Patients injuries

Health Care Provider Liability to Third Person for Patient Injury... 

Cause/Effect Strategic risk Performance risk Financial Risk Budget constraint low or no return Low or no return patient injury Reputation Risk Loss of customers/ trading partners Privacy Risk Human Capital Risk Skill shortage key personnel loss... 

Operational risk Psychosocial risk Data theft/loss patient injury Productivity loss increased health benefits Loss of customers/ trading partners Data theft ... 

For jobs with high numbers of nonfatal injuries and illnesses, overexertion is the leading event. These injuries result from lifting objects or, in the case of nursing aides and order-ties, patients. Injuries from overexertion accounted for about one third of all the nonfatal injuries in 1994 it took a median of five days for those injured to recuperate. 

Numerous reports of medication errors are being reported, some of which have resulted in patient injury or death. In a number of these reports, a medication was mistakenly administered either because the drug container (bag, ampule, prehlled syringe and bottle) was similar in appearance to the intended medication s container or because the packages had similar labeling. Obviously, the severity of such errors depends largely on the medication administered. 

Runkle, D.C. The Scientific Investigation of Avoidable Patient Injury Two Approaches. In Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care Schettler, A.L., Zipperer, L.A., Eds. National Patient Safety Foundation Chicago, 1998 51-52. 

Dispensing a medication for an unlabeled use, dose, or dosage form does not violate federal law. In fact, to date, no pharmacist is known to have been prosecuted for dispensing a product for an unlabeled use. However, a deviation from the safe and effective guidelines provided in the product labeling does expose the pharmacist to some liability. A pharmacist may be subject to malpractice action if patient injury results from the administration of a medication for an unlabeled use. ... 

Sevoflurane (ULTANE Figure 13-3) is a clear, colorless, volatile liquid at room temperature and must be stored in a sealed bottle. It is nonflammable and nonexplosive in mixtures of air or oxygen. Sevoflurane can undergo an exothermic reaction with desiccated CO absorbent (BARA-lyme) to produce airway bums or spontaneous ignition, explosion, and fire. Care must be taken to ensure that sevoflurane is not used with an anesthesia machine in which the COj absorbent has been dried by prolonged gas flow through the absorbent. Sevoflurane reaction with desiccated CO absorbent also can produce CO, which can result in serious patient injury. 

Medication errors are the most common cause of patient injuries in a hospital. It is therefore critical that the nurse avoid situations that frequently result in medication errors. If an error occurs, assess the patient and notify the nurse in charge and the physician. Follow your hospital s policy for preparing an incident report. Review the steps that caused the error to occur. 

Fortunately, the intrinsic safety associated with a host of medical devices has continued to evolve and improve. Somewhat ironically, however, not until the safety weaknesses (i.e., latent conditions) have been exposed through patient injury, death, or costly lawsuits. The development of the return electrode monitor within electrosurgical units is a prime example. By continually interrogating the impedance within the return electrode-patient circuit, this feature disables the electrosurgical unit should the impedance become too high. Burns due to compromised or failed return electrodes are now largely prevented. 

Continued acknowledgment and improvement in device human factors—especially as they apply to the device-user interface. As devices become increasingly human-friendly and their operation more intuitively obvious, the consequence of use errors is minimized, and patient injuries and deaths are also reduced. One of the best ways of assessing the human factors associated with device design is still done through prepurchase evaluations performed within the user s actual clinical environment. Here, the Agency for Healthcare Research and Quality also recommends ... 

Indicators can also be classified as sentinel-event indicators and aggregate data indicators. A performance measurement of an individual event that triggers further analysis is called a sentinel-event indicator. These are often undesirable events that do not occur often. These are often related to safety issues and do not lend themselves easily to quality-improvement opportunities. An example may include equipment failures that result in a patient injury. 

Physical therapy focuses on evaluating and diagnosing movement dysfunctions as well as treating a patient injury. As compared with physical therapy, occupational... 

The Harvard Medical Practice Study reviewed patient records of 30, 121 randomly chosen hospitalizations from 51 randomly chosen acute care, non-psychiatric hospitals in New York State in 1984. The goal was to better understand the epidemiology of patient injury and to inform efforts to reform systems of patient compensation. The focus was therefore on injuries that might eventually lead to legal action. Minor errors and those causing only minor discomfort or inconvenience were not addressed. 

Join us in converting a culture of blame that hides information about risk and error into a culture of safety that flushes information out and enables us to prevent or quickly recover from mistakes before they become patient injuries. 

To demonstrate and the value and effectiveness of this hybrid technique, we developed a model that explores how risk of specific adverse events changes overtime as a function of several system constraints. In particular, we are examining the impact of reimbursement, financial penalties and productivity pressures on the risk of hospital-acquired adverse events such as infections, medication errors, falls and other patient injuries. In detail, the model includes ... 

Paper based surveys are more useful than web based surveys for hospital staff. Significant local support is required to increase participation in the survey. Safety culture factors explained more variance in safety behaviour measures than they did variance of worker and patient injury rates. 

Medical Practice Studies (MPS) conducted in the United Kingdom, Canada, Australia, New Zealand, France, the Netherlands, and Denmark reported patient injury rates from 7.5% to 15% [2,12,24]. 

Causes of Patient Injuries and Examples of Factors Endangering Patient Safety at Various Levels of Health Care... 

Professionals working in the area of health care have identified many causes of patient injuries. Eight fundamental mechanisms (i.e., basic causes) through which a patient may be injured or killed are as follows [8] ... 

In regard to health care, safety culture has even greater importance, as safety applies not only to the workforce but also to the patients who may get injured due to staff actions. Various studies conducted over the years clearly indicate that the existence of a positive safety culture is essential for reducing preventable patient injuries and their cost to society at large [12-14]. 

Each year, a vast sum of money is spent to produce various types of medical devices throughout the world. Their usability has become an important issue, because various studies conducted over the years indicate that poorly designed human-machine interfaces of medical devices significantly increase the risk for the occurrence of human errors [1-4], These errors can directly or indirectly result in patient injury or death. 

Chapter 3 presents introductory aspects of safety and human factors. Chapter 4 is devoted to methods considered useful to perform patient safety analysis. These methods include failure modes and effect analysis (FMEA), fault tree analysis (FTA), root cause analysis (RCA), hazard and operability analysis (HAZOP), six sigma methodology, preliminary hazard analysis (PFfA), interface safety analysis (ISA), and job safety analysis (JSA). Patient safety basics are presented in Chapter 5. This chapter covers such topics as patient safety goals, causes of patient injuries, patient safety culture, factors contributing to pahent safety culture, safe practices for better health care, and patient safety indicators and their selection. 

The majority of paediatric foot fractures heal well with conservative treatment. However, the change in trends of recreational activities, with some children now participating in motor sports, has meant increasing numbers of more severe foot injuries being seen in younger patients. Injuries in adolescence commonly take on similar patterns to those seen in adults. 

In everyday situations, overlooking human factors leads to errors, frustration, alienation from technology, and, eventually, a failure to exploit the potential of people and technology. In safety-critical systems, however, such as nuclear power plants, hospitals, and aviation, the consequences can threaten the quality of hfe of virtually everyone on the planet. In the United States, for example, preventable medical errors are the eighth leading cause of death in hospitals alone, errors cause 44,000 to 98,000 deaths annually, and patient injuries cost between 17 billion and 29 billion annually (lOM, 1999). 

By "exposure to hazard" we mean any condition, decision, behavior, activity, cultural standard, process, or system (or lack thereof) that increases the probability of the patient s suffering a preventable adverse event. In short, any malfunction in any element of the blueprint that increases the patient s jeopardy constitutes an exposure and is a root cause of preventable adverse events. By "preventable adverse event" we mean healthcare-caused harm, i.e., a patient injury that is not an inevitable or necessary outcome of the patient s illness but rather the result of the care he or she received. Table 2-2 shows some common healthcare safety exposures and related preventable adverse events. 

The random variability in adverse event frequency means that, to lead effectively, a leader requires leading indicators. Leading indicators are measures of variables that can be shown to have a statistically valid, predictive relationship to adverse event frequency. When viewed in relation to lagging indicators (for example, the number of adverse events in a period of time), leading indicators allow organizations to take proactive steps to prevent patient injuries. Table 2-3 shows some healthcare safety leading indicators. 

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