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Oakley PA, Haas JW, Woodham T, Fortner M, Harrison DE. Subjective and Objective Improvement in a 39-Year-Old Male Suffering From Severe Chronic Pain and Disability Using Chiropractic BioPhysics® Protocols Following Rear-Impact Motor Vehicle Crash With a 10-Month Long-Term Follow-Up. Cureus 2023; 15:e50849. [PMID: 38125689 PMCID: PMC10732608 DOI: 10.7759/cureus.50849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 12/23/2023] Open
Abstract
We present the case of a patient receiving structural rehabilitation following a rear-impact motor vehicle collision (MVC). Medications did not alleviate the symptoms of the crash injuries. Resolution of injury-caused pain and disability was found following postural and structural rehabilitation treatment. A 39-year-old male was injured in a rear-impact collision between two very large vehicles. Severe migraine headaches, neck pain, and radiculopathy, as well as lower back pain, were the result of the crash. Patient-reported outcomes (PROs) demonstrated that the symptoms were causing severe disability and poor health-related quality of life (HRQoL) measures. Radiographs found spine alignment abnormalities consistent with rear impact MVC. Chiropractic Biophysics® (CBP®) structural rehabilitation was performed. Following a treatment regimen involving strengthening weakened and damaged muscles, postural and spinal traction, postural spinal manipulative therapy (SMT), and home therapies resulted in the resolution of the symptoms. All outcome measures demonstrated improvement, including Short-Form 36 question health questionnaire (SF-36), quadruple visual analog scale (QVAS), headache disability index (HDI), neck disability index (NDI), revised Oswestry disability index (RODI), as well as significant measured improvements found on radiographs. Spine pain and altered alignment are frequent results of MVCs. If left uncorrected, these abnormalities increase the likelihood of chronic pain and disability. Combined low back pain (LBP), neck pain (NP), headache (HA), and radiculopathy, as found in our subject, significantly pre-dispose the individual to poor HRQoL, years lived with disability (YLDs) and increased the global burden of disease (GBD). Physicians who treat injured patients should have a repeatable, reliable, valid, and efficacious method to reduce pain, increase range of motion (ROM), improve spine alignment, and improve the performance of activities of daily living (ADLs). Further, larger studies of injured patients are necessary to determine if the CBP® protocol reduces GBD caused by MVC injuries.
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Affiliation(s)
- Paul A Oakley
- Physical Medicine and Rehabilitation, York University, Toronto, CAN
| | - Jason W Haas
- Physical Medicine and Rehabilitation, CBP NonProfit, Windsor, USA
| | - Thomas Woodham
- Physical Medicine and Rehabilitation, Western Plains Chiropractic, Gillette, USA
| | - Miles Fortner
- Physical Medicine and Rehabilitation, Western Plains Chiropractic, Gillette, USA
| | - Deed E Harrison
- Physical Medicine and Rehabilitation, CBP NonProfit, Eagle, USA
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Rohrmeier C, Abudan Al-Masry N, Keerl R, Bohr C, Mueller S. A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. Eur Arch Otorhinolaryngol 2022; 279:5423-5431. [PMID: 35767060 PMCID: PMC9519680 DOI: 10.1007/s00405-022-07448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022]
Abstract
Purpose Wrong-site surgeries are rare but potentially serious clinical errors. Marking the surgical site is crucial to preventing errors, but is hindered in the ENT field by the presence of many internal organs. In addition, there is no standardized marking procedure. Methods Here, an ENT surgical-marking procedure was developed and introduced at a clinic. The procedure was evaluated through anonymized questionnaires. This study was conducted over a 6-month period by interviewing patients and, at the beginning and end of this period, doctors and other surgical staff. Results The internal organ-marking problem was solved by applying a fixed abbreviation for each procedure onto the shoulder in addition to marking the skin surface as close to the organ as possible. The procedure was described as practicable by 100% of the interviewees; 75% of the ENT physicians and 96.3% of the other surgical staff considered the procedure highly important for preventing site confusion, and 75% of the physicians had a consequently greater feeling of safety. Of the 248 patients surveyed, 96.0% considered the marking procedure useful, and 75.8% had a consequently greater feeling of safety. For 52.0%, the marking reduced their fear of the operation. Conclusions For the first time, a standardized procedure was developed to mark the site of ENT surgery directly, uniformly and safely on patients. The procedure was judged to be useful and practicable and was also deemed crucial for preventing site confusion. Patients felt safer and less fearful of the operation due to the marking.
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Affiliation(s)
- Christian Rohrmeier
- Faculty of Medicine, University of Regensburg, 93042, Regensburg, Germany. .,ENT Medicinal Office, Bahnhofstr. 19, 94315, Straubing, Germany.
| | - Narmeen Abudan Al-Masry
- Department of Otorhinolaryngology, St. Elisabeth Hospital, St.-Elisabeth-Str. 23, 94315, Straubing, Germany
| | - Rainer Keerl
- Department of Otorhinolaryngology, St. Elisabeth Hospital, St.-Elisabeth-Str. 23, 94315, Straubing, Germany
| | - Christopher Bohr
- Department of Otorhinolaryngology, University of Regensburg, 93042, Regensburg, Germany
| | - Steffen Mueller
- Department of Oral and Maxillofacial Surgery, University of Regensburg, 93042, Regensburg, Germany
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3
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Minyé HM, Benjamin E. High-reliability organisation principles implemented in dentistry. Br Dent J 2022; 232:879-885. [PMID: 35750834 DOI: 10.1038/s41415-022-4354-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/21/2021] [Indexed: 11/09/2022]
Abstract
Introduction/objectives Successful dentistry inherently requires high-reliability and situational awareness to provide consistent high-quality care. However, treatment errors still occur in dentistry as they do in medicine. The importance of avoiding error is elevated for dentistry due to the increased frequency of irreversible procedures in each patient interaction compared to non-surgical specialties in medicine. Although a universal protocol for time-out exists, wrong-site procedures are a persistent healthcare issue in dentistry.Data By implementing high-reliability organisations (HROs) principles to dentistry, improved safety and quality can be achieved.Sources There are five essential principles that HROs have been observed to adhere to: preoccupation with failure; situational awareness/sensitivity to operations; a reluctance to simplify; deference to expertise; and commitment to resilience. Deep examination of the potential vulnerabilities in dentistry, using HRO ideology will create effective process improvement strategies. It fosters a culture of accountability using systematic problem-solving as opposed to condemnation.Study selection Implementation of HRO principles will improve the existing universal time-out process, while placing quality and performance at the central focus of strategic success.Conclusions Dentists can adopt these HRO principles into their practices to create effective process improvement strategies.
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Affiliation(s)
- Helena M Minyé
- Centre for Reconstructive Dentistry and Oral Surgery, P.C. (Professional Corporation), Dallas, Texas, USA; Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
| | - Evan Benjamin
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA; Ariadne Labs, Brigham and Women´s Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Ayorinde AA, Williams I, Mannion R, Song F, Skrybant M, Lilford RJ, Chen YF. Publication and related bias in quantitative health services and delivery research: a multimethod study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.
Objectives
To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.
Methods
The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).
Results
We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.
Conclusions
This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.
Study registration
This study is registered as PROSPERO CRD42016052333 and CRD42016052366.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Abimbola A Ayorinde
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iestyn Williams
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Russell Mannion
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Magdalena Skrybant
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Abstract
STUDY DESIGN Broad narrative review of current literature and adverse event databases. OBJECTIVE The aim of this review is to report the current state of wrong-site spine surgery (WSSS), whether the Universal Protocol has affected the rate, and the current trends regarding WSSS. METHODS An updated review of the current literature on WSSS, the Joint Commission sentinel event statistics database, and other state adverse event statistics database were performed. RESULTS WSSS is an adverse event that remains a potentially devastating problem, and although the incidence is difficult to determine, the rate is low. However, given the potential consequences for the patient as well as the surgeon, WSSS remains an event that continues to be reported alarmingly as often as before the implementation of the Universal Protocol. CONCLUSIONS A systems-based approach like the Universal Protocol should be effective in preventing wrong-patient, wrong-procedure, and wrong-sided surgeries if the established protocol is implemented and followed consistently within a given institution. However, wrong-level surgery can still occur after successful completion of the Universal Protocol. The surgeon is the sole provider who can establish the correct vertebral level during the operation, and therefore, it is imperative that the surgeon design and implement a patient-specific protocol to ensure that the appropriate level is identified during the operation.
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Affiliation(s)
- John G. DeVine
- Medical College of Georgia, Augusta University, Augusta, GA, USA,John G. DeVine, Department of Orthopaedic Surgery, Medical College of Georgia, Augusta University, 1120 15th Street, BA3300, Augusta, GA 30912, USA.
| | | | | | - Keith Jackson
- Eisenhower Army Medical Center, Fort Gordon, GA, USA
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Valori R, Cortas G, de Lange T, Salem Balfaqih O, de Pater M, Eisendrath P, Falt P, Koruk I, Ono A, Rustemović N, Schoon E, Veitch A, Senore C, Bellisario C, Minozzi S, Bennett C, Bretthauer M, Dinis-Ribeiro M, Domagk D, Hassan C, Kaminski MF, Rees CJ, Spada C, Bisschops R, Rutter M. Performance measures for endoscopy services: A European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. United European Gastroenterol J 2018; 7:21-44. [PMID: 30788114 DOI: 10.1177/2050640618810242] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/07/2018] [Indexed: 12/18/2022] Open
Abstract
The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a list of key performance measures for endoscopy services. We recommend that these performance measures be adopted by all endoscopy services across Europe. The measures include those related to the leadership, organization, and delivery of the service, as well as those associated with the patient journey. Each measure includes a recommendation for a minimum and target standard for endoscopy services to achieve. We recommend that all stakeholders in endoscopy take note of these ESGE endoscopy services performance measures to accelerate their adoption and implementation. Stakeholders include patients and their advocacy groups; service leaders; staff, including endoscopists; professional societies; payers; and regulators.
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Affiliation(s)
- Roland Valori
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - George Cortas
- University of Balamand Faculty of Medicine, St. George Hospital University Medical Center, Beirut, Lebanon
| | - Thomas de Lange
- Department of Transplantation, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Omer Salem Balfaqih
- Thamar University, Medical College, Dhamar; and Hadramout University, Medical College, Mukalla, Yemen
| | - Marjon de Pater
- Dept. of Gastroenterology Endoscopy, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Pierre Eisendrath
- Hepato-Gastroenterology department, CHU Saint-Pierre, Université libre de Bruxelles, Brussels, Belgium
| | - Premysl Falt
- University Hospital Olomouc, and Faculty of Medicine, Palacky University, Olomouc, Czech Republic; and Faculty of Medicine, Charles University, Hradec Kralove, Czech Republic
| | - Irfan Koruk
- Department of Gastroenterology, Istanbul Bilim University Medical School, Istanbul, Turkey
| | - Akiko Ono
- Unidad de Endoscopia Digestiva, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Nadan Rustemović
- GI Endoscopy Unit, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Erik Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Andrew Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Carlo Senore
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | | | - Silvia Minozzi
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Cathy Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Coláiste Ríoga na Máinleá in Éirinn, Dublin, Ireland
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Mario Dinis-Ribeiro
- Servicio de Gastroenterologia, Instituto Portugues de Oncologia Francisco Gentil, Porto, Portugal
| | - Dirk Domagk
- Department of Medicine I, Josephs-Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education and Department of Gastroenterological Oncology; and Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center, and Institute of Oncology, Warsaw, Poland; and Department of Health Management and Health Economics, University of Oslo, Norway
| | - Colin J Rees
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | - Cristiano Spada
- Digestive Endoscopy and Gastroenterology Unit, Poliambulanza Foundation, Brescia; and Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Catholic University, Rome, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
| | - Mathew Rutter
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK.,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
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Gadelkareem RA. Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. I. Surgical Never Events: 1. Urological Wrong-Surgery Catastrophes and Disabling Complications. Curr Urol 2018; 11:73-78. [PMID: 29593465 PMCID: PMC5836182 DOI: 10.1159/000447197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/19/2017] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Surgical never events are preventable harmful non-intentional human errors. Urology is a common surgical specialty for their occurrence. PATIENTS AND METHODS A retrospective search of our center's data was done during the period 2006-2016 for surgical never events. Each included case was studied for the primary diagnosis, procedure, and subspecialty, never event type and timing, needed extra-interventions, urologist/procedure proportioning, outcomes, and possible underlying causes of the event. RESULTS Of more than 55,000 different urological interventions, 61 patients were involved in never events. Wrong procedures represented 75% of the never events, and endourology and urolithiasis subspecialties were more often involved. The main detectable underlying factor was the disproportion between the levels of the procedure class and the qualification of the urologist (41%). Thirty-four cases had extra-procedures. The short-term harm effect represented the final outcome in 42% of all events. Death, permanent organ loss, and long-term harm represented 20, 15, and 23%, respectively. CONCLUSION Urological surgical never events are rare, but their final outcomes could be catastrophic, even leading to death.
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Affiliation(s)
- Rabea A. Gadelkareem
- *Rabea A. Gadelkareem, Elgamaa Street, Assiut University, EG–71515, Assiut (Egypt), E-Mail
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Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open 2016; 6:e012555. [PMID: 27687901 PMCID: PMC5051502 DOI: 10.1136/bmjopen-2016-012555] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. DESIGN Systematic review of systematic reviews. DATA SOURCES PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. STUDY SELECTION English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. RESULTS Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design. CONCLUSIONS The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.
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Affiliation(s)
- Marieke Zegers
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Gijs Hesselink
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Wytske Geense
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Hub Wollersheim
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Hurst D. Little research on effective tools to improve patient safety in the dental setting. Evid Based Dent 2016; 17:38-9. [PMID: 27339232 DOI: 10.1038/sj.ebd.6401163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Data sourcesMedline via OVID, Embase via OVID, HMIC via OVID, CINAHL via EBSCO and Web of Science.Study selectionDescriptive, observational and experimental studies that used or described the development of patient safety interventions relating to dental care. Outcomes of interest were: patient safety, harm prevention, risk minimisation, patient satisfaction and patient acceptability, professional acceptability, efficacy, cost-effectiveness and efficiency.Data extraction and synthesisAll titles and abstracts were screened by at least two authors. The eligible studies were data extracted by two authors, with disagreements resolved by a third reviewer if necessary. A narrative approach was taken and quality assessed using CASP tools.ResultsNine studies were identified. Four described the use of checklists, three the use of reporting systems, one the use of electronic reminders and one the use of trigger tools. The risk of bias in the studies was high.ConclusionsThe available literature on patient safety is in its infancy. Surgical checklists may be effective in reducing surgical errors.
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Affiliation(s)
- Dominic Hurst
- Dental Public Health Unit, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK and Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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