Jens-Christian Schwindt, Reinhold Stockenhuber, Sybille Haider, Bertram Schadler, Eva Schwindt
{"title":"Identifying and Mitigating Latent Safety Threats in Neonatal Resuscitation Rooms Across Nine Hospitals Through In Situ Simulation Training.","authors":"Jens-Christian Schwindt, Reinhold Stockenhuber, Sybille Haider, Bertram Schadler, Eva Schwindt","doi":"10.1097/PTS.0000000000001373","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001373","url":null,"abstract":"<p><strong>Introduction: </strong>To ensure effective care in rare events such as neonatal resuscitation, high levels of system safety and error management are essential. It is thus imperative to mitigate avoidable errors and latent safety threats (LSTs). This study examined the use of safety reports (SR) from 3-day interdisciplinary, high-fidelity neonatal in situ simulation trainings (SIMs) to classify LSTs and assess their recurrence or resolution across successive SIMs.</p><p><strong>Methods: </strong>We retrospectively screened the SR of 9 Austrian hospitals for LSTs and grouped the identified LSTs into 3 main categories: (1) equipment, environment, and ergonomics (EEE); (2) knowledge, skills and training (KST); and (3) systems, pathways, and resources (SPR). The LSTs from consecutive SR were compared for each hospital.</p><p><strong>Results: </strong>A large number of LSTs were identified: 271 in 9 initial reports (SR1) and 129 in the 9 follow-ups (SR2). Comparing SR2 with SR1, fewer LSTs were reported in all 3 categories in all 9 hospitals (ranging from -37% to -79%). We detected fewer than half of the number of LSTs in SR2 for EEE (-62%). LSTs in KST were almost halved in SR2 (-45%), and marginally changed in SPR (-10%). A third SR (SR3) obtained in 4 hospitals indicated a further reduction in overall LSTs (-21% to -60%).</p><p><strong>Conclusion: </strong>This study shows that SIMs effectively reduce LSTs in neonatal care, with SR highlighting significant improvements, particularly in equipment-related issues. SIMs prove to be a valuable tool for enhancing safety and driving continuous improvement in neonatal care settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144217318","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":"Impact of Structured Morbidity and Mortality (M&M) Meetings on Clinician Engagement and Patient Safety Culture.","authors":"Emily Steel, Kylie Sellwood, Monika Janda","doi":"10.1097/PTS.0000000000001370","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001370","url":null,"abstract":"<p><strong>Objectives: </strong>To explore the range of experiences and opinions of people participating in morbidity and mortality (M&M) meetings at a public health service, and the perceived effects of a structured approach to the meetings on clinician engagement and patient safety culture.</p><p><strong>Methods: </strong>Semistructured interviews and focus groups were conducted with 13 participants from a large public health service (14,000 staff) in Australia. A semistructured interview guide was used to explore the experiences and opinions of committee chairs and M&M meeting members. Thematic analysis was used to identify key themes from transcripts.</p><p><strong>Results: </strong>Five themes were identified: (1) purpose, (2) attendance, (3) formality, (4) case selection and review, and (5) leadership and culture. Within these 5 themes, clear differences emerged in experiences between chairs and members and between individual participants. Factors associated with variation in experiences and opinions of participants included the nature and extent of their individual, previous, and current involvement in M&Ms and with the state of development of their local M&M meeting's purpose, leadership, and governance.</p><p><strong>Conclusions: </strong>A high level of maturity is required for M&M meetings to meet the diverse and competing needs of clinicians and health services. Structural elements such as a meeting agenda and register of recommended actions may assist junior staff and/or staff who do not attend regularly. Reflective and respectful leaders can foster psychological safety for members. Organisations can support their staff with the administration and communications for M&M meetings and help to share the learnings across departments and hospitals through clinical governance systems.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144188324","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-04-14DOI: 10.1097/PTS.0000000000001345
Won Hee Sim
{"title":"Development and Evaluation of a Multifaceted Intervention Program for Preventing Medication Administration Errors by Nurses.","authors":"Won Hee Sim","doi":"10.1097/PTS.0000000000001345","DOIUrl":"10.1097/PTS.0000000000001345","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to develop and evaluate a multifaceted intervention program based on the Systems Engineering Initiatives for Patient Safety (SEIPS) model to prevent medication administration errors (MAEs) by nurses in an adult general ward of a comprehensive hospital in Seoul, South Korea.</p><p><strong>Methods: </strong>The program was developed using the Analysis, Design, Development, Implementation, Evaluation (ADDIE) model with a 3-round Delphi survey conducted with 16 experts. Strategies were categorized under the SEIPS model and finalized into a program with 9 domains and 21 interventions. A pretest-posttest design with 73 nurses (36 experimental, 37 control) evaluated the program's effectiveness in a tertiary care hospital in Seoul, South Korea. Surveys on patient safety culture, medication safety practices, and error rates were analyzed before and after a 3-month intervention using double-difference and time-series methods.</p><p><strong>Results: </strong>The DID analysis demonstrated significant improvements in patient safety culture perception (0.42, P <0.001) and medication safety compliance (0.53, P <0.001), with large effect sizes ( d =1.07 and d =1.41, respectively). However, changes in self-reported medication error rates between groups were not statistically significant ( P =0.555), likely due to the short intervention period.</p><p><strong>Conclusion: </strong>The program improved patient safety awareness and medication safety compliance, validating its approach. This study highlights the importance of theoretically based interventions and suggests shifting from solely nurse education to addressing systemic issues for medication safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"226-239"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12105961/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144054710","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-04-14DOI: 10.1097/PTS.0000000000001347
Nam-Ju Lee, Nari Kim
{"title":"A Comprehensive Analysis of Patient Safety Research in Nursing: Trends, Topics, and Future Directions.","authors":"Nam-Ju Lee, Nari Kim","doi":"10.1097/PTS.0000000000001347","DOIUrl":"10.1097/PTS.0000000000001347","url":null,"abstract":"<p><strong>Objectives: </strong>This study aimed to comprehensively analyze patient safety research in the field of nursing over the past 20 years to identify key research topics and emerging trends.</p><p><strong>Methods: </strong>Structural topic modeling, a text mining methodology to identify latent topics from large volumes of unstructured textual data, was conducted on 6072 articles published in the Ovid Medline, Ovid Embase, Cumulative Index to Nursing and Allied Health Literature, and PubMed databases from January 2000 to April 2023. Based on the structural topic modeling results, we performed the Mann-Kendall trend test and conducted community detection.</p><p><strong>Results: </strong>The analysis identified 39 unique topics, which were categorized into 4 communities: medication safety, structure, processes, and outcomes. Interest in patient safety culture, patient safety education, and qualitative research methodologies has been increasing, while traditional topics such as medical error analysis and nurse staffing have shown a decreasing trend.</p><p><strong>Conclusions: </strong>The scope of patient safety research in the field of nursing is gradually expanding, with an evident shift in research focus. Our findings provide crucial information for setting future research directions and advancing nursing practice and policy, ultimately contributing to improvements in patient safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e29-e39"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144017588","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-01-14DOI: 10.1097/PTS.0000000000001312
Anthony Duncan, Rachel Leyk, Devendranath Mannuru, Steven Briggs, Khaled Zreik
{"title":"A Comprehensive Approach to Reducing Patient Safety Indicators (PSI-90).","authors":"Anthony Duncan, Rachel Leyk, Devendranath Mannuru, Steven Briggs, Khaled Zreik","doi":"10.1097/PTS.0000000000001312","DOIUrl":"10.1097/PTS.0000000000001312","url":null,"abstract":"<p><strong>Background: </strong>PSI-90, a composite measure comprising ten indicators, reflects the quality of care during hospital stays. The Hospital-Acquired Condition Reduction Program (HACRP), a Centers for Medicare and Medical Services (CMS) program, assesses hospital performance based on quality measures, including PSI-90, with financial implications for poor performers.</p><p><strong>Objectives: </strong>To evaluate PSI events, establish workflows for accurate documentation, and foster collaboration across clinical and administrative teams, with the ultimate objective of reducing PSI events.</p><p><strong>Methods: </strong>Essential actions involved designating a PSI nurse reviewer and a quality physician advisor, securing the involvement of executive leadership, adopting computer-assisted coding technology, and promoting teamwork among Clinical Documentation Improvement (CDI), coding, and Health Information Management (HIM) teams.</p><p><strong>Results: </strong>The collaborative efforts yielded a 45% reduction in PSI events, leading to estimated cost avoidance of $1.4 million, and exemption from HACRP penalties. Lessons learned encompassed the importance of executive leadership support, data-driven decision-making, and ongoing education.</p><p><strong>Conclusion: </strong>This study shows the significance of collaboration, leadership support, and data utilization in PSI reduction efforts. Furthermore, it shows benefit of a surgical quality officer in advancing patient safety, aligning with ACS recommendations.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e24-e28"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142972952","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-03-13DOI: 10.1097/PTS.0000000000001333
A Hiyama
{"title":"Characteristics of Fall Occurrence in Hospitals and the Factors Influencing Falls That Require Additional Medical Care: Based on an Accident Database.","authors":"A Hiyama","doi":"10.1097/PTS.0000000000001333","DOIUrl":"10.1097/PTS.0000000000001333","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to analyze accident reports of hospitals across Japan, and identify the characteristics of fall occurrence in hospitals and the factors influencing falls that require additional medical care.</p><p><strong>Methods: </strong>Data on falls that occurred inside hospitals between 2012 and 2021 were collected from the Project to Collect Medical Near-Miss/Adverse Event Information database of the Japan Council for Quality Health Care. The data were analyzed using binomial logistic regression analysis (the reduced variable method, likelihood ratio) with the requirement/nonrequirement of additional medical care as the dependent variable.</p><p><strong>Results: </strong>Out of all falls that occurred between 2012 and 2021, 78.9% required additional medical care. Of these, 758 reported irreversible disability, and 57 reported deaths. Most falls occur in the hospital room or corridor. The orthopedic surgery and psychiatry departments were the most common departments associated with fall occurrence. Gait disturbance and dementia/amnesia were the most common conditions prevailing before the fall. Weekdays (odds ratio=1.151), mornings (odds ratio=1.117), and two-shift work schedules (odds ratio=1.261) were the determinants of falls requiring additional medical care.</p><p><strong>Conclusions: </strong>Falls requiring additional care in Japanese hospitals were more likely to occur on weekdays and mornings. Staffing conditions, rather than months of experience and hours worked the week before, determined falls requiring additional medical care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"290-296"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143606899","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-04-10DOI: 10.1097/PTS.0000000000001352
Richard A Young, Somer Blair, Kari Teigen, David Li, Kimberly G Fulda, Anna Espinoza, Ayse P Gurses, Samantha I Pitts, Zachary N Hendrix, Yan Xiao
{"title":"Ambulatory Medication Safety Events in High-risk Patients With Diabetes Before and After a COVID-19 Clinic Slowdown.","authors":"Richard A Young, Somer Blair, Kari Teigen, David Li, Kimberly G Fulda, Anna Espinoza, Ayse P Gurses, Samantha I Pitts, Zachary N Hendrix, Yan Xiao","doi":"10.1097/PTS.0000000000001352","DOIUrl":"10.1097/PTS.0000000000001352","url":null,"abstract":"<p><strong>Objectives: </strong>We aimed to assess possible changes in medication safety over a mandatory pre-/post- COVID-19 clinic slowdown in a high-risk population of patients with diabetes seen at a safety net clinic.</p><p><strong>Methods: </strong>Retrospective chart review of all patient encounters 1 year before and after the slowdown. The study cohort were all patients with poorly controlled diabetes established pre-COVID-19 who were prescribed 4+ chronic medications. Each clinic note was abstracted for reports of any medication-related problems. The primary outcomes were measures of health care system utilization and potential adverse drug events (ADEs).</p><p><strong>Results: </strong>Out of 762 patients with diabetes, 59 were poorly controlled and formed the high-risk study cohort: age 53.0±11 years, 69% female, 17% White, 29% Hispanic, and 43% African American. There were similar numbers of patient encounters pre-/post-slowdown (7.68 clinic visits vs. 4.2 clinic visits plus 3.19 telehealth visits), cancellations (2.54 vs. 2.97), and no-shows (2.17 vs. 1.98). There was no change in the number of prescribed medications pre-/post-slowdown (12.1 vs. 11.7), but more potential adverse medication events (6/380 (1.6%) vs. 17/429 (4.0%), P =0.04). Of all abstracted medication-related problems, the majority were in diabetic medications 57/78 (73.1%), and of those, most involved insulin 43/57 (75.4%). Eleven preventable ADEs over the 2-year period were observed, all involved insulin, and were often affected by patient work system challenges such as self-administration and timing.</p><p><strong>Conclusions: </strong>There was a small increase in potential adverse medication events among a cohort of high-risk patients during the COVID-19 pandemic. The most common ADE was hypoglycemia associated with insulin.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"240-245"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143812755","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-02-03DOI: 10.1097/PTS.0000000000001320
Natalie B Simon, Kara M Barnett, BobbieJean Sweitzer, Nicole Gates, Steve Yun, Kristie Kim, Bridget Marcinkowski, Joseph M Hendrix
{"title":"Dental Anesthesia Guidelines and Regulations of US States and Major Professional Organizations: A Review.","authors":"Natalie B Simon, Kara M Barnett, BobbieJean Sweitzer, Nicole Gates, Steve Yun, Kristie Kim, Bridget Marcinkowski, Joseph M Hendrix","doi":"10.1097/PTS.0000000000001320","DOIUrl":"10.1097/PTS.0000000000001320","url":null,"abstract":"<p><p>This summary reviews guidelines and regulations pertaining to dental anesthesia across the United States, including guidelines of the American Dental Association (ADA), American Association of Oral and Maxillofacial Surgeons (AAOMS), and American Society of Anesthesiologists (ASA). The analysis addresses a range of requirements, including definitions of anesthesia and requirements for training and certification across professional societies and the 50 US states, with a focus on office-based settings. Strikingly, substantial variation exists among state rules and regulations and the ADA, AAOMS, and ASA guidelines with implications for variations of care, outcomes, and patient safety. We examined definitions of sedation and general anesthesia, patient selection and evaluation, fasting requirements, emergency preparedness, drug administration, monitoring, equipment, procedure selection, education and training requirements, permit requirements, life support certifications, reporting of adverse events, and inspection requirements. This comprehensive analysis serves to educate dental practitioners and office staff, patients, primary care providers, and state dental boards about the regulatory landscape of dental anesthesia. Our findings establish a foundation for future research and policy development aimed at improving consistency, best practices, and safety in dental anesthesia practices.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"258-281"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12207547/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143191099","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-03-12DOI: 10.1097/PTS.0000000000001332
Soo Yeon Kim, Ching Chen, Chenjuan Ma
{"title":"Patient Safety Culture and Home Health Care.","authors":"Soo Yeon Kim, Ching Chen, Chenjuan Ma","doi":"10.1097/PTS.0000000000001332","DOIUrl":"10.1097/PTS.0000000000001332","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e41"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143606851","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}
Journal of Patient SafetyPub Date : 2025-06-01Epub Date: 2025-03-14DOI: 10.1097/PTS.0000000000001335
M Imelda Wright, Shuying Sha, Lynne A Hall
{"title":"Development and Psychometric Evaluation of the Wright Normalization of Deviance (NOD) Scale.","authors":"M Imelda Wright, Shuying Sha, Lynne A Hall","doi":"10.1097/PTS.0000000000001335","DOIUrl":"10.1097/PTS.0000000000001335","url":null,"abstract":"<p><strong>Objectives: </strong>Normalization of deviance (NOD) occurs when individuals and teams depart from acceptable performance standards until the adopted way of practice becomes the new norm. There is little research on the incidence of NOD in health care, and there is no validated instrument to measure it. Identification and quantification of NOD is critical for the evaluation of the effectiveness of interventions designed to reduce its adverse consequences. The objective was to develop and psychometrically evaluate the Wright Normalization of Deviance Scale.</p><p><strong>Methods: </strong>Items for the scale were drawn from existing qualitative interview data and a review of relevant literature. Expert judges independently reviewed the initial item pool and rated each item for relevance and clarity. A sample of 222 respondents who work in a variety of high-risk environments was recruited via email, social media, and ResearchMatch. Cronbach alpha and item analysis were used to identify problematic items for elimination. The latent structure of the scale was explored using principal component analysis.</p><p><strong>Results: </strong>The approach to item development and expert judging supported content validity of the NOD. The latent structure identified using principal component analysis was consistent with the dimensions the scale was intended to measure. The final set of 27 items had four dimensions and each had good internal consistency (Cronbach alphas ranged from 0.72-0.94).</p><p><strong>Conclusions: </strong>The Wright NOD Scale demonstrated content and construct validity along with good internal consistency. It can be used by any high-risk organization, including health care, to facilitate identification of NOD, so that mitigating strategies can be applied.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"213-219"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143626073","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}