Hodgejohannesen8876

CONCLUSIONS Medical record review with a trigger tool is a reasonably well-researched method for the evaluation of the medical records for AEs. However, looking at the World Health Organization criteria, much research is still lacking or of moderate quality. Especially for the cost of detecting AEs, valuable information is missing. Moreover, knowledge of how MRR changes quality and safety of care should be evaluated.OBJECTIVES Educating healthcare professionals in patient safety is essential to achieving sustainable improvements in care. This study aimed to identify the key constituents of patient safety education alongside its facilitators and barriers from a frontline perspective. METHODS An electronic survey was sent to 592 healthcare professionals and educators in patient safety education in the United Kingdom. Two independent reviewers conducted a thematic analysis of the free-text data. Themes focused on effective content, learning practices and facilitators and barriers to patient safety education. RESULTS Of 592 individuals completing the survey, 545 (92%) submitted analyzable responses. Interrater reliability of coding was high with Cohen k value of 0.86. Participants endorsed experiential and interactive learning as ideal modalities for delivery and expressed a need for content to be based on real clinical cases and tailored to the needs of the learners. The most commonly mentioned facilitators were standardization of methods and assessment (49%), dedicated funding (21%), and culture of openness (20%). Staffing problems and high workload (41%) and lack of accessibility of training (23%) were identified as primary barriers of efficacy and uptake. CONCLUSIONS This study identified key factors to the success of patient safety education in terms of content and delivery alongside facilitators and barriers. Future curricula developers and interventions should improve standardization, funding, culture, and access so as to optimize education programs to enhance patient safety.OBJECTIVES Thirteen suspicious deaths occurred in an intensive care unit of Tuscany, Italy, in 2015. All patients developed sudden unexplained coagulopathy leading to severe bleeding. None of them had been prescribed heparin, but supertherapeutic concentrations of heparin were found. After a nurse was arrested on suspicion of murdering Human Factor and Ergonomics (HF/E) experts received a mandate to identify system failures. According to the judgment of the Court of First Instance on April 2019, the nurse was found guilty (of first degree murder? Manslaughter?) METHODS The HF/E group used a two-pronged safety analysis understanding the conditions in which the healthcare practitioners were working in the period when the suspicious deaths emerged and reviewing the clinical records. RESULTS Fourteen patients admitted to the intensive care unit in 2014 and 2015 were selected on the basis of markedly abnormal coagulation tests (n = 13) or a family member's complaint (n = 1). 4-MU In 13 cases, a massive, abrupt hemorrhage in the presence of an unexpected abnormality of coagulation tests occurred, whereas the fourteenth patient had the only prolongation of coagulation markers without bleeding. All cases examined classified as adverse events related to a coagulation disorder. Human factor and ergonomics analysis identified a number of latent and active failures that contributed to the event and provided a set of important recommendations for safety improvement. CONCLUSIONS When presented with a manifest, albeit suspected, wrongdoing with lethal consequences for patients, forensic investigators and safety investigators have distinctly different goals and methods. We believe that a memorandum of understanding between HF/E and forensic investigative teams provides an operative framework for allowing co-existence and fosters collaboration. The pursuit of safe care as a new emerging right for patients and balancing the right to legal justice with the right to safer healthcare merit further investigation and discussion.INTRODUCTION Thorough documentation is of utmost importance in a patient hospital experience. It forms an accurate record of an inpatient stay, facilitates handover between medical colleagues, and is also a legal document. Medical notes tend to be detailed and insightful on admission, but the daily ward round notes have often fallen short of expectation. With most patient records entered by junior level of staff, it is important to ensure that adequate documentation occurs. METHODS We analyzed notes entered in patient charts at set periods and compared them against standards set out in the Royal College of Surgeons Ireland and England, as well as Medical Council guidelines from the two countries. After this, a pro forma was established to standardize the medical record keeping on patient ward rounds. Compliance with guidelines was assessed by comparing notes before introduction of the pro forma and after their introduction. RESULTS Before its introduction, 0% of notes fulfilled the full criteria selected for the pro forma documentation. After intervention, there was a good initial response, with notes capturing an average 86% of the required information. A reaudit of compliance 2 months after introduction showed a 9% decrease of information completeness to 75%. CONCLUSIONS Introduction of a pro forma for the documentation of daily ward rounds improved compliance of ward round notes when compared with internationally recognized guidelines, with no additional time required during ward rounds. Despite improved compliance, continued effort is needed to achieve a better standard of care.OBJECTIVE The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room. METHODS A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included clinicians' ratings of NRE severity and contributory factors and trained research assistants' ratings of preventability.