Journal of Patient Safety

OBJECTIVE: Design criteria specifications (needs, obstacles, and context-of-use considerations) for continuing safe and efficient patient care activities during downtime were identified by using phenomenological analysis. METHODS: Interview transcripts from medical personnel who had experience with downtime incidents were examined using a phenomenological approach. This process allowed for the identification of design criteria for performing downtime patient care activities...

OBJECTIVES: Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. The article describes a grant initiative undertaken by the Agency for of Healthcare Research and Quality that brings these disciplines together to test new ideas that could make health care safer...

AIM: The aim of the study was to review reported falls in critical care units to see whether the causes and results were different from those described in a general hospital population. METHODS: We reviewed and classified patient safety incidents describing falls from critical care units in the North West of England between 2009 and 2017. The classification reviewed patient and staff factors contributing to the fall, the environment of the fall, and the reported consequences...

OBJECTIVES: Improving nursing home safety is important to the quality of resident care. Increasing evidence points to the relationship between actual safety and a strong safety climate, i.e., staff agreement about safety norms. This national study focused on Veterans Health Administration nursing homes (Community Living Centers [CLCs]), assessing direct care staff and senior managers' agreement about safety norms. METHODS: We recruited all 134 CLCs to participate in the previously validated CLC Employee Survey of Attitudes about Resident Safety...

BACKGROUND: The epidemiology of hospital adverse reactions (ARs), particularly allergic reactions, or hypersensitivity reactions (HSRs), is poorly defined. To determine priorities for allergy safety in healthcare, we identified and described safety reports of allergic reactions. METHODS: We searched the safety report database of a large academic medical center from April 2006 to March 2016 using 101 complete, truncated, and/or misspelled key words related to allergic symptoms, treatments, and culprits (e...

OBJECTIVE: Multihospital collaboration for safety improvements is increasingly common, but strategies for developing bundles when effective evidence-based practices are not well described are limited. The Children's Hospitals' Solutions for Patient Safety (SPS) Network sought to further reduce patient harm by developing improvement bundles when preliminary evidence was limited. METHODS: As part of the novel Pioneer process, cohorts of volunteer SPS hospitals collaborated to identify a harm reduction bundle for carefully selected hospital-acquired harm categories where evidence-based practices were limited...

OBJECTIVE: The aim of the study was to assess the feasibility, satisfaction, and effectiveness of a care transition intervention with pharmacist home visit and subsequent anticoagulation expert consultation for patients with new episode of venous thromboembolism within a not-for-profit health care network. METHODS: We randomized patients to the intervention or control. During the home visit, a clinical pharmacist assessed medication management proficiency, asked open-ended questions to discuss knowledge gaps, and distributed illustrated medication instructions...

OBJECTIVE: The aim of the study was to design and validate a new tool to measure the security perceived by witnesses of patient care and hospital transfers, after requesting urgent assistance via the "061" phone number. METHODS: This is a descriptive observational, cross-sectional, design, and validation study of a scale conducted by telephone interview. Witnesses of urgent assistance and transfers by prehospital emergency medical services in the province of Cadiz, in the south of Spain, were the subjects of study...

OBJECTIVE: Opioid analgesics are a mainstay for acute pain management, but postoperative opioid administration has risks. We examined the prevalence, risk factors, and consequences of opioid-related adverse drug events (ORADEs) in a previously opioid-free surgical population. METHODS: A retrospective, observational, cohort study using administrative, billing, clinical, and medication administration data from two hospitals. Data were collected for all adult patients who were opioid-free at admission, underwent surgery between October 1, 2015, and September 30, 2016, and received postoperative opioids...

OBJECTIVES: The aim of this study was to assess patient safety culture (PSC) in maternal and child health (MCH) institutions in China and its individual, organizational, and regional variations. METHODS: Using the PSC survey for MCH institutions (PSCS-MCHI), 2021 valid respondents from 25 participating institutions were investigated in three regions (Beijing, Zhejiang, and Jiangxi) of China. Patient safety culture and its subscale scores (1-5) and factors associated with PSC as revealed by multilevel modeling...

OBJECTIVES: This study conducted a survey to examine how the general public in Korea perceives patient engagement for patient safety and to identify vulnerable groups and contents priorities of patient engagement education for the general public. METHODS: We developed a questionnaire based on previous studies and conducted one-on-one interviews with 600 individuals from the public. Then, we conducted descriptive statistical analyses (i.e., frequency, percentage, and averages) on the questionnaire items...

OBJECTIVE: This study aimed to determine whether there was an association between the organizational culture and the hospital's readiness to benefit from "Just Culture" training. METHODS: The "Just Culture" Assessment Tool and the Competing Values Framework surveys were administered before and 6 weeks after a structured "Just Culture" training session to 172 care providers and administrators on similar units at two community for-profit hospitals of compatible size and offering comparable services in suburban communities...

OBJECTIVES: Eighteen years ago, the Institute of Medicine estimated that medical errors in hospital were a major cause of mortality. Since that time, reducing patient harm and improving the culture of patient safety have been national health care priorities. The study objectives were to describe the current state of patient safety in pediatric acute care settings and to assess whether modifiable features of organizations are associated with better safety culture. METHODS: An observational cross-sectional study used 2015-2016 survey data on 177 hospitals in four U...

OBJECTIVES: The aim of the study was to determine whether race differences exist in voluntarily reported harmful patient safety events in a large 10 hospital healthcare system on a high reliability organization journey. METHODS: From July 1, 2015, to June 30, 2017, employees in a healthcare system based in Washington, District of Columbia, and Maryland voluntarily reported harmful patient safety events by type using a Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified as "black," "white," or "other" (N = 5038)...

OBJECTIVES: All organizations seek to minimize the risks that their operations pose to public safety. This task is especially significant if they deal with complex or hazardous technologies. Five decades of research in quantitative risk analysis have generated a set of risk management frameworks and practices that extend across a range of such domains. Here, we investigate the risk culture in three commercial enterprises that require exceedingly high standards of execution: radiation oncology, aviation, and nuclear power...

OBJECTIVES: The term "second victim" was seminally coined by Wu, in recognition of the profound and long-lasting impact adverse events and medical errors may have on medical practitioners. Since the conception of this vocable over a decade ago, the term second victim has been internationally accepted and is widely used in discussion of this important topic. Notwithstanding its widespread use, controversy surrounds the term second victim in light of the traditional connotations with the word "victim...

OBJECTIVE: The aim of the study was to examine whether miscarriage treatment-related morbidities and adverse events vary across facility types. METHODS: A retrospective cohort study compared miscarriage treatment-related morbidities and adverse events across hospitals, ambulatory surgery centers (ASCs), and office-based settings. Data on women who had miscarriage treatment between 2011 and 2014 and were continuously enrolled in their insurance plan for at least 1 year before and at least 6 weeks after treatment were obtained from a large national private insurance claims database...

OBJECTIVE: Our previous study showed that the issue of drug library update delays on wireless intravenous (IV) infusion pumps of one major vendor was widespread and significant. However, the impact of such a delay was unclear. The objective of this study was to quantify the impact of pump library update delays on patient safety in terms of missed and false infusion programming alerts. METHODS: The study data sets included infusion logs and drug libraries from three hospitals of one health system from January 2015 to December 2016...

BACKGROUND: Although problems during transdermal patch administration are primarily caused by insufficient knowledge, patient education programs are lacking. We compared patient education by a clinical pharmacist on knowledge on correct patch administration with routine counseling during patient-physician consultation in a pilot study. METHODS: After baseline assessment of knowledge and difficulties with patch administration, patients in the outpatient pain clinic of Heidelberg University Hospital were allocated to intervention (n = 12) or control group (n = 11)...

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