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1

Hyatt, Rick D. "Nurse Perceptions: The Relationship Between Patient Safety Culture, Error Reporting and Patient Safety in U.S. Hospitals." Franklin University / OhioLINK, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=frank1607988520967849.

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2

Armitage, Gerry R. "The contributory factors in drug errors and their reporting." Thesis, University of Bradford, 2008. http://hdl.handle.net/10454/14783.

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The aim of this thesis is to examine the contributory factors in drug errors and their reporting so as to design an enhanced reporting scheme to improve the quality of reporting in an acute hospital trust. The related research questions are: 1. What are the contributory factors in drug errors? 2. How effective is the reporting of drug errors? 3. Can an enhanced reporting scheme, predicated on the analysis of local documentary and interview data, identify the contributory factors in drug errors and improve the quality of their reporting in an acute hospital trust? The study aim and research questions reflect a growing consensus, articulated by Boaden and Walshe (2006), that patient safety research should focus on understanding the causes of adverse events and developing interventions to improve safety. Although there are concerns about the value of incident reporting (Wald & Shojania 2003, Armitage & Chapman 2007), it would appear that error reporting systems remain a high priority in advancing patient safety (Kohn et al 2000, Department of Health 2000a, National Patient Safety Agency 2004, WHO & World Alliance for Patient Safety 2004), and consequently it is the area chosen for intervention in this study. Enhancement of the existing scheme is based on a greater understanding of drug errors, their causation, and their reporting.
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Biquet, Jean-Marc. "Patient safety in medical humanitarian action : medical error prevention and management." Thesis, Lyon, 2020. http://www.theses.fr/2020LYSE1038.

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La sécurité des patients est reconnue depuis une vingtaine comme un des éléments essentiels de la qualité des soins et est devenu une partie intégrante des systèmes de santé. Elle se déclinée en règlementations, outils et stratégies qui touchent tous les secteurs de la médecine. Aujourd’hui les recherches et applications de la sécurité des patients concernent surtout les systèmes de santé des pays les plus développés alors même que deux-tiers des incidents de sécurité estimés se produisent dans les pays à revenu faible ou moyen. Une phase exploratoire a permis de confirmer que la sécurité du patient et la détection et gestion des erreurs médicales n’ont pas encore eu de traduction structurée, adaptée au secteur de l’aide médicale humanitaire. Afin d’essayer de comprendre les raisons de ce décalage, cette thèse s’intéresse au statut actuel et aux perspectives de la sécurité des patients dans l'action médicale humanitaire. Une première partie se penche sur les développements dans les sciences de la sécurité et de la gestion des risques et aborde l’état de connaissance actuelle et les principaux développements en matière de sécurité des patients, et de la gestion des erreurs médicales en particulier. Suit une analyse des caractéristiques de l’action médicale telle que déployée par les organisations médicales.La deuxième phase de la thèse se centre sur des entretiens semi-directifs avec du personnel médical et paramédical actifs au sein de 6 organisations médicales humanitaires pour connaître l’état actuel des développements en matière de sécurité du patient et de la gestion des erreurs médicales. 39 entretiens ont été menés avec du personnel international médical ou paramédical ayant 2 ans d’expérience minimum dans le secteur humanitaire pour comprendre leurs connaissances, attitudes et attentes en matière de sécurité du patient et de la gestion des erreurs médicales dans leur secteur.Il apparait clairement que s’il n’existe actuellement pas encore dans le secteur d’approche structurée de la question de la sécurité du patient et plus spécifiquement de la gestion des erreurs médicales, cela répond clairement à une attente de la part du personnel humanitaire interviewé. Les raisons invoquées pour expliquer ce manque sont de deux ordres. Il y a celles en lien avec les spécificités de l’action médicale humanitaire et celles que l’on a pu retrouver dans les systèmes de santé des pays de l’OCDE.Cette recherche, la première du genre selon nos informations, identifie la motivation du personnel médical et paramédical du secteur humanitaire à s’engager à mener une véritable révolution culturelle pour rendre l’offre de soins plus sûre, même dans des situations précaires<br>Patient safety is recognized for some 20 years as one of the essential elements of healthcare quality and has become an integral part of healthcare systems. It encompasses regulations, tools and strategies that affect all sectors of medicine. Today, research and implementation in the area of patient safety pertain above all to healthcare systems in the most developed countries whereas two thirds of estimated safety incidents occur in low- or mid-income countries.An exploratory phase aiming at developing the research strategy confirmed that patient safety, per se, and the detection and management of medical errors have not yet been translated into the humanitarian assistance sector in a structured and adapted way. In order to understand the reasons for this gap this thesis aims to understand what the current status and perspectives of patient safety in medical humanitarian action are. An initial phase explored developments in the knowledge of safety and risk management and the current state of knowledge and the main developments in patient safety and especially medical error management were explored. Follows an analysis of the characteristics of medical action as carried out by medical humanitarian organisations.The second part of the thesis is centred on semi-directive discussions with medical and paramedical personnel active within six medical humanitarian organisations to understand the knowledge, attitudes and practises with regards to patient safety and medical error management. 39 interviews were done with international medical and paramedical staff with minimum 2 years of experience in the humanitarian sector. It appears clearly that, while there may not yet be a structured approach in the sector regarding patient safety and, specifically, medical error management, this clearly corresponds to an expectation on the part of the humanitarian personnel interviewed.This research, to our knowledge the first of its kind, demonstrates the eagerness of the medical and paramedical staff engaged in humanitarian action to commit to an internal cultural revolution towards a safer healthcare provision, even in precarious situations. Catching up the delays in adopting adapted patient safety and medical error management policies would reinforce the accountability to the vulnerable populations assisted by these organisations and save more lives, the essence of humanitarian purpose
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4

Söderberg, Johan. "Sources of preanalytical error in primary health care : implications for patient safety." Doctoral thesis, Umeå universitet, Klinisk kemi, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-21256.

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Background Venous blood tests constitute an important part in the diagnosis and treatment of patients. However, test results are often viewed as objective values rather than the end result of a complex process. This has clinical importance since most errors arise before the sample reaches the laboratory. Such preanalytical errors affect patient safety and are often due to human mistakes in the collection and handling of the sample. The preanalytical performance of venous blood testing in primary health care, where the majority of the patients contact with care occurs, has not previously been reported. Aims To investigate venous blood sampling practices and the prevalence of haemolysed blood samples in primary health care. Methods A questionnaire investigated the collection and handling of venous blood samples in primary health care centres in two county councils and in two hospital clinical laboratories. Haemolysis index was used to evaluate the prevalence of haemolysed blood samples sent from primary health care centres, nursing homes and a hospital emergency department. Results and discussion The results indicate that recommended preanalytical procedures were not always followed in the surveyed primary health care centres. For example, only 54% reported to always use name and Swedish identification number, and 5% to use photo-ID, the two recommended means for patient identification. Only 12% reported to always label the test tubes prior to blood collection. This increases the possibility of sample mix-up. As few as 6% reported to always allow the patient to rest at least 15 minutes before blood collection, desirable for a correct test result. Only 31% reported to have filed an incident report regarding venous blood sampling, indicating underreporting of incidents in the preanalytical phase. Major differences in the prevalence of haemolysed blood samples were found. For example, samples collected in the primary health care centre with the highest prevalence of haemolysed samples were six times (95% CI 4.0 to 9.2) more often haemolysed compared to the centre with the lowest prevalence. The significant variation in haemolysed samples is likely to reflect varying preanalytical conditions. Conclusions This thesis indicates that the preanalytical procedure in primary health care is associated with an increased risk of errors with consequences for patient safety and care. Monitoring of haemolysis index could be a valuable tool for estimating preanalytical sample quality. Further studies and interventions aimed at the preanalytical phase in primary health care are clearly needed.
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5

Denny, Diane. "Medical Error Reporting and Patient Safety: An Exploration of Our Underreporting Dilemma." Diss., Temple University Libraries, 2017. http://cdm16002.contentdm.oclc.org/cdm/ref/collection/p245801coll10/id/427730.

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Business Administration/Interdisciplinary<br>Ph.D.<br>Studies suggest that the majority of hospital errors go unreported. Equally disturbing is that data surrounding near miss events that could have harmed patients has been found to be even sparser. At the core of any medical error reporting effort is a desire to obtain data that can be used to reduce the frequency of errors, reveal the cause of errors, and empower those involved in the healthcare delivery system with the insight required to design methods to prevent the flaws that allow mistakes to occur. Aligned with the adage that “we can’t fix what we don’t know is broke”, the question is raised why does underreporting exist? The likelihood of reporting medical errors is explored as a manifestation of culture. Factors studied include communication and feedback, teamwork, fear of retribution, and leadership support (top management and supervisor). Data is presented using a nationally recognized instrument—the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety survey. Findings from the research are mixed with little positive relationship between the model and number of events reported although each factor is found to be positively associated with an employee’s perceived frequency by which near miss and no harm events are reported. While advances in patient safety have materialized, the act of employees’ actually reporting events still pales in comparison to the number of errors that have likely occurred, regardless of efforts to advance culture. To explore influencers beyond those found in the AHRQ Culture of Safety survey, an overlapping model is presented. This includes studying various underlying factors, such as understanding what constitutes a reportable event, ease of reporting, and knowledge of the processes supporting data submission, along with attempting to better assess the impact of the direct supervisor and incentives in influencing behavior. Findings suggest that these additional factors do contribute, albeit modestly, to the act of reporting errors. When adding tenure and patient interaction to the model, a higher percentage of the variance is explained. In terms of perceived frequency of reporting near misses and no harm events, this model yields similar results to the first, explaining approximately 28% of the variance. The two factors most positively associated with perceived frequency of reporting near miss and no harm events are communication and feedback and infrastructure —suggesting that some unexplored relationship may exist between the overlapping models.<br>Temple University--Theses
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Jenkins, James J. "Laboratory data and patient safety." Columbus, Ohio : Ohio State University, 2005. http://rave.ohiolink.edu/etdc/view?acc%5Fnum=osu1135271306.

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7

Wilson, Katherine Ann. "Does safety culture predict clinical outcomes?" Doctoral diss., University of Central Florida, 2007. http://digital.library.ucf.edu/cdm/ref/collection/ETD/id/2919.

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Patient safety in healthcare has become a national objective. Healthcare organizations are striving to improve patient safety and have turned to high reliability organizations as those in which to model. One initiative taken on by healthcare is improving patient safety culture--shifting from one of a 'no harm, no foul' to a culture of learning that encourages the reporting of errors, even those in which patient harm does not occur. Lacking from the literature, however, is an understanding of how safety culture impacts outcomes. While there has been some research done in this area, and safety culture is argued to have an impact, the findings are not very diagnostic. In other words, safety culture has been studied such that an overall safety culture rating is provided and it is shown that a positive safety culture improves outcomes. However, this method does little to tell an organization what aspects of safety culture impact outcomes. Therefore, this dissertation sought to answer that question but analyzing safety culture from multiple dimensions. The results found as a part of this effort support previous work in other domains suggesting that hospital management and supervisor support does lead to improved perceptions of safety. The link between this support and outcomes, such as incidents and incident reporting, is more difficult to determine. The data suggests that employees are willing to report errors when they occur, but the low occurrence of such reportable events in healthcare precludes them from doing so. When a closer look was taken at the type of incidents that were reported, a positive relationship was found between support for patient safety and medication incidents. These results initially seem counterintuitive. To suggest a positive relationship between safety culture and medication incidents on the surface detracts from the research in other domains suggesting the opposite. It could be the case that an increase in incidents leads an organization to implement additional patient safety efforts, and therefore employees perceive a more positive safety culture. Clearly more research is needed in this area. Suggestions for future research and practical implications of this study are provided.<br>Ph.D.<br>Department of Psychology<br>Sciences<br>Psychology PhD
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D'Esmond, Lynn Berggren Knapp. "Distracted Practice and Patient Safety: The Healthcare Team Experience: A Dissertation." eScholarship@UMMS, 2016. https://escholarship.umassmed.edu/gsn_diss/41.

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Purpose: The purpose of this study was to explore the experiences of distracted practice across the healthcare team. Definition: Distracted practice is the diversion of a portion of available cognitive resources that may be needed to effectively perform/carry out the current activity. Background: Distracted practice is the result of individuals interacting with the healthcare team, the environment and technology in the performance of their jobs. The resultant behaviors can lead to error and affect patient safety. Methods: A qualitative descriptive (QD) approach was used that integrated observations with semi-structured interviews. The conceptual framework was based on the distracted driving model and a completed concept analysis. Results: There were 22 observation sessions and 32 interviews (12 RNs, 11 MDs, and 9 Pharmacists) completed between December, 2014 and July 2015. Results suggested that distracted practice is based on the main theme of cognitive resources which varies by the subthemes of individual differences; environmental disruptions; team awareness; and “rush mode”/time pressure. Conclusions and Implications: Distracted practice is an individual human experience that occurs when there are not enough cognitive resources available to effectively complete the task at hand. In that moment an individual shifts from thinking critically, being able to complete their current task without error, to not thinking critically and working in an automatic mode. This is when errors occur. Additional research is needed to evaluate intervention strategies to reduce and prevent distracted practice.
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Sims, Dana Elizabeth. "THE IMPACT OF INTRAORGANIZATIONAL TRUST AND LEARNING ORIENTED CLIMATE ON ERROR REPORTING." Doctoral diss., University of Central Florida, 2009. http://digital.library.ucf.edu/cdm/ref/collection/ETD/id/2247.

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Insight into opportunities for process improvement provides a competitive advantage through increases in organizational effectiveness and innovation As a result, it is important to understand the conditions under which employees are willing to communicate this information. This study examined the relationship between trust and psychological safety on the willingness to report errors in a medical setting. Trust and psychological safety were measured at the team and leader level. In addition, the moderating effect of a learning orientation climate at three levels of the organization (i.e., team members, team leaders, organizational) was examined on the relationship between trust and psychological safety on willingness to report errors. Traditional surveys and social network analysis were employed to test the research hypotheses. Findings indicate that team trust, when examined using traditional surveys, is not significantly associated with informally reporting errors. However, when the social networks within the team were examined, evidence that team trust is associated with informally discussing errors was found. Results also indicate that trust in leadership is associated with informally discussing errors, especially severe errors. These findings were supported and expanded to include a willingness to report all severity of errors when social network data was explored. Psychological safety, whether within the team or fostered by leadership, was not found to be associated with a willingness to informally report errors. Finally, learning orientation was not found to be a moderating variable between trust and psychological safety on a willingness to report errors. Instead, organizational learning orientation was found to have a main effect on formally reporting errors to risk management and documenting errors in patient charts. Theoretical and practical implications of the study are offered.<br>Ph.D.<br>Department of Psychology<br>Sciences<br>Psychology PhD
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Burke, Darlene M. "Enhancing the patient safety culture of ABSN students through instruction on medical error recovery." Thesis, Capella University, 2014. http://pqdtopen.proquest.com/#viewpdf?dispub=3610403.

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<p> Attitudes toward patient safety are the foundation of patient safety culture. Nursing students begin to formulate their attitudes toward patient safety while in educational programs. Nursing faculty have been challenged in their efforts to enhance the patient safety culture of students because there is a lack of empirical evidence as to which teaching strategies positively affect student attitudes toward patient safety. The purpose of this study was to examine the relationship between a 50-minute teaching module based upon the concept of medical error recovery and 9 dimensions of patient safety culture as measured by the Attitudes to Patient Safety Questionnaire. The guiding framework for the study was the reciprocal interactive theory of patient safety culture in nursing. The conceptual model used to illuminate the role of nurses in recovering medical errors in the educational intervention was the modified Eindhoven model of near-miss events. The sample comprised 4 student cohorts (N = 142) enrolled in an accelerated bachelor of science in nursing (ABSN) program at one university, with 4 participants lost to follow-up (n = 138). A quasi-experimental, nonequivalent control group, pretest/posttest design was used to compare mean attitude scores between the control (n = 75) group and the intervention group (n = 63) after statistically controlling for the pretest. ANCOVA revealed statistically higher mean attitude scores for the intervention group in 5 of 9 dimensions of patient safety culture with a small-medium effect size associated with the intervention: patient safety training, error inevitability, professional incompetence as error cause, patient's role in error, and importance of patient safety culture in curriculum. The results supported the use of a short-duration educational session on medical error recovery to enhance a subset of patient safety culture dimensions among ABSN students.</p>
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Monzani, Aline Aparecida Silva. ""A ponta do iceberg: o método de notificação de erros de medicação em um hospital geral privado no município de Campinas-SP"." Universidade de São Paulo, 2006. http://www.teses.usp.br/teses/disponiveis/22/22132/tde-16082006-223547/.

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Observações realizadas na prática de enfermagem indicam que erros na administração de medicamentos são passíveis de ocorrer e, de fato ocorrem. Como causas têm-se, entre outras, a sobrecarga de trabalho da equipe de enfermagem, o conhecimento insuficiente sobre os medicamentos, número elevado de medicamentos lançados no mercado anualmente, a qualidade das prescrições médicas, enfim, falhas no sistema de medicação de uma maneira geral. Uma forma de diminuir os erros de medicação é a sua notificação, o que permite o estudo das suas causas, podendo então preveni-los. Desta forma, este estudo foi desenvolvido com os seguintes objetivos: descrever e analisar os erros de medicação notificados em um Hospital Geral Privado no município de Campinas-SP e o relatório de ocorrências utilizado por esta instituição e, propor um relatório de erros de medicação. Trata-se de um estudo descritivo exploratório, retrospectivo e longitudinal, que foi dividido em duas fases: na primeira foi realizada a análise dos erros de medicação ocorridos e na segunda fase a entrevista com os profissionais. Foram analisados 39 erros de medicação no período de janeiro de 1999 a dezembro de 2005, onde 13 (33,3%) estavam relacionados à administração de medicamento não prescrito e 10 (25,6%) a erros de omissão. A entrevista foi realizada com 64 profissionais e destes, 45 (70,3%) não conhecem o relatório de ocorrências utilizado na instituição. Dos 19 (29,7%) profissionais que o conhecem, todos o consideram adequado para o relato dos erros de medicação, além disso, 30 (46,9%) profissionais acreditam que os erros de medicação são notificados na instituição. Entretanto com o número de erros notificados em um período de 6 anos, ficou claro que a subnotificação é uma realidade vivenciada pela instituição. Desta forma, foi proposto um modelo de relatório de notificação de erros, estruturado de acordo com dados da literatura e de órgãos e instituições governamentais. Conclui-se que os profissionais da instituição não têm conhecimento da situação atual vivenciada pela instituição com relação aos erros de medicação e à subnotificação destes erros. Além disso, o relatório de ocorrências da instituição está incompleto, necessita ser revisado e divulgado dentro da instituição a fim de envolver toda a equipe multidisciplinar, aumentar o número de erros relatados e desta forma, implementar estratégias de ação para evitar novos erros e, consequentemente, aumentar a segurança dos pacientes e a qualidade da assistência prestada.<br>Observations made within nursing practice indicate that errors in the ministering of medicaments are liable to occur and in fact they do. As causes, amongst others, there is the workload of the nursing team, the insufficient knowledge of medicaments, the large number of medicaments launched in the market each year, the quality of medical prescriptions, ultimately, failure in the medication system in a general manner. One way to lower medication errors is to notify them, which leads to the study of the causes and enables their prevention. In this way, this study was developed with the following objectives: to describe and analyze the notified medication errors in a General Private Hospital in the city of Campinas-SP and the incident report used by the institution and propose a report on medication errors. This deals with a longitudinal and retrospective study which is exploratory, descriptive and divided into two fases: in the first an analysis of the medication errors was performed and in the second an interview with the professionals. In the period of January 1999 to December 2005, 39 medication errors were analyzed, whereby 13 (33,3%) were related to the ministering of non-prescribed medication and 10 (25,6%) were related to errors of omission. The interview was performed with 64 professionals and of these, 45 (70,3%) did not know about the incident report used at the institution. Of the 19 (29,7%) professional who did know about the report, all considered it to be adequate for reporting medication errors. In addition to this, 30 (46,9%) professionals believe that medication errors are notified to the institution. However with the low number of errors notified in the period of 6 years, it is clear that the true picture at the institution is quite different. Due to this, a model of Error Notification Report, that was structured according to data from literature and from governmental organs and institutions, was proposed. It is concluded that the professionals of this institution have no knowledge of the present situation, which occurs inside their institution. Also, the institution’s incident report is incomplete, needs to be revised and disclosed within the institution in order to involve the entire multi-disciplinary team, increase the number of errors reported, thereby implementing action strategies to avoid new errors and consequently increase the safety of patients and the quality of the rendered assistance.
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Wheeler, Daniel Wren. "Weakened by strengths : drugs in solution, medication error and drug safety." Thesis, University of Oxford, 2008. http://ora.ox.ac.uk/objects/uuid:238087a5-120b-4a3d-9437-5840cecf8b6a.

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The concentrations of some drug solutions are often expressed as ratios or percentages. This system simplified prescription and dispensing when Imperial measures such as grains and minims were used. Ampoules of powerful vasoactive drugs such as catecholamines and potentially toxic local anaesthetics are still labelled as ratios and percentages, seemingly through habit or tradition than for any useful clinical reason. This thesis argues that adherence to this outdated system is confusing, causes drug administration errors, and puts patients at risk. Internet-based questionnaires were used to quantify medical students’ and doctors’ understanding of ratios and percentages. A substantial minority of almost 3000 doctors could not convert between ratios, percentages and mass concentration correctly, made dosing errors of up to three orders of magnitude in written clinical scenarios, and struggled with conversions between metric units. These findings are strong arguments for expressing drug concentrations as mass concentration and providing better drug administration teaching. High fidelity patient simulation was used to examine the influence of clearer ampoule labelling and intensive drug administration teaching. This allowed critical incidents to be reproduced realistically, clinical performances to be assessed, and outcome measures to be accurately recorded. Randomised controlled trials were conducted that demonstrated positive influences of both interventions for doctors and students. The difficulties that nurses encounter when preparing infusions of these drugs on critical care units were also studied and are reported. The findings presented should be sufficient to persuade regulatory authorities to remove ratios and percentages from ampoule labels – a straightforward, cheap, commonsense intervention. The lack of effective clinical error reporting systems and the extreme practical difficulties of conducting clinical trials in this field mean that a firm link between this intervention and patient outcome is unlikely ever to be made, but this should not be an excuse for maintaining the status quo.
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Cunningham, Thomas Raymond. "A comprehensive approach to preventing errors in a hospital setting: Organizational behavior management and patient safety." Diss., Virginia Tech, 2009. http://hdl.handle.net/10919/26279.

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Estimates of the number of U.S. deaths each year resulting from medical errors range from 44,000 (Institute of Medicine, 1999) to 195,000 (HealthGrades, 2004). Additionally, instances of medical harm are estimated to occur at a rate of approximately 15 million per year in the U.S., or about 40,000 per day (Institute for Healthcare Improvement, 2007). Although several organizational behavior management (OBM) intervention techniques have been used to improve particular behaviors related to patient safety, there remains a lack of patient-safety-focused behavioral interventions among healthcare workers. OBM interventions are often applied to needs already identified within an organization, and the means by which these needs are determined vary across applications. The current research addresses gaps in the literature by applying a broad needs-assessment methodology to identify patient-safety intervention targets in a hospital and then translating OBM intervention techniques to identify and improve the prevention potential of responses to reported medical errors. A content analysis of 17 months of descriptions of follow-up actions to error reports for nine types of the most-frequently-occurring errors was conducted. Follow-up actions were coded according to a taxonomy of behavioral intervention components, with accompanying prevention scores based on criteria developed by Geller et al. (1990). Two error types were selected for intervention; based on the highest frequency of reporting and lowest average follow-up prevention score. Over a three-month intervention period, managers were instructed to respond to these two error types with active communication, group feedback, and positive reinforcement strategies. Results indicate improved prevention potential as a consequence of improved corrective action for targeted errors. Future implications for identifying and classifying responses to medical error are discussed.<br>Ph. D.
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Echeverri, Ana Lucia Hincapie. "Relationship between Perceived Healthcare Quality and Patient Safety." Diss., The University of Arizona, 2013. http://hdl.handle.net/10150/283602.

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The objectives of this study were to examine the association between patient perceived healthcare quality and self-reported medical, medication, and laboratory errors using cross-sectional and cross-national questionnaire data from eleven countries. In this research, quality of care was measured by a multi-faceted construct, which adopted the patient's perspectives. Five separated quality of care scales were assessed: Access to Care, Continuity of care, Communication of Care, Care Coordination, and Provider's Respect for Patients' Preferences. The findings from this investigation support a number of other published studies suggesting that Coordination of Care is an important predictor of perceived patient safety. After adjusting for potentially important confounding variables, an increase in peoples' perceptions of Coordination of Care decreased the likelihood of self-reporting medical errors (OR =0.605, 95% CI: 0.569 to 0.653), medication errors (OR =0.754, 95% CI: 0.691 to 0.830), and laboratory errors (OR =0.615, 95% CI: 0.555 to 0.681). Finally, results showed that the healthcare system type governing care processes modifies the effect of Coordination of Care on self-reported medication errors.
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Steyrer, Johannes, Michael Schiffinger, Huber Clemens, Andreas Valentin, and Guido Strunk. "Attitude is everything? The impact of workload, safety climate, and safety tools on medical errors: A study of intensive care units." Lippincott Williams & Wilkins, 2013. http://dx.doi.org/10.1097/HMR.0b013e318272935a.

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Background: Hospitals face an increasing pressure towards efficiency and cost reduction while ensuring patient safety. This warrants a closer examination of the trade-off between production and protection posited in the literature for a high-risk hospital setting (intensive care). Purposes: Based on extant literature and concepts on both safety management and organizational/safety culture, this study investigates to which extent production pressure (i.e., increased staff workload and capacity utilization) and safety culture (consisting of safety climate among staff and safety tools implemented by management) influence the occurrence of medical errors and if/how safety climate and safety tools interact. Methodology / Approach: A prospective, observational, 48-hour cross-sectional study was conducted in 57 intensive care units. The dependent variable is the incidence of errors affecting those 378 patients treated throughout the entire observation period. Capacity utilization and workload were measured by indicators such as unit occupancy, nurse-/physician-to-patient ratios, levels of care, or NEMS scores. The safety tools considered include Critical Incidence Reporting Systems, audits, training, mission statements, SOPs/checklists and the use of barcodes. Safety climate was assessed using a psychometrically validated four-dimensional questionnaire. Linear regression was employed to identify the effects of the predictor variables on error rate, as well as interaction effects between safety tools and safety climate. Findings: Higher workload has a detrimental effect on safety while safety climate - unlike the examined safety tools - has a virtually equal opposite effect. Correlations between safety tools and safety climate as well as their interaction effects on error rate are mostly nonsignificant. Practice Implications: Increased workload and capacity utilization increase the occurrence of medical error; an effect that can be offset by a positive safety climate but not by formally implemented safety procedures and policies. (authors' abstract)
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Cunningham, Thomas R. "A Behavioral Evaluation of the Transition to Electronic Prescribing in a Hospital Setting." Thesis, Virginia Tech, 2006. http://hdl.handle.net/10919/31873.

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The impact of Computerized Physician Order Entry (CPOE) on the dependent variables of medication-order compliance and time to first dose of antibiotic was investigated in this quasi-experimental study of a naturally-occurring CPOE intervention. The impact of CPOE on compliance and time to first dose was assessed by comparing measures of these variables from the intervention site and a non-equivalent control before and during intervention phases. Medication orders placed using CPOE were significantly more compliant than paper-based medication orders (p<.001), and first doses of antibiotic ordered using CPOE were delivered significantly faster than antibiotic orders placed using the paper-based system (p<.001). Findings support previous research indicating the positive impact of CPOE on patient safety as well as justify and enable future interventions to increase CPOE adoption and use among physicians. Additionally, data collected in this study will be used to provide behavior-based feedback to physicians as part of CPOE adoption and use intervention strategies to be explored in the forthcoming research.<br>Master of Science
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Rasmussen, Erin M., and Erin M. Rasmussen. "Improving Patient Safety and Incident Reporting Through Use of the Incident Decision Tree." Diss., The University of Arizona, 2017. http://hdl.handle.net/10150/626648.

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Background: Preventable medical error accounts for approximately 98,000 deaths in the hospital setting each year. A proposed solution to decreasing medical error encompasses the development of a culture of safety. Safety culture has been defined as a common set of values and beliefs that are shared by individuals within an organization that influence their actions and behaviors. In 2015, the safety culture of Registered Nurses (RN) and Patient Care Technicians (PCT) who regularly worked in the Intensive Care Unit (ICU) and Cardiovascular Intensive Care Unit (CVICU) at Flagstaff Medical Center (FMC) was assessed using the Hospital Survey on Patient Safety Culture. This survey functioned as a needs assessment and demonstrated that ICU/CVICU staff had negative reactions to safety culture and error reporting on eight of twelve composites tested. Based off these results, the Incident Decision Tree (IDT) was selected as an intervention to help improve the areas identified in the needs assessment. Purpose: The aims of this quality improvement project included: 1) Development of a protocol for IDT use by ICU/CVICU managers; 2) Implementing the IDT; and 3) Administering a post IDT implementation survey. Methods: The IDT was implemented during a 4-week period in the ICU/CVICU at FMC. During this time, managers used the IDT when processing reported error. Post implementation, an online survey was administered over the course of two weeks to ICU/CVICU managers and unit based RNs and PCTs to reassess their perceptions on the IDT, error reporting, and safety culture. Results: During the implementation period, 23 errors were reported in the ICU/CVICU at FMC with management utilizing the IDT a total of 12 times. Analysis of the reportable data demonstrated that of the 12 incidents, seven were attributed to system failures. The remaining five incidents were processed using the “foresight test.” Conclusions: Results from the post implementation survey demonstrated that ICU/CVICU staff felt the IDT contributed to a non-punitive environment. Staff also reported the IDT helped to increase communication after an error occurred. Lastly, the majority of staff felt the IDT increased transparency in the error reporting process.
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Robinson, Mary Jane. "Diagnostic Medical Errors and Their Impact on Patient Safety." Thesis, Northcentral University, 2018. http://pqdtopen.proquest.com/#viewpdf?dispub=10787186.

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<p> The purpose for this qualitative research was to provide comparative data to determine if there was areas in need of improvement when it pertained to medical errors. Researchers have validated that initiating measures for continuous improvement would minimize error rates and benefit the clinicians and their patients. Patient safety was important and cause major concerns, therefore this research explored categories that influenced decision-making processes or conditions that causes deficit in reasoning, which could have an impact on cognitive abilities. Therefore, medical errors are a research worthy problem; since they cause phenomenon, conflict within managerial processes, and was a contributing factor for malpractice payouts, per a report from 2015 Institute of Medicine. As a result, researchers validated that initiating measures for continuous improvement would benefit the clinicians and their patients by minimizing errors or keeping them at a minimum. Utilizing the qualitative approach provided the best framework to narrow down cause and effects to validate the importance of support that relates to memory and relational network through retrieval-mediated learning. This research provides evidence that medical errors occurred during decision-making processes with (90%) cognitive errors, anchoring (75.7%), and (78.6%) premature closure. As a result, this qualitative research concentrated on constructs, such as, data collection from observation of prior research from scholarly, empirical, peered reviewed articles; <i>Medical Journals</i>, and education materials to provide pertinent information on diagnostic medical errors for the material within this investigation. The results from this study indicated, although, there was suggestions to improve patient-safety no significant decrease in medical harm occurred, therefore additional investigations will provide a valuable contribution to the body of knowledge and conditions for continuous improvement.</p><p>
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19

Ridelberg, Mikaela. "Towards safer care in Sweden? : Studies of influences on patient safety." Doctoral thesis, Linköpings universitet, Avdelningen för hälso- och sjukvårdsanalys, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-127307.

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Patient safety has progressed in 15 years from being a relatively insignificant issue to a position high on the agenda for health care providers, managers and policymakers as well as the general public. Sweden has seen increased national, regional and local patient safety efforts since 2011 when a new patient safety law was introduced and a four-year financial incentive plan was launched to encourage county councils to carry out specified measures and meet certain patient safety related criteria. However, little is known about what structures and processes contribute to improved patient safety outcomes and how the context influences the results. The overall aim of this thesis was to generate knowledge for improved understanding and explanation of influences on patient safety in the county councils in Sweden. To address this issue, five studies were con-ducted: interviews with nurses and infection control practitioners, surveys to patient safety officers and a document analysis of patient safety reports. Patient safety officers are healthcare professionals who hold key positions in their county council’s patient safety work. The findings from the studies were structured through a framework based on Donabedian’s triad (with a contextual element added) and applying a learning perspective, highlight areas that are potentially important to improve the patient safety in Swe-dish county councils. Study I showed that the conditions for the county councils’ patient safety work could be improved. Conducting root-cause analysis and attaining an organizational culture that encourages reporting and avoids blame were perceived to be of importance for improving patient safety. Study II showed that nurses perceived facilitators and barriers for improved pa-tient safety at several system levels. Study III revealed many different types of obstacles to effective surveillance of health care-associated infec-tions (HAIs), the majority belonging to the early stages of the surveillance process. Many of the obstacles described by the infection control practi-tioners restricted the use of results in efforts to reduce HAIs. Study IV of the Patient Safety Reports identified 14 different structure elements of patient safety work, 31 process elements and 23 outcome elements. These reports were perceived by patient safety officers to be useful for providing a structure for patient safety work in the county councils, for enhancing the focus on patient safety issues and for learning from the patient safety work that is undertaken. In Study V the patient safety officers rated efforts to reduce the use of antibiotics and improved communication be-tween health care practitioners and patients as most important for attaining current and future levels of patient safety in their county council. The patient safety officers also perceived that the most successful county councils regarding patient safety have good leadership support, a long-term commitment and a functional work organisation for patient safety work. Taken together, the five studies of this thesis demonstrate that patient safety is a multifaceted problem that requires multifaceted solutions. The findings point to an insufficient transition of assembled data and information into action and learning for improved patient safety.
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Hilario, Grace. "Patient Safety Problems, Procedures, and Systems Associated with Safety Reporting and Turnover." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7103.

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Research has shown that 400,000 people die every year due to preventable medical errors. Medical error reporting and safety is a responsibility of all members of a health care organization. Creating an environment that addresses and prevents potential or actual safety problems can help reduce the incidence of medical errors made by nurses in the workplace. The purpose of this quantitative research study was to determine if nurses' perceptions of safety problems and error-preventing procedures and systems affected their comfort in reporting safety problems and intent to leave. High-reliability theory was the theoretical foundation for this study. Data were obtained from 1,171 surveys completed by newly licensed registered nurses located in 51 different metropolitan statistical areas and 9 counties. SPSS Version 25 was used to conduct a secondary data analysis including descriptive statistics, bivariate analysis, and multiple logistic regression for each variable. Themes that emerged from the data analysis included the importance of education on safety protocols and improving nurse satisfaction and nurse retention. The findings of the study might contribute to social change by creating an increased awareness for nurse leaders, managers, and newly licensed registered nurses in ensuring that there is improved comfort of reporting and appropriate error-preventing procedures and system in the health care environment. Increased awareness will allow for action and improved protocols to enhance the overall safety and quality of care for nurses and their patients.
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Ledger-Scott, Margaret. "Improving patient safety by reducing the risk of prescribing errors." Thesis, University of Sunderland, 2010. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.517871.

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22

Hagiwara, Magnus. "Development and Evaluation of a Computerised Decision Support System for use in pre-hospital care." Doctoral thesis, Hälsohögskolan, Högskolan i Jönköping, HHJ. Kvalitetsförbättring och ledarskap inom hälsa och välfärd, 2014. http://urn.kb.se/resolve?urn=urn:nbn:se:hj:diva-23781.

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The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care. The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design. The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time. The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient.
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23

Marshall, Trisha L. M. D. "Diagnostic Learning Opportunities: Increasing Physician Reporting of Suspected Diagnostic Errors." University of Cincinnati / OhioLINK, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1592171499312483.

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24

Durand, Marcus L. "The evaluation of methods for the prospective patient safety hazard analysis of ward-based oxygen therapy." Thesis, Cranfield University, 2009. http://dspace.lib.cranfield.ac.uk/handle/1826/4480.

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When even seemingly benign and routine processes fail in healthcare, people sometimes die. The profound effect on the patient’s families and the healthcare staff involved is clear (Vincent and Coulter, 2002), while further consequences are felt by the institution involved, both financially and by damage to reputation. The trend in healthcare for learning through experience of adverse events is no longer a viable philosophy (Department of Health,Sir Ian Carruthers OBE and Pauline Philip, 2006). In order to make progress towards preventative learning, three Prospective Hazard Analysis (PHA) methods used in other industries were evaluated for use in the area of ward based healthcare. Failure Modes and Effects Analysis (FMEA), Fault Tree Analysis (FTA) and Hazard and Operability Analysis (HAZOP) were compared to each other in terms of ease of use, information they provide and the manner in which it is presented. Their results were also compared to baseline data produced through empirical research. Oxygen Therapy was used in this research as an example of a common ward based therapy. The resulting analysis listed 186 hazards almost all of which could lead to death, especially if combined. FTA and FMEA provided better system coverage than HAZOP and identified more hazards than were contained in the initial hazard identification method common to both techniques. FMEA and HAZOP needed some modification before use, with HAZOP requiring the most extensive adjustment. FTA has a very useful graphical presentation and was the only method capable of displaying causal linkage, but required that hazards be translated into events for analysis. It was concluded that formal Prospective Hazard Analysis (PHA) was applicable to this area of healthcare and presented added value through a combination of detailed information on possible hazards and accurate risk assessment based on a combination of expert opinion and empirical data. This provides a mechanism for evidence based identification of hazard barriers and safeguards as well as a method for formal communication of results at any stage of an analysis. It may further provide a very valuable vehicle for documented learning through prospective analysis incorporating feedback from previous experience and adverse incidents. The clear definition of systems and processes that form part of these methods provides a valuable opportunity for learning and the enduring capture and dissemination of tacit knowledge that can be continually updated and used for the formulation of strategies for safety and quality improvement.
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Richter, Jason. "Organizational Factors of Safety Culture Associated with Perceived Success in Patient Handoffs, Error Reporting, and Central Line-Associated Bloodstream Infections." The Ohio State University, 2013. http://rave.ohiolink.edu/etdc/view?acc_num=osu1372867558.

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26

Olsson, Åsa. "Sjuksköterskors uppfattningar om avvikelser och avvikelserapportering inom vården : en kvalitativ studie." Thesis, Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap, 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-176926.

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Syfte: Att undersöka sjuksköterskors uppfattningar om avvikelser i vården och om bakomliggande orsaker till dessa samt inställningar till avvikelserapportering och -hantering. Studien syftade även till att undersöka uppfattningar om hur nyanställda sjuksköterskor påverkas av rådande inställningar till detta på en vårdavdelning. Metod: Kvalitativ metod med explorativ design. Bekvämlighetsurval tillämpades och data samlades in med hjälp av semistrukturerade intervjuer med sex sjuksköterskor från en medicinsk vårdavdelning på ett svenskt universitetssjukhus. Dataanalysen genomfördes med fenomenografisk metod. Resultat: Sjuksköterskornas generella uppfattningar om förekommande avvikelser inom vården kan sammanfattas som säkerhetsbrister för patienter och personal. Orsakerna till avvikelser kan indelas i flera kategorier varav ”hög arbetsbelastning” är den mest omfattande. Närapå samtliga orsaker kan härledas till brister i organisation och/eller ledning. Att avvikelser inträffar anses allvarligt men mänskligt och ofrånkomligt. Sjuksköterskorna har olika attityder till avvikelserapportering t.ex. att man ser det som ett led i förbättringsarbetet eller utser syndabockar. Generellt uppfattas att avvikelser underrapporteras. Ett antal faktorer såsom graden av säkerhetsrisk, tidsbrist samt tvivel på uppföljning uppfattas som avgörande för om man väljer att rapportera en avvikelse eller inte. Sjuksköterskorna efterfrågar feedback och information om rapporterade avvikelser. Nyanställda sjuksköterskor uppfattas påverkas starkt av andra sjuksköterskor gällande attityder till avvikelser såväl som avvikelserapportering.<br>Aim: To examine nurses' opinion about errors in their profession and the underlying causes of these. A further aim was to study attitudes towards error reporting and to examine whether more experienced colleagues’ opinion concerning error making and error reporting had any effect on newly employed inexperienced nurses. Methods: The study was qualitative with an explorative design. Convenience sampling was applied and data was collected by semi-structural interviews. Six nurses from a medical care unit participated in the study and data was analyzed with a phenomenographic method. Results: The major category of nurses' views about error making included lack of patient safety and working environment issues is another category. It could all be summed up in one major category called ”lack of safety” including both patients and personnel. Several categories were identified as causes of error making, among those high workload is the most frequently mentioned cause. Nearly all of the causes can be traced to lacking in organization and/or management. The fact that errors occur are regarded as severe but human and inevitable. Several attitudes towards reporting errors were emerged from the data, for example regarding it as a tool of improvement work or finding scapegoats. The most common view was that errors are underreported and a number of factors regarding nurses' willingness to report the errors were found, for example severeness of the error, lack of time and doubt in follow up. Nurses wished to get feedback and information about reported errors. Inexperienced nurses were highly influenced by their senior colleagues concerning both error making and error reporting.
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Sousa, Fernanda Raphael Escobar Gimenes de. "A segurança de pacientes na terapêutica medicamentosa e a influência da prescrição médica. Análise da administração de medicamentos em unidades de clínica médica." Universidade de São Paulo, 2007. http://www.teses.usp.br/teses/disponiveis/22/22132/tde-13112007-155334/.

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Eventos adversos aos medicamentos e erros de medicação são muito comuns na prática assistencial e podem ocorrer em qualquer etapa do processo da terapia medicamentosa, contribuindo com a ocorrência de iatrogenias nos pacientes devido ao uso incorreto dos medicamentos ou a sua omissão. Neste contexto, encontramse as prescrições médicas que têm papel ímpar na prevenção do erro, uma vez que prescrições ambíguas, ilegíveis ou incompletas podem contribuir com a ocorrência destes eventos. Esta investigação teve o propósito de analisar a redação de prescrições médicas em unidades de clínica médica de cinco hospitais Brasileiros, comparar os dados obtidos entre os hospitais e propor recomendações para a prevenção de futuros erros de medicação. Tratou-se de um estudo descritivo que utilizou de dados secundários obtidos de uma pesquisa multicêntrica realizada em 2005. A população foi composta por 1.425 medicamentos administrados em discordância com a prescrição. Deste total, a administração de medicamentos em horário diferente do prescrito foi o mais freqüente nos cinco hospitais investigados, correspondendo a 76,0%. A análise da redação da prescrição revelou que 93,6% continham siglas e/ou abreviaturas, 10,7% não apresentavam dados do paciente, 4,3% omitiram informações sobre o medicamento e 4,2% apresentavam alterações e/ou suspensão do medicamento. Com a implantação do sistema computadorizado de prescrições, associada à prática da educação continuada e permanente dos profissionais envolvidos no sistema de medicação será possível minimizar os danos causados aos pacientes hospitalizados decorrentes da administração de medicamentos e, consequentemente, melhorar a qualidade do cuidado prestado.<br>Adverse events related to medicines and medication errors are very common in the health care assistance and can occur at any stage of the medication process, contributing with the occurrence of iatrogenys in the patients due to the incorrect use of medicines or its omission. In this context, we find medical orders which has uneven role in the prevention of medication error, once ambiguous, unreadable or incomplete medication order may contribute with the occurrence of these events. This study had the intention to analyze the writing of medical orders at internal medicine units of five Brazilian hospitals, to compare data between these hospitals and to consider recommendations for the prevention of future medication errors. This descriptive study used secondary data from a multicentric research occurred in 2005. The population was composed of 1.425 medications given in discordance with the medical order. From this total, the medication administration at different schedule administration time was the most frequent error found at the five hospitals investigated, corresponding to 76.0%. The analysis of the writing of the medical order disclosed that 93.6% contained acronyms and/or abbreviations, 10.7% did not present any information about the patient, 4.3% had omitted information about the medicine and 4.2% presented alterations and/or suspension of the medicine. With the implantation of the computerized prescription order entry system, associate to the practice of continued and permanent education of the involved professionals in the system of medication it will be possible to minimize the damage caused to the patients in the hospital deriving from the administration of medicine and, therefore, improve the quality of the care given.
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Gray, Michael David Thomas Robert Evans. "Data mining medication administration incident data to identify opportunities for improving patient safety." Auburn, Ala., 2009. http://hdl.handle.net/10415/1998.

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29

Sarac, Cakil. "The Association Between Organizational Culture And Individual Factors On Medical Practice." Master's thesis, METU, 2007. http://etd.lib.metu.edu.tr/upload/12608501/index.pdf.

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The aim of the present research was to investigate the relationships between patient safety culture within hospitals and individual factors on medical practice among physicians. A total of 240 physicians from ten different hospitals completed the Medical Practice Questionnaire, Hospital Survey on Patient Safety Culture, Maslach Burnout Inventory and Eysenck Personality Questionnaire Revised- Abbreviated Form. In order to assess frequency and types of medical errors, Medical Practice Questionnaire was developed by the author. Factor analysis of this Questionnaire demonstrated the existence of four subscales named as Patient Management/Information Delivery Errors, Execution Errors, Procedure Related errors and One Source Errors. ANOVA results revealed that males conduct more Procedure Related Errors than females. In support of the hypothesis, a number of differences observed on patient safety culture between types of institutions that public hospitals received lower scores on most of the safety dimensions. Regression analysis results revealed that personality dimensions and burnout levels were significantly related to types and frequency of errors. Considering significant predictors, while the extravert participants were found to report more Patient Management/Information Delivery, Execution and Procedure Related errors, Neurotics were found to report lower levels of errors on these three dimensions. Regression analysis of burnout levels showed that depersonalization were also associated with these three error dimensions.The level of depersonalization were found to increase the frequency of Patient Management/Information Delivery, Execution and Procedure Related Errors. The research findings however, did not support the assertion in a manner that safety culture dimensions were not found to have main effects on types of errors. The limitations of the current research and implications for further research were discussed.
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Dempsey, Jared. "Speaking up for safety : examining factors which influence nurses' motivation to mitigate patient risk by challenging colleagues in situations of potential medical error." Thesis, University of Aberdeen, 2011. http://digitool.abdn.ac.uk:80/webclient/DeliveryManager?pid=166094.

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Research suggests that individuals in the workplace might have a difficulty sharing their perceptions of risk and challenging unsafe behaviours. This thesis utilises The Theory of Planned Behaviour to examine which factors promote or hinder healthcare workers’ willingness to speak up and confront clinicians’ risky behaviours that could lead to medical error and hence endanger patient safety. The Theory of Planned Behaviour addresses issues surrounding intentions garnered from explicitly measured variables; in addition the thesis further sought to identify attitudes to speaking up using an implicit measure approach, and an approach using a computerbased, scenario-placement, reaction time methodology. Overall, the results of the thesis’s four studies suggest that nurses’ decisions to speak up are influenced by a variety of negative and positive beliefs. These beliefs include the effect speaking up has on the nurse speaking up and the patient; the support and actions of other nurses and medical personnel; and nurses feelings of confidence, knowledge and experience. Nurses also demonstrated a belief that they are more likely to speak up than their peers. Results also suggested that nurses speak up to individuals that they trust and distrust, indicating that trust and distrust are not polar opposites. The findings suggest that if speaking up is to be promoted practitioners need to address nurses’ negative beliefs—this is especially true with regard to fears about speaking up to authority figures. Nurses stated beliefs that they are more likely to speak up than their peers might be a result of presentation-bias or self-bias, if the cause is self-bias then training nurses to be more assertive and challenge risk might be made more difficult by nurses’ collective denial that they have any difficulties speaking up.
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Pereira, Francisco Gilberto Fernandes. "Erros de medicaÃÃo antibacteriana e a interface com a seguranÃa do paciente." Universidade Federal do CearÃ, 2015. http://www.teses.ufc.br/tde_busca/arquivo.php?codArquivo=15092.

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nÃo hÃ<br>A seguranÃa relacionada ao sistema de medicaÃÃo tem sido objeto de pesquisas recentes, principalmente, em relaÃÃo aos antibacterianos que possuem alta especificidade farmacolÃgica e podem ter sua aÃÃo prejudicada em detrimento de erros associados Ãs fases de preparo e administraÃÃo. Assim, o estudo teve como objetivo geral: Analisar os fatores comportamentais e ambientais envolvidos na ocorrÃncia de erros durante as etapas de preparo de administraÃÃo de antibacterianos. Trata-se de um estudo observacional, exploratÃrio e transversal, de natureza quantitativa, realizado entre agosto a dezembro de 2014 em Hospital da Rede Sentinela em Fortaleza. A amostra compreendeu 44% das doses de antibiÃticos das clÃnicas mÃdicas A e B, 108 e 157, respectivamente. A coleta de dados se deu em duas fases: a primeira para caracterizar o perfil sÃcio ocupacional dos profissionais de enfermagem; e a segunda para identificar as adequaÃÃes e inadequaÃÃes comportamentais e ambientais nas fases de preparo e administraÃÃo. Os dados foram organizados em tabelas e analisados por meio da estatÃstica descritiva e analÃtica. Todos os princÃpios bioÃticos foram respeitados, conforme aprovaÃÃo da pesquisa pelo Comità de Ãtica da Universidade Federal do CearÃ, protocolo nÃmero 660.897. Os resultados permitiram realizar as seguintes inferÃncias: a concretizaÃÃo do preparo e administraÃÃo dos antibacterianos foi realizada por tÃcnicos de enfermagem (100%), predominantemente do sexo feminino, na faixa etÃria de 31 a 40 anos, que concluÃram a formaÃÃo entre os Ãltimos dez a 20 anos e atuam na Ãrea por um perÃodo semelhante, no entanto, hà menos de dez anos na instituiÃÃo onde a pesquisa foi realizada. Sobre a influÃncia de fatores ambientais verificou-se que durante o preparo houve inadequaÃÃo em 136 observaÃÃes na variÃvel limpeza e em 187 na organizaÃÃo. A dimensÃo para o preparo foi inadequada na ClÃnica MÃdica A (3,8m2), e os itens iluminaÃÃo, temperatura e ruÃdo foram extremamente oscilantes nos trÃs turnos e nas duas clÃnicas, com mÃdias geralmente acima do recomendado. Quanto Ãs variÃveis comportamentais observou-se: fontes produtoras de interrupÃÃes em 145 doses durante o preparo, e, no entanto, nÃo foram estatisticamente significativas para aumentar o tempo de preparo dos antibiÃticos (p=0,776). Houve maior frequÃncia de nÃo-conformidades respectivamente nas clÃnicas A e B quanto ao itens: comportamento de utilizaÃÃo da prescriÃÃo 86 (79,6%) e 157 (100%); confirmaÃÃo do nome do paciente 68 (62,9%) e 142 (90,4%); e, monitoramento 84 (77,7%) e 82 (52,2%). Jà a ClÃnica MÃdica B apresentou maiores Ãndices de conformidade no controle do tempo de infusÃo 84 (53,5%) e checagem imediata 93 (59,2%). Fator que contribuiu para aumentar as chances de interaÃÃo medicamentosa foi a ausÃncia de diretrizes com informaÃÃes sobre o medicamento (p=0,003). A principal categoria de erro encontrada foi o erro de dose (157). Jà o antibiÃtico mais comumente utilizado foi a Piperaciclina + Tazobactan com 51 doses. Conclui-se que o ambiente de trabalho e o comportamento adotado pelos profissionais de enfermagem sÃo condiÃÃes que podem favorecer a ocorrÃncia de erros com antibiÃticos.
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Doyle, Mary Davis. "Impact of the Bar Code Medication Administration (BCMA) System on Medication Administration Errors." Diss., Tucson, Arizona : University of Arizona, 2005. http://etd.library.arizona.edu/etd/GetFileServlet?file=file:///data1/pdf/etd/azu%5Fetd%5F1093%5F1%5Fm.pdf&type=application/pdf.

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33

Star, Kristina. "Safety of Medication in Paediatrics." Doctoral thesis, Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-197323.

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Background: In paediatrics, the limited documentation to guide medication, the lack of suitable dosage forms, and the continuous development in childhood present a scenario where safety of medication is a particular challenge. Aim: To explore reported adverse drug reactions (ADRs) and the challenges in prescribing and administering medicines in paediatrics, in order to identify and suggest areas needing international surveillance within medication safety and improvement in the clinical setting. Methods: Four exploratory studies were conducted. Worldwide reporting of suspected ADRs (individual case safety reports, ICSR) with ages 0-17 years were examined overall. Twenty published case reports and ICSRs for adolescents, who developed a rare and incompletely documented ADR (rhabdomyolysis) during antipsychotic medicine use, were analysed in-depth. Prescribed doses of anti-inflammatory medicines were studied in a UK electronic health record database. Transcribed focus group interviews with 20 registered nurses from four paediatric wards in Sweden were analysed for factors that may promote or hinder safe medication practices. Descriptive statistics, multiple regression, and content analyses were used. Results: Although, skin reactions and anti-infective medicines were most frequently reported, and more reported in paediatric patients than in adults, medication errors and adverse reactions related to psychostimulant medicines were reported with increased frequency during 2005 to February 2010. The in-depth case analysis emphasised the need for increased vigilance following changes in patients’ medicine regimens, and indicated that ICSRs could contribute with clinically valuable information. Prescribed dose variations were associated with type of dosage form. Tablets and capsules were prescribed with a higher dose than liquid dosage forms. Six themes emerged from the interviews: preparation and administration was complex; medication errors caused considerable psychological burden; support from nurse colleagues was highly valued; unfamiliar medication was challenging; clear dose instructions were important; nurses handling medications needed to be accorded higher priority. Conclusions: Age-specific screening of ICSRs and the use of ICSRs to enhance knowledge of ADRs and medication errors need to be developed. Access to age-appropriate dosage forms is important when prescribing medicines to children. To improve medication safety practices in paediatric care, interdisciplinary collaborations across hospitals on national or even global levels are needed.
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34

Schnoor, Jörg, Christina Rogalski, Roberto Frontini, Nils Engelmann, and Christoph-Eckhardt Heyde. "Case report of a medication error by look-alike packaging." Universitätsbibliothek Leipzig, 2015. http://nbn-resolving.de/urn:nbn:de:bsz:15-qucosa-162688.

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Background: The acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing patient safety are LASA as well as high workload. Case presentation: A critical incident report of medication errors of opioids for postoperative analgesia by lookalike packaging highlights the LASA aspects in everyday scenarios. A change to a generic brand of medication saved costs of up to 16% per annum. Consequently, confusion of medication incidents occurred due to the similar appearance of the newly introduced generic opioid. Due to consecutive underdosing no life-threatening situation arose out of this LASA based medication error. Conclusion: Current recommendations for the prevention of LASA are quite extensive; still, in a system with a lump sum payment per case not all of these security measures may be feasible. This issue remains to be approached on an individual basis, taking into consideration local set ups as well as financial issues.
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35

Bertilsson, Sara, and Sanna Engman. "Sjuksköterskors erfarenheter av hinder vid avvikelserapportering : En allmän litteraturstudie." Thesis, Högskolan i Halmstad, Akademin för hälsa och välfärd, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:hh:diva-43461.

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Avvikelserapportering är en viktig del i sjuksköterskors arbete för att upptäcka brister inom verksamheten som kunnat medföra vårdskada och onödigt lidande för patienten. Trots regler och riktlinjer kring avvikelserapportering beslutar sjuksköterskor vid vissa tillfällen att inte rapportera en avvikelse. Syftet med litteraturstudien var att beskriva sjuksköterskors erfarenheter av hinder vid avvikelserapportering. En allmän litteraturstudie genomfördes med tio vetenskapliga artiklar med kvalitativ ansats. Därefter sammanställdes insamlade data genom innehållsanalys. För att beskriva sjuksköterskors erfarenheter av hinder vid avvikelserapportering identifierades fyra kategorier: bristande kunskap, brist på tid, brist på återkoppling och känslor av skam och rädsla. I resultatet framkom det att okunskap kring avvikelsehantering samt hög arbetsbelastning i förhållande till tidsbrist utgjorde ett hinder för sjuksköterskors avvikelserapportering. Sjuksköterskor uttryckte bristande återkoppling av avvikelser som en avgörande faktor i viljan att fortsätta rapportera avvikelser. Slutligen var känslor av skam och rädsla ett återkommande hinder för sjuksköterskorna. En ledning och verksamhet som kan skapa förutsättningar och hanterar dessa faktorer samt uppmuntrar till avvikelserapportering kan generera till fler avvikelserapporter. Samtidigt krävs fortlöpande kompetensutveckling och utbildning inom ämnesområdet för att sambandet mellan avvikelser och patientsäkerhet skall tydliggöras.<br>Error reporting is an important tool in detecting deficiencies and errors in healthcare services that could otherwise result in healthcare injuries and unnecessary suffering for patients. Despite rules and guidelines with requirements on error reporting, nurses sometimes decide not to report incidents. The aim of the literature study was to describe nurses' experiences of obstacles in error reporting. A general literature study was conducted with ten scientific articles with a qualitative approach. The collected data were then compiled through content analysis. Four categories of factors are identified: lack of knowledge, lack of time, lack of feedback and feelings of shame and fear. The results show that incident management and a high workload coupled with lack of time constitute an obstacle to nurses’ error reporting. Nurses express a lack of feedback on incidents as a decisive factor in the willingness to continue to report. Finally, feelings of shame and fear is a recurring obstacle for nurses. The study indicates that health systems management and leadership could generate higher levels of error reporting by paying close attention to these factors and encourage error reporting. At the same time, continuing professional development and training in the subject area for nurses are required to clarify the connection between incidents and patient safety
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Fabri, Peter J. "The validation of a methodology for assessing the impact of hybrid simulation training in the minimization of adverse outcomes in surgery." [Tampa, Fla.] : University of South Florida, 2007. http://purl.fcla.edu/usf/dc/et/SFE0002085.

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37

Miller, Kristi, Lisa Haddad, and Kenneth D. Phillips. "Educational Strategies for Reducing Medication Errors Committed by Student Nurses: A Literature Review." Digital Commons @ East Tennessee State University, 2016. https://dc.etsu.edu/ijhse/vol3/iss1/2.

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Medication errors cause harm, yet most of them are preventable (Institute of Medicine, 2006). Nurses spend 40% of their time administering medications; therefore they play a key role in the reduction of medication errors. Little empirical evidence has been collected about the effectiveness of nursing education in reducing medication errors committed by nursing students. Traditional educational interventions focus on the five rights of medication administration; however, the literature shows that interventions focused on instilling a culture of safety have a greater impact on reducing medication errors. The purpose of this article is to review educational strategies that have been implemented and tested in pre-licensure nursing programs to reduce medication errors committed by nursing students.
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38

Luz, Glaucia Ranquine. "Erro de medicação: a visão do enfermeiro neonatologista." Universidade do Estado do Rio de Janeiro, 2014. http://www.bdtd.uerj.br/tde_busca/arquivo.php?codArquivo=6681.

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O manejo da terapia medicamentosa em unidade de terapia intensiva neonatal é complexo e agrega inúmeras drogas. Nesse sentido, manter a atenção ao preparar e administrar corretamente os medicamentos é fundamental em todo o período de assistência ao recém-nascido. Portanto, faz-se necessário que os enfermeiros tenham o entendimento acerca do conceito do erro com medicação, para que possa identificá-lo, bem como os fatores contribuintes para sua ocorrência. Diante do exposto, esta pesquisa teve como objetivos: analisar o entendimento dos enfermeiros neonatologistas sobre o conceito do erro de medicação em uma unidade de terapia intensiva neonatal; conhecer na visão destes enfermeiros quais os fatores contribuintes para a ocorrência desse erro e discutir a partir desta visão como estes fatores podem afetar a segurança do neonato. Metodologia: trata-se de uma pesquisa qualitativa, do tipo descritiva. O cenário do estudo foi uma unidade de terapia intensiva neonatal de um hospital universitário, situado no município do Rio de Janeiro. Os sujeitos foram 14 enfermeiros entre plantonistas e residentes que atuavam no manejo da terapia medicamentosa. Para a coleta dos dados utilizou-se a entrevista semiestruturada, que foram analisadas através da análise de conteúdo de Bardin, emergindo 04 categorias: Diversos conceitos sobre erros de medicação; Fatores humanos contribuintes ao erro de medicação; Fatores ambientais contribuintes ao erro de medicação e Conhecendo como os fatores contribuintes ao erro podem afetar a segurança do paciente. Para as enfermeiras o erro de medicação significa errar um dos cinco certos na administração de medicamentos (paciente, dose, via, horário e medicamento certo), e este pode acontecer em alguma parte do sistema de medicação. Neste sentido, elas entendem que uma pessoa não pode ser considerada a única responsável pela ocorrência de um erro medicamentoso. Quanto aos fatores contribuintes ao erro de medicação elencaram aqueles relacionados à prescrição medicamentosa (letra ilegível, prescrição da dose e via incorretas), ao próprio profissional de enfermagem (como sobrecarga de trabalho, número reduzido de profissionais e os múltiplos vínculos empregatícios) e ao ambiente de trabalho (ambiente inadequado e estressante; conversas paralelas com os colegas e os ruídos no setor). Na visão das enfermeiras, os fatores contribuintes ao erro podem afetar a segurança do recém-nascido, levando às situações de danos a sua saúde, podendo trazer consequências clínicas e risco de óbito. O estudo aponta a necessidade de se buscar sistemas de medicação mais confiáveis e seguros. Neste sentido, é imprescindível desenvolver e implementar programas de educação centrados nos princípios gerais da segurança do paciente. Além disso, é de suma importância que as políticas públicas de saúde, direcionem ações para o aprimoramento de medidas na segurança do RN, do sistema de medicação e da cultura de segurança.<br>The management of drug therapy in a neonatal intensive care unit is complex and combines innumerous drugs. In this way, paying attention in the correct preparation and administration of drugs is fundamental in the whole period of assistance to the newborn infants. Therefore, is necessary that the nurses have the understanding of the concept of medication error, in order to be able to identify it as well as the contributing factors for its occurrence. In the presence of what was told, this research had as its aims: to analyze the understanding of the neonatal nurses of the concept of medication error in a neonatal intensive care unit; to apprehend from the perspective of these nurses, which contributing factor could affect the safety of the neonate. Methodology: it is a qualitative research with a descriptive design. The study setting was a neonatal intensive care unit from a university hospital in the city of Rio de Janeiro. The participants were 14 nurses, attending and resident physicians, which operate in the management of drug therapy. For the data collection a semi-structured interview was used, and then analyzed through the content analysis of Bardin, from what 04 categories emerged: different concepts of medication error; human contributing factors to the medication error; environmental contributing factors to the medication error; and understanding how the contributing factors to the medication error can affect the safety of the patient. For the nurses the medication error means making a mistake in one of the five rights in the medication administration (the right patient, the right dose, the right route, the right time, and the right drug), and this can happen in any part of the medication-use process. Thus, they understand that one person cannot be considered the only responsible for the occurrence of a medication error. About the contributing factors to the medication error it was listed those related to the medical prescription (illegible handwriting, dosage prescription, and incorrect route of administration), to the nurses (such as work overload, reduced number of workers and multiple jobs) and to the work environment (unsuitable and stressful environment, casual conversation with the co-workers and noises in the ward). From the nurses perspective the contributing factors to the error can affect the safety of the newborn, causing harm to its health, what could have clinical consequences and risk of death. The study points to the necessity of searching for medication-use processes more reliable and safer. In this way, to develop and to implement educational programs centered on the general principles of patient safety. Moreover, it is extremely important that the public health policies conduct actions for the improvement of measures for the safety of the newborn, the medication-use process, and the safety culture.
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39

Åberg, Fredrik. "Det värsta som kan hända : en studie om lex Maria-anmälda felexpedieringar på svenska apotek." Thesis, Linnéuniversitetet, Institutionen för kemi och biomedicin (KOB), 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:lnu:diva-68920.

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Det har gjorts forskning kring felexpedieringar på apotek, om deras typer, bakomliggande orsaker och potentiella åtgärder mot dem. En svensk författning, kallad lex Maria, säger att alla händelser som orsakat eller hade kunnat orsaka allvarliga vårdskador skall utredas av vårdgivaren och anmälas till Inspektionen för vård och omsorg (IVO). IVO tar ett beslut i ärendet, som tillsammans med händelsen sammanfattas i ett särskilt beslutsdokument. Syftet med detta examensarbete var att undersöka vilka kategorier av felexpedieringar av läkemedel och andra produkter på apotek som kan leda till allvarliga vårdskador, och att ta reda på vilka av dessa kategorier som är vanligast förekommande. Detta gjordes genom att läsa samtliga lex Maria-beslut som tagits av IVO under 2016 gällande händelser på apotek. Felen som beskrevs i besluten kategoriserades utifrån ett antal kategorier som bestämts utifrån tidigare forskning kring felexpedieringar. Sammanlagt lästes 39 beslut. I dessa förekom följande kategorier av felexpedieringar, ordnade med den vanligaste först: fel läkemedel, fel dos, missat att upptäcka och korrigera förskrivarfel, fel styrka, fel patient, obehörig patient, uteblivet läkemedel, etikett på fel läkemedel, skrivit fel i datorn, fel kvantitet, fel läkemedelsform, fel iordningställning, fel tid, fel på verbal information, inte expedierat författningsmässigt. Flera av besluten sattes i mer än en av kategorierna. De fyra första kategorierna utgjorde tillsammans 60 % av de identifierade felen. Examensarbetets resultat, som till stor del stämmer överens med resultat från tidigare forskning, indikerar att lex Maria-anmälningar från apotek kan vara representativa för felexpedieringar överlag, och inte bara de som kan leda till allvarliga vårdskador. Informationen om felexpedieringar som kom fram i studien kan vara av nytta för farmaceuter och annan apotekspersonal för att de ska undvika fel vid arbete på apotek. Examensarbetets upplägg och resultat ger många uppslag till framtida forskning om felexpedieringar, inklusive deras konsekvenser, bakomliggande orsaker, och potentiella åtgärder. Dessa studier skulle vara lättare att göra om det fanns mer centralt sammanställd och allmänt tillgänglig statistik och information om felexpedieringar i Sverige, inte bara om de som kan leda till allvarliga vårdskador.
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40

Pukk, Härenstam Karin. "Learning from patient injury claims : an assessment of the potential of patient injury claims to a safety information system in healthcare /." Stockholm, 2007. http://diss.kib.ki.se/2007/978-91-7357-153-1/.

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41

Solti, Imre. "Influence of Organizational, Operational, Financial AndEnvironmental Factors on Hospitals' Adoption of Computerized Physician Order Entry Systems for Improving Patient Safety: A Resource Dependence Approach." VCU Scholars Compass, 2006. https://scholarscompass.vcu.edu/etd/1283.

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This study examines specific organizational, operational, financial and environmental characteristics to identify factors that are associated with increased likelihood of hospitals' CPOE adoption decision in six rollout regions of the Leapfrog initiatives.Resource dependence theory provides theoretical basis for the study. The study is retrospective observational in design. Individual hospitals are the unit of analysis. The Leapfrog Group's 2002-survey collection serves the primary data source. Univariate statistical methods along with bivariate and ordinal logistic regression models are used to analyze the data. The models provided support for multiple hypotheses for both the adoption and early adoption decisions of study hospitals. The operational characteristics of ownership, in-house physician staff, case mix index and the environmental characteristic of HMO penetration rate had a positive effect on management's adoption decisions. The operational characteristic excess capacity, the organizational characteristic community orientation, the financial characteristic of operating income per admission, and the environmental characteristic of number of HMO contracts had a significant negative effect on CPOE adoption decisions.
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42

Rudström, Håkan. "Iatrogenic Vascular Injuries." Doctoral thesis, Uppsala universitet, Kärlkirurgi, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-194346.

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Iatrogenic vascular injuries (IVIs) and injuries associated with vascular surgery can cause severe morbidity and death. The aims of this thesis were to study those injuries in the Swedish vascular registry (Swedvasc), the Swedish medical injury insurance where insurance claims are registered, the Population and Cause of death registries, and in patient records, in order to explore preventive strategies. Among 87 IVIs during varicose vein surgery 43 were venous, mostly causing bleeding in the groin. Among 44 arterial injuries, only 1/3 were detected intraoperatively. Accidental arterial stripping predominated, with poor outcome. Four patients died, all after venous injuries. IVIs increased over time, and constitute more than half of the vascular injuries registered in the Swedvasc. Lethal outcome was more common (4.9%) among patients suffering IVIs than among non-iatrogenic vascular injuries (2.5%). Risk factors for death were age, diabetes, renal insufficiency and obstructive lung-disease. Fifty-two patients died within 30 days after IVI. The most common lethal IVIs were puncture during endovascular procedures (n=24, 46%), penetrating trauma during open surgery (11) and occlusion after compression (6). Symptoms were peripheral ischemia (n=19), external bleeding (14), and hypovolemic chock without external bleeding (10). Most died within two weeks (n=36, 69%). After &gt;2 weeks the IVI as a cause of death was uncertain. Among 193 insurance claims after vascular surgery during 2002-2007, nerve injuries (91) and wound infections (22) dominated. Most patients suffered permanent injuries, three died. Patients with insurance claims were correctly registered in the Swedvasc in 82%. In 32 cases of popliteal artery injury during knee arthroplasty symptoms were bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Only twelve injuries (38%) were detected intraoperatively. Patency at 30 days was 97%, but only seven (22%) patients had complete recovery. Six of those had intraoperative diagnosis of popliteal injury and immediate vascular repair. In conclusion, registration of IVIs is increasing and outcome is often negatively affected by diagnostic and therapeutic delay. Not all fatalities after IVIs are attributable to the injury itself. The most common causes of insurance claims after vascular surgery were nerve injuries, and 82% were correctly registered in Swedvasc.
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Serracant, Barrera Anna. "Errors en cirurgia general. Puntuació i detecció dels errors més rellevants. Pla d’actuació per a disminuir-ne la incidència." Doctoral thesis, Universitat Autònoma de Barcelona, 2018. http://hdl.handle.net/10803/666731.

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INTRODUCCIÓ: La seguretat del pacient està a l’orde del dia. Part d’aquesta es basa en aconseguir un sistema sanitari el més absent possible d’efectes adversos evitables (EA evitables), que són aquells secundaris a errors assistencials. Una de les metodologies establertes com a eina per promocionar la seguretat dels pacients és a través de l’existència de recollides d’efectes adversos (EA) o incidents i d’errors assistencials. A dia d’avui, manca un registre establert i estandarditzat, a nivell mundial, per a tal efecte. MATERIAL I MÈTODES: El treball de tesis doctoral presentat és dut a terme en el servei de cirurgia general i de l’aparell digestiu d’un hospital amb una capacitat de 466 llits d’aguts. S’ha realitzat un registre diari d’EA, EAE i la detecció d’errors assistencials. A través d’aquest registre s’han aïllat els errors assistencials. Es tracta d’una recollida de dades que s’acosta a l’ideal ja que és de caràcter prospectiu, voluntària, absenta de culpa o impune, anònima i independent dels estaments organitzatius de l’hospital. La limitació principal de la recollida de dades usada és la codificació dels EA, EA evitables i errors. Al no existir una font universal, els resultats obtinguts de treballar amb aquestes dades no són comparables ni generalitzables. RESULTATS I DISCUSSIÓ: S’han analitzat els 1006 errors assistencials detectats segons la classificació taxonòmica de la Joint Commission on Accreditation of Healthcare Organizations, que valora l’impacte de l’error, el tipus d’error, qui i a on es duu a terme i la causa de l’error. Aquesta classificació permet saber que la majora dels errors aïllats en el nostre centre tenen un impacte físic lleu o temporal, sense poder determinar l’impacte psicològic; la majoria són de tipus maneig; la majoria són comesos per personal mèdic i/o infermeria, a nivell de la planta d’hospitalització i a quiròfan; la majoria són de causa humana, secundaris a l’error en la realització de tasques de manera inconscient. Tot i així, es tracta d’una eina difícil d’utilitzar i els resultat de la seva aplicació és considerat poc útil. S’ha creat una eina per tal de detectar els errors assistencials més rellevants, que són els definits com a errors que compleixen tres característiques alhora: ser els més freqüents, els més greus i els de més difícil detecció. Aquesta eina s’anomena NPR modificat, extreta del mètode de l’Anàlisi Modal de Fallides i Efectes. Gràcies a aquesta eina s’ha calculat el número de risc de 1004 errors. El número de risc s’ha calculat a través de la multiplicació de 3 puntuacions determinades a partir de 3 ítems diferents: GxAxD (G: gravetat segons la classificació de Dindo-Clavien; A: incidència segons la incidència d’EA del servei durant més de 10 anys; D: probabilitat de detecció segons una escala subjectiva pre-determinada). A partir d’aquest número de risc s’han estratificat els errors i s’han detectat els errors més rellevants. Tot i el caràcter subjectiu de l’ítem D en el càlcul del número de risc, s’ha determinat una concordança inter-observador bona (índex kappa ponderat de 0,66). Un cop coneguts els errors rellevants més freqüents s’ha seleccionat, com a error diana, l’error relacionat amb la medicació habitual del pacient. S’han dissenyat unes mesures senzilles i de fàcil reproducció, s’han aplicat i s’ha objectivat una disminució de la incidència d’aquests errors diana. Aconseguint, per tant, disminuir la incidència d’EA evitables i una millora de la seguretat dels nostres pacients. CONCLUSIÓ: S’ha aconseguit disminuir la incidència d’EA evitables al detectar els errors més rellevants a través de la creació d’una nova eina.<br>INTRODUCTION: Patient safety has gained interest last decades. Patient safety focuses on avoiding adverse events (AE), especially preventable AE, which are related to a healthcarerelated error. Studies of patient safety emphasize the need to record and learn from the AE that occur at healthcare services. Data collection is one of the most widely used strategies. Nowadays, there is no worldwide established and standardized record for this purpose. MATERIAL AND METHODS: The study is carried out in the general and digestive surgery of a hospital with 466 acute beds. There has been a daily registration of AE, preventable AE and the detection of healthcare-related errors. The healthcare-related errors have been isolated through this record. Data collection is close to the ideal since it is prospective, voluntary, unpunished, anonymous and independent. The main limitation of the collected data used is the coding of AE, avoidable AE and healthcare-related errors. Since there is no universal source, the results obtained from working with these data are not comparable or generalizable. RESULTS AND DISCUSSION: We analysed 1006 healthcare-related errors according to the Joint Commission on Accreditation of Healthcare Organizations taxonomic classification, which evaluates the error impact, the type of error, who and where it is carried out and the cause of the error. This classification allows to know that most of our healthcare-related errors isolated have a slight or temporary physical impact, without being able to determine the psychological impact; the majority are patient management type; most are committed by medical personnel and / or nursing, at the level of the hospitalization plant and the operating room; Most are of human cause, secondary to an unconscious error. Even so, it is a difficult tool to use and the result of its application is considered to be very little useful. A tool has been created to detect the most relevant healthcare-related errors, which are defined as errors that fulfill three characteristics at the same time: being the most frequent, the most serious and the most difficult to detect. This tool is called modified NPR, originally from the Health Care Failure Mode Effects and Analysis. Thanks to this tool, the risk number of 1004 errors has been calculated. The risk number has been calculated through the multiplication of 3 scores determined from 3 different items: GxAxD (G: gravity according to the classification of Dindo-Clavien; A: incidence according to the EA incidence of the service for more of 10 years; D: probability of detection according to a predetermined subjective scale). From this risk number, errors have been stratified and the most relevant errors have been detected. The subjective character of item D (risk number calculation) has been checked and a good inter-observer concordance (kappa index of 0.66) was determined. Once known the most frequent healthcare-related errors, the error related to the usual medication of the patient has been selected as a target error. Some easy and simple measures have been designed, have been applied and a reduction in the incidence of these targeted errors has been objected. Achieving, therefore, reducing the incidence of preventable AE and an improvement in our patient safety. CONCLUSION: An avoidable AE incidence reduction has been achieved through the use of a new tool that detects the most relevant healthcare-related errors.
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44

Skaria, Rinku Saju. "Medical Errors in the Operating Room Attributable to Communication Breakdown and its Effects on Patient Safety." Thesis, The University of Arizona, 2014. http://hdl.handle.net/10150/321958.

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45

Roque, Rúben Rodrigues. "Erros pré-analíticos em anatomia patológica: prevalência, caracterização e consequências para a segurança do doente." Master's thesis, Escola Nacional de Saúde Pública. Universidade Nova de Lisboa, 2013. http://hdl.handle.net/10362/11270.

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RESUMO - A literatura disponível revela que a maioria dos erros relacionados com os exames anatomopatológicos ocorre na fase pré-analítica. Existem alguns estudos que quantificam e caracterizam estes erros mas, não foram encontrados artigos publicados sobre o tema em hospitais portugueses. Foi objetivo deste estudo determinar qual a prevalência e características dos erros pré-analíticos em amostras anatomopatológicas e as suas consequências para a segurança do doente. Analisaram-se 10574 casos de exames anatomopatológicos, de cinco hospitais da região de Lisboa e Vale do Tejo. Os serviços de anatomia patológica registaram e caracterizaram, durante vinte dias, erros detetados nas amostras anatomopatológicas com origem nos serviços requisitantes. Posteriormente os hospitais foram caracterizados quanto aos procedimentos relativos à fase pré-analítica. A prevalência de erros aferida foi de 3,1% (n=330), com um intervalo de confiança a 95% compreendido entre os valores 2,8% e 3,5%. Para além destes resultados destacam-se os seguintes pontos: i. As amostras histológicas têm 4,1% de prevalentes e as de citologia 0,9%; ii. Foram registados erros em 2,6% das requisições e em 1,5% dos contentores com as amostras; iii. A aceitação dos casos com erro é a ação mais frequente (66,9%), seguida pela devolução (24,4%) e retenção (8,7%); iv. Os hospitais com sistemas de notificação de erros e normas escritas para aceitação de amostras têm menor prevalência de erros; v. O impacte dos erros detetados na segurança dos doentes é difícil de determinar, sendo que os mais críticos relacionam-se com amostras devolvidas a fresco, meio de colheita inadequado ou com amostras danificadas. Este estudo permitiu determinar a prevalência e caracterizar os erros pré-analíticos envolvendo amostras anatomopatológicas em hospitais portugueses. Reflete a dimensão atual do problema e efetua recomendações para a sua mitigação. A prevalência de erros encontrada é inferior às publicadas em estudos semelhantes.<br>ABSTRACT - Several studies showed that most errors related with anatomic pathology analysis occur in the pre-analytical phase. There are some studies that quantify and characterize these errors, none, to our best knowledge, were made in portuguese laboratories. The objective of this study was to determine the prevalence and characteristics of pre-analytical errors in anatomic pathology samples, and their implications for patient safety. In this investigation 10574 cases for anatomic pathology examination were analyzed in five hospitals in the region of Lisbon. The pathology laboratories recorded and characterized, for twenty days, errors detected in samples originating in services requesting these examinations. Subsequently, procedures for pre-analytical phase were characterized for each hospital. The prevalence of error obtained was 3.1% (n=330). The 95% confidence interval lies between the values 2.8% and 3.5%. Other results were: i. Errors occur in 4.1% of histology specimens and 0,9% of cytology specimens; ii. Errors were found in 2.6 % of the requisition forms and in 1.5% of samples containers; iii. Acceptance of cases with error is the action most frequent (66.9%), followed by rejection (24.4%) and retention (8.7%); iv. Services with error reporting systems and written standards for acceptance of samples have lower prevalence of errors; v. The impact of these errors on patient safety are difficult to determine, the most critical are related to rejection of non-fixed specimens, inappropriate fixative or damaged samples. This study allowed us to determine the prevalence and characterize the pre-analytical errors involving anatomic pathology samples in portuguese hospitals, shows the size of the problem and makes recommendations for their mitigation. The prevalence of errors found is lower than those published in similar studies.
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46

Oliveira, Junior Maurício Lauro de. "Segurança do paciente: análise da adequação da prescrição em um hospital de ensino em relação ao protocolo do Ministério da Saúde." Niterói, 2017. https://app.uff.br/riuff/handle/1/5004.

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Submitted by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-10-26T11:46:46Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO MAURICIO OLIVEIRA JUNIOR.pdf: 1023259 bytes, checksum: 4ed2457b73e6102347a2ed9685dc851c (MD5)<br>Approved for entry into archive by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-10-26T11:47:08Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO MAURICIO OLIVEIRA JUNIOR.pdf: 1023259 bytes, checksum: 4ed2457b73e6102347a2ed9685dc851c (MD5)<br>Made available in DSpace on 2017-10-26T11:47:08Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO MAURICIO OLIVEIRA JUNIOR.pdf: 1023259 bytes, checksum: 4ed2457b73e6102347a2ed9685dc851c (MD5) Previous issue date: 2017<br>Universidade Federal Fluminense. Centro de Ciências Médicas. Hospital Universitário Antônio Pedro<br>A primeira etapa da chegada do medicamento até o paciente se inicia através da elaboração da prescrição, sendo um dos pontos críticos e que influencia diretamente possíveis erros em etapas posteriores. No Brasil, através da portaria 529 de 2013 do Ministério da Saúde fica instituído o Programa Nacional de Segurança do Paciente que tem como objetivo estimular a cultura de segurança e para isso determina algumas ações e estratégias. Ainda em 2013 é lançado uma coleção de 6 protocolos de segurança, ente eles o de prescrição, uso e administração de medicamentos, que traz orientação para minimização do risco quanto ao processo de utilização do medicamento dentro de estabelecimentos de saúde. O presente estudo teve como objetivos analisar a adequação das prescrições em um hospital universitário frente ao protocolo, analisando para tal os diferentes setores e quantificando os tipos de prescrições existentes. Para tanto foi feito um estudo retrospectivo, onde foram analisadas 2006 prescrições, totalizando 20255 medicamentos onde a média foi de 10,10 ± (5,10) medicamentos por prescrição. Dessas, 100% (n=2006) tiveram algum tipo de erro, 47,6% (n=954) tiveram antibióticos prescritos e 87,5% (n=1755) de injetáveis prescritos. Dos medicamentos analisados 79,2% (n=16049) foram prescritos pelo nome genérico e 96,4% (n=19524) constavam na lista de padronização do hospital. Quanto ao tipo de prescrições 73,8% (n=1480) foram digitadas, 16,7% (n=336) foram manuscritas e 9,5% (n=190) foram mistas, sendo que 5,98% (n=120) foram consideradas ilegíveis (n=6), ou parcialmente ilegíveis (n=114) e desse total 94,2% (n=112) foi proveniente das prescrições manuscritas o que mostra uma associação entre a legibilidade e o tipo de prescrição. É importante ressaltar que a busca pela qualidade e segurança é um processo constante, devendo estar sempre em evolução na instituição, e diante do exposto, a identificação das inadequações, pode contribuir com o direcionamento das ações internas para minimizar os riscos aos pacientes, assim como servir como base para estudos futuros<br>The first stage of the arrival of the drug to the patient begins with the elaboration of the prescription, being one of the critical points and that directly influences possible errors in later stages. In Brazil, starting in 2013, the National Patient Safety Program (PNSP) is set up in order to stimulate the safety culture, and for this purpose it determines some actions and strategies. Also in 2013, a collection of 6 safety protocols, including prescription, use and administration of medicines, is launched, which provides guidance on risk minimization regarding the process of drug use within health facilities. The present study had as objectives to analyze the adequacy of the prescription of a university hospital regarding such protocol, analyzing the different sectors and quantifying the types of prescriptions available. For that, a retrospective study was carried out, where 2006 prescriptions were analyzed and a total of 20255 drugs were used, where the average was 10.10 ± (5.10) prescription medications. Of these, 100% (n = 2006) had some type of error, 47.56% (n = 954) had prescribed antibiotics and 87.49% (n = 1755) of prescribed injectables. Of the drugs analyzed, 79.23% (n = 16049) were prescribed by the generic name and 96.39% (n = 19524) were on the hospital standardization list. Regarding the type of prescriptions 73.8% (n = 1480) were entered 16.7% (n = 336) were handwritten and 9.5% (n = 190) were mixed, with 5.98% (n=120 were considered illegible (n = 6) or partially illegible (n = 114) and 94.2% (n = 112) came from handwritten prescriptions, which shows an association between readability and type of prescription. It is important to emphasize that the search for quality and safety is a constant process, and should always be evolving in the institution and before the exposed the identification of the inadequacies, can contribute with the direction of the internal actions to minimize the risks as well as to serve as basis for studies Futures
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47

Fusco, Lori A. "Medication Safety Competence of Undergraduate Nursing Students." Case Western Reserve University Doctor of Nursing Practice / OhioLINK, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=casednp158558798038964.

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48

Gallo, Paula Furquim. "Tecnologia em saúde e segurança na administração de medicamentos em pacientes hospitalizados: uma revisão integrativa." Universidade de São Paulo, 2015. http://www.teses.usp.br/teses/disponiveis/22/22134/tde-08032016-153622/.

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Eventos Adversos (EA) são recorrentes nas instituições de saúde e incluem os erros de administração de medicamentos, que podem acontecer nas mais diversas fases do processo dessa administração, da prescrição ao monitoramento do paciente. Atualmente, busca-se pela diminuição de danos desnecessários a um nível mínimo dentro dos limites aceitáveis por meio de ferramentas tecnológicas. Frente ao exposto objetivou-se buscar e analisar as evidências científicas, disponíveis na literatura nacional e internacional, a respeito do uso da tecnologia na segurança dos pacientes hospitalizados, considerando a administração de medicamentos. Utilizou-se a Prática Baseada em Evidências (PBE) como referencial teórico para o presente estudo. Realizou-se a Revisão Integrativa da literatura nas bases de dados CINAHL, LILACS e MEDLINE; a questão norteadora da pesquisa foi: Quais intervenções que utilizam tecnologia têm sido empregadas aos pacientes hospitalizados com o intuito de aumentar a segurança, no que diz respeito a administração de medicamentos? Totalizou-se 10 estudos, publicados no período de janeiro de 2010 a dezembro de 2014, que atendiam aos critérios de inclusão. Após a análise dos dados foi possível identificar que o uso da tecnologia na saúde envolveu: Bomba de Infusão \"Inteligente\"; Sistema de Alertas e Ferramentas de Apoio à Decisão Clínica; Código de Barras e Sistema Eletrônico de Registro de Medicamentos; Prescrição Médica Eletrônica e Bases de Dados Computadorizada. Verificou-se que a segurança do paciente, nos estudos em questão, foi incrementada com a utilização de uma ou mais ferramentas tecnológicas, resultando em diminuição dos erros de administração de medicamentos e favorecendo a segurança aos pacientes<br>Adverse Events (AE) are recurrent in health institutions and include medication administration errors that can occur in several stages of the process of this administration, since the prescription until the patient monitoring. Currently, they seek the reduction of unnecessary damage to a minimum within acceptable limits through technological tools .Based on this, the objective was to seek and analyze the scientific evidence available in the national and international literature regarding the use of technology in the safety of hospitalized patients considering drug administration. The Evidence-Based Practice (EBP) was used as the theoretical framework for this study. An Integrative Literature Review was performed in CINAHL, LILACS and MEDLINE databases; the guiding research question was: What interventions using technology have been employed to hospitalized patients in order to increase security, as regards the administration of medication? It amounted to 10 studies published from January 2010 to December 2014, which matched to the inclusion criteria. After analyzing the data it was observed that the use of health technology involved: Smart Pump; System Alerts and Clinical Decision Support Tools; Bar Code and Electronic System for Drug Registration; Computerized Physician Order Entry and Computerized Databases. It was found that the safety of the patient, in these studies concerned, was increased with the use of one or more technological tools, resulting in decreased drug administration errors and favoring the safety of the patient
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49

Aldhwaihi, Khaled Abdulrahman. "Types and contributing factors of dispensing errors in hospital pharmacies." Thesis, University of Hertfordshire, 2015. http://hdl.handle.net/2299/17119.

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Background: Dispensing medication is a chain of multiple stages, and any error during the dispensing process may cause potential or actual risk for the patient. Few research studies have investigated the nature and contributory factors associated with dispensing errors in hospital pharmacies. Aim: To determine the nature and severity of dispensing errors reported in the hospital pharmacies at King Saud Medical City (KSMC) hospital in Saudi Arabia, and at Luton and Dunstable University Hospital (L&D) NHS Foundation Trust in the UK; and to explore the pharmacy staff perceptions of contributory factors to dispensing errors and strategies to reduce these errors. Materials and Methods: A mixed method approach was used and encompassed two phases. Phase I: A retrospective review of dispensing error reports for an 18-month period at the two hospitals. The potential clinical significance of unprevented dispensing errors was assessed. Data was analysed using descriptive statistics in SPSS and A Fisher's test was used to compare the findings. Phase II: Self-administered qualitative questionnaires (open-ended questions) were distributed to the dispensary teams in KSMC and L&D hospitals. Content analysis was applied to the qualitative data using NVivo qualitative analysis software. Result: Dispensing the wrong medicine or the incorrect strength were the most common dispensing error types in both hospitals. Labelling errors were also common at the L&D pharmacy dispensary. The majority of the unprevented dispensing errors were assessed to have minor or moderate potential harm to patients. Look-alike/sound-alike medicines, high workload, lack of staff experience, fatigue and loss of concentration during work, hurrying through tasks and distraction in the dispensary were the most common contributory factors suggested. Ambiguity of the prescriptions was a specified factor in the L&D pharmacy, while poor pharmacy design and unstructured dispensing process were specified contributory factors in the KSMC pharmacy. Conclusions: Decreasing distractions and enhancing the pharmacy design and the dispensing workflow are necessary to reduce dispensing errors. Furthermore, monitoring and reporting errors and educating the dispensary team about these errors is also needed. Automation and e-prescribing systems may improve dispensing efficiency and safety. The findings of this study reemphasise the fact that dispensing errors are prevalent in hospital pharmacies. Efficient interventions need to be implemented to mitigate these errors.
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50

Cosic, Matea, and Albulena Uka. "Läkemedelshanteringsprocessen : Inom äldreomsorgen hos Socialförvaltningen." Thesis, Tekniska Högskolan, Högskolan i Jönköping, JTH, Industriell organisation och produktion, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:hj:diva-31736.

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Purpose The purpose of this study is to conduct a survey of the Process of Drug Management in elderly care from when a drug is prescribed to when it is discarded. The purpose also includes to investigate how the various activities are linked to each other and to identify errors for the patient safety. In order to fulfil the purpose, two issues have been formulated: 1. What activities are currently in the Process of Drug Management in elderly care? 2. What deviations can occur in the Process of Drug Management and can be errors for the patient safety? Method In order to fulfil the purpose, a case study was made on the Social Service of the elderly care. Empirical data has been collected through interviews, observations and questionnaires. Further on the empirical data has been analysed and compared with the theoretical framework in order to achieve the purpose of the study. Findings The five main activities which have been identified in the Process of Drug Management are Prescription, Requisition and Check, Storage, Readying and Administration and finally Follow-up. In order to identify errors for the patient safety in the different activities, a value stream map has been designed where the risk has been placed and later on discussed. Errors for the patient safety exist among other factors such as due to lack in communication and information, human factors such as stress, lack of sleep, cultural shocks and lack of motivation for work. The study also shows that there is lack of responsibility among the various operators in the process. Implications The process of drug management in elderly care is a problem area because of its complexity where deviations often occur which results in errors for the patient safety. The guidelines within elderly care are about the same throughout Sweden, which leads to the fact that development in order to prevent errors of the patient safety can take place within other organizations. Deviations are unfortunately making an impact in the first activity, “Prescription”, which contributes to additional deviations in the following activities. In order to improve the patient safety, developing the quality within the organization and within the Process of Drug Management should be a priority. Limitations The aim of the study was to gain a deeper insight into the process of Drug Management and identify errors for the patient safety. Wishful thinking is to investigate several more units in order to get a clearer picture of the problem area from different angles.<br>Syfte Syftet med denna studie är att göra en kartläggning av läkemedelshanteringsprocessen inom äldreomsorgen från det att ett läkemedel skrivs ut till att det sedan kasseras. Syftet omfattar även att undersöka hur olika aktiviteter är kopplade till varandra och att identifiera patientsäkerhetsriskerna. För att uppfylla detta syfte har två frågeställningar formulerats: 1. Vilka aktiviteter ingår idag i läkemedelshanteringsprocessen inom äldreomsorgen? 2. Vilka avvikelser kan förekomma i läkemedelshanteringsprocessen och som kan vara patientsäkerhetsrisker? Metod För att uppnå ett resultat gjordes en fallstudie på socialförvaltningens äldreomsorg. Empirisk data har samlats in med hjälp av intervjuer, observationer och enkäter. Empirin har sedan analyserats och jämförts med det teoretiska ramverket för att uppnå studiens syfte. Resultat De fem olika huvudaktiviteter som har identifierats i läkemedelshanteringsprocessen är ordination, rekvisition och kontroll, förvaring, iordningsställande och administrering och till sist uppföljning. För att kunna identifiera patientsäkerhetsriskerna i de olika aktiviteterna har en kartläggning av flödet utförts. De identifierade riskerna placerades sedan ut i processflödet och diskuterades. Patientsäkerhetsriskerna förekommer bland annat på grund av kommunikations- och informationsbrister, mänskliga faktorer så som stress, sömnbrist, kulturkrockar samt motivationsbrist i arbetet. Studien visar även att det förekommer brister i ansvarsfördelningen hos de olika aktörerna i flödet. Implikationer Det uppstår många problem i läkemedelshanteringsprocessen inom äldreomsorgen på grund av dess komplexitet. När avvikelser förekommer i processen uppstår patientsäkerhetsrisk. Socialstyrelsen och landstingen reglerar äldreomsorgen med liknade riktlinjer i hela landet vilket kan leda till att ett förbättringsarbete i en organisation kan appliceras inom andra organisationer för att undvika patientsäkerhetsrisker. Att implementera en kvalitetsutveckling i form av ett förbättringsarbete i läkemedelshanteringsprocessen kan bidra till en ökad patientsäkerhet. Begränsningar Målet med studien var att få en djupare inblick i läkemedelshanteringsprocessen samt att identifiera patientsäkerhetsrisker. Önskvärt hade varit att undersöka flera enheter inom samma organisation för att få en tydligare bild av problemområdet från olika delar i organisationen och därmed flera olika perspektiv på vilka problem som kan uppstå i processen.
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