Journal of patient safety and risk management最新文献

{"title":"Root cause analysis to identify major barriers to the promotion of patient safety in Japan","authors":"Masaru Kurihara, T. Watari, Shintaro Kosaka, Kiichi Enomoto, Toru Kimura, Kaori Taniguchi, Satoshi Watanuki, Kiwamu Nagoshi, S. Koizumi","doi":"10.1177/25160435221144134","DOIUrl":"https://doi.org/10.1177/25160435221144134","url":null,"abstract":"Objectives Despite existing patient safety measures, both outside and inside hospitals, barriers to patient safety prevail. We aimed to identify the current contributory factors to patient safety in Japan. Methods This qualitative study included nine expert Japanese health care providers working both inside and outside hospitals. These participants, who included six physicians, one nurse, one pharmacist, and one physical therapist, work across a broad spectrum in government policy and public health, academia, and safety management. Root cause analysis using the online Kawakita Jiro method (KJ method or affinity diagram) was conducted. We labeled and summarized the classification in a fishbone diagram to elucidate barriers to patient safety in Japan. Results We identified specific factors in six main groups: the hospital system, education, law and policy, culture and society, patient centricity, and multidisciplinary cooperation. Quality of care, patient engagement, and shortage of patient safety specialists were crucial factors for multiple groups. Conclusions This study clarifies components of patient safety in Japan and provides basic data for promoting comprehensive patient safety in the future. Periodic root cause analysis of comprehensive patient safety issues can help develop strategies to promote patient safety at both the hospital and national levels.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"1 1","pages":"9 - 14"},"PeriodicalIF":0.0,"publicationDate":"2022-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76506345","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":"Development of risk inventory for hospitals in India","authors":"J. S. Fidelis, Lallu Joseph, K. D. Souza, K. Sankaranarayanan, Vijay Agarwal","doi":"10.1177/25160435221142672","DOIUrl":"https://doi.org/10.1177/25160435221142672","url":null,"abstract":"Introduction With the ever-increasing hazards and associated risks in healthcare, the healthcare facilities should have a comprehensive enterprise risk management program. Risk management in Indian Healthcare is nascent and not structured. With the increasing potentially compensable events, workplace violence, cybersecurity threats, complex accreditation standards, old infrastructure and ever-changing legal and political scenarios, the risk inventory is expanding, leading to litigations due to lack of mitigation strategies. This study focuses on developing a comprehensive organization wide enterprise risk inventory for the healthcare facilities in India. Method Secondary data from published studies were collated and 25 risk factors were identified. Interviews with 12 domain experts further identified 38 context and country-specific risks. The identified 63 risks were sent to 20 senior healthcare risk managers. Forty-three risks were unique and were validated by the senior healthcare risk managers. Twenty risks out of 63 identified had similar meaning. These 20 risks were reworded, rephrased and merged into eight risks by the senior healthcare risk managers. The 51 risks were endorsed by the 12 domain experts. The identified risk factors were surveyed among the risk managers from various hospitals to understand the importance and ranking of the risk in the Indian context. Results Sentinel events/Never events appeared in different rank orders and seems to be among the top five risks as perceived by professionals in India. Second highest ranked risk was ‘Staff attrition’. The data analysis showed the different attributes of survey participants, such as the size of the organization with respect to bed capacity and length of time working in the field of risk management. Conclusion The results provide valuable insights into the perception of risk based on hospital size and the educational background of risk managers. This inventory may help hospitals develop strategies for mitigating, controlling and monitoring risks for better hospital management.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"31 1","pages":"21 - 30"},"PeriodicalIF":0.0,"publicationDate":"2022-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72753540","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":"Taking action against medical accidents: A brief history of AvMA and clinical risk management in the NHS.","authors":"Christopher Sirrs","doi":"10.1177/25160435221135120","DOIUrl":"https://doi.org/10.1177/25160435221135120","url":null,"abstract":"<p><p>Established in 1982, Action against Medical Accidents (AvMA)-originally named Action for Victims of Medical Accidents-was effectively the first charity in Britain dedicated to 'patient safety'. This article provides a historical analysis of the origins and work of AvMA, situating its background in the medical negligence 'crisis' of the 1970s and 1980s, growing consumerism in healthcare, and the significant barriers to justice patients confronted following a clinical incident. It also explores AvMA's impacts on evolving attitudes towards patient harm and safety in the NHS. The article asserts that in addition to supporting patients and campaigning for changes in legal procedures, AvMA played an instrumental role in raising the political profile of adverse health events ('medical accidents'). By supporting claimant solicitors and increasing their chances of legal success, AvMA contributed to the rising tide of negligence claims, which incentivised NHS trusts and health authorities to introduce clinical risk management (CRM). By 2000, CRM was being framed as part of a broader mission to improve quality and safety in healthcare, and AvMA was recognised as a key stakeholder in the new patient safety agenda.</p>","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"27 6","pages":"248-255"},"PeriodicalIF":0.0,"publicationDate":"2022-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9723504/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10332930","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":"The practical, ethical and legal reasons why patients should not be transferred between NHS trusts for phage therapy.","authors":"Joshua D Jones,&nbsp;Pamela R Ferguson,&nbsp;Mehrunisha Suleman","doi":"10.1177/25160435221120300","DOIUrl":"https://doi.org/10.1177/25160435221120300","url":null,"abstract":"<p><p>Bacteriophages (phages) are naturally occurring viruses of bacteria that have a long history of use as antimicrobials, known as phage therapy. The antibiotic resistance crisis has driven renewed interest in phage therapy, which has been used on an unlicensed compassionate basis in various Western contexts. The option to use unlicensed medicines exists to allow clinicians to respond to genuine clinical needs arising in their own patients. However, in the UK some clinicians may, in the absence of suitable patients of their own, seek to transfer patients from other NHS trusts into their own Trust. This article sets out why patient transfer is not necessary and the practical, ethical and legal reasons why patients should not be transferred between NHS Trusts for phage therapy. Phage preparations should always be transported to the patient and the patient treated in the Trust in which they would have received care in the absence of phage. We enclose suggested best practice guidelines for adoption across the UK that will protect patient safety and safeguard clinicians and Trusts from potential litigation.</p>","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"27 6","pages":"263-267"},"PeriodicalIF":0.0,"publicationDate":"2022-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9720457/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9921168","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":"Success and succession at AvMA: 40 years of minding the gap in patient safety and justice","authors":"A. Wu, H. Hughes","doi":"10.1177/25160435221142482","DOIUrl":"https://doi.org/10.1177/25160435221142482","url":null,"abstract":"This editorial marks an important occasion for Action against Medical Accidents (AvMA), the path-breaking charity for patient safety and justice. The timing is noteworthy in two respects. First, it is their 40th anniversary as a charity. They may have been the first patient organization focused on patient safety and they have played a significant role in the birth and raising of the patient safety movement, both in the UK and worldwide. Second, Peter Walsh, who has served as Chief Executive for 20 of those years, is stepping down. The Journal has been published in association with AvMA for its entire existence, so these are seismic events for us. We should begin with personal thanks to Peter for his partnership with me over the five years that I’ve led the Journal. I first met Peter in London in November, 2010 during the relaunch of the NHS policy of Being Open about medical errors. The policy, originally adopted in 2005, promotes “greater openness with patients and families when things go wrong,” stating that “sorry is not an admission of liability and it is the right thing to do.” I had assembled a group of international experts for a day-long meeting on open disclosure of adverse events. Innovative policies and practices being implemented in Australia, New Zealand, Canada, and the US were shared with NHS leaders and other key stakeholders. During the discussions, I witnessed Peter’s passionate insistence on justice for injured patients. In subsequent meetings, he campaigned earnestly for an additional legal “duty of candour” to disclose in the UK. He was justifiably proud when the efforts of AvMA helped to pass this legislation in 2014. When I took over as Editor-in-Chief of the Journal in 2018, Peter had been in place since the inception of its predecessor Clinical Risk. He was a gracious host, helping to bring about a warm handoff as we transitioned to a new name and a more international focus. Since then, he has helped the Journal deliver medico-legal content, while keeping the important perspective of patients. Congratulations are also in order for AvMA, which can notch up several achievements. It is evident that AvMA helped create the market for malpractice claims in the UK, providing structures and support to both injured patients and plaintiff’s attorneys. This has contributed to an increase in malpractice claims. Although not all would view this as an unmitigated good, it has increased the number of injured people able to receive needed compensation. In addition, it promoted the uptake of clinical risk management in the NHS. AvMA has long provided a unique resource to the community in the form of a helpline for patients who have been injured by health care. Services include free support and advice to callers, as well as the handling of more complex casework and inquests. In a complex healthcare system, this service has been a lifeline for patients and families who don’t know how to raise concerns, or who are seeking explanations for wh","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"14 1","pages":"243 - 245"},"PeriodicalIF":0.0,"publicationDate":"2022-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74619045","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":"‘Putting the ‘patient’ in patient safety’: An editorial by Peter Walsh, chief executive of Action against Medical Accidents (1 January 2003–31 December 2022)","authors":"P. Walsh","doi":"10.1177/25160435221140450","DOIUrl":"https://doi.org/10.1177/25160435221140450","url":null,"abstract":"","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"48 1","pages":"246 - 247"},"PeriodicalIF":0.0,"publicationDate":"2022-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76729502","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":"Glaucoma-related malpractice litigation in the United States: A review of the WestLaw database","authors":"Jae-Chiang Wong, Nikki A. Mehran, Mark Andriola, Daniel Lee, J. Myers, N. Kolomeyer","doi":"10.1177/25160435221139686","DOIUrl":"https://doi.org/10.1177/25160435221139686","url":null,"abstract":"Purpose Gaining understanding of glaucoma-related malpractice litigation may highlight ways to improve patient care and minimize risk of litigation. This study aims to analyze the outcomes and characteristics of glaucoma-related malpractice litigation. Materials and Methods The Westlaw legal database (Thomson Reuters, New York, NY, USA) was used to identify cases regarding ‘malpractice’ AND ‘glaucoma’ or related terms. Cases were analyzed for characteristics such as alleged cause of malpractice, outcome, and demographics. Results The initial search terms yielded 498 results, 107 of which met further inclusion criteria. 38 (36%) were resolved via jury trial. Of these, verdicts in favor of the plaintiff were issued in 14 cases (34%), with median adjusted damages of $702,986. Of all 107 cases in the study reviewed, 65 (61%) resulted in verdicts in favor of the defendant. Ophthalmologists were named as defendants in 85% of the cases (with glaucoma specialists representing 7% of the ophthalmologists); optometrists in 24%. Sixty percent of the cases involved non-surgical treatment. The most common medical reasons for litigation were failure to diagnose (38%), and inappropriate/negligent treatment (36%). The most commonly litigated surgical procedures were cataract surgery (48%) and iridotomy/iridectomy (19%). Conclusion Glaucoma-malpractice litigation has increased, with medical mismanagement alleged in the majority of cases. Defendants are frequently successful in obtaining pre-trial dismissal, but the risk of liability increases in cases going to trial. A minority of cases involved glaucoma specialists. This historical analysis of glaucoma-related malpractice cases might provide perspective and aid physicians seeking to avoid litigation.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"122 1","pages":"47 - 54"},"PeriodicalIF":0.0,"publicationDate":"2022-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75427738","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":"Sustained barcode medication administration rates less than 2 percent in a large healthcare system","authors":"S. Boehme, Paul D. Wohlt, J. Valentine, R. Ensign","doi":"10.1177/25160435221137145","DOIUrl":"https://doi.org/10.1177/25160435221137145","url":null,"abstract":"Purpose Implementation of bar code medication administration (BCMA) technology is an effective strategy to decrease medication administration errors. Consistent use of BCMA technology within a hospital system should result in improved patient safety through the reduction of medication related administration errors. Based on this premise, a large health system established an annual goal to reduce BCMA override rates to less than 2%. Methods A large health system located in the Intermountain West developed a BCMA override reporting tool to assist with reducing BCMA override rates. An essential component of the reporting tool is the visual management strategy which allows caregivers to easily identify goal progress. The tool also includes information that managers can use to determine how often their direct reports override medications. Pharmacy caregivers can also use the data from the reporting tool to address specific issues related to medications that do not scan properly. Results Implementation of the tool and education on its use, resulted in individual follow up with nursing units and nurses, ultimately producing sustained barcode overrides less than 2%. Conclusion By implementing reporting systems that identifies specific opportunities for improvement, barcode override rates can be decreased to less than 2% in a large healthcare system.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"82 1","pages":"268 - 274"},"PeriodicalIF":0.0,"publicationDate":"2022-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83132451","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":"Investigating areas for improvement in the transition from hospital-to-home for frail older adults: A mixed methods study","authors":"Leanne Skerry, Emily K. Kervin, N. Hanson, P. Jarrett, R. McCloskey","doi":"10.1177/25160435221135115","DOIUrl":"https://doi.org/10.1177/25160435221135115","url":null,"abstract":"Background The planning and execution of discharge plans to successfully transition frail older adults from hospital-to-home can be a complicated endeavour. Objective To identify areas for improvement in the transitional process of frail older adults who were discharged from hospital based, geriatric units to their homes in the community. Method A prospective multi-phased mixed methods design was used, and cross-case thematic analysis of Phase 2 data were triangulated with Phase 1 findings. Results Thematic analysis findings indicated several related areas of importance within the transitional process: 1) Coordination of discharge; 2) Transition-to-home planning; 3) Home and community care; 4) Following of recommendations; and, 5) Medical follow-up. Conclusions Strengthening communication between stakeholders, as well as the implementation of harmonized policies and guidelines are needed to facilitate more consistent care delivery and provide patients and families with information on what to expect during the transitional process.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"118 1","pages":"275 - 284"},"PeriodicalIF":0.0,"publicationDate":"2022-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81308943","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 the emergency service work environment on the patient safety attitudes of nurses","authors":"Nuriye Kizir, E. Ozsaker","doi":"10.1177/25160435221138667","DOIUrl":"https://doi.org/10.1177/25160435221138667","url":null,"abstract":"Background A safe working environment in the health sector contributes significantly to employee and patient safety and supports positive patient outcomes. Nurses play an important role in improving the healthcare quality related to patient safety practices. This study aimed to investigate the effect of the emergency service work environment on nurses’ patient safety attitudes. Methods This cross-sectional study was conducted in the emergency departments of 15 tertiary public hospitals and university hospitals in Izmir, Turkey. 288 nurses who worked 6 months or more in emergency departments were included in the sample. The personal information form, safety attitudes questionnaire, and work environment scale were used in the data collection. Results The total mean score for the safety attitudes questionnaire was 136.69 ± 22.14, and the total mean score for Work Environment Scale was 84.51 ± 12.02. A positive correlation was detected between the Safety Attitudes Questionnaire total score and Work Environment Scale total score (r = 0.38, p < 0.001). Conclusion The patient safety attitudes of the emergency room nurses were moderately positive, the nurses evaluated the working environment positively, and positive work environments affected patient safety attitudes positively.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"28 1","pages":"126 - 132"},"PeriodicalIF":0.0,"publicationDate":"2022-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89842680","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}