Cải thiện An toàn trong Chăm sóc Sức khỏe: Vượt ra ngoài Các Tình trạng Thoái hóa Bệnh viện Thông thường

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Diagnostic errors in a PICU: insights from the morbidity and mortality conference. Pediatr Crit Care Med. 2015;16:468–76. https://doi.org/10.1097/PCC.0000000000000398. Benavidez OJ, Gauvreau K, Geva T. Diagnostic errors in congenital echocardiography: importance of study conditions. J Am Soc Echocardiogr. 2014;27:616–23. https://doi.org/10.1016/j.echo.2014.03.001. Davalos MC, Samuels K, Meyer AND, Thammasitboon S, Sur M, Roy K, et al. Finding diagnostic errors in children admitted to the PICU. Pediatr Crit Care Med. 2017;18:265–71. https://doi.org/10.1097/PCC.0000000000001059. Ball JR. Preface. In: Improving diagnosis in health care. Washington D.C: National Academy Press; 2015. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22(Suppl 2):ii58–64. https://doi.org/10.1136/bmjqs-2012-001712.These two articles are part 1 and 2 of a single manuscript. Both are important because they represent an excellent single source for learning about cognitive bias, it’s impact on decision making, and strategies for improving decision making. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22:ii65–72. https://doi.org/10.1136/bmjqs-2012-001713. These two articles are part 1 and 2 of a single manuscript. Both are important because they represent an excellent single source for learning about cognitive bias, it’s impact on decision making, and strategies for improving decision making. Croskerry P. When I say…cognitive debiasing. Med Educ. 2015;49:656–7. https://doi.org/10.1111/medu.12670. Schiff GD, Kim S, Abrams R, Cosby K, Lambert B, Elstein A, et al. Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in patient safety: from research to implementation (volume 2: concepts and methodology). Rockville: Agency for Healthcare Research and Quality (US); 2005. •• Seshia SS, Young GB, Makhinson M, Smith PA, Stobart K, Croskerry P. Gating the holes in the swiss cheese (part 1): Expanding Professor Reason’s model for patient safety. J Eval Clin Pract. 2018;24:187–97. https://doi.org/10.1111/jep.12847. This article is important for demonstrating how standard modeling of harm events using the Swiss Cheese model can be used to further understanding and investigation of cognition and decision making. Graber ML, Kissam S, Payne VL, Meyer AND, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21:535–57. https://doi.org/10.1136/bmjqs.2011.000149. •• Gupta A, Harrod J, Quinn M, Manojlovich M, Fowler KE, Singh H, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis. 2018;5:151–6. https://doi.org/10.1515/dx.2018.0014. This article exposes the reader to the impact system based factors have on individual decision making and explores how improving system factors leads to improvement in decision making. Deevakar R, Iyengar S, Singh H. Using fault trees to advance understanding of diagnostic errors. Jt Comm J Qual Patient Saf. 2017;43:598–605. https://doi.org/10.1016/j.jcjq.2017.06.007. Trowbridge RL. Twelve tips for teaching avoidance of diagnostic errors. Med Teach. 2008;30:496–500. https://doi.org/10.1080/01421590801965137. Graber ML, Rencic J, Rusz D, Papa F, Croskerry P, Zierler B, et al. Improving diagnosis by improving education: a policy brief on education in healthcare professions. Diagnosis. 2018;5:107–18. https://doi.org/10.1515/dx.2018.0033. Reilly JB, Ogdie AR, Von Feldt JM, Myers JS. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. BMJ Qual Saf. 2013;22:1044–50. https://doi.org/10.1136/bmjqs.2013.001987. Moffett BS, Goldstein SL. Acute kidney injury and increasing nephrotoxic-medication exposure in noncritically-ill children. Clin J Am Soc Nephrol. 2011;6(4):856–63. https://doi.org/10.2215/CJN.08110910. Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int. 2007;71(10):1028–35. https://doi.org/10.1038/sj.ki.5002231. Zappitelli M. Epidemiology and diagnosis of acute kidney injury. Semin Nephrol. 2008;28(5):436–46. https://doi.org/10.1097/s40272-016-0205-1. Slater MB, Gruneir A, Rochon PA, Howard AW, Koren G, Parshuram CS. Risk factors of acute kidney injury in critically ill children. Pediatr Crit Care Med. 2016;17(9):e391–8. https://doi.org/10.1097/PCC.0000000000000859. Menon S, Kirkendall ES, Nguyen H, Goldstein SL. Acute kidney injury associated with high nephrotoxic medication exposure leads to chronic kidney disease after 6 months. J Pediatr. 2014;165(3):522–527 e522. https://doi.org/10.1016/j.jpeds.2014.04.058. Goldstein SL, Kirkendall E, Nguyen H, Schaffzin JK, Bucuvalas J, Bracke T, et al. Electronic health record identification of nephrotoxin exposure and associated acute kidney injury. Pediatrics. 2013;132(3):e756–67. https://doi.org/10.1542/peds.2013-0794. •• Goldstein SL, Mottes T, Simpson K, et al. A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury. Kidney Int. 2016;90(1):212–21. https://doi.org/10.1016/j.kint.2016.03.031 This article is important for demonstrating how the use of robust implementation strategies leads to changes in physician performance and sustained improvement in nepherotoxic medication associated acute kidney injury. This work contributed to the adoption of the findings by Solutions for Patient Safety and spread of the improvement to other Children’s Hospitals. Glanzmann C, Frey B, Vonbach P, Meier CR. Drugs as risk factors of acute kidney injury in critically ill children. Pediatr Nephrol. 2016;31(1):145–51. https://doi.org/10.1007/s00467-015-3180-9. Mishra J, Dent C, Tarabishi R, Mitsnefes MM, Ma Q, Kelly C, et al. Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet. 2005;365(9466):1231–8. https://doi.org/10.1016/S0140-6736(05)74811-X. Vossoughi S, Perez G, Whitaker BI, Fung MK, Stotler B. Analysis of pediatric adverse reactions to transfusions. Transfusion. 2018;58(1):60–9. https://doi.org/10.1111/trf.14359. Gauvin F, Lacroix J, Robillard P, Lapointe H, Hume H. Acute transfusion reactions in the pediatric intensive care unit. Transfusion. 2006;46(11):1899–908. https://doi.org/10.1111/j.1537-2995.2006.00995.x. Istaphanous GK, Wheeler DS, Lisco SJ, Shander A. Red blood cell transfusion in critically ill children: a narrative review. Pediatr Crit Care Med. 2011;12(2):174–83. https://doi.org/10.1097/PCC.0b013e3181e30d09. Chegondi M, Sasaki J, Raszynski A, Totapally BR. Hemoglobin threshold for blood transfusion in a pediatric intensive care unit. Transfus Med Hemother. 2016;43(4):297–301. https://doi.org/10.1159/000446253. •• Doctor A, Cholette JM, Remy KE, Argent A, Carson JL, Valentine SL, et al. Recommendations on RBC transfusion in general critically ill children based on hemoglobin and/or physiologic thresholds From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018;19(9S Suppl 1):S98–s113. https://doi.org/10.1097/PCC.0000000000001590 This article and really all articles from 34–39 represent an excellent summary of current guidelines for limiting transfusions in pediatrics as a way to decrease harm associated with transfusions by decreasing unnecessary transfusions. Demaret P, Emeriaud G, Hassan NE, Kneyber MCJ, Valentine SL, Bateman ST, et al. Recommendations on RBC transfusions in critically ill children with acute respiratory failure from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018;19(9S Suppl 1):S114–s120. https://doi.org/10.1097/PCC.0000000000001619. Karam O, Russell RT, Stricker P, Vogel AM, Bateman ST, Valentine SL, et al. Recommendations on RBC transfusion in critically ill children with nonlife-threatening bleeding or hemorrhagic shock from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018;19(9S Suppl 1):S127–s132. https://doi.org/10.1097/PCC.0000000000001605. Cholette JM, Willems A, Valentine SL, Bateman ST, Schwartz SM. Recommendations on RBC transfusion in infants and children with acquired and congenital heart disease from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018;19(9S Suppl 1):S137–s148. https://doi.org/10.1097/PCC.0000000000001603. Steiner ME, Zantek ND, Stanworth SJ, Parker RI, Valentine SL, Lehmann LE, et al. Recommendations on RBC transfusion support in children with hematologic and oncologic diagnoses from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018;19(9S Suppl 1):S149–s156. https://doi.org/10.1097/PCC.0000000000001610. Tasker RC, Turgeon AF, Spinella PC. Recommendations on RBC transfusion in critically ill children with acute brain injury from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018;19(9S Suppl 1):S133–s136. https://doi.org/10.1097/PCC.0000000000001589. Tropello ST, Ravitz AD, Romig M, Pronovost PJ, Sapirstein A. Enhancing the quality of care in the intensive care unit. Crit Care Clin. 2013;29:113–24. https://doi.org/10.1016/j.ccc.2012.10.009. Romig M, Tropello SP, Dwyer C, Wyskiel RM, Ravitz A, Benson J, et al. Developing a comprehensive model of intensive care unit processes: concept of operations. J Patient Saf. 2015. https://doi.org/10.1097/PTS.0000000000000189. Thornton KC, Schwarz JJ, Gross AK, Anderson WG, Liu KD, Romig MC, et al. Project Emerge Collaborators. Crit Care Med. 2017;45:1531–7. https://doi.org/10.1097/CCM.0000000000002556. Joy RA, Ben-Tzion K. Human factors and systems engineering approach to patient safety for radiotherapy. Int J Radiat Oncol Biol Phys. 2008;71:S174–7. https://doi.org/10.1016/j.ijrobp.2007.06.088.