2021_Book_TextbookOfPatientSafetyAndClin

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17 Patient Safety in Internal Medicine also for post-round briefing to summarize all issues, identify and prioritize tasks, and delegate responsibilities appropriately [80]. IRs are proactive nurse rounds to check patients at set intervals. During IRs, nurses assess patient’s experience and essential care needs (4 P: positioning, pain, personal needs, and placement). In terms of patient safety, positioning check helps to prevent pressure ulcers, personal needs (i.e., toilet) and placement of personal items checks reduce falls. Nevertheless, IRs facilitate team to organize workload [80]. 17.2.5.3 Clinical Records Keeping clinical records (CRs) is an integral component in good professional practice and the delivery of high-quality care. Regardless of the type of documentation (electronic or paper), a good and updated CRs allow continuity and coordination of care, aid informed decision-making, avoid repetition of tests or other investigations, improve communication between the various health professionals and improve time management. Bad CRS misinform healthcare professionals and patients, prolong hospitalization, jeopardize patient care leads to serious incidents and increase medical-legal risk [84]. Figure 17.3 summarizes what to do and not to do to keep good medical records. 17.3 Safety Practices and Implementation Strategy 231 According to the Agency for Healthcare Research and Quality and the National Quality Forum “a Patient Safety Practice is a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the healthcare system across a range of diseases and procedures” [85]. In 2001 [86] and 2013 [85], an international panel conducted an evidence-based assessment of patient safety strategies (PSSs). The PSSs were categorized according to the following aspects: frequency and severity of the problem addressed, strength of evidence of the effectiveness of the safety strategy, the evidence or potential harmful consequence of the safety strategy, an estimation of implementation difficulties and costs. It categorizes each PSS according to the following: the scope of the underlying problem that the PSS addresses (its frequency and severity); the strength of evidence about the effectiveness of the safety strategy; the evidence or potential for harmful consequences of the strategy; a rough estimate of the cost of implementing the strategy (low, medium, or high); and an assessment of the difficulty of implementing the strategy. As a result of this process, 10 PSSs were identified as “strongly encouraged” and other 12 as “encouraged” for adoption [85]. Here, we report some safety practices relevant to IM, most of them included in the list of strongly encouraged or encouraged for adoption [87]. 17.3.1 Prevention of Age and Frailty- Related Adverse Events Falls. The rate of falls in acute care hospitals varies from 1 to 9 per 1000 bed-days. The first effective strategy relies on the timely recognition of patients with risk factors for falls (Table 17.10) [88]. The National Institute for Health and Care Excellence (NICE) recommends to regard as the population at risk all inpatients older than 65 and those between 50 and 64 who are identified as being at high risk of falling [89]. Actually, some tools are available to discriminate between highand low-risk patients, but they may show limitations in specific populations. Morse Falls Score (MFS) and STRATIFY Score are the two most widely validated tools. However, they were not judged to be diffusely adopted and generate greater benefits than nursing staff clinical judgment [90]. NICE guidelines do not recommend any predictive score [89]. Besides, various assessments and interventions should take place (Table 17.11): (1) all aspects of the inpatient environment —including flooring, lighting, and furniture— must be identified and addressed; (2) high-risk patients should be considered for multifactorial evaluation in order to timely identify cognitive impairment, incontinence, fall history,
232 M. L. Regina et al. Fig. 17.3 What healthcare operators have to do and not to do to keep good clinical records Not to do Use abreviations To do Use dated entires and write clear, accurate and legible notes Make offensive, humorous or personal comments Use structured note (i.e. SOAP: Subjective, Objective, Assessment and Plan) Use ambiguous terms Make records at the same time as the events you are recording or as soon as possible afterwards Make objective Delete or alter the contests of clinical notes in a way that is untrackable Report anyoral communications (phone call, person conversation, etc) and subsequent actions Do not put the documents in chronological order Do not forget informed consent Report anynoncompliance Document ojections regarding care or case management Medication allergies and adverse reactions are prominently noted in the record Do not put diagnostic and laboratory reports into the record, if they were not reviewed by a pracitioner
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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
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162 development of new receptor ant
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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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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 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 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
Page 231 and 232: 228 cation rates there substantiall
Page 233: 230 well-structured, concise, focus
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
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Page 275 and 276: 272 40. World Health Organization (
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19 Patient Safety in Orthopedics an
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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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