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Dolbec A, Doucet C, Pohlman KA, Sobczak S, Pagé I. Assessing adverse events associated with chiropractic care in preschool pediatric population: a feasibility study. Chiropr Man Therap 2024; 32:9. [PMID: 38481318 PMCID: PMC10938841 DOI: 10.1186/s12998-024-00529-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/23/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Manual therapies are commonly used by healthcare professionals when caring for children. However, few prospective studies have evaluated their adverse events (AEs). This study aims to assess the feasibility of a pragmatic prospective study aiming to report the immediate and delayed (48-hours post-treatment) AEs associated with manual therapies in children aged 5 or younger. Preliminary data on AEs frequency are also reported. METHODS Between July 2021 and March 2022, chiropractors were recruited through purposive sampling and via a dedicated Facebook group for Quebec chiropractors interested in pediatrics. Legal guardians of patients aged 5 or younger were invited to fill out an online information and consent form. AEs were collected using the SafetyNET reporting system, which had been previously translated by the research team. Immediate AEs were collected through a questionnaire filled out by the legal guardian immediately after the treatment, while delayed AEs were collected through a questionnaire sent by email to the legal guardian 48 h after the treatment. Feasibility was assessed qualitatively through feedback from chiropractors and quantitatively through recruitment data. RESULTS Overall, a total of 28 chiropractors expressed interest following the Facebook publication, and 5 participated. An additional two chiropractors were enrolled through purposive sampling. In total, 80 legal guardians consented to their child's participation, and data from 73 children were included for the analysis of AEs. At least one AE was reported in 30% of children (22/73), and AEs were mainly observed immediately following the treatment (16/22). The most common AEs were irritability/crying (11 children) or fatigue/tiredness (11 children). Feasibility analysis demonstrated that regular communication between the research team and clinicians, as well as targeting clinicians who showed great interest in pediatrics, were key factors for successful research. CONCLUSION Results suggest that it is feasible to conduct a prospective pragmatic study evaluating AEs associated with manual therapies in private practices. Direct communication with the clinicians, a strategic clinicians' recruitment plan, and the resulting administrative burden should be considered in future studies. A larger study is required to confirm the frequency of AEs reported in the current study. TRIAL REGISTRATION ClinicalTrials.gov., NCT05409859, Registered on June 3 2022. https://clinicaltrials.gov/study/NCT05409859 .
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Affiliation(s)
- Anne Dolbec
- Département d'anatomie, Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada
- Groupe de recherche sur les affections neuromusculosquelettiques (GRAN), Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada
| | - Chantale Doucet
- Département de chiropratique, Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada
| | - Katherine A Pohlman
- Research Center, Parker University, 2540 Walnut Hill Lane, 75229, Dallas, TX, USA
| | - Stéphane Sobczak
- Département d'anatomie, Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada
- Groupe de recherche sur les affections neuromusculosquelettiques (GRAN), Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada
- Chaire de recherche en anatomie fonctionnelle, Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada
| | - Isabelle Pagé
- Département de chiropratique, Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada.
- Centre Interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSS-CN), 525 Boul. Wilfrid-Hamel, G1M 2S8, Québec, Québec, Canada.
- Groupe de recherche sur les affections neuromusculosquelettiques (GRAN), Université du Québec à Trois-Rivières, 3351 Boul. des Forges, G8Z 4M3, Trois-Rivières, Québec, Canada.
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Keating G, Hawk C, Amorin-Woods L, Amorin-Woods D, Vallone S, Farabaugh R, Todd A, Ferrance R, Young J, O'Neill Bhogal S, Sexton H, Alevaki H, Miller J, Parkin-Smith G, Schielke A, Robinson A, Thompson R. Clinical Practice Guideline for Best Practice Management of Pediatric Patients by Chiropractors: Results of a Delphi Consensus Process. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2024; 30:216-232. [PMID: 37902954 PMCID: PMC10954607 DOI: 10.1089/jicm.2023.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
Objective: To build upon existing recommendations on best practices for chiropractic management of children by conducting a formal consensus process and best evidence synthesis. Design: Best practice guide based on recommendations from current best available evidence and formal consensus of a panel of experienced practitioners, consumers, and experts for chiropractic management of pediatric patients. Methods: Synthesis of results of a literature search to inform the development of recommendations from a multidisciplinary steering committee, including experts in pediatrics, followed by a formal Delphi panel consensus process. Results: The consensus process was conducted June to August 2022. All 60 panelists completed the process and reached at least 80% consensus on all recommendations after three Delphi rounds. Recommendations for best practices for chiropractic care for children addressed these aspects of the clinical encounter: patient communication, including informed consent; appropriate clinical history, including health habits; appropriate physical examination procedures; red flags/contraindications to chiropractic care and/or spinal manipulation; aspects of chiropractic management of pediatric patients, including infants; modifications of spinal manipulation and other manual procedures for pediatric patients; appropriate referral and comanagement; and appropriate health promotion and disease prevention practices. Conclusion: This set of recommendations represents a general framework for an evidence-informed and reasonable approach to the management of pediatric patients by chiropractors.
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Affiliation(s)
- Genevieve Keating
- Fielding Graduate University, Santa Barbara, CA, USA
- Private Practice, Melbourne, Australia
| | - Cheryl Hawk
- US-Clinical Compass, Lexington SC, USA
- Texas Chiropractic College, TX, USA
| | - Lyndon Amorin-Woods
- School of Allied Health, Murdoch University, Murdoch, Australia
- Private Practice, Perth, Australia
| | - Deisy Amorin-Woods
- Edith Cowan University, Joondalup, Australia
- Private Practice, Insight Counselling, Perth, Australia
| | | | - Ronald Farabaugh
- Advanced Medicine Integration Group, Columbus, OH, USA
- Clinical Compass, Columbus, OH, USA
| | - Angela Todd
- Private Practice, Sale, Australia
- Aus-ACA, Sale, Australia
| | | | | | | | | | | | - Joyce Miller
- Anglo European College of Chiropractic, Bournemouth, United Kingdom
| | - Gregory Parkin-Smith
- Private Practice, Perth, Australia
- School of Allied Health, Murdoch University, Murdoch, Australia
| | | | | | - Robyn Thompson
- Private Practice, The Thompson Method Breastfeeding, Melbourne, Australia
- Australian Catholic University, Fitzroy, Australia
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Kuan AS, Chen SP, Wang YF, Wang SJ. Prolonged headache with vaccine- and dose-specific headache pattern associated with vaccine against SARS-CoV-2 in patients with migraine. Cephalalgia 2023; 43:3331024231208110. [PMID: 37851648 DOI: 10.1177/03331024231208110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
OBJECTIVE To examine SARS-CoV-2 vaccine-related headache characteristics and risk factors in migraine patients. METHODS This retrospective cohort study included 732 migraine patients who had AstraZeneca Vaxzevria, Pfizer-BioNTech Comirnaty, or Moderna Spikevax vaccines. Participants provided information through questionnaires and headache diaries. Headache frequency before and after vaccination and factors associated with headache risk were examined. RESULTS Approximately a third of patients reported increased headache the day after having primary and booster doses, with mean increase ± SD of 1.9 ± 1.2 and 1.8 ± 1.1 days/week, respectively. Proportions of migraine patients with headache (after vaccination vs. before vaccination) increased after having primary-dose Vaxzevria (35.3% vs. 22.8%, p < 0.001) but not Spikevax (23.8% vs. 26.7%, p = 0.700) or Comirnaty (33.2% vs. 25.8%, p = 0.058). Headache proportion increased after having all three boosters (Vaxzevria 27.1% vs. 17.9% p = 0.003; Comirnaty 34.1% vs. 24.5% p = 0.009; Spikevax 35.2% vs. 24.8% p = 0.031). For primary dose with Vaxzevria and Comirnaty, headache risk increased on the vaccination day, peaked on the day after vaccination, and subsided within a week, while for Spikevax headache risk rose gradually after vaccination, peaked on the seventh post-vaccination day and subsided subsequently. For booster dose, headache risk generally increased on the vaccination day, peaked on the day after vaccination, and subsided gradually with fluctuating pattern within a month. Our study also showed that headache increased on the day before primary dose but not booster dose vaccination and it may be attributable to stress associated with having to undertake new vaccines. Multivariable analyses showed that depression was associated with headache. CONCLUSION Prolonged headache with vaccine- and dose-specific headache pattern was found. Patients with higher risks of vaccine-related headache must be informed of the potential worsening headache.
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Affiliation(s)
- Ai Seon Kuan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Feng Wang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Khalil R, Petrushkin H, Rees A, Westcott M. The incidence, presenting clinical findings and treatment patterns of Birdshot Retinochoroiditis in a high-prevalence region: findings from Northern Ireland, England and Wales. Eye (Lond) 2023; 37:2817-2825. [PMID: 36765269 PMCID: PMC10482920 DOI: 10.1038/s41433-023-02425-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 01/10/2023] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Birdshot Retinochoroiditis (BSRC) is a rare, chronic posterior uveitis that is strongly associated with HLA-A*29.2 positivity. To date, no robust incidence studies of BSRC have been undertaken. We present the first epidemiological study of BSRC in a high-prevalence region. METHODS In collaboration with the British Ophthalmological Surveillance Unit, all new cases of BSRC between May 2017 and June 2019 were prospectively collected. Presenting demographics, symptoms, signs and treatment modalities were collected. A follow-up questionnaire twelve months later was also sent. RESULTS Thirty-seven confirmed cases meeting the reporting criteria were identified. Twenty-three cases had both baseline and follow-up data. The total population incidence of BSRC was 0.035 cases per 100,000 person-years [95% CI 0.025-0.048 cases per 100 000 people]. 97.3% were HLA-A*29 positive. The median age was 46 years, with females making up 78% of patients. There were no significant differences in the latitudinal incidence of BSRC. At presentation, floaters were the most common symptom. Optic disc swelling was the most common sign. Mean presenting visual acuity was independent of symptom duration. Combined systemic corticosteroids and immunomodulatory therapy were the most common treatments at baseline and follow-up. Intravitreal steroids were equally popular at follow-up. CONCLUSIONS This study provides the first nationwide estimate of the incidence of BSRC in a high-prevalence region. Cases were more common in females, with a broad range of presentation ages. No significant latitudinal effect of incidence was identified. Systemic therapy with steroids and IMT remain the most common treatments.
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Affiliation(s)
- Rana Khalil
- Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, D02 YN77, Republic of Ireland.
| | - Harry Petrushkin
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, United Kingdom
- Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, United Kingdom
- UCL Institute of Ophthalmology, 11-43 Bath St, London, EC1V 9EL, United Kingdom
| | - Angela Rees
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, United Kingdom
| | - Mark Westcott
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, United Kingdom
- Queen Mary University of London, Mile End Rd, Bethnal Green, London, E1 4NS, United Kingdom
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Thomas M, Swait G, Finch R. Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. Chiropr Man Therap 2023; 31:9. [PMID: 36793096 PMCID: PMC9933370 DOI: 10.1186/s12998-023-00477-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/19/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Safety incident (SI) reporting and learning via incident reporting systems (IRSs) is used to identify areas for patient safety improvement. The chiropractic patient incident reporting and learning system (CPiRLS) is an online IRS that was launched in the UK in 2009 and, from time to time, has been licensed for use by the national members of the European Chiropractors' Union (ECU), members of Chiropractic Australia and a Canada-based research group. The primary aim of this project was to analyse the SIs submitted to CPiRLS over a 10-year period to identify key areas for patient safety improvement. METHOD All SIs reported to CPiRLS between April 2009 and March 2019 were extracted and analysed. Descriptive statistics were used to describe: (1) the frequency of SI reporting and learning by the chiropractic profession, and (2) the character of reported SIs. Key areas for patient safety improvement were developed following a mixed methods approach. RESULTS A total of 268 SIs were recorded on the database over the 10-year period, 85% of which originated from the UK. Evidence of learning was documented in 143 (53.4%) SIs. The largest subcategory of SIs related to post-treatment distress or pain (n = 71, 26.5%). Seven key areas for patient improvement were developed including: (1) patient trip/fall, (2) post treatment distress/pain, (3) negative effects during treatment, (4) significant post-treatment effects, (5) syncope, (6) failure to recognize serious pathology, and (7) continuity of care. CONCLUSION The low number of SIs reported over a 10-year period suggests significant under-reporting, however, an upward trend was identified over the 10-year period. Several key areas for patient safety improvement have been identified for dissemination to the chiropractic profession. Improved reporting practice needs to be facilitated to improve the value and validity of reporting data. CPiRLS is important in identifying key areas for patient safety improvement.
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Affiliation(s)
- Mark Thomas
- Institute of Health and Social Care, London South Bank University, London, UK.
| | - Gabrielle Swait
- Royal College of Chiropractors, Chiltern House, 45 Station Road, Henley on Thames, Oxfordshire, RG9 1AT UK
| | - Rob Finch
- Royal College of Chiropractors, Chiltern House, 45 Station Road, Henley on Thames, Oxfordshire, RG9 1AT UK
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Roy B, Webb A, Walker K, Morgan C, Badawi N, Nunez C, Eslick G, Kent AL, Hunt RW, Mackay MT, Novak I. Prevalence & Risk Factors for Perinatal Stroke: A Population-Based Study. Child Neurol Open 2023; 10:2329048X231217691. [PMID: 38116020 PMCID: PMC10729630 DOI: 10.1177/2329048x231217691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/23/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023] Open
Abstract
Objectives The study objective was to calculate the birth prevalence of perinatal stroke and examine risk factors in term infants. Some risk factors are present in healthy infants, making it difficult to determine at-risk infants. Study Design Prospective population-based perinatal stroke data were compared to the Australian general population data using chi-squared and Fisher's exact tests and multivariable logistic regression analysis. Results Sixty perinatal stroke cases were reported between 2017 and 2019. Estimated stroke prevalence was 9.6/100,000 live births/year including 5.8 for neonatal arterial ischemic stroke and 2.9 for neonatal hemorrhagic stroke. Eighty seven percent had multiple risk factors. Significant risk factors were cesarean section (p = 0.04), 5-min Apgar score <7 (p < 0.01), neonatal resuscitation (p < 0.01) and nulliparity (p < 0.01). Conclusions Statistically significant independent risk factors do not fully explain the cause of perinatal stroke, because they are not a direct causal pathway to stroke. These data now require validation in a case-control study.
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Affiliation(s)
- Bithi Roy
- The University of Sydney Children's Hospital Westmead Clinical School, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- The University of Notre Dame Australia, Sydney, Australia
| | - Annabel Webb
- Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Karen Walker
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- RPA Newborn Care, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Catherine Morgan
- The University of Sydney Children's Hospital Westmead Clinical School, Sydney, Australia
- Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Nadia Badawi
- The University of Sydney Children's Hospital Westmead Clinical School, Sydney, Australia
- Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Sydney, Australia
| | - Carlos Nunez
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- The Australian Paediatric Surveillance Unit, Sydney, Australia
| | - Guy Eslick
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- The Australian Paediatric Surveillance Unit, Sydney, Australia
| | - Alison L Kent
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Australian National University College of Health and Medicine, Canberra, ACT, Australia
| | - Rod W Hunt
- Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
- Dept of Paediatrics, Monash University, Melbourne, Australia
- Monash Newborn, Monash Health, Melbourne, Australia
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Parkville, Australia
- Neuroscience Research, Murdoch Children's Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Iona Novak
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
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Funabashi M, Holmes MM, Pohlman KA, Salsbury S, O'Beirne M, Vohra S, Mior S. "Doing our best for patient safety": An international and interprofessional qualitative study with spinal manipulative therapy providers in community-based settings. Musculoskelet Sci Pract 2021; 56:102470. [PMID: 34735865 DOI: 10.1016/j.msksp.2021.102470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/24/2021] [Accepted: 10/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patient safety research is expanding from hospitals to community-based healthcare settings. Knowledge gaps persist among manual therapy professions that may impede patient safety initiatives within musculoskeletal care settings. OBJECTIVES To describe perceptions of patient safety among chiropractors and physiotherapists who provide spinal manipulation therapy (SMT). DESIGN Qualitative descriptive study. METHOD Cross-sectional data were collected using the SafetyNET Survey to Support Quality Improvement. SMT providers (n = 705) in 3 countries completed surveys, with 84 providing written responses to an open-ended question about patient safety. Qualitative thematic analysis described providers' perceptions about patient safety within their practice. RESULTS SMT providers' perceptions were influenced by professional, patient, and practice setting factors. Five themes and 10 supporting categories were developed. Doing Our Best for Patient Safety concerned Avoiding Mistakes and Prioritizing Safety.Putting Patients First focused on Developing Relationships and Individualizing Care.Working and Learning Together advocated for Interprofessional Communication and Collaborative Learning. Organizing Practice Processes emphasized Standardizing Procedures and Benchmarking Progress.Considering Practitioner Identity highlighted how Recognizing Difference among SMT providers and Challenging Fears of other healthcare professionals and patients about SMT were important for enhancing patient safety. CONCLUSION Findings align with World Health Organization guiding principles that the nature of healthcare settings influence patient safety strategies. Most responses focused on individual strategies to prevent adverse events. However, this approach may overlook the benefits of identifying and documenting adverse events, setting time to discuss adverse events with clinic members, standardizing clinical practices, and building transparent patient safety cultures across healthcare professions and settings.
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Affiliation(s)
- Martha Funabashi
- Division of Research and Innovation, Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, ON, M2H 3J1, Canada; Department of Chiropractic, Université du Québec à Trois-Rivières, 3351, Boulevard des Forges, Trois-Rivières, Quebec, G9A 5H7, Canada.
| | - Michelle M Holmes
- AECC University College, Parkwood Campus, Parkwood Rd, Bournemouth, BH5 2DF, UK.
| | | | - Stacie Salsbury
- Palmer College of Chiropractic, 1000 Brady Street, Davenport, IA, 52803, USA.
| | - Maeve O'Beirne
- Department of Family Medicine and Community Health Sciences, Faculty of Medicine, University of Calgary, 2500 University Dr. NW, Calgary, AB, T2N 1N4, Canada.
| | - Sunita Vohra
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.
| | - Silvano Mior
- Division of Research and Innovation, Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, ON, M2H 3J1, Canada; Institute for Disability and Rehabilitation Research at Ontario Tech University and CMCC, 2000 Simcoe Street North, Oshawa, ON, L1G 0C5, Canada.
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