Seguridad del paciente / Patient safety

Enero 18, 2018. No. 2966

Viñetas en seguridad del paciente. Volumen 1 Vignettes in Patient Safety - Volume 1 Edited by Michael S. Firstenberg and Stanislaw P. Stawicki, ISBN 978-953-51-3520-3, Print ISBN 978-953-51-3519-7, 186 pages, Publisher: InTech, Chapters published September 13, 2017 under CC BY 3.0 license DOI: 10.5772/66106 Edited Volume It is clearly recognized that medical errors represent a significant source of preventable healthcare-related morbidity and mortality. Furthermore, evidence shows that such complications are often the result of a series of smaller errors, missed opportunities, poor communication, breakdowns in established guidelines or protocols, or system-based deficiencies. While such events often start with the misadventures of an individual, it is how such events are managed that can determine outcomes and hopefully prevent future adverse events. The goal of Vignettes in Patient Safety is to illustrate and discuss, in a clinically relevant format, examples in which evidence-based approaches to patient care, using established methodologies to develop highly functional multidisciplinary teams, can help foster an institutional culture of patient safety and high-quality care delivery. Libro / Book / Livre Viñetas en seguridad del paciente. Volumen 2 Vignettes in Patient Safety - Volume 2 Edited by Michael S. Firstenberg and Stanislaw P. Stawicki, ISBN 978-953-51-3731-3, Print ISBN 978-953-51-3730-6, 200 pages, Publisher: InTech, Chapters published January 10, 2018 under CC BY 3.0 license DOI: 10.5772/intechopen.69032 Edited Volume Over the past two decades, the healthcare community increasingly recognized the importance and the impact of medical errors on patient safety and clinical outcomes. Medical and surgical errors continue to contribute to unnecessary and potentially preventable morbidity and/or mortality, affecting both ambulatory and hospital settings. The spectrum of contributing variables-ranging from minor errors that subsequently escalate to poor communication to lapses in appropriate protocols and processes (just to name a few)-is extensive, and solutions are only recently being described. As such, there is a growing body of research and experiences that can help provide an organized framework-based upon the best practices and evidence-based medical principles-for hospitals and clinics to foster patient safety culture and to develop institutional patient safety champions. Based upon the tremendous interest in the first volume of our Vignettes in Patient Safety series, this second volume follows a similar vignette-based model. Each chapter outlines a realistic case scenario designed to closely approximate experiences and clinical patterns that medical and surgical practitioners can easily relate to. Vignette presentations are then followed by an evidence-based overview of pertinent patient safety literature, relevant clinical evidence, and the formulation of preventive strategies and potential solutions that may be applicable to each corresponding scenario. Throughout the Vignettes in Patient Safety cycle, emphasis is placed on the identification and remediation of team-based and organizational factors associated with patient safety events. The second volume of the Vignettes in Patient Safety begins with an overview of recent high-impact studies in the area of patient safety. Subsequent chapters discuss a broad range of topics, including retained surgical items, wrong site procedures, disruptive healthcare workers, interhospital transfers, risks of emergency department overcrowding, dangers of inadequate handoff communication, and the association between provider fatigue and medical errors. By outlining some of the current best practices, structured experiences, and evidence-based recommendations, the authors and editors hope to provide our readers with new and significant insights into making healthcare safer for patients around the world. Libro / Book / Livre Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information World Congress on Regional Anesthesia & Pain Medicine April 19-21, 2018, New York City, USA Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Seguridad del paciente / Patient safety

Enero 9, 2017. No. 2564

Seguridad de los pacientes ambulatorios Patient Safety in Ambulatory Settings Editors Shekelle PG, Sarkar U, Shojania K, Wachter RM, McDonald K, Motala A, Smith P, Zipperer L, Shanman R. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Oct. Report No.: 16(17)-EHC033-EF. BACKGROUND: Even though most medical care occurs in ambulatory settings, the patient safety movement originated in, and has been mainly focused on, adverse events in hospitalized patients. However, it is increasingly clear that the ambulatory setting is critically important. Ambulatory care differs substantially from inpatient care in ways that affect patient safety hazards and interventions. To better understand the scope of ambulatory care safety issues and the types of evaluations that have been reported for ambulatory patient safety practice (PSP), we have been tasked by AHRQ to provide an overview of key issues relating to the interventions. PURPOSE: This Technical Brief had the following guiding questions: What are the evidence-based hospital patient safety practices that may be applicable to the ambulatory care setting? What are the ambulatory care patient safety practices that have been studied in the literature? Which ones have not been broadly implemented or studied beyond a single ambulatory care center? What tools, settings, and other factors (such as implementation of Patient-Centered Medical Home and team-based care) may influence the implementation and spread of ambulatory care patient safety practices? METHODS: We integrated insights from discussions with eight Key Informants (KIs) with a literature scan of 28 safety topics/strategies. FINDINGS: KIs identified medication safety, diagnosis, transitions, referrals, and testing as important ambulatory care safety topics, and strategies that addressed communications, health IT, teams, patient engagement, organizational approaches, and safety culture as the most important strategies. The literature search found a moderate number of published intervention evaluations for e-prescribing, medication errors and adverse events, pharmacist-based interventions, and transitions from hospital to ambulatory care. There were few published evaluations of interventions for other targets/strategies. These results will assist AHRQ in developing a research agenda in ambulatory patient safety. SUMMARY AND IMPLICATIONS: Both key informant interviews and the literature scan reveal important differences between inpatient and ambulatory safety. There are significant gaps in ambulatory safety research, including a notable lack of studies on patient engagement and timely and accurate diagnosis. Key informants recommend prospective, large-scale studies in diverse ambulatory settings to develop and test ambulatory safety interventions. PDF Sistemas de informe de incidentes: estudio comparativo de dos hospitales Incident reporting systems: a comparative study of two hospital divisions. Hewitt T1, Chreim S2, Forster A3. Arch Public Health. 2016 Aug 15;74:34. doi: 10.1186/s13690-016-0146-8. eCollection 2016. Abstract BACKGROUND: Previous studies of incident reporting in health care organizations have largely focused on single cases, and have usually attended to earlier stages of reporting. This is a comparative case study of two hospital divisions' use of an incident reporting system, and considers the different stages in the process and the factors that help shape the process. METHOD: The data was comprised of 85 semi-structured interviews of health care practitioners in general internal medicine, obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. This work is part of a larger qualitative study found elsewhere in the literature. RESULTS: The findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback). CONCLUSIONS: The differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. Implications for practice are addressed. KEYWORDS: Internal medicine; Medical errors; Neonatology; Obstetrics; Patient safety; Qualitative research PDF Mejorando los informes sobre eventos de seguridad entre residentes y profesores Improving Patient Safety Event Reporting Among Residents and Teaching Faculty. Louis MY1, Hussain LR2, Dhanraj DN1, Khan BS1, Jung SR1, Quiles WR1, Stephens LA1, Broering MJ1, Schrand KV1, Klarquist LJ1. Ochsner J. 2016 Spring;16(1):73-80Abstract BACKGROUND: A June 2012 site visit report from the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review revealed that residents and physicians at TriHealth, Inc., a large, nonprofit independent academic medical center serving the Greater Cincinnati area in Ohio, had an opportunity to improve their awareness and understanding of the hospital's system for reporting patient safety concerns in 3 areas: (1) what constitutes a reportable patient safety event, (2) who is responsible for reporting, and (3) how to use the hospital's current reporting system. METHODS: To improve the culture of patient safety, we designed a quality improvement project with the goal to increase patient safety event reporting among residents and teaching faculty. An anonymous questionnaire assessed physicians' and residents' attitudes and experience regarding patient safety event reporting. An educational intervention was provided in each graduate medical education program to improve knowledge and skills related to patient safety event reporting, and the anonymous questionnaire was distributed after the intervention. We compared the responses to the preintervention and postintervention questionnaires and tracked monthly patient safety event reports for 1 year postintervention. RESULTS: The number of patient safety event reports increased following the educational intervention; however, we saw wide variability in reporting per month. On the postintervention questionnaire, participants demonstrated improved knowledge and attitudes toward patient safety event reporting. CONCLUSION: The goal of this unique project was to increase patient safety event reporting by both residents and teaching faculty in 6 residency programs through education. We achieved this goal through an educational intervention tailored to the institution's new event reporting system delivered to each residency program. We clearly understand that improvements in quality and patient safety require ongoing effort. The keys to ongoing sustainability include (1) developing patient safety faculty and resident experts in each training program to teach patient safety and to be role models, (2) working toward decreasing the barriers to reporting, and (3) providing timely feedback and system changes. KEYWORDS: Education-graduate-medical; hospital incident reporting; medical errors; patient safety; quality improvement; risk management PDF 5to Curso Internacional de Anestesiología cardiotorácica, vascular, ecocardiografía y circulación extracorpórea. SMACT Mayo 4-6, 2017, Mexicali, México Informes Dr. Hugo Martínez Espinoza bajamed@hotmail.com  Regional Anesthesiology and Acute Pain Medicine Meeting April 6-8, 2017, San Francisco, California, USA ASRA American Society of Regional Anesthesia and Pain Medicine Información / Information California Society of Anesthesiologists Annual Meeting April 27-30, 2017 San Francisco California Información / Information

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