Adverse Events In Health Care Research Articles

Psychosocial and behavioral therapy in conjunction with medication for opioid use disorder: Patterns, predictors, and association with buprenorphine treatment outcomes

IntroductionCurrent evidence indicates that buprenorphine is a highly effective treatment for opioid use disorder (OUD), though premature medication discontinuation is common. Research on concurrent psychosocial and behavioral therapy services and related outcomes is limited.The goal of this study was to define patterns of OUD-related psychosocial and behavioral therapy services received in the first 6 months after buprenorphine initiation, identify patients' characteristics associated with service patterns, and examine the course of buprenorphine treatment, including the association of therapy with medication treatment duration. MethodsWe analyzed 2013–2018 MarketScan Multi-State Medicaid claims data. The sample included adults aged 18–64 years at buprenorphine initiation with treatment episodes of at least 7 days (n = 61,976). We used group-based trajectory models to define therapy service patterns and multinomial logistic regression to identify pre-treatment patient characteristics associated with therapy trajectories. Multinomial propensity-score weighted Cox proportional hazards regression estimated time to buprenorphine discontinuation and unweighted Cox proportional hazards models estimated risk of adverse health care events during buprenorphine treatment (all-cause and opioid-related inpatient and emergency department services, overdose treatment). ResultsWe identified three trajectories of psychosocial and behavioral therapy services: none (73.8%), low-intensity (17.2%), and high-intensity (9.0%). Compared to those without therapy, low-intensity and high-intensity service patterns were associated with behavioral health diagnoses and medical treatment for opioid overdose in the baseline period prior to buprenorphine initiation. The hazard of buprenorphine discontinuation was significantly lower for low-intensity (HR = 0.55; 95% CI, 0.54–0.57) and high-intensity (HR = 0.71; 95% CI, 0.67–0.74) therapy groups compared to those without therapy services. Yet patients in the high-intensity therapy group had increased risk of opioid-related health care events during buprenorphine treatment, including medical treatment for opioid overdose (HR = 1.29; 95% CI, 1.01–1.64). ConclusionMost patients received little or no OUD-related psychosocial and behavioral therapy after initiating buprenorphine treatment. Patients who received therapy had characteristics indicating greater treatment needs as well as more complex treatment courses. Concurrent therapy services may help to address premature buprenorphine discontinuation, particularly for patients with high-risk clinical profiles; however, future prospective research should determine whether therapy is effective for extending buprenorphine retention.

Effectiveness and sustainability of the WHO multimodal hand hygiene improvement strategy in the University Hospital Bouak\xe9, Republic of C\xf4te d'Ivoire in the context of the COVID-19 pandemic

IntroductionThe most frequent adverse events in healthcare are healthcare-associated infections, whose burden is highest in resource-limited settings. In addition, low resource settings often lack Hand Hygiene (HH) knowledge and reliable supply to disinfectant, a necessity emphasized by the past West African Ebola Epidemic and the ongoing COVID-19 pandemic. PASQUALE aims to increase patient safety by introducing the WHO multimodal HH strategy in the University Hospital Bouaké, Côte d’Ivoire.MethodsAssessment of HH knowledge, perception and compliance was performed 12 months before, right after the intervention and at a ten months interval using questionnaires for knowledge and perception and direct observation for compliance. The intervention consisted of a HH training and the introduction of local production of alcohol-based hand-rub. In the absence of a control group, the effectiveness of the intervention was assessed by a before-and-after study.ResultsBaseline knowledge score was 14/25, increased significantly to 17/25 (p < 0.001) upon first and decreased to 13/25 in second follow-up. Compliance showed a significant increase from 12.7% to 36.8% (p < 0.001) in first and remained at 36.4% in second follow-up. Alcohol-based hand-rub production and consumption almost doubled after first confirmed COVID-19 case in Côte d’Ivoire.ConclusionThe WHO HH improvement strategy is an effective and pandemic-adaptable method to increase long-term HH compliance. This study emphasizes that the implementation of the strategy to build a robust system is of utmost importance.

Governance for Patient Safety: A Framework of Strategy Domains for Risk Management.

Adverse events in healthcare are primarily due to system failures rather than individuals. Risk reduction strategies should therefore focus on strengthening systems, bringing about improvements in governance, and targeting individual practices or products. The purpose of this study was to conduct a scoping review to develop a global framework of management strategies for sustaining a safety-oriented culture in healthcare organizations, focusing on patient safety and the adoption of good safety-related practices. We conducted a search on safety-related strategies in 2 steps. The first involved a search in the PubMed database to identify effective, broadly framed, cross-sector domains relevant to clinical risk management strategies in healthcare systems. In the second step, we then examined the strategies adopted by running a scoping review for each domain. Our search identified 8 strategy domains relevant to patient safety: transformational leadership, patient engagement, human resources management quality, innovation technology, skills certification, education in patient safety, teamwork, and effective communication. This scoping review explores management strategies key to healthcare systems' efforts to create safety-oriented organizations. Improvement efforts should focus particularly on the domains identified: combined together, they would nurture an overall safety-oriented culture and have an impact on preventable adverse events.

Healthcare-associated infections in the surgical setting: How to prevent and treat them

Healthcare-associated infections (HAIs) are infections that patients can get while receiving medical care. These infections are often preventable and represent one of the most common adverse events in health care. Patients with medical devices (central lines, urinary catheters and ventilators) or who undergo surgical procedures are at risk of acquiring HAIs. The most common HAIs are surgical site infections, urinary tract infections, pneumonia, bloodstream infections and Clostridioides difficile infections. This review takes into consideration the aspects of both prevention and treatment of the most common HAIs and the aspects related to a possible behavior change among health-care workers in the surgical setting.

Controlling the Uncontrollable: Patient Safety and Medication Management From the Perspective of Registered Nurses in Municipal Home Health Care

Most adverse events in health care are related to medication management and they are almost always preventable. Increased knowledge of patient safety related to medication management in home health care is an urgent issue to provide safe care for all patients regardless of where the health care takes place. This study explored patient safety within medication management in municipal home health care. Vignettes were used as stimulus during qualitative interviews with registered nurses. Three main themes with related subthemes were identified as challenges to patient safety within medication management in home health care: (1) challenges to information transfer, (2) challenges related to delegation, and (3) challenges of advanced medical treatments in the home. The issue of transfer of information permeated our findings. Coordinating medications, delegating tasks, along with more advanced care require clear communication between care providers to be compatible with patient safety within medication management in home health care.

Desirable Non-Technical Skills for Paramedicine: A Delphi Study

Introduction Non-technical skills (NTS) are a causative factor in many adverse events in healthcare. Although this is the case, NTS have been explored in the paramedic literature in isolation, with no current list of desirable paramedic NTS within the literature. This study aims to gather consensus opinions on which NTS are considered important for an operational paramedic. Methods A modified Delphi technique was utilised to achieve the study aim. Participants were required to rate each NTS on a ten-point Likert scale. For an NTS to reach a consensus, it was required to be rated within two Likert scale points of the mode score by 80% of participants. Results There were 17 participants in the Delphi study (n=17). The study ran for a total of three rounds, and 33 of 35 NTS reached consensus. The top five NTS were communication, problem-solving, situational awareness, professionalism, and interpersonal skills. Two NTS did not reach consensus; these were empathy and cognitive offloading. These two did not reach consensus despite being rated six or higher by all participants. Conclusions The results of this Delphi study have created the first expert-based list of important NTS for a paramedic. This will have significant implications for the paramedic field as we now have a foundation of which NTS is vital for a paramedic to complete their duties. These results can begin to form the foundation of a future paramedic behavioural marker systems will improve paramedic performance and ultimately lead to improved patient safety.

A Performance Improvement Project to Improve Hand-off Communication Documentation within the Surgical Services Department

Over 80% of adverse events in healthcare are due to miscommunication. To improve patient safety, The Joint Commission recommended the use of standardized hand-off communication tools in 2012. One acute care hospital in Southeast Florida implemented standardized handoff reports in 2014 with few revisions since that time. The COVID-19 pandemic brought to light additional critical information was needed to keep patients and staff safe, such as laboratory results indicating the need for isolation precautions. The nurses within the surgical services noticed this critical information was not sufficiently included in the handoff report. The lack of this information led to unnecessary staff exposures and delays in treatment. The quality improvement nurse noticed a significant drop in the use of the standardized hand-off report form used during this time. This drop in compliance lead to concerns for patient and staff safety.

A review of patient safety communication in multicultural and multilingual healthcare settings with special attention to the U.S. and Canada

Abstract Purpose The present work aims to raise awareness of the issue of patient safety communication in multicultural and multilingual healthcare settings and to present strategies on how to overcome emerging cultural and language barriers and enable healthcare providers to reduce the risk of miscommunication, prevent inequalities and disparities, and provide their patients with safe and quality care. It also strives to present the policies and measures the United States and Canada have implemented and the strategies U.S. experts have developed to advance effective communication between provider and patient. Methods The literature review was conducted on academic works and publications by health associations, institutes of health, and government departments in topics such as adverse events in health care and strategies to reduce cross-cultural miscommunications and on guides for hospitals. Results/Discussion Cultural diversity in a patient population, language barriers, and a lack of effective communication can impose an increased threat on an individual's health. In order to radically decrease the incidence of adverse events, policies and systems on how to manage multinational and multilingual medical environments should be created at a national level. Cultural competence is also key to delivering care that meets patients' social and cultural needs; furthermore, developing a language access plan and providing language assistance (interpretation, translation) for those in need can greatly contribute to providing quality care. Conclusions Clear communication is key to quality care and patient safety in multicultural and multilingual healthcare environments, but to significantly reduce the incidence of adverse events, policies and systems should be created at a national level.

Inpatient Subspecialty Consultations: A New Target for High-Value Pediatric Hospital Care?

Inpatient Subspecialty Consultations: A New Target for High-Value Pediatric Hospital Care?

Association of Opioid Consumption Profiles After Hospitalization With Risk of Adverse Health Care Events

Although better pain management has guided policies for opioid use over the past few decades, evidence is limited regarding how patterns of use are associated with the risk of potentially avoidable opioid-related adverse events. To estimate the risk of harms associated with opioid dose and duration of use, and to ascertain whether the risk is modified by treatment indication and age. This ad hoc cohort study followed up patients who were enrolled in a cluster randomized trial of medication reconciliation between October 1, 2014, and November 30, 2016, 12 months after they were discharged from the McGill University Health Centre in Montreal, Quebec, Canada. To be eligible for this study, patients needed to have filled at least 1 opioid prescription 3 months after discharge. Patients with a history of using methadone or buprenorphine were excluded. Data analyses were performed between February 1, 2019, and February 28, 2020. Time-varying measures of opioid use included current use, daily morphine milligram equivalent (MME) dose, cumulative and continuous use duration, and type of ingredients in prescription opioids used. Hospitalization records, dispensed prescriptions records, and postdischarge interviews were used to evaluate adherence to the opioid prescriptions after discharge. Opioid-related emergency department visits, hospital readmissions, or all-cause death. Outcomes were ascertained using provincial medical services claims and hospitalization databases. Of 3486 participants in the cluster randomized trial (mean [SD] age of 69.6 [14.9] years; 2010 men [57.7%]), 1511 patients were included in this ad hoc cohort study. Among those with at least 1 opioid dispensation, 241 patients (15.9%) experienced an opioid-related emergency department visit, hospital readmission, or death. Results from marginal structural Cox proportional hazards regression models showed more than a 2-fold increase in the risk of opioid-related adverse events associated with a cumulative use duration of more than 90 days (adjusted hazard ratio, 2.56; 95% CI, 1.25-5.27) compared with 1 to 30 days. A 3-fold risk increase was found with a mean daily dose higher than 90 MME (adjusted hazard ratio, 3.51; 95% CI, 1.58-7.82) compared with 90 MME or lower. This study found an association between risk of adverse health care events and higher opioid doses and longer treatment duration. This finding can inform policies for limiting opioid duration and dose to attenuate the risk of avoidable morbidity.

An integrated literature review on cultural management systems and patient safety

The incidence of adverse events in healthcare is a global problem with negative consequences for all stakeholders including patients, their family members, health professionals and the government. Patient safety and patient safety culture lie at the heart of all adverse events within healthcare settings. The culture of an organization determines its approach to problem solving and determines how individuals within that setting work; this is also true for patient safety culture and the reduction of adverse events within healthcare organizations. The aim of this study was to assess, identify and have a better understanding of the importance of patient safety culture within the healthcare organization and to create insights on the impact of cultural management systems regarding patient safety. The research method of this study is an integrated literature of the patient safety culture and perspectives of healthcare workers, assessed using the Modified Stanford Instrument (MSI) and Manchester Patient Safety Framework (MaPSaF). Analysis of the data revealed that health professionals working in the same organizations have differing opinions on the same topic; therefore, there is need for open communication and a systematic approach to establishing the right safety culture within healthcare organizations. In conclusion, establishing the right culture and having systematic ways of measurement enable improvements and the ability of organizations to learn from their mistakes. There is paucity of data with respect to the use of these tools in the respective countries (Canada and United Kingdom) even though the tools are the national tools established through rigorous research. Therefore, a study of MaPSaF in New Zealand was also analyzed. There is need for further research and publications to enable learning on patient safety, which will reduce the incidence of adverse events and associated consequences in healthcare organizations.

Perceptions of Long-Term Care Nurses and Nursing Assistants about Communication Related to Residents’ Care

<strong>Context:</strong> Research shows ineffective healthcare team communication is linked to sentinel and adverse healthcare events (Gooch 2016; Robson 2016; Wagner et al. 2018). Long-term care (LTC) facilities face unique challenges of caring for frail elderly (Young 2003), who are at increased risk for cascading negative health events beginning with functional decline (Lakshmi 2014). Frequent, effective nursing team communication is essential to providing safe care for these individuals. (Castle 2007; Cortes et al. 2004; Foulkes 2011; Griffin et al. 2016; Howe 2013; Madden et al. 2017; Siegel &amp; Young 2010). <strong>Objective:</strong> The purpose of this study was to use findings from a survey of staff to inform a quality improvement initiative (Appendix A) to enhance nursing team communication. The study explored the perceptions of LTC nursing staff (i.e., registered nurses (RNs), licensed practical nurses (LPNs), and unlicensed assistive personnel (UAPs) about their communication related to resident care. <strong>Methods:</strong> A cross-sectional, descriptive survey design was used to explore perceptions of nursing staff working in a LTC setting about their communication. <strong>Findings:</strong> All levels of nursing staff contributed useful information regarding nursing staff communication, including their contributions, their communication, the frequency of communication, and the methods of communicating. <strong>Limitations:</strong> This study was done at one LTC facility, which limits the generalizability of the findings, though the study can be replicated easily at the city, state, regional, or national level to explore LTC nursing team communication in public and private facilities, including government LTC facilities (i.e., for veterans). <strong>Implications:</strong> Evidence-based standardized communication tools succinctly implemented for communication between nursing staff will bridge patient care communication barriers and positively impact teamwork, leadership, and workplace culture while improving resident and facility outcomes.

Enhanced hospital-wide communication and interaction by team training to improve patient safety.

ABSTRACTCommunication errors are the most important cause of adverse events in healthcare. The current study aimed to improve hospital-wide employee teamwork and reduce adverse medical events for patients arising from miscommunication. In our hospital, when patient safety incidents and accidents occur, staff from various occupations submit incident reports to the Department of Patient Safety via an electronic reporting system; over 11,000 cases are reported each year. We surveyed the incident reports submitted in our institution from 2016 to 2018. All incidents related to miscommunication were identified, and relevant information was collected from the original electronic incident reports. Incident severity classification is commonly divided into near-miss or adverse events. We extracted only the required incident information items for this study, and processed information concerning individuals (e.g., reporters and target patients) anonymously. This study was approved by the Institutional Review Board of the study hospital. The authors declare no conflicts of interest associated with this study. Team training for all employees reduced adverse events for patients. The coefficient of determination (R squared value) was –0.32. This suggests our approach may be slightly but significantly effective for developing the fundamental strengths of the medical team. Quality improvement is continuous, and seamless efforts to improve the effectiveness of medical teams at our hospital will continue.

P54 Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

AimsProblems with medication account for 10–20% of all adverse healthcare events in the NHS, costing between £200–400 million per year.1 Children are more likely to experience medication related harm.2 International reviews of the prevalence of drug-related problems are over ten years old.3 There is a need for a focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK to support the development and targeting of interventions to improve medication safety.4MethodsNine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to September 2018. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children, and quality appraisal of the studies was conducted.Results26 studies were included; none of which specifically reported on the prevalence of ADEs. Three ADR studies reported a median prevalence of 28.3% of patients (IQR 13); &gt;70% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors and the median prescribing error rate in all paediatric contexts was 10.7% of prescriptions (IQR 6) Seven studies explored prescribing errors in PICU and the prevalence was twice that in non-ICU areas (11.1% prescriptions; IQR 2.9 versus 6.5% prescriptions; IQR 4.3). The median rate of dose prescribing errors was 11.1% doses prescribed (IQR 10.6). Four studies reported administration errors of which three used consistent methods. Across these three studies, a median prevalence of 12.4% of administrations (IQR 7.3) was found. Administration technique errors represented 53% of these errors (IQR 14.7). Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 33% (IQR 13) of prescribed medication with 70.3% (IQR 14) classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors.ConclusionsChildren are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm, there is an urgent need for outcome-focussed research on preventable ADEs in paediatric hospital settings in the UK. A deeper understanding of medication processes for children in hospital from a systems and theoretical perspective will also support the development and tragetting of effective interventions to improve patient safety.ReferencesChief Medical Officer. An Organisation With a Memory. London; 2000.Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114–2120.Ghaleb MA, Barber N, Franklin BD, Yeung VWS, Khaki ZF, Wong ICK. Systematic review of medication errors in pediatric patients. Ann Pharmacother 2006;40:1766–1776.

Safety Climate Associated with Adverse Events in Nursing Homes: A National VA Study

Adverse events in health care are leading causes of morbidity and mortality, prompting health care organizations to investigate their antecedents. In nursing homes, safety climate—how staff typically think about safety and act on safety issues—is a potential contributor to adverse events, particularly pressure ulcers, falls, and falls‐related injuries. Yet, research to date is equivocal as to whether a more positive safety climate improves safety for residents living in nursing homes.We conducted a cross‐sectional analysis of the association between safety climate and adverse events, measured in 2017 and 2018 in 56 VA Community Living Centers (CLCs, or nursing homes) nationwide. Safety climate was measured by the previously validated Community Living Center Employee Survey on Resident Safety (CESARS), completed by nurses, nursing assistants, and clinicians. The CESARS has seven domains: safety priorities, supervisor commitment to safety, senior management commitment to safety, personal attitudes about safety, environmental safety, co‐worker interactions around safety, and global rating of CLC; higher CLC‐level domain scores indicate better ratings. 2017‐18 Minimum Data Set (MDS) measured four CLC‐level adverse events: percent of residents who had any falls, major injuries from falls, catheter use, and new/worsened pressure ulcers. Beta‐logistic regression models with random effects were used to examine the impact of staff‐specific safety climate domain scores on each adverse event, adjusted by year (2017/2018) and CLC‐level characteristics (CLC’s operating beds, nursing staffing level, and employee satisfaction/engagement).1397 and 1645 VA CLC staff responded to the CESARS in 2017 and 2018, respectively.There were significant associations between all four adverse events and three of the safety climate domains: expected, inverse associations with two domains and unexpected associations with one domain (P &lt; .05). Better ratings of supervisor commitment to safety and environmental safety were each associated with lower rates of three out of the four adverse events, as expected. That is, better ratings of supervisor commitment to safety were significantly associated with lower rates of (1) falls (OR 0.33, 95% CI 0.11‐0.97, clinicians), (2) major injuries from falls (OR 0.33, 95% CI 0.11‐0.97, clinicians), and (3) catheter use (OR 0.42, 95% CI 0.21‐0.85, nurses). Better ratings of environmental safety were significantly associated with lower rates of (1) major injuries from falls (OR = 0.48, 95% CI 0.24‐0.93, nurses), (2) catheter use (OR 0.55, 95% CI 0.32‐0.93, nursing assistants), and (3) pressure ulcers (OR 0.23, 95% CI 0.09‐0.61, clinicians). Better global CLC ratings were unexpectedly associated with higher rates of only catheter use. No other safety climate domains had significant associations.In summary, supervisor commitment to safety (eg, supervisor responsiveness to safety concerns) and environmental safety (eg, presence of grab bars in bathrooms) emerged as elements of safety climate central to lower rates of adverse events in nursing homes. The role of safety climate in lower rates of adverse events was observed across all three groups of frontline staff. Our study thus suggests the potential of safety climate to impact resident safety outcomes.Improving environmental design and supervisory practices with frontline staff could reduce adverse events in nursing homes.Department of Veterans Affairs.

Comment les MERM travaillant en radiothérapie perçoivent-ils leurs compétences dites “soft”?

ObjectivesResearch in the last decade shows growing interest for soft skills in healthcare, due to awareness of the influence of adverse events in healthcare. However, there was no specific study about non-technical skills used by therapists in the French radiation oncology departments. What are these behavioral competencies that medical radiation technologists (MRT) use in their work to deliver safe and efficient healthcare? MethodWe built a self-assessment grid of 40 non classified soft skills for the active MRT to fulfill. This tool was sent to a total of 8 private and public radiation oncology department's head therapists. First, the 42 sampled MRTs had to choose how much they felt reflected in each of the listed soft skills. Second, they were asked to select 5 skills that they felt were the most important for a radiation therapist from the 40 soft skills in the initial grid. ResultsThe 5 soft skills MRTs think they have include the following: conscientiousness, working autonomously, listening, diligence, and working in a multidisciplinary team. The three they think they have the least are: being creative, managing conflicts, and being bold.For the skills that they felt were the most important , MRT selected: being conscientious, listening, working in a multidisciplinary team, showing empathy, and anticipating. ConclusionThese results show that the skills known in the Big Five personality traits model as “conscientiousness” and “agreeableness” come first. Conscientiousness and listening skills are the biggest skills for the radiation therapists, because these are the skills they think they have the most, and also because they consider these skills as the most useful for an MRT. The radiation therapists surveyed did not think they were bold, nor creative, nor able to manage conflicts. The way the MRT perceives themselves is as a conscientious technician and a nice caregiver, compliant with what is expected from them professionally and in the society.

Impacto de un plan de mejora de calidad en la validación de la prescripción de fármacos sobre la seguridad de los pacientes hospitalizados

Background and objectivesMedication errors are the most common adverse events in healthcare. Pharmaceutical validation (PV) seeks to reduce them. The aims of this study were to assess the impact of the introduction of an automated tool for the validation (VPAT) of the high clinical relevance drugs prescription (HCRD) over time of pharmaceutical intervention (PI), and to quantify the number of medication errors detected before and after its implementation. Material and methodsA two phase retrospective-observational single centre study was designed. A pre-intervention phase (Pre-P): PV of beds with Unit Dose Dispensing (October 2015 - February 2016), was followed by a post-intervention phase (Post-P): PV using a VPAT of HCRD in hospital patients (October 2016 - February 2017).HCRD were selected from the list of high-risk drugs of Institute for Safe Medication Practices. The data was obtained from the PI record (Access®) and the computerised prescription. The variables collected were: age and gender of the patients included, data of drugs prescription, and time to PI. ResultsA total of 477 PI were analysed in 404 patients, with a mean age of 65.9±19.5 years (53.22% women). The mean time up to PI was 25.6±24.72h in the Pre-P, and 18.87±20.44h in the Post-P (P=0.01). In Pre-P, 106 PI were performed (35.85% prevention of adverse reactions) compared to 371 PI (39.62% medication reconciliation) in Post-P. ConclusionsThe VPAT enabled a greater number of medication errors to be detected and intervened in hospitalised patients, with a significantly reduced time to PI.

Action after Adverse Events in Healthcare: An Integrative Literature Review.

Adverse events are common in healthcare. Three types of victims of patient-related adverse events can be identified. The first type includes patients and their families, the second type includes healthcare professionals involved in an adverse event and the third type includes healthcare organisations in which an adverse event occurs. The purpose of this integrative review is to synthesise knowledge, theory and evidence regarding action after adverse events, based on literature published in the last ten years (2009–2018). In the studies critically evaluated (n = 25), key themes emerged relating to the first, second and third victim elements. The first victim elements comprise attention to revealing an adverse event, communication after an event, first victim support and complete apology. The second victim elements include second victim support types and services, coping strategies, professional changes after adverse events and learning about adverse event phenomena. The third victim elements consist of organisational action after adverse events, strategy, infrastructure and training and open communication about adverse events. There is a lack of comprehensive models for action after adverse events. This requires understanding of the phenomenon along with ambition to manage adverse events as a whole. When an adverse event is identified and a concern expressed, systematic damage preventing and ameliorating actions should be immediately launched. System-wide development is needed.

A educação permanente para promoção da segurança do paciente pediátrico: uma revisão integrativa

Este artigo tem como objetivo investigar a produção científica acerca da utilização da educação permanente para promoção da segurança do paciente pediátrico. Trata-se de uma revisão integrativa de artigos oriundos das bases de dados ADOLEC, LILACS, BDENF e SciELO e PubMed publicados entre 2015 a 2019. A Educação Permanente em Saúde (EPS) é uma estratégia que incorpora novas reflexões no ambiente trabalhado e é baseada na aprendizagem significativa para transformação das práticas profissionais. Considerando que a ocorrência de eventos adversos nos cuidados em saúde é uma preocupação mundial, a ampliação de ações, como a introdução de estratégias educativas no meio profissional, pode ser uma importante medida para promoção da segurança da criança. No que tange aos resultados, 04 estudos atenderam aos critérios de inclusão da pesquisa, emergindo como categorias empíricas: Abordagens para a Segurança do Paciente Pediátrico e Contribuições da Educação Permanente em favor da Segurança do Paciente Pediátrico. Concluiu-se que a EPS, através da utilização de metodologias ativas de aprendizagem, pode sensibilizar profissionais para as práticas seguras em favor da criança, porém ainda são escassos os estudos desta temática.

Learning non-technical skills in surgery.

Skills other than technical or clinical competences are also recognized as essential in surgery. Most serious adverse events in health care are related to non-technical skill (NTS) failures. This has fostered interest in teaching surgeons about NTS. Reproducible evaluation scales, inspired by management strategies in the air transportation industry have been created in health care and some have been fashioned and validated specifically for surgeons. The list of NTS varies according to authors but one usually finds the same division into two main categories: social skills (communication, teamwork, leadership) and cognitive competences (situational awareness, decision-making). Stress and fatigue affect the implementation of these skills. Simulation is an efficient manner to teach NTS. The goals and exact modalities of how to teach NTS remains to be defined.