scholarly journals A prospective study of patient safety incidents in gastrointestinal endoscopy

2016 ◽  
Vol 05 (01) ◽  
pp. E83-E89 ◽  
Author(s):  
Manmeet Matharoo ◽  
Adam Haycock ◽  
Nick Sevdalis ◽  
Siwan Thomas-Gibson
Keyword(s):  
Patient Safety ◽  
Safety Issue ◽  
Care Center ◽  
Tertiary Care ◽  
Diagnostic Procedures ◽  
Therapeutic Endoscopy ◽  
Near Misses ◽  
Never Events ◽  
Oxygen Monitoring ◽  
Patient Safety Incidents

Abstract Background and study aims Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included. PSIs were defined as any safety issue that had the potential to or directly adversely affected patient care: PSIs included near misses, complications, adverse events and “never events”. PSIs were reviewed by an expert panel and categorized for severity and nature via expert consensus. Results One hundred and forty procedures (92 diagnostic, 48 therapeutic) over 37 lists (experienced operators n = 25, trainees n = 12) were analyzed. One hundred forty PSIs were identified (median 1 per procedure, range 0 – 7). Eighty-six PSIs (61 %) occurred in 48 therapeutic procedures. Zero PSIs were detected in 13 diagnostic procedures. 21 (15 %) PSIs were categorized as severe and 12 (9 %) had the potential to be “never events,” including patient misidentification and wrong procedure. Forty PSIs (28 %) were of intermediate severity and 78 (56 %) were minor. Oxygen monitoring PSIs occurred most frequently. Conclusion This is the first study documenting the range and frequency of PSIs in endoscopy. Although many errors are minor without immediate consequence, further work should identify whether prevention of such recurrent errors affects the incidence of severe errors, thus improving safety and quality.

scholarly journals Trend Analysis of Patient Safety Incidents and Their Associated Factors in Korea Using National Patient Safety Report Data (2017~2019)

2021 ◽  
Vol 18 (16) ◽  
pp. 8482
Author(s):  
Sunhwa Shin ◽  
Mihwa Won
Keyword(s):  
Patient Safety ◽  
Trend Analysis ◽  
Medical Department ◽  
Patient Age ◽  
Near Misses ◽  
Safety Report ◽  
Patient Âgé ◽  
Report Data ◽  
Sentinel Events ◽  
Patient Safety Incidents

This study analyzed trends in patient safety incidents (PSIs) and the factors associated with the PSIs by analyzing 2017–2019 Patient Safety Report data in Korea. We extracted 2940 records in 2017, 5889 in 2018, and 7386 in 2019, from hospitals with more than 200 beds, and used all 16,215 cases for analysis. SPSS 25.0 was used for a multi-nominal logistic regression analysis. The PSI trend analysis, the standardized Jonckheere–Terpstra test was significant. On analyzing the probability of adverse events based on near misses, the significant variables were patient age, the season when PSIs occurred, incident reporter, hospital size, the location of PSIs, the type of PSIs, and medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient sex, patient age, incident reporter, the type of PSIs, and medical department. To prevent sentinel events in PSIs, female and older patients are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities and report voluntarily.

Patient Safety Rounds in a Pediatric Tertiary Care Center

2008 ◽  
Vol 34 (1) ◽  
pp. 5-12 ◽  
Author(s):  
Michael L. Rinke ◽  
Karen P. Zimmer ◽  
Christoph U. Lehmann ◽  
Paul Colombani ◽  
George Dover ◽  
...  
Keyword(s):  
Patient Safety ◽  
Care Center ◽  
Tertiary Care ◽  
Tertiary Care Center

scholarly journals Building Usability Knowledge for Health Information Technology: A Usability-Oriented Analysis of Incident Reports

2019 ◽  
Vol 10 (03) ◽  
pp. 395-408 ◽  
Author(s):  
Romaric Marcilly ◽  
Jessica Schiro ◽  
Marie Catherine Beuscart-Zéphir ◽  
Farah Magrabi
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Safety Issue ◽  
Free Text ◽  
Negative Outcomes ◽  
Safety Issues ◽  
Incident Reports ◽  
Patient Safety Incidents

Background The contribution of usability flaws to patient safety issues is acknowledged but not well-investigated. Free-text descriptions of incident reports may provide useful data to identify the connection between health information technology (HIT) usability flaws and patient safety. Objectives This article examines the feasibility of using incident reports about HIT to learn about the usability flaws that affect patient safety. We posed three questions: (1) To what extent can we gain knowledge about usability issues from incident reports? (2) What types of usability flaws, related usage problems, and negative outcomes are reported in incidents reports? (3) What are the reported usability issues that give rise to patient safety issues? Methods A sample of 359 reports from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database was examined. Descriptions of usability flaws, usage problems, and negative outcomes were extracted and categorized. A supplementary analysis was performed on the incidents which contained the full chain going from a usability flaw up to a patient safety issue to identify the usability issues that gave rise to patient safety incidents. Results A total of 249 reports were included. We found that incident reports can provide knowledge about usability flaws, usage problems, and negative outcomes. Thirty-six incidents report how usability flaws affected patient safety (ranging from incidents without consequence, to death) involving electronic patient scales, imaging systems, and HIT for medication management. The most significant class of involved usability flaws is related to the reliability, the understandability, and the availability of the clinical information. Conclusion Incidents reports involving HIT are an exploitable source of information to learn about usability flaws and their effects on patient safety. Results can be used to convince all stakeholders involved in the HIT system lifecycle that usability should be considered seriously to prevent patient safety incidents.

scholarly journals Head injury alert: A new level of trauma activation?

Trauma ◽  
2019 ◽  
Vol 22 (3) ◽  
pp. 213-219 ◽  
Author(s):  
Daniel Ricaurte ◽  
Daniel Slack ◽  
Aaron Gilson ◽  
Michael Nowicki ◽  
Monika Nelson ◽  
...  
Keyword(s):  
Patient Safety ◽  
Head Injury ◽  
Injury Severity ◽  
Care Center ◽  
Tertiary Care ◽  
Injured Patient ◽  
Community Hospitals ◽  
Specific Patient ◽  
Head Ct ◽  
Trauma Activation

Introduction Trauma activation requires mobilization of significant resources to be available at short notice. In 2014, the American College of Surgeons Committee on Trauma issued its latest recommendations for care of the injured patient. Amongst trauma activation criteria, elderly patients that fell from any height on anticoagulation were included. We hypothesized that a reduced trauma team could preserve patient safety while reducing time and cost spent. Method A ‘Head Injury Alert’ was created to denote anti-coagulated patients with a GCS > 14 who fell from a height of <20 feet. An ED attending, surgical resident and one nurse evaluate the patient with the goal of obtaining a head CT within 30 min of presentation. Data were prospectively acquired from June 2017 to August 2018, which included age, anticoagulation, injury severity score (ISS), time-to-CT, outcomes, missed injuries, disposition and activations requiring escalation of care. Results Two hundred and seventy-seven head injury activations occurred; 55% of patients were female, while 45% were male. Average age was 78 years old. The most common anticoagulant was Warfarin (31%). 50% of patients were discharged, 47% were admitted, 2% died before disposition and 1% were transferred to a tertiary care center; 7% required admission to the ICU. The average time-to-CT was 25 min and ISS ranged from 0 to 26. Twenty-two patients (7%) presented with positive head CT. Of the five deaths, three patients had intracranial hemorrhage, one pneumonia present on admission and one cardiac arrest. Conclusion This level III evidence, prospective study suggests head injury alert can be safely applied as a new level of trauma activation at community hospitals. It helps identify a specific patient population and injury mechanism that can be safely triaged using limited resources. With this, community hospitals can maximize their resources and minimize cost, while maintaining patient safety.

scholarly journals OC-012 A structured evaluation of patient safety incidents and never events in endoscopy: Abstract OC-012 table 1

Gut ◽  
2012 ◽  
Vol 61 (Suppl 2) ◽  
pp. A5.2-A5
Author(s):  
M K Matharoo ◽  
A Haycock ◽  
N Sevdalis ◽  
S Thomas-Gibson
Keyword(s):  
Patient Safety ◽  
Never Events ◽  
Patient Safety Incidents

EPIDEMIOLOGY AND OUTCOMES OF ELECTRIC BURN INJURY AT TERTIARY CARE CENTER IN JODHPUR, RAJASTHAN

2019 ◽  
Vol 3 (6) ◽  
Author(s):  
Bharti Saraswat ◽  
Ashok Yadav ◽  
Krishna Kumar Maheshwari
Keyword(s):  
Burn Injury ◽  
Low Voltage ◽  
Care Center ◽  
Tertiary Care ◽  
The Body ◽  
Electrical Injury ◽  
Age Group ◽  
Electric Circuits ◽  
Medical College ◽  
Social Burden

Background- Electric burns and injuries are the result of electric current passing through the body. Temporary or permanent damage can occur to the skin, tissues, and major organs. Methods- This prospective study was carried out on patients admitted in burn unit of department of surgery M.G. Hospital associated with Dr. S.N. Medical College Jodhpur. Records of the patients admitted from January 2018 to December 2018 were studied. Bed head tickets of the patients evaluated in detail. Results- In our study out of 113 patients maximum no. of patients were in age group of 21-30 years 44 (38.94%) followed by age group <11 years in 21 (18.58%) patients and age group of > 60 years in only 3 (2.65%).39 (34.51%) patients were farmer and 15 (13.27%) were electrician in out of 113 total patients, while 37 (32.74%) were without any occupation. 65 (57.52%) cases of high voltage (HV) electrical injury and 48 (42.48%) cases were of low voltage (LV) electrical injury. Conclusion- Morbidity leading to permanent disabilities make the person physically dependent on others. It can be prevented by educating the people about the proper handling to electric circuits & devices. Proper communication among the electricians may help in lowering such accidents. Proper rehabilitation of the handicapped person & employment to the member of the affected family may reduce the social burden caused by such electricity concerned accidents.

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