Improving Capnography Use for Critically Ill Emergency Patients: An Implementation Study
Conclusions
Documented capnography use increased with simple interventions but with no positive trend. Additional work is needed to improve use, including further evaluation of capnography’s implementation in the ED. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Evaluation of the Green Cross Method Regarding Patient Safety Culture and Incidence Reporting
Conclusions
The implementation of the GC method has a positive impact on patient safety culture and PAE reporting. However, the method does not seem to have the same impact in physician units as in units with nursing staff, which calls for further investigation. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Self-Reported Neurotoxic Symptoms in Hip Arthroplasty Patients With Highly Elevated Blood Cobalt: A Case-Control Study
This study aimed to investigate the prevalence of self-reported neurotoxicity and cognitive defects in hip replacement patients with markedly raised blood cobalt.
Methods
Case group comprised 53 patients with metal-on-metal (MoM) implants and a history of blood Co ≥20 μg/L for a median of 3 years (interquartile range, 2–5 years). The control group comprised 53 patients with ceramic-on-ceramic prostheses and blood Co (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Social Determinants of Health and Patient Safety: An Analysis of Patient Safety Event Reports Related to Limited English-Proficient Patients
Conclusions
This study found that it is challenging to determine the direct role of certain social determinants of health (e.g., language barriers) in safety events. In many cases, the language barrier was not addressed in the event report. Furthermore, when the language barrier was addressed, solution themes typically involved weaker, less sustainable suggested actions. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
A High-Reliability Organization Framework for Health Care: A Multiyear Implementation Strategy and Associated Outcomes
Objectives
Applying high-reliability organization (HRO) principles to health care is complex. No consensus exists as to an effective framework for HRO implementation or the direct impact of adoption.
Methods
The Veterans Health Administration (VHA) National Center for Patient Safety established the high-reliability hospital (HRH) model for HRO adoption and piloted HRH in collaboration with the Truman VA Medical Center (Truman) during a 3-year intervention period (January 1, 2016–December 31, 2018). High-reliability hospital components are as follows: annual patient safety (PS) assessment, annual PS culture sur...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research
Optimizing Discharge Summaries: A Multispecialty, Multicenter Survey of Primary Care Clinicians
Conclusions
High-yield content should be presented at the beginning of the discharge summary and conveyed in a brief, succinct manner to ensure maximal utility of the document as a transition of care tool. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research
What Can We Learn From the Past? Pandemic Health Care Workers’ Fears, Concerns, and Needs: A Review
Discussion
Despite being hailed by the media as heroes, HCWs face social stigmatization and experienced high levels of anxiety and fear regarding personal safety and the health of their colleagues and family. Health care workers are more likely to seek peer-to-peer psychological support but also benefit from knowing that formal psychological supports are available to them. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research
The Impact of Malpractice Claims on Physicians’ Well-Being and Practice
Objectives
Malpractice litigation causes extreme stress. We examine the psychological impact of malpractice claims on physicians’ well-being and the consequences on patient care.
Methods
A confidential telephone survey, administered to physicians with both open and closed claims from the previous year, explored symptoms, well-being changes, needs, impairments, and practice changes.
Results
Of the 282 respondents, more than half (56.38%) reported a notable psychological reaction to the malpractice claim, with no differences between the open and closed claims (P = 0.2477) or between closed claims with and...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: The Health Care Manager Source Type: research
Missed Acute Coronary Syndrome During Telephone Triage at Out-of-Hours Primary Care: Lessons From A Case-Control Study
This study compared the recorded triage calls of patients with chest discomfort contacting the OHS-PC in whom an ACS was missed (cases), with triage calls involving matched controls with chest discomfort but without a missed ACS (controls), with the aim to assess the predictors of missed ACS.
Methods
A case-control study with data from 2013 to 2017 of 9 OHS-PC in the Netherlands. The cases were matched 1:8 with controls based on age and sex. Clinical, patient, and call characteristics were univariably assessed, and general practitioner experts evaluated the triage while blinded to the final diagnosis or the case-con...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Suicide and Suicide Attempts on Veterans Affairs Medical Center Outpatient Clinic Areas, Common Areas, and Hospital Grounds
Conclusions
Clinical changes including environmental assessments and interventions, staff training on identifying suicide risk characteristics, policy changes toward improving contraband search techniques, and medications risk assessment, as well as timely access to care may be effective mitigation strategies toward preventing suicides of this nature. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Psychometric Evaluation of the Korean Version of Hospital Survey on Patient Safety Culture
Conclusions
Despite the acceptable model fit of the Korean version of HSOPSC, the psychometric properties of this instrument require further investigation to ensure it is an effective tool to measure patient safety culture and identify areas for improvement in the Korean health care system. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Medication Errors in Anesthesiology: Is It Time to Train by Example? Vignettes Can Assess Error Awareness, Assessment of Harm, Disclosure, and Reporting Practices
Background
Perioperative medication errors (MEs) are complex, multifactorial, and a significant source of in-hospital patient morbidity. Anesthesiologists’ awareness of error and the potential for harm is not well understood, nor is their attitude to reporting and disclosure. Anesthesiologists are not routinely exposed to medication safety training.
Methods
Ten clinical vignettes, describing an ME or a near miss, were developed using eDelphi consensus. An online survey instrument presented these vignettes to anesthesiologists along with a series of questions assessing error awareness, potential harm severity, ...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
A Retrospective, Matched Case-Control Study on the Risk Factors of Falls and Varying Severities of Fall-Related Injuries in Inpatients
This study was to investigate the factors that influence falls and the severity of fall-related injuries in inpatients.
Methods
We adopted a retrospective, matched case-control design and conducted this study at a teaching hospital in Taiwan. Our study period ran from January 2016 to December 2019. We searched for inpatients with official fall records and obtained data from 823 patients, and then established a control group comprising 331 matching patients based on age, sex, length of hospital stay at time of fall incident, and ward type, thereby resulting in 1154 patients in all. A cumulative logistic regression mo...
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
Characterization of Medication Errors in a Medical Intensive Care Unit of a University Teaching Hospital in South Korea
Conclusions
In conclusion, MEs are prevalent in the MICU in Korea, most commonly prescribing errors. Although mostly benign, harmful events including deaths may occur due to MEs, mainly associated with antibiotics. Systematic strategies to minimize these potentially fatal MEs are urgently needed. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 31, 2021 Category: Health Management Tags: Original Studies Source Type: research
“Disbelief and Sadness”: First-Year Health Profession Students’ Perspectives on Medical Errors
Conclusions
First-year health profession students responded to medical error with strong emotion and distress. Their responses largely represent an individualistic view of healthcare in both the causes and solutions to medical errors. No differences in response themes were observed by discipline. This study represents our students’ emotional responses to a medical error scenario. The qualitative responses and reactions of students to the Sheridan video offered opportunities to tease out nuances that would otherwise be unavailable in a typical attitudes survey. We noted a individualistic view of healthcare in both the...
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
