PATIENT SAFETY最新文献

{"title":"Implementing a Compliance Monitoring Process to Promote Chlorhexidine Gluconate Bathing and Hand Hygiene: An Initiative to Decrease Central Line–Associated Bloodstream Infections","authors":"Tanisha Davis, Susanne Wittmann, Beth A. Prairie, Nancy Dugan, Patricia Reiser, Leah Goclano, Rose Dziobak","doi":"10.33940/001c.121071","DOIUrl":"https://doi.org/10.33940/001c.121071","url":null,"abstract":"Chlorhexidine gluconate (CHG) bathing has proven to reduce central line–associated bloodstream infections (CLABSI) in hospitalized patients. The aim of this study is to evaluate whether the implementation of a compliance monitoring process for CHG bathing and strict hand hygiene as part of the traditional CLABSI prevention bundle will reduce the overall hospital CLABSI standardized infection ratio (SIR). A quasi-experimental study was conducted in intensive care and non-intensive care inpatient hospital units in an urban 361-bed teaching hospital in Western Pennsylvania. The pre-intervention period consisted of January–August 2021, the intervention period consisted of September–November 2021, and the post-intervention and sustainability period consisted of December 2021–June 2022. A compliance monitoring process for the initiation of a daily bath using a 4% CHG solution and strict hand hygiene surveillance was implemented as part of the standard CLABSI prevention bundle (which includes standardized insertion checklists and processes, daily necessity assessment, dressing change and integrity standards, five moments hand hygiene standards, CHG disk [Biopatch], end caps [Curos], and care of tubing). A statistically significant increase in hand hygiene (p=<0.001) and in CHG bathing compliance (p=0.014) helped reduce the overall hospital CLABSI SIR from 1.45 to 0.82, standing for an overall 43.4% decrease. Cost reduction was statistically significant (p=0.011) and was an estimated $1.4 million dollars in savings for the hospital. Incorporate the compliance monitoring component for CHG bathing and hand hygiene as part of the best strategy for CLABSI bundle prevention within the healthcare system.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"59 52","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141929244","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unmasking the Contributing Factors to Oxygen Disruption Events in the Inpatient Environment and Emergency Department","authors":"Lucy S. Bocknek, Deanna-Nicole C. Busog, Raj M. Ratwani, Jessica L. Handley, Katharine T. Adams, Rebecca Jones, Seth Krevat","doi":"10.33940/001c.117580","DOIUrl":"https://doi.org/10.33940/001c.117580","url":null,"abstract":"Medical oxygen is frequently used in healthcare settings. Challenges with oxygen disruption, such as oxygen tanks running out due to communication issues between staff or tanks not being set up properly, have been noted in the limited existing literature. Challenges and patient safety issues associated with oxygen disruption persist. Utilizing a human factors approach, our study aims to understand the contributing factors and context of oxygen disruption–related patient safety event reports in the inpatient setting and provide person-based and system-based solutions. Through keyword matching, we identified and then qualitatively analyzed 298 patient safety event reports to understand the factors contributing to oxygen disruption, patient location when the oxygen disruptions occurred, hand-off breakdowns by healthcare team member role, and whether high supplemental oxygen was being administered. The most frequent contributing factor to oxygen disruption was the patient not being transferred to another source of oxygen (n=135 of 298, 45.3%), followed by tank found empty (n=107, 35.9%), patient connected to a functioning oxygen source, no oxygen flowing (n=25, 8.4%), oxygen delivery device malfunction (n=22, 7.4%), and no oxygen available (n=9, 3.0%). Over one-third of all oxygen disruption events occurred on the unit where the patient was admitted (n=109 of 298, 36.6%). Roughly 40% of reports involved a hand-off breakdown (n=123 of 298, 41.3%) and the most frequent breakdowns occurred between a nurse and a patient transporter (n=47 of 123, 38.2%). Almost one quarter of reports involved a patient with high supplemental oxygen requirements (n=74 of 298, 24.8%). Oxygen disruption events can have serious patient safety implications. Many of the oxygen disruption events we reviewed occurred due to lack of situational awareness and hand-off breakdowns. Combining person-based solutions, such as paper-based tools and checklists, with system-based solutions involving central monitoring and supervisory systems may help reduce the risk of oxygen disruption events.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"24 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141806224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Free Text as Part of Electronic Health Record Orders: Context or Concern?","authors":"Sadaf Kazi, Jessica L. Handley, Arianna P. Milicia, Raj M. Ratwani, Katharine T. Adams, Rebecca Jones, Seth Krevat","doi":"10.33940/001c.118587","DOIUrl":"https://doi.org/10.33940/001c.118587","url":null,"abstract":"When placing orders into the electronic health record (EHR), prescribers often use free-text information to complement the order. However, the use of these free-text fields can result in patient safety issues. The objective of our study was to develop a deeper understanding of the conditions under which free-text information, or special instructions, are used in the EHR and the patient safety issues associated with their use, through an analysis of patient safety event (PSE) reports. We identified 847 PSE reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between January 1, 2021, and December 31, 2022; this dataset was reduced to 677 after controlling for oversampling from particular facilities. After limiting to reports that mentioned the terms “special instructions,” “order instructions,” “order comments,” or “special comments,” we analyzed a total of 329 reports. A physician and human factors expert independently reviewed the reports and assigned each a code from the following categories: general care process, medication class, information expressed in the special instruction, special instruction issue, department or staff for which special instruction was intended, and whether the error reached the patient. Almost three quarters of the special instruction reports were related to Medication (n=233 of 329, 70.8%), followed by Laboratory/Blood Bank (n=54, 16.4%), and Radiology (n=23, 7.0%). Medication classes most frequently associated with special instructions included infectious disease medications (n=51 of 230, 22.2%), antithrombotic/antithrombotic reversal agents (n=32, 13.9%), and nutritional/electrolytes/intravenous fluids (n=32, 13.9%). Nearly one quarter each of medication-related special instructions were about timing (n=58 of 233, 24.9%) and dosing (n=54, 23.2%); most about laboratory/blood bank were related to the site of the blood draw (n=33 of 54, 61.1%), and many involving radiology were related to radiology/echocardiography instructions (n=16 of 23, 69.6%). The most frequent issues associated with special instructions were containing information contradictory to the order or other information (n=62 of 329, 18.8%); being confusing, incorrect, or used incorrectly (n=58, 17.6%); and not seen (n=25, 7.6%), not viewable (n=11, 3.3%), or instructions absent (n=11, 3.3%). In more than half of the reports, special instructions were intended for nursing staff (n=184 of 329, 55.9%), followed by pharmacy (n=49, 14.9%), radiology (n=21, 6.4%), and laboratory/blood bank (n=20, 6.1%). The error reached the patient in roughly three quarters (n=243 of 329, 73.9%) of the reports reviewed. Special instructions are frequently used to provide additional context about medication orders and laboratory and radiology procedures and are often intended for nurses and pharmacists. However, these instructions can result in errors and may cause patient harm. Based on our analysis, we provide EHR design strategies and policies and ","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"12 10","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141810695","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Technology Failures","authors":"Shirley Dominick","doi":"10.33940/001c.120538","DOIUrl":"https://doi.org/10.33940/001c.120538","url":null,"abstract":"","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":" 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141829229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Analysis of an Academic Medical Center’s Corrective Action Plan in Response to Fatal Medication Error Using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness","authors":"Aubrey R Stolte, Yasmin M Siwy, Sarah B Tanios, Daniel D Degnan","doi":"10.33940/001c.117504","DOIUrl":"https://doi.org/10.33940/001c.117504","url":null,"abstract":"Neuromuscular blocking agents (NMBAs) are high-alert medications that require special handling, necessitating a robust process that prevents medication error, identifies near misses, and ultimately protects patients from harm. One patient at a large academic medical center (AMC) was given vecuronium, a neuromuscular blocking agent, instead of midazolam, and died as a result. Thus, AMC was tasked by the Centers for Medicare & Medicaid Services (CMS) to make a list of actions to prevent a subsequent incident. When assessing AMC’s corrective action plan in comparison to the Institute for Safe Medication Practices’ hierarchy of effectiveness of risk-reduction strategies, it was revealed that 76% of strategies were of low leverage, 16% were of medium leverage, and 8% were of high leverage. In this context, AMC’s corrective action plan should have integrated more system-based interventions, which include medium- or high-leverage strategies, rather than relying heavily on initiatives dependent on human action. Despite the lack of these systemic tools, CMS granted approval for the plan. Overlooking these systemic tools may amplify patient harm and negatively impact workforce satisfaction and efficiency. Moreover, the absence of a “just culture” also plays a role in patient harm. Therefore, recognizing that medication errors in healthcare are predominantly attributed to human error highlights the importance of fostering a just culture that advocates for system accountability to enhance patient safety.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"30 45","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141684466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving Accessibility to Outpatient Department Through Reduction of Third Next Available Appointment in Tertiary Hospital in Taif, Saudi Arabia","authors":"Reynan S. Bautista, Muhammad H. Abid, Lamiaa Elmasry, Abdulaziz S. Almalki, Marynette De Vera, Jean B. De Asis, Jamal Al Nofeye","doi":"10.33940/001c.115928","DOIUrl":"https://doi.org/10.33940/001c.115928","url":null,"abstract":"The Outpatient Department (OPD) of Al Hada Armed Forces Hospital - Taif Region (AHAFH) plays a critical role in providing specialized medical services to a diverse population in Taif region, Saudi Arabia. The hospital faces the challenge of ensuring timely access to a comprehensive array of 40 specialized services and subspecialties, supported by 120 rooms in the OPD. This article outlines a significant understanding of the patient flow process and queuing mechanism in the context of the OPD and the dynamics of supply and demand. Our project was initiated during the last few weeks of fourth quarter 2020, which revealed a concerning trend of increasing the third next available appointment (TNAA), surpassing the optimal target of <14 days. The study used pre-test and post-test monitoring of the TNAA. Patients’ categories of referral were identified as urgent and routine. We also established a referral and discharge criteria for each clinic specialty and reminder messages on patient appointments 24 hours and 48 hours prior to their actual appointment. The Plan-Do-Study-Act (PDSA) model for improvement was utilized to implement action plans and interventions to address the increase of TNAA (in days) in the OPD. Weekly huddles were conducted to monitor project progress, action plans, data, and challenges. During the intervention phase, notable changes were observed in the control chart, including shifts in TNAA mean decreasing from 9.4 days to 5.6 days after the implementation of four PDSA cycles. Moreover, the average TNAA in each quarter showed consistent reduction in TNAA, with an average of six days in Q1 2022. The study sheds light on the complexity of managing the patient flow and access in an outpatient setting. By implementing effective strategies and continuous and vigilant monitoring of the outcomes, outpatient departments can strive to ensure that patients receive specialized care in a timely manner.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"22 24","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141354519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Alteplase- and Tenecteplase-Related Errors and Risk Mitigation Strategies in the Treatment of Acute Ischemic Stroke: A Study of Event Reports From 52 Hospitals","authors":"Myungsun Ro, Matthew A. Taylor, Rebecca Jones","doi":"10.33940/001c.117322","DOIUrl":"https://doi.org/10.33940/001c.117322","url":null,"abstract":"Background: Alteplase and tenecteplase are thrombolytic agents used to treat patients with acute ischemic stroke (AIS). Despite the convenient bolus dosing of tenecteplase, its off-label use for AIS creates new patient safety challenges that are understudied. Methods: The study was conducted in two parts. In Part I, we queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports involving alteplase and tenecteplase that were submitted between 2017 and 2022. Based on results from Part I, in Part II we narrowed the query to reports submitted in 2021–2022 and applied inclusion criteria to identify reports that described a medication error involving the use of alteplase or tenecteplase to treat AIS. In Part II, all reports were reviewed and coded for stages of the medication-use process, associated factors, and event type. Results: Part I results (N=858) showed a decrease in reports of alteplase events and an increase in reports of tenecteplase events. In Part II (N=92), 52% of reports involved alteplase and 48% involved tenecteplase. Wrong dose was the most frequently coded event type for both medications at a combined 48%. Several tenecteplase-related events were attributed to unfamiliarity with the medication, confusion between indications, and incorrect use of the electronic health record (EHR) or failure to use the EHR, whereas many errors unique to alteplase occurred during the multistep calculation, preparation, and administration processes. Conclusions: Safety events involving alteplase and tenecteplase in the treatment of AIS are diverse. We present a list of potential strategies to prevent and mitigate errors involving these high-alert medications and encourage providers to adopt those that are meaningful to their workflow and practice setting.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"11 6","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141382321","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Impact of Outpatient Parenteral Antimicrobial Therapy (OPAT) in Al Hada Armed Forces Hospital, Taif, Saudi Arabia","authors":"Jean B. De Asis, Abdulrahman Al Ghamdi, Muhammed H. Abid, Jamal Al Nofeye, Reynan S. Bautista","doi":"10.33940/001c.116148","DOIUrl":"https://doi.org/10.33940/001c.116148","url":null,"abstract":"In the realm of healthcare quality, outpatient parenteral antimicrobial therapy (OPAT) has emerged as the gold standard for managing patients who have transitioned from inpatient care but still require extended intravenous antimicrobial treatment. The adoption of OPAT at Al Hada Armed Forces Hospital in Taif, Saudi Arabia, not only bolsters patient satisfaction but also serves as a catalyst for reduced hospitalization durations, lower rates of emergency department readmissions, and an overall reduction in healthcare expenditures. The main objective of this study was to evaluate the effectiveness of OPAT in a tertiary center facility in Saudi Arabia. In this retrospective investigation, we conducted a thorough review of patient records spanning from November 2020 to October 2021. Our study encompassed all patients who had intravenous antibiotics and were participants in the hospital’s OPAT program during this specific timeframe. Our primary goal was to achieve a 20% reduction in the total number of hospital bed days related to long-term antibiotic therapy. The incorporation of OPAT has yielded a multifaceted transformation within the hospital. Over the span of one year, from November 2020 to October 2021, there was a notable decrease in the proportion of patients requiring intravenous antibiotics. This percentage initially dropped from 23% to 12% with the implementation of the OPAT quality improvement project, and later, it reached an even lower 8%. This positive transformation not only had a positive impact on patient care but also led to significant cost savings, exceeding 2 million riyals. These savings were primarily driven by the reduction in hospitalization duration and the more efficient allocation of resources. Moreover, this improvement contributed to the avoidance of 673 patient days of hospitalization, thereby creating additional resources for more critical cases. OPAT has emerged as a pivotal component of Al Hada Armed Forces Hospital’s commitment to elevating healthcare quality. This abstract offers a concise insight into the quality-driven impact of OPAT within a specific healthcare context, underlining its capacity to optimize patient care, enhance healthcare efficiency, and elevate resource allocation. Ongoing research and continuous evaluation will play a critical role in refining and expanding the OPAT program while preserving its quality-oriented perspective.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"20 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141271816","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Caffeinated Energy Drinks and Supplements: A Wake-Up Call for Consumers and Healthcare Providers","authors":"Alexandra Lichvar, Amrit Pabla, Nhu Emily Nguyen, Patrick McDonnell","doi":"10.33940/001c.116073","DOIUrl":"https://doi.org/10.33940/001c.116073","url":null,"abstract":"","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":" 15","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140998879","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What to Know About Glacial Acetic Acid: Stop Using It","authors":"Myungsun Ro","doi":"10.33940/001c.116280","DOIUrl":"https://doi.org/10.33940/001c.116280","url":null,"abstract":"","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"44 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141010383","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}