ORIGINAL_ARTICLE
Causal Inference and Analysis of Surgery Cancellation Risks
Introduction: The provision of services in hospitals is the final level of the health care system chain, which usually provides the patients with advanced medical services, such as surgery. On the other hand, the cancellation of elective surgeries is one of the problems, which reduces the quality of service delivery and decreases hospital's efficiency and patients' satisfaction followed by increases in patients' costs. This study presented an approach based on a fuzzy inference system to better assess these hazards and eliminate the related risks and investigate effective factors in the cancellation of elective surgeries. Materials and Methods: The present study conducted a case study in Shahid Arefian Hospital Urmia, Iran, during 2016-2017. Principal factors of surgery cancellations were collected from surgery documents in the hospital. These factors were divided into five classes, including paraclinical, clinical, systematic, surgeon, and patient. The hazards identified in these classes caused surgery cancellation. They were identified using the contribution of an expert team, including operating room supervisors, female and male surgery hospitalization supervisors, as well as two physicians. Results: According to the results, the proposed approach was more appropriate for creating discrimination between surgery cancellation hazards, compared to the traditional risk priority number (RPN) method. Surgeon fatigue, high PPT and PT, and airway problems were the first to third important hazards with RPNs equal to 120, 105, and 96, respectively. On the other hand, according to obtained results, not having internal medicine specialist counseling, low thyroid stimulating hormone, and unavailability of beds at intensive care units were three important and priority potential hazards with FRPNs equal to 8, 8, and 6, respectively. Conclusion: The proposed approach can better map hospital experts’ opinions to the fuzzy-based risk assessment system since it employs linguistic variables by hospitals’ experts, compared to conventional approaches. Moreover, it can help the hospital managements apply hospital resources to maximise their impacts on improving hospital efficiency.
https://psj.mums.ac.ir/article_15169_040ae77f9ce1d9b00d0c593a06df1b50.pdf
2020-01-01
3
12
10.22038/psj.2020.38946.1218
Elective surgery cancellation
Fuzzy failure mode and effects analysis
Quality Improvement
Operating room
Patient-facing risk assessment
Azra
Alizadeh
alizadeh.azra@umsu.ac.ir
1
Department of Internal Medicine, Urmia University of Medical Sciences, Urmia, Iran.
LEAD_AUTHOR
Milad
Eshkevari
m.eshkevari@ine.uut.ac.ir
2
Faculty of Industrial Engineering, Urmia University of Technology, Urmia, Iran.
AUTHOR
Mohammad Reza
Pashaei
dr.pashaei@yahoo.com
3
Department of Gastroenterology, Urmia University of Medical Sciences, Urmia, Iran.
AUTHOR
Mustafa
Jahangoshai Rezaee
m.jahangoshai@uut.ac.ir
4
Faculty of Industrial Engineering, Urmia University of Technology, Urmia, Iran.
AUTHOR
Varabyova, Yauheniya, and Julia Maria Miller. “The Efficiency of Health Care Production in OECD Countries: A Systematic Review and Meta-Analysis of Cross-Country Comparisons.” Health policy (Amsterdam, Netherlands). 2016; 120(3): 252–63.
1
Fong, Abigail J, Meghan Smith, and Alexander Langerman. “Efficiency Improvement in the Operating Room.” Journal of Surgical Research. 2016; 204(2): 371–83.
2
Gabriel RA, Wu A, Huang CC, Dutton RP, Urman RD. “National Incidences and Predictors of Inefficiencies in Perioperative Care.” Journal of Clinical Anesthesia. 2016; 31: 238–46.
3
Vaughn Lisa M. Melissa DeJonckheere, and Jayant Nick Pratap. “Putting a Face and Context on Pediatric Surgery Cancelations: The Development of Parent Personas to Guide Equitable Surgical Care.” Journal of Child Health Care. 2017; 21(1): 14–24.
4
Lee, CM, Rodgers C, Oh AK, Muckler VC. “Reducing Surgery Cancellations at a Pediatric Ambulatory Surgery Center.” AORN Journal. 2017; 105(4): 384–91.
5
Butaru F, Chen Q, Clark B, Das S, Lo AW, Siddique A. “Risk and Risk Management in the Credit Card Industry.” Journal of Banking and Finance. 2017; 72: 218–39.
6
Maskrey Shaun A, Nick J, Mount Colin R, Thorne, and Ian Dryden. “Participatory Modelling for Stakeholder Involvement in the Development of Flood Risk Management Intervention Options.” Environmental Modelling and Software. 2016; 82: 275–94.
7
Sousa, Vitor, Nuno M. Almeida, Luís A. Dias. “Risk-Based Management of Occupational Safety and Health in the Construction Industry - Part 2: Quantitative Model.” Safety Science. 2015; 74: 184–94.
8
Zwietering MH. “Risk Assessment and Risk Management for Safe Foods: Assessment Needs Inclusion of Variability and Uncertainty, Management Needs Discrete Decisions.” International Journal of Food Microbiology. 2015; 213: 118–23.
9
Aven Terje. “Risk Assessment and Risk Management: Review of Recent Advances on Their Foundation.” European Journal of Operational Research. 2016: 253(1): 1–13. http:// dx. doi. org/10.1016/j.ejor.2015.12.023.
10
Dimitriadis, P.A., Iyer, S. and Evgeniou, E. . “The Challenge of Cancellations on the Day of Surgery.” International Journal of Surgery. 2013; 11(10): 1126–30.
11
Laisi Jaana, H. Tohmo, and U. Keränen. “Surgery Cancelation on the Day of Surgery in Same-Day Admission in a Finnish Hospital.” Scandinavian Journal of Surgery. 2013; 102(3): 204–8.
12
Li L, Liu H, Hou X. “Machine Learning Methods for Bioinformatics.”http:// people. cs. missouri.edu/~chengji/mlbioinfo/mlbioinfo.htm.
13
Kaddoum, R., Fadlallah, R., Hitti, E., Fadi, E.J. and El Eid, G. “Causes of Cancellations on the Day of Surgery at a Tertiary Teaching Hospital.” BMC health services research. 2016; 16(1): 259.
14
Taymorlu, M.G., Alizadeh, A., Izadbakhsh,H., Yadeghari, O., Rezaee, M.J. "Investigation of effective factors in the cancellation of elective surgeries in Shahid Arefian Hospital, Urmia, Iran." Medical Journal of Mashhad University of Medical Sciences, 2017; 60(3): 567-579.
15
Zadeh, L.a. “Fuzzy Sets.” Information and Control. 1965; 8(3): 338–53.
16
Chang KH, Cheng CH. “A Risk Assessment Methodology Using Intuitionistic Fuzzy Set in FMEA.” International Journal of Systems Science. 2010;41(12):1457-71.
17
ORIGINAL_ARTICLE
Assessment of Medication Administration Error Reporting Among Hospital Nurses in Indonesia
Introduction: Nurses play a vital role in the maintenance and promotion of patient safety, as well as medication administration in hospitals. In one small state government-owned hospital in South Jakarta, medication errors were the most reported type of patient safety incidents accounting for 52.5% of incidents which occurred within 2016 to September 2018. Nonetheless, only a small percentage (9.25%) of those reports was presented by nurses. The present study aimed to determine the factors associated with medication administration error (MAE) reporting among nurses. Materials and Methods: A cross-sectional study, followed by qualitative research, was conducted at a state government-owned hospital in Jakarta Indonesia within November 2018-April 2019. Total sampling was used to obtain the 44 clinical nurses included in the quantitative study. The qualitative study used focus group discussion and in-depth interviews of selected informants. Results: Consequences of reporting was found to be correlated with MAE reporting among nurses (P=0.013). There was no statistically significant organizational factor or socio-demographic characteristic associated with medication administration error reporting. Through qualitative measures, the factors that most influenced and inhibited error reporting included administrative response and the consequences of reporting. Moreover, managers’ support, understanding and self- awareness of the importance of reporting, and a non-blaming culture were recognized as the factors which support error reporting. Conclusion: As evidenced by the obtained results, medication administration error reporting is still low. Reporting incidents can be improved by fostering a non-blaming safety culture. Further studies are recommended to investigate the occurrence of medication errors, as well as reported errors.
https://psj.mums.ac.ir/article_15204_23d0994d0f3d9843f613fbe7830fff70.pdf
2020-01-01
13
23
10.22038/psj.2020.43466.1244
Incident reporting
medication administration error
nurse
Indira- Puspita
Prihartono
indirapuspita_24@yahoo.com
1
Health Administration and Policy, Faculty of Public Health, University of Indonesia, Depok, Indonesia
LEAD_AUTHOR
Adik
Wibowo
kacapiring97@yahoo.com
2
Health Administration and Policy, Faculty of Public Health, University of Indonesia, Depok, Indonesia
AUTHOR
National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors [Internet]. 2018 [cited 2018 May 1]. Available from: https:// www. nccmerp. org/about-medication-errors
1
WHO. WHO launches global effort to halve medication-related errors in 5 years [Internet]. WHO. 2017 [cited 2018 Jun 1]. Available from: http://www.who.int/news-room/detail/ 29-03-2017-who-launches-global-effort- to-halve-medication-related-errors-in-5-years
2
KARS. Standar Nasional Akreditasi Rumah Sakit. 2017;421.
3
Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC. National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings [Internet]. Vol. 41, Critical Care Medicine. 2013. p. 389–98. Available from: https:// www.copus.com/ inward/record. uri?eid=2-s2.0-84873352956& doi=10.1097% 2FCCM. 0b013e318274156a&partnerID= 40 &md 5= b2f580f8614d21925d72640 c3ae f3179
4
Chalasani SH, Ramesh M. Towards patient safety: assessment of medication errors in the intensive care unit in a developing country’s tertiary care teaching hospital. Eur J Hosp Pharm [Internet]. 2017 Nov 1;24(6):361 LP – 365. Available from: http:// ejhp.bmj. com/ content/24/6/361.abstract
5
Wakefield BJ, Uden-Holman T, Wakefield DS. Development and validation of the Medication Administration Error Reporting Survey. Adv Patient Saf From Res to Implement Vol 4 Programs, Tools, Prod (AHRQ Publ No 05-0021-4). 2005;
6
Bahadori M, Ravangard R, Aghili A, Sadeghifar J, Gharsi Manshadi M, Smaeilnejad J. The Factors Affecting the Refusal of Reporting on Medication Errors from the Nurses’ Viewpoints: A Case Study in a Hospital in Iran. ISRN Nurs [Internet]. 2013 Apr 9;2013:876563. Available from: http://www.ncbi.nlm. nih.gov/pmc/ articles/ PMC3649500/
7
Rutledge DN, Retrosi T, Ostrowski G. Barriers to medication error reporting among hospital nurses. J Clin Nurs [Internet]. 2018 Mar 1;27(9–10):1941–9. Available from: https:// doi.org/10.1111/jocn.14335
8
Handler SM, Perera S, Olshansky EF, Studenski SA, Nace DA, Fridsma DB, et al. Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting. J Am Med Dir Assoc [Internet]. 2007 Nov 22;8(9):568–74. Available from: http:// www. ncbi.nlm.nih.gov/pmc/articles/PMC2151929/
9
Richter JP, McAlearney AS, Pennell ML. Evaluating the Effect of Safety Culture on Error Reporting: A Comparison of Managerial and Staff Perspectives. Am J Med Qual [Internet]. 2014 Jul 28;30(6):550–8. Available from: https:// doi.org/ 10.1177/1062860614544469
10
Hwang J-I, Ahn J. Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals. Asian Nurs Res (Korean Soc Nurs Sci) [Internet]. 2015 Mar;9(1):14–20. Available from: https://search.proquest.com/docview/1667271464?accountid=17242.
11
Maurer MJ. Nurses’ perceptions of and experiences with medication errors. Univ Toledo [Internet]. 2010;2(1):12–4. Available from: http://www.ncbi.nlm.nih.gov/pued/17335520
12
Archer S, Hull L, Soukup T, Mayer E, Athanasiou T, Sevdalis N, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. BMJ Open [Internet]. 2017 Dec 1;7(12). Available from: http://bmjopen.bmj. com/content/7/12/e017155.abstract
13
Jember A, Hailu M, Messele A, Demeke T, Hassen M. Proportion of medication error reporting and associated factors among nurses: a cross sectional study. BMC Nurs [Internet]. 2018 Mar;17(1):9. Available from: https:// doi.org/10. 1186/s12912-018-0280-4
14
Sorra J, Gray L, Streagle S. Hospital Survey on Patient Safety Culture: User’s Guide [Internet]. AHRQ Publication. 2016. Available from: http://www. ahrq.gov/ professionals/ quality-patientsafety/ patientsafetyculture/ hospital/ index.html
15
National Patient Safety Agency. Seven steps to patient safety A guide for NHS staff Seven steps to patient safety Step 1 Build a safety culture Step 2 Lead and support your staff Step 3 Integrate your risk management activity Step 4 Promote reporting Step 5 Involve and communicate with. London: National Patient Safety Agency; 2013.
16
Wakefield DJ Wakefield B, Uden-Holman T, Blegen M. Perceived barriers in reporting medication administration errors. Vol. 1, Best practices and benchmarking in healthcare : a practical journal for clinical and management application. 1996. 191–197 p.
17
Bayazidi S, Zarezadeh Y, Zamanzadeh V, Parvan K. Medication Error Reporting Rate and its Barriers and Facilitators among Nurses. J caring Sci [Internet]. 2012;1(4):231–6. Available from: http://www. ncbi.nlm.nih. gov/pubmed/ 25276700%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4161082.
18
Engeda E. Incident Reporting Behaviours and Associated Factors among Nurses Working in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia. Vol. 2016, Scientifica. 2016. 1–7 p.
19
Hewitt T, Chreim S, Forster A. Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices. Vol. 00, Journal of patient safety. 2014.
20
Neuspiel DR, Stubbs EH, Liggin L. Improving Reporting of Outpatient Pediatric Medical Errors. Pediatrics [Internet]. 2011 Dec 1; 128(6):112–3. Available from: http:// pediatrics. aappublications. org/content/128/6/e1608. abstract.
21
Rogers E, Griffin E, Carnie W, Melucci J, Weber RJ. A Just Culture Approach to Managing Medication Errors. Hosp Pharm [Internet]. 2017 Apr;52(4):308–15. Available from: https:// www.ncbi.nlm.nih.gov/pubmed/28515512.
22
Battard J. Nonpunitive response to errors fosters a just culture. Vol. 48, Nursing Management (Springhouse). 2017. 53–55 p.
23
ORIGINAL_ARTICLE
Impact of Leadership Style on Patient Safety Culture in the Department of Radiodiagnosis
Background: Healthcare organisation is a high reliability establishment hence, tackles safety on daily basis. To achieve the desired level of safety, leaders need to work and behave in a way to make it a priority. This is because leadership principles have a relationship with patient safety culture. Objective: To assess the impact of leadership style on patient safety culture in Radiodiagnosis. Materials and Method: This study was carried out among 80 health workers in Radiodiagnostic department of two tertiary health institutions. Two adopted questionnaires were used to collect data. Leadership style was assessed from subordinates’ perspective so questionnaires on leadership style were administered to 76 out of the 80 enrollees; excluding to 4 leaders in both units of the study areas. All enrollees were given questionnaires on patient safety culture to fill. The impact of leadership styles on patient safety culture was determined using Chi-square test of association, Results: Transformational and lassiez faire leadership styles have no significant association with all the domains of patient safety culture. Transactional leadership style shows a significant association with two domains of patient safety culture. However, it does not have a significant association with other domains of patient safety culture. An overall chi-square analysis shows that no significant association exists between patient safety culture and transformational (p= 0.156), transactional (p= 0.156) and lassiez faire (p= 0.659) leadership styles. Conclusion: There is no significant association between any of the leadership styles and culture of patient safety. Keywords: Leadership, Patient, safety culture, Radiodiagnosis, Health Institution.
https://psj.mums.ac.ir/article_15207_b98e121c99772df2b499412545f8a4a2.pdf
2020-01-01
25
30
10.22038/psj.2020.41439.1236
health institution
Leadership
patient
Radiodiagnosis
Safety culture
Chioma
Akuchukwu-Okafor
beholi80@yahoo.com
1
Nnamdi Azikiwe University Teaching Hospital, Nnewi Anambra State ,Nigeria.
LEAD_AUTHOR
Ime
Okon
emaediong@yahoo.com
2
Uyo Teaching Hospital Cross River, Nigeria.
AUTHOR
Anthony
Ugwu
tonybullng@yahoo.com
3
Nnamdi Azikiwe University Faculty of Health sciences and Technology, Okofia campus NNewi.
AUTHOR
Emmanuel
Chukwuemeka
ee.chukwuemeka@unzik.edu.ng
4
Nnamdi Azikiwe University, Awka
AUTHOR
Momodou B – Measuring the current trend of patient safety culture in The Gambia hospital. An MSc thesis 2012. Retrieved: 25/8/15.
1
Garbutt J, Waterman AD, Kapp JM, Dungaun W C, Lenenison W, Fraser V & Gallagher TH. Lost opportunities: How physicians communicate about medical errors. J. Health affiliation, 2008; 27(1); 246-55.
2
Ketring SP& White JP - Developing a systemwide approach to patient safety: the first year. J. Joint Comm. Qual. Impr. 2002; 28(6):287-295.
3
Obinna C. Patient safety in Nigeria is non-negotiable. Available at: www. vanguardngr.com, 2011 (Retrieved: 23/6/15).
4
Gadd S, Collins, AM (2002). Safety Culture: A review of the literature HSL/2002/25. Sheffield: Health & Safety Laboratory p.3. Available at: www. hse.gov.uk/ research/ hsl (Retrieved: 15/9/2015).
5
Ring L. Leadership and patient safety: A Review of Literature. J. of Nursing Regulation 2013; 14(10): 1-60
6
Mcfadden KL, Ilenegen SC, Gowenll CR. The safety chain: Transformational leadership’s effects on patient safety culture, initiatives outcomes. J. of operation manag. 2009; 27(5): 390-404.
7
Leonard M, Frankel – How can a leader influence safety culture. Thoughtful paper, 2012.
8
Joint commission board – The essential role of leadership in developing safety culture. Sentinel event; 57: 1-8.
9
Clarke JK. The role of leaders of healthcare organisation in patient safety. Am. J. of Med. Qual 2007; 22(5): 311-18.
10
Stewart K. Unprofessional behaviour and patient safety. The Int. J of clini. Leadership 2011; 17: 93-101.
11
Nyeberg A, Bernin P, Theorell T (2005) - Impact of leadership on the health of subordinates. Printed at ElandersGotab Stockholm, Sweden by National Institute for work and life: pp 97-102.
12
Bass B, Riggio RE. Transformational leadership, Lawrence Erlbaum Associates Mahwah. NJ. International Journal of Conflict Management, 2009; 20(4): 340-54
13
Doucet O, Poitras J. the impact of leadership on workplace conflict. Int. J. of Conflict Manage 2009; 20(4): 340-54.
14
Solvejg K, Karl BC, Jan M. Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study. BMJ, 2016. Doi: 10.1136/ bmjopen-2015-010180
15
Wagner LM, Capezuti E, Rice JC .Nurses perception of safety culture in long term care settings. J. of nursing scholarship 2009; 41(2): 184-92.
16
Jarret MP. Patient safety and leadership: Do you walk the walk? J. of healthcare manag. 2017; 62(2): 88-92.
17
Murphy L. Leadership, nursing and patient safety within a hospital based learning organisations. A PhD thesis, 2016. http:?? Ir.lib.uwo.ca/etd/4011
18
Tejada MT, Scandura TR, Pillai R. The multifactor leadership questionnaire revisited: Pyschometric properties and recommendations. The Leadership Quaterly J, 2001; 12: 31-52.
19
Squires M, Tourangeau A, Laschinger HK, Doran D. The link between leadership and safety outcomes in hospitals. J. of Nurs. Manag, 2010; 18, 914-925. doi:10.1111/j.1365-2834. 2010. 01181x
20
Kesseler O. Leadership, safety culture and patient safety culture in hospitals: In search of evidence. BMC healthcare serv. research 2014; 14(supp 2): 64.
21
ORIGINAL_ARTICLE
Evaluation of Tranexamic Acid Effect on Consequences of Upper Gastrointestinal Bleeding in Patients Referring to the Emergency Department; a Randomized Clinical Trial
Introduction: Upper gastrointestinal bleeding is one of the major and emergent causes of mortality and morbidity around the world. The tranexamic acid has been raised since years ago as a therapeutic intervention. Therefore, prize of exact and timely treatment of upper gastrointestinal bleeding, the present study aimed to evaluate the effects of systemic tranexamic acid on the possible consequences of upper gastrointestinal bleeding such as need for blood transfusion, admission in intensive care unit (ICU), surgery to control bleeding or eventually short-term mortality. Materials and Methods: This double-blind randomized clinical trial included 88 patients with upper gastrointestinal bleeding in a referral academic gastrointestinal center. Patients with symptoms of upper gastrointestinal bleeding referred to the emergency department were randomly divided into two groups: intervention group (n=45) who treated with tranexamic acid in addition to receive standard therapy for upper gastrointestinal bleeding, and control group (n=43) treated with standard therapy for upper gastrointestinal bleeding and placebo (distilled water). Results: Administration of tranexamic acid along with the standard therapy for upper gastrointestinal bleeding in the intervention group caused reduction in mortality and recurrent bleeding compared to the control group. There is no difference between two groups in need for surgery, hemotransfusion and ICU admission. Conclusion: Due to the beneficial effects of tranexamic acid administration on reducing mortality and bleeding recurrence in patients with upper gastrointestinal bleeding, added this drug to the standard therapy may have a favorable potential for upper gastrointestinal bleeding.
https://psj.mums.ac.ir/article_15308_006289b4b575f4cc45cc3f4caa5c2ad1.pdf
2020-01-01
31
36
10.22038/psj.2020.43904.1246
Intubation
Gastrointestinal hemorrhage
Tranexamic acid
Morteza
Talebi doluee
talebidm@mums.ac.ir
1
Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
AUTHOR
Sayyed Majid
Sadrzadeh
sadrzadehm@mums.ac.ir
2
Department of Emergency Medicine. Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
AUTHOR
Elnaz
Vafadar-Moradi
vafadarme@mums.ac.ir
3
Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
LEAD_AUTHOR
Hamid
Zamani moghadam
zamanimh@mums.ac.ir
4
Department of Emergency Medicine, Faculty Of Medicine, Mashhad University of Medical science , Mashhad, Iran
AUTHOR
Sanaz
Javdani
sa_javdani@yahoo.com
5
Department of Emergency Medicine, Faculty Of Medicine, Mashhad University of Medical science , Mashhad, Iran
AUTHOR
Adrian J. Stanley, Loren Laine. Management of acute upper gastrointestinal bleeding.BMJ 2019; 364: l536 doi: 10.1136/bmj. l536.
1
Barkan AN, Almadi M, Kuipers EJ, laine L, Sung J, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations from the International Consensus Group. AnnIntern Med. 2019; 171(11): 805-22.
2
Lim CH, Vani D, Shah SG, Everett SM, Rembacken BJ. The outcome of suspected upper gastrointestinal bleeding with 24-hour access to upper gastrointestinal endoscopy: a prospective cohort study. Endoscopy.2006; 38(6):581-5.
3
Masoodi M, Saberifiroozi M. Etiology and Outcome of Acute Gastrointestinal Bleeding in Iran:A Review Article. Middle East J Dig Dis.2012 Oct; 4(4): 193–8.
4
Rafeey M, Shoaran M, Majidy H. Diagnostic Endoscopy and Clinical Characteristics of Gastrointestinal Bleeding in Children: a 10-Year Retrospective Study. Iranian Red Crescent Medical Journal. 2013 September; 15(9): 794-7.
5
Beyda R, Johari d. Tranexamic acid for upper gastrointestinal bleeding. AcadEmerg mrd .2019 (5); dohi: 10, 13835.
6
Yasim A,Asik R, Atahan E. Effects of topical applications of aprotinin and tranexamic acid on blood loss after open heart surgery. Anadolu Kardiyol Derg. 2005; 5(1):36-40.بر ا
7
Gluud LL, klingenberg SK, Langholz SE. Systematic review: tranexamic acidfor upper gastrointestinal bleeding. Alimentary Pharmacology and Therapeutics.2008; 27(9): 752-8.
8
Ghosh S, Watts D, Kinner M. Management of gastrointestinal haemorrhage. Postgrad Med J. 2002; 78:4-14.
9
Yehia AH, Koleib MH, Abdelazim IA, Ahmed Atik. Tranexamic acid reduces blood loss during and after cesarean section: A double blinded, randomized, controlled trial. Asian Pacific Journal of Reproduction. 2014; 3(1):53-6.
10
Hedelin H, Teger-Nilsson AC, Peterson HI, Pettersson S. Effects of tranexamic acid and local fibrin deposition of fibrinolysis and granulation tissue formation in preformed cavities. Thromb Res .1984; 33(1):33-8.
11
Kazemi SM, Mosaffa F, Eajazi A, Kaffashi M, Daftari Besheli L, Bigdeli MR, et al. The Effect of Tranexamic Acid on Reducing Blood Loss in Cementless Total Hip Arthroplasty under Epidural Anesthesia. Orthopedics. 2010; 33(1):1-17.
12
ORIGINAL_ARTICLE
Effect of Emotional Intelligence on the Quality of Nursing Care from the Perspectives of Patients in Educational Hospitals
Introduction: Nurses often work in stressful environments and it is widely accepted that emotions can exert profound effects on the quality of care in hospital settings. Therefore, the impact of emotional intelligence on the performance of nurses has been the focus of numerous studies. The present study aimed to assess the relationship between emotional intelligence and quality of nursing care from the perspectives of patients in hospitals affiliated to Tehran University of medical sciences. Materials and Methods: The current descriptive-analytic cross-sectional study was conducted on nurses and patients in four selected hospitals affiliated to Tehran University of medical sciences in 2016. Sample size was based on sample size formula in nurses with limited population and patients with unlimited population with 95% confidence level. Finally, a total number of 300 nurses and 270 patients were selected. Data collection tools included standardized Emotional Intelligence Questionnaire and Parasuraman Questionnaire (hospital quality assessment). Results: The best score of nurses’ emotional intelligence was reported in the social self- awareness domain (3.9), while the lowest score was detected in self- motivation domain (3.02). In general, it can be concluded that emotional intelligence in nurses was higher than average with 3.2. The results of the present study indicated that there was no significant relationship between emotional intelligence and the quality of nursing care in selected hospitals. Conclusion: As evidenced by the obtained results, there is a significant relationship between some aspects of the quality of hospital services (e.g., sympathy, assurance, and tangible) and emotional intelligence. Nonetheless, a significant relationship was not confirmed between nurses’ emotional intelligence and the quality of hospital services.
https://psj.mums.ac.ir/article_15309_95a18b9ca11ca2ee204608f40c4cfd2f.pdf
2020-01-01
37
43
10.22038/psj.2020.41216.1233
Emotional intelligence
Nursing care
Tehran University of medical sciences Hospitals
Jila
Najafpour
zhila.najafpoor@gmail.com
1
School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran.
AUTHOR
Fatemeh
Keshmiri
keshmiri1395@gmail.com
2
Educational Development Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
AUTHOR
Soosan
Rahimi
s.rahimi71@yahoo.com
3
School of Allied Medical, Tehran University of Medical sciences, Tehran, Iran.
AUTHOR
Zahra
Bigdeli
z.bigdeli@yahoo.com
4
School of Allied Medical, Tehran University of Medical sciences, Tehran, Iran.
AUTHOR
Parastoo
Niloofar
parastoo.niloofar@yahoo.com
5
Department of Epidemiology and Biostatistics, Tehran University of Medical sciences, Tehran, Iran.
AUTHOR
Abbas
Homauni
abbashomauni1368@yahoo.com
6
School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran.
LEAD_AUTHOR
Salovey P, Mayer J. Emotional intelligence. Imagination, Cognition, and Personality 1990;9(3):185–211.
1
Ciarrochi J, Forgus J, Myer J. Emotional intelligence in everyday life. London: Psychology Press. 2001;69.
2
Mayer J, Caruso D. Emotional intelligence meets traditional standards for an Intelligence. Journal of Intelligence. 1999; 27: 267-98.
3
Profetto J, Bulmer k. Emotional intelligence and nursing: An integrative literature review,International Journal of Nursing Studies. 2009;46:1624–36.
4
Mayer J, Salovey P, Caruso D. Emotional intelligence: new ability or eclectic traits? The American Psychologist. 2008;63(6):503–17.
5
Cadman C, Brewer J. Emotional intelligence: a vital prerequisite for recruitment in nursing. Journal of Nursing Management. 2001;9(6)321-4.
6
Schwirian P. Evaluating the performance of nurses: a multidimensional approach. Nursing Research 1978;27(6):347–51.
7
Beauvais A, Brady N, O'Shea E. Emotional intelligence and nursing performance among nursing students. Nurse Education Today (2011;31:396-401.
8
Lafferi A. The spiritual dimension of emergency care. Journal of Emergency Nursing. 1998;24:475- 83.
9
Manimaran S, Sindhya R, Venkateshwaran P. A Study of Patients Expectation and Satisfaction in Dindigul Hospitals. Asia J Manage Res. 2010:31-43.
10
Uzun O. Patient satisfaction with nursing care at a university hospital in Turkey. J Nurs Care Qual. 2.
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Naeem H, Saif M, Khalil W. Emotional intelligence and its impact on service quality-empirical evidence from the Pakistani banking sector. International Business & Economics Research Journal (IBER). 2011;7(12).
12
Rao P. Emotional intelligence: the Sine Qua Non for a clinical leadership toolbox. J Commun Disord. 2006;39(4):309-10.
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Deadrick L, Bruce R. Service with a smile, legal and emotional issues. J Qual Manage. 2001;6(1):99-110.
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Ranjbar M, Bahrami M, Hadizadeh F, Arab M. Nurses' Emotional Intelligence Impact on the Quality of Hospital Services. Iran Red Cres Med J. 2012;14(12):758-63 DOI: 10.5 812 /ircmj. 926.
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Bar-on R. the Bar on model of Emotional intelligent skills development training. unpublished raw data,. Texas University KingSville. 2006.
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Aremu A. A confluence of credentialing, career experience, selfefficacy, emotional intelligence, and motivation on the career commitment of young police in Ibadan, Nigeria. Policing: Intern J Police Strategies Manag. 2005;28(4):609-18.
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Slaski M, Cartwright S. Emotional intelligence training and its implications for stress, health and performance Stress and Health. 2003;19(4):233-9.
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Aberman R, et al. The training of emotional in financial advisors. (www Eiconsortiumorg). 2005.
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Por J, Barriball L, Fitzpatrick J, Roberts J. Emotional intelligence: Its relationship to stress, coping, well-being and professional performance in nursing students. Nurse Education Today. 2011;31:855–60.
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Antonakis J, Ashkanasy N, Dasborough M. Does leadership need emotional intelligence? . The Leadership Quarterly. 2009;20(2):247-61.
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Caruso D, Salovey R.The emotionally intelligent manager. Jossey-Bass, San Francisco. 2004.
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shareh H, Yazdandust R, Tabatabai M. The relationship between emotional intelligence and risk factors in adolescent girls running away from home. wwwsidir. 2006.
23
Jackson J, Chamberlain J, Kroenke K. Predictors of patient satisfaction. Social Science and Medicine J. 20001;5:609–20.
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O’Connell B, Young J, Twigg D. Patient satisfaction with nursing care: a measurement conundrum. International Journal of Nursing Practice. 1999;72:5-7.
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Mirghafoori H, Ahmadabadi Z. Analaysis of the service quality of medical centers using ServQual model (case: Shahid Rahnemon Hospital). Journal of Shahid Sadoughi University of Medical Sciences and Health Services. 2007;15(2):84-92.(Persian)
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McCabe C. Nurse-patient communication: an exploration of patients' experiences. J Clin Nurs. 2004;13(1):41-9.
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Noorihekmat S. The analysis of service quality gap in Tehran University of medical sciences hospitals. Tehran: Tehran university of medical sciences. 2007:(Persian)
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Ranjbar, Bahrami M, Zare H. Analysis of SERVQUAL in Shahid Sadoghi hospital Yazd, Iran. hormozgan J. 2011;16(4).
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Lau P, khatibiakbar A, gun d. Service quality: a study of the luxury hoteles in Malaysia. Journal of American academy of business. 2005;7(2):10-46.
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James L. Linking Outcomes to the Quality of the Process of Nursing Care A dissertaiton in nursing, University of Pennsylvania, UMI number: 3328614, Pro quest website: accsess date: (30/8/2009). 2008.
32
Zareh Z, anusheh m, vanaki Z. Quality of nursing performance and patient satisfaction with specific parts of the heart. tabib shrgh j. 2007;10(1):3-27.
33
ORIGINAL_ARTICLE
Human Milk Banks: A Narrative Review
Introduction: Not all mothers can provide sufficient milk, and infants admitted to a neonatal ward are less likely to be exclusively breastfed. Current recommendations are for the use of mother’s own milk (MOM), and pasteurized donor human milk (PDHM) is the next best choice. The present article was prepared as a tool to study the optimal organization of Human milk banks (HMB) and to contribute to the diffusion of the culture and promotion of breastfeeding and summarize current best practices for the handling of PDHM. Materials and Methods: PubMed, Embase and Cochrane were searched using the search term combination “human milk banks” OR “pasteurized donor human milk”. Results: HMB are responsible for human milk (HM) promotion, collection, processing, protection, quality control, distribution and support. The quality of expressed HM is the result of adequate hygienic-sanitary conditions, from expression to administration, and the evaluation of nutritional, immunological, chemical, and microbiological characteristics. It is essential a multidisciplinary team to support an HMB. Conclusion: In settings where donor HM supplies are limited, prioritization of infants by medical status is key. The manner in how investments in human milk feeding are applied should be targeted. The purchase cost of PDHM should be compared with the purchase costs of other nutrition interventions routinely used in care for critically ill neonates.
https://psj.mums.ac.ir/article_15310_eeb97f14da6598e61f32506561feca0a.pdf
2020-01-01
45
52
10.22038/psj.2020.42356.1239
Breast Feeding
Infant formula
Milk Banks
Low birth weight
Very low birth weight
José-Sousa
Vale
josepedrov9@gmail.com
1
ARSLVT, USF Marginal - R. Egas Moniz 9010, Piso 2, 2765-618 São João do Estoril, Lisboa, Portugal.
LEAD_AUTHOR
João
Miranda
2
Serviço Pediatria Centro Hospitalar Vila Nova Gaia/Espinho - R. Conceição Fernandes 1079, Vila Nova de Gaia, 4434-502 Vila Nova de Gaia.
LEAD_AUTHOR
Joana-Sousa
Nunes
3
Serviço Ginecologia/Obstetrícia Hospital Senhora da Oliveira Guimarães, R. dos Cutileiros 114, Creixomil, 4835-044 Guimarães.
LEAD_AUTHOR
Mariana
Veiga
4
Serviço de Ginecologia/Obstetrícia Hospital de Cascais Dr. José Almeida - Avenida Brigadeiro Victor Novais Gonçalves 2755-009 Alcabideche.
LEAD_AUTHOR
Borges MS, Oliveira AM d. M, Hattori WT, Abdallah VOS. Quality of human milk expressed in a human milk bank and at home. J Pediatr (Rio J). 2017;(xx). doi:10.1016/j.jped.2017.07.004
1
Spatz DL, Robinson AC, Froh EB. Cost and Use of Pasteurized Donor Human Milk at a Children’s Hospital. JOGNN - J Obstet Gynecol Neonatal Nurs. 2018; 47(4):583-588. doi: 10.1016/j. jogn.2017.11.004.
2
Buckle A, Taylor C. Cost and Cost-Effectiveness of Donor Human Milk to Prevent Necrotizing Enterocolitis: Systematic Review. Breastfeed Med. 2017;12(9):bfm.2017.0057. doi:10.1089/ bfm.2017.0057.
3
Trang S, Zupancic JAF, Unger S, et al. Cost-Effectiveness of Supplemental Donor Milk Versus Formula for Very Low Birth Weight Infants. Pediatrics. 2018;141(3):e20170737. doi:10.1542 /peds.2017-0737.
4
Affumicato L, Sánchez Tamayo T, Espinosa Fernandez MG, et al. Satellite center of human milk: Analysis of cost reduction. J Healthc Qual Res. 2018;33(1):3-9.doi:10.1016/j.cali. 2017. 12.005.
5
Moro GE. History of Milk Banking: From Origin to Present Time. Breastfeed Med. 2018;13(S1):S-16-S-17. doi:10.1089/ bfm.2018. 29077.gem.
6
Jahan Y, Rahman A. Human milk banking can be an innovative approach for developing countries. Heal Promot Perspect. 2018; 8(4):249-251. doi:10.15171/hpp.2018.34.
7
Steele C. Best Practices for Handling and Administration of Expressed Human Milk and Donor Human Milk for Hospitalized Preterm Infants. Front Nutr. 2018;5(September):1-5. doi:10.3389/fnut.2018.00076
8
Kwazulu-Natal DHP of K-N. Guidelines for the Establishment and Operation of Human Milk Banks in Kwazulu-Natal. 2014;(October). http://www.hmbasa.org.za/wp-content/ uploads/ 2015/02/ Human-Milk-Bank-KZN-Guidlines. pdf.
9
Arslanoglu S, Bertino E, Tonetto P, et al. Amendment to 2010 Italian guidelines for the establishment and operation of a donor human milk bank. J Biol Regul Homeost Agents. 2012;26 (3Suppl):61-64. doi:10.3109/14767058.2010. 512414
10
Hartmann BT, Pang WW, Keil AD, Hartmann PE, Simmer K. Best practice guidelines for the operation of a donor human milk bank in an Australian NICU. Early Hum Dev. 2007; 83 (10):667-673.doi:10.1016/ j.earlhumdev. 2007. 07.012.
11
Schlotterer HR, Perrin MT. Effects of Refrigerated and Frozen Storage on Holder-Pasteurized Donor Human Milk: A Systematic Review. Breastfeed Med. 2018;13(7):465-472. doi:10.1089/bfm.2018.0135. 13. Price E, Weaver G, Hoffman P, et al. Decontamination of breast pump milk collection kits and related items at home and in hospital: guidance from a Joint Working Group of the Healthcare Infection Society & Infection Prevention Society*. J Infect Prev. 2016; 17(2): 53-62. doi:10.1177/1757177415613566 14. Gayà A, Calvo J. Improving Pasteurization to Preserve the Biological Components of Donated Human Milk. Front Pediatr. 2018;6(October):1-6. doi:10.3389/ fped. 2018.00288 15. Fernández L, Ruiz L, Jara J, Orgaz B, Rodríguez JM. Strategies for the Preservation, Restoration and Modulation of the Human Milk Microbiota. Implications for Human Milk Banks and Neonatal Intensive Care Units. Front Microbiol. 2018;9(November):2676.doi:10. 3389/ fmicb.2018.02676. 16. Simmer K. Human Milk Fortification. Nestle Nutr Inst Workshop Ser. 2015;81:111-121. doi:10.1159/000365808 17. Rochow N, Landau-Crangle E, Fusch C. Challenges in breast milk fortification for preterm infants. Curr Opin Clin Nutr Metab Care. 2015;18(3):276-284. doi:10.1097/MCO.0000 0000 00000167 18. Sauret A, Andro-Garçon MC, Chauvel J, et al. Osmolality of a fortified human preterm milk: The effect of fortifier dosage, gestational age, lactation stage, and hospital practices. Arch Pediatr. 2018;25(7):411-415. doi:10.1016/j. arcped.2018.08.006 19. Kreins N, Buffin R, Michel-Molnar D, Chambon V, Pradat P, Picaud J-C. Individualized Fortification Influences the Osmolality of Human Milk. Front Pediatr. 2018;6(October):1-6. doi:10.3389/fped.2018.00322.
12
ORIGINAL_ARTICLE
Risk and Preventability of Adverse Events at a Finnish Tertiary Hospital Using Modified Global Trigger Tool
Objective: To evaluate the risk and preventability of adverse events (AEs) at a 600-bed, tertiary teaching hospital in Kuopio, Finland. Material and methods: The review of patient records was organized using the Institute for Healthcare Improvement’s Global Trigger Tool which was modified so that patient's point of view was emphasized. A bi-monthly random sample of hospital charts was selected between October 2014 and April 2016. The association with AEs of factors such as patients' age, sex, emergency vs. elective admission, multimedication, nursing care intensity raw points and categorized reasons for arrival were studied. A binary logistic regression model was employed to evaluate the risk of AEs. Result: We found 140 AEs / 1000 patient days and 91 AEs / 100 admissions. Overall, 46 % of hospital admissions (n=305) had an AE. Nursing care intensity raw points influenced the incidence of AEs (OR 1.238, P<0.001), and multimedication (OR 2.897, P=0.001) and nursing care intensity (OR 1.158, P=0.008) predicted preventable AEs. The incidence of all and preventable AEs were significantly influenced by age group (≥65-year vs younger, OR 2.303, P Conclusion: Focusing on the patient's point of view, we found a high number of AEs in the study population. The risk for AE was influenced by age group ≥65 years and high nursing care intensity, especially in internal medicine/pulmonology and oncology. Efforts should be focused on these patients to improve patient safety.
https://psj.mums.ac.ir/article_15243_9178d90b564de76d9b53c45d54c21015.pdf
2020-01-01
53
63
10.22038/psj.2020.42781.1241
Organizational improvement
Patient safety
Preventable adverse events
Marjo
Kervinen
marjo.kervinen@kuh.fi
1
Kuopio University Hospital, Medical Center, Kuopio, Finland.
LEAD_AUTHOR
Kaisa
Haatainen
kaisa.haatainen@kuh.fi
2
Kuopio University Hospital, Medical Administration, Kuopio, Finland and University of Eastern Finland, Kuopio campus, Kuopio, Finland.
AUTHOR
Ministry of Social Affairs and Health. Government resolution. Patient and client safety strategy 2017-2021. Publications 2017:11. http://urn.fi/URN:ISBN:978-952-00-3958-5.
1
Adler L, Yi D, Li M, McBroom B, Hauck L, Sammer C et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J Patient Saf 2018;14(2):67-73. doi:10. 1097/PTS. 00000000000001.
2
Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press 2013. https:// doi.org/ 10.17226/13444.
3
von Plessen C, Kodal AM, Anhøj J. Experiences with global trigger tool reviews in five Danish hospitals: an implementation study. BMJ Open 2012;2:e001324. doi: 10.1136/ bmjopen-2012-001324.
4
Rutberg H, Borgstedt-Risberg M, Gustafson P, Unbeck M. Adverse events in orthopedic care identified via the Global Trigger Tool in Sweden – implications on preventable prolonged hospitalizations.Patient Saf Surg 2016;10:23. doi:10.1186/s13037-016-0112-y.
5
Rutberg H, Borgstedt-Risberg M, Sjödahl R, Nordqvist P, Valter L, Nilsson L. Characterizations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method. BMJ Open 2014; 4(5): e004879.doi:10.1136/bmjopen-2014-004879.
6
Mevik K, Griffin FA, Hansen TE, Deilkås ET, Vonen B. Does increasing the size of bi-weekly samples of records influence results when using the Global Trigger Tool? An observational study of retrospective record reviews of two different sample sizes. BMJ Open 2016;6(4):e010700. doi: 10.1136/bmjopen-2015-010700.
7
Deilkås ET, Borgstedt Risberg M, Haugen M, Lindstrøm JC, Nylén U, Rutberg H et al.Exploring similarities and differences in hospital adverse event rates between Norway and Sweden using Global Trigger Tool. BMJ Open 2017;7: e012492. doi: 10.1136/bmjopen-2016-012492.
8
Haukland EC, von Plessen C, Nieder C, Vonen B. Adverse events in hospitalized cancer patients: a comparison to a general hospital population. Acta Oncol 2017;56(9):1218-1223. doi: 10.1080/0284186X.2017.1309063.
9
Doupi P, Peltomaa K, Kaartinen M, Öhman J. IHI Global Trigger Tool and patient safety monitoring in Finnish hospitals - Current experiences and future trends. Report 2013_019. National Institute for Health and Welfare 2013. http://urn.fi/URN:ISBN:978-952-245-999-2.
10
Järvelin, J. Studies on Filed and Compensated Claims for Patient Injuries. Academic Dissertation. National Institute for Health and Welfare. Tampere: Juvenes Print - Finnish University Print Ltd 2012. http:// urn.fi/URN:ISBN:978-952-245-750-9.
11
Rafter N, Hickey A, Condell S, Conroy R, O'Connor P, Vaughan D, Williams D. Adverse events in healthcare: learning from mistakes. QJM.2015;108(4):273-277.doi:10. 1093/ qjmed/ hcu 145.
12
Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety. Health Aff (Millwood). 2018; 37(11):1736–1743.doi:10. 1377/ hlthaff.2018.0738.
13
Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc. 2014;89(8):1116–1125. doi: 10.1016/j.mayocp.2014.05.007.
14
Griffin F, Resar R. IHI Global Trigger Tool for measuring adverse events. 2nd edn. Cambridge, Massachusetts: Institute for Healthcare Improvement 2009.
15
Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. Development and evaluation of the institute for healthcare improvement global trigger tool. J Patient Saf 2008; 4(3):169-177. doi: 10.1097/PTS.0b013e318183a475.
16
Kurutkan MN, Usta E, Orhan F, Simsekler MC. Application of the IHI Global Trigger Tool in measuring the adverse event rate in a Turkish healthcare setting. Int J Risk Saf Med. 2015;27(1):11-21.doi:10.3233/JRS-150639.
17
Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011; 30(4):581-589. doi: 10.1377/hlthaff.2011.0190.
18
Doupi P. Using EHR data for Monitoring and Promoting Patient Safety: Reviewing the Evidence on trigger Tools. In: Mantas J, et al, eds. Quality of Life through Quality of Information. IOS Press 2012:786-790. doi:10.3233/978-1-61499-101-4-786.
19
Mayor S, Baines E, Vincent C, Lankshear A, Edwards A, Aylward M et al. Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study. Health Services and Delivery Research 2017;5(9):1-226. https:// www.ncbi. nlm.nih.gov/books/NBK424600/pdf/Bookshelf_NBK424600.pdf. doi:10.3310/hsdr05090.
20
Hibbert PD, Molloy CJ, Hooper TD, Wiles LK, Runciman WB, Lachman P et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care 2016; 28(6):640-649. doi:10.1093/intqhc/mzw115.
21
Rauhala A, Fagerström L. Determining optimal nursing intensity: the RAFAELA method. J Adv Nurs 2004 Feb;45(4):351-9. https://doi. org/10.1046/j.1365-2648.2003.02918.x.
22
Pérez ZA, Gutiérrez SM, Rodriquez CL, Andrés EE, Gómez A, Ruiz-López P. Detection of adverse events in general surgery using the " Trigger Tool" methodology. Cir Esp 2015; 93(2): 84-90. doi: 10.1016/j.ciresp.2014.08.007.
23
Najjar S, Hamdan M, Euwema MC, Vleugels A, Sermeus W, Massoud R et al. The Global Trigger Tool shows that one out of seven patient suffers harm in Palestinian hospitals: challenges for launching a strategic safety plan. Int J Qual Health Care 2013;25(6):640-647. doi: 10.1093/intqhc/mzt066.
24
Hwang JI, Chin HJ, Chang Y-S. Characteristics associated with the occurrence of adverse events: a retrospective medical record review using the Global Trigger Tool in a fully digitalized tertiary teaching hospital in Korea. J Eval Clin Pract 2014;20:27-35. doi: 10.1111/ jep.12075.
25
Hwang JI, Kim J, Park JW. Adverse Events in Korean Traditional Medicine Hospitals: A Retrospective Medical Record Review. J Patient Saf 2015 May.doi:10.1097/PTS.0000000000000 190.
26
Kennerly DA, Kudyakov R, da Graca B, Saldaña M, Compton J, Nicewander D et al. Characterization of Adverse Events Detected in a Large Health Care Delivery System Using an Enhanced Global Trigger Tool over a Five-Year Interval. Health Serv Res2014;49(5):1407-1425. doi: 10.1111/1475-6773.12163.
27
Zhang E, Hung S-C, Wu C-H, Chen L-L, Tsai M-T, Lee W-H. Adverse event and error of unexpected life-threatening events within 24 h of emergency department admission. Am J Emerg Med 2017; 35(3):479-483. http://dx.doi. org/10.1016/j.ajem.2016.11.062.
28
Statistics Finland. Available 28 May 2019 at: https://findikaattori.fi/en/81.
29
Härkänen M, Kervinen M, Ahonen J, Voutilainen A, Turunen H, Vehviläinen-Julkunen K. Patient-specific risk factors of adverse drug events in adult inpatients – evidence detected using the Global Trigger Tool method. J Clin Nurs 2015 Feb;24(3-4): 582-91.doi:10.1111/jocn. 12714.
30
Fagerström L, Kinnunen M, Saarela J. Nursing workload, patient safety incidents and mortality: an observational study from Finland. BMJ Open 2018 Apr 24;8(4):e016367. doi: 10.1136/bmjopen-2017-016367.
31
Lipczak H, Knudsen JL, Nissen A. Safety hazards in cancer care: findings using three different methods. BMJ Qual Saf 2011;20:1052-56. http:// dx.doi. org/10. 1136/ bmjqs. 2010. 050856.
32
Sahlström M, Partanen P, Azimirad M, Selander T, Turunen H. Patient participation in patient safety-An exploration of promoting factors. J Nurs Manag 2019;27(1):84-92. doi: 10.1111/jonm.12651.
33
ORIGINAL_ARTICLE
Hemoptysis and Upper Gastrointestinal Bleeding In Two Patients Presenting With Aluminum Phosphate Intoxication (Oral and Inhaled): A Case Study
Introduction: The inhalation of aluminum phosphate and ingestion of aluminum phosphate tablets lead to clinical toxicity with different and nonspecific clinical symptoms. Two patients referred to Imam Reza Hospital Poisoning Emergency Center of Mashhad, Iran, one of whom was a 28-year-old male with oral consumption of four aluminum phosphide tablets, and the second case was a 29-year-old woman who was poisoned by inhalation. Both cases had symptoms of pulmonary and upper gastrointestinal bleeding during the brief hospitalization that resulted in their mortalities. Case Report: The first case is a 29-year-old man who consumed four oral tablets about 1.5 h before referral. He was intubated with the evidence of hemoptysis and upper gastrointestinal bleeding after about 4 h. The second patient is a young woman who had abdominal pain, nausea, and vomiting since the day before referral, and she told that she did not have any underlying diseases. During stabilization and patient evaluation, she suddenly became unresponsive with asystole. The CPR started with the evidence of hemorrhage within the intubation tube. Conclusion: There are currently no studies or reports of hemorrhagic complications in patients. In these two cases, there was no evidence of pulmonary hemorrhage and upper gastrointestinal bleeding which warrants further investigation and evaluation considering that these patients were young and with no underlying disease.
https://psj.mums.ac.ir/article_15206_a25d76750da3c9cfd05832f132db3735.pdf
2020-01-01
65
67
10.22038/psj.2020.46055.1261
Aluminum Phosphate
Inhalation
Hemorrhage Poising
Elnaz
Vafadar Moradi
vafadarme@mums.ac.ir
1
Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
LEAD_AUTHOR
Hamid Reza
Mokhtari
mokhtarihr971@mums.ac.ir
2
Department of Emergency Medicine. Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
AUTHOR
Sayyed Majid
Sadrzadeh
sadrzadehm@mums.ac.ir
3
Department of Emergency Medicine. Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
AUTHOR
Behrang
Rezvani Kakhki
rezvanikb@mums.ac.ir
4
Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
AUTHOR
Goel A, Aggarwal P. Pesticide poisoning. National medical journal of India.2007;20(4): 182.
1
Jaiswal S, Verma R, Tewari N. Aluminum phosphide poisoning: Effect of correction of severe metabolic acidosis on patient outcome. Indian journal of critical care medicine: peer-reviewed, official Publication of Indian Society of Critical Care Medicine. 2009;13(1):21.
2
Nosrati A, Karami M, Esmaeilnia M. Aluminum Phosphide Poisoning: A Case Series in North Iran. Asia Pacific Journal of Medical Toxicology. 2013;2(3):111-3 .
3
Singh R, Rastogi S, Singh D. Cardiovascular manifestations of aluminium phosphide intoxication. The Journal of the Association of Physicians of India.1989;37(9): 590-2.
4
Misra U, Tripathi A, Pandey R, Bhargwa B. Acute phosphine poisoning following ingestion of aluminium phosphide. Human toxicology. 1988;7(4):343-5.
5
Anger F, Paysant F, Brousse F, Le Normand I, Develay P, Galliard Y, et al. Fatal aluminum phosphide poisoning. J Anal Toxicol 2000; 24(2): 90-2.
6
Singh S, Singh D, Wig N, Jit I, Sharma BK. Aluminum phosphide ingestion-a clinico-pathologic study. J Toxicol Clin Toxicol 1996; 34(6): 703-6. doi:10.3109/1556365960901 3832.
7
Bumbrah GS, Krishan K, Kanchan T, Sharma M, Sodhi GS. Phosphide poisoning: a review of literature. Forensic Sci Int 2012; 214(1-3): 1-6. doi: 10.1016/j. forsciint.2011.06.018.
8
Moghadamnia AA. An update on toxicology of aluminum phosphide. Daru 2012; 20(1): 25. doi: 10.1186/2008-2231-20-25.
9
Proudfoot AT. Aluminium and zinc phosphide poisoning. Clin Toxicol 2009; 47(2): 89-100. doi: 10.1080/15563650802520675.
10
Shadnia S, Rahimi M, Pajoumand A, Rasouli MH, Abdollahi M. Successful treatment of acute aluminium phosphide poisoning: possible benefit of coconut oil. Hum Exp Toxicol 2005; 24(4):215-8. doi:10.1191/0960327105 ht513oa.
11
Hosseinian A, Pakravan N, Rafiei A, Feyzbakhsh S. Aluminum phosphide poisoning known as rice tablet: a common toxicity in North Iran. Indian J Med Sci 2011; 65(4): 143-50. doi: 10.4103/0019-5359.104777.
12
Sharma A, Dishant VG, Kaushik JS, Mittal K. Aluminum phosphide (celphos) poisoning in children: a 5-year experience in a tertiary care hospital from northern India. Indian J Crit Care Med 2014; 18(1): 33-6. doi: 10.4103/0972-5229.125434.
13
Shadnia S, Sasanian G, Allami P, Hosseini A, Ranjbar A, Amini-Shirazi N, et al. A retrospective 7-years study of aluminum phosphide poisoning in Tehran: opportunities for prevention. Hum Exp Toxicol 2009; 28(4): 209-13. doi: 10.1177/0960327108097194.
14
Mehrpour 0, Jafarzadeh M, Abdollahi M. A systematic review of aluminium phosphide poisoning. Arh Hig Rada Toksikol 2012; 63(1): 61-73. doi:10.2478/10004-1254-63-2012-2182.
15