How do we recognise serious clinical incidents?
Russell Kelsey in Patient Safety, 2016
At the root of this question of recognition is the issue of causation. Causation will recur again and again as the key element that is often lost sight of in incident investigation and reporting. The point about incident reporting and investigation is being able to identify and learn from those episodes of patient contact in which the actions of clinicians or service systems altered the natural progression of pathology in an adverse way. What this means is that the severity of the outcome for the patient is not actually the point. The outcome is just a trigger point to think about causation. The point is whether the healthcare intervention (or lack of intervention) did something to cause the death or severe harm suffered by the patient. The reason that the issue of causation is so crucial is that this has a direct link to whether learning may arise from the case. If a healthcare provider has done something that may have caused an adverse outcome, then identifying the causative action(s) (or lack of action(s)) may enable us to learn how to avoid doing (or not doing) the same thing in the future. The key element of the definition of a patient-safety incident are the words ‘lead to’, in the sense that an error of care (an act or omission) must not only have occurred but that this must also have led to the adverse outcome. An error of care may not lead to the adverse outcome. An adverse outcome may occur without there being an error of care.
Risk and Patient Safety for the Legal Nurse Consultant
Julie Dickinson, Anne Meyer, Karen J. Huff, Deborah A. Wipf, Elizabeth K. Zorn, Kathy G. Ferrell, Lisa Mancuso, Marjorie Berg Pugatch, Joanne Walker, Karen Wilkinson in Legal Nurse Consulting Principles and Practices, 2019
Providing quality health care is not easy. The demands are round the clock and unpredictable with respect to volume and acuity. Often only a few staff are available to flawlessly execute simultaneous urgent salutary actions to restore health and save lives. There is always the specter of a bad outcome, patient/customer dissatisfaction, and an adverse outcome causing serious harm, disability, or death. The challenge is to deliver rapid, reliable, and reproducible quality care for the patients served and retain competent and engaged staff. Active interaction, training, education, and coaching of staff by senior leaders has tremendous power in developing situational awareness of risk. The value placed on risk mitigation by leaders is demonstrated by keen interest in the organization’s safety environment through executive rounding and hiring of talented directors/managers of risk and safety programs who continuously promote safe actions throughout the enterprise.
Neuropharmacology for Older Adults
José León-Carrión, Margaret J. Giannini in Behavioral Neurology in the Elderly, 2001
Elderly people take an average of three different medications when treated for neurological or psychiatric symptoms. There is, however, a significant (57%) percentage of medical errors in treatment, with the subsequent potential for adverse outcomes. Errors in dosage seem to be the most common, followed by the prescription of medication inappropriate to the patient or to which the patient is allergic.20 In light of this, precautionary measures should be taken when prescribing psychotropics or neurological medication. To begin with, the number of different medications should be reduced to a necessary minimum. Once the necessary medication is established, the lowest possible dosage for each must be determined. The best policy is to start at a low dosage and to monitor the effects continually to establish the most effective dosage. When a patient is under the care of more than one physician, the physicians should consult one other concerning the medication they prescribe to avoid the risk of adverse reactions or collateral effects of the different drugs. Anticipating and then controlling any possible side effects is a way of preventing an adverse outcome of treatment. It is the duty of neurologists and psychiatrists to set a standard in the pharmacological treatment of neurological and psychiatric patients.
The evolution of stent grafts for endovascular repair of abdominal aortic aneurysms: how design changes affect clinical outcomes
Published in Expert Review of Medical Devices, 2019
Blake R. Bewley, Andrew B. Servais, Payam Salehi
The reduction of limb occlusion has been met with similar success as well. The risk factors and disease progression for iliac limb thrombosis have become widely accepted and prevention, instead of treatment, is the most widely used modality to ensure endograft longevity. Having iliac artery angulation of greater than 60 degrees, small iliac arteries, significant pre-implantation artery calcification, device kinking, and endograft oversizing of greater than 15% are significant risk factors for limb occlusion. Patients with more risk factors are, predictably, more likely to develop this adverse outcome. Once risk factors are identified prevention of limb thrombosis can be attempted [92,93]. More flexible endografts are less likely to suffer from kinking due to their ability to conform to tortuous anatomy without permanent deformation. Intraoperative removal ok kinks or device twisting with balloon angioplasty has also been employed to decrease prevalence of limb thrombosis. Patients with unavoidable risk factors can also be placed on antiplatelet therapy for the first year post-EVAR, as the most limb occlusions are encountered in the first 6 months post-implantation [92]. Much like distal sealing, the maturation of endografts and standards of practice have been highly effective at preventing this adverse clinical outcome.
Prevention and management of endocarditis after transcatheter pulmonary valve replacement: current status and future prospects
Published in Expert Review of Medical Devices, 2021
At this point, clear and ongoing education is probably our most potent and effective tool for reduction of endocarditis risk and severity in patients who undergo TPVR. This includes educating not only the patient and family, but ensuring that the primary medical providers are aware of the risk of endocarditis and maintain a low threshold for investigating this potential adverse outcome when patients have relevant symptoms. In patients who are diagnosed with endocarditis after TPVR, a subset present in extremis or with severe RVOT obstruction or RV dysfunction, and prompt supportive therapy, including ECMO if appropriate, should be entertained. Mortality related to endocarditis in this context is uncommon, and when it does occur is usually related to infection Staph aureus. More generally, a diagnosis of endocarditis does not mandate removal of the valve, and in fact, a majority of reported patients have not undergone surgical treatment. Moreover, while detection of vegetations or septic pulmonary embolism establishes a definitive diagnosis of endocarditis after TPVR, those findings do not necessarily require explanting the valve either. Involvement of other valves and pacing wires, which is not uncommon, should be determined as well.
Predictability of adverse outcomes in hypertensive disorders of pregnancy: a multicenter prospective cohort study
Published in Hypertension in Pregnancy, 2021
Daniela N. Vasquez, Andrea V. Das Neves, Vanina M. Aphalo, Laura Vidal, Miriam Moseinco, Jorge Lapadula, Analía Santa-Maria, Graciela Zakalik, Raúl A. Gomez, Mónica Capalbo, Claudia Fernandez, Enrique Agüero-Villareal, Santiago Vommaro, Marcelo Moretti, Silvana B. Soli, Florencia Ballestero, Juan P. Sottile, Viviana Chapier, Carlos Lovesio, José Santos, Fernando Bertoletti, Fernando A. Mos, Alejandro Risso-Vazquez, Mercedes Esteban-Chacon, Santiago Illutovich, Sebastián Chapela, Cecilia I. Loudet, José L. Scapellato, Alfredo D. Intile, Elisa Estenssoro
While the other risk factors for composite adverse outcome are more straightforward, understanding why receiving health care in the public sector is included is imperative. In Argentina, the level of intervention in both the public and private sectors are exactly the same. However, patients who arrive to third level public hospitals are often transferred from other first- or second-level health-care facilities after having either waited too long due to lack of disease recognition resulting from low level of education, or the inability to advocate for themselves effectively and not being taken seriously. In addition, patients using the public healthcare system often have poor prenatal care for the same reasons (3). Patients admitted with advanced disease are prone to more complications, many of which could be prevented by empowering women and improving education and healthcare access, among other actions (3,26).
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