Journal of Patient Safety最新文献

{"title":"Optimizing Event Reporting to Drive a Culture of Learning and Safety: A System-Based Approach to Mitigating Harm Through Near-Miss and No-Harm Reporting.","authors":"Joon Yong Moon, Carina Welp, Matt Nold, Joe Nienow, Taylor Rader, Kannan Ramar, Jennifer B Cowart","doi":"10.1097/PTS.0000000000001424","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001424","url":null,"abstract":"<p><strong>Background: </strong>Patient safety event reporting systems are essential for identifying potential risks and improving patient outcomes. However, traditional systems frequently face issues of under-reporting, particularly concerning near-miss and no-harm events, thereby limiting opportunities for organizational learning and harm prevention. This initiative used quality improvement principles to design a new reporting system at our institution to enhance safety culture.</p><p><strong>Methods: </strong>Following extensive stakeholder feedback and multidisciplinary collaboration, a new system was implemented on July 22, 2022. Key features included streamlined reporting, centralized data analysis, and enhanced transparency.</p><p><strong>Results: </strong>Overall event reporting as well as proportional reporting of near-miss and no-harm events increased significantly from around 60% preimplementation to 80% after implementation. Staff engagement also improved, as shown by a steady rise in the number of unique event reporters and reviewers.</p><p><strong>Conclusions: </strong>The new reporting system has improved reporting overall, with increases in near-miss and no-harm events, along with increased staff engagement with the reporting and review process. Our experience offers practical lessons for institutions seeking to strengthen the learning value of event reporting systems. The principles we identified with simplifying ease of use, integrating into the EHR, improving data transparency, and encouraging greater involvement with event review, along with clear oversight protocols, apply beyond our institution and are not limited to a specific PSRS product or system. These initial outcomes support a culture of safety and bolster organizational learning, with future study needed on long-term effects on patient safety outcomes, staff involvement, and increased trust.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-10-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145245572","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":"Missed Nursing Care in Nursing Homes and Causes: A Systematic Review.","authors":"Simone Cosmai, Valentina Trezzi, Laura Mansi, Cristina Chiari, Maria Colleoni, Alessandra Valsecchi, Alberto Gibellato, Diego Lopane, Stefano Mancin, Beatrice Mazzoleni","doi":"10.1097/PTS.0000000000001425","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001425","url":null,"abstract":"<p><strong>Introduction: </strong>Missed nursing care refers to necessary nursing care activities that, due to various factors, are either not provided, partially provided, or delayed from the planned schedule. Missed nursing care (MNC) is a significant issue in nursing homes, undermining care quality and increasing the risk of adverse events and preventable hospitalizations. This systematic review aims to identify the most frequently reported MNC by nursing staff in nursing homes and the associated causes.</p><p><strong>Methods: </strong>The review was conducted following the guidelines of the \"JBI Manual for Evidence Synthesis\" and using the PRISMA ScR checklist. A search yielded 1468 articles: 85 from PubMed, 1115 from Scopus, 164 from Embase, and 104 from CINAHL. Screening removed 1386 duplicates, identifying 82 potentially relevant articles. After title and abstract review, 72 were excluded for irrelevance, resulting in 9 studies included in this review. Study selection defined inclusion criteria, focusing on quantitative studies involving registered nurses working in nursing homes.</p><p><strong>Results: </strong>The most frequently omitted nursing care activities in nursing homes include patient mobilization, assistance with feeding, and personal hygiene care. Key causes identified were staff shortages, high patient care complexity, and limited resource availability.</p><p><strong>Discussion: </strong>The findings confirm that MNC in nursing homes is primarily influenced by organizational and structural factors, requiring a systemic approach to improve care quality. Targeted interventions, such as better resource planning, improved staff management, and measures to enhance nurse well-being, could significantly reduce the incidence of missed care. Future research, particularly longitudinal studies, may provide further insights into more effective prevention of MNC, while the development of specific assessment tools for nursing homes could enhance MNC measurement and support targeted interventions.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-10-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208209","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":"Evaluating Safety Concerns for Pediatric Mental and Behavioral Health Patients and Providers in the Emergency Department: A Systems Perspective.","authors":"Anjali Joseph, Sahar Mihandoust, Mina Shokrollahi Ardekani, Ann Dietrich, Meera Narasimhan","doi":"10.1097/PTS.0000000000001357","DOIUrl":"10.1097/PTS.0000000000001357","url":null,"abstract":"<p><strong>Objective: </strong>The objective of this study was to determine key issues related to the safety of pediatric mental and behavioral (MBH) patients in the emergency department (ED), as well as related provider safety issues from a systems perspective.</p><p><strong>Methods: </strong>Semistructured interviews were conducted with 55 staff members from 4 ED units in rural and urban hospitals. Utilizing the Systems Engineering Initiative for Patient Safety framework, interviews were coded in Atlas.ti for physical environment, tasks, roles, technology, organization, and safety.</p><p><strong>Results: </strong>Self-harm, harm to others, and elopement were the frequently mentioned safety concerns. The type of ED (general adult, non-MBH unit) and presence of ligatures in patient care areas increased risks to patient safety. ED layout, patient visibility, and proximity to exits increased elopement risks. The ED environment was seen as a trigger for patient agitation, exacerbating MBH conditions. Major challenges in safety incident prevention and response included inadequate pediatric de-escalation training and ineffective use of protective shields. Technological barriers affecting safety encompass issues with the accessibility and reliability of panic buttons.</p><p><strong>Conclusions: </strong>The study calls for a comprehensive approach to safety in the ED, integrating organizational policies, environment design, technology use, staff training, and resource management, setting the stage for future enhancements in safety for both pediatric MBH patients and health care providers.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S29-S35"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453101/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132333","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":"Understanding Clinical Decision Support Failures in Pediatric Intensive Care Units via Applied Systems Safety Engineering and Human Factors Problem Analysis: Insights From the DISCOVER Learning Lab.","authors":"Matthew Zackoff, Anabel Graciela, Kelly Collins, Daniel Loeb, Andrea Meisman, Kyesha James, Jose Generoso, Karina Ortega, Bain Butcher, Christina Cifra, Colleen Badke, Maya Dewan","doi":"10.1097/PTS.0000000000001358","DOIUrl":"10.1097/PTS.0000000000001358","url":null,"abstract":"<p><strong>Objectives: </strong>Children receiving care in pediatric intensive care units (PICUs) are vulnerable to decompensation and diagnostic error due to the complex and dynamic nature of pediatric critical illness. In the PICU, the few clinical decision support (CDS) tools that have been implemented to support diagnostic accuracy (i.e., the ability to detect the presence of a condition) have not led to an increase in clinician adoption of desired practices nor demonstrated clear clinical benefit.</p><p><strong>Methods: </strong>The DISCOVER Learning Lab analyzed workflow and failure modes in diagnosing and managing clinical decompensation in the PICU, using systems safety engineering and human factors to examine intersections with established CDS. Methods employed included qualitative interviews, workflow mapping, immersive virtual reality (VR) systems testing via a digital twin environment, and a failure modes effect analysis.</p><p><strong>Results: </strong>Workflow mapping and qualitative interviews revealed barriers to communication, workflow inefficiencies, and limited access to up-to-date clinical information during critical events in the PICU. The immersive VR systems testing elucidated how PICU staff members currently interact with CDS tools and how various tools could better integrate into or influence clinical workflows. Critical failure modes were identified with corresponding opportunity areas for intervention.</p><p><strong>Conclusions: </strong>The application of a systems safety engineering and human factors approach to problem analysis, partnered with novel use of immersive VR and digital twin technology, led to valuable insights into common failure modes and potential opportunity areas to improve diagnostic accuracy and care delivery in a quaternary referral center PICU.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S21-S28"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453092/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132438","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":"Improving Telehealth Transition of Care Programs Focused on Readmission Reduction.","authors":"Patricia Spaar, Garrett Zabala, Ryan E Anderson, Ethan Booker, Raj M Ratwani, Seth A Krevat","doi":"10.1097/PTS.0000000000001367","DOIUrl":"10.1097/PTS.0000000000001367","url":null,"abstract":"<p><strong>Introduction: </strong>Suboptimal transitional care from the hospital to home can result in poor health outcomes, increased costs, and readmissions. Telehealth-based transitional care programs have shown some improvements in readmission rates; however, it is unclear why some patients benefit while others do not. This study evaluated a connected transitional care (CTC) program that provided high-risk patients with timely post-discharge telehealth appointments conducted by a nurse practitioner. Our focus was on understanding why some patients participating in the program benefit and are not readmitted while others are readmitted.</p><p><strong>Methods: </strong>We analyzed readmission rates for patients referred to the program and compared those who engaged, by completing a telehealth visit, to those who did not. For those patients who did engage, we conducted chart reviews of a subset of patients who were not readmitted compared with those who were readmitted to extract themes and understand differences that could serve to improve the CTC program.</p><p><strong>Results: </strong>Of 1374 patients referred to the CTC program, 443 (32.2%) engaged by completing a telehealth visit. Those who engaged in the program had a readmission rate of 18.7% compared with 21.3% for those who did not, resulting in a relative risk reduction of 12%. Chart reviews comparing patients who engaged and were not readmitted (32 charts reviewed) with those who were readmitted (18 charts reviewed) revealed several differences. Patients who were not readmitted were seen sooner after discharge, had greater family/caregiver involvement, had social needs addressed, required less language interpretation, and had fewer instances of altered mental status.</p><p><strong>Conclusions: </strong>This study suggests that a telehealth transition program may reduce readmissions, although a more rigorous statistical analysis is needed. Importantly, the qualitative chart review suggests several areas for improvement, including engaging family/caregivers, providing better social need support, and developing ways to support behavioral health.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S60-S64"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453088/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132338","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":"Starting a High-Fidelity Simulation-Based Hospital Quality and Safety Program: Ten Tips for Success.","authors":"Paul S Jansson, Raghu R Seethala, Andrew J Eyre","doi":"10.1097/PTS.0000000000001405","DOIUrl":"10.1097/PTS.0000000000001405","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e161-e163"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144849458","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 TRANS-SAFE Patient Safety Learning Laboratory: A Protocol for Systems Improvement for Psychosocial Safety in Transgender Care.","authors":"Tara N Cohen, Jennifer T Anger, Hanna Barton, Jill Blumenthal, Amanda Gosman, Falisha Kanji, Rai Khamisa, Jejo Koola, Priya Lewis, Maja Marinkovic, Bixby Marino-Kibbee, Maxwell Moore, Kyle Okamuro, Shanaya Sidhu, Victor Trasvina, Florin Vaida, Alan J Card","doi":"10.1097/PTS.0000000000001383","DOIUrl":"10.1097/PTS.0000000000001383","url":null,"abstract":"<p><strong>Objectives: </strong>This study aims to advance patient safety science by identifying and addressing the systemic causes of psychosocial harm among transgender and gender nonbinary (TGNB) individuals. The 4-year TRANS-SAFE patient safety learning laboratory (PSLL) will follow a 6-phase systems engineering approach to study ways to improve the safety of TGNB patients.</p><p><strong>Methods: </strong>This study involves conducting a systematic scoping review, interviews with patients, providers, and community members, and observations of TGNB patient and provider experiences to identify determinants of avoidable patient suffering. In addition, the PSLL will provide financial support for pre-doctorate and post-doctorate research scholars in the TGNB community. Human-centered solutions will be co-designed to mitigate psychosocial harm among TGNB individuals. Interventions will be developed through engagement with stakeholders in an iterative process of co-design and evaluation.</p><p><strong>Results: </strong>Interventions will be evaluated in real and simulated clinical environments for effectiveness, acceptability, usability, feasibility of implementation, and sustainability. A structural innovation of this PSLL is its focus on sustainment and dissemination, which will be facilitated through the development of a TRANS-SAFE certification process for health care organizations in partnership with the World Professional Association for Transgender Health (WPATH).</p><p><strong>Conclusions: </strong>This PSLL will address a fundamental gap in the science and practice of patient safety by assessing and addressing psychosocial patient harm in a high-risk population that has been too often neglected in the patient safety literature.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e145-e155"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12354228/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144486743","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":"Clinician Communication and Patient Safety in Pediatrics: A Practical Application of Human-Centered Design for Problem Identification and Analysis.","authors":"Halley Ruppel, Brooke Luo, James Won, Christopher P Bonafide, Kimberly Albanowski, Austin DeChalus, Brianna Reed, Amina N Khan, Alexis Z Tomlinson, Andi Fu, Jess Ettore, Marion Leary","doi":"10.1097/PTS.0000000000001403","DOIUrl":"10.1097/PTS.0000000000001403","url":null,"abstract":"<p><strong>Background: </strong>We established a Patient Safety Learning Lab (AHRQ R18HS029473) to examine the sociotechnical system that drives interprofessional communication in pediatric inpatient settings in the context of evolving communication technologies, and to co-create and evaluate solutions with clinician end users. Here, we describe the use of human-centered design and system engineering processes for the Problem Analysis phase of this project.</p><p><strong>Methods: </strong>We applied the \"Empathize\" and \"Define\" steps of the design thinking process to our Problem Analysis. The goal of the Empathize step is to generate a comprehensive understanding of a problem(s) as experienced by the end user. We conducted interviews and observations with interprofessional clinicians from pediatric inpatient units in a single children's hospital. We used other operational and clinical data to triangulate findings (clinician secure messaging metadata, survey data, and policies/procedures). In the \"Define\" step, we iteratively developed user-centered problem statements.</p><p><strong>Results: </strong>Data synthesized for the problem analysis included: interviews with 28 clinicians, 32 hours of unit observations; metadata for 433,432 secure messages; 155 free-text clinician survey responses; and 40 communication-related policies/procedures. The Problem Analysis revealed communication challenges in the following domains for clinicians providing frontline care (i.e., bedside nurses, residents, frontline fellows): (1) efficiently locating and contacting other members of the care team; (2) communicating urgency level of information; and (3) managing high volume of minimally informative messages.</p><p><strong>Conclusions: </strong>Practical application of human-centered design and systems thinking contributed to a more holistic understanding of communication challenges, and their patient safety implications, from the perspective of multiple end-user groups.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S89-S95"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453098/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132286","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":"Assessing and Comparing Perceptions of Patient Safety Culture Among 4579 Health Care Staff in 13 General and Specialized Hospitals: A Cross-Sectional Study.","authors":"Qian Lin, Dan Zhang, Calvin Kalun Or","doi":"10.1097/PTS.0000000000001377","DOIUrl":"10.1097/PTS.0000000000001377","url":null,"abstract":"<p><strong>Background: </strong>Although general and specialized hospitals have distinct roles and characteristics that can lead to differences in patient safety culture, there is a limited number of studies examining these differences.</p><p><strong>Objectives: </strong>To assess and compare health care staff's perceptions of patient safety culture between general and specialized hospitals.</p><p><strong>Methods: </strong>A cross-sectional questionnaire-based study of 4579 health care staff members, including physicians; nurses; other health care providers; and administrative staff, was conducted at 5 general and 8 specialized public hospitals in a major city in China. The Hospital Survey on Patient Safety Culture questionnaire was used to measure 12 dimensions of patient safety culture. The differences in perception of the 12 dimensions between general and specialized hospitals were analyzed using a χ 2 test.</p><p><strong>Results: </strong>In general and specialized hospitals, positive ratings for \"communication openness, overall perceptions of patient safety, teamwork across departments, and handoffs and transitions\" ranged from 50% to 70%. Positive ratings for \"staffing\" and \"nonpunitive response to errors\" were <50%. Positive ratings for 8 of the dimensions analyzed were significantly lower in general hospitals than in specialized hospitals, with differences ranging from 2.23% to 4.4%. Within subgroups of health care staff, the dimensions with significant differences varied across professions. Specifically, among physicians, 9 out of 12 dimensions had lower positive ratings in general hospitals than in specialized hospitals, with differences ranging from 3.84% to 7.23%.</p><p><strong>Conclusions: </strong>General hospitals exhibited a more negative patient safety culture than specialized hospitals and thus require more proactive efforts to enhance their patient safety culture, especially among physicians. Both types of hospitals should urgently address issues related to \"staffing\" and \"nonpunitive response to errors.\"</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"467-479"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12445181/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144286927","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":"Design and Development of an Intervention to Improve the Quality and Safety of Pediatric Dental Sedation: A Human-Centered Design Approach.","authors":"Kawtar Zouaidi, Jan Yeager, Suhasini Bangar, Sayali Tungare, Urvi Mehta, Janelle Urata, Alfa-Ibrahim Yansane, Thomas Tanbonliong, Jungsoo Kim, Emily Sedlock, Krishna Kumar Kookal, Yan Xiao, Tokede Oluwabunmi, Heiko Spallek, Amy Franklin, Gregory W Olson, Joel White, Elsbeth Kalenderian, Muhammad F Walji","doi":"10.1097/PTS.0000000000001401","DOIUrl":"10.1097/PTS.0000000000001401","url":null,"abstract":"<p><strong>Background: </strong>There are gaps in understanding the experiences of children, parents, and providers during dental conscious sedation. This study aimed to capture and analyze these experiences to identify opportunities for improvement and enhance the quality and safety of pediatric dental conscious sedation.</p><p><strong>Methods: </strong>A human-centered design approach was used to examine the conscious sedation experience in 2 US advanced education pediatric dental clinics. Researchers conducted field observations, interviews with providers and parents, and providers focus groups to explore experiential factors. Data were transcribed and analyzed using content thematic analysis. Insights from the data were used to explore and generate new solutions to improve dental conscious sedation quality and safety.</p><p><strong>Results: </strong>A total of 25 observations, 18 interviews (9 providers, 9 parents), and 4 provider focus groups were conducted across both sites. The process identified 4 key improvement opportunities: helping providers navigate the ambiguity of patient behavior, facilitating rapport building between providers and patients/parents, aligning expectations and supporting sedation sensemaking, and making the sedation experience more patient-centered. A multicomponent intervention was developed to address these needs, including a parent-facing brochure, a patient educational video, and an enhanced set of sedation records for providers to document patient and sedation information.</p><p><strong>Conclusions: </strong>This study used human-centered design to identify key challenges in pediatric dental conscious sedation and develop a multicomponent intervention in collaboration with patients, parents, and providers. The research demonstrates the potential of this approach to enhance sedation quality and safety, with future studies needed to assess its impact.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S72-S80"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453093/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132308","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}