Journal of Patient Safety最新文献

{"title":"Global Burden and Epidemiologic Transition of Adverse Effects of Medical Treatment: A 30-year Analysis.","authors":"Zhiwei Xu, Chunlei Han, Xuesong Guo, Zhenli Zhu, Jun Zhang","doi":"10.1097/PTS.0000000000001534","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001534","url":null,"abstract":"<p><strong>Background: </strong>Adverse effects of medical treatment (AEMT) pose a substantial global health burden, yet their epidemiological profile remains incompletely characterized. This multinational study aims to characterize the burden of AEMT to guide the development of evidence-based, targeted prevention strategies across diverse health systems.</p><p><strong>Methods: </strong>This study analyzed the global epidemiology of AEMT from 1990 to 2021 using data from the GBD study. Age-standardized rates with 95% UIs were obtained for incidence (ASIR), mortality (ASMR), YLDs, YLLs, and DALYs to systematically evaluate the burden of AEMT. Furthermore, the Epidemiological Transition Effect (ETE) index was introduced to quantify shifts in AEMT burden patterns. Percentage changes with 95% UIs for each metric were calculated between 1990 and 2021. Subgroup analyses were also conducted stratified by age, sex, and region.</p><p><strong>Results: </strong>The global ASIR of AEMT was estimated at 150.11 per 100,000 (95% UIs: 131.19-171.81) in 2021. Meanwhile, the global ASMR in 2021 was 1.53 per 100,000, reflecting a 36% decrease since 1990. Similarly, the YLLs fell to 62.66 per 100,000, a reduction of 40% compared with 1990. In the same year, the global YLDs were 1.53 per 100,000. From 1990 to 2021, DALYs attributable to AEMT declined by 40%, reaching 64.19 per 100,000 population in 2021. Children under 5 years demonstrated disproportionately high YLLs and DALYs. The global ETE value was low at 0.02, indicating that the burden of AEMT was primarily driven by premature mortality. Significant sex disparity was observed, with higher burden rates among females and pronounced peaks among.</p><p><strong>Conclusions: </strong>This comprehensive analysis reveals a significant global reduction in the AEMT burden since 1990. Given the disproportionately high burden observed among children-characterized by substantial YLLs due to premature mortality-public health strategies should address not only fatal AEMT events but also prioritize targeted interventions for this vulnerable pediatric population.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148425652","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":"Impact of Nursing Leadership for Surgical Excellence Program on Perioperative Care and Patient Safety in Low-Income Countries: A Mixed-Methods Study.","authors":"Teshager Worku, Belinda Karimi, Senait Bitew, Richard Kajubi, Tihitena N Mammo","doi":"10.1097/PTS.0000000000001555","DOIUrl":"10.1097/PTS.0000000000001555","url":null,"abstract":"<p><strong>Background: </strong>To evaluate the impact of the NLSE program on perioperative nurse capabilities, nurse and patient satisfaction, nursing practices, and patient safety, and to explore experiences related to leadership, workflow, safety culture, and standardization in 3 Ethiopian hospitals.</p><p><strong>Methods: </strong>A prospective quasi-experimental pre/postintervention mixed-methods study design was conducted from December 2023 to August 2024 at 3 major Ethiopian hospitals. The NLSE intervention comprised tailored training, mentorship, and nurse-led quality improvement initiatives. Quantitative data were collected from 9 fellows, 3 facility mentors, 112 perioperative nurses (65 at baseline, 47 postintervention), and 257 surgical patients using validated Likert-scale questionnaires. Statistical analyses, including paired t tests, χ 2 tests, and ordinal logistic regression, were performed using SPSS Version 27. Qualitative data from 18 key informant in-depth interviews were analyzed thematically using ATLAS.ti.</p><p><strong>Results: </strong>Nurse fellows demonstrated significant improvements in self-reported capabilities (knowledge, skills, and confidence) on quality improvement (QI), evidence-based practice, patient safety, and clinical leadership (mean difference: 0.2-0.8; P <0.001). Patient satisfaction scores also increased, with courtesy, comfort, privacy, and a quiet environment as significant predictors. Nurse satisfaction improved in areas such as motivation, recognition, and support. Qualitative findings supported these results, highlighting enhanced teamwork, communication, and patient safety culture.</p><p><strong>Conclusions: </strong>The NLSE program significantly enhanced perioperative nurse capabilities, nurse and patient satisfaction, and patient safety practices. These findings support the adoption of multimodal, nurse-led interventions to strengthen perioperative care and outcomes in low-resource settings. We highly recommend scaling up the NLSE program framework in such environments.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148377659","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":"Trauma in Health Care Settings: A Twelve-year Medico-legal Case Series and Comparative Analysis of Out-of-court Versus In-court Litigation.","authors":"Valentina Calamano, Rosario Barranco, Fabio Comero, Giuseppe Di Pientrantonio, Isabella Caristo, Francesco Ventura","doi":"10.1097/PTS.0000000000001525","DOIUrl":"10.1097/PTS.0000000000001525","url":null,"abstract":"<p><strong>Background: </strong>Falls and traumas in the hospital setting represent one of the main categories of preventable adverse events, with significant clinical, medico-legal, and economic consequences. The phenomenon particularly affects the elderly population and is amplified by demographic aging, patient clinical complexity, and the structural characteristics of health care facilities.</p><p><strong>Materials and methods: </strong>This retrospective study analyses traumatic claims received by the Claims Management Committee of the Policlinico San Martino Hospital in Genoa between 2013 and 2024. All traumatic events occurring within the hospital and related to care or work activities were included. For each case, the event dynamics, type of injury or death, medico-legal process, and amounts paid were analyzed. Extrahospital traumas, nontraumatic claims, and cases lacking adequate documentation were excluded.</p><p><strong>Results: </strong>Out of 1796 total claims, 150 (8.35%) involved traumatic events. Cases showed a predominance of females (70.7%) with a mean age of 64 years. Structural risk was the most frequent (43.3%), followed by clinical risk (34.7%) and occupational risk (22.0%), highlighting the role of environmental hazards. Injuries were mostly fractures (79%), frequently affecting the lower limbs; cranial trauma accounted for the majority of deaths (8%). Seventy-six percent of disputes were resolved extrajudicially, while 20% proceeded to judicial settlement. The total expenditure amounted to €2,447,412.90 (≈$2,820,000), with significantly higher average costs in judicial cases.</p><p><strong>Conclusions: </strong>Hospital traumatic events have a significant clinical, medico-legal, and economic impact. Integrated preventive strategies and increased extrajudicial management are key elements to reduce traumatic events and related claims.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147976406","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":"Implementing Shortened Fasting Protocols Before Cardiac Catheterization: A Quality Improvement Initiative.","authors":"Marija Corovic, Abiramy Srirangan, Brian McGrath, Laura Sheehan, Matthew McFarling, J D Schwalm, Tej Sheth, Nicholas Valettas, Natalia Pinilla-Echeverri, James Velianou, Michael Tsang, Sanjit Jolly, Matthew Sibbald, Shamir Mehta, Ekta Khemani, Renu Syal, Madhu K Natarajan","doi":"10.1097/PTS.0000000000001552","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001552","url":null,"abstract":"<p><strong>Objectives: </strong>Recent randomized controlled trials (RCTs) challenge the routine practice of keeping patients NPO (\"nil per os\") after midnight before diagnostic cardiac catheterization. Shorter fasting durations improve patient experience without increasing risks; however, systematic uptake into routine practice remains limited. At a high-volume cardiac care centre, patients were still being required to fast from midnight, despite emerging evidence. To assess the feasibility of shifting long‑standing practice patterns, we established a >70% adherence target for uptake of a shortened fasting protocol.</p><p><strong>Methods: </strong>A structured quality improvement initiative using sequential Plan-Do-Study-Act (PDSA) cycles modified pre-procedural fasting protocols to permit a light meal up to 2 hours before cardiac catheterization and clear fluids until the procedure (i.e., intervention). Patient experience surveys were administered to intervention and control groups in 2 PDSA cycles, followed by a post-implementation intervention group. The primary outcome was adherence to shortened fasting protocols (>70% target). Secondary outcomes included patient comfort, satisfaction, safety events, and sustained uptake.</p><p><strong>Results: </strong>Cycle 1 included 97 outpatients (37 control, 60 intervention), cycle 2 included 84 inpatients (40 control, 44 intervention), and 45 patients were in the post-implementation group. Target adherence was met (77% in cycle 1, 82% in cycle 2, and 79% at post-implementation). Patients in the intervention groups reported lower hunger (cycle 1 outpatients) and lower nausea (cycle 2 inpatients), while satisfaction scores remained consistently high across all groups. No aspiration, intubation, or escalation to higher-level care was observed.</p><p><strong>Conclusions: </strong>Shortening fasting requirements to 2 hours before cardiac catheterization was feasible to implement in a high‑volume cardiac centre.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148363140","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":"Completion and Compliance of the Surgical Safety Checklist in a Secondary-Level Hospital in Canton Thurgau, Switzerland: A Retrospective Analysis.","authors":"Dennis Wegner, Thomas Horn, Pascal Probst, Markus K Mueller, JoEllen Welter, Alexander Dullenkopf","doi":"10.1097/PTS.0000000000001464","DOIUrl":"10.1097/PTS.0000000000001464","url":null,"abstract":"<p><strong>Objectives: </strong>Surgical safety checklists (SSCs) are widely used tools aimed at reducing postoperative complications and mortality. While compliance is generally high, adherence to individual checklist sections and completeness can vary. This study aimed to assess compliance and completion rates of a locally modified 6-section SSC.</p><p><strong>Methods: </strong>We conducted a retrospective analysis of all inpatient and outpatient surgeries performed at a secondary-level hospital in northeastern Switzerland between January 1 and March 31, 2023. The presence and completeness of the scanned SSCs in the electronic medical records were evaluated. Multivariable logistic regression models were used to identify factors associated with missing or incomplete SSCs.</p><p><strong>Results: </strong>A total of 2376 surgeries were analyzed. Overall, SSC compliance was high, with a scanned checklist present in 98% (n=2329) of cases; however, only 73% (n=1734) were fully completed. Missing or incomplete SSCs were more frequent in emergency procedures, outpatient surgeries, cases with local anesthesia, procedures performed on Fridays, certain surgical departments, lower-volume operating rooms, and earlier positions in the surgical schedule. Multivariable analysis confirmed that emergency procedures and the use of local anesthesia were independently associated with lower odds of full SSC completion. No clear associations were found with age, sex, health insurance type, or whether procedures were performed during regular operating hours. The \"Sign-In\" and \"Team Time-Out\" sections had the highest completion rates, whereas \"Patient Ready for Operating Room\" and \"Sign-Out\" were most frequently omitted.</p><p><strong>Conclusions: </strong>This study demonstrated a high overall rate of SSC compliance, though variation among checklist sections was observed. Specific contexts-particularly emergency and outpatient settings-were associated with reduced completeness, indicating opportunities for targeted quality improvement.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e81-e86"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146030301","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":"Impact of Respiratory Protective Equipment on Verbal Communication in the Anesthetic Environment.","authors":"Andrew Michael Armson, Christopher Robert Bennett, Benjamin Richard Morris","doi":"10.1097/PTS.0000000000001473","DOIUrl":"10.1097/PTS.0000000000001473","url":null,"abstract":"<p><strong>Objectives: </strong>The increased use of respiratory protective equipment (RPE) during and since the COVID-19 pandemic has highlighted its adverse impact on communication, particularly in high-stakes environments such as anesthesia and surgery, where clear verbal exchange is essential. This study examines how different types and combinations of RPE-including surgical masks, FFP-3 masks, and powered air-purifying respirators (PAPRs)-affect speech intelligibility in the anesthetic setting.</p><p><strong>Methods: </strong>Twenty-one NHS theater staff participated in speech intelligibility testing conducted in a standard anesthetic room. Performance was assessed using single-word, consonant-nucleus-consonant (CNC) tests under various RPE conditions, including combinations of masks and PAPRs.</p><p><strong>Results: </strong>Significant reductions in word recognition accuracy were observed when speakers wore RPE, with FFP-3 masks producing a more pronounced reduction than surgical masks. Communication was further impaired when listeners used PAPRs, particularly when speakers simultaneously wore FFP-3 masks. In contrast, intelligibility was not significantly affected when speakers used PAPRs alone.</p><p><strong>Conclusions: </strong>RPE, principally devices that obscure the mouth, substantially impairs verbal communication in the anesthetic environment, with FFP-3 masks causing the greatest reduction in speech clarity. PAPRs introduce additional barriers, especially for listeners. To mitigate these effects, health care professionals should select RPE that balances protection with communication needs. Additional strategies, such as reducing background noise, enhancing RPE design, and implementing alternative communication methods may further improve verbal exchanges in critical care settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"278-282"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146120267","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":"Risk Factors for Mechanical Restraint Use in Non-ICU Hospitalized Patients With Delirium.","authors":"George Book, Meghan Thomas, Jingwen Zhang, Justin Marsden, Marc Heincelman, Andrew Schriener, Benjamin Kalivas","doi":"10.1097/PTS.0000000000001557","DOIUrl":"10.1097/PTS.0000000000001557","url":null,"abstract":"<p><strong>Objective: </strong>We investigated demographic and clinical factors that contribute to a patient receiving mechanical restraints while hospitalized, with particular focus on the results of delirium screening and receipt of antipsychotics as risk factors.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study of all non-ICU adult patients admitted to a large academic hospital between August 1, 2018, and January 31, 2021. Sociodemographic data, the results of the brief confusion assessment method (bCAM) screening, and receipt of antipsychotic medication were collected and analyzed. Univariate and multivariable logistic regression analyses were used to determine the impact of receipt of an order for mechanical restraints on the primary outcome.</p><p><strong>Results: </strong>The study included 23,366 non-ICU admissions, of which 408 received mechanical restraints during their hospitalization. There were 1379 (5.90%) admissions with a positive delirium screen, and 4939 (21.5%) of patients received an antipsychotic. When adjusting for sociodemographic factors, receiving an antipsychotic had an OR of 9.1 (95% CI: 6.41-12.93) for having an order for mechanical restraints. A positive bCAM had an OR of 27.94 (95% CI: 18.65-41.86), and a positive bCAM and receipt of an antipsychotic had an OR of 190.30 (95% CI: 135.34-267.58) of having an order for mechanical restraints.</p><p><strong>Conclusions: </strong>Our findings support the understanding that delirium and antipsychotics are enormous risk factors for a patient receiving mechanical restraints. And while many patients receive antipsychotics first, some do not, representing an important area for improvement in patient safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148354570","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":"Safeguarding Against Falls From the Operating Room Table During Emergence From Anesthesia: A Simple Strategy.","authors":"Vimi Rewari, Geetha S Thota, Rashmi Ramachandran","doi":"10.1097/PTS.0000000000001484","DOIUrl":"10.1097/PTS.0000000000001484","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e75-e76"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147504033","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":"Patient Safety Culture and Its Associated Factors Among Health Care Professionals in Ethiopia: A Systematic Review and Meta-Analysis.","authors":"Mengistu Ewunetu, Bekalu Mekonen Belay, Yeshiambaw Eshetie, Gebre Kassaw Yirga, Melese Kebede Hailu, Tigabu Munye Aytenew, Birhanu Mengist Munie, Yirgalem Abere","doi":"10.1097/PTS.0000000000001469","DOIUrl":"10.1097/PTS.0000000000001469","url":null,"abstract":"<p><strong>Background: </strong>This systematic review and meta-analysis aimed to assess patient safety culture among health care professionals in Ethiopia. In addition, the study identifies key factors associated with patient safety culture.</p><p><strong>Methods: </strong>We systematically searched PubMed, HINARI, ScienceDirect, Cochrane Library, Google Scholar, and African Journals Online on March 4, 2025, to identify relevant primary research articles. The quality of the included studies was assessed using the Newcastle-Ottawa Scale checklist. We estimated the pooled prevalence of patient safety culture using a random-effects model. We calculated the aggregated prevalence of patient safety culture using a random-effects model. Heterogeneity across studies was evaluated using the I ² statistic. Publication bias was assessed through the visual inspection of funnel plots and confirmed by Egger test.</p><p><strong>Results: </strong>The pooled prevalence of patient safety culture in Ethiopia was 44.24% (95% CI: 39.31-49.17; I ²=94%). Participation in patient safety programs (OR=1.56; 95% CI: 1.27-1.93; I ²=85%), adverse event reporting (OR=1.55; 95% CI: 1.2-8.10; I ²=40.33%), training (OR=3.30; 95% CI: 1.20-9.07; I ²=95.08%), age (OR=0.24; 95% CI: 0.13-0.85; I ²=91.94%), work experience (OR=2.10; 95% CI: 4.30-9.45; I ²=74.1%), and educational status (OR=3.70; 95% CI: 1.22-11.28; I ²=67.6%) were associated factors of patient safety culture.</p><p><strong>Conclusions: </strong>The pooled prevalence of patient safety culture in Ethiopia was found to be low. Therefore, the Ministry of Health should take action by giving special attention to the identified factors, providing training, and encouraging active participation in patient safety initiatives.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"300-307"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146054677","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":"An Observational Study of Disparities in Voluntary Event Reporting in a Large Academic Health System.","authors":"Ellen Pittman, Miranda R Jones, Katherine Hoops, Ann Kane, Katelyn Brant, Angela Green, Allen Kachalia, Joseph Perno, Jeanette Nazarian, Jennifer Abele, Atul Rohatgi, George Cheely, Carrie Herzke, Peter Hill, David Stockwell","doi":"10.1097/PTS.0000000000001474","DOIUrl":"10.1097/PTS.0000000000001474","url":null,"abstract":"<p><strong>Objectives: </strong>Identifying and preventing patient safety events is a goal for institutions that provide quality care; understanding and mitigating disparities in care is another. The mainstay of safety event detection, voluntary event reporting (VER), is prone to bias and under-reporting; previous research suggests this creates disparities in reported events. We aim to explore disparities in voluntary event reporting that may exist in a large, academic health system.</p><p><strong>Methods: </strong>We conducted a retrospective review of inpatient-associated safety events submitted to our health system's VER system from April 2021 to July 2022 and compared the cohort's demographics to those of all admitted patients during the same period.</p><p><strong>Results: </strong>Pediatric patients, who are over-represented in the overall VER system (23% vs. 20%, P <0.001), are under-represented among most harmful events ( P <0.001). Female patients, who are under-represented in the VER system (50.1% vs. 56.5%, P <0.001), remain so only in lower harm events. Other groups are over-represented in the VER system, including patients who are English-speaking (93.8% vs. 92.9%), non-Hispanic or Latino (88.9% vs. 82.4%), Black/African American (33.3% vs. 28.7%), and from areas of high neighborhood deprivation (23.5% vs. 18.9%) (all P <0.001).</p><p><strong>Conclusions: </strong>Disparities in VER were observed in a large academic health system. We conducted a broad analysis, including novel variables that have yet to be evaluated robustly in the literature, and we do find important disparities in these variables. Further research is needed to understand the mechanism for disparities to mitigate bias in reporting. Implementation of more objective methods of event detection may help reduce disparities.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"290-295"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147327888","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}