INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE最新文献

Background: The COVID-19 pandemic has increased the interest in the right to health, which represents a relatively new concept brought about by progress in medical science and the evolution of societies. The Italian Constitution, in article 32, states the right to health without specifications about the parameter of sex, assuming that this fundamental right is property of women and men indiscriminately.

Objective: To assess whether the right to health has actually been achieved in an equal way from the standpoint of sex, and whether a hypothetically "neutral" approach is actually convincing and profitable in this context.

Methods: This paper analyzes the topic of gender medicine from a scientific and legal perspective, based on current medical literature and its implementation in the Italian and European legal systems.

Results: Gender medicine is the only credible response to sex- and gender-based inequalities affecting the right to health, as it provides tools to address persisting inequalities in prevention and treatment, thus pursuing health for all: women and men.

Conclusions: The importance of this path was underlined also by the Summit and the Rome Declaration of 21 May 2021, acknowledging that the topic of sex and gender can no longer be overlooked in focusing a correct and equal healthcare approach.

Background: Member States (MSs) retain the powers to arrange their own national health care systems. However, EU has progressively developed an important co-ordination role. Such an institutional and legal framework has had a significant impact on how citizens' right to health is dealt with at the European level.

Objective: The article intends to prove that the greater the cooperation among MSs the better for citizens' right to health.

Methods: EU law - Directive 2011/24/EU.

Results: The Rome Declaration highlights the importance of all-of-society and health-in-all-policies approach. This underlines the "strategic" importance of the right to health.

Conclusions: The Rome Declaration may contribute to identifying public health not only as an individual, fundamental right but also as an obligation on both EU and Member States to ensure that right.

Background: Governmental regulations of drug registration and licensing are not always followed by healthcare providers.

Objective: To explore the global research growth and patterns on systemic use of off-label and unlicensed drugs to gain knowledge about the magnitude of the problem and the main research themes encountered in this field.

Methods: SciVerse Scopus was searched for papers on off-label and unlicensed drug use from 1990 until December 31, 2020, without any language limitations. A bibliometric methodology was adopted to present the following indicators: top-cited documents, the most productive countries, top active journals, international research collaboration, the most frequent author keywords, and research themes.

Results: The search query returned 1320 papers with an h-index of 66, published in 721 different journals. The Hospital Pharmacy journal ranked first (n = 43, 3.3%). In total, 5777 authors (median = 3) from 85 different countries contributed to the retrieved papers. The USA (n = 381, 28.9%) ranked first, followed distantly by Germany and Italy. The percentage of documents with international authors for active countries was from 8.8% for China to 42.3% for the Netherlands. The most frequent author keyword next to off-label was children/pediatrics. The keyword unlicensed was less frequently encountered than that for off-label. Major research themes in the retrieved papers focused on off-label drug use in hospitalized children/pediatrics, biological drugs such as rituximab and rFVIIa, psychiatric disorders, regulations, and questionnaire-based knowledge/attitude studies among community pharmacists and physicians.

Conclusions: Research activity on off-label drug use has witnessed a general increase in the past two decades. The major research theme was off-label drug use in hospitalized children/pediatrics/neonates. The USA and certain European countries made a major contribution to this field.

Background: Patients in psychiatric inpatient settings are at increased risk of developing physical health complications due to the structure of inpatient wards, the metabolic side-effects of antipsychotic medications and socioeconomic factors. Robust physical health monitoring and interventions are paramount in reducing this health inequality.

Objective: To improve the quality of physical health interventions in the ward environment and empower patients to follow healthy lifestyle guidance to reduce their risk of metabolic syndrome.

Methods: Patient weight and waist circumference data were collected at baseline and weekly throughout the 8-week intervention period. A questionnaire was recorded from baseline to week-5 to assess patient understanding. Two Plan-Do-Study-Act (PDSA) cycles were completed: (1) Series of weekly psychoeducation sessions and group exercise and (2) Implementation of healthy living diaries.

Results: Our data did not demonstrate any definitive impact upon the waist circumference and weight of participants. However, analysis of the questionnaires showed a consistent trend in knowledge improvement.

Conclusion: Whilst our aim of reducing patient weight and waist circumference was not realised, there was a significant impact on participant's knowledge, demonstrating a subjective benefit of our interventions. Our project also highlighted inconsistencies in physical health measurements and data collection, providing vital information for further quality improvement measures.

Background: Advance care treatment escalation plans (TEPs) are often lost between healthcare settings, leading to duplication of work and loss of patient autonomy.

Objective: This quality improvement project reviewed the usage of TEP forms and aimed to improve completeness of documentation and visibility between admissions.

Methods: Over four months we monitored TEP form documentation using a standardised data extraction form. This examined section completion, seniority of documenting clinician and transfer of forms to our hospital electronic patient record (EPRO). We added reminders to computer monitors on wards to improve EPRO upload.

Results: Initial data demonstrated that 95% of patients (n = 230) had a TEP, with 99% of TEPs recording resuscitation status. However, other sections were not well documented (patient capacity 57% completion and personal priorities 45% completion, respectively). Only 11.9% of TEPs documented consultant involvement. Furthermore, only 44% of TEPs with a do not attempt resuscitation (DNACPR) decision were uploaded. Following this, we added reminders to computer monitors explaining how to upload TEP decisions to EPRO, which increased EPRO uploads to 74%.

Conclusion: Communication of TEPs needs improving across healthcare settings. This project showed that the use of a physical reminder can greatly improve communication of treatment escalation decisions. Furthermore, this intervention has inspired future projects aiming at making communication more sustainable through the use of discharge summaries.

Background: Adverse events in hospitals may jeopardize the safety of patients. Failure in professional autonomy, organizational learning or in the contact between these two factors may explain the occurrence of injurious incidents in hospitals.

Objective: To study reasons for failure in contact between professional autonomy and organizational learning in resilient management of specialized health care through document analysis.

Methods: A total of 20 reports from the Norwegian Board of Health Supervision were evaluated by a retrospective in-depth document analysis. In the analysis of adverse events, we applied the Braut model to identify function or failure of 1. Professional autonomy, 2. Organizational learning and 3. Contact between professional autonomy and organizational learning.

Results: Multivariable regression analysis showed that failure in organizational learning was the only explanatory variable for failure in contact between doctors and nurses autonomy and organizational learning. Failure in organizational learning had the strongest effect on failure in contact between doctors and nurse's autonomy and organizational learning (B = 1.69; 95% CI = 0.45 to 2.92). Failure in professional autonomy showed no significant effect on this contact.

Conclusions: Failure in organizational learning is associated with failure in contact between professional autonomy and organizational learning. Failure in professional autonomy did not influence this contact.

Background: Human error has been studied for large decades with special application to critical infrastructures and processes where the impact of such errors can induce severe or catastrophic consequences. In this sense it is of utmost importance to extend this type of analysis to other fields as medicine.

Objective: This study proposes a semi-quantitative human error risk assessment methodology, including the analysis of the so-called Performance Shaping Factors (PSFs), in order to contribute to health services improvement.

Methods: A questionnaire including the considered PSFs is answered in order to determine the impact of each PSF and its influence on human error. It allows performing a Human Error Risk Assessment (HERA) for both the patient (HERAp) and the quality of the service (HERAq).

Results: The results show the PSFs with the highest impact factor. After applying corrective measures, it is possible to observe the impact on the reduction of the risk for patient and for the quality of the service.

Conclusions: The application of the methodology with the inclusion of the impact of PSFs allows minimizing or mitigating failure modes with greater risk as well as increasing patient safety and promoting a better quality of medical procedures.

Background: Previous reports have shown that there are long waiting times to commence therapy in the community-based mental health programme, IAPT (Improving Access to Psychological Therapies).

Objective: This study aimed to explore both causes and potential solutions to alleviate the burden of these waits.

Methods: A Systematic Literature Review (SLR) and Semi-Structured Interviews (SSIs) were conducted to identify causes and effects of these waits. Consequently, meaningful recommendations were made and tested with the aim of improving IAPT's waiting times.

Results: SLR and SSIs revealed high 'Did Not Attend' (DNA) rates and a lack of support between initial appointments as being both a cause and effect of long waits. The identified issues were tackled with the development of an app design. Expert interviews and a mass survey fuelled the iterative process leading to a final prototype. Notable features included: therapist profile page, smart appointment reminders and patient timeline. Positive feedback was received from university students and ICS Digital, with scope to trial the app within Manchester CCG.

Conclusions: In the long run, the app aims to indirectly shorten waiting times by addressing treatment expectations and serving as an IAPT companion along the patient journey, thus reducing anxiety and consequently DNAs.

Background: The General Medical Council (GMC) states that all intimate examinations should have a chaperone offered. Documentation of chaperone identity, or patient's refusal, is essential.

Objective: This project aimed to improve documentation of chaperones during intimate examination of patients based in a Surgical Admissions Unit (SAU) within a large tertiary hospital in the Southwest of the UK.

Methods: A Plan-Do-Study-Act (PDSA) cycle structure was used. Initial data collection and planning occurred in December 2019. Intervention implementation and analysis occurred from January 2020 to March 2021. Intervention 1 involved presenting results at a clinical governance meeting. Intervention 2 was information posters in the SAU and intervention 3 involved training sessions for nursing staff. Intervention 4 was editing the surgical clerking proforma.

Results: Prior to interventions, chaperone identity or patient's refusal was correctly documented only 9.7% (N = 7 out of 72) of the time. Intervention 1 increased this to 34.6%. Following interventions 3 and 4, correct documentation was 25.0% and 28.6% respectively. After intervention 4 correct documentation was at 59.1%.

Conclusions: Initial documentation of chaperones was poor. Interventions 1 to 3 were successful in educating clinicians how to document accurately, but engaging individuals in person was more successful than passive education through posters. Changing the proforma structure was the most successful intervention. This suggests a visual reminder for clinicians at the point of contact with the patient is the most effective way to encourage correct documentation of chaperones, improving patient care and clinical practice.

Background: Malnutrition adversely affects clinical outcomes, necessitating a prompt and accurate assessment of nutritional status on admission. A variety of tools exist to aid nutritional assessment, of which the malnutrition universal screening tool (MUST) is recommended, but remains difficult to implement in practice.

Objective: The aim of this audit was to improve the utilisation of the malnutrition universal screening tool (MUST) in the Acute Medical Unit (AMU) at Queen Elizabeth Hospital, King's Lynn. Specifically, patients should have a completed and accurate MUST score within 6 hours of arrival to AMU and high-risk patients (MUST score ≥2) should be referred to dieticians within 48 hours of admission. The first cycle was conducted by March 2019 and the second cycle was completed 1 year later to allow assessment of interventions actioned after the first cycle.

Methods: We conducted a two-cycle audit evaluating the MUST completion and dietician referral rate of high-risk patients (defined as MUST ≥2) on the Acute Medical Unit in a district general hospital, with the standards of 80% and 100% respectively. A questionnaire was distributed after the first cycle exploring nurses' current experience and competence in using MUST.

Results: In the first cycle, MUST scores were calculated correctly in 111/150 patients (74%) and 1/9 (11%) high-risk patients were referred to dieticians. After interventions, MUST scores were calculated correctly in 77/101 patients (76%) and 2/4 high-risk patients (50%) were referred to dieticians. The nurses (n = 19) who took part in the questionnaire felt confident in MUST completion, but the average score in an objective assessment was 67%.

Conclusions: As per the literature, the first cycle demonstrated the under-utilisation of MUST in clinical practice. In response, we proposed additional face-to-face training for existing staff, the inclusion of an e-learning module within the staff's induction, and provision of ward MUST 'troubleshooting' booklets. MUST utilisation rates improved upon re-auditing, but not to target standards. We will need to consider potential barriers to sustainable change and implement interventions such as identification of nursing champions to overcome them.