2021_Book_TextbookOfPatientSafetyAndClin

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33 Lessons Learned from the Japan Obstetric Compensation System for Cerebral Palsy: A Novel System… 483 presence of pediatrician, and necessary transfer of mother and/or baby should be taken into consideration among other factors. • Neonatal resuscitation should be in line with the latest clinical guidelines. In addition, indication of hypothermia should be deliberated when baby is resuscitated. • The medical chart may be produced after care and must record details such as complaints of the pregnant mother, internal examination, ultrasonography, fetal heart rate monitoring, transfer of the mother, and the performance of a cesarean section. (d) System to provide emergent care • Standardized emergency communication flow should be implemented for prompt treatment of the patient, covering the receipt of a call from a patient who complains of symptoms suggestive of placental abruption (i.e., vaginal bleeding, abdominal pain stiffness of the abdomen, decrease of fetal movement) and its prompt correspondence to medical professionals. • Institutional standards should be created for the prompt treatment of placental abruption as to prompt forced delivery without transfer, request of maternal and/ or neonatal transfer and presence of pediatrician in reference to context of the institution such as staffing for emergent surgery, care to provide the patient including blood transfusion, neonatal resuscitation, other neonatal care including hypothermia, etc. • Procedures should be established for emergent calls for medical staff and effective communication of the level of emergency. In addition, emergency systems should be routinely improved through simulation training to provide emergent care. • Childbirth facilities should be ready in advance to provide care for a patient who has been transferred with placental abruption or probable placental abruption. It is desirable for care plans to be deliberated upon the arrival of the patient, evaluating the well-being of the fetus and placental abruption. For academic and professional societies: (a) Research on the cause and early diagnosis of placental abruption is encouraged to aggregate individual cases. (b) Public outreach is encouraged to let it be widely known that • Placental abruption is an emergent state of disease which threatens the life of the fetus. • Placental abruption may have profound consequences for the mother. • Patients should consult a childbirth facility as soon as possible when they suspect they may suffer the disease. (c) The development of guidelines for the education of pregnant mothers should be encouraged. The guidelines should outline symptoms which suggest placental abruption and actions they must take. For central and local governments: (a) Maternal/fetal transfer systems should be reinforced on a regional scale when they are at risk, as should regional centers for perinatal care. In particular, it is recommended to establish transfer systems beyond prefectural jurisdiction. (b) Projects should be financed to research causes and early diagnosis of placental abruption. Further Readings 1. Japan Council for Quality Health Care, Japan Obstetric Compensation System for Cerebral Palsy (JOCS-CP). Available from: www.sanka-hp.jcqhc. or.jp/index.html (in Japanese). 2. Ushiro S, Suzuki H, Ueda S. Japan Obstetric Compensation System for Cerebral Palsy: Strategic system of data aggregation, investigation, amelioration and no-fault compensation. J Obstet Gynaecol
484 Res. 2019;45(3):493–513. https://doi.org/10.1111/ jog.13906. 3. The Japan Obstetric Compensation System for Cerebral Palsy patterns. Cardiotocograms of cerebral palsy cases-interpretations and considerations of FHR. Part 1 of the book: http://www.sanka-hp.jcqhc. or.jp/documents/statistics/pdf/Cardiotocograms_ of_Cerebral_Palsy_Cases_No.1.pdf. Part 2 of the book: http://www.sanka-hp.jcqhc.or.jp/documents/ statistics/pdf/Cardiotocograms_of_Cerebral_ S. Ushiro et al. Palsy_Cases_No.2.pdf. Part 3 of the book: http:// www.sanka-hp.jcqhc.or.jp/documents/statistics/pdf/Cardiotocograms_of_Cerebral_Palsy_ Cases_No.3.pdf. Part 4 of the book: http://www. sanka-hp.jcqhc.or.jp/documents/statistics/pdf/ Cardiotocograms_of_Cerebral_Palsy_Cases_ No.4.pdf. 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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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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Page 429 and 430: 30 Non-technical Skills in Healthca
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Page 433 and 434: Medication Safety Hooi Cheng Soon,
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Page 445 and 446: 31 Medication Safety quently when m
Page 447 and 448: 31 Medication Safety 31.5 Final Rec
Page 449 and 450: 31 Medication Safety 451 ity and im
Page 451 and 452: 31 Medication Safety 453 Open Acces
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: 482 cific monitoring procedures (1)
Page 483 and 484: 486 19. In the most severe cases, t
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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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