Confusion between Repevax and Revaxis vaccines has resulted in a number of 'patient safety incidents' and 'near misses' being reported

2005 ◽  
Vol &NA; (1054) ◽  
pp. 2
Author(s):  
&NA;
Author(s):  
Sunhwa Shin ◽  
Mihwa Won

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.


2016 ◽  
Vol 05 (01) ◽  
pp. E83-E89 ◽  
Author(s):  
Manmeet Matharoo ◽  
Adam Haycock ◽  
Nick Sevdalis ◽  
Siwan Thomas-Gibson

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.


2021 ◽  
Vol 30 (4) ◽  
pp. 254-255
Author(s):  
John Tingle

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some key reports and sources of information that can help inform patient safety teaching and learning


PLoS ONE ◽  
2017 ◽  
Vol 12 (2) ◽  
pp. e0165455 ◽  
Author(s):  
Philippe Michel ◽  
Jean Brami ◽  
Marc Chanelière ◽  
Marion Kret ◽  
Anne Mosnier ◽  
...  

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