BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for preho...BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors.METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all.RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classifi cation resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure.CONCLUSION: Communication defi cits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.展开更多
BACKGROUND:Medication errors are a common source of adverse healthcare incidents particularly in the emergency department(ED) that has a number of factors that make it prone to medication errors.This project aims to r...BACKGROUND:Medication errors are a common source of adverse healthcare incidents particularly in the emergency department(ED) that has a number of factors that make it prone to medication errors.This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED.METHODS:In 2009,a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems.RESULTS:Responsible officers were assigned to look after seven error-prone areas.Strategies were proposed,discussed,endorsed and promulgated to eliminate the problems identified.A reduction of medication incidents(Ml) from 16 to 6 was achieved before and after the improvement work.CONCLUSION:This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.展开更多
BACKGROUND:The Joint Commission accreditation manual contains standards in improving organization performance related to report and review of patient care issues causing unexpected harm.In spite of regulations mandati...BACKGROUND:The Joint Commission accreditation manual contains standards in improving organization performance related to report and review of patient care issues causing unexpected harm.In spite of regulations mandating reporting,it remains inconsistent,varying by provider type and hospital.Our purpose was to determine current attitudes,knowledge,and practice of error reporting among emergency department(ED) providers.METHODS:We administered a survey assessing ED staff practice regarding error reporting.Questions involved reporting of errors in which the practitioner was directly involved,errors the practitioner observed,and general awareness of reporting mandates.We also questioned individuals regarding fear of repercussions for reporting.RESULTS:Fifty-two surveys were returned.For most errors,providers were more likely to tell their supervisor about the issue than to tell the patient.Seventeen percent of respondents did not think that referring errors for review was their job.Only 31%of respondents were aware of standardized institution-wide pathways to report errors.Any respondent who was aware of the institution-wide pathway also felt responsibility for error reporting.Thirty-three percent of the respondents were concerned about negative repercussions from reporting errors.In querying the hospital reporting system,263 cases were referred for quality issues over the previous year,51%of them were referred by nurses,27%by medical technicians(MTs),2%by mid-level providers(MLPs),1%by physicians,and 19%by other personnel.CONCLUSION:Although most of the ED staff are responsible for patient safety,most are not aware of systems available to assist in reporting,and even many do not utilize those systems.展开更多
Previous investigation of drug calculation skills of qualified paramedics has highlighted poor mathematical ability with no published studies having been undertaken on undergraduate paramedics. There are three major e...Previous investigation of drug calculation skills of qualified paramedics has highlighted poor mathematical ability with no published studies having been undertaken on undergraduate paramedics. There are three major error classifications. Conceptual errors involve an inability to formulate an equation from information given, arithmetical errors involve an inability to operate a given equation, and finally computation errors are simple errors of addition, subtraction, division and multiplication. The objective of this study was to determine if undergraduate paramedics at a large Australia university could accurately perform common drug calculations and basic mathematical equations normally required in the workplace. A cross-sectional study methodology using a paper-based questionnaire was administered to undergraduate paramedic students to collect demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions. Ethics approval was granted. The mean score of correct answers was 39.5% with one student scoring 100%, 3.3% of students （n=3） scoring greater than 90%, and 63% （n=58） scoring 50% or less, despite 62% （n=57） of the students stating they ＇did not have any drug calculations issues＇. On average those who completed a minimum of year 12 Specialist Maths achieved scores over 50%. Conceptual errors made up 48.5%, arithmetical 31.1 % and computational 17.4%. This study suggests undergraduate paramedics have deficiencies in performing accurate calculations, with conceptual errors indicating a fundamental lack of mathematical understanding. The results suggest an unacceptable level of mathematical competence to practice safely in the unpredictable prehospital environment.展开更多
BACKGROUND: The inability of paramedics to perform accurate calculations may result in a compromise of patient safety which may result from under or over dosing of drugs, incorrect joules for defibrillation, or a majo...BACKGROUND: The inability of paramedics to perform accurate calculations may result in a compromise of patient safety which may result from under or over dosing of drugs, incorrect joules for defibrillation, or a major adverse event such as death. The objective of this study was to identify the drug calculation and mathematical ability of qualified operational paramedics.METHODS: The study used a cross-sectional design with a paper-based calculation questionnaire. Twenty paramedics enrolled in an intensive care paramedic course were eligible to participate in the study. The questionnaire consisted of demographic, drug calculation(seven questions), and mathematical(five) questions. Students were given no notice of the impending study and use of a calculator was not permitted.RESULTS: All eligible students participated in the study. The average time employed as a paramedic was 7.25 years, SD 2.5 years, range four years to twelve years. Four(20%) students got all 12 questions correct, and five(41.6%) got 50% or less. The average score was 8.6(71.7%) correct, SD 2.8 correct, range 3 to 12 correct questions. There were eight(40%) conceptual errors, 12(60%) arithmetical errors, and five(25%) computational errors.CONCLUSION: The results from this study supports similar international studies where paramedic's ability to undertake mathematical and drug calculations without a calculator varies, with some results highlighting the paramedics mathematical skills as a potential risk to patient safety. These results highlight the need for regular continuing mathematical and drug calculation practice and education to ensure a lower error rate.展开更多
Purpose： The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. ...Purpose： The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach： We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our design, implementation,and evaluation of the ontology at its initial stage. Findings： We describe the design and initial outcomes of the ontology implementation. The evaluation results demonstrate the clinical validity of the ontology by a self-developed survey measurement. Research limitations： The proposed ontology was developed and evaluated using a small number of information sources. Presently, US data are used, but they are not essential for the ultimate structure of the ontology.Practical implications： The goal of improving patient safety can be aided through investigating patient safety reports and providing actionable knowledge to clinical practitioners.As such, constructing a domain specific ontology for patient safety reports serves as a cornerstone in information collection and text mining methods.Originality/value： The use of ontologies provides abstracted representation of semantic information and enables a wealth of applications in a reporting system. Therefore, constructing such a knowledge base is recognized as a high priority in health care.展开更多
文摘BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors.METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all.RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classifi cation resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure.CONCLUSION: Communication defi cits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.
文摘BACKGROUND:Medication errors are a common source of adverse healthcare incidents particularly in the emergency department(ED) that has a number of factors that make it prone to medication errors.This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED.METHODS:In 2009,a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems.RESULTS:Responsible officers were assigned to look after seven error-prone areas.Strategies were proposed,discussed,endorsed and promulgated to eliminate the problems identified.A reduction of medication incidents(Ml) from 16 to 6 was achieved before and after the improvement work.CONCLUSION:This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.
文摘BACKGROUND:The Joint Commission accreditation manual contains standards in improving organization performance related to report and review of patient care issues causing unexpected harm.In spite of regulations mandating reporting,it remains inconsistent,varying by provider type and hospital.Our purpose was to determine current attitudes,knowledge,and practice of error reporting among emergency department(ED) providers.METHODS:We administered a survey assessing ED staff practice regarding error reporting.Questions involved reporting of errors in which the practitioner was directly involved,errors the practitioner observed,and general awareness of reporting mandates.We also questioned individuals regarding fear of repercussions for reporting.RESULTS:Fifty-two surveys were returned.For most errors,providers were more likely to tell their supervisor about the issue than to tell the patient.Seventeen percent of respondents did not think that referring errors for review was their job.Only 31%of respondents were aware of standardized institution-wide pathways to report errors.Any respondent who was aware of the institution-wide pathway also felt responsibility for error reporting.Thirty-three percent of the respondents were concerned about negative repercussions from reporting errors.In querying the hospital reporting system,263 cases were referred for quality issues over the previous year,51%of them were referred by nurses,27%by medical technicians(MTs),2%by mid-level providers(MLPs),1%by physicians,and 19%by other personnel.CONCLUSION:Although most of the ED staff are responsible for patient safety,most are not aware of systems available to assist in reporting,and even many do not utilize those systems.
文摘Previous investigation of drug calculation skills of qualified paramedics has highlighted poor mathematical ability with no published studies having been undertaken on undergraduate paramedics. There are three major error classifications. Conceptual errors involve an inability to formulate an equation from information given, arithmetical errors involve an inability to operate a given equation, and finally computation errors are simple errors of addition, subtraction, division and multiplication. The objective of this study was to determine if undergraduate paramedics at a large Australia university could accurately perform common drug calculations and basic mathematical equations normally required in the workplace. A cross-sectional study methodology using a paper-based questionnaire was administered to undergraduate paramedic students to collect demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions. Ethics approval was granted. The mean score of correct answers was 39.5% with one student scoring 100%, 3.3% of students （n=3） scoring greater than 90%, and 63% （n=58） scoring 50% or less, despite 62% （n=57） of the students stating they ＇did not have any drug calculations issues＇. On average those who completed a minimum of year 12 Specialist Maths achieved scores over 50%. Conceptual errors made up 48.5%, arithmetical 31.1 % and computational 17.4%. This study suggests undergraduate paramedics have deficiencies in performing accurate calculations, with conceptual errors indicating a fundamental lack of mathematical understanding. The results suggest an unacceptable level of mathematical competence to practice safely in the unpredictable prehospital environment.
文摘BACKGROUND: The inability of paramedics to perform accurate calculations may result in a compromise of patient safety which may result from under or over dosing of drugs, incorrect joules for defibrillation, or a major adverse event such as death. The objective of this study was to identify the drug calculation and mathematical ability of qualified operational paramedics.METHODS: The study used a cross-sectional design with a paper-based calculation questionnaire. Twenty paramedics enrolled in an intensive care paramedic course were eligible to participate in the study. The questionnaire consisted of demographic, drug calculation(seven questions), and mathematical(five) questions. Students were given no notice of the impending study and use of a calculator was not permitted.RESULTS: All eligible students participated in the study. The average time employed as a paramedic was 7.25 years, SD 2.5 years, range four years to twelve years. Four(20%) students got all 12 questions correct, and five(41.6%) got 50% or less. The average score was 8.6(71.7%) correct, SD 2.8 correct, range 3 to 12 correct questions. There were eight(40%) conceptual errors, 12(60%) arithmetical errors, and five(25%) computational errors.CONCLUSION: The results from this study supports similar international studies where paramedic's ability to undertake mathematical and drug calculations without a calculator varies, with some results highlighting the paramedics mathematical skills as a potential risk to patient safety. These results highlight the need for regular continuing mathematical and drug calculation practice and education to ensure a lower error rate.
基金supported by a grant from AHRQ, 1R01HS022895a patient safety grant from the University of Texas system, #156374
文摘Purpose： The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach： We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our design, implementation,and evaluation of the ontology at its initial stage. Findings： We describe the design and initial outcomes of the ontology implementation. The evaluation results demonstrate the clinical validity of the ontology by a self-developed survey measurement. Research limitations： The proposed ontology was developed and evaluated using a small number of information sources. Presently, US data are used, but they are not essential for the ultimate structure of the ontology.Practical implications： The goal of improving patient safety can be aided through investigating patient safety reports and providing actionable knowledge to clinical practitioners.As such, constructing a domain specific ontology for patient safety reports serves as a cornerstone in information collection and text mining methods.Originality/value： The use of ontologies provides abstracted representation of semantic information and enables a wealth of applications in a reporting system. Therefore, constructing such a knowledge base is recognized as a high priority in health care.
