2021_Book_TextbookOfPatientSafetyAndClin

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17 Patient Safety in Internal Medicine 215 Phase Process Adverse event Contributing factors Physical examination Diagnostic omission or delay Drug–disease interaction Inadequate skills Superficial examination Knowledge deficit Distraction, fatigue Busy and noisy environment Outlier status Hospital stay Initial diagnosis and therapy Clinical monitoring; response to pathological findings Medication process Diagnostic work-up Wrong, delayed, or omitted diagnosis or treatment Hurry, external pressure Premature closure Unexpected death or clinical worsening Unexpected intensive care transfer Diagnostic or therapeutic omission or delay Adverse drug reactions due to: ordering/ storing errors, inappropriate, or wrong prescription, wrong administration Drug–drug and drug–disease interactions Wrong, delayed, or omitted diagnosis or treatment Hurry, external pressure Premature closure Inadequate skills Knowledge deficit Missed diagnostic clues Distraction, fatigue Busy and noisy environment Inadequate or lacking computerized order entry Unexperienced team High workload Patient unable to ask for help Lack, inadequacy, or violation of policies Wrong identification or transcription Knowledge deficit Medical record not available, illegible, not informative Allergy or contraindications not assessed Inadequate or lacking computerized order entry Lack of supervision Poor teamwork Lack, inadequacy, or violation of policies Distraction, fatigue Busy and noisy environment Inadequate skills knowledge deficit Missed diagnostic clues Medical record not available, illegible, not informative Missed request Allergy or contraindications not assessed Poor planning Poor teamwork Lack of supervision Inadequate or lacking computerized order entry Distraction, fatigue Busy and noisy environment (continued)
216 M. L. Regina et al. Table 17.1 (continued) Phase Process Adverse event Contributing factors Consultations Identification errors Wrong, delayed, or omitted diagnosis or treatment See identification errors Planning deficit Medical record not available, illegible, not informative Inadequate skills knowledge deficit Missed diagnostic clues Inadequate or lacking computerized order entry Missed request Poor teamwork Distraction, fatigue Busy and noisy environment Invasive procedures General care Wrong procedure, wrong patient, or wrong site Omitted or delayed procedure Preventable complications (i.e., pneumothorax during thoracentesis) Falls, delirium, healthcare-related infections (HAI), suicide, entrapment, wandering, healthcare-related venous thromboembolism, etc. See identification errors Inadequate skills Inappropriate timing or indication Patient not informed and informed consent not signed Uncooperative patient Medical record not available, illegible, not informative or updated Poor planning Allergy or contraindications not assessed Missed request Unexperienced operator Lack of supervision Lack or inadequacy of devices Inadequate or lacking computerized order entry Distraction, fatigue Busy and noisy environment Lack, inadequacy, or violation of policies Unsuitable footwear Wet floor Busy and noisy environment Inappropriate or omitted basic care Gloves, soap, water, or alcohol hand-rub unavailable or underused Inadequate skills knowledge deficit Lack, inadequacy, or omission of risk stratification Medical record not updated, illegible, or not informative Poor teamwork Lack of supervision Poor vigilance Poor or omitted patient education Fragile patient Patient cognitive impairment Lack, inadequacy, or violation of policies
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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
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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
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 and 214: 210 Table 16.1 Common and Recurrent
Page 215 and 216: 212 improved clinical surveillance
Page 217: 214 (only IM wards or all medical w
Page 221 and 222: 218 Table 17.2 Types and preventabi
Page 223 and 224: 220 nicians were certain resulted w
Page 225 and 226: 222 M. L. Regina et al. Table 17.5
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 237 and 238: 234 M. L. Regina et al. Table 17.12
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
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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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