Post on 05-Apr-2018
transcript
7/31/2019 Errors Appendix
1/8
7/31/2019 Errors Appendix
2/8
7/31/2019 Errors Appendix
3/8
7/31/2019 Errors Appendix
4/8
7/31/2019 Errors Appendix
5/8
HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary
Term Definition Metrics Measurementmethod
Surgicalerrors Errorsintheperformanceofsurgicalprocedures.Ina
laparoscopic task,skillbasederrorsinvolveddropped
objectsandobjectsplacedinaccuratelyinthedisc
eitherontheirsideorincompletelywithinthezone;
knowledgebased
errors
occurred
when
objects
were
placedinthewrongzone(Moorthyetal.,2003).
Numberoferrorsina
surgicaltask(taskerror
score)(Moorthyetal.,
2003;Pluyteretal.,2010)
Surgerysimulationsystem
XitactLC3.0virtualrealitysimulator(XitactSA,Morges,
Switzerland).Theclipandcutassessed(CCA)taskintheClip
andCut(C&C)modulewasused.Taskerrorswererecordedby
thesimulator
(Pluyter
et
al.,
2010).
Adverseeventreportingsystem
Apassivereportingsystem.Thenurseandphysicianinvolved
inamedicationerrorcompleteanincidentreportand
documentthe
incident.
The
severity
of
patient
harm
is
rated
asnone,mild,moderate,orsevere.Medicationerrorsare
thensenttothepharmacydepartmentandenteredintoa
spreadsheetdatabase(Kingetal.,2003).
Theannualmedicationerrorindexwasmeasuredbythe
hospitalsstandardsystemforreportingadverseevents
(Hendrich,Fay,&Sorrells,2004).
Errorsweredocumentedonastandarderrorreportingform
completedbythenursecommittingtheerrorand/orstaff
discovering
the
error
(Booker
&
Roseman,
1995).
Transport,patientintra
hospitaltransport
Transportofpatientswithinthehospital(Ulrich&Zhu,
2007)
Numberofpatient
transportsbetweennursing
units/month(Hendrich,
Fay,&Sorrells,2004).
Medicalandoperationaldata
DatacollectedfromTransitionSystem,Inc.(TSI)by
Vanderbilt UniversityMedicalCenter,Nashville,TN(Hendrich,
Fay,&Sorrells,2004).
MedicalErrors:Glossary|5
7/31/2019 Errors Appendix
6/8
7/31/2019 Errors Appendix
7/8
7/31/2019 Errors Appendix
8/8
HealthcareEnvironmentalTermsandOutcomeMeasures:AnEvidencebasedDesignGlossary
Medicalerrors:Matrixofrelationships
Variable Medication
errors
Medication
administration
procedural
Adversedrug
event
Surgicalerrors Intrahospital
patienttransfer
Distraction/Interruption
Noise
Lightfixture
Illuminationlevel
Daylight
Acuityadaptableroom
Barcodeassisteddispensing
system
Bedside
assortment
picking
(BAP)
trolley
Physicalconfigurationofdrug
stockshelvesComputerizedphysicianorder
entry(CPOE)
Note:Cellsshadedingrayindicatetheexistenceofevidencesupportingrelationshipsbetweenenvironmentalfeaturesandoutcomes
Environment
feature
Outcome
MedicalErrors:MatrixofRelatioships|1