Department Of Surgery At A Large Urban Medical Center – Infection Control Investigation And Workplace Safety Plan

Questions for the infectious control nurse in the first meeting

The Chief of General Surgery and the head of pathology department can provide the data about the last 12 months incidents and outbreaks happened on the organization. The entire staff of the organization reports any incidence that is harmful and can lead to infection to the Chief of general surgery and the head of pathology department. The head of pathology department also talks to the entire infection control team and department so that he can get enough knowledge about the infection control status of the organization. Further, these higher authorities of the organization can arrange data of other organization’s infection control management to compare the status of their infection control management. Therefore, from these two dignities, informations of other organizations infection control management, update about this organizations infection control system and data about the infection throughout the country. Therefore, it is important to meet such higher authorities to search for data about infection in past 12 months.

Surgical site infections are generally linked with the increased length of stay. This additional stay in the hospital increase the clinical, economical and psychological implications on the patients. Such infection can occur in any hospital at any point of time making the hospital organization and the patient suffer from infections. This generally occurs when the tissue, organ or spaces becomes exposed during the surgery.

According to the research of Rosenthal et al. (2013), they gathered data from 66 cities of 30 countries including the United Arab Emirates and the study included four continents of the world. This study also included patients who went for surgery from January 2005 to December 2010. The Surgical site infection in that case was divided into 31 types and after that, they gathered data from 7523 infections. Nearly 5.8 percent of the patients reported that they had to take readmission in hospitals as they were suffering from infections and the infection had several implications on their life. However, further research of these patients proved that they were suffering from nosocomial infection and only 20 percent of them were affected with surgical site infection. The clinical implication about the harassment the patients need to suffer from due to the infection that occurs in the operation theatre. In few cases, the patients lost their lives while suffering from surgical site infection. Therefore, the patient mostly suffers the clinical implication.

Financial and legal complication has to be suffered by the organization or the patients both. It is not possible for every patient to spend too much money for his or her surgeries. Therefore, financially they have to suffer from such infection. In USA, from 2008 to 2014, 20 percent people were suffering from nosocomial infections. The cost on every individual was around $544 -$1220 and maximum of the patients were not willing to pay the bill as this was the fault of the organization (Center for Disease Control and Prevention 2017). The legal consequences are also problematic as the organization is answerable for the infection and the government may summon those organizations for a justification. The organization has to suffer a lot about the legal consequences and the government can take string actions about the organization. Therefore the organization should promote the rules to stop or minimize the hospital acquired infection or surgical site infection can improve the organizations status.

Inputs from Chief of General Surgery and head of pathology department

The plan to promote workplace safety include options both the staff and the patient need to be active. There are few recommendations and suggestions that the organization can implement in the workforce to improve the quality of healthcare. These are world health organization’s recommendations on implementing environmental and infection control program. The organization should also include trained environmental services staff in the organization so that they can carry out high touch cleaning activities, implement procedures to educate the staff using cutouts and high quality pictures. These staffs can also contribute to overcome language barrier and literacy barrier and the complete organization can acquire proper knowledge about health and hygienic practices. Further, the organization should implement the basic practice of hygiene and cleaning practices. The organization should emphasize on proper cleaning procedures and mechanism to reduce infection.

After implementing different laws and norms in the organization and World Health Organization driven regulations about infection control and surgical site infections, the hospital should start arrange workshops and training sessions. This will help to create and spread awareness in the employees and hospital staff so that they can prevent any kind of infection in front of their eyes.

Clinical risk management delivery of safe and quality health care to the ailing patients, and it involves the installation of devices and instruments that helps to reduce the errors that occurs due to the healthcare delivery. In clinical risk management, the main aim is to identify the risk reduce the harm upon the patients. The other objective of risk management includes the identification of the errors that arise due to delivery of care, understand the reasons that contribute to the risk, learning from the mistakes committed earlier and also from the poor clinical outcomes, to ensure that proper action is taken to reduce the incidence of the problem in future, installation of the certain systems that specialize in risk reduction. Thus, risk management as a whole has its applicability and usability in the healthcare services, in the conduct of medical research and medical analysis conducted on human trials.

Clinical risk management is a good and ethical clinical practice through which healthcare institutes are held accountable, so that they put a lot of emphasis in the proper delivery of the healthcare services. This is achieved only through the creation of environment that promotes transparent and responsible delivery of clinical care that strives to minimize the errors, issues that arise during care delivery. According to Li (2013), there are several categories of risk: clinical risks are the risks that are associated with the delivery of clinical services, corporate risks are the risks that arise due to improper management of healthcare delivery, strategic risks are the risks that arise due to the mismanagement at the executive level and planning procedures, operational risks are classified as risks that are associated with the everyday delivery of healthcare services and activities within an organization, the project related risks are kinds of risks that arise during the lifecycle of the project and the risks are commonly identified by the team that is involved in the project. The clinical and the corporate risks often come across and leads to risks that impair the corporate and clinical functions. The clinical risk management according to the case study involves a 5 step process which involves the establishment of the context of the risk, identification of the risk, analysis of the risk, evaluation of the risk, treatment of risks. Health staffs and the concerned hospitals must consult and communicate effectively with both the external and internal stakeholder to review and monitor the risks associated with the healthcare delivery and the management must assess the clinical outcomes for effective management of the clinical risks.

Clinical, financial, and legal implications of infections

Outpatient clinics are the specialized departments of the hospitals which provide healthcare service like the diagnostics and tests, medical treatments which do not require the patient to stay overnight in the hospital and which do not require the bed for the patient. Modern outpatient clinics also provide the minor surgical procedures (Kehle-Forbes et al. 2016). Assessment of quality healthcare in the outpatient clinics through the Maxwell classification include the 6 dimensions of quality. The classification includes effectiveness, efficiency, acceptability, access, equity and relevance. Below are the following assessment criteria (Mosadeghrad 2012):

• Effectiveness- the outpatient clinics treats the patients effectively through the qualified nurses that possess the requisite skills. These clinics have the advanced technology that suffice the requirements of a variety of patients. A majority of the patients receive the requisite amount of healthcare which do not require further hospitalization.
• Efficiency- the outpatient clinics have the necessary healthcare devise that perform well under the effective staffs. These clinics manages the patient medical records effectively which result in improved and effective patient outcomes.
• Acceptability- outpatient clinics provide resting places and seats for the family members of the patient. Information gained from the family members of the concerned patients are applied during the designing the treatment framework for that patient. Along with the treatment procedures, the valuable feedbacks are also recorded which are utilized in the proper management and healthcare delivery.
• Access- the outpatient clinics are found to cater to the needs of the patients and treat a large number of patients within the set time limits and timelines so that the patients do not have to wait for longer periods to be attended by the staffs.
• Equity- the type of healthcare service delivered by the outpatient clinics are devoid of any biasness, because the service provided oversteps the social class, ethnic, regional and cultural differences among the patients and provide them with the quality service.
• Relevance- outpatient clinics make use of the resources it has in hand effectively, and this is evident from the whole range of patients that it handles. This is ultimately helpful for the patients in terms of social wellbeing, when considered. Better healthcare standards and productivity enhancements are the two vital differences that outpatient clinics service makes to the common people. Thus, even within the constrained resources the outpatient clinics deliver the health services to the patients without hospitalizing them.

Ineffectiveness of health range from several issues that arise in the delivery of medical healthcare services. This ineffectiveness can be categorized into several types: ineffective service delivery from the infection control nurse, registered nurse, clinical staffs, the departmental nurse heads, improper usage of healthcare devices and the hospital mismanagement. The two examples can consolidate the ineffective that arise in health care services.

The lack of communication, and role ambiguity among the registered nurses plays a major role in the delivery of healthcare services. When the new graduate nurse undergoes the transition to a practitioner, these nurses often make mistake in the medication management. The reasons for the mistake can be attributed to the role ambiguity. Role ambiguity is an ambiguous situation in which the nurse does not understand the role that she needs to deliver. Often in this kind of situations, the nurse is unable to administer the right medication to the concerned patient because the newly graduated nurse finds it difficult to understand what, how, how much, where she will administer the medication. The prime reason behind such ineffectiveness is the lack of confidence of the novice nurses. Although they gain these nurses gain the theoretical knowledge, they lack the same in the practical aspects. This creates a gap in the knowledge and application, and the gap widens due to the role ambiguities. Therefore, this series of events results in ineffective delivery of healthcare services.  

Another example includes the scenario of an infection control measure which are not followed by the clinical staffs and the registered nurse when they handle patients. It is the duty of the infection control nurses to look after the infection control measures in the hospital, and the infection control nurses bear the responsibility of maintaining a germ free environment where a patient having an infectious disease do not spread the disease to the other patients in the hospitals. However, the clinical staff and the nurses do not use the surgical mask and the gloves when they move the patient in or out of the ward. The patients may carry communicable diseases and clinical staffs and staff nurses when come in contact with such patient risks of contracting the germs. Thus, infection control nurse often guides the clinical staffs and the staff nurses to follow the standard operating procedures before handling such patients. Considering this issue, it is seen that when the clinical staffs and the staff nurses do no wear the surgical masks and the gloves violates the standard operating procedures leads to the spread of germs among the hospital premises. Thus, it can be inferred that such violation of safe measures also hinders the smooth transition of healthcare services and leads to ineffectiveness.

Plan for promoting workplace safety

Total quality management is a vital issue in the present day of hospital management. Due to the increased incidence of governmental regulations, hospital management push, and customer influences. Hence, the preconception that government was the only service provider of health, that preconception has changed depending on the rise in numbers of the private entities that provide the health care services. The market of health care is evolving and ever demanding, this competitive market has led to quality management in the delivery of health services. To be competitive and be able to maintain the overall health care quality, the managers of the hospital needs to be empowered so that they can analyze several critical situations. Process the necessary data that will help in the effective decision making, patient care, staff management, providing effective training to the staffs and nurses, effective management of resources, handling of the changing market scenarios, effective communication of the duties, improvement programs for the hospital staffs.

There are certain key concepts upon whom the total quality management stands. The first and the foremost concept is the effective participation of the employees of the hospitals or the clinical staffs and the staff nurses. When the main workforce works as a team along with the synchronized direction from the management section, then it gets easy for the team to perform task with positive outcomes. Even the teamwork among the doctors or the physicians yields a positive outcome when they study a critical case and aid in the assessment of the possible treatment procedures. The next concept is based upon the measurement and quality improvement goals. Customer satisfaction is the prime criteria of all the hospital that strives to provide quality health care to the patients. Thus, a clear depicted goal and measurement of the quality of health care delivered helps the hospital or a clinic to compete effectively with the other health delivery services. The hospital management can conduct an internal audit which will identify the old devices that needs to be changed in order to deliver proper health care to the patients. Also, it is often seen that some hospitals have certain departments that needs renovation, such department can be identified and renovated so that they can deliver better health care services.

Management of risks in accordance with the Maxwell’s and Donabedian’s classification provides a platform through which the determination of several dimensions of quality can be achieved and measures can be undertaken to meet the risks that arise due to risks (Ferlay et al. 2015).

• Effectiveness- it reveals the facts that the employees have the required set of skills to use the devices, equipment and the staffs are in requisite numbers who can effectively manage the work load. Risk management also allows to identify the problems related to effective delivery of services and hence allows the hospital management authorities to avoid the chances of failures.
• Efficiency- risk management stresses on finalizing the decisions that help to achieve best outcomes out of less resource utilization. This helps in the effective management of resource utilization. It also deals with the interventions that have negative outcome in a hospital setting.
• Relevance- risk management uses the data that helps to determine that the intervention provided is appropriate according to the situation. It also helps to ensure that the invention is in accordance with the medical procedures and the interventions are applicable for the different patient ailing situations.
• Acceptability- risk management uses the patient information from the patient health responses which thus increases the quality of care can be effectively intervened to the patients. This practice increases the patient satisfaction and support.
• Access- risk management deals with the possibilities of the patients and not assessing them. The concerned risk mangers come up with the plans that best suits the patients and likewise the medication is intervened to the patient. This reduces the risk that are associated with negative patient outcomes and also the issues that hinders the proper delivery of medication to the patients.
• Equity- risk management also manages the provisions that are associated with the delivery of healthcare so that the healthcare is free from any bias and the outcomes are positive. Risk management also consider and includes the various inequalities that arise due to the inefficiencies in the healthcare delivery and strives to reduce the probability of the occurrence of the issues (Moore et al. 2015).

Risk management and Donabedian’s, Maxwell’s classification of quality

Topic: Health information system: Identification, prevention of errors and ways to improvement

Health information system is a term that describe the storing, acquiring, retrieving and using the healthcare information of the patient stored in the cloud of one healthcare organization to other healthcare providers. This system helps the patient as well as the healthcare organization by sharing the data using different information technology to foster better collaboration between them. This information system is the collaboration of computer science, information technology, management science, behavioral science and planning technology (Andargoli et al. 2017). This information system includes every data of the patient starting from their medical history, their genetic description, their current medical situation and the prescribed medication they are following. This information system uses the knowledge of patient care with the understanding of health informatics tool and informatics concepts. With the help of these informations, the system provides assessment and knowledge of the patient’s medical condition to the healthcare professional, patient and their families. Further, it help to characterize, refine and evaluate the interventions that the professional is going to apply on the patient and develop and implement those interventions on the patient (Busse, Aboneh and Tefera 2014).

This healthcare informatics system are generally of four types. The first type is for easy classification of information and known as tactical and operational system.  This system divides the patients depending on their gender, age and critical medical conditions. The second type is known as administrative and clinical system and it helps to manage the details of the patients on the administrative level. The third system is depending on the electronic Medical records or EMRs, it is the subject, and task based system. The fourth system is for the management and billing of these patients depending upon the service they acquired from the healthcare providers. This system is known as the financial system for tracking revenues. All these systems are designed to manage the healthcare process for every patient using any of the healthcare providers. The reason behind such complexity gradient of this informatics is depending on the usage. At lower level, the informatics has to be simple and usable because the staff that handles such system need to acquire the system completely. The staff using such healthcare system need to understand the importance of this data at local as well as national level and hence, they need to be provided with proper training and induction so that they put every information related to the patient and organization correctly to the cloud (Shortliffe and Cimino 2013).

Assessing quality healthcare in outpatient clinics

There are six components of the healthcare information system such as the resources for health information system, data sources, indicators, data management, information products and dissemination and use. The resources include legislative, regulatory, and planning framework that helps to coordinate between the six components. The indicators are there to encompass determinants of health, system input-output and health status. The data sources are can be of two types, population based approach like census and population survey and institution based approach like service, individual or resource records. Data management covers all the information starting from collection, storage, process compilation, usage and analysis. Data acquired from this system must be transferred to other institutions so that the patient can acquire better healthcare. Finally, the sixth component talks about its accessibility to all the healthcare professionals starting from small dispensaries to big hospitals (Wager, Lee and Glaser 2017).

In spite of these positive effects of this healthcare informatics system, there are certain errors in the healthcare informatics system. There are several unethical incidences where the data of patients are being used with wrong intentions. Instances of using the patients data without receiving the consent has been seen several times in recent past and therefore ethical consideration of such system is necessary. Confidentiality is also a big concern for the healthcare informatics as without that, the data can be used for any anti-social activities or unethical incidences. Need of It security is also an important factor as the access right need to be decided. It is important for the institution to decide the restriction of availability of the data and hence, there should be little mechanism to access and review the access request within the organization for patient as well as institution’s safety (Porter and Lee 2013).

The prime focus of this assignment is to find the risk and gaps associated with the healthcare informatics and set up objectives to do the same effectively. Further, the assignment will present some data and depending on that, it will analyze the findings and the future implications for that. Finally, the assignment will include some recommendations and suggestions to mend all the gaps present and use the informatics for the beneficiary of the patients

The prime objective of this assignment to find out the gaps present in the health informatics system throughout Bahrain. Further, the objective continues with the prime reasons for the gaps and the ways these organizations are following to mend the gap. To achieve this objective, the goals that need to be met are:

• Reveal the reasons behind the errors in healthcare management. The reason can be human error, software related, or legislation related.
• Identification and application of principles for the improvement in the healthcare informatics.
• Remove all the situations that influence the error and eliminate those using appropriate steps.
• Forcing the government to amend changes in the informatics system so that the hospital authority cannot use the data without the consent of the patient. Hence, implement the ethical consideration for the healthcare informatics is the final goal that will help to achieve the objectives for the assignment.

The data has been collected online so that all the staff can contribute to the survey as per their convenience and depending upon their own spare time. The reason of the online data collection was the complexity of the survey as well. The subject of the survey was related t their occupation and if they were not given with the luxury of response, the survey would have suffered. Therefore, this time and luxury of response was given to them. The survey was conducted into 5 major hospitals of Bahrain and their 40 staff, who take care of the healthcare information system. The reason for targeting this population within the organization was the prime focus of the topic. The topic was mainly based on the technical terms and knowledge therefore the population chosen for the survey was those technicians or officials, who deal with such system.

The researcher has targeted such population for the survey and created a 10-question questionnaire including four close-ended and six open ended question to find out the reason, impact and preventive measures of the errors in the healthcare informatics system. This online questionnaire was sent to 40 high authorities and staffs of the informatics departments of five top hospitals of the Bahrain. The findings are displayed in the tabular form prepared using the M.S. Excel sheets.

The first question was set to find out the age group working in the informatics departments of these hospitals. The Options were set according to the recruitment status of Bahrain in recent times.

Maximum of the respondents were of 35-45 age group and hence, bears experiences. The second majority was of age group 25 to 35 and they responded to the survey. However, despite of higher amount of elder higher authorities in those organizations, only 10 percent responded to the survey and the total response for the survey become 75 percent.

The second question was set to assess the experience of these staffs. According to the responses, maximum of the staff hat were working in the healthcare informatics system had 5 to ten years of experience. Only 10 percent of the total staffs of those five hospitals had 20 years of experience and hence, the changes of errors during uploading or editing data in the HIS s higher as they are new to the system.

The main reason for healthcare informatics system error was found to be the human factor as per the responses collected from the organizations. The response clearly indicates the human factor as the primary source of error and after that, the organizational error was the second most important factor. However, shockingly, only 20 percent responses indicated towards the technological errors and 13 percent indicated towards the framework related errors.

The next open-ended question was to identify the impact of the above-mentioned errors on the scope of practice of the healthcare professionals. The options provided to the respondents were related to their termination or penalties. The response collected from the survey supported legal consequences against the staff due to whom, the information system suffered. 23 percent supported overtime whereas 16 percent and 13 percent people supported suspension and monetary punishment respectively. However, only 6 percent employee supported termination of the accused staff.  

The sixth closed-ended question was to analyze the awareness of the management staff of the organizations. They question was set according to the norms of the closed ended question and the respondents were provided with five responses. Maximum of the respondents (40 percent) responded that the management of their healthcare facility was aware of the informatics errors that was happening. However, 26 percent contradicted the opinion and selected the option, which states that management is aware, but did not want to implement any changes. 13 percent believed that the management in snot aware and 20 percent selected neutral as their point of view.

The next closed-ended question was to assess the satisfaction level of the employees by the action their management took to stop the HIS related problems. The responses was divided into three categories. Maximum people were moderately satisfied or neutral with the steps the management was taking to remove the healthcare informatics system related errors. The second highest response was given to not satisfied option and 26.7 percent people were not satisfied with the actions of their management.

The next question was an open-ended question and the question was set to identify the steps that need to be taken according to the employees of those hospitals to minimize the HIS errors. Maximum of the respondents selected training, whereas application of new IT, legislation norm and compensation got 20, 16.7 and 10 percent respectively.

Further, the next closed-ended question was focused on the opinion of the employees about the theoretical and practice based models to lower the rate of error and for the betterment of the HIS. 47 percent people agreed to the fact, 33 percent people strongly agreed to the fact and 3.3 percent people disagreed to the fact.

The next question was put up to assess the responses of the employees about the removal of the contributing factors. Their response was restricted to four options. 33 percent employees responded that they agree to the fact about removal of the factors will help in improvement of the errors in the HIS facility. 30 percent people agreed to the abovementioned fact and 6.7 percent people disagreed to the fact.

The last question was about the most plausible method for the implementation of the best practice to use the HIS records. Maximum people responded to implement new IT act for the usage of the data. The second highest response was to the change in legislation option. 6.7 and 16.7 percent of respondents respectively responded seeking consent from the patient and the data restriction option.

There are very few instances, when the healthcare professional is accused of performing errors in the healthcare informatics and maximum of the errors occurs unconsciously. Therefore, the staffs are generally not agreeing to the fact that they have to bear the responsibility of the error occurring. However, due to the fact that maximum of the employees working in the organization did not had much experience about working with such technology, maximum of the employees of those five organizations opted for punishments such as monetary penalty, suspension and overtime. The survey also point out to the opinions of the working staff of healthcare informatics system of five different hospitals about the fact that the management not amending change policies. This is may be because of the higher cost of the systematic reform that they do not want to implement in their organization. Consequently, the response of the sixth question was given, as 27 percent of the employees were not satisfied with the actions the management took to decrease or remove the cases of errors in healthcare informatics. Response of the seventh question was very crucial, the staff responded to the question was inclusive of those people who made mistakes while using the informatics software. Hence, the response was of biggest concern as 46 percent of people demanded proper training for their improvement. The tenth question, which focused on the plausible method for change in the usage of HIS for betterment of the society and maximum of the respondents, responded to new IT law or reform in the existing IT laws. As the report mentioned earlier, reform in the It law is important, as determination of access is important to restrict the usage for unauthorized organizations. The analysis of these data are presented in the next section.

The rate of healthcare informatics system error is at higher level in Bahrain and the reason behind such error find to be the human error and organizational error. The human error can be f different type, such as lack of knowledge of the system or negligence at work. However, in both the conditions the consequences are to be suffered by the patient. The patient loss the faith in the healthcare system and the quality of the healthcare system is degraded.

It was found from the survey that maximum of the employees think that the human error can be removed by different interventions such as training and induction whereas organizational error can be removed by implementing newer and improved IT and legislative norms in the organization. They opted for legislative option for organizational error as they think that organization is not willing to change the full of error HIS in their organization. Hence, they are hopeful towards the government and legislation to implement new norms or laws through which the change in the healthcare informatics can be amended.

The survey also put forward the fact that majority of the elder staff working in the healthcare informatics system are not willing to share their positive and negative experiences with the newer staff. Therefore, the newer staff are not been able to learn the experiences of veterans, which can help them to gain knowledge. Healthcare informatics was evolved to benefit the patient’s by sharing their experiences to other organizations. However, violation of different ethical aspect of HIS such as privacy and confidentiality can lead to violation of ethical code of conduct. Physicians in this case, does not have as they can just provide the information to the health informatics staff to upload that in the system. Therefore, staffs such as ward boys, lab attendants, paramedical workers and others should not be accused of this course of action.

There are so many things that the stakeholders of healthcare informatics can learn from the findings of this study. First thing, that can be recommended to the staff handling the healthcare informatics will be availing proper training and knowledge about the information technology. Maximum of the staff handling the informatics were new in the survey and were unable to troubleshoot the system if any such situation arises. Therefore, guidance, training or induction will provide them with opportunities, which will help them to learn the informatics system clearly. The training will further allow them learn the tricks to troubleshoot if any problem occurs in the system. In the course, they should maintain a good communication skill with all their colleagues including senior workers. This practice will involve the seniors in the mainstream work and they will feel their importance in the organization. Thereby, the will teach all the newcomers with their experience to deal with any adverse situation while operating software.

The third recommendation is for the management system of the organizations that did not take proper action about errors in healthcare informatics system. The management should understand that according to the government every healthcare setting has to upload the correct data of each patient receiving care. This is for the betterment of the patient. If the patient wish to seek care from any other healthcare facility, he/she will be able to do that with the help of the details available I the cloud of healthcare information system.

Management should also make sure that there are sufficient equipment available for any situation. Further, there is enough role of the government and that cannot be neglected. Government is the prime stakeholder of this system as the complete HIS is reviewed and regulated by the government itself. Therefore, the government should track the system by keeping an eye on the status of the system. It should also guide or punish the organization as per the ethical code of conduct.

Reduction in the error of healthcare informatics system can lead to increase the quality healthcare and safety aspect in healthcare. It will further provide the framework and the assessment process and outcome will depend on it. This is because healthcare is a mixture of difficult technologies and human operators who deal with all those technologies to help the humankind. Efforts to reduce the level of errors during healthcare informatics should be proportional to their impact on outcome and the cost needed to prevent them.

References:

Andargoli, A.E., Scheepers, H., Rajendran, D. and Sohal, A., 2017. Health information systems evaluation frameworks: A systematic review. International journal of medical informatics, 97, pp.195-209.

Busse, H., Aboneh, E.A. and Tefera, G., 2014. Learning from developing countries in strengthening health systems: an evaluation of personal and professional impact among global health volunteers at Addis Ababa University’s Tikur Anbessa Specialized Hospital (Ethiopia). Globalization and health, 10(1), p.64.

Center for Disease Control and Prevention (2017). HAI Data and Statistics | HAI | CDC. [online] Cdc.gov. Available at: https://www.cdc.gov/hai/surveillance/index.html

Ferlay, J., Soerjomataram, I., Dikshit, R., Eser, S., Mathers, C., Rebelo, M., Parkin, D.M., Forman, D. and Bray, F., 2015. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International journal of cancer, 136(5).

Kehle-Forbes, S.M., Meis, L.A., Spoont, M.R. and Polusny, M.A., 2016. Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice, and Policy, 8(1), p.107.

Li, W., Zeng, S., Yu, L.S. and Zhou, Q., 2013. Pharmacokinetic drug interaction profile of omeprazole with adverse consequences and clinical risk management. Therapeutics and clinical risk management, 9, p.259.

Moore, L., Lavoie, A., Bourgeois, G. and Lapointe, J., 2015. Donabedian’s structure-process-outcome quality of care model: Validation in an integrated trauma system. Journal of Trauma and Acute Care Surgery, 78(6), pp.1168-1175.

Mosadeghrad, A.M., 2012. A conceptual framework for quality of care. Materia socio-medica, 24(4), p.251.

Porter, M.E. and Lee, T.H., 2013. The strategy that will fix health care. Harvard business review, 91(10), pp.1-19.

Rosenthal, V.D., Richtmann, R., Singh, S., Apisarnthanarak, A., Kübler, A., Viet-Hung, N., Ramírez-Wong, F.M., Portillo-Gallo, J.H., Toscani, J., Gikas, A. and Dueñas, L., 2013. Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005–2010. Infection Control & Hospital Epidemiology, 34(6), pp.597-604.

Shortliffe, E.H. and Cimino, J.J. eds., 2013. Biomedical informatics: computer applications in health care and biomedicine. Springer Science & Business Media. 

Wager, K.A., Lee, F.W. and Glaser, J.P., 2017. Health care information systems: a practical approach for health care management. John Wiley & Sons. 

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