Journal of Patient Safety最新文献

{"title":"Vitrectomy After Cataract Surgery as a Patient Safety Indicator: A Rapid Review to Support Benchmarking Within the Austrian Inpatient Quality Indicators Framework.","authors":"Amin Sharifan, Arianna Gadinger, Christopher Cooper, Alexander Braun","doi":"10.1097/PTS.0000000000001492","DOIUrl":"10.1097/PTS.0000000000001492","url":null,"abstract":"<p><p>Cataract surgery is the most common surgical procedure in high-income countries. It is considered relatively safe and rarely has serious complications. Nevertheless, a quality assessment of the care structures is important, and Inpatient Quality Indicators (IQIs) have already been established at the system level. The Austrian Inpatient Quality Indicator system (A-IQI) uses a nationwide benchmark and annually reports the vitrectomy rate based on all cataract operations as a quality indicator for complications. The primary objective of this study is to validate the Inpatient Quality Indicator for Vitrectomy as a measure of complications during or after cataract surgery, using international comparative values. We conducted a rapid review, searching for studies in MEDLINE and EMBASE from 2012 to 2024. For the data synthesis, we applied a meta-analysis. A total of 3792 studies were screened, of which 25 were eligible. The rapid review showed that the vitrectomy rate following cataract surgery was 1.29% [95% uncertainty interval (UI) 0.78-2.11, I2 =99.6%] when reported per eye. In contrast, the pooled vitrectomy rate was 0.80% (95% UI: 0.37-1.74, I2 =99.6%) when reported per patient. This shows that the Austrian benchmark is lower in terms of procedures, but higher in terms of patients. However, due to the A-IQI data using procedures rather than patients as the denominator, a comparison with procedural reporting is recommended. The vitrectomy rate in the A-IQI reporting falls short. The literature shows differences in terms of severity and the number of operations performed per surgeon. Though the A-IQI process and the claims data used show potential, it can be seen that the A-IQI indicator underestimates the rates of complications.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e151-e161"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13492642/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147595525","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 Importance of Using Multiple Safety Evaluation Systems in Hospitals: A Comparison of Critical Incident Reporting System (CIRS), Assurance of Quality in Surgery (AQC), and the Global Trigger Tool (GTT).","authors":"Ivan Adamovic, Lukas Kraehenbuehl, Johannes Brachmann","doi":"10.1097/PTS.0000000000001479","DOIUrl":"10.1097/PTS.0000000000001479","url":null,"abstract":"<p><strong>Background: </strong>Accurate detection of adverse events (AEs) and patient harm is fundamental for improving patient safety in hospitals. The primary objective of this study is to evaluate the sensitivity of the Institute for Healthcare Improvement (IHI), the Global Trigger Tool (GTT) in detecting adverse events compared with the Assurance of Quality in Surgery (AQC) surgical database and the voluntary Critical Incident Reporting System (CIRS) in a Swiss hospital setting. Specifically, we aim to quantify the detection gap between these 3 systems.</p><p><strong>Methods: </strong>A retrospective review was conducted over a 12-month period between January 1st and December 31st, 2024. Analyzing data from 3 distinct surveillance methods: (1) Voluntarily submitted reports via the Critical Incident Reporting System (CIRS) were reviewed for all reported incidents; (2) For the GTT, 20 monthly randomly selected medical records of surgical inpatients (aged 18+, minimum 24-h stay, excluding orthopedics) were reviewed monthly; (3) Assurance of Quality in Surgery (AQC) data was manually entered for all operated surgical inpatients (excluding orthopedics), with rigorous quality checks performed by the authors. The findings from these systems were then compared.</p><p><strong>Results: </strong>An evaluation of CIRS for 2024 revealed only one reported case within the surgical department. Concurrently, AQC statistics indicated 283 completed surgical inpatient procedures, with 17 (6.01%) resulting in complications (surgical and nonsurgical). Furthermore, among 596 stationary patients treated in 2024, the GTT identified 58 patients (9.73%) with at least one AE. Number of overlapping cases between the GTT and the AQC reporting systems was 14.</p><p><strong>Conclusion: </strong>AQC is a particularly valuable tool, especially for operated patients. The Global Trigger Tool (GTT) boasts a wider range of applicability. Its strength lies in its ability to systematically identify potential adverse events through the review of patient records of operated and not operated patients. Sole reliance on voluntary reporting is insufficient for comprehensive adverse event detection. We advise the hospitals to adopt an additional system to complement the voluntary reporting CIRS system.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"411-417"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146107763","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 and Emotional Exhaustion Among ICU Professionals: A Five-Year Longitudinal Study.","authors":"Chih-Hsuan Huang, Hsin-Hung Wu, Yii-Ching Lee, Li Li","doi":"10.1097/PTS.0000000000001462","DOIUrl":"10.1097/PTS.0000000000001462","url":null,"abstract":"<p><strong>Objectives: </strong>Emotional exhaustion among ICU professionals poses a significant threat to both health care quality and staff well-being. While patient safety culture (PSC) is recognized as a potential buffer, its longitudinal impact on emotional exhaustion remains underexplored, particularly within high-intensity clinical environments like ICUs. This study investigates how ICU professionals' perceptions of PSC influence the progression of emotional exhaustion over a 5-year period, highlighting shifts in organizational and psychological predictors.</p><p><strong>Methods: </strong>A 5-year longitudinal survey (2020-2024) was conducted in a regional teaching hospital in Taiwan. A total of 1213 valid responses were collected from ICU physicians and nurses using the Chinese version of the Safety Attitudes Questionnaire (CSAQ), which includes 6 PSC dimensions and an emotional exhaustion scale. Stepwise multiple regression was used annually to identify significant predictors of emotional exhaustion.</p><p><strong>Results: </strong>Findings revealed a temporal shift in the predictors of emotional exhaustion. In 2020, organizational support factors-job satisfaction (β=-0.523, p <0.001) and perceptions of management (β=-0.443, p <0.001)-were significant negative predictors, while safety climate showed a counterintuitive positive association (β=0.264, p =0.004). From 2021 to 2024, stress recognition emerged as the most consistent protective factor (β range=-0.366 to -0.537, p <0.001). Interestingly, teamwork climate, often considered beneficial, was positively associated with emotional exhaustion in later years, suggesting added interpersonal burdens in collaborative ICU settings.</p><p><strong>Conclusions: </strong>Emotional exhaustion in ICU professionals is shaped by dynamic interactions between organizational structures and individual-level coping resources. Early burnout prevention should focus on institutional support, while long-term strategies should promote stress awareness and carefully manage team-based expectations. These findings provide health care leaders with actionable insights to design adaptive, stage-specific interventions to sustain psychological resilience in high-stress clinical environments.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"405-410"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146013047","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":"Trends in Patient Safety Management Systems by Hospital Size in Japanese Acute Care Hospitals.","authors":"Ryo Onishi, Yosuke Hatakeyama, Ryosuke Hayashi, Kanako Seto, Kunichika Matsumoto, Tomonori Hasegawa","doi":"10.1097/PTS.0000000000001476","DOIUrl":"10.1097/PTS.0000000000001476","url":null,"abstract":"<p><strong>Objectives: </strong>National policies and efforts of medical associations have promoted patient safety management systems mainly in acute care hospitals. However, evidence on the long-term impact of these initiatives in Japan remains limited. This study assessed trends in patient safety systems and their implementation in Japanese acute care hospitals.</p><p><strong>Methods: </strong>We conducted a secondary analysis of nationwide biennial surveys of patient safety managers from 2015 to 2023. Surveys targeted a stratified random sample of hospitals based on bed size and examined the implementation of systems for detecting and analyzing medical incidents, along with experiences of serious adverse events. Trend analyses by hospital size were conducted using the Cochran-Armitage test. Analyses were conducted as exploratory trend analyses using available-case data.</p><p><strong>Results: </strong>The organizational commitment to patient safety was well maintained, as reflected in the assignment of a safety manager and department. Adverse event reporting systems were widely adopted throughout the period, and systematic reviews of all inpatient deaths rose significantly (25.0% in 2015 to 70.5% in 2023). However, advanced incident analysis methods remained underutilized, particularly in small hospitals (<200 beds). The proportion of hospitals experiencing serious medical accidents increased, especially among large hospitals (≥400 beds).</p><p><strong>Conclusions: </strong>Over the past decade, Japanese acute care hospitals have made notable progress in developing patient safety infrastructures. While foundational systems were widely implemented, adoption of advanced analytical tools remains uneven. The rise in reported serious events may reflect improved detection and identification capabilities, or a simple increase in medical accidents. Sustained policy support and customized strategies for smaller hospitals are essential for continued advancement.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"369-376"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146107864","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":"Reframing Safety: Human Factors for Safer, Smarter, Human-Centered Health Care.","authors":"Asfand Khan, Aimen Farooq, Albert J Boquet, Tara N Cohen","doi":"10.1097/PTS.0000000000001523","DOIUrl":"10.1097/PTS.0000000000001523","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e169-e172"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147876291","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":"Teamwork in the Operating Room: A Survey on Anesthesiologist-Surgeon Interaction in a German University Hospital Setting.","authors":"Alexandra Trinks, Patrick Scheiermann, Josefine Schardey, Jens Werner, Mathilda Knoblauch","doi":"10.1097/PTS.0000000000001467","DOIUrl":"10.1097/PTS.0000000000001467","url":null,"abstract":"<p><strong>Objective: </strong>Effective communication between surgeons and anesthesiologists in the operating room (OR) is essential for patient safety, but communication deficits remain a leading cause of medical errors.</p><p><strong>Methods: </strong>An anonymous, interdisciplinary online survey was conducted to assess communication in the OR at a single university hospital. The target population included all surgeons and anesthesiologists, regardless of career level (n=837). The questionnaire consisted of 28 items covering 5 thematic domains. It was distributed via email and available from January to March 2024. No incentives were provided. Data were analyzed descriptively and comparatively using the χ 2 test.</p><p><strong>Results: </strong>A total of 183 participants (55% anesthesiologists, 45% surgeons) were eligible. A desire for more or substantially more communication in the OR was expressed by 67% of respondents. Preventable incidences caused by communication deficits were reported by 65% of participants, with anesthesiologists being significantly more likely to report both. Gender-based discrimination in the OR was experienced by 36% of respondents with both anesthesiologists and female physicians being significantly more often affected.</p><p><strong>Conclusions: </strong>This interdisciplinary survey revealed communication gaps, preventable incidents linked to poor communication, and perceived gender-based discrimination between anesthesiologists and surgeons in the OR. Sixty-five percent of respondents link these deficits to preventable patient safety incidents. These results can serve as an exemplary case for similar hospital organizations or acute care settings and help promote gender equality. These findings underscore the need for respectful dialogue and strong interdisciplinary collaboration in operating rooms.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"400-404"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13492649/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146107781","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":"Exploring the Accuracy of Near-Miss Reporting: A Mixed-Methods Study.","authors":"Asma Alfayez, Duaa Aljabri, Arwa Althumairi, Eshtiaq Alfaraj, Ahmed Alkwaiti, Turki Alanzi","doi":"10.1097/PTS.0000000000001463","DOIUrl":"10.1097/PTS.0000000000001463","url":null,"abstract":"<p><strong>Objective: </strong>To explore health care professionals' descriptions of near-miss events and assess the validity using the World Health Organization (WHO) patient safety classification framework.</p><p><strong>Methods: </strong>A total of 2805 near-miss reports were reviewed from a tertiary hospital from 2021 to 2024 using a retrospective, mixed-methods approach. Descriptive statistics were used to examine reporting trends and patterns. Qualitative analysis was performed through evaluating each report's narrative using a structured decision-making process based on WHO criteria to determine whether it qualified as a near miss, adverse event, no-harm incident, or reportable circumstances.</p><p><strong>Results: </strong>Eighty-four percent were validated as true near misses, mostly related to medication safety. However, significant misclassification was observed in patient care and workplace safety reports, where many events were incorrectly labeled as near misses despite involving patient harm or reaching the patient without causing harm.</p><p><strong>Conclusion: </strong>The findings reveal substantial near-miss detection and reporting by the pharmacy department, in particular, which signifies the pharmacists' role in validating prescriptions for patient safety. It simultaneously identifies critical reporting gaps related to the misunderstanding of safety event taxonomy by the reporting staff, which limits the accuracy of reported data and the potential resolution. Therefore, the study emphasizes the need for adopting a near-miss reporting framework that is comprehensive and standardized with a transparent definition, a structured analytical methodology, and a robust feedback mechanism to streamline the reporting process to ensure consistency of near-miss reporting across departments and optimize patient safety efforts.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"349-356"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146031224","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":"Implementing Artificial Intelligence in Clinical Systems Without Creating New Patient Safety Risks: Ten Tips for Success.","authors":"Samita M Heslin","doi":"10.1097/PTS.0000000000001545","DOIUrl":"10.1097/PTS.0000000000001545","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e176-e180"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148260095","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":"Effectiveness and Safety of Continuous Quality Improvement and Failure Mode and Effect Analysis for Preventing Adverse Events in Hospitalized Patients: A Systematic Review of Complex Interventions.","authors":"Steffany Villate-Soto, Juan D Muñoz-Loaiza, Hernando Gaitán-Duarte, Daniela Durán-Mejía, Sonia Tariba-Forero","doi":"10.1097/PTS.0000000000001486","DOIUrl":"10.1097/PTS.0000000000001486","url":null,"abstract":"<p><strong>Background: </strong>This study aimed to assess the effectiveness and safety of continuous quality improvement (CQI) and failure mode and effect analysis (FMEA) in preventing adverse events (AEs) in hospitalized patients.</p><p><strong>Methods: </strong>This systematic review included randomized controlled trials, quasiexperiments, and time-series studies that used CQI or FMEA in hospital processes and evaluated AEs. Studies published in English, Portuguese, and Spanish from September 2010 to September 2024 were searched in the MEDLINE/PubMed, Embase/Elsevier, CENTRAL, and LILACS databases. Two authors independently applied the study selection criteria and extracted data on methodology, patient population, and the effect of CQI or FMEA on AEs. We evaluated the risk of bias for before and after (B&A) studies with a control group and time-series studies, critically appraised the quality of B&A studies without a control group, determined causal inference strength for quasiexperiments, and reported quality for CQI studies. Moreover, we presented a narrative synthesis of results along with an assessment of evidence certainty determined using the GRADE approach. The register code at PROSPERO is CRD42021254216.</p><p><strong>Results: </strong>Of the 20,433 titles, 107 were subjected to full-text review, and 59 studies were analyzed. Forty-nine studies (83%) used CQI, whereas 10 used FMEA. The most studied category was related to catheters. Although the analyzed studies predominantly reported a reduction in AEs, evidence certainty was very low for 93% of the intervened processes.</p><p><strong>Conclusions: </strong>CQI and FMEA studies revealed a potential reduction of AEs in various processes. However, these results should be cautiously applied to clinical practice due to very low evidence certainty. Moreover, further research with improved control of confounding factors is needed.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e99-e116"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13492653/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147488086","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":"Medications for Individuals With Visual Impairment: Development and Content Assessment of a Medication Decision Support Tool.","authors":"Théodora Merenda, Mahault Waroux, Francis Vanderbist, Stéphanie Patris","doi":"10.1097/PTS.0000000000001487","DOIUrl":"10.1097/PTS.0000000000001487","url":null,"abstract":"<p><strong>Objective: </strong>Many medications can cause ocular adverse drug events that interfere with visual function. In individuals with pre-existing visual impairment, this necessitates heightened vigilance to ensure safe and appropriate management. In addition, some pharmaceutical dosage forms are challenging for these patients to utilise. The objective was to develop a medication decision support tool and assess its content to assist in the prescription and dispensation of medications for individuals living with visual impairment.</p><p><strong>Methods: </strong>An analysis of the Summary of Product Characteristics and a literature search were performed to identify high-risk medications and complex dosage forms for individuals with visual impairment. A medication decision support tool was created, and a Delphi survey for consensus building was conducted by a French-speaking European panel of experts. The experts were invited to indicate their degree of agreement on a Likert scale and descriptive statistics were produced using IBM SPSS software. This process was repeated until a consensus was reached between all experts.</p><p><strong>Results: </strong>Initially, 744 medications were included in the tool, that is, 40.5% of the medications marketed in Belgium. The tool was divided into 2 parts: Part 1 is related to high-risk medications while Part 2 is focused to pharmaceutical dosage forms. Four rounds of the Delphi method were necessary to the panel of 9 experts to evaluate the tool. Ultimately, 836 compounds were included in the tool, that is, 45.4% of the medications marketed in Belgium.</p><p><strong>Conclusion: </strong>The consensus process ensured a consolidated and relevant tool for disseminating high-quality content to Belgian community pharmacists and physicians. Although the analysis focused on medications marketed in Belgium, it is evident that many of these are also utilized in other European countries, thereby indicating that the approach may hold relevance beyond the Belgian context.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e117-e126"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147327902","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}