Journal of Patient Safety最新文献_第5页

Use of Failure Mode and Effect Analysis Methods in Pediatric and Adolescent Hospital Care-A Scoping Review. 失效模式和效果分析方法在儿科和青少年医院护理中的应用——范围综述

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-15 DOI: 10.1097/PTS.0000000000001350

Aino Färlin-Helin, Sakari Suominen, Outi Tuominen

{"title":"Use of Failure Mode and Effect Analysis Methods in Pediatric and Adolescent Hospital Care-A Scoping Review.","authors":"Aino Färlin-Helin, Sakari Suominen, Outi Tuominen","doi":"10.1097/PTS.0000000000001350","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001350","url":null,"abstract":"Introduction: Adverse events (AEs) leading to harm to patients are prevalent across health care. However, a considerable share of AEs are preventable. Failure Mode and Effect Analysis (FMEA) has been effectively used to enhance patient safety and quality. Failure Mode and Effect Analysis (FMEA) has been effectively used to enhance patient safety and quality. This scoping review aims to provide an overview of the studies reporting the use of FMEA, failure mode and criticality analysis (FMECA), and health care Failure Mode and Effect Analysis (HFMEA) in pediatric and adolescent hospital care.Methods: We conducted a systematic search of Web of Science, Scopus, Embase, Cochrane, CINAHL, and PubMed for relevant literature published since 1999. Papers were analyzed based on the FMEA process steps.Results: Eighteen papers were included in the review, assessing 21 processes, primarily involving drug prescribing, dispensing, and administration. Participants in the risk assessment came from various occupational groups. Risk priority numbers varied based on severity, occurrence, and detection. A total of 220 high-risk risk priority numbers were identified. Improvement actions had not been systematically reported.Conclusions: FMEA, FMECA, and HFMEA were successfully used to ensure patient safety in pediatric and adolescent hospital care. These methods can be used to effectively identify possible failures in healthcare processes and in quality improvement and risk reduction. They also enable prioritizing the targets of improvement actions. In addition, the use of risk analysis methods may result in increased awareness of potential safety risks among the workers who have participated in risk assessment.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144023598","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

Physician, Physician Assistant, Nurse Practitioner, and Pharmacist State Board Disciplinary Actions: Cross-sectional Analysis of the United States in 2023. 医师、医师助理、执业护士和药剂师州委员会纪律处分：2023年美国横断面分析。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-11 DOI: 10.1097/PTS.0000000000001337

Jon Lewis, Paul M Miller, Sydnee Hill, Olivia Younger, Alison Lemme, Peyton Wahl

{"title":"Physician, Physician Assistant, Nurse Practitioner, and Pharmacist State Board Disciplinary Actions: Cross-sectional Analysis of the United States in 2023.","authors":"Jon Lewis, Paul M Miller, Sydnee Hill, Olivia Younger, Alison Lemme, Peyton Wahl","doi":"10.1097/PTS.0000000000001337","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001337","url":null,"abstract":"Objective: The objective of this research is to audit, summarize, and analyze state board disciplinary actions reported to the public and the National Practitioner Data Bank (NPDB) in the United States in 2023 for MD, DO, PA, NP, and PharmD health care providers (HCPs).Methods: Researchers extracted disciplinary action data from state board public publications for select HCPs and compared this data to disciplinary actions reported through the NPDB Public Use Data File. Parametric (i.e., analysis of variance and t tests) and nonparametric (i.e., Kruskal-Wallis and Wilcoxon) statistical tests were utilized for data analysis. The primary outcome was an analysis of average disciplinary action rates per 1000 HCPs. Secondary outcomes analyzed included state board publicly reported disciplinary action outcomes and infractions.Results: Respectively, 3165 and 4037 disciplinary actions were identified from state board publications and the NPDB. PAs and NPs had a lower incurrence of disciplinary actions from state boards when compared with MDs, DOs, and PharmDs. There was significant underreporting of disciplinary actions to the public by MD and PharmD state boards. Of all the ad hoc outcomes and infractions researched, sexual misconduct was the only category with statistically significant differences between HCPs and with applicability for further analysis. Results indicated MDs had a higher incurrence of sexual misconduct disciplinary actions when compared with other HCPs. Significant underreporting of sexual misconduct to the NPDB was identified for MD, DO, PA, NP, and PharmD state boards.Conclusions: Results of this audit are indicative of a system functioning asynchronously, opaquely, and ineffectively. To better serve the public, all state boards must regularly and publicly report disciplinary actions.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144021844","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

Value of Incident Reporting to Address Real-time Safety Opportunities During the COVID-19 Pandemic. 在 COVID-19 大流行期间，事件报告对把握实时安全机遇的价值。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-08 DOI: 10.1097/PTS.0000000000001344

Pamela S Roberts, Nandita Raman, Brandi Rico, Edward Seferian

{"title":"Value of Incident Reporting to Address Real-time Safety Opportunities During the COVID-19 Pandemic.","authors":"Pamela S Roberts, Nandita Raman, Brandi Rico, Edward Seferian","doi":"10.1097/PTS.0000000000001344","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001344","url":null,"abstract":"Objectives: A strong safety culture encourages staff to identify and report safety events and near misses through an incident reporting system. The objectives were to: (1) assess the effectiveness of real-time reporting of safety events for timely identification of trends and improvement opportunities in a rapidly changing environment and (2) determine temporal changes in safety event categories throughout the 4 COVID-19 pandemic waves in Southern California.Methods: This retrospective study involved all safety incidents reported in patients over age 18 related to the care of COVID-19 through the hospital's incident reporting system, CS-Safe from March 17, 2020 to February 25, 2022.Results: There were 5843 suspected and confirmed COVID-19 cases across the 4 waves. The reported events primarily were associated with patients between the ages of 65 and 84 years, with the majority (62.7%) male, white (65.4%), and non-Hispanic (73.5%). Most events reported were related to clinical care issues (41.6%). A difference in the rates of safety incidents was observed across the waves. The highest rate of medication management-related safety incidents was in wave 2 (0.25 incidents/1000 d) and the highest rate of incidents occurred in critical care in wave 3 (1.20 incidents/1000 d).Conclusions: The alignment of COVID-19-related safety incidents across the 4 waves with the occurrences during this time demonstrates the value of real-time reporting in identifying trends and opportunities for improvement in a rapidly changing environment. Hence, real-time assessment of events can be valuable in concurrently addressing demands during unprecedented situations.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796352","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

Tirelessly Striving Towards the Challenging Goal of Patient Safety: A Content Analysis of Patient Advocacy Dialogs on Facebook. 不懈地努力实现患者安全的挑战性目标：Facebook上患者倡导对话的内容分析。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 DOI: 10.1097/PTS.0000000000001343

Riley Wolynn, Beth L Hoffman, Scotland Huber, Paul E Phrampus, Jaime E Sidani

{"title":"Tirelessly Striving Towards the Challenging Goal of Patient Safety: A Content Analysis of Patient Advocacy Dialogs on Facebook.","authors":"Riley Wolynn, Beth L Hoffman, Scotland Huber, Paul E Phrampus, Jaime E Sidani","doi":"10.1097/PTS.0000000000001343","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001343","url":null,"abstract":"Objectives: Patient experiences are focal points in the discourse around medical errors and patient safety, with social media offering new avenues to explore them. This study aimed to understand patient and family perspectives through a mixed-method analysis of posts made to a public Facebook group focused on patient safety.Methods: A total of 200 posts posted between November 21, 2022 and June 23, 2023 were manually extracted and double-coded by 2 independent human coders using a systematically developed codebook. Frequencies were calculated and χ2 tests were performed to analyze associations between codes. A grounded theory approach was used to qualitatively analyze key themes in the posts.Results: Of the 141 posts deemed relevant to patient safety, the majority (85%) included links to external news sources or information, rather than direct accounts of personal experiences. The most frequently discussed error types were surgical errors (28%) and infections (17%). The most frequent content codes were policy and regulatory issues (35%) and patient empowerment and advocacy (33%). Posts containing links had significantly more discussions about empowerment and advocacy, infections in vulnerable populations, and policy and advocacy compared with those without links. Overarching qualitative themes included the personal impact of medical errors, systemic challenges, the importance of empowerment through education, and the role of community support.Conclusions: This study underscores the importance of online communities in influencing patient safety discourse. Findings support the utility of using social media data for patient safety research and provide unique insights into patient concerns and advocacy efforts.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143755421","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

Patient Falls in the Operating Room: The Danger of an Obese Patient on an Unlocked Operating Room Table. 病人在手术室摔倒：一个肥胖病人在未上锁的手术台上的危险。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-22 DOI: 10.1097/PTS.0000000000001317

Russell K McAllister, Craig J Lilie, Emily H Garmon

引用次数: 0

The Relationship Between Medical Error Attitudes of Surgical Nurses and Evidence-based Work Environment. 外科护士医疗差错态度与循证工作环境的关系

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-15 DOI: 10.1097/PTS.0000000000001311

Esma Gökçe, Aysel Doğan, Demet Özer

{"title":"The Relationship Between Medical Error Attitudes of Surgical Nurses and Evidence-based Work Environment.","authors":"Esma Gökçe, Aysel Doğan, Demet Özer","doi":"10.1097/PTS.0000000000001311","DOIUrl":"10.1097/PTS.0000000000001311","url":null,"abstract":"Background: It is important for health care professionals to use evidence-based practice during surgical procedures to ensure patient safety and prevent medical errors.Aims: The aim of this study was to examine the relationship between surgical nurses' perceptions of their work environment's support for evidence-based practice and their attitudes toward medical errors.Methods: The descriptive cross-sectional study was conducted between February and May 2023. A total of 105 nurses participated in the study. A personal information form, a medical errors attitude scale, and an evidence-based practice work environment scale were used to collect the data.Results: It was determined that 92 (87.6%) of the participants used evidence-based practice. It was determined that the answers given by the nurses to the scales had very high reliability, and the mean score of the attitude scale in medical errors was 3.90 (Cronbach-α coefficient 0.770), and the mean score of the evidence-based practice work environment scale was 2.90 (Cronbach-α coefficient 0.840). In addition, according to the correlation, a positive, weak, and statistically significant correlation was found between the total scores of the attitude scale in medical errors and the evidence-based practice work environment scale ( P <0.05).Conclusion: As a result of the study, it was determined that nurses' attitudes toward preventing medical errors were positive and their perceptions of support for evidence-based practice work environments were high. In this direction, it can be said that the attitudes toward preventing medical errors of nurses whose working environment is supported by evidence-based practice can be positively affected and error tendencies in surgical clinics can be reduced.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"133-137"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142980272","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

Mobile Phones in the Operating Room: A Call for Strict Regulation to Ensure Patient Safety. 手术室使用手机：呼吁严格监管以确保患者安全。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-14 DOI: 10.1097/PTS.0000000000001315

Saeid Amini Rarani

引用次数: 0

Automated Computerized-based Intervention to Identify Hypomagnesemia in Primary Care Patients With Arrhythmia. 以计算机为基础的自动干预识别心律失常初级保健患者的低镁血症。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2024-12-23 DOI: 10.1097/PTS.0000000000001308

Maite López-Garrigós, Miguel Ahumada, María Leiva-Salinas, Alvaro Blasco, Emilio Flores, Carlos Leiva-Salinas

{"title":"Automated Computerized-based Intervention to Identify Hypomagnesemia in Primary Care Patients With Arrhythmia.","authors":"Maite López-Garrigós, Miguel Ahumada, María Leiva-Salinas, Alvaro Blasco, Emilio Flores, Carlos Leiva-Salinas","doi":"10.1097/PTS.0000000000001308","DOIUrl":"10.1097/PTS.0000000000001308","url":null,"abstract":"Objectives: Hypomagnesemia early diagnosis and consequently early, timely magnesium supplementation is of utmost benefit, but it often goes underdiagnosed. The objective was to show and monitor an intervention to identify hypomagnesemia in patients with arrhythmia.Methods: A cross-sectional study was designed in the laboratory. In primary care patients, the Laboratory Information System would automatically add a serum magnesium test when sample availability is present in any request when a diagnosis of arrhythmia is made. We counted the number of detected patients with hypomagnesemia (serum magnesium <1.7 mg/dL, <0.7 mmol/L), and calculated the cost in reagent of each identified case.Results: In 430 patients with arrhythmia, serum magnesium was measured, and 41 (9.5%) had hypomagnesemia results. One patient showed severe hypomagnesemia values (<1.2 mg/dL and <0.49 mmol/L). Patients with a deficit were significantly ( P <0.01) older than the total group of patients with normal magnesium values (66.3±13.2 versus 61.6±12.5). Each case represented a cost of 3.15€ in reagent.Conclusions: The automated computer-based intervention to identify patients with hypomagnesemia was useful and affordable, given the cost per detected case.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"138-142"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869573","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

Needs Assessment for Home Modification and Risk Factors for Home Unintentional Injuries in Post-total Knee Arthroplasty Patients. 全膝关节置换术后患者居家改造需求评估及居家意外伤害风险因素。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-14 DOI: 10.1097/PTS.0000000000001313

Saowalak Tongta, Patarawan Woratanarat, Siwadol Wongsak, Rossarin Phonakhae, Nartanong Arunwilai, Thira Woratanarat

{"title":"Needs Assessment for Home Modification and Risk Factors for Home Unintentional Injuries in Post-total Knee Arthroplasty Patients.","authors":"Saowalak Tongta, Patarawan Woratanarat, Siwadol Wongsak, Rossarin Phonakhae, Nartanong Arunwilai, Thira Woratanarat","doi":"10.1097/PTS.0000000000001313","DOIUrl":"10.1097/PTS.0000000000001313","url":null,"abstract":"Objectives: Home assessment and modification are crucial to prevent fall and fall-related injuries, especially in vulnerable subjects. This study assessed the need for home modifications and investigated risk factors associated with home injuries in post-total knee arthroplasty (TKA) patients.Methods: This study was conducted at the university hospital from July 2022 to July 2023. The patients who had undergone TKA without perioperative complications were recruited. The demographics, clinical data, home environmental factors, needs for home modification, and factors related to home unintentional injury were collected at 2 weeks postoperatively. The analysis was done by using descriptive statistics, and logistic regression.Results: A total of 140 patients were included. The occurrence of falls within 2 weeks after TKA was 33.57%. The location of falls was the home entrance (29.09%), living room (23.64%), and bathroom (18.18%). About 38.5% of the patients explicitly needed home modifications. Falls were associated with inefficient grab bars [adjusted odds ratio=3.26, 95% CI=1.37-7.81, P =0.008] and lighting (adjusted odds ratio=12.83, 95% CI=1.36-121.34, P =0.026).Conclusions: Falls among post-TKA patients were frequently occurred. Preoperative home assessment and home modifications should be done in order to minimize risks of falls, particularly in common locations.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"143-149"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142972954","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

The Association Between Health Care Staff Engagement and Patient Safety Outcomes: A Systematic Review and Meta-analysis: Erratum. 医护人员敬业度与患者安全结果之间的关系：一项系统回顾和荟萃分析：勘误。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-03-24 DOI: 10.1097/PTS.0000000000001324

引用次数: 0