1,312 research outputs found
Exploring the causes of adverse events in hospitals and potential prevention strategies
Objectives
To examine the causes of adverse events
(AEs) and potential prevention strategies to minimise the
occurrence of AEs in hospitalised patients.
Methods
For the 744 AEs identified in the patient record
review study in 21 Dutch hospitals, trained reviewers
were asked to select all causal factors that contributed
to the AE. The results were analysed together with data
on preventability and consequences of AEs. In addition,
the reviewers selected one or more prevention strategies
for each preventable AE. The recommended prevention
strategies were analysed together with four general
causal categories: technical, human, organisational and
patient-related factors.
Results
Human causes were predominantly involved in
the causation of AEs (in 61% of the AEs), 61% of those
being preventable and 13% leading to permanent
disability. In 39% of the AEs, patient-related factors were
involved, in 14% organisational factors and in 4%
technical factors. Organisational causes contributed
relatively often to preventable AEs (93%) and AEs
resulting in permanent disability (20%). Recommended
strategies to prevent AEs were quality assurance/peer
review, evaluation of safety behaviour, training and
procedures. For the AEs with human and patient-related
causes, reviewers predominantly recommended quality
assurance/peer review. AEs caused by organisational
factors were considered preventable by improving
procedures.
Discussion
Healthcare interventions directed at human
causes are recommended because these play a large
role in AE causation. In addition, it seems worthwhile to
direct interventions on organisational causes because the
AEs they cause are nearly always believed to be
preventable. Organisational factors are thus relatively
easy to tackle. Future research designs should allow
researchers to interview healthcare providers that were
involved in the event, as an additional source of
information on contributing factors.
Analysis of the Physicochemical State of C-Reactive Protein in Different Preparations Including 2 Certified Reference Materials
Impact of beach replenishment on the fauna of a sandy beach at the Dutch islands of Texel and Ameland
Implementing a Social Norms Approach to Reduce Alcohol Abuse on Campus: Lessons learned in the shadow of The World\u27s Largest Six-Pack
Many institutions of higher education are struggling with the problem of excessive alcohol consumption by students. Colleges and universities want to be ‘good neighbors’ in their communities and must limit legal and social risks that result from excessive alcohol consumption by students. At the same time, colleges and universities operate in an increasingly challenging marketplace where many prospective students seek out institutions with a ‘party school’ reputation. Thus, higher education institutions are finding it difficult to define and carry out alcohol reduction measures that satisfy all constituents. This article discusses the approach taken at the University of Wisconsin—La Crosse. UW-L is an institution that identified a serious alcohol consumption problem and had to address the problem in a community where high levels of alcohol consumption are socially and culturally condoned. The article profiles the UW-L community and discusses the campaign model and strategy chosen. Quantitative and qualitative measures of success are discussed, along with lingering issues of resistance. The article ends with a summary of current issues and future directions being taken by the campaign
Exclusive electromagnetic production of strangeness on the nucleon : review of recent data in a Regge approach
In view of the numerous experimental results recently released, we provide in
this letter an update on the performance of our simple Regge model for
strangeness electroproduction on the nucleon. Without refitting any parameters,
a decent description of all measured observables and channels is achieved. We
also give predictions for spin transfer observables, recently measured at
Jefferson Lab which have high sensitivity to discriminate between different
theoretical approaches.Comment: 5 pages, 5 figure
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