Shoulder Dystocia Documentation: An Evaluation of a Documentation Training Intervention
Conclusions: Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

TRIAD VII: Do Prehospital Providers Understand Physician Orders for Life-Sustaining Treatment Documents?
Conclusions: In the Pennsylvania prehospital setting, POLST documents can be confusing, presenting a risk to patient safety. Additional research, standardized education, training, and/or safeguards are required to facilitate patient choice and protect safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

TRIAD VI: How Well Do Emergency Physicians Understand Physicians Orders for Life Sustaining Treatment (POLST) Forms?
Conclusions: Significant confusion exists among members of the Pennsylvania chapter of the American College of Emergency Physicians regarding the use of POLST in critically ill patients. This confusion poses risk to patient safety. Additional training and/or safeguards are needed to allow patient choice as well as protect their safety. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

“Identification and Description of Randomized Controlled Trials and Systematic Reviews on Patient Safety Published in Medical Journals”: A Librarian’s Response
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Letter to the Editor Source Type: research

English as a Second Language is a Risk for an Adverse Drug Event
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Letter to the Editor Source Type: research

The Relationship Between Tort Reform and Medical Utilization
Conclusion: The comparison of the Dartmouth Atlas Medicare Reimbursement Data with Malpractice Reform State Rankings, which are used by the PRI, did not support the hypothesis that defensive medicine is a driver of rising health-care costs. Additionally, comparing Medicare reimbursements, premedical and postmedical tort reform, we found no consistent effect on health-care expenditures. Together, these data indicate that medical tort reform seems to have little to no effect on overall Medicare cost savings. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Original Article Source Type: research

Avoidable Iatrogenic Hypoglycemia in Patients on Peritoneal Dialysis: The Risks of Nonspecific Glucose Monitoring Devices and Drug-Device Interaction
Conclusions: Non-nephrology HCPs are unaware that POC glucometers are nonglucose specific and do not possess comprehensive knowledge of drug metabolism, particularly for uncommonly seen agents. The case reports highlight the absolute need for use of glucose-specific assays in BG determinations for patients using icodextrin within 2 weeks of hospitalization. To avoid future devastating consequences including severe hypoglycemia, coma, or death related to the drug-device interaction described, hospital protocols should require that all PD patients’ BGs are measured in central chemistry laboratories. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Original Article Source Type: research

Mobile Physician Reporting of Clinically Significant Events—A Novel Way to Improve Handoff Communication and Supervision of Resident on Call Activities
Conclusions: Advances in information technology now permit clinically significant events that take place during “off hours” to be identified and reported (via handoff) to next providers and to supervisors via collated reports. This information permits hospital leaders to correct safety issues quickly and effectively, while attending physicians are able to use information gleaned from the reports to optimize rounding plans and to provide additional oversight of trainee on call patient management decisions. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Original Article Source Type: research

A Tool to Determine Financial Impact of Adverse Events in Health Care: Healthcare Quality Calculator
Conclusions: The Healthcare Quality Calculator determines financial impact of poor patient outcomes and the benefit of initiatives to improve quality. The calculator can identify quality issues that would provide the largest financial benefit if improved; however, it cannot identify specific interventions. The calculator provides a tool to improve transparency regarding both short- and long-term financial consequences of funding, or failing to fund, initiatives to close gaps in quality or improve patient outcomes. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Original Article Source Type: research

Understanding Safety Culture in Long-Term Care: A Case Study
Conclusions: This study highlights the importance of understanding a unit’s safety culture and identifies the PSCIT as a useful framework for planning future improvements to safety culture maturity. Incorporating mixed methods in the study of health care safety culture provided a good model that can be recommended for future use in research and LTC practice. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Original Article Source Type: research

Predicting Potential Postdischarge Adverse Drug Events and 30-Day Unplanned Hospital Readmissions From Medication Regimen Complexity
Objectives: To determine whether medication regimen complexity (MRC) could predict likelihood for occurrence of potential adverse drug events (ADEs), unplanned 30-day hospital readmission, or 30-day emergency department use in patients transitioning from hospital to home care. Methods: Hospital discharge medication lists and medication lists constructed during visits to patients’ homes were analyzed for 213 participants. MRC was quantified with the Medication Regimen Complexity Index (MRCI). The potential for ADEs was based on medication discrepancies detected between the discharge and patient reported home medicatio...
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Original Article Source Type: research

Conflict of Interest, Dr Charles Denham and the Journal of Patient Safety
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - November 21, 2014 Category: Health Management Tags: Editorial Source Type: research

Utilization of Simulation for the Introduction of New Software Technology to the Clinical Setting
Conclusions: Simulation can be used to improve the rollout of new software in a tertiary care center. Staff satisfaction associated with this type of learning activity was high, and a communicated level of comfort was achieved as a result of the simulation-based experiential learning. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Original Articles Source Type: research

The Relationship Between Hospital Systems Load and Patient Harm
Conclusions: The results of this analysis are highly suggestive of a relationship between Hospital Systems Load and patient harm. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Original Articles Source Type: research

Mentorship for Newly Appointed Physicians: A Strategy for Enhancing Patient Safety?
Conclusions: Offering mentorship to all newly appointed physicians in their first substantive post in health care may be a useful strategy to support the development of their clinical, professional, and personal skills in this transitional period that may also enhance the safety of patient care. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Original Articles Source Type: research

Emergency Department Experience With Nonoral Contrast Computed Tomography in the Evaluation of Patients for Appendicitis
Conclusions: Abdominal CT scan without the use of oral contrast is accurate to allow for appropriate decision making by emergency physicians and general surgeons. In our series, no patients required repeat scanning. Further assessment by larger studies is appropriate. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Original Articles Source Type: research

Older Folks in Hospitals: The Contributing Factors and Recommendations for Incident Prevention
Conclusions: Although systems are in place for incident reporting and analysis of the contributing factors, improvement depends upon clinicians taking responsibility for anticipating and moderating risk using previous data to identify system weaknesses and monitoring improvements especially in hospitalized older patients. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Original Articles Source Type: research

Patient Perceptions of Surgical Informed Consent: Is Repeat Back Helpful or Harmful?
Conclusions: Patients were highly satisfied with RB during surgical IC RB is not detrimental to the consent process and may improve informed consent for surgery. Trial Registration: Clinical Trials Identifier NCT00288899 http://www.clinicaltrials.gov (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Original Articles Source Type: research

The Relationship Between Nurse Staffing and Failure to Rescue: Where Does It Matter Most?
Conclusions: We did not observe any of the expected associations between the nurse staffing variables and FTR for either general care unit or ICU discharges. The comprehensive risk adjustments provided adequate “leveling of the playing field” to evaluate the impact of unit-based nurse staffing levels on FTR mortality. Future studies should evaluate the influence of unit environment and patient risk. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Original Articles Source Type: research

An Overview of Measurement Activities in the Partnership for Patients
Abstract: The Partnership for Patients, launched in April 2011, is a national quality improvement initiative from the Department of Health and Human Services that has set ambitious goals for U.S. providers to improve patient safety and care transitions. This paper outlines the initiative’s measurement strategy, describing four measurement-related objectives: (1) to track national progress toward the program goals that U.S. hospitals reduce preventable adverse events by 40% and readmissions by 20%; (2) to support local quality improvement measurement in participating hospitals by providing the appropriate tools, train...
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Special Issue: Partnership for Patients Source Type: research

An Appeal for Safe and Appropriate Imaging of Children
No abstract available (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - September 1, 2014 Category: Health Management Tags: Invited Commentary Source Type: research