Journal of Patient Safety最新文献

{"title":"Estimating the Effect of Disclosure of Patient Safety Incidents in Diagnosis-Related Patient Safety Incidents: A Cross-sectional Study Using Hypothetical Cases.","authors":"Noor Afif Mahmudah, Dasom Im, Minsu Ock","doi":"10.1097/PTS.0000000000001256","DOIUrl":"10.1097/PTS.0000000000001256","url":null,"abstract":"<p><strong>Background: </strong>Disclosure of patient safety incidents (DPSIs) is a strategic measure to reduce the problems of patient safety incidents (PSIs). However, there are currently limited studies on the effects of DPSIs on resolving diagnosis-related PSIs. Therefore, this study aimed to estimate the effects of DPSIs using hypothetical cases, particularly in diagnosis-related PSIs.</p><p><strong>Methods: </strong>A survey using 2 hypothetical cases of diagnosis-related PSIs was conducted in 5 districts of Ulsan Metropolitan City, Korea, from March 18 to 21, 2021. The survey used a multistage stratified quota sampling method to recruit participants. Multiple logistic regression and linear regression analyses were performed to determine the effectiveness of DPSIs in hypothetical cases. The outcomes were the judgment of a situation as a medical error, willingness to revisit and recommend the hypothetical physician, intention to file a medical lawsuit and commence criminal proceedings against the physicians, trust score of the involved physicians, and expected amount of compensation.</p><p><strong>Results: </strong>In total, 620 respondents, recruited based on age, sex, and region, completed the survey. The mean age was 47.6 (standard deviation, ±15.1) years. Multiple logistic regression showed that DPSIs significantly decreased the judgment of a situation as a medical error (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.79), intention to file a lawsuit (OR, 0.53; 95% CI, 0.42-0.66), and commence criminal proceedings (OR, 0.43; 95% CI, 0.34-0.55). It also increased the willingness to revisit (OR, 3.28; 95% CI, 2.37-4.55) and recommend the physician (OR, 8.21; 95% CI, 4.05-16.66). Meanwhile, the multiple linear regression demonstrated that DPSIs had a significantly positive association with the trust score of the physician (unstandardized coefficient, 1.22; 95% CI, 1.03-1.41) and a significantly negative association with the expected amount of compensation (unstandardized coefficient, -0.18; 95% CI, -0.29 to -0.06).</p><p><strong>Conclusions: </strong>DPSIs reduces the possibility of judging the hypothetical case as a medical error, increases the willingness to revisit and recommend the physician involved in the case, and decreases the intent to file a lawsuit and commence a criminal proceeding. Although this study implemented hypothetical cases, the results are expected to serve as empirical evidence to apply DPSIs extensively in the clinical field.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"516-521"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141903318","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":"From Theory to Policy in Resilient Health Care: Policy Recommendations and Lessons Learnt From the Resilience in Health Care Research Program.","authors":"Siri Wiig, Hilda Bø Lyng, Veslemøy Guise, Eline Ree, Birte Fagerdal, Heidi Dombestein, Lene Schibevaag, Jeffrey Braithwaite, Cecilie Haraldseid-Driftland","doi":"10.1097/PTS.0000000000001258","DOIUrl":"10.1097/PTS.0000000000001258","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e109-e114"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141903319","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 and Evaluation of Clinical Decision Support for Apixaban Dosing in a Community Teaching Hospital.","authors":"Rebecca Cope, Maram Sarsour, Evan Sasson, Hasan Badran, Ka Yeun Kim, Rachel Quinn","doi":"10.1097/PTS.0000000000001265","DOIUrl":"10.1097/PTS.0000000000001265","url":null,"abstract":"<p><strong>Objectives: </strong>This study aimed to describe and evaluate the transition from a specialty service-based prospective order approval system to a computerized clinical decision support (CCDS) tool for apixaban dosing at a community teaching hospital. The primary objective was to assess the impact of the transition on the appropriateness of apixaban prescribing.</p><p><strong>Methods: </strong>A CCDS tool for apixaban dosing was developed and implemented using interprofessional collaboration. A retrospective chart review was conducted for apixaban orders placed before (preimplementation) and after (postimplementation) the CCDS transition. The primary outcome was the percent change in inappropriate apixaban orders, with secondary outcomes exploring percent change of apixaban orders with inappropriate dosing in different patient groups and indications per package insert.</p><p><strong>Results: </strong>Fifty orders were assessed in both arms, with 8% of orders preimplementation and 10% postimplementation deemed inappropriate. After accounting for questionable orders, overall appropriateness of prescribing was 88% preimplementation and 84% postimplementation ( P = 0.7). Challenges with implementation of CCDS included working with available information technology resources and facilitating acceptance of a new ordering process.</p><p><strong>Conclusions: </strong>The implementation of a CCDS tool for apixaban dosing at a community teaching hospital demonstrated comparable rates of appropriateness to the previous specialty service-based approval process. While the transition streamlined resources and improved efficiency, ongoing efforts are needed to address specific dosing challenges. Future research should explore the sustainability and generalizability of CCDS tools in diverse healthcare settings.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"474-477"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141749377","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":"Care Home Safety Incidents and Safeguarding Reports Relating to Hospital to Care Home Transitions: A Retrospective Content Analysis.","authors":"Craig Newman, Stephanie Mulrine, Katie Brittain, Pamela Dawson, Celia Mason, Michele Spencer, Kate Sykes, Lesley Young-Murphy, Justin Waring, Jason Scott","doi":"10.1097/PTS.0000000000001267","DOIUrl":"10.1097/PTS.0000000000001267","url":null,"abstract":"<p><strong>Objective: </strong>The purpose of this study was to further the understanding of reported patient safety events at the interface between hospital and care home including what active failings and latent conditions were present and how reporting helped learning.</p><p><strong>Methods: </strong>Two care home organizations, one in the North East and one in the South West of England, participated in the study. Reports relating to a transition and where a patient safety event had occurred were sought during the COVID-19 (SARS-CoV-2) virus prepandemic and intrapandemic periods. All reports were screened for eligibility and analyzed using content analysis.</p><p><strong>Results: </strong>Seventeen South West England care homes and 15 North East England care homes sent 114 safety incident reports and after screening 91 were eligible for review. A hospital discharge transition (n = 78, 86%) was most common. Pressure damage (n = 29, 32%), medication errors (n = 26, 29%) and premature discharge (n = 21, 23%) contributed to 84% of the total reporting. Many 'active failings' (n = 340) were identified with fewer latent conditions (failings) (n = 14, 15%) being reported. No examples of individual learning were identified. Organization and systems learning were identified in 12 reports (n = 12, 13%).</p><p><strong>Conclusions: </strong>The findings highlight potentially high levels of underreporting. The most common safety incidents reported were pressure damage, medication errors, and premature discharge. Many active failings causing numerous staff actions were identified emphasizing the cost to patients and services. Additionally, latent conditions (failings) were not emphasized; similarly, evidence of learning from safety incidents was not addressed.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"478-489"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142074275","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":"Development and Psychometric Analysis of a Patient-Reported Measure of Diagnostic Excellence for Emergency and Urgent Care Settings.","authors":"Kelly T Gleason, Vadim Dukhanin, Susan K Peterson, Natalia Gonzalez, J M Austin, K M McDonald","doi":"10.1097/PTS.0000000000001271","DOIUrl":"10.1097/PTS.0000000000001271","url":null,"abstract":"<p><strong>Background: </strong>Emergency and urgent care settings face challenges with routinely obtaining performance feedback related to diagnostic care. Patients and their care partners provide an important perspective on the diagnostic process and outcome of care in these settings. We sought to develop and test psychometric properties of Patient-Report to IMprove Diagnostic Excellence in Emergency Department settings (PRIME-ED), a measure of patient-reported diagnostic excellence in these care settings.</p><p><strong>Methods: </strong>We developed PRIME-ED based on literature review, expert feedback, and cognitive testing. To assess psychometric properties, we surveyed AmeriSpeak, a probability-based panel that provides sample coverage of approximately 97% of the U.S. household population, in February 2022 to adult patients, or their care partners, who had presented to an emergency department or urgent care facility within the last 30 days. Respondents rated their agreement on a 5-point Likert scale with each of 17 statements across multiple domains of patient-reported diagnostic excellence. Demographics, visit characteristics, and a subset of the Emergency Department Consumer Assessment of Healthcare Providers & Systems were also collected. We conducted psychometric testing for reliability and validity.</p><p><strong>Results: </strong>Over a thousand (n = 1116) national panelists completed the PRIME-ED survey, of which 58.7% were patients and 40.9% were care partners; 49.6% received care at an emergency department and 49.9% at an urgent care facility. Responses had high internal consistency within 3 patient-reported diagnostic excellence domain groupings: diagnostic process (Cronbach's alpha 0.94), accuracy of diagnosis (0.93), and communication of diagnosis (0.94). Domain groupings were significantly correlated with concurrent Emergency Department Consumer Assessment of Healthcare Providers & Systems items. Factor analyses substantiated 3 domain groupings.</p><p><strong>Conclusions: </strong>PRIME-ED has potential as a tool for capturing patient-reported diagnostic excellence in emergency and urgent care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"498-504"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142082399","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":"Comparing Guidelines to Daily Practice When Screening Older Patients for the Risk of Functional Decline in Hospitals: Outcomes of a Functional Resonance Analysis Method (FRAM) Study.","authors":"Meggie D Meulman, Hanneke Merten, Barbara van Munster, Cordula Wagner","doi":"10.1097/PTS.0000000000001263","DOIUrl":"10.1097/PTS.0000000000001263","url":null,"abstract":"<p><strong>Objectives: </strong>Dutch hospitals are required to screen older patients for functional decline using 4 indicators: malnutrition, delirium, physical impairment, and falls, to recognize frail older patients promptly. The Functional Resonance Analysis Method was employed to deepen the understanding of work according to the protocols (work-as-imagined [WAI]) in contrast to the realities of daily practice (work-as-done [WAD]).</p><p><strong>Methods: </strong>Data have been collected from 3 hospitals (2 tertiary and 1 general) and 4 different wards: an internal medicine ward, surgical ward, neurology ward, and a trauma geriatric ward. WAI models were based on national guidelines and hospital protocols. Data on WAD were collected through semistructured interviews with involved nurses (n = 30).</p><p><strong>Results: </strong>Hospital protocols were more extensive than national guidelines for all screening indicators. Additional activities mainly comprised specific preventive interventions or follow-up assessments after adequate measurements. Key barriers identified to work according to protocols included time constraints, ambiguity regarding task ownership, nurses' perceived limitations in applying their clinical expertise due to time constraints, insufficient understanding of freedom-restricted interventions, and the inadequacy of the Delirium Observation Scale Score in patients with neurological and cognitive problems. Performance variability stemmed from timing issues, frequently attributable to time constraints.</p><p><strong>Conclusions: </strong>The most common reasons for deviating from the protocol are related to time constraints, lack of knowledge, and/or patient-related factors. Also, collaboration among relevant disciplines appears important to ensure good health outcomes. Future research endeavors could shed a light on the follow-up procedures of the screening process and roles of other disciplines, such as physiotherapists.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"461-473"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141861305","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":"Compensation After Surgical Treatment for Hallux Valgus: A Review of 369 Claims to the Norwegian System of Patient Injury Compensation 2010-2020.","authors":"Per-Henrik Randsborg, Tommy Frøseth Aae, Ida Rashida Khan Bukholm, Rune Bruhn Jakobsen","doi":"10.1097/PTS.0000000000001268","DOIUrl":"10.1097/PTS.0000000000001268","url":null,"abstract":"<p><strong>Purpose: </strong>The aim of the study is to identify the most common avoidable patient injuries related to hallux valgus surgery.</p><p><strong>Methods: </strong>We assessed the claims reported to the Norwegian System of Patient Injury Compensation (NPE) following surgery for hallux valgus in light of hospital volume. Data from NPE was categorized according to age, sex, reason for claim, and reason for accepted/rejected claim. The institutions were grouped by catchment population into low volume (<150,000), middle volume (150,000-300,000), and high volume (>300,000) institutions. The effect of hospital volume on the likelihood of an accepted claim was estimated.</p><p><strong>Results: </strong>NPE received 369 claims of which 173 (46.9%) were accepted. The main reason for accepted claims was recurrence of the deformity, wrong level osteotomy or insufficient fixation. A quarter of the claims were accepted because of lack of indication and one in 5 accepted claims was due to a postoperative infection. Patient treated at low-volume institutions had a higher fraction of accepted claims ( P < 0.01). The odds ratio for an accepted claim in the low volume hospitals was 5.8 (95% confidence interval 4.1-8.3) compared with the middle- and high-volume institutions.</p><p><strong>Conclusions: </strong>The likelihood of a treatment error that leads to compensation was higher in low-volume institutions.</p><p><strong>Level of evidence: </strong>Level II Prospective cohort study.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e104-e108"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142074276","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 Nature of Adverse Events in Dentistry.","authors":"Bunmi Tokede, Alfa Yansane, Muhammad Walji, D Brad Rindal, Donald Worley, Joel White, Elsbeth Kalenderian","doi":"10.1097/PTS.0000000000001255","DOIUrl":"10.1097/PTS.0000000000001255","url":null,"abstract":"<p><strong>Objectives: </strong>Learning from clinical data on the subject of safety with regards to patient care in dentistry is still largely in its infancy. Current evidence does not provide epidemiological estimates on adverse events (AEs) associated with dental care. The goal of the dental practice study was to quantify and describe the nature and severity of harm experienced in association with dental care, and to assess for disparities in the prevalence of AEs.</p><p><strong>Methods: </strong>Through a multistaged sampling procedure, we conducted in-depth retrospective review of patients' dental and medical records.</p><p><strong>Results: </strong>We discovered an AE proportion of 1.4% (95% CI, 1.1% to 1.8). At least two-thirds of the detected AEs were preventable. Eight percent of patients who experienced harm due to a dental treatment presented only to their physician and not to the dentist where they originally received care.</p><p><strong>Conclusions: </strong>Although most studies of AEs have focused on hospital settings, our results show that they also occur in ambulatory care settings. Extrapolating our data, annually, at least 3.3 million Americans experience harm in relation to outpatient dental care, of which over 2 million may be associated with an error.</p><p><strong>Practical implications: </strong>Measurement is foundational in enabling learning and improvement. A critical first step in preventing errors and iatrogenic harm in dentistry is to understand how often these safety incidents occur, what type of incidents occur, and what the consequences are in terms of patient suffering, and cost to the healthcare system.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"454-460"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141793843","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 Harm Events and Associated Cost Outcomes Reported to a Patient Safety Organization.","authors":"Susanne Miller, David C Stockwell","doi":"10.1097/PTS.0000000000001254","DOIUrl":"10.1097/PTS.0000000000001254","url":null,"abstract":"<p><strong>Objectives: </strong>The aims of the study were to describe inpatient harm events detected via an automatic electronic trigger system (ETS) and to consider their financial consequences.</p><p><strong>Methods: </strong>Over a 27-month period, inpatient harm events were identified and documented in 1 healthcare system with 37 acute care facilities. Patients who experienced harm (all harm or preventable harm only) were compared with similar patients who did not. Clinical, financial, and demographic data were used to identify labor-adjusted direct variable costs (DVC) and potential differences in length of stay (LOS) associated with all-harm, preventable-harm, and nonharmed cohorts. Age-adjusted Charlson Comorbidity Index, case mix index, diagnosis-related groups, major diagnostic category, sex, age, location, diagnosis, adverse event category and subcategory, preventability, and harm severity were used to compare cohorts. Total harm events reported via the ETS and the health system's voluntary event reporting system were compared.</p><p><strong>Results: </strong>Nearly 93,000 encounters for all-harm (n = 25,665) and nonharmed cohorts (n = 67,217) were compared by random sampling of diagnosis-related group-matched all-harm and nonharmed groups to ensure similar clinical conditions, as measured by Charlson Comorbidity Index and case mix index. Sampling (2 groups, n = 100 and n = 200) showed that increased LOS was associated with harm; yet other clinical comparators were similar across groups. the preventable-harm subcohort had longer LOS (10.7 versus 5.9 days) and higher DVC ($13,442 versus $8024) than the nonharmed cohort. Identification of harm events was nearly 6-fold higher with the ETS than with the voluntary event reporting system.</p><p><strong>Conclusions: </strong>Patients with preventable harm had increased LOS that was associated with higher DVC per preventable-harm encounter in a large US healthcare system.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e92-e96"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141749378","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":"Response to the Letter to the Editor by Cioccari et al.","authors":"Leah M Konwinski, Caryn Steenland, Kayla Miller, Brian Boville, Robert Fitzgerald, Robert Connors, Elizabeth K Sterling, Alicia Stowe, Surender Rajasekaran","doi":"10.1097/PTS.0000000000001262","DOIUrl":"10.1097/PTS.0000000000001262","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e117"},"PeriodicalIF":1.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141735372","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}