Journal of Patient Safety最新文献

{"title":"SCALPEL: A Structured Handoff Protocol for Scrub Nurses in the Operating Room for Patient Safety.","authors":"Saeid Amini Rarani","doi":"10.1097/PTS.0000000000001331","DOIUrl":"10.1097/PTS.0000000000001331","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e73"},"PeriodicalIF":1.7,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143524806","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":"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":"10.1097/PTS.0000000000001344","url":null,"abstract":"<p><strong>Objectives: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions: </strong>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.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"371-376"},"PeriodicalIF":1.7,"publicationDate":"2025-08-01","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}

{"title":"Patient Safety Culture Research: A Bibliometric Analysis From 2001 to 2023.","authors":"Tianli Huang, Yan Wu","doi":"10.1097/PTS.0000000000001338","DOIUrl":"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":"e62-e72"},"PeriodicalIF":1.7,"publicationDate":"2025-08-01","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}

{"title":"Unveiling Disparities in Patient Rights Awareness and Practice: Insights From Artificial Neural Networks.","authors":"Loai M Saadah, Dalal B Alnatour, Mumen S Hadidi, Fadia F Samara, Sana S Shakhshir, Wafa'a M Alnsour, Maisa K Saket","doi":"10.1097/PTS.0000000000001326","DOIUrl":"10.1097/PTS.0000000000001326","url":null,"abstract":"<p><strong>Background: </strong>High-quality universal health care coverage for all patients is the common theme in patient rights. However, pertinent investigations on this topic within the context of Jordanian health care are absent. This systematic review, coupled with a pooled artificial intelligence analysis of the data in retrieved studies, paves the way for such research by pooling data sets sourced from across the Middle East and North Africa (MENA) region.</p><p><strong>Methods: </strong>National Library of Medicine (NLM), through its secondary database of primary literature (PubMed), was queried with the terms \"Patient\" and \"Rights\" in April 2024. Quantitative surveys from MENA containing individual item assessments mapped to 1 of the 7 domains of Jordan National Patient Rights Charter were pooled. Finally, factors extracted for all studies were then used to build an artificial neural network (ANN) to test the hypothesis that information asymmetry in both awareness and practice of patient rights exist even among health care providers.</p><p><strong>Results: </strong>A total of 8 studies with 131 survey items were identified in the MENA region. All items tested either knowledge (awareness) or practice (implementation) of respondents regards patient rights except for 25 items in one study which measured both. ANN converged to a best net of multilayer feedforward with 3 hidden nodes. Patient right domain, from Jordanian Patient Rights Charter, ranked first and respondent type second as most important among the variables. However, there was huge and statistically significant asymmetry between students 0.602 (0.499 to 0.853), patients 0.627 (0.518 to 0.636), and nurses 0.492 (0.340 to 0.786) on one side and clinicians 1.166 (1.025 to 1.258) on the other side in the ANN model (both paired t test and Wilcoxon signed rank test P <0.0001) for any pairwise comparisons.</p><p><strong>Conclusions: </strong>Jordan National Patient Charter can fit any patient right item one could think of in the infinite space of patient rights. Huge information asymmetry exists in both awareness and implementation between practicing professionals and society but also among the different health professions.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"317-323"},"PeriodicalIF":1.7,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143416065","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":"Tools for Assessing Medication Safety Processes in Nursing Homes: A Systematic Review.","authors":"Ramesh Sharma Poudel, Kylie A Williams, Lisa G Pont","doi":"10.1097/PTS.0000000000001379","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001379","url":null,"abstract":"<p><strong>Objective: </strong>This systematic review aimed to identify tools for measuring the quality of medication safety-related processes in nursing homes.</p><p><strong>Methods: </strong>We systematically searched Medline, Embase, and CINAHL databases to identify studies describing tools for measuring medication safety-related processes or systems supporting medication safety in nursing homes. Databases were searched from their inception to June 2022. For each tool, the individual items included in the tool were mapped to the 9 steps and 3 background processes of the medication management pathway and the methodological quality was assessed using the Appraisal of Indicators through Research and Evaluation (AIRE) Instrument.</p><p><strong>Results: </strong>Four tools for assessing medication safety-related processes or systems in the nursing home setting were identified. The tools varied substantially in terms of development, content (number of key elements and items), focus and quality. Only one tool, the Canadian Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC), addressed all 9 steps and 3 background processes of the medication management pathway and had a high overall quality rating as per the AIRE instrument.</p><p><strong>Conclusions: </strong>While the Canadian MSSA-LTC tool had the widest focus and highest quality of the 4 tools identified, the choice of a tool by an individual nursing home or care organization will depend on the purpose of the assessment and processes of interest as well as the validity of the tool in the jurisdiction in which it is being used. Awareness of the differences and limitations of each tool in the relevant context should facilitate this endeavour.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144692152","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":"Enhancing Fall Risk Assessment After Total Knee Arthroplasty: The Role of the Sitting-rising Test.","authors":"Abdul Moeez Awais, Abdul Raffay Awais, Laiba Khurram","doi":"10.1097/PTS.0000000000001388","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001388","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144692151","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 National Position Paper for the Strategic Development of HealthCare Simulation in Italy.","authors":"Pier Luigi Ingrassia, Alessandro Barelli, Enrico Benedetti, Silvia Bressan, Luca Carenzo, Fausto D'Agostino, Francesco DiMeco, Giovanni Esposito, Alessandro Perin, Alfonso Piro, Giovanni Scambia, Andrea Silenzi, Stefano Sironi, Antonio Ursone, Pierpaolo Sileri","doi":"10.1097/PTS.0000000000001393","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001393","url":null,"abstract":"<p><strong>Background: </strong>Simulation-based education is an essential tool in modern health care, enhancing technical, behavioral, and decision-making skills while improving patient safety and clinical outcomes. In Italy, health care simulation has developed over the past 2 decades, with multiple scientific societies and educational initiatives promoting its use. However, the absence of national data and standardized educational frameworks presents a barrier to its widespread adoption. Recognizing these challenges, the Italian Ministry of Health convened a panel of experts to establish a strategic framework for simulation in health care, aiming to standardize methodologies, promote quality assurance, and foster collaboration across institutions.</p><p><strong>Methods: </strong>The panel, composed of experts in health care simulation, clinical practice, and risk management, conducted a series of telematic meetings from April 2022 to July 2022. A consensus-driven approach was adopted to review existing literature, identify key areas for development, and formulate practical recommendations.</p><p><strong>Results: </strong>Key recommendations include: establishing a national registry of simulation programs, defining accreditation criteria for simulation-based education, standardizing professional competencies for simulation educators, integrating simulation into health care curricula and continuous professional development, developing national standards for simulation-based training in new technologies and clinical procedures, utilizing simulation in public health preparedness and emergency response planning, promoting research funding and inter-institutional collaborations.</p><p><strong>Conclusion: </strong>This position paper provides a strategic roadmap for standardizing simulation-based education across the Italian health care system. By establishing national standards and fostering collaboration, simulation can significantly improve patient safety, care quality, and health care system resilience.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144627425","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 Efficacy and Safety of Peripherally Inserted Central Catheters in Neuro Intensive Care Management: A Retrospective Study.","authors":"Dong-Mei Li, Lu Meng, Long-Juan Yu, Li-Fen Gan, Dong-Wei Dai, Huo-Hong Qian, Jian-Min Liu","doi":"10.1097/PTS.0000000000001378","DOIUrl":"10.1097/PTS.0000000000001378","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to analyze the efficacy and safety of peripherally inserted central catheters (PICCs) inserted by the PICC nursing team in the neuro intensive care unit (ICU).</p><p><strong>Methods: </strong>A retrospective analysis was conducted on 756 patients admitted to the neuro ICU of a clinical neurosciences center in Shanghai, China, between January 2019 and December 2022. All patients required elective central venous access and had a PICC inserted by the PICC nursing team. Data on patient demographics, catheter type, insertion approach, puncture site, tip position, insertion success rate, and complications were extracted from electronic medical records using Questionnaire Star software. The study compared outcomes before and after the implementation of a specialized training program for the PICC nursing team, which included theoretical and practical training on PICC insertion techniques, maintenance, and complications management.</p><p><strong>Results: </strong>Following the implementation of the trained PICC nursing team, significant changes were observed in catheter type and insertion technique. The use of 3-way valve Solo catheters and power-injectable open-ended catheters increased, while the use of 3-way valve catheters decreased. In addition, the use of ultrasound-guided modified Seldinger technique (MST) increased significantly, with a corresponding decrease in conventional PICC insertion and MST without ultrasound guidance. Malpositioned tips occurred in 6.3% of cases. Notably, after the implementation of the trained team, complications significantly decreased ( P <0.05) and the first-attempt success rate significantly increased ( P <0.05) compared with the period before the training program.</p><p><strong>Conclusions: </strong>In neuro ICU patients, the use of PICCs inserted by a well-trained, competent PICC nursing team demonstrated improved outcomes, including reduced complications, increased first-attempt success rates, and higher quality of care. These findings highlight the importance of specialized training for PICC nursing teams in neurointensive care management.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144585378","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":"Development of an Evidence-Based Instrument to Justify the Use of Physical Restraint in General Adult Ward Settings: A Systematic Review.","authors":"Lap Fung Tsang, Kin Fung So, Cheuk Fung Ng, Tak Po Cheung, Ka Po Lo, Siu Keung Tang, Lok Man Leung","doi":"10.1097/PTS.0000000000001380","DOIUrl":"10.1097/PTS.0000000000001380","url":null,"abstract":"<p><strong>Background: </strong>Physical restraint is commonly applied in the clinical settings despite numerous studies presenting its paucity of efficacy and safety. Despite the various tangible and intangible factors associated with moral and safety issues, nurses must make decisions on restraint use in ethical dilemmas. Health care providers often find it challenging to make appropriate decisions regarding the use of physical restraint in demanding clinical environments without a standard and objective assessment tool.</p><p><strong>Objectives: </strong>The objectives aimed to identify effective instrument to justify the decision-making regarding the use of physical restraint in general adult ward settings.</p><p><strong>Methods: </strong>A literature search was conducted on several electronic databases, including Medline, PubMed, CINAHL Complete, Embase, and Cochrane Library, using subject MeSH headings and relevant keywords to identify any relevant studies pertaining to the research question. Only articles written in English from January 2014 to March 2024 were considered. The search was filtered by screening for articles with the full-text availability, cohort studies that are not considered an experimental studies, systematic reviews, or meta-analysis. The reference lists of literatures were also searched to identify any further relevant studies.</p><p><strong>Results: </strong>Eight studies were included in this review, consisting of 6 cohort studies, 1 stepped-wedge randomized controlled trial, and 1 systematic review. The quality of the studies ranged from low to moderate, with the risk of bias being moderate to high. The interventions retrieved from the included studies can be categorized as restraint decision instruments, restraint preventive interventions and restraint preventive strategies. All included studies reported a significantly improved rate of restrained patients in the intervention group comparing to the control group. The rate of restrained patient days decreased significantly in the intervention group. There was no significant difference in the rate and number of accidental catheter removal, fall incident, and length of stay.</p><p><strong>Conclusions: </strong>Implementing the evidence-based instrument can help improve patient outcomes, reduce inappropriate use of physical restraint, and provide a structured decision-making process for health care staff. An evidence-based assessment instrument is developed to assess patients who are necessary to be given physical restraint, and further stringent research is necessary to evaluate the effect of such instrument. Training on least restrictive techniques and effective strategies is crucial for nurses to ensure adherence of nurses and appropriate care for patients.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144585422","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":"Experiences of Activities Perceived as Delegable Among Nurses in Medical and Surgical Settings Can Help to Guide Health Care Policies: A Qualitative Phenomenological Study.","authors":"Silvia Gonella, Alessio Conti, Martina Arlorio, Paola Cuoghi, Valerio Dimonte, Sara Campagna","doi":"10.1097/PTS.0000000000001389","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001389","url":null,"abstract":"<p><strong>Objectives: </strong>Nurses may invest up to 70% of their working time in activities outside the nursing scope of practice. Gaining insight into their experiences may inform policy decisions. This paper explores nurses' experiences of activities they perceived as delegable.</p><p><strong>Methods: </strong>This is a secondary analysis of qualitative data that contributed to a mixed-methods explanatory sequential study. Twenty nurses who work in the medical and surgical wards of four Italian public hospitals were purposively identified and interviewed. Inductive thematic analysis was performed.</p><p><strong>Results: </strong>Three main themes: (1) missing delegation, (2) losing role identity, and (3) being at the breaking point. The moral obligation to compensate for organizational deficiencies and poor relational dynamics was the main reason for missing delegation. Nurses felt in an assembly line with increased risk of errors and threats to patients' safety, overwhelmed by the workload, dissatisfied with the quality of care provided, and experienced several negative feelings, including anger, annoyance, demoralization, and frustration.</p><p><strong>Conclusions: </strong>Organizational and educational support is essential to develop effective delegation abilities.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144576767","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}