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.

scholarly journals 245. The impact of patient safety report and sentinel events on the prescribing and practice habits of infectious disease physicians

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S122-S122
Author(s):  
Vidya S Kollu ◽  
Zareen Zaidi ◽  
Jonathan J Cho ◽  
Andrew Abbott ◽  
Lennox Archibald ◽  
...  
Keyword(s):  
Infectious Disease ◽  
Patient Safety ◽  
Adverse Events ◽  
Laboratory Tests ◽  
Prescribing Practices ◽  
Prescribing Habits ◽  
Safety Report ◽  
Sentinel Event ◽  
Sentinel Events ◽  
The Impact

Abstract Background Adverse events associated with antimicrobials range from mild to severe and may cause distress or harm to patients, and anxiety for prescribers. The basic tenets of prescribing antimicrobials are based on knowledge of the disease, pharmacokinetics, and pharmacodynamics of the prescribed agent, and effectiveness of the therapy. Inappropriate prescribing can increase costs and may cause reactions or the emergence of resistance. There is a paucity of published data on the prescribing habits of physicians after a sentinel event or patient safety report. Thus, we carried out this study to ascertain whether patient safety reports and sentinel events influence physician antimicrobial prescribing practices Methods We invited Infectious Disease physicians at the University of Florida to participate in a survey of their perception of risks and prescribing habits after a sentinel event. Participants were interviewed using a standardized questionnaire. Data were analyzed using Epi Info statistical software. Thematic analyses were performed on the open-ended interview questions. Results Of 17 faculty and fellows who participated in the survey, 5 (29.4%) had been practicing infectious disease for 1–3 years, 3 (17.6%) for 4–6 years, 2 (11.7%) for 7–9 years, and 7 (41.1 %) for >nine years. Two (11.7%) had a patient safety report filed against them. All participants had experienced at least one sentinel event involving an antimicrobial agent. Sixteen (94%) changed their practice after sentinel events; 8 (47%) increased the frequency of ordering laboratory tests, and 7 (41%) indicated they might change to more expensive antimicrobials with better safety profiles. Eight (47%) participants endorsed hypervigilance when using antibiotics Conclusion We found that sentinel events affect physicians’ prescribing practices and monitoring of antimicrobial therapy. The most frequent changes included closer follow-up and obtaining more laboratory tests. However, some participants avoided certain antimicrobial agents or used more expensive therapies with better safety profiles. Although physicians use evidence-based medicine to alter their prescribing habits, serious adverse events can have an impact on the way we practice Disclosures Jonathan J. Cho, MD, Novartis (Shareholder)

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.

POCUS Findings in Critically Ill Patients in Emergency Department

2021 ◽  
Vol 104 (Suppl. 1) ◽  
pp. S54-S58
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Vena Cava ◽  
Admission Rate ◽  
Point Of Care Ultrasound ◽  
True Positive ◽  
Medical Department ◽  
Patient Age ◽  
Patient Disposition ◽  
Patient Âgé

Background: Point of care ultrasound (POCUS) has been shown to improve diagnostic accuracy and has been used in a variety of contexts. However, the utility of POCUS as applied to critically ill patients has not been well studied. Materials and Methods: This was a retrospective descriptive study of critically ill patients who had received POCUS at Srinagarind Hospital’s Emergency Medical Department between July 2019 and June 2020. Data was collected from one year of POCUS studies and included ultrasound clips and images, patient age and sex, chief complaint, final diagnosis, and patient disposition. The data was described using descriptive statistics, including medians, counts and percentages. Results: POCUS data was collected from 2,500 studies performed on 369 patients. Median patient age was 62.7 years; 51.6% of patients were female. Top indications of POCUS scans were of respiratory (34.42%) and cardiovascular system (23.58%) presentations. The most frequent study types performed were cardiac, lung, and inferior vena cava examinations. Abnormal ultrasound findings were found in 258 patients (69.92%). True-positive ultrasound results were found in 162 patients (43.9%). The admission rate of critically ill patients was highest among patients who had true-positive results. Conclusion: The prevalence of positive POCUS results was quite high in critically ill patients. Moreover, POCUS showed high accuracy. The number of admitted patients was highest among patients who had true-positive ultrasound results. Keywords: Ultrasonography, Critical illness, Emergency medicine

Gestion orthopédique d’une ankylose de l’ATM chez l’enfant

2020 ◽  
Vol 54 (4) ◽  
pp. 407-418
Author(s):  
Pamela Villalon-Pooley ◽  
Camila Hernandez-Veliz ◽  
Maria Fernanda Pinto-Chavez ◽  
Pierre Bourdiol
Keyword(s):  
Patient Age ◽  
Patient Âgé

Parmi les fractures cranio-faciales, celles affectant le condyle mandibulaire font partie des fractures les plus souvent rencontrées chez le patient en âge pédiatrique. L’évolution sans traitement peut produire une ankylose temporo-mandibulaire entraînant troubles fonctionnels et asymétrie de la croissance cranio-faciale. Le traitement traditionnellement chirurgical est d’un pronostic généralement réservé. Dans cet article est présenté le cas d’un patient, âgé de quatre ans, atteint d’ankylose fibreuse de l’articulation temporo-mandibulaire gauche, suite probable d’une fracture du col du condyle non-diagnostiquée. La libération fonctionnelle de la fibro-ankylose articulaire a été l’objectif de la première étape thérapeutique. Celle-ci a été suivie, à l’âge de sept ans, d’une distraction articulaire obtenue au moyen de butées occlusales controlatérales disposées côté droit. Ceci a produit un ajustement de la croissance dento-alvéolaire assurant à la fois un rattrapage du déficit de croissance unilatéral de départ et une néoformation condylienne par remodelage de l’articulation temporo-mandibulaire gauche. Quatre années après la mise en route de la phase orthopédique initiale, la fonction articulaire restaurée et l’équilibre facial obtenu restent stables chez ce jeune patient

Hemmkörperentwicklung bei Hämophilie-Patienten nach Präparate wechsel

2012 ◽  
Vol 32 (S 01) ◽  
pp. S39-S42 ◽  
Author(s):  
S. Kocher ◽  
G. Asmelash ◽  
V. Makki ◽  
S. Müller ◽  
S. Krekeler ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Observational Study ◽  
Retrospective Observational Study ◽  
Frequent Change ◽  
Patient Age ◽  
Treatment Regimens ◽  
Patient Âgé ◽  
The Relationship ◽  
Observation Period

SummaryThe retrospective observational study surveys the relationship between development of inhibitors in the treatment of haemophilia patients and risk factors such as changing FVIII products. A total of 119 patients were included in this study, 198 changes of FVIII products were evaluated. Results: During the observation period of 12 months none of the patients developed an inhibitor, which was temporally associated with a change of FVIII products. A frequent change of FVIII products didn’t lead to an increase in inhibitor risk. The change between plasmatic and recombinant preparations could not be confirmed as a risk factor. Furthermore, no correlation between treatment regimens, severity, patient age and comorbidities of the patients could be found.

Hämophilie-Zentrum Bonn 1980 – 2009

2011 ◽  
Vol 31 (S 01) ◽  
pp. S4-S10 ◽  
Author(s):  
I. Besmens ◽  
H.-H. Brackmann ◽  
J. Oldenburg
Keyword(s):  
Young Patients ◽  
Severe Form ◽  
Coagulation Disorder ◽  
Care Providers ◽  
Long Distance ◽  
Patient Age ◽  
Patient Âgé ◽  
Number Of Patients ◽  
Clotting Disorder ◽  
Regional Character

SummaryThe Bonn Haemophilia Care Center provides patient care on a superregional level. The centre’s large service area is, in part, due to the introduction of haemophilia home treatment and related to this the individualized prophylaxis in children and adults by Egli and Brack-mann in Bonn in the early 1970s, that represented a milestone in German haemophilia therapy. Epidemiologic patient data from the two selected time points, 1980 and 2009, are evaluated to illustrate the change in the composition of the patient clientele. In 1980 a total of 639 patients were treated at the Bonn Haemophilia Center. 529 patients exhibited a severe form and 110 a non-severe form of the respective clotting disorder. In 2009 the Bonn Haemophilia Center took care for a total of 837 patients. There were 445 patients who suffered from a severe form of the considered clotting disorder while 392 showed a non-severe course. The number of less severely affected patients has increased significantly in 2009. Patients in 1980 were predominantly suffering from a severe form and most had to travel more than 150 km from their homes to the treatment center. In 2009 the number of patients living a medium-long distance from the care provider has significantly increased while the number of patients living more than 150km from the center has decreased. Comparing 2009 to 1980 a growth of the center’s regional character becomes apparent, especially when patient age and severity of the coagulation disorder are taken into consideration. The regional character was more strongly pronounced with milder disease severity and lower patient age. Due to the existence of well established primary haemophilia care in CCCs in Germany, the trend for the recent years is that the proportion of young patients that choose haemophilia care providers closer to their homes is increasing.

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