Patient Safety in Surgery最新文献

{"title":"Assessing Equipment, Supplies, and Devices for Patient Safety Issues","authors":"R. Ratwani, Katharine T. Adams, Tracy C. Kim, Deanna-Nicole Busog, Jessica L. Howe, Rebecca Jones, Seth Krevat","doi":"10.33940/data/2023.3.2","DOIUrl":"https://doi.org/10.33940/data/2023.3.2","url":null,"abstract":"Background: Medical equipment, supplies, and devices (ESD) serve a critical function in healthcare delivery and how they function can have patient safety consequences. ESD-related safety issues include malfunctions, physically missing ESDs, sterilization, and usability. Describing ESD-related safety issues from a human factors perspective that focuses on user interactions with ESDs can provide additional insights to address these issues. \u0000\u0000Methods: We manually reviewed ESD patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System to identify ESD-related safety issues using a taxonomy that was informed by the Food and Drug Administration Manufacturer and User Facility Device Experience taxonomy. This taxonomy consisted of the following high-level categories: malfunctions, physically missing, sterilization, and usability. The type of ESD and associated components or ESD subtypes, event classification, and care area group were noted for each report. \u0000\u0000Results: Of the 450 reports reviewed, the most frequent ESD-related safety issue coded was malfunction (n=365 of 450, 81.1%) followed by sterilization (n=40 of 450, 8.9%), usability (n=36 of 450, 8.0%), and physically missing (n=9 of 450, 2.0%). Among the coded malfunctions, software/output problem (n=122 of 365, 33.4%) was the most frequent, followed by general malfunction (n=103 of 365, 28.2%); material integrity (n=72 of 365, 19.7%); and activation, positioning, or separation (n=68 of 365, 18.6%). The most frequent ESDs noted were infusion pump, instrument set, and intravenous, and the most frequent components/subtypes noted were alarm/alert, tubing, and tray. \u0000\u0000Conclusion: ESD-related patient safety issues, especially malfunctions, impact patient care despite current policies and practices to address these issues. Healthcare facilities may be able to address some ESD-related patient safety issues during procurement through use of the accompanying procurement assessment tool.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"41 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73788120","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":"Improving Sepsis Compliance With Human Factors Interventions in a Community Hospital Emergency Room","authors":"Megan Kiser","doi":"10.33940/culture/2023.3.3","DOIUrl":"https://doi.org/10.33940/culture/2023.3.3","url":null,"abstract":"Background: Adherence to best practices for sepsis management at a small community hospital was below system, state, and national benchmarks and affected vital indicators, including mortality. This study aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions. \u0000\u0000Methods: The Plan-Do-Study-Act quality improvement methodology was used for this project. Baseline metrics included sepsis bundle compliance following CMS (Centers for Medicare & Medicaid Services) core measure standards, hospital morality, sepsis triage screening, and physician order set use. \u0000Interventions: Several human factors workflows and tools were used to boost early identification with screening opportunities and enhance staff awareness of sepsis indicators. \u0000\u0000Results: With the interventions, the hospital’s compliance with sepsis best practice treatment improved by a 23 percentage-point increase from baseline. Sepsis triage screening also increased and remained consistent after project interventions. \u0000\u0000Conclusions: With the project, using human factors tools enhanced staff engagement and increased sepsis awareness. Engagement increased sepsis identification and screening in a small community hospital setting.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"55 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74182570","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":"Online Supplement to “Informing Healthcare Alarm Design and Use: A Human Factors Cross-Industry Perspective”","authors":"Zoe Pruitt, Lucy Bocknek, Deanna-Nicole Busog, Patricia Spaar, Arianna Milicia, Jessica Howe, Ella Franklin, Seth Krevat, Rebecca Jones, Raj Ratwani","doi":"10.33940/med/2023.3.7","DOIUrl":"https://doi.org/10.33940/med/2023.3.7","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":"20 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":"135897862","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":"Preventing Central Line Bloodstream Infections: An Interdisciplinary Virtual Model for Central Line Rounding and Consultation","authors":"Erin Lightheart, M. Guyton, Cheryl Gilmar, Jillian Tuzio, M. Ziegler, C. Kucharczuk","doi":"10.33940/med/2023.3.6","DOIUrl":"https://doi.org/10.33940/med/2023.3.6","url":null,"abstract":"Background: Central line–associated bloodstream infections (CLABSI) account for many harms suffered in healthcare and are associated with increased costs and disease burden. Central line rounds, like medical rounds, are a multidisciplinary bedside assessment strategy for all active central lines on a unit. In-person line rounds in this 144-bed oncology acute care setting are challenging due to a variety of unchangeable factors. The aim was to develop a process for addressing concerning central lines in this context. \u0000\u0000Methods: The project team designed a HIPAA-protected, text-based process for assessing central lines for risk factors contributing to infection. Staff initiated a consultation via a virtual platform with an interdisciplinary team composed of oncology and infectious diseases experts. The virtual discussion included recommendations for a line-related plan of care. \u0000\u0000Results: The number of consultations averaged about five per month, with 27.4% resulting in the central line being removed, which is believed to have contributed to an overall reduction in infection rates. The CLABSI standardized infection ratio, a risk-adjusted measure which accounts for patient acuity and volumes, improved from 0.85 prior to the intervention (November 2020–October 2021) to 0.57 after the intervention (November 2021–August 2022), a 33% reduction. \u0000\u0000Conclusion: A virtual process for central line consultation and interdisciplinary planning was effective and, in this setting, perhaps optimal. This type of process could be applied to nearly any aspect of clinical care where teams are solving problems in an environment with complex geography and relationships.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"168 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80571960","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":"Online Supplement to “Assessing Equipment, Supplies, and Devices for Patient Safety Issues”","authors":"Raj Ratwani, Katharine Adams, Tracy Kim, Deanna-Nicole Busog, Jessica Howe, Rebecca Jones, Seth Krevat","doi":"10.33940/supplement/2023.3.8","DOIUrl":"https://doi.org/10.33940/supplement/2023.3.8","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":"356 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":"135897863","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":"Informing Healthcare Alarm Design and Use: A Human Factors Cross-Industry Perspective","authors":"Zoe M. Pruitt, Lucy S. Bocknek, Deanna-Nicole Busog, Patricia A. Spaar, Arianna P. Milicia, Jessica L. Howe, Ella S. Franklin, Seth Krevat, Rebecca Jones, R. Ratwani","doi":"10.33940/med/2023.3.1","DOIUrl":"https://doi.org/10.33940/med/2023.3.1","url":null,"abstract":"Background: Alarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment, or intervention and play a critical safety role in high-risk industries. Healthcare relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. Automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. These guidelines may provide important insights for advancing patient safety in healthcare.\u0000\u0000Methods: We identified documents containing alarm design and use guidelines from the automotive, aviation, and nuclear industries that have been endorsed by oversight agencies. These guidelines were reviewed by human factors and clinical experts to identify those most relevant to healthcare, qualitatively analyze the relevant guidelines to identify meaningful topics, synthesize the guidelines under each topic to identify key commonalities and differences, and describe how the guidelines might be considered by healthcare stakeholders to improve alarm design and use.\u0000\u0000Results: A total of 356 guidelines were extracted from industry documents (2012–present) and 327 (91.9%) were deemed relevant to healthcare. A qualitative analysis of relevant guidelines resulted in nine distinct topics: Alarm Reduction, Appropriateness, Context-Dependence, Design Characteristics, Mental Model, Prioritization, Specificity, Urgency, and User Control. There were several commonalities, as well as some differences, across industry guidelines. The guidelines under each topic were found to inform the auditory or visual modality, or both. Certain guidelines have clear considerations for healthcare stakeholders, especially technology developers and healthcare facilities.\u0000\u0000Conclusion: Numerous guidelines from other high-risk industries can inform alarm design and use in healthcare. Healthcare facilities can use the information presented as a framework for working with their technology developers to appropriately design and modify alarming technologies and can evaluate their clinical environments to see how alarming technologies might be improved.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"221 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81130448","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":"Events That Inspired Change: The Importance of Sharing What Happened to Stop It From Happening Again","authors":"E. Myers, Caitlyn Allen","doi":"10.33940/001c.74079","DOIUrl":"https://doi.org/10.33940/001c.74079","url":null,"abstract":"Reporting events that caused harm or could have caused harm to patients is not just a law in Pennsylvania, it’s also one of the best ways to improve patient safety. Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They also are essential tools for triggering widespread change throughout a facility—and beyond.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91121017","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":"Masthead - March 2023","authors":"","doi":"10.33940/001c.74090","DOIUrl":"https://doi.org/10.33940/001c.74090","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"39 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78861719","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":"View From the Top: An Interview With Patient Safety Authority Chair, Dr. Nirmal Joshi","authors":"Nirmal Joshi, Caitlyn Allen","doi":"10.33940/001c.74081","DOIUrl":"https://doi.org/10.33940/001c.74081","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"125 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83719316","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":"Are complications related to the perineal post on orthopaedic traction tables for surgical fracture fixation more common than we think? A systematic review.","authors":"Andrea Attenasio,&nbsp;Matthew J Kraeutler,&nbsp;Ian S Hong,&nbsp;Suriya Baskar,&nbsp;Deepak V Patel,&nbsp;Craig Wright,&nbsp;Jaclyn M Jankowski,&nbsp;Frank A Liporace,&nbsp;Richard S Yoon","doi":"10.1186/s13037-023-00355-y","DOIUrl":"https://doi.org/10.1186/s13037-023-00355-y","url":null,"abstract":"<p><strong>Background: </strong>Traction tables have long been utilized in the management of fractures by orthopaedic surgeons. The purpose of this study was to systematically review the literature to determine the complications inherent to the use of a perineal post when treating femur fractures using a traction table.</p><p><strong>Methods: </strong>A systematic review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) using PubMed, EMBASE, and Cochrane Library. The search phrase used was \"fracture\" AND \"perineal\" AND \"post\" AND (\"femur\" OR \"femoral\" OR \"intertrochanteric\" OR \"subtrochanteric\"). Inclusion criteria for this review were: level of evidence (LOE) of I - IV, studies reporting on patients surgically treated for femur fractures, studies reporting on patients treated on a fracture table with a perineal post, and studies that reported the presence or absence of perineal post-related complications. The rate and duration of pudendal nerve palsy were analyzed.</p><p><strong>Results: </strong>Ten studies (2 prospective and 8 retrospective studies; 2 LOE III and 8 LOE IV) were included consisting of 351 patients of which 293 (83.5%) were femoral shaft fractures and 58 (16.5%) were hip fractures. Complications associated with pudendal nerve palsies were reported in 8 studies and the mean duration of symptoms ranged between 10 and 639 days. Three studies reported a total of 11 patients (3.0%) with perineal soft tissue injury including 8 patients with scrotal necrosis and 3 patients with vulvar necrosis. All patients that developed perineal skin necrosis healed through secondary intention. No permanent complications relating to pudendal neurapraxia or soft tissue injuries were reported at final follow-up timepoints.</p><p><strong>Conclusion: </strong>The use of a perineal post when treating femur fractures on a fracture table poses risks for pudendal neurapraxia and perineal soft tissue injury. Post padding is mandatory and supplemental padding may also be required. Appropriate perineal skin examination prior to use is also important. Occurring at a higher rate than previously thought, appropriate post-operative examination for any genitoperineal soft tissue complications and sensory disturbances should not be ignored.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"5"},"PeriodicalIF":3.7,"publicationDate":"2023-03-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10031869/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9524289","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}