Safety Errors Research Articles

The Tuscan Mobile Simulation Program: a description of a program for the delivery of in situ simulation training.

Simulation has become a critical aspect of medical education. It allows health care providers the opportunity to focus on safety and high-risk situations in a protected environment. Recently, in situ simulation, which is performed in the actual clinical setting, has been used to recreate a more realistic work environment. This form of simulation allows for better team evaluation as the workers are in their traditional roles, and can reveal latent safety errors that often are not seen in typical simulation scenarios. We discuss the creation and implementation of a mobile in situ simulation program in emergency departments of three hospitals in Tuscany, Italy, including equipment, staffing, and start-up costs for this program. We also describe latent safety threats identified in the pilot in situ simulations. This novel approach has the potential to both reduce the costs of simulation compared to traditional simulation centers, and to expand medical simulation experiences to providers and healthcare organizations that do not have access to a large simulation center.

Study of Safety Management on Nursing Care in Oncologic Department

<strong>Objective: </strong>To improve the service quality of the department/hospital in an all-round way through strengthening management, improving attitude towards service, standardizing medical service, enhancing medical service quality and guaranteeing medical safety. <strong>Method:</strong> Nursing safety management is analyzed to develop protective measures for medical safety. <strong>Result</strong>: The department does not have any accident or dispute over severe medical safety errors. <strong>Conclusion:</strong> Nursing safety management is strengthened to considerably improve medical safety and lower the rate of medical error accident and dispute.

Study of Safety Management on Nursing Care in Oncologic Department

Objective: To improve the service quality of the department/hospital in an all-round way through strengthening management, improving attitude towards service, standardizing medical service, enhancing medical service quality and guaranteeing medical safety. Method: Nursing safety management is analyzed to develop protective measures for medical safety. Result : The department does not have any accident or dispute over severe medical safety errors. Conclusion: Nursing safety management is strengthened to considerably improve medical safety and lower the rate of medical error accident and dispute.

Notes from the Field: Injection Safety and Vaccine Administration Errors at an Employee Influenza Vaccination Clinic--New Jersey, 2015.

On September 30, 2015, the New Jersey Department of Health (NJDOH) was notified by an out-of-state health services company that an experienced nurse had reused syringes for multiple persons earlier that day. This occurred at an employee influenza vaccination clinic on the premises of a New Jersey business that had contracted with the health services company to provide influenza vaccinations to its employees. The employees were to receive vaccine from manufacturer-prefilled, single-dose syringes. However, the nurse contracted by the health services company brought three multiple-dose vials of vaccine that were intended for another event. The nurse reported using two syringes she found among her supplies to administer vaccine to 67 employees of the New Jersey business. She reported wiping the syringes with alcohol and using a new needle for each of the 67 persons. One of the vaccine recipients witnessed and questioned the syringe reuse, and brought it to the attention of managers at the business who, in turn, reported the practice to the health services company contracted to provide the influenza vaccinations.

Ethics, errors and education in surgical operating room

Patient safety errors in OR may originate from: surgeon on account of forgetfulness, inattention, poor motivation, carelessness, negligence and recklessness; Hospital system due to understaffing, inadequate equipment, fatigue, time pressure and inexperience.Quality surgical training is crucial for creation of surgical workforce for health care delivery. The surgical trainees during ‘Junior Residency’ need training in both ‘Surgical’ and ‘Communication’ OR skill. The surgical skill learnt in OR is: competence in ‘basic surgical techniques’; skill of ‘assistance and minor surgeries’: hernia repair, appendectomy, skin grafting and laparoscopic skills. During‘Senior Residency’ independent surgicaljudgment and performance of advanced surgical procedures to gain extensive operating experience.The non‐surgical skill that promotes patient safety in OR are ‘communication skill’ and ‘team skill’.The ’supervised progressive responsibility model of surgical training’ has elements embedded for patient safety. Surgical trainer promotes trainee’s skill and ensures patient safety as well the highest quality of surgery, through gradual decreasing levels of supervision in OR, namely Direct Supervision where the trainer is physically present;Indirect supervision where the trainer becomes available within few minutes; oversight where after the surgery review is providedwith feedback and progress monitoring where progress is monitored and supervision is done only in complex surgeries. Supervised surgical training helps creation of skilled practicing surgeon and ensures patient safety.

In situ simulation as a tool for patient safety: a systematic review identifying how it is used and its effectiveness

BackgroundIn situ simulation is an emerging technique involving interdisciplinary teams working through simulated scenarios which replicate events encountered in healthcare institutions, particularly those which are either low frequency or associated...

Reporting “perceptions”

This issue of The Journal includes a study that is noteworthy for two very different reasons. Guise et al from the Oregon Health Sciences University remind us that health care often begins with the emergency medical services (EMS) system. Although the quality and safety of inpatient hospital care has been the subject of a wealth of initiatives and reports, there has been little work done examining the prevention of safety events and errors in the over one million pediatric EMS encounters annually. Although the report does not address the issue directly, it provides a nice map of several targets for safety studies in the pediatric prehospital environment.What also is noteworthy about the study is the approach. On its face, the study was accomplished by a survey of EMS providers to obtain their thoughts about potential causes of safety events. The Journal receives scores of manuscripts reporting such surveys, the bulk of which we do not publish. The article by Guise et al, however, is a model of how surveys can be designed and implemented to produce reliable results. From selection of the target population, to survey design and testing, to implementation and reporting, this article sets a standard by which such studies can be judged.Article page 1143▶ This issue of The Journal includes a study that is noteworthy for two very different reasons. Guise et al from the Oregon Health Sciences University remind us that health care often begins with the emergency medical services (EMS) system. Although the quality and safety of inpatient hospital care has been the subject of a wealth of initiatives and reports, there has been little work done examining the prevention of safety events and errors in the over one million pediatric EMS encounters annually. Although the report does not address the issue directly, it provides a nice map of several targets for safety studies in the pediatric prehospital environment. What also is noteworthy about the study is the approach. On its face, the study was accomplished by a survey of EMS providers to obtain their thoughts about potential causes of safety events. The Journal receives scores of manuscripts reporting such surveys, the bulk of which we do not publish. The article by Guise et al, however, is a model of how surveys can be designed and implemented to produce reliable results. From selection of the target population, to survey design and testing, to implementation and reporting, this article sets a standard by which such studies can be judged. Article page 1143▶ Patient Safety Perceptions in Pediatric Out-of-Hospital Emergency Care: Children's Safety InitiativeThe Journal of PediatricsVol. 167Issue 5PreviewTo characterize emergency medical service (EMS) providers' perceptions of the factors that contribute to safety events and errors in the out-of-hospital emergency care of children. Full-Text PDF

An Evaluation of Training Procedures for Animal Shelter Volunteers

This study evaluated the effects of 3 training procedures on the correct implementation of a dog walking and enrichment protocol (DWEP). During the shelter’s typical training, volunteers correctly implemented just over half of all DWEP steps (M = 55.2%). Correct implementation of the DWEP procedure improved when participants completed a video-based self-training package (M = 75.3%) but did not reach the preestablished mastery criterion of 85% fidelity with 0 safety errors. Correct implementation improved during coaching (M = 90.6%), which consisted of modeling and positive and corrective feedback, and was maintained during 1-week and 1-month follow-up probes. Criterion performance was demonstrated by 2 of 3 participants at the conclusion of the study.

Complications of hemodialysis treatments due to dialysate contamination and composition errors.

Although hemodialysis is a routine outpatient treatment for millions of patients with a proven safety record, accidents and errors do occur from time to time. Many nephrologists are unaware of the technical aspects of providing a safe and reliable dialysate and rely on the support and advice of renal technologists. Complications may arise due to bacterial and chemical contamination of potable water, errors in dialysate acid or bicarbonate solution composition and proportioning, and resetting machine conductivity and temperature controls. As such, clinicians need to be aware of the possible complications of hemodialysis so that these are recognized promptly to provide appropriate management and minimize patient harm.

Patient Safety Perceptions in Pediatric Out-of-Hospital Emergency Care: Children's Safety Initiative

To characterize emergency medical service (EMS) providers' perceptions of the factors that contribute to safety events and errors in the out-of-hospital emergency care of children. We used a Delphi process to achieve consensus in a national sample of 753 emergency medicine physicians and EMS professionals. Convergence and stability were achieved in 3 rounds, and findings were reviewed and interpreted by a national expert panel. Forty-four (88%) states were represented, and 66% of participants were retained through all 3 rounds. From an initial set of 150 potential contributing factors derived from focus groups and literature, participants achieved consensus on the following leading contributors: airway management, heightened anxiety caring for children, lack of pediatric skill proficiency, lack of experience with pediatric equipment, and family members leading to delays or interference with care. Somewhat unexpectedly, medications and communication were low-ranking concerns. After thematic analysis, the overarching domains were ranked by their relative importance: (1) clinical assessment; (2) training; (3) clinical decision-making; (4) equipment; (5) medications; (6) scene characteristics; and (7) EMS cultural norms. These findings raise considerations for quality improvement and suggest important roles for pediatricians and pediatric emergency physicians in training, medical oversight, and policy development.

The Wisdom of Crowds.

The Wisdom of Crowds.

Crib of Horrors: One Hospital's Approach to Promoting a Culture of Safety.

The Institute of Medicine’s landmark report To Err Is Human revealed that tens of thousands of patient safety errors occur in hospitals across the United States every year.1 Canadian studies in both adult and pediatric hospitals corroborated these findings, revealing that 1 in 13 patients are victims of medical errors.2 To reduce these errors, it is important to have a culture where adverse events can be openly discussed and learned from in the hopes of preventing recurrences.3,4 In the pediatric setting, an open culture is one where everyone involved in the care of children, including the children themselves and their families, can speak up and be heard. The Montreal Children’s Hospital is an academic pediatric hospital that provides medical and surgical care to children 0 to 18 years of age. Results from patient and staff satisfaction surveys and from first-hand experience of front-line staff indicated that the safety culture could be improved at the hospital. Therefore, 3 physicians founded an interest group called “Champions for Patient Safety” to facilitate discussions and learning opportunities pertaining to patient safety, and broad participation is encouraged … Address correspondence to Nadine Korah, MDCM, MSc, FRCPC, The Montreal Children’s Hospital, 1001 Decarie Blvd. Montreal, QC, Canada H4A 3J1. E-mail: nadine.korah{at}mcgill.ca

Sepsis: Medical errors in Poland.

Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases.

Goal-oriented dynamic test generation

ContextMemory safety errors such as buffer overflow vulnerabilities are one of the most serious classes of security threats. Detecting and removing such security errors are important tasks of software testing for improving the quality and reliability of software in practice. ObjectiveThis paper presents a goal-oriented testing approach for effectively and efficiently exploring security vulnerability errors. A goal is a potential safety violation and the testing approach is to automatically generate test inputs to uncover the violation. MethodWe use type inference analysis to diagnose potential safety violations and dynamic symbolic execution to perform test input generation. A major challenge facing dynamic symbolic execution in such application is the combinatorial explosion of the path space. To address this fundamental scalability issue, we employ data dependence analysis to identify a root cause leading to the execution of the goal and propose a path exploration algorithm to guide dynamic symbolic execution for effectively discovering the goal. ResultsTo evaluate the effectiveness of our proposed approach, we conducted experiments against 23 buffer overflow vulnerabilities. We observed a significant improvement of our proposed algorithm over two widely adopted search algorithms. Specifically, our algorithm discovered security vulnerability errors within a matter of a few seconds, whereas the two baseline algorithms failed even after 30min of testing on a number of test subjects. ConclusionThe experimental results highlight the potential of utilizing data dependence analysis to address the combinatorial path space explosion issue faced by dynamic symbolic execution for effective security testing.

Effect of perceived risk on nuclear power plant operators’ safety behavior and errors

Safety behavior and human errors are major concerns for nuclear power plant operators. The present study investigated how nuclear power plant operators’ perceived risk influences the quality of their own work performance in terms of safety behavior and errors. In total, 349 operators from two nuclear power plants in China participated in the present study. We found that perceived risk had a negative linear relationship with safety behavior and a quadratic relationship with errors. Leader support played a moderating role in the relationships between perceived risk, safety behavior, and errors. These results supported the job demands–resources model and provided further evidence for the relationship between perceived risk and outcomes related to safety behavior and errors. Our findings suggest that an effective way to address the issue of high perceived risk is to provide a supportive environment.

Effects of Fatigue on Residents' Performance in Laparoscopy

The influence of fatigue on residents' performance in laparoscopy was prospectively assessed through a computer-based virtual reality simulation (VRS) model. Twenty-six residents (14 novices, 12 experienced) were recruited. In the first stage, each participant was initially tested on 8 VRS-based tasks. In the second, run-in stage, each resident had 8 hours of hands-on practice of the specific tasks chosen. Finally, participants were evaluated before and after 24 hours on call. For each task, a set of parameters reflecting proficiency, efficacy, and safety were documented. In most of the tasks assessed, sleep deprivation had a significant deleterious effect on the performance of residents, both in terms of efficiency (time to complete the task), and safety (errors). These observations were more pronounced among novices. For example, in camera manipulation at a 30-degree angle, the total time to complete the task was slower after sleep deprivation (novices: sleep deprivation = 136 seconds, control = 119 seconds; experienced: sleep deprivation = 112 seconds, control = 103 seconds; p = 0.03). Moreover, accuracy rates were lower after sleep deprivation: in the "grasping and clipping" task, a lower accuracy rate after sleep deprivation was noted (novices: sleep deprivation = 82.8%, control = 87.9%; experienced: sleep deprivation = 87.6%, control = 90.8%; p = 0.05). In this prospectively controlled study we observed reduced efficiency and safety in the performance of residents after sleep deprivation. Using an innovative study design, we eliminated the learning curve bias. Compared with novices, experienced residents performed relatively better after a night shift, and this may be attributed to better adaptation to sleep deprivation.

Drug induced diseases (DID): Need for more awareness & research.

Drug induced diseases (DID): Need for more awareness & research.

Quantitative Analysis of the Construction Industry Workers’ Perception of Risk in Municipalities Surrounding Salvador

The behavior and the degree of precaution in the actions of industrial workers facing situations that could cause injury and/or accidents are correlated to their risk perceptions. In Brazil, the civil construction industry leads statistics on occupational accidents in most of the regions. In view of this circumstance, the present paper has the purpose of researching the perception that civil construction workers of the surrounding municipalities of Salvador have in relation to the risks to which they are exposed, through the analysis of factors that are decisive for this perception. Hence, statistical verifications were performed using the Statistical Package for the Social Sciences software and for determining the reliability of the researched items, Cronbach's Alpha coefficient was used. With this, for the development of the research, a quantitative analysis was carried out with 160 workers from different companies of the construction industry in the region, involving the application of Likert scale questionnaire, used as tools for the evaluation of risk perception. The analysis of the perception of the workers demonstrated that for improvement of the risk perception and, consequently, minimization of safety errors, it is necessary to invest in long-term preventive and predictive actions, capable of concentrating efforts in the anticipation of accidents and considering the personal and collective health and safety variables of these workers, transforming, in this manner, their perceptions into measurable indicators for enforcement of risk management and for the formation of an effective safety culture.

EFFECTS OF FATIGUE ON REAL-WORLD DRIVING IN DISEASED AND CONTROL PARTICIPANTS.

This study evaluated real world driver errors and sleepiness in 66 drivers with Obstructive Sleep Apnea (OSA) and 34 matched controls (24 younger and 22 older). Driving errors and driver state were derived from analyses of video data from "black-box" event recorders. Sleep fragmentation data in OSA was derived from actigraphy for 15 days prior to beginning standard treatment (positive airway pressure, PAP) and 15 days after beginning PAP treatment. Prior to starting PAP, OSAs appeared sleepier than controls in general and particularly at intersections, while making safety errors following nights with high levels of fragmented sleep compared to matched controls. Adverse effects of sleep fragmentation during the pre-PAP phase were reduced post-PAP. Greater hours of PAP-use were associated with lower sleepiness and errors on the road. PAP-use was associated with a decrease in high sleep fragmented nights. Findings suggest reduction in acute sleepiness is unlikely to be the only mediating factor that explains the driving safety benefits of PAP in OSA.

Cognitive functioning differentially predicts different dimensions of older drivers’ on-road safety

The extent to which deficits in specific cognitive domains contribute to older drivers’ safety risk in complex real-world driving tasks is not well understood. We selected 148 drivers older than 70 years of age both with and without neurodegenerative diseases (Alzheimer disease–AD and Parkinson disease–PD) from an existing driving database of older adults. Participant assessments included on-road driving safety and cognitive functioning in visuospatial construction, speed of processing, memory, and executive functioning. The standardized on-road drive test was designed to examine multiple facets of older driver safety including navigation performance (e.g., following a route, identifying landmarks), safety errors while concurrently performing secondary navigation tasks (“on-task” safety errors), and safety errors in the absence of any secondary navigation tasks (“baseline” safety errors). The inter-correlations of these outcome measures were fair to moderate supporting their distinctiveness. Participants with diseases performed worse than the healthy aging group on all driving measures and differences between those with AD and PD were minimal. In multivariate analyses, different domains of cognitive functioning predicted distinct facets of driver safety on road. Memory and set-shifting predicted performance in navigation-related secondary tasks, speed of processing predicted on-task safety errors, and visuospatial construction predicted baseline safety errors. These findings support broad assessments of cognitive functioning to inform decisions regarding older driver safety on the road and suggest navigation performance may be useful in evaluating older driver fitness and restrictions in licensing.