Journal of patient safety and risk management最新文献

{"title":"Ensuring the quality and quantity of personal protective equipment (PPE) by enhancing the procurement process in Northern Ireland during the coronavirus disease 2019 pandemic: Challenges in the procurement process for PPE in NI.","authors":"Kathryn Burnett,&nbsp;Suzanne Martin,&nbsp;Catherine Goudy,&nbsp;John Barron,&nbsp;Linda O'Hare,&nbsp;Peter Wilson,&nbsp;Glenda Fleming,&nbsp;Michael Scott","doi":"10.1177/25160435211057385","DOIUrl":"https://doi.org/10.1177/25160435211057385","url":null,"abstract":"<p><p>This article outlines the purchasing process for personal protective equipment that was established for Health and Social Care in Northern Ireland in response to the outbreak of coronavirus disease 2019. The Business Services Organisation Procurement and Logistics Service, who are the sole provider of goods and services for Health and Social Care organisations, was faced with an unprecedented demand for personal protective equipment in response to the coronavirus disease 2019 pandemic. The usual procurement process was further complicated by changing messages within guidelines which resulted in confusion and anxiety when determining whether or not a product would meet the required safety guidance and was therefore suitable for purchase. In order to address these issues in a rapidly changing and escalating scenario the Department of Health asked the Business Services Organisation Procurement and Logistics Service to work with the Medicines Optimisation Innovation Centre to maximise the availability of personal protective equipment whilst ensuring that it met all requisite quality and standards. A process was implemented whereby the Medicines Optimisation Innovation Centre validated all pertinent essential documentation relating to products to ensure that all applicable standards were met, with the Business Services Organisation Procurement and Logistics Service completing all procurement due diligence tasks in line with both normal and coronavirus disease 2019 emergency derogations. It is evident from the data presented that whilst there were a significant number of potential options for supply, a large proportion of these were rejected due to failure to meet the quality assurance criteria. Thus, by the process that was put in place, a large number of unsuitable products were not purchased and only those that met extant standards were approved.</p>","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"27 1","pages":"42-49"},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8926917/pdf/10.1177_25160435211057385.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40314121","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":"How will state medical boards handle cases involving disclosure and apology for medical errors?","authors":"D. Wojcieszak","doi":"10.1177/25160435211070096","DOIUrl":"https://doi.org/10.1177/25160435211070096","url":null,"abstract":"Surveys were sent to 68 American state medical boards, including territories of the United States, inquiring how they handle—or will handle—cases involving disclosure and apology after medical errors. Surveys were not sent to specialty boards. Thirty-eight state medical boards (n  =  38, 56%) responded to the survey, with 31 completing the survey (46% completion rate) and seven boards (n  =  7) providing explanations for nonparticipation and other thoughts; 30 boards did not respond in any manner. Boards that completed the survey indicated that disclosure and apology and other positive post-event behavior by physicians are likely to be viewed favorably and disclosing physicians will not be easy targets for disciplinary measures, though boards also stressed they view each case on the merits and patient safety is their top priority. Recommendations are made for policy makers and other stakeholders.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"4 1","pages":"15 - 20"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74941460","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":"Awareness and understanding among patients about patient safety in India: A cross-sectional questionnaire-based study","authors":"S. Bhowmick, Snigdha Banerjee, Saibal Das, A. Nath, Debarati Kundu, Anupama Das, Nina Das, K. Ray, S. Purkayastha","doi":"10.1177/25160435211065672","DOIUrl":"https://doi.org/10.1177/25160435211065672","url":null,"abstract":"Background There is a dearth of studies from India evaluating the awareness of patient safety. This study was performed to gain insight into the Indian patients’ awareness about patient safety and evaluate their willingness in promoting the same. Methods In this cross-sectional study, online interactive sessions pertaining to patient safety and patient safety culture were arranged by clinical pharmacologists for 800 urban patients post-discharge from a tertiary care hospital in India. A validated questionnaire was used, and the responses were analysed using descriptive statistics. Results A total of 635 patients [mean age, 43.2  ±  10.3 years; 385 (60.6%) males] responded. A total of 93.4% of the patients were aware of the term “patient safety” and 35.3% faced situations where they felt that patient safety was compromised. Of these patients, 64.3% reported to higher authorities when faced with such situations, while the remaining either ignored the issue or had no idea about how to deal with the same. A total of 99.2% of the patients never participated in any patient safety program; nevertheless, 94.5% of them were willing to participate in the same. Accessibility to information about patient care was deemed essential by 58.3% of the patients. Conclusions Although the overall awareness about patient safety among urban Indian patients is high, there is a lack of awareness about ways of dealing with patient safety issues. Given the high level of interest in participating in patient safety programs, such programs should routinely include patients for optimizing the chances for safer provision of health care.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"226 1","pages":"21 - 25"},"PeriodicalIF":0.0,"publicationDate":"2022-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80143941","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":"Medications at discharge aren't just for the long haul: A model for the management of short-term medications","authors":"S. Sharara, A. Arbaje, S. Cosgrove, A. Gurses, Kathryn Dzintars, S. Keller","doi":"10.1177/25160435211065853","DOIUrl":"https://doi.org/10.1177/25160435211065853","url":null,"abstract":"Unsuccessful medication management (MM) after hospital discharge contributes to suboptimal outcomes including readmissions, emergency department visits, and death. Prior models and toolkits for MM at the hospital-to-home transition such as the Agency for Healthcare Research and Quality Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation focus on the patient and healthcare workers and not on other factors that may impact MM. While the Transition Model of MM describes the hospital-to-home transition of MM tasks among older adults with a particular focus on the MM work system, it focuses on initiation or continuation of chronic medications. However, many medications in classes responsible for the greatest number of readmissions are not intended to be taken chronically. Examples include antibiotics, opioids, and steroids, which are often prescribed for short durations; and diuretics, hypoglycemics, and vitamin K antagonists, which require careful titration. Short-term MMmay require changes to standard MMmodels, as shortterm medications need to be started immediately on discharge, and stopped or adjusted within just a few days or weeks after discharge. We will describe the current state of short-term MM at the hospital-to-home transition and hazards to short-term MM (Figure 1), and suggest how to address these hazards. The work systems of the hospital and the home intertwine in short-term MM at the hospital-to-home transition. The hospital work system and home work system interact with ambulatory pharmacies and clinics and each other. We will describe each work system, necessary processes in each work system for short-term MM, and associated hazards.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"20 1","pages":"6 - 8"},"PeriodicalIF":0.0,"publicationDate":"2021-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73986447","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 in long-term care facilities and the COVID-19 pandemic","authors":"A. Wu, J. McIntyre","doi":"10.1177/25160435211059871","DOIUrl":"https://doi.org/10.1177/25160435211059871","url":null,"abstract":"Significant parts of the world are growing old. During this century, several regions will experience a marked increase in the proportion of adults over 65 years old. This transition is well underway in the United States as the so-called baby boomers, born between 1946 and 1964, began turning 65 in 2011. It is projected that the US population aged 65 and over will reach 83.7 million by 2050, equivalent to more than 20% of the entire population. The US is not unique in this. By 2040, the median age in Japan will be 70, and it is anticipated that Asia, Latin America and the Caribbean will join Europe and North America as having more people older than 60 than children under age 15. The need for long-term care is growing alongside the rapidly aging population. In 2018, over 14 million Americans needed long-term care services. By 2025, it is projected that 1 out of every 5 Americans will be retirement age, and just over half of those individuals will require long-term care. Despite unprecedented growth in the long-term care industry, there are serious deficiencies in patient safety and quality of care. In the US, the Office of the Inspector General estimated that 22% of Medicare beneficiaries in skilled nursing facilities, and 46% in long-term care hospitals experienced adverse events. Over half of these adverse events were thought to be preventable. Reports also suggest that a large majority of nursing homes fail to meet federal quality standards. The most common safety issues in long-term care include pressure ulcers, falls, medication administration errors and nosocomial infection. It has been suggested that the high incidence of adverse events in long-term care compared to hospitals is due to lower levels of staff training, lower staff to resident ratios, longer term stays, and a broader scope of care. In the US, there have long been attempts to improve the quality of long-term care, beginning with the Nursing Home Reform Act in 1987, which imposed federal standards to bolster inspections and nursing home quality enforcement. The 2006 Advancing Excellence in America’s Nursing Homes Campaign, which later morphed into the National Nursing Home Quality Improvement Campaign, was another attempt, which promoted nine goals to improve quality in nursing homes. In 2013 the Commission on Long-term Care adopted 28 public policy recommendations in service delivery, workforce and financing in long-term care. There have also been attempts to measure patient safety in long-term care settings, such as the “Nursing Home Compare” program offered by the Centers for Medicare & Medicaid Services. However, the scores in these systems have been criticized as having a weak and inconsistent relationship between facility metrics and actual performance. In the US, improvements have been stymied by a general lack of research focused on quality of care and patient safety in long-term care settings, with a specific lack of studies on the effectiveness of improvement initiative","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"87 1","pages":"234 - 236"},"PeriodicalIF":0.0,"publicationDate":"2021-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73621745","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":"“We’re on our way:” A message from the mountains","authors":"A. Hannawa","doi":"10.1177/25160435211058145","DOIUrl":"https://doi.org/10.1177/25160435211058145","url":null,"abstract":"How do we improve the quality and safety of care? In healthcare, we commonly look at outcome measures when pondering this question. But safety-critical processes are not visible in these measures. And if they remain undetected, they can be a dormant source of sudden harm. This past year, I have immersed myself into the study of mountain rescues as part of a funded scientific investigation. At patient safety meetings, I have long encountered comparisons to the airline industry. “What can healthcare learn from aviation safety?” Patient safety research has begun to compare healthcare teams with flight crews. It has implemented aviation-based “Crew Resource Management (CRM)” models into the healthcare setting. But on what foundation? From a scientific standpoint, building this bridge into practice based on purely theoretical arguments seems insufficient. Instead of accepting the validity of this comparison at face value, I decided to take a closer look at safety-relevant processes in a context where both industries work together to save patients’ lives. Where this comparison is not merely a rhetorical exercise, but observable in practice. This is how I came to participate in airborne mountain rescues. I have spent all of the past year flying along with rescue teams and analyzing hundreds of rescues at the regional emergency call center (144). I interviewed all participating actors in this highly interprofessional setting, where pilots, physicians, paramedics, mountain guides, and 144-staff must work together smoothly under high-stakes conditions to prevent harm while saving patients’ lives. One of the rescues I attended was on a warm Friday afternoon in the Fall of 2020. We had just brought an injured skier with a shoulder dislocation from a ski slope at 4,000 m elevation to the regional hospital, when we were called about a patient with cardiac arrest in a nearby mountain village. The primary difficulty of airborne rescues is always to find a place to land the helicopter. Sometimes, if there is no possibility to exit by foot, the physician or mountain guide have to rappel from the airborne helicopter on a 200 meter free-hanging rope to be with the patient. In the case of this particular rescue, there was a meadow where we could land. The son and wife of the patient waived at us frantically, signaling us to follow them. Still in glacier suits and loaded with the heavy resuscitation equipment, we followed them into their house. The physician immediately asked pointed questions to find out what happened. The son’s voice shifted between hope, despair and distress as he proclaimed repeatedly: “He’s dead, I think he’s already dead.” Through repeated questioning, the story emerged: The patient, a man of about age 60, had been chopping wood behind the house when he felt a sudden, severe pain in his chest and collapsed. The son and his wife had brought him back into the house and laid him on the couch in the living room, where the patient shortly after procl","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"7 1","pages":"240 - 242"},"PeriodicalIF":0.0,"publicationDate":"2021-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76011208","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":"Reducing unintended retained foreign objects in operating rooms: a proactive risk assessment framework to improve patient safety","authors":"Maryam Tabibzadeh, Zarna Patel","doi":"10.1177/25160435211044608","DOIUrl":"https://doi.org/10.1177/25160435211044608","url":null,"abstract":"According to a study by Johns Hopkins, an average of 251,454 Americans die annually from medical errors. Medical error is the third leading cause of death in the U.S. after heart disease and cancer. Unintended retained foreign objects (URFOs) has been identified as the most common sentinel event by The Joint Commission. This paper proposes a proactive risk assessment framework to enhance patient safety in operating rooms by addressing the URFOs issue. This framework is developed by integrating the 10 traits of a positive safety culture, initially introduced by the nuclear industry and later adopted by other industries, with an accident investigation methodology called AcciMap, originally developed by Rasmussen. The AcciMap is a hierarchical framework consisting of several layers: government and regulatory bodies, company (hospital), (surgery division) management, (operating room) staff, and work. Thirty main categories of socio-technical contributing causes of URFOs were captured across the AcciMap layers. Organizational factors were identified as the root cause of questionable decisions made by staff and management. Financial and budget constraints, inadequate training infrastructure, absence of a risk management infrastructure, and leadership failure are the most influential organizational factors contributed to URFOs. Our mapping of the aforementioned positive safety culture traits on the AcciMap depicted that the four traits of Work Processes, Leadership Safety Values and Actions, Effective Communication, and Continuous Learning had the most influence on the URFOs issue. Associated recommendations to these findings are provided to contribute to reducing risks of URFOs instances.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"7 1","pages":"26 - 41"},"PeriodicalIF":0.0,"publicationDate":"2021-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74402646","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":"Kendal at Ithaca beats COVID-19","authors":"Charles Wilcox","doi":"10.1177/25160435211057879","DOIUrl":"https://doi.org/10.1177/25160435211057879","url":null,"abstract":"","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"242 1","pages":"237 - 239"},"PeriodicalIF":0.0,"publicationDate":"2021-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74968900","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":"Consumer background and composition on state medical boards: Who are these citizen members and do they adequately protect the public?","authors":"D. Wojcieszak","doi":"10.1177/25160435211054343","DOIUrl":"https://doi.org/10.1177/25160435211054343","url":null,"abstract":"The composition and background of members of state medical boards, including public or citizen members, can impact the functionality and public perception of medical boards in the United States. This study analyzed the number of public members on each state medical board and their professional backgrounds or expertise to regulate the medical profession. The findings show that for nearly half of state medical boards public members comprise at least a quarter of their voting members; however, more than half of public members for all state medical boards have no measurable medical experience or background, including in patient safety. The need for public members to have medical expertise or background – especially in patient safety -- is discussed along with potential policy recommendations.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"15 1","pages":"267 - 271"},"PeriodicalIF":0.0,"publicationDate":"2021-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81863084","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 self-reported empathy and communication skills through harm in healthcare response training","authors":"Aimee Samuels, M. Broome, T. McDonald, Chii-Hui Peterson, Julie A. Thompson","doi":"10.1177/25160435211047643","DOIUrl":"https://doi.org/10.1177/25160435211047643","url":null,"abstract":"Objective Communication and Resolution Programs (CRP) were developed to equip healthcare organizations with tools to respond when physical and psychological harm occurs. Our objective was to assess development of empathic behaviors and communication skills through CRP training based upon the Agency for Healthcare Research and Quality (AHRQ) CANDOR toolkit to assess the ability to develop and improve empathic behaviors and communication skills. Methods The Jefferson Scale of Empathy, the CANDOR Communication Assessment Questionnaire and a self-assessment were used pre- and post-intervention to analyze development of empathy, growth of communication, and improvement in confidence and knowledge through 6 h of virtual education over a six-week course. Results Self-reported communication, confidence and knowledge improved with statistical significance and small to moderate effect size in both men and women. A statistically significant improvement of self-reported empathy scores t (22)  =  2.23, p  =  .037; (95% CI  =  0.41 to 11.5) for women only represented a small to moderate effect size (Cohen’s d  =  0.46). While there was no improvement in Cognitive Complexity, (Cohen’s d  =  0.065) mean pre-post .42 (SD  =  6.52); Message Design Logic improved with statistical significance in paired pre-and post-assessment (Z  =  -3.28, p  =  .001). Notably, previous attendance at CANDOR classes demonstrated no impact on improvement of scores. Conclusions Our findings demonstrate improvement in self-reported empathy and communication skills through harm in healthcare response training. Healthcare organizations should carefully consider investing in CANDOR training for the benefit of patients, their families, and healthcare workforce members.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"81 1","pages":"251 - 260"},"PeriodicalIF":0.0,"publicationDate":"2021-10-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82136347","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}