Qual Saf Health Care
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Qual Saf Health Care · Aug 2006
Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change.
Nosocomial infections occur in approximately 10% of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost. ⋯ A systematic approach through collaboration with IHI's IMPACT initiative may have contributed to significant improvements in care in the ICU setting. Multidisciplinary teams appeared to improve communication, and bundles provided consistency of evidence based practices. The flow meetings allowed for rapid prioritization of activity and a new decision making culture empowered team members. The impact of these changes needs to be assessed more widely using rigorous study designs.
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Developments in surgical technology and procedure have accelerated and altered the work carried out in the operating theatre/room, but team modelling and training have not co-evolved. Evidence suggests that team structure and role allocation are sometimes unclear and contentious, and coordination and communication are not fully effective. ⋯ An effective training strategy might be to incorporate teamwork with other technical skills training in simulation. However, the measures employed for enhancing teamwork in training and practice will need to vary in their object of analysis, level of technical specificity, and system scope.
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Qual Saf Health Care · Jun 2006
Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients.
In medication safety research studies medication related events are often classified by type, seriousness, and degree of preventability, but there is currently no universally reliable "gold standard" approach. The reliability (reproducibility) of this process is important as the targeting of prevention strategies is often based on specific categories of event. The aim of this study was to determine the reliability of reviewer judgements regarding classification of paediatric inpatient medication related events. ⋯ Trained reviewers can reliably assess paediatric inpatient medication related events for the presence of an ADE and for its seriousness. Assessments of preventability appeared to be a more difficult judgement in children and approaches that improve reliability would be useful.
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Qual Saf Health Care · Jun 2006
Computer based medication error reporting: insights and implications.
Despite the growing use of error reporting tools, the healthcare industry is inexperienced in receiving, understanding, and analyzing these reports. ⋯ Despite clear imperfections in the data captured, medication error reporting tools are effective as a means of collecting reliable information on errors rapidly and in real time. Our data suggest that administration errors are at least as common as prescribing errors in children. Further research is needed, not only in the area of computerized physician order entry (CPOE) for children, but also on ways to make the dispensing and administration of medications safer.
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Qual Saf Health Care · Jun 2006
Active surveillance using electronic triggers to detect adverse events in hospitalized patients.
Adverse events (AEs) occur with alarming frequency in health care and can have a significant impact on both patients and caregivers. There is a pressing need to understand better the frequency, nature, and etiology of AEs, but currently available methodologies to identify AEs have significant limitations. We hypothesized that it would be possible to design a method to conduct real time active surveillance and conducted a pilot study to identify adverse events and medical errors. ⋯ This methodology of active surveillance allows for the identification and assessment of adverse events among hospitalized patients. It provides a unique opportunity to review events at or near the time of their occurrence and to intervene and prevent harm.