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What Else Can Health Care Learn From the Aerospace and Defense Industries?
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Solutions for Leaders Source Type: research

The Relationships Among Perceived Patients' Safety Culture, Intention to Report Errors, and Leader Coaching Behavior of Nurses in Korea: A Pilot Study
Conclusions: There is a need in health care settings for coaching by nurse managers to provide quality nursing care and thus improve patient safety. Programs that are systematically developed and implemented to enhance the coaching behaviors of nurse managers are crucial to the improvement of patient safety and nursing care. Moreover, a systematic analysis of the causes of malpractice, as opposed to a focus on the punitive consequences of errors, could increase error reporting and therefore promote a culture in which a higher level of patient safety can thrive. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact?
Conclusions: We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Organizational, Cultural, and Psychological Determinants of Smart Infusion Pump Work Arounds: A Study of 3 U.S. Health Systems
Conclusions: Hospitals may significantly improve adherence to smart pump safety features by addressing the nontechnical causes of work arounds and by providing more leadership and formalized training for resolving smart pump–related problems. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Racial and Ethnic Disparities in Patient Safety
Conclusions: To our knowledge, this is the first methodological review of racial/ethnic disparities in patient safety in the United States. The evidence on the existence of disparities in adverse events was mixed. Poor stratification of outcomes by race/ethnicity and consideration of geographic and hospital-level variations explain the inconclusive evidence; variations in the quality of care at hospitals should be considered in studies using national databases. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Review Article Source Type: research

A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children’s Hospital
Conclusions: A daily safety brief can be successfully implemented in a children’s hospital. Communication between departments and awareness of daily events were improved. Implementation of a daily safety brief is a step toward becoming a high reliability organization. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Computerized Dose Range Checking Using Hard and Soft Stop Alerts Reduces Prescribing Errors in a Pediatric Intensive Care Unit
Objective: An enhanced dose range checking (DRC) system was developed to evaluate prescription error rates in the pediatric intensive care unit and the pediatric cardiovascular intensive care unit. Methods: An enhanced DRC system incorporating “soft” and “hard” alerts was designed and implemented. Practitioner responses to alerts for patients admitted to the pediatric intensive care unit and the pediatric cardiovascular intensive care unit were retrospectively reviewed. Results: Alert rates increased from 0.3% to 3.4% after “go-live” (P (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Using Natural Language Processing to Extract Abnormal Results From Cancer Screening Reports
Conclusions: Our study developed NLP models that accurately extract abnormal results from mammography and Pap smear reports. Plans include using NLP technology to generate real-time alerts and reminders for providers to facilitate timely follow-up of abnormal results. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices
Conclusions: Physicians and nurses use various frames that bound their views of self and peer incident reporting—further progress should incorporate an understanding of these deep-seated views and beliefs. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Improving Insulin Administration Through Redesigning Processes of Care: A Multidisciplinary Team Approach
Conclusions: Decreased errors of omission as well as improved administration and documentation of coverage insulin were demonstrated by this multimodal process change. Scheduled standardized order sets, extensive nursing staff education, and enhanced efficiency of the existing process led to improved outcomes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room
Conclusions: Providers should take into account patient characteristics and procedure types when assessing the risks of harmful sedation-related complications. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 22, 2017 Category: Health Management Tags: Original Articles Source Type: research

Computed Tomography Dose Monitoring: Is Radiation Dose the Wrong Patient Imaging Risk to Manage?
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Letter to the Editor Source Type: research

Deep Needle Procedures: Improving Safety With Ultrasound Visualization
Abstract: Promoting patient safety and increasing health care quality have dominated the health care landscape during the last 15 years. Health care regulators and payers are now tying patient safety outcomes and best practices to hospital reimbursement. Many health care leaders are searching for new technologies that not only make health care for patients safer but also reduce overall health care costs. New advances in ultrasonography have made this technology available to health care providers at the patient’s bedside. Point-of-care ultrasound assistance now aids providers with real-time diagnosis and with visualiz...
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Review Article Source Type: research

The Second Victim Experience and Support Tool: Validation of an Organizational Resource for Assessing Second Victim Effects and the Quality of Support Resources
Conclusions: The SVEST can be used by health care organizations to evaluate second victim experiences of their staff and the quality of existing support resources. It can also provide health care organization leaders with information on second victim–related support resources most preferred by their staff. The SVEST can be administered before and after implementing new second victim resources to measure perceptions of effectiveness. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Original Articles Source Type: research

Patient Handoffs: Is Cross Cover or Night Shift Better?
Conclusions: We did not find a difference in physicians' transfer of information during 2 handoffs among providers taking traditional call or on night shift. Development of tools to measure handoff consistency is needed. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Original Articles Source Type: research

Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions
Conclusions: Current strategies aimed at increasing patient awareness of patient safety may not be enough. The findings suggest that providing the context for interaction to occur between nursing staff and patients as well as targeted interventions aimed at increasing patient control may be needed to ensure patient involvement in patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Original Articles Source Type: research

Application of Failure Mode Effect Analysis to Improve the Care of Septic Patients Admitted Through the Emergency Department
Conclusions: Patient safety and care reliability issues are a major concern in health care. This study suggests that tools such as FMEA can enable a detailed analysis of the care process of septic patients by outlining potential failure modes and guiding improvement efforts. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Original Articles Source Type: research

Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers
Conclusions: The intervention targets improvements in skin preparation; proper administration of antibiotics; staff training in infection control principles, including practices for the prevention of glove punctures; and procedures to ensure the removal of watches, jewelry, and artificial nails. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Original Articles Source Type: research

Safety Perceptions of Health Care Leaders in 2 Canadian Academic Acute Care Centers
Conclusions: The significant differences in response between board/administrative leaders and those involved in frontline patient care suggest that a weak safety culture exists in these 2 health care organizations. The cultivation of a stronger organizational safety culture, in alignment with HRO principles, could lead to lower rates of preventable mishaps and support risk identification and mitigation in perioperative settings. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Original Articles Source Type: research

TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care
Conclusions: For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 19, 2017 Category: Health Management Tags: Original Articles Source Type: research

Disclosing Adverse Events to Patients: International Norms and Trends
Conclusions: Potential solutions include health worker education coupled with incentives to embed policy into practice, better communication about approaches beyond the punitive, legislation that allows both disclosure to patients and quality improvement protection for institutions, apology protection for providers, comprehensive disclosure programs that include patient compensation, delinking of patient compensation from regulatory scrutiny of disclosing physicians, legal and contractual requirements for disclosure, and better measurement of its occurrence and quality. A longer-term solution involves educating the public ...
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Original Articles Source Type: research

Pharmacy Survey on Patient Safety Culture: Benchmarking Results
Conclusions: Patient counseling consistently had the highest PPS among composites measured, but opportunities existed for improvement in all aspects measured. Future research should identify and assess interventions targeted to improving the patient safety culture in pharmacy. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Original Articles Source Type: research

Screening Electronic Health Record–Related Patient Safety Reports Using Machine Learning
Conclusions: Machine learning and text mining are useful additions to the patient safety toolkit and can be used to semiautomate screening and analysis of unstructured text in safety reports from frontline staff. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Original Articles Source Type: research

Prospective Assessment of Inpatient Boxed Warning Prescriber Adherence
Conclusions: Boxed warning nonadherence is a concern in the inpatient setting, specifically with NSAID use in general medicine patients and antipsychotic use in ICU patients. More than half of boxed warning nonadherence occurred in medications restarted from home, which emphasizes the need for medication evaluation during transitions of care. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Original Articles Source Type: research

Naloxone Triggering the RRT: A Human Antidote?
Conclusion: Naloxone-triggered activation of the RRT resulted in reduced opioid-related inpatient cardiac arrests without adversely affecting pain satisfaction scores. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Original Articles Source Type: research

Addressing Patient Safety in Rapid Response Activations for Nonhospitalized Persons
Conclusion: Nonhospitalized patients requiring RRT activation often have complex pre-existent illnesses. A standardized team composition for both inpatients and NHPs in crisis is an appropriate administrative structure enhancing patient safety in hospitals where ambulatory and inpatient facilities are combined. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Original Articles Source Type: research

Integrating Data From the UK National Reporting and Learning System With Work Domain Analysis to Understand Patient Safety Incidents in Community Pharmacy
Conclusions: Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Original Articles Source Type: research

Estimating Hospital-Related Deaths Due to Medical Error: A Perspective From Patient Advocates
Abstract: The authors present a viewpoint regarding the quality of data used in estimating the number of preventable hospital deaths in the United States. Data derived from countries with a nationalized healthcare system with well-defined and near uniform implementation of standards may not be applicable to the fragmented noncentralized delivery system found in the United States. Although U.S. studies evaluating preventable mortality have based their projections on a small sample size, it is unlikely that this observation is due to chance, because other studies evaluating adverse events, a precursor to preventable mortalit...
Source: Journal of Patient Safety - February 17, 2017 Category: Health Management Tags: Invited Commentary Source Type: research

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana
Conclusions: This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 19, 2016 Category: Health Management Tags: Original Articles Source Type: research

Identifying Facilitators and Barriers for Patient Safety in a Medicine Label Design System Using Patient Simulation and Interviews
Conclusions: For optimizing medicine labels and obtaining the full benefit of label design features on patient safety, it is necessary to consider the context in which they are used. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 19, 2016 Category: Health Management Tags: Original Articles Source Type: research

The Role of Safety Culture in Influencing Provider Perceptions of Patient Safety
Conclusions: This research supports the role that safety culture plays in the promotion and maintenance of patient safety activities for health-care providers. As such, it is recommended that the introduction of new patient safety strategies follow a thorough exploration of an organization’s safety culture. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 19, 2016 Category: Health Management Tags: Original Articles Source Type: research

Integrating Patient Safety in the OMFS Curriculum: Survey of 4-Year Residency Programs
Conclusions: The results of this study indicate that the majority of 4-year OMFS programs include patient safety education in the residency curriculum, although the duration of training and integration of acquired knowledge into practice varied among participants. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 19, 2016 Category: Health Management Tags: Original Articles Source Type: research

TRIAD IV: Nationwide Survey of Medical Students’ Understanding of Living Wills and DNR Orders
Conclusion: Our data indicate that the majority of students failed to understand the key elements of a living will; adding a code status designations improved correct responses with the exception of the term DNR. Misunderstanding of advance directives is a nationwide problem and jeopardizes patient safety. Medical School ethics curricula need to be improved to ensure competency with respect to understanding advance directives. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 19, 2016 Category: Health Management Tags: Original Articles Source Type: research

Development of an Electronic Pediatric All-Cause Harm Measurement Tool Using a Modified Delphi Method
Conclusions: Application of a modified Delphi method on an expert-constructed list of 108 triggers, focusing on severity and frequency of harms as well as detectability of triggers in an electronic medical record, resulted in a final list of 51 pediatric triggers. Pilot testing this list of pediatric triggers to identify all-cause harm for pediatric inpatients is the next step to establish the appropriateness of each trigger for inclusion in a global pediatric safety measurement tool. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 19, 2016 Category: Health Management Tags: Original Articles Source Type: research

A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes
Abstract: This is a systematic review of the literature on unintended consequences of clinical interventions to reduce falls, catheter-related urinary tract infection, and vascular catheter-related infections in hospitalized patients. A systematic search of the literature was conducted in CINAHL and PubMed. We developed a screening tool and a two-stage screening process to identify relevant articles. Nine articles met inclusion criteria, and of those, 8 reported on interventions to reduce patient falls. Four studies reported a positive, unexpected benefit; 3 studies reported a negative, unexpected detriment; and 4 reported...
Source: Journal of Patient Safety - November 19, 2016 Category: Health Management Tags: Review Article Source Type: research

Three Simple Rules to Improve Medication Safety
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Tips for Success Source Type: research

Setting Up a Patient Care Call Center After Potential HCV Exposure
Conclusions: A successful patient notification and follow-up effort requires a multidisciplinary team, internal and external communication, collection of data over an extended period, and coordination of patient information. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Case Report Source Type: research

Building a Highway to Quality Health Care
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Editorial Source Type: research

Pharmacists Views and Practices in Regard to Sales of Antibiotics Without a Prescription in Madinah, Saudi Arabia
Conclusions: Pharmacist views and practices are alarming. The results of this study show that this practice will continue to spread unless strict enforcement is put in place, Lack of clear understanding of the limitations of pharmacist’s scope of practice. Results of these studies can be extrapolated to other countries in the region and other countries of the similar social and professional development status. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Article Source Type: research

Improving Patient Safety Culture in Primary Care: A Systematic Review
Conclusions: These studies in general practice provide a first understanding of improvement strategies and their effect in primary care. As the level of evidence was low, no clear preference can be determined. Further research is needed to help practices make an informed choice for an intervention. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Review Article Source Type: research

Associations of Injurious Falls and Self-Reported Incapacities: Analysis of the National Health Interview Survey
Conclusions: A subset of the NHIS questions are positively associated with injurious falls in the previous 12 months and may be of use in identifying adults at greater risk of future falls. The NHIS questions may serve to identify persons in need of targeted preventive services. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Rapid Learning of Adverse Medical Event Disclosure and Apology
Introduction: Despite published recommended best practices for full disclosure and apology to patients and families after adverse medical events, actual practice can be inadequate. The use of “cognitive aids” to help practitioners manage complex critical events has been successful in a variety of fields and healthcare. We wished to extend this concept to disclosure and apology events. The aim of this study was to test if a brief opportunity to review a best practice guideline for disclosure and apology would improve communication performance. Methods: Thirty pairs of experienced obstetricians and labor nurses ...
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Multidisciplinary Testing of Floor Pads on Stability, Energy Absorption, and Ease of Hospital Use for Enhanced Patient Safety
Conclusions: Floor pads do exist that show promise for hospital use that absorbing energy without major impacts on balance during sit-to-stand. Although only commercially available pads were investigated, results may inform the design and multidisciplinary testing of other floor surfaces. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Measuring Adverse Events in Hospitalized Patients: An Administrative Method for Measuring Harm
Conclusion: The AHMT is sufficiently accurate for use as a within hospital tool to reliably detect and track harm. Nevertheless, it is not recommended as a tool to make comparisons across institutions, which has policy and payment implications. Further research using administrative harm detection, including the use of a broader set of measures and electronic health records, is needed. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department
Conclusion: Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists
Conclusions: Inadequate error feedback to staff and insufficient preventative procedures increase the likelihood that near-miss errors will be underreported. Hospitals seeking to improve near-miss error reporting should improve error-reporting infrastructures to enable feedback, which, in turn, would create a more preventative system that improves patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Continuous Mandatory Onsite Consultant Intensivists in the ICU: Impacts on Patient Outcomes
Conclusions: An improved survival rate was observed only among medical patients admitted to the ICU with mandatory continuous access to a consultant intensivist, despite the presence of greater disease severity in the population admitted to this unit. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Drug-Related Harms in Hospitalized Medicare Beneficiaries: Results From the Healthcare Cost and Utilization Project, 2000–2008
Conclusions: Potentially preventable drug harms are a growing clinical and financial burden. Comparative outpatient drug safety should be analyzed using Medicare claim databases. In-hospital management of drug safety should target patients with multimorbidity and functional decline. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Physicians' Practice of Dispensing Medicines: A Qualitative Study
Conclusions: Despite being expected to dispense, and the patient safety issues involved in giving drugs to patients to use at home, physicians do not feel that they have been trained to undertake this task. These findings from 1 hospital raise questions about the wider quality and safety of this practice. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Safety Culture in Indian Hospitals: A Cultural Adaptation of the Safety Attitudes Questionnaire
Conclusions: This study reveals promising initial results for patient safety culture in India, but further study is needed. The development and validation of the SAQ-Gujarati allow additional hospitals to evaluate their patient safety culture. As the first rendition of the SAQ to an Indian setting, the tool could help to initiate safety discourse and improve the potential for institutions to provide feedback to their staff members. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research