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

Improving Resident Morning Sign-Out by Use of Daily Events Reports
Conclusions: The collection of key clinical handoff information and its automatic forwarding to incoming providers reduced the average duration of resident morning sign-out and significantly enhanced provider perceptions regarding patient safety and the quality of handoff information. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

Emotion and Coping in the Aftermath of Medical Error: A Cross-Country Exploration
Conclusions: Clinicians in the United Kingdom and the United States experience professional and personal disruption after an error. A number of factors may influence clinician recovery; these factors should be considered in the provision of comprehensive support programs so as to improve clinician recovery and ensure higher quality, safer patient care. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

Attributable Length of Stay and Mortality of Major Bleeding as a Complication of Therapeutic Anticoagulation in the Intensive Care Unit
Conclusions: Major bleeding while receiving anticoagulation is associated with a substantial increase in ICU and hospital length of stay. (Source: Journal of Patient Safety)
Source: Journal of Patient Safety - February 19, 2015 Category: Health Management Tags: Original Articles Source Type: research

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