Journal of Patient Safety最新文献

{"title":"Second Victims in Mental Health Care.","authors":"Deborah Oyine Aluh, Jesus David Cortes","doi":"10.1097/PTS.0000000000001277","DOIUrl":"10.1097/PTS.0000000000001277","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"20 8","pages":"e144"},"PeriodicalIF":1.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142677561","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":"Using Patient Experience Surveys to Identify Potential Diagnostic Safety Breakdowns: A Mixed Methods Study.","authors":"Kelley M Baker, Mark Brahier, Mara Penne, Mary A Hill, Siara Davis, William J Gallagher, Kristen E Miller, Kelly M Smith","doi":"10.1097/PTS.0000000000001283","DOIUrl":"10.1097/PTS.0000000000001283","url":null,"abstract":"<p><strong>Objectives: </strong>One in 20 outpatients in the United States experiences a diagnostic error each year, but there are no validated methods for collecting feedback from patients on diagnostic safety. We examined patient experience surveys to determine whether patients' free text comments indicated diagnostic breakdowns. Our objective was to evaluate associations between patient-perceived diagnostic breakdowns reported in free text comments and patients' responses to structured survey questions.</p><p><strong>Methods: </strong>We conducted an exploratory mixed methods study using data from patient experience surveys collected from adult ambulatory care patients March 2020 to June 2020 in a large U.S. health system. Data analysis included content analysis of qualitative data and statistical analysis of quantitative data.</p><p><strong>Results: </strong>In 2525 surveys with negative comments, 619 patients (24.5%) identified diagnostic breakdowns, including issues with accuracy (n = 282, 46%), timeliness (n = 243, 39%), or communication (n = 290, 47%); some patients (n = 181) reported breakdowns in multiple categories. Patients who gave a low average score (50 or less on a 100-point scale) on provider questions were almost seven times more likely to perceive a diagnostic breakdown than patients who scored their provider higher. Similarly, patients who gave a low average score on practice-related questions were twice as likely to perceive a diagnostic breakdown.</p><p><strong>Conclusions: </strong>Patient feedback in routinely collected patient experience surveys is a valuable and actionable information source on diagnostic breakdowns in the ambulatory setting. The more easily monitored structured survey data provide a screening method to identify encounters that may have included a patient-perceived diagnostic breakdown and therefore require further examination.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"556-563"},"PeriodicalIF":1.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11804938/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142299273","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}

{"title":"Rethinking Surgical Safety: Investigating the Impact of Gamified Training on Severe Flow Disruptions in Surgery.","authors":"Tara Cohen, Falisha Kanji, Jennifer Zamudio, Catherine Breese, Ray Avenido, Christine Yoshizawa, Stephanie Bartkowicz, Kenneth Catchpole, Jennifer Anger","doi":"10.1097/PTS.0000000000001279","DOIUrl":"10.1097/PTS.0000000000001279","url":null,"abstract":"<p><strong>Objectives: </strong>There is a need for effective and engaging training methods to enhance technical and nontechnical skills in robotic-assisted surgery (RAS), where deficiencies can compromise safety and efficiency. This study aims to evaluate the impact of a gamified team training intervention, the \"RAS Olympics,\" on the safety and efficiency of RAS procedures.</p><p><strong>Methods: </strong>The study was conducted at a 958-bed tertiary care academic medical center in with a robust robotic surgery program. A total of 56 RAS procedures (general, urology, and gynecology) were included in the analysis, with a mix of procedure types representative of the surgical caseload at the medical center. A pretest posttest experimental design was employed, comparing the frequency and severity of flow disruptions (FD) between preintervention, postintervention without \"RAS Olympics\" participants, and postintervention with \"RAS Olympics\" participants. The \"RAS Olympics\" involved safety hazard identification, troubleshooting, workspace navigation, instrument retrieval, and turnover optimization.</p><p><strong>Results: </strong>Postintervention cases with \"RAS Olympics\" participants exhibited significantly lower overall FDs compared to the postintervention control group. The reduction was particularly notable during phase 3 (surgeon on console) and in cases involving more severe FDs.</p><p><strong>Conclusions: </strong>Gamified team training interventions may improve the safety and efficiency of RAS procedures. The positive outcomes underscore the potential of innovative and engaging training methods to address the evolving challenges in surgical practice, emphasizing the relevance of gamification in healthcare education. As the healthcare landscape continues to advance, incorporating such interventions may be crucial in ensuring the adaptability and competence of surgical teams.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"20 8","pages":"593-598"},"PeriodicalIF":1.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142677555","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":"Associations Between Oversedation and Agitation in Postanesthesia Recovery Room and Subsequent Severe Behavioral Emergencies.","authors":"Mary Labib, Atousa Deljou, Robert J Morgan, Darrell R Schroeder, Juraj Sprung, Toby N Weingarten","doi":"10.1097/PTS.0000000000001275","DOIUrl":"10.1097/PTS.0000000000001275","url":null,"abstract":"<p><strong>Objectives: </strong>Hospital-based behavioral emergency response teams (BERT) respond to acute behavioral disturbances among hospitalized patients. We aimed to examine associations between altered mental status in postanesthesia care unit (PACU) and behavioral disturbances on surgical wards requiring BERT activation.</p><p><strong>Methods: </strong>Electronic medical records of patients who underwent general anesthesia and were admitted to the PACU between May 2018-December 2020 were reviewed for episodes of BERT activations on surgical wards. Characteristics of BERT patients were compared with the rest of surgical population during the same period to examine risk factors for BERT.</p><p><strong>Results: </strong>Of 56,275 adult surgical patients, 133 patients had 178 BERT activations (incidence 2.4, 95% confidence interval [CI] 2.0-2.8 per 1000 admissions), with 21 being for physical assault. The risk for BERT activation was increased with each decade over age of 50 as well as younger age (30 versus 50 y), male sex (odds ratio [OR] = 2.48, 95% CI 1.69, 3.62), longer procedures (OR = 1.08 per 30 minutes, 95% CI 1.05, 1.11), and alterations in mental status in PACU, with both moderate/deep sedation (OR = 1.63, 95% CI 1.04, 2.57) and agitation/combative state (OR = 8.47, 95% CI 5.13, 14.01), P < 0.001 for all comparisons.</p><p><strong>Conclusions: </strong>Early postoperative agitation and oversedation are associated with BERT activation on surgical wards. Altered mental status in PACU should be conveyed to accepting hospital units so healthcare staff can be vigilant for the potential development of behavioral disturbances.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"535-541"},"PeriodicalIF":1.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142074274","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 Compliance With Work-Hour Restrictions Through Safety Culture and Leadership in Medical Residencies.","authors":"Waseem Jerjes","doi":"10.1097/PTS.0000000000001278","DOIUrl":"10.1097/PTS.0000000000001278","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e145"},"PeriodicalIF":1.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142330509","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 Influence of Hospital Physician Integration on Culture of Patient Safety.","authors":"Soumya Upadhyay, Lung-Chang Chien","doi":"10.1097/PTS.0000000000001280","DOIUrl":"10.1097/PTS.0000000000001280","url":null,"abstract":"<p><strong>Background: </strong>Medical errors are responsible for a large number of deaths every year in the Unites States. Hospitals use various strategies including leadership, staffing, and structural changes to deal with this concerning issue. Hospital physician integration is a structural strategy to possibly improve patient safety. Using the conceptual lens of Donabedian's Structure Process Outcome model, this study aims to investigate how hospital physician integration affects organizational, management, and communication attributes of patient safety culture.</p><p><strong>Methods: </strong>A pooled cross sectional study design using the Hospital Survey on Patient Safety Culture, the American Hospital Association data, and Area Health Resource File was used to analyze the relationship between hospital physician integration and organizational and management patient safety culture attributes. The dataset comprised of hospital level data from 2021 and 2022 for patient safety culture and hospital characteristics and contained a final sample of 205 observations. The independent variable was levels of integration across five levels. Three attributes of safety culture were chosen-positive perceptions of communication openness, organizational learning, and hospital management support for patient safety. The control variables were organizational characteristics. Multivariable linear regression was used as the analytic method.</p><p><strong>Results: </strong>Findings demonstrated a statistically significant correlation between higher level of hospital physician integration and positive perceptions of hospital management support for patient safety. There are 0.063 higher positive perceptions of hospital management support for patient safety for higher levels of integration compared with lower levels of integration ( P < 0.05). Perceptions of communication openness and organizational learning did not demonstrate a statistically significant correlation with any level of hospital physician integration.</p><p><strong>Conclusions: </strong>Hospital physician integration and hospital management support for patient safety were moderately but significantly related. Hospital physician integration allows resources to become available for physician. As physicians take on management roles management of resources and eventually performance can improve, there is a need for future research in this area to examine if integration is a step in the right direction to overcome the challenges of patient safety and if investments in resources and training can be beneficial to safety culture.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"542-548"},"PeriodicalIF":1.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478501","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":"Knowledge and Practices Regarding Prevention of Central Venous Catheter Removal-Associated Air Embolism: A Survey of Nonintensive Care Unit Medical and Nursing Staff.","authors":"Maria Karlinskaya, Liad Scharf, Nadav Sarid","doi":"10.1097/PTS.0000000000001287","DOIUrl":"10.1097/PTS.0000000000001287","url":null,"abstract":"<p><strong>Introduction: </strong>Air embolism is a potentially serious complication of central venous catheter (CVC) use. While CVC insertion is usually performed by a trained specialist, extraction is frequently the responsibility of junior staff members. This complication can be easily prevented by following several simple measures described in common guidelines.</p><p><strong>Aim: </strong>We conducted a single-center survey to assess knowledge and practices concerning the prevention of air embolism associated with CVC removal among healthcare workers from nonintensive care units.</p><p><strong>Methods: </strong>The correct answers to the questionnaire were determined according to best-practice recommendations for CVC removal. Based on a comparison of the total sum of correct answers between the categories of groups, factors that predicted the level of knowledge were identified using an independent sample t test.</p><p><strong>Results: </strong>Of the 156 respondents, one-third were unfamiliar with air embolism as a complication of CVC extraction. Almost 80% were unaware of the existence of a CVC removal protocol. Almost half of respondents did not follow guidelines regarding patient position when removing a CVC, 72% did not ask the patient to perform the Valsalva maneuver during the procedure, and 54% did not ask the patient to remain supine after the procedure. Adherence to the protocol was correlated with professional experience, with a lower level among those with experience of less than 1 year and, particularly, among interns.</p><p><strong>Conclusions: </strong>Our survey revealed inappropriately low awareness of CVC removal-associated air embolism risk and low familiarity with CVC removal best-practice recommendations among nonintensive care unit healthcare workers. Staff members with experience of less than 1 year, including interns, were found to have a lower level of knowledge. These findings emphasize the importance of development and distribution an internal hospital protocol and the integration of educational intervention into a preliminary internship program.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"571-575"},"PeriodicalIF":1.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142511132","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":"Situations and Risk Factors of Unplanned Extubation of Nasogastric Tubes in Inpatients: A Retrospective Study.","authors":"Wen-Pei Chang, Yen-Kuang Lin","doi":"10.1097/PTS.0000000000001274","DOIUrl":"10.1097/PTS.0000000000001274","url":null,"abstract":"<p><strong>Objective: </strong>The aim of the study is to understand whether the risk factors of the unplanned extubation (UE) of nasogastric (NG) tubes vary among different inpatient situations.</p><p><strong>Methods: </strong>Inpatients who experienced UE between 2009 and 2022 at a medical center were selected, and electronic medical records were used to collect patient background data and their conditions during UE. A total of 302 patients were included in our analysis.</p><p><strong>Results: </strong>Conscious patients were at greater risk of UE when coughing, scratching their nose, blowing their nose, or sneezing than those who were confused (odds ratio [OR] = 0.07, P < 0.001) and those who were drowsy or comatose (OR = 0.15, P = 0.026). During activity, repositioning, bathing, or changing incontinence pads, the risk of UE was higher in patients whose hands were not restrained at the time of UE than in those whose hands were restrained (OR = 0.05, P = 0.004), higher in those with companions than in those without companions (OR = 7.78, P = 0.002), and higher in those with longer NG tube placement time (OR = 1.05, P = 0.008). Accidental extubation (OR = 2.62, P = 0.007) occurred more frequently during activity, repositioning, bathing, or changing incontinence pads.</p><p><strong>Conclusions: </strong>There is an increased risk of UE in conscious patients during activity, repositioning, bathing, or changing incontinence pads. Patients inserted with an NG tube for a longer period of time were at greater risk of accidental extubation during activity, repositioning, bathing, or changing incontinence pads irrespective of whether a companion could aid them if their hands were or were not restrained.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"505-511"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142113806","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":"Using a Patient Portal to Screen Patients for Symptoms After Starting New Medications.","authors":"Sonam Shah, Alejandra Salazar, Samuel Bennett, Aneesha Fathima, Renuka Kandikatla, Tewodros Eguale, Maria Mirica, Pamela Garabedian, Lynn A Volk, Adam Wright, Gordon D Schiff","doi":"10.1097/PTS.0000000000001264","DOIUrl":"10.1097/PTS.0000000000001264","url":null,"abstract":"<p><strong>Objective: </strong>Conduct systematic proactive pharmacovigilance screening for symptoms patients experienced after starting new medications using an electronic patient portal. We aimed to design and test the feasibility of the system, measure patient response rates, provide any needed support for patients experiencing potentially drug-related problems, and describe types of symptoms and problems patients report.</p><p><strong>Methods: </strong>We created an automated daily report of all new prescriptions, excluding likely non-new and various over-the-counter meds, and sent invitations via patient portal inviting patients to inquire if they had started the medication, and if \"yes,\" inquire if they had they experienced any new symptoms that could be potential adverse drug effects. Reported symptoms were classified by clinical pharmacists using SOC MeDra taxonomy, and patients were offered follow-up and support as desired and needed.</p><p><strong>Results: </strong>Of 11,724 included prescriptions for 9360 unique patients, 2758 (29.4%) patients responded. Of 2616 unique medication starts, patients reported at least 1 new symptom that represented a potential adverse drug reaction (ADR) in 678/2616 (25.9%). Nearly one-third of those experiencing new symptoms (30.3%) reported 2 or more new symptoms after initiating the drug. GI disorders accounted for 30% of the total reported ADRs.</p><p><strong>Conclusions: </strong>Systematic portal-based surveillance for potential adverse drug reactions was feasible, had higher response rates than other methods (such as automated interactive phone calling), and uncovered rates of potential ADRs (roughly 1 in 4 patients) consistent with other methods/studies.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"449-453"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141903320","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":"Introduction of a Novel Patient Safety Advisory: Evaluation of Perceived Information With a Modified QPP Questionnaire-A Case-Control Study.","authors":"Bojan Tubic, Margareta Bånnsgård, Susanne Gustavsson, My Engström, Johanna Moreno, Caterina Finizia","doi":"10.1097/PTS.0000000000001269","DOIUrl":"10.1097/PTS.0000000000001269","url":null,"abstract":"<p><strong>Objectives: </strong>Adverse events (AEs) may result in serious injuries or death. AEs occur in approximately 9.2% of hospitalizations, with a potential preventability of 43.5%. The aim of this study was to examine whether use of an illustrated patient safety advisory affected information transfer to inpatients regarding how they can participate in their own care to decrease the risk of AEs.</p><p><strong>Methods: </strong>All patients in the control (n = 129) and case/intervention (n = 511) groups received verbal information from healthcare personnel. The intervention group also received the illustrated patient safety advisory, \"Your safety at the hospital.\" Before discharge, patients completed the Quality from the Patient's Perspective questionnaire.</p><p><strong>Results: </strong>Mean patient age was 64.6/62.4 years in the intervention/control group, respectively, and 50% were men. Significant differences between groups were observed for most questions presented from the perceived reality of care perspective, in favor to the intervention group. Patients at surgical wards indicated higher scores on 9 of 12 Quality from the Patient's Perspective questions. Patients with hospital stays ≥4 days, at surgical wards, and living with someone else, placed higher subjective importance to questions concerning, e.g., protection/infection, nutrition, risk of falls and pressure ulcers, and discharge information.</p><p><strong>Conclusions: </strong>Using an illustrated patient safety advisory to complement oral information about patient safety risks resulted in positive responses and a significant difference was demonstrated in how information is perceived. The safety advisory could be used as a tool to decrease AEs. Patients who live alone may need more focused patient safety information to encourage involvement in their own care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"20 7","pages":"490-497"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142308849","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}