Journal of patient safety and risk management最新文献

{"title":"The lived experiences of metal hypersensitivity","authors":"Dzifa Dordunoo, G. Doane, Jett Carey, J. A. Lagura, A. Mallidou, Jans van der Merwe, Scott Schroeder","doi":"10.1177/25160435231190197","DOIUrl":"https://doi.org/10.1177/25160435231190197","url":null,"abstract":"Immunological responses to metal ions can occur in people with metal implantable devices. Nevertheless, patients are not routinely asked about metal hypersensitivity nor tested for it prior to surgical procedures. Moreover, we have not identified any published literature on patients’ experiences with this condition. We undertook this study to better understand the experiences of patients with metal hypersensitivity and to determine what information would help them make an informed decision about implantable medical devices with metal compositions. This is a patient-oriented research using an interpretative phenomenological methodology. We enrolled 16 people from five countries (Canada, New Zealand, Spain, the UK, and the USA) who experienced metal hypersensitivity following implantable medical device. We collected data from in-depth, semi-structured interviews focused on pre-procedural patient education and postoperative experiences to elucidate the barriers and opportunities related to metal hypersensitivity. We analyzed the data using interpretative phenomenological analysis. The majority were white biological women between the ages of 34 and 65. None of the participants were informed about immunological responses to metals in implants during the consenting process. They encountered many challenges when symptoms of metal hypersensitivity occurred. The outcomes for the few who had the implants removed were mixed. Hypersensitivity reactions to metal need to be discussed as part of the consenting process, and addition strategies are needed to mitigate this issue in the health system.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"17 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73286971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The effect of clinical risk management training on patient safety competency and related aspects in nursing students","authors":"Mahnaz Padash, S. Miri, Mansooreh Azizzadeh Forouzi, Somayeh Jouparinejad, Jamileh Farokhzadian","doi":"10.1177/25160435231190198","DOIUrl":"https://doi.org/10.1177/25160435231190198","url":null,"abstract":"Background Students’ exposure to clinical risk management during their studentships can improve their safety competency, comfort speaking up about patient safety, and attitudes toward patient safety education. This study aimed to determine the effect of clinical risk management training on nursing students’ patient safety competency, attitudes toward broader aspects of patient safety in professional education, and comfort in speaking up about patient safety. Methods This experimental study used stratified sampling to assign 56 nursing students to intervention and control groups (28 students in each group). The intervention group received clinical risk management training in three three-hour sessions. The Health Professional Education in Patient Safety Survey was used to collect data from both groups before and one month after the intervention. Results The study found no statistically significant difference in patient safety competency and its subscales between the intervention and control groups in the pretest stage, but these competencies increased significantly in the intervention group in the post-test stage compared to the control group. The mean scores of attitudes toward broader aspects of patient safety in professional education and comfort speaking up about patient safety did not differ significantly between the intervention and control groups in the pre-test stage, but they increased significantly in the intervention group in the post-test stage compared with the control group. Conclusion It is recommended that clinical risk management and patient safety training be applied to the nursing curriculum so that nursing students become competent to provide safe care in clinical settings.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"38 1","pages":"170 - 176"},"PeriodicalIF":0.0,"publicationDate":"2023-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87208453","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":"Unintentionally retained foreign objects (URFOs): Adverse events influenced by the pandemic. A case series and literature review","authors":"A. Seabra, Aline Brenner de Souza, Renata Silva Artioli, Raniel Tagaytayan, W. Berends, Janelle Sanders, T. Vivas-Buitrago, Karen Hoenig Rigamonti, D. Rigamonti","doi":"10.1177/25160435231185437","DOIUrl":"https://doi.org/10.1177/25160435231185437","url":null,"abstract":"Despite being recognized as a preventable serious adverse event more than a century ago, Unintentionally Retained Foreign Objects (URFOs) continue to occur. They, in fact, remain the second most common Sentinel Event (SE) reported to The Joint Commission (TJC). A large private Hospital, after many years of URFO-free practice, experienced four (4) cases of URFOs during a 12-month period (March 9, 2021–March 4, 2022). Three cases occurred in the Operating Room (OR), and one case occurred in Labor & Delivery. All four cases involved the abdomen. The URFO was a sponge in two cases, a retractor wrapped in a pad in one case, and a surgical specimen in one case. Our review confirmed that the characteristics of our cases were similar to those reported by the Joint Commission. The main contributing factor was the closure of the wound without performing the sponge/instrument count. This safety breach resulted from a combination of factors: the inexperience of the nursing staff caused by a dramatic 40% turnover during the pandemic, the lack of assigned responsibility to perform the counting, and the willingness of the surgeon to skip the count. To address the main factors, we implemented a multipronged approach that includes the following: standardization of the protocols of sponge counting, hand-off with shift change, and of double surgical team involvement; assignment of the counting responsibility to two nurses; and education of the new nurses and of independent practitioners about the OR procedures with monitoring of correct implementation.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"31 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86769411","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":"Gender differences of fatigue in the workplace for surgeons","authors":"Jacob Thomas Merriman, James E Humphries, Roberto Ferrero, I. Hennessey","doi":"10.1177/25160435231185389","DOIUrl":"https://doi.org/10.1177/25160435231185389","url":null,"abstract":"Purpose Previous literature identifies increased burnout in female surgeons and contributors to fatigue outside of work. However, it is not yet understood whether there are gender discrepancies of contributors to fatigue or coping mechanisms for workplace fatigue in surgeons. This study aims to identify gender differences in causes of fatigue, how fatigue occurs and any interventions/strategies that surgeons may use/know to try and mitigate the effects of fatigue. Methods Using an online questionnaire at a single hospital in England, the questionnaire asked whether surgeons had been subject to any contributors to fatigue at work and what contributes to their fatigue at work using a list of multiple-choice answers. Results 97% of surgeons suffer from at least one contributor to fatigue. Females were statistically more likely to suffer from musculoskeletal injuries at work than males and more likely to suffer from mental exhaustion. Females were significantly more likely to contribute fatigue to prolonged static postures, lack of control during the shift and high levels of demand. To mitigate fatigue, females were significantly more likely to change positions whilst operating. Males were less reluctant to adopt Microbreaks during surgery to reduce musculoskeletal fatigue. Conclusions Our analysis identifies gender differences with coping mechanisms and the onset of fatigue. There is still a stigma attached to workplace fatigue in surgeons. Acknowledgement of these gender differences in fatigue is critical to reducing the statistical likelihood of fatigue onset in both genders. Further research should identify whether surgical operating rooms are adequately suitable for females.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"8 1 1","pages":"163 - 169"},"PeriodicalIF":0.0,"publicationDate":"2023-06-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75792689","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":"Medication error during nonoperating room anesthesia—a case report","authors":"Ivan Kostadinov, A. Stecher, V. Novak-Jankovič, P. Poredoš","doi":"10.1177/25160435231185042","DOIUrl":"https://doi.org/10.1177/25160435231185042","url":null,"abstract":"Despite a lot has already been done in the field of safety improvement during anesthesia, medication errors still occur during everyday practice. Syringe or ampule swaps are usually the most frequent type of medication error. Recent studies prove that nearly 80% of these errors are preventable. In our case, 30 mg (3 ml) of dopamine (Dopamin Fresenius 10 mg/ml) was injected to the patient’s intravenous line instead of 3 mg (3 ml) midazolam (Midazolam Accord 1 mg/ml) during the preparation for the carotid artery stenting procedure in nonoperating room environment. The error was realized immediately after the application. Besides temporary fulminant hypertensive reaction, tachycardia, restlessness, skin rush, troponin leak, and temporary ST-segment depression, there were no permanent consequences to the patient's health. The team was able to perform the planned procedure 30 min after the event. This medication error of ampule swap, packages of which were stored in the medication cupboard one above the other, was caused by alignment of the latent vulnerable layers of the safety system (Swiss Cheese Model of System Error and Hot Cheese Model) plus the influence of the environmental factors and active failures done by the anesthesia staff. After this event, new safety measures were established by introducing color-coded ISO 26825:2020 syringe labeling, new anesthesia trolleys with color-coded medication compartments, and color-coded medication storage cupboards. Besides this safety committee was formed for the promotion of medication safety education programs.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"44 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89899778","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":"Social determinants of patient safety: A bridge to better quality of care","authors":"A. Wu","doi":"10.1177/25160435231181855","DOIUrl":"https://doi.org/10.1177/25160435231181855","url":null,"abstract":"There is now broad appreciation that one of the fundamental drivers of the health of individuals and communities are social determinants of health (SDOH). SDOH are the conditions in the environments in which people are born, live, learn, work, play, worship, and age. These factors affect a wide range of health, functioning, and quality of life outcomes. These can be grouped into different domains, such as economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. SDOH influence the health of people in ways both positive and negative. They have become a high priority because they contribute to health disparities in populations, and reduce the potential for health and wellbeing for individuals. But there has been relatively little attention on how they might be related to problems with patient safety.3–5 It is time to bring patient safety into the SDOH conversation. SDOH also influence the quality of health care delivery, and significantly, affect patient safety.6–10 For example, low health literacy can reduce the ability of individuals to use medications safely. Health literacy has two important components, personal health literacy and organizational health literacy. An individual with diabetes with limited personal health literacy is more likely to misunderstand the correct way to use insulin to maintain their blood sugar within the required narrow therapeutic range. An organization with low health literacy fails to enable all individuals to find, understand, and use information and service to help them make medical decisions and care for themselves. In such an organization, it may be difficult for the person with diabetes to maintain the medications and equipment needed to prevent hypoglycemic episodes. For related reasons associated with comprehension, there is evidence that language barriers also undermine patient safety. Another example of adverse effects of SDOH is the impact of inconsistent transportation on access to healthcare. A patient on anticoagulant medication for atrial fibrillation who has unreliable transportation may be unable to consistently attend appointments for monitoring and wind up suffering from a bleeding episode or stroke. If we ignore the effects of SDOH, systems designed to improve safety and quality can increase disparities and impede quality improvement. For example, a study by Thomas et al. suggested that existing voluntary adverse event reporting systems may underestimate harmful patient safety events in members of racial minorities. We are likely to find economies of scale by joining forces devoted to improving safety and equity. Both are core aspects of healthcare quality, and leveraging existing resources could save time and effort. Chin, and Sivashankar and Gandhi suggest that an efficient strategy for health systems would be to integrate equity into existing quality and safety frameworks and infrastructure. The resulti","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"27 1","pages":"96 - 98"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75563003","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":"Management of bloodborne pathogen exposures in primary care: A quality improvement project","authors":"Sarah E. Hewitt, Erik Southard","doi":"10.1177/25160435231178077","DOIUrl":"https://doi.org/10.1177/25160435231178077","url":null,"abstract":"Background Exposure to bloodborne pathogens poses a serious risk to healthcare workers. As more primary care providers are being asked to perform occupational health services, the evaluation and treatment of bloodborne pathogen (BBP) exposures can be overwhelming. Lack of knowledge about how to handle these encounters can lead to poor outcomes, including conversion to human immunodeficiency virus (HIV) and hepatitis B virus if not handled properly. To assist providers with understanding best practices for the management of exposures, a detailed protocol and targeted education were developed. The protocol addressed the importance of evaluating the source patient for HIV, hepatitis B virus, and hepatitis C virus; injured workers were assessed for the same items, tetanus status, and the need for post-exposure prophylaxis (PEP). Methods A retrospective chart review for 12 months before the implementation of the protocol and eight months after implementation was completed to assess compliance with five evidence-based criteria and the appropriate use of PEP when indicated. Findings Variables of interest included (a) correct identification of the source patient, (b) accuracy of source patient labs, (c) completion of same-day employee labs, (d) accuracy of employee labs, and (e) evaluation of the employee's tetanus status. The rate of completion of these categories ranged from 14% to 43% in pre-protocol cases (n = 7), and 100% in post-protocol cases (n = 7). Conclusions The combination of targeted education and a detailed protocol for evaluating and treating BBP exposures resulted in increased compliance with best-practice care; the project also improved employee satisfaction.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"7 1","pages":"177 - 185"},"PeriodicalIF":0.0,"publicationDate":"2023-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84217806","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 systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): A tool for patient safety in hospitals","authors":"Benjamin T. Bremner, Carl Heneghan, Jeffrey K Aronson, G. Richards","doi":"10.1177/25160435231198685","DOIUrl":"https://doi.org/10.1177/25160435231198685","url":null,"abstract":"Patient harm due to unsafe healthcare is widespread, potentially devastating, and often preventable. Hoping to eliminate avoidable harms, the World Health Organization (WHO) published the Global Patient Safety Action Plan in July 2021. The UK's National Health Service relies on several measures, including ‘never events’, ‘serious incidents’, ‘patient safety events’ and coroners’ Prevention of Future Deaths reports (PFDs) to monitor healthcare quality and safety. We conducted a systematic narrative review of PubMed and medRxiv on 19 February 2023 to explore the strengths and limitations of coroners’ PFDs and whether they could be a safety tool to help meet the WHO's Global Patient Safety Action Plan. We identified 17 studies that investigated a range of PFDs, including preventable deaths involving medicines and an assessment during the COVID-19 pandemic. We found that PFDs offered important information that could support hospitals to improve patient safety and prevent deaths. However, inconsistent reporting, low response rates to PFDs, and difficulty in accessing, analysing and monitoring PFDs limited their use and adoption as a patient safety tool for hospitals. To fulfil the potential of PFDs, a national system is required that develops guidelines, sanctions failed responses and embeds technology to encourage the prevention of future deaths.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"7 1","pages":"227 - 236"},"PeriodicalIF":0.0,"publicationDate":"2023-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73837712","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":"Assessing patient safety culture among healthcare professionals in Ibadan South-west region of Oyo State, Nigeria","authors":"Chukwuemeka Abel, Ezechi Oliver, A. Folahanmi","doi":"10.1177/25160435231172826","DOIUrl":"https://doi.org/10.1177/25160435231172826","url":null,"abstract":"Objectives Patient safety culture is essential to improve care, prevent adverse events, and deliver quality healthcare service. The levels of patient safety culture and adverse events in Nigerian healthcare institutions are still widely underreported. The main objective of this study was to assess patient safety culture among healthcare professionals in primary and secondary healthcare facilities in Ibadan South-west local government area of Oyo State, Nigeria. Methods In this cross-sectional study, investigators collected data with the English version of the Hospital Survey on Patient Safety Culture version 2.0 questionnaire. They analyzed data using the Statistical Package for the Social Sciences (SPSS) software with descriptive statistics, Pearson Correlation Analysis, and one-way analysis of variance. Results A total of 271 healthcare professionals participated in the study. Study findings showed the overall perception of patient safety culture to be 72.1%. Among patient safety dimensions, Teamwork (88.5%) and Reporting Patient Safety Events (47.4%) were the highest and lowest percentage of positive responses, respectively. Conclusions Patient safety culture is an emerging concept in Nigeria. The assessed dimensions showed the need to improve the safety culture among healthcare professionals. Therefore, stakeholders, policymakers, and managers should employ policies, strategies, and programs to enhance safety culture across all healthcare institutions.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"268 1","pages":"116 - 125"},"PeriodicalIF":0.0,"publicationDate":"2023-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76950953","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":"Critical vulnerabilities for diversion of controlled substances in the emergency department: Observations and healthcare failure mode and effect analysis","authors":"Maaike de Vries, M. Fan, Dorothy Tscheng, M. Hamilton, P. Trbovich","doi":"10.1177/25160435231174309","DOIUrl":"https://doi.org/10.1177/25160435231174309","url":null,"abstract":"Objectives Drug theft by healthcare workers is a recognized problem in emergency departments (EDs) that can lead to patient, healthcare worker, and organization harm. Diversion takes various forms, including tampering with syringes, pilfering from waste containers and falsely documenting drug administration. Before implementing risk-mitigating interventions, we need a detailed understanding of the vulnerabilities in ED medication-use processes. This study sought to identify the critical failure modes (CFMs) within EDs that increase diversion risk and characterize the system factors contributing to CFMs. Methods Between June 2018 and February 2019, we conducted observations in two Ontario EDs. Observers recorded tasks carried out by nurses, pharmacists, and physicians. We performed a Healthcare Failure Mode and Effect Analysis, informed by the observation data, to proactively identify CFMs in the medication-use processes. Failure modes were coded for their effects on diversion risk and the contributing system factors. Results We identified 28 CFMs that increase diversion risk by enabling inappropriate access to controlled substances or compromising documentation. CFMs are multifactorial, stemming primarily from factors related to person (e.g., intent to divert) and tools/technology (e.g., limited automatic reconciliation of records), followed by organization (e.g., practices that diffuse accountability), environment (e.g., workspaces that obscure illicit behaviours), and task (e.g., unstructured processes leading to lapses). Conclusion The study findings inform opportunities to revise vulnerable processes and bolster safeguards, decreasing diversion risk and protecting patients and healthcare workers.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"1 1","pages":"99 - 107"},"PeriodicalIF":0.0,"publicationDate":"2023-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80111065","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}