Journal of patient safety and quality improvement最新文献

{"title":"Risk and Preventability of Adverse Events at a Finnish Tertiary Hospital Using Modified Global Trigger Tool","authors":"Marjo H Kervinen, K. Haatainen","doi":"10.22038/PSJ.2020.42781.1241","DOIUrl":"https://doi.org/10.22038/PSJ.2020.42781.1241","url":null,"abstract":"Objective To evaluate the risk and preventability of adverse events (AEs) at a 600-bed, tertiary teaching hospital in Kuopio, Finland. Material and methods The review of patient records was organized using the Institute for Healthcare Improvement’s Global Trigger Tool which was modified so that patient's point of view was emphasized. A bi-monthly random sample of hospital charts was selected between October 2014 and April 2016. The association with AEs of factors such as patients' age, sex, emergency vs. elective admission, multimedication, nursing care intensity raw points and categorized reasons for arrival were studied. A binary logistic regression model was employed to evaluate the risk of AEs. Result We found 140 AEs / 1000 patient days and 91 AEs / 100 admissions. Overall, 46 % of hospital admissions (n=305) had an AE. Nursing care intensity raw points influenced the incidence of AEs (OR 1.238, P<0.001), and multimedication (OR 2.897, P=0.001) and nursing care intensity (OR 1.158, P=0.008) predicted preventable AEs. The incidence of all and preventable AEs were significantly influenced by age group (≥65-year vs younger, OR 2.303, P Conclusion Focusing on the patient's point of view, we found a high number of AEs in the study population. The risk for AE was influenced by age group ≥65 years and high nursing care intensity, especially in internal medicine/pulmonology and oncology. Efforts should be focused on these patients to improve patient safety.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"34 1","pages":"53-63"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74481354","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":"Human Milk Banks: A Narrative Review","authors":"J. Vale, J. Miranda, J. Nunes, M. Veiga","doi":"10.22038/PSJ.2020.42356.1239","DOIUrl":"https://doi.org/10.22038/PSJ.2020.42356.1239","url":null,"abstract":"Introduction: Not all mothers can provide sufficient milk, and infants admitted to a neonatal ward are less likely to be exclusively breastfed. Current recommendations are for the use of mother’s own milk (MOM), and pasteurized donor human milk (PDHM) is the next best choice. The present article was prepared as a tool to study the optimal organization of Human milk banks (HMB) and to contribute to the diffusion of the culture and promotion of breastfeeding and summarize current best practices for the handling of PDHM. Materials and Methods: PubMed, Embase and Cochrane were searched using the search term combination “human milk banks” OR “pasteurized donor human milk”. Results: HMB are responsible for human milk (HM) promotion, collection, processing, protection, quality control, distribution and support. The quality of expressed HM is the result of adequate hygienic-sanitary conditions, from expression to administration, and the evaluation of nutritional, immunological, chemical, and microbiological characteristics. It is essential a multidisciplinary team to support an HMB. Conclusion: In settings where donor HM supplies are limited, prioritization of infants by medical status is key. The manner in how investments in human milk feeding are applied should be targeted. The purchase cost of PDHM should be compared with the purchase costs of other nutrition interventions routinely used in care for critically ill neonates.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"17 5","pages":"45-52"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72558692","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":"Causal Inference and Analysis of Surgery Cancellation Risks","authors":"Azra Alizadeh, Milad Eshkevari, M. Pashaei, M. Rezaee","doi":"10.22038/PSJ.2020.38946.1218","DOIUrl":"https://doi.org/10.22038/PSJ.2020.38946.1218","url":null,"abstract":"Introduction The provision of services in hospitals is the final level of the health care system chain, which usually provides the patients with advanced medical services, such as surgery. On the other hand, the cancellation of elective surgeries is one of the problems, which reduces the quality of service delivery and decreases hospital's efficiency and patients' satisfaction followed by increases in patients' costs. This study presented an approach based on a fuzzy inference system to better assess these hazards and eliminate the related risks and investigate effective factors in the cancellation of elective surgeries. Materials and Methods The present study conducted a case study in Shahid Arefian Hospital Urmia, Iran, during 2016-2017. Principal factors of surgery cancellations were collected from surgery documents in the hospital. These factors were divided into five classes, including paraclinical, clinical, systematic, surgeon, and patient. The hazards identified in these classes caused surgery cancellation. They were identified using the contribution of an expert team, including operating room supervisors, female and male surgery hospitalization supervisors, as well as two physicians. Results According to the results, the proposed approach was more appropriate for creating discrimination between surgery cancellation hazards, compared to the traditional risk priority number (RPN) method. Surgeon fatigue, high PPT and PT, and airway problems were the first to third important hazards with RPNs equal to 120, 105, and 96, respectively. On the other hand, according to obtained results, not having internal medicine specialist counseling, low thyroid stimulating hormone, and unavailability of beds at intensive care units were three important and priority potential hazards with FRPNs equal to 8, 8, and 6, respectively. Conclusion The proposed approach can better map hospital experts’ opinions to the fuzzy-based risk assessment system since it employs linguistic variables by hospitals’ experts, compared to conventional approaches. Moreover, it can help the hospital managements apply hospital resources to maximise their impacts on improving hospital efficiency.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"39 1","pages":"3-12"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84941757","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":"Assessment of Medication Administration Error Reporting Among Hospital Nurses in Indonesia","authors":"Indira Prihartono, A. Wibowo","doi":"10.22038/PSJ.2020.43466.1244","DOIUrl":"https://doi.org/10.22038/PSJ.2020.43466.1244","url":null,"abstract":"Introduction: Nurses play a vital role in the maintenance and promotion of patient safety, as well as medication administration in hospitals.  In one small state government-owned hospital in South Jakarta, medication errors were the most reported type of patient safety incidents accounting for 52.5% of incidents which occurred within 2016 to September 2018. Nonetheless, only a small percentage (9.25%) of those reports was presented by nurses. The present study aimed to determine the factors associated with medication administration error (MAE) reporting among nurses. Materials and Methods: A cross-sectional study, followed by qualitative research, was conducted at a state government-owned hospital in Jakarta Indonesia within November 2018-April 2019.  Total sampling was used to obtain the 44 clinical nurses included in the quantitative study. The qualitative study used focus group discussion and in-depth interviews of selected informants. Results: Consequences of reporting was found to be correlated with MAE reporting among nurses (P=0.013). There was no statistically significant organizational factor or socio-demographic characteristic associated with medication administration error reporting. Through qualitative measures, the factors that most influenced and inhibited error reporting included administrative response and the consequences of reporting. Moreover, managers’ support, understanding and self- awareness of the importance of reporting, and a non-blaming culture were recognized as the factors which support error reporting. Conclusion: As evidenced by the obtained results, medication administration error reporting is still low.  Reporting incidents can be improved by fostering a non-blaming safety culture. Further studies are recommended to investigate the occurrence of medication errors, as well as reported errors.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"17 1","pages":"13-23"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77234396","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":"Impact of Leadership Style on Patient Safety Culture in the Department of Radiodiagnosis","authors":"C. Okafor, I. Okon, A. Ugwu, E. Chukwuemeka","doi":"10.22038/PSJ.2020.41439.1236","DOIUrl":"https://doi.org/10.22038/PSJ.2020.41439.1236","url":null,"abstract":"BackgroundHealthcare organisation is a high reliability establishment hence, tackles safety on daily basis. To achieve the desired level of safety, leaders need to work and behave in a way to make it a priority. This is because leadership principles have a relationship with patient safety culture.ObjectiveTo assess the impact of leadership style on patient safety culture in Radiodiagnosis.Materials and MethodThis study was carried out among 80 health workers in Radiodiagnostic department of two tertiary health institutions. Two adopted questionnaires were used to collect data. Leadership style was assessed from subordinates’ perspective so questionnaires on leadership style were administered to 76 out of the 80 enrollees; excluding to 4 leaders in both units of the study areas. All enrollees were given questionnaires on patient safety culture to fill. The impact of leadership styles on patient safety culture was determined using Chi-square test of association,ResultsTransformational and lassiez faire leadership styles have no significant association with all the domains of patient safety culture. Transactional leadership style shows a significant association with two domains of patient safety culture. However, it does not have a significant association with other domains of patient safety culture. An overall chi-square analysis shows that no significant association exists between patient safety culture and transformational (p= 0.156), transactional (p= 0.156) and lassiez faire (p= 0.659) leadership styles.ConclusionThere is no significant association between any of the leadership styles and culture of patient safety. Keywords: Leadership, Patient, safety culture, Radiodiagnosis, Health Institution.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"72 1","pages":"25-30"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74911109","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":"Effect of Emotional Intelligence on the Quality of Nursing Care from the Perspectives of Patients in Educational Hospitals","authors":"J. Najafpour, F. Keshmiri, Soosan Rahimi, Z. Bigdeli, P. Niloofar, A. Homauni","doi":"10.22038/PSJ.2020.41216.1233","DOIUrl":"https://doi.org/10.22038/PSJ.2020.41216.1233","url":null,"abstract":"Introduction: Nurses often work in stressful environments and it is widely accepted that emotions can exert profound effects on the quality of care in hospital settings. Therefore, the impact of emotional intelligence on the performance of nurses has been the focus of numerous studies. The present study aimed to assess the relationship between emotional intelligence and quality of nursing care from the perspectives of patients in hospitals affiliated to Tehran University of medical sciences. Materials and Methods: The current descriptive-analytic cross-sectional study was conducted on nurses and patients in four selected hospitals affiliated to Tehran University of medical sciences in 2016. Sample size was based on sample size formula in nurses with limited population and patients with unlimited population with 95% confidence level. Finally, a total number of 300 nurses and 270 patients were selected. Data collection tools included standardized Emotional Intelligence Questionnaire and Parasuraman Questionnaire (hospital quality assessment). Results: The best score of nurses’ emotional intelligence was reported in the social self- awareness domain (3.9), while the lowest score was detected in self- motivation domain (3.02). In general, it can be concluded that emotional intelligence in nurses was higher than average with 3.2. The results of the present study indicated that there was no significant relationship between emotional intelligence and the quality of nursing care in selected hospitals. Conclusion: As evidenced by the obtained results, there is a significant relationship between some aspects of the quality of hospital services (e.g., sympathy, assurance, and tangible) and emotional intelligence. Nonetheless, a significant relationship was not confirmed between nurses’ emotional intelligence and the quality of hospital services.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"27 1","pages":"37-43"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83712458","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":"Investigating the causes of death in children at Children's Hospital of Tabriz","authors":"N. Bilan, M. Ebrahimi, Zakiyeh Ebadi, B. Abdinia","doi":"10.22038/PSJ.2019.43050.1243","DOIUrl":"https://doi.org/10.22038/PSJ.2019.43050.1243","url":null,"abstract":"Introduction and Objective: Death has long been considered because of its substantial impacts on population dynamics. Specifically, child mortality is one of the most important indicators of development and one of the determinants of life expectancy. Investigation of child mortality causes and elimination of preventable cases can play a major role in the health and productivity of the community. Materials and Methods: The present research was a retrospective study in which the medical records of dead children in Children’s Hospital of Tabriz were extracted from 2011 to 2016 and their demographics were recorded in special checklists. Finally, the obtained data were statistically analyzed. Results: The most common causes of child mortality in the studied hospital were congenital heart defects (15%), cancer (8.8%), and other congenital anomalies (8.6%), respectively. The mortality rate for males and females was equal to 55.8% and 44.2%. In addition, the highest mortality rate was related to those aged one month to 2 years (83.8%) and then 2-7 years (10.2%), and 7-18 years (6.1%). The findings also indicated that most dead children were living in urban areas. Discussion and Conclusion: Maternal nutrition improvement, gestational diabetes control, vaccination improvement, and increased awareness of health sector staff can be effective in reducing genetic anomalies and deaths caused by them. Therefore, special planning should be done for interventions such as referral for genetic counseling and genetic tests before cousin marriages. Moreover, pregnant women should be trained in unnecessary drug use and non-exposure to radiation and chemicals.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"2015 1","pages":"163-166"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86978185","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":"Contextual factors interfacing with quality of care in the emergency department: A micro-ethnographic study","authors":"A. Mirhaghi, M. Ebrahimi, Mohsen Noghani-Dokht-Bahmani, A. Heydari","doi":"10.22038/PSJ.2019.40868.1231","DOIUrl":"https://doi.org/10.22038/PSJ.2019.40868.1231","url":null,"abstract":"Introduction: Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. The influence of nurses’ belief systems on triage decision making has not to the authors’ knowledge been addressed. This study attempted to gain an understanding of the ED nurses’ culture of practice with respect to contextual factors that affect triage decision making. Methods: A focused micro-ethnographic study based on Spradley’s developmental research sequence (DRS) has been conducted in the emergency department of the Mashhad University hospital, Iran, from February 2014 to February 2015. Data were collected during 300 hours of participant observations that were accompanied by formal and informal interviews, then analyzed based on Spradley’s DRS. Results: Nine study participants were formally interviewed. From these interviews, eight core beliefs emerged related to nurses’ culture of practice: namely, triage decision making is arbitrary; the facility/locale of the emergency medicine department is the pivotal contextual factor affecting decision making; not every nurse can be assigned to triage; each patient assumes the existence of an emergency condition; the on-duty physician must be known; triage decision making must be considered plausible by colleagues; “they” tell us something, we should do something else; and triage guidelines are not practical. Conclusion: Contextual factors have a strong tendency to guide triage decision making and violate the principle of patient acuity (that is, that patients with the most acute medical conditions should be prioritized). In response, triage guidelines need to integrate the priorities of patients, nurses, physicians, and administrators.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"1 1","pages":"145-154"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89108645","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":"The Modified Cappuccini Test: A Proxy Indicator For Patient Safety in The Operating Theatre","authors":"James A Morris, S. Mckeon, J. Super, R. Dyke, K. Reynolds, J. Hardman, R. Anakwe","doi":"10.22038/PSJ.2020.44679.1257","DOIUrl":"https://doi.org/10.22038/PSJ.2020.44679.1257","url":null,"abstract":"Introduction: \u0000We report our experience with a modified audit tool, the modified Cappuccini test used to assess the availability and readiness of senior and expert help and supervision for trainee anaesthetists in the operating environment. \u0000Materials and Methods: \u0000We sought to provide assurance as to the level of supervision for surgical and anaesthetic trainees within our organisation, a large tertiary centre in an urban environment. We would expect this to have a direct impact on patient safety in the operative environment and also on the training experience. We modified the Cappuccini test so that it could be used for surgical and anaesthetic trainees .Over 11 days we visited operating theatres across our institution and interviewed 195 trainees (anaesthetists and surgeons) undertaking operating lists. \u0000Results: \u000096 (49.2%) anaesthetic trainees and 99 (50.8%) surgical trainees were interviewed. 166 (85.1%) trainees were being directly supervised by a consultant. 29 (14.9%) trainees were being remotely supervised without a physical consultant presence16 (55.2%) of these were anaesthetic trainees and the remainder were surgical trainees2 (6.9%) trainees stated that they were unsure who was directly supervising them. For the 29 remotely supervised trainees, we contacted 19(65.5%) supervising consultants/senior doctors all of whom were aware that they were supervising the operating list and confirmed that they were available to attend if required. \u0000Conclusion: \u0000The modified Cappuccini test is a simple and helpful tool, providing assurance as to the level of and access to senior and skilled supervision in the operating theatre and with the potential to be modified and deployed in a number environments. We suggest that it is a useful proxy indicator of supervision and potentially also, patient safety in the operating theatre environment. We recommend that for operating lists which are remotely supervised, the name and method of contact for the senior supervising anaesthetist or surgeon should be explicitly stated at the beginning of each case.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"121 43","pages":"185-187"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91403453","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":"The nature of errors in emergency department and the role of detectors: A qualitative study","authors":"A. Abbaszadeh, F. Borhani, Poya Farokhnezhad Afshar, M. Ajri-Khameslou","doi":"10.22038/PSJ.2019.43894.1248","DOIUrl":"https://doi.org/10.22038/PSJ.2019.43894.1248","url":null,"abstract":"Abstract Objectives: Understanding the nature of errors and the way errors are detected by nurses has a major role in preventing and reducing complications of errors. The present study aims to investigate the nature of errors and identify factors detecting errors in the emergency department. Methods: The present qualitative study was conducted with participation of 20 emergency department nurses according to Elo & Kyngas (2008) content analysis method. Data were collected through semi-structured in-depth interviews. Sampling began purposively and continued until data saturation was reached. Results: Analysis of data led to the extraction of two main categories, including nature of errors and error detectors. The nature of errors consisted of two subcategories, namely, lurking errors and indistinguishable of errors. Error detectors comprised four subcategories, namely, personal detectors, team detectors, client detectors, and organizational detectors. Conclusion: The present study results showed that errors in the emergency department are vague in nature and difficult to detect. Nurses use various sources to identify errors. In the context of the present study, human sources, especially nurses and patients have a key role in identifying and detecting errors. These sources of error detection should be reinforced by health organizations.","PeriodicalId":16681,"journal":{"name":"Journal of patient safety and quality improvement","volume":"66 1","pages":"137-143"},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81185733","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}