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Journal of Patient Safety

Ethan P Larsen, Ali Haskins Lisle, Bethany Law, Joseph L Gabbard, Brian M Kleiner, Raj M Ratwani
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...
February 9, 2019: Journal of Patient Safety
Kerm Henriksen, David Rodrick, Erin N Grace, Marjorie Shofer, P Jeffrey Brady
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...
February 9, 2019: Journal of Patient Safety
Antony N Thomas, Joanna E Balmforth
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...
February 9, 2019: Journal of Patient Safety
Emma D Quach, Lewis E Kazis, Shibei Zhao, Sarah McDannold, Valerie Clark, Christine W Hartmann
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...
February 9, 2019: Journal of Patient Safety
Kimberly G Blumenthal, Anna R Wolfson, Yu Li, Claire M Seguin, Neelam A Phadke, Aleena Banerji, Elizabeth Mort
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...
January 31, 2019: Journal of Patient Safety
Anne Lyren, Aaron Dawson, David Purcell, James M Hoffman, Lloyd Provost
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...
January 31, 2019: Journal of Patient Safety
Alok Kapoor, Valentina Landyn, Joann Wagner, Pamela Burgwinkle, Wei Huang, Joel Gore, Frederick A Spencer, Robert Goldberg, David D McManus, Chad Darling, Edwin Boudreaux, Bruce Barton, Kathleen M Mazor
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...
January 29, 2019: Journal of Patient Safety
Juan-Antonio Péculo-Carrasco, Mónica Rodríguez-Bouza, María-Del-Mar Casal-Sánchez, José-Manuel de-la-Fuente-Rodríguez, Antonio Puerta-Córdoba, Hugo-José Rodríguez-Ruiz, César-Pedro Sánchez-Almagro, Inmaculada Failde
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...
January 21, 2019: Journal of Patient Safety
Richard D Urman, Diane L Seger, Julie M Fiskio, Bridget A Neville, Elizabeth M Harry, Scott G Weiner, Belinda Lovelace, Randi Fain, Jessica Cirillo, Jeffrey L Schnipper
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...
January 21, 2019: Journal of Patient Safety
Yuanyuan Wang, Yanjun Fan, Xiaoli Wang, Yuanying Ma, Chunmei Wu, Huifeng Shi, Hui Han, Weiwei Liu, Chaojie Liu
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...
January 10, 2019: Journal of Patient Safety
Hyeon-Jeong Lee, Seung Gyeong Jang, Ji Eun Choi, Won Lee, Jeehee Pyo, Minsu Ock, Sang-Il Lee
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...
January 10, 2019: Journal of Patient Safety
Donald Scott David
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...
December 29, 2018: Journal of Patient Safety
Eileen T Lake, Kathryn E Roberts, Paula D Agosto, Elizabeth Ely, Amanda P Bettencourt, Elizabeth S Schierholz, Warren D Frankenberger, Gianluca Catania, Linda H Aiken
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...
December 28, 2018: Journal of Patient Safety
Angela D Thomas, Chinmay Pandit, Seth A Krevat
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)...
December 21, 2018: Journal of Patient Safety
Ahmed Abdulla, Kristen R Schell, Michael C Schell
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...
December 19, 2018: Journal of Patient Safety
Mary-Elizabeth Tumelty
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...
December 18, 2018: Journal of Patient Safety
Sarah C M Roberts, Nancy Beam, Guodong Liu, Ushma D Upadhyay, Douglas L Leslie, Djibril Ba, Jennifer L Kerns
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...
December 3, 2018: Journal of Patient Safety
Kang-Yu Hsu, Poching DeLaurentis, Yuval Bitan, Daniel D Degnan, Yuehwern Yih
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...
March 2019: Journal of Patient Safety
Anette Lampert, Jens Kessler, Phoebe Washington-Dorando, Hubert J Bardenheuer, Emilia M Bocek Eknes, Johannes Krisam, Walter E Haefeli, Hanna M Seidling
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)...
December 2018: Journal of Patient Safety
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December 2018: Journal of Patient Safety
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