Institution of Just Culture Physician Peer Review in an Academic Medical Center
Conclusions Given the recognized benefits, this approach is being considered for implementation on a broader scale within service-line quality initiatives across the University of Pittsburgh Medical Center health system. Although first implemented among faculty, consideration of incorporation into graduate medical education programs is ongoing. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Study Source Type: research

Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage?
Interruptions are thought to be significantly associated with medication administration errors. Researchers have tried to reduce medication errors by decreasing or eliminating interruptions. In this article, we argue that interventions are often (perhaps unreflectively) based on one particular model of risk reduction—that of barriers placed between the source of risk and the object-to-be-protected. Well-intentioned interventions can lead to unanticipated effects because the assumptions created by the risk model are not critically examined. In this article, we review the barrier model and the assumptions it makes abou...
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Review Article Source Type: research

High-Alert Medication Stratification Tool-Revised: An Exploratory Study of an Objective, Standardized Medication Safety Tool
Objective To develop an objective tool designed to standardize the identification of high-alert medications (HAMs) according to patient safety risk. Methods Medications were evaluated using the High-Alert Medication Stratification Tool (HAMST). Tool revision occurred through assessing medications on an organization-approved HAM list and comparing scores with control medications not included on the list. Because of variations in HAMST interpretation by end users in interdisciplinary committees, a revision of the scoring tool was completed to create the High-Alert Medication Stratification Tool–Revised (HAMS...
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Reducing and Sustaining Duplicate Medical Record Creation by Usability Testing and System Redesign
Conclusions Usability testing was an effective method to reveal problems and aid system redesign to deliver a more user friendly system, hence reducing the potential for medical record duplication. Greater standards for usability would ensure that these improvements can be realized before rather than after exposing patients to risks. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Evaluation of a Broad-Spectrum Partially Automated Adverse Event Surveillance System: A Potential Tool for Patient Safety Improvement in Hospitals With Limited Resources
Conclusions The surveillance system showed variable sensitivity levels across a broad range of AE categories with an acceptable PPV, overcoming certain limitations associated with other harm detection methods. The number of cases captured was substantial, and none had been previously detected or voluntarily reported. For hospitals with limited resources, this methodology provides valuable safety information from which interventions for quality improvement can be formulated. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Medication Errors at Hospital Admission and Discharge: Risk Factors and Impact of Medication Reconciliation Process to Improve Healthcare
Objective First, the aim of the study was to assess the prevalence, characteristics, and severity of unintended medication discrepancies (UMDs) and medication errors (MEs) at admission and discharge of hospitalization. Second, the aim of the study was to identify clinical and hospitalization factors associated with risk of UMDs as well as characteristics of the medication reconciliation process associated with UMDs detection. Methods This prospective observational study included all adult patients admitted from 2013 to 2015 in the Endocrinology-Diabetology-Nutrition Department of Montpellier Hospital, France. Cl...
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

The Ideal Hospital Discharge Summary: A Survey of U.S. Physicians
Background Hospital discharge summaries enable communication between inpatient and outpatient physicians. Despite existing guidelines for discharge summaries, they are frequently suboptimal. Objective The aim of this study was to assess physicians’ perspectives about discharge summaries and the differences between summaries’ authors (hospitalists) and readers (primary care physicians [PCPs]). Methods A national survey of 1600 U.S. physicians was undertaken. Primary measures included physicians’ preferences in discharge summary standardization, content, format, and audience. Results ...
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Limited Documentation and Treatment Quality of Glycemic Inpatient Care in Relation to Structural Deficits of Heterogeneous Insulin Charts at a Large University Hospital
Objectives Insulin charts represent a key component in the inpatient glycemic management process. The aim was to evaluate the quality of structure, documentation, and treatment of diabetic inpatient care to design a new standardized insulin chart for a large university hospital setting. Methods Historically grown blank insulin charts in use at 39 general wards were collected and evaluated for quality structure features. Documentation and treatment quality were evaluated in a consecutive snapshot audit of filled-in charts. The primary end point was the percentage of charts with any medication error. Results ...
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Situation-Dependent Medical Device Risk Estimation: Design and Evaluation of an Equipment Management Center For Vendor-Independent Integrated Operating Rooms
Conclusions An automated operating room monitoring system with an integrated risk assessment and Time And Resource Management System module is a new way to assist the staff being outside of a vendor-independent integrated operating room, who are nevertheless involved in processes in the operating room. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Descriptive Analysis of Patient Misidentification From Incident Report System Data in a Large Academic Hospital Federation
Conclusion These results illustrate that misidentification errors are still common in France. This work contributes to enhancing interest in IRS data analysis to define or refine patient safety improvement strategies related to misidentification errors in healthcare institutions. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Development of Survey Scales for Measuring Exposure and Behavioral Responses to Disruptive Intraoperative Behavior
Conclusions We have developed scales measuring exposure and responses to disruptive behavior. They generate valid and reliable scores when surveying operating room clinicians, and they overcome the limitations of previous tools. These survey scales are freely available. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Development and Psychometric Evaluation of the Speaking Up About Patient Safety Questionnaire
Conclusions Patient safety concerns, speaking up, and withholding voice were frequently reported. With this questionnaire, we present a tool to systematically assess and evaluate important aspects of speaking up in HCOs. This allows for identifying areas for improvement, and because it is a short survey, to monitor changes in speaking up—for example, before and after an improvement project. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Test-Retest Reliability of an Experienced Global Trigger Tool Review Team
Conclusions The very experienced GTT team could not reproduce harm rates found in earlier reviews. We conclude that GTT in its present form is not a reliable measure of harm rate over time. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Prescribing Errors With Low-Molecular-Weight Heparins
Conclusions The frequency of prescribing errors was 34% in a tertiary care hospital. Being a patient with prophylactic LMWH use on a medical ward is a determinant for LMWH prescribing error. Interventions that will lead to better electronic recording of body weight and more awareness among medical doctors may reduce the total number of prescribing errors. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Sustaining Teamwork Behaviors Through Reinforcement of TeamSTEPPS Principles
Conclusions Sustained improvement in teamwork behaviors requires reinforcement. Level of Evidence Level III, prospective pre-post cohort study. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Patient Safety Climate in General Public Hospitals in China: A Multiregion Study
Conclusions Fear of shame and fear of blame are the most important barriers to the improvement of patient safety in the hospitals of China. Facility characteristics contributed somewhat to hospital patient safety climate in some dimensions. The initiatives to improve hospital patient safety climate are necessary and its implementation strategies needs to be shared. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research

Leading Causes of Anesthesia-Related Liability Claims in Ambulatory Surgery Centers
Conclusions Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research

Applying Decision Science to the Prioritization of Healthcare-Associated Infection Initiatives
Conclusions A decision support methodology such as our proof of concept could aid hospital executives in prioritizing the quality improvement initiatives within their hospital, with more complete data. Because hospitals continue to struggle in improving quality of care with tighter budgets, a formal decision support mechanism could be used to objectively prioritize patient safety and quality initiatives. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research

Patient Safety Activity Under the Social Insurance Medical Fee Schedule in Japan: An Overview of the 2010 Nationwide Survey
This study aims to address the patient safety performance status at hospitals implementing the PPSCF. Methods A nationwide questionnaire survey targeting 2674 hospitals with the PPSCF was performed in 2010 to 2011. The 627 participant hospitals were divided into the following three groups: 178 hospitals implementing PPSCF 1 with 400 beds or more (group A), 286 hospitals implementing PPSCF 1 with 399 beds or fewer (group B), and 163 hospitals implementing PPSCF 2 (group C). Results The mean numbers (standard errors) of patient safety managers were 1.45 (0.07) in group A, 1.12 (0.04) in group B, and 0.37 (0.12)...
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Detach Yourself: The Positive Effect of Psychological Detachment on Patient Safety in Long-Term Care
The objective of this study was to examine the relationship between psychological detachment and patient safety. In addition, the ability of teams to create a safe environment to discuss errors and take personal risks, i.e., psychological safety, was explored as an underlying condition for psychological detachment. Methods A total of 1219 caregivers (response rate = 44%) from 229 teams in two long-term care organizations completed a survey on psychological safety and psychological detachment at T0. Team managers rated patient safety of those teams at two points in time (T0 and T1). Results Two-level regressio...
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Impact of an Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis of Adverse Events in Health Care Facilities: Results of a Randomized Controlled Trial
Conclusions For the two scenarios tested, more relevant CAPAs were identified with the new tool than with usual tools. Further research is needed to assess the effectiveness of the new tool for other types of adverse events and its impact on patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Is There a Mismatch Between the Perspectives of Patients and Regulators on Healthcare Quality? A Survey Study
Conclusions The predominant clinical approach taken by regulators does not match the patients’ perspective of what is relevant for healthcare quality. In addition, patients seem to be more tolerant of what they perceive to be clinical or management errors than of perceived relational deficiencies in care providers. If regulators want to give patients a voice, they should expand their horizon beyond the medical framework. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 24, 2021 Category: Health Management Tags: Original Studies Source Type: research

Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement With Standardized Versus Procedure-Specific Consent Forms
Conclusions Consent is a complex process, and obtaining informed consent is far from straightforward. A statistically significant improvement in patient’s recall with the use of procedure-specific consent forms was identified, and based on this, we would advocate their use. However, overall patient recall in both groups was poor. We believe that improving the quality of informed consent may require the sum of small gains, and the use of procedure-specific consent forms may aid in this regard. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Study Source Type: research

Using Economic Evaluation to Illustrate Value of Care for Improving Patient Safety and Quality: Choosing the Right Method
To scale and sustain successful quality improvement (QI) interventions, it is recommended for health system leaders to calculate the economic and financial sustainability of the intervention. Many methods of economic evaluation exist, and the type of method depends on the audience: providers, researchers, and hospital executives. This is a primer to introduce cost-effectiveness analysis, budget impact analysis, and return on investment calculation as 3 distinct methods for each stakeholder needing a measurement of the value of QI at the health system level. Using cases for the QI of hospital-acquired condition rates (e.g.,...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Review Article Source Type: research

Life-Threatening and Fatal Adverse Drug Events in a Danish University Hospital
Conclusions Ten life-threatening and fatal ADEs were uncovered as not reported in the incident reporting system. Further steps are needed for recognition and prevention of this patient safety challenge. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

Continuous Capnography Reduces the Incidence of Opioid-Induced Respiratory Rescue by Hospital Rapid Resuscitation Team
Objective The aim of this study was to determine the impact of end tidal carbon dioxide or capnography monitoring in patients requiring patient-controlled analgesia (PCA) on the incidence of opioid-induced respiratory depression (OIRD) in the setting of rapid response. Methods A retrospective analysis was conducted in an urban tertiary care facility on the incidence of OIRD in the setting of rapid response as defined by a positive response to naloxone from January 2012 to December 2015. In March 2013, continuous capnography monitoring was implemented for all patients using PCA. Results The preintervention...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

Classifying Adverse Events in the Dental Office
Conclusions Adverse events found during the chart review process were successfully classified using the novel dental AE type and severity classifications. Understanding the type of AEs and their severity are important steps if we are to learn from and prevent patient harm in the dental office. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

A Theoretical Model of Flow Disruptions for the Anesthesia Team During Cardiovascular Surgery
Conclusions By defining a calculable error space associated with these disruptions, this research provides a conceptual metric that can serve in the identification and design of targeted interventions. This method serves as a proactive approach for recognizing systemic threats, affording healthcare workers the opportunity to mitigate the development and incidence of preventable errors precedently. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

Why an Open Disclosure Procedure Is and Is not Followed After an Avoidable Adverse Event
Conclusions The culture of safety, the experience of blame, and the expectations about the outcome from communicating an AAE to patients affect the frequency of open disclosure. Nurses are more willing than physicians to participate in open disclosure. Health care organizations must act to establish a framework of legal certainty for professionals. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

Assessment of Automating Safety Surveillance From Electronic Health Records: Analysis for the Quality and Safety Review System
Conclusions Although EHRs contain a wealth of information, abstracting information from these records is still very challenging, particularly for complex questions, such as those concerning patient adverse events. In this work, we developed a heuristic framework, which can be applied to help guide conversations around the feasibility of automating QSRS data abstraction. This framework does not aim to replace testing with real data but complement the process by providing initial guidance and direction to subject matter experts to help prioritize, which abstraction questions to test for feasibility using real data. (Sour...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

Using Prospective Risk Analysis Tools to Improve Safety in Pharmacy Settings: A Systematic Review and Critical Appraisal
Conclusions The prospective risk analysis methods included in this review revealed relevant safety issues and hold significant potential for risk reduction. They were deemed suitable for application in both inpatient and outpatient pharmacy settings and should form an integral part of any patient safety improvement strategy. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Review Article Source Type: research

Making Patient Safety Event Data Actionable: Understanding Patient Safety Analyst Needs
Conclusions Major gaps in the analysis of patient safety report data were identified. Despite software to support reporting, many reports come from other sources. Transforming data are burdensome because of recategorization of events and integration with other data sources, processes that can be automated. Surprisingly, trend identification was mostly based on patient analyst memory, highlighting a need for new tools that better support analysts. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

Preoperative Site Marking: Are We Adhering to Good Surgical Practice?
Conclusions Based on our findings, surgeons may not be adhering to “Good Surgical Practice”; practice is widely variable and surgeons are largely opposed and resistant to marking patients unless laterality is involved. We suggest that all surgeons need to be actively engaged in the design of local marking protocols to gain support, change practice, and reduce errors. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

The Consequences of Whistle-blowing: An Integrative Review
Conclusions Whistle-blowing is an avenue to improving patient safety in healthcare. The findings from this integrated review will help shape new whistle-blowing policies. Future whistle-blowing policies must minimize negative consequences to whistle-blowers while enhancing levels of patient safety and quality of care rendered. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Review Article Source Type: research

Simulation-Based Assessment Identifies Longitudinal Changes in Cognitive Skills in an Anesthesiology Residency Training Program
We describe observed improvements in nontechnical or “higher-order” deficiencies and cognitive performance skills in an anesthesia residency cohort for a 1-year time interval. Our main objectives were to evaluate higher-order, cognitive performance and to demonstrate that simulation can effectively serve as an assessment of cognitive skills and can help detect “higher-order” deficiencies, which are not as well identified through more traditional assessment tools. We hypothesized that simulation can identify longitudinal changes in cognitive skills and that cognitive performance deficiencies can then...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

A Report of Information Technology and Health Deficiencies in U.S. Nursing Homes
Conclusions These results highlight the necessity to understand benefits of implementing NH IT and demonstrating its impact on patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity
Conclusions A set of triggers for detecting ADEs in elderly patients with multimorbidity have been developed, following the consensus of a panel of experts. Subsequent validation in clinical practice is needed to confirm the accuracy and efficiency of these triggers for this population. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Studies Source Type: research

“Attention Everyone, Time Out!”: Safety Attitudes and Checklist Practices in Anesthesiology in Germany. A Cross-Sectional Study
Conclusions Our study paints a heterogeneous picture of the implementation, usage, and safety attitudes concerning the Safe Surgery Checklist as promoted by the WHO. The lack of standardized execution and team-mindedness can be taken as further evidence for the importance of interdisciplinary training focusing on human factors, communication, and collaboration rather than the mere implementation by decree. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research

TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care?
Objective The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM). Methods Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% respon...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research

Adverse Events Detection Through Global Trigger Tool Methodology: Results From a 5-Year Study in an Italian Hospital and Opportunities to Improve Interrater Reliability
We present the main findings of the implementation of the Italian version of the GTT and evaluate efforts to improve the interrater reliability over time. Methods The Italian version of the GTT was developed and implemented at the San Bonifacio Hospital, a 270-bed secondary care acute hospital in Verona, Italy. Ten clinical records randomly selected every 2 weeks were reviewed from 2009 to 2014. Two-stage interrater reliability assessment between team members was conducted on 2 subsamples of 50 clinical records before and after the implementation of specific review rules and staff training. Results Among 1320...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research

Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-Associated Infections in United States Hospitals
Objective Healthcare-associated infections (HAIs) pose a challenge to patient safety. Although studies have explored individual level, few have focused on organizational factors such as a hospital’s safety infrastructure (indicated by Leapfrog Hospital Safety Score) or workplace quality (Magnet recognition). The aim of the study was to determine whether Magnet and hospitals with better Leapfrog Hospital Safety Scores have fewer HAIs. Methods Ordered probit regression analyses tested associations between Safety Score, Magnet status, and standardized infection ratios, depicting whether a hospital had a Clost...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor
Conclusions The mnemonic SWIFT, with formalized curricula for obstetrical resident training focusing on new learners and increased faculty involvement and reinforcement, may result in improvement of handoffs on the labor floor. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Articles Source Type: research

Intravenous Administration Errors Intercepted by Smart Infusion Technology in an Adult Intensive Care Unit
Conclusions Our study contributes additional evidence of the impact of IV smart pump/DERS technology. These pumps effectively intercepted severe infusion errors and significantly prevented adverse drug events related to dosing. Our results support the implementation of this technology in ICUs as a minimum safety standard and could help drive an IV infusion safety initiative in Mexico. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Articles Source Type: research

Simulation-Based Education Enhances Patient Safety Behaviors During Central Venous Catheter Placement
We describe the effect of simulation-based education on residents’ adherence to protocols for and performance of central venous access. Methods Internal medicine and emergency medicine residents underwent a central venous access course that included a lecture, video presentation, readings, and simulation demonstrations presented by faculty. Baseline data were collected before the course was initiated. After a skills session where they rehearsed their ultrasound-guided central venous access skills, residents were evaluated using a procedural checklist and written knowledge exam. Residents also completed questio...
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Articles Source Type: research

Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Error Reporting System
Conclusions The method is applicable for compiling a hospital-specific high-alert medication list and related analysis of key process safety risks contributing to MEs. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Articles Source Type: research

Safety Culture in the Operating Room: Variability Among Perioperative Healthcare Workers
Conclusions We observed significant variability in perioperative safety culture, across dimensions of safety climate, professional roles, and levels of training. These variations in safety culture should be addressed when implementing culture change programs in the perioperative setting. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Articles Source Type: research

Quality of Handoffs in Community Pharmacies
Conclusions Handoffs occur frequently and are problematic in community pharmacies. Current pharmacy environments offer limited support to conduct good handoffs, and as a result, pharmacists report loss of information. This could present as a significant patient safety hazard. Future interventions should target facilitating better communication during shift changes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 26, 2021 Category: Health Management Tags: Original Articles Source Type: research

Reducing Surgery Scheduling Errors in Multihospital System
Objective The purpose of this study was to assess whether bundled team training interventions for surgeons and office staff could effectively improve the accuracy of surgery scheduling, minimizing scheduling factors that may contribute to occurrence of wrong site surgery. Methods This quasi-experimental observational study used an interrupted time series design to explore surgery scheduling errors (SSEs) and implemented bundled team training interventions intended to reduce SSEs at a Pacific Northwest Regional Surgery Scheduling Department. Each preintervention and postintervention segment consisted of 16 weekly...
Source: Journal of Patient Safety - July 22, 2021 Category: Health Management Tags: Original Studies Source Type: research

Evaluating the Impact of Radio Frequency Identification Retained Surgical Instruments Tracking on Patient Safety: Literature Review
Conclusions Based on the existing literature, RFID technology seems to have the potential to substantially improve patient safety by reducing RSI errors, although the body of evidence is currently limited. Better designed research studies are needed to get a clear understanding of this domain and to find new opportunities to use this technology and improve patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - July 22, 2021 Category: Health Management Tags: Original Studies Source Type: research

Motivating Physicians to Report Adverse Medical Events in China: Stick or Carrot?
Conclusions This survey suggests that punishment and reward have potential to motivate Chinese physicians to report AMEs. However, the implementation strategies of these control mechanisms may not be universally applicable and should be carefully designed on the basis of the specific characteristics of the practice site. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - July 22, 2021 Category: Health Management Tags: Original Studies Source Type: research