-partner” approach that establishes direct and active participation in ensuring one’s own safety in care: the patient should become a member of the healthcare team. It is necessary to reaffirm the idea that patient safety is not in the hands of one professional in particular, but in the hands of each healthcare worker. All healthcare organizations have the unavoidable duty to introduce and support the training of all healthcare workers in specific matters of safety. The probability of making mistakes decreases when the environment is designed with error prevention in mind, incorporating well-structured tasks, processes, and systems. For the continuous improvement, healthcare systems must have immediate access to information that supports learning from experience in order to identify and implement measures that prevent error. Therefore, healthcare systems must dispense with the “blame and shame” culture which prevents acknowledgment of errors and hampers learning and must promote a “safety culture” which allows insight to be gained from past errors. A safety culture can only be established in an open and transparent environment and only if all levels of the organization are involved. In this context, an efficient reporting system should be a cornerstone for healthcare organizations, collecting experiences and data (e.g., of adverse events and near misses) and providing feedback from professionals. In addition, it is essential to guarantee N. Dhingra-Kumar et al. support for professionals involved in adverse events; the “second victims” of an adverse event are healthcare workers who might have been emotionally traumatized. Without adequate support, a second victim experience can harm the emotional and physical health of the involved professional, generate self-doubt regarding their clinical skills and knowledge, reduce job satisfaction to the point of wanting to leave the healthcare profession, and, as a result of all these issues, can affect patient safety. Another area for improvement is the synergy between patient safety, safety allied programs, health and clinical program and healthcare activities such as accreditation and management of quality of care. Therefore, regardless of the way such functions are structured within countries and healthcare organizations, the branches of patient safety, safety allied programs and quality of care must collaborate to identify common priorities, tools, actions, and indicators to align efforts and enhance outcomes. The needs brought about by the international movement of people and the differences in safety priorities across the globe have focused the attention on the importance of an international, common strategy for patient safety. To this end, strong commitment is needed from the major international healthcare organizations for the creation of international networks and the sharing of knowledge, programs, tools, good practices, and benchmarking according to standardized indicators. Thus, the global strategy for patient safety must involve three distinct steps. The first step is to secure strong international commitment, including both high-income and low- and middle-income countries, with particular emphasis on those which have not yet been involved, especially in the low- and middle-income group. The second step is to focus on specific patient safety issues that depend on local context and require tailored solutions. The third step is to coordinate between all stakeholders to optimize impacts, avoid the duplication of efforts, and pool programs, strategies, and tools. It is also essential to identify trends and recurring issues and evaluate shared indicators. This strategy should form part of a “glocal” approach
8 Patient Safety in the World adopted by all countries, regions, and healthcare organizations: the selection of specific actions tailored on the particularity of each context, while benefitting from the new level of collaboration, knowledge, and opportunities afforded by globalization. Bibliography 1. Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press (US); 2000. 2. Global priorities for patient safety research. Geneva: World Health Organization; 2009. Available from: http://apps.who.int/iris/bitstream/handle/10665/44205/9789241598620_eng.pdf;jsessionid =86A5928D299B2CC2B9EBAA241F34663D?seque nce=1. Accessed 10 Feb 2020. 3. Quality of care: patient safety. Report by the Secretariat (A55/13), Geneva: World Health Organization; 2002. Available from: https://www.who.int/patientsafety/ worldalliance/ea5513.pdf?ua=1&ua=1. Accessed 10 Feb 2020. 4. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Paris: OECD; 2017. Available from: http://www.oecd. org/els/health-systems/The-economics-of-patientsafety-March-2017.pdf. Accessed 14 Feb 2020. 5. Patient safety-global action on patient safety. Report by the Director-General. Geneva: World Health Organization; 2019. Available from: https://apps. who.int/gb/ebwha/pdf_files/WHA72/A72_26-en.pdf. Accessed 13 Feb 2020. 6. Patient safety in developing and transitional countries. New insights from Africa and the Eastern Mediterranean. Geneva: World Health Organization; 2011. Available from: http://www.who.int/patientsafety/research/emro_afro_report.pdf?ua=1. Accessed 12 Feb 2020. 7. Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent C, El-Assady R, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ. 2012;344:832. 8. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety in primary and ambulatory care: flying blind. Paris: OECD; 2018. https://doi. org/10.1787/baf425ad-en. Accessed 10 Feb 2020. 9. Atken M, Gorokhovich L. Advancing the responsible use of medicines: applying levers for change. Parsippany, NJ: IMS Institute for Healthcare Informatics; 2012. Available from: http://papers. ssrn.com/sol3/papers.cfm?abstract_id=2222541. Accessed 13 Feb 2020. 97 10. WHO global patient safety challenge: medication without harm. Geneva: World Health Organization; 2017. Available from: http://apps.who.int/iris/bitstream/10665/255263/1/WHO-HIS-SDS-2017.6-eng. pdf?ua=1&ua=1. Accessed 11 Feb 2020. 11. Report on the burden of endemic health careassociated infection worldwide. Geneva: World Health Organization; 2011. Available from: http://apps.who.int/iris/bitstream/ handle/10665/80135/9789241501507_eng. pdf?sequence=1. Accessed 14 Feb 2020. 12. Suetens C, Latour K, Kärki T, Ricchizzi E, Kinross P, Moro ML, et al. Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017. Euro Surveill. 2018;23(46):1800516. 13. WHO guidelines for safe surgery 2009: safe surgery saves lives. Geneva: World Health Organization; 2009. Available from: http://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng. pdf?sequence=1. Accessed 10 Feb 2020. 14. Bainbridge D, Martin J, Arango M, Cheng D. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380(9847):1075–81. 15. Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease attributable to contaminated injections given in healthcare settings. Int J STD AIDS. 2004;15(1):7–16. 16. Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23(9):727–31. 17. Khoo EM, Lee WK, Sararaks S, Samad AA, Liew SM, Cheong AT, et al. Medical errors in primary care clinics—a cross sectional study. BMC Fam Pract. 2012;26(13):127. 18. National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington, DC: National Academies Press; 2015. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK338596/pdf/<strong>Book</strong>shelf_NBK338596.pdf. Accessed 10 Feb 2020. 19. Singh H, Graber ML, Onakpoya I, Schiff G, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484–94. 20. Clinical transfusion process and patient safety: aidemémoire for national health authorities and hospital management. Geneva: World Health Organization; 2010. Available from: http://www.who.int/bloodsafety/clinical_use/who_eht_10_05_en.pdf?ua=1. Accessed 14 Feb 2020. 21. Janssen MP, Rautmann G. The collection, testing and use of blood and blood components in Europe. Strasbourg: European Directorate for the Quality of Medicines and HealthCare (EDQM) of the Council of Europe; 2014. Available from: https://www.edqm.
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Textbook of Patient Safety and Clin
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Liam Donaldson • Walter Ricciardi
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Foreword As a member of the 17th le
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Preface Despite the extensive atten
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Acknowledgements The volume editors
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xii Contents 11 Adverse Event Inves
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Part I Introduction
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4 explain how to prepare and update
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6 considered preventable) [11]. Fur
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8 W. Ricciardi and F. Cascini the l
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10 W. Ricciardi and F. Cascini inte
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12 maximized or perhaps even realiz
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14 steps in obtaining, managing, an
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16 quality improvement methodologie
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18 99. Morciano C, et al. Policies
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20 Reason travelled the world makin
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22 For each hospital unit, other do
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24 As head of clinical risk managem
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26 R. Tartaglia Table 2.1 Differenc
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28 R. Tartaglia Open Access This ch
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30 otherwise efficient brains lead
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32 • A routine violation is basic
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34 Table 3.1 Framework of contribut
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36 H. Higham and C. Vincent The con
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38 H. Higham and C. Vincent recogni
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40 H. Higham and C. Vincent Table 3
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Page 79 and 80: 68 death of my late husband, Pat, f
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148 for research in patient safety
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150 hospital in Kenya with focus on
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152 Haines et al. (2002) proposed a
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154 G. Dagliana et al. Fast Track -
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156 G. Dagliana et al. 11. Jha AK,
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Part III Patient Safety in the Main
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162 development of new receptor ant
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164 Physician burnout and the psych
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166 S. Damiani et al. Fig. 13.1 In
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168 mortality and has rapidly becom
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170 ing to patient safety and share
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172 ability to cope with the workin
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174 2. Vlayen A, Verelst S, Bekkeri
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Safe Surgery Saves Lives Francesco
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14 Safe Surgery Saves Lives manner
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14 Safe Surgery Saves Lives not yet
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14 Safe Surgery Saves Lives In a su
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14 Safe Surgery Saves Lives 14.15.1
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14 Safe Surgery Saves Lives • Tea
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Emergency Department Clinical Risk
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15 Emergency Department Clinical Ri
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206 • Pragmatic: in a healthcare
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208 Risks associated with pregravid
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210 Table 16.1 Common and Recurrent
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212 improved clinical surveillance
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214 (only IM wards or all medical w
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216 M. L. Regina et al. Table 17.1
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218 Table 17.2 Types and preventabi
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220 nicians were certain resulted w
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224 Table 17.6 “Debiasing questio
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226 in care. At a minimum, medicati
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228 cation rates there substantiall
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230 well-structured, concise, focus
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232 M. L. Regina et al. Fig. 17.3 W
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236 Table 17.14 Risk factors for as
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238 Table 17.16 Common risk factors
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240 In patients with kidney disease
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242 Table 17.19 Clinical response t
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244 stones. Giordano’s test posit
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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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268 and breast cancer) and can be r
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270 happened during the first three
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272 40. World Health Organization (
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Patient Safety in Orthopedics and T
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19 Patient Safety in Orthopedics an
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Patient Safety and Risk Management
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20 Patient Safety and Risk Manageme
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Patient Safety in Pediatrics Sara A
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21 Patient Safety in Pediatrics eve
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21 Patient Safety in Pediatrics of
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21 Patient Safety in Pediatrics Cri
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21 Patient Safety in Pediatrics of
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Patient Safety in Radiology Mahdieh
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22 Patient Safety in Radiology The
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22 Patient Safety in Radiology indu
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22 Patient Safety in Radiology CA a
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22 Patient Safety in Radiology Refe
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Organ Donor Risk Stratification in
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23 Organ Donor Risk Stratification
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23 Organ Donor Risk Stratification
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326 M. Plebani et al. Fig. 24.1 The
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328 ical laboratory and the definit
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330 • Findings of external accred
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332 M. Plebani et al. Fig. 24.2 Mod
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334 laboratory medicine professiona
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336 (WHO) website on the incidence
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338 54. Magnezi R, Hemi A, Hemi R.
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340 In 2010 this condition represen
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342 which should be slightly smalle
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344 needed by the pulse waveform to
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346 washed properly prior to steril
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348 ocular reaction without infecti
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350 large retrospective cohort stud
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352 • Lack of appropriate skills.
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354 scription [126]. Furthermore, a
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356 time and knowledge to young doc
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358 48. Barry P, Gettinby G, Lees F
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360 implant versus intravitreal ant
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Part IV Healthcare Organization
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366 causes of safety incidents and
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368 • Human factors such as teamw
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370 access to the Emergency Room. F
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372 that many doctors simply choose
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374 E. Alti and A. Mereu Open Acces
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376 components (people, technology,
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378 J. Braithwaite et al. Hence, cl
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380 stakeholders to figure out how
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382 J. Braithwaite et al. Clinician
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384 27.5.3 Social Networks in a War
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386 J. Braithwaite et al. Fig. 27.9
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388 representations the essential l
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390 21. Pomare C, Churruca K, Ellis
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Measuring Clinical Workflow to Impr
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28 Measuring Clinical Workflow to I
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Shiftwork Organization Giovanni Cos
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29 Shiftwork Organization influenci
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29 Shiftwork Organization Many epid
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29 Shiftwork Organization quences o
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29 Shiftwork Organization in shift
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Non-technical Skills in Healthcare
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30 Non-technical Skills in Healthca
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Medication Safety Hooi Cheng Soon,
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31 Medication Safety • Be familia
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31 Medication Safety 439 Table 31.1
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31 Medication Safety to be made bet
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31 Medication Safety medication reg
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31 Medication Safety and contexts,
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31 Medication Safety quently when m
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31 Medication Safety 31.5 Final Rec
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31 Medication Safety 451 ity and im
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31 Medication Safety 453 Open Acces
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456 studies in recent years have hi
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458 F. Ranzani and O. Parlangeli in
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460 Any difficulty encountered by t
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462 32.4.2 The Usability Assessment
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464 23. Parlangeli O, Mengoni G, Gu
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466 S. Ushiro et al. No-fault compe
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468 33.2 The Meaning of “No-Fault
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470 S. Ushiro et al. figure of 2.3
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472 S. Ushiro et al. Childbirth fac
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474 • When cerebral palsy is caus
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476 (c) (d) (e) (f) (g) (h) (i) (j)
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478 115 bpm to 80 bpm and complete
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480 • It is desirable that system
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482 cific monitoring procedures (1)
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484 Res. 2019;45(3):493-513. https:
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486 19. In the most severe cases, t
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488 Phases 3 and 4, strong emphasis
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490 Phases 5 and 6 focus is on the
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492 during a pandemic to promote tr
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494 M. Tanzini et al. the mother, p
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496 All four abilities are necessar
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