Most of the available knowledge management systems pay little attention to two important aspects:... more Most of the available knowledge management systems pay little attention to two important aspects: the need of supporting emerging communities of interest together with the official organizational structure; and the need of cluing together knowledge associated with any kind of involved entity including people, communities, and informal knowledge. The MILK system enhances knowledge discovery and sharing by providing services addressing these aspects and supplying innovative interfaces and interaction styles. The goal of MILK is to become a familiar environment integrated in the every-day activities of dynamic modern workers. To meet the users ’ needs, the solution proposed by MILK roots in ethnographic analysis capturing the common practices within an organization.
Care transitions are critical moments which may expose patients to adverse events and generate or... more Care transitions are critical moments which may expose patients to adverse events and generate organizational failures. Ineffective care transition processes lead to higher hospital readmission rates and costs and patients can be harmed when the many moving parts of their care process are not effectively coordinated.
Epidemiological data from the literature are few for patient safety in pediatrics and there is a ... more Epidemiological data from the literature are few for patient safety in pediatrics and there is a need for comparing experiences and applied solutions in different contexts. A study published in 2012 underlined that the 79% of adverse events in children happened in intensive care unit, the incidence on admissions is of 6,5 and 44,7% of these adverse events are preventable. The promotion of patient safety in pediatrics requires also patient and family programs of information and education to increase awareness about risk factors and behaviors to prevent harms. The aim of project is to design a multidimensional approach to patient safety and to pilot three patient safety practices: preventing children’s falls through the use of the Modify Humpty Dumpty Fall Scale validated in Italian; the appropriate transition of care and the early evaluation of patient deterioration through the Pediatric Early Warning Score. All pilots have been realized by adopting a systemic approach with solutions...
We aimed at investigating the effect of a short time low load repetitive task on the local muscle... more We aimed at investigating the effect of a short time low load repetitive task on the local muscle oxygenation kinetics in presence of delayed onset muscle soreness. Computer work was investigated as a model of low load repetitive task. Nine healthy male subjects participated in an experimental protocol consisting of a rest period and two blocks, each including two maximum voluntary contractions (MVC) of isometric bilateral shoulder elevation and a computer work session with 2 or 5 min duration between the MVCs in each block. Then a set of unaccustomed eccentric exercise (ECC) of shoulder elevation was implemented to induce delayed onset muscle soreness (DOMS) in the trapezius muscle. Identical experimental blocks were performed immediately and 24h after ECC. Local tissue saturation index (TSI) was continuously recorded over upper trapezius throughout the experiment. TSI parameters such as mean TSI at rest, during computer work as well as TSI drop, recovery and their descending and a...
The burden of unsafe care is still very high all around the globe. A study conducted in 2012 in A... more The burden of unsafe care is still very high all around the globe. A study conducted in 2012 in African and Middle Eastern Countries reports that in developing countries the incidence of adverse event is 8,2% and of these 83% are preventable. WHO estimates that about 287.000 are maternal deaths, 1 million fetal deaths during intrapartum period and 3 million deaths of infants during the neonatal period. WHO promoted a campaign for adopting the Safe Childbirth Checklist (SCC), that is an organized list of evidence-based essential birth practices, which targets the major causes of maternal deaths, intrapartum-related stillbirths and neonatal deaths that occur in health-care facilities. The objectives of the project are: introducing the WHO SCC in one hospital of Kenya and evaluating the locally adapted tool in terms of impact on safety and quality and its usability and feasibility. The Centre for Clinical Risk Management and Patient Safety, the Centre for Global Health, the University Hospital of Siena the Ruaraka Uhai Neema Hospital undersigned a partnership following the WHO African Partnership for Patient Safety model for implementing safety and quality in the maternal and neonatal area in particular through the use of the WHO SCC. The WHO SCC has been adopted with a positive feedback from midwifes. The childbirth checklist has increased the delivery of some essential childbirth-related care practices and the appropriateness during the administration of antibiotic therapy and antihypertensive treatment. The twinning model proposed by WHO has the potential to go far beyond patient safety issue it can advance efforts towards building resilient health systems.
This paper focuses on how to build up a clinical risk management system in healthcare organizatio... more This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, to achieve this result, a change in cultural attitudes is needed. It can be obtained by developing adequate tools for risk analysis, which should focus on the peculiarities of the healthcare systems. A no-blame culture should be shared. This culture
This paper focuses on how to build up a clinical risk management system in healthcare organizatio... more This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, for achieving this result, a change in the cultural attitudes is needed. It can be obtained by developing adequate tools for risk ...
This paper is a critical presentation of the work done by the authors during the past years in tw... more This paper is a critical presentation of the work done by the authors during the past years in two European Projects in the knowledge management area: Klee&Co (Knowledge and Learning Environments for European & Creative Organisations - ESPRIT Program) and MILK (Multimedia Interaction for Learning and Knowing - IST Program). Both projects focus on the dynamic vision of knowledge management
In February 2007, three organs from an human immunodeficiency virus (HIV)-positive donor were tra... more In February 2007, three organs from an human immunodeficiency virus (HIV)-positive donor were transplanted at two hospitals in the Tuscany Regional Health Care Service, owing to a chain of errors during the donation process. The heart-beating donor was a 41-year-old woman who died as a result of head trauma. The patient's history did not highlight any risky behavior. The available data on previous hospital admissions reported a negative result on HIV testing. During the donation process, the result of the lab test performed for evaluation of organ suitability was mistakenly transcribed from positive to negative. This wrong negative result was then included in the donation record without any cross-check. Therefore, the Regional Transplant Center allocated the liver and both kidneys. The patient also donated tissues, and a second laboratory conducted an evaluation of suitability for the tissue banks. During this process, only 5 days after the successful transplantation procedures, the positive HIV result was fed back to the Regional Transplant Center and the previous error discovered. Transplanted patients were immediately assessed and then treated with antiretroviral medications. A national commission soon performed a systems analysis of the adverse event. Besides the active error committed during the manual transcription for the HIV lab test result, the commission also identified technological factors, such as the lack of integration between the lab machine, the laboratory information system (LIS), and the donor record, as well as organizational factors, such as the distribution to two different labs of the suitability evaluation for organs and tissues. Recommendations included: automatic transmission of lab test results from the lab machine to the LIS and to the donor record, centralization of lab tests for suitability evaluation of organs and tissues, a training program to develop a proactive quality and safety culture in the regional network of donation and transplantations.
Cross-unit handovers transfer responsibility for the patient among healthcare teams in different ... more Cross-unit handovers transfer responsibility for the patient among healthcare teams in different clinical units, with missed information, potentially placing patients at risk for adverse events. We analysed the communications between high-acuity and low-acuity units, their content and social context, and we explored whether common conceptual ground reduced potential threats to patient safety posed by current handover practices. We monitored the communication of five content items using handover probes for 22 patient transitions of care between high-acuity 'sender units' and low-acuity 'recipient units'. Data were analysed and discussed in focus groups with healthcare professionals to acquire insights into the characteristics of the common conceptual ground. High-acuity and low-acuity units agreed about the presence of alert signs in the discharge form in 40% of the cases. The focus groups identified prehandover practices, particularly for anticipatory guidance that r...
Most of the available knowledge management systems pay little attention to two important aspects:... more Most of the available knowledge management systems pay little attention to two important aspects: the need of supporting emerging communities of interest together with the official organizational structure; and the need of cluing together knowledge associated with any kind of involved entity including people, communities, and informal knowledge. The MILK system enhances knowledge discovery and sharing by providing services addressing these aspects and supplying innovative interfaces and interaction styles. The goal of MILK is to become a familiar environment integrated in the every-day activities of dynamic modern workers. To meet the users' needs, the solution proposed by MILK roots in ethnographic analysis capturing the common practices within an organization.
Incident-reporting systems (IRS) are tools that allow front-line healthcare workers to voluntary ... more Incident-reporting systems (IRS) are tools that allow front-line healthcare workers to voluntary report adverse events and near misses. The WHO has released guidelines that outline the basic principles on how to design and implement successful IRS in healthcare organisations. A written survey was administered with an assisted self-assessment technique to a representative sample of healthcare workers in Italian hospitals with and without IRS. Data were collected using two different 16-item questionnaires. The questionnaires targeted two issues: (1) workers' experience of patient safety incidents and (2) their expectations on incident reporting. 70% of respondents confirmed involvement in a patient safety incident, but only 40% utilised an IRS to formally report the event. The data indicate that information regarding patient safety incidents is not communicated throughout the entire organisation. Research findings are consistent with the available evidence on healthcare workers' experience of patient safety incidents.
Most of the available knowledge management systems pay little attention to two important aspects:... more Most of the available knowledge management systems pay little attention to two important aspects: the need of supporting emerging communities of interest together with the official organizational structure; and the need of cluing together knowledge associated with any kind of involved entity including people, communities, and informal knowledge. The MILK system enhances knowledge discovery and sharing by providing services addressing these aspects and supplying innovative interfaces and interaction styles. The goal of MILK is to become a familiar environment integrated in the every-day activities of dynamic modern workers. To meet the users ’ needs, the solution proposed by MILK roots in ethnographic analysis capturing the common practices within an organization.
Care transitions are critical moments which may expose patients to adverse events and generate or... more Care transitions are critical moments which may expose patients to adverse events and generate organizational failures. Ineffective care transition processes lead to higher hospital readmission rates and costs and patients can be harmed when the many moving parts of their care process are not effectively coordinated.
Epidemiological data from the literature are few for patient safety in pediatrics and there is a ... more Epidemiological data from the literature are few for patient safety in pediatrics and there is a need for comparing experiences and applied solutions in different contexts. A study published in 2012 underlined that the 79% of adverse events in children happened in intensive care unit, the incidence on admissions is of 6,5 and 44,7% of these adverse events are preventable. The promotion of patient safety in pediatrics requires also patient and family programs of information and education to increase awareness about risk factors and behaviors to prevent harms. The aim of project is to design a multidimensional approach to patient safety and to pilot three patient safety practices: preventing children’s falls through the use of the Modify Humpty Dumpty Fall Scale validated in Italian; the appropriate transition of care and the early evaluation of patient deterioration through the Pediatric Early Warning Score. All pilots have been realized by adopting a systemic approach with solutions...
We aimed at investigating the effect of a short time low load repetitive task on the local muscle... more We aimed at investigating the effect of a short time low load repetitive task on the local muscle oxygenation kinetics in presence of delayed onset muscle soreness. Computer work was investigated as a model of low load repetitive task. Nine healthy male subjects participated in an experimental protocol consisting of a rest period and two blocks, each including two maximum voluntary contractions (MVC) of isometric bilateral shoulder elevation and a computer work session with 2 or 5 min duration between the MVCs in each block. Then a set of unaccustomed eccentric exercise (ECC) of shoulder elevation was implemented to induce delayed onset muscle soreness (DOMS) in the trapezius muscle. Identical experimental blocks were performed immediately and 24h after ECC. Local tissue saturation index (TSI) was continuously recorded over upper trapezius throughout the experiment. TSI parameters such as mean TSI at rest, during computer work as well as TSI drop, recovery and their descending and a...
The burden of unsafe care is still very high all around the globe. A study conducted in 2012 in A... more The burden of unsafe care is still very high all around the globe. A study conducted in 2012 in African and Middle Eastern Countries reports that in developing countries the incidence of adverse event is 8,2% and of these 83% are preventable. WHO estimates that about 287.000 are maternal deaths, 1 million fetal deaths during intrapartum period and 3 million deaths of infants during the neonatal period. WHO promoted a campaign for adopting the Safe Childbirth Checklist (SCC), that is an organized list of evidence-based essential birth practices, which targets the major causes of maternal deaths, intrapartum-related stillbirths and neonatal deaths that occur in health-care facilities. The objectives of the project are: introducing the WHO SCC in one hospital of Kenya and evaluating the locally adapted tool in terms of impact on safety and quality and its usability and feasibility. The Centre for Clinical Risk Management and Patient Safety, the Centre for Global Health, the University Hospital of Siena the Ruaraka Uhai Neema Hospital undersigned a partnership following the WHO African Partnership for Patient Safety model for implementing safety and quality in the maternal and neonatal area in particular through the use of the WHO SCC. The WHO SCC has been adopted with a positive feedback from midwifes. The childbirth checklist has increased the delivery of some essential childbirth-related care practices and the appropriateness during the administration of antibiotic therapy and antihypertensive treatment. The twinning model proposed by WHO has the potential to go far beyond patient safety issue it can advance efforts towards building resilient health systems.
This paper focuses on how to build up a clinical risk management system in healthcare organizatio... more This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, to achieve this result, a change in cultural attitudes is needed. It can be obtained by developing adequate tools for risk analysis, which should focus on the peculiarities of the healthcare systems. A no-blame culture should be shared. This culture
This paper focuses on how to build up a clinical risk management system in healthcare organizatio... more This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, for achieving this result, a change in the cultural attitudes is needed. It can be obtained by developing adequate tools for risk ...
This paper is a critical presentation of the work done by the authors during the past years in tw... more This paper is a critical presentation of the work done by the authors during the past years in two European Projects in the knowledge management area: Klee&Co (Knowledge and Learning Environments for European & Creative Organisations - ESPRIT Program) and MILK (Multimedia Interaction for Learning and Knowing - IST Program). Both projects focus on the dynamic vision of knowledge management
In February 2007, three organs from an human immunodeficiency virus (HIV)-positive donor were tra... more In February 2007, three organs from an human immunodeficiency virus (HIV)-positive donor were transplanted at two hospitals in the Tuscany Regional Health Care Service, owing to a chain of errors during the donation process. The heart-beating donor was a 41-year-old woman who died as a result of head trauma. The patient's history did not highlight any risky behavior. The available data on previous hospital admissions reported a negative result on HIV testing. During the donation process, the result of the lab test performed for evaluation of organ suitability was mistakenly transcribed from positive to negative. This wrong negative result was then included in the donation record without any cross-check. Therefore, the Regional Transplant Center allocated the liver and both kidneys. The patient also donated tissues, and a second laboratory conducted an evaluation of suitability for the tissue banks. During this process, only 5 days after the successful transplantation procedures, the positive HIV result was fed back to the Regional Transplant Center and the previous error discovered. Transplanted patients were immediately assessed and then treated with antiretroviral medications. A national commission soon performed a systems analysis of the adverse event. Besides the active error committed during the manual transcription for the HIV lab test result, the commission also identified technological factors, such as the lack of integration between the lab machine, the laboratory information system (LIS), and the donor record, as well as organizational factors, such as the distribution to two different labs of the suitability evaluation for organs and tissues. Recommendations included: automatic transmission of lab test results from the lab machine to the LIS and to the donor record, centralization of lab tests for suitability evaluation of organs and tissues, a training program to develop a proactive quality and safety culture in the regional network of donation and transplantations.
Cross-unit handovers transfer responsibility for the patient among healthcare teams in different ... more Cross-unit handovers transfer responsibility for the patient among healthcare teams in different clinical units, with missed information, potentially placing patients at risk for adverse events. We analysed the communications between high-acuity and low-acuity units, their content and social context, and we explored whether common conceptual ground reduced potential threats to patient safety posed by current handover practices. We monitored the communication of five content items using handover probes for 22 patient transitions of care between high-acuity 'sender units' and low-acuity 'recipient units'. Data were analysed and discussed in focus groups with healthcare professionals to acquire insights into the characteristics of the common conceptual ground. High-acuity and low-acuity units agreed about the presence of alert signs in the discharge form in 40% of the cases. The focus groups identified prehandover practices, particularly for anticipatory guidance that r...
Most of the available knowledge management systems pay little attention to two important aspects:... more Most of the available knowledge management systems pay little attention to two important aspects: the need of supporting emerging communities of interest together with the official organizational structure; and the need of cluing together knowledge associated with any kind of involved entity including people, communities, and informal knowledge. The MILK system enhances knowledge discovery and sharing by providing services addressing these aspects and supplying innovative interfaces and interaction styles. The goal of MILK is to become a familiar environment integrated in the every-day activities of dynamic modern workers. To meet the users' needs, the solution proposed by MILK roots in ethnographic analysis capturing the common practices within an organization.
Incident-reporting systems (IRS) are tools that allow front-line healthcare workers to voluntary ... more Incident-reporting systems (IRS) are tools that allow front-line healthcare workers to voluntary report adverse events and near misses. The WHO has released guidelines that outline the basic principles on how to design and implement successful IRS in healthcare organisations. A written survey was administered with an assisted self-assessment technique to a representative sample of healthcare workers in Italian hospitals with and without IRS. Data were collected using two different 16-item questionnaires. The questionnaires targeted two issues: (1) workers' experience of patient safety incidents and (2) their expectations on incident reporting. 70% of respondents confirmed involvement in a patient safety incident, but only 40% utilised an IRS to formally report the event. The data indicate that information regarding patient safety incidents is not communicated throughout the entire organisation. Research findings are consistent with the available evidence on healthcare workers' experience of patient safety incidents.
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Papers by S. Albolino