2021_Book_TextbookOfPatientSafetyAndClin

More documents

Recommendations

Info

16 Obstetric Safety Patient (a) obstetric triage for the identification of protocols and specific care paths. (b) the application of guidelines and protocols for different clinical situations related to the birth path. (c) the use of checklists to analyze the most vulnerable points of the process accurately. (d) simulations. (e) the collection of data in delivery rooms must be precise and systematic, if the data collected will not be truthful or will be collected and described incorrectly, all the conclusions and consequent corrective measures will be wrong [26]. Additional elements on which accident prevention is based are: optimization of internal and external communication, communication with the patient, organization of the team and clinical documentation. However, intervening in these areas does not represent a specificity of the maternal infantile path but that of the prevention of adverse events in all medical-surgical disciplines. In conclusion, the resulting safety system, developed following the study of the various phases of error determinism in three areas (training, organizational and technological), allows the implementation of risk control strategies that avoid the repetition of circumstances that lead to mistakes. The set of actions identified constitute a sort of risk control plan in the maternal and child area which, by improving the quality of the services provided to the mother and the newborn, should guarantee their safety [27]. Safeguarding the health and life of the mother and the future baby are the main objectives of a correct clinical course of pregnancy [28]. References 1. Leape LL. Reporting of adverse events. N Engl J Med. 2002;347(20):1633–8. 2. Godlee F. Are we at risk of being at risk? BMJ. 2010;341:c4766. 3. NHS National Reporting and Learning System Feedback Report. Safety first: a report for patients, clinicians and healthcare managers. 2006. 211 4. Pettker CM. Systematic approaches to adverse events in obstetrics, part II: event analysis and response. Semin Perinatol. 2017;41(3):156–60. 5. Pettker CM. Systematic approaches to adverse events in obstetrics, part I: event identification and classification. Semin Perinatol. 2017;41:151–5. 6. Antony J, Zarin W, Pham B, et al. Patient safety initiatives in obstetrics: a rapid review. BMJ Open. 2018;8:e020170. 7. RCOG, RCM, RCA, RCPCH. Safer childbirth. Minimum standards for the organisation and delivery of care in labour. London: RCOG Press; 2007. p. 1–80. 8. https://resolution.nhs.uk/services/claims-management/ clinical-schemes/clinical-negligence-scheme-for-trusts/ maternity-incentive-scheme/. 9. NHS Litigation Authority. Clinical negligence scheme for trusts maternity clinical risk management standards 2012-13. Managing risk DNV. 2012. 10. ACOG Committee Opinion. Patient safety in obstetrics and gynecology, no. 447. 2009, reaffirmed 2019. 11. Pronovost PJ, Holzmuller CG, Ennen CS, Fox HE. Overview of progress in patient safety. Am J Obstet Gynecol. 2011;204:5–10. 12. Clark SL, Meyers RN, Frye DR, et al. A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system. Am J Obstet Gynecol. 2012;207:441–5. 13. WHO Safe Childbirth Checklist: implementation guide improving the quality of facility-based delivery for mothers and newborns. WHO Library Cataloguing. 2015. 14. Alkema L, ChouD, HoganD, etal. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016;387(10017):462–474. 15. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol. 2005;106:1228–34. 16. Clark SL, Belfort M, Dildy GA et al Maternal death in the 21st century: causes, prevention and relationship to cesarean delivery. Am J Obstet Gynecol. 2008;199(1):36e1–36e5. 17. Spector JM, Agrawal P, Kodkany B, et al. Improving quality of care for maternal and newborn health: prospective pilot study of the WHO Safe Childbirth Checklist Program. PLoS One. 2012;7(5):e35151. 18. Philip Banfield P, Roberts C. The early detection of maternal deterioration in pregnancy. London: The Health Foundation; 2015. 19. Maslovitz S, Barkai G, Lessing JB, et al. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007;109:1295–300. 20. Zuckerwise LC, Lipkind HS. Maternal early warning systems—towards reducing preventable maternal mortality and severe maternal morbidity through
212 improved clinical surveillance and responsiveness. Semin Perinatol. 2017;41(3):161–5. 21. Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267–70. 22. Singh S, McGlennan A, England A, Simons R. A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS). Anaesthesia. 2012;67:12–8. 23. Mackintosh N, Watson K, Rance S, Sandall J. Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study. BMJ Qual Saf. 2014;23(1):26–34. 24. RCOG, Clinical Governance Advice. Improving patient safety: Risk management for maternity and gynaecology, no. 2. 2005. A. Ragusa et al. 25. Ragusa A, Crescini C. Emergenze Urgenze in sala parto, Piccin. 2015. 26. Svelato A, Ragusa A, Manfredi P. General methods for measuring and comparing medical interventions in childbirth: a framework. BMC Pregn Childbirth. 2020 (in press). 27. Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol. 2014;211:319–25. 28. Gazzetta Ufficiale 131 del 7 giugno 2000. Decreto Ministeriale del 24.4.2000. Piano Sanitario Nazionale 1998-2000. Progetto Obiettivo Materno Infantile (POMI). Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Page 1 and 2:
Textbook of Patient Safety and Clin
Page 3 and 4:
Liam Donaldson • Walter Ricciardi
Page 5 and 6:
Foreword As a member of the 17th le
Page 7 and 8:
Preface Despite the extensive atten
Page 9 and 10:
Acknowledgements The volume editors
Page 11 and 12:
xii Contents 11 Adverse Event Inves
Page 13 and 14:
Part I Introduction
Page 15 and 16:
4 explain how to prepare and update
Page 17 and 18:
6 considered preventable) [11]. Fur
Page 19 and 20:
8 W. Ricciardi and F. Cascini the l
Page 21 and 22:
10 W. Ricciardi and F. Cascini inte
Page 23 and 24:
12 maximized or perhaps even realiz
Page 25 and 26:
14 steps in obtaining, managing, an
Page 27 and 28:
16 quality improvement methodologie
Page 29 and 30:
18 99. Morciano C, et al. Policies
Page 31 and 32:
20 Reason travelled the world makin
Page 33 and 34:
22 For each hospital unit, other do
Page 35 and 36:
24 As head of clinical risk managem
Page 37 and 38:
26 R. Tartaglia Table 2.1 Differenc
Page 39 and 40:
28 R. Tartaglia Open Access This ch
Page 41 and 42:
30 otherwise efficient brains lead
Page 43 and 44:
32 • A routine violation is basic
Page 45 and 46:
34 Table 3.1 Framework of contribut
Page 47 and 48:
36 H. Higham and C. Vincent The con
Page 49 and 50:
38 H. Higham and C. Vincent recogni
Page 51 and 52:
40 H. Higham and C. Vincent Table 3
Page 53 and 54:
42 assessment and prevention was no
Page 55 and 56:
44 of human error, 2nd: 1983: Bella
Page 57 and 58:
46 ment of theories on how to deliv
Page 59 and 60:
48 all times, not only when there i
Page 61 and 62:
50 healthcare, pursued by enthusias
Page 63 and 64:
52 15. National Academies of Scienc
Page 65 and 66:
54 In this chapter, I will reflect
Page 67 and 68:
56 hospital, there may be 50 indivi
Page 69 and 70:
58 medicals, these are part of the
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
Page 83 and 84:
72 enced some kind of harm due to h
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
Page 93 and 94:
7 Human Factors and Ergonomics in H
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Patient Safety in the World Neelam
Page 103 and 104:
8 Patient Safety in the World 95 8.
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
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
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
Page 171 and 172: 166 S. Damiani et al. Fig. 13.1 In
Page 173 and 174: 168 mortality and has rapidly becom
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
Page 185 and 186: 14 Safe Surgery Saves Lives not yet
Page 187 and 188: 14 Safe Surgery Saves Lives In a su
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
Page 195 and 196: 15 Emergency Department Clinical Ri
Page 209 and 210: 206 • Pragmatic: in a healthcare
Page 211 and 212: 208 Risks associated with pregravid
Page 213: 210 Table 16.1 Common and Recurrent
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
Page 223 and 224: 220 nicians were certain resulted w
Page 227 and 228: 224 Table 17.6 “Debiasing questio
Page 229 and 230: 226 in care. At a minimum, medicati
Page 231 and 232: 228 cation rates there substantiall
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
Page 249 and 250: 246 in practice. Swiss Med Wkly. 20
Page 251 and 252: 248 procedures done by general inte
Page 253 and 254: 250 tion: a systematic review and m
Page 255 and 256: 252 162. Improvement IfH. What is a
Page 257 and 258: 254 and therapeutic strategies, all
Page 259 and 260: 256 direct effect of radiotherapy o
Page 261 and 262: 258 obtaining treatment consent and
Page 263 and 264: 260 A. Marcolongo et al. Table 18.1
Page 265 and 266:
262 A. Marcolongo et al. Toxicities
Page 267 and 268:
264 nies that are aimed at building
Page 269 and 270:
266 A. Marcolongo et al. tissues. B
Page 271 and 272:
268 and breast cancer) and can be r
Page 273 and 274:
270 happened during the first three
Page 275 and 276:
272 40. World Health Organization (
Page 277 and 278:
Patient Safety in Orthopedics and T
Page 279 and 280:
19 Patient Safety in Orthopedics an
Page 281 and 282:
Page 283 and 284:
Page 285 and 286:
Page 287 and 288:
Page 289 and 290:
Patient Safety and Risk Management
Page 291 and 292:
20 Patient Safety and Risk Manageme
Page 293 and 294:
Page 295 and 296:
Page 297 and 298:
Page 299 and 300:
Page 301 and 302:
Patient Safety in Pediatrics Sara A
Page 303 and 304:
21 Patient Safety in Pediatrics eve
Page 305 and 306:
21 Patient Safety in Pediatrics of
Page 307 and 308:
21 Patient Safety in Pediatrics Cri
Page 309 and 310:
21 Patient Safety in Pediatrics of
Page 311 and 312:
Patient Safety in Radiology Mahdieh
Page 313 and 314:
22 Patient Safety in Radiology The
Page 315 and 316:
22 Patient Safety in Radiology indu
Page 317 and 318:
22 Patient Safety in Radiology CA a
Page 319 and 320:
22 Patient Safety in Radiology Refe
Page 321 and 322:
Organ Donor Risk Stratification in
Page 323 and 324:
23 Organ Donor Risk Stratification
Page 325 and 326:
23 Organ Donor Risk Stratification
Page 327 and 328:
326 M. Plebani et al. Fig. 24.1 The
Page 329 and 330:
328 ical laboratory and the definit
Page 331 and 332:
330 • Findings of external accred
Page 333 and 334:
332 M. Plebani et al. Fig. 24.2 Mod
Page 335 and 336:
334 laboratory medicine professiona
Page 337 and 338:
336 (WHO) website on the incidence
Page 339 and 340:
338 54. Magnezi R, Hemi A, Hemi R.
Page 341 and 342:
340 In 2010 this condition represen
Page 343 and 344:
342 which should be slightly smalle
Page 345 and 346:
344 needed by the pulse waveform to
Page 347 and 348:
346 washed properly prior to steril
Page 349 and 350:
348 ocular reaction without infecti
Page 351 and 352:
350 large retrospective cohort stud
Page 353 and 354:
352 • Lack of appropriate skills.
Page 355 and 356:
354 scription [126]. Furthermore, a
Page 357 and 358:
356 time and knowledge to young doc
Page 359 and 360:
358 48. Barry P, Gettinby G, Lees F
Page 361 and 362:
360 implant versus intravitreal ant
Page 363 and 364:
Part IV Healthcare Organization
Page 365 and 366:
366 causes of safety incidents and
Page 367 and 368:
368 • Human factors such as teamw
Page 369 and 370:
370 access to the Emergency Room. F
Page 371 and 372:
372 that many doctors simply choose
Page 373 and 374:
374 E. Alti and A. Mereu Open Acces
Page 375 and 376:
376 components (people, technology,
Page 377 and 378:
378 J. Braithwaite et al. Hence, cl
Page 379 and 380:
380 stakeholders to figure out how
Page 381 and 382:
382 J. Braithwaite et al. Clinician
Page 383 and 384:
384 27.5.3 Social Networks in a War
Page 385 and 386:
386 J. Braithwaite et al. Fig. 27.9
Page 387 and 388:
388 representations the essential l
Page 389 and 390:
390 21. Pomare C, Churruca K, Ellis
Page 391 and 392:
Measuring Clinical Workflow to Impr
Page 393 and 394:
28 Measuring Clinical Workflow to I
Page 395 and 396:
Page 397 and 398:
Page 399 and 400:
Page 401 and 402:
Shiftwork Organization Giovanni Cos
Page 403 and 404:
29 Shiftwork Organization influenci
Page 405 and 406:
29 Shiftwork Organization Many epid
Page 407 and 408:
29 Shiftwork Organization quences o
Page 409 and 410:
29 Shiftwork Organization in shift
Page 411 and 412:
Non-technical Skills in Healthcare
Page 413 and 414:
30 Non-technical Skills in Healthca
Page 415 and 416:
Page 417 and 418:
Page 419 and 420:
Page 421 and 422:
Page 423 and 424:
Page 425 and 426:
Page 427 and 428:
Page 429 and 430:
Page 431 and 432:
Page 433 and 434:
Medication Safety Hooi Cheng Soon,
Page 435 and 436:
31 Medication Safety • Be familia
Page 437 and 438:
31 Medication Safety 439 Table 31.1
Page 439 and 440:
31 Medication Safety to be made bet
Page 441 and 442:
31 Medication Safety medication reg
Page 443 and 444:
31 Medication Safety and contexts,
Page 445 and 446:
31 Medication Safety quently when m
Page 447 and 448:
31 Medication Safety 31.5 Final Rec
Page 449 and 450:
31 Medication Safety 451 ity and im
Page 451 and 452:
31 Medication Safety 453 Open Acces
Page 453 and 454:
456 studies in recent years have hi
Page 455 and 456:
458 F. Ranzani and O. Parlangeli in
Page 457 and 458:
460 Any difficulty encountered by t
Page 459 and 460:
462 32.4.2 The Usability Assessment
Page 461 and 462:
464 23. Parlangeli O, Mengoni G, Gu
Page 463 and 464:
466 S. Ushiro et al. No-fault compe
Page 465 and 466:
468 33.2 The Meaning of “No-Fault
Page 467 and 468:
470 S. Ushiro et al. figure of 2.3
Page 469 and 470:
472 S. Ushiro et al. Childbirth fac
Page 471 and 472:
474 • When cerebral palsy is caus
Page 473 and 474:
476 (c) (d) (e) (f) (g) (h) (i) (j)
Page 475 and 476:
478 115 bpm to 80 bpm and complete
Page 477 and 478:
480 • It is desirable that system
Page 479 and 480:
482 cific monitoring procedures (1)
Page 481 and 482:
484 Res. 2019;45(3):493-513. https:
Page 483 and 484:
486 19. In the most severe cases, t
Page 485 and 486:
488 Phases 3 and 4, strong emphasis
Page 487 and 488:
490 Phases 5 and 6 focus is on the
Page 489 and 490:
492 during a pandemic to promote tr
Page 491 and 492:
494 M. Tanzini et al. the mother, p
Page 493:
496 All four abilities are necessar
show all

2021_Book_TextbookOfPatientSafetyAndClin

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?