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Journal of Patient Safety

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https://www.readbyqxmd.com/read/30020194/defining-patient-safety-events-in-inpatient-psychiatry
#1
Steven C Marcus, Richard C Hermann, Sara Wiesel Cullen
OBJECTIVES: The past 20 years have seen the emergence of a national movement to improve hospital-based healthcare safety in the United States. However, much of the foundational work and subsequent research have neglected inpatient psychiatry. The aim of this article was to advance a comprehensive approach for conceptualizing patient safety in inpatient psychiatry as framed by an application of the Institute of Medicine patient safety framework. METHODS: This article develops a framework for characterizing patient safety in hospital-based mental health care...
July 17, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29994819/how-to-identify-organizational-high-alert-medications
#2
Lotta Schepel, Lasse Lehtonen, Marja Airaksinen, Outi Lapatto-Reiniluoto
OBJECTIVES: High-alert medications may cause significant patient harm when used in error. Hospital-specific safety data should be used to customize high-alert medication lists to fit the local context. The aim of this study was to identify organizational high-alert medications by evaluating university hospital's data on adverse drug reaction (ADR) and medication error (ME). METHODS: The Anatomical Therapeutic Chemical (ATC) codes and top active substances in ADR (n = 401) and ME (n = 11,668) reports of Helsinki University Hospital from 2015-2016 were analyzed and compared with hospitals' drug consumption and the Institute for Safe Medication Practices' (ISMP) list of high-alert medications...
July 7, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29994818/preoperative-anticoagulation-management-in-everyday-clinical-practice-an-international-comparative-analysis-of-work-as-done-using-the-functional-resonance-analysis-method
#3
Nikki L Damen, Marit S de Vos, Marco J Moesker, Jeffrey Braithwaite, Rob A F de Lind van Wijngaarden, Jason Kaplan, Jaap F Hamming, Robyn Clay-Williams
OBJECTIVES: Preoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. METHODS: The study was conducted at an Australian and European Cardiothoracic Surgery Department...
July 7, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29994817/understanding-the-types-and-effects-of-clinical-interruptions-and-distractions-recorded-in-a-multihospital-patient-safety-reporting-system
#4
Kathryn M Kellogg, Joseph S Puthumana, Allan Fong, Katharine T Adams, Raj M Ratwani
OBJECTIVES: Interruptions and distractions have been shown to be a frequent occurrence across health care and have been linked to negative outcomes that create potential patient safety risks. Although observational studies have catalogued interruption frequency and source, the impact of an interruption is difficult to observe. We analyzed patient safety event (PSE) reports related to interruptions to identify clinical processes reported to be frequently interrupted and the reported outcomes of those interruptions...
July 7, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29985885/changes-in-patient-safety-culture-in-palestinian-public-hospitals-impact-of-quality-and-patient-safety-initiatives-and-programs
#5
Motasem Hamdan, Abed Alraʼoof Saleem
OBJECTIVES: To assess the changes in the patient safety culture between 2011 and 2016 after the implementation of patient safety initiative in Palestinian public hospitals. METHODS: A cross-sectional quantitative design employed using the Hospital Survey on Patient Safety Culture to collect data. Participants were 1,229 clinical and nonclinical employees from all public hospitals in the West Bank. RESULTS: Significant improvements were observed in patient safety culture with positive responses to 10 (83...
July 7, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29985887/criticality-of-maternal-complications-during-childbirths
#6
Jean Guglielminotti, Ruth Landau, Cynthia A Wong, Guohua Li
BACKGROUND: The incidence of severe maternal morbidity is increasing in the United Sates. To improve maternal outcomes, three maternal complications have been selected for priority intervention based on their proportionate mortality and preventability: obstetric hemorrhage, severe hypertension, and venous thromboembolism. This approach excludes complications that are not associated with high mortality but significantly contribute to maternal morbidity. The aim of this study was to provide an alternative ranking of maternal complications requiring interventions using cost-based criticality analysis...
June 28, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29985886/pressure-ulcer-rate-in-multidisciplinary-hospital-units-after-multifactorial-intervention-a-stepped-wedge-cluster-randomized-controlled-trial
#7
Mohamadreza Jafary, Hossin Adibi, Kamran Shayanfard, Mehri Zohdi, Zahra Godarzi, Mehdi Yaseri, Zhila Najafpour
OBJECTIVES: This study was conducted to measure the effectiveness of interventions in decreasing the rates of pressure ulcer in a general hospital setting. METHODS: Sixteen units in a general hospitals in Iran participated in this stepped-wedge, cluster randomized controlled trial during a 45-week study period. This trial has a one-sided crossover design from control to intervention. The units were randomly assigned fulfilling entry criteria. After the approval by the governing board of hospital, the manipulative intervention, in addition to usual care, was implemented on patients with a Braden criterion of 14 or less...
June 28, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29957680/encouraging-patients-to-speak-up-about-problems-in-cancer-care
#8
Kathleen M Mazor, Aruna Kamineni, Douglas W Roblin, Jane Anau, Brandi E Robinson, Benjamin Dunlap, Cassandra Firneno, Thomas H Gallagher
OBJECTIVES: Many patients with cancer believe that something has gone wrong in their care but are reluctant to speak up. This pilot study sought to evaluate the impact of an intervention of active outreach to patients undergoing cancer treatment, wherein patients were encouraged to speak up if they had concerns about their care and to describe the types of concerns patients reported. METHODS: Patients receiving cancer care at two sites were randomly assigned to an intervention or control group...
June 27, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29957679/the-psychiatry-morbidity-and-mortality-incident-reporting-tool-increases-psychiatrist-participation-in-reporting-adverse-events
#9
David S Kroll, Andrea D Shellman, David F Gitlin
OBJECTIVES: Although the reporting of adverse events (AEs) is widely thought to be a key first step to improving patient safety in hospital systems, underreporting remains a common problem, particularly among physicians. We aimed to increase the number of safety reports filed by psychiatrists in our hospital system. METHODS: We piloted an online survey for psychiatry-specific AE reporting, the Psychiatry Morbidity and Mortality Incident Reporting Tool (PMIRT) for a 1-year period...
June 27, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29944601/the-association-between-professional-burnout-and-engagement-with-patient-safety-culture-and-outcomes-a-systematic-review
#10
Sarah E Mossburg, Cheryl Dennison Himmelfarb
OBJECTIVES: In the last 20 years, there have been numerous successful efforts to improve patient safety, although recent research still shows a significant gap. Researchers have begun exploring the impact of individual level factors on patient safety culture and safety outcomes. This review examines the state of the science exploring the impact of professional burnout and engagement on patient safety culture and safety outcomes. METHODS: A systematic search was conducted in CINAHL, PubMed, and Embase...
June 25, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29913462/curriculum-development-and-implementation-of-a-national-interprofessional-fellowship-in-patient-safety
#11
Bradley V Watts, Linda Williams, Peter D Mills, Douglas E Paull, Jeffrey A Cully, Stuart C Gilman, Robin R Hemphill
OBJECTIVES: Developing a workforce skilled in improving the safety of medical care has often been cited as an important means to achieve safer care. Although some educational programs geared toward patient safety have been developed, few advanced training programs have been described in the literature. We describe the development of a patient safety fellowship program. METHODS: We describe the development and curriculum of an Interprofessional Fellowship in Patient Safety...
June 15, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29901654/patient-and-physician-experience-with-interhospital-transfer-a-qualitative-study
#12
Stephanie K Mueller, Evan Shannon, Anuj Dalal, Jeffrey L Schnipper, Patricia Dykes
OBJECTIVES: Although existing data suggest marked variability in interhospital transfer (IHT), little is known about specific factors that may impact the quality and safety of this care transition. We aimed to explore transferred patients' and involved physicians' experience with IHT to better understand the components of the transfer continuum and identify potential targets for improvement. METHODS: We performed a qualitative study using individual interviews of adult patients recently transferred to cardiology, general medicine, and oncology services at a tertiary care academic medical center, as well as their transferring physician, accepting attending physician, and accepting/admitting resident physician...
June 12, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29894440/psychometric-analysis-of-a-survey-on-patient-safety-culture-based-tool-for-emergency-medical-services
#13
Remle P Crowe, Rebecca E Cash, Alex Christgen, Tina Hilmas, Lee Varner, Amy Vogelsmeier, William S Gilmore, Ashish R Panchal
OBJECTIVE: Evaluating organizational safety culture is critical for high-stress, high-risk professions such as prehospital emergency medical services (EMS). The aim of the study was to evaluate the psychometric properties of a safety culture instrument for EMS, based on the Agency for Healthcare Research and Quality's widely used Surveys on Patient Safety Culture (SOPS). METHODS: The final EMS-adapted instrument consisted of 37 items covering 11 safety culture domains including 10 domains from existing SOPS instruments and one new domain for communication while en route to an emergency call...
June 11, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29894439/patient-safety-incidents-reported-by-the-general-public-in-korea-a-cross-sectional-study
#14
Minsu Ock, Min-Woo Jo, Eun Young Choi, Sang-Il Lee
OBJECTIVES: Previous studies have demonstrated that the general public can report various patient safety incidents (PSIs) that are not identified by other methods. In this study, we investigated the characteristics of PSIs that the general public experience in Korea. METHODS: In face-to-face surveys, participants were asked to report the frequency and type of PSIs, level of patient harm, and whether the PSIs were perceived as a medical error. We conducted logistic regression analysis to identify the sociodemographic factors of participants associated with their PSI experiences...
June 11, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29894438/look-alike-medication-packages-and-patient-safety
#15
Shih-Chieh Shao, Edward Chia-Cheng Lai, Kok Loon Owang, Hui-Yu Chen, Yuk-Ying Chan
Medication errors substantially threaten patient safety, and their prevention requires clinical vigilance. We present a case of taking the wrong drug due to a dispensing error by pharmacists involving medication packaging confusion, and we report how we prevent similar dispensing errors by thorough investigation and intervention. This case emphasizes the need for constant attention by hospital, medical industry, and regulatory authorities to avoid look-alike medication packaging in the interest of medication safety...
June 11, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29894437/-the-invisible-staff-a-qualitative-analysis-of-environmental-service-workers-perceptions-of-the-va-clostridium-difficile-prevention-bundle-using-a-human-factors-engineering-approach
#16
Eric Yanke, Helene Moriarty, Pascale Carayon, Nasia Safdar
OBJECTIVES: Using a novel human factors engineering approach, the Systems Engineering Initiative for Patient Safety model, we evaluated environmental service workers' (ESWs) perceptions of barriers and facilitators influencing adherence to the nationally mandated Department of Veterans Affairs Clostridium difficile infection (CDI) prevention bundle. METHODS: A focus group of ESWs was conducted. Qualitative analysis was performed employing a visual matrix display to identify barrier/facilitator themes related to Department of Veterans Affairs CDI bundle adherence using the Systems Engineering Initiative for Patient Safety work system as a framework...
June 11, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29878948/supporting-clinicians-after-adverse-events-development-of-a-clinician-peer-support-program
#17
Michael A Lane, Brianne M Newman, Mary Z Taylor, Meg OʼNeill, Chiara Ghetti, Robin M Woltman, Amy D Waterman
BACKGROUND: Many healthcare organizations have developed processes for supporting the emotional needs of patients and their families after medical errors or adverse events. However, the clinicians involved in such events may become "second victims" and frequently experience emotional harm that impacts their personal and professional lives. Many "second victims," particularly physicians, do not receive adequate support by their organizations. METHODS: A multidisciplinary team was assembled to create a clinician peer support program (PSP) at a large academic medical center including both adult and pediatric hospitals...
June 6, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29870516/multicenter-study-of-device-associated-infection-rates-bacterial-resistance-length-of-stay-and-mortality-in-intensive-care-units-of-2-cities-of-vietnam-international-nosocomial-infection-control-consortium-findings
#18
Nguyen Viet Hung, Phan Thi Hang, Victor D Rosenthal, Le Thi Anh Thu, Le Thi Thu Nguyet, Ngo Quy Chau, Truong Anh Thu, Dinh Pham Phuong Anh, Tran Thi My Hanh, Tran Thi Thuy Hang, Dang Thi Van Trang, Nguyen Phuc Tien, Vo Thi Hong Thoa, Đao Quang Minh
OBJECTIVE: The aim of the study was to report the results of the International Nosocomial Infection Control Consortium (INICC) study conducted from May 2008 to March 2015. METHODS: A device-associated healthcare-acquired infection surveillance study in three adult intensive care units (ICUs) and 1 neonatal ICU from 4 hospitals in Vietnam using U.S. the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC/NHSN) definitions and criteria as well as INICC methods...
June 4, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29870515/do-intensive-care-units-in-poland-need-recommendations-for-good-practice-in-labeling-intravenous-medicines
#19
Katarzyna Kwiecień-Jaguś, Wioletta Mędrzycka-Dąbrowska, Katarzyna Czyż-Szypenbeil, Katarzyna Lewandowska
No abstract text is available yet for this article.
June 4, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29870514/shared-leadership-in-healthcare-action-teams-a-systematic-review
#20
Sarah Janssens, Robert Simon, Michael Beckmann, Stuart Marshall
OBJECTIVES: The aims of this review were to consolidate the reported literature describing shared leadership in healthcare action teams (HCATs) and to review the reported outcomes related to leadership sharing in healthcare emergencies. METHODS: A systematic search of the English language literature before November 2017 was performed using PsycINFO, MEDLINE, PubMed, CINAHL, and EMBASE. Articles describing sharing of leadership functions in HCATs were included. Healthcare teams performing routine work were excluded...
June 4, 2018: Journal of Patient Safety
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