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Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification

BACKGROUND: There is a paucity of patient safety information from the community sector related to the medically fragile population requiring home mechanical ventilation (HMV). To improve safety, the risks HMV patients encounter must first be understood. OBJECTIVES: To describe patient safety inciden...

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Autores principales: Yang, Lily, Nonoyama, Mika, Pizzuti, Regina, Bwititi, Philip, John, George
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Canadian Society of Respiratory Therapists 2016
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6073515/
https://www.ncbi.nlm.nih.gov/pubmed/30123023
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author Yang, Lily
Nonoyama, Mika
Pizzuti, Regina
Bwititi, Philip
John, George
author_facet Yang, Lily
Nonoyama, Mika
Pizzuti, Regina
Bwititi, Philip
John, George
author_sort Yang, Lily
collection PubMed
description BACKGROUND: There is a paucity of patient safety information from the community sector related to the medically fragile population requiring home mechanical ventilation (HMV). To improve safety, the risks HMV patients encounter must first be understood. OBJECTIVES: To describe patient safety incidents within the HMV population and discuss opportunities for preventing harm. METHODS: A retrospective observational review of on-call logs from the Ontario Ventilator Equipment Pool (VEP) was conducted. Classification of 248 on-call logs from April 1, 2011 to March 21, 2012 was completed using the standardized tool of the World Health Organization’s (WHO) Patient Safety Taxonomy – International Classification System to quantitatively describe the types of incidents arising. Analysis of data classification was completed using descriptive and nonparametric statistics. RESULTS: Patient incidents were positive in 188 on-call logs; emerging from these were 227 incident types. Patient incident types included medical device issues (99 device failures, 41 user errors, 12 equipment availability), documentation (20 unavailable labels/prescriptions, four unclear information), clinical processes (16 inadequate treatment or general care) and clinical administration (10 inadequate handover or transfer of care). Patient incidents were associated with mild harm in 87 cases. CONCLUSIONS: The on-call logs were a good source of quality improvement data to understand harm and patient safety issues emerging in the HMV population. However, establishing a formal incident review and reporting system is required to provide a more comprehensive understanding.
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spelling pubmed-60735152018-08-17 Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification Yang, Lily Nonoyama, Mika Pizzuti, Regina Bwititi, Philip John, George Can J Respir Ther Original Article BACKGROUND: There is a paucity of patient safety information from the community sector related to the medically fragile population requiring home mechanical ventilation (HMV). To improve safety, the risks HMV patients encounter must first be understood. OBJECTIVES: To describe patient safety incidents within the HMV population and discuss opportunities for preventing harm. METHODS: A retrospective observational review of on-call logs from the Ontario Ventilator Equipment Pool (VEP) was conducted. Classification of 248 on-call logs from April 1, 2011 to March 21, 2012 was completed using the standardized tool of the World Health Organization’s (WHO) Patient Safety Taxonomy – International Classification System to quantitatively describe the types of incidents arising. Analysis of data classification was completed using descriptive and nonparametric statistics. RESULTS: Patient incidents were positive in 188 on-call logs; emerging from these were 227 incident types. Patient incident types included medical device issues (99 device failures, 41 user errors, 12 equipment availability), documentation (20 unavailable labels/prescriptions, four unclear information), clinical processes (16 inadequate treatment or general care) and clinical administration (10 inadequate handover or transfer of care). Patient incidents were associated with mild harm in 87 cases. CONCLUSIONS: The on-call logs were a good source of quality improvement data to understand harm and patient safety issues emerging in the HMV population. However, establishing a formal incident review and reporting system is required to provide a more comprehensive understanding. Canadian Society of Respiratory Therapists 2016-09-01 2016 /pmc/articles/PMC6073515/ /pubmed/30123023 Text en http://creativecommons.org/licenses/by-nc/4.0/ This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact reprints@pulsus.com
spellingShingle Original Article
Yang, Lily
Nonoyama, Mika
Pizzuti, Regina
Bwititi, Philip
John, George
Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification
title Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification
title_full Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification
title_fullStr Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification
title_full_unstemmed Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification
title_short Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification
title_sort home mechanical ventilation: a retrospective review of safety incidents using the world health organization international patient safety event classification
topic Original Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6073515/
https://www.ncbi.nlm.nih.gov/pubmed/30123023
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