Journal of Patient Safety最新文献

{"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":"https://doi.org/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":""},"PeriodicalIF":1.7,"publicationDate":"2026-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","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":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing CLABSI in a Tertiary ICU: A Quasi-Experimental Study of a Layered Quality Improvement Initiative.","authors":"Gianmarco Sirago, Emanuele Rollo, Fiorenza Zotti, Biagio Solarino, Alessandro Dell'Erba, Davide Ferorelli","doi":"10.1097/PTS.0000000000001450","DOIUrl":"10.1097/PTS.0000000000001450","url":null,"abstract":"<p><strong>Introduction: </strong>Central line-associated bloodstream infections (CLABSI) present a major challenge in health care today. Achieving and maintaining significant reductions in CLABSI rates often requires complex, structured interventions; yet, real-world data from high-complexity settings remain scarce. This report outlines a quality improvement initiative and assesses its impact on CLABSI rates and procedural practices in a high-risk hospital setting.</p><p><strong>Materials and methods: </strong>We conducted a single-center, quasi-experimental pre-post study. The intervention involved a layered, multifaceted approach that included: (a) the \"4E\" (Engage, Educate, Execute, Evaluate) model as a framework for institutional change; (b) the implementation of a standardized CVC insertion checklist; (c) targeted education on evidence-based guidelines, including optimal site selection; and (d) direct observation with performance feedback. The preintervention group (n=169) included patients from July 2022 to June 2023, with data collected retrospectively. The post-intervention group (n=227) included patients from July 2023 to December 2024, with data collected prospectively.</p><p><strong>Results: </strong>Data analysis revealed a significant decline in the overall CLABSI rate from 12.43% before intervention to 3.52% afterward ( P <0.001). At the same time, procedural practices changed notably: jugular vein insertions decreased from 14.20% to 1.76%, while basilic vein insertions rose from 31.95% to 42.73%. Bivariate analyses identified key factors associated with CLABSI risk.</p><p><strong>Conclusion: </strong>Implementing a structured, layered quality improvement approach was associated with a significant decrease in CLABSI rates. While the study design does not allow for isolating the effects of individual components-such as the 4E framework, the checklist, or the changes in insertion practices-the results strongly suggest that a systematic strategy which combines a guiding framework, practical tools, and adherence to evidence-based practices effectively enhances patient safety in complex clinical settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"207-214"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145811772","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":"Aviation and Anesthesia: Not That Similar.","authors":"Edward J Walter, Sean R Crawford, Timothy A Barrell, Dianne Lesch, Amish Patel","doi":"10.1097/PTS.0000000000001447","DOIUrl":"10.1097/PTS.0000000000001447","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e60-e61"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145851248","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":"Root Cause Analysis, Action, and Audit (RCA3): A Novel Approach to Sustainably Reduce Medication Errors.","authors":"Ghada Hussain Al Mardawi, Rajkumar Rajendram","doi":"10.1097/PTS.0000000000001445","DOIUrl":"10.1097/PTS.0000000000001445","url":null,"abstract":"<p><strong>Background: </strong>Medical errors threaten patient safety. Although root cause analysis (RCA) is commonly used to investigate medication errors, such errors often recur, posing ongoing risks to patient safety. The RCA2 framework, introduced by the National Patient Safety Foundation, aimed to strengthen traditional RCA by emphasizing action-oriented outcomes. To further enhance sustainability, we implemented RCA3-an iterative process adding follow-up audits to evaluate long-term effectiveness of corrective actions. We aim to highlight RCA3's ability to maintain the effectiveness of interventions in preventing medication errors.</p><p><strong>Methods: </strong>After a hydralazine overdose in a pregnant patient with pre-eclampsia, we conducted RCA2 and audited recommendations 3 weeks post-implementation and re-evaluated after 1 year to identify any lapses due to impracticality or lack of sustainability. This enhanced approach, called RCA3, builds on RCA2 by adding routine audits assessing implementation, long-term effectiveness, and medication error recurrence within 12 months.</p><p><strong>Results: </strong>Compared with lapses identified during the RCA2 re-audit, no medication errors reoccurred for over a year after implementing RCA3 recommendations. Successful interventions focused on modifying computerized physician order entry systems (CPOE) and added specific medication preparation/disposal instructions to departmental guidelines and CPOE order sets.</p><p><strong>Conclusions: </strong>RCA3, a novel approach incorporating sustainability audits, may be more effective than the standard RCA2 process in preventing medication error recurrence. RCA3 prioritizes effective, practical, and sustainable actions while distinguishing passive abandonment from active roll back. Thus, RCA3 offers health care systems a valuable tool to enhance patient safety and prevent errors.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"22 3","pages":"182-189"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147730549","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":"Summary of Best Evidence for Lateral-Prone Surgical Position Management.","authors":"Jingjing Zhou, Xiaoping Chen, Jianhui Huang, Mengxiao Jiang","doi":"10.1097/PTS.0000000000001448","DOIUrl":"10.1097/PTS.0000000000001448","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate and consolidate evidence related to the management of lateral-prone surgical positioning from national and international sources, aiming to provide an evidence-based foundation for clinical practice.</p><p><strong>Methods: </strong>Using the \"6S\" evidence model, a comprehensive search was conducted in Chinese and English databases, guideline websites, and professional society websites. We included all relevant evidence concerning the management of lateral-prone surgical positioning: clinical practice guidelines, systematic reviews, evidence summaries, clinical decisions, expert consensus, and randomized clinical trials. Search records were included from the establishment of each database up to June 30, 2024. Two researchers with expertise in evidence-based nursing independently screened and assessed the quality of the search results.</p><p><strong>Results: </strong>Nine documents, consisting of 7 guidelines and 2 expert consensus documents, were included. In total, 28 pieces of evidence related to the management of lateral-prone surgical positioning were summarized. These address 6 key areas: prepositioning assessment, preparation of appropriate positioning equipment and supplies, teamwork, positioning, postpositioning checks, and intraoperative considerations.</p><p><strong>Conclusion: </strong>This study synthesizes the best evidence available related to the management of lateral-prone surgical positioning, thus providing an evidence-based foundation for surgical teams. Health care professionals should apply this evidence selectively, considering clinical contexts and physician preferences.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"238-244"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13089819/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145913435","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":"Gender Differences in Patient Safety Incident Risk Among Early Career Resident Physicians: A Cross-Sectional Analysis.","authors":"Aomi Katagiri, Caroline Kamau-Mitchell, Masaru Kurihara, Takashi Watari, Yuji Nishizaki, Kohta Katayama, Kazuya Nagasaki, Hiroyuki Kobayashi, Atsushi Mizuno, Kei Nakashima, Yasuharu Tokuda","doi":"10.1097/PTS.0000000000001465","DOIUrl":"10.1097/PTS.0000000000001465","url":null,"abstract":"<p><strong>Objectives: </strong>Previous literature suggest that female physicians have better patient outcomes, following guidelines and evidence-based practices. This study explored the potential roles of workload and psychological burden in shaping the association between gender and patient safety incidents among early career resident physicians. This study aims to improve training environments during early medical careers.</p><p><strong>Methods: </strong>We analyzed cross-sectional data from the 2022 General Medicine In-Training Examination (GM-ITE) in Japan, including 6063 resident physicians in their first or second postgraduation year. Serious patient safety incidents were collected via anonymous questionnaire, defined as deaths or serious adverse events resulting from medical errors made by the resident physicians themselves occurring during the past 12 months. Multilevel mixed-effects logistic regression accounted for hospital differences and additionally examined working conditions, including working hours, night shifts, burnout, and co-worker disruption.</p><p><strong>Results: </strong>Female resident physicians had a lower risk of serious patient safety incidents (odds ratio (OR) 0.71, 95% CI: 0.59-0.85) after considering co-worker disruption as a mediator. Males had a U-shaped association between weekly working hours and patient safety incidents (<45 h: OR 2.07, 95% CI: 1.39-3.09, ≥80 h: OR 1.35, 95% CI: 1.05-1.74), while females showed a dose-response association, especially with ≥80 hours (OR 2.10, 95% CI: 1.43-3.09). There was no significant interaction of physician gender with burnout or night shift frequency.</p><p><strong>Conclusions: </strong>Female resident physicians experienced fewer serious patient safety incidents. Reducing working hours may benefit female resident physicians in preventing serious patient safety incidents.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e64-e69"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146031221","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":"Association Between Antenatal COVID-19 Vaccination and Neonatal Outcomes.","authors":"Napatsorn Thewaran, Wasin Laohavinij, Surasith Chaithongwongwatthana, Patarawan Woratanarat, Vitool Lohsoonthorn, Thira Woratanarat","doi":"10.1097/PTS.0000000000001446","DOIUrl":"10.1097/PTS.0000000000001446","url":null,"abstract":"<p><strong>Objectives: </strong>COVID-19 vaccines are essential public health tools for prevention and control the pandemic. There is still misinformation regarding their safety in pregnant women, particularly in countries with widely used heterologous vaccination. This study investigated the association between maternal COVID-19 vaccination during pregnancy and important neonatal outcomes.</p><p><strong>Methods: </strong>A retrospective cohort study was conducted involving 4032 pregnant women at King Chulalongkorn Memorial Hospital, Thailand, between September 2021 and December 2023. Demographics, vaccination characteristics and adverse neonatal outcomes were collected. The analysis was done by using descriptive statistics and logistic regression.</p><p><strong>Results: </strong>Of 4032 participants, 1657 (41.1%) received COVID-19 vaccines during pregnancy, mostly mRNA vaccines (60.6%). Vaccination was significantly associated with a lower rate of stillbirth [adjusted odds ratio (aOR): 0.41, 95% CI: 0.16-0.97] and SGA (aOR: 0.27, 95% CI: 0.08-0.90). Vaccination during the second or third trimester was specifically associated with a lower rate of abortion, stillbirth, SGA, and low 5-minute Apgar scores compared with unvaccinated pregnancies. Adequately vaccinated individuals had significantly fewer overall adverse neonatal outcomes compared with partially vaccinated individuals. In addition, mRNA vaccination was associated with a lower abortion and stillbirth rate compared with no vaccination.</p><p><strong>Conclusions: </strong>Maternal COVID-19 vaccination during pregnancy was not associated with increased adverse neonatal outcomes and was associated with lower rate of stillbirth and small for gestational age. More favorable associations were observed for vaccination in the second or third trimester and for adequate vaccination, and mRNA vaccination showed a lower rate of abortion and stillbirth compared with no vaccination, supporting the safety of vaccination in pregnancy.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"190-198"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145776224","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":"Learning From the Machine's Mistakes: Embedding AI Error Detection Into Primary Care Safety Culture.","authors":"Waseem Jerjes, Azeem Majeed","doi":"10.1097/PTS.0000000000001453","DOIUrl":"10.1097/PTS.0000000000001453","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e54-e56"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145821726","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 Modified Trigger Tool for Identification of Patient Harm in Palliative Care Patients. A Pilot Study From Norway.","authors":"Espen Klingenberg, Anne K Lindahl, Kathrine Brenne, Milada Hagen, Olav M S Fredheim","doi":"10.1097/PTS.0000000000001449","DOIUrl":"10.1097/PTS.0000000000001449","url":null,"abstract":"<p><strong>Background: </strong>Patient harm in the hospitalized palliative care population is underexplored. The distinctive areas of harm relevant to palliative care patients are not captured by existing instruments developed to identify patient harm in general patient populations. Therefore, a tailored approach could aid in the identification of patient harm and the improvement of patient safety in palliative care.</p><p><strong>Objectives: </strong>The aim of the study was to describe the performance and suitability of a modified version of the Global Trigger Tool (GTT) applied to palliative care patients.</p><p><strong>Design: </strong>Hospital records of 256 consecutive patients at a Norwegian palliative care ward were independently reviewed for triggers and cases of patient harm by 2 reviewers. The modified trigger tool was based on the generic GTT and primarily adhered to its methodology. Some GTT triggers not relevant for palliative care patients were omitted, and new triggers and categories of harm were introduced based on clinical experience and publications on patient harm in palliative care.</p><p><strong>Results: </strong>Four hundred and one triggers (1.6 per hospitalization), and 109 cases of harm were identified. The most frequent triggers were Readmission within 14 days (89 triggers) and Other (60 triggers), while the majority of harm (65 cases) were classified as overtreatment/overdiagnosis or disturbed dying/poor symptom control. The positive predictive value for identifying patient harm was 0.27. Inter-rater reliability for identifying harm was κ=0.590 (95% CI: 0.461-0.718).</p><p><strong>Conclusion: </strong>The modified trigger tool identifies patient harm and disturbed dying in palliative care patients. However, further development is required before the routine implementation of this tool.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"199-206"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145795267","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":"Global Burden of Adverse Effects of Medical Treatment, 1990-2021: Trends, Inequities, and Projections From the Global Burden of Disease Study 2021.","authors":"Jie Yang","doi":"10.1097/PTS.0000000000001440","DOIUrl":"10.1097/PTS.0000000000001440","url":null,"abstract":"<p><strong>Objectives: </strong>To examine the trends and future projections of adverse effects of medical treatment (AEMT) burden at the global, regional, and national levels based on the latest Global Burden of Disease (GBD) 2021 data.</p><p><strong>Methods: </strong>We analyzed the incidence, mortality, and disability-adjusted life years (DALYs) of AEMT based on the GBD 2021 data. Trends were assessed using the estimated annual percentage change (EAPC), and future projections were modeled via the Nordpred age-period-cohort (APC) framework.</p><p><strong>Results: </strong>Globally, incident cases of AEMT increased by 68.50% from 1990 to 2021, yet age-standardized incidence rate (ASIR) declined in most countries and territories, and the age-standardized mortality rate (ASMR) decreased. Regionally, high sociodemographic index (SDI) regions experienced a 1.72% annual rise in ASIR, whereas low SDI regions saw a 12.87% rise in mortality. National disparities were pronounced, with the United States and India bearing the highest burdens. Projections suggest declining incidence rates but rising deaths, driven by factors like demographic shifts and health care expansion.</p><p><strong>Conclusions: </strong>Despite progress in reducing mortality and disability rates, the absolute AEMT burden remains relatively heavy, with considerable inequities across development settings. The findings reveal a critical paradox that high-resource systems face escalating risks from complex interventions, whereas low-resource settings struggle with preventable fatalities. Our findings inform global safety initiatives by highlighting the paradoxical burdens in high- and low-resource systems, calling for tailored, context-specific policy responses.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"22 3","pages":"173-181"},"PeriodicalIF":1.7,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147730416","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}