Journal of Patient Safety最新文献

{"title":"Compensation After Surgical Treatment for Hallux Valgus: A Review of 369 Claims to the Norwegian System of Patient Injury Compensation 2010-2020.","authors":"Per-Henrik Randsborg, Tommy Frøseth Aae, Ida Rashida Khan Bukholm, Rune Bruhn Jakobsen","doi":"10.1097/PTS.0000000000001268","DOIUrl":"10.1097/PTS.0000000000001268","url":null,"abstract":"<p><strong>Purpose: </strong>The aim of the study is to identify the most common avoidable patient injuries related to hallux valgus surgery.</p><p><strong>Methods: </strong>We assessed the claims reported to the Norwegian System of Patient Injury Compensation (NPE) following surgery for hallux valgus in light of hospital volume. Data from NPE was categorized according to age, sex, reason for claim, and reason for accepted/rejected claim. The institutions were grouped by catchment population into low volume (<150,000), middle volume (150,000-300,000), and high volume (>300,000) institutions. The effect of hospital volume on the likelihood of an accepted claim was estimated.</p><p><strong>Results: </strong>NPE received 369 claims of which 173 (46.9%) were accepted. The main reason for accepted claims was recurrence of the deformity, wrong level osteotomy or insufficient fixation. A quarter of the claims were accepted because of lack of indication and one in 5 accepted claims was due to a postoperative infection. Patient treated at low-volume institutions had a higher fraction of accepted claims ( P < 0.01). The odds ratio for an accepted claim in the low volume hospitals was 5.8 (95% confidence interval 4.1-8.3) compared with the middle- and high-volume institutions.</p><p><strong>Conclusions: </strong>The likelihood of a treatment error that leads to compensation was higher in low-volume institutions.</p><p><strong>Level of evidence: </strong>Level II Prospective cohort study.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e104-e108"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142074276","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 Nature of Adverse Events in Dentistry.","authors":"Bunmi Tokede, Alfa Yansane, Muhammad Walji, D Brad Rindal, Donald Worley, Joel White, Elsbeth Kalenderian","doi":"10.1097/PTS.0000000000001255","DOIUrl":"10.1097/PTS.0000000000001255","url":null,"abstract":"<p><strong>Objectives: </strong>Learning from clinical data on the subject of safety with regards to patient care in dentistry is still largely in its infancy. Current evidence does not provide epidemiological estimates on adverse events (AEs) associated with dental care. The goal of the dental practice study was to quantify and describe the nature and severity of harm experienced in association with dental care, and to assess for disparities in the prevalence of AEs.</p><p><strong>Methods: </strong>Through a multistaged sampling procedure, we conducted in-depth retrospective review of patients' dental and medical records.</p><p><strong>Results: </strong>We discovered an AE proportion of 1.4% (95% CI, 1.1% to 1.8). At least two-thirds of the detected AEs were preventable. Eight percent of patients who experienced harm due to a dental treatment presented only to their physician and not to the dentist where they originally received care.</p><p><strong>Conclusions: </strong>Although most studies of AEs have focused on hospital settings, our results show that they also occur in ambulatory care settings. Extrapolating our data, annually, at least 3.3 million Americans experience harm in relation to outpatient dental care, of which over 2 million may be associated with an error.</p><p><strong>Practical implications: </strong>Measurement is foundational in enabling learning and improvement. A critical first step in preventing errors and iatrogenic harm in dentistry is to understand how often these safety incidents occur, what type of incidents occur, and what the consequences are in terms of patient suffering, and cost to the healthcare system.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"454-460"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141793843","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 Harm Events and Associated Cost Outcomes Reported to a Patient Safety Organization.","authors":"Susanne Miller, David C Stockwell","doi":"10.1097/PTS.0000000000001254","DOIUrl":"10.1097/PTS.0000000000001254","url":null,"abstract":"<p><strong>Objectives: </strong>The aims of the study were to describe inpatient harm events detected via an automatic electronic trigger system (ETS) and to consider their financial consequences.</p><p><strong>Methods: </strong>Over a 27-month period, inpatient harm events were identified and documented in 1 healthcare system with 37 acute care facilities. Patients who experienced harm (all harm or preventable harm only) were compared with similar patients who did not. Clinical, financial, and demographic data were used to identify labor-adjusted direct variable costs (DVC) and potential differences in length of stay (LOS) associated with all-harm, preventable-harm, and nonharmed cohorts. Age-adjusted Charlson Comorbidity Index, case mix index, diagnosis-related groups, major diagnostic category, sex, age, location, diagnosis, adverse event category and subcategory, preventability, and harm severity were used to compare cohorts. Total harm events reported via the ETS and the health system's voluntary event reporting system were compared.</p><p><strong>Results: </strong>Nearly 93,000 encounters for all-harm (n = 25,665) and nonharmed cohorts (n = 67,217) were compared by random sampling of diagnosis-related group-matched all-harm and nonharmed groups to ensure similar clinical conditions, as measured by Charlson Comorbidity Index and case mix index. Sampling (2 groups, n = 100 and n = 200) showed that increased LOS was associated with harm; yet other clinical comparators were similar across groups. the preventable-harm subcohort had longer LOS (10.7 versus 5.9 days) and higher DVC ($13,442 versus $8024) than the nonharmed cohort. Identification of harm events was nearly 6-fold higher with the ETS than with the voluntary event reporting system.</p><p><strong>Conclusions: </strong>Patients with preventable harm had increased LOS that was associated with higher DVC per preventable-harm encounter in a large US healthcare system.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e92-e96"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141749378","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":"Response to the Letter to the Editor by Cioccari et al.","authors":"Leah M Konwinski, Caryn Steenland, Kayla Miller, Brian Boville, Robert Fitzgerald, Robert Connors, Elizabeth K Sterling, Alicia Stowe, Surender Rajasekaran","doi":"10.1097/PTS.0000000000001262","DOIUrl":"10.1097/PTS.0000000000001262","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e117"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141735372","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":"Defects in Value Associated With Hospital-Acquired Conditions: How Improving Quality Could Save U.S. Healthcare $50 Billion.","authors":"William V Padula, Peter J Pronovost","doi":"10.1097/PTS.0000000000001259","DOIUrl":"10.1097/PTS.0000000000001259","url":null,"abstract":"<p><strong>Abstract: </strong>Hospital-acquired conditions in the United States are considered avoidable complications but remain common statistics reflecting on health system performance and are a leading cause of patient fatality. Currently, over 3.7 million patients experience a hospital-acquired condition in the United States each year, which costs the U.S. healthcare delivery system an excess of $48 billion. Evidence-based clinical practice guidelines for common hospital-acquired conditions (e.g., infections, falls, pressure injuries) to reduce risk to the patient. In each of these instances, preventing the outcome with these guidelines costs less than treating the outcome, in addition to keeping the patient safe from harm. By applying the framework of defects in value to hospital-acquired conditions, we estimate that U.S. health systems could avert this $48 billion in spending on treating harmful hospital-acquired conditions; more so, these systems of care could recuperate over $35 billion after investing proportionally in a system that delivers greater quality by preventing hospital-acquired conditions over treating them. Currently, the Centers for Medicare and Medicaid Services only withholds reimbursements for hospital-acquired conditions and penalizes health systems with high rates of these outcomes. However, payers do not offer any reward-based incentives for hospital-acquired condition prevention. A series of policy and health system solutions, including tracking of hospital-acquired condition rates in electronic health records, identifying centers of excellence at reducing rates of harm with the use of clinical practice guidelines, and rewarding them monetarily for reduced rates could create equal-sided risk and opportunity to engage health systems in improved performance.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"512-515"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141861306","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":"Advancing Patient Safety: Harnessing Multimedia Tools to Alleviate Perioperative Anxiety and Pain.","authors":"Hanzala Ahmed Farooqi, Rayyan Nabi, Zeeshan Hayder","doi":"10.1097/PTS.0000000000001260","DOIUrl":"10.1097/PTS.0000000000001260","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e115-e116"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141761934","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":"Translation and Comprehensive Validation of the Hebrew Survey on Patient Safety Culture (HSOPS 2.0).","authors":"Yaffa Ein-Gal, Roni Sela, Dana Arad, Martine Szyper Kravitz, Shuli Hanhart, Nethanel Goldschmidt, Efrat Kedmi-Shahar, Yuval Bitan","doi":"10.1097/PTS.0000000000001253","DOIUrl":"10.1097/PTS.0000000000001253","url":null,"abstract":"<p><strong>Objectives: </strong>The study aim was to create an updated valid translation into Hebrew of the AHRQ's survey on patient safety culture for hospitals, version 2.0. It also suggested a supplementary section about workers' safety. Comparable and valid measurement tools are important for national and international benchmarking of patient safety culture in hospitals.</p><p><strong>Methods: </strong>The process was carried out by a designated committee according to AHRQ translation guidelines. Methodology included several translation cycles, 6 semistructured cognitive interviews with health workers, and a web-based pilot survey at 6 general hospitals. Main analyses included an exploratory factor analysis, a comparison of the differences in results between versions 1 and 2 of the survey to the differences reported by AHRQ, and content analysis of open-ended questions.</p><p><strong>Results: </strong>A total of 483 returned questionnaires met the inclusion criterion of at least 70% completion of the questionnaire. The demographic distributions suggested this sample to be satisfactory representative. Cronbach's alpha for the translated questionnaire was 0.95, meaning a high internal consistency between the survey items. An exploratory factor analysis revealed 8 underlying factors, and a secondary analysis further divided the first factor into 2 components. The factors structure generally resembled HSOPS 2.0 composite measures. Analyses of the new section about health workers' safety showed high involvement and possible common themes.</p><p><strong>Conclusions: </strong>The study demonstrated good psychometric properties-high reliability and validity of the new translated version of the questionnaire. This paper may serve other countries who wish to translate and adapt the safety culture survey to different languages.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e97-e103"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141761936","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 Relationship Between Work Environment and Missed Nursing Care in Nurses: The Moderator Role of Profession Self-Efficacy.","authors":"Cennet Çiriş Yildiz, Seda Değirmenci Öz, Berra Yilmaz Kuşakli, Irem Korkmaz","doi":"10.1097/PTS.0000000000001266","DOIUrl":"10.1097/PTS.0000000000001266","url":null,"abstract":"<p><strong>Aims: </strong>This study aimed to examine the relationship between work environment and missed nursing care (MNC) in nurses and determine whether profession self-efficacy has a moderator role in this relationship.</p><p><strong>Design: </strong>A quantitative, cross-sectional, correlational study design was used to test the study model.</p><p><strong>Methods: </strong>The study was conducted with 433 nurses in 2 city hospitals in Istanbul, Turkey. Data were collected between November 2022 and February 2023 using the \"MISSCARE Survey-Turkish,\" the \"Work Environment Scale,\" and the \"Nursing Profession Self-Efficacy Scale.\"</p><p><strong>Results: </strong>The participants had a mean Nursing Profession Self-Efficacy Scale score of 66.67 ± 14.37, a mean Work Environment Scale score of 84.96 ± 13.62, a mean elements of MNC score of 1.30 ± 0.73, and a mean reason for MNC score of 3.18 ± 0.78. Nursing profession self-efficacy was determined to be positively related to the work environment of the participants and their reasons for MNC (respectively, r = 0.276 and r = 0.114) and negatively related to elements of MNC ( r = -0.216) ( P < 0.05). There was also a negative relationship between the work environment and elements of MNC ( r = -0.249; P < 0.05). Profession self-efficacy had a significant moderator role in the relationship between the work environment and elements of MNC. Having low or moderate levels of profession self-efficacy moderated the negative effects of the work environment on elements of MNC.</p><p><strong>Conclusions: </strong>There is a need for interventions to reduce elements of missed nursing care in nurses. Especially nurses and/or nurse managers may have difficulties in improving their work environment, considering its multifaceted structure. In such cases, administrators can reduce missed nursing care by increasing the profession self-efficacy of nurses. Therefore, profession self-efficacy should be considered in addition to interventions for the work environment to improve care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"522-527"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142074277","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":"Increased Risk and Unique Clinical Course of Patient Safety Indicator-3 Pressure Injuries Among COVID-19 Hospitalized Patients.","authors":"Jennifer B Cowart,Jorge Sinclair De Frías,Benjamin D Pollock,Camille Knepper,Nora Sammon,Sadhana Jonna,Trisha Singh,Shivang Bhakta,Lorenzo Olivero,Shari Ochoa,Kannan Ramar,Pablo Moreno Franco","doi":"10.1097/pts.0000000000001276","DOIUrl":"https://doi.org/10.1097/pts.0000000000001276","url":null,"abstract":"BACKGROUNDThe COVID-19 pandemic introduced unique challenges to healthcare systems, particularly in relation to patient safety and adverse events during hospitalization. There is limited understanding of COVID-19's association with some patient safety indicators (PSIs).OBJECTIVESThis study aimed to investigate the impact of COVID-19 infection on the rate of PSI-3 events and its implications on quality metrics. We compared PSI-3 event rates between COVID-19-infected and uninfected patients and examined the clinical characteristics of COVID-19 patients experiencing PSI-3 events.METHODSThis is a retrospective study at Mayo Clinic hospitals between January 2020 and February 2022, analyzing patients meeting PSI-3 denominator eligibility criteria. PSI-3 events were identified using AHRQ WinQI software. Patients were categorized based on COVID-19 status. Patient demographics, characteristics, and PSI-3 rates were compared. A case series analysis described clinical details of COVID-19 patients with PSI-3 events.RESULTSOf 126,781 encounters meeting PSI-3 criteria, 8674 (6.8%) had acute COVID-19 infection. COVID-19-infected patients were older, more likely to be male, non-white, and had private insurance. PSI-3 rates were significantly higher in COVID-19 patients (0.21% versus 0.06%, P < 0.0001), even after risk adjustment (adjusted risk ratio, 3.24, P < 0.0001). The case series of 17 COVID-19 patients with PSI-3 events showed distinctive clinical characteristics, including higher medical device-related pressure injuries, and greater predisposition for head, face, and neck region.CONCLUSIONSAcute COVID-19 infection correlates with higher PSI-3 event rates. Current quality indicators may require adaptation to address the pandemic's complexities and impact on patient safety. Further research is needed to comprehensively understand the intricate relationship between COVID-19 and patient outcomes.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"10 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142261866","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":"\"What Else Could It Be?\" A Scoping Review of Questions for Patients to Ask Throughout the Diagnostic Process.","authors":"Mary A Hill,Tess Coppinger,Kimia Sedig,William J Gallagher,Kelley M Baker,Helen Haskell,Kristen E Miller,Kelly M Smith","doi":"10.1097/pts.0000000000001273","DOIUrl":"https://doi.org/10.1097/pts.0000000000001273","url":null,"abstract":"BACKGROUNDDiagnostic errors are a global patient safety challenge. Over 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures.OBJECTIVESThe goal of the scoping review was to identify, summarize, and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process. This is the first step in a larger study to co-design a patient-facing question prompt list for patients to use throughout the diagnostic process.METHODSMedline and Google Scholar were searched to identify question lists in the peer-reviewed literature. Organizational websites and a search engine were searched to identify question lists in the gray literature. Articles and resources were screened for eligibility and data were abstracted. Interrater reliability (K = 0.875) was achieved.RESULTSA total of 5509 questions from 235 resources met inclusion criteria. Most questions (n = 4243, 77.02%) were found in the gray literature. Question lists included an average of 23.44 questions. Questions were most commonly coded along the diagnostic process categories of treatment (2434 questions from 250 resources), communication of the diagnosis (1160 questions, 204 resources), and outcomes (766 questions, 172 resources).CONCLUSIONSDespite recommendations for patients to ask questions, most question prompt lists focus on later stages of the diagnostic process such as communication of the diagnosis, treatment, and outcomes. Further research is needed to identify and prioritize diagnostic-related questions from the patient perspective and to develop simple, usable guidance on question-asking to improve patient safety across the diagnostic continuum.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"63 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142211928","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}