Psychometric Properties of the Latin American Spanish Version of the Hospital Survey on Patient Safety Culture Questionnaire in the Surgical Setting
Conclusions
Psychometric analyses provided overall support for 9 of the 12 initial factors of patient safety culture. Our findings suggest that more validation studies need to be conducted before applying safety dimensions from the original HSPSC to perioperative settings only. By providing this initial tool, we hope to stimulate further studies and the patient safety research agenda in this part of the world. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Evaluation of Learning Teams Versus Root Cause Analysis for Incident Investigation in a Large United Kingdom National Health Service Hospital
Conclusions
We observed that learning team investigations that targeted process-focused problems generated more actions and a higher number of system-focused actions. There is a difference in culture created during learning team investigations. Although learning teams are not suitable for all investigations, they represent a readily reproducible and valuable addition to the investigative toolkit. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Patient Safety Threats in Information Management Using Health Information Technology in Ambulatory Cancer Care: An Exploratory, Prospective Study
Conclusions
The current design and implementation of HIT systems do not support adequate information management: clinicians needed to play very close attention and improvise to avoid errors in using HIT and treat cancer patients safely. It is important to take the clinical front-end practice into account when evaluating or planning further HIT improvements. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Wheelchair Mobility–Related Injuries Due to Inadvertent Lower Extremity Displacement on Footplates: Analysis of the FDA MAUDE Database From 2014 to 2018
Conclusions
We observed inherent weaknesses in the MAUDE database reporting process and a concerning level of reporting bias. Although there were limited reports of injuries related to ILED on the footplate during wheelchair mobility, the injuries reported were significant. More standardized reporting of the mechanism and impact of these injuries is needed to better inform wheelchair design, prescription, and patient/family education. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
In-Hospital Fall and Fracture Risk With Conditions in the Elixhauser Comorbidity Index: An Analysis of State Inpatient Data
Conclusions
Administrative data can be used to track various fall-related outcomes occurring during inpatient treatment. Several conditions of the Elixhauser Comorbidity Index were identified as increasing the risk of fall-related outcomes and should be considered when evaluating a patient’s risk of falling. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Safety Analysis of 13 Suspicious Deaths in Intensive Care: Ergonomics and Forensic Approach Compared
Conclusions
When presented with a manifest, albeit suspected, wrongdoing with lethal consequences for patients, forensic investigators and safety investigators have distinctly different goals and methods. We believe that a memorandum of understanding between HF/E and forensic investigative teams provides an operative framework for allowing co-existence and fosters collaboration. The pursuit of safe care as a new emerging right for patients and balancing the right to legal justice with the right to safer healthcare merit further investigation and discussion. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Intersystem Medical Error Discovery: A Document Analysis of Ethical Guidelines
Conclusions
Ethics codes provide little guidance on communication regarding IMED scenarios, and in some cases, the guidance is internally conflicting. National professional and patient safety organizations should work to provide a framework for providers and facilities to communicate regarding these ethically and professionally challenging scenarios. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Patients’ Perspectives of Diagnostic Error: A Qualitative Study
Conclusions
This study uses the recent IOM definition of diagnostic error to provide insights into diagnostic error from the patient perspective. We found that diagnostic errors were commonly reported by hospitalized adults and have a profound impact on patients’ well-being. Patients’ insights regarding potential causes and prevention strategies may help identify opportunities to reduce diagnostic errors. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers, and Discharges: Do They Serve Organizations, Staff, or Patients?
Objective
The aim of the study was to analyze content of incident reports during patient transitions in the context of care of older people, cardiology, orthopedics, and stroke.
Methods
A structured search strategy identified incident reports involving patient transitions (March 2014–August 2014, January 2015–June 2015) within 2 National Health Service Trusts (in upper and lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopedics, and stroke. Content analysis identified the following: incident classifications; active failures; latent conditions; patient/relative inv...
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Knowledge, attitudes, and Expectations of Medical Staff Toward Medical Error Management Policies in Humanitarian Medicine: A Qualitative Study
Conclusions
Interviewed staff expressed high expectations of receiving guidance from their organizations and support to adopt clear patient safety and medical error management policies adapted to their complex operational and clinical realities. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
A Call for the Application of Patient Safety Culture in Medical Humanitarian Action: A Literature Review
Conclusions
The adoption of strategies and a culture of safety will need to be adapted to address the variety of intervention contexts and to respond first to the fears and expectations of humanitarian staff. Medical humanitarian organizations, in the absence of an overarching authority for the sector, have a major responsibility in the development of a general patient safety policy applicable in all their operations. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Review Articles Source Type: research
Expert Consensus on Currently Accepted Measures of Harm
Conclusions
The World Café method effectively prioritized measures/triggers of high clinical importance including those that can be used in chart review, which is considered the gold standard. A future goal is to validate these measures using electronic surveillance mechanisms to decrease the need for chart review. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals: A Retrospective Patient Record Review Study
Conclusions
Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Next of Kin Involvement in Regulatory Investigations of Adverse Events That Caused Patient Death: A Process Evaluation (Part I – The Next of Kin’s Perspective)
Conclusions
Although the meeting was emotionally challenging, the next of kin had a positive experience of being involved in the investigation and believed that their information contributed to improving the investigation process. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
Next-of-Kin Involvement in Regulatory Investigations of Adverse Events That Caused Patient Death: A Process Evaluation (Part II: The Inspectors’ Perspective)
Conclusions
Involvement of next of kin in regulatory investigation of adverse events causing patient death contributes to a better understanding of work as done in clinical practice and contributes to strengthen the learning potential in resilience. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2021 Category: Health Management Tags: Original Studies Source Type: research
