Qual Saf Health Care
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To describe relationships between teamwork behaviours and errors during neonatal resuscitation. ⋯ Vigilance is an important behaviour for error management. Assertion may have caused errors, or perhaps was an indicator for some other factor that caused errors. Teams may have preferred to resolve errors directly, rather than using errors as opportunities to teach their teammates. These observations raise important questions about the appropriate use of some teamwork behaviours and how to include them in team training programmes.
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Qual Saf Health Care · Feb 2010
The hospital standardised mortality ratio: a powerful tool for Dutch hospitals to assess their quality of care?
To use the hospital standardised mortality ratio (HSMR), as a tool for Dutch hospitals to analyse their death rates by comparing their risk-adjusted mortality with the national average. ⋯ Overall hospital HSMRs and mortality at individual diagnostic group level can be monitored using statistical process control charts to give an early warning of possible problems with quality of care. The use of routine data in a standardised and robust model can be of value as a starting point for improvement of Dutch hospital outcomes. HSMRs have been calculated for several other countries.
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Qual Saf Health Care · Dec 2009
An engineered solution to the maladministration of spinal injections.
An overview is provided of the progress made in a Department of Health (DH) initiative to implement an engineered solution to the maladministration of spinal injections. In an effort to eliminate the possibility of misconnection errors at the spinal route, the DH is investigating the potential for dedicated spinal equipment that will be incompatible with standard Luer syringes, needles and associated devices. ⋯ Usability testing of two prototype connection systems concluded that one design was inadequate, as the non-Luer element was provided as a separable adapter. The second connection system was modified following the first round of testing, and achieved improved satisfaction ratings from clinicians in round two. This system was selected to proceed to a pre-implementation evaluation and the research team are currently evaluating its acceptability in clinical use.
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Qual Saf Health Care · Dec 2009
Evidence-based chronic heart failure management programs: reality or myth?
Chronic heart failure management programmes (CHF-MPs) have become part of standard care for patients with chronic heart failure (CHF). ⋯ CHF-MPs are being implemented rapidly throughout Australia. However, many of these programmes do not adhere to expert clinical guidelines for the management of patients with CHF. This poor translation of evidence into practice highlights the inconsistency and questions the quality of health-related outcomes for these patients.
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Qual Saf Health Care · Dec 2009
Patient safety on the otolaryngology service: the role of an established rapid response system.
To study the medical emergencies occurring on a tertiary otolaryngology service identified using a rapid response system (RRS). ⋯ Although otolaryngology care units attempt to prevent adverse events, emergencies still occur. RRSs identify deteriorating otolaryngology patients who are at increased risk for mortality. RRSs are an efficient mechanism of intervention during a medical emergency. RRSs provide a convenient method of identifying medical/system errors and educational opportunities.