Journal of Patient Safety最新文献

{"title":"Considerations and Challenges When Using Clinical and Vital Record Review for Suicide Research.","authors":"Sarah A Arias, Brandon A Gaudiano, Gary Epstein-Lubow, Sarah Zylberfuden, Lauren M Weinstock","doi":"10.1097/PTS.0000000000001325","DOIUrl":"10.1097/PTS.0000000000001325","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e8-e17"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11932785/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143383562","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":"Situational Analysis of the Medication Practices in Brazilian Hospitals: A Multicenter Study.","authors":"Pedro Henrique Guimarães, Mário Borges Rosa, Adriano Max Moreira Reis, Kirla Barbosa Detoni, Gabriela de Paula Guimarães Rodrigues, Mariana Martins Gonzaga Nascimento","doi":"10.1097/PTS.0000000000001314","DOIUrl":"10.1097/PTS.0000000000001314","url":null,"abstract":"<p><strong>Objective: </strong>To carry out a situational analysis of the medication practices in Brazilian hospitals through the Medication Safety Self-Assessment for Hospitals and the factors associated with better performance in the evaluation.</p><p><strong>Methods: </strong>This is a multicenter cross-sectional study in which the results of the application of the Medication Safety Self-Assessment for Hospitals, between 2015 and 2020, in 30 Brazilian hospitals were described. In addition, whether the institutional profile was associated with higher self-assessment scores (better performance in the evaluation) was also evaluated.</p><p><strong>Results: </strong>An average proportion of points obtained of 36.7±10.9% was identified (minimum=11.5%; maximum=59.7%), from a score ranging from 0 to 1826 points. The need to improve the use of devices for the preparation and administration of drug solutions, professional development, and patient education was highlighted. A positive association was identified between higher scores and the large or very large size of the hospitals ( P =0.026) and having accreditation certification ( P =0.007).</p><p><strong>Conclusions: </strong>The study made it possible to identify the main weak points and opportunities for improvement of the medication system in the evaluated hospitals, bringing important reflection to national institutions.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"127-132"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143014440","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 5-year Review of Characteristics and Outcomes of Trauma Surgery Patients Leaving Against Medical Advice.","authors":"Joseph D Quick, Lauren E Powell, Erica Bien, Nellie R Adams, Sam A Miotke, Ruth J Barta","doi":"10.1097/PTS.0000000000001310","DOIUrl":"10.1097/PTS.0000000000001310","url":null,"abstract":"<p><strong>Objectives: </strong>The objective of this study was to characterize the demographic, social, economic, and clinical factors of trauma surgery patients leaving against medical advice (AMA).</p><p><strong>Methods: </strong>Data were retroactively obtained from a level-one trauma center in a medium-sized metropolitan area from January 2017 to December 2021. The sample population consisted of patients admitted or treated by the trauma surgical service.</p><p><strong>Results: </strong>In the 5-year study period, 130 surgical patients left AMA and met the inclusion criteria for this study. The average patient was 38.8 years old. The majority were male (77.7%) and White (47.7%). It was found that 74.6% of patients had insurance, 23.6% were experiencing homelessness, and 6.2% required an interpreter. A large percentage of patients had a past medical history significant for depression (31.5%), anxiety disorders (25.4%), and substance use disorder (68.5%). Analysis of the hospital time course of this patient population indicated that patients were most often admitted to trauma surgery (70.0%) and most often required consults by neurosurgery (28.5%). Procedures were performed for 81.5% of patients and social services were consulted for 60.8% of patients. Only 50.8% of patients who left AMA were noted to receive discharge instructions. Nearly half (44.6%) of the patients returned to a hospital to receive additional care within 1 month of their initial AMA discharge date.</p><p><strong>Conclusions: </strong>A concerning number of trauma surgery patients left without discharge instructions, possibly leading to a high rate of 30-day hospital readmission. Future studies are needed to examine and further characterize the relationship between discharge protocol and outcomes of patients leaving AMA.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"159-164"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142972951","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 Prevention and Treatment of Postoperative Delirium in the Elderly: A Narrative Systematic Review of Reviews.","authors":"Simon Deblois, Nicolas Bergeron, Thien Tuong Minh Vu, Gabriel Paquin-Lanthier, Bénédicte Nauche, Alfons Pomp","doi":"10.1097/PTS.0000000000001318","DOIUrl":"10.1097/PTS.0000000000001318","url":null,"abstract":"<p><strong>Objectives: </strong>Postoperative delirium (POD) is a common complication after major surgeries, posing significant challenges to patient recovery and outcomes, particularly among the elderly. A narrative systematic review was conducted to assess the clinical effectiveness and safety of interventions aimed at preventing and treating POD.</p><p><strong>Methods: </strong>A review of the literature from 2017 to September 29, 2023, was conducted using MEDLINE, EMBASE, and CINAHL. Systematic reviews, with or without meta-analyses, as well as practice guidelines, were included. Participants were adults, ≥60 years. The methodological quality of included reviews was appraised using AMSTAR 2.</p><p><strong>Results: </strong>After the search strategy identified 2295 references, 36 review studies were selected. Multicomponent interventions, incorporating both pharmacological and nonpharmacological approaches, demonstrate promise, particularly in hip fracture patients. Notably, dexmedetomidine emerges as a potential preventive measure, showing a notable reduction in delirium incidence following cardiac surgery. While several pharmacological interventions show potential, evidence remains inconclusive, necessitating further investigation. Similarly, varying anesthesia type and monitoring methods has mixed outcomes on delirium prevention. Despite methodological variations and quality appraisal limitations, this review underscores the importance of multicomponent interventions and the potential efficacy of dexmedetomidine in mitigating POD. Integration of evidence-based protocols into clinical practice is advocated to improve patient outcomes. However, the complex interplay between intervention components calls for further research to optimize delirium management strategies.</p><p><strong>Conclusions: </strong>The strength of evidence associated with multicomponent interventions and dexmedetomidine use should require a genuine commitment from health care institutions to support their integration into efficient strategies to prevent and treat POD. Ongoing research is vital to uncover their full potential and refine clinical protocols, ultimately enhancing patient care outcomes.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"174-192"},"PeriodicalIF":1.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143191101","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":"Ambulatory Medication Errors and Adverse Events Involved in Medicine-Related Malpractice Cases From 2011 to 2021.","authors":"Susan Boisvert, Melissa Nelson, Jacqueline Ross","doi":"10.1097/PTS.0000000000001300","DOIUrl":"10.1097/PTS.0000000000001300","url":null,"abstract":"<p><strong>Objectives: </strong>The aims of the study were to identify the characteristics of medication-related malpractice claims occurring in the ambulatory setting across 2 time periods.</p><p><strong>Methods: </strong>A retrospective, descriptive study was used. Ambulatory medication-related closed malpractice events from loss years of 2011-2021 were analyzed. Analysis included gender and age, injury severity, location, major injury, medications, primary and secondary services, roles, contributing factors, primary drivers, indemnity paid, and disposition status. Findings were analyzed using the Candello Explore tool.</p><p><strong>Results: </strong>Five hundred four ambulatory medication-related closed malpractice events were included. Family medicine (19.4%) and internal medicine (10.4%) services had the largest number of claims. The top medications were anti-infectants (16.4%), narcotics (15.6%), and anticoagulants (14.4%). Medication-related claims were multifactorial, averaging 4.1 contributing factors per claim. Clinical judgment issues were found in over 55% of the claims, and communication factors were observed in almost 48% of the claims. In the comparison analysis, 433 claims from 2011 to 2015 and 161 claims from 2016 to 2021 were evaluated. A statistical decrease in claims involving anticoagulants and narcotics ( P  = 0.01) was seen in the second period. There was a statistical increase in claims involving pharmacy dispensing errors during the 2016-2021 period ( P  = 0.03).</p><p><strong>Conclusions: </strong>Adverse drug events in ambulatory care are multifactorial. Errors in the technical process of ordering and managing medications, patient education, patient adherence, and pharmacy dispensing were the primary drivers of ambulatory medication malpractice claims in this study.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"111-117"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142984970","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 a Standardized Tool for Root Cause Analysis Selection.","authors":"Eric Wahlstedt, Brittany E Levy, Emma Scott, Wesley Stephens, Kristen E Fletcher, Andrew Harris","doi":"10.1097/PTS.0000000000001291","DOIUrl":"10.1097/PTS.0000000000001291","url":null,"abstract":"<p><strong>Objectives: </strong>This study sought to determine if a standardized root cause analysis (RCA 2 ) selection algorithm, developed by the Veterans Affairs, would select high-risk events for RCA.</p><p><strong>Methods: </strong>Physician-entered incident reports for all surgical service admissions and perioperative visits were queried over 12 months in the DATIX Clinical Incident Management System. Independent reviewers assigned potential harm and event frequency scores using an institutional scoring system and then calculated and rounded average scores. These were classified using RCA 2 terminology (catastrophic, major, moderate, minor for harm; frequent, occasional, uncommon, remote for frequency). The scores were then evaluated with the standardized Safety Assessment Code Matrix (SAC) algorithm from the National Patient Safety Foundation's RCA 2 guidelines to determine Potential Harm Scores. The SAC combines severity and probability to determine the necessity of conducting an RCA. Catastrophic and major high-frequency events (matrix score = 3) were classified as \"RCA recommended.\" The study then compared cases selected for RCAs using the updated RCA 2 algorithm against cases selected using a current, institutional-specific RCA selection process.</p><p><strong>Results: </strong>One hundred four cases were reviewed, comprising 20 catastrophic, 48 major harm, 26 moderate harm, and 10 minor harm events. After removing 9 high-variance cases, our institution's current selection process selected 18 cases for RCAs, including 6/20 catastrophic, 8/39 major harm, and 4/36 moderate/minor harm events. Only 17.3% of cases had an RCA completed, while the standardized RCA 2 algorithm recommended investigation for 56.7% of patient safety events, based on SAC Matrix scoring. Current RCA selection processes rendered 4 RCAs on low potential harm or low-frequency events, while 45 potential high-frequency, high potential harm events did not complete RCAs.</p><p><strong>Conclusions: </strong>Standardizing the selection of patient safety incidents for RCA using the RCA 2 algorithm improves case identification based on the event frequency and potential harm score. Thus, this algorithm has the potential to advance patient safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"101-105"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142511120","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 Optimized Use of a Contact-Free Continuous Monitoring System on Clinical Outcomes During COVID-19.","authors":"Alice Kim, Patricia C Dykes, Darren Scully, Paula Wolski, Calvin Franz, Stuart Lipsitz, Graham Lowenthal, Matthew Wien, David W Bates","doi":"10.1097/PTS.0000000000001298","DOIUrl":"10.1097/PTS.0000000000001298","url":null,"abstract":"<p><strong>Objectives: </strong>The purpose of this study was to examine the impact of a contact-free continuous monitoring system on clinical outcomes including unplanned intensive care unit (ICU) transfer (primary), length of stay (LOS), code blue, and mortality. A secondary aim was to evaluate the return on investment associated with implementing the contact-free continuous monitoring program during the COVID public health emergency.</p><p><strong>Methods: </strong>An interrupted time series evaluation was conducted to examine the association between the use of contact-free continuous monitoring and clinical outcomes. A cost-benefit analysis was planned to evaluate the return on investment.</p><p><strong>Results: </strong>Use of contact-free continuous monitoring was not significantly associated with unplanned ICU transfers, deaths, ICU LOS, and or rapid response team calls. However, there were significant increases in code blue events ( P  = 0.02) and mean hospital LOS ( P  = 0.01) in the postimplementation period when compared with the preimplementation period. Due to the lack of improvement, costs were calculated but a cost-benefit analysis was not conducted.</p><p><strong>Conclusions: </strong>Contact-free continuous monitoring bed use during the COVID-19 public health emergency was not associated with improvements in clinical outcomes, although there was substantial confounding. Future studies should include large randomized controlled trials to control for factors not under direct experimental control including unit staffing, staff turnover, and differences in the patient population related to surges in the COVID-19 pandemic.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"106-110"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142607149","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":"Intelligent Verification Tool for Surgical Information of Ophthalmic Patients: A Study Based on Artificial Intelligence Technology.","authors":"Hui Lin, Xiaofang Huang, Yaying Sheng, Ning Tang, Hengli Lian, Wenjie Zhang, Lvjun Zhao, Hanqing Zhu, Pingjun Chang, Yingxuan Guo","doi":"10.1097/PTS.0000000000001295","DOIUrl":"10.1097/PTS.0000000000001295","url":null,"abstract":"<p><strong>Objective: </strong>With the development of day surgery, the characteristics of \"short, frequent and fast\" ophthalmic surgery are becoming more prominent. However, nurses are not efficient in verifying patients' surgical information, and problems such as patient privacy leakage are becoming more prominent. To improve the situation, we developed a new augmented reality (AR)-based tool for visual recognition and artificial intelligent (AI) interpretation of the pattern and location of patient surgical skin markings for the verification of the correct surgical site and procedure. The tool can also display a variety of other verbally requested patient information. The purpose of this proposal is to evaluate its feasibility of use by surgical nurses in a real clinical setting.</p><p><strong>Methods: </strong>We developed a tool with image recognition technologies to interpretation patient surgical skin markings and match the information obtained with the patients surgical records, thus, verify the patient's surgical information. Verification includes the proper surgical site and type of procedure to be performed. Nurses can interact with the device through its speech recognition capabilities and the device provides them with a variety of other requested patient information via a heads-up display. Three hundred patients in an outpatient ophthalmology clinic were divided into an AR intelligent verification experimental group and a manual verification control group. The accuracy of information verification, work time consumption, and economic cost data were compared between the 2 groups to evaluate the effectiveness of the AR Surgical Information Intelligent Verification Tool in clinical patient surgical information verification.</p><p><strong>Results: </strong>There was no statistically difference in the correct rates of patient surgical information review between the experimental group (95.33%) and the control group (98.67%) (χ 2  = 2.934, P  = 0.087). The median time for information verification was 10.00 (10.00, 11.00) seconds in the experimental group and 21.00 (20.00, 24.00) seconds in the control group, a statistically difference (Z = 0.000, P  < 0.001). The experimental group saved 11 seconds per patient per review compared with the control group. Considering 10,531 surgeries in 2023, printing 1 page of surgical information per 9 patients and requiring 4 copies, 4680 pages of printing paper could be saved.</p><p><strong>Conclusions: </strong>The AR Surgical Information Intelligent Verification Tool has advantages in assisting medical staff in patient surgical information verification, improving nursing efficiency, preventing surgical mark errors or nonstandardization, protecting patient privacy, and saving costs. It has certain research and application value in the scenario of patient surgical information verification in ophthalmic day ward.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"62-68"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11832179/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478498","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":"A Cohort Study of Nonfood Choking Incidents in the Hospital.","authors":"Mari Akaiwa, Tatsuya Norii, Yutaka Igarashi","doi":"10.1097/PTS.0000000000001302","DOIUrl":"10.1097/PTS.0000000000001302","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e3-e5"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869568","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":"It's Called \"Informed Consent,\" But How \"Informed\" Are Patients? A Patient Perspective on Informed Consent in a Tertiary Care Hospital in Saudi Arabia.","authors":"Jenny L Gray, Iskandar C Mrad, Aseel M AlAyed, Fadwa A AlHawas, Najlaa M Faiq AbdulHameed, Zubeda B Mahomed, Mashail A AlWtaid, Abdullah A Bany Hamdan, AlWaleed M AlHarbi, Mohammed AlHasani","doi":"10.1097/PTS.0000000000001306","DOIUrl":"10.1097/PTS.0000000000001306","url":null,"abstract":"<p><strong>Objectives: </strong>To examine the patient's perspective of the informed consent process, particularly with regards to reading the informed consent form, understanding and recall of the informed consent.</p><p><strong>Methods: </strong>Between June and August 2022, 281 patients/proxies at King Fahad Medical City, Saudi Arabia, were surveyed within 7 days before having a medical procedure.</p><p><strong>Results: </strong>In all, 66.2% of patients did not read the consent before signing. Around 76.2% of patients said they fully understood the information given, 14.9% only partially understood, and 8.9% stated that they had not understood. A total of 90.4% of patients were able to recall their diagnosis. About 27.4% were unable to state any benefit of the procedure. In all, 19.9% were unaware if there was an alternative to the procedure. Around 40.6% were unable to state any risks and only 58.4% could remember at least one risk.</p><p><strong>Conclusions: </strong>A consent may be technically valid even when the patient has little understanding of the process; therefore, we must strive to ensure that we have ethically valid consent. From our findings, we conclude that informed consent has to be provided in an environment conducive to optimal patient understanding, for example, by ensuring that there is adequate time for explanation, preferably a day or 2 before the procedure. Informed consent should not be taken immediately before a (nonurgent) procedure. Secondly, due to the great variance in understanding between patients, it is vital for the physician to assess the patient's understanding of the consent process, this may be achieved using feedback methodology.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"89-94"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142980299","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}