2021_Book_TextbookOfPatientSafetyAndClin

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17 Patient Safety in Internal Medicine 235 Headboard Footboard Rail Rail 7 5 6 2 3 Matress 4 1 Fig. 17.4 Areas where patients are most often entrapped. Zone 1: between the headboard or footboard and the mattress; zone 2: under the rails; zone 3: between the rail and the mattress; zone 4: under the ends of the rail; zone 5: between the 2 bed rails; zone 6: between the end of the rail and the edge of the headboard or footboard; zone 7: within the rails [100] Table 17.13 Areas of the bed at risk for entrapment and recommendations from the US Food and Drug Administration (FDA) [99] Zones Definition Recommendations Zone 1 Any open space within the perimeter of the rail A loosened bar or rail can modify the size of the space. The recommended space is
236 Table 17.14 Risk factors for aspiration pneumonia [103–105] Impaired swallowing Impaired consciousness Increased amount of gastric content reaching the lungs Conditions impairing the cough reflex Others Esophageal disease, including dysphagia, head/neck cancer, stricture, achalasia, scleroderma, polymyositis Chronic obstructive pulmonary disease Neurologic diseases, including seizures, multiple sclerosis, Parkinson’s disease and parkinsonism, stroke, dementia Extubation from mechanical ventilation Stroke or intracerebral hemorrhage Cardiac arrest Drug overdose and medications, such as narcotic agents, general anesthetic agents, and some antidepressant agents Alcohol abuse Percutaneous enteral tube feeding, especially when associated with gastric dysmotility and cognitive impairment Gastro-esophageal reflux Gastroparesis Stroke Medications Alcohol Degenerative neurologic diseases Male sex Smoking Diabetes mellitus and swallowing reflexes showed more consisting results [106–108]. Oral hygiene may represent an important preventive action in non-ventilated patients: it has been demonstrated that chlorhexidine or mechanical oral cleaning reduce up to 60% risk of aspiration pneumonia [109]. However, it is important to remember that chlorhexidine can be toxic if aspirated into the lungs, especially by ventilated patients. The association of oral care to supplemental nutrition also demonstrated to lower aspiration pneumonia [110]. Anyway, a M. L. Regina et al. comprehensive oral care program (manual tooth, gum brushing, chlorhexidine mouthwashes, and upright positioning during feeding) evaluated in a cluster-randomized controlled trial conducted among nursing home residents showed a higher number of pneumonias/lower respiratory tract infections in the intervention group [111]. On the other hand, a short course (≤24 h) of prophylactic β-lactam antibiotics was shown to reduce the risk of aspiration around the time of endotracheal intubation [112]. Delirium is a neuropsychiatric syndrome characterized by altered consciousness and attention with cognitive, emotional, and behavioral symptoms. It occurs among hospitalized patients—mainly in elderly frail people—at a rate from 14% to 56% and increases morbidity and mortality [113]. In this condition, multiple risk factors have been identified so that suggested intervention is obviously multicomponent. Evidence shows that they are effective in preventing delirium onset in at-risk patients in a hospital setting, without significant associated harms but it is insufficient to identify which multicomponent interventions are the most beneficial, and which components within a program provide the most benefit [114, 115]. The aim of primary prevention is to prevent physiological derangements by early mobilization, good hydration, sleep enhancement, family and caregiver involvement, in addition to physiotherapy and rehabilitation, as summarized in Table 17.15. Since it is usually triggered by different factors, prevention strategies need to be reassessed during hospital stay [114]. Approaches including the education of nursing aides and caregivers, music therapy and psychotherapy gave no definitive results [114]. The main recently published studies on pharmacological approach are summarized in a review by Oh et al. [114]. In general, antipsychotic drugs did not demonstrate any clear benefit in preventing delirium [116], similarly to cholinesterase inhibitors, ketamine, melatonin, and melatonin-receptor agonist (ramelteon) [117, 118]. Hence, there is a lack of support in using drugs for prevention or treatment of delirium, especially when considered as a unique entity.
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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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14 Safe Surgery Saves Lives manner
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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
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 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 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: 234 M. L. Regina et al. Table 17.12
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
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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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