2021_Book_TextbookOfPatientSafetyAndClin

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25 Patient Safety in Ophthalmology electronic multi-centre audit of 55 567 operations: anaesthetic techniques and complications. Eye. 2009;23(1):50–5. 18. Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, et al. The Cataract National Dataset electronic multi-centre audit of 55 567 operations: updating benchmark standards of care in the United Kingdom and internationally. Eye. 2009;23:38. 19. Stein JD. Serious adverse events after cataract surgery. Curr Opin Ophthalmol. 2012;23(3):219–25. 20. Chakrabarti A, Nazm N. Posterior capsular rent: prevention and management. Indian J Ophthalmol. 2017;65:1359. 21. NICE. Cataracts in adults: management [Internet]. Cataracts in adults: management. 2017. Available from: https://www.nice.org.uk/guidance/ng77. 22. Schmidbauer JM, Vargas LG, Apple DJ, Escobar- Gomez M, Izak A, Arthur SN, et al. Evaluation of neodymium:yttrium-aluminum-garnet capsulotomies in eyes implanted with AcrySof intraocular lenses. Ophthalmology. 2002;109:1421. 23. Thompson AM, Sachdev N, Wong T, Riley AF, Grupcheva CN, McGhee CN. The Auckland Cataract Study: 2 year postoperative assessment of aspects of clinical, visual, corneal topographic and satisfaction outcomes. Br J Ophthalmol. 2004;88:1042. 24. Raj SM, Vasavada AR, Johar SRK, Vasavada VA, Vasavada VA. Post-operative capsular opacification: a review. Int J Biomed Sci. 2007;3(4):237–50. 25. Wormstone IM. Posterior capsule opacification: a cell biological perspective. Exp Eye Res. 2002;74(3):337–47. 26. Pandey SK, Apple DJ, Werner L, Maloof AJ, Milverton EJ. Posterior capsule opacification: a review of the aetiopathogenesis, experimental and clinical studies and factors for prevention. Indian J Ophthalmol. 2004;52:99–112. 27. Awasthi N, Guo S, Wagner BJ. Posterior capsular opacification: a problem reduced but not yet eradicated. Arch Ophthalmol. 2009;127:555. 28. Stein JD, Grossman DS, Mundy KM, Sugar A, Sloan FA. Severe adverse events after cataract surgery among medicare beneficiaries. Ophthalmology. 2011;118(9):1716–23. 29. Erie JC, Raecker ME, Baratz KH, Schleck CD, Robertson DM. Risk of retinal detachment after cataract extraction, 1980–2004: a population-based study. Trans Am Ophthalmol Soc. 2006;113(11):2026–32. 30. Kassem R, Greenwald Y, Achiron A, Hecht I, Man V, Ben Haim L, et al. Peak occurrence of retinal detachment following cataract surgery: a systematic review and pooled analysis with internal validation. J Ophthalmol. 2018;2018:1. 31. Hermann MM, Kirchhof B, Fauser S. Temporal occurrence of retinal detachments after cataract surgery. Acta Ophthalmol. 2012;90(8):e594–6. 32. Neal RE, Bettelheim FA, Lin C, Winn KC, Garland DL, Zigler JS. Alterations in human vitreous humour following cataract extraction. Exp Eye Res. 2005;80(3):337–47. 33. Olsen T. The incidence of retinal detachment after cataract surgery. Open Ophthalmol J. 2012;6:79. 357 34. Haddad WM, Monin C, Morel C, Larricart P, Quesnot S, Ameline B, et al. Retinal detachment after phacoemulsification: a study of 114 cases. Am J Ophthalmol. 2002;133(5):630–8. 35. Bellan L, Ahmed IIK, MacInnis B, Mann C, Noël F, Sanmugasunderam S. Canadian Ophthalmological Society evidence-based clinical practice guidelines for cataract surgery in the adult eye. Can J Ophthalmol. 2008;43(Suppl. 1):S7–33. 36. Ray S, D’Amico DJ. Pseudophakic cystoid macular edema. Semin Ophthalmol. 2002;17:167. 37. Grzybowski A, Sikorski BL, Ascaso FJ, Huerva V. Pseudophakic cystoid macular edema: update 2016. Clin Interv Aging. 2016;11:1221–9. 38. Kim SJ, Schoenberger SD, Thorne JE, Ehlers JP, Yeh S, Bakri SJ, et al. Topical nonsteroidal antiinflammatory drugs and cataract surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2015;122:2159. 39. Lim BX, Lim CHL, Lim DK, Evans JR, Bunce C, Wormald R. Prophylactic non-steroidal antiinflammatory drugs for the prevention of macular oedema after cataract surgery. Cochrane Database of Systematic Reviews. 2016;11(11):CD006683. 40. Wielders LHP, Lambermont VA, Schouten JSAG, Van Den Biggelaar FJHM, Worthy G, Simons RWP, et al. Prevention of cystoid macular edema after cataract surgery in nondiabetic and diabetic patients: a systematic review and meta-analysis. Am J Ophthalmol. 2015;160:968. 41. Wielders LHP, Schouten JSAG, Winkens B, van den Biggelaar FJHM, Veldhuizen CA, Murta JCN, et al. European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1. J Cataract Refract Surg. 2018;44(4):429–39. 42. Obuchowska I, Mariak Z. Risk factors of massive suprachoroidal hemorrhage during extracapsular cataract extraction surgery. Eur J Ophthalmol. 2005;15:712. 43. Eriksson A, Koranyi G, Seregard S, Philipson B. Risk of acute suprachoroidal hemorrhage with phacoemulsification. J Cataract Refract Surg. 1998;24:793. 44. Ling R, Cole M, James C, Kamalarajah S, Foot B, Shaw S. Suprachoroidal haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features, management, and outcomes. Br J Ophthalmol. 2004;88(4):478–80. 45. Laube T, Brockmann C, Bornfeld N. Massive suprachoroidal hemorrhage: surgical management and outcome. GMS Ophthalmol Cases. 2015;5:Doc10. 46. Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery (Review). Cochrane Database Syst Rev. 2017;(2):CD006364. 47. Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, et al. Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. 2005;123(5):613–20.
358 48. Barry P, Gettinby G, Lees F, Peterson M, Revie C, Seal D, et al. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978–88. 49. Group EVS. Results of the Endophthalmitis Vitrectomy study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113(12):1479–96. 50. Barry P, Cordovés L, Gardner S. ESCRS guidelines for prevention and treatment of endophthalmitis following cataract surgery. 2013. https://www.escrs. org/downloads/Endophthalmitis-Guidelines.pdf. 51. Kuhn F, Gini G. Complete and early vitrectomy for endophthalmitis (CEVE) as today’s alternative to the endophthalmitis vitrectomy study. Vitr Surg. 2007:53–68. 52. Kuhn F, Gini G. Vitrectomy for endophthalmitis. Ophthalmology. 2006;113:714. 53. Olson RJ, Braga-Mele R, Chen SH, Miller KM, Pineda R, Tweeten JP, et al. Cataract in the adult eye preferred practice pattern. Am Acad Ophthalmol. 2017;124(2):P1–119. 54. Vogel A, Dick B, Krummenauer F. Reproducibility of optical biometry using partial coherence interferometry: intraobserver and interobserver reliability. J Cataract Refract Surg. 2001;27:1961. 55. Cavallini GM, Saccarola P, D’Amico R, Gasparin A, Campi L. Impact of preoperative testing on ophthalmologic and systemic outcomes in cataract surgery. Eur J Ophthalmol. 2004;14:369. 56. Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery (review). Cochrane Syst Rev. 2019;(1):CD007293. 57. The Royal College of Ophthalmologists. Cataract Surgery Guidelines 2010. The Royal College of Ophthalmologists: London, 2010. Available at: https:// www.rcophth.ac.uk/wp-content/uploads/2014/12/2010- SCI-069-Cataract-Surgery-Guidelines-2010-SEPTEM- BER-2010-1.pdf. 58. Butler TKH. Risk stratification and assessment in cataract surgery. J Cataract Refract Surg. 2012;38:184. 59. Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, et al. The Cataract National Dataset electronic multicentre audit of 55 567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye. 2009;23(1):31–7. 60. Kim BZ, Patel DV, Sherwin T, McGhee CNJ. The Auckland Cataract Study: assessing preoperative risk stratification systems for phacoemulsification surgery in a teaching hospital. Am J Ophthalmol. 2016;171:145–50. 61. Han JV, Patel DV, Wallace HB, Kim BZ, Sherwin T, McGhee CNJ. Auckland Cataract Study III: refining preoperative assessment with cataract risk stratification to reduce intraoperative complications. Am J Ophthalmol. 2019; https://doi.org/10.1016/j. ajo.2018.09.026. M. Lippera et al. 62. Blomquist PH, Sargent JW, Winslow HH. Validation of Najjar-Awwad cataract surgery risk score for resident phacoemulsification surgery. J Cataract Refract Surg. 2010;36:1753. 63. Royal College. Local anaesthesia for ophthalmic surgery. Joint guidelines from the Royal College of Anaesthetists and the Royal College of Ophthalmologists. Curr Anaesth Crit Care. 2012. 64. Grzybowski A, Ascaso FJ, Kupidura-Majewski K, Packer M. Continuation of anticoagulant and antiplatelet therapy during phacoemulsification cataract surgery. Curr Opin Ophthalmol. 2015;26:28. 65. Benzimra JD, Johnston RL, Jaycock P, Galloway PH, Lambert G, Chung AKK, et al. The Cataract National Dataset electronic multicentre audit of 55 567 operations: antiplatelet and anticoagulant medications. Eye. 2009;23:10. 66. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery. Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32(3):407–10. 67. Speaker MG, Milch FA, Shah MK, Eisner W, Kreiswirth BN. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98(5):639–49. 68. Wood A, Conner R. Guideline for preoperative patient skin antisepsis. In: Guidelines for perioperative practice. Denver, CO: Association of Perioperative Registered Nurses; 2015. 69. Pathengay A, Flynn HW, Isom RF, Miller D. Endophthalmitis outbreaks following cataract surgery: causative organisms, etiologies, and visual acuity outcomes. J Cataract Refract Surg. 2012;38:1278. 70. Hellinger WC, Bacalis LP, Edelhauser HF, Mamalis N, Milstein B, Masket S, et al. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg. 2007;33(6):1095–100. 71. Tinley CG, Frost A, Hakin KN, McDermott W, Ewings P. Is visual outcome compromised when next day review is omitted after phacoemulsification surgery? A randomised control trial. Br J Ophthalmol. 2003;87:1350. 72. Tan JHY, Newman DK, Klunker C, Watts SE, Burton RL. Phacoemulsification cataract surgery: is routine review necessary on the first post-operative day? Eye. 2000;14(Pt 1):53–5. 73. Borkar DS, Moustafa GA, Eton EA, Koulisis N, Kloek CE, Borboli-Gerogiannis S, et al. Incidence of unexpected peripheral retinal findings on dilated examination 1 month after cataract surgery: results in the Perioperative Care for Intraocular Lens Study. J Cataract Refract Surg. 2018;44:780. 74. Tan CS, Lim LW, Ting DS. The role of dilated fundus examination following cataract surgery. J Cataract Refract Surg. 2019;45(1):113.
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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
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270 happened during the first three
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272 40. World Health Organization (
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Patient Safety in Orthopedics and T
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19 Patient Safety in Orthopedics an
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Patient Safety and Risk Management
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20 Patient Safety and Risk Manageme
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Patient Safety in Pediatrics Sara A
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21 Patient Safety in Pediatrics eve
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21 Patient Safety in Pediatrics of
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Page 311 and 312: Patient Safety in Radiology Mahdieh
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Page 321 and 322: Organ Donor Risk Stratification in
Page 323 and 324: 23 Organ Donor Risk Stratification
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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
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Page 347 and 348: 346 washed properly prior to steril
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Page 353 and 354: 352 • Lack of appropriate skills.
Page 355 and 356: 354 scription [126]. Furthermore, a
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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
Page 375 and 376: 376 components (people, technology,
Page 377 and 378: 378 J. Braithwaite et al. Hence, cl
Page 379 and 380: 380 stakeholders to figure out how
Page 381 and 382: 382 J. Braithwaite et al. Clinician
Page 383 and 384: 384 27.5.3 Social Networks in a War
Page 385 and 386: 386 J. Braithwaite et al. Fig. 27.9
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Page 389 and 390: 390 21. Pomare C, Churruca K, Ellis
Page 391 and 392: Measuring Clinical Workflow to Impr
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Page 401 and 402: Shiftwork Organization Giovanni Cos
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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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