2021_Book_TextbookOfPatientSafetyAndClin

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Obstetric Safety Patient Antonio Ragusa, Shin Ushiro, Alessandro Svelato, Noemi Strambi, and Mariarosaria Di Tommaso 16 16.1 Introduction A. Ragusa (*) · A. Svelato Obstetrics and Gynecology Department, Fatebenefratelli Hospital, San Giovanni Calibita, Rome, Italy S. Ushiro Division of Patient Safety, Kyushu University Hospital, Fukuoka, Japan e-mail: ushiro@surg2.med.kyushu-u.ac.jp N. Strambi · M. Di Tommaso Department of Health Sciences, Obstetrics and Gynecology, University of Florence, Careggi Hospital Florence, Florence, Italy Fetal Maternal Department, AOU Careggi Hospital, Florence, Italy e-mail: mariarosaria.ditommaso@unifi.it In healthcare, the patient safety system which has been developed following the study of the various phases necessary for its determination, supplies strategies to avoid the repetition of circumstances that originally has led an individual to make mistakes. In fact, the culture of risk management, starting from the consideration that the errors are not eliminable, is based on the belief that they need to be properly analyzed, implementing intervention strategies that avoid its repetition, in order to become good learning opportunities. The risk is the condition or potential event, intrinsic or extrinsic to the process, which can modify the expected outcome. It is measured in terms of probability and consequences, as a product of the probability that a specific event can occur and the seriousness of the damage that can follow this. In the calculation of risk, human ability to identify and contain the consequences of the potentially harmful event is also considered [1]. In obstetrics, there is cultural confusion regarding the concept of risk, as a measurement of the probability of damage in a given population, and the concept of risk as the presence of danger for an individual. That is, the approach which considers all women to be at risk, without systematically defining the degree of probability with which a complication can occur in a specifically assisted obstetric condition, is not functional, nor positive regarding assistance for several reasons: • Cultural: the culture of risk increases the anxiety of operators and women. While scientific investigation of uncertainty promises to increase safety; in actual fact, it increases our insecurity, distorting the emphasis on the prevention of impending risks, and transforming the majority of healthy pregnant women into pre-sick people. • Organizational: no healthcare system can always guarantee maximum efficiency. It is useful that the organization is optimized for a significant event, while it is reasonable to apply low intensity assistance in the normal course of activity. © The Author(s) <strong>2021</strong> L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management, https://doi.org/10.1007/978-3-030-59403-9_16 205
206 • Pragmatic: in a healthcare system, operators cannot be kept on continuous alert so as not to let down their guard precisely in the circumstances in which they should be fully present. • Epidemiological: the value of a diagnostic test useful to highlight the presence of a maternal or fetal pathology depends on the knowledge of the a priori probability that pathology occurs in the population under investigation. For Bayes’ theorem, the positive predictive value of a diagnostic test is directly related to the prevalence of the negative outcome, to be avoided in the population under investigation [2]. In other words, the presence of a pathological test is really indicative of pathology, the greater the a priori prevalence of the same in the subject undergoing the test. Vice versa, the percentage of false positives of the test is greater the lower the probability of the appearance of pathology in the subject undergoing the test. If the prevalence is not taken into account, there will be a much more frequent alarm than necessary. For example, in a physiological population with low probability (
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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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58 medicals, these are part of the
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60 facility and could therefore bec
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62 health. It is hoped that the Che
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64 Medication Without Harm, invites
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66 21. World Alliance for Patient S
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68 death of my late husband, Pat, f
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70 S. Sheridan et al. test. A separ
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72 enced some kind of harm due to h
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74 S. Sheridan et al. member of The
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76 6.7.1 Example: Canada 6.7.1.1 Wo
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78 All stakeholders must accept, va
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Human Factors and Ergonomics in Hea
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7 Human Factors and Ergonomics in H
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Patient Safety in the World Neelam
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8 Patient Safety in the World 95 8.
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8 Patient Safety in the World adopt
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Infection Prevention and Control An
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9 Infection Prevention and Control
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The Patient Journey Elena Beleffi,
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10 The Patient Journey 119 End of e
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10 The Patient Journey 121 Fig. 10.
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10 The Patient Journey advocates) i
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10 The Patient Journey Table 10.2 T
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10 The Patient Journey 7. Internati
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130 from these interactions that pe
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132 Data integration is certainly t
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134 organizational processes, such
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136 Table 11.3 Scheme of contributo
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138 tocol requires one or more exte
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140 system failure. Quantification
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142 8. Carayon P, editor. Handbook
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144 similar industries, in terms of
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146 (2002) argue is a more effectiv
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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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Page 173 and 174: 168 mortality and has rapidly becom
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Page 177 and 178: 172 ability to cope with the workin
Page 179 and 180: 174 2. Vlayen A, Verelst S, Bekkeri
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Page 183 and 184: 14 Safe Surgery Saves Lives manner
Page 185 and 186: 14 Safe Surgery Saves Lives not yet
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Page 189 and 190: 14 Safe Surgery Saves Lives 14.15.1
Page 191 and 192: 14 Safe Surgery Saves Lives • Tea
Page 193 and 194: Emergency Department Clinical Risk
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Page 213 and 214: 210 Table 16.1 Common and Recurrent
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Page 219 and 220: 216 M. L. Regina et al. Table 17.1
Page 221 and 222: 218 Table 17.2 Types and preventabi
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Page 227 and 228: 224 Table 17.6 “Debiasing questio
Page 229 and 230: 226 in care. At a minimum, medicati
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Page 233 and 234: 230 well-structured, concise, focus
Page 235 and 236: 232 M. L. Regina et al. Fig. 17.3 W
Page 239 and 240: 236 Table 17.14 Risk factors for as
Page 241 and 242: 238 Table 17.16 Common risk factors
Page 243 and 244: 240 In patients with kidney disease
Page 245 and 246: 242 Table 17.19 Clinical response t
Page 247 and 248: 244 stones. Giordano’s test posit
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Page 251 and 252: 248 procedures done by general inte
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Page 255 and 256: 252 162. Improvement IfH. What is a
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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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