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Journal of Patient Safety

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https://www.readbyqxmd.com/read/28492422/increasing-patient-clinician-concordance-about-medical-error-disclosure-through-the-patient-tips-model
#1
William Martinez, David Browning, Pamela Varrin, Barbara Sarnoff Lee, Sigall K Bell
OBJECTIVE: To test whether an educational model involving patients and family members (P/F) in medical error disclosure training for interprofessional clinicians can narrow existing gaps between clinician and P/F views about disclosure. METHOD: Parallel presurveys/postsurveys using Likert scale questions for clinicians and P/F. RESULTS: Baseline surveys were completed by 91% (50/55) of clinicians who attended the workshops and 74% (65/88) of P/F from a hospital patient and family advisory council...
May 10, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28471774/adapting-cognitive-task-analysis-to-investigate-clinical-decision-making-and-medication-safety-incidents
#2
Alissa L Russ, Laura G Militello, Peter A Glassman, Karen J Arthur, Alan J Zillich, Michael Weiner
OBJECTIVES: Cognitive task analysis (CTA) can yield valuable insights into healthcare professionals' cognition and inform system design to promote safe, quality care. Our objective was to adapt CTA-the critical decision method, specifically-to investigate patient safety incidents, overcome barriers to implementing this method, and facilitate more widespread use of cognitive task analysis in healthcare. METHODS: We adapted CTA to facilitate recruitment of healthcare professionals and developed a data collection tool to capture incidents as they occurred...
May 3, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28452918/detecting-medication-administration-errors
#3
Marianne L Durham, Ann Jankiewicz
No abstract text is available yet for this article.
April 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28452917/quality-of-handoffs-in-community-pharmacies
#4
Ephrem Abebe, Jamie A Stone, Corey A Lester, Michelle A Chui
OBJECTIVES: The aims of the study were to characterize handoffs in community pharmacies and to examine factors that contribute to perceived handoff quality. METHODS: A cross-sectional study of community pharmacists in a Midwest State of the United States. Self-administered questionnaires were used to collect information on participant and practice setting characteristics. Data were analyzed using descriptive statistics and multivariate logistic regression. RESULTS: A total of 445 completed surveys were returned (response rate, 82%)...
April 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28452916/never-events-in-uk-general-practice-a-survey-of-the-views-of-general-practitioners-on-their-frequency-and-acceptability-as-a-safety-improvement-approach
#5
Susan J Stocks, Rahul Alam, Paul Bowie, Stephen Campbell, Carl de Wet, Aneez Esmail, Sudeh Cheraghi-Sohi
BACKGROUND: Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the United Kingdom and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to general practitioner (GPs) as a Q&SI approach, is currently unknown. The study aims to estimate (1) the frequency of 10 NEs occurring within GPs' own practices and (2) the extent to which the NE approach is perceived as acceptable for use...
April 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28452915/leapfrog-hospital-safety-score-magnet-designation-and-healthcare-associated-infections-in-united-states-hospitals
#6
Amy L Pakyz, Hui Wang, Yasar A Ozcan, Michael B Edmond, Timothy J Vogus
OBJECTIVE: Healthcare-associated infections (HAIs) pose a challenge to patient safety. Although studies have explored individual level, few have focused on organizational factors such as a hospital's safety infrastructure (indicated by Leapfrog Hospital Safety Score) or workplace quality (Magnet recognition). The aim of the study was to determine whether Magnet and hospitals with better Leapfrog Hospital Safety Scores have fewer HAIs. METHODS: Ordered probit regression analyses tested associations between Safety Score, Magnet status, and standardized infection ratios, depicting whether a hospital had a Clostridium difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection standardized infection ratio that was "better," "no different," or "worse" than a National Benchmark as per Centers for Disease Control and Prevention's National Healthcare Safety Network definitions...
April 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28452914/cost-benefit-analysis-of-a-support-program-for-nursing-staff
#7
Dane Moran, Albert W Wu, Cheryl Connors, Meera R Chappidi, Sushama K Sreedhara, Jessica H Selter, William V Padula
OBJECTIVES: A peer-support program called Resilience In Stressful Events (RISE) was designed to help hospital staff cope with stressful patient-related events. The aim of this study was to evaluate the impact of the RISE program by conducting an economic evaluation of its cost benefit. METHODS: A Markov model with a 1-year time horizon was developed to compare the cost benefit with and without the RISE program from a provider (hospital) perspective. Nursing staff who used the RISE program between 2015 and 2016 at a 1000-bed, private hospital in the United States were included in the analysis...
April 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28452913/improving-patient-safety-in-handover-from-intensive-care-unit-to-general-ward-a-systematic-review
#8
Ida Wibrandt, Anne Lippert
OBJECTIVES: Despite of the increasing knowledge about patient safety improvements in the handover process in hospitals, we still lack knowledge about what magnitude of patient safety gains can be expected from improvements in handover between the intensive care unit (ICU) and the general ward. The aim of this systematic review was to investigate which handover tools are devised and evaluated with the aim of improving patient safety in the handover process from ICU to ward and whether the described handover tools fulfill their purpose...
April 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28452912/effects-of-a-brief-team-training-program-on-surgical-teams-nontechnical-skills-an-interrupted-time-series-study
#9
Brigid M Gillespie, Emma Harbeck, Evelyn Kang, Catherine Steel, Nicole Fairweather, Kriengsak Panuwatwanich, Wendy Chaboyer
BACKGROUND: Up to 60% of adverse events in surgery are the result of poor communication and teamwork. Nontechnical skills in surgery (NOTSS) are critical to the success of surgery and patient safety. The study aim was to evaluate the effect of a brief team training intervention on teams' observed NOTSS. METHODS: Pretest-posttest interrupted time-series design with statistical process control analysis was used to detect longitudinal changes in teams' NOTSS. We evaluated NOTSS using the revised NOTECHS weekly for 20 to 25 weeks before and after implementation of a team training program...
April 27, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28448292/show-back-developing-and-testing-of-a-simulation-based-assessment-method-for-identifying-problems-in-self-management-of-medications-in-older-adults
#10
Alok Kapoor, Laura Burns, Janice B Foust, Maureen Sarno, Jeanne Callahan-Lydon, Paula Schultz, Jennifer Donovan, Abir Kanaan, Sybil Crawford, Jerry H Gurwitz, Kathleen M Mazor
Case reports or submissions to regular features, such as "Near Misses" or "Tips for Success," need no abstracts.
April 26, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28430700/prescriber-compliance-with-liver-monitoring-guidelines-for-pazopanib-in-the-postapproval-setting-results-from-a-distributed-research-network
#11
Sumitra Shantakumar, Beth L Nordstrom, Susan A Hall, Luc Djousse, Myrthe P P van Herk-Sukel, Kathy H Fraeman, David R Gagnon, Karen Chagin, Jeanenne J Nelson
OBJECTIVES: Pazopanib received US Food and Drug Administration approval in 2009 for advanced renal cell carcinoma. During clinical development, liver chemistry abnormalities and adverse hepatic events were observed, leading to a boxed warning for hepatotoxicity and detailed label prescriber guidelines for liver monitoring. As part of postapproval regulatory commitments, a cohort study was conducted to assess prescriber compliance with liver monitoring guidelines. METHODS: Over a 4-year period, a distributed network approach was used across 3 databases: US Veterans Affairs Healthcare System, a US outpatient oncology community practice database, and the Dutch PHARMO Database Network...
April 20, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28426522/patient-safety-culture-survey-in-pediatric-complex-care-settings-a-factor-analysis
#12
Amanda J Hessels, Meghan Murray, Bevin Cohen, Elaine L Larson
OBJECTIVES: Children with complex medical needs are increasing in number and demanding the services of pediatric long-term care facilities (pLTC), which require a focus on patient safety culture (PSC). However, no tool to measure PSC has been tested in this unique hybrid acute care-residential setting. The objective of this study was to evaluate the psychometric properties of the Nursing Home Survey on Patient Safety Culture tool slightly modified for use in the pLTC setting. METHODS: Factor analyses were performed on data collected from 239 staff at 3 pLTC in 2012...
April 19, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28376058/a-systematic-review-of-measurement-tools-for-the-proactive-assessment-of-patient-safety-in-general-practice
#13
Sinéad Lydon, Margaret E Cupples, Andrew W Murphy, Nigel Hart, Paul OʼConnor
BACKGROUND: Primary care physicians have reported a difficulty in understanding how best to measure and improve patient safety in their practices. OBJECTIVES: The aims of the study were to identify measures of patient safety suitable for use in primary care and to provide guidance on proactively monitoring and measuring safety. METHODS: Searches were conducted using Medline, Embase, CINAHL and PsycInfo in February 2016. Studies that used a measure assessing levels of or attitudes toward patient safety in primary care were considered for inclusion...
April 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
#14
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...
April 4, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28368966/intravenous-administration-errors-intercepted-by-smart-infusion-technology-in-an-adult-intensive-care-unit
#15
Rebecca Ibarra-Pérez, Fabiola Puértolas-Balint, Elizabeth Lozano-Cruz, Sergio E Zamora-Gómez, Lucila I Castro-Pastrana
OBJECTIVES: The aim of the study was to investigate the efficacy of intravenous (IV) smart pumps with drug libraries and dose error reduction system (DERS) to intercept programming errors entailing high risk for patients in an adult intensive care unit (ICU). METHODS: A 2-year retrospective study was conducted in the adult ICU of the Hospital Juárez de México in Mexico City to evaluate the impact of IV smart pump/DERS (Hospira MedNet) technology implementation...
April 1, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28368965/current-status-of-parkinsonism-related-adverse-events-and-associated-drugs-in-korea
#16
Siin Kim, Hae Sun Suh
OBJECTIVE: The aim of the study was to explore the current status of drug-induced parkinsonism and drugs possibly related to drug-induced parkinsonism in Korea. METHODS: We conducted a cross-sectional study using the Korea Adverse Event Reporting System database between July 1, 2010, and June 30, 2015. We identified all adverse event reports associated with parkinsonism. RESULTS: There were 1402 adverse event reports associated with parkinsonism...
April 1, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28333698/misuse-of-pediatric-medications-and-parent-physician-communication-an-interactive-voice-response-intervention
#17
Kathleen E Walsh, Janine Bacic, Barrett D Phillips, William G Adams
BACKGROUND: Children take 1 medication each week on average at home. Better communication between parents and providers could support safer home medication use and prevent misuse of pediatric medications, such as intentional underdosing or overdosing. Our primary objective was to assess the impact of an interactive voice response system on parent-provider communication about medications. METHODS: Parents of children 4 months to 11 years of age with upcoming well child visits were invited to call our interactive voice response system, called Personal Health Partner (PHP), which asked questions about the child's health and medication use...
March 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28333697/medication-reconciliation-during-hospitalization-and-in-hospital-home-interface-an-observational-retrospective-study
#18
Elisabetta Volpi, Alessandro Giannelli, Giulio Toccafondi, Monica Baroni, Sara Tonazzini, Stefania Alduini, Stefania Biagini, Rosa Gini, Tommaso Bellandi, Michele Emdin
OBJECTIVE: Medication errors are one of the leading causes of patient harms. Medication reconciliation is a fundamental process that to be effective, it should be embraced during each single care transition. Our objectives were to investigate current medication reconciliation practices in the 2 Fondazione Toscana Gabriele Monasterio hospitals and comprehensively assess the quality of medication reconciliation practices between inpatient and outpatient care by analyzing the medication patterns 6 months before admission, during hospitalization, and 9 months after discharge for a selected group of patients with cardiovascular diseases...
March 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28306611/the-patients-perspective-hematological-cancer-patients-experiences-of-adverse-events-as-part-of-care
#19
Jamie Bryant, Mariko Carey, Rob Sanson-Fisher, Heidi Turon, Andrew Wei, Bryone Kuss
OBJECTIVE: To describe in a sample of patients with a confirmed diagnosis of a hematological cancer: (a) the proportion who self-report experiencing an unexpected adverse event as part of their care; (b) how the adverse event was handled by the health-care organization; and (c) the sociodemographic, disease, and treatment characteristics associated with experiencing an adverse event. DESIGN: Cross sectional survey. SETTING: Three Australian hematological oncology treatment centers...
March 17, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28306610/30-day-potentially-avoidable-readmissions-due-to-adverse-drug-events
#20
Olivia Dalleur, Patrick E Beeler, Jeffrey L Schnipper, Jacques Donzé
OBJECTIVE: To analyze the patterns of potentially avoidable readmissions due to adverse drug events (ADEs) to identify the most appropriate risk reduction interventions. METHODS: In this observational study, we analyzed a random sample of 534 potentially avoidable 30-day readmissions from 10,275 consecutive discharges from the medical department of an academic hospital. Readmissions due to ADEs were reviewed to identify the causative drugs and the severity and interventions to prevent them...
March 17, 2017: Journal of Patient Safety
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