Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration
Conclusions
Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.
Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Strength of Improvement Recommendations From Injurious Fall Investigations: A Retrospective Multi-Incident Analysis
Conclusions
This study found that only 8.5% of recommendations were classified as strong. This suggests that a major challenge lies in formulating robust recommendations; hence, efforts should focus on enhancing the strength of improvement recommendations. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Perceptions of Stakeholders Toward “Hospital at Home” Program in Singapore: A Descriptive Qualitative Study
Conclusions
This study offered insights into HaH from the perspectives of stakeholders in Singapore and facilitate the planning of future HaH pilot programs in multiracial Singapore and other Asian countries. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Impact on Patient Safety Culture by the Intervention of Multidisciplinary Medical Teams
Conclusions
Our ward-based multidisciplinary team system had a positive effect on PSC, which demonstrates the following: when team performance is better, patient safety climate is also better. We should keep the ward-based multidisciplinary team system, improve its performance, and maximize positive attitudes about PSC among our staff. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Rates of Adverse Events in Hospitalized Patients After Summer-Time Resident Changeover in the United States: Is There a July Effect?
Conclusions
Patients admitted to teaching hospitals in July/August are not at increased risk of adverse events. These findings should reassure patients and medical educators that patients are not excessively endangered by admission to the hospital during these months. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: The Health Care Manager Source Type: research
Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review
Conclusions
The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: The Health Care Manager Source Type: research
The Analysis of Hospital Readmission Rates After the Implementation of Hospital Readmissions Reduction Program
Conclusions
Our figures show that targeted programs, such as HRRP, may have a positive impact on readmission rates. We, however, observe some graphical evidence that nontargeted conditions could exhibit similar trends. Because of heterogeneity in hospital and patient characteristics, it is pivotal for researcher to consider them in formal analyses. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: The Health Care Manager Source Type: research
Safety of Elderly Fallers: Identifying Associated Risk Factors for 30-Day Unplanned Readmissions Using a Clinical Data Warehouse
Conclusions
Reducing early unplanned readmission is crucial, especially in elderly patients susceptible to falls. Our results indicate that the probability of unplanned readmission is higher for patients with specific characteristics that should be taken into consideration in interventions designed to reduce this burden. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Catching Fire: Are Operating Room Fires a Concern in Orthopedics?
Conclusions
Fires pose a risk in surgery, even in an orthopedics setting. Room oxygen can supply enough oxidizing power for a fire to occur, especially with the ubiquitous nature of ignition sources and fuels in the OR. Prevention is key with these events. Operating room personnel education must be sought, and surgeons should be mindful of the fire components in the OR. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Registered Nurses’ and Medical Doctors’ Experiences of Patient Safety in Health Information Exchange During Interorganizational Care Transitions: A Qualitative Review
Conclusions
The results of this review identified several advantages of HIE, namely, improvements in patient safety based on reduced human error. Nevertheless, a lack of usability and functionality can amplify the effects of human error and increase the risk of adverse events. In addition, HCPs’ individual actions in HIE were found to influence patient safety. Hence, the cognitive and sociotechnical perspectives of work related to HIE should be studied. In addition, HCPs’ experiences of each stage of HIE deployment should be clarified to ensure a high standard of patient safety. Registration: PROSPERO CRD4202022063...
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Review Article Source Type: research
A Worldwide Bibliometric Analysis of Published Literature on Medication Errors
Conclusions
For the first time, a bibliometric analysis of medication errors research in the world has been conducted and demonstrated that there is a wealth of contributions already being made that are well aligned to the World Health Organization challenge. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Psychometric Properties of the Safety Climate Survey in Austrian Acute Care: Factor Structure, Reliability, and Usability
Conclusions
The German Safety Climate Survey measures safety climate multidimensionally rather than unidimensionally and demonstrated some limitations in factor structures and item loadings but overall had satisfactory reliability of the 6 subscales. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Validation of the German Version of the Second Victim Experience and Support Tool—Revised
Conclusion
The G-SVESTR is a valid and reliable testing instrument for the evaluation of second victim experiences in different medical professions. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Reducing Falls in Dementia Inpatients Using Vision-Based Technology
We examined whether a remote digital vision-based monitoring and management system had an impact on the prevention of falls.
Methods
Our study was conducted within the Manor dementia inpatient wards at the Coventry and Warwickshire Partnership Trust. Data were retrieved from incident reports before and 22 months after installation of the system. We examined number of night time falls, severity of fall, number of paramedic visits and A&E admissions, and the number of enhanced observations during both time periods.
Results
There was a significant 48% reduction in the number of nighttime falls (P (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
Adverse Events Associated With Electromyogram Endotracheal Tubes in Thyroid and Parathyroid Surgery
Conclusions
The most commonly reported adverse events associated with electromyogram endotracheal tubes include loss of response to nerve stimulation, cuff perforation, ventilation failure, and airway trauma. Subsequent interventions include reintubation, tracheostomy, extended hospitalization, and aborted cases. Surgical teams should consider these adverse events when consenting patients and using these devices in thyroid and parathyroid cases. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - March 31, 2022 Category: Health Management Tags: Original Studies Source Type: research
