Recent scholarly efforts have sought to examine the cumulative impact of deleterious adverse childhood exposures on various mental health outcomes. Lifetime prevalence rates for depressive disorders are approximately 20% among adolescents. Depression is ranked as the leading cause for disability and fourth leading contributor to the global burden of disease in the world. The purpose of this study was to determine the cumulative impact of adolescent adverse experiences on outcomes of depression, suicide ideation, and overall mental distress in a cohort of 125 adolescent girls receiving public assistance. The adverse exposures studied were personal victimization, household dysfunction, and community violence exposures. Across the three categories of exposures, adolescents reported that community exposures were the highest 92.8%, followed by household dysfunction 89.6 %, and lastly, personal victimization 80%. Over 40% reported experiencing more than seven adverse exposures. There was a doubling in the incidence of depression by the fourth year, and an almost ten percent increase in mental distress by the fourth year. Evidence of a significant direct association was found for those experiencing victimization with depression and suicide ideation. The total Adolescent Adverse Exposures (AAE) score was positively correlated with the CES-D scores in the last three years of the study, however not with suicide ideation. The cumulative impact or 'dose-response' relationship of such exposures on depression, suicide ideation, or change over time was not found. In contradiction with general beliefs and existing literature, a significant negative association was found with depression and having a parent incarcerated or experiencing the divorce of parents. This finding suggests given the homogeneity of this population, experiencing both poverty and high levels of exposure to victimization, that having an incarcerated parent or parental divorce may be potentially protective mitigating the stressful experiences of continued victimization. The results of this study offer evidence of high prevalence rates of adversity occurring in the lives of these already at risk adolescents. A call for efforts to reduce community violence and personal victimization in the context of poverty are needed to prevent the growing rates of depression and suicide ideation for these fragile families and adolescence.

Inledning Intrahospitala transporter av intensivvårdpatient är ett ansvarsfullt arbetsmoment och en stor del av intensivvårdssjuksköterskans och undersköterskans arbete. Det är riskfyllt eftersom tillbud med patient och utrustning kan ske. Syfte: Syftet var att beskriva förekomsten av tillbud och typ av tillbud under intrahospitala transporter av intensivvårdspatienter, samt jämföra om det finns skillnader i förekomst av antalet tillbud under olika tidpunkter på dygnet och skillnad mellan akut respektive planerad transport. Syftet var också att undersöka sjuksköterskors och undersköterskors upplevda grad av stress och trötthet under transporten samt om det finns skillnad i förekomst av trötthet och/eller stress vid transporter där det sker tillbud respektive inte sker tillbud. Metod: Studien är kvantitativ, deskriptiv och jämförande. Förekomst av tillbud samt upplevelse av stress/trötthet besvarades på ett svarsformulär av sjuksköterska och undersköterska under eller direkt efter intrahospital transport. Totalt ingår 42 transporter. Resultat: Tillbud förekom vid 19 transporter. Inga skillnader i förekomst av tillbud mellan dagtransporter och nattransporter eller mellan akuta och planerade transporter kunde ses. Sjuksköterskor och undersköterskor rapporterade mer stress vid de transporter där det förekommit tillbud än vid de där tillbud inte förekommit. Slutsats: Tillbud förekommer i knappt hälften av intrahospitala transporter och sjuksköterskor och undersköterskor rapporterar mer stress i samband med transporter med tillbud än transporter utan tillbud. / Introduction: Intrahospital transport of critical care patient is a responsible working operation and much of the critical care nurse and the assistant nurses´ work. It is risky, because incidents of patient and equipment can happen. Purpose: The objective was to describe the occurrence of incidents and types of incidents during intrahospital transport of ICU patients, and compare if there are differences in the occurrence of incidents during different times of day and the difference between emergency and planed transportation. The aim was to investigate nurses and assistans nurses´ perceived level of stress and fatigue during transport and if there are differences in the incidence of fatigue and/or stress during transport where  incidents occurs or not occurs. Method: The study is quantitative, descriptive and comparative. The presence of the incident and the experience of stress/fatigue were answered on a response form of nurses and assistant nurse during or immediately after intrahospital transport. A total of 42 transports are included. Results: Adverse events occurred at 19 transports. No differences in the occurrence of incidents between day transports and night transport or between acute and planned transports could be seen. Nurses and assistant nurses reported more stress during the transports, where there have been adverse events than in those were adverse events had not occurred. Conclusion: Adverse events occurs in almost half of intrahospital transport and nurses and assistant nurses reported more stress associated with transports with adverse events other than the transports without adverse events.

Aim of the study: To evaluate the implementation status of the quality management system (QMS) in the Lithuanian general hospitals. Objectives: 1. To survey the attitudes of the hospital managers and the managers of the local medical audit group towards QMS. 2. To establish the key problems arising in QMS implementation process. 3. To establish the benefits brought by QMS to the hospital. 4. To survey the attitudes of the respondents towards the adverse event management. Results: QMS have been implemented in 63.9 per cent of the Lithuanian general hospitals. This system is currently under implementation in 22.2 per cent of the hospitals mentioned, and no QMS have been implemented so far in 13.9 per cent of the Lithuanian general hospitals. More than one third of institutions have implemented the ISO standard. Institutions wich have alredy implemented the QMS enjoy higer patient satisfaction (accordingly 5,36 (1,05) and 4,18 (2,14)), improved quality of the services provided (accordingly 6,09 (0,32) ir (4,83 (1,64)). The functioning QMS improves motivation of the employees (4,60) and the patient safety (5,83). Hospitals with the well-functioning QMS more actively record (accordingly 4,78 (2,19) and 2,73 (1,62)) and analyse adverse events (accordingly 5,41 (2,01) and 3,09 (1,97)). Recording of adverse events helps to identify problems (6,41), improve the quality of the services provided (6,13). Conclusions: 1. QMS have been implemented in more than a half of the Lithuanian... [to full text]

Background: Exemestane is a drug of great interest for breast cancer prevention, because it inhibits estrogen production. Estrogen may operate by increasing breast density, a well-established biomarker for increased breast cancer risk. The NCIC CTG MAP.2 trial examined the efficacy of exemestane in decreasing breast density. Menopausal health-related quality of life (HRQL) and adverse events were also carefully monitored during the study. Purpose: To elucidate the impact of exemestane on menopausal HRQL and to examine the relationship between clinician and participant methods of reporting side effects. Methods: 98 postmenopausal women with increased breast density were randomized to exemestane or placebo daily for one year. HRQL was measured with the MENQOL questionnaire, which has four domains. Mean changes in MENQOL domain scores from baseline were compared between treatment groups using the Wilcoxon rank-sum test. The difference between groups in the proportion of women with a clinically meaningful decline was compared by domain with the Chi-square test; change scores were considered worsened if increased by ≥ 0.5 points. The association between time-to-decline in menopausal HRQL and treatment was evaluated using Cox PH regression. The kappa statistic quantified the level of agreement between participant-reported and clinician-reported symptoms. Kaplan-Meier estimates of time-to-decline as communicated by clinicians and participants were compared, using three thresholds to define meaningful change. Results: No significant differences in mean change scores were detected, however, a significantly greater proportion of women on exemestane experienced a clinically meaningful decline in physical menopausal HRQL at three months (absolute difference=19%, p= 0.03), while the absolute difference approached significance for vasomotor menopausal HRQL at six months (21%, p= 0.05), and at nine months (21%, p=0.06). The rate of decline in physical menopausal HRQL was 2.08 times greater (95% CI 1.10-3.94) in the exemestane group compared to the placebo group. Agreement between raters was low for all symptoms except hot flashes; in general participants detected symptoms more rapidly than clinicians, regardless of the defined cut-off for meaningful change on the MENQOL. Conclusions: A subset of women on exemestane experienced significant declines in physical and vasomotor symptoms. Generally, participants reported symptoms more frequently and faster than clinicians. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-06-06 23:55:24.011

Purpose: Patients’ perspectives of informed consent for chiropractic care have not been investigated. This study explored how patients of chiropractors perceived the exchange of risk information during informed consent. Methods: Interviews were conducted with 26 participants, recruited from chiropractic clinics. Interview transcripts were analyzed using a constant comparative method of analysis. Findings: Participants experienced informed consent as an on-going process where risk perceptions were shaped throughout four distinct stages. In the first stage information acquired prior to arriving at the clinic for treatment shaped perceptions of risk. In the second stage participants assessed the perceived competence of the practitioners. Participants then signed the consent form and discussed the risks with t heir practitioner. Finally, they communicated with their practitioners during treatment to ensure their pain threshold was not crossed. Conclusion: These findings suggest that patients perceive informed consent as a social process involving on-going communication with their practitioners.

Darbo tikslas. Išaiškinti ligoninės gydytojų ir slaugytojų požiūrį į pacientų saugos gerinimo galimybes. Uždaviniai. Ištirti gydytojų ir slaugytojų nuomonę apie sveikatos priežiūros profesionalų tobulinimo ir pacientų mokymo svarbą ir tematiką saugiai sveikatos priežiūrai užtikrinti; išaiškinti gydytojų ir slaugytojų nuomonę apie tinkamiausią nepageidaujamų įvykių registravimo sistemų pobūdį; palyginti gydytojų ir slaugytojų nuomones apie profesinio tobulinimosi ir pacientų mokymo svarbą bei tinkamiausią nepageidaujamų įvykių registravimo sistemų pobūdį. Tyrimo metodika. Gydytojų ir slaugytojų požiūrio į pacientų saugos gerinimo galimybes tyrimas atliktas „N“ ligoninėje, taikant anoniminės anketinės apklausos metodą. Tyrime dalyvavo 182 medicinos darbuotojai - 45,6 proc. gydytojų ir 54,4 proc. slaugytojų (atsako dažnis 88,3 proc.). Statistinė duomenų analizė atlikta SPSS 21 for Windows. Statistinių hipotezių tikrinimui naudotas chi kvadrato kriterijus. Rezultatai. 64,8 proc. apklaustųjų mano, jog medicinos darbuotojams tobulintis, norint pagerinti pacientų saugą, yra svarbu. Jų nuomone, profesionalus svarbiausia yra mokyti apie NĮ, jų prevenciją, komandinį SP profesionalų darbą bei SP profesionalų - pacientų bendravimą. Statistiškai reikšmingai didesnė dalis gydytojų negu slaugytojų mano, kad SP profesionalus yra labai svarbu mokyti apie NĮ, jų prevenciją bei SP profesionalų - pacientų bendravimą. 70,9 proc. apklaustųjų teigia, kad pacientus mokyti jų saugos klausimais yra... [toliau žr. visą tekstą] / Aim of the study. To find out the opinion of physicians and nurses about the possibilities to improve patient safety. Objectives. To explore the opinion of physicians and nurses about the importance and subjects of health care professionals and patients education to ensure the safety of health care; to clarify the opinion of physicians and nurses about the most appropriate type of adverse event reporting system; to compare the opinions of physicians and nurses about the importance of health care professionals and patients education and the most appropriate type of adverse event reporting system. Methods. The study of the opinion of physicians and nurses about the possibilities to improve patient safety was conducted in "N" hospital, using an anonymous questionnaire survey method. There were 182 medical staff participating in the survey – 45.6 percent of them were physicians and 54.4 percent - nurses (response rate – 88.3 percent). Statistical data analysis was performed by using SSPS 21 program for Windows. Chi-square test was used to test the statistical hypothesis. Results. 64.8 percent of respondents believe that it is important for medical staff to participate in training courses in order to improve patient safety. They state that the key subjects of medical staff training courses are adverse events, prevention, teamwork in health care and health care professionals-patients communication. A statistically significantly greater proportion of physicians than nurses believe... [to full text]

PURPOSE: The purpose of this study was to compare the rate of grade 3-4 immune related adverse events (irAEs) in patients with advanced metastatic melanoma treated with the combined anti-CTLA-4 and anti-PD-immune-therapy at the Dana Farber Cancer Institute(DFCI), to that of the published rate of grade 3-4 irAEs among patients treated with the same combination of check-point therapy in the pivotal phase II and phase III trials that led to the FDA approval of the combination regimen. This study also measures the tumor response with the Ipi-Nivo combination therapy and overall-survival of patients in the study cohort at DFCI. METHODS/PROCEDURES: This is a retrospective cohort study conducted at DFCI during 2014 to 2016 among stage III/IV melanoma patients treated outside of the clinical trials with the Ipi-Nivo combination therapy. Chart review of the electronic medical record(EMR) was conducted to abstract the data for this study. irAEs were graded and classified as per the NCI-CTCAE v.4.0 guidelines. The comparison of the rate of grade 3 4 toxicity in the clinical settings at DFCI and the clinical trials was performed using a one sample proportion hypothesis test. For efficacy assessment of tumor response, RECIST1.1 criterion was used to ascertain the best clinical response. RESULTS: During an overall follow-up period of 600 days, 52 patients were treated on expanded access protocol (EAP) and commercial Ipi-Nivo combination therapy at DFCI. The rate of grade 3-4 immune mediated toxicity for this cohort of patients treated outside of clinical trials was 32.6%. The average rate of grade 3-4 irAEs reported in phase II/III clinical trials was approximately 55%. The results from the one-proportion hypothesis test [(P-value: 0.002) (95% C.I: 19.14-46.23)], prove that patients in the “real world” clinical settings have a different safety profile than patients treated in the clinical trials. The rate of grade 3-4 irAEs was found to be lower (19.14% to 46.23%) in the population treated with Ipi/Nivo combination therapy at the DFCI, compared to the check-mate clinical trials (approximately 55%) CONCLUSION: The results from the study indicate a lower rate of grade 3-4 irAEs in patients treated at DFCI, in comparison with the patients treated in the clinical trials for the Ipi-Nivo combination group. The results support the need for preemptive safety signal detection of symptoms of irAEs to improve patient’s safety. However, larger database studies are required for the generalizability of this results to a wider patient population treated outside of DFCI.

Introduction: In recent decades, there has been considerable international attention directed towards minimising healthcare-associated harm and improving the safety of hospital care. More recently, this attention has broadened to include primary medical care. In 2002, the World Health Assembly recognised the issue of inadequate levels of patient safety as a major threat to global public health. In the following years, many countries have developed national strategies for the measurement, monitoring and prevention of patient safety incidents (PSIs) and their outcomes. Experience accumulated from secondary care has shown that the initial steps for understanding patient safety include the systematic identification of the most frequent and most harmful threats. However, the safety profile of primary care dentistry remains poorly investigated. As a result, current evidence cannot provide reliable estimates of the types of PSIs in primary care dentistry, the causes of these incidents, or the associated disease burden caused by such incidents. In medicine, improvements in patient safety were achieved at a national level by developing a shared conceptual understanding, the standardisation of terminology and through preventive initiatives such as the introduction of a national incident reporting and learning system. In the United Kingdom (UK), the England and Wales’ National Reporting Learning System (NRLS) has been an important source of insight, from the perspectives of the reporter, into understanding why PSIs occur. This initiative has led to the implementation of patient safety oriented policies to monitor and reduce cases of healthcare-associated harm. Examples of such policy initiatives include national guidelines and national safety recommendations to encourage the reporting of serious reportable events called ‘never events’ (NEs). These are defined as serious, preventable PSIs that should not occur if the available preventive measures are implemented. At a national level, serious incidents and NEs must be reported to the NRLS and/or other reporting systems. However, little is known about NEs in dentistry as wrong-tooth extractions are the only currently defined NE that has a clear application in dentistry. Although surgical NEs, such as wrong-site surgery and wrong implants may be related to dental procedures, these overlap with procedures conducted in secondary care. As a result, there is no agreed list of NEs for primary care dentistry. The overall aim of my PhD was to explore patient safety, its concepts, including error and harm, and how these can help to create an understanding of the types of PSIs that occur in primary care dentistry, their contributory factors and their consequences. In addition, I also aimed to identify NEs with the greatest need and opportunity for future intervention strategies, in order to improve patient safety in primary care dentistry. Methodology and methods: My PhD was conducted in three phases. For the first phase, I conducted a systematic scoping review of the empirical evidence published over a 20-year period (1994-2014). To achieve this, I searched MEDLINE and EMBASE for articles reporting incidents that could have or did result in unnecessary harm from primary dental care. I also extracted and synthesised data on the types and frequencies of PSIs (including NEs) and adverse outcomes. Then, for the second phase, I undertook an exploratory sequential mixed-methods evaluation, which involved the qualitative exploration and analysis of a weighted-by-year randomised sample (n=2,000) of the most severe incident reports from primary care dentistry submitted to the England and Wales’ NRLS. This approach generated three coding frameworks, aligned to the International Classification for Patient Safety developed by the World Health Organization, for i) the classification of incidents, ii) contributor y factors and iii) incident outcomes. These coding frameworks informed the quantitative analysis, during which myself together with a trained second coder, applied codes to deconstruct the narrative of these patient safety incident reports whilst retaining the meaning of the report. To assess inter-rater reliability, Cohen’s Kappa statistic was calculated for the primary incident type which was defined as “the incident that resulted in the outcome experienced by the patient.” Finally, for the third phase, I undertook an electronic Delphi exercise to achieve international agreement on NEs for primary care dentistry. The results obtained from Phases 1 and 2 were used to identify candidate NEs. I then invited an international panel of 41 experts to complete two rounds of questionnaires; 32 (78%) agreed to participate and completed the first round, and 29 (91%) completed the second round. I provided anonymised controlled feedback between rounds and used a cut-off of 80% agreement to define consensus. The results from the first stage built the evidence base for the second and third phases. Likewise, the results from the second phase further informed the third and final stage of my PhD. Results: I undertook a systematic scoping review which demonstrated: a) there were considerable differences in definitions for terms used to describe patient safety, b) that a range of populations had been studied, and c) that major differences in sampling strategies exist between studies. The main five PSIs I identified were errors in i) diagnosis/examination, ii) treatment planning, iii) communication, iv) procedural errors and v) the accidental ingestion or inhalation of foreign objects. However, little attention has been paid to wider organisational factors such as problems within the physical environment, scheduling (e.g. errors in managing appointments) and patient access, management and lines of responsibility. Also there is very little evidence of interest in researching into the influence of policies for either quality or patient safety assurance. The retrieved evidence was used to build a conceptual literature-derived model of patient safety risks in primary care dentistry. This model helped to bring structure to the analysis of the 1,456 patient incident reports that were eligible for analysis out of a total of 2,000. These reports described incidents across the preoperative (40.3%; n=587), intra-operative (56.1%; n=817) and post-operative (3.6%; n=52) clinical stages of care delivery. Further analysis showed the more frequently reported incidents were related to a) delays in treatment (333/1,456; 22.9%), b) procedural errors (220/11,456; 15.1%), c) medication-related adverse incidents (160/1,456; 11.0%), d) equipment failure (90/1,456; 6.2%) and e) errors in obtaining or processing x-rays (87/1,1456; 6.0%). Only 5.3% (77/1,456) of the incidents resulted in harmful outcomes. Of the 77 incidents that resulted in a harmful outcomes (n=77; 5.3%), around half were due to wrong tooth extractions (37/77; 48.1%) and resulted in unnecessary procedures. Three out of the 1,456 incidents (0.2%) resulted in death. Data from the scoping review and the mixed-method analysis informed a list of 42 candidate NEs. I further sought and achieved international consensus for 23 of these NEs. These were related to routine assessment, and pre-operative, intra-operative and post-operative stages of dental procedures. Conclusions: The findings from my PhD have revealed that patient safety research in dentistry is mostly descriptive and poorly organised with various approaches to defining and measuring PSIs and their outcomes. This poor organisation of patient safety research also includes differing study designs and patient populations studied. The evidence-based conceptual framework from the systematic scoping review, and coding frameworks from analysis of PSI reports selected from a national database, can bring structure to future work by providing a robust approach to classifying PSIs, their contributory factors and outcomes. / My research findings also show that PSI reports are an important source of information that can generate important insights about patient safety in primary care dentistry. The mixed-method analysis of PSI reports showed that most incidents in primary dental care do not result in harm. PSIs that resulted in harmful outcomes more frequently occurred intra-operatively. My findings also reveal that unsafe care in dentistry is not limited to human error, but can also be ascribed to the presence of other administrative or organisational flaws that contribute to the reported incidents. Future initiatives to improve and research clinical practice should focus on improving administrative processes to reduce delays in treatment. Also, the reduction of procedural errors through the standardisation of x-rays, medication prescription and other clinical procedures is needed. Lastly, I have constructed the first comprehensive international list of NEs for primary care dentistry. I believe my findings, including the list of NEs, can provide an evidence-base which will encourage researchers to further expand the patient safety research and development agenda in dentistry, as well as encouraging decision-makers and professional bodies to translate my findings into quality improvement strategies.

Este trabalho apresenta os resultados de uma pesquisa que teve como objetivo avaliar o desempenho de métodos de mineração de textos na previsão e detecção de Eventos Adversos (EA). A primeira etapa foi a revisão sistemática da literatura que buscou identificar os métodos de mineração de textos e as áreas da saúde que esses estão sendo aplicados para prever e detectar EA. Após essa etapa foi realizada uma aplicação de métodos de mineração de textos para prever Infecções do Sítio Cirúrgico (ISC) a partir do texto livre de descrições cirúrgicas no Hospital de Clínicas de Porto Alegre (HCPA). Por fim, métodos de mineração de textos foram aplicados para detectar ISC a partir do texto das evoluções de pacientes 30 (trinta) dias após uma cirurgia. Como resultados, destaca-se a identificação dos melhores métodos de pré-processamento e mineração de textos para prever e detectar ISC no HCPA, podendo ser aplicados a outros EA. O método Stochastic Gradient Descent (SGD) apresentou o melhor desempenho, 79,7% de ROC-AUC na previsão de EA. Já para detecção de EA o melhor método foi o Logistic Regression, com desempenho 80,6% de ROC-AUC. Os métodos de mineração de textos podem ser usados para apoiar de maneira eficaz a previsão e detecção de EA, direcionando ações de vigilância para a melhoria da segurança do paciente. / This work presents the results of a research that aimed to evaluate the performance of text mining methods in the prediction and detection of Adverse Events (AE). The first step was the systematic review of the literature that sought to identify the methods of text mining and the health areas they are being applied to predict and detect AE. After this step, an application of text mining methods was performed to predict Surgical Site Infections (SSI) from the free text of medical records at Hospital de Clínicas de Porto Alegre (HCPA). Finally, text mining methods were applied to detect SSI from the text of medical records 30 (thirty) days after surgery. As results, is highlight the identification of the best methods of pre-processing and text mining to predict and detect SSI in the HCPA, and can be applied to other AE. The Stochastic Gradient Descent (SGD) presented the best performance, 79.7% of ROC-AUC in the prediction of AE. Already for the detection of AE the best method was the Logistic Regression, with performance 80.6% of ROC-AUC. Text mining methods can be used to effectively support the prediction and detection of AE by directing surveillance actions to improve patient safety.

Healthcare risk management consists of continuous consideration of potential adverse situations and their prevention. In this sense, healthcare facilities consider any source of uncertainty to be a risk which must be eliminated or, at least, reduced. International studies show that up to 70% of adverse events could be prevented. Reasons for observing various types of adverse events may differ in individual healthcare facilities. However, most adverse events are observed in an effort to prevent their consequences upon patients' health.