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Variations in healthcare provider training & experience [45] [52] and failure to acknowledge the prevalence and seriousness of medical errors also increase the risk. [53] [54] The so-called July effect occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979 to 2006 ...
Patient safety is a discipline focused on improving health care through the prevention, reduction, reporting, and analysis of errors and other types of unnecessary harm that often lead to adverse patient events.
Healthcare systems are complex in that they are diverse in both structure (e.g. nursing units, pharmacies, emergency departments, operating rooms) and professional mix (e.g. nurses, physicians, pharmacists, administrators, therapists) and made up of multiple interconnected elements with adaptive tendencies in that they have the capacity to change and learn from experience.
2012: As of 2 November 2012 in the New England Compounding Center meningitis outbreak, 753 cases of fungal infection occurred with 64 deaths due to contaminated injectable medication. 2012: 2012 Pakistan fake medicine crisis; 2017: medical cannabis in California found to contain dangerous bacteria and fungi, causing at least one fatality. [19]
A never event is the "kind of mistake (medical error) that should never happen" in the field of medical treatment. [1] According to the Leapfrog Group never events are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." [2]
A Mortality Review Task Force reviews and selects cases to be presented at each M&M conference. Cases selected include all deaths, significant patient injuries, and near-death situations. A core team of senior quality consultants prepares the selected cases for presentation, gathering and reviewing information that may have caused the case.
After the trial, a Change.org petition requesting clemency for Vaught quickly garnered over 200,000 signatures. [2] [14]In response to the public backlash, the prosecutor's office issued a statement in which it defended its decision to prosecute Vaught: "The jury's conviction of Radonda Vaught was not an indictment against the nursing profession or the medical community.
For example, in a study examining the effect of the drug apixaban on the occurrence of thromboembolism, 8.8% of placebo-treated patients experienced the disease, but only 1.7% of patients treated with the drug did, so the relative risk is 0.19 (1.7/8.8): patients receiving apixaban had 19% the disease risk of patients receiving the placebo. [4]