One Fourth of Unplanned Transfers to a Higher Level of Care Are Associated With a Highly Preventable Adverse Event

Marquet, Kristel; Claes, Nerée; Troy, Elke De; Kox, Gaby; Droogmans, Martijn; Schrooten, Ward; Weekers, Frank; Vlayen, Annemie; Vandersteen, Marjan; Vleugels, Arthur

doi:10.1097/ccm.0000000000000932

Cited by 50 publications

(60 citation statements)

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“…Among all the studies analyzed, the greatest emphasis was given to medication errors, [13][14][15][16][17][18][19][20][22][23][29][30][31][32][33][34][35][37][38]40,[42][43] this is due to the choice of studies that recommended analyzing the errors done by the nursing team, who are mainly responsible for this activity. Falls were reported in four studies, but with less incidences.…”

Section: Discussionmentioning

confidence: 99%

“…The human factor, i.e., the nursing professionals themselves, also carry the burden of the causes of errors, and the most frequent causes attributed to the individual staff and professional are: distraction , 16,19,[21][22]27,38,42,44 communication failures [13][14]17,[24][25][26][27][28][29][30][31][32][34][35] and lack of knowledge. 14,[17][18][19]21,[29][30]32,34,38,44 Distractions and communication failures are reported in other studies as factors that may predispose the occurrence of errors during care, since distractions take the professional from the focus, which at that moment is the patient, and efficient communication between the team can minimize and even prevent errors.…”

mentioning

confidence: 99%

“…Thus, the category of organizational processes management had the greatest prominence, 13,[17][18][19]22,26,[34][35]38,40 because management can contribute to the appearance of other causes, such as: deficiencies in the physical infrastructure, 13,17,19,21,29,37,44 shortages in the workforce [13][14][16][17]19,[21][22][24][25][26]34 and the work overload of the professionals. 13-14,16 ,19.21-23.25-26,34,37-38,44 In the study that analyzed medicine labeling, 44 there was a surprising result which showed that 43% of medicines were considered "possibly similar", 44% had the "same color label or packaging" and the "same word order", being that 50.7% of the medicines were identified as having "same color of the words".…”

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confidence: 99%

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Nursing Errors: A Study of the Current Literature

Forte

Pires

Padilha

et al. 2017

Texto contexto - enferm.

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Objective:to characterize what the current literature states about nursing errors, with a specific review on how these errors are communicated to society by the media.Method: a qualitative documental research, characterized as an integrative literature review, performed using four databases and guided by a formal protocol, in the period from 2011 to 2015, by two independent collaborators. The analysis of the studies occurred through the analysis of thematic content articulated with the resources of the Atlas.ti software.Results: 32 studies were analyzed and organized into two macro categories: main errors practiced by the nursing team; reported forms of prevention to avoid errors. Such categories reveal that most of the errors are made with medication, the main causes are related to work overload and management problems, and the main sources of prevention are to improve working conditions, continuing education and safety culture. ERROS DE ENFERMAGEM: O QUE ESTÁ EM ESTUDO 1 RESUMOObjetivo: caracterizar o que a literatura atual versa a respeito dos erros de enfermagem, em especial de como esses erros são comunicados à sociedade pela imprensa.Método: pesquisa qualitativa, documental, caracterizada como revisão integrativa de literatura, realizada em quatro bases de dados e orientada por um protocolo formal, no período de 2011 a 2015, por duas colaboradoras independentes. A análise dos estudos encontrados se deu por meio da análise de conteúdo temática articulada com os recursos do software Atlas.ti.Resultados: foram analisados 32 estudos e organizados em duas macrocategorias: principais erros praticados pela equipe de enfermagem; e causas relatadas e formas de prevenção para evitar os erros. Tais categorias revelam que a maioria dos erros é de medicação, as principais causas estão relacionadas à sobrecarga de trabalho e a problemas do âmbito da gestão, e as principais fontes de prevenção são a melhoria das condições de trabalho, a educação continuada e a cultura de segurança.Conclusão: os erros de enfermagem são multideterminados e seu enfrentamento requer medidas no âmbito profissional e institucional. DESCRITORES: ERRORES DE ENFERMERÍA: QUÉ ESTÁ EN ESTUDIOObjetivo: caracterizar lo que la literatura actual versa sobre los errores de enfermería, en especial de cómo estos errores son comunicados a la sociedad por la prensa.Método: investigación cualitativa, documental, caracterizada como revisión integrativa de literatura, realizada en cuatro bases de datos y orientada por un protocolo formal, en el período de 2011 a 2015, por dos colaboradoras independientes. El análisis de los estudios encontrados se dio por medio del análisis de contenido temático articulado con los recursos del software Atlas.ti.Resultados: se analizaron 32 estudios y organizados en dos macrocategorías: principales errores cometidos por el equipo de enfermería; Y las causas relatadas y formas de prevención para evitar los errores. Estas categorías revelan que la mayoría de los errores son de medicación, las principales causas están re...

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Nursing Errors: A Study of the Current Literature

Forte

Pires

Padilha

et al. 2017

Texto contexto - enferm.

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“…Therefore, this could be implied that fewer incidents were due to unexpected and unpreventable events and more failures occurred in routine procedures. About 89% of failures were regarded as potentially preventable in this study, and this was estimated from 37.9% to 85% in other studies [4,8,[20][21][22].…”

Section: Discussionmentioning

confidence: 99%

Research Paper: Risk Assessment of Surgical Procedures in a Referral Hospital

Rezaei

Yarmohammadian

Taleghani

et al. 2017

hdq

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Background: Adverse Events (AEs) due to failure in healthcare procedures are common. These procedures are often evaluated independently. The objectives of this study are to investigate the nature of the failures in healthcare procedures of the surgical patients, assessing the frequency of these failures and preventability, and exploring their consequences, underlying causes, and prevention strategies in a referral hospital in the center of Iran. Materials and Methods:This study is a prospective quantitative and qualitative research. Focus Group Discussion (FGD) meetings have been conducted to understand potential failures, their consequences, causes, and prevention strategies. Afterwards, the frequencies of these concepts have been determined separately in predefined subcategories in each step of the process. Results:The first phase of the patient care process was the most risk-prone phase. Temporary or permanent disability at the time of discharge (final impacts), inflammation/infection (injuries), the rule-based behavior associated with coordination (causes), information and communication, preventability more than 50 were the most frequent failures and had achieved the highest score. Conclusion:Failures of healthcare processes are preventable to a high degree, although patients injure frequently. Interventions to mitigate these failures will enhance the reliability of surgical procedures.

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“…The purpose is to identify high-risk patients in hospitals at an early stage in order to prevent deterioration in their condition and potentially improve their outcome. (7). Two previous meta-analyses concluded that the introduction of such teams is associated with a reduction in cardiac arrest rates, and some studies have found a decrease in mortality (8,9).…”

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confidence: 99%