Journal of Patient Safety

BACKGROUND: Medical errors are responsible for a large number of deaths every year in the Unites States. Hospitals use various strategies including leadership, staffing, and structural changes to deal with this concerning issue. Hospital physician integration is a structural strategy to possibly improve patient safety. Using the conceptual lens of Donabedian's Structure Process Outcome model, this study aims to investigate how hospital physician integration affects organizational, management, and communication attributes of patient safety culture...

OBJECTIVE: Healthcare workers involved in, and negatively affected by, patient safety incidents are referred to as second victims. The Second Victim Experience and Support Tool-Revised (SVEST-R) can reveal the second victim's degree of negative experiences and the desirability of the support options. However, a Japanese version of the SVEST-R (J-SVESTR) has not yet been developed. This study aimed to translate and adapt the SVEST-R into Japanese and validate its psychometric properties...

OBJECTIVES: The objective of this study was to determine the incidence and types of adverse events (AEs), including preventable and ameliorable AEs, in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs. METHODS: This was a prospective cohort study of patients at risk for AEs in 2 urban academic hospitals from August 2020 to January 2022. Eighty-one eligible patients who were being admitted to any internal medicine or hospitalist service were recruited from the ED of these hospitals by a trained nurse...

No abstract text is available yet for this article.

OBJECTIVES: One in 20 outpatients in the United States experiences a diagnostic error each year, but there are no validated methods for collecting feedback from patients on diagnostic safety. We examined patient experience surveys to determine whether patients' free text comments indicated diagnostic breakdowns. Our objective was to evaluate associations between patient-perceived diagnostic breakdowns reported in free text comments and patients' responses to structured survey questions...

BACKGROUND: The COVID-19 pandemic introduced unique challenges to healthcare systems, particularly in relation to patient safety and adverse events during hospitalization. There is limited understanding of COVID-19's association with some patient safety indicators (PSIs). OBJECTIVES: This study aimed to investigate the impact of COVID-19 infection on the rate of PSI-3 events and its implications on quality metrics. We compared PSI-3 event rates between COVID-19-infected and uninfected patients and examined the clinical characteristics of COVID-19 patients experiencing PSI-3 events...

BACKGROUND: Diagnostic errors are a global patient safety challenge. Over 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures. OBJECTIVES: The goal of the scoping review was to identify, summarize, and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process...

OBJECTIVE: The aim of the study is to understand whether the risk factors of the unplanned extubation (UE) of nasogastric (NG) tubes vary among different inpatient situations. METHODS: Inpatients who experienced UE between 2009 and 2022 at a medical center were selected, and electronic medical records were used to collect patient background data and their conditions during UE. A total of 302 patients were included in our analysis. RESULTS: Conscious patients were at greater risk of UE when coughing, scratching their nose, blowing their nose, or sneezing than those who were confused (odds ratio [OR] = 0...

BACKGROUND: Emergency and urgent care settings face challenges with routinely obtaining performance feedback related to diagnostic care. Patients and their care partners provide an important perspective on the diagnostic process and outcome of care in these settings. We sought to develop and test psychometric properties of Patient-Report to IMprove Diagnostic Excellence in Emergency Department settings (PRIME-ED), a measure of patient-reported diagnostic excellence in these care settings...

PURPOSE: The aim of the study is to identify the most common avoidable patient injuries related to hallux valgus surgery. METHODS: We assessed the claims reported to the Norwegian System of Patient Injury Compensation (NPE) following surgery for hallux valgus in light of hospital volume. Data from NPE was categorized according to age, sex, reason for claim, and reason for accepted/rejected claim. The institutions were grouped by catchment population into low volume (<150,000), middle volume (150,000-300,000), and high volume (>300,000) institutions...

OBJECTIVES: Hospital-based behavioral emergency response teams (BERT) respond to acute behavioral disturbances among hospitalized patients. We aimed to examine associations between altered mental status in postanesthesia care unit (PACU) and behavioral disturbances on surgical wards requiring BERT activation. METHODS: Electronic medical records of patients who underwent general anesthesia and were admitted to the PACU between May 2018-December 2020 were reviewed for episodes of BERT activations on surgical wards...

OBJECTIVE: The purpose of this study was to further the understanding of reported patient safety events at the interface between hospital and care home including what active failings and latent conditions were present and how reporting helped learning. METHODS: Two care home organizations, one in the North East and one in the South West of England, participated in the study. Reports relating to a transition and where a patient safety event had occurred were sought during the COVID-19 (SARS-CoV-2) virus prepandemic and intrapandemic periods...

OBJECTIVES: The aims of the study are to investigate differences in rates of adverse safety events between nonelderly adult patients with Medicaid and those with private insurance and to assess whether differences are driven by differences in access to quality hospitals or differences in the quality of care delivered within hospitals. DATA SOURCE: Inpatient records from 26 states in 2017 were collected from the Agency for Health Care Research and Quality's Hospital Cost and Utilization Project...

AIMS: This study aimed to examine the relationship between work environment and missed nursing care (MNC) in nurses and determine whether profession self-efficacy has a moderator role in this relationship. DESIGN: A quantitative, cross-sectional, correlational study design was used to test the study model. METHODS: The study was conducted with 433 nurses in 2 city hospitals in Istanbul, Turkey. Data were collected between November 2022 and February 2023 using the "MISSCARE Survey-Turkish," the "Work Environment Scale," and the "Nursing Profession Self-Efficacy Scale...

OBJECTIVE: Conduct systematic proactive pharmacovigilance screening for symptoms patients experienced after starting new medications using an electronic patient portal. We aimed to design and test the feasibility of the system, measure patient response rates, provide any needed support for patients experiencing potentially drug-related problems, and describe types of symptoms and problems patients report. METHODS: We created an automated daily report of all new prescriptions, excluding likely non-new and various OTC meds, and sent invitations via patient portal inviting patients to inquire if they had started the medication, and if "yes," inquire if they had they experienced any new symptoms that could be potential adverse drug effects...

BACKGROUND: Disclosure of patient safety incidents (DPSIs) is a strategic measure to reduce the problems of patient safety incidents (PSIs). However, there are currently limited studies on the effects of DPSIs on resolving diagnosis-related PSIs. Therefore, this study aimed to estimate the effects of DPSIs using hypothetical cases, particularly in diagnosis-related PSIs. METHODS: A survey using 2 hypothetical cases of diagnosis-related PSIs was conducted in 5 districts of Ulsan Metropolitan City, Korea, from March 18 to 21, 2021...

No abstract text is available yet for this article.

OBJECTIVE: The aim of the study is to determine diagnostic traction for shoulder dystocia and to assess whether applied traction is modifiable with force training. METHODS: We tethered a force-measuring fetal mannequin (PROMPT, Limbs & Things) within a simulated pelvis such that it would not deliver. We asked participants to apply traction to diagnose shoulder dystocia then stop. Blinded from participants' view, we recorded the peak traction. We then asked them to apply what they perceived to be 20 lb (89 N) traction...

OBJECTIVES: Dutch hospitals are required to screen older patients for functional decline using 4 indicators: malnutrition, delirium, physical impairment, and falls, to recognize frail older patients promptly. The Functional Resonance Analysis Method was employed to deepen the understanding of work according to the protocols (work-as-imagined [WAI]) in contrast to the realities of daily practice (work-as-done [WAD]). METHODS: Data have been collected from 3 hospitals (2 tertiary and 1 general) and 4 different wards: an internal medicine ward, surgical ward, neurology ward, and a trauma geriatric ward...

Hospital-acquired conditions in the United States are considered avoidable complications but remain common statistics reflecting on health system performance and are a leading cause of patient fatality. Currently, over 3.7 million patients experience a hospital-acquired condition in the United States each year, which costs the U.S. healthcare delivery system an excess of $48 billion. Evidence-based clinical practice guidelines for common hospital-acquired conditions (e.g., infections, falls, pressure injuries) to reduce risk to the patient...