Journal of patient safety and quality improvement最新文献

{"title":"Barriers to Reporting Medical Errors: A Qualitative Study in Iran","authors":"S. Samadi, Fateme Alipour, Z. Shahvari","doi":"10.22038/PSJ.2021.56316.1315","DOIUrl":"https://doi.org/10.22038/PSJ.2021.56316.1315","url":null,"abstract":"Introduction: This study aimed to emphasize the challenges in the error reporting system as one of the professionalism codes in clinical settings in hospitals affiliated to Tehran University of Medical Sciences, Tehran, Iran. Materials and Methods: In total, 23 focused group discussion sessions were conducted with 85 faculty members, assistants, and interns, as well as 165 staff members in 2016. The participants were selected using a purposeful sampling method. Furthermore, the views of four faculty members were gathered again via emails in 2020 to ensure data accuracy. The extracted codes were managed using conventional content analysis through MAXQDA software. Results: Analysis of participants' discussions led to the identification of 105 codes, which were classified into six sub-categories and two main categories, including \"barriers to reporting errors of peers \" and \"barriers to self-reporting errors\". Conclusion: Most of the non-reporting errors are due to participant’s concerns. Such concerns are generally the result of poor system management or are merely misunderstandings; accordingly, errors' addressing only requires gaining a person's trust. The seriousness of the system in persuading people to report errors is one of the most important ways to gain a person's trust.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"19 1","pages":"65-71"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88886684","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluation of the Difference between Cirrhotic Patients Receiving Propranolol and Those Receiving Propranolol Plus Losartan in terms of Renal Artery Resistive Index","authors":"M. Bayani, Ladan Fakhriyehasl, S. K. Nezam, B. Bayani","doi":"10.22038/PSJ.2021.55640.1312","DOIUrl":"https://doi.org/10.22038/PSJ.2021.55640.1312","url":null,"abstract":"Introduction: Portal hypertension is one of the main clinical complications of chronic liver diseases. In only 30% of cirrhotic patients who take propranolol, the hepatic venous pressure reduces to under 12 mm/Hg. The results of studies on the efficiency of losartan (an angiotensin II receptor antagonist) in reducing portal hypertension have been controversial so far. Hepatic venous pressure gradient (HVPG) is measured using an invasive method of catheterization. Studies have shown that the measurement of the renal resistive index (RI) by Doppler ultrasonography has a direct relationship with HVPG. The study population included cirrhotic patients who referred to Ali-ibn-Abi Talbe Clinic, Zahedan, Iran. This clinical trial was conducted based on a self-controlled method. Materials and Methods: In total, 30 cirrhotic patients who met the inclusion criteria were selected for the study.  The patients were treated with propranolol 10 mg twice a day for one month, and losartan was then added to their medication regimen. The renal RI of patients was measured before and after losartan administration. Results: The mean of renal RI of patients treated with both propranolol and losartan (0.659±0.58) was higher than that of the patients treated with only propranolol (0.635±0.597) (P=0.005). Conclusion: Our results showed that cirrhotic patients who received propranolol had high renal RI before and after receiving losartan. Accordingly, it seems that losartan had no effects on reducing HVPG hypertension in patients taking propranolol.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"59 1","pages":"91-97"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85810093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intraoperative Cardiovascular Instability in a Child Following Instillation of Phenylephrine Eye Drops","authors":"S. Hughes","doi":"10.22038/PSJ.2021.53982.1300","DOIUrl":"https://doi.org/10.22038/PSJ.2021.53982.1300","url":null,"abstract":"Introduction: The use of topical mydriatics is well described in ophthalmic surgery, one of these being phenylephrine eye drops which are available in 1%, 2.5% and 10% solutions. They are classically used to improve operating conditions but there have been recurrent concerns regarding serious adverse reactions as a direct consequence of systemic absorption. Case Reports: We present the case of a 10-year-old boy who presented for eyelid laceration repair and examination under general anaesthesia of the eye, after a severe dog bite injury. Shortly after instillation of 10% phenylephrine eye drops, the anaesthetist noticed a sudden bradycardia associated with profound hypertension. Surgery was temporarily stopped, volatile anaesthetic reduced and atropine boluses administered. Within minutes, blood pressure and heart rate normalized. The administration of the eye drops was determined to be the cause of this haemodynamic instability. Conclusion: A brief literature review has enabled us to raise awareness within our department regarding this important safety concern in paediatric ophthalmic surgery, in addition to exploring management options in the case of inadvertent intravascular absorption.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"167 1","pages":"129-132"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75487315","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Institutional Practices of a Private Hospital in Saudi Arabia: An Initiative to Improve the Hospital’s Safety Culture","authors":"J. L. Abella","doi":"10.22038/PSJ.2021.53516.1296","DOIUrl":"https://doi.org/10.22038/PSJ.2021.53516.1296","url":null,"abstract":"Introduction: Study findings pertain to a private healthcare facility in the Eastern Region of Saudi Arabia, which highlighted its healthcare organization’s implementation of hospital-wide approach aimed at promoting culture change to enhance patient safety. Patient safety is a vital component of quality health care. Health care organizations continually strive for improvement, leading to a growing recognition of the importance of establishing a safe culture, most especially within the Kingdom of Saudi. Materials and Methods: The hospital's culture of safety was investigated using a descriptive research design. The study further discusses how the hospital was able to improve the safety culture within the confines of their organization by instituting several programs which forms as the framework of the hospital’s commitment to safety. The study covers all the healthcare professional of the hospital (clinical and non-clinical) to provide their perception on the topic. Results: This study yielded more than sixty percent (60%) response rate for three consecutive years which strongly supports the findings of the study. The institution’s safety culture has dramatically improved from 2017’s result of 46.4%, 58.6% (2018) and 74.4% in 2019 after engaging an organizational intervention which includes; leadership patient safety walk rounds, good catch campaign, improvement projects, adoption of lean management, continuous organization learning and development, quality accreditation and an intensified leadership support. A number of dimensions contributed to the highest perception of patient safety, including teamwork within and across units, organizational learning and continuous quality improvement, management support for patient safety, and an increase in the perception of overall patient safety culture by staff. Conclusion: The result suggested that the commitment of all healthcare professionals within the organization and an active engagement of managers and executives will absolutely result to positive change in the institution’s culture of safety.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"11 1","pages":"121-128"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86279810","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Causes and Risk Factors for Hospital Readmission in Patients with Ureteral Stones Treated With Transurethral Lithotripsy","authors":"M. Tavakkoli, Atena Aghaee, Saeed Eslami Hasan Abadi, A. Yarahmadi, A. Sharif, Salman Soltani","doi":"10.22038/PSJ.2021.51195.1285","DOIUrl":"https://doi.org/10.22038/PSJ.2021.51195.1285","url":null,"abstract":"Introduction: Urinary tract stones are recognized as the third most prevalent disease in urology. Transurethral lithotripsy (TUL) is the most prevalent surgical modality for ureteral stones. Some patients experience hospital readmission and possibly another surgical intervention after TUL. The present study aimed to assess the causes and risk factors of readmission in patients with ureteral stones treated with TUL. Materials and Methods: This cross-sectional study was conducted on all the patients who underwent TUL in Imam Reza Hospital in Mashhad, northeast of Iran, from March 2018 to September 2019. The case group consisted of 67 patients who were hospitalized due to primary urinary stone-related complications. The patients who were admitted for the removal of double J (DJ) catheter (n=118) were regarded as the control group. Results: The most common causes of hospital readmission were re-TUL for the removal of the remnant urinary stones when patients came back for DJ catheter removal (29.9%). The second and third causes of readmission were fever after DJ catheter removal (20.9%) and fever after TUL (14.9%). The main risk factors for hospital readmission were stone size, age, and male gender. Conclusion: As evidenced by the results of the present study, stone size, age, and male gender were the major risk factors for hospital readmission after TUL. The most common causes of readmission were re-TUL at the time of DJ catheter removal, fever after DJ catheter removal, and fever after TUL.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"65 1","pages":"73-77"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76269751","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Balanced and Imbalanced Performance Evaluation using Balanced Scorecard and Analytic Hierarchy Process","authors":"A. Najar, S. Tabatabaee, Elaheh Houshmand, Hosein Ebrahimipour, Hadi Zomorodi Niat","doi":"10.22038/PSJ.2021.44671.1254","DOIUrl":"https://doi.org/10.22038/PSJ.2021.44671.1254","url":null,"abstract":"Introduction: This study aimed to compare the performance evaluation of a selected hospital through weighting and not weighting the indices using a hybrid approach. Materials and Methods: This mixed-method study was conducted in a Specialized Hospital in Mashhad, Iran. In the group discussion sessions of the scorecard team, a list of performance indices was prepared in four perspectives using a balanced scorecard approach. The indices were selected using the Delphi method and measured in the hospital afterward. In the first method, the percentage of realization of each index was measured based on the expected value of the index in the hospital, and the overall performance score was obtained. In the second method, the weight of each perspective and index was calculated using the standard hierarchy analysis questionnaire, and the coefficient of the significance of each index and perspective was considered in hospital performance based on the expected quantity of the index. Eventually, the performance of the hospital was compared using these two methods. Results: Based on the results obtained from the application of the weighting method, the processes and customer perspectives obtained the highest and the lowest scores, respectively. The score of the hospital’s performance in this method was obtained at 89.27%. However, in the method without weighting, the processes and financial perspectives obtained the highest and the lowest scores, respectively, and the score of the hospital’s performance was estimated at 82.63%. Conclusion: The score of perspectives and indices will be different when the significance of perspectives and indices are ignored, which results in an incorrect (downgraded) estimation of the organization performance.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"83 1","pages":"79-90"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73907518","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Knowledge and Attitude toward Patients’ Safety among Clinical Students in a South Western University, Nigeria","authors":"O. Oyediran, Helen-Chinyere Ofor, Emmaunel-Olufemi Ayandiran, I. O. Ojo","doi":"10.22038/PSJ.2021.53753.1298","DOIUrl":"https://doi.org/10.22038/PSJ.2021.53753.1298","url":null,"abstract":"Introduction: The study investigated the knowledge, attitude, sources of knowledge, as well as the relationship between knowledge and attitude towards patients' safety among clinical students in Obafemi Awolowo University. Materials and Methods: The study adopted a descriptive cross-sectional design and 281 students were selected from the Department of Nursing Science, Medicine, Dentistry, Medical Rehabilitation and Pharmacy using a convenient sampling technique. A semi-structured questionnaire was used to collect data and the data were analyzed by using Statistical Package for Social Sciences (version 25). Data were presented with descriptive and inferential statistics. Results: Findings from this study revealed that respondents' mean age was 21.56±3.20 with the majority of the respondents (65.5%) being within 20-24 years old. 68.7% of the respondents had good knowledge, 19.6% had fair knowledge and 11.7% had poor knowledge. The result also showed that more than half of the respondents ((69.4%) were taught about patient safety as part of my course of study in my department while less than half (46.3%) learnt about patient safety on their own.  The result further showed that 64.1% had a negative attitude while 35.9% had a positive attitude towards patient safety. There was a significant relationship between clinical students’ knowledge and their course of study (Chi-square value =26.90, P-value >0.01). Conclusion: This study established that clinical students have a good knowledge of patient safety but with negative attitude towards patient safety. Hence, the health professionals’ educators need to integrate patient safety curriculum into the education of young health professionals.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"39 1","pages":"99-107"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77722726","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Role of Patient Safety Incident Reporting Systems in Home Hospitalization","authors":"Laura De La Torre-Pérez, Carmen Hernández-Carcereny, I. F. Bazaga, Andreu Prat-Marin, M. J. Luengo","doi":"10.22038/PSJ.2021.52154.1289","DOIUrl":"https://doi.org/10.22038/PSJ.2021.52154.1289","url":null,"abstract":"Introduction: The present study aimed to assess the effectiveness of the current hospital-based electronic patient safety incident reporting system (IRS) in the improvement of patient safety in home hospitalization (HH). Materials and Methods: Out of 6381 patient safety reports voluntarily presented by healthcare professionals in a tertiary hospital in Barcelona between 2016 and 2019, all those related to HH were analyzed.  They were characterized by incident type, description, risk and year, the ways to get notified, patient’s age, and the results of the analysis. Moreover, falls were classified depending on circumstances. Results: Based on the results, 68 HH incident reports were related to the following factors: use of medication (n=2), procedures (1), patient’s behavior (n=1), and falls (n=64). Regarding the damage degree, the incidents were reported as extreme risk (n=1), high (n=8), moderate (n=27),  low (29),  and very low risk (n=3). The majority of patients involved in the incidents were more than 60 years old. Out of the reported falls, 8 cases were categorized as high risk, and 32 cases reported health consequences. Moreover, 19 falls from height, 31 cases of falling while sitting or lying, and 30 incidents classified as unknown were identified. Conclusion: Patient safety is a matter of great concern, especially in HH but with some differential features. The IRS can play a peculiar role in minimizing patient safety risks and promoting a safety culture. The results of the present study pointed to some frequent risks and suggested improving opportunities in HH. Nonetheless, further studies are needed to design tailored patient safety interventions in HH, as well as a tailored IRS adapted to this growing setting.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"49 1","pages":"19-27"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77587731","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Viewpoints of Nurses and Therapeutic Staff toward Patient Safety Culture: A Case Study in Ardabil, Iran","authors":"Somayeh Zeynizadeh-Jeddi, M. Yousefian, Frouz Amani, A. Pirzadeh, Maryam Faraji-Fard","doi":"10.22038/PSJ.2021.54574.1302","DOIUrl":"https://doi.org/10.22038/PSJ.2021.54574.1302","url":null,"abstract":"Introduction: The improvement of Patient Safety Culture (PSC) is the first step in patient immunity promotion. This study aimed to investigate the viewpoints of nurses and therapeutic staff toward PSC. Materials and Methods: This cross-sectional study was conducted on 70 nurses and staff working at Alavi Hospital, Ardabil, Iran, in 2019. The data were collected using a patient safety culture standard questionnaire entitled \"A Hospital Survey on Patient Safety Culture\", which was completed by all participants. Subsequently, the collected data were analyzed in SPSS software (version 24) according to the questionnaire guideline. Results: According to the results, 56 (80%) and 14 (20%) participants had moderate and high levels of PSC, respectively. The highest level of respecting PSC was observed in those with work experience of up to 21 years and operating room staff. Furthermore, PSC showed a significant relationship with hospital work experience and organizational position. Conclusion: The obtained results revealed the moderate level of PSC among nurses and hospital staff in Ardabil, Iran, which required future programing by hospital managers to promote PSC. Moreover, it is recommended to provide a reporting system and encourage the personnel to report the errors and modify the nurses in sections based on work loading.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"34 1","pages":"55-60"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78856270","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Safety Indicators in Clinical Laboratories: An Exploratory Survey among Costa Rican Laboratory Professionals","authors":"Daniel Quesada-Yamasaki, Johan Alvarado-Ocampo, Ana Lucía Chinchilla-Ureña, Edgardo Arce-Soto","doi":"10.22038/PSJ.2021.54960.1307","DOIUrl":"https://doi.org/10.22038/PSJ.2021.54960.1307","url":null,"abstract":"Introduction: Patient safety indicators (PSIs) focus on the prevention of complications and minimization of unnecessary patient risk. Using the methodology known as SMART, the most suitable indicators may be selected by the evaluation of five essential criteria (i.e., specificity, measurability, attainability, relevance, and timeliness).Therefore, the current study aimed to collect and analyze information regarding PSIs related to clinical laboratories in order to support organizations in the process of indicator selection. Materials and Methods: The most widely accepted PSIs for clinical laboratories were identified through a literature review. The indicators were evaluated by conducting a survey on a deliberate sample of 77 laboratory professionals. The answers were analyzed in terms of the frequency of responses for sensitivity, measurability, attainability, relevance, and timeliness. The overall performance of the indicators was assessed using a composite score encompassing the five SMART criteria. Results: The indicators with the best overall performance were tests without internal controls, internal controls with unacceptable performance, critical values communicated in time, unacceptable performance in external controls, and requests with errors concerning patient identification. Significant differences were observed among the top-, mid-, and bottom-performing groups of indicators. Conclusion: The results of the present study revealed the importance of the active participation of the professional community as an essential activity to determine the most appropriate PSIs. In the case of this study in Costa Rica, this community seems to value quality control processes and pre-analytical requirements as key indicators to monitor patient safety in clinical laboratories.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"12 1","pages":"3-17"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90756198","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}