Journal of Patient Safety最新文献

{"title":"Patient Safety Indicators During the Initial COVID-19 Pandemic Surge in the United States.","authors":"Jorge A Rodriguez, Lipika Samal, Sandya Ganesan, Nina H Yuan, Matthew Wien, Kenney Ng, Hu Huang, Yoonyoung Park, Amol Rajmane, Gretchen Purcell Jackson, Stuart R Lipsitz, David W Bates, David M Levine","doi":"10.1097/PTS.0000000000001216","DOIUrl":"10.1097/PTS.0000000000001216","url":null,"abstract":"<p><strong>Objective: </strong>The COVID-19 pandemic presented a challenge to inpatient safety. It is unknown whether there were spillover effects due to COVID-19 into non-COVID-19 care and safety. We sought to evaluate the changes in inpatient Agency for Healthcare Research and Quality patient safety indicators (PSIs) in the United States before and during the first surge of the pandemic among patients admitted without COVID-19.</p><p><strong>Methods: </strong>We analyzed trends in PSIs from January 2019 to June 2020 in patients without COVID-19 using data from IBM MarketScan Commercial Database. We included members of employer-sponsored or Medicare supplemental health plans with inpatient, non-COVID-19 admissions. The primary outcomes were risk-adjusted composite and individual PSIs.</p><p><strong>Results: </strong>We analyzed 1,869,430 patients admitted without COVID-19. Among patients without COVID-19, the composite PSI score was not significantly different when comparing the first surge (Q2 2020) to the prepandemic period (e.g., Q2 2020 score of 2.46 [95% confidence interval {CI}, 2.34-2.58] versus Q1 2020 score of 2.37 [95% CI, 2.27-2.46]; P = 0.22). Individual PSIs for these patients during Q2 2020 were also not significantly different, except in-hospital fall with hip fracture (e.g., Q2 2020 was 3.42 [95% CI, 3.34-3.49] versus Q4 2019 was 2.45 [95% CI, 2.40-2.50]; P = 0.01).</p><p><strong>Conclusions: </strong>The first surge of COVID-19 was not associated with worse inpatient safety for patients without COVID-19, highlighting the ability of the healthcare system to respond to the initial surge of the pandemic.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"247-251"},"PeriodicalIF":2.2,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140111864","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":"Perceptions of U.S. and U.K. Incident Reporting Systems: A Scoping Review.","authors":"Pamela J Gampetro, Anne Nickum, Celeste M Schultz","doi":"10.1097/pts.0000000000001231","DOIUrl":"https://doi.org/10.1097/pts.0000000000001231","url":null,"abstract":"The aim of the study is to evaluate the extent, range, and nature of the literature that concerns healthcare providers' perceptions following the use of incident reporting systems (IRSs) in the United States (U.S.) and the United Kingdom (U.K.). Literature was compared describing providers' perceptions of reporting patient safety incidents using IRSs from healthcare systems built on public, private, for-profit, or nonprofit insurers in the U.S., with providers' perceptions using an IRS within a universal government supported healthcare system in the U.K.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"11 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140828252","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":"Major Clinical Adverse Events of Breast Implant in the Manufacturer and User Facility Device Experience Database.","authors":"Bing Su, Lichuan Chen, Bohan Zhang, Hong Wang, Jie Zhou, Benjun Du","doi":"10.1097/pts.0000000000001219","DOIUrl":"https://doi.org/10.1097/pts.0000000000001219","url":null,"abstract":"Search the Manufacturer and User Facility Device Experience database to collect information on adverse events of breast implant. We analyzed the local complications and the breast implant illness (BII) of silicone breast implants, as well as saline breast implants separately, aim to provide a reference for women who want to breast augmentation.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"1 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140630069","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":"Enhanced Free-Text Search for Aggregated Medication Error Report Analysis and Risk Detection.","authors":"Ville Valkonen, Susanna Saano, Kaisa Haatainen, Miia Tiihonen","doi":"10.1097/pts.0000000000001218","DOIUrl":"https://doi.org/10.1097/pts.0000000000001218","url":null,"abstract":"Detecting medication errors (MEs) and learning from them are the key elements of medication safety management in health care. While the aggregation of the data and learning across the ME reports could help detect and manage organizational risks, the inconsistent and partly missing structural data complicate the analysis. The objective of this study was to examine whether an analysis of free-text data of aggregated ME reports could contribute to the detection of organizational risks.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"89 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140575694","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 Effectiveness of Public Awareness Initiatives Aimed at Encouraging the Use of Evidence-Based Recommendations by Health Professionals: A Systematic Review.","authors":"Esther Jie Tian, Cathy Nguyen, Lilian Chung, Chloe Morris, Saravana Kumar","doi":"10.1097/PTS.0000000000001202","DOIUrl":"10.1097/PTS.0000000000001202","url":null,"abstract":"<p><strong>Objectives: </strong>Public awareness initiatives have attracted growing attention globally, as a strategy to reduce low-value care and disinformation. However, knowledge gap remains in determining their effects. The aim of this systematic review was to summarize existing evidence to date on global effectiveness of public awareness initiatives.</p><p><strong>Methods: </strong>Primary quantitative studies focusing on passive delivery of public awareness initiatives that targeted health professionals were included. Eligible studies were identified through search of MEDLINE, Embase, Emcare, the Cochrane Library, PsycINFO, Business Source Complete, Emerald Insight, and Google (initially on December 19, 2018, followed by updated search between July 8-10, 2019, and then between March 8-9, 2022) and the reference list of relevant studies. Methodological quality of included studies was assessed using modified McMaster critical appraisal tool. A narrative synthesis of the study outcomes was conducted.</p><p><strong>Results: </strong>Twenty studies from United States, United Kingdom, Canada, Australia, and multicountry were included. Nineteen studies focused on Choosing Wisely initiative and one focused on National Institute of Clinical Excellence reminders. Most studies investigated one recommendation of a specialty. The findings showed conflicting evidence on the effectiveness of public awareness initiatives, suggesting passive delivery has limited success in reducing low-value care among health professionals.</p><p><strong>Conclusions: </strong>This review highlights the complexity of change in an established practice pattern in health care. As passive delivery of public awareness initiatives has limited potential to initiate and sustain change, wide-ranging intervention components need to be integrated for a successful implementation.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"147-163"},"PeriodicalIF":1.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139900778","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":"Vulnerability to Decubitus Ulcers and Their Association With Healthcare Utilization: Evidence From Nationwide Inpatient Sample Dataset From 2016 to 2020 in US Hospitals.","authors":"Sun Jung Kim, Mar Medina, Kaci Hotz, Juliy Kim, Jongwha Chang","doi":"10.1097/PTS.0000000000001194","DOIUrl":"10.1097/PTS.0000000000001194","url":null,"abstract":"<p><strong>Objective: </strong>The aim of the study is to identify vulnerable populations at risk of developing decubitus ulcers and their resultant increase in healthcare utilization to promote the use of early prevention methods.</p><p><strong>Methods: </strong>The National Inpatient Sample of the United States was used to identify hospitalized patients across the country who had a length of stay of 5 or more days (N = 9,757,245, weighted N = 48,786,216) from 2016 to 2020. We examined the characteristics of the entire inpatient sample based on the presence of decubitus ulcers, temporal trends, risk of decubitus ulcer development, and its association with healthcare utilization, measured by discounted hospital charges and length of stay. The multivariate survey logistic regression model was used to identify predictors for decubitus ulcer occurrence, and the survey linear regression model was used to measure how decubitus ulcers are associated with healthcare utilization.</p><p><strong>Results: </strong>Among 48,786,216 nationwide inpatients, 3.9% had decubitus ulcers. The percentage of inpatients with decubitus ulcers who subsequently experienced increased healthcare utilization rose with time. The survey logistic regression results indicate that patients who were Black, older, male, or those reliant on Medicare/Medicaid had a statistically significant increased risk of decubitus ulcers. The survey linear regression results demonstrate that inpatients with decubitus ulcers were associated with increased hospital charges and longer lengths of stay.</p><p><strong>Conclusions: </strong>Patients with government insurance, those of minority races and ethnicities, and those treated in the Northeast and West may be more vulnerable to pressure ulcers and subsequent increased healthcare utilization. Implementation of early prevention methods in these populations is necessary to minimize the risk of developing decubitus ulcers, even if upfront costs may be increased. For example, larger hospitals were found to have a lower risk of decubitus ulcer development but an increased cost of preventative care. Hence, it is imperative to explore and use universal, targeted preventative methods to improve patient safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"164-170"},"PeriodicalIF":1.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11487002/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138832534","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":"An Analysis of Incident Reports Related to Electronic Medication Management: How They Change Over Time.","authors":"Madaline Kinlay, Wu Yi Zheng, Rosemary Burke, Ilona Juraskova, Lai Mun Rebecca Ho, Hannah Turton, Jason Trinh, Melissa T Baysari","doi":"10.1097/PTS.0000000000001204","DOIUrl":"10.1097/PTS.0000000000001204","url":null,"abstract":"<p><strong>Objective: </strong>Electronic medication management (EMM) systems have been shown to introduce new patient safety risks that were not possible, or unlikely to occur, with the use of paper charts. Our aim was to examine the factors that contribute to EMM-related incidents and how these incidents change over time with ongoing EMM use.</p><p><strong>Methods: </strong>Incidents reported at 3 hospitals between January 1, 2010, and December 31, 2019, were extracted using a keyword search and then screened to identify EMM-related reports. Data contained in EMM-related incident reports were then classified as unsafe acts made by users and the latent conditions contributing to each incident.</p><p><strong>Results: </strong>In our sample, 444 incident reports were determined to be EMM related. Commission errors were the most frequent unsafe act reported by users (n = 298), whereas workarounds were reported in only 13 reports. User latent conditions (n = 207) were described in the highest number of incident reports, followed by conditions related to the organization (n = 200) and EMM design (n = 184). Over time, user unfamiliarity with the system remained a key contributor to reported incidents. Although fewer articles to electronic transfer errors were reported over time, incident reports related to the transfer of information between different computerized systems increased as hospitals adopted more clinical information systems.</p><p><strong>Conclusions: </strong>Electronic medication management-related incidents continue to occur years after EMM implementation and are driven by design, user, and organizational conditions. Although factors contribute to reported incidents in varying degrees over time, some factors are persistent and highlight the importance of continuously improving the EMM system and its use.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":"20 3","pages":"202-208"},"PeriodicalIF":1.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140208001","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":"Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014-2020): Findings From Taiwan Patient Safety Reporting System.","authors":"Dulmaa Munkhtogoo, Yueh-Ping Liu, Sheng-Hui Hung, Pi-Tuan Chan, Chih-Hung Ku, Chung-Liang Shih, Pa-Chun Wang","doi":"10.1097/PTS.0000000000001196","DOIUrl":"10.1097/PTS.0000000000001196","url":null,"abstract":"<p><strong>Objectives: </strong>Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity.</p><p><strong>Methods: </strong>Longitudinal secondary data (over 2014-2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system. The numbers and incidence rates (per 1000 inpatient days) of reported MAEs were calculated. The harm severity levels of six major MAE categories were analyzed. Trend and generalized estimating equation analyses were conducted to investigate changes in MAE patterns.</p><p><strong>Results: </strong>Trend analyses revealed significant decreasing trends in the number (4763-3107 per year; Jonckheere-Terpstra test = -1.952, P = 0.05) and incidence rates (0.92-0.62 per 1000 inpatient days; β = -0.5017, P = 0.00) of harmful MAEs over 7-year study period. Among the most frequently reported MAEs, tube-related events exhibited the most significant decreasing trend (28%-23.8%; Jonckheere-Terpstra test = -2.854, P = 0.00). The reported numbers, incidence rates, and severity of falls and tube-related events dropped significantly.</p><p><strong>Conclusions: </strong>By analyzing representative longitudinal MAE data, this study demonstrated the effectiveness of nationwide patient safety improvement campaigns in Taiwan. Our data reveal significant reductions in the reported numbers, incidence rates, and severity of several major MAEs. Specifically, our data indicate significant reductions in the incidence and severity of tube-related events, which can be beneficial for patient safety improvement efforts.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"171-176"},"PeriodicalIF":1.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139404914","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":"Patients' Experiences of Dental Diagnostic Failures: A Qualitative Study Using Social Media.","authors":"Enihomo Obadan-Udoh, Rachel Howard, Luke Carmichael Valmadrid, Muhammad Walji, Elizabeth Mertz","doi":"10.1097/PTS.0000000000001198","DOIUrl":"10.1097/PTS.0000000000001198","url":null,"abstract":"<p><strong>Objective: </strong>Despite the many advancements made in patient safety over the past decade, combating diagnostic errors (DEs) remains a crucial, yet understudied initiative toward improvement. This study sought to understand the perception of dental patients who have experienced a dental diagnostic failure (DDF) and to identify patient-centered strategies to help reduce future occurrences of DDF.</p><p><strong>Methods: </strong>Through social media recruitment, we conducted a screening survey, initial assessment, and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis, or delayed diagnosis on patient lives. Audio recordings of patient interviews were transcribed, and a hybrid thematic analysis approach was used to capture details about 4 main domains of interest: the patient's DDF experience, contributing factors, impact, and strategies to mitigate future occurrences.</p><p><strong>Results: </strong>Dental patients endured prolonged suffering, disease progression, unnecessary treatments, and the development of new symptoms as a result of experiencing DE. Poor provider communication, inadequate time with provider, and lack of patient self-advocacy and health literacy were among the top attributes patients believed contributed to the development of a DE. Patients suggested that improvements in provider chairside manners, more detailed patient diagnostic workups, and improving personal self-advocacy; along with enhanced reporting systems, could help mitigate future DE.</p><p><strong>Conclusions: </strong>This study demonstrates the valuable insight the patient perspective provides in understanding DEs, therefore aiding the development of strategies to help reduce the occurrences of future DDF events. Given the challenges patients expressed, there is a significant need to create an accessible reporting system that fosters constructive clinician learning.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"177-185"},"PeriodicalIF":1.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11487042/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139724650","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":"Impact of Repeated Reimbursement Penalties on Hospital Total Quality Scores.","authors":"Alice Brewer, M Courtney Hughes, Kunal N Patel","doi":"10.1097/PTS.0000000000001199","DOIUrl":"10.1097/PTS.0000000000001199","url":null,"abstract":"<p><strong>Objectives: </strong>The incidence of hospital-acquired conditions (HACs) is a serious public health issue with implications ranging from patient morbidity and mortality to negative financial impacts on patients and health care systems. Despite substantial efforts to address and reduce HACs, research into the effect of quality improvement programs is inconclusive. This study seeks to better understand the relationship between repeated reimbursement penalties and improvement in HAC quality scores.</p><p><strong>Methods: </strong>A quantitative comparative analysis of U.S. health care data was conducted. Data on quality outcomes and hospital characteristics were sourced from the Hospital-Acquired Condition Reduction Program from fiscal years 2018 and 2019 and the Centers for Medicare & Medicaid Services Inpatient Prospective Payment System impact files, respectively.</p><p><strong>Results: </strong>In total, 3123 U.S. hospitals were analyzed to compare differences between total HAC scores of hospitals with and without penalties in consecutive years. Hospitals with repeated penalties had significantly greater improvement in scores ( t497.262 = -13.00, P < 0.001), and the impact was greatest in small hospitals (<100 beds). Repeated penalties had a smaller impact on disproportionate share hospitals (Cohen d = 0.73). Among all hospitals, the effect of repeated penalties was large (Cohen d = 0.75).</p><p><strong>Conclusions: </strong>This study suggests that repeated penalties can improve quality scores in U.S. hospitals. However, the effect may be exaggerated for smaller hospitals and those that serve patient populations with a relatively higher socioeconomic status. The reason disproportionate share hospitals did not show as much improvement as nondisproportionate hospitals may be because hospitals serving vulnerable populations often have fewer resources.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"198-201"},"PeriodicalIF":1.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139404912","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}