Purpose: Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all... Show morePurpose: Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting. Materials & methods: In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting. Results: The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when con -sidering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs. Conclusions: Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients. ? 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). Show less
Meeuwsen, F.C.; Luyn, F. van; Blikkendaal, M.D.; Jansen, F.W.; Dobbelsteen, J.J. van den 2019
BackgroundSurgical Process Modelling (SPM) offers the possibility to automatically gain insight in the surgical workflow, with the potential to improve OR logistics and surgical care. Most studies... Show moreBackgroundSurgical Process Modelling (SPM) offers the possibility to automatically gain insight in the surgical workflow, with the potential to improve OR logistics and surgical care. Most studies have focussed on phase recognition modelling of the laparoscopic cholecystectomy, because of its standard and frequent execution. To demonstrate the broad applicability of SPM, more diverse and complex procedures need to be studied. The aim of this study is to investigate the accuracy in which we can recognise and extract surgical phases in laparoscopic hysterectomies (LHs) with inherent variability in procedure time. To show the applicability of the approach, the model was used to automatically predict surgical end-times.MethodsA dataset of 40 video-recorded LHs was manually annotated for instrument use and divided into ten surgical phases. The use of instruments provided the feature input for building a Random Forest surgical phase recognition model that was trained to automatically recognise surgical phases. Tenfold cross-validation was performed to optimise the model for predicting the surgical end-time throughout the procedure.ResultsAverage surgery time is 12827min. Large variability within specific phases is seen. Overall, the Random Forest model reaches an accuracy of 77% recognising the current phase in the procedure. Six of the phases are predicted accurately over 80% of their duration. When predicting the surgical end-time, on average an error of 16 +/- 13min is reached throughout the procedure.Conclusionsp id=ParThis study demonstrates an intra-operative approach to recognise surgical phases in 40 laparoscopic hysterectomy cases based on instrument usage data. The model is capable of automatic detection of surgical phases for generation of a solid prediction of the surgical end-time. Show less
Is de geboden cardiologische zorg `sufficiently safe' ? Dit proefschrift richtte zich op de vraag hoe je kwaliteit van zorg kan meten om te kijken of de geboden zorg voor de behandeling van acuut... Show moreIs de geboden cardiologische zorg `sufficiently safe' ? Dit proefschrift richtte zich op de vraag hoe je kwaliteit van zorg kan meten om te kijken of de geboden zorg voor de behandeling van acuut coronair syndroom sufficiently safe is en deed dit middels twee methoden: lokaal dossieronderzoek ten aanzien van patiëntveiligheid (Deel 1) en nationaal declaratie data-registratie voor kwaliteit-van-zorg onderzoek (Deel 2). Waar declaratiedata in detail moet inleveren, levert dossieronderzoek in op de efficiëntie. De twee verschillende methodes vullen elkaar aan en dienen een verschillend doel: veiligheid en kwaliteit van zorg. De geboden zorg lijkt veilig, maar toch ervaart 13% zorggerelateerde schade bij de behandeling van een acuut coronair syndroom. Welk onderzoek is hiervoor nodig? Dossieronderzoek is zeer arbeidsintensief, zelfs een onderzoek binnen het heldere MISSION!-protocol leidt nog tot heterogene antwoorden op causale relaties van zorggerelateerde schade. Real-time monitoring van afwijkende processen met reeds geregistreerde data biedt meer inzicht in zorggerelateerde schade. De geboden zorg lijkt volgens de richtlijnen te gaan, maar toch krijgt slechts 49% zijn preventieve medicatie. Ook hier is ruimte voor verbetering. Toekomstige analyses met declaratiedata, gecombineerd met klinische data en andere databronnen, kan meer inzicht geven om zo de kwaliteit van zorg continu te blijven verbeteren. Show less
Quality and safety improvement is a relatively novel discipline in healthcare practice and research that solidified in the early 21st century. Since then, various systems have been installed to... Show moreQuality and safety improvement is a relatively novel discipline in healthcare practice and research that solidified in the early 21st century. Since then, various systems have been installed to collect information on various types of adverse outcomes, such as adverse events, incidents and patient complaints. Data from these systems can be used to evaluate care delivered to individual cases as well as to study aggregated data for patterns, trends and other insights. More research is warranted to assess whether these systems actually meet the objective of continuous, systemwide learning and improvement. It was expected that existing practices could benefit from individual optimization as well as better integration, because most of this intelligence is currently stored and used in isolation. The research in this PhD thesis focused on how we can learn most effectively from various types of adverse outcomes in healthcare, in order to continuously improve the care delivered to patients. Specific research questions included how we can learn from: i) case discussions at morbidity and mortality conferences ; ii) integrating available information sources (e.g., incidents, patient experiences); iii) the context of everyday practice that produces both adverse and desired outcomes. Show less
This thesis assessed methods to identify possible hazards to patient safety of new surgical instruments in minimally invasive surgery, before their introduction in daily clinical practice. Using a... Show moreThis thesis assessed methods to identify possible hazards to patient safety of new surgical instruments in minimally invasive surgery, before their introduction in daily clinical practice. Using a newly developed uterine manipulator and uterine power morcellators as a template, the concepts of a clinically driven approach and a prospective risk inventory were explored. Show less
Quality assessment is surgical care is very important, though very difficult. With this thesis we attempted to overcome the limitations of currently used quality indicators and developed a dynamic... Show moreQuality assessment is surgical care is very important, though very difficult. With this thesis we attempted to overcome the limitations of currently used quality indicators and developed a dynamic, unique quality assessment tool to reflect upon individual surgical performance with case-mix correction.To substantiate the development of this new quality instrument, the implementation of laparoscopic hysterectomy in the Netherlands and in residency program was assessed, relevant case-mix characteristics for laparoscopic hysterectomy were explored, several ways to monitor surgical quality were analyzed and attempts were made to make quality registries less comprehensive for clinicians. Subsequently, patient risk factors in laparoscopic hysterectomy were identified to enhance patient safety and finally to improve the surgical quality of laparoscopic hysterectomy. Show less
Healthcare systems have become more effective but are also more complex with greater use of new technologies and interventions. This can result in incidents and life threatening events during... Show moreHealthcare systems have become more effective but are also more complex with greater use of new technologies and interventions. This can result in incidents and life threatening events during patients’ hospitalization and affect the quality of care and patient safety. The objective of the investigations was to assess the tools that are available to measure and monitor quality of care in critically ill patients and the effect of implementing some of these tools on quality of care. Show less
Brunsveld-Reinders, A.H.; Ludikhuize, J.; Dijkgraaf, M.G.W.; Arbous, M.S.; Jonge, E. de; COMET Study Grp 2016
In recent years a flow of media reports about unsafe situations in operating rooms have reached the general public. Awareness of the importance of patient safety also reached politicians. The... Show moreIn recent years a flow of media reports about unsafe situations in operating rooms have reached the general public. Awareness of the importance of patient safety also reached politicians. The report by the Dutch inspectorate of health care __Risico__s minimaal invasieve chirurgie onderschat__ (Risks minimally invasive surgery underestimated) stressed that patient safety is especially at risk in Minimally Invasive Surgery. Therefore patient safety became a focus of research and quality improvement, also in minimally invasive surgery. The current thesis aimes to give insight into patient safety risk factors in minimally invasive surgery. Of all examined risk factors minimally invasive surgical skills appeared to be directly related to patient safety. Therefore special focus for training of these skills is necessary. Previous research has shown that during simulation training objective assessment of economy of movements and time is possible. However, until recently there was no way to objectively assess one of the most important surgical skills: tissue handling. The development of a force sensor has made it possible to measure interaction forces with artificial tissue. In this thesis the clinical implications of a force sensor and the need of this new technology within training of minimally invasive surgical skills is examined. Show less
Martijn, L.; Jacobs, A.; Amelink-Verburg, M.; Wentzel, R.; Buitendijk, S.; Wensing, M. 2013
Although hospitals increasingly opt for the laparoscopic over the conventional approach and the decline in diagnostic procedures is well compensated by an increase in numbers of all types of... Show moreAlthough hospitals increasingly opt for the laparoscopic over the conventional approach and the decline in diagnostic procedures is well compensated by an increase in numbers of all types of therapeutic procedures, the implementation of laparoscopic hysterectomy in the Netherlands seems to be hampered and scattered (chapter 2). The majority of hospitals that apply laparoscopic hysterectomy perform only a minority of the total volume of procedures, whereas the minority of hospitals performs a high annual caseload of procedures. From our studies, preference and referral tendencies seem to be suboptimal, despite knowledge indication and advantages of this minimally invasive technique (chapter 4). Gynecologists employed in a hospital that did not perform laparoscopic hysterectomies were much less likely to refer candidates for this procedure, despite basic knowledge about the indication and limitations of the approach. Furthermore, patient related factors, such as body mass index and uterus weight, might play a role in this tendency. The level of experience (expressed in number of laparoscopic hysterectomies performed) did not significantly influence the laparoscopist__s opinion on body mass index, uterus weight and previous abdominal surgery as restrictive characteristics for the laparoscopic approach. Both, performers as well as referring colleagues regarded a high body mass index, big uterus weight and previous abdominal surgery as restricting parameters for the laparoscopic approach. This is worrisome, as we know that the majority of these __challenging__ patients have an uneventful procedure (85%) and especially since there is evidence that the obese patient is better served by a laparoscopic approach than by conventional abdominal surgery. Furthermore, it was shown that with growing popularity of this procedure (half of laparoscopic hysterectomy performing gynecologists had less than five years experience), a steady state of implementation of this advanced laparoscopic surgical procedure has yet not been reached. The Laparoscopic Assisted Vaginal Hysterectomy (LAVH), a variant of laparoscopic hysterectomy, showed to be generally performed by inexperienced surgeons in low volume hospitals, while adverse events and blood loss were increased compared to Total Laparoscopic Hysterectomy (chapter 3 and chapter 5). In our prospective study in 79 surgeons (the LapTop! study), we observed that the success of surgical outcomes was significantly influenced by uterus weight, body mass index, ASA classification and previous abdominal surgeries, next to the type of laparoscopic hysterectomy (chapter 5). Surgical experience also predicted the successful outcome of laparoscopic hysterectomy with respect to blood loss and adverse events. However, also an experience independent surgical skills factor was identified, representing a crucial determinant in measuring quality of surgery. This skills factor was also present in the probability of conversion to laparotomy in the same cohort (chapter 6). The majority of conversions were performed because of strategic considerations, while uncontrollable bleeding was the main adverse event leading to a reactive conversion. A high body mass index and increased uterus weight predicted conversion probability, while experience did not.vaginal and abdominal hysterectomy (chapter 7). Therefore, minimally invasive surgery is not necessarily minimally painful. However, patients in the minimally invasive group reported a steeper decline in pain scores postoperatively. Acquiring and maintaining skills in laparoscopic hysterectomy by mentorship showed to be effective, safe and durable, as indication, operative time and adverse event rates were comparable to those of the mentor in his own hospital during and after completing the mentorship program (chapter 8). Assessment of skills in advanced laparoscopic surgery is increasingly demanded. Prediction of surgical skills based on __in vitro__ box trainers outcomes was not conclusive as surgeons with suboptimal average clinical outcomes could not be indicated by means of a box trainer task (chapter 9). However, __real time__ risk-adjusted clinical monitoring of performance by means of cumulative sum (CUSUM) analysis appeared to be a valuable tool in order to signal derailing performance in a timely fashion (chapter 10). This is paramount, as in laparoscopic hysterectomy no definitive accomplishment of the proficiency curve is foreseen and applying relevant predictors of quality of surgery should guard patient safety. Show less
Henken, K.R.; Jansen, F.W.; Klein, J.; Stassen, L.P.S.; Dankelman, J.; Dobbelsteen, J.J. van den 2012
The safety of an organization can be improved by investigating and correcting the many processes that shape performance at the __sharp end__. Errors do not occur of themselves, but arise within the... Show moreThe safety of an organization can be improved by investigating and correcting the many processes that shape performance at the __sharp end__. Errors do not occur of themselves, but arise within the context of the work environment. Where the environment is one that makes errors by individuals more likely, we can identify the underlying problems that will have been present in the system, often recognized but long tolerated. The factors that make errors more likely, can be characterized as Latent Risk Factors (LRFs). The prospective identification of LRFs can lead to removal of error-inducing conditions before they can contribute to patient injury. Identifying LRFs will improve patient safety by improving the conditions that set the working environment for the occurrence of errors. Interventions aimed at unfavorable LRFs may contribute to patient safety in the Operating Theatre. Staff from Operating Theatre and Intensive Care Unit is able to detect these shortcomings but differ in their scope of the present risks. Unfavorable LRFs can act as stressful triggers at the workplace. If staff cannot control such stress this may negatively affect their well-being. The key to a healthy workplace is to control the deficiencies in the structure of the working environment. Show less
