Adverse events and near misses relating to information management in a hospital

2016 ◽  
Vol 45 (2) ◽  
pp. 55-63 ◽  
Author(s):  
Virpi Jylhä ◽  
David W Bates ◽  
Kaija Saranto
Keyword(s):  
Adverse Events ◽  
Information Management ◽  
Near Misses

scholarly journals Adverse medication events in a psychiatric practice: a naturalistic study

2013 ◽  
Vol 37 (12) ◽  
pp. 395-397
Author(s):  
Eugene G. Breen
Keyword(s):  
Adverse Event ◽  
Adverse Events ◽  
Adverse Drug Events ◽  
Psychiatric Training ◽  
Clinical Implications ◽  
Naturalistic Study ◽  
Near Misses ◽  
Significant Events ◽  
Core Module ◽  
Sector Service

Aims and methodTo document the number and type of adverse medication events in a psychiatric sector service. Significant new adverse events were collated by the author and team over 30 months. Intervention to prevent any adverse event was enacted as soon as any were noticed or anticipated.ResultsThirty-six significant events occurred including three deaths and nine near misses. Corrective action was taken immediately any adverse event occurred. Inadequate communication between various hospital clinics, general practitioner practices, psychiatric clinics and pharmacies was the biggest avoidable cause of adverse events.Clinical implicationsAwareness of adverse drug events is essential in psychiatry. Clear, transparent pathways of prescribing are a key requirement to reduce avoidable adverse medication events. Psychopharmacology is a core module for psychiatric training.

scholarly journals ADVERSE EVENTS AND NEAR MISSES IN HOSPITALIZATION UNITS OF A SPECIALIZED HOSPITAL IN CARDIOLOGY

2019 ◽  
Vol 23 ◽  
Author(s):  
Gabriela Marcellino de Melo Lanzoni ◽  
Aliny Fernandes Goularte ◽  
Cintia Koerich ◽  
Emilene Reisdorfer ◽  
Marina Miotello ◽  
...  
Keyword(s):  
Adverse Events ◽  
Near Misses ◽  
Specialized Hospital

Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center

2017 ◽  
Vol 43 (1) ◽  
pp. 5-15 ◽  
Author(s):  
William Martinez ◽  
Lisa Soleymani Lehmann ◽  
Yue-Yung Hu ◽  
Sonali Parekh Desai ◽  
Jo Shapiro
Keyword(s):  
Adverse Events ◽  
Medical Center ◽  
Academic Medical Center ◽  
Near Misses ◽  
Academic Medical

Disclosing adverse events and near misses to parents of neonates

2019 ◽  
Vol 43 (8) ◽  
pp. 151182
Author(s):  
Brian S. Carter ◽  
John D. Lantos
Keyword(s):  
Adverse Events ◽  
Near Misses

scholarly journals Identification by families of pediatric adverse events and near misses overlooked by health care providers

2011 ◽  
Vol 184 (1) ◽  
pp. 29-34 ◽  
Author(s):  
J. P. Daniels ◽  
K. Hunc ◽  
D. D. Cochrane ◽  
R. Carr ◽  
N. T. Shaw ◽  
...  
Keyword(s):  
Health Care ◽  
Adverse Events ◽  
Health Care Providers ◽  
Care Providers ◽  
Near Misses

Raising the safety bar: The hematology/oncology patient safety committee.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 144-144
Author(s):  
Myrna Rita Nahas ◽  
Jessica A. Zerillo ◽  
Stephen A. Cannistra ◽  
Cheryle Totte
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Peer Review ◽  
Healthcare Provider ◽  
Medical Center ◽  
Healthcare Delivery ◽  
Healthcare Providers ◽  
Oncology Patient ◽  
Near Misses ◽  
Safety Committee

144 Background: Enhancing patient safety can prevent unintended outcomes arising from defects in healthcare delivery systems. The Hematology/Oncology Patient Safety Committee (HOPSC) at Beth Israel Deaconess Medical Center (BIDMC) is a multidisciplinary team of healthcare providers that meets monthly to review inpatient and outpatient adverse events, near misses, and medical errors that impact patient safety. Methods: Our aim was to quantify and qualify the cases that the HOPSC has reviewed from 2012-2013. In order to identify trends in event reporting, we reviewed the number of events reported to the HOPSC in both the inpatient and outpatient settings. We further subdivided events into two categories: medication-related and non-medication related. Additionally, we delineated which healthcare provider initiated the reporting of each event. Results: Over the two-year period, a total number of 1,061 events were reported to the HOPSC. Of these, 259 were medication-related events. Of the events reported, 40 were by a physician/NP and 1,021 were by a nurse. There was a discrepancy in the type of event reported (24.4% medication vs. 75.6% non-medication related) as well as in the type of reporter (3.8% physician/NP vs. 96.2% nurse). Of all the events reported, 8 were escalated to the Department of Medicine Peer Review Committee. Conclusions: Through review of healthcare provider event reports, the HOPSC has identified several types of adverse events and near misses in the Hematology/Oncology division at BIDMC. The events are mostly reported by inpatient nurses and are primarily medication-related. Given this skewed reporting pattern, we will investigate the reasons why reporting by physicians, especially in the outpatient setting, is limited. Our reported outline of the HOPSC operations may also guide oncology practices elsewhere in their own development of patient safety peer review committees. [Table: see text]

scholarly journals Construction of Clinical Pathway Information Management System under the Guidance of Evidence-Based Medicine

2021 ◽  
Vol 2021 ◽  
pp. 1-12
Author(s):  
Xinyu Wang ◽  
Jie Chen ◽  
Fang Peng ◽  
Jingtai Lu
Keyword(s):  
Adverse Events ◽  
Information Management ◽  
Clinical Pathway ◽  
Evidence Based Medicine ◽  
Medical Staff ◽  
Management System ◽  
Information Management System ◽  
Evidence Based ◽  
Work Efficiency ◽  
Based Medicine

This study focuses on clinical pathways guided by evidence-based medicine (EBM). With the clinical pathway as the center, the subjective and objective medical knowledge of medical staff are collected, and a clinical pathway management system guided by EBM is established through a unified process; user demand analysis; main considerations; implementation, evaluation, and monitoring of the clinical path; and dictionary maintenance, to help hospitals fully regulate medical behaviors. Next, the study displays the path access prompt box, area 1 management page, table management page, exit prompt box, mutation record page, doctor order interface, revocation of execution, and monitoring interface, and the system designed is compared with the Beijing Shankang Technology (ASK) clinical data management system in terms of user experience. The results showed that the reporting rate of medical adverse events in the system in this study was 0.21%, and the work efficiency was increased by 14%. In terms of users’ satisfaction, the hospital managers’ satisfaction was 84 ± 5.36%, and it was 95 ± 4.72% for medical staff and 88 ± 4.91% for system administrators, superior to the ASK system; the differences were statistically significant ( P < 0.05 ). In conclusion, the clinical pathway information management system is in line with the working environment of medical staff, and the synchronous monitoring and management of medical quality are achieved through digital means, which can reduce the occurrence of medical adverse events and improve the work efficiency of medical staff.

scholarly journals A study of cases reported as incidents in a public hospital from 2011 to 2014

2016 ◽  
Vol 50 (5) ◽  
pp. 861-867 ◽  
Author(s):  
Leila Bernarda Donato Göttems ◽  
Maria do Livramento Gomes dos Santos ◽  
Paloma Aparecida Carvalho ◽  
Fábio Ferreira Amorim
Keyword(s):  
Retrospective Study ◽  
Adverse Events ◽  
Medical Devices ◽  
Public Hospital ◽  
Healthcare Professionals ◽  
Federal District ◽  
Near Misses ◽  
Hospitalization Time ◽  
The Moment ◽  
Intravenous Medication

Abstract OBJECTIVE Analyzing incidents reported in a public hospital in the Federal District, Brasilia, according to the characteristics and outcomes involving patients. METHOD A descriptive and retrospective study of incidents reported between January 2011 and September 2014. RESULTS 209 reported incidents were categorized as reportable occurrences (n = 22, 10.5%), near misses (n = 16, 7.7%); incident without injury (n = 4, 1.9%) and incident with injury (adverse events) (n = 167, 79.9%). The average age of patients was 44 years and the hospitalization time until the moment of the incident was on average 38.5 days. Nurses were the healthcare professionals who most reported the incidents (n = 55, 67%). No outcomes resulted in death. CONCLUSION Incidents related to blood/hemoderivatives, medical devices/equipment, patient injuries and intravenous medication/fluids were the most frequent. Standardizing the reporting processes and enhancing participation by professionals in managing incidents is recommended.

Derivation of a Taxonomy to Categorize Adverse Events and Near-Misses in Transport Medicine

2011 ◽  
Vol 30 (5) ◽  
pp. 254-255 ◽  
Author(s):  
Russell MacDonald ◽  
Richard Yelle ◽  
Jo-Anne Oake-Vecchiato ◽  
Christian Melis ◽  
Blair L. Bigham
Keyword(s):  
Adverse Events ◽  
Near Misses
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