Author Of 2 Presentations
THE USE OF CONTINUOUS ELECTROENCEPHALOGRAM MONITORING TO DETECT LATE ONSET OF SUBCLINICAL SEIZURES AND ABNORMAL HEAD MRI IMAGE IN INFANTILE ABUSIVE HEAD TRAUMA- CASE REPORT
Abstract
Background
Some infants with traumatic brain injury have been reported having biphasic clinical courses with abnormal head magnetic response imaging (MRI) images resembling acute encephalopathy with biphasic seizures and late reduced diffusion (AESD), which is the most common encephalopathy in Japanese children.
Objectives
We report a Japanese case of infantile traumatic brain injury with a biphasic clinical course and abnormal late head MRI image resembling AESD. It was diagnosed as abusive head trauma (AHT).
Methods
Case report.
Results
Case: A previously healthy 8-mouth-old boy fell backwards and presented with seizures for sixty minutes. Right after arrival, he was intubated because of consciousness disturbance. Brain computed tomography (CT) showed right acute subdural hematoma. He underwent barbiturate coma therapy (BCT) for the next 48 hours aiming at suppression-burst pattern on continuous electroencephalogram (cEEG) due to prolonged seizures. On day four, he had second phase of seizures detected by cEEG monitoring. Therefore, he underwent BCT for the next 48 hours again. On day five, he underwent brain MRI showing subcortical white matter lesions on diffusion-weighed image, mimicking AESD. On day thirty-six, he was discharged with developmental regression and tubal enteral feeding.
Conclusion
Late onset of subclinical seizures in infantile head trauma can be successfully detected by using cEEG for further neurological treatment.
COMBINED STRATEGY FOR INCREASING INCIDENT REPORTS - DIDACTIC LECTURES AND IMMEDIATE FEEDBACK OF ROOT CAUSE ANALYSIS IN PICU
- Yoko Akamine, Japan
- Atsushi Ujiro, United States of America
- Yasunori Otsuka, United States of America
- Hiroshi Yamamoto, United States of America
- Taiki Haga, United States of America
- Hirofumi Iwata, United States of America
- Hikoaki Ohba, United States of America
- Takao Kazuta, United States of America
Abstract
Background
Physicians report less incidents than nurses. Factors that hinder physicians from reporting incidents are known as fear of punitive action, legal ramifications, belief that only bad doctors make mistakes. However, even low level incidents are rich sources of learning. How can we raise awareness for patient safety with creating non-punitive culture and increase reports from physicians?
Objectives
To create non-punitive culture and increase the number of incident reports from physicians, we conducted single-center prospective interventional study in our ten-bed PICU.
Methods
The monthly number of incident reports by physicians from January to December 2018 were compared pre- and post-intervention periods using independent two-tailed t-test. The intervention was consisted of two parts, starting in July 2018. One of the interventions was the series of didactic lectures for raising awareness of importance of non-punitive patient safety culture, the other was immediate feedback of solutions derived from regular team-based root cause analysis to the staffs.
Results
The number of incident reports was significantly increased in the period of post-intervention compared with pre-intervention (P<0.001).
Conclusion
Combined strategy consisted of educational lectures to raise awareness of importance of non-punitive patient safety culture and immediate feedback of solutions derived from root cause analysis of reported incidents had significant impact on increasing incident reports from physicians in our PICU. Educational lectures might provide basic understanding of non-punitive culture and how incident reporting system benefit both patients and healthcare providers. Immediate feedback of root cause analysis might provide specific solutions that motivate them to report more incidents as rich sources of learning.
Presentation files
-
Combined Strategy for Increasing Incident Reports_final 13.06.2019 07:17
-
Combined Strategy for Increasing Incident Reports_final2 19.06.2019 16:27
-
Combined Strategy for Increasing Incident Reports_final3 19.06.2019 16:55
Video on Demand
Presenter of 1 Presentation
COMBINED STRATEGY FOR INCREASING INCIDENT REPORTS - DIDACTIC LECTURES AND IMMEDIATE FEEDBACK OF ROOT CAUSE ANALYSIS IN PICU
- Yoko Akamine, Japan
- Atsushi Ujiro, United States of America
- Yasunori Otsuka, United States of America
- Hiroshi Yamamoto, United States of America
- Taiki Haga, United States of America
- Hirofumi Iwata, United States of America
- Hikoaki Ohba, United States of America
- Takao Kazuta, United States of America
Abstract
Background
Physicians report less incidents than nurses. Factors that hinder physicians from reporting incidents are known as fear of punitive action, legal ramifications, belief that only bad doctors make mistakes. However, even low level incidents are rich sources of learning. How can we raise awareness for patient safety with creating non-punitive culture and increase reports from physicians?
Objectives
To create non-punitive culture and increase the number of incident reports from physicians, we conducted single-center prospective interventional study in our ten-bed PICU.
Methods
The monthly number of incident reports by physicians from January to December 2018 were compared pre- and post-intervention periods using independent two-tailed t-test. The intervention was consisted of two parts, starting in July 2018. One of the interventions was the series of didactic lectures for raising awareness of importance of non-punitive patient safety culture, the other was immediate feedback of solutions derived from regular team-based root cause analysis to the staffs.
Results
The number of incident reports was significantly increased in the period of post-intervention compared with pre-intervention (P<0.001).
Conclusion
Combined strategy consisted of educational lectures to raise awareness of importance of non-punitive patient safety culture and immediate feedback of solutions derived from root cause analysis of reported incidents had significant impact on increasing incident reports from physicians in our PICU. Educational lectures might provide basic understanding of non-punitive culture and how incident reporting system benefit both patients and healthcare providers. Immediate feedback of root cause analysis might provide specific solutions that motivate them to report more incidents as rich sources of learning.
Presentation files
-
Combined Strategy for Increasing Incident Reports_final 13.06.2019 07:17
-
Combined Strategy for Increasing Incident Reports_final2 19.06.2019 16:27
-
Combined Strategy for Increasing Incident Reports_final3 19.06.2019 16:55