Pathy's Principles and Practice of Geriatric Medicine - Группа авторов

Скачать книгу

safety and quality. Continuing attention needs to be paid to the education and training of individual clinicians regarding the unique decision‐making, assessment, and team skills necessary to provide excellent care for older people. We should be particularly mindful of strategies for the early detection, prevention, and management of the geriatric syndromes and effective ways of tailoring treatment to the individual. Crucially, safety and quality of care will also be enhanced if the ongoing problems with ageism and attitudes toward older people and their care can be addressed.

      The Centre for Patient Safety and Service Quality, Imperial College London, is funded by the National Institute for Health Research.

      Key points

       Older people are more vulnerable than younger patients to healthcare‐associated harm and its consequences. This tendency is associated with frailty and comorbidity rather than age alone – as our populations age, systems of care need to be designed with this in mind.

       Older people experience a wider range of adverse events than their younger counterparts in the hospital, including the geriatric syndromes, yet patient safety in this population is comparatively under‐researched.

       There is a need to improve the measurement of safety and quality of care in older people and to better understand patient safety for older people in non‐hospital settings.

       Key areas of focus for improving patient safety for older people include designing safer healthcare systems for older people; the early detection, prevention, and management of the geriatric syndromes; providing education to individual clinicians to enhance decision‐making, assessment, and team skills; and efforts to reduce ageism and negative attitudes toward older people and their care.

      1 1. Vincent C. Patient Safety. 2nd ed. Wiley‐Blackwell; 2010.

      2 2. Donaldson L. An organisation with a memory. Clin Med. 2002; 2:452.

      3 3. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Institute of Medicine, National Academies Press; 2000.

      4 4. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370–6.

      5 5. Darzi A. High quality care for all. NHS Next Stage Review Final Report. The Stationery Office; 2008.

      6 6. Mills DH. Report of the Medical Insurance Feasibility Study. California Medical Association; 1977.

      7 7. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370–6.

      8 8. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Med J Aust. 1995; 163: 458–71.

      9 9. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000; 38:261–71.

      10 10. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001; 322:517–19.

      11 11. Davis P, Lay‐Yee R, Briant R, et al. Adverse events in New Zealand public hospitals I: occurrence and impact. N Z Med J. 2002; 115:U271.

      12 12. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004; 170:1678–86.

      13 13. Forster AJ, Asmis TR, Clark HD, et al. Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ. 2004; 170:1235–40.

      14 14. Michel PP, Quenon JL, Djihoud AA, et al. French national survey of inpatient adverse events prospectively assessed with ward staff. Qual Saf Health Care. 2007; 16:369–77.

      15 15. Sari AB, Sheldon TA, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007; 334:79.

      16 16. Sousa P, Uva AS, Serranheira F, et al. Estimating the incidence of adverse events in Portuguese hospitals: a contribution to improving quality and patient safety. BMC Health Services Research. 2014; 14:311.

      17 17. Rafter N, Hickey A, Conroy RM, et al. The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals – a retrospective record review study. BMJ Qual Saf. 2017; 26:111–119. doi:10.1136/bmjqs‐2015‐004828.

      18 18. Nilsson L, Borgstedt‐Risberg M, Soop M, et al. Incidence of adverse events in Sweden during 2013–2016: a cohort study describing the implementation of a national trigger tool. BMJ Open. 2018; 8:e020833. doi:10.1136/bmjopen‐2017‐020833.

      19 19. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med. 2003; 18:61.

      20 20. Michel P, Quenon JL, de Sarasqueta AM, et al. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ. 2004; 328: 1–5 doi 10.1136/bmj.328.7433.199.

      21 21. Reason J. Managing the Risks of Organizational Accidents. Ashgate Publishing; 1997.

      22 22. Reason J. Human error: models and management. BMJ. 2000; 320:768–70.

      23 23. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002; 9:1184–204.

      24 24. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005; 142:115–20.

      25 25. Vincent C, Taylor‐Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998; 316:1154–7.

      26 26. Blais R, Bruno D, Bartlett G. Can we use incident reports to detect hospital adverse events? J Patient Saf. 2008; 4(1):9.

      27 27. Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet. 1994; 343:1609–13.

      28 28. Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population based review of medical records. BMJ. 2000; 320:741–4.

      29 29. Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. International Journal for Quality in Health Care. 2013; 25: 542–554.

      30 30. Tsilimingras D, Rosen AK, Berlowitz DR. Patient safety in geriatrics: a call for action. J Gerontol A Biol Sci Med Sci. 2003; 58:M813–9.

      31 31. Asher RAJ. Dangers of going to bed. Qual Saf Health Care. 1947; 2:967.

      32 32. Boyd CM, Landefeld CS, Counsell SR, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008; 56:2171–9.

      33 33. Spinewine A, Schmader K, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007; 370:173–84.

      34 34. Page R II, Ruscin JM. The risk of adverse drug events and hospital‐related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother. 2006; 4:297–305.

      35 35. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324:377–84.

      36 36. Department of Health. Prescriptions dispensed in the community: statistics for 1993–2003, England. Department of Health, London; 2004.

      37 37. Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist. Drugs Aging. 2003; 20:817–32.

      38 38.

Скачать книгу