PATIENT SAFETY最新文献

{"title":"Transition to a Restraint-Free Inpatient Behavioral Health Setting","authors":"Dawn Bausman, Shawna Gigliotti, Margaret Meshok","doi":"10.33940/001c.115424","DOIUrl":"https://doi.org/10.33940/001c.115424","url":null,"abstract":"The use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioral health settings since the field’s early infancy. The use of restraints has a harmful impact on both patients and providers alike, contraindicating the therapeutic treatment environment aimed to support the healing journey. Using a strategy of leadership, workplace development, and data, the use of mechanical restraints was fully eliminated from a 252-bed inpatient setting. Performance was sustained over the following year. The goal of this project was to fully eliminate the use of mechanical restraints in an inpatient behavioral health setting. Adopting the Six Core Strategies for Reducing Seclusion and Restraint Use, the hospital sought to provide staff with alternative tools supported by an evidence-based practice. The result would be a reduction of trauma and injury occurring during the restraint process. This quality improvement project identified processes, structures, and patient outcomes related to restraint reduction within the organization. Each opportunity for improvement included a needs assessment for the identified barriers. The action steps necessary to implement change and accomplish the goal of reducing the use of four-point mechanical restraints in hospitalized patients were guided by trauma-informed care and the Six Core Strategies, in turn decreasing physical and psychological injuries, and improving patient care. Progress toward zero mechanical restraints was incremental. Both qualitative and quantitative data were used on a daily basis to support staff interventions. Active investment from leadership and allied professions provided support for a culture shift that went from using mechanical restraint almost daily to a culture where mechanical restraint is seen as a failure. This success was sustained through 2022 and is now a standard expectation for care at Belmont. This project enabled the removal of mechanical restraints from an acute inpatient behavioral health hospital servicing children, adolescents, and adults. The factors that supported the success of this project were true endorsement from leadership, robust staff training, and continuous feedback and supervision. Sustainability over at least one year was achieved. Belmont is not the first inpatient setting to eliminate restraints for its programming; however, this project provides additional evidence that a restraint-free inpatient setting is possible with sufficient investment in staff and training. Using trauma-free interventions was an additional quality benefit that has enhanced the advantages of the way this program was designed. The implementation of this model and supporting interventions can provide a roadmap for other programs seeking to enhance the inpatient experience for both staff and patients.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"9 5‐6","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141007152","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":"Long-Term Care Healthcare-Associated Infections in 2023: An Analysis of 23,970 Reports","authors":"Shawn Kepner, Amanda Bennett, Rebecca Jones","doi":"10.33940/001c.116555","DOIUrl":"https://doi.org/10.33940/001c.116555","url":null,"abstract":"The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the United States. In addition to over 4.7 million acute care reports, the PA-PSRS database contains more than 420,000 long-term care (LTC) healthcare-associated infection (HAI) reports. LTC HAI data from PA-PSRS were extracted on March 1, 2024. Infection counts were calculated based on report submission date and rates were calculated based on infection confirmation date. Reports submitted by LTC facilities and specific care areas were included for infection rates each month if resident and device days were also entered in PA-PSRS for the facility and care area. A total of 23,970 infection reports were submitted by Pennsylvania’s LTC facilities in 2023, representing an 18.6% increase from 2022. The overall infection rate increased by 11.4%, from 0.88 in 2022 to 0.98 in 2023, and all six regions of the state had an increase in infection rate. The Northeast region had the highest rate, with 1.28 reports per 1,000 resident days, and the Southeast region had the lowest rate, at 0.72. The overall rate increase was driven by rates of urinary tract infection (UTI) and skin and soft tissue infection (SSTI), which increased by 20.1% and 17.4%, respectively. Within the UTI infection type, symptomatic urinary tract infection (SUTI) rates increased by 21.1% and catheter-associated urinary tract infection (CAUTI) rates increased by 11.8%. There was an increase in the total number and rate of infections reported to PA-PSRS in 2023.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"7 8","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140674090","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":"Patient Safety Trends in 2023: An Analysis of 287,997 Serious Events and Incidents From the Nation’s Largest Event Reporting Database","authors":"Shawn Kepner, Rebecca Jones","doi":"10.33940/001c.116529","DOIUrl":"https://doi.org/10.33940/001c.116529","url":null,"abstract":"The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.7 million acute care event reports dating back to 2004. In this article, we analyze the patient safety event reports submitted to PA-PSRS in 2023. We extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Report counts are based on report submission date, and rates are based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). In 2023, 287,997 reports were submitted to PA-PSRS, which is a considerable increase from 2022 but very close to the 2021 total. Reports of serious and high harm events increased by 20.6% and 25.0%, respectively, representing the largest annual increases historically. Of the 287,997 reports, 96.0% were from hospitals, 3.8% were from ambulatory surgical facilities, and 0.2% were from birthing centers and abortion facilities. The vast majority (95.9%) of the 2023 reports were incidents, with the remaining 4.1% classified as serious events. The reporting rate based on event occurrence date for hospitals in the first half of 2023 was 30.0 reports per 1,000 patient days; for ASFs, the rate was 9.9 reports per 1,000 surgical encounters. For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, which accounted for 33.1% of acute care event reports submitted in 2023. From a distribution perspective, the greatest increase in percent of total reports in 2023 occurred with event type Medication Error, and the greatest increase for serious events was with event type Complication of Procedure/Treatment/Test (P/T/T). Almost half of the increase in Complication of P/T/T was with subtype Complication following surgery or invasive procedure (48.2%; 968 of 2,009), and 54.6% (529 of 968) of reports in this subtype were due to unplanned returns to the operating room. The number of total reports, serious events, and high harm events, as well as preliminary reporting rates for hospitals and ASFs, all increased in 2023. Patient Safety Authority will continue working with Pennsylvania healthcare facilities to support high-quality reporting and patient safety practices.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"78 19","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140675303","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":"Patient Safety Alert: Serious Harm Associated With Failure to Adjust Clozapine Dosing","authors":"","doi":"10.33940/001c.90674","DOIUrl":"https://doi.org/10.33940/001c.90674","url":null,"abstract":"","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"78 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139177560","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":"A Resident-Driven Quality Initiative for Reducing Opioid Prescribing in Patients Undergoing Elective General Surgery Procedures, With Long-Term Follow-Up","authors":"R. Lamm, Megan Lundgren, Adrienne Christopher, Jacob Woodroof, Lindsay Edwards, Christopher Kustera, Charles J. Yeo, Kristin M. Noonan, H. Lavu, Caitlyn M. Costanzo, Scott Cowan","doi":"10.33940/001c.89737","DOIUrl":"https://doi.org/10.33940/001c.89737","url":null,"abstract":"The opioid epidemic has been declared a public health emergency in the United States—and major news outlets have labeled operating rooms as “unintended gateways.” In response to this emergency, our academic institution sought to decrease our contribution to the potential diversion pool—the opioids surgeons prescribe to patients which go unused. Patients undergoing common surgical procedures between August 2017 and March 2018 were identified. Patients were contacted by phone and consented, and opioid use data was collected. The potential diversion pool was calculated as pills prescribed minus pills consumed for each patient and procedure, and subgroup analysis was performed to correlate the number of opioid pills taken within 24 hours before hospital discharge to the number taken after discharge. Surveys were completed for 357 patients. Overall, 6,831 of the 12,061 tablets prescribed were unused (57%). Patients who took 7 or more doses of oral opioids in the last 24 hours before discharge had significantly fewer (30%) pills remaining compared to patients who took 0–6 doses (68% remaining). Ninety-nine of 111 patients (89%) who took 0 tablets 24 hours prior to discharge left with an opioid prescription, creating a diversion pool of 2,419 pills remaining out of 3,353 prescribed (72%). Based on a 95% confidence interval of procedural opioid consumption, prescribing guidelines were created within a toolkit designed to set preoperative expectations, promote use of nonopioid analgesics, and provide opioid disposal information. We have continued to track our data, with low opioid prescribing patterns. Surgical departments can develop opioid reduction toolkits aimed at reducing the potential diversion pool of opioids in our communities. Such toolkits have a sustained positive impact.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"89 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139177374","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":"2022 Pennsylvania Patient Safety Reporting: Updated Rates for Acute Care Event Reports","authors":"Shawn Kepner","doi":"10.33940/001c.88054","DOIUrl":"https://doi.org/10.33940/001c.88054","url":null,"abstract":"","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"11 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139271249","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":"No Time To Lose: Meet the Physician Predicting the Healthcare of Tomorrow","authors":"Eyal Zimlichman, Caitlyn Allen","doi":"10.33940/001c.88053","DOIUrl":"https://doi.org/10.33940/001c.88053","url":null,"abstract":"Introducing Dr. Eyal Zimlichman, chief transformation officer at Sheba Medical Center. His job is to predict the future of healthcare—then figure out how to make it reality.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"29 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139272853","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":"Implementation of Vital Sign and Activity Guidelines for the Outpatient Therapist","authors":"Joseph Adler, Jennifer Dekerlegand","doi":"10.33940/001c.88307","DOIUrl":"https://doi.org/10.33940/001c.88307","url":null,"abstract":"Despite having training to assess vital signs (heart rate, blood pressure, and oxygen saturation), monitoring in outpatient therapy clinics is infrequent, and no guideline existed to support therapists. The goal of this project was to implement an evidence-based guideline in the outpatient therapy setting with the primary goal of improving patient safety by detecting asymptomatic, dangerously high blood pressure. With stakeholder involvement across the organization, an evidence-based vital sign guideline was created and implemented across the 25 Good Shepherd Penn Partners outpatient therapy clinics (occupational, physical, and speech therapy) over a three-year period. Competency completion, volume of guideline-appropriate medical event reports, and documentation of vital signs were used to measure success. The interventions were studied in a phased approach over a three-year period and included therapist education and competency, assessment of guideline application and utilization, and knowledge translation to clinical practice. All outpatient therapists (N=185) completed the guideline education and competency within the expected six-month time period. A statistically significant increase in the number of medical events was reported across outpatient clinics, from six preceding implementation to 66 after project completion (p-value=0.02). Upon project completion, therapists correctly applied the guideline 94% of the time. This project developed and implemented an evidence-based guideline to improve the consistency of blood pressure monitoring across our organization’s entire outpatient therapy service line. By substantially increasing blood pressure monitoring, we were able to proactively identify known or unknown abnormalities to positively impact patient safety in the ambulatory setting.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"12 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139272392","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":"A Knife Is Not a Pill Cutter (And Other Home Medication Safety Tips)","authors":"Kathleen E. Walsh, Michelle Bell, Caitlyn Allen","doi":"10.33940/001c.88516","DOIUrl":"https://doi.org/10.33940/001c.88516","url":null,"abstract":"Children are more than twice as likely as adults to experience a medication error at home. Dr. Kathleen Walsh, pediatrician at Boston Children’s Hospital, discusses why that is the case and tips to keep kids (and anyone) safe.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"48 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139275342","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":"Are They Aligned? An Analysis of Social Media-Based Nurse Well-Being Concerns and Well-Being Programs","authors":"Arianna P. Milicia, Jessica L. Handley, Christian L. Boxley, Deanna-Nicole Busog, Seth Krevat, Nate Apathy, Daniel Marchalik, Raj M. Ratwani, Ella S. Franklin","doi":"10.33940/001c.88305","DOIUrl":"https://doi.org/10.33940/001c.88305","url":null,"abstract":"Nurse burnout and distress pose patient safety risks due to impaired nurse attention, increased likelihood of medical error, and increased nurse turnover leading to a reduction in the number of nurses available to deliver care. Some healthcare facilities have launched well-being programs in response to increasing rates of burnout. Many of these programs are based on survey data which may be incomplete, resulting in programs that are not as comprehensive as they should be. We sought to identify nurse concerns related to burnout and well-being through analysis of social media data. We aligned these concerns with well-being program leader perceptions of factors contributing to burnout and well-being program initiatives. We conducted a qualitative study composed of two parts: social media analysis and semistructured interviews with well-being leaders. The social media analysis focused on 120 nurse comments on Reddit that were retrieved based on a keyword search using the terms “burnout,” “stress,” and “wellbeing.” The interviews were conducted with nine well-being leaders from seven different healthcare systems. Well-being program leaders were asked about factors contributing to burnout and lack of well-being, initiatives to address these factors, and metrics used to evaluate their programs. The social media comments and interview data were reviewed by two experts to identify topics, themes, and subthemes grounded in wellness models. Of the 120 social media comments analyzed, the most frequent topic was Lack of Meaningful Recognition, Compensation, and Influence (n=46 of 120, 38.3%), followed by Work Environment (n=43, 35.8%) and Uninformed or Misinformed Public (n=31, 25.8%). Several themes emerged and the most prevalent was Constrained Professional Agency with the most prevalent subtheme of health system or macrosystem policies or regulations that limit nurses’ ability to respond effectively to patient care needs. Of the seven healthcare systems interviewed, the most common topics that emerged from asking about the factors contributing to the lack of nurse well-being were the Work Environment (n=6 of 7, 85.7%), followed by Lack of Meaningful Recognition, Compensation, and Influence (n=4, 57.1%), and Inadequate or Inaccessible Well-Being Resources (n=3, 42.9%). Several novel initiatives were identified, and most healthcare systems relied on surveys as their key metric. The social media analysis revealed nurse concerns that may not be identified as factors contributing to lack of well-being by well-being program leaders. There is an opportunity to optimize our understanding of nurse concerns around well-being through social media, and an opportunity to better align nurse concerns with the focus of well-being programs.","PeriodicalId":509285,"journal":{"name":"PATIENT SAFETY","volume":"64 19","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139275429","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}