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Peard LM, Teplitsky S, Annabathula A, Gunnar W, Mills P, Harris A. Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. Can J Urol 2023; 30:11467-11472. [PMID: 37074745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Adverse events in urologic procedures are poorly studied. This study analyzes the Veterans Health Administration (VHA) Root Cause Analysis (RCA) data for patient safety adverse events during urologic procedures performed in a VHA operating room (OR). MATERIALS AND METHODS The VHA National Center for Patient Safety RCA database was queried for fiscal years 2015-2019 using urologic terms including vasectomy, prostatectomy, nephrectomy, cystectomy, cystoscopy, lithotripsy, ureteroscopy, urethral, TURBT, etc. RCAs for events outside a VHA OR were excluded. Cases were categorized based on type of event. RESULTS Sixty-eight RCAs were identified for 319,713 urologic procedures. The most common pattern identified was equipment or instrument issue, including broken scopes or smoking light cords, with 22 cases. Eighteen RCAs involved a sentinel event, including 12 retained surgical items (RSI) (surgical sponge, retained guidewire) and 6 wrong site surgeries (WSS) (incorrect laterality, wrong procedure) representing a serious safety event rate of 1 in 17,762 procedures. In addition, 8 RCAs pertained to medical or anesthesia events (incorrect dosing, postoperative myocardial infarction), 7 to pathology errors (missing or mislabeled specimen), 4 to incorrect patient information or consent, and 4 to surgical complications (hemorrhage, duodenal injury). In 2 cases there was inappropriate work up. One case caused a delay in treatment, one case had an incorrect count, and one case identified lack of credentialing. CONCLUSIONS RCAs of patient safety adverse events occurring during urologic OR procedures highlight the need for targeted quality improvement projects to prevent WSS events, prevent RSI events, and maintain properly functioning equipment.
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Affiliation(s)
- Leslie M Peard
- Department of Urology, University of Kentucky, Lexington, Kentucky, USA
| | - Seth Teplitsky
- Department of Urology, University of Kentucky, Lexington, Kentucky, USA
| | | | - William Gunnar
- National Center for Patient Safety, Veterans Health Administration, Ann Arbor, Michigan, USA
| | - Peter Mills
- National Center for Patient Safety, Veterans Health Administration, White River Junction, Vermont, USA
| | - Andrew Harris
- Department of Urology, University of Kentucky, Lexington, Kentucky, USA
- Veterans Affairs Medical Center, Lexington, Kentucky, USA
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Rose SW, Ickes M, Patel M, Rayens MK, van de Venne J, Annabathula A, Schillo B. Centering equity in flavored tobacco ban policies: Implications for tobacco control researchers. Prev Med 2022; 165:107173. [PMID: 35870576 PMCID: PMC9722530 DOI: 10.1016/j.ypmed.2022.107173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/07/2022] [Accepted: 07/17/2022] [Indexed: 01/03/2023]
Abstract
To achieve equity in protection from poor health outcomes due to tobacco use, tobacco control policies and interventions need to affect socially disadvantaged groups more strongly than advantaged groups. Flavored tobacco bans have been seen as a policy with this potential. However, tobacco control researchers, in close concert with policy advocates, need to consider how to center equity throughout the policy process to achieve equitable outcomes from banning flavored tobacco. In this commentary, we outline the rationale for how and why tobacco control researchers should consider equity throughout the policy process to help fully achieve the potential of flavored tobacco ban policies. These recommendations emerged from a presentation at the Vermont Center on Behavior and Health 2021 Conference. Specifically, we focus on recommendations for tobacco control researchers to center equity including partnering with communities in agenda setting, examining how various policy formulations or exemptions may increase or decrease disparities, determining where flavor policies need to reach and whether policies are equitably reaching all populations disproportionately burdened by flavored tobacco, assessing whether policy implementation/enforcement is carried out equitably to maximize policy benefits, and evaluating policy impact with as much granularity as possible. Considering the entire policy process is central to enhancing equitable outcomes from banning flavored tobacco. Tobacco control researchers can play a key role in ensuring that these policies are viewed through an equity lens to, not just improve population health, but also to reduce harms to those disproportionately burdened by use of flavored products.
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Affiliation(s)
- Shyanika W Rose
- University of Kentucky, Lexington, KY, USA; Markey Cancer Center, Lexington, KY, USA.
| | | | - Minal Patel
- Truth Initiative Schroeder Institute, Washington, DC, USA
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Rose SW, Annabathula A, Westneat S, van de Venne J, Hrywna M, Ackerman C, Lee JG, Sesay M, Giovenco DP, Spillane T, Hudson SV, Delnevo CD. Neighborhood distribution of availability of newer tobacco products: A US four-site study, 2021. Prev Med Rep 2022; 30:102028. [PMID: 36325253 PMCID: PMC9619027 DOI: 10.1016/j.pmedr.2022.102028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/15/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
Audits of tobacco retailers can identify marketing patterns as newer tobacco products are introduced in the US. Our study examined store and neighborhood correlates of availability of nicotine pouches and disposable e-cigarettes in four US sites. We conducted standardized store audits of n = 242 tobacco retailers in 2021 in different states: New Jersey, Kentucky, North Carolina, and New York. We geocoded stores linking them with census tract demographics. We conducted unadjusted and adjusted Poisson regression of availability of each product with correlates of the proportion of Non-Hispanic White residents, households under poverty, proximity to schools, site, and store type. Nicotine pouches and disposable e-cigarettes were each available in around half the stores overall, but availability differed across sites (range: 76 %-32 %). In adjusted analyses, nicotine pouches were less likely to be available in each store type vs chain convenience (IRR range 0.2-0.6) and more likely in stores in census tracts with a greater percentage of non-Hispanic White residents (IRR range 1.8-2.3). In contrast, disposable e-cigarettes were more likely to be available in tobacco/vape shops (IRR 1.9 (1.4-2.5) than convenience stores and less likely in non-specialty store types like groceries (IRR 0.2 (0.1-0.4). Newer tobacco products like nicotine pouches and disposable e-cigarettes were widely available in stores across sites, but retail marketing patterns appear to differ. As these product types become subject to increased regulation as they go through the FDA pre-market authorization process, understanding patterns and changes in the retail environment is critical to inform potential policies regulating their sale and marketing.
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Affiliation(s)
- Shyanika W. Rose
- University of Kentucky, College of Medicine, Behavioral Science and Center for Health Equity Transformation, Lexington, KY, USA,University of Kentucky, Markey Cancer Center, Lexington, KY, USA,Corresponding author.
| | - Arati Annabathula
- University of Kentucky, College of Medicine, Behavioral Science and Center for Health Equity Transformation, Lexington, KY, USA
| | - Susan Westneat
- University of Kentucky, College of Medicine, Behavioral Science and Center for Health Equity Transformation, Lexington, KY, USA,University of Kentucky, College of Public Health, Epidemiology and Biostatistics, Lexington, KY, USA
| | - Judy van de Venne
- University of Kentucky, College of Medicine, Behavioral Science and Center for Health Equity Transformation, Lexington, KY, USA
| | - Mary Hrywna
- Rutgers Center for Tobacco Studies, New Brunswick, NJ, USA,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, NJ, USA,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Joseph G.L. Lee
- Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, NC, USA
| | - Mahdi Sesay
- Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, NC, USA
| | - Daniel P. Giovenco
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York City, NY, USA
| | - Torra Spillane
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York City, NY, USA
| | - Shawna V. Hudson
- Dept of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Cristine D. Delnevo
- Rutgers Center for Tobacco Studies, New Brunswick, NJ, USA,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, NJ, USA,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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