Journal of patient safety and risk management最新文献

{"title":"Liberal use of local anaesthetic and the risk of toxicity in elective arthroplasties at a tertiary teaching hospital","authors":"Luke McConnell, J. Bulman","doi":"10.1177/25160435221135307","DOIUrl":"https://doi.org/10.1177/25160435221135307","url":null,"abstract":"Background Local anaesthetic systemic toxicity (LAST) is a life-threatening potential complication that may follow the administration of local anaesthetic (LA) drugs, and is cumulative across the drug class. Local anaesthetics are commonly administered via different routes for elective orthopaedic procedures – both by anaesthetists and surgeons. We hypothesized that total doses of LA may be routinely encroaching upon toxicity. Methods All total hip or knee arthroplasties (THAs and TKAs) performed within a 3 month period at the John Hunter Hospital (tertiary referral centre and teaching hospital) were audited to assess total administration of LA. Demographics, surgical characteristics, use of general anaesthesia or sedation, and use of local anaesthetic via any route of administration was recorded. For each patient, a weight-based theoretical maximum safe dose was calculated and compared against the dose they received. Data is presented as mean ± SD, percentages. Statistical significance was determined at p < 0.05. Results 130 THAs and TKAs were identified within the audit period. 52 patients exceeded their drug-class theoretical maximum safe dose. 49 patients exceeded their weight-based maximum dose for a single LA agent, in all cases ropivacaine. Non-obese individuals receive significantly higher mean dose than obese individuals (119.4% [98.6–140.3] vs 78.82% [65.95–91.69], p = 0.001). No LAST events were identified. Conclusions Patients who received elective total hip or knee arthroplasties were exposed to concerningly high total doses of local anaesthetic, suggesting that greater awareness of the additive toxicity of drugs within this class is required.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"63 1","pages":"256 - 262"},"PeriodicalIF":0.0,"publicationDate":"2022-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88520712","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":"What really matters for patient safety: Correlation of nurse competence with international patient safety goals","authors":"Zubia Kalsoom, Gideon Victor, H. Virtanen, N. Sultana","doi":"10.1177/25160435221133955","DOIUrl":"https://doi.org/10.1177/25160435221133955","url":null,"abstract":"Background Optimal level of nurse competence is imperative for patient safety and quality of care. A research gap exists in empirical evidence for associating nurses’ competencies with patient safety. Purpose The primary purpose of this study was to measure the association between general ward nurses' competencies with international patient safety goals. Method Correlational research design was adopted. Stratified random sampling was used to recruit (n  =  182) nurses working in two JCIA accredited and non-JCIA hospitals. Data were collected using the Competency Inventory for Registered Nurses and International Patient Safety Goals. The research was approved by the Institutional review board and ethics committee. Findings The regression analysis showed enhancement of patient safety with an improvement in nurse competencies R2  =  0.238. Nurse competencies showed a moderate positive association with an overall patient safety such as critical thinking and research aptitude (r  =  0.420, P – Value < 0.001), teaching coaching (r  =  0.469, P- Value <0.01), professional development (r  =  0.436, P – Value < 0.001), legal and ethical practices (r  =  0.434, P –Value < 0.001), interpersonal relationships (r  =  0.430, P –Value < 0.001), Leadership (r  =  0.400, P –Value < 0.001), and Clinical Care (r  =  0.541, P –Value < 0.001). Moreover, experience and professional education show positive association with both, patient safety and nurses’ competencies. Conclusion Nurses’ clinical competencies are crucial to enhance patient safety. Personal and professional attributes affect the competencies of nurses and patient safety. Hospital management should take mandatory steps to ensure improving nurses’ competencies for better patient safety.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"28 1","pages":"108 - 115"},"PeriodicalIF":0.0,"publicationDate":"2022-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80935326","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":"Were security guards responsible for patient's death? Leanne Walsh (for Gareth Walsh, deceased) v. Northumbria Healthcare NHS Foundation Trust (Newcastle upon Tyne County Court – Judge Freedman – 19 May 2021)","authors":"J. Mead","doi":"10.1177/25160435221126800","DOIUrl":"https://doi.org/10.1177/25160435221126800","url":null,"abstract":"","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"22 10 1","pages":"285 - 287"},"PeriodicalIF":0.0,"publicationDate":"2022-10-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82768801","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":"Pursuing a saboteur of patient safety: The hidden curriculum","authors":"A. Wu","doi":"10.1177/25160435221129332","DOIUrl":"https://doi.org/10.1177/25160435221129332","url":null,"abstract":"There is a fundamental problem at the heart of health care: the problem of human error. Health care relies primarily on humans taking care of other humans. Because we are fallible, there will always be errors in clinical practice. James Reason, generally regarded as the father of safety science, saw the issue as being viewed in two ways: the person approach, and the system approach. The person approach focuses on the errors and violations of individuals, and aims remedial efforts at front line workers. The system approach traces causal factors to the system as whole, and prescribes remedies at multiple levels. Reason explained persuasively that “we cannot change the human condition, but we can change the conditions under which people work.” By designing systems to avert errors and allow recovery when they do occur, we can create the conditions to reduce harm from health care. Ironically, humans in the system are stubbornly resistant to accepting the more effective system approach. They seem blinded to just how common errors are in healthcare, and are often in denial about the frequency of adverse events. This is in part because elements of the system itself perpetuate the idea that a few unreliable “bad apples” are responsible for safety problems in medicine. This example of failing to see the forest for the trees – the system of healthcare for the actions of individual frontline providers – frustrates efforts to improve patient safety. Today, healthcare organizations aspire to achieve high reliability, to reduce errors and recover from their effects. But designing high reliability systems first requires being constantly aware of the possibility of failure. A difficult challenge in medical education and training is to conquer the invisible forces that prevent leaders, managers, frontline clinicians, and patients from understanding the inevitably of medical errors. There is a “hidden curriculum” that prevents us from seeing with system lenses. The formal curriculum is what is consciously intended, endorsed, and taught. But medical education is more than the transmission of knowledge and skills. It is also a socialization process. The hidden curriculum is a set of influences that function at the level of organizational culture. It includes norms and values that can undermine the messages of the stated curriculum. These are taught implicitly and daily – in the halls, and elevators, and through other channels. For example, while we are taught that some patients need more time and attention, the productivity measures employed by institutions signal that increasing the volume of services is the priority. In patient safety, a pervasive message in the hidden curriculum is that errors are uncommon, and are caused by a small number of individuals who should be blamed for inattention, carelessness, moral weakness, or incompetence. This message is especially difficult to root out, as it is founded upon a universal cognitive bias referred to as “fundamental a","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"14 1","pages":"199 - 200"},"PeriodicalIF":0.0,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82406277","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 managerial patient safety practices that influence adverse events reporting among nurses in the Savannah Region, Ghana","authors":"Samson Alhassan, A. Kwashie, Yennuten Paarima, Adelaide Maria Ansah Ofei","doi":"10.1177/25160435221123465","DOIUrl":"https://doi.org/10.1177/25160435221123465","url":null,"abstract":"Introduction Patient safety is a global concern for both health professionals and the public. Studies show that evaluating patient safety culture can help improve patient safety outcomes. Nursing care strategically places nurses at the centre of patient safety promotion and their proximity to patients makes them the drivers of patient safety. Managerial decisions regarding patient safety impact greatly on patient safety outcomes in the healthcare organization. This study aimed to assess the managerial patient safety practices that influence adverse event reporting in three hospitals in the Savannah Region of Ghana. Methods A quantitative cross-sectional design was used to collect data from 210 participants in three hospitals. Data were analysed using descriptive, Pearson's correlation and linear regression. Results It was found that patient safety practices with good positive rating scores were management support (56.6%), managers' expectations (62.8%) and feedback about errors (56.2%). Areas with weak patient safety practices were staffing levels (42.4%), open communication (40.2%) and non-punitive response to errors (36.7%). Again, nurses' attitude towards adverse events reporting was generally low (37.3%). Managerial patient safety practices that had significant associations with adverse events reporting were management support (r = .18, p < .001), open communication (r = .19, p < .001), non-punitive to errors (r = .21, p < .001) and feedback about errors (r = .37, p < .001). Again, the significant predictors of adverse events reporting were feedback about errors (β = .36, p < .001) and non-punitive response to errors (β = .21, p < .01). Conclusion Nurses perceived patient safety culture in their units to be good. Although nurses' attitude towards adverse events reporting was low, the significant predictors of adverse events reporting were feedback about errors and non-punitive response to errors. Therefore, healthcare managers should continually strengthen patient safety to ensure optimal care outcomes. Implications for nursing practice Feedback on errors and non-punitive response to errors had a great influence on adverse events reporting, managerial failure to provide feedback and a non-punitive work environment could result in under-reporting of adverse events. This can be a major threat to patient safety; hence clinical practice should be aware of this and put in strategies to appropriately address them.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"22 1","pages":"218 - 228"},"PeriodicalIF":0.0,"publicationDate":"2022-09-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80491055","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":"Features of incident reports that prompt reviewer feedback and organisational change: A retrospective review","authors":"Aathavan Shanmuga Anandan, David Johnson","doi":"10.1177/25160435221124970","DOIUrl":"https://doi.org/10.1177/25160435221124970","url":null,"abstract":"Objectives Identifying and recording system failures through incident reporting and enacting appropriate preventative change improves patient outcomes. This study identified the characteristics of a hospital incident report, based on severity of incident (Safety Assessment Code (SAC)) score, classification of report and reporter occupation, that prompted reviewer feedback and stimulated organisational change. Methods Incident reports registered within the RiskMan data repository between January to December 2020 were collated. During the 12-month period, a total of 2250 reports were recorded within the data repository. Feedback was provided for 71 of these reports, with 19 of these reports constituting organisational change. Results Four key findings were determined by the study. Deterioration was the most likely classification of the incident report to receive feedback, as well as feedback of organisational change. SAC 1 reports were significantly more likely to receive feedback than SAC 3 & 4. There was no significant difference in receiving organisational change feedback between SAC 1 and SAC 2. Incident reports by ‘medical’ staff were significantly more likely to receive feedback than ‘nursing’, ‘admin’, and ‘other’ occupations. Conclusions This study identified characteristics of incident reporting that result in organisational change recommendations. The small number of incident reports that received feedback is an area for improvement in this clinical site. Understanding the nature of the incident reports that are prioritised when making organisational change can shed light on further areas for improvement. Future investigations could examine which recommendations were implemented, as well as evaluate the barriers and enablers to executing change.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":" 47","pages":"209 - 217"},"PeriodicalIF":0.0,"publicationDate":"2022-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72385162","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":"“I’m concerned”: A multi-site assessment of emergency medicine resident speaking up behaviors","authors":"N. Feldman, N. Volz, Tim Snow, Lillian Wong, S. Hock, David K. Barnes, S. Bentley","doi":"10.1177/25160435221123464","DOIUrl":"https://doi.org/10.1177/25160435221123464","url":null,"abstract":"Introduction According to the Institute of Medicine, 98,000 annual deaths are caused by preventable errors. Speaking up about patient safety or professionalism concerns when they arise allows medical staff to move from bystanders to active participants in the prevention of patient harm. This study assesses the current climate around speaking up for patient safety and unprofessional behavior by Emergency Medicine (EM) resident physicians and compares it to previously published data from other specialties. Methods A multi-site, descriptive, cross-sectional design was utilized based on previously published Speaking Up Climate Safety and Professionalism Scales. EM residents at 3 programs in the United States were surveyed, and their responses were compared to previously published responses from other specialties. Results 102 residents from 3 EM residency programs responded to the survey, yielding a response rate of 54.3%. Responses on the survey fell close to the neutral response (3 on a 5-point Likert scale) on all measures, indicating opportunity for improvement. However, EM responses were significantly more favorable than responses from other specialties on several questions. Conclusion This assessment demonstrates room for improvement on speaking up behaviors among EM residents but also suggests that unique features of EM may contribute to a relatively more positive speaking up climate compared to other specialties, which may inform strategies to increase speaking up behaviors. For example, deliberate practice of situations requiring strong teamwork and strategies to reduce traditional hierarchies may help emulate the climate that tends to occur organically in EM.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"3 1","pages":"229 - 233"},"PeriodicalIF":0.0,"publicationDate":"2022-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76302356","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":"Alcoholism and American healthcare: The case for a patient safety approach","authors":"L. Zipperer, R. Ryan, Barbara Jones","doi":"10.1177/25160435221117952","DOIUrl":"https://doi.org/10.1177/25160435221117952","url":null,"abstract":"Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioral health condition. The aims of this paper are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population. The authors performed a narrative review of the literature on the current state of AUD treatment and patient safety, finding extensive evidence that patients with AUD usually go undiagnosed, unreferred and untreated. When they do receive AUD treatment, little evidence was found to indicate that a patient safety approach is incorporated into their care. Behavioral medicine is virgin territory for the patient safety movement. Medical care and behavioral medicine in the United States currently constitute two separate and unequal systems generally lacking in pathways of communication or care coordination for AUD patients. Significant barriers include institutional culture, individual and systemic bias against those with AUD, and health care infrastructure, especially the separation of medical and behavioral treatment. It is the authors’ conclusion that care of patients with AUD is unsafe. We advocate for the patient safety approach common in American hospitals to be extended to AUD treatment. Experienced patient safety leaders are in the strongest position to initiate collaboration between the mainstream medical and substance abuse treatment communities to reduce harm for this patient population.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"28 1","pages":"201 - 208"},"PeriodicalIF":0.0,"publicationDate":"2022-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87486478","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":"Value-based analysis of a Singaporean post-ED discharge support program for older adults","authors":"Colin E.C. Ong, Phillip Phan, Christine Xia Wu, Zhaoqi Chen, L. Quek","doi":"10.1177/25160435221113955","DOIUrl":"https://doi.org/10.1177/25160435221113955","url":null,"abstract":"Objective We evaluated the effectiveness of a post emergency department (ED) discharge intervention for frail, older adult patients in reducing hospital admissions. Methods 9-month retrospective real-world evaluation of a quality improvement intervention comparing frail adults 65-years and older who received a post-ED discharge intervention program (SAFE-Lite) with those who were eligible but declined and received usual care instead. The primary outcomes were the differences in rates of first acute hospital admission at 30- and 60-days post-ED discharge. The difference in primary outcome between the two groups was compared using the Cox proportional hazards model. We report adjusted hazards ratios (HRs) with 95% CIs for age, gender, Triage Risk Screening Tool (TRST) scores, as well as baseline ED utilization and acute hospital admission rates in the past year. Results There were 66 patients in the intervention group and 46 patients in the control group. There was no significant difference in risk of acute hospital admission at both 30 days (15 vs. 13%, HR = 0.92, 95% CI: 0.35–2.41) and 60 days (21 vs. 16%, HR = 0.97, 95% CI: 0.42–2.21) for the intervention and control groups. Conclusion Compared to usual post-ED discharge care, SAFE-Lite showed no difference in reducing 30- and 60-day admissions of frail, older patients.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"33 1","pages":"166 - 171"},"PeriodicalIF":0.0,"publicationDate":"2022-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82903641","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":"Third Time’s the Charm: Strengthening Global Efforts to Reduce Medication-Related Harm","authors":"A. Wu, A. Mair, I. Papieva, Ayda Taha, Neelam Dhingra","doi":"10.1177/25160435221120362","DOIUrl":"https://doi.org/10.1177/25160435221120362","url":null,"abstract":"I begin every day taking the same pill regimen: a cholesterol-lowering agent for familial hyperlipidemia, a proton-pump inhibitor for gastrointestinal reflux, and an over-the-counter antihistamine for chronic allergies. (AW) I am not exceptional. Over half of US adults take two or more pills a day, and nearly half take three prescription medications a week, putting me squarely in the middle of the road. Worldwide, numbers are slightly lower but comparable. For older adults the numbers are greater: three out of five older adults in the US take five or more prescriptions a day. Prescription medications help people around the world treat medical conditions, but they can also cause harm if overused, underused, not monitored, or otherwise misused. Since the beginning of the patient safety era, unsafe medication practices and medication errors have been the leading cause of injury and avoidable harm in health care systems across the globe. But most people, most of the time, fail to appreciate the potential downsides of medication use. The need to take multiple medications can be just as problematic, resulting in frequent health care contacts and an increased likelihood of medication related harm. These risks proliferate in specific situations, and at transition points at different levels, locations, and settings of care. Medication errors occur at every point in the labyrinthine medication use system. At the center lie prescribing, ordering, storage, dispensing, preparation, administration, and monitoring practices. Medication errors are multidimensional and may occur because of the weak medication systems and practices, which face increasing numbers of medications, routes of delivery and formulations, human factors, complexity of use, and broader system issues. In many cases, unsafe medication practices can result in severe harm, disability and even death. Although countless strategies have been developed to address the frequency and impact of medication errors, their implementation has been variable. We assert that patients and families can play a key role in taking medications safely and effectively. Healthcare professionals need to ensure that patients are empowered to do this. The COVID-19 pandemic highlighted many areas where medications were used inappropriately. Some were not supported by scientific studies, such as ivermectin and hydroxchloroquine, and caused significant harms. There were conspicuous examples of inappropriate antibiotic prescribing. Antibiotic use has been described in more than 70% of cases of COVID-19, often for the suspicion of bacterial superinfection in one series this was judged inappropriate in over a third. There were many cases related to the use of complementary and alternative medicines, used despite limited evidence for their effectiveness. Moreover, the disruptions in the health care systems caused by the pandemic resulted in more frequent self-care practices, which also has implications for medication safety. The","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"10 1","pages":"157 - 159"},"PeriodicalIF":0.0,"publicationDate":"2022-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73373082","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}