Journal of patient safety and risk management最新文献_第2页

Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professionals after adverse patient events 在不良患者事件后影响第二受害者经历和支持需求的OB/GYN和儿科保健专业人员的因素

Journal of patient safety and risk management Pub Date : 2023-09-26 DOI: 10.1177/25160435231200968

Enid Y Rivera-Chiauzzi, Kirsten A Riggan, Lily Huang, Robyn E Finney, Megan A Allyse

{"title":"Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professionals after adverse patient events","authors":"Enid Y Rivera-Chiauzzi, Kirsten A Riggan, Lily Huang, Robyn E Finney, Megan A Allyse","doi":"10.1177/25160435231200968","DOIUrl":"https://doi.org/10.1177/25160435231200968","url":null,"abstract":"There is growing recognition that clinical and nonclinical healthcare professionals may become “second victims” following adverse patient events, medical errors, or patient-related injuries. In addition to the trauma-associated symptoms experienced by second victims, unprocessed second victim experience (SVE) can lead to burnout and leaving the healthcare workforce. To better understand the risk factors and support needs of affected healthcare professionals after a SVE, we conducted in-depth qualitative interviews with twelve staff in obstetrics & gynecology and pediatrics at a large academic medical institution in the upper Midwest of the U.S. Several participants indicated that it was not the patient outcome itself that precipitated the SVE, but associated factors such as moral distress or communication challenges. Participants discussed the role of their work unit culture in post-SVE processing, expressing that units perceived as blame-seeking or where adverse events were not openly discussed, hindered their recovery. While desired support mechanisms were individualized, participants stressed the importance of immediate and proactive support, such as through a peer support program, and long-term support mechanisms for lingering symptoms. As attrition of the healthcare workforce continues to be a significant concern, it is essential that we understand and meet the post-SVE support needs of affected staff, to promote holistic care following adverse patient events.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"62 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134957893","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}

引用次数: 0

A thematic analysis of National Institute for Health and Care Excellence responses to coroners’ concerns’ 国家健康和护理卓越研究所对验尸官担忧的回应的专题分析

Journal of patient safety and risk management Pub Date : 2023-09-20 DOI: 10.1177/25160435231202597

Sara Southall, Alison Tariq, Hannah Patrick, Kevin Harris, Chris Bird

{"title":"A thematic analysis of National Institute for Health and Care Excellence responses to coroners’ concerns’","authors":"Sara Southall, Alison Tariq, Hannah Patrick, Kevin Harris, Chris Bird","doi":"10.1177/25160435231202597","DOIUrl":"https://doi.org/10.1177/25160435231202597","url":null,"abstract":"In England and Wales, law requires that coroners issue a Prevention of Future Death (PFD) report when they believe that action should be taken to prevent future deaths. Prevention of Future Death reports therefore provide an opportunity to learn and prevent harm. This study thematically analyses PFD reports received by the National Institute for Health and Care Excellence (NICE) along with the organisation's response. We undertook a framework analysis of PFD reports, the organisation's response, and supporting documents or correspondence. Our framework was developed with a deductive approach, with themes pre-selected using areas of interest to the inquiry, including NHS England's national standards for patient safety investigation. The review includes 39 reports dated from 2012 to 2020. Common health areas involved were intrapartum care and head injuries. Coroners frequently raised the issue of a lack of relevant NICE guidance, with NICE most often committing to reflecting on the issues raised through its established processes. Recent responses demonstrated greater consideration of implementation and engagement actions, along with a more collaborative approach and person-centred tone. This report provides insight into the PFD report practices of a national guidance producing and standard setting body in the UK. The report supports system-level understanding of current practices in relation to PFD reports. However, there are no means to assess if the Chief Coroner's Office and the wider safety system considered them an adequate response or whether the actions taken were effective. Recommendations are made to support transparency, learning and collaboration in an evolving patient safety landscape.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"158 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136308569","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}

引用次数: 0

Using stakeholder intervention refinement teams to develop approaches for real-time integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions 利用利益相关者干预改进小组制定方法，在老年人从医院到家庭医疗保健过渡期间实时整合患者报告的安全信息

Journal of patient safety and risk management Pub Date : 2023-09-06 DOI: 10.1177/25160435231199975

A. Arbaje, Sylvan Greyson, Maningbè B. Keita Fakeye, D. Hohl, Kimberly Carl, Yea-Jen Hsu, Bruce Leff

{"title":"Using stakeholder intervention refinement teams to develop approaches for real-time integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions","authors":"A. Arbaje, Sylvan Greyson, Maningbè B. Keita Fakeye, D. Hohl, Kimberly Carl, Yea-Jen Hsu, Bruce Leff","doi":"10.1177/25160435231199975","DOIUrl":"https://doi.org/10.1177/25160435231199975","url":null,"abstract":"Background The hospital-to-home transition remains a high-risk care interval for older adults. Skilled home health (HH) agencies are uniquely positioned to address care-transitions-associated patient safety threats. We previously developed the Hospital-to-Home-Health Transition Quality (H3TQ) Index to identify safety issues after hospital discharge. Our objective is to evaluate a participatory ergonomics process engaging stakeholders to develop strategies to implement the H3TQ into HH agency workflow to improve transition-associated safety issues in real-time. Methods Stakeholders participated in three, two-hour Intervention Refinement Team (IRT) meetings with a focus on: (1) identifying facilitators and barriers to collect H3TQ data in real-time, (2) integration of H3TQ into workflows, and (3) sharing H3TQ safety threat information to improve care transition safety outcomes. We used the human factors engineering-informed Systems Ambiguity Framework to guide the structure of IRT meetings and qualitative data analysis to evaluate the IRT process itself. Results Stakeholders (N = 9) represented patients, family caregivers, and HH staff. Stakeholders identified three key strategies for H3TQ implementation: (1) mechanism and timing of H3TQ data collection using multiple platforms; (2) data sharing conditions for safety reporting across the health system; and (3) identification of targeted care transitions outcomes for improvement. Participants highly rated IRT meetings regarding meeting usefulness, comfort, and degree of input into the discussion. Conclusions The IRT participatory ergonomics process was successful. Stakeholders identified strategies to facilitate implementation of the H3TQ implementation to improve the hospital-to-HH. IRTs have potential application to other health system issues related to the care of people with complex needs.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"6 1","pages":"201 - 207"},"PeriodicalIF":0.0,"publicationDate":"2023-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79074362","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}

引用次数: 1

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system 在大型卫生系统中，药剂师主导的入院药物和解对患者结果的影响

Journal of patient safety and risk management Pub Date : 2023-08-27 DOI: 10.1177/25160435231193584

Joan Kramer, L. Hayley Burgess, Carley Warren, M. Schlosser, Sarah Fraker, Megan Hamilton

{"title":"Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system","authors":"Joan Kramer, L. Hayley Burgess, Carley Warren, M. Schlosser, Sarah Fraker, Megan Hamilton","doi":"10.1177/25160435231193584","DOIUrl":"https://doi.org/10.1177/25160435231193584","url":null,"abstract":"Performing accurate medication history and reconciliation is recognized to reduce medication discrepancies and errors resulting in improved patient safety. This quality improvement project retrospectively evaluated the impact of a newly implemented pharmacy-led admission medication reconciliation program for several hospitals. In 2020, a pharmacy-led admission medication reconciliation program was implemented in 16 hospitals across a large health system. The program targeted high-risk, complex inpatients admitted through the emergency department and directly to the hospital. Medication history technicians captured the best possible medication list and medication reconciliation pharmacists reviewed the list, collaborating with providers to complete reconciliation, and intervening to optimize drug therapy. A retrospective, pre-post analysis was performed comparing the preimplementation time period of June to November 2019 to the postimplementation time period of June to November 2020. Outcomes evaluated included pharmacy staff productivity, adverse drug events (ADEs), complications, and healthcare professional satisfaction. A total of 311,473 patients were admitted to the 16 hospitals during the pre- and postimplementation time periods. During the six-month postimplementation period, nearly 80,000 medication histories and reconciliations were completed, with 39.9% of those histories requiring medication clarification. Both the ADE rate and complication rate decreased significantly after program implementation, 12% decrease ( p < 0.017) and 14% decrease ( p < 0.001), respectively. Healthcare professional survey results from nurse, physician, and pharmacist respondents indicated a statistically significant improvement in satisfaction. After implementation of pharmacy-led admission medication reconciliation, patient ADEs and complications decreased during hospitalization, and physician, nurse, and pharmacist satisfaction significantly improved.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"34 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84299298","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}

引用次数: 0

Patient activated rapid response – the ‘999’ for patients admitted to hospital 病人启动快速反应-入院病人的“999”

Journal of patient safety and risk management Pub Date : 2023-08-01 DOI: 10.1177/25160435231199338

Merveille Ngoya Ntumba, Eirian Edwards, Filip Haegdorens, Peter Walsh, C. Subbe

{"title":"Patient activated rapid response – the ‘999’ for patients admitted to hospital","authors":"Merveille Ngoya Ntumba, Eirian Edwards, Filip Haegdorens, Peter Walsh, C. Subbe","doi":"10.1177/25160435231199338","DOIUrl":"https://doi.org/10.1177/25160435231199338","url":null,"abstract":"Background Patient activated rapid response (PARR) services allow patients and family members to escalate care in hospital without agreement by their primary care team. Methods This paper explores the evidence base for PARR and examines the experience of a sample of patients to identify barriers and opportunities for PARR. These are then used to develop a framework for the measurement of PARR that can be applied to quantify clinical impact and develop new research. Results The observed number of escalation events by patients and family members is small. Interviews with patients suggested concerns of patients in undermining staff and difficulties to recall the mechanics of escalation during periods of acute illness. The Quadruple aim could be used as a framework to quantify impact: In a functioning PARR system earlier recognition of illness can be facilitated by patients and this should lead to 1. a reduction in cardiac arrests and preventable deaths, 2. timely admission to critical care with shorter (cheaper) length of stay, 3. better patient engagement and Patient Reported Experience measures and 4. flatter hierarchies with higher staff satisfaction. Conclusion PARR services are in the early stages of implementation. We present a framework to measure improvement of services and research.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"46 1","pages":"156 - 162"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73915727","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}

引用次数: 1

Why did it make sense at the time? Applying an ecological dynamics perspective to analyse local rationality 为什么这在当时是有意义的?运用生态动力学的视角分析地方理性

Journal of patient safety and risk management Pub Date : 2023-08-01 DOI: 10.1177/25160435231191318

Paul Stretton

引用次数: 0

Achieving a restorative Just Culture through the patient safety incident response framework 通过患者安全事件响应框架实现恢复性公正文化

Journal of patient safety and risk management Pub Date : 2023-08-01 DOI: 10.1177/25160435231194397

Olivia Lounsbury, Mark Sujan

{"title":"Achieving a restorative Just Culture through the patient safety incident response framework","authors":"Olivia Lounsbury, Mark Sujan","doi":"10.1177/25160435231194397","DOIUrl":"https://doi.org/10.1177/25160435231194397","url":null,"abstract":"Despite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"81 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135002808","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}

引用次数: 0

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023 关于患者和家属如何改善患者安全的五项战略:2023年世界患者安全日

Journal of patient safety and risk management Pub Date : 2023-08-01 DOI: 10.1177/25160435231199275

Albert W Wu, Irina Papieva, Susan Sheridan, Kiran Gupta, Helen Haskell, Ayda Taha, Elliott R Haut, Maki Kajiwara, Neelam Dhingra

{"title":"Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023","authors":"Albert W Wu, Irina Papieva, Susan Sheridan, Kiran Gupta, Helen Haskell, Ayda Taha, Elliott R Haut, Maki Kajiwara, Neelam Dhingra","doi":"10.1177/25160435231199275","DOIUrl":"https://doi.org/10.1177/25160435231199275","url":null,"abstract":"World Patient Safety Day (WPSD) 2023 will be observed on 17 September with the theme “Engaging patients for patient safety” and the slogan “Elevate the voice of patients!” This timely theme spotlights the crucial role patients, families, caregivers, patient advocates, and patient organizations play in the safety of health care, and also highlights the importance of empowering and engaging them in the efforts aimed at reducing avoidable harm in health care. Meaningful patient engagement can reduce the burden of harm by up to 15%, and also save billions of dollars each year. Established in 2019 by the World Health Assembly (WHA) through resolution WHA72.6, WPSD calls for global solidarity and concerted action by all countries and international partners to improve patient safety. The commemoration of the Day brings together stakeholders to discuss the issues associated with the theme of the Day, identify the key approaches to address them, highlight different perspectives, and reconfirm the commitment by all to patient safety. The objectives for WPSD 2023 are to:","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"25 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135002801","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}

引用次数: 1

Assessment of drug-related problems associated with narrow therapeutic index drugs: A prospective cohort study 窄治疗指数药物相关问题的评估:一项前瞻性队列研究

Journal of patient safety and risk management Pub Date : 2023-07-28 DOI: 10.1177/25160435231190192

Charmi Manoj Chhatrala, Bhanu Kumar M, R. Madhan, S. Chalasani, Jehath Syed, N. Pal

{"title":"Assessment of drug-related problems associated with narrow therapeutic index drugs: A prospective cohort study","authors":"Charmi Manoj Chhatrala, Bhanu Kumar M, R. Madhan, S. Chalasani, Jehath Syed, N. Pal","doi":"10.1177/25160435231190192","DOIUrl":"https://doi.org/10.1177/25160435231190192","url":null,"abstract":"A narrow therapeutic index drug (NTID) has a narrow window between its effective doses and doses that can cause adverse toxic effects, necessitating strict monitoring for drug safety. This study aimed to identify and classify the drug-related problems (DRPs) associated with the use of NTI drugs. A prospective cohort study was carried out in the in-patient departments of General Medicine, Paediatrics, Cardiology, and Neurology at a tertiary care hospital over a nine-month period. Patients of either gender receiving at least one NTID included after obtaining their consent. The patients were followed until their discharge for any DRP occurrence. The list of the NTIDs was compiled through a review of literature review and the hospital's formulary. Hepler & Strand's classification was adopted to classify the identified DRPs. The odds ratio with a 95% confidence interval was used to determine the predictors for DRP occurrence. A total of 241 DRPs associated with NTIDs were identified among 120 patients. Drug–drug interactions accounted for 61% of the DRPs, followed by subtherapeutic dosing (18.26%) and adverse drug reactions (9.96%). On average, each patient experienced 2.74 DRPs. The predictors for DRP occurrence included gender (odds ratio [OR] 2.65, p = .012), comorbid conditions (OR 2.947, p < .001), polypharmacy involving more than 11 drugs (OR 3.987, p < .033), and a hospital stay exceeding 7 days (OR 1.087, p = .022). Despite providing the best therapeutic care, DRPs associated with NTIDs persist and can compromise patient safety. Therefore, involving clinical pharmacists in the early detection of DRPs can enhance overall patient safety.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"53 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89823655","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}

引用次数: 0

Explanatory factors relating to medication error reporting among emergency medicine clinicians: A qualitative study 急诊医师用药错误报告的相关解释因素:一项定性研究

Journal of patient safety and risk management Pub Date : 2023-07-25 DOI: 10.1177/25160435231188545

F. Bakhshi, A. Nasrabadi, Rebecca J Mitchell, M. Bagherabadi, F. Saghafi, S. Varaei

{"title":"Explanatory factors relating to medication error reporting among emergency medicine clinicians: A qualitative study","authors":"F. Bakhshi, A. Nasrabadi, Rebecca J Mitchell, M. Bagherabadi, F. Saghafi, S. Varaei","doi":"10.1177/25160435231188545","DOIUrl":"https://doi.org/10.1177/25160435231188545","url":null,"abstract":"Objectives We used an in-depth qualitative approach to investigate the factors that contribute to medication error (ME) reporting among emergency department (ED) clinicians. More specifically, we explored the explanatory factors relating to underreporting by the different staff involved in ED medication management, the underlying processes involved in clinician and manager responses to MEs, and programmatic factors that impede and facilitate ME reporting. Methods We applied a purposive maximum variation sampling to recruit interview participants in nursing, medical, and pharmacy roles. We conducted semistructured interviews based on an interview guide. We performed a thematic analysis of all data and developed a general content model. Results The developed model shows how the series of extracted themes—norms of reporting, reporting culture, and evaluation and feedback—affect one another. The theme norms of reporting were mainly influenced by clinicians’ knowledge and attitudes. The theme of reporting culture directly affected ME reporting. Evaluation and feedback affected all factors that contributed to ME reporting. Participants’ intention to report was mainly affected by the extent to which the reporting led to an obvious outcome. Conclusions The comprehensive model of ME reporting provides guidance for healthcare leaders who strive to increase such reporting. The model encompasses broad concepts that are not limited to ME reporting and may be applicable to improving reporting for all kinds of medical errors.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"19 1","pages":"215 - 221"},"PeriodicalIF":0.0,"publicationDate":"2023-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81387243","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}

引用次数: 1