Journal of Patient Safety最新文献

{"title":"A Prospective Randomized Controlled Simulation Study to Test a Proof-of-Concept Real-Time Periprocedural Decision Support System to Aid in Timely Diagnosis and Intervention on Patient Deterioration.","authors":"Anthony Dinkel, Justin Talluto, Vikranth Chinthareddy, Kevin McCarthy, Dolly Vijaykumar, Steven B Greenberg, Andrew R Locke, Claire Heshmat, Nathan Huey, Stacey Ellender, Fred E Shapiro","doi":"10.1097/PTS.0000000000001573","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001573","url":null,"abstract":"<p><strong>Objectives: </strong>The recent pilot simulation study by Greenberg and colleagues introduced a proof-of-concept audio-visual support system for anesthesiology professional management of perioperative patient deterioration. The results demonstrated that real-time decision support for providers may enhance diagnostic accuracy/efficiency. In collaboration with Greenberg and colleagues, the authors from Massachusetts General Brigham (MGB) similarly developed a realistic operating room simulation environment at Massachusetts General Hospital (MGH) Learning Center. Here, the ability of anesthesiology trainees to accurately diagnose and treat using audio-visual cues was measured.</p><p><strong>Methods: </strong>This study is a prospective, randomized controlled pilot trial adapted from a recent study further investigating the impact of audio-visual decision support on anesthesiology resident and student nurse anesthetist diagnostic accuracy and efficiency. This study took place entirely at Massachusetts General Hospital Center for Simulation and Innovation. Twenty-one anesthesiology trainees were randomized into 2 groups: (1) standard of care (control) versus (2) audio-visual cue group (experimental). The experimental group received audio-visual cues such as a choice of possible diagnoses from an experienced anesthesiologist and subsequent recommended interventions from the Stanford emergency manual and based on changes in the simulated patient's vitals. Each participant underwent 3 experimental simulations where patient deterioration occurs. These included: anaphylaxis, amniotic fluid embolism (AFE), and pulseless electrical activity (PEA) arrest during a pediatric dental case. Key time points and accuracy of diagnoses and treatment steps were recorded.</p><p><strong>Results: </strong>The simulation scenario recordings for 10 anesthesiology residents and 11 student nurse anesthetists of various training years were investigated. For the anaphylaxis scenario, there was a statistically significant increase in the number of participants who correctly executed intervention 1 in the intervention group compared with the control group (P=0.0015). For the AFE scenario, there was a statistically significant increase in the median time to intervention 1 for SRNAs in the intervention group compared with the control group (P=0.01). However, there was a statistically significant decrease in the median time to intervention 1 for residents in the intervention group compared with the control group (P=0.01). For the pediatric dental scenario, there was a statistically significant increase in the number of participants in the intervention group versus the control group who made the correct diagnosis 2 (P=0.005). In addition, there was a statistically significant increase in the number of participants in the intervention group versus the control group who made the correct diagnosis 3 (P=0.023).</p><p><strong>Conclusions: </strong>The results indicate that real","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148664717","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 Impact of Nursing Work Environment, Ethical Leadership, and Organizational Communication on General Hospital Nurses' Perception of Just Culture: A Cross-Sectional Study.","authors":"Eun Hye Kim, Soyoung Yu, Yea Seul Yoon","doi":"10.1097/PTS.0000000000001572","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001572","url":null,"abstract":"<p><strong>Objectives: </strong>This study examined how the nursing work environment, ethical leadership, and organizational communication influenced just culture among hospital nurses and identified factors associated with just culture.</p><p><strong>Methods: </strong>A descriptive cross-sectional design was used. Data were collected from 199 nurses working in 7 hospitals (3 general hospitals, 1 women's hospital, and 3 small hospitals) in a metropolitan region of South Korea. Using a structured online questionnaire, we measured the nursing work environment, ethical leadership, organizational communication, and just culture. Multiple regression analysis was performed to identify factors significantly associated with just culture.</p><p><strong>Results: </strong>Ethical leadership emerged as the strongest predictor of just culture (β=0.460, P<0.001), followed by organizational communication (β=0.268, P<0.001). While the nursing work environment demonstrated a significant correlation with just culture (r=0.587, P<0.001), its effect was not significant in the final regression model. The overall model accounted for 51.8% of the variance in just culture. These findings suggest that day-to-day leadership behaviors and robust communication mechanisms exert a greater influence on nurses' perceptions of just culture than broader structural factors.</p><p><strong>Conclusions: </strong>Ethical leadership and open organizational communication appear pivotal for sustaining a culture of fairness and learning, while the work environment may operate through indirect pathways. Health care managers should prioritize ethical leadership development and strengthen communication systems to promote just culture and enhance patient safety outcomes.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148609134","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 Quality Improvement Initiative to Improve Secure Patient Upload of Urgent Postoperative Digital Photographs.","authors":"Daehee Jeong, Sara Saffari, Caitlin Marks, Victoria Peck, Amy Kells","doi":"10.1097/PTS.0000000000001568","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001568","url":null,"abstract":"<p><strong>Objectives: </strong>Digital photography is a highly useful and increasingly widespread tool for remote postoperative triaging of patient concerns, especially during after-hours settings. As this tool becomes a standardized component of medical workflows, safeguards must be placed to ensure the secure transfer of this protected health information through official encrypted channels. To address this concern, our group conducted a quality improvement initiative to increase the proportion of patients who can upload photographs through official dashboards, such as MyChart in Epic, during after-hours calls.</p><p><strong>Methods: </strong>Our group conducted a multidisciplinary collaboration to identify reasons as to why patients were unable to provide photographs through MyChart. Interventions to facilitate patient education and workflow were developed and tested through Plan-Do-Study-Act cycles.</p><p><strong>Results: </strong>A total of 122 patient encounters were included in our study. Interventions included specially designed handouts and streamlining provider workflows to educate patients about photograph upload. The proportion of after-hours callers who uploaded a photograph to MyChart when requested increased from 44% to 78%. One year after the conclusion of our study, sustainment data over a 3-month period showed that 72% of patients continued to practice secure photograph upload practices.</p><p><strong>Conclusions: </strong>Our group aimed to improve the rate of patient-mediated photograph uploads through MyChart for secure, HIPAA-compliant data transfer. Our findings demonstrated that patients may initially face challenges navigating these digital platforms. We present several interventions that can be easily adopted by institutions seeking to strengthen postoperative triaging and patient safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148593952","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":"Strengthening Telemetry Safety Through Standardized Physiological Parameter Monitor Technician Education: A Practice-Based Framework.","authors":"Katherine Mitchell, Vera Lopez, Laura Lopez, Benjamin Policicchio, Jacob Turmell, Rose Ríos","doi":"10.1097/PTS.0000000000001550","DOIUrl":"10.1097/PTS.0000000000001550","url":null,"abstract":"<p><strong>Background: </strong>Centralized monitoring units (CMUs) can enhance electrocardiographic (ECG)/physiologic monitoring, yet variability in technician training and communication can undermine patient safety and reduce CMU efficiency. This review synthesizes evidence on the competencies, workflows, and technological supports needed to optimize ECG/physiologic monitoring technician performance within CMUs.</p><p><strong>Methods: </strong>A narrative review of published studies, professional guidelines, and human factors research was conducted to evaluate technician responsibilities, training standards, alarm management practices, and CMU operational models. A standardized competency framework was proposed based on data obtained from included studies.</p><p><strong>Results: </strong>There is a lack of consistency in technician rhythm interpretation skills, alarm validation accuracy, and communication pathways. Evidence supports American Heart Association (AHA)-aligned foundational training, simulation-based alarm scenario practice, and structured escalation protocols. Operational factors-including patient load, alarm burden, and cognitive workload-substantially influence safety performance. Emerging technologies such as AI decision support and enhanced visualization tools may reduce nonactionable alarms and improve detection of clinically meaningful events. Performance metrics spanning patient safety, operational reliability, and workforce outcomes provide a framework to evaluate CMU effectiveness.</p><p><strong>Conclusions: </strong>ECG/physiologic monitoring technicians are central to effective CMU operation, yet the absence of national training standards contributes to variability in performance and potential patient harm, including preventable patient safety risks such as delayed arrhythmia recognition, alarm fatigue, and communication breakdowns. Implementing a competency-based, standardized training curriculum can improve alarm accuracy, enhance early detection of patient deterioration, and strengthen CMU reliability. Ongoing education and workload-aware operational design remain essential to sustain high-quality centralized monitoring.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148377675","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":"Implementation of an Enterprise Data Analytics Solution: A Quality Improvement Project to Enhance Infusion Safety Through Smart Pump Technology Compliance.","authors":"Johlee S Odinet, Richard Stansbury, Claire Knight, Diana W Maultsby, Nicole S Wilson","doi":"10.1097/PTS.0000000000001570","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001570","url":null,"abstract":"<p><strong>Objectives: </strong>Appropriate use of smart infusion pumps offers an opportunity to reduce IV medication administration errors. Published literature shows that most hospitals do not meet ISMP targets for DERS compliance. This project aimed to implement an infusion analytics platform to streamline data review, improve investigative efficiency, and inform efforts to enhance infusion administration safety.</p><p><strong>Methods: </strong>A quality improvement project using longitudinal measurement was conducted from November 2023 to May 2025 at a large health system comprising 47 hospitals and 500+ clinics. Hospital sizes range from critical access (<50 beds) to tertiary academic medical centers (>500 beds). Intravenous medication administration data were captured using a vendor-provided data analytics platform and analyzed to identify opportunities for improving infusion safety and compliance.</p><p><strong>Results: </strong>Over 5.6 million infusions programmed on large-volume and syringe pumps were analyzed over 18 months. DERS compliance increased by 1.1% during the project period. Interoperability compliance increased from 67.4% to 68.9%. Total DERS alerts decreased from 28,040 to 10,960 (-6.65% of total infusions). Following implementation, drug library managers reported that the time required to run monthly compliance reports decreased on average by 50%, and individual event investigations decreased by 75%.</p><p><strong>Conclusion: </strong>Implementation of an enterprise infusion analytics platform enabled more efficient data review and improved access to actionable insights. Actions taken were associated with improvements in DERS compliance, interoperability adoption, and a reduction in pump alerts. Further research around smart pump alerts may explore clinician-based factors influencing smart infusion pump alerts and alert response rates, clinical appropriateness of overrides, or alert dwell time.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148551229","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":"Divergent 5-Year Trajectories of Emotional Exhaustion in Internal Medicine and Surgery: Longitudinal Associations With Patient Safety Culture.","authors":"Chih-Hsuan Huang, Hsin-Hung Wu, Yii-Ching Lee, Li Li","doi":"10.1097/PTS.0000000000001564","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001564","url":null,"abstract":"<p><strong>Objectives: </strong>Patient safety culture (PSC) is a critical organizational determinant of health care quality and workforce well-being; however, its longitudinal relationship with emotional exhaustion across clinical contexts remains unclear. This study investigated how PSC dimensions influenced 5-year patterns of emotional exhaustion among internal medicine and surgical health care professionals in a high-pressure teaching hospital.</p><p><strong>Methods: </strong>A repeated cross-sectional design was used using data collected annually from 2020 to 2024 at a regional teaching hospital in Taiwan. The Chinese version of the Safety Attitudes Questionnaire (CSAQ) was administered, yielding 939 valid responses from internal medicine and surgical staff. Stepwise multiple linear regression analyses were conducted for each year to identify department-specific predictors and examine temporal variations in PSC influences on emotional exhaustion.</p><p><strong>Results: </strong>Predictors of emotional exhaustion varied over time and between departments. During the early study period, organizational support factors-particularly job satisfaction and perceptions of management-were the strongest negative predictors. As the COVID-19 pandemic stabilized, stress recognition emerged as a consistent protective factor across multiple years. In surgical departments, teamwork climate showed a positive association with emotional exhaustion in certain periods, suggesting that intensive collaboration demands may increase emotional strain. Furthermore, discrepancies between perceived managerial support and actual working conditions indicated potential resource misalignment, especially within internal medicine settings.</p><p><strong>Conclusions: </strong>The relationship between PSC and emotional exhaustion is dynamic and context-dependent. These findings underscore the importance of phase-specific psychological support, improved alignment between task demands and organizational resources, and department-tailored interventions to enhance workforce well-being and support safer, higher-quality health care delivery.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148537316","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":"Topical Airway Anesthesia for Tracheal Intubation Prevents Intraoperative Hypotension and Improves Outcomes in Severe Traumatic Brain Injury by Reducing Anesthesia Induction: A Single-Center, Single-Blinded, Randomized Trial.","authors":"Nan Ying Ju, Wen Guan Lin, Wei Bao Jia, Xue Lin, Fei Yu Ren, Wei Gao","doi":"10.1097/PTS.0000000000001563","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001563","url":null,"abstract":"<p><strong>Objectives: </strong>Anesthesia induction is a key risk factor for intraoperative hypotension due to the cardiovascular system's suppression of induction anesthetics, and intraoperative hypotension significantly affects mortality linked to traumatic brain injury (TBI). Topical airway anesthesia could optimize intubation conditions with less induction anesthetic. This study aimed to determine whether topical airway anesthesia for tracheal intubation can prevent intraoperative hypotension by reducing the need for induction anesthetics in TBI patients.</p><p><strong>Methods: </strong>A total of 120 patients with severe TBI who underwent craniectomy without preoperative intubation were randomized into the standard anesthesia (C) group or the topical airway anesthesia for intubation (T) group. The patients in the C group received standard anesthesia induction, and those in the T group received topical airway anesthesia without standard induction anesthetics. Intraoperative systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded at the designated time points. In-hospital mortality, ICU morbidity, ICU stay duration, and neurological outcomes at discharge and 6 months postoperatively were evaluated. Postoperative injury to the heart, kidney, and liver was assessed.</p><p><strong>Results: </strong>A total of 52 patients in the C group and 51 in the T group completed the trial. After intubation, the SBP and DBP in the T group were significantly greater than in the C group (P<0.05). The in-hospital mortality and ICU morbidity rates in the T group were lower than in the C group (P<0.05). The T group also had lower postoperative injury rates to the heart, kidney, and liver in was lower (P<0.05). While neurological recovery at discharge was improved in the T group, the difference was not statistically significant (P>0.05), except for the number of moderate and severe comas (P<0.05). The neurological score at 6 months postoperatively was increased in the T group (P<0.05).</p><p><strong>Conclusions: </strong>Topical airway anesthesia for tracheal intubation was associated with higher intraoperative blood pressure, lower in-hospital mortality and ICU morbidity rates, and improved neurological outcomes in patients with severe TBI. These findings suggest that reducing induction anesthetics through topical airway anesthesia may be a promising strategy for managing anesthesia in TBI patients, though confirmation in larger multicenter trials is warranted.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148521327","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":"Post-Mortem Access and the Coronial Process: A National Survey of Clinician Perspectives to Inform Learning, Safety, and Policy.","authors":"Suhaib Ahmad, Eleanor Jane Turner, Pankaj Madan, Richard Egan, Jonathan Barry, Bilal Al-Sarireh, Scott Caplin, Andrew Beamish, Dean Harris, Mohammed Hammoda, Edgar Gelber, Anil Lala, Graham Whiteley, Peter Young, Hazem Al Momani, Hashim Al-Sarireh, Ahmad Al-Sarireh, Ahmed Ahmed","doi":"10.1097/PTS.0000000000001565","DOIUrl":"10.1097/PTS.0000000000001565","url":null,"abstract":"<p><strong>Objectives: </strong>Post-mortem examinations are central to coronial investigations in the United Kingdom. However, treating clinicians do not routinely receive post-mortem findings before submitting statements unless granted Interested Person status. While this approach safeguards investigative independence, its practical impact on clinicians' engagement, learning, and professional well-being remains underexplored.</p><p><strong>Methods: </strong>A national, cross-sectional, anonymous survey of UK clinicians across grades and specialties was conducted. The survey examined experiences of coronial processes, access to post-mortem findings, perceived effects on statement accuracy, reflective learning, clinical behavior, and support for bereaved families. Quantitative data were analyzed descriptively, and free-text responses underwent inductive thematic analysis.</p><p><strong>Results: </strong>Eighty-six clinicians responded, representing a range of specialties and seniority. Among applicable respondents, 83% reported that post-mortem reports were not consistently available before statement submission. Limited access was associated with difficulty drafting accurate factual witness statements and clinical reports requested by the Coroner's Office, increased stress and uncertainty, reduced opportunities for reflective learning, and behavioral changes consistent with defensive practice. Clinicians also reported reduced confidence in communicating with bereaved families when post-mortem findings were unavailable. The majority supported structured disclosure models, including redacted summaries and multidisciplinary learning discussions.</p><p><strong>Conclusions: </strong>Clinicians perceive timely access to post-mortem findings as important for accurate reporting, reflective learning, and meaningful family engagement. Proportionate and structured disclosure practices, while preserving coronial independence, may strengthen collaboration between clinical and coronial systems and support patient safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148609185","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":"Racial Disparities in Medical Errors Among Women: A Systematic Review and Meta-Analysis.","authors":"Vanessa I Batubo, Fatima H M Elasha, Boluwarin F Adeniyi-Ibrahim, Renee Thomas-Venugopal, Prakash V A K Ramdass","doi":"10.1097/PTS.0000000000001566","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001566","url":null,"abstract":"<p><strong>Objectives: </strong>Medical errors are a leading cause of preventable harm worldwide and disproportionately affect women and racial minorities. However, evidence regarding racial disparities in medical errors among women remains inconsistent, and it is unclear whether disparities reflect differences in overall error rates or differences in specific types of errors. This study aimed to quantify racial disparities in medical errors among Black and White women receiving medical care.</p><p><strong>Methods: </strong>A systematic review and meta-analysis was conducted following PRISMA guidelines. EMBASE, PubMed, Google Scholar, ScienceDirect, and Web of Science were searched for peer-reviewed studies examining racial disparities in medical errors among women. Random-effects meta-analyses were performed in RStudio to calculate pooled odds ratios (ORs) and 95% CIs.</p><p><strong>Results: </strong>Thirteen studies involving 3,608,296 women were included in the systematic review, and 11 studies were included in the meta-analysis. Overall, Black women had higher odds of experiencing medical errors compared with White women; however, the association was not statistically significant (OR=1.18, 95% CI: 0.68-2.06). Subgroup analyses demonstrated that patient safety events were significantly more common among Black women (OR=1.19, 95% CI: 1.02-1.39), whereas diagnostic and human errors showed no significant racial differences. Further analysis revealed a significant difference between underdiagnosis in Black women and overdiagnosis in White women.</p><p><strong>Conclusions: </strong>Although overall medical error rates did not differ significantly between Black and White women, Black women were more likely to experience underdiagnosis and patient safety events, whereas overdiagnosis was more frequently observed among White women.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148450031","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 Association Between Transfer Note Documentation and Appropriateness of Interhospital Transfer: A Pilot Study.","authors":"Kennedy E Gallagher, Stephanie K Mueller, Joshua A Marks, Jeffrey M Riggio, Alan A Kubey","doi":"10.1097/PTS.0000000000001559","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001559","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate the association of a templated interhospital transfer (IHT) note on transfer appropriateness and clinical outcomes.</p><p><strong>Methods: </strong>We conducted a retrospective, single-center study of 100 IHTs to the Department of Medicine services between May and June 2023. The exposure was the type of documentation at the time of transfer, categorized as templated note, nontemplated note, or no note. The primary outcome was appropriateness of transfer, determined by 2 independent adjudicators using a standardized framework developed as part of the POINT Study. Documentation type by clinical specialty and reason for transfer were assessed, with statistical analyses of clinical outcomes limited to those with an incidence >5% (ie, escalation/downgrade in level of care within 24 h of transfer and 30 d mortality).</p><p><strong>Results: </strong>Among 100 transfers, 81 (81%) were deemed appropriate and 19 (19%) were deemed inappropriate. Documentation was present in 59%, including templated (35%) and nontemplated notes (24%). IHTs without documentation had the highest appropriateness rate (87.8%, 36/41), compared with templated notes (29/35, 82.9%; P=0.15) and nontemplated notes (66.7%, 16/24; P=0.042). Downgrades were more common in inappropriate transfers with nontemplated notes (50.0%, 4/8) than in appropriate transfers with templated notes (10.3%, 3/29; P=0.012).</p><p><strong>Conclusions: </strong>Structured IHT documentation was inconsistently used and did not predict the appropriateness of transfer. Transfers without documentation were most often appropriate, suggesting straightforward cases may not require formal notes. In contrast, nontemplated notes in inappropriate transfers showed high downgrade rates, implying that unstructured documentation may inflate perceived acuity. Further evaluation of documentation strategies is needed to support appropriate transfer decision-making.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148450050","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}