Journal of patient safety and risk management最新文献

{"title":"MR- safety: Evaluation of compliance with screening routines using a structured screening interview","authors":"B. Hansson, Matea Simic, J. Olsrud, K. Markenroth Bloch, T. Owman, P. Sundgren, I. Björkman-Burtscher","doi":"10.1177/25160435221077493","DOIUrl":"https://doi.org/10.1177/25160435221077493","url":null,"abstract":"Background Magnetic resonance (MR) safety procedures are designed to allow patients, research subjects and personnel to enter the MR-scanner room under controlled conditions and without the risk to be harmed during the examination. Ferromagnetic objects in the MR-environment or inside the human body represent the main safety risks potentially leading to human injuries. Screening for MR-safety risks with dedicated procedures is therefore mandatory. As human errors during the screening procedure might align and lead to an incident compliance is essential. Purpose To evaluate compliance with a documented structured MR-safety screening process. Method Written and signed MR-safety screening documentation collected at a national 7T MR facility during a four-year period was evaluated for compliance of trained personnel with multi-step MR-safety routines. We analysed whether examinations were performed or why they were not performed. Data analysis further included descriptive statistics of the study population (age, gender and patient or healthy volunteer status), identification of missing documents and omitted or incorrect answers, and whether these compliance shortcomings concerned predominantly administrative or MR-safety related issues. Results Documentation of the screening process in 1819 subjects was incomplete in 19% of subjects. The most common documentation shortcoming was omitted fields. Out of 478 omitted answer-fields in 307 subjects, 36% were of administrative nature and 64% related directly to MR-safety issues. Conclusion Compliance with MR-safety screening procedures cannot be taken for granted and deficiencies to comply with screening routines were revealed. Documentation shortcomings concerned both administrative and MR-safety related issues.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89497742","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":"To improve patient safety, lean in","authors":"A. Wu, M. Norvell","doi":"10.1177/25160435221081661","DOIUrl":"https://doi.org/10.1177/25160435221081661","url":null,"abstract":"Early in the last decade, “lean in” became a rallying cry for women in business, taken from the title of the book by Sheryl Sandberg, then Chief Operating Officer of Facebook, and her collaborator Neil Scovell. The expression was orginally intended to encourage women to confront workplace discrimination and aim for leadership roles. Since then, it has taken on a broader meaning, i.e., to “take on or embrace something difficult or unpleasant, usually through determination or perseverance; to find a way to benefit from, or alleviate the harm of, risk, uncertainty and difficult situations.” The expression has practical and even literal meaning in our field of health care. Recently, one of us (MN) went to see a patient in a pediatric neuro-behavioural unit. It is a place with a high staff-to-patient ratio because these patients have an elevated likelihood of being dangerous to themselves and those around them. As he was being oriented to the unit he noticed all the staff members were wearing jackets with thick sleeves, arm protection, and sturdy face shields. He asked his nurse guide about this and she said, “You never know what will happen here. If a patient bites you, don’t follow your instinct and pull away—you will make it a worse injury. If you are bitten, lean into them. It will put them off balance and others will come to help.” When attacked, when cornered, when you don’t know your next move, rather than react and run, lean into the situation. Leaning in, and the mindset that goes along with it, can improve patient safety, and help to foster a culture of safety. Important examples include disclosing adverse events to patients and families, supporting distressed colleagues, and addressing workarounds and near misses. As humans, most of us have an aversion to confronting difficult conversations. Every clinician has certainly been there. We know there are times when we must talk to a patient about something awkward and potentially volatile. Even though we know that we should have that conversation, sometimes we avoid it. Disclosing adverse events is an important example. Harmful medical errors cause great distress for patients and their families. Physicians know that when they make a mistake, they should attempt to correct it, disclose it to the patient, and apologize. It is the patient’s right to know when they have been injured by an error, and disclosure is an important component of professionalism in medicine. However, physicians are afraid of the reactions these disclosures may elicit, and that they could harm their personal careers. In reality, there is considerable evidence that supports disclosure of adverse events to patients, including some suggesting that it is helpful in resolving the issue and does not increase the chances of legal action. And, although an apology does not erase the adverse event, it can have profound healing effects for both the patient and physician. The right strategy for organizations and individuals is to lean ","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80703286","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":"Ensuring the quality and quantity of personal protective equipment (PPE) by enhancing the procurement process in Northern Ireland during the coronavirus disease 2019 pandemic: Challenges in the procurement process for PPE in NI.","authors":"Kathryn Burnett,&nbsp;Suzanne Martin,&nbsp;Catherine Goudy,&nbsp;John Barron,&nbsp;Linda O'Hare,&nbsp;Peter Wilson,&nbsp;Glenda Fleming,&nbsp;Michael Scott","doi":"10.1177/25160435211057385","DOIUrl":"https://doi.org/10.1177/25160435211057385","url":null,"abstract":"<p><p>This article outlines the purchasing process for personal protective equipment that was established for Health and Social Care in Northern Ireland in response to the outbreak of coronavirus disease 2019. The Business Services Organisation Procurement and Logistics Service, who are the sole provider of goods and services for Health and Social Care organisations, was faced with an unprecedented demand for personal protective equipment in response to the coronavirus disease 2019 pandemic. The usual procurement process was further complicated by changing messages within guidelines which resulted in confusion and anxiety when determining whether or not a product would meet the required safety guidance and was therefore suitable for purchase. In order to address these issues in a rapidly changing and escalating scenario the Department of Health asked the Business Services Organisation Procurement and Logistics Service to work with the Medicines Optimisation Innovation Centre to maximise the availability of personal protective equipment whilst ensuring that it met all requisite quality and standards. A process was implemented whereby the Medicines Optimisation Innovation Centre validated all pertinent essential documentation relating to products to ensure that all applicable standards were met, with the Business Services Organisation Procurement and Logistics Service completing all procurement due diligence tasks in line with both normal and coronavirus disease 2019 emergency derogations. It is evident from the data presented that whilst there were a significant number of potential options for supply, a large proportion of these were rejected due to failure to meet the quality assurance criteria. Thus, by the process that was put in place, a large number of unsuitable products were not purchased and only those that met extant standards were approved.</p>","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8926917/pdf/10.1177_25160435211057385.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40314121","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How will state medical boards handle cases involving disclosure and apology for medical errors?","authors":"D. Wojcieszak","doi":"10.1177/25160435211070096","DOIUrl":"https://doi.org/10.1177/25160435211070096","url":null,"abstract":"Surveys were sent to 68 American state medical boards, including territories of the United States, inquiring how they handle—or will handle—cases involving disclosure and apology after medical errors. Surveys were not sent to specialty boards. Thirty-eight state medical boards (n  =  38, 56%) responded to the survey, with 31 completing the survey (46% completion rate) and seven boards (n  =  7) providing explanations for nonparticipation and other thoughts; 30 boards did not respond in any manner. Boards that completed the survey indicated that disclosure and apology and other positive post-event behavior by physicians are likely to be viewed favorably and disclosing physicians will not be easy targets for disciplinary measures, though boards also stressed they view each case on the merits and patient safety is their top priority. Recommendations are made for policy makers and other stakeholders.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74941460","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":"Awareness and understanding among patients about patient safety in India: A cross-sectional questionnaire-based study","authors":"S. Bhowmick, Snigdha Banerjee, Saibal Das, A. Nath, Debarati Kundu, Anupama Das, Nina Das, K. Ray, S. Purkayastha","doi":"10.1177/25160435211065672","DOIUrl":"https://doi.org/10.1177/25160435211065672","url":null,"abstract":"Background There is a dearth of studies from India evaluating the awareness of patient safety. This study was performed to gain insight into the Indian patients’ awareness about patient safety and evaluate their willingness in promoting the same. Methods In this cross-sectional study, online interactive sessions pertaining to patient safety and patient safety culture were arranged by clinical pharmacologists for 800 urban patients post-discharge from a tertiary care hospital in India. A validated questionnaire was used, and the responses were analysed using descriptive statistics. Results A total of 635 patients [mean age, 43.2  ±  10.3 years; 385 (60.6%) males] responded. A total of 93.4% of the patients were aware of the term “patient safety” and 35.3% faced situations where they felt that patient safety was compromised. Of these patients, 64.3% reported to higher authorities when faced with such situations, while the remaining either ignored the issue or had no idea about how to deal with the same. A total of 99.2% of the patients never participated in any patient safety program; nevertheless, 94.5% of them were willing to participate in the same. Accessibility to information about patient care was deemed essential by 58.3% of the patients. Conclusions Although the overall awareness about patient safety among urban Indian patients is high, there is a lack of awareness about ways of dealing with patient safety issues. Given the high level of interest in participating in patient safety programs, such programs should routinely include patients for optimizing the chances for safer provision of health care.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80143941","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":"Medications at discharge aren't just for the long haul: A model for the management of short-term medications","authors":"S. Sharara, A. Arbaje, S. Cosgrove, A. Gurses, Kathryn Dzintars, S. Keller","doi":"10.1177/25160435211065853","DOIUrl":"https://doi.org/10.1177/25160435211065853","url":null,"abstract":"Unsuccessful medication management (MM) after hospital discharge contributes to suboptimal outcomes including readmissions, emergency department visits, and death. Prior models and toolkits for MM at the hospital-to-home transition such as the Agency for Healthcare Research and Quality Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation focus on the patient and healthcare workers and not on other factors that may impact MM. While the Transition Model of MM describes the hospital-to-home transition of MM tasks among older adults with a particular focus on the MM work system, it focuses on initiation or continuation of chronic medications. However, many medications in classes responsible for the greatest number of readmissions are not intended to be taken chronically. Examples include antibiotics, opioids, and steroids, which are often prescribed for short durations; and diuretics, hypoglycemics, and vitamin K antagonists, which require careful titration. Short-term MMmay require changes to standard MMmodels, as shortterm medications need to be started immediately on discharge, and stopped or adjusted within just a few days or weeks after discharge. We will describe the current state of short-term MM at the hospital-to-home transition and hazards to short-term MM (Figure 1), and suggest how to address these hazards. The work systems of the hospital and the home intertwine in short-term MM at the hospital-to-home transition. The hospital work system and home work system interact with ambulatory pharmacies and clinics and each other. We will describe each work system, necessary processes in each work system for short-term MM, and associated hazards.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73986447","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 in long-term care facilities and the COVID-19 pandemic","authors":"A. Wu, J. McIntyre","doi":"10.1177/25160435211059871","DOIUrl":"https://doi.org/10.1177/25160435211059871","url":null,"abstract":"Significant parts of the world are growing old. During this century, several regions will experience a marked increase in the proportion of adults over 65 years old. This transition is well underway in the United States as the so-called baby boomers, born between 1946 and 1964, began turning 65 in 2011. It is projected that the US population aged 65 and over will reach 83.7 million by 2050, equivalent to more than 20% of the entire population. The US is not unique in this. By 2040, the median age in Japan will be 70, and it is anticipated that Asia, Latin America and the Caribbean will join Europe and North America as having more people older than 60 than children under age 15. The need for long-term care is growing alongside the rapidly aging population. In 2018, over 14 million Americans needed long-term care services. By 2025, it is projected that 1 out of every 5 Americans will be retirement age, and just over half of those individuals will require long-term care. Despite unprecedented growth in the long-term care industry, there are serious deficiencies in patient safety and quality of care. In the US, the Office of the Inspector General estimated that 22% of Medicare beneficiaries in skilled nursing facilities, and 46% in long-term care hospitals experienced adverse events. Over half of these adverse events were thought to be preventable. Reports also suggest that a large majority of nursing homes fail to meet federal quality standards. The most common safety issues in long-term care include pressure ulcers, falls, medication administration errors and nosocomial infection. It has been suggested that the high incidence of adverse events in long-term care compared to hospitals is due to lower levels of staff training, lower staff to resident ratios, longer term stays, and a broader scope of care. In the US, there have long been attempts to improve the quality of long-term care, beginning with the Nursing Home Reform Act in 1987, which imposed federal standards to bolster inspections and nursing home quality enforcement. The 2006 Advancing Excellence in America’s Nursing Homes Campaign, which later morphed into the National Nursing Home Quality Improvement Campaign, was another attempt, which promoted nine goals to improve quality in nursing homes. In 2013 the Commission on Long-term Care adopted 28 public policy recommendations in service delivery, workforce and financing in long-term care. There have also been attempts to measure patient safety in long-term care settings, such as the “Nursing Home Compare” program offered by the Centers for Medicare & Medicaid Services. However, the scores in these systems have been criticized as having a weak and inconsistent relationship between facility metrics and actual performance. In the US, improvements have been stymied by a general lack of research focused on quality of care and patient safety in long-term care settings, with a specific lack of studies on the effectiveness of improvement initiative","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73621745","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":"“We’re on our way:” A message from the mountains","authors":"A. Hannawa","doi":"10.1177/25160435211058145","DOIUrl":"https://doi.org/10.1177/25160435211058145","url":null,"abstract":"How do we improve the quality and safety of care? In healthcare, we commonly look at outcome measures when pondering this question. But safety-critical processes are not visible in these measures. And if they remain undetected, they can be a dormant source of sudden harm. This past year, I have immersed myself into the study of mountain rescues as part of a funded scientific investigation. At patient safety meetings, I have long encountered comparisons to the airline industry. “What can healthcare learn from aviation safety?” Patient safety research has begun to compare healthcare teams with flight crews. It has implemented aviation-based “Crew Resource Management (CRM)” models into the healthcare setting. But on what foundation? From a scientific standpoint, building this bridge into practice based on purely theoretical arguments seems insufficient. Instead of accepting the validity of this comparison at face value, I decided to take a closer look at safety-relevant processes in a context where both industries work together to save patients’ lives. Where this comparison is not merely a rhetorical exercise, but observable in practice. This is how I came to participate in airborne mountain rescues. I have spent all of the past year flying along with rescue teams and analyzing hundreds of rescues at the regional emergency call center (144). I interviewed all participating actors in this highly interprofessional setting, where pilots, physicians, paramedics, mountain guides, and 144-staff must work together smoothly under high-stakes conditions to prevent harm while saving patients’ lives. One of the rescues I attended was on a warm Friday afternoon in the Fall of 2020. We had just brought an injured skier with a shoulder dislocation from a ski slope at 4,000 m elevation to the regional hospital, when we were called about a patient with cardiac arrest in a nearby mountain village. The primary difficulty of airborne rescues is always to find a place to land the helicopter. Sometimes, if there is no possibility to exit by foot, the physician or mountain guide have to rappel from the airborne helicopter on a 200 meter free-hanging rope to be with the patient. In the case of this particular rescue, there was a meadow where we could land. The son and wife of the patient waived at us frantically, signaling us to follow them. Still in glacier suits and loaded with the heavy resuscitation equipment, we followed them into their house. The physician immediately asked pointed questions to find out what happened. The son’s voice shifted between hope, despair and distress as he proclaimed repeatedly: “He’s dead, I think he’s already dead.” Through repeated questioning, the story emerged: The patient, a man of about age 60, had been chopping wood behind the house when he felt a sudden, severe pain in his chest and collapsed. The son and his wife had brought him back into the house and laid him on the couch in the living room, where the patient shortly after procl","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76011208","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":"Reducing unintended retained foreign objects in operating rooms: a proactive risk assessment framework to improve patient safety","authors":"Maryam Tabibzadeh, Zarna Patel","doi":"10.1177/25160435211044608","DOIUrl":"https://doi.org/10.1177/25160435211044608","url":null,"abstract":"According to a study by Johns Hopkins, an average of 251,454 Americans die annually from medical errors. Medical error is the third leading cause of death in the U.S. after heart disease and cancer. Unintended retained foreign objects (URFOs) has been identified as the most common sentinel event by The Joint Commission. This paper proposes a proactive risk assessment framework to enhance patient safety in operating rooms by addressing the URFOs issue. This framework is developed by integrating the 10 traits of a positive safety culture, initially introduced by the nuclear industry and later adopted by other industries, with an accident investigation methodology called AcciMap, originally developed by Rasmussen. The AcciMap is a hierarchical framework consisting of several layers: government and regulatory bodies, company (hospital), (surgery division) management, (operating room) staff, and work. Thirty main categories of socio-technical contributing causes of URFOs were captured across the AcciMap layers. Organizational factors were identified as the root cause of questionable decisions made by staff and management. Financial and budget constraints, inadequate training infrastructure, absence of a risk management infrastructure, and leadership failure are the most influential organizational factors contributed to URFOs. Our mapping of the aforementioned positive safety culture traits on the AcciMap depicted that the four traits of Work Processes, Leadership Safety Values and Actions, Effective Communication, and Continuous Learning had the most influence on the URFOs issue. Associated recommendations to these findings are provided to contribute to reducing risks of URFOs instances.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74402646","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":"Kendal at Ithaca beats COVID-19","authors":"Charles Wilcox","doi":"10.1177/25160435211057879","DOIUrl":"https://doi.org/10.1177/25160435211057879","url":null,"abstract":"","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74968900","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}