Why do we STILL not Follow Procedures?

2017 ◽  
Vol 61 (1) ◽  
pp. 1664-1668 ◽  
Author(s):  
Colin Drury ◽  
Catherine Drury Barnes ◽  
Michelle R. Bryant
Keyword(s):  
Adverse Events ◽  
Hierarchical Classification ◽  
Contributing Factors ◽  
Classification Schemes ◽  
Event Classification ◽  
Good Practices ◽  
Aviation Maintenance ◽  
Significant Potential ◽  
Regulated Industries

Even though in aviation maintenance, as in many other regulated industries, written procedures are mandated, we still see “Failure to Follow Procedures” as a contributing factor in too many event/ incident/ accident reports (Drury and Johnson, 2013). This paper details an aviation maintenance project that seeks to find recurring patterns of events, contributing factors to these events, and potential good practices that, if followed, will reduce the incidence and/or severity of these events. Over 100 reference sources were examined to provide a framework of event classification. A total of 154 events selected for procedures content from ASRS was analyzed, plus 93 NTSB reports of failure to follow procedures accidents. Hierarchical classification schemes for contributing factors and potential good practices were derived and compared across sources. The main findings were that both design of the procedure itself and the organizational milieu surrounding its use had significant potential for reducing these adverse events.

scholarly journals Debilitating Skin Toxicity Associated with Pembrolizumab Therapy in an 81-Year-Old Female with Malignant Melanoma

2016 ◽  
Vol 9 (3) ◽  
pp. 833-839 ◽  
Author(s):  
Muhammad O. Khokhar ◽  
Jacob Kettle ◽  
Amruth R. Palla
Keyword(s):  
Malignant Melanoma ◽  
Adverse Effects ◽  
Adverse Events ◽  
Drug Toxicity ◽  
Immune Therapy ◽  
Skin Toxicity ◽  
Significant Potential ◽  
Immune Mediated ◽  
Related Drug

Frequently described immune-mediated adverse effects of immune therapy include dermatological complications, hepatitis, colitis, pneumonitis, and endocrinopathies. As utilization of pembrolizumab and related agents continues to expand both in the available indications as well as duration of exposure, there remains a significant potential to uncover previously undescribed adverse events. From a dermatological standpoint, 39% of patients receiving pembrolizumab therapy experience some form of skin-related drug toxicity [Naidoo et al.: Ann Oncol 2015;26: 2375–2391]. We describe a case of pembrolizumab-induced disabling autoimmune ectodermal toxicity.

Good Practices for Handling Adverse Events Detected through Patient Registries

2008 ◽  
Vol 42 (5) ◽  
pp. 421-428 ◽  
Author(s):  
Nancy A. Dreyer ◽  
Neha Sheth ◽  
Anne Trontell ◽  
Richard E. Gliklich
Keyword(s):  
Adverse Events ◽  
Patient Registries ◽  
Good Practices

scholarly journals Analysis of notifications of adverse events in a private hospital

2019 ◽  
Vol 18 (3) ◽  
pp. 314-343
Author(s):  
Alcides Viana de Lima Neto ◽  
Fernanda Antunes da Silva ◽  
Genilza Maria De Oliveira Lima Brito ◽  
Tatiana Mari A Nóbrega Elias ◽  
Bruna Aderita Cortez de Sena ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Private Hospital ◽  
Medication Administration ◽  
Contributing Factors ◽  
Event Notification ◽  
Adverse Incident ◽  
Compromise Patient Safety ◽  
Current Context ◽  
Human Failure

Introducción: La seguridad del paciente, en el contexto actual, pasó a ser investigada en los diversos campos de la salud, con el objetivo de reducir la incidencia de daños y eventos adversos a los pacientes. Objetivo: Identificar y analizar los eventos adversos que comprometen la seguridad del paciente durante la asistencia de enfermería en un hospital privado. Métodos: Investigación exploratoria, documental y retrospectiva. El instrumento de recolección de datos fue el informe de notificación de eventos adversos utilizado por el hospital compuesto por cuestiones abiertas y cerradas. Resultados: Se analizaron 262 informes de notificación de eventos adversos / incidentes que ocurrieron en el período de 2015 a 2016. Se demuestra que los factores contribuyentes para la ocurrencia de los eventos adversos fueron causados por fallo humano. Del total de formularios analizados, 161 (61,83%) indicaron descuido y distracción. La omisión se destacó con 11 (4,20%) casos. La falta de atención con el paciente propició 116 (44,27%) errores en la administración de medicamentos, 46 (17,56%) fallos durante la digitación y transcripción de la prescripción médica y 35 (13,36%) fallos en la asistencia. Conclusión: Se percibe que los incidentes son causados por factores humanos y de posible reversión. Cuando son investigados, pueden ser minimizados, lo que contribuye a la calidad y seguridad en el cuidado al paciente. Introduction: patient safety, in the current context, began to be investigated in the different health fields, aiming to reduce the incidence of damages and adverse events to patients. Objective: to identify and analyze adverse events that compromise patient safety during nursing care in a private hospital. Methods: exploratory, documentary and retrospective research. The instrument of data collection was the report of adverse event notification used by the hospital composed of open and closed questions. Results: the researchers analyzed 262 reports of adverse/incident events that occurred in the period 2015 to 2016. The contributing factors for the occurrence of adverse events were caused by human failure. Of the total number of forms analyzed, 161 (61.83%) reported carelessness and distraction. The omission was highlighted with 11 (4.20%) cases. The lack of attention with the patient led to 116 (44.27%) errors in medication administration, 46 (17.56%) failures during the typing and transcription of the medical prescription and 35 (13.36%) failures in care. Conclusion: the incidents are caused by human factors, with possible reversion. When investigated, they can be minimized, which contributes to quality and safety in patient care. Introdução: A segurança do paciente, no contexto atual, passou a ser investigada nos diversos campos da saúde, com o objetivo de reduzir a incidência de danos e eventos adversos aos pacientes. Objetivo: Identificar e analisar os eventos adversos que comprometem a segurança do paciente durante a assistência de enfermagem em um hospital privado. Métodos: Pesquisa exploratória, documental e retrospectiva. O instrumento de coleta de dados foi o relatório de notificação de eventos adversos utilizado pelo hospital composto por questões abertas e fechadas. Resultados: Analisaram-se 262 relatórios de notificação de eventos adversos/incidentes que ocorreram no período de 2015 a 2016. Demonstra-se que o fatores contribuintes para a ocorrência dos eventos adversos foram causados por falha humana. Do total de formulários analisados, 161 (61,83%) apontaram descuido e distração. A omissão se destacou com 11 (4,20%) casos. A falta de atenção com o paciente propiciou 116 (44,27%) erros na administração de medicamentos, 46 (17,56%) falhas durante a digitação e transcrição da prescrição médica e 35 (13,36%) falhas na assistência. Conclusão: Percebe-se que os incidentes são causados por fatores humanos e de possível reversão. Quando investigados, podem ser minimizados, o que contribui para a qualidade e segurança no cuidado ao paciente.

The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study of Endobronchial Intubation: An Analysis of 2,000 Incident Reports

2020 ◽  
Vol 103 (10) ◽  
pp. 1022-1027
Keyword(s):  
Adverse Events ◽  
Incident Report ◽  
Preventive Strategies ◽  
Contributing Factors ◽  
Study Objective ◽  
Endobronchial Intubation ◽  
Anesthesia Service ◽  
Keywords Anesthesia ◽  
Incident Reports ◽  
Voluntary Basis

Background: The Royal College of Anesthesiologists of Thailand hosted a multicentered project, namely the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study. Objective: The aims of the present study were to investigate incidences, contributing factors and suggested preventive strategies of anesthesia-related complications particularly the endobronchial intubation (EBI). Materials and Methods: The PAAd Thai study was a collaborative incident report among 22 hospitals across Thailand. After approval by the Institutional Ethical Committee, the structured incident report together with open ended data record form of anesthesia-related complications such as cardiac arrest, death within 24 hours, and respiratory complications including EBI were requested to be sent to the data management center together with monthly statistics of anesthesia service in each hospital for 12 months (between January 2015 and December 2015) on an anonymous and voluntary basis. The EBI reports were reviewed by three anesthesiologists. Any discretion was discussed to achieve a consensus. Descriptive statistics were used. Results: Among the first 2,000 incident reports, there were 23 EBIs, at the rate of 1.06:10,000 (95% CI 0.62 to 1.49) or 1.15% of all reports. Two-thirds of the incidents occurred in patients with age less than 5 years old and more than 60 years old, and in elective cases. The common sites of surgery were trunk, head and neck, and laparoscopic procedures. EBIs were diagnosed by pulse oximeter (13 cases, 54.0%), increased airway pressure (four cases, 17.2%) and clinical monitoring (four cases 17.2%). Common phases of detection were pre-induction (one case, 4.3%), induction (nine cases, 39.2%), maintenance (12 cases, 52.2%), and emergence (one case, 4.3%). Contributing factors were lack of knowledge, inexperience, and haste, while factors minimizing the incidents were having experience and vigilance. Suggested preventive strategies were additional training, including simulation, practice guidelines, improvement of supervision, and communication. Conclusion: The authors have found that EBI was uncommon, but it is one of the serious anesthesia-related adverse events. It can happen anytime during the entire course of anesthesia. Under these circumstances, careful monitoring and vigilance of the anesthesiologists is essential. Keywords: Anesthesia, Complication, Endobronchial intubation, Intubation, Hypoxia

The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study of Anesthetic Equipment Malfunction or Failure: An Analysis of 2206 Incident Reports

2021 ◽  
Vol 104 (2) ◽  
pp. 286-292
Keyword(s):  
Adverse Events ◽  
Present Report ◽  
Perioperative Complications ◽  
Pediatric Anesthesia ◽  
Contributing Factors ◽  
Case Record ◽  
Mortality And Morbidity ◽  
Surgical Safety ◽  
Anesthesia Equipment ◽  
Incident Reports

Background: Anesthesia equipment problems may contribute to anesthesia mortality and morbidity. The Royal College of Anesthesiologists of Thailand initiated a multicentered incident reporting study namely the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study to investigate perioperative complications including equipment malfunction or failure. Materials and Methods: The present report was a descriptive prospective study. After the Institutional Ethical approval with informed consent was waived, the case record form comprising structured and narrative information parts was requested to be filled within 24 hours of occurrence of anesthesia equipment malfunction or failure in 22 large government hospitals across Thailand between January and December 2015. Three senior anesthesiologists reviewed the incident reports. Any discrepancy was discussed to achieve a consensus. Descriptive statistics were used for analysis. Results: Out of 2,206 incident reports, there were 47 (2.1%) equipment malfunction or failure involving anesthetic machine (36.0%), anesthetic circuit (27.6%), laryngoscope (17.0%) and monitoring (12.7%) in operating theatre (97.8%), pediatric anesthesia (19.1%), and emergency condition (21.2%). Diagnoses of incidents was either clinical detection (82.9%) or detection by monitoring equipment (48.9%). Outcomes of incidents were trivial with full recovery. The incidents were considered as results from human factor (38.3%), preventable (46.8%), and might be prevented with surgical safety checklists (34.0%). Conclusion: Equipment malfunction or failure incidents were unusual and did not lead to serious consequence. Common contributing factors were ineffective equipment, non-adherence to surgical checklists, haste, and inexperience of performers. Factors to minimize the incidents were equipment checking, having experience, and comply to surgical checklists. Quality assurance activity, standard and regular equipment maintenance, adherence to surgical checklists, and additional training were suggested as corrective measures. Keywords: Anesthesia, Complications, Equipment malfunction, Equipment failure, Human factors, Surgical checklist

scholarly journals CRT-711 Publicly Reported Adverse Events with the Edwards SAPIEN Valve - Trends and Event Classification in the FDA MAUDE Database

2014 ◽  
Vol 7 (2) ◽  
pp. S55
Author(s):  
Sarkis Kiramijyan ◽  
Joseph L. Thomas ◽  
Aram Gabrielyan ◽  
Vinoy Prasad ◽  
Nimish Patel ◽  
...  
Keyword(s):  
Adverse Events ◽  
Event Classification ◽  
Edwards Sapien ◽  
Edwards Sapien Valve

scholarly journals Exchange Rate Flexibility: How Should We Measure It?

2020 ◽  
Vol 31 (4) ◽  
pp. 881-900 ◽  
Author(s):  
Michael Bleaney ◽  
Mo Tian
Keyword(s):  
Exchange Rate ◽  
Classification Scheme ◽  
Exchange Rate Flexibility ◽  
Classification Schemes ◽  
Significant Potential

AbstractThis paper first examines some recent exchange rate classification schemes. There is little evidence of a trend towards greater agreement between schemes. There is a probability of between 16 and 28% that a peg in one classification scheme is coded as a float in a different scheme, or vice versa. This probability is much smaller for the tightest forms of peg and the most volatile floats. Continuous indices of exchange rate flexibility are analysed and shown to have significant potential, despite the lack of interest in them shown in previous research.

scholarly journals Analysis of Patient Safety Incidents in Primary Care Reported in an Electronic Registry Application

2021 ◽  
Vol 18 (17) ◽  
pp. 8941
Author(s):  
Montserrat Gens-Barberà ◽  
Núria Hernández-Vidal ◽  
Elisa Vidal-Esteve ◽  
Yolanda Mengíbar-García ◽  
Immaculada Hospital-Guardiola ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Care Delivery ◽  
Contributing Factors ◽  
Notification System ◽  
Corporate Website ◽  
Critical Areas ◽  
Service Setting ◽  
Health Centres

Objectives: (1) To describe the epidemiology of patient safety (PS) incidents registered in an electronic notification system in primary care (PC) health centres; (2) to define a risk map; and (3) to identify the critical areas where intervention is needed. Design: Descriptive analytical study of incidents reported from 1 January to 31 December 2018, on the TPSC Cloud™ platform (The Patient Safety Company) accessible from the corporate website (Intranet) of the regional public health service. Setting: 24 Catalan Institute of Health PC health centres of the Tarragona region (Spain). Participants: Professionals from the PC health centres and a Patient Safety Functional Unit. Measurements: Data obtained from records voluntarily submitted to an electronic, standardised and anonymised form. Data recorded: healthcare unit, notifier, type of incident, risk matrix, causal and contributing factors, preventability, level of resolution and improvement actions. Results: A total of 1544 reports were reviewed and 1129 PS incidents were analysed: 25.0% of incidents did not reach the patient; 66.5% reached the patient without causing harm, and 8.5% caused adverse events. Nurses provided half of the reports (48.5%), while doctors reported more adverse events (70.8%; p < 0.01). Of the 96 adverse events, 46.9% only required observation, 34.4% caused temporary damage that required treatment, 13.5% required (or prolonged) hospitalization, and 5.2% caused severe permanent damage and/or a situation close to death. Notably, 99.2% were considered preventable. The main critical areas were: communication (27.8%), clinical-administrative management (25.1%), care delivery (23.5%) and medicines (18.4%); few incidents were related to diagnosis (3.6%). Conclusions: PS incident notification applications are adequate for reporting incidents and adverse events associated with healthcare. Approximately 75% and 10% of incidents reach the patient and cause some damage, respectively, and most cases are considered preventable. Adequate and strengthened risk management of critical areas is required to improve PS.

Sign in / Sign up

Export Citation Format

Share Document