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Journal of Patient Safety

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https://www.readbyqxmd.com/read/29166298/evaluation-of-a-broad-spectrum-partially-automated-adverse-event-surveillance-system-a-potential-tool-for-patient-safety-improvement-in-hospitals-with-limited-resources
#1
Melody Saikali, Alain Tanios, Antoine Saab
OBJECTIVE: The aim of the study was to evaluate the sensitivity and resource efficiency of a partially automated adverse event (AE) surveillance system for routine patient safety efforts in hospitals with limited resources. METHODS: Twenty-eight automated triggers from the hospital information system's clinical and administrative databases identified cases that were then filtered by exclusion criteria per trigger and then reviewed by an interdisciplinary team. The system, developed and implemented using in-house resources, was applied for 45 days of surveillance, for all hospital inpatient admissions (N = 1107)...
November 21, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29166297/assessing-patients-perceptions-of-safety-culture-in-the-hospital-setting-development-and-initial-evaluation-of-the-patients-perceptions-of-safety-culture-scale
#2
Clara Monaca, Beate Bestmann, Martina Kattein, Daria Langner, Hardy Müller, Tanja Manser
OBJECTIVES: Both, patient satisfaction and hospital safety culture have been recognized as key characteristics of healthcare quality and patient safety. Thus, both characteristics are measured widely to support quality and safety improvement efforts. However, because safety culture surveys focus exclusively on the perspective of hospital staff, the complimentary information to be gained from patients' perceptions of safety culture has received little research attention so far. We aimed to develop a measure explicitly focusing on patients' perceptions of safety culture in the hospital setting and perform an initial evaluation of its measurement properties...
November 21, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29140887/inconsistencies-between-two-cross-cultural-adaptations-of-the-hospital-survey-on-patient-safety-culture-into-french
#3
Bastien Boussat, Patrice François, Gérald Gandon, Joris Giai, Arnaud Seigneurin, Thomas Perneger, José Labarère
OBJECTIVES: Two cross-cultural adaptations of the 12-dimension Hospital Survey on Patient Safety Culture (HSOPSC) into French coexist: the Occelli and Vlayen versions. The objective of this study was to assess the psychometric properties of the Occelli version in comparison with those reported for the Vlayen and the original US versions of this instrument. METHODS: Using the original data from a cross-sectional study of 5,064 employees at a single university hospital in France, we examined the acceptability, internal consistency, factorial structure, and construct validity of the Occelli version of the HSOPSC...
November 15, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29140886/safety-of-venipuncture-sites-at-the-cubital-fossa-as-assessed-by-ultrasonography
#4
Kanae Mukai, Yukari Nakajima, Tomotaka Nakano, Manami Okuhira, Aya Kasashima, Rina Hayashi, Misaki Yamashita, Tamae Urai, Toshio Nakatani
OBJECTIVE: The aim of the present observational study was to identify safe and suitable venipuncture sites for nursing in the clinical setting using ultrasonography to measure the depth and cross-sectional area of each superficial vein before and after tourniquet application as well as the distance between each superficial vein and the median nerve or brachial artery. METHODS AND RESULTS: Twenty healthy volunteers (21.8 [0.6] y) were recruited. The visible rate of each superficial vein before and after tourniquet application was 65% for the basilic vein, 90% to 95% for the median cubital vein, and 65% to 80% for the cephalic vein...
November 15, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29116954/impact-of-an-original-methodological-tool-on-the-identification-of-corrective-and-preventive-actions-after-root-cause-analysis-of-adverse-events-in-health-care-facilities-results-of-a-randomized-controlled-trial
#5
Anthony Vacher, Sana El Mhamdi, Alain dʼHollander, Marion Izotte, Yves Auroy, Philippe Michel, Jean-Luc Quenon
OBJECTIVE: The aim of the study was to assess the effectiveness of a new methodological tool for the identification of corrective and preventive actions (CAPAs) after root cause analysis of health care-related adverse events. METHODS: From January to June 2010, we conducted a randomized controlled trial involving risk managers from 111 health care facilities of the Aquitaine Regional Center for Quality and Safety in Health Care (France). Fifty-six risk managers, randomly assigned to two groups (intervention and control), identified CAPAs in response to two sequentially presented adverse event scenarios...
November 8, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112035/how-can-safer-care-be-achieved-patient-safety-officers-perceptions-of-factors-influencing-patient-safety-in-sweden
#6
Mikaela Ridelberg, Kerstin Roback, Per Nilsen
OBJECTIVE: This study aimed to survey health care professionals in Sweden on the factors that they believe have been most important in reaching the current level of patient safety and achieving safer care in the future as well as the characteristics of the county councils that have been the most successful in achieving safe care. METHODS: The study population consisted of 222 patient safety officers, that is, health care professionals with strategic positions in patient safety work in the county councils...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112034/learning-from-incident-reporting-analysis-of-incidents-resulting-in-patient-injuries-in-a-web-based-system-in-swedish-health-care
#7
Eva-Lena Ahlberg, Johan Elfström, Madeleine Risberg Borgstedt, Annica Öhrn, Christer Andersson, Rune Sjödahl, Per Nilsen
OBJECTIVES: Incident reporting (IR) systems have the potential to improve patient safety if they enable learning from the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council. METHODS: The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112033/barriers-to-speaking-up-about-patient-safety-concerns
#8
Jason M Etchegaray, Madelene J Ottosen, Theresa Dancsak, Eric J Thomas
OBJECTIVES: We sought to examine the association between willingness of health-care professionals to speak up about patient safety concerns and their perceptions of two types of organizational culture (ie, safety and teamwork) and understand whether nursing professionals and other health-care professionals reported the same barriers to speaking up about patient safety concerns. METHODS: As part of an annual safety culture survey in a large health-care system, we asked health-care professionals to tell us about the main barriers that prevent them from speaking up about patient safety concerns...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112032/room-traffic-in-orthopedic-surgery-a-prospective-clinical-observational-study-of-time-of-day
#9
Priya G Patel, Alex C DiBartola, Laura S Phieffer, Thomas J Scharschmidt, Joel L Mayerson, Andrew H Glassman, Susan D Moffatt-Bruce, Carmen E Quatman
OBJECTIVE: High rates of operating room (OR) traffic may contribute to surgical air contamination and surgical site infections (SSIs). The purpose of this study was to evaluate room traffic patterns in orthopedic implant procedures to determine the frequency of door openings and if time of day had an effect on room traffic. METHODS: In 2015, OR traffic was assessed in orthopedic implant cases. Room traffic was reported as the number of door openings per minute. Counts of how many people were present in the operating room were noted in 5-minute intervals from the time of sterile case opening to dressing placement...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112031/how-differences-between-manager-and-clinician-perceptions-of-safety-culture-impact-hospital-processes-of-care
#10
Jason Richter, Olena Mazurenko, Abby Swanson Kazley, Eric W Ford
OBJECTIVE: Evidenced-based processes of care improve patient outcomes, yet universal compliance is lacking, and perceptions of the quality of care are highly variable. The purpose of this study is to examine how differences in clinician and management perceptions on teamwork and communication relate to adherence to hospital processes of care. METHODS: Hospitals submitted identifiable data for the 2012 Hospital Survey on Patient Safety Culture and the Centers for Medicare and Medicaid Services' Hospital Compare...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112030/nurses-views-highlight-a-need-for-the-systematic-development-of-patient-safety-culture-in-forensic-psychiatry-nursing
#11
Anssi Kuosmanen, Jari Tiihonen, Eila Repo-Tiihonen, Markku Eronen, Hannele Turunen
BACKGROUND: Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing. OBJECTIVES: The aim of this qualitative study was to describe nurses' views of patient safety culture in their working unit and daily hospital work in 2 forensic hospitals in Finland. METHODS: Data were collected over a period of 1 month by inviting nurses to answer an open-ended question in an anonymous Web-based questionnaire...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112029/identifying-risks-and-opportunities-in-outpatient-surgical-patient-safety-a-qualitative-analysis-of-veterans-health-administration-staff-perceptions
#12
Hillary J Mull, Amy K Rosen, Martin P Charns, Kamal M F Itani, Peter E Rivard
OBJECTIVES: Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112028/implementation-of-an-electronic-checklist-to-improve-patient-handover-from-ward-to-operating-room
#13
Kristine H Münter, Thea P Møller, Doris Østergaard, Lone Fuhrmann
OBJECTIVE: Research has identified numerous safety risks in perioperative patient handover. In handover from ward to operating room (OR), patients are often transferred by a third person. This adds to the risk of loss of important information and of caregivers in the OR not identifying possible risk factors. The aim of this study was to describe the implementation process and completion rate of a new preoperative, ward-to-OR checklist. Our goal was a 90% fulfillment. METHOD: This study is a prospective, observational study in a Danish University Hospital including all patients undergoing surgery in 2013...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112027/dentists-survey-on-adverse-events-during-their-clinical-training
#14
Alfredo Alan Osegueda-Espinosa, Leonor Sánchez-Pérez, Bernardo Perea-Pérez, Elena Labajo-González, A Enrique Acosta-Gio
BACKGROUND: Adverse events (AEs) begin challenging the safe practice of dentistry early when students start treating patients at dental school. We assessed the frequency with which dentists caused common AEs during their undergraduate clinical training. METHODS: A convenience sample of dentists, graduated from more than 34 dental schools in Mexico and other Spanish speaking countries, answered a confidential, self-administered questionnaire with closed-format questions on common AEs they caused and their active errors that could have led to AEs in the teaching clinics...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112026/nursing-home-patient-safety-culture-perceptions-among-us-and-immigrant-nurses
#15
Laura M Wagner, Barbara L Brush, Nicholas G Castle, John B Engberg, Elizabeth A Capezuti
Patient safety is a global concern, yet little is known about how and whether perceptions of patient safety culture (PSC) vary by nurses' countries of origin and preparation. This is particularly important in American nursing homes (NHs), which are increasingly hiring non-US born and prepared nurses to fill staffing needs. OBJECTIVES: This study compared the PSC perceptions of foreign and domestic born and trained nurses working in urban NHs in 5 states to analyze how nurses' PSC perceptions corresponded to their personal and professional characteristics...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112025/the-impact-of-adverse-events-on-clinicians-what-s-in-a-name
#16
Albert W Wu, Jo Shapiro, Reema Harrison, Susan D Scott, Cheryl Connors, Linda Kenney, Kris Vanhaecht
Unanticipated patient adverse events can also have a serious negative impact on clinicians. The term second victim was coined to highlight the experience of health professionals with these events and the need to effectively support them. However, there is some controversy over use of the term second victim. This article explores terminology used to describe the professionals involved in adverse events and services to support them. There is a concern that use of the term victim may connote passivity or stigmatize involved clinicians...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112024/evaluation-of-patient-safety-culture-in-community-pharmacies
#17
Ephrem A Aboneh, Jamie A Stone, Corey A Lester, Michelle A Chui
OBJECTIVE: Medication errors are common in community pharmacies. Safety culture is considered a factor for medication safety but has not been measured in this setting. The objectives of this study were to describe safety culture measured using the Agency for Healthcare Research and Quality (AHRQ) Community Pharmacy Survey on Patient Safety Culture and to assess predictors of overall patient safety. METHODS: This is a cross-sectional survey of community pharmacists practicing in Wisconsin measuring safety culture...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112023/behavior-of-anesthesiology-residents-in-a-situation-of-intravenous-route-occlusion-during-syringe-pump-use-in-a-simulated-intensive-care-unit
#18
Takayuki Kariya, Tetsuya Miyashita, Hitoshi Sato, Hiromasa Kawakami, Takahisa Goto
INTRODUCTION: Unintentional catecholamine flush caused by inappropriate release of an intravenous occlusion during use of a syringe pump in the intensive care unit (ICU) can have dangerous consequences in patients receiving critical care. We investigated whether anesthesiology residents understood how to deal with syringe pump occlusion in a simulated ICU setting. METHODS: We set up a mannequin that virtually simulated a sedated patient under mechanical ventilation after cardiac surgery, with epinephrine and dopamine being infused by syringe pumps to maintain blood pressure at 100/50 mm Hg...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29112022/handover-structure-and-quality-in-the-acute-medical-assessment-unit-a-prospective-observational-study
#19
Ineke van der Wulp, Else P Poot, Prabath W B Nanayakkara, Stephan A Loer, Cordula Wagner
OBJECTIVES: Inadequate patient handovers are associated with the occurrence of medical errors. The objective of the present study was to explore the structure and quality of handovers in the acute medical assessment unit. METHODS: A prospective observational study was conducted in an academic hospital in the Netherlands. Handover structure was observed by ordering handover information according to the elements of the Situation, Background, Assessment, Recommendation, and Read back (SBAR-R) handover tool...
November 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28376057/measurement-as-a-performance-driver-the-case-for-a-national-measurement-system-to-improve-patient-safety
#20
Thomas R Krause, Kristen J Bell, Peter Pronovost, Jason M Etchegaray
Safety metrics in healthcare settings stand apart from those in all other industries. Despite improvements in the measurement and prevention of adverse health outcomes following the 1999 Institute of Medicine report, no fully operational national-level program for monitoring patient harm exists. Here, we review the annual rate of fatal adverse events in healthcare settings in the United States on the basis of previous research, assess the current state of measurements of patient harm, propose a national standard to both quantify harm and act as a performance driver for improved safety, and discuss additional considerations such as accountability and implications for tort reform under this standard...
November 4, 2017: Journal of Patient Safety
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