153 research outputs found

    Dynamic checklists:design, implementation and clinical validation

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    Dynamic checklists:design, implementation and clinical validation

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    The Ethical Obligation for Disclosure of Medical Error in the Intensive Care Unit

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    The very facts that humans are fallible and that they are integrally involved in the delivery of healthcare and medical treatment guarantee that medical errors will occur despite the best of training, skills and vigilance, precautions, or preventive procedures. While medical errors occur across the spectrum of care and treatment, the propensity for their occurrence and the severity of the damage they are likely to inflict are undeniably greatest in the hospital intensive care unit (ICU). The fundamentals of biomedical ethics require nothing less than a thorough systematic analysis of the sources of error in the ICU, along with a comprehensive, coordinated approach to preventing error to the extent humanly possible and to handling and mitigating the effects of error whenever they do occur. Through the chapters of this dissertation, the research and analysis has provided the following: 1) a detailed account, to the extent that it has been documented, of the high frequency of errors occurring in the U.S. in general and specifically in hospital intensive care units, as well as the range and extent of the harm done to patients and family members, both physically and financially; 2) a classification and analysis of the proximate, intermediate and ultimate causes of and contributing factors to medical errors, which in addition to identifying causation has formed the basis for this dissertation’s recommendations aimed at developing procedures and protocols to effectively reduce errors to the greatest degree possible while minimizing their harmful impact; 3) an in-depth analysis of expectations, grounded in biomedical ethics, for dealing with the consequences of medical errors including disclosure and communication, the expectations of patients and family members, the attitudes and concerns of medical professionals, the disconnect between these two groups, and recommendations for procedures and protocols to ensure prompt, complete, and just handling of all consequences of the error; 4) an in-depth framework, based on Western religious and cultural foundations, for both those responsible for and those injured by medical errors to interact in handling the consequences of the error, as well as all of the communication which it engenders; and 5) proposals for numerous procedures and protocols, both for lessening the vulnerability of hospital ICU patients to suffering the effects of an error and for addressing and counteracting the variety of systemic problems which create or heighten the propensity for the occurrence of medical errors

    The system of aseptic preparation of intravenous drugs in clinical care settings

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    Abstract A review of the literature on blood stream infections caused by contaminated intravenous infusates which are prepared in clinical care settings found that this common nursing procedure poses at times a significant and life-threatening risk to patients. The guidance and regulations surrounding the preparation of intravenous drugs in clinical care settings suggests that this procedure is extremely complex and poses many different potential hazards to patients. This thesis set out to determine how the infection risks are being addressed in practice by asking the questions: ‘What is the system of intravenous drug preparation in clinical care settings in NHS Scotland?’ and, ‘How does it work in practice?’ Several data sources were utilised: six locations, in specialities where the literature identified significant outbreaks had occurred, were examined for potential contamination risk. Observations (78) of infusate preparations were undertaken and, where available, written procedures were compared with observed practices. Finally, analyses were made of 71 questionnaires, completed by the nurses who prepare intravenous drugs, regarding their opinions of the procedures’ safety and when they perform redundancy checks. The conclusion of this study is that the system of preparing intravenous drugs in clinical care settings by nurses is, as a consequence of potential infusate contamination, error-prone and unreliable. The reasons for this conclusion are now detailed. o Due to a lack of mandatory environmental standards, and the provision of poor environments, there is a risk of infusate contamination from environmental sources and consequently, a risk to patients of infusate-related blood stream infections (IR-BSI). o Some in use equipment poses contamination risks to patients’ infusates. Equipment that could reduce the contamination risk is not always available and in some instances such safety-enhancing equipment has been removed. o There are no complete written procedures which mirror what is done in practice. At present, from a human-factors perspective, it is not easy for the nurse to do the right thing, or to be sure exactly what is the right thing to do. o The procedure, in practice, has the required elements of an aseptic procedure, but the execution of the procedure is more often not performed aseptically. o The procedure of intravenous drug preparation as observed is mainly an interrupted aseptic procedure and as such the recommencement of the aseptic procedure requires repeated hand hygiene. o The nurses’ opinions of safety vary, as did their assessment of the infection risk to their patients, but it is clear that intravenous drug preparation is not a much-loved nursing procedure and some nurses find it very stressful. o There is no asepsis quality control built into the system. Aseptic steps are the least likely to be performed as a redundancy check compared to the mandatory checks of ‘right patient, right drug and right dose’. o The information available to the nurses, from the drug companies, from the makers of equipment and from national agencies does not identify with sufficient clarity the infection risks, or detail how to negate them. Suggestions for improvement to the six procedures and environments are clear once the procedure steps are colour-coded as either aseptic or non-aseptic; validity testing of these improvements is however, still needed. The systems’ vulnerabilities observed in this research appear to stem from a chain of external influences including an underestimation of the problem size and the actions needed to prevent it in evidence-based guidelines and mandatory guidance. This leads to poor recognition of the risk of IR-BSI in clinical practice. The problem of infusate contamination causing IR-BSIs is further compounded by the fact that it is not caused by a single organism and does not always present as a disease in real time, that is, over the lifetime of the infusion. As a consequence, this presents surveillance difficulties in terms of definitions, data collection and analysis. Finally, although the diagnosis of a blood stream infection for an individual patient remains relatively easy, it is not easy to recognise a contaminated infusate as the origin of the problem. All these challenges make both the recognition of the problem and agreement on prevention strategies, extremely challenging. In summary, the main conclusion of this thesis is that the preparation of infusates in clinical care settings, which occurs approximately 3,000,000 times a year in NHSScotland, is from an aseptic perspective, error-prone and unreliable. Recommendations to optimise patient safety include, changing the procedure locally and, with the utmost urgency, the production of minimum environmental standards. The results of this study are relevant to all hospitals in Scotland and throughout the United Kingdom where the current regulations apply and similar procedures are performed

    Acting in Time: Transport Nurses optimising critically ill patients for transfer to a regional ECMO centre. A Grounded Theory Study

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    Regionalisation and centralisation of Intensive Care Units, coupled with demographic changes, have resulted in an increased demand for inter-hospital transport. The Conventional ventilatory support vs Extracorporeal membrane oxygenation for Severe Adult Respiratory Failure Trial (CESAR), validated the use of ECMO in the UK for critically ill adults. The H1N1 Influenza A epidemic in 2009, led to four more adult ECMO centres being designated, and more recently the World Health Organisation (WHO, 2020), recommended ECMO for eligible patients in the COVID-19 pandemic. A critical incident occurred while I was undertaking the transport of a critically ill adult, which led to the unplanned use of mobile ECMO, still in its infancy. Seeking answers to the questions raised from this incident a research proposal was formed in order to investigate what could be learnt from the actions of transport nurses in promoting stability and preventing deterioration of patient acuity during the transport process. A grounded theory approach was used to try and understand the processes and strategies that experienced transport nurses used in optimising their patients’ stability and generate a substantive theory in explaining their timely actions. Under a pragmatic paradigm, this grounded theory study utilised the methods of Retrospective Medical Records Review and Interviews. Quantitative random sampling of 50 patients retrieved to a regional ECMO centre, allowed the collection of vital physiological variables staged over three time points. Data analysis showed that two out of the eight variables demonstrated a statistical significance in deterioration. Qualitative unstructured interviews from six transport nurses revealed a variety of activities, proactive and reactive, cognitive and physical, with overwhelming attention to time constraints, employed to benefit the patient. An explanatory theory was identified. Acting in Time encapsulated extant theory from the Secure Base Model (SBM) in fostering studies, and the Actor-Network Theory (ANT), from sociological literature. Acting in Time made overt the core virtues, practices, and skills of the transport nurse in aiming to reduce the risks associated will transport of the critically ill adult while striving to maintain patient stability. The study identified a growing need for centralisation, coordination, standardisation, audit, education and training for all those involved in transporting critically ill patients to a regional ECMO centre. It recommends that dedicated regional transport centres should be implemented for the transport of the adult critical care patient. A centralised database should be created for the import of data from the regional transport teams. Education for all nurses, not just transport nurses, needs to be available to deliver high quality care at any point of patient retrieval. A curriculum for transport education for nurses is outlined. This research reinforces and adds to the Intensive Care Society and Faculty of Intensive Care Medicine (ICS & FICM, 2019), and standards of education for nurses enhanced

    Visual Analytics of Electronic Health Records with a focus on Acute Kidney Injury

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    The increasing use of electronic platforms in healthcare has resulted in the generation of unprecedented amounts of data in recent years. The amount of data available to clinical researchers, physicians, and healthcare administrators continues to grow, which creates an untapped resource with the ability to improve the healthcare system drastically. Despite the enthusiasm for adopting electronic health records (EHRs), some recent studies have shown that EHR-based systems hardly improve the ability of healthcare providers to make better decisions. One reason for this inefficacy is that these systems do not allow for human-data interaction in a manner that fits and supports the needs of healthcare providers. Another reason is the information overload, which makes healthcare providers often misunderstand, misinterpret, ignore, or overlook vital data. The emergence of a type of computational system known as visual analytics (VA), has the potential to reduce the complexity of EHR data by combining advanced analytics techniques with interactive visualizations to analyze, synthesize, and facilitate high-level activities while allowing users to get more involved in a discourse with the data. The purpose of this research is to demonstrate the use of sophisticated visual analytics systems to solve various EHR-related research problems. This dissertation includes a framework by which we identify gaps in existing EHR-based systems and conceptualize the data-driven activities and tasks of our proposed systems. Two novel VA systems (VISA_M3R3 and VALENCIA) and two studies are designed to bridge the gaps. VISA_M3R3 incorporates multiple regression, frequent itemset mining, and interactive visualization to assist users in the identification of nephrotoxic medications. Another proposed system, VALENCIA, brings a wide range of dimension reduction and cluster analysis techniques to analyze high-dimensional EHRs, integrate them seamlessly, and make them accessible through interactive visualizations. The studies are conducted to develop prediction models to classify patients who are at risk of developing acute kidney injury (AKI) and identify AKI-associated medication and medication combinations using EHRs. Through healthcare administrative datasets stored at the ICES-KDT (Kidney Dialysis and Transplantation program), London, Ontario, we have demonstrated how our proposed systems and prediction models can be used to solve real-world problems
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