Fatal Accidental Intrathecal Injection of Vindesine

Tournel, Gilles; Bécart-Robert, A.; P, Courtin; Hédouin, V.; Gosset, D.

doi:10.1111/j.1556-4029.2006.00241.x

Cited by 26 publications

(13 citation statements)

References 11 publications

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“…In oncology, prevention and management of errors are particularly critical because the patients' health status is poor and the drugs employed are toxic, have a low therapeutic index and are susceptible to be implicated in drug-drug interactions [13,14,15,16,17]. Most studies of medication errors in cancer care report high rates of severe events [18,19,20].…”

Section: Introductionmentioning

confidence: 99%

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Ranchon¹,

You²,

Salles³

et al. 2013

Chemotherapy

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Background: To reduce the occurrence of medication errors, a systemic approach was developed combining anti-neoplastic medication error reviews and morbidity and mortality conferences (M&MCs). We report the first experience of implementing this strategy in oncology. Methods: The case reports submitted to combined reviews were prepared by physicians and pharmacists, and medication error(s) were described and chronological and root-cause analyses were performed. Results: Ten combined reviews were conducted, which involved the departments of haematology, medical oncology, pneumology, gastroenterology and clinical oncology pharmacy. A total of 91 errors were analysed, of which 3 had reached the patient. Thirty-four corrective actions were proposed; 53% consisted of changes in practice, 35% in procedural reminders and 12% in on-ward education sessions. Conclusions: The combination of medication error reviews and M&MCs appears to be an efficient means of improving cancer patient safety and personnel proficiency. This multidisciplinary work is indispensable to improve future patient management through the critical analysis of past medical errors.

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Section: Introductionmentioning

confidence: 99%

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Ranchon¹,

You²,

Salles³

et al. 2013

Chemotherapy

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“…In an address Assault with the intention to commit grievous bodily harm and common assault to children (under 18 years) represent 9.7 and 11.8%, respectively, of all assaults [5]. Assaults with a sharp object in children are reported scarcely in the medical literature with mainly single case reports in the recent literature [6,7]. A report form the South African Medical Research Council in 2002 revealed that approximately 17% of school pupils carried weapons and that approximately 30% of school pupils had been involved in a physical assault in the past 6 months [8].…”

Section: Discussionmentioning

confidence: 98%

Assaults with a sharp object in small children: a 16-year review

Dijk

Numanoglu

et al. 2008

Pediatr Surg Int

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Injuries as a result of assaults with sharp object in small children are rare and data on them are scarce. The Red Cross War Memorial Children's Hospital is presently the only Children's Hospital in South Africa with a dedicated Level 1 trauma unit for children under the age of 13 years, and we have an annual trauma load of over 10,000 patients. A retrospective review was performed using the Data Base of the Child Accident Prevention Foundation of Southern Africa at the Red Cross War Memorial Children's Hospital in Cape Town. All children who were coded as an 'assault with sharp object' were included in this study. Five-hundred-and-fifty-one (551) patients were retrospectively reviewed, of which 373 (68%) were boys and 177 (32%) girls. The mean age of the children was 7 years. The majority of children (51%) sustained injuries at the head or neck region, 26% sustained an injury at the trunk and 26% at the extremities. The majority of children sustained minor injuries (62%), thirtythree (33%) moderate and 5% severe injuries. Three children died. The most commonly recorded object used in the assault was glass or (broken) bottles (33%) and knives (18%). Other objects recorded included sticks, stones, pens, pencils, scissors, machetes and nails. The majority of perpetrators were known to the child. Assaults with a sharp object in small children are relatively rare and represent only 0.328% of all paediatric trauma patients. Although rare, these injuries carry a significant morbidity and even mortality. The majority of injuries occurred at home. Prevention programmes, specifically targeting the caretakers, should be implemented to prevent these tragic injuries.

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“…Misdiagnoses and treatment errors performed by hospital physicians are alarmingly common (Aronson 2008;Font Noguera, Climent, and Poveda Andrés 2008). Making matters even worse, some of them are fatal (Dettmeyer et al 2001;Tournel et al 2006). In order to improve patient safety in hospitals, a new design approach is needed (Grout 2007;Grout and Toussaint 2010).…”

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confidence: 98%

Lean design improves both health-care facilities and processes: a literature review

Reijula

Nevala

Lahtinen

et al. 2014

Intelligent Buildings International

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This article presents a literature review of the challenges and possibilities for Lean design in modern health-care facilities. Many of today's health-care facilities are in dire need of renovation since limited financial resources among health-care demand improved work process efficiency, safety and employee well-being. Lean philosophy has been successfully implemented into hospitals with up-and-running hospital processes, but has not been thoroughly tested as a design methodology. The principles of Lean do not contradict with user-centric, participatory or ergonomic design approaches and thus the possibilities of using Lean as a complementary design methodology to the aforementioned approaches are discussed in this article. Lean fundamentals are also useful when dealing with change management issues. Lean offers a fundamentally solid ideology and a wide range of toolsmany of which seem fitting to solve several urgent design problems in today's health-care design.

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Fatal Accidental Intrathecal Injection of Vindesine

Cited by 26 publications

References 11 publications

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Assaults with a sharp object in small children: a 16-year review

Lean design improves both health-care facilities and processes: a literature review

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