Dosing Cefepime for Renal Function Does Not Completely Prevent Neurotoxicity in a Patient With Kidney Transplant
We report a case of nonconvulsive status epilepticus from dose-adjusted cefepime in a kidney transplant patient. The timing of symptoms along with clinical and electroencephalographic improvement after discontinuation of cefepime was critical to the diagnosis. Whether we should adjust the dose of cefepime differently in a patient with transplanted kidney to prevent neurotoxicity is unknown. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Case Reports Source Type: research

Cultural Impact on Medication Instructions: The Case of the Turkish Teaspoon
Medication errors are preventable events related to inappropriate medication use that could potentially result in patient harm. Here we present a patient encounter that has exemplified the importance of appropriate communication and the inevitable role of every individual in ensuring appropriate prescription medication use. Multidisciplinary efforts are required to ensure patient safety in today’s systems based practice. This case highlights cultural barriers to the practice of medicine and the growing need to explore and address them appropriately. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Case Reports Source Type: research

Physicians and Students Take to the Streets to Ask: What Do People Want From Their Health Care?
With the aim of better understanding what the public (as opposed to “patients”) wants from health care, this study asked people on the street, “What does the right health care mean to you?” Responses ranged from “Caring about me more than just in the appointment” to “That everyone should see exactly what medical treatment costs.” A qualitative analysis revealed that all responses fell into 2 overarching categories: health care at the interpersonal level and health care at the system level. Approximately 66.7% of responses included system-level factors, whereas 59% of response...
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Standardized Consent: The Effect of Information Sheets on Information Retention
Conclusions Consent remains challenging even with a standardized process. Information retention improves significantly with the use of information sheets. We advocate the use of standard consent and provision of patient information sheets for commonly performed procedures. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Understanding Medication Schedules: Do Pictograms Help?
Conclusions In this pilot study, the use of pictograms did not significantly improve participants' ability to correctly fill a pillbox. However, most participants preferred pictograms to text labels. Further research is needed to determine the efficacy of pictograms in specific populations. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

A Systematic Review of Primary Care Safety Climate Survey Instruments: Their Origins, Psychometric Properties, Quality, and Usage
Conclusions and Relevance Valid and reliable instruments, which are context specific to the healthcare environment for intentional use, are essential to accurately assess SC. Key recommendations include further establishing the construct and criterion-related validity of existing instruments as opposed to developing additional surveys. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Intravenous Infiltration Resulting in Compartment Syndrome: A Systematic Review
Conclusion Compartment syndrome affects patients of all ages with a significant number of patients being pediatric and specifically younger than 1 year. Patients at highest risk of developing CS requiring surgery from IV infiltration are likely to have barriers to communication. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Review Article Source Type: research

Commentary on “Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims?: One Healthcare System's Experience” by Painter LM, Kidwell KM, Kidwell RP, et al
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Invited Commentary Source Type: research

Evaluation of a Computer Application for Retrospective Detection of Vitamin K Antagonist Treatment Imbalance
Conclusions Our study shows the great potential of the ADE scorecards for detecting cofactors of VKA overdoses and gives an argument to include complex rules in the knowledge bases used for the detection and identification of ADEs in large medical databases. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

An Assessment of Basic Patient Safety Skills in Residents Entering the First Year of Clinical Training
Conclusions Developing and hardwiring basic patient safety skills is essential for creating an institutional culture of safety. We used a simulated patient scenario to provide a baseline assessment of 2 important safety skills. The results obtained demonstrate poor compliance with hand hygiene and patient identification. Our results suggest that there is a need for additional training and perhaps new methods of training and reinforcement in medical school and beyond, to hardwire these basic patient safety skills. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

The Safety Stand-down: A Technique for Improving and Sustaining Hand Hygiene Compliance Among Health Care Personnel
The objective of this study was to determine whether a safety stand-down can improve HH compliance. Methods We adapted and borrowed from the military an approach known as a stand-down. A mandatory Hand-Hygiene Leadership Safety Summit was called for all hospital leaders—physicians and nonphysicians. Four days later, a hospital-wide 15-minute–long safety stand-down occurred, during which all nonessential activity was suspended and action plans to improve HH compliance were discussed. All medical sections and hospital departments were required to submit written action plans. After the stand-down, HH compliance...
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Label Design Affects Medication Safety in an Operating Room Crisis: A Controlled Simulation Study
Conclusions The redesigned labels helped participants correctly select hetastarch from the cart, thus preventing some potentially catastrophic medication errors from reaching the simulated patient. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

The Trigger Tool as a Method to Measure Harmful Medication Errors in Children
Conclusions The original pediatric medication-focused trigger tool yielded only false-positive scores and left unsafe situations undiscovered. We conclude that a multifaceted method remains the preferred method to detect harmful MEs. The additional value of the trigger tool stays unclear. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims? One Health Care System's Experience
Conclusions and Relevance Implementation of a mandated serious event disclosure law in Pennsylvania was not associated with an overall increase in malpractice claims filed. Among events of similar degree of harm, disclosed events had higher compensation paid compared with those that had not been disclosed. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events
Introduction Implementation of the World Health Organization checklists has reduced major surgical complications and errors; however, the impact of preoperative briefings on intraoperative adverse events has not been assessed. Materials and Methods A prospective case-control study assessing the association between preoperative briefings and minor, potentially major, and major adverse intraoperative events was performed in 2 phases. Phase 1 involved prospective data collection for all trauma and orthopedic lists during a 2-week period. Changes were implemented as a result of the findings, and after this, the study was ...
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Medication Review and Patient Outcomes in an Orthopedic Department: A Randomized Controlled Study
Conclusions The study showed that the patients receiving usual care had a significantly longer time to the first unplanned contact to a physician after discharge; however, the fact that less than 1 of 5 recommendations was adopted by the physicians raises concerns as to whether this finding could be attributable to the intervention. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes
Conclusions This all-cause harm safety study indicates that inpatient harm has negative financial outcomes for hospitals and negative clinical outcomes for patients. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Seamless Transitions: Achieving Patient Safety Through Communication and Collaboration
Conclusions A culture of patient safety was facilitated by a registered nurse transitions coach through consistent communication and flow of patient information during patient hand offs across the care continuum. More than 1000 patients are already admitted to the next iteration of the TRACS program, resulting in a sustainable enterprise. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Case Reports Source Type: research

Cupping (Hijama) Treatment: Benign or Sinister?
We present a hitherto unreported complication of bilateral subdural hemorrhage associated with this therapy, highlighting the need for vigilance in patients presenting with headache because they may get misdiagnosed unless history for such therapies is explored. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Case Reports Source Type: research

Radiation Exposure: Optimizing Image Quality or Image Utility?
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Letter to the Editor Source Type: research

A Comparison of Error Rates Between Intravenous Push Methods: A Prospective, Multisite, Observational Study
Conclusions The ready-to-administer group demonstrated a statistically significant lower observed error rate, suggesting that use of this product is associated with fewer observed preparation and administration errors in the clinical setting. Future studies should be completed to determine the potential for patient harm associated with these errors and improve clinical practice because it relates to the safe administration of IV push medications. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community Hospitals
Conclusions Driven by the combination of a repository of evidence-based tools and best practices, readily available data on PrU rates, and local flexibility with processes, the Reducing Hospital Acquired–PrUs Program represents the successful operationalization of improvement in a wide variety of facilities. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report
Conclusions Preventing wrong IOL implant adverse events requires diligence beyond performance of the preprocedural time-out. In 2013, the VHA has modified policy to ensure double check of preprocedural calculations and implant read-back with positive impact. Continued analysis of contributing human factors and improved surgical team communication are warranted. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root Cause Analysis Is Not the Best Model for Error Investigation in Mental Health Services
Conclusions Although the RCA model offers a formal and systematic approach to the review of serious critical incidents in mental health, it is not the model of best fit. Only 65% of recommendations made through RCA reviews are implemented within 12 months. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

A Measure of Barriers Toward Medical Disclosure Among Health Professionals in the United Arab Emirates
Conclusions The disclosure of medical mistakes requires preliminary considerations to effectively and compassionately disclose these events to patients. The validity and reliability of the results support the use of this scale at hospitals as part of the health care providers' disclosure processes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Medications and Patient Characteristics Associated With Falling in the Hospital
Conclusions This study identified medications and patient characteristics associated with increased risk for falling in the hospital. High-risk medications identified in this study may serve as targets for medication review or adjustment, which have been recommended as a component of multifaceted fall prevention programs. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

“The Jackson Table Is a Pain in the…”: A Qualitative Study of Providers’ Perception Toward a Spinal Surgery Table
Conclusions This study is relevant to everyday practice for spinal surgical team members and advances our understanding of how surgical teams qualitatively view the current process of patient positioning for spinal surgery. Providers recommended best practices for using the Jackson Table, which can be achieved through standardized practice for transfer of patients, educational tools, and checklists for equipment before patient transfer and positioning. This research has identified several important practice opportunities for improving provider and patient safety in spine surgery. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

High Rate of Implementation of Proposed Actions for Improvement With the Healthcare Failure Mode Effect Analysis Method: Evaluation of 117 Analyses
Conclusions Most of the proposed actions were implemented. The use of HFMEA can be improved using fewer team leaders but with more experience. The work involved in writing a report can be reduced without loss of impact on the organization. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Interventional Procedures Outside of the Operating Room: Results From the National Anesthesia Clinical Outcomes Registry
This study examines the impact of procedural locations and types of anesthetics on patient outcomes in non-operating room anesthesia (NORA) locations. The National Anesthesia Clinical Outcomes Registry database was examined to compare OR to NORA anesthetic complications and patient demographics. Methods The National Anesthesia Clinical Outcomes Registry database was examined for all patient procedures from 2010 to 2013. A total of 12,252,846 cases were analyzed, with 205 practices contributing information, representing 1494 facilities and 7767 physician providers. Cases were separated on the basis of procedure location,...
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Original Articles Source Type: research

Accountability: Challenges to Getting It Right
This article proposes that it is the wrong question, and the failure to apply patient safety science in clinical practice is contributing to the ambiguity fueling the debate. To transform accountability from a source of confusion to a powerful tool for fulfilling health care's fiduciary responsibility to protect patients from harm, we need to reframe our approach. This article presents the science and strategies to create clarity that will redirect the dialogue from a debate in which accountability resides to one about learning for improvement when adverse events occur. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Review Article Source Type: research

When Doing Wrong Feels So Right: Normalization of Deviance
Normalization of deviance is a term first coined by sociologist Diane Vaughan when reviewing the Challenger disaster. Vaughan noted that the root cause of the Challenger disaster was related to the repeated choice of NASA officials to fly the space shuttle despite a dangerous design flaw with the O-rings. Vaughan describes this phenomenon as occurring when people within an organization become so insensitive to deviant practice that it no longer feels wrong. Insensitivity occurs insidiously and sometimes over years because disaster does not happen until other critical factors line up. In clinical practice, failing to do tim...
Source: Journal of Patient Safety - February 18, 2018 Category: Health Management Tags: Review Article Source Type: research

Shoulder Dystocia Documentation: An Evaluation of a Documentation Training Intervention—Observations
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Letter to the Editor Source Type: research

Bacterial Misidentification in a Resource-Limited Microbiology Laboratory Setting and Quality Improvement Strategies
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Case Report Source Type: research

Development of a Medication Safety and Quality Survey for Small Rural Hospitals
Conclusions The survey can be used to conduct a short medication safety assessment specific to a limited number of areas and services in CAHs. It showed good ability to discriminate medication safety levels across participating sites and highlighted opportunities for improvement. It may need modification if case mix or services differ in other states or if the status quo of medication safety in CAHs or related standards advance. The described process of survey development might be helpful to support such modifications. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Transparency When Things Go Wrong: Physician Attitudes About Reporting Medical Errors to Patients, Peers, and Institutions
Objectives Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency. Methods We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey. We used bivariate correlations, principal components analysis, and linear regression to determine whether and how physician attitudes about ...
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

An Evaluation of Shared Mental Models and Mutual Trust on General Medical Units: Implications for Collaboration, Teamwork, and Patient Safety
This study examines nurse-physician teamwork and collaboration, a critical component in the delivery of safe patient care, on general medical units. To that end, we assess shared mental models and mutual trust, 2 coordinating mechanisms that help facilitate teamwork, among nurses and physicians working on general medical units. Methods Data were collected from 37 nurses and 42 physicians at an urban teaching medical center in the Northeastern United States. Shared mental model questionnaire items were iteratively developed with experts' input to ensure content validity. Mutual trust items were adapted from an existing s...
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets
Conclusions Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians' clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units
Conclusions This study shows that CRM requires preparation and implementation, both of which require time and dedication. It is promising to note that all 3 ICUs have developed multiple quality improvement initiatives and aim to continue doing so. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Screening Questions for Nonsteroidal Anti-inflammatory Drug Risk Knowledge
Conclusions Screening questions for subjective NSAID risk awareness and health literacy are predictive of objectively tested NSAID knowledge and can be used to triage patients as well as subsequently initiate and direct a conversation about NSAID risk. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

From Bad to Worse: Anemia on Admission and Hospital-Acquired Anemia
Background Anemia at hospitalization is often treated as an accompaniment to an underlying illness, without active investigation, despite its association with morbidity. Development of hospital-acquired anemia (HAA) has also been associated with increased risk for poor outcomes. Together, they may further heighten morbidity risk from bad to worse. Objectives The aims of this study were to (1) examine mortality, length of stay, and total charges in patients with present-on-admission (POA) anemia and (2) determine whether these are exacerbated by development of HAA. Design/Setting/Patients In this cohort investigatio...
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Efficacy and Cost-Benefit Analysis of a Global Environmental Cleaning Algorithm on Hospital-Acquired Infection Rates
Conclusions This global environmental cleaning protocol was associated with decreased HAIs and hospital costs. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Magnitude of Anemia at Discharge Increases 30-Day Hospital Readmissions
Background Anemia during hospitalization is associated with poor health outcomes. Does anemia at discharge place patients at risk for hospital readmission within 30 days of discharge? Our objectives were to examine the prevalence and magnitude of anemia at hospital discharge and determine whether anemia at discharge was associated with 30-day readmissions among a cohort of hospitalizations in a single health care system. Methods From January 1, 2009, to August 31, 2011, there were 152,757 eligible hospitalizations within a single health care system. The endpoint was any hospitalization within 30 days of discharge. The...
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Medical Harm: Patient Perceptions and Follow-up Actions
Conclusions In this sample of self-reported patient harms, we found a perception of inadequate apology. Nearly half of patient harm events are reported to an oversight agency, and roughly one-fifth result in a malpractice claim. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

The Effects of Hospital Safety Scores, Total Price, Out-of-Pocket Cost, and Household Income on Consumers' Self-reported Choice of Hospitals
Conclusions When shown Hospital Safety Score and cost information, consumers chose safer hospitals in 97% of cost and safety scenarios. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Interhospital Facility Transfers in the United States: A Nationwide Outcomes Study
Objectives Patient transfers between hospitals are becoming more common in the United States. Disease-specific studies have reported varying outcomes associated with transfer status. However, even as national quality improvement efforts and regulations are being actively adopted, forcing hospitals to become financially accountable for the quality of care provided, surprisingly little is known about transfer patients or their outcomes at a population level. This population-wide study provides timely analyses of the characteristics of this particularly vulnerable and sizable inpatient population. We identified and compared...
Source: Journal of Patient Safety - December 1, 2017 Category: Health Management Tags: Original Articles Source Type: research

Shoulder Dystocia Documentation: An Evaluation of a Documentation Training Intervention—Observations
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Letter to the Editor Source Type: research

Bacterial Misidentification in a Resource-Limited Microbiology Laboratory Setting and Quality Improvement Strategies
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Case Report Source Type: research

Development of a Medication Safety and Quality Survey for Small Rural Hospitals
Conclusions: The survey can be used to conduct a short medication safety assessment specific to a limited number of areas and services in CAHs. It showed good ability to discriminate medication safety levels across participating sites and highlighted opportunities for improvement. It may need modification if case mix or services differ in other states or if the status quo of medication safety in CAHs or related standards advance. The described process of survey development might be helpful to support such modifications. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

Transparency When Things Go Wrong: Physician Attitudes About Reporting Medical Errors to Patients, Peers, and Institutions
Objectives: Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency. Methods: We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey. We used bivariate correlations, principal components analysis, and linear regression to determine whether and how physician attitudes about tr...
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

An Evaluation of Shared Mental Models and Mutual Trust on General Medical Units: Implications for Collaboration, Teamwork, and Patient Safety
This study examines nurse-physician teamwork and collaboration, a critical component in the delivery of safe patient care, on general medical units. To that end, we assess shared mental models and mutual trust, 2 coordinating mechanisms that help facilitate teamwork, among nurses and physicians working on general medical units. Methods: Data were collected from 37 nurses and 42 physicians at an urban teaching medical center in the Northeastern United States. Shared mental model questionnaire items were iteratively developed with experts' input to ensure content validity. Mutual trust items were adapted from an existing sc...
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research