Dissertations / Theses on the topic 'Patient safety outcomes'
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O'Brien, Roxanne Louise. "Keeping patients safe: The relationship between patient safety climate and patient outcomes." Diss., Search in ProQuest Dissertations & Theses. UC Only, 2009. http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&res_dat=xri:pqdiss&rft_dat=xri:pqdiss:3378501.
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Thornlow, Deirdre. "Relationship of patient safety practices to patient outcomes." Saarbrücken VDM Verlag Dr. Müller, 2007. http://d-nb.info/991198212/04.
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RinaldiFuller, Julie. "Patient to nurse ratios and safety outcomes for patients." [Denver, Colo.] : Regis University, 2008. http://165.236.235.140/lib/JRinaldiFuller2008.pdf.
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Wilson, Katherine Ann. "Does safety culture predict clinical outcomes?" Doctoral diss., University of Central Florida, 2007. http://digital.library.ucf.edu/cdm/ref/collection/ETD/id/2919.
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Patient safety in healthcare has become a national objective. Healthcare organizations are striving to improve patient safety and have turned to high reliability organizations as those in which to model. One initiative taken on by healthcare is improving patient safety culture--shifting from one of a 'no harm, no foul' to a culture of learning that encourages the reporting of errors, even those in which patient harm does not occur. Lacking from the literature, however, is an understanding of how safety culture impacts outcomes. While there has been some research done in this area, and safety culture is argued to have an impact, the findings are not very diagnostic. In other words, safety culture has been studied such that an overall safety culture rating is provided and it is shown that a positive safety culture improves outcomes. However, this method does little to tell an organization what aspects of safety culture impact outcomes. Therefore, this dissertation sought to answer that question but analyzing safety culture from multiple dimensions. The results found as a part of this effort support previous work in other domains suggesting that hospital management and supervisor support does lead to improved perceptions of safety. The link between this support and outcomes, such as incidents and incident reporting, is more difficult to determine. The data suggests that employees are willing to report errors when they occur, but the low occurrence of such reportable events in healthcare precludes them from doing so. When a closer look was taken at the type of incidents that were reported, a positive relationship was found between support for patient safety and medication incidents. These results initially seem counterintuitive. To suggest a positive relationship between safety culture and medication incidents on the surface detracts from the research in other domains suggesting the opposite. It could be the case that an increase in incidents leads an organization to implement additional patient safety efforts, and therefore employees perceive a more positive safety culture. Clearly more research is needed in this area. Suggestions for future research and practical implications of this study are provided.Ph.D.
Department of Psychology
Sciences
Psychology PhD
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Wynn, Gareth. "Improving ablation outcomes in atrial fibrillation : improving procedural efficacy, safety, and patient selection." Thesis, Imperial College London, 2015. http://hdl.handle.net/10044/1/29109.
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Atrial fibrillation (AF) is a major health problem, affecting 1-2% of the population. AF reduces quality of life (QoL) and increases morbidity and mortality. Catheter ablation (CA) is the most efficacious means of restoring sinus rhythm but is not always successful and is occasionally associated with serious complications. Several questions are currently unanswered. True procedural effectiveness, particularly long-term, remains uncertain, especially in more advanced disease. The best technique for achieving success remains an issue of considerable debate and as yet, few, if any, means exist to predict when acute electrical success will translate into sustained clinical benefit. CA is indicated for symptomatic relief but QoL, both as a treatment outcome and as a guide to patient selection, has generally been overlooked in the published literature. Finally, although the maxim, 'First, do no harm' may often be ascribed erroneously to Hippocrates, it remains a central tenet of medical practice. However, little previous research has focussed on improving the safety of CA. I have attempted to tackle these issues from a number of angles. I have performed a comprehensive literature review and a retrospective analysis of ablation outcomes at Liverpool Heart and Chest Hospital, the largest and longest such data from the UK, to ascertain a comprehensive, up-to-date assessment of practice. In an effort to improve procedural success, I carried out a multicentre randomised controlled trial testing two ablation strategies. A sub-study tests the hypothesis that clinical outcomes can be predicted by a novel measure of effective ablation. Two further studies aim to improve safety, through use of ultrasound to guide venous access, and to better understand QoL in AF - a theme throughout the thesis - which may help improve selection of appropriate patients for CA. Together, I hope these studies will help physicians improve the outcomes of CA for their patients.
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Burström, Lena. "Patient Safety in the Emergency Department : Culture, Waiting, and Outcomes of Efficiency and Quality." Doctoral thesis, Uppsala universitet, Institutionen för kirurgiska vetenskaper, 2014. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-223987.
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The overall aim of this thesis was to investigate patient safety in the emergency department (ED) and to determine whether this varies according to patient safety culture, waiting, and outcomes of efficiency and quality variables. I: Patient safety culture was described in the EDs of two different hospitals before and after a quality improvement project. The questionnaire “Hospital Survey on Patient Safety Culture” was used to investigate the patient safety culture. The main finding was that the staff at both hospitals scored more positively in the dimension Team-work within hospital after implementing a new work model aimed at improving patient flow and patient safety in the ED. Otherwise, we found only modest improvements. II: Grounded theory was used to explore what happens in the ED from the staff perspective. Their main concern was reducing patients’ non-acceptable waiting time. Management of waiting was improved either by increasing the throughput of patient flow by structure pushing and by shuffling patients, or by changing the experience of waiting by calming patients and by feinting to cover up. III: Three Swedish EDs with different triage models were compared in terms of efficiency and quality. The median length of stay was 158 minutes for physician-led team triage compared with 243 and 197 minutes for nurse–emergency physician and nurse–junior physician triage, respectively. Quality indicators (i.e., patients leaving before treatment was completed, the rate of unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days) improved under the physician-led team triage. IV: Efficiency and quality variables were compared from before (2008) to after (2012) a reorganization with a shift of triage model at a single ED. Time from registration to physician decreased by 47 minutes, and the length of stay decreased by 34 minutes. Several quality measures differed between the two years, in favour of 2012. Patients leaving before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days all improved despite the reduced admission rate. In conclusion, the studies underscore the need to improve patient safety in the ED. It is important to the patient safety culture to reduce patient waiting because it dynamically affects both patients and staff. Physician-led team triage may be a suitable model for reducing patient waiting time and increasing patient safety.
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Maddocks, Jordan Scott. "Trends in Adherence and Patient Outcomes in a Safety Net Medication Therapy Management Program." University of Toledo Honors Theses / OhioLINK, 2011. http://rave.ohiolink.edu/etdc/view?acc_num=uthonors1309357633.
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Hada, Adriana H. "Transforming patient outcomes through effective nursing clinical handover." Thesis, Queensland University of Technology, 2022. https://eprints.qut.edu.au/228671/14/Adriana%20Hada%20Thesis.pdf.
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This thesis explored the effect of nursing handover strategies to facilitate the provision of standardised handover communication and enhancement of patient safety in the inpatient wards of a tertiary metropolitan Australian hospital. The outcomes included improved nursing compliance with best practice nursing shift-to-shift handover, and improved direct patient outcomes, including a reduction in falls, pressure injuries, and medication errors. The findings of this research contribute to a theoretical understanding of best practice nursing shift-to-shift handover in the participating wards and could influence nursing practice, education, policy, and future research for the benefit of patient safety and quality of care.
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Havaei, Farinaz. "The effect of mode of nursing care delivery and skill mix on quality and patient safety outcomes." Thesis, University of British Columbia, 2016. http://hdl.handle.net/2429/59936.
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Aims: This study examined the effect of various components of a model of nursing care delivery, the mode of nursing care delivery and nursing skill mix on (a) quality of nursing care (i.e., nurse reported quality of nursing care and nursing tasks left undone), (b) patient adverse events, and (c) nurse outcomes (i.e., job satisfaction and emotional exhaustion) after controlling for nurse demographic characteristics, work environment and workload factors. This study also explores the moderating effects of mode of nursing care delivery and skill mix on the relationship between workload factors and the five outcome variables.
Background: Research into redesigning care delivery has typically focused on only one care delivery component at a time (e.g., skill mix). There exists little research focusing on both components, and controlling for one factor while the other is investigated to determine quality of nursing care delivery and nurse and patient outcomes.
Method: This cross-sectional exploratory correlational survey study drew upon secondary data from 416 direct care registered nurses (RNs) from medical-surgical settings.
Results: Nurses working in a team-based mode of care delivery reported a greater number of nursing tasks left undone compared to those working in a total patient care mode of delivery. Nurses working in a skill mix with licensed practical nurses (LPNs) reported a higher frequency of patient adverse events compared to those working in a skill mix without LPNs. Two moderating effects were found. At higher levels of acuity, nurses in a team-based mode of care delivery reported a higher frequency of patient adverse events than did nurses in a total patient care mode of delivery. At higher levels of acuity, nurses working in a skill mix with LPNs reported lower levels of emotional exhaustion than nurses in a skill mix without LPNs.
Conclusion: Models of nursing care delivery components influenced quality and safety outcomes.
Implications: To be effective, a team-based mode of care delivery requires collaborative teamwork. Policy makers, administrators and healthcare providers should work together to clarify and optimize the scopes of practice for RNs and LPNs.Applied Science, Faculty of
Nursing, School of
Graduate
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Baughn, Daniel. "Care for the socially disadvantaged: The role of race and gender on the physician-patient relationship and patient outcomes in a safety net primary care clinic." VCU Scholars Compass, 2012. http://scholarscompass.vcu.edu/etd/2882.
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Compared to the general population, socially disadvantaged patients have higher rates of chronic illness and require more complex medical care. They also endorse higher levels of psychological distress and tend to engage in behavioral risk factors such as poor diet, physical inactivity, and smoking. These issues are particularly concerning given that this population tends to adhere less to medical recommendations, has limited access to health resources, and receives poorer treatment from providers. In an effort to address this disparity, The Affordable Care Act will expand health care access to an additional 23 million uninsured and 17 million underinsured Americans. However, simply expanding access to health care without examining and improving upon factors related to the physician-patient relationship would not fully address the health care needs of this population. This study sought to improve the quality of care received by socially disadvantaged patients by better understanding the role of race and gender on the physician-patient communication process and patient outcomes in a safety net primary care clinic. The study sample consisted of 330 low-income, uninsured/underinsured African American and White patients and 41 resident physicians. Overall, African American patients and their doctors and White doctors and their patients were viewed as engaging in the highest levels of communication. South Asian physicians, and male South Asian physicians in particular, had the lowest levels of communication and the patients of these providers experienced less improvement in their physical health. Patient education level influenced physicians’ perceptions of their patients to the extent that patients with higher educational levels were viewed as engaging in lower levels of communication. Last, indicators of a good physician-patient relationship were associated with higher levels of patient reported adherence. Practice implications and areas for future research are discussed.
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Manges, Kirstin. "Transition to home study: the influence of interprofessional team shared mental models on patient post-hospitalization outcomes." Diss., University of Iowa, 2018. https://ir.uiowa.edu/etd/6193.
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Background: The quality of team-based care impacts patient post-hospitalization outcomes, yet there is a gap in our understanding of how specific team processes impact patient post-hospitalization outcomes. Shared Mental Models (SMMs) is a team process from organizational psychology; it provides an understanding of how providers coordinate complex tasks as a team. SMMs are the team members’ organized knowledge needed for effective team performance. Military research shows that teams with more convergent SMMs have higher performance and better outcomes. In healthcare, patient discharge exemplifies an activity that requires a high level of coordination among interprofessional team members. Two relevant domains of SMMs are Taskwork SMM (team assessment of patient’s readiness for hospital discharge) and Teamwork SMM (quality of day of discharge teamwork). Because of the newness of SMM to healthcare, we lack measures to understand SMMs among interprofessional discharge teams.
Study Purpose & Aims: The purpose was to pilot a novel measurement approach assessing SMMs of discharge teams, and explore their relationships to patient 30-day post-hospitalization outcomes (quality of care transition and utilization of unplanned medical services). Aim 1 determined the content and degree of convergence of discharge teams’ SMMs (taskwork and teamwork). Aim 2 examined the relationship between discharge team SMMs and patient post-hospitalization outcomes.
Methods: A prospective longitudinal pilot study was used to examine the SMMs of 64 unique discharge events in three inpatient units at a single hospital. Discharge team members independently completed a questionnaire measuring the Teamwork SMM (using the Shared Mental Model Scale) and the Taskwork SMM (using the Discharge Provider-Readiness for Hospital Discharge Scale). Data were collected from the patient 30 days post-discharge to determine the quality of transition (using the Care Transition Measure or CTM-15) and use of unplanned utilization of medical services (unplanned readmission or ED visit). Interrater Agreement (r*wg(j)) was used to determine the SMM convergence (or level of agreement) among the discharge team. The relationship between SMMs and the quality of transition outcome (n = 42) was determined using standard regression analysis. Logistic regression was used determine the relationship of SMMs with utilization of unplanned medical services (n = 56).
Results: Overall, discharge teams reported high levels of Taskwork SMMs (M = 8.46, SD =.91) and Taskwork SMM Convergence (M = .90, SD =.10), indicating that the discharge team perceived and agreed that patients had high levels of readiness for hospital discharge. Discharge teams also reported having high-quality Teamwork SMMs (M = 6.11, SD = 0.39) and Teamwork SMM Convergence (M = .85, SD = .10), suggesting that most discharge teams perceived and agreed that high quality teamwork was provided during the discharge process. Discharge events from the three inpatient units significantly differed in their Teamwork and Teamwork SMM content and convergence scores. Discharge teams’ Teamwork SMMs and Taskwork SMMs were positively associated with the CTM-15 score, while controlling for key contextual factors (t = 3.94, p = .001; t = 3.94, p = .001, respectively).
Conclusion : Discharge teams’ Taskwork SMM and Teamwork SMM was positively associated with patient-reported quality of transition from the hospital. There was insufficient evidence to support that utilization of unplanned medical services is related to discharge teams’ SMMs. Measuring the SMMs of the discharge team provides a method for assessing a team process critical to safe patient discharges.
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Bonner, Alice F. "Certified Nursing Assistants’ Perceptions of Nursing Home Patient Safety Culture: Is There a Relationship to Clinical or Workforce Outcomes?: A Dissertation." eScholarship@UMMS, 2008. https://escholarship.umassmed.edu/gsn_diss/10.
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Patient safety culture (PSC) is a critical factor in creating high reliability healthcare organizations. However, few studies to date have correlated PSC measures with actual safety outcomes. In particular, nursing home studies have only recently appeared in the literature. Nursing homes differ from hospitals in that the vast majority of direct care is provided by certified nursing assistants (CNAs), not licensed nurses. Thus nursing home PSC could differ in important ways from PSC in acute care institutions.
This dissertation was a secondary data analysis that examined whether CNAs’ perceptions of patient safety culture were correlated with clinical outcomes in a random sample of 74 nursing homes in five randomly selected states. This study matched CNA PSC survey data using the Hospital Survey of Patient Safety Culture (HSOPSC) with Minimum Data Set (MDS), Area Resource File (ARF) and Online Survey Certification and Reporting (OSCAR) data from those same homes during the first two quarters of 2005. In the original study, 1579 nurse aides out of 2872 completed the survey, for a 55% response rate.
In addition to clinical outcomes, this study examined the relationship between CNA PSC scores and staff turnover. The relationship between certain demographic variables, such as level of education, tenure as a CNA, and PSC scores was evaluated. The relationship between certain facility characteristics, such as profit status and bed occupancy was also assessed. An exploratory factor analysis of the original HSOPSC instrument was re-run for this nursing home CNA sample.
Data were analyzed using Poisson regression and multilevel techniques; descriptive statistics were compiled for demographic data. Major findings from the regression analyses and combined GEE models suggest that certain factors, such as CNA turnover and LPN staffing may predict CNA PSC scores. CNA PSC scores were associated with rates of falls and restraint use, but were not associated with differences in pressure ulcer rates in this sample. Few associations for CNA PSC with individual subscales were identified. The exploratory factor analysis revealed some potential differences in how items and subscales factored in this nursing home CNA population.
This dissertation represents an important step in the evaluation of CNA PSC in nursing homes and the relationship of PSC to safety outcomes. Future work on nursing home PSC and clinical and workforce outcomes is described.
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Leveille, Deborah. "Deliberate Practice of IV Medication Procedures by Student Nurses: Feasibility, Acceptability, and Preliminary Outcomes: A Dissertation." eScholarship@UMMS, 2015. https://escholarship.umassmed.edu/gsn_diss/42.
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Background: Medication errors continue to be one of the most prevalent problems in healthcare related to patient safety, often resulting in injury or death, with higher incidences of error occurring with intravenous medications. The purpose of this study was to explore the use of deliberate practice (DP) with second-degree nursing students in developing and maintaining fundamental intravenous medication management practices required for safe practice.
Method: This was a feasibility study using a two-arm, single-blind, randomized controlled trial design. Vygotsky’s Zone of Proximal Development model was used to explore the use of a DP teaching intervention to achieve competency in skills associated with safe IV medication management. A convenience sample of first-year, first-semester nursing students enrolled in an accelerated graduate program (N = 32) were invited to participate; 19 enrolled, and 12 completed the study. Students (n = 12) received three 30- minute one-on-one practice sessions at 2-week intervals with an expert nurse (the intervention group focused on IV skills and the control group on skills unrelated to IVs). Pre- and post-intervention instruments tested participants’ confidence with IV management and safety skills. The primary outcome was their ability to safely administer and monitor IV medications during a 20-minute videotaped medication administration scenario.
Results: Low recruitment (19 of 32) and high attrition (37%) were observed. Participants completing the study (5 in the intervention group and 7 in the control group) reported that the time required to attend the sessions was not burdensome (91.7%); time allotted was adequate (100%); 100% reported positive experience; 91.7% found the DP sessions essential to learning. Change in confidence scores for IV skills were not significant (P = 0.210), but were higher in the intervention group (2.97–4.14 = 1.50 change) compared to the control group (2.71–3.77 = 1.04 change). Significant differences were found in overall medication administration skills between the control and intervention groups (t [-2.302], p = 0.044) in favor of the intervention group, particularly with medication preparation skills (p = 0.039). Overall raw scores were low in both groups; only 16–42 (26%–70%) of the total 60 steps required for safe practice were completed. Participants scored lowest in the evaluation phase, with all participants performing less than 50% of the 14 steps.
Conclusion: Even though participant satisfaction was high, significant attrition occurred. Students reported the DP sessions to be beneficial and they felt more confident in performing skills, but three 30-minute sessions (90 minutes) were not adequate to develop, maintain, or refine all the IV-management skills associated with safe medication practices. Determining the length and duration of DP sessions as well as comparing the efficacy of DP sessions between individual and group sessions with varying doses and frequencies is needed to advance our understanding of using DP within nursing education.
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Chukmaitov, Askar S. "Variations in Quality Outcomes Among Hospitals in Different Types of Health Systems." VCU Scholars Compass, 2005. https://scholarscompass.vcu.edu/etd/1414.
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Although prior research has found differences in costs and financial performance across different types of hospital systems, there has been no systematic study of variations in patient quality of care or safety indicators across different systems. Our study examines whether five main types of health systems - centralized (CHS), centralized physician/insurance (CPIHS), moderately centralized (MCHS), decentralized (DHS), and independent (IHS) - as well as other hospital characteristics are associated with differences in quality of patient care. Data were assembled for 6 years (1995 - 2000) from multiple sources. We used 4 AHRQ risk adjusted inpatient quality indicators (IQIs) and 5 risk-adjusted patient safety indicators (PSIs) as dependent variables. Random effects models were used in the analysis.It was found that the IQI and PSI models have different patterns. In the IQI models, CHS hospitals have lower AMI, CHF, Stroke, and Pneumonia mortality rates than hospitals in other system types. The PSI models did not indicate any systems' effects on adverse event rates. It was also found that system hospitals' compliance with the JCAHO performance area indicator for availability of patient specific information was associated with lower rates of CHF, Stroke, Pneumonia, and Infection due to medical care.The findings suggest that centralization of hospital structures may improve internal clinical processes by enhancing coordination of activities, communication between providers, timely adjustments of processes of care delivery and structures to external pressures. A lack of systems' effect on adverse events may be explained by a newness of the patient safety issues for hospitals and possible changes in reporting patterns of medical errors after the Institute of Medicine report of 1999. A system hospitals' compliance with the JCAHO performance area indicator may indicate improvements in information and clinical record systems.Hospital systems hold much potential for hospitals in improving patient quality of care and safety because they provide a laboratory for studying the health care process and sharing lessons across multiple institutions. Based on our findings, we recommend that future studies use a combination of IQIs and PSIs when examining institutional quality of care because both provide different and complementary information.
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Fabri, Peter J. "The validation of a methodology for assessing the impact of hybrid simulation training in the minimization of adverse outcomes in surgery." [Tampa, Fla.] : University of South Florida, 2007. http://purl.fcla.edu/usf/dc/et/SFE0002085.
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Duff, Beverley. "Development and evaluation of an integrated clinical learning model to inform continuing education for acute care nurses." Thesis, Queensland University of Technology, 2010. https://eprints.qut.edu.au/42622/1/Beverley_Duff_Thesis.pdf.
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Background Significant ongoing learning needs for nurses have occurred as a direct result of the continuous introduction of technological innovations and research developments in the healthcare environment. Despite an increased worldwide emphasis on the importance of continuing education, there continues to be an absence of empirical evidence of program and session effectiveness. Few studies determine whether continuing education enhances or develops practice and the relative cost benefits of health professionals’ participation in professional development. The implications for future clinical practice and associated educational approaches to meet the needs of an increasingly diverse multigenerational and multicultural workforce are also not well documented. There is minimal research confirming that continuing education programs contribute to improved patient outcomes, nurses’ earlier detection of patient deterioration or that standards of continuing competence are maintained. Crucially, evidence-based practice is demonstrated and international quality and safety benchmarks are adhered to. An integrated clinical learning model was developed to inform ongoing education for acute care nurses. Educational strategies included the use of integrated learning approaches, interactive teaching concepts and learner-centred pedagogies. A Respiratory Skills Update education (ReSKU) program was used as the content for the educational intervention to inform surgical nurses’ clinical practice in the area of respiratory assessment. The aim of the research was to evaluate the effectiveness of implementing the ReSKU program using teaching and learning strategies, in the context of organisational utility, on improving surgical nurses’ practice in the area of respiratory assessment. The education program aimed to facilitate better awareness, knowledge and understanding of respiratory dysfunction in the postoperative clinical environment. This research was guided by the work of Forneris (2004), who developed a theoretical framework to operationalise a critical thinking process incorporating the complexities of the clinical context. The framework used educational strategies that are learner-centred and participatory. These strategies aimed to engage the clinician in dynamic thinking processes in clinical practice situations guided by coaches and educators. Methods A quasi experimental pre test, post test non–equivalent control group design was used to evaluate the impact of the ReSKU program on the clinical practice of surgical nurses. The research tested the hypothesis that participation in the ReSKU program improves the reported beliefs and attitudes of surgical nurses, increases their knowledge and reported use of respiratory assessment skills. The study was conducted in a 400 bed regional referral public hospital, the central hub of three smaller hospitals, in a health district servicing the coastal and hinterland areas north of Brisbane. The sample included 90 nurses working in the three surgical wards eligible for inclusion in the study. The experimental group consisted of 36 surgical nurses who had chosen to attend the ReSKU program and consented to be part of the study intervention group. The comparison group included the 39 surgical nurses who elected not to attend the ReSKU program, but agreed to participate in the study. Findings One of the most notable findings was that nurses choosing not to participate were older, more experienced and less well educated. The data demonstrated that there was a barrier for training which impacted on educational strategies as this mature aged cohort was less likely to take up educational opportunities. The study demonstrated statistically significant differences between groups regarding reported use of respiratory skills, three months after ReSKU program attendance. Between group data analysis indicated that the intervention group’s reported beliefs and attitudes pertaining to subscale descriptors showed statistically significant differences in three of the six subscales following attendance at the ReSKU program. These subscales included influence on nursing care, educational preparation and clinical development. Findings suggest that the use of an integrated educational model underpinned by a robust theoretical framework is a strong factor in some perceptions of the ReSKU program relating to attitudes and behaviour. There were minimal differences in knowledge between groups across time. Conclusions This study was consistent with contemporary educational approaches using multi-modal, interactive teaching strategies and a robust overarching theoretical framework to support study concepts. The construct of critical thinking in the clinical context, combined with clinical reasoning and purposeful and collective reflection, was a powerful educational strategy to enhance competency and capability in clinicians.
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Andrews, P. J. "A prospective, controlled study on 131 patients assessing patient safety and nasal function outcomes following human olfactory mucosa biopsy as a source of cells for central nervous system regeneration during Endoscopic Sinus Surgery." Thesis, University College London (University of London), 2016. http://discovery.ucl.ac.uk/1530783/.
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Hypotheses: The primary hypothesis states; olfactory harvesting is a safe procedure and does not incur a reduction in nasal function including the sense of smell when compared to a control group. The secondary hypothesis states; ESS improves olfactory outcome in CRS patients with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Materials and Methods: Full Ethical and Research and Development (R&D) approval was granted; Ref: 05/Q0512/103. 131 patients were recruited over a 2 year period and non-randomised into the olfactory biopsy and control arms. Statistical significance was accepted at the 5% level (< 0.05) and powered at 80%. Complication rates as well as patient and surgeon reported outcome measures were recorded in each arm both pre operatively and 6 months post operatively. The sense of smell was evaluated using the University of Pennsylvania Smell Identification Test (UPSIT). Results: 65 patients underwent superior turbinate biopsy with 66 controls. The complication rate, the nasal function and the sense of smell outcomes of the biopsy group were statistically the same when compared to the control group. In the CRS subgroup analysis the sense of smell improved in both groups following ESS but only in the CRSwNP subgroup was it found to be significant. Conclusions: The primary hypothesis was shown to be true and demonstrated that patient morbidity and beneficial outcomes following harvesting human olfactory nasal mucosa during ESS is statistically the same when compared to the control group. The secondary hypothesis was equally shown to be true and demonstrated that sinus surgery improved olfaction in both the CRSwNP and CRSsNP subgroups but only in the CRSwNP subgroup was the olfactory improvement significant.
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Willemyns, Amanda Jo-Anne. "Under the carpet : the politics and trauma of patient harm." Thesis, Queensland University of Technology, 2010. https://eprints.qut.edu.au/46266/1/Amanda_Willemyns_Thesis.pdf.
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Few studies have investigated iatrogenic outcomes from the viewpoint of patient experience. To address this anomaly, the broad aim of this research is to explore the lived experience of patient harm. Patient harm is defined as major harm to the patient, either psychosocial or physical in nature, resulting from any aspect of health care. Utilising the method of Consensual Qualitative Research (CQR), in-depth interviews are conducted with twenty-four volunteer research participants who self-report having been severely harmed by an invasive medical procedure. A standardised measure of emotional distress, the Impact of Event Scale (IES), is additionally employed for purposes of triangulation. Thematic analysis of transcript data indicate numerous findings including: (i) difficulties regarding patients‘ prior understanding of risks involved with their medical procedure; (ii) the problematic response of the health system post-procedure; (iii) multiple adverse effects upon life functioning; (iv) limited recourse options for patients; and (v) the approach desired in terms of how patient harm should be systemically handled. In addition, IES results indicate a clinically significant level of distress in the sample as a whole.
To discuss findings, a cross-disciplinary approach is adopted that draws upon sociology, medicine, medical anthropology, psychology, philosophy, history, ethics, law, and political theory. Furthermore, an overall explanatory framework is proposed in terms of the master themes of power and trauma. In terms of the theme of power, a postmodernist analysis explores the politics of patient harm, particularly the dynamics surrounding the politics of knowledge (e.g., notions of subjective versus objective knowledge, informed consent, and open disclosure). This analysis suggests that patient care is not the prime function of the health system, which appears more focussed upon serving the interests of those in the upper levels of its hierarchy.
In terms of the master theme of trauma, current understandings of posttraumatic stress disorder (PTSD) are critiqued, and based on data from this research as well as the international literature, a new model of trauma is proposed. This model is based upon the principle of homeostasis observed in biology, whereby within every cell or organism a state of equilibrium is sought and maintained. The proposed model identifies several bio-psychosocial markers of trauma across its three main phases. These trauma markers include: (i) a profound sense of loss; (ii) a lack of perceived control; (iii) passive trauma processing responses; (iv) an identity crisis; (v) a quest to fully understand the trauma event; (vi) a need for social validation of the traumatic experience; and (vii) posttraumatic adaption with the possibility of positive change.
To further explore the master themes of power and trauma, a natural group interview is carried out at a meeting of a patient support group for arachnoiditis. Observations at this meeting and members‘ stories in general support the homeostatic model of trauma, particularly the quest to find answers in the face of distressing experience, as well as the need for social recognition of that experience. In addition, the sociopolitical response to arachnoiditis highlights how public domains of knowledge are largely constructed and controlled by vested interests. Implications of the data overall are discussed in terms of a cultural revolution being needed in health care to position core values around a prime focus upon patients as human beings.
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Murray, Brett Richard. "The use of emergency lights and sirens by ambulances and their effect on patient outcome and public safety." Thesis, Boston University, 2013. https://hdl.handle.net/2144/21225.
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Thesis (M.A.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.The use of emergency lights and sirens as warning devices by ambulances is a hotly debated topic within the Emergency Medical Services. For the last few decades, research has shown that lights and sirens have only a minimal effect on time required to transport patients to the hospital, and essentially no positive effect on patient outcome. Meanwhile, thousands of ambulance crashes occur every year (usually during the operation of lights and sirens), and its possible that's tens of thousands of crashes are occurring as a result of a passing ambulance, though not directly involving the ambulance itself. This paper is meant to provide a thorough review of the science behind the use of lights and sirens, the risks they pose to EMS providers, patients, and the public, and strategies to help curb the cost they pose both in dollars and lives. The available literature on this subject all points to the use of lights and sirens being out dated, ineffective, and dangerous, and yet almost nothing has been done to solve the problems they cause. Continued research and development is needed to help make ambulances safer for their occupants, more effective driver training programs need to be offered to EMS providers, and protocols need to be adopted to limit the unnecessary use of L&S.
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Subirana, Mireia. "The influence of nursing structure and process variables on patients' outcomes and safety within a High Dependency Unit." Thesis, University of Leeds, 2012. http://etheses.whiterose.ac.uk/2584/.
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Outcomes of nursing practice are used to refer to patient outcomes related to, or as a consequence of, nursing care. This research, comprised two studies, extends the investigation about outcomes of nursing practice. Following Donabedian's framework, the aim was to explore which nursing structure and process variables influence patients' outcomes and safety within a Spanish High Dependency Unit (HDU) and to gain insight into the nurses' and patients' perspectives about the outcome of nursing and how nurses contribute to patient outcomes and safety. The prospective observational study (Study I) examines if nurses structure and process variables are associated with patients' outcomes and safety in a HDU. The exploratory interview study (Study II) undertaken in the same setting reveals the nurses' and patients' perspectives. To inform the research, a literature review on healthcare quality and a concept analysis of 'the outcomes of nursing practice' was undertaken. Findings from Study I reproduce similar results to those reported in the wider literature. Nurses' variables, such as years of experience or educational level, impact on patients' outcomes such as mortality and failure to rescue. Theoretical explanations generated by grounded theory in Study II, from the patients' perspective, highlight the core category of 'adapting to HDU admission' and for nurses that of 'enabling patient comfort'. This nurses' intervention led to patient adaptation promoting better patient outcomes and safe process of care. The study adds to knowledge about the outcomes of nursing care, within the particular context of the HDU, and points to ways that the nurse promotes patients outcomes and safety. Recommendations for future research suggest the need to develop instruments to systematically test the link between nursing interventions to patients' safety and outcomes. The main recommendations for nurse education and training and within practice relate to promoting the importance of patient comfort as an essential aspect of care and the monitoring of its achievement. Recommendations at management level include the need to be aware and to guarantee the necessary conditions to deliver quality and safe care.
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Bunch, Jacinda Lea. "Rapid response systems : evaluation of program context, mechanism, and outcome factors." Diss., University of Iowa, 2014. https://ir.uiowa.edu/etd/1558.
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Prevention of in-hospital cardiac arrest (IHCA) is critical to reducing morbidity and mortality as both the rates of return to pre-hospital functional status and overall survival after IHCAs are low. Early identification of patients at risk and prompt clinical intervention are vital patient safety strategies to reduce IHCA. One widespread strategy is the Rapid Response System (RRS), which incorporates early risk identification, expert consultation, and key clinical interventions to bedside nurses caring for patients in clinical deterioration. However, evidence of RRS effectiveness has been equivocal in the patient safety literature.
This study utilized a holistic Realistic Evaluation (RE) framework to identify important clinical environment (context) and system triggers (mechanisms) to refine our understanding of an RRS to improve local patient emoutcomesem and develop a foundation for building the next level of evidence within RE research. The specific aims of the study are to describe a RRS through context, mechanism, and outcome variables; explore differences in RRS outcomes between medical and surgical settings, and identify relationships between RRS context and mechanism variables for patient outcomes.
Study RRS data was collected retrospectively from a 397-bed community hospital in the Midwest; including all adult inpatient RRS events from May 2006 (2 weeks post-RRS implementation) through November 2013. RRS events were analyzed through descriptive, comparative, and proportional odds (ordinal) logistic regression analyses.
The study found the majority of adult inpatient RRS events occurred in medical settings and most were activated by staff nurses. Significant differences were noted between RRS events in medical and surgical settings; including patient status changes in the preceding 12 hours, event trigger patterns, and immediate clinical outcomes. Finally, proportional odds logistic regression revealed significant relationships between context and mechanism factors with changes in the risk of increased clinical severity immediately following at RRS event. RE was utilized to structure a preliminary study to explore the complex variables and relationships surrounding RRSs and patient outcomes. Further exploration of settings, changes in clinical status, staffing and resource access, and the ways nurses use RRSs is necessary to promote the early identification of vulnerable patients and strengthen hospital patient safety strategies.
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Januel, Jean-Marie. "Les données de routine des séjours d’hospitalisation pour évaluer la sécurité des patients : études de la qualité des données et perspectives de validation d’indicateurs de la sécurité des patients." Thesis, Lyon 1, 2011. http://www.theses.fr/2011LYO10355/document.
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Évaluer la sécurité des patients hospitalisés constitue un enjeu majeur de la gestion des risques pour les services de santé. Le développement d’indicateurs destinés à mesurer les événements indésirables liés aux soins (EIS) est une étape cruciale dont le défi principal repose sur la performance des données utilisées. Le développement d’indicateurs de la sécurité des patients – les Patient Safety Indicators (PSIs) – par l’Agency for Healthcare Research and Quality (AHRQ) aux Etats Unis, utilisant des codes de la 9ème révision (cliniquement modifiée) de la Classification Internationale des Maladies (CIM) présente des perspectives intéressantes. Nos travaux ont abordé cinq questions fondamentales liées au développement de ces indicateurs : la définition du cadre nosologique, la faisabilité de calcul des algorithmes et leur validité, la qualité des données pour coder les diagnostics médicaux à partir de la CIM et leur performance pour comparer plusieurs pays, et la possibilité d’établir une valeur de référence pour comparer ces indicateurs. Certaines questions demeurent cependant et nous proposons des pistes de recherche pour améliorer les PSIs : une meilleure définition des algorithmes et l’utilisation d’autres sources de données pour les valider (i.e., données de registre), ainsi que l’utilisation de modèles d’ajustement utilisant l’index de Charlson, le nombre moyen de diagnostics codés et une variable de la valeur prédictive positive, afin de contrôler les variations du case-mix et les différences de qualité du codage entre hôpitaux et paysAssessing safety among hospitalized patients is a major issue for health services. The development of indicators to measure adverse events related to health care (HAE) is a crucial step, for which the main challenge lies on the performance of the data used for this approach. Based on the limitations of the measurement in terms of reproducibility and on the high cost of studies conducted using medical records audit, the development of Patient Safety Indicators (PSI) by the Agency for Healthcare Research and Quality (AHRQ) in the United States, using codes from the clinically modified 9th revision of the International Classification of Diseases (ICD) shows interesting prospects. Our work addressed five key issues related to the development of these indicators: nosological definition; feasibility and validity of codes based algorithms; quality of medical diagnoses coding using ICD codes, comparability across countries; and possibility of establishing a benchmark to compare these indicators. Some questions remain, and we suggest several research pathways regarding possible improvements of PSI based on a better definition of PSI algorithms and the use of other data sources to validate PSI (i.e., registry data). Thus, the use of adjustment models including the Charlson index, the average number of diagnoses coded and a variable of the positive predictive value should be considered to control the case-mix variations and differences of quality of coding for comparisons between hospitals or countries
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Fischer, Shira H. "Factors Associated with Ordering and Completion of Laboratory Monitoring Tests for High-Risk Medications in the Ambulatory Setting: A Dissertation." eScholarship@UMMS, 2011. https://escholarship.umassmed.edu/gsbs_diss/543.
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Since the Institute of Medicine highlighted the devastating impact of medical errors in their seminal report, “To Err is Human” (2000), efforts have been underway to improve patient safety. A portion of medical errors are due to medication errors, and a large portion of these can be attributed to inadequate laboratory monitoring.
In this thesis, I attempt to address this small but important corner of this patient safety endeavor. Why are patients not getting their laboratory monitoring tests? Do they fail to complete them or do doctors not order the tests in the first place? Which prescribers and which patients are least likely to do what is needed for testing to happen and what interventions would be most promising?
To address these questions, I conducted a systematic review of existing interventions. I then proceeded with three aims: 1) To identify reasons that patients give for missing monitoring tests; 2) To identify patient and provider factors associated with monitoring test ordering; and 3) To identify patient and provider factors associated with completion of ordered testing.
To achieve these aims, I worked with patients and data at the Fallon Clinic. For aim 1, I conducted a qualitative analysis of their reasons for missing tests as well as reporting completion and ordering rates. For aims 2 and 3, I used electronic medical record data and conducted a regression with patient and provider characteristics as covariates to identify factors contributing to test ordering and completion.
Interviews revealed that patients had few barriers to completion, with forgetting being the most common reason for missing a test. The quantitative studies showed that: older patients with more interactions with the health care system were more likely to have tests ordered and were more likely to complete them; providers who more frequently prescribe a drug were more likely to order testing for it; and drug-test combinations that were particularly dangerous, indicated by a black box warning, were more likely to have appropriate ordering, though for these combinations, primary care providers were less likely to order tests appropriately, and patients were less likely to complete tests.
Taken together, my work can inform future interventions in laboratory monitoring and patient safety.
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Champ-Rigot, Laure. "Nouvelles perspectives diagnostiques et thérapeutiques dans la prise en charge rythmologique des patients en situation d'insuffisance cardiaque Rationale and Design for a Monocentric Prospective Study: Sleep Apnea Diagnosis Using a Novel Pacemaker Algorithm and Link With Aldosterone Plasma Level in Patients Presenting With Diastolic Dysfunction (SAPAAD Study) Usefulness of sleep apnea monitoring by pacemaker sensor in elderly patients with diastolic dysfunction : the SAPAAD Study Clinical outcomes after primary prevention defibrillator implantation are better predicted when the left ventricular ejection fraction is assessed by magnetic resonance imaging Predictors of clinical outcomes after cardiac resynchronization therapy in patients ≥75 years of age: a retrospective cohort study Comparison between novel and standard high-density 3D electro-anatomical mapping systems for ablation of atrial tachycardia Safety and acute results of ultra-high density mapping to guide catheter ablation of atrial arrhythmias in heart failure patients Long-term clinical outcomes after catheter ablation of atrial arrhythmias guided by ultra-high density mapping system in heart failure patients." Thesis, Normandie, 2019. http://www.theses.fr/2019NORMC430.
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L’insuffisance cardiaque est un problème de santé publique dans les pays développés, touchant 1 à 2% de la population générale, mais dont la prévalence atteint 10% après 70 ans. Les progrès thérapeutiques ont permis d’améliorer le pronostic des patients, notamment ceux ayant une altération de la fonction systolique ventriculaire gauche. Les troubles du rythme sont fréquents et nécessitent une pris en charge particulière au cours des situations d’insuffisance cardiaque. Cependant, il reste des questions non résolues : comment améliorer l’efficacité du traitement de l’insuffisance cardiaque à fonction systolique préservée, comment mieux sélectionner les patients pouvant bénéficier de la prévention primaire de la mort subite par un défibrillateur implantable, les patients âgés peuvent-ils bénéficier de la même prise en charge que les patients plus jeunes, et pour finir comment améliorer les résultats de l’ablation de fibrillation auriculaire dans les situations d’insuffisance cardiaque. Nous avons mis en place une étude prospective chez des patients présentant une dysfonction diastolique pour évaluer l’intérêt de l’algorithme de surveillance de l’apnée du sommeil disponible dans des stimulateurs cardiaques. En parallèle, nous avons analysé l’impact de l’évaluation par résonance magnétique des patients candidats à un défibrillateur sur la prédiction des évènements rythmiques, mais aussi le devenir des patients de plus de 75 ans appareillés avec un système de resynchronisation cardiaque. Enfin, nous nous sommes intéressés aux résultats d’un nouveau système de cartographie électroanatomique ultra-haute densité pour guider les procédures d’ablation de troubles du rythme supraventriculaires complexes chez des patients insuffisants cardiaques comparés à des patients contrôlesHeart failure is a major public health issue in developed countries, with a prevalence of 1-2% of global population, rising to 10% after 70 years of age. Therapeutic progresses have succeeded in improving patients’ prognosis, particularly in case of reduced left ventricular ejection fraction. Rhythm abnormalities are frequent, and need special consideration in case of heart failure. Meanwhile, there are still some gaps in the evidence: heart failure with preserved systolic function is complex and difficult to treat, primary prevention of sudden cardiac death is effective but there is a need to better select candidates, whether elderly patients should be treated as younger individuals, and finally how to improve outcomes of atrial fibrillation catheter ablation. Firstly, we have conducted a prospective study to evaluate the Sleep Apnea Monitoring algorithm provided in a novel pacemaker in patients with diastolic dysfunction. Besides, we analyzed whether magnetic resonance imaging could predict cardiac outcomes in patients with an implantable cardioverter defibrillator better than echocardiography. We also reported the outcomes of the cardiac resynchronization therapy in patients ≥75 years old compared to younger patients. Finally, we studied the results of a novel ultra-high density mapping system to guide ablation procedures of complex atrial arrhythmias in heart failure patients compared to controls
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Guisier, Florian. "Contribution à l'identification de marqueurs de la réponse des carcinomes bronchiques non à petites cellules aux immunothérapies Anti-PD1 immunotherapy for NSCLC with actionable oncogenic driver mutations Janus or Hydra : the many faces of T helper cells in the human tumour microenvironment A rationale for surgical debulking to improve anti-PD1 therapy outcome in non small cell lung cancer Efficacy and safety of anti-PD-1 immunotherapy in pretreated NSCLC patients with BRAF, HER2 or MET mutation or RET-translocation. GFPC 01-2018." Thesis, Normandie, 2019. http://www.theses.fr/2019NORMR148.
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L’immunothérapie par anti-PD1/PD L1 a bouleversé la prise en charge du cancer bronchique non à petites cellules (CBNPC) depuis 2015, offrant notamment la perspective d’un contrôle prolongé de la maladie métastatique. Néanmoins la majorité des patients ne tire pas de bénéfice de ces traitements. Il est donc indispensable d’identifier des biomarqueurs permettant de mieux Sélectionner les patients pour l’immunothérapie. A partir d’un modèle murin de CBNPC, nous avons établi le rôle du volume tumoral comme facteur prédictif de la réponse à un traitement par anti-PD1. La mesure du volume tumoral métabolique sur les données du PET scan préthérapeutique d’une cohorte de 48 patients porteurs d’un CBNPC métastatique et traités par Nivolumab a permis de confirmer ce rôle. Dans notre modèle murin, une chirurgie de cytoréduction permettait d’améliorer l’efficacité du traitement par anti-PD1. Dans une seconde étude, nous avons analysé l’efficacité des traitements par anti-PD1/PD-L1 dans le CBNPC avec mutation BRAF, MET ou HER2 ou translocation RET. Ces altérations oncogéniques sont autant de biomarqueurs permettant de proposer un traitement par thérapie ciblée, mais l’efficacité des anti-PD1/PD-L1 dans ces sous-groupes est mal connue. Des études antérieures suggèrent que cette efficacité est réduite. Nous avons mené une étude multicentrique nationale, réunissant 107 patients de 21 centres. : 26 BRAF-V600, 18 BRAF-nonV600, 30 MET, 23 HER2, 9 RET. Les taux de réponse aux anti-PD1/PD-L1 étaient de 26%, 33%, 27%, 38% et 38%, respectivement, soit des taux similaires à ceux de la population générale de CBNPC. Nos résultats incitent à poursuivre les études dans ces sous-groupes de patients puisque certains d’entre eux tirent un bénéfice prolongé des anti-PD1/PD-L1Since 2015, anti-PD1/PD-L1 immunotherapy has emerged as a standard of care for non-small cell lung cancer (NSCLC), demonstrating a higher rate of long-term control of stage IV disease. Nonetheless, most patients do not derive benefit from these drugs. Reliable biomarkers are needed to better select patients for immunotherapy. Studying a mouse model of NSCLC, we identified tumor volume as a predictive marker of response to anti-PD1 therapy. We confirmed this role in a cohort of 48 NSCLC patients treated with Nivolumab, in whom metabolic tumor volume was assessed on pretherapeutic PET-scan. Moreover, in our mouse model, debulking surgery enhanced the efficacy of anti-PD1 treatment. In a second study, we analysed the efficacy of anti-PD1/PD-L1 treatment in NSCLC patients with BRAF, MET or HER2 mutations or RET translocation. These subgroups of patients were overlooked in clinical trials and previous studies suggest they are not good candidates for immunotherapy. We collected data from 107 patients in 21 centers : -26 BRAF-V600, 18 BRAF-nonV600, 30 MET, 23 HER2, 9 RET. Response rates to anti-PD1/PD-L1 treatment were 26%, 33%, 27%, 38% and 38%, respectively. These are close to the ones observed in unselected NSCLC patients. Our results emphasize the need for more studies in these patients, since some of them derive durable benefit from anti-PD1/PD-L1 treatment
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Thornlow, Deirdre Kling. "The relationship of hospital systems and utilization of patient safety practices to patient outcomes /." 2007. http://wwwlib.umi.com/dissertations/fullcit/3239960.
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Chih-An, Lin, and 林芷安. "The Relationship between Patient Safety Strategies and the Related Outcomes." Thesis, 2007. http://ndltd.ncl.edu.tw/handle/55674501974180463467.
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碩士逢甲大學
經營管理碩士在職專班
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The purpose of this study is to explore current strategies for patient safety at Taiwan Hospitals. Repots by the Institute of Medicine highlight concerns about the staggering number of medical errors that occur in the U.S. healthcare system. These reports have exerted considerable pressure on hospitals to establish programs that reduce errors and improve patient safety. Followed the global trend, Taiwan Government and Hospitals also pay a lot of attention to Patient Safety. Department of Health established Patient Safety Committee to enhance the issue. A previous research study identifies seven critical strategies for reducing hospital errors based on U.S. nationwide survey of 525 hospitals. These strategies include (1) partnership with stakeholders, (2) reporting errors free of blame, (3) open discussion of errors, (4) cultural shift, (5) education and training, (6) statistical analysis of data, and (7) system redesign. We follow McFadden, Stock, Gowen 3rd (2006) research, examined the perceptions of health care quality directors about the importance of these seven patient safety strategies, the factors that act as barriers, the level of adoption of these strategies, and benefits resulting from implementation of these strategies. Our results indicate that a considerable gap exists between current hospital practices and the perceived importance of various approaches to improving patient safety. All strategies were reported highly importance and moderate level implementation. Results of analysis reveal that bigger perceived importance and actual implementation are both associated with better outcomes, such as statistical analysis of data. Moreover, the regression analysis also reveals that smaller barriers are associated with better outcome such as lack of top management support and lack of knowledge/understanding. The findings provide specific directions for enhancing patient safety programs at hospital in the future.
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Haskins, Helena Elizabeth Maria. "An action plan to enhance a sustainable culture of safety to improve patient outcomes." Thesis, 2019. http://hdl.handle.net/10500/26185.
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Sustainability is a complex system of interaction between a hospital, individual,
community, and environmental factors that is required to work in harmony to keep a
patient healthy. With the complexities that exist within healthcare, the nurse leader is
required to ensure that the care environment, processes and the safety behaviours
required from nurses to provide safe healthcare is in place and sustained to contribute
to the enhancement of patient safety, whilst in the care of the diverse nursing
workforce. The aim of the study is to develop an action plan to sustain best safety
culture practices for improved patient outcomes in hospitals with a culturally diverse
nursing workforce.
Methodology: A multiple method design was utilised to study the safety culture and
positive work environment (hospital climate) that exists among culturally diverse
nurses and how it is managed by the nurse managers in order to identify and describe actions that can be included in an action plan to sustain best safety culture practices
for improved patient outcomes. Purposeful and convenience sampling methods were
used in the study. Two hospitals, with a very diverse nursing workforce were
purposefully selected to participate in the study. Pretesting of the questionnaire and
e-Delphi embedded assessment validation instrument were done by participants not
part of sample groups. Phase 1: The Hospitals outcomes data for nursing admission
assessment within 24-hours, falls and hospital acquired pressure ulcer incidences and
hand hygiene rates were collected on a checklist. Phase 2: Two questionnaires (1) nurses capturing: biographical data and culture, patient safety (nursing admission
assessment within 24-hours, falls and HAPU and hand hygiene), and safety culture
and positive work environment (hospital climate); (2) nurse managers capturing:
biographical data and culture, patient safety (nursing admission assessment within 24-
hours, falls and HAPU and hand hygiene), safety culture and Positive Work
Environment (hospital climate) and just culture practices. Phase 3: the Draft e-Delphi
action plan with embedded assessment validation instrument was developed. Phase
4: The panel experts selected to validate the e-Delphi draft action plan with embedded
assessment validation instrument in pre-determined rounds.
Data analysis: Phase 1: The outcomes data was displayed in bar graphs and
illustrated that (1) the nursing admission assessment within 24 hour period not been
sustained over time for the medical, surgical, paediatric and critical care areas; (2) a
hundred and sixty two fall incidence; (3) ninety six HAPU incidences and (4) hand
hygiene rate of between 80-94% being reported. Phase 2: A participation rate of
46.33% by nurses and 73.91% by nurse managers were achieved. The data for the 2
questionnaires indicated the need to include 54 action statement to address the
culture, patient safety, hospital climate (PWE), safety culture and just culture gaps
identified. Phase 3: the e-Delphi draft action plan developed based on literature review
and data from phase 1 and phase 2. Phase 4: 100% participation rate was achieved.
Consensus was reached within two rounds that the 54 action statements are essential
and important for patient safety and identified the responsible persons required
enacting on action statement and timeframe required to complete action.
Recommendation: The Action Plan to enhance a sustainable Culture of Safety to
improve patient outcomes were decided by panel experts. Plan to disseminate the
plan among the CNO for implementation.Health Studies
D. Litt. et Phil. (Health Studies)
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Twigg, DE. "Patient safety : evaluation of the impact of nursing hours per patient day staffing method in Western Australia." Thesis, 2009. http://hdl.handle.net/10453/28014.
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University of Technology, Sydney. Faculty of Nursing, Midwifery and Health.In March 2002 Western Australia (WA) mandated a new staffing method—nursing hours per patient day (NHPPD). This method used a “bottom up” approach to classify each hospital ward into one of seven categories using characteristics such as patient complexity, intervention levels, the presence of high dependency beds, the emergency/elective patient mix and patient turnover. Once classified, NHPPD were prescribed for each ward. The purpose of this study was two-fold focusing on data from three adult tertiary hospitals (four of seven ward categories: A, B, C and D combined), and individual ward categories A, B, C and D at one adult tertiary hospital. The first purpose was to determine the impact of implementing this staffing method (NHPPD) on nursing-sensitive outcomes (NSOs). The second was to determine the relationship between skill mix and NSOs following implementation of NHPPD. The research design was an interrupted time series and used retrospective analysis of administrative data. Patient and staffing data using the NHPPD method over a four year period were analysed. The 14 NSOs were central nervous system (CNS) complications, wound infections, pulmonary failure, urinary tract infection, pressure ulcer, pneumonia, deep vein thrombosis, ulcer, gastritis and upper gastrointestinal bleed, sepsis, physiologic/metabolic derangement, shock/cardiac arrest, mortality, failure to rescue and length of stay. The study found significant decreases in the rates of nine NSOs when examining hospital-level data following implementation of NHPPD (including mortality, sepsis and pneumonia). At the ward level, significant decreases in the rates of five NSOs (including mortality, shock/cardiac arrest and UTIs) occurred. Significant decreases in rates of eight NSOs (including failure to rescue, mortality and pneumonia) occurred with each 1% increase in RN hours across the three hospitals. At ward category level, significant decreases in the rates of five NSOs occurred with every 1% increase in RN hours (including failure to rescue, DVT and pneumonia). The findings of this study suggest a richer skill mix, even with relatively small changes (1%), continues to benefit patients by improving NSOs. This study also provides nurse leaders with evidence to support the continuation of the NHPPD staffing method. It also adds to evidence about the importance of nurse staffing to patient safety, evidence that must influence policy. Moreover, this study is one of the first to empirically review a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a “one-size-fits-all” approach.
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Lawton, R., J. K. O'Hara, L. Sheard, C. Reynolds, K. Cocks, Gerry R. Armitage, and J. Wright. "Can staff and patient perspectives on hospital safety predict harm-free care? An analysis of staff and patient survey data and routinely collected outcomes." 2015. http://hdl.handle.net/10454/9261.
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NoPatients have the potential to provide feedback on the safety of their care. Recently, tools have been developed that ask patients to provide feedback on those factors that are known to contribute to safety, therefore providing information that can be used proactively to manage safety in hospitals. The aim of this study was to investigate whether the safety information provided by patients is different from that provided by staff and whether it is related to safety outcomes. Data were collected from 33 hospital wards across 3 acute hospital Trusts in the UK. Staff on these wards were asked to complete the four outcome measures of the Hospital Survey of Patient Safety Culture, while patients were asked to complete the Patient Measure of Safety and the friends and family test. We also collated publicly reported safety outcome data for 'harm-free care' on each ward. This patient safety thermometer measure is used in the UK NHS to record the percentage of patients on a single day of each month on every ward who have received harm-free care (i.e. no pressure ulcers, falls, urinary tract infections and hospital acquired new venous thromboembolisms). These data were used to address questions about the relationship between measures and the extent to which patient and staff perceptions of safety predict safety outcomes. The friends and family test, a single item measure of patient experience was associated with patients' perceptions of safety, but was not associated with safety outcomes. Staff responses to the patient safety culture survey were not significantly correlated with patient responses to the patient measure of safety, but both independently predicted safety outcomes. The regression models showed that staff perceptions (adjusted r(2)=0.39) and patient perceptions (adjusted r(2)=0.30) of safety independently predicted safety outcomes. When entered together both measures accounted for 49% of the variance in safety outcomes (adjusted r(2)=0.49), suggesting that there is overlap but some unique variance is also explained by these two measures. Based on responses to the Patient Measure of Safety it was also possible to identify differences between the acute Hospital Trusts. The findings suggest that although the views of patients and staff predict some overlapping variance in patient safety outcomes, both also offer a unique perspective on patient safety, contributing independently to the prediction of safety outcomes. These findings suggest that feedback from patients about the safety of the care that they receive can be used, in addition to data from staff to drive safety improvements in healthcare. TRIAL REGISTRATION NUMBER: ISRCTN07689702.
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Flabouris, Athanasios. "Medically staffed, out of hospital critical care patient transport (retrieval) services : performance, incidents and patient outcomes." 2008. http://hdl.handle.net/2440/59657.
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The provision of equitable access to health care, particularly acute care remains a challenge. This challenge is often met through the provision of outreach critical care services. These services may take the form of Medical Emergency Teams responding to hospital in-patients who become acutely ill outside a hospital critical care environment (eg a general medical ward) or medically staffed retrieval services that respond to patients who become acutely ill in an out of hospital environment for which critical care resources are not immediately available and are delivered to the patient by a responding retrieval team. In both circumstances the intention is early recognition of the acutely ill patient, a timely response by a team with the desired critical care skills, where appropriate deliver the patient to a Critical Care environment (eg an Intensive Care Unit) for ongoing management and by doing so prevent potential adverse patient events. Retrieval services are becoming increasingly important as centralisation of specialty and acute medical services is increasing. These processes involve many complex interactions, with the potential for adverse patient events. Thus it is important to better understand the nature, frequency of occurrence and patient outcomes associated with out of hospital patient transportation, particularly with critically ill patients requiring admission to an Intensive Care Unit. This body of work, across a number of studies, showed that patients whose ICU source of admission was another hospital had a severity of illness that was higher than for other ICU admissions, had a greater than expected mortality and a mortality and hospital length of stay that exceeded that of similar patients, matched for demographics and casemix who had not undergone a interhospital transfer. These findings varied according to the diagnostic category (being stronger for trauma, respiratory illness, sepsis and intra cranial haemorrhage) and varied across geographical regions. These studies also showed that there was regional variation in the proportion of patients admitted to an ICU from another hospital, the proportion of such patients was increasing (particularly for sepsis) as well as patterns of variation based upon day of the week (highest occurrence Friday and Saturday) and moth of the year (mostly July to October). They also revealed that there is a negative correlation between the proportion of patients admitted to an ICU from another hospital with the proportion of elective and post operative admissions to the ICU. This information is important in regards to planning for the provision of acute care and emergency services resources. The interhospital transfer of critically ill patients has been previously documented to be associated with significant adverse patient events. However our understanding of these events in terms of contributing factors, preventability, potential for harm and minimizing factors has not been well documented. This body of work also showed that medical treatment may be altered based solely on the fact that a patient is undergoing retrieval. An example of this is the finding that such patients have a significantly greater likelihood of endotracheal intubation and mechanical ventilation that similar patients matched for demographics, severity of illness and diagnosis who have not undergone retrieval. Retrieval however can provide significant patient benefit, and this body of work illustrates that through the description of a number of unique and challenging cases and the retrieval specific factors that were associated with a good outcome for each of those cases. This information points to the importance of identifying quality in retrieval practice. This body of work outlines the original development of an incident monitoring tool for retrieval, based upon existing examples of use of the incident monitoring methodology within other medical and non medical domains. Following a retrospective review and analysis of comments from retrieval patient records and consultation a tool for Retrieval Incident Monitoring was developed. An investigation of the use of Retrieval Incident Monitoring across a number of retrieval organisations and pre hospital activities, including during deployment at a major public event (2000 Sydney Olympics) was undertaken. The findings of this study showed that the majority of incidents during retrieval are preventable (91%) and that most incidents were related to problems with equipment, then patient care, and transport operations, interpersonal communication, planning or preparation, retrieval staffing and tasking. Incidents were most likely to occur during patient transport to the receiving facility, at patient origin, during patient loading and at the retrieval service base. Contributing factors were almost equally spread between those that were system and human based. Patient harm was documented in 59% as well as a death. The importance of good crew skills/teamwork was highlighted as a minimising factor to incident occurrence. Subsequently this knowledge, experience and data was used to develop and validity a Retrieval and Ambulance Healthcare Incident Type within the generic and widely used Advanced Incident Management System (AIMS). Finally the occurrence of retrieval can be used as a quality measure for the wider health system. Ideally, because of the findings from this body of work of an associated greater than expected mortality and hospital stay of patients undergoing retrieval, particularly for certain diagnostic categories, then a measure of the occurrence of retrieval could be used as a quality indicator of health service provision across a region. As the need for retrieval will never be negated, outcomes associated with retrieval can be measured and benchmarked across a number of regions In summary, in its entirety, this work has added and tested new knowledge and methods as well as value added to existing knowledge for critical care delivery in the out of hospital environment, in particularly to medical retrieval of critically ill patients admitted to an Intensive Care Unit within Australia and New Zealand. It has developed and validated the efficacy of a new quality tool for retrieval and retrieval based quality measures. It has also pointed towards new areas of future investigation particularly in relation to factors that may favourably or adversely impact upon retrieval outcomes and outcomes of patients undergoing retrieval.http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1346925
Thesis (M.D.) - University of Adelaide, School of Medicine, 2008.
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Wardle, Gavin John. "The Impact of Adverse Events on Hospital Outcomes and Sensitvity of Cost Estimates to Diagnostic Coding Variation." Thesis, 2010. http://hdl.handle.net/1807/24909.
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Previous research has established a consensus that in-hospital adverse events are ubiquitous, cause significant harm to patients, and have important financial consequences. However, information on the extent, consequences and costs of adverse events in Canada is limited. For example, there is, as yet, no published study that has investigated the costs of adverse events in a Canadian context. This dissertation aims to redress this situation by providing Ontario-based estimates of the impact of eleven nursing sensitive adverse events on cost, death, readmission, and ambulatory care use within 90 days after hospitalization.
This dissertation also aims to contribute more broadly to the patient safety literature by quantifying the impact of diagnostic coding error in administrative data on estimates of the excess costs attributable to adverse events. Given the increasing importance of these estimates in Canada and elsewhere for hospital payment policy and for assessments of the business case for patient safety, this is an important gap in the literature.
Each of the adverse events was associated with positive excess costs, ranging from $29,501 (metabolic derangement) to $66,412 (pressure ulcers). Extrapolation from the study hospitals yielded a provincial estimate of $481 million in annual excess costs attributable to the adverse events, which represents 2.8 percent of Ontario’s total hospital expenditures. Several of the adverse events were also associated with significant excess rates of death, readmission, and ambulatory care use. These results suggest that there are economic as well as ethical reasons to improve patient safety in Ontario hospitals.
Estimates of adverse event costs were highly sensitive to coding error. The excess cost of adverse events is likely to be significantly underestimated if the error is ignored. This finding, coupled with the observation that the likelihood of error is ignored in most studies, suggests that previous assessments of the business case for patient safety may have been biased against the cost effectiveness of patient safety improvements. Furthermore, the observed extent of institutional level variation in adverse event coding indicates that administrative data are an inadequate basis for adverse event payment policies or for public reporting of adverse event rates.
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Assaye, Ashagre Molla. "Determinants of Nursing-Sensitive Patient Safety Outcomes Among Patients Admitted to Medical and Surgical Acute Care Settings in Ethiopia: A Mixed-Methods Study." Thesis, 2021. https://hdl.handle.net/2440/135137.
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Patient safety is a global concern and the risks to this safety are higher in low- and middle-income countries (LMICs). The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging. There is a shortage of empirical evidence on nurses’ contribution to the quality of care generally, and patient safety outcomes particularly, in Ethiopia: a low-income country. The main aim of this study was to identify the determinants of nursing-sensitive patient safety outcomes among admitted patients in acute medical/surgical settings in Ethiopia. Specific objectives of the study were determining the level of nurse staffing, missed nursing care and associated factors, and exploring the experience and perception of nurses working in acute care units of the study hospitals. The results of the study will generate evidence to help redesign healthcare systems to improve patient outcomes associated with nursing practice. A parallel explanatory mixed-methods study was conducted. First, a systematic review was conducted to determine the impact of nurse staffing on patient and nursing workforce outcomes in LMICs. Simultaneously, a prospective observational study was conducted comprising a survey of 517 nurses at two time points, and a medical record review to assess nursing-sensitive patient safety outcomes in two hospitals in Ethiopia. An exploratory descriptive qualitative study using in-depth semi-structured interviews was also conducted among nurses who were working in the medical and surgical acute care settings of the two study hospitals. The interviews were designed to explore the experience and perceptions of nurses about patient safety and quality of care in their respective units of the study hospitals. The systematic review found that low nurse-to-patient ratios and high nurses’ workload were associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls and abandonment of treatment in LMICs. Extended work hours, lesser experience, and working night or weekend shifts all significantly increased medication errors. Higher nurses’ workload was linked to higher levels of nurses’ burnout, needlestick and sharps injuries, intent to leave, and absenteeism. The quantitative study demonstrated that nurses working in acute care settings of the study hospitals typically work more than 40 hours per week and care for many patients per shift, which has the potential to impact patient safety. The level of missed nursing care in the study units was very high. The mean number of patients a nurse provided care for per shift was significantly associated with in-hospital mortality. For every extra patient per nursing shift, the odds of a patient dying increased by 27 percent. The qualitative study showed that nurses were very concerned for the safety of patients, the quality of care provided, as well as their own health and wellbeing, while providing care. Providing care for a high number of patients per shift, longer shift hours during night and weekend shifts, being responsible for non-nursing tasks, unfavourable work environments, inadequate resources to provide care, unclear job descriptions, inadequate financial compensation, and scant opportunities for training and capacity development were concerns routinely raised by nurses. Despite the reality of working in a poorly resourced working environment, nurses in this study could achieve positive changes through improved staff management practices that better align patient acuity with individual nurses’ education and expertise. Further, they believed that it was important that management listened to and valued clinicians’ views about models of nursing care delivery. This had the potential to not only improve patient outcomes but also the environment in which these nurses worked.Thesis (Ph.D.) -- University of Adelaide, Adelaide Nursing School, 2021
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Tsai, Rebecca Nika. "Implementation of electronic patient reported outcome measurement in a safety-net radiation oncology clinic: feasibility, initial quality of life outcomes, and social needs assessment." Thesis, 2020. https://hdl.handle.net/2144/42208.
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BACKGROUND: Patient reported outcomes (PROs) are important cancer outcomes that can be measured electronically but are understudied in the safety-net hospital setting. Routine electronic screening to address social determinants of health (SDH) has been established in primary care clinics and the emergency department of New England’s largest safety-net hospital. The burden of SDH in safety-net oncology patients is less well-studied.
This study aimed to determine the feasibility and challenges of routine administration of ePROMs in a safety-net Radiation Oncology clinic, describe treatment toxicities and quality of life (QOL) experienced by this vulnerable population during radiotherapy, and evaluate SDH and the need for SDH screening in the oncology clinic.
METHODS: Patients with lung or head and neck cancer scheduled for radiation oncology consultation from 3/2019–1/2020 were deemed eligible for electronic questionnaire participation based on primary language spoken and absence of metastases. At consultation, patients were administered a set of baseline ePROMs (EQ-5D-3L, FACT, PRO-CTCAE) and a social needs screener (THRIVE) using a widely-used cloud-based, patient-centered outcomes platform. Associations between patient demographics and questionnaire completion were retrospectively evaluated. The set of ePROMs were collected at the end of treatment to characterize treatment-related toxicities and changes in self-reported QOL.
RESULTS: In total, 99 eligible head and neck cancer (51.5%) and lung cancer (48.5%) patients were identified. Median age was 65. The majority of patients were male (71.7%), and English-speaking (82.8%). Whites, Blacks, and Asians/Others comprised 42.4%, 38.4%, and 6.1% of patients, respectively. Fifteen patients were Hispanic (15.2%). Patients were most likely to have private health insurance (39.4%), followed by joint Medicare-Medicaid (25.3%), Medicaid (17.2%), and Medicare (16.2%). Two patients were insured by Corrections (2.0%).
Eight patients (8.1%) no-showed or cancelled, while 91 patients were seen in consultation. Forty-four patients (48.4%) completed the initial questionnaires. For the remaining 47 patients (51.6%), the most common reason for lack of ePROM completion was clinic understaffing and/or clinical decision based on the absence of indication for radiotherapy (n=27, 57.4%). Ten patients refused to complete questionnaires (21.3%), with reasons cited including length of questionnaires and low energy. Ten patients were physically unable to attempt questionnaires (21.3%), for reasons including disabilities and low-literacy. Age, language, race, ethnicity, insurance, marital status, gender, and disease site were not significantly associated with ePROM completion (P≥0.05).
For patients who completed the general (QOL) questionnaire EQ-5D-3L, there was no significant difference in general QOL domains nor self-reported overall health score at baseline vs. end of treatment. For head and neck cancer patients, FACT-H&N Total scores, measuring disease-specific QOL, were significantly worse at end of treatment vs. baseline (P=0.006). For lung cancer patients, FACT-L Total scores at the end of radiation treatment were not significantly worse at end of treatment vs. baseline (P=0.953). For head and neck cancer patients who completed PRO-CTCAE, there was a significant increase in the number with moderate to very severe taste issues (P=0.008) and decrease in appetite (P=0.025) by end of treatment. For lung cancer patients, there was a trend towards an increase in the number reporting moderate to very severe nausea (P=0.083).
Eighty-one of 99 patients (81.8%) were screened for at least one SDH domain using the THRIVE screener at the study hospital. Nineteen patients (19.1%) had all 8 THRIVE social determinants of health statuses documented. Only housing status was documented for 61 patients (61.6%). There was a trend for married individuals (P=0.068) and females (P=0.074) to be associated with the completion of at least one THRIVE domain. Age, race, language, and insurance status were not associated with THRIVE screening (P>0.05). Transportation to appointments (21.1%), food insecurity (20%), and affording medications (10.5%) were the most prevalent concerns among these oncology patients, with 100% of patients who reported insecurities with medication and transportation requesting resources for these needs.
CONCLUSION: Routine ePROs collection in a busy safety-net oncology setting is feasible, but challenging and labor-intensive. Implementation was met with both patient and staff challenges and revealed the need for dedicated project management, staff training, and opportunities to increase patient accessibility. Preliminary PROs analyses revealed several significant detriments in quality of life and increased symptoms for this patient population during treatment, but additional data collection is required.
Safety-net oncology patients report significant social needs. Routine SDH screening and resource referral should be considered in these vulnerable patients. Efforts in a specialized department such as Radiation Oncology could fill gaps in existing efforts in a large safety-net hospital. Safety-net oncology clinics can likely help vulnerable cancer patients access available community resources and reduce disparities due to SDH.
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Yu-Ting, Ku, and 辜昱婷. "An Exploration of Medical Staffs' Perception of Patient Safety Culture and its Relationship with Self-evaluative Hospital Patient Safety Outcome." Thesis, 2009. http://ndltd.ncl.edu.tw/handle/90949948259502051353.
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碩士國立台北護理學院
醫護管理研究所
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Objective: The purpose of this study was to examine the relationship between the perception of patient safety culture and hospital performance on patient safety by physicians and nurses, and to compare the differences of two regression models of these two professionals. Method: A correlation design was conducted by using questionnaire to collect data of 2,409 medical staffs from ten hospitals of North Region Alliance, Department of Health during August to September, 2008. The perception of patient safety culture, refer to independent variable, was measured by using a Chinese version of Hospital Survey On Patient Safety Culture, which was originally developed by the Agency for Healthcare Research and Quality in the United State. The hospital performance on patient safety, refer to dependent variable, was measured by the outcome item of Patient Safety Grade on the same questionnaire. Results: The responses rate of physicians and nurses were 57.68% and 84.94% respectively. There were some differences in patient safety culture scores between physicians and nurses. With multiple regression analysis, 32% of variance in hospital performance perceived by physicians accounted for by three dimensions of patient safety culture--Organizational Learning/Continuous Improvement, Feedback and Communication About Error, and Hospital Management Support for Patient Safety. In addition to above three dimensions, other four dimensions of patient safety culture perceived by nurses accounted for 32% of the variance in hospital performance, which included the predictors of Teamwork Within Units, Communication Openness, Teamwork Across Hospital Units, and Hospital Handoffs and Transitions. Two regression models had some different predictors. Conclusion: The predictor variables of two regression models were varied between two professionals. According to patient safety culture perceptions which valued by different professionals, health care organizations can provide applicable education of safety and establish appropriate reward-and-punishment mechanisms to update caring services and safety measures in the future.
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Slater, B. L., R. Lawton, Gerry R. Armitage, J. Bibby, and J. Wright. "Training and action for patient safety: embedding interprofessional education for patient safety within an improvement methodology." 2012. http://hdl.handle.net/10454/7014.
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INTRODUCTION: Despite an explosion of interest in improving safety and reducing error in health care, one important aspect of patient safety that has received little attention is a systematic approach to education and training for the whole health care workforce. This article describes an evaluation of an innovative multiprofessional, team-based training program that embeds patient safety within quality improvement methods. METHODS: Kirkpatrick's "levels of evaluation" model was adopted to evaluate the program in health organizations across one city in the north of England. Questionnaires were used to assess reaction of participants to the program (Level 1). Improvements in patient safety knowledge and patient safety culture (Level 2) were assessed using a 12-item multiple-choice questionnaire and a culture questionnaire. Interviews and project-specific quantitative measurements were used to assess changes in professional practice and patient outcomes (Levels 3 and 4). RESULTS: All aspects of the program were positively received by participants. Few participants completed the MCQ at both time points, but those who did showed improvement in knowledge. There were some small but significant improvements in patient safety culture. Interviews revealed a number of additional benefits beyond the specific problems addressed. Most importantly, 8 of the 11 teams showed improvements in patient safety practices and/or outcomes. DISCUSSION: This program is an example of interprofessional education in practice and demonstrates that team-based learning using quality improvement methods is feasible and can be effective in improving patient safety, but requires time and space for participants. Alignment with continuing education arrangements could support mainstream adoption of this approach within organizations.
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Bolduc, Jolianne. "Évaluation des liens entre la composition des équipes de soins infirmiers et la qualité et sécurité des soins dans des unités de soins critiques." Thèse, 2018. http://hdl.handle.net/1866/21612.
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