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Journal of Patient Safety

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https://www.readbyqxmd.com/read/28098586/comparing-the-outcomes-of-reporting-and-trigger-tool-methods-to-capture-adverse-events-in-the-emergency-department
#1
Wen-Huei Lee, Ewai Zhang, Charng-Yen Chiang, Yung-Lin Yen, Ling-Ling Chen, Mei-Hsiu Liu, Chia-Te Kung, Shih-Chiang Hung
BACKGROUND: Little is known about which methods are best for detecting adverse events in the emergency department (ED). OBJECTIVES: This study compared the ability of trigger tool and reporting methods to capture adverse events in the ED and investigated the characteristics of the adverse events identified by each. METHODS: This 1-year prospective observational cohort study evaluated a monitoring system that combined 2 reporting methods and 5 trigger tool methods to capture adverse events in the ED of an academic medical center...
January 16, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28098585/the-missing-record-of-mental-status-in-written-sign-outs
#2
Michael Croix, Donna Miller, Jeff Whittle, Siddhartha Singh, Marilyn M Schapira, Jennifer Carnahan, Jessica Kuester, Christa Kallio, Susan Framberg, Kathlyn E Fletcher
OBJECTIVE: The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians. PATIENTS AND METHODS: This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers...
January 16, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28079641/world-health-organization-framework-multimodal-hand-hygiene-strategy-in-piedmont-italy-health-care-facilities
#3
Fabrizio Bert, Sebastian Giacomelli, Daniela Ceresetti, Carla Maria Zotti
OBJECTIVES: In 2009, the World Health Organization (WHO) introduced the "Hand Hygiene Self-Assessment Framework" (HHSAF) to evaluate the level of the application of the Multimodal Hand Hygiene Improvement Strategy (MHHIS), which defines preventive interventions, standards, and tools conceived to improve hand hygiene in healthcare facilities. The aim of our study was to evaluate the implementation of the MHHIS in Piedmont healthcare units in 2014 using the HHSAF document. METHODS: Our surveillance was performed through collection and analysis of the data from 50 Piedmont healthcare facilities recorded through the HHSAF in 2014...
January 10, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28072614/cell-phone-calls-in-the-operating-theater-and-staff-distractions-an-observational-study
#4
Alexander Avidan, Galel Yacobi, Charles Weissman, Phillip D Levin
OBJECTIVES: Cell phones are the primary communication tool in our institution. There are no restrictions on their use in the operating rooms. The goal of this study was to evaluate the extent of cell phone use in the operating rooms during elective surgery and to evaluate whether they cause staff distractions. METHODS: The following data on cell phone use were recorded anonymously: number of incoming and outgoing cell phone calls, duration of cell phone calls and their content (patient related, work related, private), who was distracted by the cell phone calls, and duration of distractions...
January 9, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28045859/data-collection-for-adverse-events-reporting-by-us-dental-schools
#5
Deborah Rooney, Kimberly Barrett, Blake Bufford, Alexandra Hylen, Matthew Loomis, Joshua Smith, Angela Svaan, Harold M Pinsky, Domenica Sweier
OBJECTIVES: Accreditation of US dental schools requires a formal system of quality assessment of clinical adverse events (AE). There is no universal system to collect, record, interpret, or release findings or trends pertaining to AEs. The objective of this study was to compare similarities and differences among the AE reporting forms used at US dental schools. METHODS: Sixteen (24%) dental schools responded to a query to provide copies of their AE forms. The forms were analyzed to identify unique AE items...
December 30, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/28009601/separate-medication-preparation-rooms-reduce-interruptions-and-medication-errors-in-the-hospital-setting-a-prospective-observational-study
#6
Saskia Huckels-Baumgart, André Baumgart, Ute Buschmann, Guido Schüpfer, Tanja Manser
BACKGROUND: Interruptions and errors during the medication process are common, but published literature shows no evidence supporting whether separate medication rooms are an effective single intervention in reducing interruptions and errors during medication preparation in hospitals. We tested the hypothesis that the rate of interruptions and reported medication errors would decrease as a result of the introduction of separate medication rooms. AIM: Our aim was to evaluate the effect of separate medication rooms on interruptions during medication preparation and on self-reported medication error rates...
December 21, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/28009600/the-detection-analysis-and-significance-of-physician-clustering-in-medical-malpractice-lawsuit-payouts
#7
Robert E Oshel, Philip Levitt
OBJECTIVES: There is evidence that most adverse events result from individual errors and that most malpractice suits with payouts reflect both patient injury and error. HYPOTHESIS: There are outlier physicians with regard to the frequency and total amount of malpractice payouts. METHODS: Using the public use file of the National Practitioner Data Bank (NPDB), we sought the percentage of physicians who lay above several cutoff points with regard to total amounts of payments and number of payments...
December 21, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27997457/outcomes-from-the-first-6-years-of-operation-of-the-central-portugal-pharmacovigilance-unit
#8
Francisco Batel-Marques, Ana Penedones, Diogo Mendes, Carlos Alves
OBJECTIVES: The aim of this study was to analyze and characterize the outcomes of the Central Portugal Regional Pharmacovigilance Unit over a 6-year period. METHODS: Spontaneous reports received between January 2009 and December 2014 were considered. The annual reporting ratios were estimated. The cases were characterized according to their seriousness, previous description, causality assessment, reporting professional, pharmacotherapeutic groups of the suspected drugs, and type of adverse drug reactions most frequently reported...
December 16, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27984440/evaluation-of-a-program-for-improving-advanced-imaging-interpretation
#9
Adam C Powell, James W Long, Erin M Kren, Amit K Gupta, David C Levin
OBJECTIVES: Self-referred imaging has grown rapidly, raising concerns about increased costs and compromised quality of care. A quality improvement program using imaging interpretation criteria was designed by a national payer to ensure that noninvasive diagnostic images are interpreted by appropriately trained physicians. The objective of this program evaluation was to compare self-referral rates before and after institution of the imaging interpretation criteria program. METHODS: The imaging interpretation criteria program allocated privileges to bill for advanced imaging interpretation according to physician specialty...
December 14, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27922906/patient-outcomes-after-early-versus-late-tracheostomy-in-the-puerto-rico-trauma-hospital
#10
Ana M Romero Vázquez, Omar García Rodríguez, Ediel Ramos Meléndez, Pablo Rodríguez Ortiz
OBJECTIVE: This study aimed to evaluate the impact of early tracheostomy (ET, ≤7 days) versus that of late tracheostomy (LT, >7 days) on outcomes such as hospital length of stay (LOS), intensive care unit (ICU) days, mechanical ventilation (MV) days, and mortality ratio. METHODS: A historical cohort study was undertaken using charts of patients admitted to the Puerto Rico Trauma Hospital who required MV and underwent tracheostomies, from 2000 to 2013. A logistic regression was performed to evaluate the association between timing of tracheostomy and complications and mortality...
December 5, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27906817/classifying-patients-complaints-for-regulatory-purposes-a-pilot-study
#11
Renée Bouwman, Manja Bomhoff, Paul Robben, Roland Friele
OBJECTIVES: It is assumed that classifying and aggregated reporting of patients' complaints by regulators helps to identify problem areas, to respond better to patients and increase public accountability. This pilot study addresses what a classification of complaints in a regulatory setting contributes to the various goals. METHODS: A taxonomy with a clinical, management, and relationship domain was used to systematically analyze 364 patients' complaints received by the Dutch regulator...
November 30, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27820722/a-multilevel-analysis-of-u-s-hospital-patient-safety-culture-relationships-with-perceptions-of-voluntary-event-reporting
#12
Jonathan D Burlison, Rebecca R Quillivan, Lisa M Kath, Yinmei Zhou, Sam C Courtney, Cheng Cheng, James M Hoffman
OBJECTIVES: Patient safety events offer opportunities to improve patient care, but, unfortunately, events often go unreported. Although some barriers to event reporting can be reduced with electronic reporting systems, insight on organizational and cultural factors that influence reporting frequency may help hospitals increase reporting rates and improve patient safety. The purpose of this study was to evaluate the associations between dimensions of patient safety culture and perceived reporting practices of safety events of varying severity...
November 3, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811599/physician-perspectives-on-interhospital-transfers
#13
Stephanie K Mueller, Jeffrey L Schnipper
OBJECTIVE: The transfer of patients between acute care hospitals (interhospital transfer [IHT]) is a common but nonstandardized process leading to variable quality and safety. The goal of this study was to survey accepting physicians regarding problems encountered in the transfer process. METHODS: A cross-sectional survey of residents and inpatient attendings from internal medicine, neurology, and surgery services at a large tertiary care referral hospital was undertaken to identify problematic aspects of the IHT process as perceived by accepting frontline providers...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811598/a-patient-reported-approach-to-identify-medical-errors-and-improve-patient-safety-in-the-emergency-department
#14
Seth W Glickman, Abhi Mehrotra, Christopher M Shea, Celeste Mayer, Jeffrey Strickler, Sandra Pabers, James Larson, Brian Goldstein, Larry Mandelkehr, Charles B Cairns, Jesse M Pines, Kevin A Schulman
OBJECTIVE: Medical errors in the emergency department (ED) occur frequently. Yet, common adverse event detection methods, such as voluntary reporting, miss 90% of adverse events. Our objective was to demonstrate the use of patient-reported data in the ED to assess patient safety, including medical errors. METHODS: Analysis of patient-reported survey data collected over a 1-year period in a large, academic emergency department. All patients who provided a valid e-mail or cell phone number received a brief electronic survey within 24 hours of their ED encounter by e-mail or text message with Web link...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811597/predictors-of-at-home-arterial-oxygen-desaturation-events-in-ambulatory-surgical-patients
#15
Chuck Biddle, Charles Elam, Laura Lahaye, Gordon Kerr, Laura Chubb, Brad Verhulst
OBJECTIVES: Little is known about the early recovery phase occurring at-home after anesthesia and surgery in ambulatory surgical patients. We studied quantitative oximetry and quality-of-life metrics in the first 48 hours after same-day orthopedic surgery examining the association between the recovery metrics and specific patient and procedural factors. METHODS: We used the STOP-Bang score to quantify patient risk for obstructive sleep apnea in 50 adult patients at 2 centers using continuous portable oximetry and patient journaling...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811596/qualitative-study-about-the-experiences-of-colleagues-of-health-professionals-involved-in-an-adverse-event
#16
Lena Ferrús, Carmen Silvestre, Guadalupe Olivera, José Joaquín Mira
OBJECTIVES: Identify what occurs among health-care providers (HCPs) after an adverse event (AE) and what colleagues could do to help them. METHOD: A qualitative study with participation by physicians and nurses from hospitals and primary care facilities. RESULTS: Fifteen HCPs and 12 health professionals with quality management responsibilities with between 8 and 30 years of experience participated; 15 (56%) were physicians (9 general practitioners, 3 surgeons, 2 intensivists, and 1 from an emergency unit), and 12 (44%) were nurses (5 worked in primary care and 7 in hospitals)...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811595/objective-assessment-of-checklist-fidelity-using-digital-audio-recording-and-a-standardized-scoring-system-audit
#17
Douglas Salgado, Kimberly R Barber, Michael Danic
OBJECTIVES: The use of the World Health Organization Surgical Safety Checklist (SSC) has been reported to significantly reduce operative morbidity and mortality rates. Recent findings have cast doubt on the efficacy of such checklists in improving patient safety. The effectiveness of surgical safety checklists cannot be fully measured or understood without an accurate assessment of implementation fidelity, most effectively through direct observations of the checklist process. Here, we describe the use of a secure audio recording protocol in conjunction with a novel standardized scoring system to assess checklist compliance rates...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811594/effect-of-implementing-a-standardized-shoulder-dystocia-documentation-form-on-quality-of-delivery-notes
#18
Lisa C Zuckerwise, Madison M Hustedt, Heather S Lipkind, Edmund F Funai, Cheryl A Raab, Christian M Pettker
OBJECTIVES: Complete and accurate documentation by the delivering provider in cases of shoulder dystocia is critical for providing clinical information and care to the patient and protecting providers from litigation risks. Standardized forms improve inclusion of certain data elements in the medical record, but the impact on subsequent narrative notes is unknown. We aimed to determine if implementation of a standardized shoulder dystocia documentation form improves obstetric provider written narrative delivery notes...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811593/the-effects-of-the-second-victim-phenomenon-on-work-related-outcomes-connecting-self-reported-caregiver-distress-to-turnover-intentions-and-absenteeism
#19
Jonathan D Burlison, Rebecca R Quillivan, Susan D Scott, Sherry Johnson, James M Hoffman
OBJECTIVES: Second victim experiences can affect the well-being of healthcare providers and compromise patient safety. The purpose of this study was to assess the relationships between self-reported second victim-related distress to turnover intention and absenteeism. Organizational support was examined concurrently because it was hypothesized to explain the potential relationships between distress and work-related outcomes. METHODS: A cross-sectional, self-report survey (the Second Victim Experience and Support Tool) of nurses directly involved in patient care (N = 155) was analyzed by using hierarchical linear regression...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27811592/hip-metallosis-and-corrosion-a-million-harmed-due-to-fda-inaction
#20
Stephen Tower
No abstract text is available yet for this article.
November 2, 2016: Journal of Patient Safety
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