Pharmacists Views and Practices in Regard to Sales of Antibiotics Without a Prescription in Madinah, Saudi Arabia
Conclusions: Pharmacist views and practices are alarming. The results of this study show that this practice will continue to spread unless strict enforcement is put in place, Lack of clear understanding of the limitations of pharmacist’s scope of practice. Results of these studies can be extrapolated to other countries in the region and other countries of the similar social and professional development status. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Article Source Type: research

Improving Patient Safety Culture in Primary Care: A Systematic Review
Conclusions: These studies in general practice provide a first understanding of improvement strategies and their effect in primary care. As the level of evidence was low, no clear preference can be determined. Further research is needed to help practices make an informed choice for an intervention. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Review Article Source Type: research

Associations of Injurious Falls and Self-Reported Incapacities: Analysis of the National Health Interview Survey
Conclusions: A subset of the NHIS questions are positively associated with injurious falls in the previous 12 months and may be of use in identifying adults at greater risk of future falls. The NHIS questions may serve to identify persons in need of targeted preventive services. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Rapid Learning of Adverse Medical Event Disclosure and Apology
Introduction: Despite published recommended best practices for full disclosure and apology to patients and families after adverse medical events, actual practice can be inadequate. The use of “cognitive aids” to help practitioners manage complex critical events has been successful in a variety of fields and healthcare. We wished to extend this concept to disclosure and apology events. The aim of this study was to test if a brief opportunity to review a best practice guideline for disclosure and apology would improve communication performance. Methods: Thirty pairs of experienced obstetricians and labor nurses ...
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Multidisciplinary Testing of Floor Pads on Stability, Energy Absorption, and Ease of Hospital Use for Enhanced Patient Safety
Conclusions: Floor pads do exist that show promise for hospital use that absorbing energy without major impacts on balance during sit-to-stand. Although only commercially available pads were investigated, results may inform the design and multidisciplinary testing of other floor surfaces. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Measuring Adverse Events in Hospitalized Patients: An Administrative Method for Measuring Harm
Conclusion: The AHMT is sufficiently accurate for use as a within hospital tool to reliably detect and track harm. Nevertheless, it is not recommended as a tool to make comparisons across institutions, which has policy and payment implications. Further research using administrative harm detection, including the use of a broader set of measures and electronic health records, is needed. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department
Conclusion: Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 23, 2016 Category: Health Management Tags: Original Articles Source Type: research

A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists
Conclusions: Inadequate error feedback to staff and insufficient preventative procedures increase the likelihood that near-miss errors will be underreported. Hospitals seeking to improve near-miss error reporting should improve error-reporting infrastructures to enable feedback, which, in turn, would create a more preventative system that improves patient safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Continuous Mandatory Onsite Consultant Intensivists in the ICU: Impacts on Patient Outcomes
Conclusions: An improved survival rate was observed only among medical patients admitted to the ICU with mandatory continuous access to a consultant intensivist, despite the presence of greater disease severity in the population admitted to this unit. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Drug-Related Harms in Hospitalized Medicare Beneficiaries: Results From the Healthcare Cost and Utilization Project, 2000–2008
Conclusions: Potentially preventable drug harms are a growing clinical and financial burden. Comparative outpatient drug safety should be analyzed using Medicare claim databases. In-hospital management of drug safety should target patients with multimorbidity and functional decline. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Physicians' Practice of Dispensing Medicines: A Qualitative Study
Conclusions: Despite being expected to dispense, and the patient safety issues involved in giving drugs to patients to use at home, physicians do not feel that they have been trained to undertake this task. These findings from 1 hospital raise questions about the wider quality and safety of this practice. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Safety Culture in Indian Hospitals: A Cultural Adaptation of the Safety Attitudes Questionnaire
Conclusions: This study reveals promising initial results for patient safety culture in India, but further study is needed. The development and validation of the SAQ-Gujarati allow additional hospitals to evaluate their patient safety culture. As the first rendition of the SAQ to an Indian setting, the tool could help to initiate safety discourse and improve the potential for institutions to provide feedback to their staff members. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Ambulatory Computerized Prescribing and Preventable Adverse Drug Events
Background: Adverse drug events (ADEs) represent a significant cause of injury in the ambulatory care setting. Computerized physician order entry reduces rates of serious medication errors that can lead to ADEs in the inpatient setting, but few studies have evaluated whether computerized prescribing in the ambulatory setting reduces preventable ADE rates in ambulatory care. Objective: To determine the rates of preventable ADEs before and after the implementation of computerized prescribing with basic clinical decision support for ordering medications. Design: Before-after study of ADE rates in practices implementing comp...
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

Hidden Barriers to Delivery of Pharmacological Venous Thromboembolism Prophylaxis: The Role of Nursing Beliefs and Practices
Conclusions: Nurses on units with low administration rates often believe they have the skills to determine which patients require pharmacological venous thromboembolism prophylaxis. They are also more likely to believe that ordered doses are discretionary and offer the medication as optional to patients. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Original Articles Source Type: research

A Perspective on the Principles of Integrity in Infectious Disease Research
This article sets forth examples of potential problems with research integrity in the infectious disease literature. We describe articles that may be spun, categories lumped together in hopes of creating a significant effect (and sometimes an insignificant one), changes in metrics, and how trials may fail because of suboptimal interventions. When examined together, the examples show that the problems are widespread and illustrate the difficulty associated with interpreting medical research. The state of the current medical literature makes it of utmost importance that all sections of the manuscript are read, including asso...
Source: Journal of Patient Safety - June 1, 2016 Category: Health Management Tags: Review Article Source Type: research

Commentary on Performance Improvement: One Psychiatry Department’s Experience
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Invited Commentary Source Type: research

Comparing the Attitudes and Knowledge Toward Incident Reporting in Junior Physicians and Nurses in a District General Hospital
Objectives: The practice of open reporting and instituting a blame-free culture improves a system’s ability to deal with risky processes, and the attitude of staff toward safety processes is a critical factor. We compared the attitudes and knowledge of incident reporting between junior physicians and nurses in a district general hospital. Methods: A questionnaire was designed to examine health care workers’ attitudes toward reporting and errors. It also assessed knowledge of incident reporting and attitudes toward training in patient safety. Staff nurses (n = 50) and junior physicians (n = 50) were sampled on ...
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Original Articles Source Type: research

Operating Room Clinicians’ Attitudes and Perceptions of a Pediatric Surgical Safety Checklist at 1 Institution
Conclusions: The surgical staff at 1 pediatric hospital who responded viewed the novel Pediatric Surgical Safety Checklist as potentially beneficial to operative patient safety by improving teamwork and communication, reducing errors, and improving efficiency. Responses varied by discipline, indicating that team members view the checklist from different perspectives. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Original Articles Source Type: research

Adherence to the 2010 American College of Cardiology Foundation Appropriate Use Criteria for Cardiac Computed Tomography: Quality Analysis at a Tertiary Referral Center
Conclusions: high across provider specialties. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Original Articles Source Type: research

Medication Administration Errors in a University Hospital
Conclusion: Medication administration errors represent a major problem in the hospital that needs urgent intervention to optimize medication administration process. The intervention should consider the identified significant determinants of medication administration errors. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Original Articles Source Type: research

Researchers’ Roles in Patient Safety Improvement
Conclusions: When working side by side with “practice,” researchers are offered and engage in several different activities. The way researchers contribute to patient safety improvement and balance between different roles depends on the purpose of the study, as well as on the underlying patient safety improvement models. Different patient safety research paradigms seem to emphasize different improvement roles, and thus, they also face different challenges. Open reflection on the underlying improvement models and roles can help researchers with different backgrounds—as well as other actors involved in patie...
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Original Articles Source Type: research

Patient, Physician, Medical Assistant, and Office Visit Factors Associated With Medication List Agreement
Conclusions: Having MAs begin their medication review with an open-ended question may be a simple, inexpensive, and easily implemented process to increase accuracy of medication lists for prescription and nonprescription medications. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Original Articles Source Type: research

Hand Hygiene Adherence Among Health Care Workers at Japanese Hospitals: A Multicenter Observational Study in Japan
Conclusions: The hand hygiene adherence in Japanese teaching hospitals in our sample was low, even lower than reported mean values from other international studies. Greater adherence to hand hygiene should be encouraged in Japan. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Original Articles Source Type: research

Acceptability of Health Care–Related Risks: A Literature Review
Conclusions: Social acceptability includes perceptions related to risks and the stated intentions of individual behavior. This concept may therefore be relevant for defining local and national patient safety priorities. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 24, 2016 Category: Health Management Tags: Review Article Source Type: research

Improving Performance During Image-Guided Procedures
Conclusions: When compared with traditional “open” procedures, the technology used during image-guided procedures places an imaging system and long thin tools between the operator and the patient. Taking a step back and reexamining how information flows through an imaging system and how actions are conveyed through human-machine interfaces suggest that much can be learned from studying system failures. In the same way that flight data recorders revolutionized accident investigations in aviation, much could be learned from recording video data during image-guided procedures. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Review Article Source Type: research

Retained Foreign Body: “Needle in a Haystack”
Abstract: Retained foreign bodies remain an area of potential patient harm. This case describes a retained needle from distant surgery discovered at the time of the needle count after myomectomy. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Case Report Source Type: research

Engaging Employees: The Importance of High-Performance Work Systems for Patient Safety
Conclusions: We used information from a literature review and executive input to create a reliable and valid HPWSs survey. Future research needs to examine whether HPWSs is associated with additional safety and quality outcomes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Original Articles Source Type: research

Sleep Quality and Vigilance Differ Among Inpatient Nurses Based on the Unit Setting and Shift Worked
Conclusions: Our data indicate that a significant number of inpatient nurses have impaired sleep quality, excessive sleepiness, and abnormal fatigue, which may place them at a greater risk of making medical errors and harming patients; these problems are especially pronounced in night shift workers. PVT results were inconsistent, but floor and day shift nurses performed better on some tasks than ICU and night shift nurses. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Original Articles Source Type: research

A Study of Rate and Predictors of Fall Among Elderly Patients in a University Hospital
Conclusions: Elderly patients with anemia, osteoporosis, and history of a fall are more prone to falls and should be considered in fall protective measures. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Original Articles Source Type: research

The German Critical Incident Reporting System for Anesthesiology: CIRSains
Conclusion: CIRSains displays the German effort to establish the Helsinki declaration. Easy accessibility, anonymity, medicolegal safety, and high flexibility resulted in high usage. The study shows a sufficient practicability of the database, but the data input has to be improved for better scientific use, for example, by implementation of more multiple-choice questions. Given the high magnitude and importance of patient safety problems, improving CIRSains remains a priority for the future. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Original Articles Source Type: research

Significant Physiological Disturbances Associated With Non-Routine Event Containing and Routine Anesthesia Cases
Conclusions: SPDs occur more often in NRE-containing cases. The incidence of approximately one NRE-independent SPD per case was similar in NRE-containing and routine case. Further research is needed to ascertain the relationship of both NREs and SPDs to patient outcomes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Original Articles Source Type: research

Predictors of Patients’ Intentions to Participate in Incident Reporting and Medication Safety
Conclusions: Interventions aimed at encouraging the participation of patients in promoting their own safety should consider the extent to which patients feel in control and capable of performing the behavior in question; this will help support patients to work with health-care professionals in ensuring safe care. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Original Articles Source Type: research

Integrating Health Information Technology to Achieve Seamless Care Transitions
Abstract: Improving care transitions, or “handoffs” as patients migrate from one care setting to another, is a priority across stakeholder groups and health-care settings and additionally is included in national health-care goals set forth in the National Quality Strategy. Although many demonstrations of improved care transitions have succeeded, particularly for hospital discharges, ensuring consistent, high-quality, and safe transitions of care remains challenging. This paper highlights the potential for health information technology to become an increasing part of effective transitional care interventions, wi...
Source: Journal of Patient Safety - December 1, 2015 Category: Health Management Tags: Original Articles Source Type: research

Ethical Issues in Patient Safety Research: A Systematic Review of the Literature
Abstract: As many as 1 in 10 patients is harmed while receiving hospital care in wealthy countries. The risk of health care–associated infection in some developing countries is as much as 20 times higher. In response, in many global regions, increased attention has turned to the implementation of a broad program of safety research, encompassing a variety of methods. Although important international ethical guidelines for research exist, literature has been emerging in the last 20 years that begins to apply such guidelines to patient safety research specifically. This paper provides a review of the literature related ...
Source: Journal of Patient Safety - August 25, 2015 Category: Health Management Tags: Review Article Source Type: research

Risk Propensity and Safe Medication Administration
Conclusions: This study is among the first to demonstrate a relationship between risk propensity and safe medication administration. Further research into personal risk taking, risk perception and its impact on patient safety, specifically safe medication administration, is needed. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 25, 2015 Category: Health Management Tags: Original Articles Source Type: research

Use of an iPad to Provide Warfarin Video Education to Hospitalized Patients
Objective: To evaluate the effectiveness of a warfarin educational video in the hospital setting and to determine patients’ satisfaction with using an iPad to view a warfarin educational video. Methods: This prospective quality improvement project included adult (≥18 years of age) patients on warfarin in the hospital. All patients completed pre-video and post-video knowledge tests on the iPad before and after viewing the educational video on warfarin therapy. Patients also completed a patient satisfaction survey. Results: Forty hospitalized patients were educated using the warfarin video and included for analysis....
Source: Journal of Patient Safety - August 25, 2015 Category: Health Management Tags: Original Articles Source Type: research

Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analysis and Examination of Prescribing Error Rates
Conclusions: Medication advice-seeking networks among staff on hospital wards are limited. Hubs of advice provision include pharmacists, junior physicians, and senior nurses. Senior physicians are poorly integrated into medication advice networks. Strategies to improve the advice-giving networks between senior and junior physicians may be a fruitful area for intervention to improve medication safety. We found that one ward with stronger networks also had a significantly lower prescribing error rate, suggesting a promising area for further investigation. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 25, 2015 Category: Health Management Tags: Original Articles Source Type: research

Locating Errors Through Networked Surveillance: A Multimethod Approach to Peer Assessment, Hazard Identification, and Prioritization of Patient Safety Efforts in Cardiac Surgery
Conclusions: We integrated the theories and methods of a diverse group of researchers to identify a broad range of hazards and good clinical practices within the cardiovascular surgical operating room. Our findings were the basis for a plan to prioritize improvements in cardiac surgical care. These study methods allowed for the comprehensive assessment of a high-risk clinical setting that may translate to other clinical settings. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 25, 2015 Category: Health Management Tags: Original Articles Source Type: research

The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review
Conclusions: The findings from this review suggest that there are emerging trends indicating that the specific patient safety culture measurement tools, the level of analysis, and selection of outcome measures are important considerations in study design. More research is needed to determine interventions that improve patient safety culture and outcomes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - August 25, 2015 Category: Health Management Tags: Original Articles Source Type: research

State-Mandated Hospital Infection Reporting Is Not Associated With Decreased Pediatric Health Care–Associated Infections
This study tests if hospitals located in states with state-mandated, facility-identified, pediatric-specific public CLABSI reporting have lower rates of CLABSIs as defined by the Agency for Healthcare Research and Quality’s Pediatric Quality Indicator 12 (PDI12). Methods: Utilizing the Kids’ Inpatient Databases from 2000 to 2009, we compared changes in PDI12 rates across three groups of states: states with public CLABSI reporting begun by 2006, states with public reporting begun by 2009 and never-reporting states. In the baseline period (2000–2003), no states mandated public CLABSI reporting. A multivaria...
Source: Journal of Patient Safety - August 25, 2015 Category: Health Management Tags: Original Articles Source Type: research

Variability of Patient Safety Culture in Belgian Acute Hospitals
Conclusions: Large comparative databases provide the opportunity to identify distinct high and low scoring groups. In our study, language, work area, and profession were identified as important safety culture predictors. Years of experience in the hospital had only a small effect on safety culture perceptions. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 26, 2015 Category: Health Management Tags: Original Articles Source Type: research

Use of Failure Modes, Effects, and Criticality Analysis to Compare the Vulnerabilities of Laparoscopic Versus Open Appendectomy
Conclusion: FMECA helped the staff compare the 2 approaches through an accurate step-by-step analysis, highlighting that laparoscopic appendectomy is feasible and safe, associated with a lower incidence of infection and other complications, reduced length of hospital stay, and an apparent lower procedure-related risk. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 26, 2015 Category: Health Management Tags: Original Articles Source Type: research

Frequency of Prescribing Errors by Medical Residents in Various Training Programs
Objectives: Medication errors are hazardous and costly. Children are at increased risk for medication errors because of weight-based dosing, limited FDA indications, and human calculation errors. The aim of this study is to determine the frequency and type of resident prescribing errors in a pediatric clinic and further compare error rates of residents in different training programs. Methods: Resident prescription error data from a pediatric clinic was collected for 5 months. Upon detection of an error, residents were notified/given feedback regarding the type of error, ways to remedy errors, and future prevention methods....
Source: Journal of Patient Safety - May 26, 2015 Category: Health Management Tags: Original Articles Source Type: research

A Safe Practice Standard for Barcode Technology
Conclusions: There is growing evidence for the efficacy of barcode solutions in improving overall medication safety. Standards for the implementation of barcode technology are proposed. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 26, 2015 Category: Health Management Tags: Original Articles Source Type: research

The Fate of Pediatric Prescriptions in Community Pharmacies
Objectives: The purpose of this study was to describe behaviors of community pharmacists related to pediatric prescriptions and examine the effect of demographic and situational factors on behaviors and confidence in performing recommended activities when dispensing medications for pediatric patients. Methods: The study employed a self-administered survey of community pharmacists in a regional chain. One intervention group attended a live continuing education session. A second intervention group received a dosing guide in the mail. One month after the intervention, both intervention groups and a control group completed the...
Source: Journal of Patient Safety - May 26, 2015 Category: Health Management Tags: Original Articles Source Type: research

Assessing the Perceived Level of Institutional Support for the Second Victim After a Patient Safety Event
Conclusions: These results validate a need by associates for emotional support after a PSE and that associates’ perception of available formal institutional support services or interventions is low. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 26, 2015 Category: Health Management Tags: Original Articles Source Type: research

The Effectiveness of a Multicenter Quality Improvement Collaborative in Reducing Inpatient Mortality
Conclusion: The study concludes with a discussion of those methods that were plausible reasons for the successes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - May 26, 2015 Category: Health Management Tags: Original Articles Source Type: research

Psychological Safety and Error Reporting Within Veterans Health Administration Hospitals
We examined organizational climate assessment interviews (n = 374) evaluating how many employees asserted willingness to report errors (or not) and their stated reasons. Finally, based on survey data, we identified 2 (psychologically safe versus unsafe) hospitals and compared their number of employees who would be willing/unwilling to report an error. Results: Psychological safety increased with supervisory level (P
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

The Reliability of AHRQ Common Format Harm Scales in Rating Patient Safety Events
Conclusions: AHRQ Common Format Harm Scale v.1.1 and v.1.2 both had moderate interrater reliability. Using Harm Scale v.1.1, respondents had difficulty distinguishing “injury limited to additional treatment” from “temporary harm,” whereas, using Harm Scale v.1.2, respondents had difficulty distinguishing moderate harm from one of the adjacent levels—mild or severe harm. This study provides valuable data that can inform harm scale revision to improve the quality of aggregate safety data used to define and direct safety efforts. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

Perceptions of Medical Errors in Cancer Care: An Analysis of How the News Media Describe Sentinel Events
Conclusions: In reports of medical errors involving cancer patients, the news media regularly blame individual clinicians for mistakes and fail to present a systems-based understanding of these events. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research