Journal of Patient Safety最新文献

Value of Incident Reporting to Address Real-time Safety Opportunities During the COVID-19 Pandemic. 在 COVID-19 大流行期间，事件报告对把握实时安全机遇的价值。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-08 DOI: 10.1097/PTS.0000000000001344

Pamela S Roberts, Nandita Raman, Brandi Rico, Edward Seferian

{"title":"Value of Incident Reporting to Address Real-time Safety Opportunities During the COVID-19 Pandemic.","authors":"Pamela S Roberts, Nandita Raman, Brandi Rico, Edward Seferian","doi":"10.1097/PTS.0000000000001344","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001344","url":null,"abstract":"Objectives: A strong safety culture encourages staff to identify and report safety events and near misses through an incident reporting system. The objectives were to: (1) assess the effectiveness of real-time reporting of safety events for timely identification of trends and improvement opportunities in a rapidly changing environment and (2) determine temporal changes in safety event categories throughout the 4 COVID-19 pandemic waves in Southern California.Methods: This retrospective study involved all safety incidents reported in patients over age 18 related to the care of COVID-19 through the hospital's incident reporting system, CS-Safe from March 17, 2020 to February 25, 2022.Results: There were 5843 suspected and confirmed COVID-19 cases across the 4 waves. The reported events primarily were associated with patients between the ages of 65 and 84 years, with the majority (62.7%) male, white (65.4%), and non-Hispanic (73.5%). Most events reported were related to clinical care issues (41.6%). A difference in the rates of safety incidents was observed across the waves. The highest rate of medication management-related safety incidents was in wave 2 (0.25 incidents/1000 d) and the highest rate of incidents occurred in critical care in wave 3 (1.20 incidents/1000 d).Conclusions: The alignment of COVID-19-related safety incidents across the 4 waves with the occurrences during this time demonstrates the value of real-time reporting in identifying trends and opportunities for improvement in a rapidly changing environment. Hence, real-time assessment of events can be valuable in concurrently addressing demands during unprecedented situations.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796352","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}

引用次数: 0

Tirelessly Striving Towards the Challenging Goal of Patient Safety: A Content Analysis of Patient Advocacy Dialogs on Facebook.

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 DOI: 10.1097/PTS.0000000000001343

Riley Wolynn, Beth L Hoffman, Scotland Huber, Paul E Phrampus, Jaime E Sidani

{"title":"Tirelessly Striving Towards the Challenging Goal of Patient Safety: A Content Analysis of Patient Advocacy Dialogs on Facebook.","authors":"Riley Wolynn, Beth L Hoffman, Scotland Huber, Paul E Phrampus, Jaime E Sidani","doi":"10.1097/PTS.0000000000001343","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001343","url":null,"abstract":"Objectives: Patient experiences are focal points in the discourse around medical errors and patient safety, with social media offering new avenues to explore them. This study aimed to understand patient and family perspectives through a mixed-method analysis of posts made to a public Facebook group focused on patient safety.Methods: A total of 200 posts posted between November 21, 2022 and June 23, 2023 were manually extracted and double-coded by 2 independent human coders using a systematically developed codebook. Frequencies were calculated and χ2 tests were performed to analyze associations between codes. A grounded theory approach was used to qualitatively analyze key themes in the posts.Results: Of the 141 posts deemed relevant to patient safety, the majority (85%) included links to external news sources or information, rather than direct accounts of personal experiences. The most frequently discussed error types were surgical errors (28%) and infections (17%). The most frequent content codes were policy and regulatory issues (35%) and patient empowerment and advocacy (33%). Posts containing links had significantly more discussions about empowerment and advocacy, infections in vulnerable populations, and policy and advocacy compared with those without links. Overarching qualitative themes included the personal impact of medical errors, systemic challenges, the importance of empowerment through education, and the role of community support.Conclusions: This study underscores the importance of online communities in influencing patient safety discourse. Findings support the utility of using social media data for patient safety research and provide unique insights into patient concerns and advocacy efforts.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143755421","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}

引用次数: 0

Patient Falls in the Operating Room: The Danger of an Obese Patient on an Unlocked Operating Room Table. 病人在手术室摔倒：一个肥胖病人在未上锁的手术台上的危险。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-22 DOI: 10.1097/PTS.0000000000001317

Russell K McAllister, Craig J Lilie, Emily H Garmon

引用次数: 0

The Relationship Between Medical Error Attitudes of Surgical Nurses and Evidence-based Work Environment. 外科护士医疗差错态度与循证工作环境的关系

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-15 DOI: 10.1097/PTS.0000000000001311

Esma Gökçe, Aysel Doğan, Demet Özer

{"title":"The Relationship Between Medical Error Attitudes of Surgical Nurses and Evidence-based Work Environment.","authors":"Esma Gökçe, Aysel Doğan, Demet Özer","doi":"10.1097/PTS.0000000000001311","DOIUrl":"10.1097/PTS.0000000000001311","url":null,"abstract":"Background: It is important for health care professionals to use evidence-based practice during surgical procedures to ensure patient safety and prevent medical errors.Aims: The aim of this study was to examine the relationship between surgical nurses' perceptions of their work environment's support for evidence-based practice and their attitudes toward medical errors.Methods: The descriptive cross-sectional study was conducted between February and May 2023. A total of 105 nurses participated in the study. A personal information form, a medical errors attitude scale, and an evidence-based practice work environment scale were used to collect the data.Results: It was determined that 92 (87.6%) of the participants used evidence-based practice. It was determined that the answers given by the nurses to the scales had very high reliability, and the mean score of the attitude scale in medical errors was 3.90 (Cronbach-α coefficient 0.770), and the mean score of the evidence-based practice work environment scale was 2.90 (Cronbach-α coefficient 0.840). In addition, according to the correlation, a positive, weak, and statistically significant correlation was found between the total scores of the attitude scale in medical errors and the evidence-based practice work environment scale ( P <0.05).Conclusion: As a result of the study, it was determined that nurses' attitudes toward preventing medical errors were positive and their perceptions of support for evidence-based practice work environments were high. In this direction, it can be said that the attitudes toward preventing medical errors of nurses whose working environment is supported by evidence-based practice can be positively affected and error tendencies in surgical clinics can be reduced.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"133-137"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142980272","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}

引用次数: 0

Automated Computerized-based Intervention to Identify Hypomagnesemia in Primary Care Patients With Arrhythmia. 以计算机为基础的自动干预识别心律失常初级保健患者的低镁血症。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2024-12-23 DOI: 10.1097/PTS.0000000000001308

Maite López-Garrigós, Miguel Ahumada, María Leiva-Salinas, Alvaro Blasco, Emilio Flores, Carlos Leiva-Salinas

{"title":"Automated Computerized-based Intervention to Identify Hypomagnesemia in Primary Care Patients With Arrhythmia.","authors":"Maite López-Garrigós, Miguel Ahumada, María Leiva-Salinas, Alvaro Blasco, Emilio Flores, Carlos Leiva-Salinas","doi":"10.1097/PTS.0000000000001308","DOIUrl":"10.1097/PTS.0000000000001308","url":null,"abstract":"Objectives: Hypomagnesemia early diagnosis and consequently early, timely magnesium supplementation is of utmost benefit, but it often goes underdiagnosed. The objective was to show and monitor an intervention to identify hypomagnesemia in patients with arrhythmia.Methods: A cross-sectional study was designed in the laboratory. In primary care patients, the Laboratory Information System would automatically add a serum magnesium test when sample availability is present in any request when a diagnosis of arrhythmia is made. We counted the number of detected patients with hypomagnesemia (serum magnesium <1.7 mg/dL, <0.7 mmol/L), and calculated the cost in reagent of each identified case.Results: In 430 patients with arrhythmia, serum magnesium was measured, and 41 (9.5%) had hypomagnesemia results. One patient showed severe hypomagnesemia values (<1.2 mg/dL and <0.49 mmol/L). Patients with a deficit were significantly ( P <0.01) older than the total group of patients with normal magnesium values (66.3±13.2 versus 61.6±12.5). Each case represented a cost of 3.15€ in reagent.Conclusions: The automated computer-based intervention to identify patients with hypomagnesemia was useful and affordable, given the cost per detected case.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"138-142"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869573","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}

引用次数: 0

Mobile Phones in the Operating Room: A Call for Strict Regulation to Ensure Patient Safety. 手术室使用手机：呼吁严格监管以确保患者安全。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-14 DOI: 10.1097/PTS.0000000000001315

Saeid Amini Rarani

引用次数: 0

Needs Assessment for Home Modification and Risk Factors for Home Unintentional Injuries in Post-total Knee Arthroplasty Patients. 全膝关节置换术后患者居家改造需求评估及居家意外伤害风险因素。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-14 DOI: 10.1097/PTS.0000000000001313

Saowalak Tongta, Patarawan Woratanarat, Siwadol Wongsak, Rossarin Phonakhae, Nartanong Arunwilai, Thira Woratanarat

{"title":"Needs Assessment for Home Modification and Risk Factors for Home Unintentional Injuries in Post-total Knee Arthroplasty Patients.","authors":"Saowalak Tongta, Patarawan Woratanarat, Siwadol Wongsak, Rossarin Phonakhae, Nartanong Arunwilai, Thira Woratanarat","doi":"10.1097/PTS.0000000000001313","DOIUrl":"10.1097/PTS.0000000000001313","url":null,"abstract":"Objectives: Home assessment and modification are crucial to prevent fall and fall-related injuries, especially in vulnerable subjects. This study assessed the need for home modifications and investigated risk factors associated with home injuries in post-total knee arthroplasty (TKA) patients.Methods: This study was conducted at the university hospital from July 2022 to July 2023. The patients who had undergone TKA without perioperative complications were recruited. The demographics, clinical data, home environmental factors, needs for home modification, and factors related to home unintentional injury were collected at 2 weeks postoperatively. The analysis was done by using descriptive statistics, and logistic regression.Results: A total of 140 patients were included. The occurrence of falls within 2 weeks after TKA was 33.57%. The location of falls was the home entrance (29.09%), living room (23.64%), and bathroom (18.18%). About 38.5% of the patients explicitly needed home modifications. Falls were associated with inefficient grab bars [adjusted odds ratio=3.26, 95% CI=1.37-7.81, P =0.008] and lighting (adjusted odds ratio=12.83, 95% CI=1.36-121.34, P =0.026).Conclusions: Falls among post-TKA patients were frequently occurred. Preoperative home assessment and home modifications should be done in order to minimize risks of falls, particularly in common locations.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"143-149"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142972954","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}

引用次数: 0

The Association Between Health Care Staff Engagement and Patient Safety Outcomes: A Systematic Review and Meta-analysis: Erratum.

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-03-24 DOI: 10.1097/PTS.0000000000001324

引用次数: 0

Decreasing Hospital-acquired Pressure Injuries During the COVID-19 Pandemic: A 5-step Quality Improvement Approach. 在COVID-19大流行期间减少医院获得性压力伤害：五步质量改进方法

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-20 DOI: 10.1097/PTS.0000000000001316

Deema Nuseir, Maya Sinno, Mary-Agnes Wilson, Matthew Hacker Teper, Dmitry Karasev, Shachi Christian, Kate Zimmerman, Victoria Bakun, Natalya Linetska, Khem Persaud, Liandi Zhang, Crystal Li, Lai Yi Koo, Deborah Lefave, Heather Stewart, Ahmed Taher

{"title":"Decreasing Hospital-acquired Pressure Injuries During the COVID-19 Pandemic: A 5-step Quality Improvement Approach.","authors":"Deema Nuseir, Maya Sinno, Mary-Agnes Wilson, Matthew Hacker Teper, Dmitry Karasev, Shachi Christian, Kate Zimmerman, Victoria Bakun, Natalya Linetska, Khem Persaud, Liandi Zhang, Crystal Li, Lai Yi Koo, Deborah Lefave, Heather Stewart, Ahmed Taher","doi":"10.1097/PTS.0000000000001316","DOIUrl":"10.1097/PTS.0000000000001316","url":null,"abstract":"Background: Hospital-acquired pressure injuries (HAPIs) are common adverse events with large burdens on patients and health systems. In 2020, during the initial waves of the COVID-19 pandemic, the incidence of admitted patients with HAPIs of stage II and above in our health system rose from 2.92% to 3.80%. In response to rising HAPI rates across our own hospital system, we established a quality aim to reduce HAPIs stage II and above by 50% over 3 years from the onset of the COVID-19 pandemic.Methods: We designed a multidisciplinary quality improvement HAPI prevention program. Our initiative had 5 key aspects: fostering governance and accountability, providing education and training, changing clinical practice, monitoring data and evaluation, and modernizing environments and equipment.Results: HAPI rate (outcome measure) declined from 3.8% at the onset of the COVID-19 pandemic to 1.6% (58% reduction, P <0.00001) postintervention. Braden Risk Assessment Tool use (process measure) improved from 88.2% to 92.2%. ( P =0.00024). Rate of patient falls with injuries (balancing measure) decreased from 1.5 per 1000 patient days to 1.0 per 1000 patient days ( P =0.0009).Conclusions: Despite working during the COVID-19 pandemic where organizational resources were constrained and infection control practices were heightened, a multidisciplinary QI HAPI prevention program, informed by evidence-based practices and supported by access to real-time data, led to an ∼58% reduction in the HAPI rate.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"151-158"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143014434","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}

引用次数: 0

Corrective Actions Taxonomy for Healthcare Incidents (CATHI): Insights From Real-world Data on Hospital-reported Incidents. 医疗事故纠正措施分类（CATHI）：来自医院报告事件的真实数据的见解。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2024-12-27 DOI: 10.1097/PTS.0000000000001309

Cátia Brazete, António Miguel Marques, Elsa Isaura S, Cláudia De Freitas, Ana Azevedo

{"title":"Corrective Actions Taxonomy for Healthcare Incidents (CATHI): Insights From Real-world Data on Hospital-reported Incidents.","authors":"Cátia Brazete, António Miguel Marques, Elsa Isaura S, Cláudia De Freitas, Ana Azevedo","doi":"10.1097/PTS.0000000000001309","DOIUrl":"10.1097/PTS.0000000000001309","url":null,"abstract":"Objectives: This study aimed to develop a taxonomy for classifying corrective actions following health care incidents in a Portuguese tertiary hospital.Methods: The study utilized a multimethods design, combining qualitative and quantitative analyses of real-world data. Thematic analysis was performed, drawing on inductive and deductive approaches. The latter was informed by the PRISMA Medical Classification/Action Matrix and the COM-B theory.Results: A total of 4644 incidents were reported between January 1, 2021 and December 31, 2022. Each incident report is accompanied by an unstructured free-text conclusion section, whose content was manually coded using NVivo QRS. A total of 910 corrective actions were found. The process of classifying these actions, in addition to the deductive approach, served as the foundation for the development of the proposed taxonomy-the Corrective Actions Taxonomy for Healthcare Incidents (CATHI). CATHI included themes such as technology, medical devices, equipment and infrastructure, procedures, information and communication, and training, among others. The taxonomy was structured into 3 levels to allow for a more detailed classification of corrective actions. A glossary was developed to improve usability, including definitions and examples derived from real-world data.Conclusions: CATHI provides a standardized approach to action implementation, allowing for prioritization of improvement efforts. This study has practical implications for enhancing patient safety and quality of care. Future research should validate this taxonomy in diverse health care settings.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"165-173"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142899588","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}

引用次数: 0