Patient Safety in Surgery最新文献

{"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}

{"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}