738 results match your criteria Journal of Patient Safety [Journal]


Identification of Design Criteria to Improve Patient Care in Electronic Health Record Downtime.

J Patient Saf 2019 Feb 9. Epub 2019 Feb 9.

Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virginia.

Objective: Design criteria specifications (needs, obstacles, and context-of-use considerations) for continuing safe and efficient patient care activities during downtime were identified by using phenomenological analysis.

Methods: Interview transcripts from medical personnel who had experience with downtime incidents were examined using a phenomenological approach. This process allowed for the identification of design criteria for performing downtime patient care activities. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000580DOI Listing
February 2019

Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health Care Delivery Research: An Ongoing Assessment.

J Patient Saf 2019 Feb 9. Epub 2019 Feb 9.

From the Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland.

Objectives: Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. The article describes a grant initiative undertaken by the Agency for of Healthcare Research and Quality that brings these disciplines together to test new ideas that could make health care safer.

Methods: Collectively known as patient safety learning laboratories, grantee teams engage in phase-based activities that parallel a systems engineering process-problem analysis, design, development, implementation, and evaluation-to gain an in-depth understanding of related patient safety problems, generate fresh ideas and rapid prototypes, develop the prototypes, ensure that developed components are implemented as an integrated working system, and evaluate the system in a simulated or clinical setting. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000577DOI Listing
February 2019

Patient Safety Incidents Describing Patient Falls in Critical Care in North West England Between 2009 and 2017.

J Patient Saf 2019 Feb 9. Epub 2019 Feb 9.

University of Manchester Medical School, Manchester, United Kingdom.

Aim: The aim of the study was to review reported falls in critical care units to see whether the causes and results were different from those described in a general hospital population.

Methods: We reviewed and classified patient safety incidents describing falls from critical care units in the North West of England between 2009 and 2017. The classification reviewed patient and staff factors contributing to the fall, the environment of the fall, and the reported consequences. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000574DOI Listing
February 2019
1 Read

Nursing Home Senior Managers and Direct Care Staff: Are There Differences in Their Perceptions of Safety Climate?

J Patient Saf 2019 Feb 9. Epub 2019 Feb 9.

Objectives: Improving nursing home safety is important to the quality of resident care. Increasing evidence points to the relationship between actual safety and a strong safety climate, i.e. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000569DOI Listing
February 2019

Allergic Reactions Captured by Voluntary Reporting.

J Patient Saf 2019 Jan 31. Epub 2019 Jan 31.

Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization.

Background: The epidemiology of hospital adverse reactions (ARs), particularly allergic reactions, or hypersensitivity reactions (HSRs), is poorly defined. To determine priorities for allergy safety in healthcare, we identified and described safety reports of allergic reactions.

Methods: We searched the safety report database of a large academic medical center from April 2006 to March 2016 using 101 complete, truncated, and/or misspelled key words related to allergic symptoms, treatments, and culprits (e. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000568DOI Listing
January 2019
1 Read

Developing Evidence for New Patient Safety Bundles Through Multihospital Collaboration.

J Patient Saf 2019 Jan 31. Epub 2019 Jan 31.

Associates in Process Improvement, Austin, Texas.

Objective: Multihospital collaboration for safety improvements is increasingly common, but strategies for developing bundles when effective evidence-based practices are not well described are limited. The Children's Hospitals' Solutions for Patient Safety (SPS) Network sought to further reduce patient harm by developing improvement bundles when preliminary evidence was limited.

Methods: As part of the novel Pioneer process, cohorts of volunteer SPS hospitals collaborated to identify a harm reduction bundle for carefully selected hospital-acquired harm categories where evidence-based practices were limited. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000564DOI Listing
January 2019

Supplying Pharmacist Home Visit and Anticoagulation Professional Consultation During Transition of Care for Patients With Venous Thromboembolism.

J Patient Saf 2019 Jan 29. Epub 2019 Jan 29.

University of Massachusetts Medical School.

Objective: The aim of the study was to assess the feasibility, satisfaction, and effectiveness of a care transition intervention with pharmacist home visit and subsequent anticoagulation expert consultation for patients with new episode of venous thromboembolism within a not-for-profit health care network.

Methods: We randomized patients to the intervention or control. During the home visit, a clinical pharmacist assessed medication management proficiency, asked open-ended questions to discuss knowledge gaps, and distributed illustrated medication instructions. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000571DOI Listing
January 2019
1 Read

Development and Validation of a Safety Scale Perceived by the Witness of Prehospital Emergency Care.

J Patient Saf 2019 Jan 21. Epub 2019 Jan 21.

Puerta del Mar Hospital in Cadiz, Andalusian Health Service, Regional Government of Andalusia, Seville.

Objective: The aim of the study was to design and validate a new tool to measure the security perceived by witnesses of patient care and hospital transfers, after requesting urgent assistance via the "061" phone number.

Methods: This is a descriptive observational, cross-sectional, design, and validation study of a scale conducted by telephone interview. Witnesses of urgent assistance and transfers by prehospital emergency medical services in the province of Cadiz, in the south of Spain, were the subjects of study. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000567DOI Listing
January 2019
4 Reads

The Burden of Opioid-Related Adverse Drug Events on Hospitalized Previously Opioid-Free Surgical Patients.

J Patient Saf 2019 Jan 21. Epub 2019 Jan 21.

Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Bedminster.

Objective: Opioid analgesics are a mainstay for acute pain management, but postoperative opioid administration has risks. We examined the prevalence, risk factors, and consequences of opioid-related adverse drug events (ORADEs) in a previously opioid-free surgical population.

Methods: A retrospective, observational, cohort study using administrative, billing, clinical, and medication administration data from two hospitals. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000566DOI Listing
January 2019

Multilevel Analysis of Individual, Organizational, and Regional Factors Associated With Patient Safety Culture: A Cross-Sectional Study of Maternal and Child Health Institutions in China.

J Patient Saf 2019 Jan 10. Epub 2019 Jan 10.

School of Psychology and Public Health, La Trobe University, Bundoora, Australia.

Objectives: The aim of this study was to assess patient safety culture (PSC) in maternal and child health (MCH) institutions in China and its individual, organizational, and regional variations.

Methods: Using the PSC survey for MCH institutions (PSCS-MCHI), 2021 valid respondents from 25 participating institutions were investigated in three regions (Beijing, Zhejiang, and Jiangxi) of China. Patient safety culture and its subscale scores (1-5) and factors associated with PSC as revealed by multilevel modeling. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000570DOI Listing
January 2019
1 Read

Assessment of Public Perception Regarding Patient Engagement for Patient Safety in Korea.

J Patient Saf 2019 Jan 10. Epub 2019 Jan 10.

Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.

Objectives: This study conducted a survey to examine how the general public in Korea perceives patient engagement for patient safety and to identify vulnerable groups and contents priorities of patient engagement education for the general public.

Methods: We developed a questionnaire based on previous studies and conducted one-on-one interviews with 600 individuals from the public. Then, we conducted descriptive statistical analyses (i. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000565DOI Listing
January 2019
3 Reads

Comparing the Evolution of Risk Culture in Radiation Oncology, Aviation, and Nuclear Power.

J Patient Saf 2018 Dec 19. Epub 2018 Dec 19.

Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.

Objectives: All organizations seek to minimize the risks that their operations pose to public safety. This task is especially significant if they deal with complex or hazardous technologies. Five decades of research in quantitative risk analysis have generated a set of risk management frameworks and practices that extend across a range of such domains. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000560DOI Listing
December 2018

The Association Between Organizational Culture and the Ability to Benefit From "Just Culture" Training.

J Patient Saf 2019 Mar;15(1):e3-e7

From the Department of Quality and Patient Safety, Universal Health Services, Temecula, CA.

Objective: This study aimed to determine whether there was an association between the organizational culture and the hospital's readiness to benefit from "Just Culture" training.

Methods: The "Just Culture" Assessment Tool and the Competing Values Framework surveys were administered before and 6 weeks after a structured "Just Culture" training session to 172 care providers and administrators on similar units at two community for-profit hospitals of compatible size and offering comparable services in suburban communities. Data were analyzed for significance using IBM SPSS software. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000561DOI Listing

The Association of the Nurse Work Environment and Patient Safety in Pediatric Acute Care.

J Patient Saf 2018 Dec 28. Epub 2018 Dec 28.

Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Objectives: Eighteen years ago, the Institute of Medicine estimated that medical errors in hospital were a major cause of mortality. Since that time, reducing patient harm and improving the culture of patient safety have been national health care priorities. The study objectives were to describe the current state of patient safety in pediatric acute care settings and to assess whether modifiable features of organizations are associated with better safety culture. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000559DOI Listing
December 2018

Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations.

J Patient Saf 2018 Dec 21. Epub 2018 Dec 21.

Quality and Safety, MedStar Health, Columbia, MD.

Objectives: The aim of the study was to determine whether race differences exist in voluntarily reported harmful patient safety events in a large 10 hospital healthcare system on a high reliability organization journey.

Methods: From July 1, 2015, to June 30, 2017, employees in a healthcare system based in Washington, District of Columbia, and Maryland voluntarily reported harmful patient safety events by type using a Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified as "black," "white," or "other" (N = 5038). Read More

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http://dx.doi.org/10.1097/PTS.0000000000000563DOI Listing
December 2018
1 Read

The Second Victim: A Contested Term?

J Patient Saf 2018 Dec 18. Epub 2018 Dec 18.

From the School of Law, University College Cork, Cork, Ireland.

Objectives: The term "second victim" was seminally coined by Wu, in recognition of the profound and long-lasting impact adverse events and medical errors may have on medical practitioners. Since the conception of this vocable over a decade ago, the term second victim has been internationally accepted and is widely used in discussion of this important topic. Notwithstanding its widespread use, controversy surrounds the term second victim in light of the traditional connotations with the word "victim. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000558DOI Listing
December 2018

Double Reading of Outsourced CT/MR Radiology Reports: Retrospective Analysis.

J Patient Saf 2018 Aug 13. Epub 2018 Aug 13.

From the department of Radiology, Nîmes University Hospital, Nîmes, France.

Objectives: Our objective was to determine disagreement rates in radiological reports provided by using a double-reading protocol in a national teleradiology company.

Methods: From January 2015 to July 2016, 134169 radiological exams from 36 French centers, benefited outsourced interpretations by certified radiologists, in both regular and after-hours activities. Of these, 2040 CT and MR-scans (1. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000525DOI Listing
August 2018
4 Reads

Miscarriage Treatment-Related Morbidities and Adverse Events in Hospitals, Ambulatory Surgery Centers, and Office-Based Settings.

J Patient Saf 2018 Dec 3. Epub 2018 Dec 3.

Center for Applied Studies in Health Economics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.

Objective: The aim of the study was to examine whether miscarriage treatment-related morbidities and adverse events vary across facility types.

Methods: A retrospective cohort study compared miscarriage treatment-related morbidities and adverse events across hospitals, ambulatory surgery centers (ASCs), and office-based settings. Data on women who had miscarriage treatment between 2011 and 2014 and were continuously enrolled in their insurance plan for at least 1 year before and at least 6 weeks after treatment were obtained from a large national private insurance claims database. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000553DOI Listing
December 2018
3 Reads

Eyes and Ears on Patient Safety: Sources of Notifications About the Health, Performance, and Conduct of Health Practitioners.

J Patient Saf 2018 Nov 21. Epub 2018 Nov 21.

Stanford University School of Medicine and Stanford Law School, Stanford, California.

Objective: The aim of the study was to describe the sources of notifications of concern ("notifications") regarding the health, performance, and conduct of health practitioners from 14 registered professions in Australia.

Methods: This retrospective cohort study analyzed 43,256 notifications lodged with the Australian Health Practitioner Regulation Agency and the Health Professional Councils Authority between 2011 and 2016. We used descriptive statistical analysis to describe the characteristics of these notifications, including their source, issue and domain, and subject. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000544DOI Listing
November 2018
1 Read

UDI2Claims: Planning a Pilot Project to Transmit Identifiers for Implanted Devices to the Insurance Claim.

J Patient Saf 2018 Nov 21. Epub 2018 Nov 21.

College of Health Solutions, Arizona State University, Phoenix, Arizona.

Background: In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000543DOI Listing
November 2018
3 Reads

OD, OS, and OU: Talking in Code?

J Patient Saf 2019 Mar;15(1):e1-e2

University of Arizona, College of Medicine, Tucson, Arizona Burrell College of Osteopathic Medicine, Las Cruces, New Mexico.

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http://dx.doi.org/10.1097/PTS.0000000000000556DOI Listing
March 2019
1 Read

Establishing a Culture of Patient Safety, Quality, and Service in Plastic Surgery: Integrating the Fractal Model.

J Patient Saf 2018 Nov 23. Epub 2018 Nov 23.

Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.

Problem: There are obstacles to effective nationwide implementation of a culture of patient safety. Plastic surgery faces unique challenges in this area because quality measures are not as well-established as in other fields. Plastic surgery may also require emphasis on patient-reported outcomes as a quality-of-life specialty with distinct concomitant analytical methods. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000554DOI Listing
November 2018

Patient Experiences With Handling of Analgesic Transdermal Patches and Challenges in Correct Drug Administration: A Pilot Study on Patient Education.

J Patient Saf 2018 Dec;14(4):e97-e101

Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany.

Background: Although problems during transdermal patch administration are primarily caused by insufficient knowledge, patient education programs are lacking. We compared patient education by a clinical pharmacist on knowledge on correct patch administration with routine counseling during patient-physician consultation in a pilot study.

Methods: After baseline assessment of knowledge and difficulties with patch administration, patients in the outpatient pain clinic of Heidelberg University Hospital were allocated to intervention (n = 12) or control group (n = 11). Read More

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http://dx.doi.org/10.1097/PTS.0000000000000538DOI Listing
December 2018
11 Reads

Patient Safety: An Important yet Neglected Issue in Nursing Education: Erratum.

Authors:

J Patient Saf 2018 Dec;14(4):246

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http://dx.doi.org/10.1097/PTS.0000000000000557DOI Listing
December 2018
9 Reads

Transitioning to E-Prescribing: Preformatted Prescription Forms Improve Safety, Formulary Compliance, Prescribing Satisfaction, and Perceived Efficiency.

J Patient Saf 2018 Dec;14(4):241-245

Internal Medicine, Olive View-UCLA Medical Center, Sylmar, CA.

Objectives: Compared with blank prescriptions, electronic prescribing (e-prescribing) is safer and more formulary-compliant, satisfying, and efficient. Owing to cost, fewer publicly funded organizations use e-prescribing but may afford preformatted prescription forms. We investigated whether preformatted prescription forms confer similar benefits as e-prescribing. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000198DOI Listing
December 2018
4 Reads

Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference.

J Patient Saf 2018 Nov 16. Epub 2018 Nov 16.

Department of Emergency Medicine, Brigham and Women's Hospital.

Objectives: We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors.

Methods: We implemented an anonymous M&M conference at an academic emergency medicine program. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000555DOI Listing
November 2018

The Ambulatory Version of the Safety Attitude Questionnaire: Psychometric Validation and Measurement Properties in Nigerian Clinical Setting.

J Patient Saf 2018 Nov 13. Epub 2018 Nov 13.

From the Department of Preventive and Social Medicine, University of Port Harcourt, Port Harcourt, Nigeria.

Background: Understanding the safety culture of health care providers can help administrators improve patient safety. However, it is difficult to measure complex constructs such as safety culture without valid and reliable tools. This study determined the measurement properties of the ambulatory version of the safety attitude questionnaire (SAQ-AV) in the Nigerian clinical setting. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000551DOI Listing
November 2018
6 Reads

Extended Patient Alone Time in Emergency Department Leads to Increased Risk of 30-Day Hospitalization.

J Patient Saf 2018 Nov 13. Epub 2018 Nov 13.

Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota.

Objectives: This study was conducted to describe patients at risk for prolonged time alone in the emergency department (ED) and to determine the relationship between clinical outcomes, specifically 30-day hospitalization, and patient alone time (PAT) in the ED.

Methods: An observational cohort design was used to evaluate PAT and patient characteristics in the ED. The study was conducted in a tertiary academic ED that has both adult and pediatric ED facilities and of patients placed in an acute care room for treatment between May 1 and July 31, 2016, excluding behavioral health patients. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000545DOI Listing
November 2018
9 Reads

Health Information and the Quality and Safety of Care for People With Disability: An Analysis of Australian Reports of Reviewable Deaths in Residential Care.

J Patient Saf 2018 Nov 13. Epub 2018 Nov 13.

Graduate School of Health, University of Technology Sydney, New South Wales, Australia.

Objective: Many Australians with disability live in residential care and require assistance to manage their health information across hybrid care settings encompassing residential care, primary and tertiary care, and allied health. In this study, we examined case study reports on people with disability living in residential care in New South Wales, Australia to (a) identify threats to the quality of care and safety for this vulnerable patient group in relation to health documentation and information infrastructure and (b) evaluate the applicability of a conceptual health information infrastructure model.

Methods: All 99 case studies were extracted from eight New South Wales Ombudsmen reports of reviewable deaths for a directed content analysis applying a conceptual model of health information infrastructure in residential care. Read More

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http://Insights.ovid.com/crossref?an=01209203-900000000-9930
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http://dx.doi.org/10.1097/PTS.0000000000000550DOI Listing
November 2018
14 Reads

Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety.

J Patient Saf 2018 Nov 9. Epub 2018 Nov 9.

Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida.

Suboptimal exchange of information can have tragic consequences to patient's safety and survival. To this end, the Joint Commission lists communication error among the most common attributable causes of sentinel events. The risk management literature further supports this finding, ascribing communication error as a major factor (70%) in adverse events. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000541DOI Listing
November 2018

Validating a Trigger Tool for Detecting Adverse Drug Events in Elderly Patients With Multimorbidity (TRIGGER-CHRON).

J Patient Saf 2018 Nov 9. Epub 2018 Nov 9.

Departamento de Farmacología y Farmacognosia de la Facultad de Farmacia, Universidad de Sevilla, Sevilla, Spain.

Purpose: The aims of the study were to evaluate the performance of an initial list developed to detect adverse drug events (ADEs) in elderly patients with multimorbidity in clinical practice, to explore the possibility of shortening the list, and to use this tool to study the incidence and characteristics of the ADEs among this population.

Methods: This observational study was conducted at 12 Spanish hospitals. A random sample of five charts from each hospital was selected weekly for retrospective review for a 12-week period. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000552DOI Listing
November 2018

The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care.

J Patient Saf 2018 Nov 7. Epub 2018 Nov 7.

Department of Applied Mathematics and Statistics, Baskin School of Engineering University of California, Santa Cruz, California.

Objectives: Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000546DOI Listing
November 2018
11 Reads

Risk Management in the Ambulatory Care Process in a Mutual Benefit Association Covering Work-Related Accidents and Diseases: Applying Modified Failure Mode and Effect Analysis (FMEA) Methodology.

J Patient Saf 2018 Nov 7. Epub 2018 Nov 7.

Area of Healthcare and Economic Benefit, MC Mutual, Barcelona, Spain.

Aim: To assess the impact of different forms of use of failure mode and effect analysis methodology for risk prioritization in the ambulatory care process in a mutual benefit association covering work-related accidents and diseases.

Methods: The study is based on a previously drafted and individually prioritized risk map by a multidisciplinary team made up of patient safety committee members from health care centers and clinics in a mutual benefit association covering work-related accidents and diseases. The professionals mainly carry out their work in the field of management (individual manager group (IMG)). Read More

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http://dx.doi.org/10.1097/PTS.0000000000000542DOI Listing
November 2018
16 Reads

Multicenter Test of an Emergency Department Trigger Tool for Detecting Adverse Events.

J Patient Saf 2018 Jul 18. Epub 2018 Jul 18.

Department of Medicine, University of Central Florida, Orlando, Florida.

Objectives: Traditional approaches to safety and quality screening in the emergency department (ED) are porous and low yield for identifying adverse events (AEs). A better approach may be in the use of trigger tool methodology. We recently developed a novel ED trigger tool using a multidisciplinary, multicenter approach. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343477PMC
July 2018
9 Reads

Advancing Patient Safety Through the Clinical Application of a Framework Focused on Communication.

J Patient Saf 2018 Oct 31. Epub 2018 Oct 31.

Objectives: The study of communication has evolved from diverse academic disciplines, yet those diverse fields are not well represented in theoretical frameworks that describe communication in health care, narrowing our ability to explain how communication affects patient safety. The purpose of this review article is to describe a conceptual framework of communication drawn from multiple academic disciplines and apply it to health care, specifically for examining communication between providers about the clinical care of their patients.

Methods: A seminal article in the field of communication that attempted to map the entire field of communication theory inspired our conceptual framework. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000547DOI Listing
October 2018
1 Read

The Role of Education in Developing a Culture of Safety Through the Perceptions of Undergraduate Nursing Students: An Integrative Literature Review.

J Patient Saf 2018 Oct 31. Epub 2018 Oct 31.

From the College of Nursing, Texas Woman's University, Houston, TX.

Objective: This integrative literature review seeks to examine research-based knowledge about the role of education in developing a culture of safety through the perspectives of undergraduate nursing students.

Methods: An integrative literature review of nursing and health databases was conducted and literature from 2009 to 2018 were reviewed. Studies focusing on patient safety education in undergraduate nursing students were analyzed to identify the current state of safety education in academia. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000548DOI Listing
October 2018
1 Read

Clinical, Economic, and Organizational Impact of the Clinical Pharmacist in an Orthopedic and Trauma Surgery Department.

J Patient Saf 2018 Oct 25. Epub 2018 Oct 25.

Centre Hospitalier Universitaire de Montpellier, Hôpital Lapeyronie, Département de Chirurgie Orthopédique du Membre Inferieur et de Traumatologie.

Aim: The aim of this study was to evaluate the clinical, economic, and organizational impact of clinical pharmacist services added to an adult orthopedic and trauma surgery unit in a university hospital.

Methods: This was a prospective, observational study performed from January to February 2017. All pharmacists' interventions were documented, and their clinical, economic, and organizational impact and the probability of adverse drug events (ADEs) were assessed using the clinical, economic and organizational scale three-dimensional scale. Read More

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http://Insights.ovid.com/crossref?an=01209203-900000000-9931
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http://dx.doi.org/10.1097/PTS.0000000000000539DOI Listing
October 2018
1 Read

Examining Medical Office Owners and Clinicians Perceptions on Patient Safety Climate.

J Patient Saf 2018 Oct 10. Epub 2018 Oct 10.

Department of Health Care Organization and Policy, School of Public Health, University of Alabama Birmingham, Birmingham, Alabama.

Objective: An essential element of effective medical practice management is having a shared set of beliefs among members regarding patient safety climate. Recognizing the need for improving patient safety, the Agency for Healthcare Research and Quality began a series of surveys to assess medical practice members' attitudes and beliefs on patient safety climate. The aim of the study was to examine owners and clinicians perceptions of their medical practice's patient safety climate. Read More

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http://Insights.ovid.com/crossref?an=01209203-900000000-9931
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http://dx.doi.org/10.1097/PTS.0000000000000540DOI Listing
October 2018
1 Read

Infrastructure Design: A Critical Element in the Care of the Patient With Obesity.

J Patient Saf 2018 Oct 10. Epub 2018 Oct 10.

Ottolino Winters Huebner, St. Louis, Missouri.

The worldwide rate of obesity continues to rise, causing healthcare systems to morph to meet the demands posed by the concomitant increase in comorbidities associated with this condition. Increasing patient weight imposes its own constraints on the safety of patients and providers; therefore, a sound healthcare facility infrastructure is required to properly address the medical needs of patients with obesity. Currently, most healthcare systems-in their attitudes, equipment, and facility design-are ill equipped to meet the needs of this epidemic. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000537DOI Listing
October 2018
12 Reads
0.880 Impact Factor

An Analysis of the FDA MAUDE Database and the Search for Cobalt Toxicity in Class 3 Johnson & Johnson/DePuy Metal-on-Metal Hip Implants.

J Patient Saf 2018 Dec;14(4):e89-e96

Health Watch USA, Solon, Ohio.

Introduction: This study was designed to determine whether systemic cobalt toxicity as an adverse event could be documented using the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for cobalt-chromium containing hip implant recipients. Class 3 Johnson & Johnson (J&J)/DePuy devices were chosen for analysis because of the large number of adverse event reports related to their Pinnacle and ASR XL Acetabular hip replacement systems. A secondary goal was to characterize the reporters who are populating the information in the MAUDE database and to evaluate the quality of the data and information submitted. Read More

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http://Insights.ovid.com/crossref?an=01209203-900000000-9931
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http://dx.doi.org/10.1097/PTS.0000000000000534DOI Listing
December 2018
3 Reads

Quality Improvement Program Outcomes for Endotracheal Intubation in the Emergency Department.

J Patient Saf 2018 Dec;14(4):e83-e88

Department of Emergency Nursing, Samsung Medical Center, Seoul, South Korea.

Objectives: We describe our 3-year experience with endotracheal intubation (ETI) outcomes during a multidisciplinary emergency department (ED)-based quality improvement (QI) program.

Methods: This was a single-center, observational study taking place during a QI program. We used a registry for airway management performed in the ED from April 2014 to February 2017. Read More

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http://Insights.ovid.com/crossref?an=01209203-900000000-9931
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http://dx.doi.org/10.1097/PTS.0000000000000536DOI Listing
December 2018
1 Read

Antithrombotic Stewardship: Assessing Use of Computerized Clinical Decision Support Tools to Enhance Safe Prescribing of Direct Oral Anticoagulants in Hospitalized Patients.

J Patient Saf 2018 Sep 25. Epub 2018 Sep 25.

Division of hematology, Department Medicines, NYU Langone Health, New York, New York.

Prescribing patterns for oral anticoagulants in patients with nonvalvular atrial fibrillation and venous thromboembolism is shifting from vitamin K antagonists, such as warfarin to the direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, and apixaban. Although many hospital systems have implemented clinical decision support or enhanced monitoring for patients prescribed warfarin, there is limited evidence to suggest similar levels of enhanced monitoring for DOACs. The antithrombotic stewardship team at our institution developed guidelines and implemented computerized clinical decision support (CCDS) tools to enhance medication and patient safety related to the DOACs. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000535DOI Listing
September 2018
1 Read

Resilience From a Stakeholder Perspective: The Role of Next of Kin in Cancer Care.

J Patient Saf 2018 Sep 11. Epub 2018 Sep 11.

Faculty of Health Sciences, SHARE - Center for Resilience in Healthcare, University of Stavanger, Stavanger, Norway.

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). Read More

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http://dx.doi.org/10.1097/PTS.0000000000000532DOI Listing
September 2018

Does Free-Text Information in Falls Incident Reports Assist to Explain How and Why the Falls Occurred in a Hospital Setting?

J Patient Saf 2018 Sep 5. Epub 2018 Sep 5.

WA Centre for Health and Ageing, Royal Perth Hospital Unit, School of Medicine & Pharmacology and Centre for Medical Research, University of Western Australia, Perth, Western Australia.

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. The falls reported occurred in a cohort of older hospital patients (mean age = 82 y) on rehabilitation wards. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000533DOI Listing
September 2018
2 Reads

Patient Safety Culture, Health Information Technology Implementation, and Medical Office Problems That Could Lead to Diagnostic Error.

J Patient Saf 2018 Aug 22. Epub 2018 Aug 22.

Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California.

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.

Methods: We used survey data from 925 medical offices nationwide that voluntarily submitted results to the 2012 Agency for Healthcare Research and Quality Medical Office Surveys on Patient Safety Culture database. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000531DOI Listing
August 2018
12 Reads

Improved Compliance and Comprehension of a Surgical Safety Checklist With Customized Versus Standard Training: A Randomized Trial.

J Patient Saf 2018 Sep;14(3):138-142

From the Departments of Cardiology.

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. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000183DOI Listing
September 2018
5 Reads

Therapeutic Duplication of Long-Acting Injectable Drugs.

J Patient Saf 2018 Sep;14(3):e74-e75

Section of Cardiology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.

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. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000526DOI Listing
September 2018
7 Reads

Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection.

J Patient Saf 2018 Aug 14. Epub 2018 Aug 14.

Intensive Care Unit, Princess Alexandra Hospital.

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. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000528DOI Listing
August 2018
3 Reads
0.880 Impact Factor

What Can Apologies in the Electronic Health Record Tell Us About Health Care Quality, Processes, and Safety?

J Patient Saf 2018 Jul 17. Epub 2018 Jul 17.

From the Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota.

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. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000514DOI Listing
July 2018
9 Reads

Adverse Effects of the Medicare PSI-90 Hospital Penalty System on Revenue-Neutral Hospital-Acquired Conditions.

J Patient Saf 2018 Jul 17. Epub 2018 Jul 17.

Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland.

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. Read More

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http://dx.doi.org/10.1097/PTS.0000000000000517DOI Listing
July 2018
16 Reads