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Keywords Patient Safety, Adverse Events...

Patient Safety, Adverse Events, Medical Error

https://read.qxmd.com/read/38515008/the-prevalence-of-incivility-in-hospitals-and-the-effects-of-incivility-on-patient-safety-culture-and-outcomes-a-systematic-review-and-meta-analysis
#1
REVIEW
Benjamin Freedman, Wendy Wen Li, Zhanming Liang, Peter Hartin, Narelle Biedermann
AIM: Workplace incivility is a barrier to safe and high-quality patient care in nursing workplaces and more broadly in tertiary hospitals. The present study aims to systematically review the existing evidence to provide a comprehensive understanding of the prevalence of co-worker incivility experienced and witnessed by nurses and other healthcare professionals, the effects of incivility on patient safety culture (PSC) and patient outcomes, and the factors which mediate the relationship between incivility and patient safety...
March 21, 2024: Journal of Advanced Nursing
https://read.qxmd.com/read/38512325/exploring-the-use-of-persuasive-system-design-principles-to-enhance-medication-incident-reporting-and-learning-systems-scoping-reviews-and-persuasive-design-assessment
#2
JOURNAL ARTICLE
Kiemute Oyibo, Paola A Gonzalez, Sarah Ejaz, Tasneem Naheyan, Carla Beaton, Denis O'Donnell, James R Barker
BACKGROUND: Medication incidents (MIs) causing harm to patients have far-reaching consequences for patients, pharmacists, public health, business practice, and governance policy. Medication Incident Reporting and Learning Systems (MIRLS) have been implemented to mitigate such incidents and promote continuous quality improvement in community pharmacies in Canada. They aim to collect and analyze MIs for the implementation of incident preventive strategies to increase safety in community pharmacy practice...
March 21, 2024: JMIR Human Factors
https://read.qxmd.com/read/38506359/-the-impact-of-regulation-and-central-management-on-patient-safety-in-israel
#3
JOURNAL ARTICLE
Yaron Niv, Yossi Tal
An adverse event is defined as an unwanted and unexpected occurrence in a medical process that may end in harm to the patient. In the USA the number of deaths due to failures reaches 253,000 per year. In Israel, over 10,000 deaths occur per year due to errors in the medical treatment of hospitalized patients, the third most common cause of death after heart disease and cancer. The main cause of failures in medical diagnosis and treatment is the complexity of the medical profession. A large number of caregivers in different medical disciplines are needed to treat one patient, therefore there are many errors, especially regarding communication between therapists...
March 2024: Harefuah
https://read.qxmd.com/read/38484839/leveraging-learning-systems-to-improve-quality-and-patient-safety-in-allergen-immunotherapy
#4
REVIEW
Alexandra E Conway, Chase Rupprecht, Priya Bansal, Irene Yuan, Ziwei Wang, Marcus S Shaker, Marylee Verdi, Joel Bradley
Adverse events occur in all fields of medicine including allergy-immunology, where allergen immunotherapy medical errors can result in significant harm. Though difficult to experience, such errors constitute opportunities for improvement. Identification of system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response is composed of four major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the Plan-Do-Study-Act cycle), and (4) communication and resolution...
March 12, 2024: Annals of Allergy, Asthma & Immunology
https://read.qxmd.com/read/38470963/predictive-power-of-dependence-and-clinical-social-fragility-index-and-risk-of-fall-in-hospitalized-adult-patients-a-case-control-study
#5
JOURNAL ARTICLE
Marco Cioce, Simone Grassi, Ivan Borrelli, Vincenzo Maria Grassi, Renato Ghisellini, Carmen Nuzzo, Maurizio Zega, Patrizia Laurenti, Matteo Raponi, Riccardo Rossi, Stefania Boccia, Umberto Moscato, Antonio Oliva, Giuseppe Vetrugno
OBJECTIVES: Accidental falls are among the leading hospitals' adverse events, with incidence ranging from 2 to 20 events per 1.000 days/patients. The objective of this study is to assess the relationship between in-hospital falls and the score of 3 DEPendence and Clinical-Social Fragility indexes. METHODS: A monocentric case-control study was conducted by retrieving data of in-hospital patients from the electronic health records. RESULTS: Significant differences between the mean scores at the hospital admission and discharge were found...
March 13, 2024: Journal of Patient Safety
https://read.qxmd.com/read/38470962/reframing-the-morbidity-and-mortality-conference-the-impact-of-a-just-culture
#6
JOURNAL ARTICLE
Karolina Brook, Aalok V Agarwala, George L Tewfik
Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error...
March 13, 2024: Journal of Patient Safety
https://read.qxmd.com/read/38470660/risk-management-and-patient-safety-in-the-artificial-intelligence-era-a-systematic-review
#7
REVIEW
Michela Ferrara, Giuseppe Bertozzi, Nicola Di Fazio, Isabella Aquila, Aldo Di Fazio, Aniello Maiese, Gianpietro Volonnino, Paola Frati, Raffaele La Russa
BACKGROUND: Healthcare systems represent complex organizations within which multiple factors (physical environment, human factor, technological devices, quality of care) interconnect to form a dense network whose imbalance is potentially able to compromise patient safety. In this scenario, the need for hospitals to expand reactive and proactive clinical risk management programs is easily understood, and artificial intelligence fits well in this context. This systematic review aims to investigate the state of the art regarding the impact of AI on clinical risk management processes...
February 27, 2024: Healthcare (Basel, Switzerland)
https://read.qxmd.com/read/38466141/fatal-adverse-events-in-femoral-neck-fracture-patients-undergoing-hemiarthroplasty-or-total-hip-arthroplasty-a-retrospective-record-review-study-in-a-nationwide-sample-of-deceased-patients
#8
JOURNAL ARTICLE
Bo Schouten, Mees Baartmans, Linda van Eikenhorst, Gooitzen P Gerritsen, Hanneke Merten, Steffie van Schoten, Prabath W B Nanayakkara, Cordula Wagner
OBJECTIVES: Patient safety is a core component of quality of hospital care and measurable through adverse event (AE) rates. A high-risk group are femoral neck fracture patients. The Dutch clinical guideline states that the treatment of choice is cemented total hip arthroplasty (THA) or hemiarthroplasty (HA). We aimed to identify the prevalence of AEs related to THA/HA in a sample of patients who died in the hospital. METHODS: We used data of a nationwide retrospective record review study...
March 8, 2024: Journal of Patient Safety
https://read.qxmd.com/read/38460442/patients-and-doctors-views-and-experiences-of-the-patient-safety-trajectory-of-breast-cancer-care
#9
JOURNAL ARTICLE
Clara Forrest, Martin J O'Sullivan, Max Ryan, Colm O'Tuathaigh, Tara Jane Browne, Kathy Rock, Mary Jane O'Leary, Deirdre Madden, Seamus O'Reilly
INTRODUCTION: Successful breast cancer outcomes can be jeopardised by adverse events. Understanding and integrating patients' and doctors' perspectives into care trajectories could improve patient safety. This study assessed their views on, and experiences of, medical error and patient safety. METHODS: A cross-sectional, quantitative 20-40 item questionnaire for patients attending Cork University Hospital Cancer Centre and breast cancer doctors in the Republic of Ireland was developed...
February 29, 2024: Breast: Official Journal of the European Society of Mastology
https://read.qxmd.com/read/38454490/the-rothman-index-predicts-unplanned-readmissions-to-intensive-care-associated-with-increased-mortality-and-hospital-length-of-stay-a-propensity-matched-cohort-study
#10
JOURNAL ARTICLE
Philip F Stahel, Kathy W Belk, Samantha J McInnis, Kathryn Holland, Roy Nanz, Joseph Beals, Jaclyn Gosnell, Olufunmilayo Ogundele, Katherine S Mastriani
BACKGROUND: Patients with unplanned readmissions to the intensive care unit (ICU) are at high risk of preventable adverse events. The Rothman Index represents an objective real-time grading system of a patient's clinical condition and a predictive tool of clinical deterioration over time. This study was designed to test the hypothesis that the Rothman Index represents a sensitive predictor of unanticipated ICU readmissions. METHODS: A retrospective propensity-matched cohort study was performed at a tertiary referral academic medical center in the United States from January 1, 2022, to December 31, 2022...
March 7, 2024: Patient Safety in Surgery
https://read.qxmd.com/read/38450356/analysis-of-intervention-employability-in-pharmacy-related-medication-safety-reports-at-a-tertiary-medical-center
#11
JOURNAL ARTICLE
Nick Crozier, Elisa Robinson, Nicole C Murtagh, Briana D Coyne
Background: The Institute for Safe Medication Practice (ISMP) suggests that patient safety reports be addressed with systematic, fail-safe, actions to prevent error recurrence. ISMP's hierarchy of effectiveness of risk reduction strategies places education-related interventions as the least effective and fail-safes at the top. UNM Hospitals creates a positive environment for safety reporting, but often we are limited to education interventions due to resource and technology constraints. This study analyzes the intervention potential and quality of pharmacy-related medication safety reports...
April 2024: Hospital Pharmacy
https://read.qxmd.com/read/38446056/importance-of-quality-of-medical-record-differences-in-patient-safety-incident-inquiry-results-according-to-assessment-for-quality-of-medical-record
#12
JOURNAL ARTICLE
Hyeran Jeong, Eun Young Choi, Won Lee, Seung Gyeong Jang, Jeehee Pyo, Minsu Ock
BACKGROUND: Medical record review is the gold standard method of identifying adverse events. However, the quality of medical records is a critical factor that can affect the accuracy of adverse event detection. Few studies have examined the impact of medical record quality on the identification of adverse events. OBJECTIVES: In this study, we analyze whether there were differences in screening criteria and characteristics of adverse events according to the quality of medical records evaluated in the patient safety incident inquiry in Korea...
February 19, 2024: Journal of Patient Safety
https://read.qxmd.com/read/38445295/berotralstat-for-long-term-prophylaxis-of-hereditary-angioedema-in-japan-parts-2-and-3-of-the-randomized-apex-j-phase-iii-trial
#13
JOURNAL ARTICLE
Daisuke Honda, Michihiro Hide, Tomoo Fukuda, Keisuke Koga, Eishin Morita, Shinichi Moriwaki, Yoshihiro Sasaki, Yusuke Suzuki, Phil Collis, Douglas T Johnston, Dianne Tomita, Bhavisha Desai, Isao Ohsawa
BACKGROUND: Berotralstat is a once-daily oral inhibitor of plasma kallikrein for the prophylaxis of hereditary angioedema (HAE) in patients ≥12 years. APeX-J aimed to evaluate the efficacy and safety of berotralstat in Japan. METHODS: APeX-J was a Phase III trial comprising 3 parts (NCT03873116). Part 1 was a randomized, placebo-controlled evaluation of berotralstat 150 or 110 mg over 24 weeks. Part 2 was a 28-week dose-blinded phase in which berotralstat-treated patients continued the same dose and placebo patients were re-randomized to berotralstat 150 or 110 mg...
March 2024: World Allergy Organization Journal
https://read.qxmd.com/read/38438961/exploring-the-influencing-factors-of-patient-safety-competency-of-clinical-nurses-a-cross-sectional-study-based-on-latent-profile-analysis
#14
JOURNAL ARTICLE
Chunling Tai, Dong Chen, Yuhuan Zhang, Yan Teng, Xinyu Li, Chongyi Ma
BACKGROUND: Clinical nurses play an important role in ensuring patient safety. Nurses' work experience, organizational environment, psychological cognition, and behavior can all lead to patient safety issues. Improving nurses' attention to patient safety issues and enhancing their competence in dealing with complex medical safety issues can help avoid preventable nursing adverse events. Therefore, it is necessary to actively identify the latent profiles of patient safety competency of clinical nurses and to explore the influencing factors...
March 4, 2024: BMC Nursing
https://read.qxmd.com/read/38421908/organizational-learning-in-the-morbidity-and-mortality-conference
#15
JOURNAL ARTICLE
Michelle Batthish, Ayelet Kuper, Claire Fine, Ronald M Laxer, G Ross Baker
INTRODUCTION: The focus of morbidity and mortality conferences (M&MCs) has shifted to emphasize quality improvement and systems-level care. However, quality improvement initiatives targeting systems-level errors are challenged by learning in M&MCs, which occurs at the individual attendee level and not at the organizational level. Here, we aimed to describe how organizational learning in M&MCs is optimized by particular organizational and team cultures. METHODS: A prospective, multiple-case study design was used...
March 2024: Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality
https://read.qxmd.com/read/38406658/practices-used-to-improve-patient-safety-culture-among-healthcare-professionals-in-a-tertiary-care-hospital
#16
JOURNAL ARTICLE
Haroon Bashir, Maira Barkatullah, Arslan Raza, Muddasar Mushtaq, Khanzada Sheraz Khan, Awais Saber, Shahid Ahmad
INTRODUCTION: A patient safety culture primarily refers to the values, beliefs, attitudes, and behaviors within a healthcare setup in a community that assists in prioritizing patient safety and encouraging the reporting of errors and near-misses in that facility. There is a direct impact of patient safety culture on how well patient safety and quality improvement programs work. The aim of this cross-sectional descriptive study was to investigate the practices to improve patient safety culture and adverse event reporting practices among healthcare professionals in a tertiary care hospital located in Mirpur Azad Jammu and Kashmir...
February 2024: Glob J Qual Saf Healthc
https://read.qxmd.com/read/38394116/a-novel-framework-for-human-factors-analysis-and-classification-system-for-medical-errors-hfacs-mes-a-delphi-study-and-causality-analysis
#17
JOURNAL ARTICLE
Mahdi Jalali, Ehsanollah Habibi, Nima Khakzad, Shapour Badiee Aval, Habibollah Dehghan
The healthcare system (HCS) is one of the most crucial and essential systems for humanity. Currently, supplying the patients' safety and preventing the medical adverse events (MAEs) in HCS is a global issue. Human and organizational factors (HOFs) are the primary causes of MAEs. However, there are limited analytical methods to investigate the role of these factors in medical errors (MEs). The aim of present study was to introduce a new and applicable framework for the causation of MAEs based on the original HFACS...
2024: PloS One
https://read.qxmd.com/read/38391835/perceptions-of-clinical-adverse-event-reporting-by-nurses-and-midwives
#18
JOURNAL ARTICLE
Anna Majda, Michalina Majkut, Aldona Wróbel, Anna Kurowska, Agata Wojcieszek, Kinga Kołodziej, Iwona Bodys-Cupak, Joanna Rudek, Krystian Barzykowski
The level of safety in healthcare units is mainly characterized by the occurrence of medical adverse events. The aim of the study was to present the experiences of reporting clinical adverse events and the perceptions of nurses working in internal medicine wards, surgical wards and midwives on these issues. The cross-sectional survey was conducted from October 2022 to April 2023. The study used the Author's Survey Questionnaire and sampling by assessment was applied. The study included nurses working in internal medicine wards and surgical wards as well as midwives at nine hospitals in a large provincial city in Poland, amounting to 745 participants...
February 11, 2024: Healthcare (Basel, Switzerland)
https://read.qxmd.com/read/38374077/the-anatomy-of-safe-surgical-teams-an-interview-based-qualitative-study-among-members-of-surgical-teams-at-tertiary-referral-hospitals-in-norway
#19
JOURNAL ARTICLE
Magnhild Vikan, Ellen Ct Deilkås, Berit T Valeberg, Ann K Bjørnnes, Vigdis S Husby, Arvid S Haugen, Stein O Danielsen
BACKGROUND: In spite of the global implementation of surgical safety checklists to improve patient safety, patients undergoing surgical procedures remain vulnerable to a high risk of potentially preventable complications and adverse outcomes. The present study was designed to explore the surgical teams' perceptions of patient safety culture, capture their perceptions of the risk for adverse events, and identify themes of interest for quality improvement within the surgical department...
February 19, 2024: Patient Safety in Surgery
https://read.qxmd.com/read/38360509/-17-years-of-the-critical-incident-reporting-and-learning-system-jeder-fehler-zaehlt-de-for-primary-care-analysis-of-reports
#20
JOURNAL ARTICLE
Anna Kowalski, Tatjana Blazejewski, Lion Lehmann, Dania Schütze, Svea Holtz, Johanna Römer, Ferdinand M Gerlach, Beate S Müller
BACKGROUND: The topic of patient safety has been a subject of much discussion since the end of the last millennium. Ensuring patient safety is a central challenge in health care. An important tool to raise awareness for and learn from adverse events and thus promote patient safety are error-reporting and learning systems (Critical Incident Reporting System = CIRS). METHODS: More than 17 years after its establishment, the CIRS "jeder-fehler-zaehlt.de" (JFZ) for German primary care has undergone a revision in terms of content and technology...
February 14, 2024: Zeitschrift Für Evidenz, Fortbildung und Qualität Im Gesundheitswesen
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