Medical good luck and medical bad luck

Every individual experiences good luck and bad luck. Three features characterize medical events associated with good luck or bad luck: There is no control over the event, the event occurs through chance or accident, and the event is of significant interest. These characteristics can be used to develop a working definition of medical luck. Medical good luck and medical bad luck are typically assigned to either the individual or to the event, but assigning these instead to the relationship between individual and event provides the opportunity for intervention. By assigning valences to each individual‐event relationship and summating them, the total good luck or bad luck associated with the event can be determined. Intervening in the medical event by increasing the valence of the significance for each affected individual to the event will increase that event's total good luck. A total valence of zero before or after intervention does not, however, imply absent medical luck but simply a combination of medical good luck and medical bad luck because significance interest in the event persists. Therefore, there is no medical luck simpliciter, only medical good luck and medical bad luck. Medical events are especially helpful to understanding good luck and bad luck, because they are non‐fictional, often generate significant interest, and are modifiable.     

Building safety into ICU care

The Institute of Medicine's (IOMs) report, "To Err is Human," recently addressed patient safety in the United States, alerting the nation to the need for improved systems of health care. Seven main findings were addressed in this report, we focus on 3: (1) patient safety is a nationwide problem, (2) health care workers are not to blame, and (3) safety and harm are products of care systems. This article discusses systems in intensive care units (ICUs) and how these systems affect patient safety. We use a case example to outline the complex chain of medical and administrative system failures that can result in an adverse event. Then we discuss evidence linking ICU organizational characteristics with patient safety, focusing on how safer systems in ICUs can directly improve patient care.     

Evidence‐based medicine meets person‐centred care: a collaborative perspective on the relationship

In a recent list‐serve, the way forward for evidence‐based medicine was discussed. The purpose of this paper was to share the reflections and multiple perspectives discussed in this peer‐to‐peer encounter and to invite the reader to think with a mind for positive change in the practice of health care. Let us begin with a simple question. What if we dared to look at evidence‐based medicine (EBM) and informed shared decision making like two wheels on a bike? They both need to be full of substance, well connected, lubricated and working in balance, propelled and guided by a competent driver, with good vision to get the bike where we want it to go. We need all the tools in the toolkit for the bike to stay operational and to meet the needs of the driver. By the same rationale, evidence alone is necessary but not sufficient for decision making; values are necessary and if neglected, may default to feelings based on social pressures and peer influence. Medical decisions, even shared ones, lack focus without evidence and application. Just as a bike may need a tune up from time to time to maintain optimal performance, EBM may benefit from a tune up where we challenge ourselves to move away from general assumptions and traditions and instead think clearly about the issues we face and how to ask well‐formed, specific questions to get the answers to meet the needs we face in health care.     

Patient safety in the NICU: a comprehensive review

Patient safety is a worldwide priority aimed at preventing medical errors before they cause death, harm, or injury. Medical errors impact 1 in 10 patients worldwide (WHO), and their implications may include death, permanent, or temporary harm, financial loss, and psychosocial harm to the patient and in some cases to the caregiver. The unique aspects and the complexity of the neonatal intensive (NICU) environment, in addition to the vulnerability of the neonatal population increase the risk for medical errors. The following article offers an overview of safety issues specific to neonatal intensive care and provides strategies and examples on how to ensure safe practice. In particular, the authors focus on strategies to improve the team process. Practice recommendations and research implications are presented.     

Medical errors,drug-related problems,and medication errors: a literature review on quality of care and cost issues

Medical errors have received a great deal of attention in recent years. The phrase medical errors is an umbrella term for all errors that occur within the health care system, including mishandled surgeries, diagnostic errors, equipment failures, and medication errors. This article is a review and discussion of the literature on the scope of medical errors, with a focus on drug-related problems and medication errors. Cost and quality ideas for addressing these issues are provided.     

Safety promotion and error reduction in perinatal care: lessons from industry

Medical error has been revealed as a significant cause of morbidity and mortality in the United States. Accordingly, patient safety and error reduction are the current focus of health care risk management. Prevalent cultures of blame and fear relative to error are counterproductive and professional cultures that focus on best practices and patient safety must be developed. Industries outside of health care offer valuable resources for error identification and reduction. In perinatal care, lessons from industry and business include application of human factors research, teambuilding, standardization, and use of electronic medical records.     

Demonstration of High-fidelity Simulation Team Training for Emergency Medicine

Emergency medicine (EM) presents many cognitive, social, and systems challenges to practitioners. Coordination and communication under stress between and among individuals and teams representing a number of disciplines are critical for optimal care of the patient. The specialty is characterized by uncertainty, complexity, rapidly shifting priorities, a dependence on teamwork, and elements common to other risky domains such as perioperative medicine and aviation. High-fidelity simulators have had a long tradition in aviation, and in the past few years have begun to have a significant impact in anesthesiology. A national, multicenter research program to document the costs of teamwork failures in EM and provide a remedy in the form of an Emergency Team Coordination Course has developed to the point that high-fidelity medical simulators will be added to the hands-on training portion of the course. This paper describes an evolving collaborative effort by members of the Center for Medical Simulation, the Harvard Emergency Medicine Division, and the MedTeams program to design, demonstrate, and refine a high-fidelity EM simulation course to improve EM clinician performance, increase patient safety, and decrease liability. The main objectives of the paper are: 1) to present detailed specifications of tools and techniques for high-fidelity medical simulation; 2) to share the results of a proof-of-concept EM simulation workshop introducing multiple mannequin/ three-patient scenarios; and 3) to focus on teamwork applications. The authors hope to engage the EM community in a wide-ranging discussion and handson exploration of these methods.     

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study

PURPOSE: The aim of this study is to determine if patient safety incidents and the system-related factors contributing to them systematically differ for medical versus surgical patients in intensive care units. MATERIALS AND METHODS: We conducted a multicenter prospective study of 646 incidents involving adult medical patients and 707 incidents involving adult surgical patients that were reported to an anonymous patient safety registry over a 2-year period. We compared incident characteristics, patient harm, and associated system factors for medical versus surgical patients. RESULTS: The proportion of safety incidents reported for medical versus surgical patients differed for only 3 of 11 categories: equipment/devices (14% vs 19%; P = .02), "line, tube, or drain" events (8% vs 13%; P = .001), and computerized physician order entry (13% vs 6%; P < or = .001). The type of patient harm associated with incidents also did not differ. System factors were similar for medical versus surgical patients, with training and teamwork being the most important factors in both groups. CONCLUSIONS: Medical and surgical patients in the intensive care unit experience very similar types of safety incidents with similar associated patient harm and system factors. Common initiatives to improve patient safety for medical and surgical patients should be undertaken with a specific focus on improving training and teamwork among the intensive care team.     

医用胶粘剂相关性皮肤损伤研究的新进展

医用胶粘剂在医疗护理环境中被广泛使用,但医务人员对其导致的皮肤损伤却没有重视.MARSI的发生率较高,可能会引起疼痛、感染等,导致患者的生活质量降低.笔者在广泛查阅文献的基础上,综述MARSI的流行病学、发病机制、类型、高危因素、预防措施和治疗措施几个方面的研究新进展,旨在为预防和护理此类皮肤损伤提供依据.     

The Importance of Needlestick and Sharps Safety for Nurses and Staff in the Interventional Radiology Setting

Needlestick injuries continue to be one of the most serious health and safety threats in our health care workplaces. Because of the invasive nature and unique procedural circumstances of interventional radiology (e.g., dark environment, sterile drapes, etc.), nurses and radiologists are at a high risk of accidental needlestick and sharps injuries. As a natural result of these procedural circumstances, the focus of the staff is on the patient and his or her well-being, and it is likely not on the safety of the staff during or after the procedure, when the risk of injury is greatest. Despite the fact that the majority of US acute care facilities have now largely converted to the use of safety-engineered medical devices, after the first decade of the Needlestick Safety and Prevention Act of 2000, a large number of nurses and other personnel still remain at serious risk of injury. By combining proactive measures—such as training staff on the correct use of medical safety devices, establishing injury prevention teams, and evaluating all medical safety devices thoroughly—with reactive measures like maintaining an accurate injury log, nurses will be able to come to work with a lessened risk of needlestick and sharps injuries and be able to educate one another on how to make these types of injuries a “never event” in the health care setting.     

Preparing placement supervisors for primary care: an interprofessional perspective from the UK

Spinal cord injury is a devastating condition, requiring extensive rehabilitation from a range of health care professionals. However, it is unclear if patients view the professionals' input into their rehabilitation in the same way as those professionals. This paper presents findings from a qualitative study into patient participation in spinal cord injury rehabilitation. The aim of the part of the study reported here was to identify whether there is agreement between health care professionals and patients perceptions of professional roles in spinal cord injury rehabilitation. Results are presented from semi-structured interviews conducted with five doctors, five physiotherapists, three occupational therapists and 20 patients in a spinal cord injury unit in England. Findings suggest considerable agreement between professionals and patients about the role those professionals play in their rehabilitation. Physiotherapists are perceived to be key to rehabilitation, occupational therapists focus on hand function but physiotherapists and occupational therapists complement each other. Doctors coordinate the team yet reduce their input as patients move out of the acute phase into rehabilitation. There are some tensions but the early input of these professionals into patients' rehabilitation may help to develop understanding of roles. Congruence between patients and professionals may mean that patients have realistic expectations and encourage a more equal relationship between them.     

Medical error,disclosure and patient safety: A global view of quality care

Medical errors are a prominent issue in health care. Numerous studies point at the high prevalence of adverse events, many of which are preventable. Although there is a range of severity in errors, they all cause harm, to the patient, to the system, or both. While errors have many causes, including human interactions and system inadequacies, the focus on individuals rather than the system has led to an unsuitable culture for improving patient safety. Important areas of focus are diagnostic procedures and clinical laboratories because their results play a major role in guiding clinical decisions in patient management. Proper disclosure of medical errors and adverse events is also a key area for improvement. Globally, system improvements are beginning to take place, however, in Canada, policies on disclosure, error reporting and protection for physicians remain non-uniform. Achieving a national standard with mandatory reporting, in addition to a non-punitive system is recommended to move forward.     

Establishment of the National Consortium for Regenerative Medicine and National Regenerative Medicine Database in Japan

With its aim to regain the function of organs that are damaged by illness or injury, regenerative medicine has become the global focus of research. To accelerate the development and establishment of sufficient safety measures in regenerative medicine in Japan, the Pharmaceuticals and Medical Devices Act and the Act on Safety of Regenerative Medicine were enacted in 2014. Advancements in regenerative medicine are anticipated to draw attention toward the development of a system that consolidates and uses valuable data from studies performed from premarketing to postmarketing stages. Data gathered from premarketing to postmarketing stages of clinical research would promote new development avenues that would lead to the establishment of appropriate evaluation methods for new regenerative medical products by data validation. Against this background, the Japanese Society for Regenerative Medicine has been working to establish a national consortium for promoting regenerative medicine and constructing a large-scale clinical data registry, called the National Regenerative Medicine Database. This article aims to introduce the current framework of regenerative medicine in Japan, with a particular focus on the activity for establishment of a national consortium for regenerative medicine and the National Regenerative Medicine Database.     

新版心身研究诊断标准及其临床应用

心理、社会变量及其与生物学变量的互动,在各种内科疾病的患病脆性、病程和临床结局中的作用至关重要,特别是非稳态负荷相关的慢性应激。新版心身医学研究标准(DCPR)为心身医学临床研究和应用提供了新的有效方法,宏观分析是确定生物和心理社会变量与医疗干预个体目标之间关系的有用工具,对患者的个体化照料必须建立在有效的心身整体化评估基础上,个体化照料整合了各种慢性病各阶段药物和心理干预,在这方面开发新的心身评估和干预模式有着广阔的情景。心理皮肤病学、心理心脏病学和心身消化病学等心身整合医学模式的快速发展,推动了医学保健多学科融合,克服了当今生物医学模式下分科细化的缺陷。心身医学模式应从宏观理念向临床可操作的理论和实践探索。     

Patient safety: honoring advanced directives

Healthcare providers typically think of patient safety in the context of preventing iatrogenic injury. Prevention of falls and medication or treatment errors is the typical focus of adverse event analyses. If healthcare providers are committed to honoring the wishes of patients, then perhaps failures to honor advanced directives should be viewed as reportable medical errors.     

Medical workforce planning in Australia: process, methodology and technical issues

This article describes the process, methods and technical issues associated with national level planning of the medical workforce in Australia. In Australia, workforce planning is also undertaken for the nursing and allied health workforces using largely similar processes and methods outlined below, with obvious modifications for differences in data sources, structures and practice. In Australia, the focus is also switching to a more integrated planning approach along care group lines, for example emergency care, diabetes care. This approach is still in its infancy and some technical and methodology issues are unresolved. Much of the health workforce planning in Australia is undertaken at the national level through the research team at the National Health Workforce Secretariat, although some work is also undertaken by individual jurisdictional health departments and other stakeholders. Information about the national health workforce agenda and the outcomes of the research and analysis is available through the Health Workforce Australia website at http://www.healthworkforce.health.nsw.gov.au. It should be acknowledged that the main sections of this article have been summarised from the 2003 publication Specialist Medical Workforce Planning In Australia, prepared by the Australian Medical Workforce Advisory Committee and the National Health Workforce Secretariat.     

Des RMM à la conception d’indicateurs de qualité et de sécurité : dix ans de travaux sur les RMM en réanimation

The intensive care unit (ICU) is an important source of life-threatening adverse events (AE), despite the monitored environment and the high density of caregivers. Indeed, ICUs are identified as high-risk settings, due to the complexity of the diagnostic or therapeutic procedures, the multiplicity of actors involved in decision management, and the multiple severe organ failures in ICU patients. Since the publication of the Institute of Medicine’s ground-breaking report, To Err is Human, Building a Safer Health Care System, in 1999, prospective studies have shown a highly variable rate of AE in ICU, according to the type of AE reported, and most of whom were medication administration errors. Medical error occurs during the implementation phase of health care procedures in about three-quarter of all cases in the ICU and there would be a cumulative effect on the risk of error. Ways of improving the systems for preventing and limiting the effects of in-ICU AE have become a major concern in the last two decades. Efficiency of medical practices founded on the evidence-based medicine matches with the standards recognized by the Health Care Authorities to promote quality of care. However, the efficiency and continuous improvement of the quality of care is insufficient for a full understanding of the concept of patient safety. Indeed, patient safety includes the effort to reduce or eliminate potentially preventable AE. Automation, computerization, double checking, and bundles of care also reduce the human errors but have limitations. A system-based approach where the determination of how the error occurred is important, as is the case in standardized mortality and morbidity conferences, which support quality improvement and safety culture in the ICU.     

Hospice and Palliative Medicine: A Novel Subspecialty of Emergency Medicine

Background: Emergency Medicine (EM) is a resuscitative discipline where the major focus in teaching and practice is to rapidly diagnose, stabilize, and initiate curative therapy. Thus, it may seem counterintuitive to have Hospice and Palliative Medicine (HPM), a specialty often perceived as a last resort measure “when no more can be done” for the patient, included as the latest subspecialty of EM. Objective: We discuss the scope of practice and the role of HPM in the emergency department (ED) to clarify some commonly held misconceptions. Discussion: HPM principles are frequently applied in ED patient care. EM clinicians routinely rely on many of the same skills that are refined and advanced by HPM when treating symptoms, facilitating goals of care discussions, communicating bad news, and integrating the treatment of the physical, psychological, and social suffering in patient care. The HPM approach to care is patient-centered as opposed to disease-centered, with a focus on the relief of distressing symptoms to improve the quality of life. This parallels ED care, where priority is given to alleviate distressing symptoms such as acute pain or vomiting, regardless of the underlying disease process. In fact, EM is one specialty in which we may submit a bill purely based on an International Classification of Diseases-9^th Revision symptom code. Conclusion: In this article we explore the background of HPM; outline the principles and core skills of HPM that are applicable to the daily practice of EM; and explore the pathway, now available, towards a subspecialty certification.