2021_Book_TextbookOfPatientSafetyAndClin

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17 Patient Safety in Internal Medicine 93. Cipriani G, Lucetti C, Nuti A, Danti S. Wandering and dementia. Psychogeriatrics. 2014;14(2):135–42. https://doi.org/10.1111/psyg.12044. 94. Rowe M. Wandering in hospitalized older adults: identifying risk is the first step in this approach to preventing wandering in patients with dementia. Am J Nurs. 2008;108(10):62–70; quiz 1. https://doi. org/10.1097/01.NAJ.0000336968.32462.c9. 95. Borbasi S, Jones J, Lockwood C, Emden C. Health professionals’ perspectives of providing care to people with dementia in the acute setting: toward better practice. Geriatr Nurs. 2006;27(5):300–8. https:// doi.org/10.1016/j.gerinurse.2006.08.013. 96. Sheth HS, Krueger D, Bourdon S, Palmer RM. A new tool to assess risk of wandering in hospitalized patients. J Gerontol Nurs. 2014;40(3):28–33; quiz 4–5. https://doi. org/10.3928/00989134-20140128-06. 97. Hospital beds—risk of patient entrapment. 2017. https://healthycanadians.gc.ca/recall-alert-rappelavis/hc-sc/2017/62960a-eng.php. Last accessed 16 Aug 2019. 98. Todd JF. Waking up to hospital bed entrapment risks. Nursing. 2008;38(1):14–5. https://doi. org/10.1097/01.NURSE.0000305896.81298.69. 99. DiBardino DM, Wunderink RG. Aspiration pneumonia: a review of modern trends. J Crit Care. 2015;30(1):40–8. https://doi.org/10.1016/j. jcrc.2014.07.011. 100. Mandell LA, Niederman MS. Aspiration pneumonia. N Engl J Med. 2019;380(7):651–63. https://doi. org/10.1056/NEJMra1714562. 101. Son YG, Shin J, Ryu HG. Pneumonitis and pneumonia after aspiration. J Dent Anesth Pain Med. 2017;17(1):1–12. https://doi.org/10.17245/ jdapm.2017.17.1.1. 102. Herzig SJ, LaSalvia MT, Naidus E, Rothberg MB, Zhou W, Gurwitz JH, et al. Antipsychotics and the risk of aspiration pneumonia in individuals hospitalized for nonpsychiatric conditions: a cohort study. J Am Geriatr Soc. 2017;65(12):2580–6. https://doi. org/10.1111/jgs.15066. 103. Hannawi Y, Hannawi B, Rao CP, Suarez JI, Bershad EM. Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis. 2013;35(5):430–43. https://doi.org/10.1159/000350199. 104. Taylor JK, Fleming GB, Singanayagam A, Hill AT, Chalmers JD. Risk factors for aspiration in community- acquired pneumonia: analysis of a hospitalized UK cohort. Am J Med. 2013;126(11):995–1001. https://doi.org/10.1016/j. amjmed.2013.07.012. 105. van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Metaanalysis of dysphagia and aspiration pneumonia in frail elders. J Dent Res. 2011;90(12):1398–404. https://doi.org/10.1177/0022034511422909. 106. Momosaki R. Rehabilitative management for aspiration pneumonia in elderly patients. J Gen Fam Med. 2017;18(1):12–5. https://doi.org/10.1002/jgf2.25. 249 107. Ohkubo T, Chapman N, Neal B, Woodward M, Omae T, Chalmers J, et al. Effects of an angiotensinconverting enzyme inhibitor-based regimen on pneumonia risk. Am J Respir Crit Care Med. 2004;169(9):1041–5. https://doi.org/10.1164/ rccm.200309-1219OC. 108. Passaro L, Harbarth S, Landelle C. Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review. Antimicrob Resist Infect Control. 2016;5:43. https://doi.org/10.1186/ s13756-016-0150-3. 109. Kaneoka A, Pisegna JM, Miloro KV, Lo M, Saito H, Riquelme LF, et al. Prevention of healthcareassociated pneumonia with oral care in individuals without mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Infect Control Hosp Epidemiol. 2015;36(8):899– 906. https://doi.org/10.1017/ice.2015.77. 110. Higashiguchi T, Ohara H, Kamakura Y, Kikutani T, Kuzuya M, Enoki H, et al. Efficacy of a new postmouthwash intervention (wiping plus oral nutritional supplements) for preventing aspiration pneumonia in elderly people: a multicenter, randomized, comparative trial. Ann Nutr Metab. 2017;71(3–4):253–60. https://doi.org/10.1159/000485044. 111. Juthani-Mehta M, Van Ness PH, McGloin J, Argraves S, Chen S, Charpentier P, et al. A cluster-randomized controlled trial of a multicomponent intervention protocol for pneumonia prevention among nursing home elders. Clin Infect Dis. 2015;60(6):849–57. https://doi.org/10.1093/cid/ciu935. 112. Valles J, Peredo R, Burgueno MJ, Rodrigues de Freitas AP, Millan S, Espasa M, et al. Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated. Chest. 2013;143(5):1219–25. https://doi.org/10.1378/ chest.12-1361. 113. Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):375–80. https://doi. org/10.7326/0003-4819-158-5-201303051-00003. 114. Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in older persons: advances in diagnosis and treatment. JAMA. 2017;318(12):1161–74. https://doi. org/10.1001/jama.2017.12067. 115. Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512–20. https://doi. org/10.1001/jamainternmed.2014.7779. 116. Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64(4):705–14. https://doi.org/10.1111/ jgs.14076. 117. Hovaguimian F, Tschopp C, Beck-Schimmer B, Puhan M. Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunc-
250 tion: a systematic review and meta-analysis. Acta Anaesthesiol Scand. 2018;62(9):1182–93. https:// doi.org/10.1111/aas.13168. 118. Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016;3:CD005563. https://doi. org/10.1002/14651858.CD005563.pub3. 119. Teale E, Young J. Multicomponent delirium prevention: not as effective as NICE suggest? Age Ageing. 2015;44(6):915–7. https://doi.org/10.1093/ageing/ afv120. 120. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect. 2003;54(4):258– 66; quiz 321. 121. Al-Tawfiq JA, Tambyah PA. Healthcare associated infections (HAI) perspectives. J Infect Public Health. 2014;7(4):339–44. https://doi.org/10.1016/j. jiph.2014.04.003. 122. Allegranzi B, Storr J, Dziekan G, Leotsakos A, Donaldson L, Pittet D. 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Chest. 2012;141(2 Suppl):e195S–226S. https://doi.org/10.1378/chest.11-2296. 126. Prandoni P, Samama MM. Risk stratification and venous thromboprophylaxis in hospitalized medical and cancer patients. Br J Haematol. 2008;141(5):587–97. https://doi. org/10.1111/j.1365-2141.2008.07089.x. 127. Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK, et al. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest. 2011;139(1):69–79. https://doi.org/10.1378/ chest.09-3081. 128. La Regina M, Orlandini F, Marchini F, Marinaro A, Bonacci R, Bonanni P, et al. Combined assessment of thrombotic and haemorrhagic risk in acute medical patients. Thromb Haemost. 2016;115(2):392–8. https://doi.org/10.1160/TH14-12-1050. M. L. Regina et al. 129. Gussoni G, Campanini M, Silingardi M, Scannapieco G, Mazzone A, Magni G, et al. In-hospital symptomatic venous thromboembolism and antithrombotic prophylaxis in internal medicine. Findings from a multicenter, prospective study. Thromb Haemost. 2009;101(5):893–901. 130. Tincani E, Crowther MA, Turrini F, Prisco D. Prevention and treatment of venous thromboembolism in the elderly patient. Clin Interv Aging. 2007;2(2):237–46. 131. Samama MM, Cohen AT, Darmon JY, Desjardins L, Eldor A, Janbon C, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in medical patients with enoxaparin study group. N Engl J Med. 1999;341(11):793–800. https://doi.org/10.1056/NEJM199909093411103. 132. Rondina MT, Wheeler M, Rodgers GM, Draper L, Pendleton RC. Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medicallyill patients. Thromb Res. 2010;125(3):220–3. https:// doi.org/10.1016/j.thromres.2009.02.003. 133. Imberti D, Legnani C, Baldini E, Cini M, Nicolini A, Guerra M, et al. Pharmacodynamics of low molecular weight heparin in patients undergoing bariatric surgery: a prospective, randomised study comparing two doses of parnaparin (BAFLUX study). Thromb Res. 2009;124(6):667–71. https://doi.org/10.1016/j. thromres.2009.04.021. 134. Schmid P, Brodmann D, Fischer AG, Wuillemin WA. Study of bioaccumulation of dalteparin at a prophylactic dose in patients with various degrees of impaired renal function. J Thromb Haemost. 2009;7(4):552–8. https://doi. org/10.1111/j.1538-7836.2009.03292.x. 135. Turpie AG, Lensing AW, Fuji T, Boyle DA. Pharmacokinetic and clinical data supporting the use of fondaparinux 1.5 mg once daily in the prevention of venous thromboembolism in renally impaired patients. Blood Coagul Fibrinolysis. 2009;20(2):114–21. https://doi.org/10.1097/ MBC.0b013e328323da86. 136. Mosarla RC, Vaduganathan M, Qamar A, Moslehi J, Piazza G, Giugliano RP. Anticoagulation strategies in patients with cancer: JACC review topic of the week. J Am Coll Cardiol. 2019;73(11):1336–49. https://doi.org/10.1016/j.jacc.2019.01.017. 137. Sullivan N, Schoelles KM. Preventing infacility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):410–6. https://doi. org/10.7326/0003-4819-158-5-201303051-00008. 138. Moore ZE, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2019;1:CD006471. https://doi. org/10.1002/14651858.CD006471.pub4. 139. Insitute for Healthcare Improvement. What is a bundle? 2016. www.ihi.org/knowledge/Pages/ ImprovementStories/WhatIsaBundle.apsx. Last accessed 28 Oct 2019.
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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
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
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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
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Page 251: 248 procedures done by general inte
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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 289 and 290: Patient Safety and Risk Management
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Page 301 and 302: 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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