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Journal of Patient Safety

Inger Johanne Bergerød, Geir S Braut, Siri Wiig
OBJECTIVE: The aim of this article was to provide new knowledge on how next of kin are co-creators of resilient performance, as seen from the viewpoint of the healthcare personnel and managers. The following research question guided the study: How are next of kin involved in shaping resilience within cancer care in hospitals? METHODS: The design of the study is a case study of cancer departments in two Norwegian hospitals. Data collection included a total of 32 qualitative semistructured interviews at two organizational levels (managers and staff)...
September 11, 2018: Journal of Patient Safety
Lex D de Jong, Jacqueline Francis-Coad, Nicholas Waldron, Katharine Ingram, Steven M McPhail, Christopher Etherton-Beer, Terry P Haines, Leon Flicker, Tammy Weselman, Anne-Marie Hill
OBJECTIVE: The aim of this study was to explore whether information captured in falls reports in incident management systems could be used to explain how and why the falls occurred, with a view to identifying whether such reports can be a source of subsequent learnings that inform practice change. METHODS: An analysis of prospectively collected falls incident reports found in the incident management systems from eight Western Australian hospitals during a stepped-wedge cluster-randomized controlled trial...
September 5, 2018: Journal of Patient Safety
Joanne R Campione, Russell E Mardon, Kathryn M McDonald
BACKGROUND: Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment or by leading to unnecessary or harmful treatment. OBJECTIVES: The aim of the study was to investigate the relationship between patient safety culture, health information technology (IT) implementation, and the frequency of problems that could lead to diagnostic errors in the medical office setting, such as unavailable test results, unavailable medical records, or unpursued abnormal results...
August 22, 2018: Journal of Patient Safety
Chiara Santomauro, Madeleine Powell, Chelsea Davis, David Liu, Leanne M Aitken, Penelope Sanderson
OBJECTIVES: Interruptions occur frequently in the intensive care unit (ICU) and are associated with errors. To date, no causal connection has been established between interruptions and errors in healthcare. It is important to know whether interruptions directly cause errors before implementing interventions designed to reduce interruptions in ICUs. The aim of the study was to investigate whether ICU nurses who receive a higher number of workplace interruptions commit more clinical errors and procedural failures than those who receive a lower number of interruptions...
August 14, 2018: Journal of Patient Safety
Meredith Campbell Britton, Beth Hodshon, Sarwat I Chaudhry
OBJECTIVES: Care transitions between hospitals and skilled nursing facilities (SNFs) are associated with disruptions in patient care and high risk for adverse events. Communication between hospital-based and SNF-based clinicians is often suboptimal; there have been calls to foster direct, real-time communication between sending and receiving clinicians to enhance patient safety. This article described the implementation of a warm handoff between hospital and SNF physicians and advanced practice providers at the time of hospital discharge...
August 9, 2018: Journal of Patient Safety
David P Lind, David R Andresen, Andrew Williams
OBJECTIVES: The following primary objectives of this study were to: (1) establish baselines of prevalence and causes of medical errors experienced by Iowans in medical settings, (2) determine whether Iowa patients were informed of the errors by the responsible healthcare providers, (3) understand reasons why Iowans who experienced medical errors did or did not report the errors, and (4) discover how Iowans view mandatory reporting of medical errors. METHODS: A total of 1010 Iowa adults took part in a telephone survey in summer 2017...
July 20, 2018: Journal of Patient Safety
Annegret F Hannawa, Richard M Frankel
OBJECTIVE: This study sought to validate the ability of a "Medical Error Disclosure Competence" (MEDC) model to predict the effects of physicians' communication skills on error disclosure outcomes in a simulated context. METHOD: A random sample of 721 respondents was assigned to 16 experimental disclosure conditions that tested the MEDC model's constructs across 2 severity conditions (i.e., minor error and sentinel event). RESULTS: Severity did not affect survey respondents' perceptions of the physician's disclosure style...
July 20, 2018: Journal of Patient Safety
Matthew G R Allaway, Guy D Eslick, Grace T Y Kwok, Michael R Cox
OBJECTIVES: Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings...
July 20, 2018: Journal of Patient Safety
John C Matulis, Frederick North
INTRODUCTION: Apologizing to patients is an encouraged practice, yet little is known about how and why providers apologize and what insights apologies could provide in improving quality and safety. OBJECTIVE: The aim of the study was to determine whether provider apologies in the electronic health record could identify patient safety concerns and opportunities for improvement. METHODS: After performing a free-text search, we randomly selected 100 clinical notes from 1685 available containing terminology related to apology...
July 17, 2018: Journal of Patient Safety
William V Padula, Joyce M Black, Patricia M Davidson, So Yeon Kang, Peter J Pronovost
OBJECTIVE: Health systems are grappling with improving the quality and safety of health care. By setting clear expectations, there is an opportunity to configure care models to decrease the risk of adverse events and promote the quality of care. The US Centers for Medicare and Medicaid Services have used Patient Safety Indicator 90 (PSI90), a composite rate of hospital-acquired conditions (HACs), to adjust payments and score hospitals on quality since 2015. However, PSI90 may be associated with adverse prioritization for preventing some conditions over others...
July 17, 2018: Journal of Patient Safety
Steven C Marcus, Richard C Hermann, Sara Wiesel Cullen
OBJECTIVES: The past 20 years have seen the emergence of a national movement to improve hospital-based healthcare safety in the United States. However, much of the foundational work and subsequent research have neglected inpatient psychiatry. The aim of this article was to advance a comprehensive approach for conceptualizing patient safety in inpatient psychiatry as framed by an application of the Institute of Medicine patient safety framework. METHODS: This article develops a framework for characterizing patient safety in hospital-based mental health care...
July 17, 2018: Journal of Patient Safety
Lotta Schepel, Lasse Lehtonen, Marja Airaksinen, Outi Lapatto-Reiniluoto
OBJECTIVES: High-alert medications may cause significant patient harm when used in error. Hospital-specific safety data should be used to customize high-alert medication lists to fit the local context. The aim of this study was to identify organizational high-alert medications by evaluating university hospital's data on adverse drug reaction (ADR) and medication error (ME). METHODS: The Anatomical Therapeutic Chemical (ATC) codes and top active substances in ADR (n = 401) and ME (n = 11,668) reports of Helsinki University Hospital from 2015-2016 were analyzed and compared with hospitals' drug consumption and the Institute for Safe Medication Practices' (ISMP) list of high-alert medications...
July 7, 2018: Journal of Patient Safety
Nikki L Damen, Marit S de Vos, Marco J Moesker, Jeffrey Braithwaite, Rob A F de Lind van Wijngaarden, Jason Kaplan, Jaap F Hamming, Robyn Clay-Williams
OBJECTIVES: Preoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. METHODS: The study was conducted at an Australian and European Cardiothoracic Surgery Department...
July 7, 2018: Journal of Patient Safety
Kathryn M Kellogg, Joseph S Puthumana, Allan Fong, Katharine T Adams, Raj M Ratwani
OBJECTIVES: Interruptions and distractions have been shown to be a frequent occurrence across health care and have been linked to negative outcomes that create potential patient safety risks. Although observational studies have catalogued interruption frequency and source, the impact of an interruption is difficult to observe. We analyzed patient safety event (PSE) reports related to interruptions to identify clinical processes reported to be frequently interrupted and the reported outcomes of those interruptions...
July 7, 2018: Journal of Patient Safety
Jean Guglielminotti, Ruth Landau, Cynthia A Wong, Guohua Li
BACKGROUND: The incidence of severe maternal morbidity is increasing in the United Sates. To improve maternal outcomes, three maternal complications have been selected for priority intervention based on their proportionate mortality and preventability: obstetric hemorrhage, severe hypertension, and venous thromboembolism. This approach excludes complications that are not associated with high mortality but significantly contribute to maternal morbidity. The aim of this study was to provide an alternative ranking of maternal complications requiring interventions using cost-based criticality analysis...
June 28, 2018: Journal of Patient Safety
Kathleen M Mazor, Aruna Kamineni, Douglas W Roblin, Jane Anau, Brandi E Robinson, Benjamin Dunlap, Cassandra Firneno, Thomas H Gallagher
OBJECTIVES: Many patients with cancer believe that something has gone wrong in their care but are reluctant to speak up. This pilot study sought to evaluate the impact of an intervention of active outreach to patients undergoing cancer treatment, wherein patients were encouraged to speak up if they had concerns about their care and to describe the types of concerns patients reported. METHODS: Patients receiving cancer care at two sites were randomly assigned to an intervention or control group...
June 27, 2018: Journal of Patient Safety
Sarah E Mossburg, Cheryl Dennison Himmelfarb
OBJECTIVES: In the last 20 years, there have been numerous successful efforts to improve patient safety, although recent research still shows a significant gap. Researchers have begun exploring the impact of individual level factors on patient safety culture and safety outcomes. This review examines the state of the science exploring the impact of professional burnout and engagement on patient safety culture and safety outcomes. METHODS: A systematic search was conducted in CINAHL, PubMed, and Embase...
June 25, 2018: Journal of Patient Safety
David Rakoff, Krishna Akella, Chandrashekar Guruvegowda, Sunil Chhajwani, SriKrishna Seshadri, Srikanth Sola
OBJECTIVE: This study aimed to determine the effect of customized training versus standard readily available training on surgical safety checklist (SSCL) compliance and comprehension. BACKGROUND: The success of the SSCL in reducing surgical mortality and morbidity depends largely on the degree of compliance among health care workers with the checklist's components. We hypothesized that a customized training program would improve comprehension of the SSCL components among health care workers...
September 2018: Journal of Patient Safety
Shih-Chieh Shao, Edward Chia-Cheng Lai, Yuk-Ying Chan, Ming-Jui Hung, Hui-Yu Chen
Long-acting medications are widely used to provide convenient ways of managing diseases, but they may cause serious harm to patients when prescribed erroneously. We present a case of hypocalcaemia as a result of therapeutic duplication of 2 long-acting bisphosphonates prescribed within days of each other by different physicians. We describe how we prevented similar medication errors through improvements in medical informatics systems. This case emphasizes the need for enhancements in medical informatics systems to avoid therapeutic duplication of long-acting medications in the interest of patient safety...
September 2018: Journal of Patient Safety
Mohamadreza Jafary, Hossin Adibi, Kamran Shayanfard, Mehri Zohdi, Zahra Godarzi, Mehdi Yaseri, Zhila Najafpour
OBJECTIVES: This study was conducted to measure the effectiveness of interventions in decreasing the rates of pressure ulcer in a general hospital setting. METHODS: Sixteen units in a general hospitals in Iran participated in this stepped-wedge, cluster randomized controlled trial during a 45-week study period. This trial has a one-sided crossover design from control to intervention. The units were randomly assigned fulfilling entry criteria. After the approval by the governing board of hospital, the manipulative intervention, in addition to usual care, was implemented on patients with a Braden criterion of 14 or less...
September 2018: Journal of Patient Safety
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