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Prevention of Human Factor Failure in Hazardous Activities
Jíra, Aleš ; Balgová, Zuzana (referee) ; Kruliš, Jiří (advisor)
The diploma thesis deals with the topic of human failures during the risk activities. The aim of the work is to apply risk analysis to the operation of a selected unnamed company that processes vegetables. The thesis is divided into three parts. In the first part, the theoretical basis is discussed and serves as a basis for a better understanding of the topic and subsequent elaboration of the analytical part. The analytical part focuses on the characteristics of the selected company, organizational structure, working positions and the operation itself and analyses these issues with the focus on human factor. The last part of the diploma thesis is dealing with suggestions leading to the prevention of human failure in risk activities. The aim of these suggestions is to improve the situation of the company.
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Fall prevention from the nurse's point of view
PAVELKOVÁ, Kateřina
The bachelor thesis focuses on fall prevention from the perspective of the general nurse. General nurses encounter falls very frequently with health care providers and should be able to act on this issue in both the prevention and management of a fall. This thesis consists of a theoretical and a research part. The theoretical part deals with the characteristics of falls and risk groups of patients and other internal and external risk factors that occupy an important role in this issue. It also discusses the role of the general nurse in fall prevention as an integral part of the practice of the profession. The thesis also deals with selected aspects of fall prevention and follow-up of fall occurrence and consequences in patients. It was also important to mention the scales used to assess falls or to reduce the risk of falls. For the research part of this bachelor's thesis, a qualitative data collection method was chosen by using the technique of semi-structured interviews conducted with general nurses of selected wards of internal type of health care providers. The aim of the research part was to find out how general nurses identify patient groups at risk for falls. Also, whether general nurses implement preventive measures for fall occurrence and how they proceed when a fall occurs. Last but not least, it was important to find out how general nurses proceed when a patient is discharged to home care.
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Compliance with departmental safety objectives in surgical wards
RAJTMAJEROVÁ, Eliška
Abstract Introduction: The Ministry of Health of the Czech Republic defined the departmental safety objectives in 2010 and their purpose is to minimize the risks of the most common adverse events that may occur during the provision of health care. Aims: The main aim of the presented work is to evaluate the observance of departmental safety goals by nurses in surgical wards in selected hospitals in the South Bohemian region. Methodology: To achieve the goals, a qualitative research method was chosen, which took place in the form of in-depth interviews. Communication partners were selected by deliberate selection. 14 individuals took part in the anonymous interviews. The research group consisted of senior, station, general and practical nurses working in surgical wards in selected hospitals in the South Bohemian Region. Results: The results of the research survey showed that the interviewed nurses working in surgical wards do not proceed uniformly in the provision of care in areas that define departmental safety goals. This concerned mainly the identification of patients, safety preoperative procedure, and the introduction of preventive measures to minimize the risk of falls and pressure ulcers. The results of the research also confirmed that nurses can provide better quality care with regard to patient safety, especially in the way of patient identification, administration of higher-risk drugs, prevention of nosocomial infections and ordering of medication by telephone. Furthermore, the results of the research survey show that nurses know and appropriately use preventive measures in the field of prevention of falls and pressure ulcers. Conclusion and recommendations for practice: Health care is inherently linked to the risk of error, so it is important that nurses provide safe care. The output of the diploma thesis is a proposal for systemic changes in the field of compliance with departmental safety objectives intended for nursing management.
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Analysis of non-cardiac adverse event of glucocorticoid pulse therapy
Polláková, Lenka ; Vlček, Jiří (advisor) ; Macek, Karel (referee)
5 ABSTRACT Candidate: Lenka Polláková1 Supervisor: prof. RNDr. Jiří Vlček, CSc.1 Consultant: doc. MUDr. Tomáš Soukup, Ph.D.2 1 Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University 2 2nd Department of Internal Gastroenterology, University Hospital in Hradec Králové Title of the master thesis: Analysis of non-cardiac adverse event of glucocorticoid pulse therapy Intravenous glucocorticoid pulse therapy (PT GC) is effective in life threatening flares of rheumatic diseases. However, due to GC's pleiotropic effect, higher doses and additive nongenomic mechanism in pulse regimen, it is not free of complications (1). The aim of theoretical part was to describe from literature research the relevance of PT GC, its non- cardiac adverse events (AE) in rheumatic patients and their influencing factors. The aim of experimental part of the study was to analyze the occurrence of non-cardiac AE in real-life setting, analyze risk factors of potential adverse drug reactions (ADR) and its complications and analyze the risk minimalization management in real-life setting. Patients were administered 1000 mg methylprednisolone in 3 to 5 doses on alternating days. Analysis includes 277 rheumatic patients with 325 pulse therapy courses. Data were collected retrospectively from their...
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Prevention of Human Factor Failure in Hazardous Activities
Jíra, Aleš ; Balgová, Zuzana (referee) ; Kruliš, Jiří (advisor)
The diploma thesis deals with the topic of human failures during the risk activities. The aim of the work is to apply risk analysis to the operation of a selected unnamed company that processes vegetables. The thesis is divided into three parts. In the first part, the theoretical basis is discussed and serves as a basis for a better understanding of the topic and subsequent elaboration of the analytical part. The analytical part focuses on the characteristics of the selected company, organizational structure, working positions and the operation itself and analyses these issues with the focus on human factor. The last part of the diploma thesis is dealing with suggestions leading to the prevention of human failure in risk activities. The aim of these suggestions is to improve the situation of the company.
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Analysis of non-cardiac adverse event of glucocorticoid pulse therapy
Polláková, Lenka ; Vlček, Jiří (advisor) ; Macek, Karel (referee)
5 ABSTRACT Candidate: Lenka Polláková1 Supervisor: prof. RNDr. Jiří Vlček, CSc.1 Consultant: doc. MUDr. Tomáš Soukup, Ph.D.2 1 Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University 2 2nd Department of Internal Gastroenterology, University Hospital in Hradec Králové Title of the master thesis: Analysis of non-cardiac adverse event of glucocorticoid pulse therapy Intravenous glucocorticoid pulse therapy (PT GC) is effective in life threatening flares of rheumatic diseases. However, due to GC's pleiotropic effect, higher doses and additive nongenomic mechanism in pulse regimen, it is not free of complications (1). The aim of theoretical part was to describe from literature research the relevance of PT GC, its non- cardiac adverse events (AE) in rheumatic patients and their influencing factors. The aim of experimental part of the study was to analyze the occurrence of non-cardiac AE in real-life setting, analyze risk factors of potential adverse drug reactions (ADR) and its complications and analyze the risk minimalization management in real-life setting. Patients were administered 1000 mg methylprednisolone in 3 to 5 doses on alternating days. Analysis includes 277 rheumatic patients with 325 pulse therapy courses. Data were collected retrospectively from their...
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Analysis of non-cardiac adverse event of glucocorticoid pulse therapy
Polláková, Lenka ; Vlček, Jiří (advisor) ; Macek, Karel (referee)
5 ABSTRACT Candidate: Lenka Polláková1 Supervisor: prof. RNDr. Jiří Vlček, CSc.1 Consultant: doc. MUDr. Tomáš Soukup, Ph.D.2 1 Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University 2 2nd Department of Internal Gastroenterology, University Hospital in Hradec Králové Title of the master thesis: Analysis of non-cardiac adverse event of glucocorticoid pulse therapy Intravenous glucocorticoid pulse therapy (PT GC) is effective in life threatening flares of rheumatic diseases. However, due to GC's pleiotropic effect, higher doses and additive nongenomic mechanism in pulse regimen, it is not free of complications (1). The aim of theoretical part was to describe from literature research the relevance of PT GC, its non- cardiac adverse events (AE) in rheumatic patients and their influencing factors. The aim of experimental part of the study was to analyze the occurrence of non-cardiac AE in real-life setting, analyze risk factors of potential adverse drug reactions (ADR) and its complications and analyze the risk minimalization management in real-life setting. Patients were administered 1000 mg methylprednisolone in 3 to 5 doses on alternating days. Analysis includes 277 rheumatic patients with 325 pulse therapy courses. Data were collected retrospectively from their...
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Identification of medication errors by nurses during simulated situations
KELBLOVÁ, Kateřina
Current status: Medication errors within the context of safe and high quality health care are one of the most frequently discussed topics of recent years. They are part of the medical process, occur in different forms, affect patients of all ages and decrease the quality of provided health care. Prescriptions of medication in medical documentation have to be clearly legible and include all the required information. Nurses' role within the medicaiton process could be described as an ultimate "safeguard" that can prevent medication errors. Goals: The objectives of this research are to assess nurses' awareness of medication errors, ssess their ability to detect medication errors and find out the level of their knowledge regarding the correct procedures and measures following medication error detection.Methodology: The research was conducted using a qualitative research method. The in-depth interviews with nurses were carried out at a surgical critical care unit at the hospital in Jindrichuv Hradec. Following the collection of a sufficient amount of data the interviews were coded using the "pen and pencil" technique and then divided into categories.Research file: In order to achieve the highest level of objectivity the research was carried out with a group of nurses who work at the same unit of a hospital department. The research file included nurses who had varied levels of education and numbers of years of experience. Results: Surgical critical care unit nurses are not aware of the exact definition of medication errors. Only one nurse was able to discuss adverse events with related consequences. The remaining nurses' awareness of medication errors corresponded to the classification described in the relevant foreign and Czech academic literature. None of the interviewed nurses detected all the errors included in the simulated scenarios. Only one nurse, who is currently completing her qualification in this specialty, detected a wrongly prescribed antidote. The simulated scenarios also included a group of high-risk medications that is commonly used at the unit. The first medication included in this group was a 7.45% solution of potassium (KCl). A majority of the participants detected the high concentration of this high-risk medication. Another high-risk medication was a 10% concentrate of NaCl in an infusion; this error was also detected by the majority of the nurses. The third high-risk medication was a wrongly prescribed insulin (it lacked the detailed description of units, time and route). This prescription error was not detected by the majority of participating nurses. Another type of medication error included in the simulated scenarios was a group of medications used specifically in critical care. Only half of the participating nurses successfully detected the errors related to the prescription of this group of medications. The last type or medication errors focused on incomplete prescription by doctors. The most frequently detected error was a prescription of an opiate that lacked the route and the least frequently detected error was a wrong prescription of an infusion administration. It is evident that the nurses always inform the doctor when they detect a medication error. They are more willing to inform the ward sister in cases of incidents caused by somebody else. Only a small group of nurses are willing to inform the senior consultant, the head nurse or the hospital management. Only one nurse associated medication error reporting with an audit. However the majority of nurses agrees that it is important to report any medication errors.Conclusion: The analysed data suggested that the nurses were aware of medication errors. The analysis of the results of the simulated scenarios suggested that nurses' ability to detect medication errors in prescriptions was related to the number of years of experience and the level of education.
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Culture safety of medical devices and pacient safety
ŠTĚRBOVÁ, Denisa
The quality issue of provided health care is the topic which is constantly getting more attention. In this area there is always even probably will be always - something to improve. The patients´ safety in healthcare facilities is affected by the so-called culture of safety.The research was conducted in six medical institutions of the South Bohemian Region, though seven were originally planned. However, I was not given the data here, probably due to the long term incapacity of the respondent. The research was focused precisely on the area of care quality and patient safety. A mixed method research (qualitative and quantitative) was deliberately used in this task. The aim was to map the most common causes of adverse events and then, based on the causes, to propose possible arrangements to prevent the occurrence of the causes. For this purpose five research questions were established.The outcomes obtained were processed into tables, plus the graphical representation of some was accompanied. Then, in the "discussion" chapter, the results were compared and analyzed in more detail.
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