Journal of patient safety and risk management最新文献

{"title":"Opportunities to mine EHRs for malpractice risk management and patient safety","authors":"Julia Adler-Milstein, U. Sarkar, R. Wachter","doi":"10.1177/25160435221097422","DOIUrl":"https://doi.org/10.1177/25160435221097422","url":null,"abstract":"The malpractice system is an important, albeit imperfect, mechanism to compensate patients for healthcare harms. In theory, the system incentivizes clinicians and health systems to provide safe and effective medical care. Yet US malpractice claims are still frequent, averaging around 50,000 annually, with payouts totaling approximately $4 billion per year. Moreover, costs associated with defending claims are large: approximately $85,000 per case. Underlying these figures is our limited understanding of malpractice risk. While sophisticated prediction models now support clinical decision-making, malpractice risk assessment largely relies on coarse categories such as specialty (e.g. obstetrics) or simple trends (e.g. a clinician who has been the subject of multiple lawsuits or patient complaints). As a result, those working to reduce malpractice risk and improve patient safety cannot identify individual clinicians or individual patients at highest risk at a given point in time, which impedes optimal targeting of resources. Further, many resources are devoted to addressing risk after an incident occurs. For example, in communication and resolution programs, health systems and insurers encourage risk management teams and clinicians to reach out to patients and families after unanticipated outcomes, to seek a resolution that may include an apology and an offer of compensation. This approach is still reactive and addresses harm events on a case-by-case basis. Where might we find a more scalable, precise, and proactive approach? Perhaps the answer is hiding in plain sight. A detailed medical record review is the cornerstone of every malpractice case. Yet, even with near-universal electronic health records (EHRs), there has been little effort to mine records in real time—and before an untoward event—for predictors of safety events or for lawsuit risk. We believe that EHRs—and specifically the data on clinician behaviors that they contain—offer untapped potential to advance malpractice risk mitigation and patient safety. Of course, some domains of malpractice risk—namely, medication errors—have been targeted for improvement by EHRs. Yet other, equally risky domains remain unaddressed. For example, failures to act on abnormal results and concerning symptoms remain major contributors to malpractice. There are many opportunities for EHR data to identify and mitigate risks by detecting when clinicians do not open or address abnormal lab or radiology results. Clinicians with significant delays can be identified and the behavior addressed, even before one of these delays leads to harm. Taken further, automated EHR-based rules could detect when a result has not been viewed, or when it has been viewed but expected subsequent actions, such as subspecialty referrals or additional testing, have not occurred. Kaiser’s SureNet program offers one example of this approach that has been implemented at scale. This is a centralized effort to identify specific high-risk una","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"1 1","pages":"160 - 162"},"PeriodicalIF":0.0,"publicationDate":"2022-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83270474","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Safety is Alive but Consumers Pose Challenges: Response to “Who Killed Patient Safety?”","authors":"D. Wojcieszak","doi":"10.1177/25160435221117642","DOIUrl":"https://doi.org/10.1177/25160435221117642","url":null,"abstract":"July 18, 2022 In the title of their recently published commentary, Hemmelgarn and colleagues posed a provocative question, “Who killed patient safety?” In the body of their essay they restated the query in a slightly softer manner, “What happened to patient safety?” The authorship team is almost entirely composed of individuals who had family members injured or killed by medical errors, and they are all accomplished experts and activists in the field of patient safety. I too lost a family member to medical errors. As a result, I have also pursued advocacy along with consulting and research on this issue. However, I view the present state of patient safety differently, specifically that the glass is half full. Patient safety is alive and well but with more work to be done. Moreover, I have some different views of the challenges we face in patient safety, which include how Americans consumers are hurting the patient safety movement. When my family and I reconciled with the hospital system where my brother Jim died in 1998 from medical errors, the hospital’s CEO had a candid conversation with me. He stated that the 1990’s was the “age of justification” during which even the worst care could be justified or ignored by healthcare professionals. I have heard similar confessions from other healthcare professionals, including risk managers, defense attorneys, and the like. Yet, over the last two decades, as I have traveled the country and worked with countless hospitals and nursing homes, I have seen with my own eyes healthcare professionals who are now working overtime to diminish and eliminate errors. They are candid about the challenges they face and their desires for improvements, both within systems and individual clinicians. Yes, they are still not as transparent with patients and families as we would like, nor are they are sharing de-identified cases and stories between healthcare systems with the frequency we would prefer. However, we should not diminish the attention, care, and work that is being put into this issue. People are trying. If anything, healthcare professionals are attempting to fix this problem because of all the medical malpractice lawsuits and negative media (and social media) attention that has caused enormous damage to the bottom line of countless entities along with personal risk of lawsuits and complaints to state medical boards. As a family member, I take comfort in this reality. We should agree that the reporting systems around medical errors are not fully developed and haphazard, at best. Those attempting to estimate injuries and deaths from medical errors are truly making guesses on incomplete information. In Year 2000, the IOM pegged the death count from medical errors somewhere between 44,000 to 98,000 Americans annually, yet Makary in 2016 suggested that medical errors are the third leading cause of death in the United States by claiming in excess of 400,000 souls annually. More recently, it has been suggested that 25 p","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"56 1","pages":"163 - 165"},"PeriodicalIF":0.0,"publicationDate":"2022-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79733728","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":"Knowledge, attitudes and practices of clinical pharmacists to medication error reporting in ministry of health and population hospitals in Egypt","authors":"Shymaa Mahmoud Youssef Elshoura, R. Mosallam","doi":"10.1177/25160435221113493","DOIUrl":"https://doi.org/10.1177/25160435221113493","url":null,"abstract":"Objective This study aimed to assess the knowledge, attitudes and practices toward medication errors (MEs) reporting among pharmacists working in Ministry of Health and Population (MOHP) hospitals in Alexandria. Methods A cross-sectional study was conducted among all pharmacists who are responsible for reporting medication errors in the Egyptian online reporting system (NO HARMe). Results The majority of pharmacists received training on MEs reporting using the Egyptian online reporting system. Around half of the pharmacists knew the correct definition for medication errors. All respondents were aware of the presence of a MEs reporting system in Egypt. Clinical pharmacists’ attitudes towards MEs reporting was favorable with an overall mean score of 4.20 ± 0.73 in a score ranging from 1 (most unfavorable attitudes score) to 5 (most favorable score). Only 60.7% of the surveyed pharmacists used the system to report MEs. Antibiotics were the most frequent drug category reported and the prescribing stage was the stage in which pharmacists perceived the greatest volume of reports were made (89.3% and 71.4%, respectively). Lack of time was the most frequently identified barrier to reporting, followed by lack of feedback to the report submitted (73.2%, 54.5%, respectively). Inconsistent with the results of other studies, fear from legal consequences and being recognized as an incompetent provider was reported by only 12.5% and 11.6% of pharmacists, respectively. Conclusion The majority of pharmacists have good knowledge and favorable attitudes towards medication error reporting, however around two fifths do not report medication errors.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"115 1","pages":"188 - 196"},"PeriodicalIF":0.0,"publicationDate":"2022-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80291671","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":"Are shifting communication styles crumbling old silos?","authors":"Gayla Miles, A. Quinlan, Nicole Frederick, Aaron R. Brown","doi":"10.1177/25160435221110898","DOIUrl":"https://doi.org/10.1177/25160435221110898","url":null,"abstract":"Clear communication is essential to provide high-quality health care. The medical environment is changing. Older physicians and nurses are retiring being replaced with younger professionals who are not as concerned with gender roles and who appreciate technical communication. Along with the changing setting is the introduction of communication frameworks that are more comprehensive and consider both verbal and nonverbal modems of communication. This article provides an anecdotal event evaluated by the Hannawa ‘SACCIA Safe Communication” framework but also considers the changing medical landscape which may be helping to dissolve miscommunication silos. The fast-paced, fluid medical environment calls for a more robust, interactive communication tool. Healthcare providers would benefit from education on the entire communicative process needed for successful communication.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"10 1","pages":"234 - 240"},"PeriodicalIF":0.0,"publicationDate":"2022-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84198766","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":"Improving patient safety and quality in India's largest hospital network through a dashboard driven approach - The Apollo Quality Program","authors":"Priti Kaur, Raju Vaishya, A. Sibal, Gaurav Loria, K. Prasad, Sangita Reddy, Shobana Kamineni, Suneeta Reddy, Preetha Reddy","doi":"10.1177/25160435221105994","DOIUrl":"https://doi.org/10.1177/25160435221105994","url":null,"abstract":"Background Quality and patient safety are the driving forces for resilient healthcare organizations. However, the healthcare leadership is central to the role of establishing the values of quality and patient safety in the organization. This task becomes extremely challenging when the safety culture has to be built across a large hospital network. Methods A comprehensive patient safety program, the Apollo Quality Program(AQP), structured in the form of a patient-safety dashboard was used as a tool to establish and strengthen the fabric of quality and safety across a large hospital network in India. The dashboard consisted of essential patient safety parameters that were measurable and objective. This dashboard was implemented across 41-hospitals of the network and improvement data monitored. These 41-hospitals varied in size and on basis of their bed strength they were categorized into 3 groups(A,B and C). For this study, the results have been presented from 2011 to 2021. Results The overall AQP scores improved indicating holistic enhancement of patient safety across Apollo Hospitals. Sustained progress, through the last nine years, was observed for various patient safety parameters in the AQP dashboard, across 41-hospitals of the network. Conclusion AQP is an innovative methodology that incorporates all the essential tenets of patient-safety. The programme led to a progressive improvement in patient-safety over the nine-years of its implementation. The enhancement was visible through compliance to the various parameters of AQP. The AQP empowered the leadership to retrospect and analyse each of their units’ performance for patient-safety and quality in systematic manner.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"15 1","pages":"172 - 180"},"PeriodicalIF":0.0,"publicationDate":"2022-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88900768","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":"Supply and Demand: Meeting the Need for Graduate Training in Patient Safety","authors":"A. Wu","doi":"10.1177/25160435221106271","DOIUrl":"https://doi.org/10.1177/25160435221106271","url":null,"abstract":"Every Spring at graduation for the Johns Hopkins Bloomberg School of Public Health, our former dean used to stand on stage before a sea of black robes, and vigorously proclaim “This is the happiest day of the year!” I found myself recently remembering that feeling. It was the evening before graduation, and I hosted a reception for the graduates of our online Masters of Applied Science in Patient Safety and Healthcare Quality. Because the program is fully online, part-time, and designed for working professionals, the majority of students had never visited our campus, and had never met other students in-person. It was remarkable to see just how many of them showed up – more than half of our 77 graduates. They appeared from as far away as the United Kingdom and the Philippines, some driving cross country with families in tow, all dressed to the nines. For them, it was an auspicious moment. One student observed that it was the first time that they had met one another, and likely the last time they would see each other. But that is not to say that they had not gotten to know their classmates, over at least two years spent completing course requirements. Most had bonded early with fellow students on-line, with whom they talked for hours about class assignments, as well as about work and everyday life. It was heartwarming to witness pairs of study-buddies meeting for the first time in person, with squeals of recognition and joy, hugs, and selfies. Students shared war stories, and recalled favorite professors and classes. Their passion and zeal were palpable. Earning an advanced degree in patient safety and quality was a watershed that had already carried several of them to new posts and careers. This moment, however, is all too rare. In the last two decades, Patient Safety and Healthcare Quality has emerged as a new field of research and practice. As the emphasis has increased on providing evidence-based, high quality, high value care, so has work to prevent adverse events, misuse of treatments, and inconsistent delivery of care. But until recently, researchers and practitioners entered the field through degrees in other fields: medicine, nursing, public health, health informatics, management or administration, or other established professions. For example, I got into patient safety after completing training in internal medicine, when the topic was still referred to as “medical error.” Although today patient safety is a priority for all health care organizations, the requisite training is neither widely nor evenly distributed. In the US, there is still relatively small number of graduate level programs specifically focused on patient safety and quality. There are increased opportunities in education and training that have grown up organically. These vary widely in topic, level of expertise, duration, cost, location, modality, intended audience, and who delivers the material. But they are not coordinated. Some offerings focus on a specific topic, such te","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"110 1","pages":"97 - 99"},"PeriodicalIF":0.0,"publicationDate":"2022-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82361842","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":"Identifying boundary spanning reporter roles in patient safety events","authors":"V. Hurley, Christian Boxley, E. Sloss, Allan Fong","doi":"10.1177/25160435221103096","DOIUrl":"https://doi.org/10.1177/25160435221103096","url":null,"abstract":"Objective We evaluated patterns in reporter roles among individuals who submitted patient safety event (PSE) reports with a focus upon understanding the extent of boundary spanning behavior through the novel use of an information entropy measure. Methods A total of 81,759 reports submitted by 13,348 unique reporters to a voluntary, centralized incident reporting system database of a large Mid-Atlantic healthcare system between January 1, 2018 and December 31, 2020 were analyzed. We used an entropy measure to identify individuals with boundary spanning roles across departments and general event types. Results We find that high department entropy characterizes technicians, administrators and physician roles while high event type entropy is noted among physicians and nurses. Physicians had both high event type and department entropy, while no other role appeared to have both high event type and departmental entropy. Several roles were associated with inversely related entropies, including nurses who demonstrated high event type entropy and low department entropy . Pharmacists demonstrated low event type entropy and high department entropy. Conclusion Our findings echo existing literature that has suggested that nurses often exhibit boundary spanning tendencies at the same time that we underscore their role in reporting diverse types of PSEs. We also find that administrators, physicians and technicians are more likely to report events from across departmental boundaries. Such information may provide health care systems with a unique perspective on PSEs and be instrumental in efforts to identify key staff roles for quality improvement in the patient safety context.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"44 1","pages":"181 - 187"},"PeriodicalIF":0.0,"publicationDate":"2022-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81040712","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":"Risk management of smart healthcare systems: Delimitation, state-of-arts, process, and perspectives","authors":"Yiliu Liu","doi":"10.1177/25160435221102242","DOIUrl":"https://doi.org/10.1177/25160435221102242","url":null,"abstract":"Sensing, communication, computation, and control technologies are facilitating smart healthcare to improve efficiency and effectiveness of medical treatment and care. This study focuses on the risk issues relevant with the adverse events where novel technical systems do not serve as expected. We discuss the unique challenges, define the scope of risk management in healthcare and review the state-of-art research on diverse topics under the framework widely used in risk management. Then, we present a systematic approach to identify the hazards to patients and other asset of interest in the perception, cyber communication, and execution of smart technologies and their operational contexts. We also investigate different methods for scenario, likelihood, and consequence analyses for specifying the risks of adverse events, and categorize the approaches of risk reduction, as the main strategy of treating risks of smart healthcare systems, into four groups of design, operation, organization, and legislation. At the last, the article proposes some research perspectives responding to the developing trend of smart healthcare.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"38 1","pages":"129 - 148"},"PeriodicalIF":0.0,"publicationDate":"2022-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79390405","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 case report a delayed diagnosis of tracheomalacia resulting in prolonged steroid therapy, repeated hospital admissions and CT scans","authors":"C. Hardy, Gwynedd Clark","doi":"10.1177/25160435221102428","DOIUrl":"https://doi.org/10.1177/25160435221102428","url":null,"abstract":"A 30-year-old patient was admitted with shortness of breath and cough. Previous electronic entries state a history of asthma and hay fever. Repeated clerking by junior doctor states admission for treatment of likely exacerbation of asthma. The patient failed to fully improve with repeated courses of oral corticosteroids, regular nebulisers and oral antibiotics. The patient failed to improve even after several repeated admissions for similar admissions. On each admission she was subjected to CT scan and steroid courses, and at one point even had the authenticity of her symptoms questioned. Eventually she was found to have a case of tracheomalacia. Unfortunately, despite the eventual diagnosis, the patient has suffered side effects due to the delayed diagnosis and repeated treatment courses.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"79 1","pages":"149 - 153"},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80906068","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":"Evaluation of patient relatives’ opinions on physical restraint","authors":"Ö. Özdemir, A. Keçeci","doi":"10.1177/25160435221102437","DOIUrl":"https://doi.org/10.1177/25160435221102437","url":null,"abstract":"Background Most of the research on physical restraint is focused on determining patients’ experiences of restraint, the consequences of restraint, and healthcare professionals’ perceptions and attitudes. The aim of this study was to determine the opinions of the relatives of patients, who are a critical component of care, about physical restraint. The study used the mixed methods research approach, which combines quantitative and qualitative data collection methods. Method The study population consisted of 984 relatives of patients hospitalized in units where physical restraint was commonly applied between January 2018 and December 2018, and the sample consisted of 277 relatives of patients. The qualitative sample of the study consisted of 22 patient's relatives who were interviewed using the maximum diversity sampling method, a purposive sampling method. The quantitative data were analyzed using frequency, percentage, Chi Square (X2-Chi Square) test, and the qualitative data were analyzed using content analysis. Results The results showed that consent for physical restraint was generally obtained from spouses, physical restraint was applied to prevent self-harm, but relatives of the patients were insufficiently informed and worried about complications. It was also found that the most frequent reasons for physical restraint were self-harm and facilitation of treatment and care for the male patients and the feeling of helplessness for the female patients. Conclusion It was determined that the relatives of patients regarded physical restraint for treatment positively, but they were worried about complications, and they were mostly insufficiently informed before the intervention.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"6 1","pages":"100 - 110"},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91112862","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}