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Journal of Patient Safety

William Martinez, James W Pichert, Gerald B Hickson, Casey H Braddy, Amy J Brown, Thomas F Catron, Ilene N Moore, Morgan R Stampfle, Lynn E Webb, William O Cooper
OBJECTIVES: The aims of the study were to develop a valid and reliable taxonomy of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals and determine the prevalence of reports describing particular types of unprofessional conduct. METHODS: We conducted qualitative content analysis of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals to create a standardized taxonomy...
March 15, 2018: Journal of Patient Safety
Sara L Ackerman, Gato Gourley, Gem Le, Pamela Williams, Jinoos Yazdany, Urmimala Sarkar
OBJECTIVE: The aim of the study was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. METHODS: Leaders from five California safety net health systems were invited to participate in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute in 2016. During each of the three Delphi rounds, the feasibility and validity of 13 proposed patient safety measures were discussed and prioritized...
March 14, 2018: Journal of Patient Safety
Kenzie A Cameron, Elaine R Cohen, Joelle R Hertz, Diane B Wayne, Debi Mitra, Jeffrey H Barsuk
OBJECTIVES: The aims of the study were to identify perceived barriers and facilitators to central venous catheter (CVC) insertion among healthcare providers and to understand the extent to which an existing Simulation-Based Mastery Learning (SBML) program may address barriers and leverage facilitators. METHODS: Providers participating in a CVC insertion SBML train-the-trainer program, in addition to intensive care unit nurse managers, were purposively sampled from Veterans Administration Medical Centers located in geographically diverse areas...
March 14, 2018: Journal of Patient Safety
Paul Abraham, Laurence Augey, Antoine Duclos, Philippe Michel, Vincent Piriou
INTRODUCTION: Patient misidentification continues to be an issue in everyday clinical practice and may be particularly harmful. Incident reporting systems (IRS) are thought to be cornerstones to enhance patient safety by promoting learning from failures and finding common root causes that can be corrected. The aim of this study was to describe common patient misidentification incidents and contributory factors related to perioperative care. DESIGN AND SETTINGS: We retrospectively analyzed IRS data reported by healthcare workers from a large academic hospital federation from 2011 to 2014...
March 9, 2018: Journal of Patient Safety
Asad A Khawaja, Dmitry Tumin, Ralph J Beltran, Joseph D Tobias, Joshua C Uffman
OBJECTIVES: General anesthesia or sedation can facilitate the completion of diagnostic radiological studies in children. We evaluated the incidence, predictors, and causes of adverse events (AEs) when general anesthesia is provided for diagnostic radiological imaging. METHODS: Deidentified data from 24 pediatric tertiary care hospitals participating in the Wake-Up Safe registry during 2010-2015 were obtained for analysis. Children 18 years or younger receiving general anesthesia for radiological procedures were identified using Current Procedural Terminology codes, and reported AEs were analyzed if they were associated with anesthetic care at magnetic resonance imaging or computed tomography locations...
March 8, 2018: Journal of Patient Safety
Linda Harrington
No abstract text is available yet for this article.
March 8, 2018: Journal of Patient Safety
Martina Buljac-Samardžić, Connie Dekker-van Doorn, Jeroen Van Wijngaarden
OBJECTIVES: Delivering health care is emotionally demanding. Emotional competencies that enable caregivers to identify and handle emotions may be important to deliver safe care, as it improves resilience and enables caregivers to make better decisions. A relevant emotional competence could be psychological detachment, which refers to the ability to psychologically detach from work and patients in off-duty hours. The objective of this study was to examine the relationship between psychological detachment and patient safety...
February 26, 2018: Journal of Patient Safety
Merrick Tan, Steven Lipman, Henry Lee, Lillian Sie, Brendan Carvalho
BACKGROUND: The impact of the electronic medical record (EMR) on nursing workload is not well understood. The objective of this descriptive study was to measure the actual and perceived time that nurses spend on the EMR in the operating room during cesarean births. METHODS: Twenty scheduled cesarean births were observed. An observer timed the circulating nurse's EMR use during each case. Immediately after each case, the nurse completed a questionnaire to estimate EMR time allocation during the case and their desired time allocation for a typical case...
February 26, 2018: Journal of Patient Safety
Stephen M Campbell, Brian G Bell, Kate Marsden, Rachel Spencer, Umesh Kadam, Katherine Perryman, Sarah Rodgers, Ian Litchfield, David Reeves, Antony Chuter, Lucy Doos, Ignacio Ricci-Cabello, Paramjit Gill, Aneez Esmail, Sheila Greenfield, Sarah Slight, Karen Middleton, Jane Barnett, Michael Moore, Jose M Valderas, Aziz Sheikh, Anthony J Avery
OBJECTIVE: Major gaps remain in our understanding of primary care patient safety. We describe a toolkit for measuring patient safety in family practices. METHODS: Six tools were used in 46 practices. These tools were as follows: National Health Service Education for Scotland Trigger Tool, National Health Service Education for Scotland Medicines Reconciliation Tool, Primary Care Safequest, Prescribing Safety Indicators, Patient Reported Experiences and Outcomes of Safety in Primary Care, and Concise Safe Systems Checklist...
February 15, 2018: Journal of Patient Safety
Eun-Mi Kim, Sun-Aee Kim, Ju-Ry Lee, Jonathan D Burlison, Eui Geum Oh
OBJECTIVES: "Second victims" are defined as healthcare professionals whose wellness is influenced by adverse clinical events. The Second Victim Experience and Support Tool (SVEST) was used to measure the second-victim experience and quality of support resources. Although the reliability and validity of the original SVEST have been validated, those for the Korean tool have not been validated. The aim of the study was to evaluate the psychometric properties of the Korean version of the SVEST...
February 13, 2018: Journal of Patient Safety
Leila Cherara, Gary L Sculli, Douglas E Paull, Lisa Mazzia, Julia Neily, Peter D Mills
OBJECTIVES: The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS: The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken...
February 13, 2018: Journal of Patient Safety
Mher Barbarian, Andrea Bishop, Patricia Alfaro, Alain Biron, Daniel Adam Brody, Gabrielle Cunningham-Allard, Alexander Sasha Dubrovsky
INTRODUCTION: Although the Child Hospital Consumer Assessment of Healthcare Providers and Systems is a validated tool for the inpatient experience, it may not address features unique to the pediatric emergency department (PED). There is currently no publicly available validated patient-reported experience survey for the PED, and what matters most in this setting remains unknown. METHODS: Twelve semistructured interviews were conducted with a convenience sample of parents of children younger than 14 years at a Canadian PED...
February 9, 2018: Journal of Patient Safety
Tom Basson, Alfred Montoya, Julia Neily, Lisa Harmon, Bradley V Watts
OBJECTIVE: The aim of the study was to improve the safety culture at a Veterans Administration hospital using evidence-based approaches. METHODS: We implemented a patient safety summit with follow-up actions. We measured safety climate before and after the summit using the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture with modifications and the Safety Attitudes Questionnaire (SAQ). The summit brought hospital leaders together to discuss patient safety topics and relate them to our hospital...
February 9, 2018: Journal of Patient Safety
Julia Kopanz, Katharina M Lichtenegger, Gerald Sendlhofer, Barbara Semlitsch, Gerald Cuder, Andreas Pak, Thomas R Pieber, Christa Tax, Gernot Brunner, Johannes Plank
OBJECTIVES: Insulin charts represent a key component in the inpatient glycemic management process. The aim was to evaluate the quality of structure, documentation, and treatment of diabetic inpatient care to design a new standardized insulin chart for a large university hospital setting. METHODS: Historically grown blank insulin charts in use at 39 general wards were collected and evaluated for quality structure features. Documentation and treatment quality were evaluated in a consecutive snapshot audit of filled-in charts...
February 9, 2018: Journal of Patient Safety
Christine Sammer, Loran D Hauck, Cason Jones, Julie Zaiback-Aldinger, Michael Li, David Classen
BACKGROUND: In 2015, the Institute of Medicine Vital Signs report called for a new patient safety composite measure to lessen the reporting burden of patient harm. Before this report, two patient safety organizations had developed an electronic all-cause harm measurement system leveraging data from the electronic health record, which identified and grouped harms into five broad categories and consolidated them into one all-cause harm outcome measure. OBJECTIVES: The objective of this study was to examine the relationship between this all-cause harm patient safety measure and the following three performance measures important to overall hospital safety performance: safety culture, employee engagement, and patient experience...
February 7, 2018: Journal of Patient Safety
Saul N Weingart, Coral L Atoria, David Pfister, David Classen, Aileen Killen, Elizabeth Fortier, Andrew S Epstein, Christopher Anderson, Allison Lipitz-Snyderman
OBJECTIVE: The aim of the study was to identify risk factors associated with medical errors and iatrogenic injuries during an initial course of cancer-directed treatment. METHODS: In this retrospective cohort study of 400 patients 18 years or older undergoing an initial course of treatment for breast, colorectal, or lung cancer at a comprehensive cancer center, we abstracted patient, disease, and treatment-related variables from the electronic medical record. We examined adverse events (AEs) and preventable AEs by risk factor using the χ or Fisher exact tests...
February 6, 2018: Journal of Patient Safety
Melissa Desmedt, Jochen Bergs, Benjamin Willaert, Ward Schrooten, Annemie Vlayen, Johan Hellings, Neree Claes, Dominique Vandijck
OBJECTIVES: The primary aim was to measure patient safety culture in two home care services in Belgium (Flanders). In addition, variability based on respondents' profession was examined. METHODS: A cross-sectional study was conducted by administering the SCOPE-Primary Care questionnaire in two home care service organizations. RESULTS: In total, 1875 valid questionnaires were returned from 2930 employees, representing a response rate of 64%...
February 1, 2018: Journal of Patient Safety
Cornel Schiess, David Schwappach, René Schwendimann, Kris Vanhaecht, Melanie Burgstaller, Beate Senn
BACKGROUND: "Second victims" are healthcare professionals traumatized by involvement in significant adverse events. Associated burdens, e.g., guilt, can impair professional performance, thereby endangering patient safety. To date, however, a model of second victims' experiences toward a deeper understanding of qualitative studies is missing. Therefore, we aimed to identify, describe, and interpret these experiences in acute-somatic inpatient settings. METHODS: This qualitative metasynthesis reflects a systematic literature search of PubMed, CINAHL, and PsycINFO, extended by hand searches and expert consultations...
January 30, 2018: Journal of Patient Safety
Maartje Kletter, G J Mendelez-Torres, Richard Lilford, Celia Taylor
OBJECTIVES: We aimed to create a library of logic models for interventions to reduce diagnostic error. This library can be used by those developing, implementing, or evaluating an intervention to improve patient care, to understand what needs to happen, and in what order, if the intervention is to be effective. METHODS: To create the library, we modified an existing method for generating logic models. The following five ordered activities to include in each model were defined: preintervention; implementation of the intervention; postimplementation, but before the immediate outcome can occur; the immediate outcome (usually behavior change); and postimmediate outcome, but before a reduction in diagnostic errors can occur...
January 24, 2018: Journal of Patient Safety
Enihomo Obadan-Udoh, Sophy Van der Berg-Cloete, Rachel Ramoni, Elsbeth Kalenderian, John George White
OBJECTIVES: In recent years, there has been an increase in research studies highlighting patients' experiences of adverse events (AEs) as well as the role of patients in promoting safety. The primary goal of the study was to assess the prevalence of dental AEs (DAEs) among dental patients in South Africa and its associated factors. The integration of the patient perspective into dental patient safety research will enhance our collective understanding of DAEs. METHODS: We conducted a cross-sectional study of adult patients at a large dental academic institution in South Africa from May to June 2015, evaluating their previous experiences of DAEs at any dental clinic in South Africa...
January 23, 2018: Journal of Patient Safety
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