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Error reduction checklists

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65 papers 0 to 25 followers
Michelle C Caruso, Jenna R Dyas, Matthew R Mittiga, Andrea S Rinderknecht, Benjamin T Kerrey
PURPOSE: Results of a study to determine whether checklist-based interventions improved the selection and administration of rapid-sequence intubation (RSI) medications in a pediatric emergency department (ED) are reported. METHODS: A retrospective study of data collected during a quality-improvement project was conducted. Data sources included the electronic health record and video review. The central intervention was use of a 21-item RSI checklist, which included guidance for the physician team leader on medication selection and timing...
September 1, 2017: American Journal of Health-system Pharmacy: AJHP
Nicole Powell-Dunford, Mark K McPherson, Joseph S Pina, Steven J Gaydos
BACKGROUND: Aviation is a classic example of a high reliability organization (HRO)-an organization in which catastrophic events are expected to occur without control measures. As health care systems transition toward high reliability, aviation practices are increasingly transferred for clinical implementation. METHODS: A PubMed search using the terms aviation, crew resource management, and patient safety was undertaken. Manuscripts authored by physician pilots and accident investigation regulations were analyzed...
May 1, 2017: Aerospace Medicine and Human Performance
Johan N Siebert, Frederic Ehrler, Christophe Combescure, Laurence Lacroix, Kevin Haddad, Oliver Sanchez, Alain Gervaix, Christian Lovis, Sergio Manzano
BACKGROUND: During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion...
February 1, 2017: Journal of Medical Internet Research
Luciana Garbayo, James Stahl
Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued...
March 2017: Medicine, Health Care, and Philosophy
Lars Mommers, Sean Keogh
Prehospital emergency medical services often operate in the most challenging and austere environments. Checklist use for complex tasks in these circumstances is useful but must make task completion simpler, faster and more effective. The SPEEDBOMB checklist for Prehospital Rapid Sequence Induction (PRSI) management rapidly addresses critical steps in the RSI process, is designed to improve checklist compliance and patient safety, and is adaptable for local circumstances.
April 2015: Emergency Medicine Australasia: EMA
Osnat Bashkin, Sigalit Caspi, Assaf Swissa, Amitai Amedi, Shai Zornano, Ruth Stalnikowicz
OBJECTIVES: Adverse events in blood collection procedures such as mismatched or unlabeled samples may have critical implications on patient safety (such as wrong diagnosis and treatments). The current study examined blood collection procedures in an emergency department before and after the application of a human factors approach for improving performance quality and preventing adverse events. METHODS: In the emergency department of a community care hospital, 190 blood collection events were observed in 2 phases: preintervention and postintervention...
February 18, 2016: Journal of Patient Safety
Julian Wijesuriya, Jonathan Brand
Airway management, particularly in non-theatre settings, is an area of anaesthesia and critical care associated with significant risk of morbidity & mortality, as highlighted during the 4th National Audit Project of the Royal College of Anaesthetists (NAP4). A survey of junior anaesthetists at our hospital highlighted a lack of confidence and perceived lack of safety in emergency airway management, especially in non-theatre settings. We developed and implemented a multifaceted airway package designed to improve the safety of remote site airway management...
2014: BMJ Quality Improvement Reports
Benjamin T Kerrey, Matthew R Mittiga, Andrea S Rinderknecht, Kartik R Varadarajan, Jenna R Dyas, Gary Lee Geis, Joseph W Luria, Mary E Frey, Tamara E Jablonski, Srikant B Iyer
OBJECTIVES: Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2<90%). This report describes a multidisciplinary initiative to improve the performance and safety of RSI in a paediatric ED. METHODS: We conducted a local improvement initiative in a high-volume academic paediatric ED...
November 2015: BMJ Quality & Safety
Elliot Long, Patrick Fitzpatrick, Domenic R Cincotta, Joanne Grindlay, Michael Joseph Barrett
BACKGROUND: Safety of emergency intubation may be improved by standardising equipment preparation; the efficacy of cognitive aids is unknown. METHODS: This randomised controlled trial compared no cognitive aid (control) with the use of a checklist or picture template for emergency airway equipment preparation in the Emergency Department of The Royal Children's Hospital, Melbourne. RESULTS: Sixty-three participants were recruited, 21 randomised to each group...
January 27, 2016: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Sophie E M Truijens, Franyke R Banga, Annemarie F Fransen, Victor J M Pop, Pieter J van Runnard Heimel, S Guid Oei
INTRODUCTION: This study aimed to explore whether multiprofessional simulation-based obstetric team training improves patient-reported quality of care during pregnancy and childbirth. METHODS: Multiprofessional teams from a large obstetric collaborative network in the Netherlands were trained in teamwork skills using the principles of crew resource management. Patient-reported quality of care was measured with the validated Pregnancy and Childbirth Questionnaire (PCQ) at 6 weeks postpartum...
August 2015: Simulation in Healthcare: Journal of the Society for Simulation in Healthcare
Narinder Kapur, Anam Parand, Tayana Soukup, Tom Reader, Nick Sevdalis
Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented...
January 2016: JRSM Open
Peter F Kemper, Martine de Bruijne, Cathy van Dyck, Ralph L So, Peter Tangkau, Cordula Wagner
INTRODUCTION: There is a growing awareness today that adverse events in the intensive care unit (ICU) are more often caused by problems related to non-technical skills than by a lack of technical, or clinical, expertise. Team training, such as crew resource management (CRM), aims to improve these non-technical skills. The present study evaluated the effectiveness of CRM in the ICU. METHODS: Six ICUs participated in a paired controlled trial, with one pretest and two post-test measurements (after 3 and 12 months)...
August 2016: BMJ Quality & Safety
Yonathan Freund, Alexandra Rousseau, Laurence Berard, Helene Goulet, Patrick Ray, Benjamin Bloom, Tabassome Simon, Bruno Riou
BACKGROUND: Medical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5-10% of visits. Due to a short length of stay, emergency patients are often managed by a sole physician - in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED...
September 4, 2015: BMC Emergency Medicine
Richard S Klasco, Richard E Wolfe, Matthew Wong, Jonathan Edlow, David Chiu, Phillip D Anderson, Shamai A Grossman
BACKGROUND: The incidence of errors and adverse events in emergency medicine is poorly characterized. OBJECTIVE: The objective was to systematically determine the rates and types of errors and adverse events in an academic, tertiary care emergency department (ED). METHODS: Prospective data were collected on all patients presenting to a tertiary-care academic medical center ED with an annual census of 55,000 patients between January 2009 and November 2012...
December 2015: American Journal of Emergency Medicine
Simon Berthelot, Eddy S Lang, Hude Quan, Henry T Stelfox
STUDY OBJECTIVE: Experts have recommended including measures of mortality in emergency department (ED) performance evaluation frameworks. This study aims to develop a hospital standardized mortality ratio (HSMR) for patients admitted to the hospital with conditions for which ED care may reduce mortality (emergency-sensitive conditions). METHODS: Data were extracted from Canadian hospital discharge databases from April 1, 2009, to March 31, 2012. The ED HSMR is the ratio of the observed deaths among patients with emergency-sensitive conditions in a hospital during a year to the expected deaths for the same patients during the reference year (2009-2010)...
April 2016: Annals of Emergency Medicine
Elizabeth H Lazzara, Joseph R Keebler, Marissa L Shuffler, Brady Patzer, Dustin C Smith, Paul Misasi
OBJECTIVE: Despite good intentions, mishaps in teamwork continue to affect patient's lives and plague the medical community at large and Emergency Medical Services (EMS) in particular. Effective and efficient management of patient care necessitates that sets of multiple teams (i.e., multiteam systems [MTSs] - EMS ground crews, EMS air crews, dispatch, and receiving hospital teams) seamlessly work together. Although advances have been made to improve teams, little research has been dedicated to enhancing MTSs especially in the critical yet often under studied domain of EMS...
October 9, 2015: Journal of Patient Safety
Samantha E Parsons, Elizabeth A Carter, Lauren J Waterhouse, Jennifer Fritzeen, Deirdre C Kelleher, Karen J Oʼconnell, Aleksandra Sarcevic, Kelley M Baker, Erik Nelson, Nicole E Werner, Deborah A Boehm-Davis, Randall S Burd
OBJECTIVE: To develop a checklist for use during pediatric trauma resuscitation and test its effectiveness during simulated resuscitations. BACKGROUND: Checklists have been used to support a wide range of complex medical activities and have effectively reduced errors and improved outcomes in different medical settings. Checklists have not been evaluated in the domain of trauma resuscitation. METHODS: A focus group of trauma specialists was organized to develop a checklist for pediatric trauma resuscitation...
April 2014: Annals of Surgery
Annamaria Bagnasco, Barbara Tubino, Emanuela Piccotti, Francesca Rosa, Giuseppe Aleo, Pasquale Di Pietro, Loredana Sasso, Laura Gambino, Donatella Passalacqua
OBJECTIVE: The aim of this study was to identify effective corrective measures to ensure patient safety in the Paediatric Emergency Department (ED). METHODS: In order to outline a clear picture of these risks, we conducted a Failure Mode and Effects Analysis (FMEA) and a Failure Mode, Effects, and Criticality Analysis (FMECA), at a Emergency Department of a Children's Teaching Hospital in Northern Italy. The Error Modes were categorised according to Vincent's Taxonomy of Causal Factors and correlated with the Risk Priority Number (RPN) to determine the priority criteria for the implementation of corrective actions...
July 2013: International Emergency Nursing
Francis A Wolf, Lawrence W Way, Lygia Stewart
OBJECTIVES: Medical team training (MTT) has been touted as a way to improve teamwork and patient safety in the operating room (OR). METHODS: OR personal completed a 1-day intensive MTT training. A standardized briefing/debriefing/perioperative routine was developed, including documentation of OR miscues, delays, and a case score (1-5) assigned by the OR team. A multidisciplinary MTT committee reviewed and rectified any systems problems identified. Debriefing items were analyzed comparing baseline data with 12 and 24-month follow-up...
September 2010: Annals of Surgery
David W Tscholl, Mona Weiss, Michaela Kolbe, Sven Staender, Burkhardt Seifert, Daniel Landert, Bastian Grande, Donat R Spahn, Christoph B Noethiger
BACKGROUND: An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e...
October 2015: Anesthesia and Analgesia
2015-10-05 22:11:00
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