2021_Book_TextbookOfPatientSafetyAndClin

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112 patients who are not but at first appear to be. Antimicrobial resistance is a major factor in determining clinical unresponsiveness to treatment and a rapid evolution to sepsis and septic shock. Sepsis patients with resistant pathogens have been found to have a higher risk of hospital mortality. Septic shock is defined as a sub-type of severe sepsis with lactate greater than or equal to 4 mmol/L or hypotension (i.e., mean arterial pressure (MAP)
9 Infection Prevention and Control sidered unpreventable (4–6 rating on the Likert scale) and only 36 deaths (12.0%; 95%CI, 8.6– 16.2%) were considered potentially preventable, of which 11 (3.7%) were definitely or moderately likely preventable and 25 (8.3%) were possibly preventable. There were no identifiable suboptimal aspects of care in 232 sepsis-associated deaths (77.3%). Of the 68 cases with suboptimal care (22.7%), the most common problems were: 1. delays in antibiotics, in 33 cases (48.5%) 2. delays in source control, in 19 cases (27.9%) 3. inappropriate empirical antibiotic therapy, in 16 cases (23.5%) Of these 68 cases, 32 deaths (47.1%) were judged to be definitely, moderately likely, or possibly preventable. Generally, the non- preventable, sepsis-associated deaths occurred in patients with major underlying comorbidities, severe, acute, concurrent illnesses, and/or florid sepsis that progressed despite optimal care. A total of 42 major errors were identified in the 36 sepsis-associated deaths that were potentially preventable. Most of the errors were related to: 1. delays in recognition and treatment of sepsis (n = 16) 2. inappropriate antibiotic therapy administered after recognition of sepsis (n = 10) 3. delays in source control (n = 7) Two patients had potentially preventable hospital- acquired infections, while three had procedural complications (i.e., bleeding and ischemia) and three had medication-related adverse events (i.e., bleeding from excessive oral anticoagulation) that triggered a cascade of events leading to sepsis and death. One patient was inadequately monitored in a hospital ward after admission and there was delayed recognition of an unstable arrhythmia. Of the 36 potentially preventable deaths, only 1 patient met criteria for hospice on admission (i.e., due to end-stage liver disease). This patient’s death was still considered possibly preventable as he did not receive Gramnegative antibiotic coverage for pneumonia 113 caused by Escherichia coli. The authors concluded that only a minority of sepsis-associated deaths in this cohort were preventable through better hospital-based care. Conclusions about the prevention of sepsis-associated deaths through better hospital-based care must be contextualized based on the care that is delivered. This study cohort was assembled from patients of three highly regarded academic medical centers and three affiliated community hospitals. The rate of suboptimal sepsis care reported in this cohort— just under 23%—is substantially lower than in other studies. For comparison, in a recent publication from New York State’s sepsis improvement efforts, adherence to a 3-h sepsis bundle increased from 53.4% to 64.7% in 183 acute care hospitals during the 27-month study period [68]. An international point prevalence study found only a 19% completion rate of all elements of a 3-h sepsis bundle [69]. The lower rate of suboptimal care reported by Rhee and colleagues suggests that sepsis care in the hospitals included in this study may have been substantially better than that in many other hospitals, with correspondingly less room for improvement and fewer sepsis- associated deaths deemed to be preventable through better hospital care; in hospitals with more deficiencies in sepsis care, more deaths from sepsis may be preventable. Despite the challenge of identifying which sepsis-associated deaths may be potentially preventable, Rhee’s study does reflect the reality that some sepsisassociated deaths are not preventable with the tools currently available for the recognition and management of sepsis. This finding should serve as a call to action to advance the sepsis research agenda [70]. Early recognition and prompt management of sepsis have been associated in numerous studies with improved patient outcomes, and current clinical practice guidelines emphasize this concept [59]. 9.7 Conclusions Successful approaches for preventing and reducing HAIs involve implementing a risk management framework to manage both human and
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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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42 assessment and prevention was no
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44 of human error, 2nd: 1983: Bella
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46 ment of theories on how to deliv
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48 all times, not only when there i
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50 healthcare, pursued by enthusias
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52 15. National Academies of Scienc
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54 In this chapter, I will reflect
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56 hospital, there may be 50 indivi
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Page 71 and 72: 60 facility and could therefore bec
Page 73 and 74: 62 health. It is hoped that the Che
Page 75 and 76: 64 Medication Without Harm, invites
Page 77 and 78: 66 21. World Alliance for Patient S
Page 79 and 80: 68 death of my late husband, Pat, f
Page 81 and 82: 70 S. Sheridan et al. test. A separ
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Page 85 and 86: 74 S. Sheridan et al. member of The
Page 87 and 88: 76 6.7.1 Example: Canada 6.7.1.1 Wo
Page 89 and 90: 78 All stakeholders must accept, va
Page 91 and 92: Human Factors and Ergonomics in Hea
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Page 101 and 102: Patient Safety in the World Neelam
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Page 105 and 106: 8 Patient Safety in the World adopt
Page 107 and 108: Infection Prevention and Control An
Page 109 and 110: 9 Infection Prevention and Control
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Page 125 and 126: The Patient Journey Elena Beleffi,
Page 127 and 128: 10 The Patient Journey 119 End of e
Page 129 and 130: 10 The Patient Journey 121 Fig. 10.
Page 131 and 132: 10 The Patient Journey advocates) i
Page 133 and 134: 10 The Patient Journey Table 10.2 T
Page 135 and 136: 10 The Patient Journey 7. Internati
Page 137 and 138: 130 from these interactions that pe
Page 139 and 140: 132 Data integration is certainly t
Page 141 and 142: 134 organizational processes, such
Page 143 and 144: 136 Table 11.3 Scheme of contributo
Page 145 and 146: 138 tocol requires one or more exte
Page 147 and 148: 140 system failure. Quantification
Page 149 and 150: 142 8. Carayon P, editor. Handbook
Page 151 and 152: 144 similar industries, in terms of
Page 153 and 154: 146 (2002) argue is a more effectiv
Page 155 and 156: 148 for research in patient safety
Page 157 and 158: 150 hospital in Kenya with focus on
Page 159 and 160: 152 Haines et al. (2002) proposed a
Page 161 and 162: 154 G. Dagliana et al. Fast Track -
Page 163 and 164: 156 G. Dagliana et al. 11. Jha AK,
Page 165 and 166: Part III Patient Safety in the Main
Page 167 and 168: 162 development of new receptor ant
Page 169 and 170: 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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