Therapeutic Duplication of Long-Acting Injectable Drugs
We describe how we prevented similar medication errors through improvements in medical informatics systems. This case emphasizes the need for enhancements in medical informatics systems to avoid therapeutic duplication of long-acting medications in the interest of patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Case Report Source Type: research

Changes in Patient Safety Culture in Palestinian Public Hospitals: Impact of Quality and Patient Safety Initiatives and Programs
Objectives To assess the changes in the patient safety culture between 2011 and 2016 after the implementation of patient safety initiative in Palestinian public hospitals. Methods A cross-sectional quantitative design employed using the Hospital Survey on Patient Safety Culture to collect data. Participants were 1,229 clinical and nonclinical employees from all public hospitals in the West Bank. Results Significant improvements were observed in patient safety culture with positive responses to 10 (83.3%) composite categories and 36 (86.0%) items of the Hospital Survey on Patient Safety Culture since the baseline su...
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Pressure Ulcer Rate in Multidisciplinary Hospital Units After Multifactorial Intervention: A Stepped-Wedge, Cluster Randomized Controlled Trial
Conclusions The multifaceted intervention proposed by the present study has succeeded in reducing rate of pressure ulcer. Multifaceted programs based on training are appropriate ways to provide essential information to patients and their caregivers, which result in improvement of their participation in therapeutic process. We recommend hospitals to use these findings as a quality improvement plan for decreasing the rate of pressure ulcer. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Supporting Clinicians After Adverse Events: Development of a Clinician Peer Support Program
Conclusions We describe the multiple steps necessary to create a successful PSP focused on physicians and midlevel providers. There is an unmet need to provide support to this group of healthcare providers after medical errors and adverse events. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases Psychiatrist Participation in Reporting Adverse Events
Conclusions The combination of an increase in awareness of event reporting with a psychiatry-specific AE reporting tool resulted in a significant improvement in the number of reports by psychiatrists. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Do Intensive Care Units in Poland Need Recommendations for “Good Practice” in Labeling Intravenous Medicines?
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Letter to the Editor Source Type: research

Look-Alike Medication Packages and Patient Safety
We present a case of taking the wrong drug due to a dispensing error by pharmacists involving medication packaging confusion, and we report how we prevent similar dispensing errors by thorough investigation and intervention. This case emphasizes the need for constant attention by hospital, medical industry, and regulatory authorities to avoid look-alike medication packaging in the interest of medication safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Case Report Source Type: research

Psychological Detachment Safer for Patient Care? A “Critical Thinking” Response
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Letter to the Editor Source Type: research

Demonstrating Improved Surgical Communication and HAndoveR Generates Earlier Discharges (DISCHARGED)
Background Weekend surgical handover at the Princess Alexandra Hospital NHS Trust in Harlow, Essex, did not fully comply with Royal College of Surgeons England guidelines. Out-of-hours care is under increased scrutiny, and we implemented a quality improvement intervention of a mandatory, standardized weekend handover form to streamline weekend care. This was shown to increase discharges and decrease lengths of stay for patients whose hospital stay included a weekend. Methods Data were collected for 15-week preimplementation and postimplementation. The number of patients handed over for senior weekend review was record...
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Article Source Type: research

Impact of Different National Ethical Requirements on Ethnographic Patient Safety Studies
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Letter to the Editor Source Type: research

Show Back: Developing and Testing of a Simulation-Based Assessment Method for Identifying Problems in Self-Management of Medications in Older Adults
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Case Report Source Type: research

Patient Safety: An Important yet Neglected Issue in Nursing Education
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Letter to the Editor Source Type: research

Does Employee Safety Matter for Patients Too? Employee Safety Climate and Patient Safety Culture in Health Care
Conclusions Medical facilities where staff have more positive perceptions of health care workplace safety climate tended to have more positive assessments of patient safety culture. This suggests that patient safety culture and employee safety climate could be mutually reinforcing, such that investments and improvements in one domain positively impacts the other. Further research is needed to better understand the nexus between health care employee and patient safety to generalize and act upon findings. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Sustained Improvement in Neonatal Intensive Care Unit Safety Attitudes After Teamwork Training
This study aimed to measure safety attitudes in the neonatal intensive care unit (NICU) before and serially after a compulsory, multidisciplinary teamwork and communication training initiative and novel sustainment program. Methods Training was administered to NICU staff and subsequent sustainment efforts were directed at enculturating core principles over the following year. A modified Agency for Healthcare Research and Quality Survey on Patient Safety Culture was administered before as well as 3 and 12 months after training. Longitudinal survey results were compared with the national Agency for Healthcare Research and...
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

U.S. Compounding Pharmacy-Related Outbreaks, 2001–2013: Public Health and Patient Safety Lessons Learned
Conclusions Recognized outbreaks linked to P-CSPs have been most commonly associated with non–patient-specific repackaging and nonsterile to sterile compounding and linked to lack of adherence to sterile compounding standards. Recently enhanced regulatory oversight of compounding may improve adherence to such standards. Additional measures to limit and control these outbreaks include vigilance when outsourcing P-CSPs, scrutiny of drivers for P-CSP demand, as well as early recognition and notification of possible outbreaks. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Review Article Source Type: research

Adverse Events in Korean Traditional Medicine Hospitals: A Retrospective Medical Record Review
Conclusions Approximately 11% of inpatients in traditional medicine hospitals experienced AEs. Because patients have a higher risk of AEs, special attention should be paid to those with altered mental status on admission, receiving various traditional medicine therapies, staying for a longer period, and having various positive triggers. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Prevalence of Implanted Medical Devices in Medicine Inpatients
Implanted medical devices (IMDs) are extremely common, yet they are not systematically documented on hospital admission. Through structured patient interviews, we determined the prevalence of IMDs in hospital inpatients. Using medical record review, we evaluated the sensitivity of the medical record reporting of IMDs on an academic medical inpatient service. Fifty-eight percent of 191 interviewees reported 1 or more IMDs. Participants who reported greater than 1 IMD were older and had more frequent hospitalizations. The most common devices reported were surgical mesh, screws, plates, or wires (n = 47); intravascular stents...
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Procedural Timeout Compliance Is Improved With Real-Time Clinical Decision Support
Conclusions Using the electronic medical record with real-time CDS improves compliance with presurgical safety checklists. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Use of Simulation to Test Systems and Prepare Staff for a New Hospital Transition
Conclusions Systems testing and education using simulation can play a meaningful role in new facility training. Key lessons included early planning, allocation of resources to the effort, flexibility to adapt to changes, and planned integration with other training activities. A formal a priori plan to address issues identified during the process is necessary. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Improved Compliance and Comprehension of a Surgical Safety Checklist With Customized Versus Standard Training: A Randomized Trial
This study aimed to determine the effect of customized training versus standard readily available training on surgical safety checklist (SSCL) compliance and comprehension. Background The success of the SSCL in reducing surgical mortality and morbidity depends largely on the degree of compliance among health care workers with the checklist's components. We hypothesized that a customized training program would improve comprehension of the SSCL components among health care workers. Methods We prospectively evaluated compliance and comprehension of a locally modified SSCL among surgeons, anesthesiologists, nurses, and p...
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Evaluation of the Prevalence of Shielding in Patients Undergoing Conventional Radiological Procedures (1 Work Shift–1 X-ray Room)
Conclusion The results of this study showed that shielding of radiosensitive organs was not performed in the majority of hospitals. More studies are needed to establish the potential causes of low shielding prevalence. If these findings, which were obtained over 1 work shift and in 1 x-ray room, are representative of a large number of medical imaging centers, this raises global concerns regarding shielding of radiosensitive organs, in particular gonad shielding. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

Curriculum Development and Implementation of a National Interprofessional Fellowship in Patient Safety
Conclusions We offer a curriculum and fellowship design for the topic of patient safety. Available evidence suggests that the fellowship results in the development of patient safety professionals. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2018 Category: Health Management Tags: Original Articles Source Type: research

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