Textbook of Patient Safety and Clinical Risk Management

Foreword
Preface
Acknowledgements
Contents
Part I: Introduction
1: Guidelines and Safety Practices for Improving Patient Safety
1.1 Introduction
1.2 The Need to Understand Guidelines Before Improving Safety
1.3 The Current Patient Safety Picture and the Demand for Guidelines
1.4 Implementing the Research on Patient Safety to Improve Clinical Practice
1.5 Working Towards Producing Guidelines That Improve Safety Practices
1.6 The Challenges of Improving Safety and the Current Limits of Guidelines
1.7 Recommendations
References
2: Brief Story of a Clinical Risk Manager
2.1 Introduction
2.2 The Start
2.3 The Evolution of the Patient Safety System
2.4 The Network of Clinical Risk Manager
2.5 Training and Instruction
2.6 Adverse Events
2.7 The First Results
2.8 The Relationship with Politics and Managers
2.9 The Italian Law on the Safety of Care
References
3: Human Error and Patient Safety
3.1 Introduction
3.2 What Is an Error?
3.3 Understanding Error
3.3.1 Slips and Lapses
3.3.2 Mistakes
3.3.3 Violations
3.4 Understanding the Influence of the Wider System
3.5 Contributory Factors: Seven Levels of Safety
3.6 Putting It All Together: Illustration of Two Cases from an Acute Care Setting
3.6.1 Case 1: An Avoidable Patient Fall
3.6.2 Case 2: An Avoidable Emergency Laparotomy in a Case of Ectopic Pregnancy
3.7 Conducting Your Own Incident Investigation
3.8 Systems Analysis of Clinical Incidents
3.8.1 From Analysis to Meaningful Action
3.9 Supporting Patients, Families, and Staff
3.10 Conclusions and Recommendations
References
4: Looking to the Future
4.1 Introduction
4.2 The Vision for the Future
4.3 The Challenges to Overcome to Facilitate Safety
4.4 Develop the Language and Culture of Safety
4.5 Promote Psychological Safety
4.6 Design for Health and for Safety
4.7 Social Determinants of Patient Safety
4.8 Harnessing Technology for the Future (Reference Chap. 33)
4.9 Conclusion
References
Overview
Develop the Language and Culture of Safety
Psychological Safety and Well-Being
Design for Safety
Social Determinants for Patient Safety
Digital Health and Patient Safety
5: Safer Care: Shaping the Future
5.1 Introduction
5.2 Thinking About Safer Healthcare
5.2.1 Accidents and Incidents: The Importance of Systems
5.2.2 Culture, Blame, and Accountability
5.2.3 Leadership at the Frontline
5.3 Global Action to Improve Safety
5.3.1 Patient Safety on the Global Health Agenda
5.3.2 World Alliance for Patient Safety: Becoming Global
5.3.3 The Global Patient Safety Challenges
5.3.4 Patients and Families: Championing Change
5.3.5 African Partnerships for Patient Safety
5.3.6 Third Global Patient Safety Challenge: Medication Without Harm
5.3.7 The 2019 WHA Resolution and World Patient Safety Day
5.4 Conclusions
References
6: Patients for Patient Safety
6.1 Introduction
6.2 What is Co-production in Healthcare?
6.3 Background: The Genesis of a Global Movement for Co-production for Safer Care
6.4 Co-Production in Research
6.4.1 Example: United States
6.4.1.1 Mothers Donating Data: Going from Research to Policy to Practice
6.4.1.2 Civil Society: Driving Patient-Centered Research to Prevent Diagnostic Errors
6.5 Co-production in Medical Professions Education Courses
6.5.1 Example: Mexico
6.5.1.1 Leveraging a Regional Network of PFPS Champions to Enhance Medical Education
6.5.2 Example: Denmark
6.5.2.1 Patients as Educators
6.6 Co-production in Healthcare Organization Quality Improvement
6.6.1 Example: Egypt
6.6.1.1 Improving Disparities in Care for New Mothers: The Power of Partnership Between a Civil Society Leader and a Public Teaching Hospital
6.6.2 Italy
6.6.2.1 Democratizing Healthcare: A Government-Driven/Citizen Partnership to Improve Patient Centeredness
6.7 Co-Production in Policy
6.7.1 Example: Canada
6.7.1.1 Working from Within: Co-producing National Policy as an Insider
6.8 Conclusion
References
7: Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents
7.1 Introduction
7.2 Application of SEIPS Model to Medical Residents
7.3 Linkage of Work System to Patient Safety and Medical Resident Well-Being
7.4 Challenges and Trade-Offs in Improving Residents’ Work System
7.5 Role of Residents in Improving Their Work System
7.6 Conclusion
References
Part II: Background
8: Patient Safety in the World
8.1 Introduction
8.2 Epidemiology of Adverse Events
8.3 Most Frequent Adverse Events
8.3.1 Medication Errors
8.3.2 Healthcare-Associated Infections
8.3.3 Unsafe Surgical Procedures
8.3.4 Unsafe Injections
8.3.5 Diagnostic Errors
8.3.6 Venous Thromboembolism
8.3.7 Radiation Errors
8.3.8 Unsafe Transfusion
8.4 Implementation Strategy
8.5 Recommendations and Future Challenges
Bibliography
9: Infection Prevention and Control
9.1 Introduction
9.2 Main Healthcare-Associated Infection
9.2.1 Urinary Tract Infections (UTIs)
9.2.2 Bloodstream Infections (BSIs)
9.2.3 Surgical Site Infections
9.2.4 Healthcare-Associated Pneumonia
9.3 Antimicrobial Resistance
9.4 Healthcare-Associated Infection Prevention
9.4.1 The Prevention and Control of Healthcare-Associated Infection: A Challenge for Clinical Risk Management
9.4.2 Risk Management Tools
9.4.2.1 Root Cause Analysis
9.4.2.2 Significant Event Audit
9.4.2.3 Process Analysis
9.4.2.4 Failure Modes and Effects Analysis
9.4.3 The Best Practices Approach
9.4.3.1 Hand Hygiene
9.4.3.2 Antimicrobial Stewardship
9.4.3.3 Care Bundles
CAUTI Maintenance Bundle
Ventilator Bundle
9.5 Engaging Patients and Families in Infection Prevention
9.6 Identification and Rapid Management of Sepsis: A Test Bed for the Integration of Risk Management and IPC
9.6.1 Sepsis and Septic Shock Today
9.6.2 Sepsis as an Adverse Event: Failures in Identification and Management
9.7 Conclusions
References
10: The Patient Journey
10.1 Introduction
10.2 The Patient Journey
10.3 Contextualizing Patient Safety in the Patient Journey
10.4 From PartecipaSalute to the Accademia del Cittadino: The Importance of Training Courses to Empower Patients
10.5 Recommendations
References
11: Adverse Event Investigation and Risk Assessment
11.1 Risk Management in Complex Human Systems and Organizations
11.1.1 Living with Uncertainty
11.1.2 Two Levels of Risk Management in Healthcare Systems
11.2 Patient Safety Management
11.3 Clinical Risk Management
11.4 Systemic Analysis of Adverse Events
11.4.1 The Dynamics of an Incident
11.4.2 A Practical Approach: The London Protocol Revisited
11.5 Analysis of Systems and Processes Reliability
11.6 An Integrated Vision of Patient Safety
References
12: From Theory to Real-World Integration: Implementation Science and Beyond
12.1 Introduction
12.1.1 Characteristics of Healthcare and Its Complexity
12.1.2 Epidemiology of Adverse Events and Medical Errors
12.1.2.1 Barriers to Safe Practice in Healthcare Settings
12.1.3 Error and Barriers to Safety: The Human or the System?
12.2 Approaches to Ensuring Quality and Safety
12.2.1 The Role of Implementation Science and Ethnography in the Implementation of Patient Safety Initiatives
12.2.1.1 WHO Twinning Partnership for Improvement (TPI) Model
12.2.1.2 Institute for Healthcare Improvement Breakthrough Collaborative
12.2.1.3 Case Study: Kenya
12.2.2 Challenges and Lessons Learned from the Field Experience and the Need for More Extensive Collaboration and Integration of Different Approaches
12.2.3 Human Factors and Ergonomics
12.3 Way Forward
12.3.1 International Ergonomics Association General Framework Model
References
Part III: Patient Safety in the Main Clinical Specialties
13: Intensive Care and Anesthesiology
13.1 Introduction
13.2 Epidemiology of Adverse Events
13.3 Most Frequent Errors
13.4 Safety Practices and Implementation Strategies
13.4.1 Medication Errors
13.4.2 Monitoring
13.4.3 Equipment
13.4.4 Cognitive Aids
13.4.5 Communication and Teamwork
13.4.6 Building a Safety Culture
13.4.7 Psychological Status of Staff and Staffing Policies
13.4.8 The Building Factor
13.5 Recommendations
References
14: Safe Surgery Saves Lives
14.1 Safety Best Practices in Surgery
14.2 Factors Which Influence Patient Safety in Surgery
14.3 Techniques and Procedures
14.4 Surgical Equipment and Instruments
14.5 Pathways and Practice Management Guidelines
14.6 Gender
14.7 Training
14.8 Costs and Risks
14.9 Infection Control
14.10 Surgical Safety Checklist
14.11 Overlap Between Surgical and Other Safety Initiatives
14.12 Technical and Non-technical Skills
14.13 Simulation
14.14 Training Future Leaders in Patient Safety
14.15 Clinical Cases
14.15.1 “I was rather sure that they were here!!!” The Case of the Missing Forceps
14.15.1.1 Case Analysis According to Risk Management Approach
14.15.2 “I used to move my left arm before surgery” A Case of Patient Positioning on the Operating Table
14.15.2.1 Case Analysis According to Risk Management Approach
14.15.3 “My clinic note said to remove the left lung nodule” A Case of Wrong Site Surgery
Bibliography
15: Emergency Department Clinical Risk
15.1 Background of Emergency Departments
15.2 Epidemiology of Adverse Events in Emergency Department
15.3 Most Frequent Errors Depends on: Patient, Provider, and System
15.4 Safety Practices and Implementation Strategy
15.4.1 Infrastructure Requirement
15.4.2 Basic Clinical Management Process and Protocols for Quality Emergency Care
15.4.3 Establishing a Unit Quality Department
15.4.4 Measuring Quality of Performance (Quality Indicators)
15.4.5 Sharing Best Practices
15.4.6 Adapting to Changing Realities
15.4.6.1 Digitization
15.4.6.2 Measuring Patient Feedback
Service Excellency
Clinical Audit
15.4.6.3 Test Optimization
15.4.6.4 Work Culture
Safety
Reference to Standards
Communication Best Practice
Culture of Safety
Standardize
Regulation
Financial Incentive
Liability Reform
15.5 Clinical Cases About Worse Practices That Didn’t Consider the Importance of Non-Technical Skills/Technical Skills
15.5.1 Non-Technical Skills Case
15.5.2 Technical Skills: Central Venous Line
15.6 Recommendation
References
16: Obstetric Safety Patient
16.1 Introduction
16.2 Patient Safety
16.3 Most Frequent Errors and Adverse Events
16.4 Recommendation
References
17: Patient Safety in Internal Medicine
17.1 Epidemiology of Adverse Events
17.2 Most Common Errors
17.2.1 Patient Identification Errors
17.2.2 Clinical Reasoning Errors
17.2.3 Medication Errors
17.2.3.1 Special Focus: Oxygen and Noninvasive Ventilation
17.2.4 Interventional Procedure-Related Errors
17.2.5 Communication Errors
17.2.5.1 Handoff
17.2.5.2 Ward Round
17.2.5.3 Clinical Records
17.3 Safety Practices and Implementation Strategy
17.3.1 Prevention of Age and Frailty-Related Adverse Events
17.3.2 Prevention of Healthcare-Associated Infections
17.3.3 Prevention of Venous Thromboembolism
17.3.4 Prevention of Pressure Ulcers
17.3.5 Clinical Monitoring by Early Warning Scores
17.3.6 Sepsis Bundles
17.3.7 Safe Management of Outlier Patients
17.4 Case Studies
17.4.1 Case Study 1
17.4.2 Case Study 2
17.4.3 Epicrisis and Recommendations
17.4.3.1 Clinical Case 1
17.4.3.2 Clinical Case 2
References
18: Risks in Oncology and Radiation Therapy
18.1 Introduction
18.2 The Epidemiological Context
18.3 Epidemiology of Adverse Effects
18.4 Medication Errors in Oncology Practice
18.5 Safety Practices and Implementation Strategy in Clinical Oncology
18.6 Radiotherapy
18.7 Safety Practices and Implementation Strategy for Radiotherapy
18.8 Volumes–Outcomes Relationship in Surgery
18.9 Case History
18.10 Final Recommendations
References
19: Patient Safety in Orthopedics and Traumatology
19.1 Introduction
19.2 Epidemiology of Adverse Advent
19.3 Most Frequent Errors
19.4 Safety Practices and Implementation Strategy
19.5 Clinical Cases
19.5.1 Case 1
19.5.2 Case 2
19.6 Recommendations
References
20: Patient Safety and Risk Management in Mental Health
20.1 Introduction
20.2 Epidemiology of Adverse Events in Patients Receiving Mental Healthcare
20.2.1 Nondrug-Related Adverse Events
20.2.1.1 Falls
20.2.1.2 Assault
20.2.1.3 Sexual Contact
20.2.1.4 Self-Harm
20.2.1.5 Other Nondrug Adverse Events
20.2.2 Drug Adverse Events
20.3 Medical Errors in Psychiatric Care
20.3.1 Common Errors and Dangerous Outcomes
20.3.1.1 Medication Errors
20.3.1.2 Restraint and Seclusion
20.3.1.3 Suicide
20.3.2 Nondrug Medical Error
20.3.2.1 Errors Contributing to Elopement
20.3.2.2 Errors Contributing to Contraband
20.3.2.3 Other Errors
20.4 Safety Practices and Implementation Strategies
20.4.1 Role of the Hospital Environment in Patient Safety
20.4.2 Role of Organizational Management in Patient Safety
20.4.3 Role of Staff in Patient Safety
20.4.4 Role of the Patient in Patient Safety Practices
20.5 Conclusion
20.6 Case Studies
20.6.1 Case Example 1
20.6.1.1 Discussion
20.6.2 Case Example 2
20.6.2.1 Discussion
References
21: Patient Safety in Pediatrics
21.1 Epidemiology of Adverse Events in Pediatrics: Some Numbers and Some Reflections
21.2 The Importance of Understanding the Context for Patient Safety Practices for Pediatrics
21.2.1 Simulation as a Key Factor for Implementation of Solutions for Safety in Pediatrics
21.2.2 Clinical Case: Safe Care in Pediatric Emergency
21.2.2.1 9.15 pm
21.2.2.2 9.18 pm
21.2.2.3 9.20 pm
21.2.2.4 9.24 pm
21.2.2.5 9.27 pm
21.2.2.6 9.32 pm
21.2.2.7 9:34 pm
21.2.2.8 Final Considerations
References
22: Patient Safety in Radiology
22.1 Introduction
22.2 Radiation Protection
22.3 Magnetic Resonance Imaging (MRI) Hazards
22.3.1 Static Magnetic Fields (SMF)
22.3.2 Gradient Magnetic Fields (GMF)
22.3.3 Radiofrequency (RF) Magnetic Field
22.3.4 Implants and Devices
22.4 Contrast Agent-Related Risks
22.4.1 Patient Selection
22.4.2 Identify the Risk Factors and Contraindications
22.4.3 Safe Injection of Contrast Agents
22.4.4 Allergy-Like and Chemotoxic Reactions
22.4.5 Adverse Events Related to Iodinated Contrast Agents
22.4.6 Adverse Events Related to Gadolinium-Based Contrast Agents (GBCA)
22.5 Conclusion
References
23: Organ Donor Risk Stratification in Italy
23.1 Background
23.1.1 The Donor Risk
23.1.2 The Principles of Donor Risk Evaluation
23.1.3 The Risk Evaluation Process
23.1.3.1 Organ Procurement
23.1.3.2 Posttransplant Course
23.1.4 The Donor Risk Categories
23.2 Discussion
References
24: Patient Safety in Laboratory Medicine
24.1 Epidemiology of Adverse Events
24.1.1 Laboratory Medicine as a Driver in Ensuring Patient Safety
24.1.2 From Laboratory-Related Errors to Diagnostic Errors
24.2 Safety Practices and Implementation Strategy
24.2.1 ISO 15189 Accreditation
24.2.2 Quality Indicators
24.2.3 Professional Competence: Education and Skill
24.2.4 Risk Management Procedures
24.3 Clinical Cases
24.4 Recommendations
References
25: Patient Safety in Ophthalmology
25.1 Introduction
25.2 Epidemiology of Adverse Events: Safety Practices and Implementation Strategy
25.2.1 Cataract Surgery
25.2.1.1 Intraoperative Adverse Events
25.2.1.2 Postoperative Adverse Events
25.2.1.3 Safety Practices and Implementation Strategy in Cataract Surgery
A. Preoperative Care
Patient Assessment
Supplemental Evaluation
Risk Stratification
B. Perioperative Care
Patient Alimentation and Therapy
Prophylaxis of Infections and Sterility
C. Postoperative Care
D. Training
25.2.2 Intravitreal Injection Therapy
25.2.2.1 Adverse Events, Safety Practices, and Implementation Strategy
25.3 Most Frequent Errors: Safety Practices and Implementation Strategy
25.3.1 The Most Common Medical Errors and Preventive Strategies in Ophthalmology
25.3.1.1 Wrong-Site Eye Surgery
Introduction
Causes and Risk Factors
Preventive Strategies
A. The Universal Protocol
B. Consent Form
25.3.1.2 Cataract Surgery-Related Errors
Introduction
Causes and Risk Factors
Preventive Strategies
25.3.1.3 Intravitreal Therapy-Related Errors
Introduction
Preventive Strategies
25.3.1.4 Medication-Related Errors in Ophthalmology
Introduction
Causes and Risk Factors
Preventive Strategies
25.4 Clinical Case
25.4.1 Clinical Case Recommendations
25.5 Recommendations
25.6 Conclusion
References
Part IV: Healthcare Organization
26: Community and Primary Care
26.1 Epidemiology of Adverse Event
26.2 Most Frequent Errors
26.2.1 Preclinical Errors
26.2.2 Clinical Errors
26.3 Clinical Cases
26.3.1 Clinical Case: Being Alert
26.3.2 Clinical Case: A Foreseeable Error
26.4 Safety Procedures
26.4.1 Diagnosis
26.4.2 Prescribing
26.4.3 Communication
26.4.4 Organizational Change
26.5 Recommendations
References
27: Complexity Science as a Frame for Understanding the Management and Delivery of High Quality and Safer Care
27.1 The Complexities of Healthcare
27.2 Managing Complexity
27.3 Responding to Complexity
27.4 Researching Quality and Safety Using Complexity Thinking
27.5 Real World Examples
27.5.1 The Lynch Syndrome Study
27.5.2 Research on Medical Emergency Teams
27.5.3 Social Networks in a Ward and an Emergency Department
27.5.4 Australian Genomics as a Learning Community
27.5.5 The Deepening Our Understanding of Quality in Australia Studies
27.6 Extending These Ideas and Studies to the Future Organisation of Quality and Safety
27.7 Where to From Here?
27.8 Recommendations
References
28: Measuring Clinical Workflow to Improve Quality and Safety
28.1 What Is Clinical Workflow?
28.2 Studying Clinical Workflow
28.2.1 Approaches for Studying Clinical Workflows
28.2.2 Time and Motion Studies
28.2.3 What Types of Questions Can Clinical Workflow Studies Answer?
28.2.4 Interruptions
28.2.5 Multitasking
28.3 Cultural and Organisational Considerations in Conducting Clinical Workflow Studies
28.4 Data Quality, Analysis and Interpretation in Clinical Workflow Studies
28.4.1 Important Practical Considerations with Ensuring Data Quality in Workflow Studies
28.4.2 Analysis
28.4.3 Inter-observer Reliability
28.4.4 Disseminating Findings to Influence Practice and Policy
28.5 Conclusion
References
29: Shiftwork Organization
29.1 Introduction to Shift Work
29.1.1 Definition and Main Features
29.1.2 Chronobiological Aspects
29.2 Effects of Shift Work on Worker Health and Impact on Patient Safety
29.2.1 Sleep Deprivation and Vigilance
29.2.2 Interference in Performance Efficiency and Patient Safety
29.2.3 Health Disorders
29.3 Preventive Actions and Recommendations
29.3.1 Ergonomic Criteria for the Organization of Shift Schedules
29.3.2 Other Organizational Aspects
29.4 Some Considerations for Resident Doctors
References
30: Non-technical Skills in Healthcare
30.1 Introduction
30.1.1 Practical Overview of NTS Training Topics in Healthcare
30.2 Performance Shaping Factors
30.3 Planning and Preparation Skills
30.4 Situation Awareness and Perception of Risk
30.4.1 ‘Perception of Risk’
30.5 Expert Decision-Making
30.5.1 Metacognition
30.5.2 Affect
30.5.3 Communication and Decision-Making
30.5.4 Stress and Decision-Making
30.6 Communication
30.6.1 Specific/Directed/Acknowledged Communication
30.6.2 Briefings and Handovers
30.6.3 SBAR
30.6.4 Escalation of Concern: Graded Assertiveness
30.7 Teamwork and Leadership Skills
30.7.1 The ‘Anatomy’ of Teams
30.7.2 Unidisciplinary Teams
30.7.3 Multidisciplinary Teams
30.7.4 Committees
30.7.5 Improving Team Performance
30.7.6 Calling for Help Early: Team Assembly
30.7.7 Team Structure: Clear Leader, Roles and Goals
30.7.8 Team-Oriented Communication
30.7.9 Decision-Making
30.7.10 Managing Workload and Time
30.7.11 Team Situation Awareness
30.7.12 Team Familiarity, Group Climate and Interpersonal Conflict
30.7.13 Debriefing
30.7.14 Leadership, Command and Control
30.7.15 Leadership Styles and Situational Leadership
30.7.16 Transferable Command and Control
30.8 Teaching Non-technical Skills
30.9 Summary
References
31: Medication Safety
31.1 Introduction
31.1.1 A Focus on Transitions of Care, Polypharmacy and High-Risk Situations
31.1.2 Learning Objectives
31.1.3 Learning Outcomes: Knowledge and Performance
31.1.3.1 Knowledge Requirements
31.1.3.2 Performance Requirements
31.2 Medication Safety in Transitions of Care
31.2.1 Prevalence of Medication Discrepancies
31.2.2 Medication-Related Harm During Transitions of Care
31.2.3 Making Medication Use Safer During Transitions of Care
31.2.3.1 Medication Reconciliation
31.2.3.2 Information Clarity and Availability at All Transition of Care Points
Appropriate Tools and Technology
Electronic Health Records (EHRs)
Information to Support Safe Use of Medications
31.2.3.3 Patient Engagement and Education
31.2.3.4 Monitoring and Measurement
31.3 Medication Safety in Polypharmacy
31.3.1 Prevalence of Polypharmacy
31.3.2 Medication-Related Harm in Polypharmacy
31.3.3 Approaches for Addressing Polypharmacy
31.3.3.1 Measuring Appropriateness of Medications
31.3.3.2 Medication Reviews
31.3.3.3 Rational Prescribing
31.3.3.4 Deprescribing
31.3.3.5 Health System Changes
31.3.3.6 Practical Tips
31.3.3.7 Practicing Patient-Centred Care
31.4 High-Risk Situations in Medication Safety
31.4.1 Medication Errors and Related Harm in High-Risk Situations
31.4.1.1 High-Risk Medications
31.4.1.2 High-Risk Patients
31.4.1.3 High-Risk Contexts
31.4.2 Some Ways to Ensure Medication Safety in High-Risk Situations
31.4.2.1 High-Risk Medications
31.4.2.2 High-Risk Patients
31.4.2.3 High-Risk Contexts
31.5 Final Recommendations and Conclusions
References
32: Digital Technology and Usability and Ergonomics of Medical Devices
32.1 Introduction
32.2 Some Studies on Medical Devices
32.3 Beneficiaries of Usable Medical Devices
32.4 Usability Evaluation
32.4.1 Methods for Usability Assessment
32.4.2 The Usability Assessments in Reality
32.5 Conclusion
References
33: Lessons Learned from the Japan Obstetric Compensation System for Cerebral Palsy: A Novel System of Data Aggregation, Investigation, Amelioration, and No-Fault Compensation
33.1 Context for the Introduction of the JOCS-CP: Increasing Conflict Over Cerebral Palsy and Hopes for a No-Fault Compensation System
33.2 The Meaning of “No-Fault Compensation” in the JOCS-CP
33.3 Compensation Driven by the Indemnity Insurance Mechanism
33.4 Monetary Compensation
33.5 Epidemiology of Adverse Events
33.6 Investigation: Identifying Error During Delivery
33.7 Controversy on Disclosing Preventability in Individual Cases
33.7.1 Guidance for “The Items to Consider for Better Obstetrical/Perinatal Care” Section of the Investigative Report
33.7.2 Guidance for Handling Questions from Guardians/Families During the Investigative Process
33.8 Survey on the Investigative Report
33.9 Most Frequent Errors
33.10 Safety Practices and Implementation Strategy
33.11 Two Clinical Cases
33.11.1 Case 1
33.11.1.1 Clinical Course
33.11.1.2 Probable Cause of Cerebral Palsy
33.11.1.3 Evaluation of Procedures
33.11.1.4 Recommendations
33.11.2 Case 2
33.11.2.1 Clinical Course
33.11.2.2 Probable Cause of Cerebral Palsy
33.11.2.3 Evaluation of Procedures
33.11.2.4 Recommendations
33.12 Recommendations
33.12.1 Vacuum Delivery
33.12.2 Administration of Uterine Contracting Agents
33.12.3 Fetal Heart Rate Monitoring
33.12.4 Care for Placental Abruption
Further Readings
34: Coping with the COVID-19 Pandemic: Roles and Responsibilities for Preparedness
34.1 Introduction
34.2 COVID-19 Summary
34.3 Magnitude of COVID-19
34.4 Fundamental Aspects of the WHO Pandemic Plan
34.4.1 Phases
34.4.2 Framework
34.4.3 Overarching Goals
34.4.4 Key Actions
34.5 Criticalities in the Application of the WHO Pandemic Approach During the COVID-19 Outbreak
34.5.1 Planning and Coordination
34.5.2 Situation Monitoring and Assessment
34.5.3 Prevention and Containment
34.5.4 Healthcare System Response
34.5.5 Communication
34.5.5.1 Make the Message Clear
34.5.5.2 Keep the Message Consistent
34.5.5.3 Timeliness
34.5.5.4 Monitor Social Media
34.5.5.5 Select the Most Appropriate Method of Communication
34.6 Improvement Actions Based on Lessons Learned
34.6.1 General Guidelines
34.6.2 Guidelines for Obstetrics and Pediatrics
34.6.3 Guidelines for Caring for Immunocompromised Patients
34.6.4 Guidelines for Special Contexts
34.6.5 Guidelines for General Practitioners
34.6.6 Guidelines for Long-Term Care Facilities
34.6.7 Guidelines for Hemodialysis Patients
34.7 Conclusions
References