2021_Book_TextbookOfPatientSafetyAndClin

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2 Brief Story of a Clinical Risk Manager tant changes which have provided strength to all those working in the field of clinical risk management. It has created specific clinical risk management centers in each Italian region with the aim of collecting data on adverse events and promoting best safety practices. It has also protected reporting and learning systems by preventing the use of the internally produced documents for judicial purposes. This law also provides specific training for those who decide to become clinical risk managers in hospitals. The professional certification system implemented in our country is giving further value to this professional role. Finally, it has provided regulation for scientific societies around the generation of guidelines and recommendations for safety of care. It is not yet clear whether hospitals can become “highly reliable organizations” [21] but this law could contribute thanks to the changes it produces. References 27 1. Miller LJ, Lu W. These are the world’s healthiest nations. www.bloomberg.com/news/ articles/2019-02-24/spain-tops-italy-as-world-shealthiest-nation-while-u-s-slips. 2. World Health Organization. The World Health Report 2000—health systems: improving performance. Geneva: WHO; 2000. www.who.int/whr/2000/en/ whr00_en.pdf?ua=1. Accessed 12 May 2014. 3. Corte dei Conti. Referto al Parlamento sulla gestione finanziaria dei servizi sanitari regionali. Esercizio 2017. Deliberazione N. 13/SEZAUT/2019/FRG. 4. Health Consumer Powerhouse. Euro health consumer index 2018. https://healthpowerhouse.com/media/ EHCI-2018/EHCI-2018-report.pdf. 5. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317(7150):61–5. https://doi. org/10.1136/bmj.317.7150.61. 6. Kohn LT, Corrigan JM, Donaldson MS, Institute of Medicine Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, DC: National Academic Press; 1999. 7. Reason J. Human error: models and management. BMJ. 2000;320:768–70. https://doi.org/10.1136/ bmj.320.7237.768. 8. Vincent C. Clinical risk management: enhancing patient safety. London: BMJ <strong>Book</strong>s; 2001. 9. Vincent C, Batalden P, Davidoff F. Multidisciplinary centres for safety and quality improvement: learning from climate change science. BMJ Qual Saf. 2011;20(Suppl1):i73–8. 10. Nuti S, Tartaglia R, Niccolai F. Rischio Clinico e Sicurezza del Paziente. Rischio clinico e sicurezza del paziente. Modelli e soluzioni nel contesto internazionale Ed. Bologna: Il Mulino; 2007. 11. Bellandi T, Albolino S, Tartaglia R, Bagnara S. Human factors and ergonomics in patient safety management. In: Human factors and ergonomics in health care and patient safety. 2nd ed. Boca Raton, FL: CRC Press Taylor & Francis Group; 2012. p. 671–90. 12. Tartaglia R, Albolino S, Bellandi T, Bianchini E, Biggeri A, Fabbro G, Bevilacqua L, Dell’Erba A, Privitera G, Sommella L. Adverse events and preventable consequences: retrospective study in five large Italian hospitals. Epidemiol Prev. 2012;35(3–4):151–61. 13. Albolino S, Tartaglia R, Bellandi T, Bianchini E, Fabbro G, Forni S, Cernuschi G, Biggeri A. Variability of adverse events in the public healthcare service of the Tuscany region. Intern Emerg Med. 2017; https:// doi.org/10.1007/s11739-017-1698-5. 14. Albolino S, Tartaglia R, Bellandi T, Amicosante AMV, Bianchini E, Biggeri A. Patient safety and incident reporting: the point of view of the Italian healthcare workers. Qual Saf Health Care. 2010;19(Suppl 3):8–12. 15. Bellandi T, Tartaglia R, Sheikh A, Donaldson L. Italy recognises patient safety as a fundamental right A new law takes a bold new step towards enhancing patient safety. BMJ. 2017;357:j2277(Published 22 May 2017). https://doi.org/10.1136/bmj.j2277. 16. Bellandi T, Albolino S, Tartaglia R, Filipponi F. Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy. Transplant Proc. 2010;42(6):2187–9. 17. Mozione N° 308 del 7 aprile 2016. In merito alla necessità di una revisione dell’attuale sistema del rischio clinico regionale e dell’autonomia del Centro regionale per la gestione del rischio clinico e la sicurezza del paziente. 18. What is risk management in healthcare? https://catalyst.nejm.org/what-is-risk-management-in-healthcare/article. 25 Apr 2018. 19. Tartaglia R, Albolino S, Bellandi T, Biancofiore G, Poli D, Bertolini G, Toccafondi G, Prineas S. Safety analysis on 13 suspicious deaths in intensive care: ergonomics and forensic approach compared. J Patient Saf. 2020; https://doi.org/10.1097/ PTS.0000000000000666. 20. Albolino S, Bellandi T, Cappelletti S, Di Paolo M, Fineschi V, Frati P, Offidani C, Tanzini M, Tartaglia R, Turillazzi E. New rules on patient’s safety and professional liability for the Italian Health Service. Curr Pharm Biotechnol. 2019;20:615–24. https://doi.org/1 0.2174/1389201020666190408094016. 21. Bagnara S, Parlangeli O, Tartaglia R. Are hospitals becoming high reliability organizations? Appl Ergon. 2010;41(5):713–8.
28 R. Tartaglia 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.
Page 1 and 2: Textbook of Patient Safety and Clin
Page 3 and 4: Liam Donaldson • Walter Ricciardi
Page 5 and 6: Foreword As a member of the 17th le
Page 7 and 8: Preface Despite the extensive atten
Page 9 and 10: Acknowledgements The volume editors
Page 11 and 12: xii Contents 11 Adverse Event Inves
Page 13 and 14: Part I Introduction
Page 15 and 16: 4 explain how to prepare and update
Page 17 and 18: 6 considered preventable) [11]. Fur
Page 19 and 20: 8 W. Ricciardi and F. Cascini the l
Page 21 and 22: 10 W. Ricciardi and F. Cascini inte
Page 23 and 24: 12 maximized or perhaps even realiz
Page 25 and 26: 14 steps in obtaining, managing, an
Page 27 and 28: 16 quality improvement methodologie
Page 29 and 30: 18 99. Morciano C, et al. Policies
Page 31 and 32: 20 Reason travelled the world makin
Page 33 and 34: 22 For each hospital unit, other do
Page 35 and 36: 24 As head of clinical risk managem
Page 37: 26 R. Tartaglia Table 2.1 Differenc
Page 41 and 42: 30 otherwise efficient brains lead
Page 43 and 44: 32 • A routine violation is basic
Page 45 and 46: 34 Table 3.1 Framework of contribut
Page 47 and 48: 36 H. Higham and C. Vincent The con
Page 49 and 50: 38 H. Higham and C. Vincent recogni
Page 51 and 52: 40 H. Higham and C. Vincent Table 3
Page 53 and 54: 42 assessment and prevention was no
Page 55 and 56: 44 of human error, 2nd: 1983: Bella
Page 57 and 58: 46 ment of theories on how to deliv
Page 59 and 60: 48 all times, not only when there i
Page 61 and 62: 50 healthcare, pursued by enthusias
Page 63 and 64: 52 15. National Academies of Scienc
Page 65 and 66: 54 In this chapter, I will reflect
Page 67 and 68: 56 hospital, there may be 50 indivi
Page 69 and 70: 58 medicals, these are part of the
Page 71 and 72: 60 facility and could therefore bec
Page 73 and 74: 62 health. It is hoped that the Che
Page 75 and 76: 64 Medication Without Harm, invites
Page 77 and 78: 66 21. World Alliance for Patient S
Page 79 and 80: 68 death of my late husband, Pat, f
Page 81 and 82: 70 S. Sheridan et al. test. A separ
Page 83 and 84: 72 enced some kind of harm due to h
Page 85 and 86: 74 S. Sheridan et al. member of The
Page 87 and 88: 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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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
Page 329 and 330:
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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