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Journal of Patient Safety

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https://www.readbyqxmd.com/read/28731933/continuous-capnography-reduces-the-incidence-of-opioid-induced-respiratory-rescue-by-hospital-rapid-resuscitation-team
#1
Mindy Stites, Jennifer Surprise, Jennifer McNiel, David Northrop, Martin De Ruyter
OBJECTIVE: The aim of this study was to determine the impact of end tidal carbon dioxide or capnography monitoring in patients requiring patient-controlled analgesia (PCA) on the incidence of opioid-induced respiratory depression (OIRD) in the setting of rapid response. METHODS: A retrospective analysis was conducted in an urban tertiary care facility on the incidence of OIRD in the setting of rapid response as defined by a positive response to naloxone from January 2012 to December 2015...
July 20, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28731932/investing-in-physicians-is-investing-in-patients-enhancing-patient-safety-through-physician-health-and-well-being-research
#2
Elizabeth Brooks, Doris C Gundersen, Michael H Gendel
Keeping medical practitioners healthy is an important consideration for workforce satisfaction and retention, as well as public safety. However, there is limited evidence demonstrating how to best care for this group. The absence of data is related to the lack of available funding in this area of research. Supporting investigations that examine physician health often "fall through the cracks" of traditional funding opportunities, landing somewhere between patient safety and workforce development priorities...
July 20, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28708671/a-systematic-review-of-primary-care-safety-climate-survey-instruments-their-origins-psychometric-properties-quality-and-usage
#3
Ciara Curran, Sinéad Lydon, Maureen Kelly, Andrew Murphy, Chloe Walsh, Paul OʼConnor
IMPORTANCE: Safety climate (SC) measurement is a common and feasible method of proactive safety assessment in primary care. However, there is no consensus on which instrument is "best" to use. OBJECTIVE: The aim of the study was to identify the origins, psychometric properties, quality, and SC domains measured by survey instruments used to assess SC in primary care settings. DATA SOURCES: Systematic searches were conducted using Medline, Embase, CINAHL, and PsycInfo in February 2016...
July 13, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28691973/a-swift-method-for-handing-off-obstetrical-patients-on-the-labor-floor
#4
Jean-Ju Sheen, Laura Reimers, Shravya Govindappagari, Ivan M Ngai, Diana Garretto, Roopali Donepudi, Pamela Tropper, Dena Goffman, Ashlesha K Dayal, Peter S Bernstein
OBJECTIVE: The aim of this study was to improve patient handoffs on the labor floor. METHODS: A prospective cohort study of obstetrics residents at Montefiore Medical Center was performed between 2012 and 2014. Labor-floor handoffs were recorded before and after didactic sessions as well as after installation of whiteboards formatted with the mnemonic SWIFT (Subject, Why?, Issues, Fetus, Tasks). Handoff transcripts were evaluated by obstetricians blinded to timing and speaker identity...
July 6, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28691972/changing-the-patient-safety-paradigm
#5
Jennifer P Stevens, Retsef Levi, Kenneth Sands
No abstract text is available yet for this article.
July 6, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28678115/a-theoretical-model-of-flow-disruptions-for-the-anesthesia-team-during-cardiovascular-surgery
#6
Albert Boquet, Tara Cohen, Fawaaz Diljohn, Jennifer Cabrera, Scott Reeves, Scott Shappell
OBJECTIVES: This investigation explores flow disruptions observed during cardiothoracic surgery and how they serve to disconnect anesthesia providers from their primary task. We can improve our understanding of this disengagement by exploring what we call the error space or the accumulated time required to resolve disruptions. METHODS: Trained human factors students observed 10 cardiac procedures for disruptions impacting the anesthesia team and recorded the time required to resolve these events...
July 3, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671915/classifying-adverse-events-in-the-dental-office
#7
Elsbeth Kalenderian, Enihomo Obadan-Udoh, Peter Maramaldi, Jini Etolue, Alfa Yansane, Denice Stewart, Joel White, Ram Vaderhobli, Karla Kent, Nutan B Hebballi, Veronique Delattre, Maria Kahn, Oluwabunmi Tokede, Rachel B Ramoni, Muhammad F Walji
BACKGROUND: Dentists strive to provide safe and effective oral healthcare. However, some patients may encounter an adverse event (AE) defined as "unnecessary harm due to dental treatment." In this research, we propose and evaluate two systems for categorizing the type and severity of AEs encountered at the dental office. METHODS: Several existing medical AE type and severity classification systems were reviewed and adapted for dentistry. Using data collected in previous work, two initial dental AE type and severity classification systems were developed...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671914/assessment-of-automating-safety-surveillance-from-electronic-health-records-analysis-for-the-quality-and-safety-review-system
#8
Allan Fong, Katharine Adams, Anita Samarth, Laura McQueen, Manan Trivedi, Tahleah Chappel, Erin Grace, Susan Terrillion, Raj M Ratwani
BACKGROUND AND OBJECTIVES: In an effort to improve and standardize the collection of adverse event data, the Agency for Healthcare Research and Quality is developing and testing a patient safety surveillance system called the Quality and Safety Review System (QSRS). Its current abstraction from medical records is through manual human coders, taking an average of 75 minutes to complete the review and abstraction tasks for one patient record. With many healthcare systems across the country adopting electronic health record (EHR) technology, there is tremendous potential for more efficient abstraction by automatically populating QSRS...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671913/the-consequences-of-whistle-blowing-an-integrative-review
#9
Charmaine R Lim, Melvyn W B Zhang, Syeda F Hussain, Roger C M Ho
BACKGROUND: Whistle-blowing provides an avenue for healthcare workers to express their concerns when there is a breach of patients' safety. Most healthcare organizations have policies in place to prevent reprisals on whistle-blowers. Despite these protective measures, whistle-blowing often leads to negative consequences. METHODS: A search of articles on whistle-blowing was conducted on MEDLINE (PubMed). Articles were included if they described the consequences of whistle-blowing in the following 3 areas: medical, nursing, and research/pharmaceutical research (Fig...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671912/errors-during-resuscitation-the-impact-of-perceived-authority-on-delivery-of-care
#10
Nicole Jane Delaloye, Kathy Tobler, Thomas OʼNeill, Afrothite Kotsakis, Jessica Cooper, Ilana Bank, Elaine Gilfoyle
OBJECTIVE: The aim of this study was to determine the influence of perceived authority on pediatric resuscitation teams' response to an incorrect order given by a medical superior. METHODS: As part of a larger multicenter prospective interventional study, interprofessional pediatric resuscitation teams (n = 48) participated in a video-recorded simulated resuscitation scenario with an infant in unstable, refractory supraventricular tachycardia. A confederate actor playing a senior physician entered the scenario partway through and ordered the incorrect dose and delivery method of the antiarrhythmic, procainamide...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671911/burnout-and-work-engagement-among-us-dentists
#11
Jean Marie Calvo, Japneet Kwatra, Alfa Yansane, Oluwabunmi Tokede, Ronald C Gorter, Elsbeth Kalenderian
BACKGROUND: Burnout is a threat to patient safety. It relates to emotional exhaustion, depersonalization, and lack of personal accomplishment. Work engagement conversely composed of levels of vigor, dedication, and absorption in one's profession. The aim of this study was to examine burnout and work engagement among US dentists. METHODS: This study used the extensively validated Maslach Burnout Inventory-Human Services Survey and Utrecht Work Engagement Scale to measure burnout in a self-administered survey of 167 US dentists who attended continuing education courses held in Boston, Pittsburg, Iowa City, and Las Vegas...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671910/changes-to-hospital-inpatient-volume-after-newspaper-reporting-of-medical-errors
#12
Haruhisa Fukuda
OBJECTIVE: The aim of this study was to investigate the influence of medical error case reporting by national newspapers on inpatient volume at acute care hospitals. DESIGN: A case-control study was conducted using the article databases of 3 major Japanese newspapers with nationwide circulation between fiscal years 2012 and 2013. Data on inpatient volume at acute care hospitals were obtained from a Japanese government survey between fiscal years 2011 and 2014. Panel data were constructed and analyzed using a difference-in-differences design...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671909/effectiveness-of-pharmacist-intervention-to-reduce-medication-errors-and-health-care-resources-utilization-after-transitions-of-care-a-meta-analysis-of-randomized-controlled-trials
#13
Gildasio S De Oliveira, Lucas J Castro-Alves, Mark C Kendall, Robert McCarthy
OBJECTIVES: Medication errors are common during transitions of care. The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition of care interventions on the reduction of medication errors after hospital discharge. METHODS: A systematic search was conducted to detect published reports of randomized trials using the National Library of Medicine's PubMed database, the Cochrane Database of Systematic Reviews, and Google Scholar inclusive to July 1, 2015...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671908/development-of-the-barriers-to-error-disclosure-assessment-tool
#14
Darlene Welsh, Dominique Zephyr, Andrea L Pfeifle, Douglas E Carr, Joseph L Fink, Mandy Jones
OBJECTIVES: An interprofessional group of health colleges' faculty created and piloted the Barriers to Error Disclosure Assessment tool as an instrument to measure barriers to medical error disclosure among health care providers. METHODS: A review of the literature guided the creation of items describing influences on the decision to disclose a medical error. Local and national experts in error disclosure used a modified Delphi process to gain consensus on the items included in the pilot...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671907/communication-training-adverse-events-and-quality-measures-2-retrospective-database-analyses-in-washington-state-hospitals
#15
Ian R Slade, Sara J Beck, C Bradley Kramer, Rebecca G Symons, Michael Cusumano, David R Flum, Thomas H Gallagher, Emily Beth Devine
OBJECTIVE: Washington State's HealthPact program was launched in 2011 as part of AHRQ's Patient Safety and Medical Liability Reform initiative. HealthPact delivered interdisciplinary communication training to health-care professionals with the goal of enhancing safety. We conducted 2 exploratory, retrospective database analyses to investigate training impact on the frequency of adverse events (AEs) and select quality measures across 3 time frames: pretraining (2009-2011), transition (2012), and posttraining (2013)...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671906/does-one-size-fit-all-assessing-the-need-for-organizational-second-victim-support-programs
#16
Hanan H Edrees, Albert W Wu
OBJECTIVE: Second victims are health care providers who are emotionally traumatized after experiencing an unanticipated patient's adverse event. To support second victims, organizations can provide a dedicated support program for their workers. The aim of this study was to assess the extent of the second victim problem in acute care hospitals in the state of Maryland, the availability of emotional support services, and the need for organizational support programs. METHODS: In-depth, semistructured interviews were conducted with 43 patient safety representatives from 38 acute hospitals in Maryland...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28671905/the-impact-of-incident-disclosure-behaviors-on-medical-malpractice-claims
#17
Priscila Giraldo, Luke Sato, Xavier Castells
OBJECTIVES: To provide preliminary estimates of incident disclosure behaviors on medical malpractice claims. METHODS: We conducted a descriptive analysis of data on medical malpractice claims obtained from the Controlled Risk Insurance Company and Risk Management Foundation of Harvard Medical Institutions (Cambridge, Massachusetts) between 2012 and 2013 (n = 434). The characteristics of disclosure and apology after medical errors were analyzed. RESULTS: Of 434 medical malpractice claims, 4...
June 30, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28665834/a-prospective-assessment-of-adverse-events-in-3-digestive-surgery-departments-from-central-tunisia
#18
Mondher Letaief, Sana El Mhamdi, Sameen Siddiqi, Rached Letaief, Abdelwaheb Morjane, Abdelaziz Hamdi
OBJECTIVE: The aim of the study was to prospectively assess the incidence, the preventability, and the factors contributing to adverse events (AEs) in surgical departments of Tunisian hospitals. METHODS: A prospective longitudinal study evaluated the incidence of AEs in surgical departments of three university hospitals in central Tunisia. The study followed 1687 admitted patients until their discharge from the hospitals based on a standard two-stage method that first included staff interviews and review of medical records based on 18 criteria and later was followed by an expert review to confirm or reject the presence of an AE...
June 29, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28665833/why-an-open-disclosure-procedure-is-and-is-not-followed-after-an-avoidable-adverse-event
#19
Irene Carrillo, José Joaquín Mira, Mercedes Guilabert, Susana Lorenzo
OBJECTIVE: The aim of the study was to analyze the relationships between factors that contribute to healthcare professionals informing and apologizing to a patient after an avoidable adverse event (AAE). METHODS: A secondary study based on the analysis of data collected in a cross-sectional study conducted in 2014 in Spain was performed. Health professionals from hospitals and primary care completed an online survey. RESULTS: The responses from 1087 front-line healthcare professionals were analyzed...
June 29, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28662001/drug-related-problems-identified-at-patients-home-a-prospective-observational-study-in-a-rural-area-of-thailand
#20
Chuenjid Kongkaew, Janthima Methaneethorn, Pajaree Mongkhon, Supinya Dechanont, Watcharaporn Taburee
OBJECTIVE: The aim of the study was to examine the prevalence rates, nature, and predictors of drug-related problems (DRPs) experienced in participants living at home in a rural Thailand. METHOD: A cross-sectional observational study was undertaken during December 2015 to January 2016. Drug-related problems were identified within a rural township having a population of 5256 by means of home visits by pharmacists. All suspected cases were then assessed for severity and preventability by clinical specialists...
June 29, 2017: Journal of Patient Safety
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