Zoekresultaten

Reporting incidents involving the use of advanced medical technologies by nurses in home care

Background: Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systematically. Objectives: To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods: A cross-sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used. Results: We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation's protocol. Conclusions: Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.

KLM, science-based targets, and the Paris Agreement. Expert Report

Reporting incidents involving the use of advanced medical technologies by nurses in home care

Background  Advanced medical technologies (AMTs), such as respiratory support or suction devices,  are increasingly used in home settings and incidents may well result in patient harm.  Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systenaticaly. Objectives  To identify the frequency of incidents when using  AMTs in home settings,  the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods  A cross- sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps,  combining data from a questionnaire and registration forms covering more than 13 000 patient contacts.  Descriptive statistics were used. Results  We identified 140 incidents (57 adverse events;  83 near misses).  The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy,  1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%),  the organisation of care (27.9%),  the nurse as a user (15.7%) and the environment (12.9%).  40% of all adverse events resulted in mild to severe harm to the patient.  Incidents had been discussed in the team (70.7%),  with the patient/informal caregiver(s) (50%),  or other actions had been taken (40.5%).  15.5% of incidents had been formally reported according to the organisation’s protocol. Conclusions  Most incidents are attributed to product failures.  Although such events predominantly cause no harm,  a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with  AMTs in home care. This study has identified a discrepancy in quality circles:  learning takes place at the team level rather than at the organisational level.

The potential of training specialist oncology nurses in real‑life reporting of adverse drug reactions

Abstract Specialist oncology nurses (SONs) have the potential to play a major role in monitoring and reporting adverse drug reactions (ADRs); and reduce the level of underreporting by current healthcare professionals. The aim of this study was to investigate the long term clinical and educational efects of real-life pharmacovigilance education intervention for SONs on ADR reporting. This prospective cohort study, with a 2-year follow-up, was carried out in the three postgraduate schools in the Netherlands. In one of the schools, the prescribing qualifcation course was expanded to include a lecture on pharmacovigilance, an ADR reporting assignment, and group discussion of self-reported ADRs (intervention). The clinical value of the intervention was assessed by analyzing the quantity and quality of ADR-reports sent to the Netherlands Pharmacovigilance Center Lareb, up to 2 years after the course and by evaluating the competences regarding pharmacovigilance of SONs annually. Eighty-eight SONs (78% of all SONs with a prescribing qualifcation in the Netherlands) were included. During the study, 82 ADRs were reported by the intervention group and 0 by the control group. This made the intervention group 105 times more likely to report an ADR after the course than an average nurse in the Netherlands. This is the frst study to show a signifcant and relevant increase in the number of well-documented ADR reports after a single educational intervention. The real-life pharmacovigilance educational intervention also resulted in a long-term increase in pharmacovigilance competence. We recommend implementing real-life, context- and problem-based pharmacovigilance learning assignments in all healthcare curricula.

Pathway to zero emissions in global tourism: opportunities, challenges, and implications.

Evaluation of KLM’s Climate Plan.