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Applying the universal protocol to improve patient safety in radiology services

R E V I E W S & A N A L Y S E S
Applying the Universal Protocol to Improve ABSTRACT
INTRODUCTION
Multiple failed organizational and Although much of the attention paid to patient and procedure verification has focused on surgery, occurrences of patient misidentification, procedure mistakes, and side or to wrong-patient, wrong-procedure, site confusion errors and near misses continue to surface outside the surgical suite. wrong-side, and wrong-site errors in Despite quality improvement efforts, the prevalence of these errors in other disciplines, radiology services. Explanations for such namely, radiology services, may be more common than generally expected and reported errors are linked to similarities in sites, in the literature. 1 In 2009, the Pennsylvania Patient Safety Authority received reports of diagnostic studies, and patient names; 652 events specifically related to wrong-procedure or test (50%), wrong-patient (30%), wrong-side (15%), and wrong-site (5%) radiology errors. Predominant testing modali- teamwork; patient and procedure fac- ties reported to the Authority included radiography (45%), computed tomography tors; and failed safety systems. Review (CT) scan (18%), mammography (15%), magnetic resonance imaging (MRI) (6%), and of events reported to the Pennsylvania ultrasound (5%). The Table outlines the number of wrong-patient, wrong-procedure, Pa tient Safety Authority in 2009 identi- wrong-side, and wrong-site events associated with each radiologic study. fied specific processes that exposed Ensuring correct patient identification is a recognized healthcare challenge, and the patients to potential harm, including acute care setting poses the greatest challenge because a wide range of interventions order and scheduling inaccuracies, are delivered in various locations by numerous staff who work in shifts.2 The radiol- patient misidentification, and inaccurate ogy staff—most notably, radiologic technologists—comes in contact with a significant procedure verification practices. Imple- number of patients on a daily basis. Failure to correctly identify patients and correlate menting and enforcing policies that their clinical information to an intended radiologic study continues to result in one of address patient identification and pro- four recognized wrong events: wrong patient, wrong procedure, wrong side, or wrong cedure verification processes to prevent site. Patient misidentification can lead to unnecessary risks, including overexposure to errors, as well as ensuring that staff are radiation, delay in diagnosis and treatment, and incorrect treatment.
continually trained, provides radiology While such errors are preventable, they continue to occur and to contribute to services with opportunities for improve- national health and patient safety concerns. Establishing policies and standard prac- ments that not only can be observed tices similar to those developed for surgery and supported by key leadership may by providers but can be expected by help radiology providers in hospitals and outpatient centers reduce variability among patients. (Pa Patient Saf Advis 2011 individual care providers and teams in preventing unintended procedures and untow- ard patient outcomes. Prevention of these events requires safety systems that ensure accurate procedure ordering and scheduling, as well as patient identification and veri-fication processes that work to ultimately prevent wrong-patient and wrong-procedure errors. It is essential that the effectiveness of implemented safety systems is continually observed, evaluated, and monitored to prevent future events. CAUSES OF THE FOUR WRONG EVENTS
Review of the 652 events identified several failed processes that accounted for the
wrong events experienced in radiologic services. These processes were categorized as
follows:
— Failure to follow site and procedure verification or procedure qualification Incorrect Order or Requisition Entry Patients were erroneously subjected to a radiology study as a result of an inaccurate order entry originating from patient care areas (e.g., floor, emergency department [ED]) or radiology registration or clerical personnel or caused by a technologist who selected the wrong option that generated an inaccurate requisition form. Improper orders included order entries that did not specify whether a procedure was to be done with Pennsylvania Patient Safety Advisory
2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A L Y S E S
Table. Wrong Events by Radiologic Study Reported to the Pennsylvania Patient Safety Authority, 2009 NUMBER OF
PERCENTAGE OF
RADIOLOGIC STUDY
WRONG EVENT
WRONG EVENTS WRONG EVENTS
Procedure
Total Number of
Events
Total Percentage of

and the test completed. Requisition tions that were the opposite of what was did not state, “no oral contrast.” intended. These types of electronic order Event reports submitted to the Authority A test order was received for dobuta- entry errors occurred because of the lack in 2009 also revealed that physician offices mine nuclear cardiac scan. The scan of verification between the placed order was started, and when the patient verifying clinical information before sched- was able to exercise, [staff] called uling a patient for a radiologic study or [physician’s] office. The physician’s procedure. These inadequate protocols led office stated that they realized they physician. Such errors contributed to the to one of the four wrong events, usually procedure-type errors that accounted for because of one of the following factors: A script was checked for “bone whole body” but the physician’s office wanted an ankle brachial index instead. The A physician ordered bilateral hands A patient arrived for a scheduled and wrist x-rays. The registrar incor- MRI of the cervical spine. The physi- rectly entered orders for bilateral hands cian’s order was for the thoracic spine. and feet. The technician did not verify MRI of thoracic spine was completed. the physician’s order and completed — An incorrect radiologic study or site The physician’s office notified MRI bilateral hands/wrists and feet x-rays. when they received results of incorrect test. Test was scheduled correctly, but pelvis were ordered with intravenous physician’s order was incorrect. contrast and no oral contrast. The patient was prepped for oral contrast Pennsylvania Patient Safety Advisory
2011 Pennsylvania Patient Safety Authority distinct patient identification (e.g., rather than using a patient’s name and date of patient. In the events in which a patient birth, for example, patients were identi- total of 98 near-miss events (i.e., a medical fied using room numbers, or procedure another patient’s name and information, or radiologic studies). Other identifica- radiologists subsequently interpreted stud- ies for the wrong patient. Interception of the error was usually made by the radiolo- reported pertaining to the improper order, hospital room because the patient misun- previous films, after reviewing records, or not actively engaged in the identification after noting the patient’s birthdate. The a screening rather than a diagnostic mam- process, or the patient for whom a study another unit, and the new patient occupy- Patient came into the hospital to ing the bed was taken for the radiologic have an ultrasound done. A [radiol- study instead. Similarly, orders may not ogy] staff member went out to the waiting room to get an outpatient for In other instances, physician orders were a chest x-ray and called for “Mary.” accurate, but scheduling errors occurred: the x-ray department where the staff mammograms instead of diagnostic, 1 (3%) patient. Requiring patients to actively member did a two-view chest x-ray. was scheduled as a diagnostic instead of a respond to questions (i.e., “What is your The staff member did not verify the screening study, and in 22 (56%) events, patient’s last name or date of birth. the type of study (screening or diagnostic) ing the patient’s information (i.e., “Are you Jane Doe?”), and accepting a “yes” Transport called to bring patient specified. All the reports indicated that the or “no” answer or a head nod, invites A to radiology. Transport brought opportunities for misidentification errors. patient B with patient A’s medical As specified by the Joint Commission’s record. Technologist verified the need to suggest the more appropriate study. NPSG, the patient’s room number or physical location should never to be used name on medical record and asked patient if her name was patient A. as an identifier because a patient’s loca- Patient responded “yes.” The exam tion may change during his or her stay. 4 Patient misidentification errors commonly was performed. Nurse then called and delayed the prescribed procedure for the informed technologist that the wrong correct patient or allowed an unnecessary patient was transported to the [radiol- procedure to be conducted on a patient.
noted in the Table. Joint Commission’s Patient was inadvertently scanned in first National Patient Safety Goal (NPSG), Additional factors that contributed error. Radiology requested this patient in the central transport tracking tification,” was established to eliminate radiographic studies from failed misiden- system not realizing there were two tification processes were transporting the patients with the same name. This wrong patient to radiology with the right patient was brought to the scanner patient. NPSG 01.01.01, “Use at least two patient chart, performing a radiographic by transport and verified that he identifiers when providing care, treatment study using the wrong patient name, was this patient (by name only). The and services,” has been in effect since selecting the wrong patient from the work second identifier (date of birth) was January 2003 and is applicable to all three list, misinterpreting the patient’s name not checked. A short time later, it Joint Commission accreditation programs or confusing patients having similar- was discovered that the wrong patient office-based surgery).3 The events reported wrong patient chart, canceling a request to the Authority consistently noted that technologists failed to use two forms of Pennsylvania Patient Safety Advisory
2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A L Y S E S
A patient arrived for an upper exter- nal arterial ultrasound exam. The sary or inappropriate radiology studies as technologist identified the patient and began asking the patient about her Issues of side or site discrepancy—usually leg symptoms. The patient described symptoms of the lower extremities, often jeopardized patient safety. Patient other forms of metal (e.g., stents, surgical rupted by phone calls and, distracted, clips, bullet shards) or current use of a such challenges of laterality, including without first verifying the physician’s for the procedure (e.g., metformin) were only one side was ordered and vice versa, order. The error was discovered after misidentification of the correct body part, the end of the exam and the patient parts when not ordered (e.g., cervical and results were checked for renal function. thoracic spine imaged when only cervical order for an abdominal x-ray to view the kidneys, ureters, and bladder ings may be accessed and reviewed in the occurred as a result of misinterpreting the (KUB) with other modifiers on the following Advisory issues: MRI (March order or prescription (e.g., MRI instead of form, “left ulcer lower extremity rule 2009), pregnancy (March 2008), and renal CT scan), administering contrast when no out osteomyelitis.” When the patient contrast was ordered or, conversely, not was questioned, he insisted on a his- tory of abdominal pain and the need tion series. The patient was taken to the radiology department where the incident, the supervisor was noti- she was asked if she was pregnant, misreading an order or the technologist’s fied. The doctor’s office was called to and she responded with a “no.” Staff failure to verify an order, duplicating pro- clarify order. Left leg [radiograph] was person was not aware that a serum cedures because previous test completion needed, not a KUB. The patient was pregnancy test had been ordered. X-ray called to return for the correct films. series was completed when the positive mislabeling images. Site misidentification A review of the event reports found that pregnancy test results were received. four (1.2%) of the wrong procedures were An elderly patient with right lower (1) technologists were distracted during the procedure, (2) technologists relied on orders, or prescriptions were illegible.
pelvis. Technologist injected iodine or when the order or physician’s prescrip- A patient registered with a bilateral creatinine [level] of 2.4. After the tion referenced an alternate side or site, rib order; [staff] misunderstood the patient [was questioned] for consent script [because] writing was sloppy. for intravenous [access], he stated he [The technologist] did the x-ray and then realized that the script really was not diabetic and had no history Staff printed report and noted addi- said “just right side” after a bilateral of kidney dysfunction or disease. [Pre- tional [breast] views needed so the vious] labs were normal. Technologist additional [studies] were performed. did not check for current lab results A patient came over to the radiology images to the radiologist, [it was] dis- department with an order for a cervi- covered that she had read the wrong cal spine x-ray. After completion, the THE ROLE OF COMMUNICATION
report from the printer. This patient ED called over and said that a lum- IN PREVENTING WRONG
needed only to have imaging on the bar spine was supposed to be done left breast. Staff did two images of instead. The order was not written the right breast as well as the left. clearly and was mistaken for a cervi- database of physician self-reported occur-rences, Colorado researchers found that Pennsylvania Patient Safety Advisory
2011 Pennsylvania Patient Safety Authority A patient was admitted complaining exam performed by another technolo- gist. The patient was then returned to ordered anterior/posterior CT scan the floor with chart documentation views. Oral contrast was sent to the completed. Radiology received a call patient. The patient was preoperative; indicating that the wrong patient the surgeon was upset because now had been transported to the depart- communication. 5 Based on their findings surgery is delayed due to contrast. The nurse and [unit] secretary did not technologists occurred with patient study period, the authors concluded that inform [radiology] that the CT scan “non-surgical disciplines equally contrib- ute to patient injuries related to wrong-site Patients were susceptible to unnecessary USE OF THE UNIVERSAL
procedures” and suggested that the proto- radiation exposure not only because they PROTOCOL IN RADIOLOGY
col be expanded to nonsurgical specialties. or a body part was misidentified, but The principles of the Universal Protocol technologists to perform studies that had discontinuity of care stem from a variety ferred to disciplines other than surgery of causes, ranging from a lack of interper- sonal communication skills to barriers in Order for abdominal ultrasound was in the “to do” box for the ultrasound technologist. The procedure was com- munication errors in the events reported pleted. Afterward, the technologist to the Authority resulted from the follow- found a “cancel” order in the system ing types of misinformation: transmission across all specialties—not just surgical mentation. The technologist found disciplines—have been urged to adhere to the “cancel” order in the recycle bin. the Universal Protocol as a standardized mation), inadequate documentation (e.g., fully improve the safety culture and completed studies or canceled orders were performance in radiology. The role of the that promote safe and accurate verifica-not documented), and failure to effec- technologist is not only to gather, docu- tion in diagnostic radiology is especially tively perform a preprocedure verification ment, and transmit patient information; important. Although laterality becomes an or time-out (e.g., proper forms of patient he or she must also verify procedures to issue in a limited number of procedures in be performed or those already completed interventional radiology, 9 the four wrong pared to other documents, the ordering or by communicating with other personnel referring physician was not contacted to and the patient to ensure that the correct the correct site is chosen. It may not be increase in the level of care, prolonged sequelae, or death.10 In addition to the Universal Protocol, the National Patient practices could fail if the proper interac- critical treatments if radiographic studies tive communication skills are not used in a surgical safety checklist especially for tion or the wrong physician is notified of patient results, and unnecessary radiation Patient arrived in the ED and radiol- ogy with “hand-off” communication form verified by nurse and transpor-tation for patient. The chart was Universal Protocol for invasive radiology verified by one technologist and the Pennsylvania Patient Safety Advisory
2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A L Y S E S
— Apply the protocol for proper patient — Provide technologists with the neces- — Involve all personnel assigned to the STRATEGIES THAT MITIGATE
PREVENTABLE WRONG EVENTS
Mitigation of preventable errors in radi- software programs that can “red flag” system safeguards that improve order and scheduling practices, patient identifica- tion, and procedure verification protocols. Consider the following strategies, which are based on a review of events submitted ordering physician before performing — Advise referring physicians and — Appoint strong leadership within the policies is essential for these practices uses a record and ‘read back’ process gists, clerks, and referring physicians) Pennsylvania Patient Safety Advisory
2011 Pennsylvania Patient Safety Authority opportunities, affect or may later affect systems, (2) discuss the successes and patient well-being. logic services may differ from those errors safety is at the forefront for all staff. in surgical settings, they are all rooted in CONCLUSION
effective safety systems. Prevention of radi- procedure verification, and ability to Implementation of quality and safety ology-related iatrogenic injuries requires strategies poses a significant challenge for the development of safety strategies and communication efforts as well as pro- radiology services, yet provides opportu- vide staff with constructive feedback. nities for improvement. The four wrong scheduling practices, patient identifica- — Share adverse events and near misses events of wrong patient, wrong procedure, tion, and procedure verification protocols frequently than healthcare providers and procedure. Such initiatives, however, are effective only if they are followed by all unnecessary exposure to radiation, delay can be used in staff training sessions in treatment, and other possible missed 10. WHO surgical safety checklist: for radio- site, wrong-procedure, and wrong-patient self-reported occurrences. Arch Surg 2010 logical interventions only [online]. 2010 adverse events: are they preventable? Arch 2. Patient identification. PA PSRS Patient E, et al. Quality initiatives: anatomy and 11. Joint Commission. PC.02.01.03, EP 20. Nov 12]. Available from Internet: http:// clinical radiology practice. Radiographics In Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace (IL): Joint 7. Scott, A. Improving communication for better patient care. Radiol Technol 2007 12. Ensuring safe, accurate medical radiation 3. US Department of Veterans Affairs. 2010 Joint Commission national patient safety 8. Joint Commission. The universal protocol Society of Radiologic Technologists. [San- performance [online]. 2010 Jan/Feb [cited details [online]. [cited 2010 Oct 12]. Avail- 13. American Registry of Radiologic Technol- ogists. Our mission [online]. [cited 2011 May 19]. Available from Internet: https:// jcfaqdetails.aspx?StandardsFaqId=145& 5. Stahel PF, Sabel AL, Victoroff MS, et al. procedure, wrong person surgery” to the mistakes. Healthc Risk Manag 2010 practice of interventional radiology. J Vasc Interv Radiol 2008 Aug;19(8):1145-51.
Pennsylvania Patient Safety Advisory
2011 Pennsylvania Patient Safety Authority PENNSYLVANIA
ADVISORY
This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 2—June 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed.
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The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org.
An Independent Agency of the Commonwealth of Pennsylvania
ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.

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