Journal of Patient Safety最新文献

{"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":"<p><strong>Background: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions: </strong>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.</p>","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}

{"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":"<p><strong>Objectives: </strong>This study aimed to develop a taxonomy for classifying corrective actions following health care incidents in a Portuguese tertiary hospital.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusions: </strong>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.</p>","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}

{"title":"Situational Analysis of the Medication Practices in Brazilian Hospitals: A Multicenter Study.","authors":"Pedro Henrique Guimarães, Mário Borges Rosa, Adriano Max Moreira Reis, Kirla Barbosa Detoni, Gabriela de Paula Guimarães Rodrigues, Mariana Martins Gonzaga Nascimento","doi":"10.1097/PTS.0000000000001314","DOIUrl":"10.1097/PTS.0000000000001314","url":null,"abstract":"<p><strong>Objective: </strong>To carry out a situational analysis of the medication practices in Brazilian hospitals through the Medication Safety Self-Assessment for Hospitals and the factors associated with better performance in the evaluation.</p><p><strong>Methods: </strong>This is a multicenter cross-sectional study in which the results of the application of the Medication Safety Self-Assessment for Hospitals, between 2015 and 2020, in 30 Brazilian hospitals were described. In addition, whether the institutional profile was associated with higher self-assessment scores (better performance in the evaluation) was also evaluated.</p><p><strong>Results: </strong>An average proportion of points obtained of 36.7±10.9% was identified (minimum=11.5%; maximum=59.7%), from a score ranging from 0 to 1826 points. The need to improve the use of devices for the preparation and administration of drug solutions, professional development, and patient education was highlighted. A positive association was identified between higher scores and the large or very large size of the hospitals ( P =0.026) and having accreditation certification ( P =0.007).</p><p><strong>Conclusions: </strong>The study made it possible to identify the main weak points and opportunities for improvement of the medication system in the evaluated hospitals, bringing important reflection to national institutions.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"127-132"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143014440","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":"Validity and Reliability Study of the Turkish Adaptation of the \"Medical Office Survey on Patient Safety Culture\".","authors":"Vildan Mevsim, Mustafa Erdem, Oğulcan Çöme, İncim Bezircioğlu","doi":"10.1097/PTS.0000000000001319","DOIUrl":"10.1097/PTS.0000000000001319","url":null,"abstract":"<p><strong>Introduction: </strong>The safety culture within health care organizations is essential for ensuring patient well-being and optimizing health care delivery. This study addresses the pressing need to establish a culture of patient safety within primary health care settings. The aim is to conduct a comprehensive validity and reliability study for the Turkish adaptation of the \"Medical Office Survey on Patient Safety Culture\" (MOSPSC) scale, designed to assess patient safety culture in primary care medical offices.</p><p><strong>Methods: </strong>The research model follows rigorous methodology, including a systematic translation and adaptation process aligned with World Health Organization guidelines. A diverse sample of 402 family physicians from primary health care centers across Turkey participated in the study. Descriptive results highlight participants' characteristics, work environments, and experiences in primary care. The scale's construct validity is evaluated using the Kaiser-Meyer-Olkin (KMO) and Bartlett tests, while its reliability is assessed through internal consistency analyses, including Cronbach α, split-half reliability, and item-total correlation.</p><p><strong>Results: </strong>Results indicate strong internal consistency, with Cronbach α values ranging from 0.42 to 0.91 for scale dimensions and an overall value of 0.89. Construct validity assessment attests to the scale's appropriateness for assessing patient safety culture. Challenges in conducting factor analysis due to participant responses are discussed.</p><p><strong>Conclusions: </strong>The study contributes to the field by providing a validated and reliable tool specifically tailored for assessing patient safety culture in primary care medical offices. The Turkish adaptation of the MOSPSC scale offers health care professionals and organizations a valuable instrument for enhancing patient safety culture, identifying areas for improvement, and ultimately optimizing patient care within primary health care settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"119-126"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143069181","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":"Considerations and Challenges When Using Clinical and Vital Record Review for Suicide Research.","authors":"Sarah A Arias, Brandon A Gaudiano, Gary Epstein-Lubow, Sarah Zylberfuden, Lauren M Weinstock","doi":"10.1097/PTS.0000000000001325","DOIUrl":"10.1097/PTS.0000000000001325","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e8-e17"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11932785/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143383562","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":"The Prevention and Treatment of Postoperative Delirium in the Elderly: A Narrative Systematic Review of Reviews.","authors":"Simon Deblois, Nicolas Bergeron, Thien Tuong Minh Vu, Gabriel Paquin-Lanthier, Bénédicte Nauche, Alfons Pomp","doi":"10.1097/PTS.0000000000001318","DOIUrl":"10.1097/PTS.0000000000001318","url":null,"abstract":"<p><strong>Objectives: </strong>Postoperative delirium (POD) is a common complication after major surgeries, posing significant challenges to patient recovery and outcomes, particularly among the elderly. A narrative systematic review was conducted to assess the clinical effectiveness and safety of interventions aimed at preventing and treating POD.</p><p><strong>Methods: </strong>A review of the literature from 2017 to September 29, 2023, was conducted using MEDLINE, EMBASE, and CINAHL. Systematic reviews, with or without meta-analyses, as well as practice guidelines, were included. Participants were adults, ≥60 years. The methodological quality of included reviews was appraised using AMSTAR 2.</p><p><strong>Results: </strong>After the search strategy identified 2295 references, 36 review studies were selected. Multicomponent interventions, incorporating both pharmacological and nonpharmacological approaches, demonstrate promise, particularly in hip fracture patients. Notably, dexmedetomidine emerges as a potential preventive measure, showing a notable reduction in delirium incidence following cardiac surgery. While several pharmacological interventions show potential, evidence remains inconclusive, necessitating further investigation. Similarly, varying anesthesia type and monitoring methods has mixed outcomes on delirium prevention. Despite methodological variations and quality appraisal limitations, this review underscores the importance of multicomponent interventions and the potential efficacy of dexmedetomidine in mitigating POD. Integration of evidence-based protocols into clinical practice is advocated to improve patient outcomes. However, the complex interplay between intervention components calls for further research to optimize delirium management strategies.</p><p><strong>Conclusions: </strong>The strength of evidence associated with multicomponent interventions and dexmedetomidine use should require a genuine commitment from health care institutions to support their integration into efficient strategies to prevent and treat POD. Ongoing research is vital to uncover their full potential and refine clinical protocols, ultimately enhancing patient care outcomes.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"174-192"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143191101","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 5-year Review of Characteristics and Outcomes of Trauma Surgery Patients Leaving Against Medical Advice.","authors":"Joseph D Quick, Lauren E Powell, Erica Bien, Nellie R Adams, Sam A Miotke, Ruth J Barta","doi":"10.1097/PTS.0000000000001310","DOIUrl":"10.1097/PTS.0000000000001310","url":null,"abstract":"<p><strong>Objectives: </strong>The objective of this study was to characterize the demographic, social, economic, and clinical factors of trauma surgery patients leaving against medical advice (AMA).</p><p><strong>Methods: </strong>Data were retroactively obtained from a level-one trauma center in a medium-sized metropolitan area from January 2017 to December 2021. The sample population consisted of patients admitted or treated by the trauma surgical service.</p><p><strong>Results: </strong>In the 5-year study period, 130 surgical patients left AMA and met the inclusion criteria for this study. The average patient was 38.8 years old. The majority were male (77.7%) and White (47.7%). It was found that 74.6% of patients had insurance, 23.6% were experiencing homelessness, and 6.2% required an interpreter. A large percentage of patients had a past medical history significant for depression (31.5%), anxiety disorders (25.4%), and substance use disorder (68.5%). Analysis of the hospital time course of this patient population indicated that patients were most often admitted to trauma surgery (70.0%) and most often required consults by neurosurgery (28.5%). Procedures were performed for 81.5% of patients and social services were consulted for 60.8% of patients. Only 50.8% of patients who left AMA were noted to receive discharge instructions. Nearly half (44.6%) of the patients returned to a hospital to receive additional care within 1 month of their initial AMA discharge date.</p><p><strong>Conclusions: </strong>A concerning number of trauma surgery patients left without discharge instructions, possibly leading to a high rate of 30-day hospital readmission. Future studies are needed to examine and further characterize the relationship between discharge protocol and outcomes of patients leaving AMA.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"159-164"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142972951","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":"Unveiling the Impact of Operational Failures on Patients: A SEIPS-based Analysis From the Perspective of Hospital Nurses.","authors":"Sem Vanbelleghem, Melissa De Regge, Yves Van Nieuwenhove, Paul Gemmel","doi":"10.1097/PTS.0000000000001341","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001341","url":null,"abstract":"<p><strong>Objectives: </strong>Operational failures (OFs) in hospital environments pose significant challenges for nurses, affecting patient care, workflow efficiency, and clinical processes. Common OFs include supply chain disruptions, communication breakdowns, and equipment failures. Although OFs are pervasive and frequent, current research primarily focuses on process improvement and employee well-being, neglecting the patient-centric perspective in this discourse. The objective of this study is to explore the impact of OFs on patient well-being through semi-structured interviews conducted with hospital nursing staff.</p><p><strong>Methods: </strong>A qualitative and exploratory approach, in accordance with the SRQR guidelines, was employed to ensure methodological rigor and transparency by providing a comprehensive understanding of the phenomenon. This multicenter study was conducted in 23 wards across 5 general hospitals in Belgium. It included in-depth, semi-structured face-to-face interviews with 26 nurses, and 2 group discussions: one with nurse managers (n=6), and another with patients (n=14). Thematic analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to examine how OFs emerge within work systems and affect patients.</p><p><strong>Results: </strong>The results indicate that minor OFs, including short delays in care or small communication lapses, can disrupt the continuity of care, leading to heightened patient stress and dissatisfaction. Conversely, major OFs, such as critical equipment breakdowns or medication errors, pose substantial and widespread risks, negatively impacting both patient experience and safety. Patients' reactions to such failures depend on the preventability of the error and the severity of its consequences, ranging from understanding to outright anger.</p><p><strong>Conclusions: </strong>The numerous day-to-day problems that nurses encounter due to poorly performing work systems can significantly compromise patient well-being and safety, ultimately affecting patient satisfaction and trust in health care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-03-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143722112","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":"Adverse Events Reported Across 15 Years of Multicenter Chiropractic Student Clinical Placements in Western Australia.","authors":"Lyndon G Amorin-Woods, Vincenzo Cascioli, Barrett E Losco, Gregory F Parkin-Smith","doi":"10.1097/PTS.0000000000001339","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001339","url":null,"abstract":"<p><strong>Aim: </strong>To report the rate and severity of adverse events (AEs) among patients receiving services at university-based chiropractic clinical placements over a 15-year period in Western Australia.</p><p><strong>Methods: </strong>Patients reporting AEs were identified from an incident register between 2008 and 2023. Details of all incidents were authenticated through extracted data from patient follow-up, clinical records, clinician reports, legal, and insurer advice and were graded (1-5) based on severity.</p><p><strong>Results and discussion: </strong>Chiropractic services were delivered by 921 chiropractic students and supervised by 44 registered chiropractors during the 15-year time span in metropolitan, rural, and remote locations. Among 410,957 clinical encounters (CE) comprising 349,075 treatment sessions for 61,882 unique patients, 20 mild (grade 1) clinical AEs were identified, yielding a crude incidence rate of 4.87 per 100,000 (95% CI: 2.79-7.52), or 1:20,548 clinical encounters. Signs and symptoms of AEs were acute or exacerbated low back pain, neck pain, and mid-back pain/shoulder pain. The most common presenting complaints among the patients reporting an AE were pain in 3 spinal regions.</p><p><strong>Conclusions: </strong>The incidence of AEs associated with chiropractic care in this population corroborates previous studies that report the rate and severity of AEs to be rare and mild.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143711791","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":"Patient Safety Culture Research: A Bibliometric Analysis From 2001 to 2023.","authors":"Tianli Huang, Yan Wu","doi":"10.1097/PTS.0000000000001338","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001338","url":null,"abstract":"<p><strong>Objectives: </strong>To perform a bibliometric analysis of research on patient safety culture from 2001 to 2023.</p><p><strong>Methods: </strong>Retrieve the SSCI and SCIE data in the Web of Science Core Collection with the title \"Patient Safety Culture\" from January 1, 2001, to December 31, 2023. HistCite, Bibliometrix Package, VOSviewer, and Jshare were used to conduct bibliometric analyses. The analysis contents included publications, distribution of countries/regions, core journals, organizations, the evolution of keywords over the years, future trends of the field, author contributions, and citation analysis.</p><p><strong>Results: </strong>A total of 595 articles authored by 2383 individuals from 1048 different sources were collected. The United States emerged as the most prolific country (N=142), while Westat Corporation was the leading institution (N=11). The number of papers issued by developing and advanced economies is gradually balanced after 2022. The top researchers were Wagner C, Hammer A, and Hasegawa T. The analysis identified 1427 keywords, with the most frequently used being \"climate,\" \"health care,\" \"adverse events,\" \"nurses,\" and \"quality.\" It was noted that trending topics such as \"healthcare providers,\" \"work environment,\" and \"high-reliability\" have gained traction recently, while earlier years saw a focus on \"climate,\" \"care,\" \"healthcare,\" \"perceptions,\" and \"nurses.\"</p><p><strong>Conclusions: </strong>Patient safety culture research is gaining increasing attention in the coming years, especially in developing countries. Future research should prioritize the \"work environment\" and \"climate\" to enhance patient safety culture, particularly addressing the \"barriers\" to improving \"management\" and \"communication.\"</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143701841","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}