2021_Book_TextbookOfPatientSafetyAndClin

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322 mented in their clinical records. The category of acceptable risk profile also includes transplantation for patients in relative clinical urgency, i.e., those with severe clinical status, impending disease progression, and consequent risk of dropout from the waiting list (e.g., advanced hepatocellular carcinoma, high model for end-stage disease (MELD) liver transplant candidates or long-standing kidney transplant patients with pretransplant sensitization). 3. Unacceptable-risk donor: This group includes donors with overt risk factors for disease transmission, with special regard to active infectious disease from multidrugresistant bacteria and metastatic malignancies. In such cases we assume that the risk of transplantation greatly exceeds the benefits of dying on the transplant waiting list. 23.2 Discussion Organ transplantation carries a small but finite risk of disease transmission [1, 2]. The risk of transmission of malignancies in organ transplantation is currently estimated between 0.01% and 0.05% [1, 2] when strict criteria for donor selection and evaluation are implemented. In such series [3, 4], only one case of melanoma is reported, thus underscoring the benefit of transplantation as compared to a 2% mortality risk for kidney and up to 17% for liver waitlist candidates in the same study period. On the opposite, lack of guidelines and inaccurate medical histories are at the basis of case reports of donor-to-recipient transmission of malignancies [5–19]. Due to stagnant donation rates, donor selection criteria have been expanded and use of nonstandard risk donors has been introduced in many countries [20]. This clearly poses considerable ethical issues that should be analyzed and taken into consideration by the competent authorities and institutions. In Italy, introduction of donor risk categories in 2004 has allowed safe use of organs from donors with malignancies, HBsAg and/or anti-HBc donors and, recently, from anti- HCV- positive and HCV RNA-positive donors in negative recipients in light of the availability of DAAs for hepatitis C treatment with no negative impact on the overall graft and patients survival rates [20]. Implementation of national guidelines and risk stratification has been crucial to achievement of favorable results. This underlies the important role of regional and national authorities/agencies and of multidisciplinary integration of all healthcare professionals along the entire continuum of the donation-transplantation process. Retrieval of clinical information can be challenging in the setting of donation after brain death (DBD) and even more in the setting of uncontrolled donation after cardiocirculatory death (uDCD), when time pressure urges professionals to achieve results (i.e., organ procurement) as quickly as possible. To this regard, active participation of donor families, general practitioners, and healthcare institutions to the donation process is pivotal to an efficient algorithm and reduction of the uncertainty margin to the lowest level (standard risk). Organ donation is truly an instance of social enterprise, and relies on efficient integration of all levels of care (primary, secondary, and tertiary). Risk control strategies can be effective only if based on comprehensive policies encompassing the entire spectrum of the donationtransplantation process. References A. Peris et al. 1. Kauffman HM, McBride MA, Cherikh WS, Spain PC, Delmonico FL. Transplant tumor registry: donor related malignancies. Transplantation. 2002;74:358–62. 2. Desai R, Collett D, Watson CJ, Johnson P, Evans T, Neuberger J. Cancer transmission from organ donors – unavoidable but low risk. Transplantation. 2012;94:1200–7. 3. Desai R, Collett D, Watson CJE, Johnson P, Evans T, Neuberger J. Estimated risk of cancer transmission from organ donor to graft recipient in a national transplantation registry. BJS. 2014;101:768–74. 4. Kauffman HM, Cherikh WS, McBride MA, Cheng Y, Hanto DW. Deceased donor with a past history of malignancy: an Organ Procurement and Transplantation Network/United Network of Organ Sharing update. Transplantation. 2007;84:272–4.
23 Organ Donor Risk Stratification in Italy 5. Sack FU, Lange R, Mehmanesh H, Amman K, Schnabel P, Zimmermann R, Dengler T, Otto HF, Hagl S. Transferral of extrathoracic donor neoplasm by the cardiac allograft. J Heart Lung Transplant. 1997;16(3):298–301. 6. Barrou B, Bitker MO, Delcourt A, Ourahma S, Richard F. Fate of renal tubulopapillary adenoma transmitted by an organ donor. Transplantation. 2001;72(3):540–1. 7. Llamas F, Gallego E, Salinas A, Virseda J, Pérez J, Ortega A, Nam SH, Gómez C. Sarcomatoid renal cell carcinoma in a renal transplant recipient. Transplant Proc. 2009;10:4422–4. 8. Ferreira GF, Azevedo de Oliveira R, Jorge LB, Nahas WC, Saldanha LB, Ianhez LE, Srougi M. Urothelial carcinoma transmission via kidney transplantation. Nephrol Dial Transplant. 2010;25:641–3. 9. Forbes GB, Goggin MJ, Dische FE, Saeed IT, Parsons V, Harding MJ, Bewick M, Rudge CT. Accidental transplantation of bronchial carcinoma from a cadaver donor to two recipients of renal allografts. J Clin Pathol. 1981;34(2):109–15. 10. Winter TC, Keller PR, Lee FT Jr, Pozniak MA. Donorderived malignancy: transmission of small-cell lung cancer via renal transplantation. J Ultrasound Med. 2001;20(5):559–62. 11. Lipshutz GS, Baxter-Lowe LA, Nguyen T, Jones KD, Ascher NL, Feng S. Death from donor-transmitted malignancy despite emergency liver retransplantation. Liver Transpl. 2003;9(10):1102–7. 12. Nair BT, Bhat SH, Narayan UV, Sukumar S, Saheed M, Kurien G, Sudhindran S. Donate organs not malignancies: postoperative small cell lung carcinoma in a marginal living kidney donor. Transplant Proc. 2007;39(10):3477–80. 13. Zelinkova Z, Geurts-Giele I, Verheij J, Metselaar H, Dinjens W, Dubbink HJ, Taimr P. Donor-transmitted 323 metastasis of colorectal carcinoma in a transplanted liver. Transpl Int. 2012;25(1):e10–5. 14. Ison MG, Nalesnik MA. An update on donor-derived disease transmission in organ transplantation. Am J Transpl. 2011;11:1123–30. 15. Zwald FO, Christenson LJ, Billingsley EM, Zeitouni NC, Ratner D, Bordeaux J, Patel MJ, Brown MD, Proby CM, Euvrard S, Otley CC, Stasko T, Melanoma Working Group of the International Transplant Skin Cancer Collaborative and Skin Care in Organ Transplant Patients, Europe. Melanoma in solid organ transplant recipients. Am J Transplant. 2010;10(5):1297–304. 16. Strauss DC, Thomas M. Transmission of donor melanoma by organ transplantation. Lancet Oncol. 2010;11:790–6. 17. MacKie RM, Reid R, Junor B. Fatal melanoma transferred in a donated kidney 16 years after melanoma surgery. N Engl J Med. 2003;348:567–8. 18. Bajai NS, Watt C, Hadjiliadis D, Gillespie C, Haas AR, Pochettino A, Mendez J, Sterman DH, Schuchter LM, Christie JD, Lee JC, Ahya VN. Donor transmission of malignant melanoma in a lung transplant recipient 32 years after curative resection. Transpl Int. 2010;23(7):e26–31. 19. Braun-Parvez L, Charlin E, Caillard S, Ducloux D, Wolf P, Rolle F, Golfier F, Flicoteaux H, Bergerat JP, Moulin B. Gestational choriocarcinoma transmission following multiorgan donation. Am J Transplant. 2010;10(11):2541–6. 20. Petrini C, Trapani S, Riva L, Floridia G, Gainotti S, Lombardini L, Masiero L, Rizzato L, Costa AN. Organ transplantation from nonstandard risk donors: midway between rigid and flexible rules. Transplant Proc. 2019;51(9):2856–9. 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.
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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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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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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
Page 291 and 292: 20 Patient Safety and Risk Manageme
Page 301 and 302: Patient Safety in Pediatrics Sara A
Page 303 and 304: 21 Patient Safety in Pediatrics eve
Page 305 and 306: 21 Patient Safety in Pediatrics of
Page 307 and 308: 21 Patient Safety in Pediatrics Cri
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Page 311 and 312: Patient Safety in Radiology Mahdieh
Page 313 and 314: 22 Patient Safety in Radiology The
Page 315 and 316: 22 Patient Safety in Radiology indu
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Page 319 and 320: 22 Patient Safety in Radiology Refe
Page 321 and 322: Organ Donor Risk Stratification in
Page 323: 23 Organ Donor Risk Stratification
Page 327 and 328: 326 M. Plebani et al. Fig. 24.1 The
Page 329 and 330: 328 ical laboratory and the definit
Page 331 and 332: 330 • Findings of external accred
Page 333 and 334: 332 M. Plebani et al. Fig. 24.2 Mod
Page 335 and 336: 334 laboratory medicine professiona
Page 337 and 338: 336 (WHO) website on the incidence
Page 339 and 340: 338 54. Magnezi R, Hemi A, Hemi R.
Page 341 and 342: 340 In 2010 this condition represen
Page 343 and 344: 342 which should be slightly smalle
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Page 347 and 348: 346 washed properly prior to steril
Page 349 and 350: 348 ocular reaction without infecti
Page 351 and 352: 350 large retrospective cohort stud
Page 353 and 354: 352 • Lack of appropriate skills.
Page 355 and 356: 354 scription [126]. Furthermore, a
Page 357 and 358: 356 time and knowledge to young doc
Page 359 and 360: 358 48. Barry P, Gettinby G, Lees F
Page 361 and 362: 360 implant versus intravitreal ant
Page 363 and 364: Part IV Healthcare Organization
Page 365 and 366: 366 causes of safety incidents and
Page 367 and 368: 368 • Human factors such as teamw
Page 369 and 370: 370 access to the Emergency Room. F
Page 371 and 372: 372 that many doctors simply choose
Page 373 and 374: 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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