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Journal of Patient Safety

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https://www.readbyqxmd.com/read/28430700/prescriber-compliance-with-liver-monitoring-guidelines-for-pazopanib-in-the-postapproval-setting-results-from-a-distributed-research-network
#1
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
#2
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
#3
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
#4
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
#5
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
#6
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
#7
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
#8
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
#9
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
#10
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
#11
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
#12
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
#13
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
#14
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
#15
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
#16
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
#17
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
#18
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
#19
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
#20
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
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