The risk assessment of adverse events of nursing activities as the element of quality management in healthcare

• Autorzy: Wiśniewska M. Z. , Grudowski P. , Konieczyńska M.

Identyfikatory

DOI

10.1515/mper-2015-0010

• Języki publikacji: EN

Abstrakty

EN

The purpose of the paper is to present MedCARVER+Shock method and Pareto analysis and its usability for the risk assessment of adverse events of nursing activities. 888 activities carried out by all 190 nurses working at the District Hospital X located in Poland were taken into account. During the research the qualitative approach was used. As the result sixteen groups of nursing activities causing the highest risk of adverse events were selected. Special attention required in: admission of a patient to the ward, sterilization, verbal communication with the patient, using of intravenous cannulas, needles, syringes, devices for transfusion of infusion liquids, servicing of hospital rooms, first aid in life-threatening situations, using medical devices and equipment. Ten basic causes of the risk of adverse events were identified, among others: lack of trainings, of modern equipment, of staff, failure to comply with procedures, lack of staff supervision, poor quality of ancillary materials, lack of management commitment. Finally MedCARVER+Shock method and Pareto analysis usability has been confirmed but it appeared that it is time-consuming and requires support from skilled professionals. Several suggestions have been put forward to improve the utility of MedCARVER+Shock.

Słowa kluczowe

EN

quality management; safety; adverse events; nursing; healthcare; risk assessment

• Wydawca: Production Engineering Committee of the Polish Academy of Sciences ; Polish Association for Production Management
• Czasopismo: Management and Production Engineering Review
• Rocznik: 2015
• Tom: Vol. 6, No. 1
• Strony: 79--86
• Opis fizyczny: Bibliogr. 20 poz., tab.

Twórcy

autor

Wiśniewska M. Z.

• The University of Gdańsk, Faculty of Management, Poland

autor

Grudowski P.

• Gdańsk University of Technology, Faculty of Management and Economics, Poland

autor

Konieczyńska M.

• The University of Gdańsk, Poland

Bibliografia

• [1] Schimmel E.M., The hazards of hospitalization, Qual. Saf. Health Care, 12, 58-64, 2003.
• [2] Caplan G.A., Ward J.A., Brennan N.J., Coconis J., Board N., Brown A., Hospital in the home: a randomized controlled trial, Med. J. Australia, 170, 156-60, 1999.
• [3] Masotti P., Green M., Shortt S.E., Hinter D., Szala-Meneok K., Adverse events in community care: developing a research agenda, Health Qual, 10, 59-65, 2007.
• [4] Blais R., Sears A.N., Doran D., Baker G.R., Mcdonald M, Mitchell L., Thales S., Assessing adverse events among home care clients in three Canadian provinces using chart review, in BMJ Qual Saf, 2013: http://qualitysafety.bmj.com/content/early/2013/07/02/bmjqs-2013-002039.full, access 7.10.2013.
• [5] The Joint Commission, Sentinel Event Glossary of Terms, 2008, http://www.jointcommission.org/SentinelEvents/se glossary.htm, access 7.10.2013.
• [6] Santacruz-Varela J., Hern´andez-Torres F., Fajardo-Dolci G., Risk assessment for patient safety in health care facilities, Cir Cir, 78, 511-521, 2010.
• [7] Sears N., Baker G.R., Barnsley J., Short S., The incidence of adverse events among home care patients, Int. J. Qual. Health C, 25, 1-13, 2013.
• [8] Sano M., Munechika M., Jin H., Kajihara C., Hamadaa C., Analysis of medication incident for improvement of medication process, Total Qual Manag Bus, 24, 7-8, 859-868, 2013.
• [9] FDA.FSIS. An overview of the CARVER plus Shock method for food sector vulnerability assessments, 2007, http://www.fsis.usda.gov/wps/wcm/connect/483f86d5-a566-44f8-90d5-05a16dbe3f78/CARVER.pdf?MOD=AJPERES, access 21.10.2013.
• [10] Wallis I., CARVER plus SHOCK method for food sector vulnerability assessments, in: Proceedings One Hundred and Tenth Annual Meeting of the United States Animal Health Association, Minneapolis: United States Animal Health Association, pp. 258-268, 2007.
• [11] Wiśniewska M., Adaptation of CARVER+Shock Method in the Preliminary Flood Risk Assessment, Contemp. Manag. Quart., 9, 3, 62-71, 2010.
• [12] Sakai K., Takatsu A., Shigeta A., Fukui K., Maebashi K., Abe S., Iwadate K., Potential medical adverse events associated with death: a forensic pathology perspective, Int. J. Qual. Health C, 22, 9-15, 2010.
• [13] Sharek P.J., Classen D., The Incidence of Adverse Events and Medical Error in Pediatrics, Pediat. Clin. of N. Am., 53, 1067-1077, 2006.
• [14] Allan A., McKillop D., The health implications of apologizing after an adverse event, Int. J. Qual. Health C, 22, 126-131, 2010.
• [15] Kripalani S., Jackson A.T., Schnipper J.L., Coleman E.A., Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists, J. Hosp. Med., 2, 314-323, 2007.
• [16] Fried M.W., Side Effects of Therapy of Hepatitis C and Their Management, Hepatology, 36, S237-S244, 2002.
• [17] Grudowski P., Quality Monitoring of Therapeutica Processes in a Small Treatment Center for Children, J. Health Qual., 27, 3, 40-43, 2005.
• [18] Walshe K., Adverse events in health care: issues in measurement, Qual. Health Care, 9, 47-52, 2000.
• [19] Tsai Y., Tang T.-W., How to improve service quality: internal marketing as a determining factor, Total Qual. Manag. Bus., 19, 11, 1117-1126, 2008.
• [20] Theodorakioglou J.D., Tsiotras G.D., The need for the introduction of quality management into Greek health care, Total Qual. Manag. Bus., 11, 8, 1153-1165, 2000.