Medication Order Errors at Hospital Admission Among Children With Medical Complexity
Objectives
We sought to characterize the nature and prevalence of medication order errors (MOEs) occurring at hospital admission for children with medical complexity (CMC), as well as identify the demographic and clinical risk factors for CMC experiencing MOEs.
Methods
Prospective cohort study of 1233 hospitalizations for CMC from November 1, 2015, to October 31, 2016, at 2 children’s hospitals. Medication order errors at admission were identified prospectively by nurse practitioners and a pharmacist through direct patient care. The primary outcome was presence of at least one MOE at hospital admission. Statis...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Failure to Rescue Deteriorating Patients: A Systematic Review of Root Causes and Improvement Strategies
Conclusions
Complications occur consistently within healthcare organizations. They represent a huge burden on patients, clinicians, and healthcare systems. Organizations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context. We propose “The 3 Rs of Failure to Rescue” of recognize, relay, and react and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future efforts at mitigating the differences in outcome from complication management between units may benefit from incorporating this...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Review Articles Source Type: research
Let the EHR Talk Loudly: An EHR-Connected Verbal Surgical Safety Checklist for Medical Procedures in the Intensive Care Unit
Conclusions
An EHR-connected verbal surgical safety checklist software can leverage information in the EHR to help with workflow and patient safety. This study shows that the software can verbally deliver clinical information with great accuracy and that most ICU staff would support replacing current time-out processes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Analysis of Risk Factors for Patient Safety Events Occurring in the Emergency Department
Objective
The aim of the study was to describe and analyze the risk factors associated with patient safety events (PSEs), defined as adverse events (AEs), preventable AEs (PAEs), and near-miss events (NMEs), in the emergency department (ED).
Methods
It was a retrospective cohort study using ED patients’ data retrieved from January 2010 to December 2016. Quality assurance issues (QAIs) used as triggers included the following: issues during procedural sedation, death within 24 hours of admission, patients’ and physicians’ complaints, returns to the ED within 72 hours, and transfers to an intensive care unit ...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
The Use of Anatomical Side Markers in General Radiology: A Systematic Review of the Current Literature
Conclusions
Although missing ASMs on x-rays were a small feature, findings from this review highlight opportunities for improvement and a need to ameliorate barriers for ASM use. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Review Articles Source Type: research
Improving Allergy Documentation: A Retrospective Electronic Health Record System–Wide Patient Safety Initiative
Conclusions
Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
A Mixed-Methods Systematic Review of the Effectiveness and Experiences of Quality Improvement Interventions in Radiology
Conclusions
The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Review Articles Source Type: research
Wide Variation in Unplanned Extubation Rates Related to Differences in Operational Definitions
Conclusions
Most UEs in our NICU population involved staff either removing ETTs from the trachea or partly removing them after internal dislodgement. In settings where ETTs removed by staff are not counted, UE rates may be substantially lower and associated risks underestimated. An inclusive, patient-centric operational definition along with a standardized classification would allow benchmarking, while enabling targeted approaches to minimize locally predominant causes of UEs. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Characteristics of Critical Incident Reporting Systems in Primary Care: An International Survey
Conclusions
We found multiple CIRS that have operated in primary care for many years and have received a high number of reports. They were largely developed in accordance with recommendations found in literature. Developers of future systems may find this overview useful. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Physician-to-Nurse Handover: A Systematic Review on the Effectiveness of Different Models
Conclusions
In times of healthcare delivery models of growing complexity, multiprofessional handover is a key component of care paths. Although there is overall consensus on the need for improving the quality and safety of multiprofessional handover, the evidence on the tools available to achieve it and the metrics to measure their impact is heterogeneous. We urge that rigorous studies are conducted to inform the planning, implementation, and monitoring of effective handover, with the ultimate aim of improving quality of care and patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Review Articles Source Type: research
Organizational Interventions to Support Second Victims in Acute Care Settings: A Scoping Study
Conclusions
This is a new area of study with little qualitative data from which to determine whether these programs are effective. Many programs had a similar design, based on the structure proposed by the same small group of experts in this new field. Concerns about potential legal proceedings hinder documentation and study of program effectiveness. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
A Systematic Review of Patient-Report Safety Climate Measures in Health Care
Conclusions
This review identified the extant patient-reported SC measures in health care and demonstrated significant variance in their coverage of SC domains, validity and reliability, and usability. Findings suggest a pressing need for a stand-alone measure that has a high validity and reliability, and assess core SC domains from the patient perspective, particularly in primary care. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Review Articles Source Type: research
Do Patients and Relatives Have Different Dispositions When Challenging Healthcare Professionals About Patient Safety? Results Before and After an Educational Program
Conclusions
After the training, participants’ willingness to challenge healthcare workers was high for all safe practices analyzed but hand hygiene. Patients and relatives had very similar willingness. After the training, participants felt confident with their knowledge about safe practices, thereby increasing their challenging attitude. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
The Effects of Interdisciplinary Bedside Rounds on Patient Centeredness, Quality of Care, and Team Collaboration: A Systematic Review
Conclusions and Implications of Key Findings
Interdisciplinary bedside round has potentially a positive influence on patient centeredness, quality of care, and team collaboration, but because of a substantial variability in definitions, design, outcomes, reporting, and a low quality of evidence, definitive results stay uncertain. Perceived barriers to use IBR are time constraints, lack of shared goals, varied responsibilities of different providers, hierarchy, and coordination challenges. Future research should primarily focus on conceptualizing IBRs, in specific the involvement of patients, before more empiric, multic...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Unique Patient-Reported Hospital Safety Concerns With Online Tool: MySafeCare
Conclusions
Although the submission rate to the application was low, MSC captured important content directly from hospitalized patients or their care partners. A web-based patient safety reporting tool for patients should be studied further to understand patient and care partner use and willingness to engage, as well as potential effects on patient safety outcomes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
