scholarly journals Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk

2021 ◽  
pp. 16-27
Author(s):  
Matthew Taylor ◽  
William Pileggi
Keyword(s):  
Reporting System ◽  
Cardiopulmonary Arrest ◽  
Violent Behavior ◽  
Healthcare Services ◽  
Intervention Package ◽  
Healthcare Facilities ◽  
Patients Âgés ◽  
Safety Reporting ◽  
History Of ◽  
Insight Into

Anesthetics and adjunct agents have a long history of being associated with patients engaging in delirious or agitated behavior in a perioperative setting. Prior to this study, few have explored the topic with a focus on safety for both the patient and staff. We explored the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports to identify bouts of delirium/ agitation associated with anesthetics and/or adjunct agents that occurred during the pre-, intra-, or postoperative period. We identified 97 event reports from 63 healthcare facilities over a two-year period. Patients’ ages ranged from 1 to 91 years and 66% of the patients were reported as male. Also, 8% of the delirium/agitation occurred preoperatively, 8% intraoperatively, and 84% postoperatively. Across all three operative periods, 62% of the reports described dangerous/nonviolent behavior and 26% described dangerous/violent behavior. Additionally, 40% of the event reports described one or more patient injuries (e.g., cardiopulmonary arrest, asphyxiation, hematoma, prolapse/dehiscence, progressive ischemia) and 36% of the patients required additional healthcare services or monitoring (e.g., intra- or interfacility transfer, additional surgical procedure). Finally, 54% of the event reports described patient behavior that created an immediate and high risk of staff harm. Overall, the current study provides novel insight into how delirium/agitation has varying safety implications depending on the operative period. We encourage readers to review Table 5, which proposes a four-phase intervention package to prevent, treat, and de-escalate bouts of delirium/agitation.

scholarly journals Challenges with Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height

2021 ◽  
pp. 48-57
Author(s):  
Elizabeth Kukielka
Keyword(s):  
Patient Safety ◽  
Lung Function ◽  
Creatinine Clearance ◽  
Body Surface ◽  
Outpatient Clinic ◽  
Reporting System ◽  
Healthcare Services ◽  
Safety Reporting ◽  
Dosing Error ◽  
Unit Of Measurement

An accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 679 event reports related to an inaccurate patient height. All events were classified by the reporting facility as incidents, meaning that the patient did not sustain an unanticipated injury or require the delivery of additional healthcare services. The most common care area group where an event occurred was outpatient/clinic (35.8%; 243 of 679). Events were categorized as being related to an error in transcription (72.5%; 492 of 679) or measurement (7.4%; 50 of 679), and the remainder were categorized as etiology of error unclear (20.2%; 137 of 679). The most common transcription errors were the use of the wrong unit of measurement, the transposition of another measurement with height, and typographical errors. Inaccurate patient heights most often led to errors in calculation of medication doses or laboratory values. The most common medication class involved in a dosing error was cancer chemotherapy. In order to ensure accuracy of patient height measurements, patients should be measured at the beginning of every healthcare encounter, units of measurement should be consistent from measurement to transcription into the electronic medical record, and estimated patient height should never be relied upon or recorded.

scholarly journals How Safety Is Compromised When Hospital Equipment Is a Poor Fit for Patients Who Are Obese

2020 ◽  
pp. 48-56
Author(s):  
Eliabeth Kukielka
Keyword(s):  
United States ◽  
Reporting System ◽  
Healthcare Providers ◽  
The United States ◽  
Healthcare Facilities ◽  
Safety Reporting ◽  
Imaging Department ◽  
Skin Tears ◽  
Hospital Equipment ◽  
Surgical Unit

Obesity is common, serious, and costly, and according to recent data, its prevalence is on the rise in the United States. Event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) indicate that some healthcare facilities do not have the necessary equipment to monitor and care for some individuals in this patient population, leading to embarrassment for patients, delays in care, and injuries to patients. An analysis of 107 events related to monitoring and patient care for patients who are obese submitted to PA-PSRS from 2009 through 2018 showed that imaging equipment, especially MRI and CT scanners, was most often implicated in event reports (49.5%; 53 events); other equipment included stretchers (24.3%; 26 events) and wheelchairs (11.2%; 12 events). Events most often occurred in an imaging department (30.8%; 33 events) or a medical/surgical unit (21.5%; 23 events). Analysts determined that 80 events (74.8%) resulted in a delay in care and that 44 events (41.1%) resulted in temporary harm to the patient, including skin tears and abrasions. Healthcare providers may not be able to prevent delays in care resulting from the unavailability of adequate equipment for patients who are obese, but they may be able to prevent harm and embarrassment for patients through proactive assessment.

scholarly journals Expansion of the Reporting System Paradigm to the United States Maritime Industry

2012 ◽  
Vol 48 (2) ◽  
Author(s):  
Jeffrey A. Bixler
Keyword(s):  
Reporting System ◽  
Safety Information ◽  
Aviation Security ◽  
The United States ◽  
Maritime Security ◽  
Maritime Industry ◽  
Safety Reporting ◽  
History Of ◽  
The Impact ◽  
System Paradigm

This paper focuses on the creation of a U.S. maritime reporting system designed to alert the industry of safety incidents and prevent accidents. A brief history of aviation safety reporting will be provided, followed by an analysis of eight recent U.S. maritime accidents that reveal a gap in maritime safety information sharing. This paper will also describe the United Kingdom's maritime reporting system and the previous work completed on a U.S. maritime reporting system. This paper concludes with the impact of terrorism on maritime security and how previous work in aviation security reporting could be incorporated into a maritime reporting system.

scholarly journals Hospital-Acquired COVID-19: Case Discussions of Two Patients Treated at a Level I Trauma Center

2021 ◽  
Vol 2021 ◽  
pp. 1-5
Author(s):  
Ryan M. Desrochers ◽  
Jonathan D. Gates ◽  
Daniel Ricaurte ◽  
Jane J. Keating
Keyword(s):  
Trauma Patients ◽  
Healthcare Facilities ◽  
Consulting Services ◽  
Potential Risk Factors ◽  
History Of ◽  
Case Discussions ◽  
Level I ◽  
Prolonged Hospital ◽  
Hospital Acquired ◽  
Insight Into

The community spread of COVID-19 is well known and has been rigorously studied since the onset of the pandemic; however, little is known about the risk of transmission to hospitalized patients. Many practices have been adopted by healthcare facilities to protect patients and staff by attempting to mitigate internal spread of the disease; however, these practices are highly variable among institutions, and it is difficult to identify which interventions are both practical and impactful. Our institution, for example, adopted the most rigorous infection control methods in an effort to keep patients and staff as safe as possible throughout the pandemic. This case report details the hospital courses of two trauma patients, both of whom tested negative for the COVID-19 virus multiple times prior to producing positive tests late in their hospital courses. The two patients share many common features including history of psychiatric illness, significant injuries, ICU stays, one-to-one observers, multiple consulting services, and a prolonged hospital course prior to discharge to a rehabilitation facility. Analysis of these hospital courses can help provide a better understanding of potential risk factors for acquisition of a nosocomial COVID-19 infection and insight into which measures may be most effective in preventing future occurrences. This is important to consider not only for COVID-19 but also for future novel infectious diseases.

scholarly journals 2019 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents From the Nation's Largest Event Reporting Database

2020 ◽  
Author(s):  
Shawn Kepner ◽  
Rebecca Jones ◽  
Caitlyn Allen ◽  
Daniel Glunk ◽  
Eric Weitz ◽  
...  
Keyword(s):  
Patient Safety ◽  
Acute Care ◽  
Reporting System ◽  
Safety Data ◽  
The United States ◽  
Event Reporting ◽  
Healthcare Facilities ◽  
Safety Reporting ◽  
The Past ◽  
The World

Pennsylvania is the only state that requires healthcare facilities to report all events of harm or potential for harm. Serious Events and Incidents are reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS)*, which is the largest repository of patient safety data in the United States, and one of the largest in the world, with over 3.6 million acute care records. The overwhelming majority (97.1%) of all acute care event reports are Incidents. For 2019, there were 284,847 Incidents and 8,553 Serious Events for a total of 293,400 reported events. The counts of all events and the percentage that are Serious Events reported over the last eight years are provided in Figure 1. The total number of event reports has increased during the last four years. The number of reported Serious Events has increased over the past three years with the largest annual increase occurring in 2019 (+5.7%). This article will show details of the PA-PSRS acute care data along with longitudinal and categorical insights that can be used for improving patient safety.

The Subaltern Speak- A Study On The Culture Of The Arunachalis With Special Reference To Mamang Dai’s The Legends Of Pensam

2019 ◽  
Vol 5 (4) ◽  
pp. 14-20
Author(s):  
Ms. Cheryl Antonette Dumenil ◽  
Dr. Cheryl Davis
Keyword(s):  
Special Reference ◽  
Small World ◽  
Natural World ◽  
Arunachal Pradesh ◽  
North East India ◽  
North East ◽  
Shared History ◽  
History Of ◽  
And Gender ◽  
Insight Into

North- East India is an under veiled region with an awe-inspiring landscape, different groups of ethnic people, their culture and heritage. Contemporary writers from this region aspire towards a vision outside the tapered ethnic channel, and they represent a shared history. In their writings, the cultural memory is showcased, and the intensity of feeling overflows the labour of technique and craft. Mamang Dai presents a rare glimpse into the ecology, culture, life of the tribal people and history of the land of the dawn-lit mountains, Arunachal Pradesh, through her novel The Legends of Pensam. The word ‘Pensam’ in the title means ‘in-between’,  but it may also be interpreted as ‘the hidden spaces of the heart’. This is a small world where anything can happen. Being adherents of the animistic faith, the tribes here believe in co-existence with the natural world along with the presence of spirits in their forests and rivers. This paper attempts to draw an insight into the culture and gender of the Arunachalis with special reference to The Legends of Pensam by Mamang Dai.

Collected Documents on the History of the Pskov Orthodox Mission: A Recent Publication

2018 ◽  
pp. 306-312
Author(s):  
Veniamin F. Zima ◽  
Keyword(s):  
Personal Data ◽  
Prisoners Of War ◽  
Inner Life ◽  
Great Patriotic War ◽  
Occupied Territories ◽  
History Of ◽  
Underground Resistance ◽  
The Baltic ◽  
The Church ◽  
Insight Into

The reviewed work is devoted to a significant, and yet little-studied in both national and foreign scholarship, issue of the clergy interactions with German occupational authorities on the territory of the USSR in the days of the Great Patriotic War. It introduces into scientific use historically significant complex of documents (1941-1945) from the archive of the Office of the Metropolitan Sergius (Voskresensky) of Vilnius and Lithuania, patriarchal exarch in Latvia and Estonia, and also records from the investigatory records on charges against clergy and employees concerned in the activities of the Pskov Orthodox Mission (1944-1990). Documents included in the publication are stored in the archives of Moscow, St. Petersburg, Estonia, Lithuania, Leningrad, Novgorod, and Pskov regions. They allow some insight into nature, forms, and methods of the Nazi occupational regime policies in the conquered territories (including policies towards the Church). The documents capture religious policies of the Nazis and inner life of the exarchate, describe actual situation of population and clergy, management activities and counterinsurgency on the occupied territories. The documents bring to light connections between the exarchate and German counterintelligence and reveal the nature of political police work with informants. They capture the political mood of population and prisoners of war. There is information on participants of partisan movement and underground resistance, on communication net between the patriarchal exarchate in the Baltic states and the German counterintelligence. Reports and dispatches of the clergy in the pay of the Nazis addressed to the Metropolitan Sergius (Voskresensky) contain detailed activity reports. Investigatory records contain important biographical information and personal data on the collaborators. Most of the documents, being classified, have never been published before.

The History of the Judahite Bench Tomb

2018 ◽  
Author(s):  
Matthew Suriano
Keyword(s):  
Iron Age ◽  
Hebrew Bible ◽  
Cultural Practices ◽  
Seventh Century ◽  
Mortuary Practices ◽  
Iron Age Ii ◽  
Gradual Development ◽  
History Of ◽  
The Dead ◽  
Insight Into

The history of the Judahite bench tomb provides important insight into the meaning of mortuary practices, and by extension, death in the Hebrew Bible. The bench tomb appeared in Judah during Iron Age II. Although it included certain burial features that appear earlier in the Middle and Late Bronze Ages, such as burial benches, and the use of caves for extramural burials, the Judahite bench tomb uniquely incorporated these features into a specific plan that emulated domestic structures and facilitated multigenerational burials. During the seventh century, and continuing into the sixth, the bench tombs become popular in Jerusalem. The history of this type of burial shows a gradual development of cultural practices that were meant to control death and contain the dead. It is possible to observe within these cultural practices the tomb as a means of constructing identity for both the dead and the living.

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