Abstract:
OBJECTIVES:Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hindsight bias. This study compared the recorded triage calls of patients with chest discomfort contacting the OHS-PC in whom an ACS was missed (cases), with triage calls involving matched controls with chest discomfort but without a missed ACS (controls), with the aim to assess the predictors of missed ACS. METHODS:A case-control study with data from 2013 to 2017 of 9 OHS-PC in the Netherlands. The cases were matched 1:8 with controls based on age and sex. Clinical, patient, and call characteristics were univariably assessed, and general practitioner experts evaluated the triage while blinded to the final diagnosis or the case-control status. RESULTS:Fifteen missed ACS calls and 120 matched control calls were included. Cases used less cardiovascular medication (38.5% versus 64.1%, P = 0.05) and more often experienced pain other than retrosternal chest pain (63.3% versus 24.7%, P = 0.02) compared with controls. Consultation of the supervising general practitioner (86.7% versus 49.2%, P = 0.02) occurred more often in cases than in controls. Experts rated the triage of cases more often as "poor" (33.3% versus 10.9%, P = 0.001) and "unsafe" (73.3% versus 22.5%, P < 0.001) compared with controls. CONCLUSIONS:To facilitate learning from serious adverse events in the future, these should also be bundled and carefully assessed without hindsight bias and within the context of "normal" clinical practice.
journal_name
J Patient Safjournal_title
Journal of patient safetyauthors
Erkelens DC,Rutten FH,Wouters LT,Kirkels HG,Poldervaart JM,de Groot E,Damoiseaux RA,Hoes AW,Zwart DLdoi
10.1097/PTS.0000000000000799subject
Has Abstractpub_date
2020-12-14 00:00:00eissn
1549-8417issn
1549-8425pub_type
杂志文章abstract:OBJECTIVE:This study aimed to gather qualitative feedback on patient perceptions of informed consent forms and elicit recommendations to improve readability and utility for enhanced patient safety and engagement in shared decision making. METHODS:Sixty interviews in personal interviews were conducted consisting of a l...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000310
更新日期:2016-08-03 00:00:00
abstract:OBJECTIVES:This study was designed to explore awareness and attitudes of community pharmacists toward the national ADR reporting system activities in the northern states of Malaysia. METHODS:A cross-sectional survey using a validated self-administered questionnaire was used in this study. The questionnaire was deliver...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000051
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e31824badce
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journal_title:Journal of patient safety
pub_type: 杂志文章
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更新日期:2020-03-23 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000346
更新日期:2017-03-17 00:00:00
abstract:OBJECTIVES:In recent years, several instruments for measuring patient safety culture (PSC) have been developed and implemented. Correct interpretation of survey findings is crucial for understanding PSC locally, for comparisons across settings or time, as well as for planning effective interventions. We aimed to evalua...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000585
更新日期:2019-03-15 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000349
更新日期:2017-06-30 00:00:00
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journal_title:Journal of patient safety
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doi:10.1097/PTS.0000000000000733
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000270
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000326
更新日期:2020-12-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e31821b8a6c
更新日期:2011-06-01 00:00:00
abstract:BACKGROUND:In the pediatric setting, adverse events occurring at the administration stage are the most common type of preventable adverse drug events. Few data are available on the effect of advice from medical professionals on medication safety. METHODS:This is a prospective cohort study of 1685 pediatric patients, 6...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181b3a9b0
更新日期:2009-09-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000578
更新日期:2021-01-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000107
更新日期:2017-03-01 00:00:00
abstract:AIMS:This study measured the effect of aviation-style team training on 3 surgical teams from different specialties. It focused on team working and communication, particularly briefing, time-out, and debriefing, and sought to understand how improvements in team skills could be implemented in a broad range of naturalisti...
journal_title:Journal of patient safety
pub_type: 杂志文章,多中心研究
doi:10.1097/PTS.0b013e3181f100ea
更新日期:2010-09-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000049
更新日期:2015-06-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e31822b07ee
更新日期:2011-09-01 00:00:00
abstract:OBJECTIVES:Drugs can come in concentrated solutions that require dilution before intravenous bolus administration. Upon dilution, the syringe can contain more than the required amount of drug. The user may mistakenly administer the full contents of the syringe, resulting in an overdose. In this cross-sectional study, w...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000770
更新日期:2020-09-08 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000117
更新日期:2015-12-01 00:00:00
abstract:INTRODUCTION:Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable s...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3182446c51
更新日期:2012-03-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000251
更新日期:2020-06-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000516
更新日期:2018-07-18 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000533
更新日期:2018-09-05 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000168
更新日期:2018-03-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
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更新日期:2019-12-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e318267c4aa
更新日期:2012-12-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181a974d9
更新日期:2009-06-01 00:00:00
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journal_title:Journal of patient safety
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更新日期:2018-06-27 00:00:00
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journal_title:Journal of patient safety
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doi:10.1097/PTS.0b013e31829e4cc0
更新日期:2014-09-01 00:00:00
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journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000397
更新日期:2020-09-01 00:00:00