Patient Safety in Surgery最新文献

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I AM Patient Safety 2023 Annual Achievement Awards 我是病人安全2023年度成就奖
IF 3.7
Patient Safety in Surgery Pub Date : 2023-06-26 DOI: 10.33940/001c.77892
Eugene Myers
{"title":"I AM Patient Safety 2023 Annual Achievement Awards","authors":"Eugene Myers","doi":"10.33940/001c.77892","DOIUrl":"https://doi.org/10.33940/001c.77892","url":null,"abstract":"Since the Patient Safety Authority introduced the I AM Patient Safety awards in 2013, this annual contest has celebrated hundreds of teams and individuals for their advancements, outcomes, and commitment to patient safety. The awards are judged by a cross-section of national and regional healthcare executives; patient safety advocates; and government, university, and patient representatives. These judges evaluated nominations from healthcare facilities throughout Pennsylvania and nationwide for innovation, impact, sustainability, and scalability. In addition to the honorees in 10 juried categories, PSA Executive Director Regina Hoffman, MBA, RN, selected a Choice Award winner for special recognition.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"55 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85838594","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}
引用次数: 0
Patient Safety Alert: Methylprednisolone and Patients With Hypersensitivity to Cow’s Milk Components 患者安全警告:甲泼尼龙和对牛奶成分过敏的患者
IF 3.7
Patient Safety in Surgery Pub Date : 2023-06-26 DOI: 10.33940/001c.77633
Catherine Reynolds, Myungsun Ro
{"title":"Patient Safety Alert: Methylprednisolone and Patients With Hypersensitivity to Cow’s Milk Components","authors":"Catherine Reynolds, Myungsun Ro","doi":"10.33940/001c.77633","DOIUrl":"https://doi.org/10.33940/001c.77633","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"1 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83004477","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}
引用次数: 0
Informing Visual Display Design of Electronic Health Records: A Human Factors Cross-Industry Perspective 电子健康档案的视觉显示设计:人因跨行业视角
Patient Safety in Surgery Pub Date : 2023-06-26 DOI: 10.33940/001c.77769
Zoe M. Pruitt, Jessica L. Howe, Lucy S. Bocknek, Arianna P. Milicia, Patricia A. Spaar, Seth Krevat, Raj M. Ratwani
{"title":"Informing Visual Display Design of Electronic Health Records: A Human Factors Cross-Industry Perspective","authors":"Zoe M. Pruitt, Jessica L. Howe, Lucy S. Bocknek, Arianna P. Milicia, Patricia A. Spaar, Seth Krevat, Raj M. Ratwani","doi":"10.33940/001c.77769","DOIUrl":"https://doi.org/10.33940/001c.77769","url":null,"abstract":"Background Despite their prevalence, poorly designed electronic health records (EHRs) are common, and research shows poor design consequences include clinician burnout, diagnostic error, and even patient harm. One of the major difficulties of EHR design is the visual display of information, which aims to present information in an easily digestible form for the user. High-risk industries like aviation, automotive, and nuclear have guidelines for visual displays based on human factors principles for optimized design. Purpose In this study, we reviewed the visual display guidelines from three high-risk industries—automotive, aviation, nuclear—for their applicability to EHR design and safety. Methods Human factors experts extracted guidelines related to visual displays from automotive, aviation, and nuclear human factors guideline documents. Human factors experts and a clinical expert excluded guidelines irrelevant to EHR. Human factors experts used a modified reflexive thematic analysis to group guidelines into meaningful topics. Disagreements were discussed until a consensus was reached. Results A total of 449 guidelines were extracted from the industry documents, and 283 (63.0%) were deemed relevant to EHRs. By industry, 12 of 44 (27.3%) automotive industry guidelines were relevant, 43 of 115 (37.4%) aviation industry guidelines were relevant, and 228 of 290 (78.6%) nuclear industry guidelines were relevant. Guidelines were grouped into six categories: alphanumeric; color, brightness, contrast, and luminance; comprehension; design characteristics; symbols, pictograms, and icons; and tables, figures, charts, and lists. Conclusion Our analysis identified visual display guidelines organized around six topics from the automotive, aviation, and nuclear industries to inform EHR design. Multiple stakeholders, including EHR vendors, healthcare facilities, and policymakers, can apply these guidelines to design new EHRs and optimize EHRs already in use.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"15 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135608692","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}
引用次数: 0
Incidence and root causes of medication errors by anesthetists: a multicenter web-based survey from 8 teaching hospitals in Ethiopia. 麻醉师用药失误的发生率和根本原因:埃塞俄比亚 8 家教学医院的多中心网络调查。
IF 2.6
Patient Safety in Surgery Pub Date : 2023-06-15 DOI: 10.1186/s13037-023-00367-8
Meseret Firde
{"title":"Incidence and root causes of medication errors by anesthetists: a multicenter web-based survey from 8 teaching hospitals in Ethiopia.","authors":"Meseret Firde","doi":"10.1186/s13037-023-00367-8","DOIUrl":"10.1186/s13037-023-00367-8","url":null,"abstract":"<p><strong>Bakground: </strong>The operating room is a demanding and time-constrained setting, in comparison to primary care settings, where perioperative medication administration is more complicated and there is a high risk that the patient will experience a medication error. Without consulting the pharmacist or seeking assistance from other staff members, anesthesia clinicians prepare, deliver, and monitor strong anesthetic drugs. The purpose of this study was to determine the Incidence and root causes of medication errors by anesthetists in Amhara region, Ethiopia.</p><p><strong>Methods: </strong>A multi-center cross sectional web-based survey study was conducted from October 1 to November 30, 2022, across eight referral and teaching hospitals of Amhara region. A self-administered semi structured questionnaire was distributed using survey planet. Data analysis was conducted using SPSS version 20. Descriptive statistics were computed and binary logistic regression was used for data analysis. A p-value < 0.05 was considered statistically significant.</p><p><strong>Results: </strong>The study included 108 anesthetists in total, yielding a response rate of 42.35%. Out of 104 anesthetists, Majority of participants (82.7%) were male. During their clinical practice, more than half (64.4%) of participants experienced atleast one drug administration error. 39 (37.50%) of the respondents revealed that they experienced more medication errors while on night shifts. Anesthetists who did not always double-check their anesthetic drugs before administration had a 3.51 higher risk of developing MAEs compared to those who always double-check anesthetic drugs before administration (AOR = 3.51; 95% CI: 1.34, 9.19). Additionally, participants who administer medications that have been prepared by someone else are about five times more likely to experience MAEs than participants who prepare their own anesthetic medications prior to administration (AOR = 4.95; 95% CI: 1.54, 15.95).</p><p><strong>Conclusion: </strong>The study found a considerable rate of errors in the administration of anaesthetic drugs. The failure to always double-check medications before administration and the use of drugs prepared by another anaesthetist were identified to be underlying root causes for drug administration errors.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"16"},"PeriodicalIF":2.6,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10273622/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10028210","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}
引用次数: 0
Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland. 手术后意外异物残留的根本原因及预防:瑞士全国专家调查。
IF 3.7
Patient Safety in Surgery Pub Date : 2023-06-09 DOI: 10.1186/s13037-023-00366-9
David Schwappach, Yvonne Pfeiffer
{"title":"Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.","authors":"David Schwappach,&nbsp;Yvonne Pfeiffer","doi":"10.1186/s13037-023-00366-9","DOIUrl":"https://doi.org/10.1186/s13037-023-00366-9","url":null,"abstract":"<p><strong>Background: </strong>Retained foreign objects (RFO) after surgery are rare, serious patient safety events. In international comparisons based on routine data, Switzerland had remarkably high RFO rates. The objectives of this study were to 1) explore national key stakeholders' views on RFO as a safety problem, its preventability and need for action in Switzerland; and 2) to assess their interpretation of Switzerland's RFO incidence compared to other countries.</p><p><strong>Methods: </strong>A semi-structured expert survey was conducted among national key representatives, including clinician experts, patient advocates, health administration representatives and other relevant stakeholders (n = 21). Data were coded and analyzed to generate themes related to the study questions following a deductive approach.</p><p><strong>Results: </strong>Experts in this study unequivocally emphasized the tragedy for individual patients affected by RFOs. Productivity pressure and the strong economization of operating rooms were perceived as detrimental to safety culture, which was seen as essential for RFO prevention, specifically by those working in the OR. RFOs were seen as \"maximally minimizable\" but not completely preventable. There was strong agreement that within country differences in RFO risk between Swiss hospitals existed. On the systems level and compared to other safety issues, RFO were having less urgency for most experts. The international comparison of RFO incidences raised serious skepticism across all groups of experts. The validity of the data was questioned and the dominant interpretation of Switzerland's high RFO incidence compared to other countries was a \"reporting artifact\" based on high coding quality in Swiss hospitals. While most experts thought that the published RFO incidence warrants in-depth analysis of the data, there was little agreement about who's role it was to initiate any further activities.</p><p><strong>Conclusions: </strong>This investigation offers valuable insights into the perspectives of significant stakeholders concerning RFOs, their root causes, and preventability. The findings demonstrate how international comparative safety data are perceived, interpreted, and utilized by national experts to derive conclusive insights.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"15"},"PeriodicalIF":3.7,"publicationDate":"2023-06-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10251694/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9602463","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}
引用次数: 0
Panniculectomy as a surgical option for the management of a deep surgical site infection after C-section in a morbidly obese woman: a case report. 一名病态肥胖妇女剖宫产后深部手术部位感染的手术选择:1例报告。
IF 3.7
Patient Safety in Surgery Pub Date : 2023-06-05 DOI: 10.1186/s13037-023-00363-y
Joël Igor Kamla, Georges Motto Bwelle, Joel Noutakdie Tochie, Landry Wakheu Tchuenkam, Brigitte Wandji, Trevor Kamto, Agnès Esiéné
{"title":"Panniculectomy as a surgical option for the management of a deep surgical site infection after C-section in a morbidly obese woman: a case report.","authors":"Joël Igor Kamla,&nbsp;Georges Motto Bwelle,&nbsp;Joel Noutakdie Tochie,&nbsp;Landry Wakheu Tchuenkam,&nbsp;Brigitte Wandji,&nbsp;Trevor Kamto,&nbsp;Agnès Esiéné","doi":"10.1186/s13037-023-00363-y","DOIUrl":"https://doi.org/10.1186/s13037-023-00363-y","url":null,"abstract":"<p><strong>Background: </strong>Obesity is an independent risk factor for the occurrence of surgical site infections (SSIs) following all types of surgeries, especially after Caesarean section (C-section). SSIs increase postoperative morbidity, health economic cost and their management is quiet complex with no universal therapeutic consensus. Herein, we report a challenging case of a deep SSI after C-section in a central morbidly obese woman managed successfully by panniculectomy.</p><p><strong>Case presentation: </strong>A 30-year-old black African pregnant woman with marked abdominal panniculus extending to the pubic area, a waist circumference = 162 cm and BMI = 47.7 kg/m<sup>2</sup> underwent an emergency CS indicated for acute fetal distress. By day five post-operation, she developed a deep parietal incisional infection unremitting to antibiotic therapy, wound dressings and beside wound debridement till the 26th postoperative day. A large abdomen panniculus and maceration of the wound enhanced by central obesity increased the risk of failure of spontaneous closure; thus, an abdominoplasty by panniculectomy was indicated. The patient underwent panniculectomy on the 26th day after the initial surgery and her post-operative course was uneventful. Wound esthetics was satisfactory three months later. Adjuvant dietary and psychological management were associated.</p><p><strong>Conclusion: </strong>Post-Caesarean deep SSI is a frequent complication in obese patients. A panniculectomy may be a safe and promising therapeutic surgical option with good cosmetic results and little postoperative complications when used in a multidisciplinary anti-obesogenic approach.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"14"},"PeriodicalIF":3.7,"publicationDate":"2023-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10242779/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9644523","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}
引用次数: 0
A formula for survival in surgery. 手术中生存的公式。
IF 3.7
Patient Safety in Surgery Pub Date : 2023-05-27 DOI: 10.1186/s13037-023-00362-z
Kjetil Søreide
{"title":"A formula for survival in surgery.","authors":"Kjetil Søreide","doi":"10.1186/s13037-023-00362-z","DOIUrl":"https://doi.org/10.1186/s13037-023-00362-z","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"13"},"PeriodicalIF":3.7,"publicationDate":"2023-05-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10225082/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9542170","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}
引用次数: 0
Utility of the Parkland Grading Scale to determine intraoperative challenges during laparoscopic cholecystectomy: a validation study on 206 patients at an academic medical center in Nepal. 帕克兰分级量表在腹腔镜胆囊切除术中确定术中挑战的应用:尼泊尔一家学术医疗中心206名患者的验证研究。
IF 3.7
Patient Safety in Surgery Pub Date : 2023-05-24 DOI: 10.1186/s13037-023-00364-x
Anup Shrestha, Abhishek Bhattarai, Kishor Kumar Tamrakar, Manoj Chand, Samjhana Yonjan Tamang, Sampada Adhikari, Harish Chandra Neupane
{"title":"Utility of the Parkland Grading Scale to determine intraoperative challenges during laparoscopic cholecystectomy: a validation study on 206 patients at an academic medical center in Nepal.","authors":"Anup Shrestha,&nbsp;Abhishek Bhattarai,&nbsp;Kishor Kumar Tamrakar,&nbsp;Manoj Chand,&nbsp;Samjhana Yonjan Tamang,&nbsp;Sampada Adhikari,&nbsp;Harish Chandra Neupane","doi":"10.1186/s13037-023-00364-x","DOIUrl":"https://doi.org/10.1186/s13037-023-00364-x","url":null,"abstract":"<p><strong>Background: </strong>Most of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy.</p><p><strong>Method: </strong>This was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale.</p><p><strong>Results: </strong>Out of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19-75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5.</p><p><strong>Conclusion: </strong>Parkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"12"},"PeriodicalIF":3.7,"publicationDate":"2023-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10207752/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9878896","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}
引用次数: 0
Quality of anesthetist communication with surgical patients in the perioperative setting: a survey at an academic tertiary referral hospital in Ethiopia. 围手术期麻醉师与外科病人沟通的质量:埃塞俄比亚一家三级专科医院的调查
IF 3.7
Patient Safety in Surgery Pub Date : 2023-05-19 DOI: 10.1186/s13037-023-00361-0
Yophtahe Woldegerima Berhe, Temesgen Agegnehu, Mulualem Endeshaw, Nurhusen Riskey, Getasew Kassaw
{"title":"Quality of anesthetist communication with surgical patients in the perioperative setting: a survey at an academic tertiary referral hospital in Ethiopia.","authors":"Yophtahe Woldegerima Berhe,&nbsp;Temesgen Agegnehu,&nbsp;Mulualem Endeshaw,&nbsp;Nurhusen Riskey,&nbsp;Getasew Kassaw","doi":"10.1186/s13037-023-00361-0","DOIUrl":"https://doi.org/10.1186/s13037-023-00361-0","url":null,"abstract":"<p><strong>Background: </strong>Effective communication is a fundamental step in providing best medical care and recognized as vital component of clinical anesthesia practice. Poor communication adversely affects patients' safety and outcome. The objective of this study was to investigate the quality of anesthetist communication from patients' perspectives at University of Gondar Comprehensive Specialized Hospital (UoGCSH), Northwest Ethiopia.</p><p><strong>Methodology: </strong>A descriptive cross-sectional study was conducted on 423 surgical patients from April 1, - May 30, 2021. Perioperative patient-anesthetist communication (PPAC) was measured by using 15-items Communication Assessment Tool graded by 5-points Likert scale. Data collection was executed during postoperative time as the patients were optimally recovered from anesthesia. The collected data were cleaned and descriptive analysis was performed.</p><p><strong>Results: </strong>A total of 400 (94.6% response rate) patients included and 226 (56.7%) were female. The median (IQR) age was 30 (25 - 40) years. Three-hundreds and sixty-one (90.3%) patients had reported good PPAC and 39 (9.8%) reported poor PPAC. The median (IQR) of PPAC scores was 53.0 (48.0 - 57.0) and range from 27 to 69. Highest mean score was observed for the item \"Talked in terms I could understand\" (4.3 ± 0.7). Lowest mean scores were observed for the item \"Checked to be sure I understood everything\" (1.9 ± 0.9). Patients who had underwent emergency surgery, no previous anesthetic exposure, had significant preoperative anxiety, no history of previous hospital admission, and moderate-severe preoperative pain were found to have poor PPAC compared to their counterparts in the proportions of 82.1%, 79.5%, 69.2%, 64.1%, and 59.0% respectively.</p><p><strong>Conclusions: </strong>There was good PPAC in our hospital from patients' perspective. However, there should be improvements in checking the degree of understanding of the delivered information, encouraging to question, disclosing next steps and involving in decision-making. Patients who underwent emergency surgery, had no previous anesthetic exposure, had clinically significant level of preoperative anxiety, had no history of previous hospital admission, and had moderate-severe preoperative pain were found to have poor PPAC.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"11"},"PeriodicalIF":3.7,"publicationDate":"2023-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10198025/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9555960","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}
引用次数: 0
Patient Safety Trends in 2022: An Analysis of 256,679 Serious Events and Incidents From the Nation’s Largest Event Reporting Database 2022年患者安全趋势:来自全国最大事件报告数据库的256,679起严重事件和事件分析
IF 3.7
Patient Safety in Surgery Pub Date : 2023-04-28 DOI: 10.33940/001c.74752
Shawn Kepner, Rebecca Jones
{"title":"Patient Safety Trends in 2022: An Analysis of 256,679 Serious Events and Incidents From the Nation’s Largest Event Reporting Database","authors":"Shawn Kepner, Rebecca Jones","doi":"10.33940/001c.74752","DOIUrl":"https://doi.org/10.33940/001c.74752","url":null,"abstract":"Pennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.5 million acute care event reports dating back to 2004. Herein, we examine patient safety event reports submitted to the PA-PSRS acute care database in 2022 and compare them to prior years. We extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Counts of reports were calculated based on report submission date, and rates were calculated based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). A total of 256,679 reports were submitted to PA-PSRS in 2022, representing an 11.1% decrease from 2021. Three facilities collectively submitted 18,601 fewer reports in 2022 compared to 2021, which accounted for 57.8% of the overall decrease. Reports of serious and high harm events increased by 7.7% and 11.1%, respectively. Of the 256,679 reports submitted, 95.9% were from hospitals, 3.9% were from ambulatory surgical facilities, and 0.2% were from birthing centers and abortion facilities. The vast majority of the 2022 reports were incidents (96.2%) as opposed to serious events (3.8%). For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 32.8% of all submitted acute care event reports in 2022. The second, third, and fourth most frequently reported event types in 2022 were Complication of Procedure/Treatment/Test, Medication Error, and Fall, accounting for 15.6%, 13.2%, and 12.8% of submitted reports, respectively. The reported event rate based on occurrence date for hospitals in the first half of 2022 was 27.5 reports per 1,000 patient days. For ASFs, the reported event rate for the first half of 2022 was 9.4 reports per 1,000 surgical encounters. There was a decrease in the number of incident reports submitted to PA-PSRS in 2022 and an increase in serious and high harm event reports. PSA will continue to work with facilities, monitor reporting, and take further action as needed.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"11 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82496529","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}
引用次数: 3
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