Qual Saf Health Care
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It has been estimated that medication error harms 1-2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services. ⋯ Research about medication error in mental healthcare is limited. In particular, very little is known about the incidence of error in non-hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error. On the basis of this and features of the organisation of mental healthcare that might predispose to medication error, priorities for future research are suggested.
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Qual Saf Health Care · Dec 2006
A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability.
Breakdown in communication among members of the healthcare team threatens the effective delivery of health services, and raises the risk of errors and adverse events. ⋯ Reasonable inter-rater reliability was shown by the instrument in assessing the relative rate of communication failures displayed per procedure. The difficulties in identifying and interpreting individual communication events reflect the delicate balance between increased subtlety and increased error. Complex team communication does not readily reduce to mere observation of events; some level of interpretation is required to meaningfully account for communicative exchanges. Although such observer interpretation improves the subtlety and validity of the instrument, it necessarily introduces error, reducing reliability. Although we continue to work towards increasing the instrument's sensitivity at the level of individual categories, this study suggests that the instrument could be used to measure the effect of team communication intervention on overall failure rates at the level of procedure.
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Qual Saf Health Care · Dec 2006
Effect of discharge instructions on readmission of hospitalised patients with heart failure: do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care?
Most nationally standardised quality measures use widely accepted evidence-based processes as their foundation, but the discharge instruction component of the United States standards of Joint Commission on Accreditation of Healthcare Organizations heart failure core measure appears to be based on expert opinion alone. ⋯ Including discharge instructions among other evidence-based heart failure core measures appears justified.
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A high number of emergency (999) calls are made for older people who fall, with many patients not subsequently conveyed to hospital. Ambulance crews do not generally have protocols or training to leave people at home, and systems for referral are rare. The quality and safety of current practice is explored in this study, in which for the first time, the short-term outcomes of older people left at home by emergency ambulance crews after a fall are described. Results will inform the development of care for this population. ⋯ The rate of subsequent emergency healthcare contacts and increased risk of death and hospitalisation for older people who fall and who are left at home after a 999 call are alarming. Further research is needed to explore appropriate models for delivery of care for this vulnerable group.