Journal of Patient Safety最新文献

{"title":"Drivers of Increased Hospital Mortality for Non-COVID-19 Conditions During COVID-19 Surges in 2020.","authors":"Karan Rai, Ivor S Douglas, Ashley R Turner, Anuj B Mehta","doi":"10.1097/PTS.0000000000001514","DOIUrl":"10.1097/PTS.0000000000001514","url":null,"abstract":"<p><strong>Background: </strong>The COVID-19 pandemic disrupted health behaviors, health care delivery, and public health systems. We evaluated whether hospital mortality among non-COVID-19 patients increased during COVID-19 surge periods and whether these effects varied across patient subgroups.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study using administrative claims from the 2020 Arizona, Iowa, Mississippi, and New York State Inpatient Databases and the California Patient Discharge Dataset. The cohort included 3,706,070 hospitalized adults aged 40 years or older without COVID-19. COVID-19 surge periods were defined for each state using the monthly average hospital COVID-19 census. Multilevel logistic regression models with hospital-level random intercepts were used to estimate adjusted odds of in-hospital mortality during surge versus nonsurge periods, adjusting for age, comorbidities, severity of illness, and hospital clustering. Interaction testing evaluated heterogeneity by race, payer, state, and ZIP code-level median household income.</p><p><strong>Results: </strong>Non-COVID-19 patients hospitalized during surge periods experienced higher all-cause in-hospital mortality compared with nonsurge periods (3.6% versus 3.3%) and 10% higher adjusted odds of death (n=6482, adjusted odds ratio: 1.10, 95% CI: 1.08-1.11). Surges disproportionately impacted patients from low-income ZIP codes ( P =0.008).</p><p><strong>Conclusions: </strong>Hospital mortality among non-COVID-19 patients increased during COVID-19 surges, independent of measured comorbidities and severity of illness, suggesting potential indirect patient safety risks associated with system strain. The greater impact observed among lower-income populations highlights vulnerabilities that may emerge during periods of extreme health care stress.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e205-e211"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147786441","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Becoming a High Reliability Organization: Structural Limitations to Continuous Quality Improvement in a Large Health Care System.","authors":"Lacey Evans, Claire H Robinson, Ariel Domlyn, Laura Damschroder, Julie Lowery, Jeremy Sussman","doi":"10.1097/PTS.0000000000001509","DOIUrl":"10.1097/PTS.0000000000001509","url":null,"abstract":"<p><strong>Objectives: </strong>The Veterans Health Administration (VHA) aims to improve patient safety by becoming a high reliability organization (HRO), which requires a culture of continuous quality improvement (CQI). Despite national HRO emphasis, conditions supporting or hindering frontline staff engagement in CQI efforts, especially skill development, are not well understood.</p><p><strong>Methods: </strong>We conducted semistructured interviews at VHA sites participating in one of 3 randomized trials to improve clinical outcomes by engaging staff in quality improvement (QI). We conducted interviews with primary care and mental health staff and leaders to assess local context, including barriers and facilitators to engaging in QI training and initiatives. Interviews were coded using the updated Consolidated Framework for Implementation Research and analyzed for cross-cutting themes.</p><p><strong>Results: </strong>Analysis of 56 interviews revealed that despite high-level leadership support for HRO principles, including patient safety, most sites lacked adequate infrastructure and leadership engagement necessary to support participation in QI training and projects. Barriers included limited time, unclear direction, burnout, and lingering COVID-19 pandemic effects. These challenges often prevented staff from developing foundational QI skills critical for entering a positive feedback loop of engagement and empowerment. Opportunities for improvement varied based on leadership style, team cohesion, role clarity, and location.</p><p><strong>Conclusions: </strong>To advance as HROs, health systems must go beyond high-level endorsement and invest in skill development and provide protected time to enable local leaders and frontline providers to do QI. Future work should explore how leaders can create sustainable conditions for improvement efforts and better align system-level goals with local realities.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"498-504"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13680771/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147786414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Behavioral Intervention Team to Reduce High-Risk Behaviors in the Acute Care Setting: A Quality Initiative.","authors":"Lucy Easler, Juliet Glover, Deborah Hurley, Nell Payne, Beth Smith, Shilpa Srinivasan, Jessica Anderson","doi":"10.1097/PTS.0000000000001505","DOIUrl":"10.1097/PTS.0000000000001505","url":null,"abstract":"<p><strong>Objectives: </strong>Medically ill patients, especially those with psychiatric comorbidities, may exhibit behavioral disturbance while hospitalized. Restlessness, removing medical devices, or wandering may lead to sentinel events such as falls, elopements, or violence. An interdisciplinary behavioral intervention team (BIT) was implemented to address and anticipate the need for behavioral health support on medical units. A retrospective review was conducted to evaluate the effects of BIT interventions on patient safety events.</p><p><strong>Methods: </strong>Two psychiatric nurses were embedded on medical/surgical units as part of medical and psychiatric interdisciplinary teams. A retrospective review was conducted to evaluate outcomes. Two time periods were examined: 6 months with early-BIT efforts and 6 months with expanded-BIT efforts. Medical records and safety reports were reviewed, and statistical analysis was conducted in SAS Enterprise Guide 8.3. Statistical significance was based on associated P -values ( P <0.05).</p><p><strong>Results: </strong>Of admitted patients during the study period (N=1413), pre-existing psychiatric diagnoses were present in 58% of cases, with mood, anxiety, and neurocognitive disorders being most common. A majority of patients were on psychotropic medications during both study periods; however, there was a significant decrease in the use of psychotropic medications with expanded-BIT efforts (71.2% versus 61.3%, P <0.001). In comparing early-BIT efforts to expanded-BIT efforts, significant reductions in workplace aggression (6.7% versus 2.3%, P <0.001), use of restraints (5.8% versus 3.4%, P =0.034), and need for security officers (4.2% versus 0.8%, P <0.001) were observed.</p><p><strong>Conclusions: </strong>Engaging BIT significantly reduced aggression, restraint use, and security officer interventions. An interdisciplinary BIT is feasible and effective in reducing negative outcomes.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"477-483"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147628897","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Development of a Toolkit to Inform Unplanned Discharge Planning in Residential Substance Use Disorder Programs.","authors":"Natalie B Riblet, Susan Stevens, Lisa Zubkoff, Brian Shiner, Melissa Ley-Thomson, Carolyn M D'aquila, Brett Rusch","doi":"10.1097/PTS.0000000000001516","DOIUrl":"10.1097/PTS.0000000000001516","url":null,"abstract":"<p><strong>Objectives: </strong>Unplanned discharge is a common patient safety problem in residential substance use disorder (SUD) programs and is associated with harm. Staff behavior can contribute to unplanned discharge. There is a lack of guidance; however, regarding the steps that staff should take to prevent unplanned discharge and related harm. A toolkit was created to guide staff in implementing best practices to manage unplanned discharge in residential SUD programs.</p><p><strong>Methods: </strong>An unplanned discharge toolkit was designed over three phases using an evidence-based framework. In phase 1, qualitative interviews were conducted with staff at 10 sites to determine toolkit content. Electronic databases and other sources were searched to locate best practices or policies. In phase 2, usability testing was conducted with content experts. In phase 3, a toolkit was drafted, and a validated survey was administered to staff to assess usability.</p><p><strong>Results: </strong>Surveyed participants completely agreed that the toolkit is acceptable and agreed that it appears feasible. A few participants identified ways to enhance the toolkit, and these recommendations were incorporated before finalizing the product.</p><p><strong>Conclusions: </strong>This is the first study to develop a toolkit of best practices to prevent unplanned discharge and related harm in residential SUD programs. On the basis of preliminary findings, the toolkit may be acceptable and feasible to implement in residential SUD programs. Future work should evaluate the impact of the toolkit on processes and outcomes.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e221-e227"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13160237/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147844682","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Digital Darkness in Cardiovascular Care: Ransomware, System Outages, and the Emerging Threat to Cardiac Patient Safety.","authors":"Ammad Ud Din, Muhammad Aftab Ahmad, Inam Ullah Khan, Azan Ahmed","doi":"10.1097/PTS.0000000000001541","DOIUrl":"10.1097/PTS.0000000000001541","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e181"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148347004","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A 1000-Fold Fentanyl Dosing Error Across Five Editions of the Grossman Baim Cardiac Catheterization Literature.","authors":"Charles A W Mulkey, David R Mitchell, Francisco J Gortes","doi":"10.1097/PTS.0000000000001542","DOIUrl":"10.1097/PTS.0000000000001542","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e182"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148254041","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Economic Burden of Unsafe Care: A Systematic Review With Narrative Synthesis on the Economic Cost of Unsafe Care in Hospitals Worldwide.","authors":"Alexander E J Wytinck, Shahenaz Najjar, Deborah Seys, Astrid Van Wilder, Katrien Kesteloot, Dirk Ramaekers, Dirk De Ridder, Alice Giese, Kris Vanhaecht","doi":"10.1097/PTS.0000000000001521","DOIUrl":"10.1097/PTS.0000000000001521","url":null,"abstract":"<p><p>Unsafe care places a substantial economic and clinical burden on health care systems worldwide, yet its cost implications remain insufficiently understood. This review synthesizes recent literature to clarify the magnitude and nature of the economic burden associated with unsafe care in hospital settings. A comprehensive search of Medline, EMBASE, and CINAHL, complemented by chain referencing, identified studies published since 2019. Of the 6364 identified articles, 25 met the inclusion criteria. Extracted data included study characteristics, methodological approaches, matching or correction variables, and reported costs and indicators of unsafe care, with all cost estimates converted to 2019 US dollars. The findings show that unsafe care in hospitals leads to considerable excess costs across multiple economic perspectives. For hospitals, the additional cost per unsafe event reached as high as $140,000. From the public payer's perspective, unsafe care accounted for up to nearly 3% of national health care spending, exceeding 0.2% of gross domestic product in some cases. From a societal perspective, unsafe care resulted in prolonged hospital stays, productivity losses, and broader economic impacts, amounting to an equivalent of up to 8% of health care expenditure. Unsafe care was consistently associated with poorer patient outcomes, including longer hospital stays, more frequent readmissions, and higher mortality. Despite heterogeneity in methods, the included studies collectively indicate that unsafe care imposes a significant economic burden while undermining patient health.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e245-e257"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147976436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prolonged Emergency Department Stay, Specialist-Visit Delay, and Disposition-Decision Delay as System-Level Risks for Preventable Sepsis Mortality.","authors":"Nattikarn Meelarp, Pattraporn Singjaroen, Sariya Suasamserm, Pimlak Chaijittiprasert, Wachira Wongtanasarasin","doi":"10.1097/PTS.0000000000001493","DOIUrl":"10.1097/PTS.0000000000001493","url":null,"abstract":"<p><strong>Objectives: </strong>Prolonged emergency department (ED) boarding is a patient-safety concern that may delay time-critical interventions in sepsis. This study evaluated whether total ED length of stay (ED-LOS) and delays in specialist visit and disposition decisions were associated with 30-day mortality among adult patients with sepsis.</p><p><strong>Methods: </strong>This retrospective observational cohort study included adults (≥18 y) presenting to the ED of a tertiary hospital in Northern Thailand between January 2019 and July 2024 with sepsis or septic shock. The primary exposure was total ED-LOS (hours), analyzed both as a continuous and a categorical variable. Secondary time intervals included door-to-fluid, door-to-antibiotic, door-to-vasopressor, specialist visit, and disposition decision times. The primary outcome was in-hospital 30-day mortality. Multivariable logistic regression adjusted for age, sex, illness severity (NEWS, MEDS, lactate), and treatment variables.</p><p><strong>Results: </strong>Among 868 patients, 19.5% died within 30 days. Median ED-LOS was 7.0 hours (IQR: 5.0-10.3) with no difference between survivors and nonsurvivors ( P =0.65). In adjusted analyses, total ED-LOS was not associated with 30-day mortality (aOR: 0.99, 95% CI: 0.97-1.02, P =0.61). However, delays in specialist visits (per 1 h increase; aOR: 0.84, 95% CI: 0.76-0.92, P <0.001) and disposition decisions (per 1 h increase; aOR: 0.94, 95% CI: 0.90-0.98, P =0.001) were independently associated with higher mortality.</p><p><strong>Conclusions: </strong>Total ED-LOS alone was not independently associated with mortality. Delays in specialist visits and disposition decisions were associated with increased mortality risk, highlighting care transitions as potential patient-safety targets in sepsis management.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"537-543"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147436784","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality of Care Transition and Patient Safety: An Investigation Into Patients After Bariatric Surgery.","authors":"Matthias Marsall, Matthias Weigl, Marco Niedergethmann, Sjaak Pouwels, Till Hasenberg, Martin Teufel, Alexander Bäuerle","doi":"10.1097/PTS.0000000000001518","DOIUrl":"10.1097/PTS.0000000000001518","url":null,"abstract":"<p><strong>Background: </strong>High quality care transition (QCT) is key to mitigating patient harm after hospital discharge to home. Nevertheless, patients' experiences of QCT are rarely investigated, particularly in acute surgical settings. Given the high relevance of bariatric surgery as the gold standard in the treatment of severely obese patients, mitigation of patient harm is gaining traction. Therefore, we aimed to determine the association between patient-experienced QCT and safety incidents and health complications after bariatric surgery.</p><p><strong>Methods: </strong>Cross-sectional survey study. Using standardized instruments, we surveyed patients about their experiences with the hospital discharge process and the occurrence of patient safety incidents and health complications. Multivariate linear models were applied to determine associations between QCT and patient-reported outcomes.</p><p><strong>Results: </strong>Among 307 surgical patients, 19% reported medication complications and 14% unplanned hospital readmissions. Most frequent health complications were constipation, nausea and vomiting, pain, diarrhea, and dysphagia, with prevalence from 65% to 16%. High levels of QCT were significantly associated with lower likelihoods of complications, for example, dysphagia, nausea and vomiting, and diarrhea. Medication complications and unplanned hospital readmissions were less likely when patients reported high QCT.</p><p><strong>Conclusions: </strong>A well-organized discharge process is associated with a lower incidence of patient safety incidents and postbariatric surgery complications. Safeguarding patients' discharge from hospitals is critical in promoting patients' health and safe care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e228-e233"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13680775/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148044071","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mortality Rates Following a Sleep Improvement Program in UK Mental Health Wards: Evidence That a Personalized Sleep Care Plan Can Be Safely Implemented.","authors":"Kirstie N Anderson, Ron Weddle, Harry Cape, Arne T Wolters, Patrick Keown","doi":"10.1097/PTS.0000000000001506","DOIUrl":"10.1097/PTS.0000000000001506","url":null,"abstract":"<p><strong>Objective: </strong>Sleep disturbance in hospital predicts worse mental health outcomes and is associated with increased length of stay. Enhanced observations are used routinely on mental health wards but disturb sleep and may not be needed for all patients. We have implemented a sleep improvement program (SleepWell) across multiple hospitals within a large UK mental health trust over 5 years. This includes ward adaptations to reduce night noise, increase daytime activity and natural light, screening for sleep disorders, and a 6-hour protected overnight sleep period if assessed as safe. Our objective was to assess the long-term patient safety and potential benefits of a ward-based sleep improvement program that includes a protected sleep period.</p><p><strong>Methods: </strong>A detailed review of every inpatient mortality was undertaken over 4 years with a comparison of age-adjusted mortality rates and both their causes and the time of death on wards with and without the SleepWell program.</p><p><strong>Results: </strong>Protected sleep was seen to be safe; there were 77 deaths over the 4 years, with the majority in older adults, but specifically there were no deaths that occurred overnight or during a protected sleep period. Older adult wards that implemented the SleepWell program had lower mortality rates than those that did not over the 4 years.</p><p><strong>Conclusions: </strong>We challenge the perceived benefit to patient safety of frequent overnight observations for all inpatients and suggest that nursing observations that disturb sleep may increase risk in themselves. A ward-based sleep improvement program that includes a protected sleep period can be safely implemented, but staff education and a personalized risk assessment are key.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"484-488"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147634674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}