Journal of Patient Safety最新文献

{"title":"Implementation and Evaluation of the OWLL Intervention to Improve the Quality and Safety of Pediatric Dental Sedation: A Mixed-Methods Approach.","authors":"Kawtar Zouaidi, Jan Yeager, Sayali Tungare, Suhasini Bangar, Janelle Urata, Alfa-Ibrahim Yansane, Jungsoo Kim, Emily Sedlock, Krishna K Kookal, Yan Xiao, Oluwabunmi Tokede, Heiko Spallek, Amy Franklin, Gregory Olson, Joel White, Elsbeth Kalenderian, Muhammad F Walji","doi":"10.1097/PTS.0000000000001460","DOIUrl":"10.1097/PTS.0000000000001460","url":null,"abstract":"<p><strong>Background: </strong>The OWLL (Open-Wide Learning Lab) intervention was developed using Human-Centered Design to improve the quality and safety of pediatric dental sedation. The intervention includes a patient-facing informational sedation brochure and video, and an enhanced set of clinical sedation records. Here, we report on the process evaluation 6 months after implementation in daily clinical practice.</p><p><strong>Methods: </strong>This study was conducted at the outpatient pediatric dental clinics of 2 large US academic dental institutions. We used a mixed-methods design to assess the fidelity, acceptability, appropriateness, and feasibility of the OWLL intervention. Quantitative data were gathered through chart reviews, while qualitative data were collected through surveys and interviews with providers and patients.</p><p><strong>Results: </strong>During implementation, the intervention was used for 81 pediatric sedation patients across sites. Overall, the intervention was well-received by both clinicians and patients. Chart reviews indicated that sedation records were consistently utilized, though occasional gaps in data completeness were observed. Providers welcomed the intervention, finding it compatible with their daily routines and easy to use. However, some challenges were reported, primarily related to time constraints and the need to adjust clinical encounters for effective intervention integration. Parents appreciated the sedation brochure and video, describing them as a valuable and positive addition to the care process.</p><p><strong>Conclusion: </strong>The findings suggest that the intervention was used and is a welcomed addition, with the potential for broader application in clinical settings to further improve patient care. Future efforts should examine the intervention's impact on patient safety outcomes across diverse clinical settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"261-267"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13277721/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146031227","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":"Restraints and Seclusion: A Multimodal Approach to Improving Face-to-Face Documentation Compliance in the Emergency Department.","authors":"Obert Xu, Kenneth DeVane, Laura Chess, Steven McGaughey, Ben Orwoll, Tonya Brockman, Beech Burns","doi":"10.1097/PTS.0000000000001455","DOIUrl":"10.1097/PTS.0000000000001455","url":null,"abstract":"<p><strong>Background: </strong>Regulatory bodies require the use of restraints and seclusion in health care settings to be strictly monitored and carefully documented. In our emergency department (ED), an internal audit uncovered low compliance with required patient safety documentation, the so-called \"face-to-face (FTF)\" assessment, within 1 hour of restraint or seclusion initiation. The primary objective of this quality improvement (QI) study is to evaluate a series of interventions as a mechanism to improve FTF documentation compliance.</p><p><strong>Methods: </strong>This project was conducted in a single-site academic ED. Patients requiring restraints and seclusion application from November 2021 to June 2024 were included. We implemented 3 plan-do-study-act (PDSA) cycles: (1) development of FTF documentation flowsheet with delayed best practice alert (BPA) trigger, (2) direct audit and clinician feedback via email, and (3) modification to immediate BPA trigger. Our primary outcome was a change in the rate of FTF documentation completion within 60 minutes of restraint or seclusion application. We used descriptive analysis to evaluate adherence rates.</p><p><strong>Results: </strong>There were 856 qualifying instances during the study period. Our intervention bundle was associated with an increase in documentation adherence from a preintervention baseline of 10.96% to a final performance of 81.28%, an absolute increase of 70.32% ( P <0.001).</p><p><strong>Conclusions: </strong>Our series of interventions, including direct feedback and technical solutions, was effective in increasing clinician FTF documentation adherence. By deploying these interventions iteratively, our approach supported practice change and behavioral modification among ED clinicians, highlighting the importance of an incremental process in changing practice and culture.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"314-321"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145758126","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":"Beyond Remission: The Need for Transparent Communication About CAR-T Adverse Effects.","authors":"Tracy R Wilson","doi":"10.1097/PTS.0000000000001477","DOIUrl":"10.1097/PTS.0000000000001477","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e73-e74"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147876254","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 Critical Threat to Patient Safety: A Bibliometric Analysis of Wrong-Site, Wrong-Side, and Wrong-Organ Surgery.","authors":"Askeri Çankaya, Hatice Özsoy, Muaz Gülşen, Meryem Yavuz van Giersbergen","doi":"10.1097/PTS.0000000000001457","DOIUrl":"10.1097/PTS.0000000000001457","url":null,"abstract":"<p><strong>Objective: </strong>Wrong-site surgery (WSS) is recognized as one of the most serious yet preventable medical errors in surgical care. It involves operations performed on the wrong anatomic site, side, patient, or at an incorrect level within the correct site. This study aims to systematically investigate prevailing themes, key research areas, and evolving scholarly trends in WSS literature, including wrong-side and wrong-organ surgeries. It also intends to provide a comprehensive resource for stakeholders focused on surgical safety.</p><p><strong>Methods: </strong>A retrospective descriptive bibliometric analysis was conducted using data retrieved from the Web of Science database on April 9, 2025. A total of 270 articles meeting predefined inclusion criteria were identified. Descriptive and predictive analyses were carried out using Microsoft Excel and ChatGPT. Bibliometric indicators were assessed with the Bibliometrix package in RStudio, while visualizations were generated via VOSviewer.</p><p><strong>Results: </strong>Between 1980 and 2025, 270 relevant publications were identified, with 28.52% published in the last 5 years, indicating continued academic interest. Spine was the most productive journal. The United States, the United Kingdom, and China were leading in publication output and citation impact. Core keywords such as \"wrong-site surgery\" and \"patient safety\" dominated co-occurrence networks.</p><p><strong>Conclusions: </strong>Despite a modest annual growth rate (1.55%), WSS research remains active. Predictive models indicate a steady increase in publication volume. With an average citation rate of 20.96 per article, the literature reflects meaningful scholarly engagement. This analysis offers critical insight into the intellectual structure and progression of WSS research.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"322-333"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145821752","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":"Safety of First Dose Remdesivir in the Hospital-at-Home Setting for Patients With COVID-19.","authors":"Emmeliene Su-Min Ong, Min Yi Martin Soo, Stephanie Qianwen Ko","doi":"10.1097/PTS.0000000000001498","DOIUrl":"10.1097/PTS.0000000000001498","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e77-e79"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147576056","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":"Clinical and Safety Outcomes of Patients Admitted to Different Specialty Wards: The Prospective, Multi-center, Controlled SISIFO Study.","authors":"Micaela La Regina, Lorenzo Federici, Elisa Romano, Francesco Orlandini, Andrea Fontanella, Antonino Mazzone, Mauro Campanini, Dario Manfellotto, Alessandro Squizzato, Riccardo Tartaglia","doi":"10.1097/PTS.0000000000001556","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001556","url":null,"abstract":"<p><strong>Objectives: </strong>Patients' admission to different specialty wards (the so-called \"outliers\") due to a hospital bed shortage may significantly reduce the quality and safety of clinical care. However, data on clinical outcomes are limited, heterogeneous, and mainly retrospective. For this reason, we performed a prospective controlled study, the Survival and Safety Issues for Medical Outliers (SISIFO) study.</p><p><strong>Methods: </strong>We conducted the SISIFO study, a prospective, multicenter, controlled study to primarily evaluate clinical and safety outcomes in outliers from October 2018 to March 2020.</p><p><strong>Results: </strong>Thirty-seven Italian Internal Medicine Units enrolled 2056 medically ill patients, 988 outliers, and 1068 controls. Overall, the median length of hospital stay was 10 days [interquartile range (IQR) 7-15]. The median stay in the different specialty wards was 2 days (IQR 2-4). The in-hospital mortality of outliers was significantly higher than that of controls (OR=2.1, 95% CI: 1.3-3.3) at multivariate analysis. Among outliers, modified early warning score (MEWS) >3, reduced mobility, and dysphagia at baseline were significantly associated with a higher risk of in-hospital death. No significant differences between \"outliers\" and controls were observed for secondary outcomes, including postdischarge 90-day mortality and readmission rate, requests for diagnostic tests, or specialist consultations. In-hospital adverse events presented some noteworthy findings.</p><p><strong>Conclusions: </strong>Our study suggests a significant increase in in-hospital mortality associated with admission to different specialty wards. Future studies should investigate the specific reasons for this finding.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148363180","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 Qualitative Study Exploring the Views and Experiences of UK Maternity Healthcare Professionals Towards Adverse Event Disclosure.","authors":"Raabia Sattar, Judith Johnson, Dileep Wijeratne, Rebecca Lawton","doi":"10.1097/PTS.0000000000001536","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001536","url":null,"abstract":"<p><strong>Objectives: </strong>Open and transparent disclosure between health care professionals and patients and/or their families after an adverse event is an important feature of high-quality patient care. Within many countries, disclosure is a legal requirement. Previous research has been well documented within the specialties of surgery and internal medicine, but literature on disclosure within maternity settings is sparse. This study aimed to explore the experiences and views of UK maternity healthcare professionals regarding the disclosure of adverse events.</p><p><strong>Methods: </strong>Semi-structured interviews were conducted and analyzed using reflexive thematic analysis. Maternity health care professionals (8 midwives and 10 obstetricians), from UK maternity services within the National Health Service (NHS), took part in the study.</p><p><strong>Results: </strong>Both midwives and obstetricians strongly emphasized the importance of honesty and transparency during disclosure. However, the following barriers were identified, which made the disclosure process challenging: uncertainty about the type of incident that occurred, uncertainty about current disclosure practices, concerns about the investigation process and legal risks, and a lack of support and training regarding disclosure. Five main themes were identified, which described midwives' and obstetricians' views and experiences of disclosure: 'Easing the burden,' 'Role of uncertainty,' 'Fear of vulnerability,' 'Personalization or professionalization,' and 'Need for further support.'</p><p><strong>Conclusions: </strong>Disclosure is an emotionally demanding task for health care professionals. There is a need for support and guidance during the disclosure process, in understanding legal and regulatory processes, and in approaching disclosure when there is uncertainty about whether an adverse event or complication has occurred.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148363131","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":"Responsive Learning and Proactive Harm Prevention: Development of a Tiered Event Review Continuum.","authors":"Orysia Bezpalko, Stephanie Powell, Elena Becker, Lauren Brennan, Kimberly DiGerolamo, Susan Ditaranto, Jason Freedman, Cheryl Gebeline-Myers, Joshua Lamaina, David H Rhodes, Lakshmi Srinivasan, Julia S Sammons","doi":"10.1097/PTS.0000000000001551","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001551","url":null,"abstract":"<p><strong>Objectives: </strong>Efforts to reduce health care-associated conditions (HACs) have increased over time, with notable success. Still, opportunities remain to reduce preventable harm in hospitalized children. The integration of both retrospective and proactive safety frameworks can enhance these efforts. We aimed to optimize our ability to learn from and prevent events of harm in hospitalized children at the Children's Hospital of Philadelphia by developing and implementing a comprehensive, standardized tiered event review continuum.</p><p><strong>Methods: </strong>Using quality improvement methodologies, we launched a multiyear initiative to develop a standardized approach to HAC reviews, incorporating learning from events after they occur and proactive planning for at-risk patients before harm events. Measures included adherence to process, analysis of attendance trends, and longitudinal outcomes following reviews. Data were analyzed following full implementation of the review process, beginning in 2017.</p><p><strong>Results: </strong>From 2017 to 2023, 2217 retrospective reviews were completed with an adherence rate of 95%. Attendees were captured across disciplines, with a majority representing nursing. One thousand two hundred eighty-six proactive reviews were completed from January 2022 to June 2024; of these, 75% of patients did not experience a subsequent harm event during their hospitalization.</p><p><strong>Conclusions: </strong>We successfully developed and implemented a tiered event review framework that spanned the continuum of retrospective and proactive approaches to safety. This structure has been fully implemented with high reliability across all inpatient areas, and has yielded important insights in patient-level, unit-level, and system-level HAC improvement efforts. Future directions include enhancing provider engagement and better capturing the longitudinal impact of proactive safety huddles on patient outcomes.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148363212","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":"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":"https://doi.org/10.1097/PTS.0000000000001541","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-06-29","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":"Psychometric Evaluation of the Japanese Version of the Hospital Survey on Patient Safety Culture 2.0 (J-HSOPS 2.0): A Nationwide Cross-sectional Study.","authors":"Yosuke Hatakeyama, Kanako Seto, Ryo Onishi, Ryosuke Hayashi, Kunichika Matsumoto, Tomonori Hasegawa","doi":"10.1097/PTS.0000000000001549","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001549","url":null,"abstract":"<p><strong>Objectives: </strong>Patient safety culture is a key determinant of health care quality and safety outcomes. The Hospital Survey on Patient Safety Culture (HSOPS) is one of the most widely used instruments for assessing safety culture in healthcare organizations. Although the revised HSOPS 2.0 has been adopted internationally, the Japanese version (J-HSOPS 2.0) has not yet been comprehensively evaluated using large-scale empirical data.</p><p><strong>Methods: </strong>We conducted a cross-sectional survey of health care professionals in hospitals participating in a nationwide patient safety culture benchmarking program in Japan. The J-HSOPS 2.0 was developed through a structured translation and adaptation process. Construct validity was assessed using confirmatory factor analysis based on the original 10-dimensional HSOPS 2.0 model. Model fit was evaluated using standard goodness-of-fit indices. Convergent validity and reliability were assessed using average variance extracted, composite reliability, and Cronbach alpha, while discriminant validity was examined using factor correlations and the Fornell-Larcker criterion.</p><p><strong>Results: </strong>Data from 76,966 hospital staff members were analyzed. The hypothesized 10-factor structure was broadly supported. Model fit indices indicated acceptable but suboptimal fit (RMSEA=0.067; CFI=0.836). Measurement invariance across professional groups was largely supported. Communication-related dimensions showed relatively strong psychometric performance and were strongly associated with overall patient safety ratings.</p><p><strong>Conclusions: </strong>The J-HSOPS 2.0 demonstrated acceptable psychometric properties and can be used for benchmarking and quality improvement in Japanese hospitals. These findings support the use of J-HSOPS 2.0 as a practical tool for identifying patient safety risks and guiding safety improvement initiatives in hospital settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-06-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148346965","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}