2021_Book_TextbookOfPatientSafetyAndClin

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452 68. Alanazi MA, Tully MP, Lewis PJ. A systematic review of the prevalence and incidence of prescribing errors with high-risk medicines in hospitals. J Clin Pharm Ther. 2016;41(3):239–45. 69. Saedder EA, Brock B, Nielsen LP, Bonnerup DK, Lisby M. Identifying high-risk medication: a systematic literature review. Eur J Clin Pharmacol. 2014;70(6):637–45. 70. Clinical Excellence Commission. High-risk medicines management policy. Sydney: NSW Ministry of Health; 2015. https://www1.health.nsw.gov.au/pds/ ActivePDSDocuments/PD2015_029.pdf. Accessed 15 Oct 2019. 71. ISMP. High-alert medications. Institute for Safe Medication Practices: Horsham, PA; 2019. http:// www.ismp.org/Tools/highAlertMedicationLists.asp. Accessed 15 Oct 2019. 72. Rinke ML, Bundy DG, Velasquez CA, Rao S, Zerhouni Y, Lobner K, et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics. 2014;134(2):338–60. 73. Kaushal R, Jaggi T, Walsh K, Fortescue EB, Bates DW. Pediatric medication errors: what do we know? What gaps remain? Ambul Pediatr. 2004;4(1):73–81. 74. Hubbard RE, O’Mahony MS, Woodhouse KW. Medication prescribing in frail older people. Eur J Clin Pharmacol. 2013;69(3):319–26. 75. Trønnes JN, Lupattelli A, Nordeng H. Safety profile of medication used during pregnancy: results of a multinational European study. Pharmacoepidemiol Drug Saf. 2017;26(7):802–11. 76. Avery A, Barber N, Ghaleb M, Franklin BD, Armstrong S, Crowe S, et al. Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study. London: General Medical Council; 2012. https://www.gmcuk.org//media/about/ investigatingtheprevalenceandcausesofprescribingerrorsingeneralpracticethepracticestudyreoprtmay2012. pdf?la=en&hash=62C1821CA5CCC5A4868B86A83 FEDE14283686C29. Accessed 15 Oct 2019. 77. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, et al. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. London: General Medical Council; 2009. https://www.gmcuk. org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf. Accessed 15 Oct 2019. 78. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–90. 79. Consuelo-Estrada JR, Gaona-Valle LS, Portillo- Rodríguez O. Lesiones por causa externa en el servicio de urgencias de un hospital en un periodo de cinco años. Gac Med Mex. 2018;154(3):302–9. 80. Zhang Y, Dong YJ, Webster CS, Ding XD, Liu XY, Chen WM, et al. The frequency and nature of drug administration error during anaesthesia H. C. Soon et al. in a Chinese hospital. Acta Anaesthesiol Scand. 2013;57(2):158–64. 81. Joint Commission International Standards for Hospital. 5th Edition. 2014. https://www.jointcom- missioninternational.org/assets/3/7/Hospital-5E- Standards-Only-Mar2014.pdf. Accessed 15 Oct 2019. 82. University of Toronto, Institute for Safe Medication Practices Canada, Physicians for Responsible Opioid Prescribing. Navigating opioids for chronic pain. Toronto, ON: Institute for Safe Medication Practices Canada; 2019. https://www.ismpcanada.org/ download/OpioidStewardship/navigating-opioids- 11x17-canada.pdf. Accessed 15 Oct 2019. 83. Routledge PA. Safe prescribing: a titanic challenge. Br J Clin Pharmacol. 2012;74(4):676–84. 84. 5 Moments for medication safety. In: Patient Safety. Geneva: World Health Organization; 2019. https://www.who.int/patientsafety/ medicationsafety/5moments/en/. Accessed 15 Oct 2019. 85. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4 Pt 1):722–9. 86. Kahn S, Abramson EL. What is new in paediatric medication safety? Arch Dis Child. 2019;104(6):596–9. 87. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 1991;151(9):1825–32. 88. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing. 2008;37(6):673–9. 89. Metsälä E, Vaherkoski U. Medication errors in elderly acute care—a systematic review. Scand J Caring Sci. 2014;28(1):12–28. 90. Lynch MM, Amoozegar JB, McClure EM, Squiers LB, Broussard CS, Lind JN, et al. Improving safe use of medications during pregnancy: the roles of patients, physicians, and pharmacists. Qual Health Res. 2017;27(13):2071–80. 91. Maxwell SRJ, Webb DJ. Improving medication safety: focus on prescribers and systems. Lancet. 2019;394(10195):283–5. 92. McDowell SE, Mt-Isa S, Ashby D, Ferner RE. Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Qual Saf Health Care. 2010;19(4):341–5. 93. Roumeliotis N, Sniderman J, Adams-Webber T, Addo N, Anand V, Rochon P, et al. Effect of electronic prescribing strategies on medication error and harm in hospital: a systematic review and meta-analysis. J Gen Intern Med. 2019;34(10):2210–23.
31 Medication Safety 453 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
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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
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328 ical laboratory and the definit
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330 • Findings of external accred
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332 M. Plebani et al. Fig. 24.2 Mod
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334 laboratory medicine professiona
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336 (WHO) website on the incidence
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338 54. Magnezi R, Hemi A, Hemi R.
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340 In 2010 this condition represen
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342 which should be slightly smalle
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344 needed by the pulse waveform to
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346 washed properly prior to steril
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348 ocular reaction without infecti
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350 large retrospective cohort stud
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352 • Lack of appropriate skills.
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354 scription [126]. Furthermore, a
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356 time and knowledge to young doc
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358 48. Barry P, Gettinby G, Lees F
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360 implant versus intravitreal ant
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Part IV Healthcare Organization
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366 causes of safety incidents and
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368 • Human factors such as teamw
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370 access to the Emergency Room. F
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372 that many doctors simply choose
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374 E. Alti and A. Mereu Open Acces
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376 components (people, technology,
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378 J. Braithwaite et al. Hence, cl
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380 stakeholders to figure out how
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382 J. Braithwaite et al. Clinician
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384 27.5.3 Social Networks in a War
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386 J. Braithwaite et al. Fig. 27.9
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388 representations the essential l
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390 21. Pomare C, Churruca K, Ellis
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Measuring Clinical Workflow to Impr
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28 Measuring Clinical Workflow to I
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Page 401 and 402: Shiftwork Organization Giovanni Cos
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Page 411 and 412: Non-technical Skills in Healthcare
Page 413 and 414: 30 Non-technical Skills in Healthca
Page 433 and 434: Medication Safety Hooi Cheng Soon,
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Page 437 and 438: 31 Medication Safety 439 Table 31.1
Page 439 and 440: 31 Medication Safety to be made bet
Page 441 and 442: 31 Medication Safety medication reg
Page 443 and 444: 31 Medication Safety and contexts,
Page 445 and 446: 31 Medication Safety quently when m
Page 447 and 448: 31 Medication Safety 31.5 Final Rec
Page 449: 31 Medication Safety 451 ity and im
Page 453 and 454: 456 studies in recent years have hi
Page 455 and 456: 458 F. Ranzani and O. Parlangeli in
Page 457 and 458: 460 Any difficulty encountered by t
Page 459 and 460: 462 32.4.2 The Usability Assessment
Page 461 and 462: 464 23. Parlangeli O, Mengoni G, Gu
Page 463 and 464: 466 S. Ushiro et al. No-fault compe
Page 465 and 466: 468 33.2 The Meaning of “No-Fault
Page 467 and 468: 470 S. Ushiro et al. figure of 2.3
Page 469 and 470: 472 S. Ushiro et al. Childbirth fac
Page 471 and 472: 474 • When cerebral palsy is caus
Page 473 and 474: 476 (c) (d) (e) (f) (g) (h) (i) (j)
Page 475 and 476: 478 115 bpm to 80 bpm and complete
Page 477 and 478: 480 • It is desirable that system
Page 479 and 480: 482 cific monitoring procedures (1)
Page 481 and 482: 484 Res. 2019;45(3):493-513. https:
Page 483 and 484: 486 19. In the most severe cases, t
Page 485 and 486: 488 Phases 3 and 4, strong emphasis
Page 487 and 488: 490 Phases 5 and 6 focus is on the
Page 489 and 490: 492 during a pandemic to promote tr
Page 491 and 492: 494 M. Tanzini et al. the mother, p
Page 493: 496 All four abilities are necessar
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