Journal of Patient Safety最新文献

{"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":"https://doi.org/10.1097/PTS.0000000000001320","url":null,"abstract":"<p><p>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.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","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":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"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":"https://doi.org/10.1097/PTS.0000000000001312","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Objectives: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-01-14","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}

{"title":"Cross-disciplinary Insights for Overcoming Speak-up Barriers in Medical Education.","authors":"Waseem Jerjes","doi":"10.1097/PTS.0000000000001297","DOIUrl":"10.1097/PTS.0000000000001297","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e1-e2"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142511119","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":"Effect of a Financial Incentive Scheme for Medication Review on Polypharmacy in Elderly Inpatients With Dementia: A Retrospective Before-and-After Study.","authors":"Takahito Morita, Yusuke Sasabuchi, Hayato Yamana, Tatsuya Hosoi, Sumito Ogawa, Hiroyuki Ohbe, Hiroki Matsui, Kiyohide Fushimi, Hideo Yasunaga","doi":"10.1097/PTS.0000000000001294","DOIUrl":"10.1097/PTS.0000000000001294","url":null,"abstract":"<p><strong>Objectives: </strong>Polypharmacy is an important healthcare issue, especially in elderly patients with dementia. As an incentive to reduce polypharmacy, a health insurance reimbursement scheme was introduced in 2016 for medication review and the reduction of medications for inpatients in Japan. However, the effects of these incentive schemes were not evaluated.</p><p><strong>Methods: </strong>We identified 1,465,881 inpatients aged ≥65 years with dementia. An interrupted time-series analysis was conducted by fitting a Prais-Winsten linear regression model. The outcome measure was the number of classes of medications prescribed during discharge.</p><p><strong>Results: </strong>No significant changes were observed in the average number of medication classes at discharge immediately after the introduction of the scheme (coefficient: -0.022, 95% confidence interval [CI]: -0.17 to 0.13). The slope change, representing the effect of the intervention over time, was also not significant (coefficient: -0.00053, 95% confidence interval: -0.0012 to 0.00018).</p><p><strong>Conclusions: </strong>The incentive scheme was not associated with a reduction in the number of medication classes at discharge among older inpatients with dementia.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"30-34"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478496","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":"Anesthesia-Specific Software Module for Voluntary Adverse Event Reporting.","authors":"Karolina Brook, Su Yeon Song, Julianna Richards, Laura Harrington, Nana Kwame Okyere-Tawiah, R Mauricio Gonzalez","doi":"10.1097/PTS.0000000000001290","DOIUrl":"10.1097/PTS.0000000000001290","url":null,"abstract":"<p><strong>Objectives: </strong>Hospital staff are expected to report adverse events to safety leaders and risk managers. At our institution, staff report adverse events via an incident reporting software system, known as \"RL.\" These \"RL reports\" are kept separate from patient medical records. Within the Anesthesiology Department, we noted low numbers of RL reports relative to known adverse events. Anesthesiology-related events were scattered within the RL software and therefore difficult to find. We hypothesized that compiling these events in one location would increase reporting rates and allow for deeper analysis of filed adverse events.</p><p><strong>Methods: </strong>We created an Anesthesia-specific RL software module, which included all anesthesia-related adverse events in one location. Additionally, we tracked the impact on RL reporting of two other quality improvement initiatives, including an intradepartmental quality assurance form, implemented during the study period.</p><p><strong>Results: </strong>The Anesthesia RL software module led to a 3.2-fold increase (P < 0.001) in the monthly average of filed RL reports. The increase was even greater (11.1-fold, P < 0.001) when excluding the most prevalent category of RL reports (Controlled Substance Discrepancies). The intradepartmental quality assurance form had minimal impact on filed RL reports. \"Controlled Substance Discrepancies,\" \"Other,\" and \"Equipment issue\" were the most common event types. Most events were classified as constituting no harm to the patient.</p><p><strong>Conclusions: </strong>Creating a specialty-specific RL software module led to increased RL reports, even when accounting for other implemented quality improvement initiatives, and allowed for deeper analysis of the filed reports. Our findings may be replicated for other specialties.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 1","pages":"48-55"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869648","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":"Enhancing Sepsis Care at an Academic Emergency Department in a Resource-Constrained Setting: A Quality Improvement Initiative.","authors":"Haytham Noureldeen, Abdullah Bakhsh, Adel Alshabasy, Maha Alawi, Ahmad Bakhribah, Nihad Nasrallah, Ohoud Aljuhani, Rahaf Margushi, Rafal Bantan, Raneem Bokhari, Sarah Idris, Lamis Alshamrani, Abeer Samman, Elaf Alharthi, Ali Alothman","doi":"10.1097/PTS.0000000000001289","DOIUrl":"10.1097/PTS.0000000000001289","url":null,"abstract":"<p><strong>Objectives: </strong>The early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study aimed to improve the proportion of patients receiving antibiotics within 1 hour of triage and compliance with sepsis bundles.</p><p><strong>Methods: </strong>A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 1, 2018, to December 31, 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. Thereafter, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared.</p><p><strong>Results: </strong>The proportion of patients receiving antibiotics within 1 hour of triage improved from 44% to 84%, intravenous crystalloid administration within 3 hours improved from 62% to 94%, serum lactic acid measurement within 3 hours improved from 62% to 94%, and vasopressor initiation within 6 hours improved from 76% to 94%. The mortality rates decreased from 32% to 21% between the 2 study periods.</p><p><strong>Conclusions: </strong>This program emphasizes the impact of a structured quality improvement program on the process and outcomes of care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"24-29"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478497","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":"AI: Promise or Peril for Patient Safety.","authors":"Beth Daley Ullem, Martin J Hatlie, Olivia Lounsbury","doi":"10.1097/PTS.0000000000001301","DOIUrl":"10.1097/PTS.0000000000001301","url":null,"abstract":"<p><strong>Abstract: </strong>Patient safety advocates identify concerns for the impact of AI on patient safety. Patients identified the following 4 main areas that AI developers, regulatory bodies, and clinical users of AI are asked to consider: data integrity and bias, efficacy, payment, and transparency toward shared learning. Increased patient involvement in the development, use assessment and oversight of the technology is critical to ensure trust and trustworthiness in the use of AI in patient care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"35-37"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142689318","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":"Learning by the Visualization of a Nurse-Led Critical Care Outreach Service Using the Functional Resonance Analysis Method.","authors":"Sabine Adriana Johanna Josepha Op 't Hoog, Mariëlle van Mersbergen-de Bruin, Nikki Laurina Mathilda Damen, Wendy Chaboyer, Anne Marie Weggelaar-Jansen, Anne M Eskes, Lilian Christina Maria Vloet, Hester Vermeulen","doi":"10.1097/PTS.0000000000001293","DOIUrl":"10.1097/PTS.0000000000001293","url":null,"abstract":"<p><strong>Objectives: </strong>Quality improvements (QIs) in dynamic and complex health care contexts require resilience and take variability into account in quality improvement. The Functional Resonance Analysis Method (FRAM) helps us understand resilience and gain insight into (un)desirable variability in the complex system of daily practice. We explored how using FRAM in the Deming cycle of a QI project can help professionals and researchers learn from, reflect upon, and improve complex processes. We used FRAM in a Dutch hospital to study a QI: Critical Care Outreach Service (CCOS).</p><p><strong>Methods: </strong>The aim was to use FRAM before and after implementation to create a FRAM model and reflect to health care professionals the mismatch between Work As Imagined (WAI) and Work As Done (WAD). The WAI FRAM model was co-created with professionals before the implementation of CCOS. We used descriptions of tasks and processes for ICU nurses and verified them in 30-minute semistructured interviews (N = 2). WAD was created by input of semistructured interviews with key professionals in CCOS (N = 21) and 3 nonparticipant observations of trained CCOS nurses. We validated WAD in 2 dialogue sessions with key professionals (N = 11). Data collection continued until saturation.</p><p><strong>Results: </strong>Juxtaposing the WAI and WAD models showed that WAD contained additional functions and highlighted unexpectedly complex functions. Reflecting on the application of FRAM with health care professionals revealed opportunities and challenges, especially time investment.</p><p><strong>Conclusions: </strong>FRAM helps professionals outline processes and tasks (WAI), learn from, and reflect upon their daily practice (WAD). FRAM models help professionals identify variability proactively to improve practices that enhance resilient performance.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"15-23"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478500","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":"Older Adult Misuse of Over-the-Counter Medications: Effectiveness of a Novel Pharmacy-Based Intervention to Improve Patient Safety.","authors":"Aaron M Gilson, Jason S Chladek, Jamie A Stone, Taylor L Watterson, Elin C Lehnbom, Emily L Hoffins, Maria E Berbakov, Jukrin Moon, Nora A Jacobson, Richard J Holden, Ronald E Gangnon, Denise L Walbrandt Pigarelli, Lauren L Welch, Edward C Portillo, Olayinka O Shiyanbola, Joel Gollhardt, Kenneth Walker, Michelle A Chui","doi":"10.1097/PTS.0000000000001288","DOIUrl":"10.1097/PTS.0000000000001288","url":null,"abstract":"<p><strong>Objectives: </strong>Older adults' (ages ≥65) inappropriate over-the-counter medications (OTC) use is prevalent, comprising Drug-Age, Drug-Drug, Drug-Disease, and Drug-Label types. Given that pharmacies sell many OTCs, structurally redesigning pharmacy aisles for improving patient safety (Senior Safe) was conceived to mitigate older adult OTC misuse, using Stop Signs and Behind-the-Counter Signs for high-risk OTCs. This study determined whether Senior Safe reduced high-risk OTCs misuse, while secondarily evaluating misuse changes for all OTCs.</p><p><strong>Methods: </strong>A randomized controlled trial design matched and randomly allocated 20 health system community pharmacies to control or intervention groups. All 288 study participants completed an OTC choice task in which they chose a hypothetical symptom scenario (pain, sleep, cough/cold/allergy), selected an OTC, and described how they would use it at symptom onset and if symptoms persisted or worsened. Reported OTC use was evaluated for each misuse type. Intervention and control sites were compared for each misuse type using multivariate modeling.</p><p><strong>Results: </strong>For high-risk OTCs, Drug-Age and Drug-Drug misuse were more likely in control sites (OR = 2.752, P = 0.004; OR = 6.199, P = 0.003, respectively), whereas Drug-Disease and Drug-Label misuse had too few occurrences in intervention sites for statistical comparisons. For all OTCs, only Drug-Age misuse was more likely for control sites (OR = 5.120, P = 0.001). Adults aged 85+ years had the greatest likelihood of all misuse types.</p><p><strong>Conclusions: </strong>Results demonstrated that older adults frequently reported multiple misuse types, highlighting safety concerns. Senior Safe reduced high-risk OTC misuse, especially for older adults younger than 85 years. Cumulatively, these findings provide insights into practice recommendations supported through regulatory guidance.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 1","pages":"38-47"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869659","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, Adaptation, and Validation of the Japanese Version of Second Victim Experience and Support Tool-Revised.","authors":"Gen Aikawa, Mitsuki Ikeda, Ayako Fukushima, Hideaki Sakuramoto, Akira Ouchi, Michiko Uchi, Nobutake Shimojo","doi":"10.1097/PTS.0000000000001292","DOIUrl":"10.1097/PTS.0000000000001292","url":null,"abstract":"<p><strong>Objective: </strong>Healthcare workers involved in, and negatively affected by, patient safety incidents are referred to as second victims. The Second Victim Experience and Support Tool-Revised (SVEST-R) can reveal the second victim's degree of negative experiences and the desirability of the support options. However, a Japanese version of the SVEST-R (J-SVESTR) has not yet been developed. This study aimed to translate and adapt the SVEST-R into Japanese and validate its psychometric properties.</p><p><strong>Methods: </strong>We performed forward and back translations of the SVEST-R and evaluated its clarity and content validity. Subsequently, we administered a cross-sectional questionnaire survey to evaluate the construct validity, internal consistency, and retest reliability of the J-SVESTR.</p><p><strong>Results: </strong>The J-SVESTR was finalized with clarity and content validity supported by a pilot test and an expert panel. In total, 224 healthcare workers responded to the J-SVESTR survey. The 9 factors and 35 items model indicated an acceptable fit (χ 2 / df = 1.811, root mean square error of approximation = 0.060, comparative fit index = 0.871, Tucker-Lewis index = 0.854, standardized root mean squared residual = 0.077). Cronbach's α values ranged from 0.68 to 0.85. The intraclass correlation coefficients ranged from 0.63 to 0.87.</p><p><strong>Conclusions: </strong>The J-SVESTR retained 9 factors and 35 items, with no item changes from the original. The psychometric properties of the J-SVESTR are acceptable. The J-SVESTR can help investigate the actual situation and desired support options for second victims in Japan.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"1-8"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478503","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}