Journal of Patient Safety最新文献_第7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

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

Decreasing Hospital-acquired Pressure Injuries During the COVID-19 Pandemic: A 5-step Quality Improvement Approach. 在COVID-19大流行期间减少医院获得性压力伤害：五步质量改进方法

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-20 DOI: 10.1097/PTS.0000000000001316

Deema Nuseir, Maya Sinno, Mary-Agnes Wilson, Matthew Hacker Teper, Dmitry Karasev, Shachi Christian, Kate Zimmerman, Victoria Bakun, Natalya Linetska, Khem Persaud, Liandi Zhang, Crystal Li, Lai Yi Koo, Deborah Lefave, Heather Stewart, Ahmed Taher

{"title":"Decreasing Hospital-acquired Pressure Injuries During the COVID-19 Pandemic: A 5-step Quality Improvement Approach.","authors":"Deema Nuseir, Maya Sinno, Mary-Agnes Wilson, Matthew Hacker Teper, Dmitry Karasev, Shachi Christian, Kate Zimmerman, Victoria Bakun, Natalya Linetska, Khem Persaud, Liandi Zhang, Crystal Li, Lai Yi Koo, Deborah Lefave, Heather Stewart, Ahmed Taher","doi":"10.1097/PTS.0000000000001316","DOIUrl":"10.1097/PTS.0000000000001316","url":null,"abstract":"Background: Hospital-acquired pressure injuries (HAPIs) are common adverse events with large burdens on patients and health systems. In 2020, during the initial waves of the COVID-19 pandemic, the incidence of admitted patients with HAPIs of stage II and above in our health system rose from 2.92% to 3.80%. In response to rising HAPI rates across our own hospital system, we established a quality aim to reduce HAPIs stage II and above by 50% over 3 years from the onset of the COVID-19 pandemic.Methods: We designed a multidisciplinary quality improvement HAPI prevention program. Our initiative had 5 key aspects: fostering governance and accountability, providing education and training, changing clinical practice, monitoring data and evaluation, and modernizing environments and equipment.Results: HAPI rate (outcome measure) declined from 3.8% at the onset of the COVID-19 pandemic to 1.6% (58% reduction, P <0.00001) postintervention. Braden Risk Assessment Tool use (process measure) improved from 88.2% to 92.2%. ( P =0.00024). Rate of patient falls with injuries (balancing measure) decreased from 1.5 per 1000 patient days to 1.0 per 1000 patient days ( P =0.0009).Conclusions: Despite working during the COVID-19 pandemic where organizational resources were constrained and infection control practices were heightened, a multidisciplinary QI HAPI prevention program, informed by evidence-based practices and supported by access to real-time data, led to an ∼58% reduction in the HAPI rate.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"151-158"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143014434","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

Corrective Actions Taxonomy for Healthcare Incidents (CATHI): Insights From Real-world Data on Hospital-reported Incidents. 医疗事故纠正措施分类（CATHI）：来自医院报告事件的真实数据的见解。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2024-12-27 DOI: 10.1097/PTS.0000000000001309

Cátia Brazete, António Miguel Marques, Elsa Isaura S, Cláudia De Freitas, Ana Azevedo

{"title":"Corrective Actions Taxonomy for Healthcare Incidents (CATHI): Insights From Real-world Data on Hospital-reported Incidents.","authors":"Cátia Brazete, António Miguel Marques, Elsa Isaura S, Cláudia De Freitas, Ana Azevedo","doi":"10.1097/PTS.0000000000001309","DOIUrl":"10.1097/PTS.0000000000001309","url":null,"abstract":"Objectives: This study aimed to develop a taxonomy for classifying corrective actions following health care incidents in a Portuguese tertiary hospital.Methods: The study utilized a multimethods design, combining qualitative and quantitative analyses of real-world data. Thematic analysis was performed, drawing on inductive and deductive approaches. The latter was informed by the PRISMA Medical Classification/Action Matrix and the COM-B theory.Results: A total of 4644 incidents were reported between January 1, 2021 and December 31, 2022. Each incident report is accompanied by an unstructured free-text conclusion section, whose content was manually coded using NVivo QRS. A total of 910 corrective actions were found. The process of classifying these actions, in addition to the deductive approach, served as the foundation for the development of the proposed taxonomy-the Corrective Actions Taxonomy for Healthcare Incidents (CATHI). CATHI included themes such as technology, medical devices, equipment and infrastructure, procedures, information and communication, and training, among others. The taxonomy was structured into 3 levels to allow for a more detailed classification of corrective actions. A glossary was developed to improve usability, including definitions and examples derived from real-world data.Conclusions: CATHI provides a standardized approach to action implementation, allowing for prioritization of improvement efforts. This study has practical implications for enhancing patient safety and quality of care. Future research should validate this taxonomy in diverse health care settings.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"165-173"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142899588","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

Validity and Reliability Study of the Turkish Adaptation of the "Medical Office Survey on Patient Safety Culture". 土耳其对“医疗办公室患者安全文化调查”的改编效度和信度研究。

IF 1.7 3区医学

Journal of Patient Safety Pub Date : 2025-04-01 Epub Date: 2025-01-29 DOI: 10.1097/PTS.0000000000001319

Vildan Mevsim, Mustafa Erdem, Oğulcan Çöme, İncim Bezircioğlu

{"title":"Validity and Reliability Study of the Turkish Adaptation of the \"Medical Office Survey on Patient Safety Culture\".","authors":"Vildan Mevsim, Mustafa Erdem, Oğulcan Çöme, İncim Bezircioğlu","doi":"10.1097/PTS.0000000000001319","DOIUrl":"10.1097/PTS.0000000000001319","url":null,"abstract":"Introduction: The safety culture within health care organizations is essential for ensuring patient well-being and optimizing health care delivery. This study addresses the pressing need to establish a culture of patient safety within primary health care settings. The aim is to conduct a comprehensive validity and reliability study for the Turkish adaptation of the \"Medical Office Survey on Patient Safety Culture\" (MOSPSC) scale, designed to assess patient safety culture in primary care medical offices.Methods: The research model follows rigorous methodology, including a systematic translation and adaptation process aligned with World Health Organization guidelines. A diverse sample of 402 family physicians from primary health care centers across Turkey participated in the study. Descriptive results highlight participants' characteristics, work environments, and experiences in primary care. The scale's construct validity is evaluated using the Kaiser-Meyer-Olkin (KMO) and Bartlett tests, while its reliability is assessed through internal consistency analyses, including Cronbach α, split-half reliability, and item-total correlation.Results: Results indicate strong internal consistency, with Cronbach α values ranging from 0.42 to 0.91 for scale dimensions and an overall value of 0.89. Construct validity assessment attests to the scale's appropriateness for assessing patient safety culture. Challenges in conducting factor analysis due to participant responses are discussed.Conclusions: The study contributes to the field by providing a validated and reliable tool specifically tailored for assessing patient safety culture in primary care medical offices. The Turkish adaptation of the MOSPSC scale offers health care professionals and organizations a valuable instrument for enhancing patient safety culture, identifying areas for improvement, and ultimately optimizing patient care within primary health care settings.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"119-126"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143069181","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