Healthcare Failure Research Articles

Secure Data Aggregation of Lightweight E-Healthcare IoT Devices With Fair Incentives

With rapid development of e-healthcare systems, patients that are equipped with resource-limited e-healthcare devices (Internet of Things) generate huge amount of health data for health management. These health data possess significant medical value when aggregated from these distributed devices. However, efficient health data aggregation poses several security and privacy issues such as confidentiality disclosure and differential attacks, as well as patients may be reluctant to contribute their health data for aggregation. In this paper, we propose a privacy-preserving heath data aggregation scheme that securely collects health data from multiple sources and guarantee fair incentives for contributing patients. Specifically, we employ signature techniques to keep fair incentives for patients. Meanwhile, we add noises into the health data for differential privacy. Furthermore, we combine Boneh–Goh–Nissim cryptosystem and Shamir’s secret sharing to keep data obliviousness security and fault tolerance. Security and privacy discussions show that our scheme can resist differential attacks, tolerate healthcare centers failures, and keep fair incentives for patients. Performance evaluations demonstrate cost-efficient computation, communication and storage overhead.

Post-abortion care: Ethical and legal duties.

Women who experience complications from abortion, whether unlawful or lawful, induced or spontaneous, need immediate post-abortion care. Delay in providing care might cause women's avoidable disability, lost childbearing capacity, or death. Rendering care is not an abortion procedure nor illegal, and does not justify conscientious objection. Harm reduction strategies to reduce effects of unsafe abortion may legitimately inform women who might consider resort to abortifacient interventions of their rights to professional post-abortion care. Healthcare practitioners' refusal or failure to provide available care might constitute ethical misconduct and attract legal liability, for instance for negligence. States are responsible to ensure healthcare practitioners' and facilities' provision of post-abortion care, including both medical care and psychological support, delivered with compassion and respect for dignity, and to suppress stigmatization of patients and/or caregivers. Mandatory reporting of patients suspected of criminal abortion violates professional confidentiality. States' failures of indicated care might constitute human rights violations.

Proactive risk assessment of vincristine use process in a teaching and referral hospital in Kenya and the implications

The chemotherapy use process is potentially risky for cancer patients. Vincristine, a "High Alert" medicine, has been associated with fatal but preventable medication errors. Consequently, there is a need to improve the use of vincristine especially in lower- and middle-income countries where there are constraints with resources and often a lack of trained personnel to administer cancer medicines. However, where there is a rising prevalence of cancer cases. These concerns can be addressed by performing proactive risk assessments using Healthcare Failure Mode Effect Analysis (HFMEA) and implementing the findings. A multidisciplinary health team driven by pharmacists identified and evaluated potential failure modes based on a vincristine use process flow diagram using a hazard scoring matrix in a leading referral hospital in Kenya. The processes evaluated were: prescribing, preparation and dispensing, transportation and storage, administration and monitoring of the use of vincristine. Seventy-seven failure modes were identified over the three-month study period, of which 25 were classified as high risk. Thirteen were adequately covered by existing control measures while 12 including one combined mode required new strategies. Two of the failure modes were single-point weaknesses. Recommendations were subsequently made for improving the administration of vincristine. HFMEA is a useful tool to identify improvements to medication safety and reduction of patient harm. The HFMEA process brings together the multidisciplinary team involved in patient care in actively identifying potential failure modes and owning the recommendations made, which are now being actively followed up in this hospital. Pharmacists are a key part of this process.

Symptomatic congenital syphilis in a tertiary neonatal unit in Cape Town, South Africa: High morbidity and mortality in a preventable disease.

Despite preventive measures and effective treatment, congenital syphilis continues to impact significantly on neonatal morbidity and mortality. There has been no recent South African (SA) published literature reviewing congenital syphilis, particularly in the context of a tertiary neonatal setting. To describe the clinical features of symptomatic neonates with congenital syphilis and to identify modifiable patient, clinical and health facility factors that contributed to syphilis infection. All positive serological tests for syphilis performed in neonates at Groote Schuur Hospital (GSH), Cape Town, SA, between 1 January 2011 and 31 December 2013 were obtained. Folders were reviewed, and neonates with clinical signs of congenital syphilis were included. Of 50 symptomatic neonates, 19 (38%) died. Twenty-eight mothers (56%) were unbooked and therefore received no antenatal care. Most mothers (98%) were inadequately treated. Health worker-related failures included poor notification and partner tracing as well as failure to recheck syphilis serology after 32 weeks' gestation in mothers who initially tested negative. Thirty-four neonates required intensive care unit admission. Two significant predictors of mortality were 1-minute and 5-minute Apgar scores <5. Hydrops fetalis was an independent risk factor for mortality, as were moderate to severely abnormal cranial ultrasound scan findings. Congenital syphilis in neonates admitted to the GSH neonatal unit was associated with substantial morbidity and mortality. The modifiable factors identified represent inadequate antenatal healthcare and health system failures. These factors are longstanding, highlighting the need to establish governance and audit processes and address the continuing socioeconomic and sociocultural barriers that mothers face as a way forward in ultimately eliminating this entirely preventable disease.

Using Proactive Risk Assessment (HFMEA) to Improve Patient Safety and Quality Associated with Intraocular Lens Selection and Implantation in Cataract Surgery

A proactive risk assessment using the Healthcare Failure Mode and Effect Analysis (HFMEA) process was completed on the intraocular lens (IOL) selection and implantation process to analyze system vulnerabilities that could cause patient harm. The three largest ophthalmology clinics based on patient surgical volume were studied in the analysis. The analysis included in-clinic eye measurements needed for IOL selection through the actual implantation of the lens in the operating room. The HFMEA process was used for the analysis. A detailed process and subprocess diagram was created through interviews and observations. A multidisciplinary team met 12 times over a 14-week period, evaluating 170 discrete process and subprocess steps and identifying 177 failure modes and 75 failure mode causes for analysis. A high degree of process variability and lack of a robust quality assurance process was found. Areas for improvement included reducing variability between and within clinics, reducing variability in processes used by surgeons, modifying equipment and software to better support the work processes, and implementing a quality assurance program requiring observation of staff performing their routine work as opposed to relying on self-reports of quality metrics. The HFMEA process provided a more complete understanding of all of the processes associated with cataract surgery. This allowed for the identification of a variety of risk factors to patient safety that had not previously been identified by the more traditional reactive analysis methods, which tend to focus only on vulnerabilities identified by a specific event.

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.

ObjectiveThe risk of medical errors increases upon transfer out of the intensive care unit (ICU). Discrepancies in the documented care plan between notes at the time of transfer may contribute to communication errors. We sought to determine the frequency of clinically meaningful discrepancies in the documented care plan for patients transferred from the pediatric ICU to the medical wards and identified risk factors.Materials and MethodsTwo physician reviewers independently compared the transfer note and handoff document of 50 randomly selected transfers. Clinically meaningful discrepancies in the care plan between these two documents were identified using a coding procedure adapted from healthcare failure mode and effects analysis. We assessed the influence of risk factors via multivariable regression.ResultsWe identified 34 clinically meaningful discrepancies in 50 patient transfers. Fourteen transfers (28%) had ≥1 discrepancy, and ≥2 were present in 7 transfers (14%). The most common discrepancy categories were differences in situational awareness notifications and documented current therapy. Transfers with handoff document length in the top quartile had 10.6 (95% CI: 1.2–90.2) times more predicted discrepancies than transfers with handoff length in the bottom quartile. Patients receiving more medications in the 24 hours prior to transfer had higher discrepancy counts, with each additional medication increasing the predicted number of discrepancies by 17% (95% CI: 6%–29%).ConclusionClinically meaningful discrepancies in the documented care plan pose legitimate safety concerns and are common at the time of transfer out of the ICU among complex patients.

Reducing errors during surgery using an improved Healthcare Failure Mode and Effect Analysis model

Background/Aims Prospective risk management is a necessary measure when managing and providing the right response to a healthcare system error. This article provides an improved model of the Healthcare Failure Mode and Effect Analysis model, which aims to reduce errors in the operating room and improve on the major defects found in the Healthcare Failure Mode and Effect Analysis model. Methods The improved model presented in this descriptive mixed-methods article was examined in 2015 on selective processes in total knee replacement in Shahid Madani Hospital's operating rooms in Karaj, Iran. Data were collected through clinical observations, individual and group interviews, and collaborative conversations with the study team. Results A total of 8 activities and 15 modes of failure were identified in 5 selection processes in total knee replacement surgery. The identified modes of failure were given scores. Ultimately, 15 potential causes and 17 measures were proposed for 12 failures. The failure of the ‘unmanaged nurse or the anaesthesia technician in the operating rooms’ had the highest priority, and ‘chest leads’ and a ‘blood pressure cuff placed in the incorrect position’ had the lowest priority. Conclusion The improved model better reported the risk priorities of failures in 9 out of 12 modes. It was also able to resolve major defects in the Healthcare Failure Mode and Effect Analysis model and produce more reliable results.

Optimization of emergency process with the HFMEA tool and effects assessment among lumbar surgery patients with muscle weakness

Objective To optimize the emergency process with the healthcare failure mode and effect analysis (HFMEA) tool among lumbar surgery patients with muscle weakness so as to shorten the first-aid time, standardize doctor-nurse behavior and improve the timely cure rate. Methods The emergency process from muscle weakness to hematoma evacuation in operating room was optimized based on the HFMEA. From June 2016 to May 2017, a total of 6 lumbar surgery patients with muscle weakness were in control group before optimization. From June 2017 to May 2018, a total of 7 lumbar surgery patients with muscle weakness were in experimental group after optimization. We compared the time from muscle weakness to effective cure of patients between two groups, and the detection rate for lumbar surgery patients with muscle weakness within 6 hours by nurses as well as the misjudgment probability for muscular strength assessment after lumbar surgery by nurses. Results After implementing optimal process, the time from muscle weakness to effective cure of patients decreased from (23.78±1.95) h to (5.37±0.78) h. The detection rate for lumbar surgery patients with muscle weakness within 6 hours by nurses increased from 33.3% to 100.0%. The misjudgment probability for muscular strength assessment after lumbar surgery by nurses decreased from 12.2% to 4.6%. Conclusions The application of HFMEA tool can optimize the muscular strength assessment management process for patients after lumbar surgery, standardize doctor-nurse behavior, shorten the first-aid time of muscle weakness and improve the detection rate for muscle weakness within 6 hours so as to guarantee the safety of patients. Key words: Muscle strength; Spinal nerves motor function; Lumbar vertebrae surgery; Healthcare failure mode and effect analysis; Nursing assessment

Clinical observations and a Healthcare Failure Mode and Effect Analysis to identify vulnerabilities in the security and accounting of medications in Ontario hospitals: a study protocol

IntroductionAn increasing number of opioids and other controlled substances are being stolen from healthcare facilities, diverting medications from their intended medical use to be used or sold illicitly. Many incidents...

NHS Inquiries and the Problem of Culture

AbstractIf inquiries are about learning the lessons of the past, why do they appear to find the same failings time and again? Bristol, Mid Staffordshire, Morecambe Bay, Liverpool Community Health are all examples of where culture went wrong. The lack of learning from inquiries is a prominent concern and one raised elsewhere in this issue. In this article, I explore why it might be that culture is repeatedly found to be the cause of healthcare failures. I start by reviewing perspectives on what culture is and the degree to which it is possible change it. I examine how culture was described in the Bristol, Mid Staffordshire, Morecambe Bay and Liverpool inquiries and question whether these are the same cultures, with the same problems, or whether they are different. I discuss possible explanations for apparent similarities, describe how cultural change occurs and conclude by drawing out the implications of focussing on culture as a threat to patient safety.

Healthcare failure mode effect analysis in the safety management of intraoperative irradiation after conservative surgery for breast cancer

Objective To explore the effects of health failure mode and effect analysis (HFMEA) in the safety management of intraoperative radiotherapy (IORT) . Methods The HFMEA group was set up to analyze the potential risks of breast cancer patients undergoing intraoperative radiotherapy from January 2014 to April 2018. The group listed the failed modes that need to be improved, identified the invalid steps that need intervention, determined the causes of the failure and calculated the risk priority number (RPN) , created the safety management plans and put them into action. Finally, the outcomes were observed and analyzed. Results After the improvement of the HFMEA, the patients' healing rate of stage-Ⅰ incision increased from 85.42% to 98.18% with statistical significance (χ2=4.184, P<0.05) . The patients' satisfaction degree scored (98.21±3.98) from the patients and (99.02±5.89) from the surgeons, both higher than those before improvement with statistical significance (t=5.24, 3.07; P<0.05) . After the improvement, the absorbed and scattered dose of the affected and contralateral skin of thyroid gland, and the absorbed and scattered dose of the affected and contralateral skin of lens were lower than those before improvement. Conclusions Through prospectively controlling non-standard operation behaviors and optimizing the process, the application of HFMEA in the intraoperative irradiation after conservative surgery for breast cancer can ensure patients' safety and improve the quality of surgeries. Key words: Breast neoplasms; Operating room; Radiotherapy; Nursing management; Nursing safety; Healthcare failure mode and effect analysis

Public policy failure in healthcare: The effect of salary reduction for new entrant consultants on recruitment in public hospitals

Abstract Policies fail or succeed for many reasons. These reasons include the decisionmaking process, which depends on the interplay of interests, as well as ideology and information. While bearing in mind that perception is often allimportant in deciding if a policy is a success or failure, this paper examines the policy failure of the 2012 decision to reduce salaries for new entrant consultants in Irish public hospitals. This salary reduction resulted in difficulties recruiting and retaining hospital consultants in the public sector. Firstly, the timeline and context of the decision are explored, taking into account the financial crisis at the time. This leads on to an examination of why this decision was made. It appears likely that self-interest on the part of the Minister for Health was a factor, and that self-interest on the part of the medical unions prevented reasonable discourse. The ideology of austerity was a predominant theme of government budgets in 2012; however, this ideology was also influential in creating an environment that allowed blame for public sector pay to be focused predominantly at public hospital consultants. Finally, I find problems with the information used in decision-making for the policy. This is evident from the irrational beliefs held by policymakers on the likelihood of recruiting consultants with lower salaries.

Preventing Harm From Fluoroscopically Guided Interventional Procedures With a Risk-Based Analysis Approach

PurposeFluoroscopically guided interventional (FGI) procedures often have lower complication rates compared with alternative surgical procedures, providing an option for patients with a high risk of perioperative mortality. Although severe radiation injuries are rare, patients receiving peak skin doses exceeding 3 Gy can suffer from radiation-induced tissue injuries, ranging from transient erythema to nonhealing wounds. As these iatrogenic injuries may manifest weeks to months postprocedure, proper diagnosis and timely medical intervention are less likely. Clinically, the lack of situational awareness for monitoring air kerma continues to be a challenge despite the recommendations of numerous organizations on ways to achieve fluoroscopy safety. For patient safety efforts, this study aimed to identify and mitigate systematic gaps associated with potentially high-radiation dose fluoroscopic procedures in US Department of Veterans Affairs (VA) and non-VA medical institutions. MethodsIn this study, a multi-institutional team utilized Healthcare Failure Mode and Effect Analysis (HFMEA) on an example implantable cardioverter defibrillator lead extraction procedure. ResultsWith this approach, 29 interventions were devised and prioritized by feasibility, cost-effectiveness, and expected clinical impact. Five of the 29 interventions were recommended for immediate implementation or piloting. ConclusionsThis work demonstrates the application of formal risk-based analysis techniques in FGI procedures. These high priority interventions may be valuable for other facilities to consider when performing potentially high–radiation dose procedures and conducting risk-benefit analyses. Formal risk analysis techniques such as the HFMEA process are recommended for other facilities to use to improve safety for their high-risk procedures.

Understanding system-focused barriers to the identification and reporting of medication errors and adverse drug events in emergency medical services

Emergency medical services (EMS) represent an important and increasingly used entry point into the healthcare system. These services are often provided in the backdrop of challenging environments, with few diagnostic resources available, and for patients of varying acuity. As a result, the potential for medication errors (MEs) and adverse drug events (ADEs) is significant. However, the identification and reporting of these occurrences is poorly understood. A healthcare failure mode and effects analysis was conducted at the Hamad Medical Corporation Ambulance Service, Qatar, to identify and mitigate potential system-focused barriers to the identification and reporting of ADEs and MEs in the EMS setting. Between May 2018 and July 2018, a process map and potential failure points were developed and identified. Probabilities, severity, and hazard scores were calculated for each failure point, and action items were developed to address these. In total, 110 potential failure points were identified among 22 sub-processes, divided between six major processes. In terms of severity, most were classified as either ‘moderate’ [n = 90 (80%)] or ‘major’ [n = 14 (13%)]. In terms of probability, failure points classified as ‘frequent’ [n = 39 (35%)] and ‘occasional’ [n = 38 (35%)] made up the majority. Through consensus, 76 failure points (69%) were deemed necessary for action. Five strategic-level, system-focused action items were identified to mitigate against the failure points meeting the criteria for action. The unique circumstances that occur within the EMS setting dictate that bespoke solutions be developed to allow for ease of implementation and ongoing success of use. Strategies that also take advantage of mobile technology are crucial for a service that has mobility as one of its core functions.

Standardised concentrations of morphine infusions for nurse/patient-controlled analgesia use in children

BackgroundStandardizing concentrations of intravenous infusions enables pre-preparation and is effective in improving patient safety by avoiding large deviations from the prescribed concentration that can occur when infusions are made individually in wards and theatres. The use of pre-prepared morphine standardized concentration infusions for paediatric nurse/patient-controlled analgesia (N/PCA) has not been previously investigated. We aimed to establish, implement and evaluate standardized concentrations of morphine in pre-filled syringes (PFS) for use in paediatric N/PCA.MethodsConcentrations of morphine in PFS for N/PCA were identified that accommodated dosage variation across a 1–50 kg weight range. The use of infusions in PFS was implemented and evaluated using mixed methods involved direct observation of healthcare professionals (HCPs), focus groups and failure mode and effects analysis, a HCP survey and medication incident reports analysis.ResultsStandardized concentrations, 3 mg, 10 mg and 50 mg morphine in 50 mL sodium chloride 0.9%, delivered prescribed continuous and bolus doses using programmable smart pumps with variable infusion rates. During the implementation, 175 morphine pre-prepared infusions were administered to 157 children (9.4 ± 5.1 years) in theatres and wards. Time taken to set up a N/PCA was 3.7 ± 1.7 min, a reduction of one third compared with the previous system. The number of incidents associated with N/PCA infusions was reduced by 41.2%, and preparation errors were eliminated. HCPs reported using morphine PFS was an easier and safer system.ConclusionA system using pre-prepared standardized concentrations of morphine for paediatric N/PCA was implemented successfully and sustainably.

Healthcare Failure Mode and Effect Analysis: Dispensing Errors in the Pharmacy of an Outpatient Department of a Public Sector Tertiary-care Teaching Hospital

Healthcare Failure Mode and Effect Analysis: Dispensing Errors in the Pharmacy of an Outpatient Department of a Public Sector Tertiary-care Teaching Hospital

CARACTERIZACIÓN DE LAS ACCIONES INSEGURAS EN ODONTOLOGÍA (AIO) EN UNA INSTITUCIÓN DE DOCENCIA-SERVICIO, MEDELLÍN (COLOMBIA), 2015-2017

Introducción: con el fin de establecer acciones para mejorar la cultura de la seguridad del paciente en instituciones públicas y privadas, parece necesario contar con sistemas de vigilancia epidemiológica. Este estudio pretende caracterizar las atenciones inseguras en odontología (AIO) según diferentes variables, en una institución pública que forma recursos humanos en salud bucal en Medellín (Colombia). Métodos: estudio descriptivo longitudinal de las AIO reportadas en la Facultad de Odontología de la Universidad de Antioquia durante el periodo 2015-2017. Para ello se diseñó un formulario mediante la herramienta Google Docs™ (disponible si se solicita a los autores). Se describieron las variables sociodemográficas mediante frecuencias absolutas y relativas y se realizaron pruebas de significancia estadística Chi cuadrado para observar diferencias entre las variables. Se contó con la aprobación ética de la institución. Resultados: durante el periodo de estudio (33 meses), se reportaron 541 AIO, el 65% durante el año 2015. La mayor frecuencia de AIO se reportó en la clínica del niño (84%). De igual manera, un 84% de estas AIO se clasificaron como fallas en la atención en salud. Estas fallas fueron reportadas mayormente por estudiantes, por hombres, por personas ≤ 24 años, por estudiantes de pregrado, y en pacientes del sexo masculino y personas ≤ 12 años. Se encontraron diferencias significativas (p &lt; 0,05) entre los diferentes tipos de AIO y las variables consideradas en el análisis, y según el periodo de ocurrencia de las atenciones y el tipo de clínica. Conclusiones: se encontraron diferencias en el reporte de AIO según las variables consideradas en el análisis.

Patient’s reaction after health-care service failure: qualitative study

PurposeThis paper aims to show the impact of service failure and to shed light on the vengeance of consumer in the health-care service.Design/methodology/approachA qualitative research through a retrospective study based on individual interviews was conducted. As this study is a sensitive topic, projective techniques were used to complement individual interviews, especially with care consumers who are reluctant subjects who prefer methods which preserve confidentiality. Practically, drawing interpretations method was used. The use of these drawings is to encourage reluctant interviewee to discuss on the study’s sensitive theme.FindingsEmpirical findings allowed first to approach care service failure in Tunisia that is an emerging post-revolutionary country-owned MENA. In this context, a comparison between the public and private sectors was proposed. Moreover, the results helped to understand service failure’s consequences related to patient’s reaction.Practical implicationsThe Ministry of Health in collaboration with managers of public and private medical institutions will have to work on capitalization of knowledge, especially those learned from unsuccessful experiences.Originality/valueMedical service failure can have multiple sources. The care consumer’s reaction to these failures can sometimes be extreme in form of revenge.

Market Failure in Health Care: A Review

ABSTRACT Market refers to a place or state where a consumers and the sellers interact either directly or indirect to trade goods and services. It is a situation where forces of demand and supply interact to determine prices of goods and services being exchanged. Healthcare is essentially one of basic human need and very limited and requires allocation and institutions to organize its allocation. Healthcare market often mentioned as to be different from many other goods and services which make it different from the perfect market. The aim of this article is to describe the characteristics of the market failure. A simple systematic review was done for this article involving English literature of public databases and journal search engines. As a result of our literature review, characteristics of market failure can be simplified and categorized based from the factor of market namely; government intervention, patient factors, and external factors. All the essential contents of market failure are discussed further in this article. For the conclusion, although there are many characteristics of market failure, the main characteristics of market failure in healthcare market is due to government interventions which subsequently cause emerging of other characteristics of market failure in healthcare market. Keywords: Market failure, Market failure in healthcare, characteristics of market failure

PCP4 - A Qualitative Investigation of Information Asymmetry for Obesity Surgery: Diversity of Patient Experiences in the Information Age and Demand-Induced Supply

A key market failure in healthcare is information asymmetry between the consumer and supplier where the level of knowledge and expertise is weighted to the supply-side (physician/surgeon). However, in the information-age, bariatric surgery patients may be more empowered in their negotiated relationship with healthcare providers. Importantly, information that empowers the consumer potentially enables ‘demand-induced-supply’ (patients demanding and receiving care that their clinician would not otherwise have offered) and has implications for healthcare resource allocation to bariatric surgery. The main objective of our study was to employ qualitative research methods to investigate the concept of information asymmetry for bariatric surgery patients in the information-age. Our study used the pre-existing health economics theory of information asymmetry to inform qualitative inductive and deductive theory building about information drivers, sources and needs for bariatric surgery patients pre- and postoperatively. Ten semi-structured focus groups of people who were waitlisted or had undergone bariatric surgery were conducted (n=49). Thematic analyses were employed to analyse verbatim transcripts. The core finding of our interpretive analysis was that irrespective of the sources and types of information that the participants used in their decision-making, most participants’ decisions to undergo bariatric surgery would be unlikely to change . We also found that psychosocial ‘drivers’ for information gathering and interpretation were fundamentally important before surgery and that the quality and consistency of validated objective healthcare information became more important to participants after their bariatric surgery. We also found that information sources relevant to participants preoperatively (e.g. family and friends, and the Internet) were different postoperatively (surgeon, allied-health professionals e.g. psychologist). It was only after bariatric surgery that many participants fully acknowledged the complexity of their psychosocial needs. We recommend that high-quality and consistent patient information be more targeted towards the psychosocial domains of health preoperatively and ongoing postoperatively.