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Journal of Patient Safety

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https://www.readbyqxmd.com/read/29346176/rapid-response-to-scan-or-not-to-scan-the-utility-of-noncontrast-ct-head-for-altered-mental-status
#1
Purujit J Thacker, Mansha Sethi, Jonathan Sternlieb, Doron Schneider, Mary Naglak, Rajeshkumar R Patel
OBJECTIVES: The aims of the study were the following: (1) to determine how often computed tomography (CT) scans of the head are obtained on rapid responses called for altered mental status (AMS), (2) to determine whether CT imaging of the head is required during all rapid responses called for AMS, (3) to determine which patients would benefit from CT scans of the head in this setting, (4) to note whether an adequate neurologic exam was documented, (5) to determine the cost of CT scans that did not change management, and (6) to examine the role of medications leading to AMS...
January 17, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29346175/long-term-impacts-faced-by-patients-and-families-after-harmful-healthcare-events
#2
Madelene J Ottosen, Emily W Sedlock, Aitebureme O Aigbe, Sigall K Bell, Thomas H Gallagher, Eric J Thomas
BACKGROUND: Patients and families report experiencing a multitude of harms from medical errors resulting in physical, emotional, and financial hardships. Little is known about the duration and nature of these harms and the type of support needed to promote patient and family healing after such events. We sought to describe the long-term impacts (LTIs) reported by patients and family members who experienced harmful medical events 5 or more years ago. METHODS: We performed a content analysis on 32 interviews originally conducted with 72 patients or family members about their views of the factors contributing to their self-reported harmful event...
January 17, 2018: Journal of Patient Safety
https://www.readbyqxmd.com/read/29283910/involvement-in-root-cause-analysis-and-patient-safety-culture-among-hospital-care-providers
#3
Bastien Boussat, Arnaud Seigneurin, Joris Giai, Kevin Kamalanavin, José Labarère, Patrice François
BACKGROUND: The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. OBJECTIVE: The aim of the study was to determine whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities. METHODS: Using the original data from a cross-sectional survey of 5064 employees at a single university hospital in France, we analyzed the differences in HSOPS dimension scores according involvement in EFC activities...
December 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29278578/situation-dependent-medical-device-risk-estimation-design-and-evaluation-of-an-equipment-management-center-for-vendor-independent-integrated-operating-rooms
#4
Marianne Maktabi, Thomas Neumuth
OBJECTIVES: The complexity of surgical interventions and the number of technologies involved are constantly rising. Hospital staff has to learn how to handle new medical devices efficiently. However, if medical device-related incidents occur, the patient treatment is delayed. Patient safety could therefore be supported by an optimized assistance system that helps improve the management of technical equipment by nonmedical hospital staff. METHODS: We developed a system for the optimal monitoring of networked medical device activity and maintenance requirements, which works in conjunction with a vendor-independent integrated operating room and an accurate surgical intervention Time And Resource Management System...
December 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29252968/application-of-a-healthcare-failure-modes-and-effects-analysis-to-identify-and-mitigate-potential-risks-in-the-implementation-of-a-national-prehospital-pediatric-rapid-sequence-intubation-program
#5
Ian Howard, Nicholas Castle, Loua Asad Al Shaikh
INTRODUCTION: Rapid sequence intubation (RSI) has become the de facto airway method of choice in the emergency airway management of adult and pediatric patients. There is significant controversy regarding pediatric RSI in the prehospital setting, given not only the complexities inherent in both the procedure and patient population, but in variations in emergency medical service models, prehospital qualifications, scope of practice, and patient exposure too. METHODS: A Healthcare Failure Mode and Effects Analysis was conducted to identify and mitigate potential hazards in the national implementation of a prehospital pediatric RSI program...
December 15, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29252967/evaluation-of-the-effects-of-radio-frequency-identification-technology-on-patient-tracking-in-hospitals-a-systematic-review
#6
Fahimeh Ebrahimzadeh, Ehsan Nabovati, Mohammad Reza Hasibian, Saeid Eslami
OBJECTIVE: The aim of this study was to systematically review all studies that evaluated the effects of using radio-frequency identification (RFID) for tracking patients in hospitals. METHODS: The PubMed and Embase databases were searched (to August 2015) for relevant English language studies, and those that evaluated the effects of a real-time locating systems with RFID for patient tracking in hospitals were identified and extracted. RESULTS: Of the 652 studies found, the 17 relevant studies were extracted for inclusion...
December 15, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29252966/patient-safety-in-hospitals-what-we-do-and-what-we-need-focus-groups-with-stakeholders-of-hospitals-in-southern-germany
#7
Julia Dinius, Rainer Gaupp, Sonja Becker, Anja S Göritz, Mirjam Körner
OBJECTIVES: To provide the basis for designing an interprofessional patient safety training for medical treatment teams, the current situation regarding patient safety and existing training programs in southern German hospitals should be explored. Moreover, need-based content regarding the subject areas teamwork, safety culture, and patient involvement should be derived, a conducive learning format suggested, and wishes and concerns regarding the training explored. METHODS: Qualitative design (focus groups) in five hospitals with different levels of care involving a total of 39 members of interprofessional teams, administration, and quality management team...
December 15, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29232260/high-alert-medication-stratification-tool-revised-an-exploratory-study-of-an-objective-standardized-medication-safety-tool
#8
Natalie C Washburn, Heather A Dossett, Andrew C Fritschle, Kerri E Degenkolb, Monica R Macik, Todd A Walroth
OBJECTIVE: To develop an objective tool designed to standardize the identification of high-alert medications (HAMs) according to patient safety risk. METHODS: Medications were evaluated using the High-Alert Medication Stratification Tool (HAMST). Tool revision occurred through assessing medications on an organization-approved HAM list and comparing scores with control medications not included on the list. Because of variations in HAMST interpretation by end users in interdisciplinary committees, a revision of the scoring tool was completed to create the High-Alert Medication Stratification Tool-Revised (HAMST-R), and the assessment was repeated...
December 12, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29206706/quantifying-dental-office-originating-adverse-events-the-dental-practice-study-methods
#9
Oluwabunmi Tokede, Muhammad Walji, Rachel Ramoni, Donald B Rindal, Donald Worley, Nutan Hebballi, Krishna Kumar, Claire van Strien, Mengxia Chen, Shaked Navat-Pelli, Hongchun Liu, Jini Etolue, Alfa Yansane, Enihomo Obadan-Udoh, Casey Easterday, Chris Enstad, Sheryl Kane, William Rush, Elsbeth Kalenderian
BACKGROUND: Preventable medical errors in hospital settings are the third leading cause of deaths in the United States. However, less is known about harm that occurs in patients in outpatient settings, where the majority of care is delivered. We do not know the likelihood that a patient sitting in a dentist chair will experience harm. Additionally, we do not know if patients of certain race, age, sex, or socioeconomic status disproportionately experience iatrogenic harm. METHODS: We initiated the Dental Practice Study (DPS) with the aim of determining the frequency and types of adverse events (AEs) that occur in dentistry on the basis of retrospective chart audit...
December 5, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29206705/institution-of-just-culture-physician-peer-review-in-an-academic-medical-center
#10
Judith K Volkar, Paul Phrampus, Dennis English, Ronald Johnson, Ashley Medeiros, Mark Zacharia, Richard Beigi
OBJECTIVES: For academic medical centers to improve quality outcomes, identification and optimization of opportunities for improvement are necessary. Effective clinical peer review frequently has limitations on timeliness, transparency, and consideration of system processes related to untoward clinical outcomes. We developed a process to overcome these barriers and capture opportunities for process improvement identified within the clinical peer review system. METHODS: A multidisciplinary committee was formed to evaluate the current process of physician peer review at Magee Womens Hospital of the University of Pittsburgh Medical Center...
December 5, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29200092/practical-considerations-in-use-of-trigger-tool-methodology-in-the-emergency-department
#11
Richard T Griffey, Ryan M Schneider, Brian R Sharp, Marie C Vrablik, Lee Adler
No abstract text is available yet for this article.
December 1, 2017: Journal of Patient Safety
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
#12
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
#13
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/29189440/patient-safety-activity-under-the-social-insurance-medical-fee-schedule-in-japan-an-overview-of-the-2010-nationwide-survey
#14
Masahiro Hirose, Toshihiko Kawamura, Mikio Igawa, Yuichi Imanaka
OBJECTIVES: Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the patient safety performance status at hospitals implementing the PPSCF. METHODS: A nationwide questionnaire survey targeting 2674 hospitals with the PPSCF was performed in 2010 to 2011...
November 16, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29189439/leading-causes-of-anesthesia-related-liability-claims-in-ambulatory-surgery-centers
#15
Darrell Ranum, Anair Beverly, Fred E Shapiro, Richard D Urman
OBJECTIVE: We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs). METHODS: We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value...
November 16, 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
#16
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
#17
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
#18
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
#19
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
#20
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
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