2021_Book_TextbookOfPatientSafetyAndClin

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17 Patient Safety in Internal Medicine 3. Think about medical mimics in case of: patient over 40 years and no previous psychiatric history, no history of similar symptoms or worsening of previous symptoms, family concern, chronic comorbidities, history of head injury, change in headache pattern, worsening after antipsychotics or anxiolytics, history of changing psychiatric diagnoses over time, difficult or unlikable patient, polypharmacy, abnormal autonomic signs, visual disturbance, visual, olfactory or tactile hallucinations, nystagmus, illusions, speech deficit, abnormal body movement [178]. 4. Have a complete medical and psychiatric history, an exhaustive review of systems to identify symptoms/signs suggestive of medical diseases, review of any drug prescription, over-the-counter and alternative medications included, a careful mental status examination, diagnostic tests for diseases known to mimic psychiatric disorders (look for head trauma, syphilis or hypothyroidism, glucose or electrolyte or blood gases alterations, sepsis, etc.) 5. Avoid incorrect assumptions (patient triaged as psychiatric, is psychiatric; patient with psychiatric history, has only psychiatric disease; young patients suffer from functional disorders; abnormal vital signs are due to mental/ emotional state) and pitfalls (cursory history from limited sources, incomplete review of system, incomplete physical and neuropsychiatric exam, failure to review medications) [179]. 17.4.3.2 Clinical Case 2 • In end-of-life care, ensure skillful communication with patients and families. • Define and share with patient and/or family realistic goals of care. • Pay attention to understanding the patient’s and family’s concerns besides competent symptom management [180]. Acknowledgments The authors gratefully thank Roberto Nardi, MD for his very helpful and accurate review and Julia Bashore, BS for the language check of this chapter. References 245 1. Schimmel EM. The hazards of hospitalization. Ann Intern Med. 1964;60:100–10. https://doi. org/10.7326/0003-4819-60-1-100. 2. Barr DP. Hazards of modern diagnosis and therapy: the price we pay. J Am Med Assoc. 1955;159(15):1452–6. 3. Moser RH. Diseases of medical progress. N Engl J Med. 1956;255(13):606–14. https://doi.org/10.1056/ NEJM195609272551306. 4. Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304(11):638–42. https://doi.org/10.1056/ NEJM198103123041104. 5. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370–6. https://doi.org/10.1056/ NEJM199102073240604. 6. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust. 1995;163(9):458–71. 7. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322(7285):517–9. https:// doi.org/10.1136/bmj.322.7285.517. 8. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38(3):261–71. https:// doi.org/10.1097/00005650-200003000-00003. 9. Madeira S, Melo M, Porto J, Monteiro S, Pereira de Moura JM, Alexandrino MB, et al. The diseases we cause: iatrogenic illness in a department of internal medicine. Eur J Intern Med. 2007;18(5):391–9. https://doi.org/10.1016/j.ejim.2006.12.009. 10. Bellido D, Leon A, Manas MD, Marchan E, Esquinas G, Ros J. Adverse events in an internal medicine: a prospective study. Rev Calid Asist. 2017;32(5):296– 8. https://doi.org/10.1016/j.cali.2017.02.003. 11. Collopy BT. Adverse events in the ‘medical’ ward. J Qual Clin Pract. 2001;21(3):49. 12. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678–86. 13. Zegers M, de Bruijne MC, Wagner C, Hoonhout LH, Waaijman R, Smits M, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care. 2009;18(4):297–302. https:// doi.org/10.1136/qshc.2007.025924. 14. Grober ED, Bohnen JM. Defining medical error. Can J Surg. 2005;48(1):39–44. 15. Nendaz M, Perrier A. Diagnostic errors and flaws in clinical reasoning: mechanisms and prevention
246 in practice. Swiss Med Wkly. 2012;142:w13706. https://doi.org/10.4414/smw.2012.13706. 16. Boostani K, Noshad H, Farnood F, Rezaee H, Teimouri S, Entezari-Maleki T, et al. Detection and management of common medication errors in internal medicine wards: impact on medication costs and patient care. Adv Pharm Bull. 2019;9(1):174–9. https://doi.org/10.15171/apb.2019.020. 17. Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections—an overview. Infect Drug Resist. 2018;11:2321–33. https://doi. org/10.2147/IDR.S177247. 18. ECRI. Institute Patient Safety Organization’s deep dive: patient identification executive summary. 2016. https://www.ecri.org/Resources/Whitepapers_and_ reports/PSO%20Deep%20Dives/Deep%20Dive_ PT_ID_2016_exec%20summary.pdf. Last accessed 25 Oct 2019. 19. Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ. 2009;338:b1860. https:// doi.org/10.1136/bmj.b1860. 20. Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences E, Medicine. Overview of diagnostic error in health care. 2015. 21. Wilson RM, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverse events from the quality in Australian health care study. Med J Aust. 1999;170(9):411–5. 22. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881–7. https://doi. org/10.1001/archinternmed.2009.333. 23. Ely JW, Levinson W, Elder NC, Mainous AG 3rd, Vinson DC. Perceived causes of family physicians’ errors. J Fam Pract. 1995;40(4):337–44. 24. Podbregar M, Voga G, Krivec B, Skale R, Pareznik R, Gabrscek L. Should we confirm our clinical diagnostic certainty by autopsies? Intensive Care Med. 2001;27(11):1750–5. https://doi.org/10.1007/ s00134-001-1129-x. 25. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493–9. https://doi.org/10.1001/ archinte.165.13.1493. 26. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singap. 2013;42(1):33–41. 27. Clinical Excellence Commission. Diagnostic error: learning resource for clinicians. 2015. http:// www.cec.health.nsw.gov.au/__data/assets/pdf_ file/0005/305843/6.Diagnostic-Error-Learningresource-for-clinicians.pdf. Last accessed 25 Oct 2019. 28. Health Research & Educational Trust. Improving diagnosis in medicine change package. 2018. http:// www.hret-hiin.org/. Last accessed 25 Oct 2019. 29. Graber ML. Educational strategies to reduce diagnostic error: can you teach this stuff? Adv Health Sci Educ Theory Pract. 2009;14(Suppl 1):63–9. https:// doi.org/10.1007/s10459-009-9178-y. M. L. Regina et al. 30. Riches N, Panagioti M, Alam R, Cheraghi-Sohi S, Campbell S, Esmail A, et al. The effectiveness of electronic differential diagnoses (DDX) generators: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0148991. https://doi.org/10.1371/journal.pone.0148991. 31. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22(Suppl 2):ii58–64. https://doi. org/10.1136/bmjqs-2012-001712. 32. Clinical Excellence Commission. Take 2—think, do Project. 2015. http://www.cec.health.nsw.gov.au/__ data/assets/pdf_file/0008/305846/3.Take-2-Think- Do-Information-for-Clinicians.pdf. Last accessed 28 Oct 2019. 33. Graber ML, Kissam S, Payne VL, Meyer AN, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535–57. https://doi. org/10.1136/bmjqs-2011-000149. 34. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Taxonomy of medication errors. 1998. https://www.nccmerp. org/sites/default/files/taxonomy2001-07-31.pdf. Last accessed 25 Oct 2019. 35. Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc. 2014;89(8):1116–25. https://doi.org/10.1016/j. mayocp.2014.05.007. 36. Elliott R, Camacho E, Campbell F, Jankovic D, Martyn St James M, Kaltenthaler E, Wong R, Sculpher M, Faria R. Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Universities of Sheffield and York; 2018. 37. Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa- Plaizier N, Waters H, Bates DW. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf. 2013;22(10):809–15. https://doi.org/10.1136/ bmjqs-2012-001748. 38. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199–205. https://doi.org/10.1007/ bf02600255. 39. Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997;25(8):1289–97. https://doi. org/10.1097/00003246-199708000-00014. 40. Jimenez Munioz AB, Muino Miguez A, Rodriguez Perez MP, Escribano MD, Duran Garcia ME, Sanjurjo SM. Medication error prevalence. Int J Health Care Qual Assur. 2010;23(3):328–38. https:// doi.org/10.1108/09526861011029389. 41. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of
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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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14 Safe Surgery Saves Lives In a su
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14 Safe Surgery Saves Lives 14.15.1
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14 Safe Surgery Saves Lives • Tea
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Emergency Department Clinical Risk
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15 Emergency Department Clinical Ri
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Page 209 and 210: 206 • Pragmatic: in a healthcare
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Page 213 and 214: 210 Table 16.1 Common and Recurrent
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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
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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: 244 stones. Giordano’s test posit
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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
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Page 265 and 266: 262 A. Marcolongo et al. Toxicities
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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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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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