Journal of Patient Safety最新文献

{"title":"Implementation of a Checklist for Surgical Inpatient Rounds: An Observational Cohort Study.","authors":"Ellie C Treloar, Ying Y Ting, Matheesha Herath, Jesse D Ey, Emma L Bradshaw, Nathanael Swan, Suzanne Edwards, Guy J Maddern","doi":"10.1097/PTS.0000000000001371","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001371","url":null,"abstract":"<p><strong>Background: </strong>The surgical ward round is the linchpin of inpatient care. Despite this, it is often pressured by external forces such as theatre times, on-call demands, or outpatient clinics. Checklists have been successful in saving lives, particularly in the operating room. Some of this work has translated to the surgical ward round, but no studies have examined the direct impact on patient communication. As a result, this study aimed to determine how a structured checklist impacted documentation and discussion in the surgical ward round.</p><p><strong>Methodology: </strong>A pre-observational and post- observational cohort intervention study was conducted to examine the impact of a 17-item checklist on the surgical ward round. Ward rounds were filmed to evaluate clinical documentation and discussion.</p><p><strong>Results: </strong>One hundred thirty-five patient encounters were recorded and transcribed over 24 months: 65 pre-intervention and 70 post-intervention. There were 59 females and 76 males. The mean age was 62 (SD=15.2). There were 105 benign cases, 30 malignant cases, 32 elective patients, and 103 emergency patients. The documentation of 'medication review', 'investigations', and 'patient concerns' significantly increased following the implementation of a checklist. Documentation of 'impression' significantly decreased. Doctor-patient communication and collaborative discussion rates of important items were not impacted by the checklist.</p><p><strong>Conclusions: </strong>This checklist did not improve discussion in the surgical ward round. However, it improved the documentation of several items on the checklist (patient's medication, investigations, and concerns). This study identifies areas where checklists can positively improve the ward round and highlights the significant areas where improvements can be made.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144152558","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":"Risk Prediction of Unplanned Extubation in Inpatients Using Random Forest and Logistic Regression Models.","authors":"Hongyi Mou, Akmal Ergashev, Bingqi Zhou, Na Ye, Xueyan Li","doi":"10.1097/PTS.0000000000001365","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001365","url":null,"abstract":"<p><strong>Background: </strong>Unplanned extubation (UEX) represents a significant risk event in hospitalized patients and is considered one of the most serious safety concerns. Prevention and early detection of these events have become essential components of high-quality nursing care.</p><p><strong>Objective: </strong>To compare random forest and logistic regression models for the prediction of UEX.</p><p><strong>Methods: </strong>In total, 775 UEX events were selected from the adverse nursing events database of a hospital in Zhejiang Province between January 2021 and December 2022 as the observation group. In addition, 775 planned extubation events were included from the database of hospitalized patients during the same period through 1:1 propensity score matching across various inpatient departments. Subsequently, patients were randomly allocated in a 7:3 ratio to form the development group and the validation group. Both random forest and logistic regression models were constructed. Their performances were compared using metrics including accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristic curve (AUC).</p><p><strong>Results: </strong>In addition, multivariate logistic regression analysis identified individuals aged 65 years and over (OR = 3.34, 95% CI: 2.43-4.59), male (OR = 1.64, 95% CI: 1.18-2.27), impaired awareness (OR = 2.56, 95% CI: 1.44-4.56), concurrent dual catheters (OR = 4.18, 95% CI: 2.77-6.32), presence of 3 or more catheters (OR = 5.55, 95% CI: 3.44-8.97), catheter indwelling time exceeding 1 week but <1 month (OR = 3.32, 95% CI: 2.04-5.41) or more than 1 month (OR = 4.51, 95% CI: 1.55-13.10), and the presence of medium-risk (OR = 0.22, 95% CI: 0.12-0.41) or high-risk catheters (OR = 0.08, 95% CI: 0.04-0.17) with secondary fixation (OR = 0.07, 95% CI: 0.04-0.12) as influential factors for UEX events in inpatients. Several variables, including catheter indwelling time, number of coexisting catheters, age, secondary fixation, and catheter grade, were selected for predicting UEX events using the random forest model. The AUC of the random forest prediction model was 0.812, while the AUC of the logistic regression prediction model was slightly lower at 0.793.</p><p><strong>Conclusion: </strong>The random forest model outperforms the logistic regression model in predicting inpatient UEX events. However, the logistic regression model remains valuable for its ability to provide intuitive explanations of the results.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144152560","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":"Structured Quality Improvement to Reduce Hospital-acquired Pressure Injuries.","authors":"Peter B Arnold, Myrtle D Tate, LaTrina Holmes-Green, Rachel B Guy, Katie Smith, Phillip Hankins, J Michael Henderson","doi":"10.1097/PTS.0000000000001363","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001363","url":null,"abstract":"<p><strong>Objectives: </strong>An Academic Medical Center in the United States faced a high rate of hospital-acquired pressure injuries (HAPIs), prompting a quality improvement (QI) project. HAPIs have not received the same level of attention for prevention as other significant hospital complications, such as central line-associated bloodstream infections (CLABSIs) and venous thromboembolism (VTE), but contribute to morbidity, increased costs, and negatively impact patient care. They can be reduced by applying core strategies for other hospital-acquired conditions (HACs). The goal was a 50% reduction in HAPIs over 18 months by teams using structured improvement tools.</p><p><strong>Methods: </strong>The program was developed by a Wound Oversight Committee and aimed to evaluate how risk assessment and early prevention could decrease the occurrence of HAPIs below the national mean. Patients admitted to this hospital between 2021 and 2023 were included in this quality project.</p><p><strong>Results: </strong>Two-person skin assessment within 4 hours of admission improved from 20% to over 80% within 18 months, leading to timely preventative measures. These interventions by teams helped reduce HAPIs from 14 to 7 per month. Standardization of collection, review, and validation of administrative data for public reporting was implemented alongside clinical improvements, with a HAPI rate decrease from 1.87 per 1000 eligible discharges in 2017 to 2019 to 0.40 in 2020 to 2022 (P-value <0.05).</p><p><strong>Conclusions: </strong>This study demonstrated that establishing a structured QI program using proven HAC reduction strategies, risk assessment and timely preventive practices significantly reduced HAPIs. The improvements observed are comparable to those seen in CLABSI and VTE rates.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144112495","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 Preoperative Povidone Nasal Swab on the Incidence of Surgical Site Infection: An Observational Study.","authors":"Michael A Edwards, Anyull D Bohorquez Caballero, Amy Glasgow, Renee Whaley, Dorin Colibaseanu, Wendelyn Bosch, Talal M Dahab, Aaron C Spaulding","doi":"10.1097/PTS.0000000000001348","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001348","url":null,"abstract":"<p><strong>Objectives: </strong>Surgical site infections (SSIs) are the most common hospital-acquired infections in the United States, of which methicillin-resistant Staphylococcus aureus (MRSA) accounts for 43%. Preoperative povidone-iodine nasal swab (PNS) is considered an effective and cost-saving treatment for Staphylococcus aureus decolonization. We aim to assess the impact of preoperative PNS on SSI incidence.</p><p><strong>Materials and methods: </strong>This retrospective observational study utilized elective surgical cases between January 1, 2018 and May 31, 2023, at a single academic medical center. The cohort was divided into PNS and no PNS groups. The cohort was propensity-matched, and Pearson χ2/Kruskal-Wallis tests were performed to compare group differences. Multivariable logistic regression was utilized to compare events between cohorts before and after matching. An alpha of <0.05 was considered significant.</p><p><strong>Results: </strong>A total of 45,998 (22,999 per group) matched participants were evaluated. On multivariate regression, the non-PNS treatment group was associated with an increase in hospital overall SSI occurrence (OR: 1.48, P= 0.02) but not specifically in-hospital methicillin-sensitive Staphylococcus aureus SSI, MRSA-SSI, or any 30-day SSI (P> 0.05). Compared with PNS treatment and prophylactic antibiotics, in-hospital SSI was higher in the absence of PNS treatment (OR: 1.83, P< 0.001), antibiotic (OR: 2.63, P< 0.001), or both (OR: 2.06, P< 0.01). Compared with PNS treatment plus prophylactic antibiotic, in-hospital MRSA-SSI was only higher in the absence of antibiotic (OR: 2.92, P< 0.01) treatment.</p><p><strong>Conclusions: </strong>Preoperative treatment with PNS may reduce overall in-hospital SSI but has no independent impact on MRSA SSI.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144112494","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":"Temporal Trends in Adverse Effects of Medical Treatment Among Chinese Children and Adolescents, 1990-2021: Evidence From the Global Burden of Disease 2021 Study.","authors":"Kun Feng, Xi Tang, Ting-Wei Zhang, Ying Luo, Zi-Yu Hua","doi":"10.1097/PTS.0000000000001366","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001366","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate the longitudinal patterns of the burden of adverse effects of medical treatment (AEMT) in children and adolescents in China from 1990 to 2021.</p><p><strong>Methods: </strong>Data used in this study were obtained from public data sets of the Global Burden of Disease 2021. AEMT was defined as harm resulting from procedures, treatments, or other contacts with the health care system. The case number, crude rates, and age-standardised rates (ASR) of incidence, deaths, and disability-adjusted life-years (DALYs), grouped by age and sex, were the primary outcomes for evaluating the burden of AEMT in Chinese children and adolescents (<20 y). The Age-Period-Cohort (A-P-C) model was used to analyze the changes in AEMT incidence rate by distinguishing the contributions of age, period, and cohort effects.</p><p><strong>Results: </strong>In China, the case number and ASR of incidence, deaths, and DALYs in children and adolescents showed significant decreasing trends from 1990 to 2021. In 2021, there were 85,649 incident cases, 369 deaths, and 31,833 DALYs. Age subgroup analysis demonstrated a substantial reduction in the burden of AEMT across 9 age groups. The A-P-C analysis indicated the highest incidence rate of AEMT in children under 5 years of age, and there were predominantly favorable trends in period and birth cohort effects.</p><p><strong>Conclusion: </strong>Although the burden of AEMT in children and adolescents in China has decreased significantly from 1990 to 2021, patient safety for children under 5 years of age still needs attention, especially for neonates.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144081394","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":"Electronic Prescribing as a Cognitive Tool: Implications for Patient Safety and Clinical Decision-making.","authors":"Waseem Jerjes","doi":"10.1097/PTS.0000000000001364","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001364","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144054987","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":"How Were Patient Safety Incidents Responded to, Investigated, and Learned From Within the English National Health Service Before the Implementation of the Patient Safety Incident Response Framework? A Rapid Review.","authors":"Gemma Louch, Carl Macrae, Rebecca Talbot, Siobhan McHugh, Jane K O'Hara","doi":"10.1097/PTS.0000000000001349","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001349","url":null,"abstract":"<p><strong>Objective: </strong>To understand how National Health Service organizations routinely responded to, investigated, and learned from patient safety incidents in England before the implementation of the Patient Safety Incident Response Framework, and to identify associated success criteria and barriers.</p><p><strong>Methods: </strong>We followed rapid review methodology and searched 2 electronic databases. We aimed to identify and synthesize literature regarding patient safety incident response, investigation, and learning within the English National Health Service, before the implementation of the Patient Safety Incident Response Framework.</p><p><strong>Results: </strong>Nineteen articles were included. A narrative synthesis generated 4 concepts: (1) a multifaceted reporting culture, (2) investigation processes, (3) the landscape of support and involvement, and (4) opportunities to learn. Barriers to incident reporting included time, task characteristics, a culture of blame, and lack of feedback. Root cause analysis was cited as the most common investigation method. Studies outlined points of support and involvement for patients and families, the importance of supporting and involving patients and families, and acknowledged contributions from patients and families may be overlooked currently. For health care staff, the need for timely and personalized support soon after an incident was emphasized. Studies underlined the limitations of current approaches to learning and improvement.</p><p><strong>Conclusions: </strong>These findings lend support to the challenges associated with health care systems' infrastructures and strategies for responding to and learning from patient safety incidents. These challenges centre on 2 interrelated issues: the investigative challenges of rigorously conducting systems analysis and learning-oriented improvement; and the relational challenges of supporting genuine relationships of care, open and honest communication, and supportive engagement after patient safety incidents.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144047891","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 Conceptualization of Health Care Resilience: A Scoping Review.","authors":"Erin J Ward, Craig S Webster","doi":"10.1097/PTS.0000000000001353","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001353","url":null,"abstract":"<p><strong>Objectives: </strong>In recent years, health care resilience has garnered increased attention, particularly since COVID-19. Resilience in health care is commonly framed across four interconnected levels: individual, team, organisational, and systemic. While individual-level resilience is relatively well explored, conceptualisations at other levels remain poorly defined.</p><p><strong>Methods: </strong>To address this gap, we conducted a scoping review exploring conceptualisations of health care resilience outside of the individual-level using systematic searches of MEDLINE, EMBASE, PsycINFO, and Google Scholar.</p><p><strong>Results: </strong>From 3734 initial records, 58 met our criteria. Of these, 7 (12.1%) articles did not explicitly define resilience. System-level resilience was the most explored (n=38, 65.5%), followed by organisational (n=12, 20.7%), and cross-level studies (n=8, 13.8%), with no studies exclusively focusing on team-level resilience. Conceptualisations of resilience revealed 5 themes: the goal of resilience; what systems are resilient to; resilience characteristics; its classification as ability, capacity, or capability; and the temporal dimension of resilience. Notably, no distinct patterns emerged specific to a conceptual level, suggesting resilience can be conceptualised across team, organisation, and system levels.</p><p><strong>Conclusions: </strong>Our findings underscore significant diversity in resilience definitions, indicating an evolving health care resilience paradigm. On the basis of these insights, we propose the following definition, applicable across all levels: health care resilience is the ability to anticipate, absorb, adapt or transform in response to everyday pressures, threats and opportunities to maintain efficient, high quality, and safe performance. A shared understanding of health care resilience would promote the critical imperative for research to bolster health care recovery post-COVID-19 and to prepare for future disruptive events.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144054482","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":"Aspects of Patient Safety Culture Most Associated With Employees' Overall Rating of Patient Safety and Whether Employees Reported Safety Events: Overall and for hospitals Predominantly Serving Black Patients.","authors":"Denise D Quigley, Lucy Schulson, Flora Sheng, Marc N Elliott, Andrew W Dick","doi":"10.1097/PTS.0000000000001354","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001354","url":null,"abstract":"<p><strong>Objectives: </strong>Care for black patients in the United States is concentrated in relatively few hospitals-known as black serving hospitals (BSHs). BSHs have high rates of safety events. Yet, it is unknown what aspects of patient safety culture are associated with employee assessments of patient safety or reporting safety events, and whether these patterns differ for hospitals predominantly serving black patients.</p><p><strong>Methods: </strong>We identified hospitals as BSH if their proportion of admitted black patients exceeded the national average (12.1%). We linked BSH status to the 2021-2022 Hospital Survey on Patient Safety Culture 2.0 (HSOPS) data, identifying 128 BSHs and 243 non-BSHs (with 107,224 and 138,028 HSOPS respondents, respectively). We examined the associations of 10 aspects of patient safety culture with 2 summary measures: employee's overall rating of patient safety and whether employees reported safety events. We fit respondent-level models, overall and stratified by BSH status, controlling for respondent characteristics. We used weights accounting for hospital HSOPS observations and to make results nationally representative. t tests were obtained from a model fully interacted with BSH status to test whether the associations for BSHs and non-BSHs were different.</p><p><strong>Results: </strong>Positive patient safety ratings were most associated with staffing/work pace, communication openness, management support of safety, and organizational learning-continuous improvement. Reporting any event was most positively associated with response to error and most negatively associated with management support. Patterns were similar for BSHs and non-BSHs, except for 4 associations: stronger positive association of organizational learning-continuous improvement with positive patient safety ratings in BSHs. Stronger negative association of staffing/work pace and communication openness with reporting any event in BSHs. Stronger positive association of communication openness with reporting any events in non-BSHs.</p><p><strong>Conclusions: </strong>Key aspects of creating hospital workplace cultures that engage in identifying events and learning from them to support patient safety differed in BSHs and non-BSHs, warranting further investigation. This knowledge may help mitigate differences in patient safety across hospitals.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144054984","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, One Health Approach, and Linking With Sustainable Development Goals (SDGs): An Indian Perspective.","authors":"Tithishri Kundu, Subhrojyoti Bhowmick, Khushboo Juneja","doi":"10.1097/PTS.0000000000001351","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001351","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144047095","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}