Journal of Patient Safety

OBJECTIVE: This study aimed to determine and evaluate interventions that improve an antibiotic stewardship program (ASP) in reduction of the amount of antibiotic use and errors in drug utilization evaluation (DUE) form completion. METHODS: A prospective quasi-experimental study was conducted to evaluate the effectiveness of the multifaceted interventions (preauthorization with computerized DUE, self-supervised checklists, and short active reminders of the antibiotic guidelines recommendations) incorporating an ASP among hospitalized internal medicine patients in a Thai tertiary care center...

OBJECTIVES: Community-dwelling older adults taking 5 or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations, such as the Food and Drug Administration, often issue guidelines to ensure medication safety, how older adults understand and mitigate the risk of harm from medication use in the home environment is poorly understood...

OBJECTIVES: We aimed to investigate the value of adding a video monitoring (VM) system with falls and costs for patients at high risk. METHODS: We conducted a retrospective, historically controlled study of adults (≥18 y old) at high risk of fall admitted at the University of Miami Hospital and Clinics from January 1 to November 30, 2020 (pre-VM) and January 1 to November 30, 2021 (post-VM); in-person sitters were available in both periods. Fall risk assessment was conducted on admission and at every nursing shift; we defined patients as high risk if their Morse Fall Scale was ≥60...

No abstract text is available yet for this article.

BACKGROUND: Direct admissions from clinic or home to the hospital may improve efficiency and reduce emergency room utilization, but nonoptimized processes may increase the risk of harm during the transition of care. Our multidisciplinary team aimed to understand and improve the process of directly admitting patients to inpatient medicine services at a large academic medical center. METHODS: In this single-institution quality improvement initiative, we identified key communication gaps within the direct admission process and implemented a handoff tool in the form of a templated note and order set to bridge those communication gaps...

OBJECTIVE: Despite the many advancements made in patient safety over the past decade, combating diagnostic errors (DEs) remains a crucial, yet understudied initiative toward improvement. This study sought to understand the perception of dental patients who have experienced a dental diagnostic failure (DDF) and to identify patient-centered strategies to help reduce future occurrences of DDF. METHODS: Through social media recruitment, we conducted a screening survey, initial assessment, and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis, or delayed diagnosis on patient lives...

OBJECTIVES: The 2 most commonly used scales worldwide are the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) and the Naranjo scales. The present study was planned to assess the degree of agreement between the 2 scales when the same adverse drug reactions (ADR) were assessed by 5 raters independently. METHODS: One hundred individual case safety reports were selected randomly from the ADR database of our institute and the details were emailed to 5 different experts (raters), who were DM Clinical Pharmacology residents from different institutes in India...

OBJECTIVE: Electronic medication management (EMM) systems have been shown to introduce new patient safety risks that were not possible, or unlikely to occur, with the use of paper charts. Our aim was to examine the factors that contribute to EMM-related incidents and how these incidents change over time with ongoing EMM use. METHODS: Incidents reported at 3 hospitals between January 1, 2010, and December 31, 2019, were extracted using a keyword search and then screened to identify EMM-related reports...

OBJECTIVES: There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines. METHODS: We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests...

BACKGROUND: Adverse events (AEs), which are associated with medical system instability, poor clinical outcomes, and increasing socioeconomic burden, represent a negative outcome of the healthcare system and profoundly influence patient safety. However, research into AEs remains at a developmental stage according to the existing literature, and no previous studies have systematically reviewed the current state of research in the field of AEs. Therefore, the aims of this study were to interpret the results of published research in the field of AEs through bibliometric analysis and to analyze the trends and patterns in the data, which will be important for subsequent innovations in the field...

No abstract text is available yet for this article.

OBJECTIVE: The objective of this study was to give an overview of the published literature on the implementation of mortality reviews in hospital settings. METHODS: We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and Web of Science databases up to August 2022 for studies describing implementation or results of implementation of hospital mortality reviews published in English or German. Quality appraisal was conducted using the Mixed Methods Appraisal Tool...

OBJECTIVES: Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS: We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020...

No abstract text is available yet for this article.

OBJECTIVES: The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process. METHODS: The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period...

OBJECTIVES: Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity. METHODS: Longitudinal secondary data (over 2014-2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system...

OBJECTIVES: The incidence of hospital-acquired conditions (HACs) is a serious public health issue with implications ranging from patient morbidity and mortality to negative financial impacts on patients and health care systems. Despite substantial efforts to address and reduce HACs, research into the effect of quality improvement programs is inconclusive. This study seeks to better understand the relationship between repeated reimbursement penalties and improvement in HAC quality scores...

BACKGROUND: Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions (WHRs) are intended to improve patient safety by reducing resident fatigue. Compliance with ACGME WHRs is not universal. PURPOSE: The purpose of this study was to identify factors that influence residents' decisions to take a postcall day (PCD) off according to ACGME WHRs. METHODS: Residents (N = 433) at one university were emailed a link to a survey in 2019...

BACKGROUND: Patients treated and transported by Helicopter Emergency Medical Services (HEMS) are prone to both flight and medical hazards, but incident reporting differs substantially between flight organizations and health care, and the extent of patient safety incidents is still unclear. METHODS: A qualitative descriptive study based on in-depth interviews with 8 experienced Norwegian HEMS physicians from 4 different bases from February to July 2020 using inductive qualitative content analysis...

OBJECTIVE: This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events. METHODS: We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier...