2021_Book_TextbookOfPatientSafetyAndClin

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16 Obstetric Safety Patient 209 near- miss events in obstetrics is recent and reports an incidence of 0.69%, but refers to a context with a careful multi-year organization on patient safety and, as such, the data cannot be generalized. In that context, the analysis of unexpected events, including near-misses, in the labor-delivery room was 3959 cases in 2010 out of a total of 203,708 births, with an incidence of 1.9%. For each near- miss event, the hazard score is reported based on four parameters: (a) the worst possible outcome; (b) the identification method; (c) the number of barriers encountered; and (d) the quality of the barriers. Through the hazard score, it is possible to outline four classes of events: (1) high-risk frequency and low hazard score; (2) high frequency and high hazard score; (3) low-risk frequency and high hazard score; (4) low-risk frequency and low hazard score [12]. Since interventions based on the use of checklists integrated into clinical practice have proven to be effective in reducing death and complications both in the area of intensive care and surgery, the World Health Organization for Developing Countries has developed a checklist, the WHO Safe Childbirth Checklist, which focuses on the major causes of morbidity and mortality in the mother and newborn during delivery [13]. In fact, patient safety has a measurable economic effect, saves lives, and reduces morbidity. The reduction in mortality associated with birth is a priority of global health and low quality care is recognized to be the factor that most contributes to birth-related harm. A systematic analysis describes global levels and trends in maternal mortality between 1990 and 2015. The global maternal mortality ratio (MMR) has a relative decline of 43.9% (34.0– 48.7) from 1990 to 2015. The MMR reduced 385 deaths per 100,000 live births (80% uncertainty interval ranges from 359 to 427) in 1990 to 216 deaths (207–249) in 2015 with 303,000 (291,000– 349,000) maternal deaths globally. Even though there is a global decrease of maternal mortality, this progress should be accelerated and immediate action is necessary to substantially reduce preventable maternal deaths [14]. The percentage of maternal deaths that can be foreseen and therefore preventable varies from 28% to 50% [15–17]. In order to introduce the patient safety concept to those making decisions especially in poor resources settings, the WHO Safe Childbirth Checklist guides the selection of patient safety policy points to ensure that the national policy is comprehensive and adequately detailed. The items on this document identify the major causes of maternal and neonatal death in developing countries. Examples include postpartum hemorrhage, dystocic labur, hypertensive disorders, intrapartum events such as suboptimal assistance to the mother, neonatal infections, and prematurity. The items are grouped to be used in four critical and crucial moments: (a) on admission of the woman to the hospital; (b) at the beginning of the expulsion period or before the cesarean section; (c) 1 h after birth and (d) before discharge [18]. The pilot study of implementation of the checklist showed a clear improvement in terms of maternal–fetal neonatal health which makes it very promising. For the preparation of checklists, the priority identification of recurrent errors is useful, as only by recognizing them can they be avoided. Table 16.1 shows in descending order, the most common and frequent errors for some obstetric emergencies, highlighted during simulations [19]. Another risk control tool in obstetrics is that of the MEOWS (Modified Early Obstetric Warning System), an early alarm system for the timely recognition and treatment of all acute pathological situations, developed on the basis of the Confidential Enquiry into Maternal and Child Health report of 2003–2005, the validation of which has proved to be a useful aid to be used at the patient’s bedside to predict morbidity, whose diagnostic criteria and alarm threshold parameters, and “trigger points,” are well defined [20, 21] and reported in Table 16.2 [22]. Furthermore, this system can be easily learned, implemented, and interpreted. Available evidence suggests that MEOWS should enhance surveillance programs and action plans in order to reduce severe maternal morbidity and mortality
210 Table 16.1 Common and Recurrent Errors Detected by Simulation Scenario Eclamptic seizure Postpartum hemorrhage Shoulder dystocia drill Breech delivery Error Inappropriate ventilation technique Incorrect treatment of MgSO 4 intoxication Underdetection of MgSO 4 intoxication No ventilation performed in an apneic patient Essential blood tests (liver and renal function, coagulation) not carried out Unfamiliarity with hydralazine dosage Incorrect dosage or dilution of MgSO 4 Foley catheter not inserted Underestimation of blood loss Unfamiliarity with prostaglandin administration to achieve myometrial contraction Late transition to the operating room Delayed administration of blood products Unfamiliarity with ergot myometrial stimulators dosage Essentials blood test (fibrinogen, PT, PTT, cross and match) not carried out Under detection of consumption coagulopathy Source of bleeding (episiotomy wound exploration, uterine cavity revision, etc.) not explored Urinary bladder not drained Inadequate documentation of the event Delayed episiotomy Ineffective suprapubic pressure Incorrect McRoberts technique No episiotomy performed Incorrect order of actions and maneuvers Incorrect fixation of the limbs Hasty attempt to deliver the arms Inappropriate Mauriceau and Bracht maneuvers No episiotomy performed by identifying, managing, and possibly avoiding preventable maternal adverse events [23]. A further element on which to base prevention is communication both between operators and with women and their relatives, focusing on information useful for current assistance. Table 16.2 Limits of trigger thresholds for MEOWS parameters Yellow trigger Red trigger Temperature (°C) 35–36 38 Systolic BP (mmHg) 150–160 or 160 90–100 Diastolic BP 90–100 >100 (mmHg) Heart rate (beat/min) 100–120 or 120 40–50 Respiratory rate 21–30 30 (breaths/min) Oxygen saturation –
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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
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150 hospital in Kenya with focus on
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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,
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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 175 and 176: 170 ing to patient safety and share
Page 177 and 178: 172 ability to cope with the workin
Page 179 and 180: 174 2. Vlayen A, Verelst S, Bekkeri
Page 181 and 182: Safe Surgery Saves Lives Francesco
Page 183 and 184: 14 Safe Surgery Saves Lives manner
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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 209 and 210: 206 • Pragmatic: in a healthcare
Page 211: 208 Risks associated with pregravid
Page 215 and 216: 212 improved clinical surveillance
Page 217 and 218: 214 (only IM wards or all medical w
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
Page 257 and 258: 254 and therapeutic strategies, all
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Page 261 and 262: 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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