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Journal of Patient Safety

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https://www.readbyqxmd.com/read/28333698/misuse-of-pediatric-medications-and-parent-physician-communication-an-interactive-voice-response-intervention
#1
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
#2
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
#3
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
#4
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
https://www.readbyqxmd.com/read/28272294/use-of-high-fidelity-simulation-to-enhance-interdisciplinary-collaboration-and-reduce-patient-falls
#5
April A Bursiek, Matthew R Hopkins, Daniel M Breitkopf, Pamela L Grubbs, Mary Ellen Joswiak, Janee M Klipfel, Kristine M Johnson
OBJECTIVES: This pilot study aimed to determine the effect of nurse/physician interdisciplinary team training on patient falls. Specifically, we evaluated team training in a simulation center as a method for targeting and minimizing breakdowns in perceptions of respect, collaboration, communication, and role misunderstanding behaviors between care disciplines. METHODS: Registered nurses (RNs) were randomly assigned to participate. Residents were divided into groups and assigned based on their availability and clinical responsibility...
March 7, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28272293/barriers-and-facilitators-of-adverse-event-reporting-by-adolescent-patients-and-their-families
#6
Payal Naresh Sawhney, Linda Sue Davis, Nancy M Daraiseh, Lisa Belle, Kathleen E Walsh
OBJECTIVES: The objectives were (1) to describe barriers and facilitators of adverse event reporting by adolescent patients and parents in a pediatric hospital and (2) to identify characteristics the participants wished to have in a formal reporting system of adverse events. METHODS: We used a qualitative design in which 6 focus groups, 3 with parents and 3 with adolescents, were conducted. The transcripts of audio recordings, notes of team debriefings, and written field notes of group behaviors were analyzed using NVivo software for qualitative data analysis...
March 7, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28257288/root-cause-analyses-of-reported-adverse-events-occurring-during-gastrointestinal-scope-and-tube-placement-procedures-in-the-veterans-health-association
#7
Christina Soncrant, Peter D Mills, Julia Neily, Douglas E Paull, Robin R Hemphill
OBJECTIVE: This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur. METHODS: This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database...
March 3, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28248749/medication-safety-in-two-intensive-care-units-of-a-community-teaching-hospital-after-electronic-health-record-implementation-sociotechnical-and-human-factors-engineering-considerations
#8
Pascale Carayon, Tosha B Wetterneck, Randi Cartmill, Mary Ann Blosky, Roger Brown, Peter Hoonakker, Robert Kim, Sandeep Kukreja, Mark Johnson, Bonnie L Paris, Kenneth E Wood, James M Walker
OBJECTIVE: The aim of the study was to assess the impact of Electronic Health Record (EHR) implementation on medication safety in two intensive care units (ICUs). METHODS: Using a prospective pre-post design, we assessed 1254 consecutive admissions to two ICUs before and after an EHR implementation. Each medication event was evaluated with regard to medication error (error type, medication-management stage) and impact on patient (severity of potential or actual harm)...
February 28, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28248748/informing-the-design-of-a-new-pragmatic-registry-to-stimulate-near-miss-reporting-in-ambulatory-care
#9
Elizabeth R Pfoh, Lilly Engineer, Hardeep Singh, Laura Lee Hall, Ethan D Fried, Zackary Berger, Albert W Wu
OBJECTIVE: Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents...
February 28, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28234730/reducing-surgery-scheduling-errors-in-multihospital-system
#10
Donna S Watson, Cynthia F Corbett, Gail Oneal, Kenn B Daratha
OBJECTIVE: The purpose of this study was to assess whether bundled team training interventions for surgeons and office staff could effectively improve the accuracy of surgery scheduling, minimizing scheduling factors that may contribute to occurrence of wrong site surgery. METHODS: This quasiexperimental observational study used an interrupted time series design to explore surgery scheduling errors (SSEs) and implemented bundled team training interventions intended to reduce SSEs at a Pacific Northwest Regional Surgery Scheduling Department...
February 24, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28234729/the-effects-of-bar-coding-technology-on-medication-errors-a-systematic-literature-review
#11
Kevin Hutton, Qian Ding, Gregory Wellman
BACKGROUND: The bar-coding technology adoptions have risen drastically in U.S. health systems in the past decade. However, few studies have addressed the impact of bar-coding technology with strong prospective methodologies and the research, which has been conducted from both in-pharmacy and bedside implementations. OBJECTIVE: This systematic literature review is to examine the effectiveness of bar-coding technology on preventing medication errors and what types of medication errors may be prevented in the hospital setting...
February 24, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28234728/a-national-study-of-patient-safety-culture-in-hospitals-in-sweden
#12
Marita Danielsson, Per Nilsen, Hans Rutberg, Kristofer Årestedt
OBJECTIVE: Using the Hospital Survey on Patient Culture, our aim was to investigate the patient safety culture in all Swedish hospitals and to compare the culture among managers, physicians, registered nurses, and enrolled nurses and to identify factors associated with high overall patient safety. METHODS: The study used a correlational design based on cross-sectional surveys from health care practitioners in Swedish health care (N = 23,781). We analyzed the associations between overall patient safety (outcome variable) and 12 culture dimensions and 5 background characteristics (explanatory variables)...
February 24, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28234727/defining-potentially-preventable-adverse-outcomes-in-medicare-elective-lung-resections
#13
Donald E Fry, Michael Pine, Susan M Nedza, David G Locke, Agnes M Reband, Gregory Pine
OBJECTIVE: The aims of the study were to develop risk-adjusted models and apply them for comparisons of hospital performance to define potentially preventable adverse outcomes (OAs) in Medicare lung resection surgery. METHODS: The Medicare Limited Data Set for 2010-2012 was used to design predictive risk models for the four OAs of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without hospital readmission, and 90-day readmissions after removal of unrelated readmission events...
February 24, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28230583/evaluating-the-impact-of-radio-frequency-identification-retained-surgical-instruments-tracking-on-patient-safety-literature-review
#14
Kumiko O Schnock, Bonnie Biggs, Anne Fladger, David W Bates, Ronen Rozenblum
BACKGROUND: Retained surgical instruments (RSI) are one of the most serious preventable complications in operating room settings, potentially leading to profound adverse effects for patients, as well as costly legal and financial consequences for hospitals. Safety measures to eliminate RSIs have been widely adopted in the United States and abroad, but despite widespread efforts, medical errors with RSI have not been eliminated. OBJECTIVE: Through a systematic review of recent studies, we aimed to identify the impact of radio frequency identification (RFID) technology on reducing RSI errors and improving patient safety...
February 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28230582/motivating-physicians-to-report-adverse-medical-events-in-china-stick-or-carrot
#15
Yajiong Xue, Jing Yang, Jing Zhang, Mengyun Luo, Zhiruo Zhang, Huigang Liang
BACKGROUND: Adverse medical events (AMEs) pose serious threats to patient safety. One of the major challenges of AME reporting is low physician engagement. This study attempted to examine how punishment and reward can improve physicians' AME reporting in China. METHODS: A survey was conducted in a large hospital with 1693 beds in China. Data were collected from 311 physicians. Ordinal and binary logistic regression was used for data analysis. RESULTS: This study reveals that both punishment and reward are positively associated with intention to report AMEs...
February 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28230581/a-handoffs-software-led-to-fewer-errors-of-omission-and-better-provider-satisfaction-a-randomized-control-trial
#16
Markos G Kashiouris, Christos Stefanou, Deepankar Sharma, Cecilia Yshii-Tamashiro, Ryan Vega, Sarah Hartingan, Charles Albrecht, Robert H Brown
BACKGROUND: Computer-assisted communication is shown to prevent critical omissions ("errors") in the handoff process. OBJECTIVE: The aim of the study was to study this effect and related provider satisfaction, using a standardized software. METHODS: Fourteen internal medicine house officers staffed 6 days and 1 cross-covering teams were randomized to either the intervention group or control, employing usual handoff, so that handoff information was exchanged only between same-group subjects (daily, for 28 days)...
February 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28230580/the-patient-perspective-on-errors-in-cancer-care-results-of-a-cross-sectional-survey
#17
Mariko Carey, Allison W Boyes, Jamie Bryant, Heidi Turon, Tara Clinton-McHarg, Robert Sanson-Fisher
OBJECTIVE: The objective of this study was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. METHODS: A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centers. Participants completed 2 paper-and-pencil questionnaires: an initial survey on demographic, disease and treatment characteristics upon recruitment; and a second survey on their experiences of errors in cancer care 1 month later...
February 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28230579/hospital-outpatient-visits-associated-with-medication-related-problems-in-thailand-a-multicenter-prospective-observational-study
#18
Supinya Dechanont, Arom Jedsadayanmata, Bodin Butthum, Chuenjid Kongkaew
OBJECTIVES: The aims of the study were to investigate the prevalence of hospital visits associated with medication-related problems (MRPs, i.e., adverse drug events [ADEs], adverse drug reactions [ADRs], nonadherence [NA] to medication, and medication error) and to identify the medications involved in hospital visits associated with MRPs in outpatient departments (OPDs). METHODS: A prospective observational study was carried out in OPD of 11 hospitals in the lower northern region of Thailand...
February 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28230578/essential-and-nonessential-blood-testing-in-the-clinical-teaching-unit
#19
Cody Sherren, Andrew Day, Roy Ilan
OBJECTIVES: The aim of the study was to evaluate the essential and nonessential blood tests ordered on the internal medicine clinical teaching units (CTUs) at Kingston General Hospital. Our aim was to establish a baseline performance measure identifying appropriate use of laboratory tests that could be used to inform improvement over time. METHODS: For an 8-week period, 14 CTU attending physicians at Kingston General Hospital were surveyed. They were asked for each of their patients, "What blood tests do you consider to be essential for tomorrow morning to maintain appropriate care for this patient?" The following day, blood tests that were ordered were compared with the "essential" list previously given by the attending physicians...
February 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28230577/suicide-and-suicide-attempts-on-hospital-grounds-and-clinic-areas
#20
Peter D Mills, Bradley V Watts, Robin R Hemphill
OBJECTIVES: The goal of this study was to describe suicide and suicide attempts that occurred while the patient was on hospital grounds, common spaces, and clinic areas using root cause analysis (RCA) reports of these events in a national health care organization in the United States. METHOD: This is an observational review of all RCA reports of suicide and suicide attempts on hospital grounds, common spaces, and clinic areas in our system between December 1, 1999, and December 31, 2014...
February 22, 2017: Journal of Patient Safety
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