Journal of Patient Safety最新文献_第4页

Putting Patients at Risk: The Effect of Health Care Provider Burnout on Patient Care in the Operating Room. A Narrative Review. 把病人置于危险之中：医疗保健提供者倦怠对手术室病人护理的影响。叙述性评论。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-09 DOI: 10.1097/PTS.0000000000001369

Juan Antonio Hueto Madrid, Judith Hargreaves, Beata Buchelt

{"title":"Putting Patients at Risk: The Effect of Health Care Provider Burnout on Patient Care in the Operating Room. A Narrative Review.","authors":"Juan Antonio Hueto Madrid, Judith Hargreaves, Beata Buchelt","doi":"10.1097/PTS.0000000000001369","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001369","url":null,"abstract":"Objectives: This review aimed to explore the prevalence of burnout among health care professionals working in the operating room (OR) and its impact on patient safety and care quality.Methods: A focused narrative review was conducted, utilizing PubMed, CINAHL, Semantic Scholar, WorldCat, Cochrane Library, and clinical trials registries. Full-text primary literature published in English between 2018 and 2024 was included. Studies specifically addressing burnout in the OR and its effects on patient safety and care quality were selected. Data extraction included prevalence rates, stress factors, and impacts on patient outcomes.Results: Burnout was found to be highly prevalent among OR health care professionals, particularly affecting surgeons, anesthesiologists, and OR nurses. Reported prevalence rates ranged from 10% to 83%, with the highest levels occurring during the COVID-19 pandemic. Burnout was linked to critical aspects of health care quality and safety, primarily through communication breakdowns and operational inefficiencies. Impaired communication contributed to safety incidents, while disruptions in OR scheduling and increased turnover times further exacerbated workflow challenges. Although studies directly connecting burnout to patient safety events were limited, burnout was consistently associated with poor decision-making, weakened teamwork, and higher staff turnover-factors that collectively undermine patient outcomes.Conclusions: Burnout among OR health care professionals poses a significant threat to both staff well-being and patient safety, a challenge that was further intensified by the COVID-19 pandemic. Addressing burnout requires a multifaceted approach, including enhanced training, workload optimization, and robust support systems. Implementing comprehensive, context-specific interventions can improve staff resilience and patient safety.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144250494","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}

引用次数: 0

Application of a Systems Theory-Based Accident Analysis Technique to Perioperative Safety Reports From the COVID-19 Pandemic. 基于系统理论的事故分析技术在新冠肺炎大流行围手术期安全报告中的应用

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-06 DOI: 10.1097/PTS.0000000000001372

Aubrey L Samost-Williams, Robert D Sinyard, Leo L Tabayoyong, Joseph R Fogarty, Rebecca D Minehart, Karen C Nanji

{"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":"https://doi.org/10.1097/PTS.0000000000001372","url":null,"abstract":"Objectives: 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.Methods: 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.Results: 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.Conclusions: 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.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-06","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}

引用次数: 0

Identifying and Mitigating Latent Safety Threats in Neonatal Resuscitation Rooms Across Nine Hospitals Through In Situ Simulation Training. 通过现场模拟培训识别和减轻九家医院新生儿复苏室的潜在安全威胁。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-05 DOI: 10.1097/PTS.0000000000001373

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":"Introduction: 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.Methods: 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.Results: 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%).Conclusion: 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.","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}

引用次数: 0

Impact of Structured Morbidity and Mortality (M&M) Meetings on Clinician Engagement and Patient Safety Culture. 结构化发病率和死亡率（M&M）会议对临床医生参与和患者安全文化的影响。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-02 DOI: 10.1097/PTS.0000000000001370

Emily Steel, Kylie Sellwood, Monika Janda

{"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":"Objectives: 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.Methods: 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.Results: 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.Conclusions: 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.","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}

引用次数: 0

Development and Evaluation of a Multifaceted Intervention Program for Preventing Medication Administration Errors by Nurses. 预防护士用药错误的多方面干预方案的制定与评价。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-01 Epub Date: 2025-04-14 DOI: 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":"Objective: 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.Methods: 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.Results: 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.Conclusion: 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.","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}

引用次数: 0

A Comprehensive Analysis of Patient Safety Research in Nursing: Trends, Topics, and Future Directions. 护理中患者安全研究的综合分析：趋势、主题和未来方向。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-01 Epub Date: 2025-04-14 DOI: 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":"Objectives: 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.Methods: 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.Results: 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.Conclusions: 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.","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}

引用次数: 0

A Comprehensive Approach to Reducing Patient Safety Indicators (PSI-90). 降低患者安全指标（PSI-90）的综合方法。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-01 Epub Date: 2025-01-14 DOI: 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":"Background: 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.Objectives: 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.Methods: 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.Results: 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.Conclusion: 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.","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}

引用次数: 0

Characteristics of Fall Occurrence in Hospitals and the Factors Influencing Falls That Require Additional Medical Care: Based on an Accident Database. 医院跌倒发生的特点及影响跌倒需要额外医疗护理的因素：基于事故数据库。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-01 Epub Date: 2025-03-13 DOI: 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":"Objective: 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.Methods: 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.Results: 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.Conclusions: 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.","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}

引用次数: 0

Dental Anesthesia Guidelines and Regulations of US States and Major Professional Organizations: A Review. 美国各州和主要专业组织的牙科麻醉指南和法规：回顾。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-01 Epub Date: 2025-02-03 DOI: 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":"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.","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}

引用次数: 0

Ambulatory Medication Safety Events in High-risk Patients With Diabetes Before and After a COVID-19 Clinic Slowdown. 高危糖尿病患者在COVID-19临床减速前后的门诊用药安全事件

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-06-01 Epub Date: 2025-04-10 DOI: 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":"Objectives: 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.Methods: 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).Results: 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.Conclusions: 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.","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}

引用次数: 0