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Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

https://arctichealth.org/en/permalink/ahliterature164254
Source
Ann Surg. 2007 Apr;245(4):526-32
Publication Type
Article
Date
Apr-2007
Author
Robert K Michaels
Martin A Makary
Yasser Dahab
Frank J Frassica
Eugenie Heitmiller
Lisa C Rowen
Richard Crotreau
Henry Brem
Peter J Pronovost
Author Affiliation
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Source
Ann Surg. 2007 Apr;245(4):526-32
Date
Apr-2007
Language
English
Publication Type
Article
Keywords
Canada
Clinical Protocols
Humans
Joint Commission on Accreditation of Healthcare Organizations
Medical Errors - prevention & control
Medical Laboratory Science
Risk factors
Safety
Safety Management - methods
Societies, Medical
Surgery Department, Hospital - organization & administration - standards
Surgical Procedures, Operative - standards
United States
United States Department of Veterans Affairs
Abstract
Review the evidence regarding methods to prevent wrong site operations and present a framework that healthcare organizations can use to evaluate whether they have reduced the probability of wrong site, wrong procedure, and wrong patient operations.
Operations involving the wrong site, patient, and procedure continue despite national efforts by regulators and professional organizations. Little is known about effective policies to reduce these "never events," and healthcare professional's knowledge or appropriate use of these policies to mitigate events.
A literature review of the evidence was performed using PubMed and Google; key words used were wrong site surgery, wrong side surgery, wrong patient surgery, and wrong procedure surgery. The framework to evaluate safety includes assessing if a behaviorally specific policy or procedure exists, whether staff knows about the policy, and whether the policy is being used appropriately.
Higher-level policies or programs have been implemented by the American Academy of Orthopaedic Surgery, Joint Commission on Accreditation of Healthcare Organizations, Veteran's Health Administration, Canadian Orthopaedic, and the North American Spine Society Associations to reduce wrong site surgery. No scientific evidence is available to guide hospitals in evaluating whether they have an effective policy, and whether staff know of the policy and appropriately use the policy to prevent "never events."
There is limited evidence of behavioral interventions to reduce wrong site, patient, and surgical procedures. We have outlined a framework of measures that healthcare organizations can use to start evaluating whether they have reduced adverse events in operations.
Notes
Cites: Anesthesiology. 2006 Nov;105(5):877-8417065879
Cites: Health Serv Res. 2006 Aug;41(4 Pt 2):1599-61716898981
Cites: J Crit Care. 2003 Jun;18(2):71-512800116
Cites: J Bone Joint Surg Am. 1998 Apr;80(4):4639563374
Cites: Crit Care Clin. 2005 Jan;21(1):1-19, vii15579349
Cites: Reg Anesth Pain Med. 2005 Jan-Feb;30(1):99-10315690274
Cites: J Bone Joint Surg Am. 2005 Oct;87(10):2193-516203882
Cites: Pediatrics. 2005 Dec;116(6):1506-1216322178
Cites: Jt Comm J Qual Patient Saf. 2006 Feb;32(2):102-816568924
Cites: Ann Intern Med. 2006 Apr 4;144(7):510-616585665
Cites: Arch Surg. 2006 Apr;141(4):353-7; discussion 357-816618892
Cites: Ann Surg. 2006 May;243(5):628-32; discussion 632-516632997
Cites: Jt Comm J Qual Patient Saf. 2006 Jun;32(6):351-516776390
Cites: Crit Care Med. 2006 Jul;34(7):1988-9516715029
Cites: JAMA. 2006 Aug 9;296(6):696-916896113
Cites: J Bone Joint Surg Am. 2003 Feb;85-A(2):193-712571293
PubMed ID
17414599 View in PubMed
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Activating knowledge for patient safety practices: a Canadian academic-policy partnership.

https://arctichealth.org/en/permalink/ahliterature129005
Source
Worldviews Evid Based Nurs. 2012 Feb;9(1):49-58
Publication Type
Article
Date
Feb-2012
Author
Margaret B Harrison
Wendy Nicklin
Marie Owen
Christina Godfrey
Janice McVeety
Val Angus
Author Affiliation
School of Nursing, Queen's University, Kingston, Ontario, Canada. margaret.b.harrison@queensu.ca
Source
Worldviews Evid Based Nurs. 2012 Feb;9(1):49-58
Date
Feb-2012
Language
English
Publication Type
Article
Keywords
Advisory Committees - organization & administration - standards
Canada
Cooperative Behavior
Delivery of Health Care - organization & administration - standards
Evidence-Based Practice - methods - organization & administration - standards
Health Knowledge, Attitudes, Practice
Humans
Patient Care Team - organization & administration - standards
Quality Assurance, Health Care - methods - organization & administration - standards
Safety Management - methods - organization & administration - standards
State Medicine - organization & administration - standards
Abstract
Over the past decade, the need for healthcare delivery systems to identify and address patient safety issues has been propelled to the forefront. A Canadian survey, for example, demonstrated patient safety to be a major concern of frontline nurses (Nicklin & McVeety 2002). Three crucial patient safety elements, current knowledge, resources, and context of care have been identified by the World Health Organization (WHO 2009). To develop strategies to respond to the scope and mandate of the WHO report within the Canadian context, a pan-Canadian academic-policy partnership has been established.
This newly formed Pan-Canadian Partnership, the Queen's Joanna Briggs Collaboration for Patient Safety (referred throughout as "QJBC" or "the Partnership"), includes the Queen's University School of Nursing, Accreditation Canada, the Canadian Patient Safety Institute (CPSI), the Canadian Institutes of Health Research, and is supported by an active and committed advisory council representing over 10 national organizations representing all sectors of the health continuum, including patients/families advocacy groups, professional associations, and other bodies. This unique partnership is designed to provide timely, focused support from academia to the front line of patient safety. QJBC has adopted an "integrated knowledge translation" approach to identify and respond to patient safety priorities and to ensure active engagement with stakeholders in producing and using available knowledge. Synthesis of evidence and guideline adaptation methodologies are employed to access quantitative and qualitative evidence relevant to pertinent patient safety questions and subsequently, to respond to issues of feasibility, meaningfulness, appropriateness/acceptability, and effectiveness.
This paper describes the conceptual grounding of the Partnership, its proposed methods, and its plan for action. It is hoped that our journey may provide some guidance to others as they develop patient safety models within their own arenas.
PubMed ID
22151727 View in PubMed
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[Adverse events management. Methods and results of a development project].

https://arctichealth.org/en/permalink/ahliterature166235
Source
Ugeskr Laeger. 2006 Nov 27;168(48):4201-5
Publication Type
Article
Date
Nov-27-2006
Author
Louise Isager Rabøl
Elisabeth Brøgger Jensen
Annemarie H Hellebek
Beth Lilja Pedersen
Author Affiliation
H:S Hvidovre Hospital, H:S Enhed for Patientsikkerhed, Hvidovre.
Source
Ugeskr Laeger. 2006 Nov 27;168(48):4201-5
Date
Nov-27-2006
Language
Danish
Publication Type
Article
Keywords
Denmark
Diagnostic Errors - prevention & control
Humans
Iatrogenic Disease - prevention & control
Malpractice
Mandatory Reporting
Medical Errors - prevention & control - statistics & numerical data
Medication Errors - prevention & control
Medication Systems, Hospital - standards
Personnel, Hospital - education
Risk Management - methods - organization & administration
Safety Management - methods - organization & administration
Abstract
This article describes the methods and results of a project in the Copenhagen Hospital Corporation (H:S) on preventing adverse events. The aim of the project was to raise awareness about patients' safety, test a reporting system for adverse events, develop and test methods of analysis of events and propagate ideas about how to prevent adverse events.
H:S developed an action plan and a reporting system for adverse events, founded an organization and developed an educational program on theories and methods of learning from adverse events for both leaders and employees.
During the three-year period from 1 January 2002 to 31 December 2004, the H:S staff reported 6011 adverse events. In the same period, the organization completed 92 root cause analyses. More than half of these dealt with events that had been optional to report, the other half events that had been mandatory to report.
The number of reports and the front-line staff's attitude towards reporting shows that the H:S succeeded in founding a safety culture. Future work should be centred on developing and testing methods that will prevent adverse events from happening. The objective is to suggest and complete preventive initiatives which will help increase patient safety.
PubMed ID
17147944 View in PubMed
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Anaesthesiologists' views on the need for point-of-care information system in the operating room: a survey of the European Society of Anaesthesiologists.

https://arctichealth.org/en/permalink/ahliterature70779
Source
Eur J Anaesthesiol. 2004 Nov;21(11):898-901
Publication Type
Article
Date
Nov-2004
Author
A. Perel
H. Berkenstadt
A. Ziv
R. Katzenelson
A. Aitkenhead
Author Affiliation
Department of Anaesthesiology and Intensive Care, Tel Aviv University, Sheba Medical Centre, Tel Hashomer, Israel.
Source
Eur J Anaesthesiol. 2004 Nov;21(11):898-901
Date
Nov-2004
Language
English
Publication Type
Article
Keywords
Adult
Anesthesiology - statistics & numerical data
Attitude of Health Personnel
Europe
Female
Health services needs and demand
Humans
Male
Medical Errors - prevention & control
Middle Aged
Operating Room Information Systems
Operating Rooms - standards
Point-of-Care Systems
Questionnaires
Research Support, Non-U.S. Gov't
Safety Management - methods - standards
Societies, Medical - standards
Abstract
BACKGROUND AND OBJECTIVE: In this preliminary study we wanted to explore the attitudes of anaesthesiologists to a point-of-care information system in the operating room. The study was conducted as a preliminary step in the process of developing such a system by the European Society of Anaesthesiologists (ESA). METHODS: A questionnaire was distributed to all 2240 attendees of the ESA's annual meeting in Gothenburg, Sweden, which took place in April 2001. RESULTS: Of the 329 responders (response rate of 14.6%), 79% were qualified specialists with more than 10 yr of experience (68%), mostly from Western Europe. Most responders admitted to regularly experiencing lack of medical knowledge relating to real-time patient care at least once a month (74%) or at least once a week (46%), and 39% admitted to having made errors during anaesthesia due to lack of medical information that can be otherwise found in a handbook. The choice ofa less optimal but more familiar approach to patient management due to lack of knowledge was reported by 37%. Eighty-eight percent of responders believe that having a point-of-care information system for the anaesthesiologists in the operating room is either important or very important. CONCLUSIONS: This preliminary survey demonstrates that lack of knowledge of anaesthesiologists may be a significant source of medical errors in the operating room, and suggests that a point-of-care information system for the anaesthesiologist may be of value.
PubMed ID
15717707 View in PubMed
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An analysis of electronic health record-related patient safety incidents.

https://arctichealth.org/en/permalink/ahliterature291518
Source
Health Informatics J. 2017 06; 23(2):134-145
Publication Type
Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't
Date
06-2017
Author
Sari Palojoki
Matti Mäkelä
Lasse Lehtonen
Kaija Saranto
Author Affiliation
University of Eastern Finland, Kuopio, Finland.
Source
Health Informatics J. 2017 06; 23(2):134-145
Date
06-2017
Language
English
Publication Type
Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't
Keywords
Electronic Health Records - instrumentation - standards - statistics & numerical data
Finland
Humans
Medical Errors - statistics & numerical data - trends
Patient Safety - standards - statistics & numerical data
Reproducibility of Results
Retrospective Studies
Safety Management - methods - standards
Abstract
The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.
PubMed ID
26951568 View in PubMed
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Anthrax: walking the fine line between precaution and panic.

https://arctichealth.org/en/permalink/ahliterature192166
Source
CMAJ. 2001 Nov 27;165(11):1528
Publication Type
Article
Date
Nov-27-2001
Author
E. Weir
Source
CMAJ. 2001 Nov 27;165(11):1528
Date
Nov-27-2001
Language
English
Publication Type
Article
Keywords
Anthrax - epidemiology - prevention & control
Attitude to Health
Bioterrorism - prevention & control - psychology - statistics & numerical data
Canada - epidemiology
Correspondence as Topic
Fear
Humans
Public Health Practice
Safety Management - methods
Notes
Cites: CMAJ. 2000 Sep 5;163(5):60811006776
Cites: CMAJ. 1998 Mar 10;158(5):633-49526481
Cites: Can Dis Wkly Rep. 1991 Feb 9;17(6):31-31903088
Cites: MMWR Morb Mortal Wkly Rep. 2001 Oct 19;50(41):889-9311686472
PubMed ID
11762587 View in PubMed
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Approaches to improving the safety of the medication use system.

https://arctichealth.org/en/permalink/ahliterature171650
Source
Healthc Q. 2005;8 Spec No:59-64
Publication Type
Article
Date
2005
Author
Stacy Ackroyd-Stolarz
Nicole Hartnell
Neil J MacKinnon
Author Affiliation
Department of Emergency Medicine, Dalhousie University, Halifax, NS. Stacy.Ackroyd@dal.ca
Source
Healthc Q. 2005;8 Spec No:59-64
Date
2005
Language
English
Publication Type
Article
Keywords
Canada
Humans
Medication Errors - prevention & control
Medication Systems, Hospital - organization & administration
National Health Programs
Safety Management - methods
Abstract
Problems associated with medication use have been consistently identified in the patient safety literature internationally. The purpose of this paper is to review components of the medication use process and offer suggestions for transforming it into a safer system. Prevention strategies are suggested for improving medication use at each stage of the system. Decision criteria are proposed that can be used by administrators and healthcare providers to allocate resources for prevention strategies that will improve medication safety.
PubMed ID
16334074 View in PubMed
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Barriers and enabling factors for safety improvements on farms in Finland.

https://arctichealth.org/en/permalink/ahliterature128887
Source
J Agric Saf Health. 2011 Oct;17(4):327-42
Publication Type
Article
Date
Oct-2011
Author
K O Kaustell
T E A Mattila
R H Rautiainen
Author Affiliation
MTT Agrifood Research Finland, Helsinki, Finland. kim.kaustell@mtt.fi
Source
J Agric Saf Health. 2011 Oct;17(4):327-42
Date
Oct-2011
Language
English
Publication Type
Article
Keywords
Accidents, Occupational - prevention & control
Agriculture - education - methods - standards
Finland
Fires - prevention & control
Health Knowledge, Attitudes, Practice
Humans
Interviews as Topic
Occupational Injuries - prevention & control
Safety Management - methods
Abstract
Systematic reviews of agricultural safety and health interventions have shown little evidence of effectiveness. In this study, we used a self-documentation and collaborative interpretation method (cultural probes, n = 9) as well as farm interviews (n = 11) to identify factors affecting the adoption and implementation of safety information. The three main barrier groups found were (1) personal characteristics of the farmer, (2) limited resources to make safety improvements, and (3) the slow incremental evolution of the physical farm environment where old, hazardous environments remain along with new, safer improvements. The enabling factors included good examples or alarming (and thus activating) examples from peers, ease of implementation of the promoted safety measures, and enforcement of regulations. The findings suggest that a user-centered approach could facilitate the development of more effective safety and health interventions. A conceptual model of the safety intervention context created in this study can be used as a framework to examine specific barriers and enabling factors in planning and implementing safety and health interventions.
PubMed ID
22164462 View in PubMed
Less detail
Source
Tidsskr Nor Laegeforen. 2015 Mar 24;135(6):585
Publication Type
Article
Date
Mar-24-2015
Author
Elisabeth Jacobsen
Source
Tidsskr Nor Laegeforen. 2015 Mar 24;135(6):585
Date
Mar-24-2015
Language
Norwegian
Publication Type
Article
Keywords
Humans
Norway
Patient Safety
Safety Management - methods
PubMed ID
25806774 View in PubMed
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A biosphere assessment of high-level radioactive waste disposal in Sweden.

https://arctichealth.org/en/permalink/ahliterature268794
Source
Radiat Prot Dosimetry. 2015 Apr;164(1-2):103-7
Publication Type
Article
Date
Apr-2015
Author
Ulrik Kautsky
Tobias Lindborg
Jack Valentin
Source
Radiat Prot Dosimetry. 2015 Apr;164(1-2):103-7
Date
Apr-2015
Language
English
Publication Type
Article
Keywords
Computer simulation
Ecosystem
Models, Theoretical
Radiation Monitoring - methods
Radiation Protection - methods
Radioactive Waste - prevention & control
Safety Management - methods
Sweden
Waste Disposal Facilities
Waste Management - methods
Abstract
Licence applications to build a repository for the disposal of Swedish spent nuclear fuel have been lodged, underpinned by myriad reports and several broader reviews. This paper sketches out the technical and administrative aspects and highlights a recent review of the biosphere effects of a potential release from the repository. A comprehensive database and an understanding of major fluxes and pools of water and organic matter in the landscape let one envisage the future by looking at older parts of the site. Thus, today's biosphere is used as a natural analogue of possible future landscapes. It is concluded that the planned repository can meet the safety criteria and will have no detectable radiological impact on plants and animals. This paper also briefly describes biosphere work undertaken after the review. The multidisciplinary approach used is relevant in a much wider context and may prove beneficial across many environmental contexts.
PubMed ID
25431486 View in PubMed
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121 records – page 1 of 13.