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

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

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

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

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

Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets
Conclusions: Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians' clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units
Conclusions: This study shows that CRM requires preparation and implementation, both of which require time and dedication. It is promising to note that all 3 ICUs have developed multiple quality improvement initiatives and aim to continue doing so. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

Screening Questions for Nonsteroidal Anti-inflammatory Drug Risk Knowledge
Conclusions: Screening questions for subjective NSAID risk awareness and health literacy are predictive of objectively tested NSAID knowledge and can be used to triage patients as well as subsequently initiate and direct a conversation about NSAID risk. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

From Bad to Worse: Anemia on Admission and Hospital-Acquired Anemia
Background: Anemia at hospitalization is often treated as an accompaniment to an underlying illness, without active investigation, despite its association with morbidity. Development of hospital-acquired anemia (HAA) has also been associated with increased risk for poor outcomes. Together, they may further heighten morbidity risk from bad to worse. Objectives: The aims of this study were to (1) examine mortality, length of stay, and total charges in patients with present-on-admission (POA) anemia and (2) determine whether these are exacerbated by development of HAA. Design/Setting/Patients: In this cohort investigation, ...
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

Efficacy and Cost-Benefit Analysis of a Global Environmental Cleaning Algorithm on Hospital-Acquired Infection Rates
Conclusions: This global environmental cleaning protocol was associated with decreased HAIs and hospital costs. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

Magnitude of Anemia at Discharge Increases 30-Day Hospital Readmissions
Background: Anemia during hospitalization is associated with poor health outcomes. Does anemia at discharge place patients at risk for hospital readmission within 30 days of discharge? Our objectives were to examine the prevalence and magnitude of anemia at hospital discharge and determine whether anemia at discharge was associated with 30-day readmissions among a cohort of hospitalizations in a single health care system. Methods: From January 1, 2009, to August 31, 2011, there were 152,757 eligible hospitalizations within a single health care system. The endpoint was any hospitalization within 30 days of discharge. The U...
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

Medical Harm: Patient Perceptions and Follow-up Actions
Conclusions: In this sample of self-reported patient harms, we found a perception of inadequate apology. Nearly half of patient harm events are reported to an oversight agency, and roughly one-fifth result in a malpractice claim. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

The Effects of Hospital Safety Scores, Total Price, Out-of-Pocket Cost, and Household Income on Consumers' Self-reported Choice of Hospitals
Conclusions: When shown Hospital Safety Score and cost information, consumers chose safer hospitals in 97% of cost and safety scenarios. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

Interhospital Facility Transfers in the United States: A Nationwide Outcomes Study
Objectives: Patient transfers between hospitals are becoming more common in the United States. Disease-specific studies have reported varying outcomes associated with transfer status. However, even as national quality improvement efforts and regulations are being actively adopted, forcing hospitals to become financially accountable for the quality of care provided, surprisingly little is known about transfer patients or their outcomes at a population level. This population-wide study provides timely analyses of the characteristics of this particularly vulnerable and sizable inpatient population. We identified and compared ...
Source: Journal of Patient Safety - November 21, 2017 Category: Health Management Tags: Original Articles Source Type: research

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