Patient Safety in Surgery最新文献

{"title":"Long-Term Care Healthcare-Associated Infections in 2022: An Analysis of 20,216 Reports","authors":"Shawn Kepner, C. Bingman, Rebecca Jones","doi":"10.33940/001c.74494","DOIUrl":"https://doi.org/10.33940/001c.74494","url":null,"abstract":"The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the United States. In addition to over 4.5 million acute care reports, the PA-PSRS database contains more than 396,000 long-term care (LTC) healthcare-associated infection (HAI) reports. LTC HAI data from PA-PSRS were extracted on March 1, 2023. Reports submitted by LTC facilities and specific care areas were included for infection rates each month if resident and device days were also entered in PA-PSRS for the facility and care area. A total of 20,216 infections were reported in 2022, representing a 12.5% increase from 2021. Overall, the reporting rate from LTC facilities increased from 0.77 in 2021 to 0.87 in 2022. Over half (56%) of the increase in overall rate is due to an increase in the respiratory tract infection rate, with another 27% due to an increase in the gastrointestinal infection rate. All six regions of the state had an increase in overall infection rate from 2021 to 2022. The North Central region of the state had the highest overall rate, as well as the largest increase in rate, with 1.14 reports per 1,000 resident days in 2022, which is an increase of 21.3% over the 2021 rate of 0.94. The Southeast region had the lowest overall rate, at 0.67, which is an 8.1% increase from 2021. The number of reports increased for all five infection types from 2021 to 2022, with gastrointestinal infections increasing the most percentagewise, by 67.7%. Of the 14 infection subtypes, 11 had an increase in number of reports from 2021 to 2022, with influenza showing the largest increase of 857 reports. Norovirus had a larger percentage increase of 942.9%, going from 70 reported infections in 2021 to 730 in 2022. The three subtypes that decreased in number had relatively smaller changes than the increases, with the largest of the decreases occurring with C. diff, which dropped by 29 reports from 2021 to 2022. There was an increase in the total number and rate of infections reported to PA-PSRS in 2022. Patient Safety Authority infection preventionists continue to note operational challenges in LTC facilities and are providing ongoing education and guidance to enhance infection prevention and surveillance strategies and improve reporting of HAIs.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"43 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73781263","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":"Multiphase preclinical assessment of a novel device to locate unintentionally retained surgical sharps: a proof-of-concept study.","authors":"Hae Sung Kang,&nbsp;Jad Khoraki,&nbsp;Jessie Gie,&nbsp;Dielle Duval,&nbsp;Susan Haynes,&nbsp;Michael Siev,&nbsp;Jay Shah,&nbsp;Fernando Kim,&nbsp;Martin Mangino,&nbsp;Levi Procter,&nbsp;Riccardo Autorino,&nbsp;Samuel Weprin","doi":"10.1186/s13037-023-00359-8","DOIUrl":"https://doi.org/10.1186/s13037-023-00359-8","url":null,"abstract":"<p><strong>Background: </strong>Retained surgical sharps (RSS) is a \"never event\" that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device (\"Melzi Sharps Finder®\" or MSF) in effective detection of RSS.</p><p><strong>Methods: </strong>The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF.</p><p><strong>Results: </strong>In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control (98.1% vs. 22.0%, p < 0.001; 1.64 min ± 1.12vs. 3.34 min ± 1.28, p < 0.001). It also had increased accuracy of determining the presence of a needle and decreased time to reach this decision (100% vs. 58.8%, p < 0.001; 1.69 min ± 1.43 vs. 4.89 min ± 0.63, p < 0.001). In-the second study, the accuracy of determining the presence of a needle and time to reach this decision were comparable in each group (88.9% vs. 100% vs. 84.5%, p < 0.49; 2.2 min ± 2.2 vs. 2.7 min ± 2.1vs. 2.8 min ± 1.7, p = 0.68). In the third study, MSF group had higher accuracy in determining the presence of a needle and decreased time to reach this decision than the control (97.0% vs. 46.7%, p < 0.001; 2.0 min ± 1.5 vs. 3.9 min ± 1.4; p < 0.001). Multivariable analysis showed that MSF use was independently associated with an accurate determination of the presence of a needle (OR 12.1, p < 0.001).</p><p><strong>Conclusions: </strong>The use of MSF in this study's RSS models facilitated the determination of presence and localization of RSS as shown by the increased rate of identification of a needle, decreased time to identification and higher accuracy in determining the presence of a needle. This device may be used in conjunction with radiography as it gives live visual and auditory feedback for users during the search for RSS.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"10"},"PeriodicalIF":3.7,"publicationDate":"2023-04-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10131432/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9729536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Compliance to perioperative anticoagulation protocols in elderly patients undergoing elective orthopedic procedures: a retrospective observational cohort study on 548 patients.","authors":"Lizzie Munk,&nbsp;Tom van Essen,&nbsp;Casper van der Hoeven,&nbsp;Peter A Nolte,&nbsp;Matthijs L Becker","doi":"10.1186/s13037-023-00357-w","DOIUrl":"https://doi.org/10.1186/s13037-023-00357-w","url":null,"abstract":"<p><strong>Background: </strong>Compliance with perioperative anticoagulation guidelines is essential to minimize bleeding and thromboembolic risks in patients undergoing surgery. Compared to vitamin-K antagonists (VKAs), perioperative management of direct oral anticoagulants (DOACs) contains fewer steps. Therefore, we hypothesized that noncompliance with guidelines in VKA users is higher than in DOAC users. The primary aim of our study was to investigate the difference in noncompliance to perioperative anticoagulant management guidelines between elderly patients using VKAs versus those using DOACs. The secondary aim was to determine the difference in occurrence of conflicting information communicated to the patients and the difference in incidence of coagulation-related adverse events.</p><p><strong>Methods: </strong>This retrospective non-controlled observational cohort study examined elderly patients undergoing elective orthopedic surgery in a teaching hospital in the Netherlands. All patients undergoing elective orthopedic surgery between 1 May 2016 and 1 January 2020, aged 70 years and over, using VKAs or DOACs were selected. Nonelective surgeries were excluded. The primary outcome was the noncompliance to perioperative anticoagulant management guidelines. Secondary outcomes were missing or conflicting information on anticoagulation management communicated to the patient and coagulation-related adverse events. For continuous data, the unpaired T-test was used and for categorical data, the chi-square test.</p><p><strong>Results: </strong>In patients using VKAs, noncompliance to one of the steps of perioperative anticoagulation management was 81%, compared to 55% in patients using DOACs (p < 0.001). In most cases, VKAs or DOACs were interrupted for longer than recommended. In 13% of patients using a VKA with perioperative bridging, bridging was not conducted as recommended in the guidelines. In 13% of patients using a DOAC, a low-molecular-weight heparin (LMWH) was prescribed while a DOAC had already been restarted postoperatively. VKA users received conflicting information about perioperative anticoagulation management more often than DOAC users (33% versus 20%; p < 0.001). No difference was seen in postoperative coagulation-related complications.</p><p><strong>Conclusion: </strong>Guidelines compliance in DOAC users is higher than in VKA users. Clinical decision support to help in selecting the right interruption interval in DOAC users, simplified standardized perioperative management, good coordination of instructions given to patients, and familiarity with updated guidelines are important in reducing noncompliance.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"9"},"PeriodicalIF":3.7,"publicationDate":"2023-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10116649/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9414524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluation of errors related to surgical pathology specimens of different hospital departments with a patient safety approach: a case study in Iran.","authors":"Seyed Saeed Tabatabaee,&nbsp;Vahid Ghavami,&nbsp;Rohollah Kalhor,&nbsp;Mohammad Amerzadeh,&nbsp;Hadi Zomorrodi-Niat","doi":"10.1186/s13037-023-00360-1","DOIUrl":"https://doi.org/10.1186/s13037-023-00360-1","url":null,"abstract":"<p><strong>Background: </strong>Most surgical specimen errors occur in the pre-analysis stage, which can be prevented. This study aims to identify errors related to surgical pathology specimens in one of the most comprehensive healthcare centers in Northeast Iran.</p><p><strong>Methods: </strong>The present study is descriptive and analytical research conducted cross-sectionally in 2021 at Ghaem healthcare center in the Mashhad University of Medical Sciences on the basis of a census sampling. We used a standard checklist to collect information. Professors and pathologists evaluated the validity and reliability of the checklist using Cronbach's alpha calculation method of 0.89. We analyzed the results using statistical indices, SPSS 21 software, and the chi-square test.</p><p><strong>Results: </strong>Out of 5617 pathology specimens studied, we detected 646 errors. The highest number of errors is the mismatch of the specimen with the label (219 cases; 3.9%) and the non-compliance of the patient's profile in the specimen sent with the label (129 cases; 2.3%), and the lowest errors are the inappropriate volume of the fixator(24 cases; 0.4%), and they accounted for insufficient sample size (25 cases; 0.4%). Based on Fisher's exact test results, there was a significant difference between the proportion of errors in different departments and months.</p><p><strong>Conclusion: </strong>Considering the frequency of labeling errors in the stage before the analysis in the pathology department, the use of barcode imprinted in specimen containers, the removal of the paper request for pathology, the use of radio frequency chip technology, the use of the rechecking system and improving communication in different departments can be effective in reducing these errors.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"8"},"PeriodicalIF":3.7,"publicationDate":"2023-04-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10114301/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9412925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Investigational medications in 9,638 hospitalized patients with severe COVID-19: lessons from the \"fail-and-learn\" strategy during the first two waves of the pandemic in 2020.","authors":"Adam C Delgado,&nbsp;Brendon Cornett,&nbsp;Ye Ji Choi,&nbsp;Christina Colosimo,&nbsp;Vincent P Stahel,&nbsp;Oliwier Dziadkowiec,&nbsp;Philip F Stahel","doi":"10.1186/s13037-023-00358-9","DOIUrl":"https://doi.org/10.1186/s13037-023-00358-9","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The early surge of the novel coronavirus disease 2019 (COVID-19) pandemic introduced a significant clinical challenge due to the high case-fatality rate in absence of evidence-based recommendations. The empirical treatment modalities were relegated to historical expertise from the traditional management of acute respiratory distress syndrome (ARDS) in conjunction with off-label pharmaceutical agents endorsed under the \"emergency use authorization\" (EUA) paradigm by regulatory agencies. This study was designed to evaluate the insights from the \"fail-and-learn\" strategy in 2020 before the availability of COVID-19 vaccines and access to reliable insights from high-quality randomized controlled trials.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A retrospective, multicenter, propensity-matched, case-control study was performed on a data registry comprising 186 hospitals from a national health care system in the United States, designed to investigate the efficacy of empirical treatment modalities during the early surge of the COVID-19 pandemic in 2020. Reflective of the time-windows of the initial two surges of the pandemic in 2020, patients were stratified into \"Early 2020\" (March 1-June 30) versus \"Late 2020\" (July 1-December 31) study cohorts. Logistic regression was applied to determine the efficacy of prevalent medications (remdesivir, azithromycin, hydroxychloroquine, corticosteroids, tocilizumab) and supplemental oxygen delivery modalities (invasive vs. non-invasive ventilation) on patient outcomes. The primary outcome measure was in-hospital mortality. Group comparisons were adjusted for covariates related to age, gender, ethnicity, body weight, comorbidities, and treatment modalities pertinent to organ failure replacement.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;From a total of 87,788 patients in the multicenter data registry screened in this study, 9,638 patients were included who received 19,763 COVID-19 medications during the first two waves of the 2020 pandemic. The results showed a minimal, yet statistically significant, association with hydroxychloroquine in \"Early 2020\" and remdesivir in \"Late 2020\" with reduced odds of mortality (odds ratios 0.72 and 0.76, respectively; P = 0.01). Azithromycin was the only medication associated with decreased odds of mortality during both study time-windows (odds ratios 0.79 and 0.68, respectively; P &lt; 0.01). In contrast, the necessity for oxygen supply showed significantly increased odds of mortality beyond the effect of all investigated medications. Of all the covariates associated with increased mortality, invasive mechanical ventilation had the highest odds ratios of 8.34 in the first surge and 9.46 in in the second surge of the pandemic (P &lt; 0.01).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;This retrospective multicenter observational cohort study on 9,638 hospitalized patients with severe COVID-19 during revealed that the necessity for invasive ventilation had the highest odds of mortality, ","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"7"},"PeriodicalIF":3.7,"publicationDate":"2023-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10088131/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9398384","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Online Supplement to “Reduction of Patient Harm Through Decreasing Urine Culture Contamination in an Emergency Department Using Multiple Process Improvement Interventions”","authors":"Clare Cowen, Shelley Frinsco, Rebecca Nosal, Faith Colen","doi":"10.33940/supplement/2023.3.9","DOIUrl":"https://doi.org/10.33940/supplement/2023.3.9","url":null,"abstract":"This supplementary material has been provided by the authors to give readers additional information about their work.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"432 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135897864","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":"Factors contributing to preventing operating room \"never events\": a machine learning analysis.","authors":"Dana Arad,&nbsp;Ariel Rosenfeld,&nbsp;Racheli Magnezi","doi":"10.1186/s13037-023-00356-x","DOIUrl":"https://doi.org/10.1186/s13037-023-00356-x","url":null,"abstract":"<p><strong>Background: </strong>A surgical \"Never Event\" is a preventable error occurring immediately before, during or immediately following surgery. Various factors contribute to the occurrence of major Never Events, but little is known about their quantified risk in relation to a surgery's characteristics. Our study uses machine learning to reveal and quantify risk factors with the goal of improving patient safety and quality of care.</p><p><strong>Methods: </strong>We used data from 9,234 observations on safety standards and 101 root-cause analyses from actual, major \"Never Events\" including wrong site surgery and retained foreign item, and three random forest supervised machine learning models to identify risk factors. Using a standard 10-cross validation technique, we evaluated the models' metrics, measuring their impact on the occurrence of the two types of Never Events through Gini impurity.</p><p><strong>Results: </strong>We identified 24 contributing factors in six surgical departments: two had an impact of > 900% in Urology, Orthopedics, and General Surgery; six had an impact of 0-900% in Gynecology, Urology, and Cardiology; and 17 had an impact of < 0%. Combining factors revealed 15-20 pairs with an increased probability in five departments: Gynecology, 875-1900%; Urology, 1900-2600%; Cardiology, 833-1500%; Orthopedics,1825-4225%; and General Surgery, 2720-13,600%. Five factors affected wrong site surgery's occurrence (-60.96 to 503.92%) and five affected retained foreign body (-74.65 to 151.43%): two nurses (66.26-87.92%), surgery length < 1 h (85.56-122.91%), and surgery length 1-2 h (-60.96 to 85.56%).</p><p><strong>Conclusions: </strong>Using machine learning, we could quantify the risk factors' potential impact on wrong site surgeries and retained foreign items in relation to a surgery's characteristics, suggesting that safety standards should be adjusted to surgery's characteristics based on risk assessment in each operating room. .</p><p><strong>Trial registration number: </strong>MOH 032-2019.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"6"},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10067209/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9593878","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reduction of Patient Harm Through Decreasing Urine Culture Contamination in an Emergency Department Using Multiple Process Improvement Interventions","authors":"Clare Cowen, Shelley Frinsco, R. Nosal, Faith N Colen","doi":"10.33940/med/2023.3.5","DOIUrl":"https://doi.org/10.33940/med/2023.3.5","url":null,"abstract":"BACKGROUND: From August 2018 to January 2019, the baseline urine sample contamination rate at an acute care hospital emergency department (ED) was 51%. Urine culture contamination is associated with unnecessary antibiotic use, repeat culture costs, and unnecessary inpatient admissions. These outcomes can lead to additional cost to the patient and healthcare system while leading to additional poor outcomes.\u0000\u0000METHODS: Culture results were reviewed and the project definition of contamination was applied. Contaminated cultures were reviewed further via manual electronic health record review of ED notes to determine documentation of collection source, education prior to clean catch collection, the cognitive and physical documented descriptions of the patient, and the name of the staff member who collected the sample.\u0000\u0000INTERVENTION: Staff were educated on appropriate midstream and straight catheter collection techniques, verbal along with picture education for patients, and appropriate identification of patients who may benefit from straight catheterization instead of clean catch. \u0000\u0000RESULTS: The combined interventions resulted in a six-month decrease of contaminated urine samples from the initial 51% to <10%, resulting in an 80% decrease.\u0000CONCLUSION: Urine culture contamination in an acute care ED was sustainably decreased through multiple process improvement interventions. Secondary outcomes included reduction in unnecessary antibiotic use, repeat urine cultures, and unnecessary admissions.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"27 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85231650","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":"Letter From the Editor","authors":"R. Hoffman","doi":"10.33940/001c.74092","DOIUrl":"https://doi.org/10.33940/001c.74092","url":null,"abstract":"This March marks the 21st Patient Safety Awareness Week, first initiated in 2002 by the National Patient Safety Foundation to invite conversations on how to reduce harm and improve care. In this issue, you will find four articles that originated from the Patient Safety Authority’s fall master class in writing. Applicants submitted a description of a recent quality improvement study and those selected participated in a two-part workshop. The facilitators, Johns Hopkins’ Olivia Lounsbury and Patient Safety editors Caitlyn Allen and Eugene Myers, helped translate tremendous patient care into publishable manuscripts. (Keep an eye out for future workshops!)","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"23 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86069685","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":"Adverse Drug Reactions in Moderate Sedation: Process Improvement During a Pandemic","authors":"J. Bayne, A. Craft, Alex Ho, Jenna Mastromarino Riley","doi":"10.33940/med/2023.3.4","DOIUrl":"https://doi.org/10.33940/med/2023.3.4","url":null,"abstract":"Background: A gap analysis identified the need for process improvement surrounding the identification and reporting of adverse drug reactions related to moderate sedation. A change to documentation was selected to address this gap. The challenge was disseminating the change in a meaningful way during a time of high census and limited staffing due to the COVID-19 pandemic. Complex adaptive systems theory was used to plan interventions in the current climate.\u0000\u0000Methods: Process improvement was organized into Plan-Do-Study-Act cycles guided by the gap analysis, literature, and aims. Quantitative data analysis was conducted using chart audits and a Likert survey.\u0000Interventions: Adoption of end-user-redesigned documentation was completed over time using one-on-one instruction, brief just-in-time education sessions at huddles, and ongoing feedback.\u0000\u0000Results: The survey results demonstrated a significant increase in adverse event knowledge (p = <0.01) and documentation confidence following just-in-time training (p < .01). Chart audits revealed an increase in identification of adverse events (p=0.03).\u0000\u0000Conclusions: Using a theory-based approach to implement process improvement is a successful way to create change in a challenging environment. Identification of adverse drug reactions related to moderate sedation increased, which is essential for evaluation and safe administration.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"88 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75915562","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}