Journal of Patient Safety最新文献

{"title":"Application of the IMB Model in the Vision of Zero Harm Caused by Magnetic Resonance Ferromagnetic Projection Accidents.","authors":"Meng Gong, Lei Qin, Longbiao Cai","doi":"10.1097/PTS.0000000000001296","DOIUrl":"10.1097/PTS.0000000000001296","url":null,"abstract":"<p><strong>Objective: </strong>The aim of the study is to explore the application of safety education based on the IMB model to prevent harm caused by magnetic resonance ferromagnetic projection accidents.</p><p><strong>Methods: </strong>One hundred ninety-six patients undergoing magnetic resonance imaging were divided into a control group of 90 cases and an observation group of 106 cases. The control group received routine safety education, while the observation group received safety education based on the IMB model in addition to routine education. The knowledge, attitudes, and behaviors related to the prevention of ferromagnetic projection accidents, as well as fear scores, were compared before and after the intervention.</p><p><strong>Results: </strong>A total of 90 cases in the control group and 106 cases in the observation group completed the study. There were statistically significant differences in the scores of knowledges, attitudes, and behaviors related to the prevention of ferromagnetic projection accidents, as well as fear scores between the 2 groups after the intervention (all P  < 0.01).</p><p><strong>Conclusions: </strong>Safety education based on the IMB model can improve the knowledge, attitudes, and behaviors of magnetic resonance imaging patients and reduce the risk of ferromagnetic projection accidents.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"57-61"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11832174/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478495","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":"COVID-19 mRNA-Vaccines During Pregnancy Are Safe Based on Postpartum Placental Immune Profiles in Both Maternal and Fetal Compartments.","authors":"Lotte E van der Meeren, Michelle Broekhuizen, Thierry T P van den Bosch, Disha Vadgama, Dana A M Mustafa, Irwin K M Reiss, Pieter L A Fraaij, Sam Schoenmakers","doi":"10.1097/PTS.0000000000001304","DOIUrl":"10.1097/PTS.0000000000001304","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e6-e7"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11832175/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869575","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 Framework for the Analysis of Communication Errors in Health Care.","authors":"John A Bender, Sreedevi Thiyagarajan, Wendy Morrish, Maisha Mims, Edward E Yackel","doi":"10.1097/PTS.0000000000001303","DOIUrl":"10.1097/PTS.0000000000001303","url":null,"abstract":"<p><strong>Objectives: </strong>The goal of this study was to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. We aimed to develop a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.</p><p><strong>Methods: </strong>This observational study used the Delphi method to develop a taxonomy code sheet for identifying communication errors reported in the Veterans Health Administration patient safety databases between April 2018 and March 2021. We also used Natural Language Processing to create a framework tool to classify the 9 types of communication errors using this taxonomy. Finally, analysis was done to identify affected clinical locations.</p><p><strong>Results: </strong>We identified 9 types of communication failures that impacted clinical outcomes using the taxonomy code sheet developed. The top 3 errors were related to nonadherence to facility standard operating procedures (993, 37.6%), followed by written errors (e.g., unclear documentation or not using plain language) (587, 22.3%) and no communication (347, 13.2%). The remaining categories of communication types are electronic (253, 9.6%), verbal (205, 7.8%), hand-off (124, 4.7%), visual (76, 2.9%), listening (41, 1.6%), and nonverbal (12, 0.5%). A cognitive aide was developed to demonstrate the step-by-step method for using the framework tool to classify the communication errors.</p><p><strong>Conclusions: </strong>The cognitive aide and the framework tool developed in this study can be used in any healthcare setting to identify and classify communication failures and mitigate potential risks contributing to safety events.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"69-81"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869570","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":"Relations Between Suicide Risk and Patient Safety Attitudes Among the Nursing Team in a Brazilian Context.","authors":"Kariciele Cristina Corrêa, Lúcio Borges de Araújo, Helenitta Melo da Silva Alves, Liz Marina Corrêa Ferreira, Frank José Silveira Miranda, Marcelle Aparecida de Barros Junqueira","doi":"10.1097/PTS.0000000000001305","DOIUrl":"10.1097/PTS.0000000000001305","url":null,"abstract":"<p><strong>Objectives: </strong>To analyze the aspects of suicide risks and their relation to patient safety attitudes among the nursing staff of a large public university hospital in Brazil.</p><p><strong>Methods: </strong>A cross-sectional and descriptive study with 226 nursing workers from a large public university hospital in Brazil. Socioprofessional information, health conditions, and family history related to suicide risk were collected through the Mini International Neuropsychiatric Interview Plus and the Safety Attitudes Questionnaire. A 95% CI was considered, and statistical tests such as the Student t test, χ 2 , analysis of variance, and multiple linear regression were used.</p><p><strong>Results: </strong>Most of the safety attitudes were below the average score considered positive (mean Safety Attitudes Questionnaire value >0.75), and 41 (18.1%) workers were considered to have any degree of suicide risk. Participants with parents or siblings who had attempted suicide were 3.44 times more likely to have moderate or high suicide risk. Negative safety attitudes were associated with health conditions and family history, considered suicide risk factors. Participants with moderate or high suicide risk were 2.83 times more likely to have worse patient safety attitudes concerning job satisfaction.</p><p><strong>Conclusions: </strong>This study reveals significant associations between patient safety attitudes and the mental health of nursing workers, expanding the view of worker health management actions and, consequently, patient safety culture.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"82-88"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869553","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 Implementation of Perioperative Geriatric Management Could Decrease the Incidence of Postoperative Delirium in the Elderly Undergoing Major Orthopedic Surgeries.","authors":"Yan Zou, Tingzhi Deng, Yu Xu, Qing Zheng, Yuan Wu, Shan Hui, Cuizhong Liu, An Wei","doi":"10.1097/PTS.0000000000001307","DOIUrl":"10.1097/PTS.0000000000001307","url":null,"abstract":"<p><strong>Objectives: </strong>This study aimed to explore the association of perioperative geriatric management (PGM) in major orthopedic surgeries.</p><p><strong>Methods: </strong>One hundred seventy-five participants aged 75 and older were in-hospital patients who underwent major orthopedic surgery from September 2020 to September 2021, and they received PGM and necessary treatment for indicators with abnormal value (the PGM group). Another 175 participants in the control group only received the evaluation part of the PGM, recruited by filtering in the electronic medical record system from March 2016 to March 2017. The treatment included joint intervention of psychiatrists and rehabilitation physicians. For example, for patients at risk for falling, evaluation of inadequate blood volume, delirium, abnormal gait, and visual impairment should be performed. The logistic regression analysis was adopted to determine the association of PGM and postoperative delirium.</p><p><strong>Results: </strong>The prevalence of postoperative delirium among participants was 13.71%. Compared with the empirical treatment group, the postoperative delirium was significantly decreased (7.43% versus 14.29%) ( P <0.05). Compared with the control group, participants were in the PGM group were at lower risk of postoperative delirium, mainly attributed to these following factors: Charlson comorbidity index <5 [odds ratio (OR)=0.620; 95% CI: 0.010-0.623], mini cog >2 (OR=0.224; 95% CI: 0.061-0.824), Confusion Assessment Method score indicating low risk (OR=0.079; 95% CI: 0.010-0.623), nutritional risk screening scale <3 (OR=0.306; 95% CI: 0.095-0.989), and major adverse cardiovascular events <3 (OR=0.253; 95% CI: 0.073-0.720). After adjusting for the length of hospital stay and reason for hospitalization, the association between the parameters above and postoperative delirium is still significant ( P <0.05).</p><p><strong>Conclusions: </strong>The implementation of the PGM could decrease the incidence of postoperative delirium significantly, which might contribute to improving the overall prognosis in elderly patients who underwent major orthopedic surgeries.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"95-100"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869588","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":"Cross-disciplinary Insights for Overcoming Speak-up Barriers in Medical Education.","authors":"Waseem Jerjes","doi":"10.1097/PTS.0000000000001297","DOIUrl":"10.1097/PTS.0000000000001297","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e1-e2"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142511119","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":"Effect of a Financial Incentive Scheme for Medication Review on Polypharmacy in Elderly Inpatients With Dementia: A Retrospective Before-and-After Study.","authors":"Takahito Morita, Yusuke Sasabuchi, Hayato Yamana, Tatsuya Hosoi, Sumito Ogawa, Hiroyuki Ohbe, Hiroki Matsui, Kiyohide Fushimi, Hideo Yasunaga","doi":"10.1097/PTS.0000000000001294","DOIUrl":"10.1097/PTS.0000000000001294","url":null,"abstract":"<p><strong>Objectives: </strong>Polypharmacy is an important healthcare issue, especially in elderly patients with dementia. As an incentive to reduce polypharmacy, a health insurance reimbursement scheme was introduced in 2016 for medication review and the reduction of medications for inpatients in Japan. However, the effects of these incentive schemes were not evaluated.</p><p><strong>Methods: </strong>We identified 1,465,881 inpatients aged ≥65 years with dementia. An interrupted time-series analysis was conducted by fitting a Prais-Winsten linear regression model. The outcome measure was the number of classes of medications prescribed during discharge.</p><p><strong>Results: </strong>No significant changes were observed in the average number of medication classes at discharge immediately after the introduction of the scheme (coefficient: -0.022, 95% confidence interval [CI]: -0.17 to 0.13). The slope change, representing the effect of the intervention over time, was also not significant (coefficient: -0.00053, 95% confidence interval: -0.0012 to 0.00018).</p><p><strong>Conclusions: </strong>The incentive scheme was not associated with a reduction in the number of medication classes at discharge among older inpatients with dementia.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"30-34"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478496","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":"Anesthesia-Specific Software Module for Voluntary Adverse Event Reporting.","authors":"Karolina Brook, Su Yeon Song, Julianna Richards, Laura Harrington, Nana Kwame Okyere-Tawiah, R Mauricio Gonzalez","doi":"10.1097/PTS.0000000000001290","DOIUrl":"10.1097/PTS.0000000000001290","url":null,"abstract":"<p><strong>Objectives: </strong>Hospital staff are expected to report adverse events to safety leaders and risk managers. At our institution, staff report adverse events via an incident reporting software system, known as \"RL.\" These \"RL reports\" are kept separate from patient medical records. Within the Anesthesiology Department, we noted low numbers of RL reports relative to known adverse events. Anesthesiology-related events were scattered within the RL software and therefore difficult to find. We hypothesized that compiling these events in one location would increase reporting rates and allow for deeper analysis of filed adverse events.</p><p><strong>Methods: </strong>We created an Anesthesia-specific RL software module, which included all anesthesia-related adverse events in one location. Additionally, we tracked the impact on RL reporting of two other quality improvement initiatives, including an intradepartmental quality assurance form, implemented during the study period.</p><p><strong>Results: </strong>The Anesthesia RL software module led to a 3.2-fold increase (P < 0.001) in the monthly average of filed RL reports. The increase was even greater (11.1-fold, P < 0.001) when excluding the most prevalent category of RL reports (Controlled Substance Discrepancies). The intradepartmental quality assurance form had minimal impact on filed RL reports. \"Controlled Substance Discrepancies,\" \"Other,\" and \"Equipment issue\" were the most common event types. Most events were classified as constituting no harm to the patient.</p><p><strong>Conclusions: </strong>Creating a specialty-specific RL software module led to increased RL reports, even when accounting for other implemented quality improvement initiatives, and allowed for deeper analysis of the filed reports. Our findings may be replicated for other specialties.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"21 1","pages":"48-55"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869648","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":"Enhancing Sepsis Care at an Academic Emergency Department in a Resource-Constrained Setting: A Quality Improvement Initiative.","authors":"Haytham Noureldeen, Abdullah Bakhsh, Adel Alshabasy, Maha Alawi, Ahmad Bakhribah, Nihad Nasrallah, Ohoud Aljuhani, Rahaf Margushi, Rafal Bantan, Raneem Bokhari, Sarah Idris, Lamis Alshamrani, Abeer Samman, Elaf Alharthi, Ali Alothman","doi":"10.1097/PTS.0000000000001289","DOIUrl":"10.1097/PTS.0000000000001289","url":null,"abstract":"<p><strong>Objectives: </strong>The early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study aimed to improve the proportion of patients receiving antibiotics within 1 hour of triage and compliance with sepsis bundles.</p><p><strong>Methods: </strong>A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 1, 2018, to December 31, 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. Thereafter, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared.</p><p><strong>Results: </strong>The proportion of patients receiving antibiotics within 1 hour of triage improved from 44% to 84%, intravenous crystalloid administration within 3 hours improved from 62% to 94%, serum lactic acid measurement within 3 hours improved from 62% to 94%, and vasopressor initiation within 6 hours improved from 76% to 94%. The mortality rates decreased from 32% to 21% between the 2 study periods.</p><p><strong>Conclusions: </strong>This program emphasizes the impact of a structured quality improvement program on the process and outcomes of care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"24-29"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142478497","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":"AI: Promise or Peril for Patient Safety.","authors":"Beth Daley Ullem, Martin J Hatlie, Olivia Lounsbury","doi":"10.1097/PTS.0000000000001301","DOIUrl":"10.1097/PTS.0000000000001301","url":null,"abstract":"<p><strong>Abstract: </strong>Patient safety advocates identify concerns for the impact of AI on patient safety. Patients identified the following 4 main areas that AI developers, regulatory bodies, and clinical users of AI are asked to consider: data integrity and bias, efficacy, payment, and transparency toward shared learning. Increased patient involvement in the development, use assessment and oversight of the technology is critical to ensure trust and trustworthiness in the use of AI in patient care.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"35-37"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142689318","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}