2021_Book_TextbookOfPatientSafetyAndClin

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298 32. Madsen T, Erlangsen A, Nordentoft M. Risk estimates and risk factors related to psychiatric inpatient suicide – an overview. Int J Environ Res Public Health. 2017;14(3):253. 33. Hussein ZN, Solomon H, Yohannis Z, Ahmed AM. Prevalence and associate factors of suicide ideation and attempt among people with schizophrenia at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. J Psychiatry. 2015;18:1. 34. Brumbles D, Meister A. Psychiatric elopement: using evidence to examine causative factors and preventative measures. Arch Psychiatr Nurs. 2013;27(1):3–9. 35. Alshowkan A, Gamal A. Nurses’ perceptions of patient safety in psychiatry wards. IOSR J Nurs Health Sci. 2019;8(1):3. A. Cuomo et al. 36. Lieberman DZ, Resnik HLP, Holder-Perkins V. Environmental risk factors in hospital suicide. Suicide Life Threat Behav. 2004;34(4):448–53. 37. Kanerva A, Lammintakanen J, Kivinen T. Patient safety in psychiatric inpatient care: a literature review. J Psychiatr Mental Health Nurs. 2012;20(6):541–8. 38. Parand A, Dopson S, Renz A, Vincent C. The role of hospital managers in quality and patient safety: a systematic review. BMJ Open. 2014;4:e005055. 39. Ajalli A, Fallahi-Khoshknab M, Hosseini MA, Mohammadi E, Nir MS. Explanation of patient safety provided by nurses in inpatient psychiatric wards in Iran: a qualitative study. Iran J Psychiatry Behav Sci. 2018;12(4):e67951. Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Patient Safety in Pediatrics Sara Albolino, Marco De Luca, and Antonino Morabito 21 Learning Objectives/Questions Covered in the Chapter • What are the most common adverse events in pediatrics? • Which are the approach and solutions to prevent harm? • What are the most critical issues for quality and safety in the process of care of children? • Which are the most effective practices and strategies for implementing them? 21.1 Epidemiology of Adverse Events in Pediatrics: Some Numbers and Some Reflections Since the publication of the 1999 IOM report “To Err Is Human: Building a Safer Health System,” S. Albolino (*) Centre for Clinical Risk Management and Patient Safety, WHO Collaborating Centre in Human Factors and Communication for the Delivery of Safe and Quality Care, Tuscany Region, Florence, Italy e-mail: albolinos@aou-careggi.toscana.it M. De Luca Simulation and Risk Management, A. Meyer Children Hospital, Florence, Italy e-mail: marco.deluca@meyer.it A. Morabito Pediatric Surgery, Meyer Children’s Hospital, University of Florence, Florence, Italy e-mail: antonino.morabito@unifi.it much has been learned about pediatric patient safety. However, adverse events still affect onethird of all hospitalized children [1]. The main areas of adverse events are hospital-acquired infections, intravenous line complications, surgical complications, and medication errors [2]. The area of medication errors that has been considered the major priority by WHO through the campaign “medication without harm” [3] for children is even more critical because of childhood development, demographics, dependency on parents and other care providers, and the different epidemiology of medical conditions [4]. In a study conducted in 2 pediatric hospitals, on 1120 admission, including more than 10,000 orders, there were 616 medication errors (5.7%) [5]. In recent years the transition to digital healthcare has been identified as a significant element that concur to medication errors, in fact the electronic clinical records can affect the safety of prescription until they are modified with customized decision support, such as weight-based and body surface area-based dosing [2]. Concerning the most critical settings for quality and safety, a study published in 2012, conducted in Canada in 8 teaching hospitals and 14 local healthcare agencies underlined that the 79% of adverse events in children happened in intensive care unit, of which more than 40% are preventable and the incidence on admissions is of 6.5% [6]. These results are similar to the studies conducted in the adult population. © The Author(s) <strong>2021</strong> L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management, https://doi.org/10.1007/978-3-030-59403-9_21 299
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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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206 • Pragmatic: in a healthcare
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208 Risks associated with pregravid
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210 Table 16.1 Common and Recurrent
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212 improved clinical surveillance
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214 (only IM wards or all medical w
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216 M. L. Regina et al. Table 17.1
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218 Table 17.2 Types and preventabi
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220 nicians were certain resulted w
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224 Table 17.6 “Debiasing questio
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226 in care. At a minimum, medicati
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228 cation rates there substantiall
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230 well-structured, concise, focus
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232 M. L. Regina et al. Fig. 17.3 W
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236 Table 17.14 Risk factors for as
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238 Table 17.16 Common risk factors
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240 In patients with kidney disease
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242 Table 17.19 Clinical response t
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244 stones. Giordano’s test posit
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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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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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