Journal of Patient Safety最新文献

{"title":"Redefining Interruptions: Events, Causes, and Impacts in Trauma Rooms.","authors":"Sara Bayramzadeh, Parnia Azini, Elaheh Malek Zadeh, Haya Mehar Mohammed, Ali F Mallat, Jessica Krizo, Steven Brooks","doi":"10.1097/PTS.0000000000001360","DOIUrl":"10.1097/PTS.0000000000001360","url":null,"abstract":"<p><strong>Objectives: </strong>Trauma rooms, as fast-paced and demanding health care environments, are highly susceptible to interruptions that can negatively impact workflow efficiency and patient safety. These interruptions often arise from human or environmental factors. This study investigates the role of the physical environment in influencing workflow interruptions by identifying key interruptive events in a trauma room, their primary sources, and outcomes using a pilot method of observational coding.</p><p><strong>Methods: </strong>This pilot study utilized video observations of 6 trauma cases in an urban level 1 trauma center. Using Noldus Observer XT 16 software, medical staff roles, interruptive events, their causes, and associated impacts were systematically coded and analyzed.</p><p><strong>Results: </strong>A total of 114 events were observed. The most common events included \"movement restrictions\" (39%), \"throwing objects\" (17%), and \"cleaning/clearing the floor\" (13%). Key causes were \"clutter/untidiness\" (32%) and \"mobile fixture/furniture location\" (21%). Frequently observed impacts included \"unnecessary task additions\" (21%) and \"hindered task completion\" (20%). The results also revealed frequent associations between causes, events, and impacts. Movement restrictions caused by clutter/untidiness often led to disentangling cables and tubing (13.2%). Similarly, movement restrictions due to mobile fixture placement required equipment repositioning in 13.2% of cases. Throwing objects, often linked to behavioral habits, contributed to clutter (16%), whereas floor clearing/cleaning due to clutter added unnecessary tasks (13%).</p><p><strong>Conclusion: </strong>The findings underscored the significant role of physical-environmental factors in workflow interruptions in trauma rooms. These insights can inform evidence-based design improvements and operational strategies for future enhancements, ultimately improving staff and patient outcomes in high-pressure health care settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S12-S20"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453099/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132284","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":"Safety-I Versus Safety-II: A Mixed-Methods Study Revealing the Imbalance of Approaches in Primary Care Medication Safety.","authors":"Richard A Young, Yan Xiao, Kimberly G Fulda, Annesha White, Ayse P Gurses","doi":"10.1097/PTS.0000000000001400","DOIUrl":"10.1097/PTS.0000000000001400","url":null,"abstract":"<p><strong>Objectives: </strong>Our objective was to develop an in-depth understanding of the barriers and facilitators for medication safety in primary care by synthesizing findings from a multiyear, multisite study of care teams, pharmacists, and patients, using Safety-I and Safety-II lenses.</p><p><strong>Methods: </strong>We used mixed methods, including a systematic literature review and interviews on medication use in ambulatory primary care. We synthesized the findings using Safety-I and Safety-II lenses to identify safety challenges and strategies.</p><p><strong>Results: </strong>Published challenges and strategies were mostly framed through a Safety-I lens: establishing ever-expanding best practice algorithms and using them to decrease variability. In contrast, our analysis of patient and professional perspectives revealed that medication safety in ambulatory settings is undermined by the complexities of distributed work systems including poorly implemented safety checks; limited support for self-management; weak safety infrastructure; conflicting interests; and external forces beyond the control of patients and primary care professionals. We also identified actions by clinicians and pharmacists to improve medication safety that fall outside traditional compliance-focused Safety-I strategies. These actions were often initiated to overcome barriers in distributed work systems, highlighting the importance of Safety-II strategies in primary care.</p><p><strong>Conclusions: </strong>This study revealed a fundamental limitation in applying Safety-I principles to primary care medication safety, particularly the assumption that all system defects can be feasibly fixed. Given the complex realities of primary care, a complementary Safety-II perspective is essential, as it recognizes the agency of professionals and patients in managing risks within distributed work systems affected by uncontrollable external forces.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S81-S88"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453097/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132317","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":"Why Is Patient Safety a Challenge? Insights From the Professionalism Opinions of Medical Students' Research.","authors":"Paul M McGurgan, Katrina L Calvert, Elizabeth A Nathan, Kiran Narula, Antonio Celenza, Christine Jorm","doi":"10.1097/PTS.0000000000001398","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001398","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7","pages":"488"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132208","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":"Determinants of Harm in Fall Incidents in Hospital Settings With 200 or More Beds in Korea.","authors":"Youngmi Kang, Eunyoung Hong","doi":"10.1097/PTS.0000000000001385","DOIUrl":"10.1097/PTS.0000000000001385","url":null,"abstract":"<p><strong>Objective: </strong>Falls are a significant patient safety concern in hospital settings, often resulting in unintended harm. This study aimed to investigate the prevalence and risk factors for falls in Korean hospitals with 200 or more beds, analyzing 13,034 incidents reported to the Korean Patient Safety Reporting and Learning System from 2017 to 2021.</p><p><strong>Methods: </strong>The level of harm was classified into 3 categories: near-miss, adverse, and sentinel events. Hospital-related factors (hospital type, bed capacity, and location and time of fall incident) and patient-related factors (sex, age group, and admitting medical department) were included in the analysis. χ 2 tests were used to evaluate differences in fall severity, and binary logistic regression identified factors associated with harmful incidents.</p><p><strong>Results: </strong>The study found that harmful falls were more likely to occur in nontertiary hospitals, particularly those with >500 beds, as well as in emergency departments. Furthermore, older female patients and those admitted to the internal medicine department are especially at risk.</p><p><strong>Conclusions: </strong>Based on the results of this study, especially in nontertiary hospitals with >500 beds, comprehensive strategies for preventing falls, including the promotion of patient safety culture, are needed to reduce fall occurrence and its associated disabilities.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"480-487"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477527","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":"e156-e160"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12445176/pdf/","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":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"\"Invert the Pyramid, Let Internists Design the Job as Pilots Do a Cockpit\": The Views of General Internal Medicine Physicians on Enhancing Well-Being Through Human Factors Engineering.","authors":"Jennifer Zamudio, Qiaoning Zhang, Martha Quinn, Karen E Fowler, Sanjay Saint, Xi Jessie Yang","doi":"10.1097/PTS.0000000000001356","DOIUrl":"10.1097/PTS.0000000000001356","url":null,"abstract":"<p><strong>Objectives: </strong>Understanding the protective factors of general internists' well-being helps maintain a resilient health care system. As human factors engineering (HFE) offers promising solutions to the challenges physicians face, it is essential to explore how internists understand the field.</p><p><strong>Methods: </strong>A cross-sectional survey focusing on the well-being of general internal medicine physicians was mailed out to a random sample of 1,463 internal medicine physicians using the American Medical Association national database. This study focused on the HFE aspects of the survey.</p><p><strong>Results: </strong>A total of 655 general internists responded to our survey (44.8% response rate). Out of 632 respondents, more than half (59.5%) believed that HFE has a role in enhancing their well-being as an internist, and roughly one-third (36.1%) were unsure. A qualitative analysis performed for the 176 open-ended responses revealed 15 unique categories, with most internists referencing their benefits for improving leadership quality, developing shared mental models among teams, and optimizing current processes.</p><p><strong>Conclusions: </strong>Our findings indicate that most internists recognize the potential of HFE to positively impact their well-being, though a substantial portion remain uncertain about its applications and benefits. This highlights a need to conduct systems analyses to identify barriers and facilitators of internists' tasks to design tailored, systemic interventions, such as support from leadership in adaptation, support during patient rounds, and improvements to the EMR system. These systemic improvements in combination with spreading HFE knowledge have the potential to enhance internist well-being.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S36-S42"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453094/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132187","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 Value of Patient Safety Learning Laboratories.","authors":"David W Bates","doi":"10.1097/PTS.0000000000001412","DOIUrl":"10.1097/PTS.0000000000001412","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 7Supp","pages":"S1-S2"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453089/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132327","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":"Pakistan's Silent Killer: How Fake and Substandard Medicines Are Destroying Patient Safety.","authors":"Kanza Farhan, Javed Iqbal, Brijesh Sathian, Ayesha Parvaiz Malik","doi":"10.1097/PTS.0000000000001407","DOIUrl":"10.1097/PTS.0000000000001407","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e164-e165"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144856730","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":"Application of a Systems Theory-Based Accident Analysis Technique to Perioperative Safety Reports From the COVID-19 Pandemic.","authors":"Aubrey L Samost-Williams, Robert D Sinyard, Leo L Tabayoyong, Joseph R Fogarty, Rebecca D Minehart, Karen C Nanji","doi":"10.1097/PTS.0000000000001372","DOIUrl":"10.1097/PTS.0000000000001372","url":null,"abstract":"<p><strong>Objectives: </strong>Nonlinear retrospective analytic techniques can allow for in-depth understanding of accidents and their causes, yet they are infrequently used in health care. The purpose of this study was to provide an example, using Causal Analysis based on Systems Theory (CAST) together with an inductive thematic analysis to understand the contextual factors contributing to one hospital's perioperative safety events.</p><p><strong>Methods: </strong>We created a hierarchical control structure of the hospital's perioperative system with input from a multidisciplinary group. We then analyzed safety events that were self-reported during a COVID surge (April 2020) using CAST to understand their contributing factors. Next, we analyzed the contributing factors using inductive qualitative thematic coding to identify system-level safety risks. We mapped each system-level safety risk to a recommendation for future mitigation.</p><p><strong>Results: </strong>We screened 122 safety reports and found 19 safety events that met inclusion criteria. The analysis revealed 245 contributing factors represented by 22 subthemes corresponding to 3 major themes: (1) vulnerable processes, being problems with workflows or communication channels; (2) personnel challenges including challenges with staff redeployment as well as cognitive and behavioural challenges; and (3) poorly designed or unavailable equipment. Each subtheme corresponded to a prevention strategy, such as creation of a central protocol hub.</p><p><strong>Conclusions: </strong>Using a nonlinear accident analysis technique together with thematic analysis, we were able to identify system-wide contributing factors to safety events. These contributing factors led to recommendations for future pandemics or crises characterized by scarce resources, limited data, and a rapidly changing environment.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"445-451"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144227310","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":"Rethinking Anesthesia Medication \"Errors\": The OR-SMART Patient Safety Learning Laboratory.","authors":"Ken R Catchpole, David M Neyens, James H Abernathy, Joshua Biro","doi":"10.1097/PTS.0000000000001384","DOIUrl":"10.1097/PTS.0000000000001384","url":null,"abstract":"<p><strong>Purpose: </strong>We combine the results of multiple studies to describe a systems engineering approach to a well-recognized patient safety problem. The goal of the Operating Room Systems-based Medication Administration error Reduction Team (OR-SMART) patient safety learning laboratory was to study the anesthesia medication work system to identify the characteristics of technologies and interventions that might feasibly reduce anesthesia medication errors.</p><p><strong>Scope: </strong>The work was conducted at 2 large urban academic medical centers: Johns Hopkins and the Medical University of South Carolina. We sampled across many different types of anesthesia work, understanding the challenges of work-as-done, and applying systems safety principles and evaluation frameworks.</p><p><strong>Methods: </strong>This was a mixed-methods study. Sources of data varied, with formal and informal interviews, formal and informal observations, video-based observations, hospital and national databases, and information from local incidents. Clinically embedded human factors professionals at both hospital sites facilitated informal sources of data. We explored the variable definitions of error; individual and organizational variability in decision-making; how syringes are used, stored, and moved within an operating room (OR); and used the Systems Engineering Initiative for Patient Safety framework to model medication processes. We were able to identify more than 100 possible interventions, and then prioritized a few for development and testing.</p><p><strong>Results: </strong>We identified medication icon labels, a syringe holder hub, and workspace design guidelines as interventions for evaluation. Significant benefits of medication label icons were found in simulation and were highly utilized in practice. The syringe hub demonstrated high acceptability at one site but substantially less at another. A virtual reality-based evaluation of the OR design found that situational awareness, visual monitoring, and available workspace were subjectively improved.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"503-509"},"PeriodicalIF":1.7,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144576783","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}