Global journal on quality and safety in healthcare最新文献

{"title":"Improving Patient Safety: Learning from Reported Hospital-Acquired Pressure Ulcers","authors":"Anthony Octo Forkuo-Minka, Augustine Kumah, Afua Yeboaa Asomaning","doi":"10.36401/jqsh-23-25","DOIUrl":"https://doi.org/10.36401/jqsh-23-25","url":null,"abstract":"\u0000 \u0000 \u0000 A hospital-acquired pressure ulcer (HAPU) is a localized lesion or injury to the underlying tissue (wound) while the patient is on admission. It occurs when standardized nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardized care for pressure ulcers or manage HAPUs results in patient harm. We aim to share lessons from a reported HAPU incident and address the knowledge gap in patient safety risk assessment, identification, and wound management at Nyaho Medical Centre (Accra, Ghana).\u0000 \u0000 \u0000 \u0000 A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyze and evaluate the interventions over 12 weeks (Aug–Oct 2021).\u0000 \u0000 \u0000 \u0000 Development of policies and a standard operating procedure for pressure ulcers and wounds improved accuracy in identifying pressure ulcer risks and management of wounds. Eighty-three patients were assessed with the pressure ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound policy and standard operating procedure (SOP) was achieved, and the number of HAPUs decreased from five to one during the study period.\u0000 \u0000 \u0000 \u0000 This study demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.\u0000","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"58 5","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139812261","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":"Practices Used to Improve Patient Safety Culture Among Healthcare Professionals in a Tertiary Care Hospital","authors":"Haroon Bashir, M. Barkatullah, Arslan Raza, Muddasar Mushtaq, Khanzada Sheraz Khan, Awais Saber, Shahid Ahmad","doi":"10.36401/jqsh-23-10","DOIUrl":"https://doi.org/10.36401/jqsh-23-10","url":null,"abstract":"\u0000 \u0000 \u0000 A patient safety culture primarily refers to the values, beliefs, attitudes, and behaviors within a healthcare setup in a community that assists in prioritizing patient safety and encouraging the reporting of errors and near-misses in that facility. There is a direct impact of patient safety culture on how well patient safety and quality improvement programs work. The aim of this cross-sectional descriptive study was to investigate the practices to improve patient safety culture and adverse event reporting practices among healthcare professionals in a tertiary care hospital located in Mirpur Azad Jammu and Kashmir.\u0000 \u0000 \u0000 \u0000 In the non-probability convenience sampling of this cross-sectional study, Divisional Headquarters Teaching Hospital in Mirpur, Azad Kashmir used the Agency for Healthcare Research and Quality Surveys on Patient Safety Culture Hospital Survey to collect data about the perceptions of healthcare professionals regarding patient safety culture within their hospital to assess the trends of patient safety culture by obtaining longitudinal data. A pre-validated questionnaire that has undergone a rigorous trial of testing to maximize the reliability and accuracy of the outcomes was distributed among clinical staff (healthcare professionals who interact with patients on a daily basis, such as nurses, doctors, pharmacists, and laboratory technicians) and administrative staff (medical superintendent, deputy medical superintendent, assistant medical superintendent, heads of departments).\u0000 \u0000 \u0000 \u0000 A total of 312 questionnaires were returned (response rate, 76%). The study found that the dimension “supervisor/manager expectation and action promoting safety” had the highest positive response rate (65.16%), and “nonpunitive response” had the lowest (27.4%). Higher scores in “nonpunitive response to error” were associated with lower rates of medication errors, pressure ulcers, and surgical site infections, and higher scores in “frequency of event reporting” were associated with lower rates of medication errors, pressure ulcers, falls, hospital-acquired infections, and urinary tract infections.\u0000 \u0000 \u0000 \u0000 We suggest that in order for hospital staff to continue providing excellent, clinically safe treatment, a well-structured hospital culture promoting patient safety is necessary. Moreover, further study is needed to determine strategies to improve patient safety expertise and awareness, and lower the frequency of adverse occurrences.\u0000","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"34 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139822308","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":"Guest Editor and Reviewer Acknowledgments: 2023","authors":"","doi":"10.36401/jqsh-23-x0","DOIUrl":"https://doi.org/10.36401/jqsh-23-x0","url":null,"abstract":"","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"83 9","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139828899","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 Venous Thromboembolism Prophylaxis Through Service Integration, Policy Enhancement, and Health Informatics","authors":"Yacoub Abuzied, Ahmad Deeb, Layla Alanizy, Rasmieh M. Al-amer, M. Alsheef","doi":"10.36401/jqsh-23-16","DOIUrl":"https://doi.org/10.36401/jqsh-23-16","url":null,"abstract":"\u0000 \u0000 \u0000 Venous thromboembolism (VTE) prevention and management are susceptible issues that require specific rules to sustain and oversee their functioning, as preventing VTE is a vital patient safety priority. This paper aims to investigate and provide recommendations for VTE assessment and reassessment through policy enhancement and development.\u0000 \u0000 \u0000 \u0000 We reviewed different papers and policies to propose recommendations and theme analysis for policy modifications and enhancements to improve VTE prophylaxis and management.\u0000 \u0000 \u0000 \u0000 Recommendations were set to enhance the overall work of VTE prophylaxis, where the current VTE protocols and policies must ensure high levels of patient safety and satisfaction. The recommendations included working through a well-organized multidisciplinary team and staff engagement to support and enhance VTE’s work. Nurses’, pharmacists’, and physical therapists’ involvement in setting up the plan and prevention is the way to share the knowledge and paradigm of experience to standardize the management. Promoting policies regarding VTE prophylaxis assessment and reassessment using electronic modules as a part of the digital health process was proposed. A deep understanding of the underlying issues and the incorporation of generic policy recommendations were set.\u0000 \u0000 \u0000 \u0000 This article presents recommendations for stakeholders, social media platforms, and healthcare practitioners to enhance VTE prophylaxis and management.\u0000","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"161 6","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139813065","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 Venous Thromboembolism Prophylaxis Through Service Integration, Policy Enhancement, and Health Informatics","authors":"Yacoub Abuzied, Ahmad Deeb, Layla Alanizy, Rasmieh M. Al-amer, M. Alsheef","doi":"10.36401/jqsh-23-16","DOIUrl":"https://doi.org/10.36401/jqsh-23-16","url":null,"abstract":"\u0000 \u0000 \u0000 Venous thromboembolism (VTE) prevention and management are susceptible issues that require specific rules to sustain and oversee their functioning, as preventing VTE is a vital patient safety priority. This paper aims to investigate and provide recommendations for VTE assessment and reassessment through policy enhancement and development.\u0000 \u0000 \u0000 \u0000 We reviewed different papers and policies to propose recommendations and theme analysis for policy modifications and enhancements to improve VTE prophylaxis and management.\u0000 \u0000 \u0000 \u0000 Recommendations were set to enhance the overall work of VTE prophylaxis, where the current VTE protocols and policies must ensure high levels of patient safety and satisfaction. The recommendations included working through a well-organized multidisciplinary team and staff engagement to support and enhance VTE’s work. Nurses’, pharmacists’, and physical therapists’ involvement in setting up the plan and prevention is the way to share the knowledge and paradigm of experience to standardize the management. Promoting policies regarding VTE prophylaxis assessment and reassessment using electronic modules as a part of the digital health process was proposed. A deep understanding of the underlying issues and the incorporation of generic policy recommendations were set.\u0000 \u0000 \u0000 \u0000 This article presents recommendations for stakeholders, social media platforms, and healthcare practitioners to enhance VTE prophylaxis and management.\u0000","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"90 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139872716","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":"Practices Used to Improve Patient Safety Culture Among Healthcare Professionals in a Tertiary Care Hospital","authors":"Haroon Bashir, M. Barkatullah, Arslan Raza, Muddasar Mushtaq, Khanzada Sheraz Khan, Awais Saber, Shahid Ahmad","doi":"10.36401/jqsh-23-10","DOIUrl":"https://doi.org/10.36401/jqsh-23-10","url":null,"abstract":"\u0000 \u0000 \u0000 A patient safety culture primarily refers to the values, beliefs, attitudes, and behaviors within a healthcare setup in a community that assists in prioritizing patient safety and encouraging the reporting of errors and near-misses in that facility. There is a direct impact of patient safety culture on how well patient safety and quality improvement programs work. The aim of this cross-sectional descriptive study was to investigate the practices to improve patient safety culture and adverse event reporting practices among healthcare professionals in a tertiary care hospital located in Mirpur Azad Jammu and Kashmir.\u0000 \u0000 \u0000 \u0000 In the non-probability convenience sampling of this cross-sectional study, Divisional Headquarters Teaching Hospital in Mirpur, Azad Kashmir used the Agency for Healthcare Research and Quality Surveys on Patient Safety Culture Hospital Survey to collect data about the perceptions of healthcare professionals regarding patient safety culture within their hospital to assess the trends of patient safety culture by obtaining longitudinal data. A pre-validated questionnaire that has undergone a rigorous trial of testing to maximize the reliability and accuracy of the outcomes was distributed among clinical staff (healthcare professionals who interact with patients on a daily basis, such as nurses, doctors, pharmacists, and laboratory technicians) and administrative staff (medical superintendent, deputy medical superintendent, assistant medical superintendent, heads of departments).\u0000 \u0000 \u0000 \u0000 A total of 312 questionnaires were returned (response rate, 76%). The study found that the dimension “supervisor/manager expectation and action promoting safety” had the highest positive response rate (65.16%), and “nonpunitive response” had the lowest (27.4%). Higher scores in “nonpunitive response to error” were associated with lower rates of medication errors, pressure ulcers, and surgical site infections, and higher scores in “frequency of event reporting” were associated with lower rates of medication errors, pressure ulcers, falls, hospital-acquired infections, and urinary tract infections.\u0000 \u0000 \u0000 \u0000 We suggest that in order for hospital staff to continue providing excellent, clinically safe treatment, a well-structured hospital culture promoting patient safety is necessary. Moreover, further study is needed to determine strategies to improve patient safety expertise and awareness, and lower the frequency of adverse occurrences.\u0000","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"49 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139881975","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 Patient Safety: Learning from Reported Hospital-Acquired Pressure Ulcers","authors":"Anthony Octo Forkuo-Minka, Augustine Kumah, Afua Yeboaa Asomaning","doi":"10.36401/jqsh-23-25","DOIUrl":"https://doi.org/10.36401/jqsh-23-25","url":null,"abstract":"\u0000 \u0000 \u0000 A hospital-acquired pressure ulcer (HAPU) is a localized lesion or injury to the underlying tissue (wound) while the patient is on admission. It occurs when standardized nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardized care for pressure ulcers or manage HAPUs results in patient harm. We aim to share lessons from a reported HAPU incident and address the knowledge gap in patient safety risk assessment, identification, and wound management at Nyaho Medical Centre (Accra, Ghana).\u0000 \u0000 \u0000 \u0000 A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyze and evaluate the interventions over 12 weeks (Aug–Oct 2021).\u0000 \u0000 \u0000 \u0000 Development of policies and a standard operating procedure for pressure ulcers and wounds improved accuracy in identifying pressure ulcer risks and management of wounds. Eighty-three patients were assessed with the pressure ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound policy and standard operating procedure (SOP) was achieved, and the number of HAPUs decreased from five to one during the study period.\u0000 \u0000 \u0000 \u0000 This study demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.\u0000","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"5 3-4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139872219","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":"Guest Editor and Reviewer Acknowledgments: 2023","authors":"","doi":"10.36401/jqsh-23-x0","DOIUrl":"https://doi.org/10.36401/jqsh-23-x0","url":null,"abstract":"","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"31 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139888874","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":"Adopting the Klein Triple Path Model of Insight for Clinical Quality Improvement","authors":"Isaac K. S. Ng","doi":"10.36401/jqsh-23-44","DOIUrl":"https://doi.org/10.36401/jqsh-23-44","url":null,"abstract":"","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"8 11","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139826984","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":"Lomitapide: A Medication Use Evaluation and a Formulary Perspective","authors":"Laila Carolina Abu Esba, Hani Alharbi","doi":"10.36401/jqsh-23-32","DOIUrl":"https://doi.org/10.36401/jqsh-23-32","url":null,"abstract":"\u0000 \u0000 \u0000 Lomitapide is approved for lowering low-density lipoprotein cholesterol (LDL-C) in homozygous familial hypercholesterolemia, which is a rare genetic disorder. The evidence regarding its safety and efficacy from a small clinical trial requires further validation for effectiveness and safety in the real world. This study aimed to use institutional data on the effectiveness and safety of lomitapide to assist in formulating a perspective on adding it to the formulary.\u0000 \u0000 \u0000 \u0000 This was a retrospective review of patients who were actively prescribed lomitapide at King Abdulaziz Medical City, Riyadh, Saudi Arabia, from 2019 to 2022. Data collection included demographics, confirmed gene mutation results, duration of lomitapide therapy, baseline, on-treatment, last LDL-C levels, percent reduction in LDL-C after 1-3 months of therapy (whichever was first available), other LDL-C lowering therapies used, liver function tests, adverse effects, and compliance.\u0000 \u0000 \u0000 \u0000 Eight adult patients were included in the review, with a mean age of 25.5 years. Approximately 75% were female, and the duration of treatment with lomitapide ranged from 9 months to 3 years. None of the patients were on continuous LDL apheresis. The mean baseline LDL-C at presentation to our facility was 17.2 mmol/L (range, 11.78–21.97 mmol/L), the mean percent drop in LDL-C with lomitapide was 34.1% (range, 0%–87%), gastrointestinal disturbances were documented in 50% of the patients, and no cases of severe liver toxicities or increase in liver enzymes were seen.\u0000 \u0000 \u0000 \u0000 In our cohort of adult patients, lomitapide showed an overall modest reduction in LDL-C, with no cases of increase in liver enzymes and documented intolerance, indicating that most patients were likely noncompliant. This review revealed important considerations when reimbursing expensive medications for rare diseases. Real-world evidence in real-time can support healthcare systems in price negotiations and reaching mutual agreements that can eventually improve patient access to care.\u0000","PeriodicalId":73170,"journal":{"name":"Global journal on quality and safety in healthcare","volume":"4 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139524707","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}