Journal of Patient Safety最新文献

Objectives: The aims of the study were to identify the characteristics of medication-related malpractice claims occurring in the ambulatory setting across 2 time periods.

Methods: A retrospective, descriptive study was used. Ambulatory medication-related closed malpractice events from loss years of 2011-2021 were analyzed. Analysis included gender and age, injury severity, location, major injury, medications, primary and secondary services, roles, contributing factors, primary drivers, indemnity paid, and disposition status. Findings were analyzed using the Candello Explore tool.

Results: Five hundred four ambulatory medication-related closed malpractice events were included. Family medicine (19.4%) and internal medicine (10.4%) services had the largest number of claims. The top medications were anti-infectants (16.4%), narcotics (15.6%), and anticoagulants (14.4%). Medication-related claims were multifactorial, averaging 4.1 contributing factors per claim. Clinical judgment issues were found in over 55% of the claims, and communication factors were observed in almost 48% of the claims. In the comparison analysis, 433 claims from 2011 to 2015 and 161 claims from 2016 to 2021 were evaluated. A statistical decrease in claims involving anticoagulants and narcotics ( P  = 0.01) was seen in the second period. There was a statistical increase in claims involving pharmacy dispensing errors during the 2016-2021 period ( P  = 0.03).

Conclusions: Adverse drug events in ambulatory care are multifactorial. Errors in the technical process of ordering and managing medications, patient education, patient adherence, and pharmacy dispensing were the primary drivers of ambulatory medication malpractice claims in this study.

Objectives: This study sought to determine if a standardized root cause analysis (RCA 2 ) selection algorithm, developed by the Veterans Affairs, would select high-risk events for RCA.

Methods: Physician-entered incident reports for all surgical service admissions and perioperative visits were queried over 12 months in the DATIX Clinical Incident Management System. Independent reviewers assigned potential harm and event frequency scores using an institutional scoring system and then calculated and rounded average scores. These were classified using RCA 2 terminology (catastrophic, major, moderate, minor for harm; frequent, occasional, uncommon, remote for frequency). The scores were then evaluated with the standardized Safety Assessment Code Matrix (SAC) algorithm from the National Patient Safety Foundation's RCA 2 guidelines to determine Potential Harm Scores. The SAC combines severity and probability to determine the necessity of conducting an RCA. Catastrophic and major high-frequency events (matrix score = 3) were classified as "RCA recommended." The study then compared cases selected for RCAs using the updated RCA 2 algorithm against cases selected using a current, institutional-specific RCA selection process.

Results: One hundred four cases were reviewed, comprising 20 catastrophic, 48 major harm, 26 moderate harm, and 10 minor harm events. After removing 9 high-variance cases, our institution's current selection process selected 18 cases for RCAs, including 6/20 catastrophic, 8/39 major harm, and 4/36 moderate/minor harm events. Only 17.3% of cases had an RCA completed, while the standardized RCA 2 algorithm recommended investigation for 56.7% of patient safety events, based on SAC Matrix scoring. Current RCA selection processes rendered 4 RCAs on low potential harm or low-frequency events, while 45 potential high-frequency, high potential harm events did not complete RCAs.

Conclusions: Standardizing the selection of patient safety incidents for RCA using the RCA 2 algorithm improves case identification based on the event frequency and potential harm score. Thus, this algorithm has the potential to advance patient safety.

Objectives: The purpose of this study was to examine the impact of a contact-free continuous monitoring system on clinical outcomes including unplanned intensive care unit (ICU) transfer (primary), length of stay (LOS), code blue, and mortality. A secondary aim was to evaluate the return on investment associated with implementing the contact-free continuous monitoring program during the COVID public health emergency.

Methods: An interrupted time series evaluation was conducted to examine the association between the use of contact-free continuous monitoring and clinical outcomes. A cost-benefit analysis was planned to evaluate the return on investment.

Results: Use of contact-free continuous monitoring was not significantly associated with unplanned ICU transfers, deaths, ICU LOS, and or rapid response team calls. However, there were significant increases in code blue events ( P  = 0.02) and mean hospital LOS ( P  = 0.01) in the postimplementation period when compared with the preimplementation period. Due to the lack of improvement, costs were calculated but a cost-benefit analysis was not conducted.

Conclusions: Contact-free continuous monitoring bed use during the COVID-19 public health emergency was not associated with improvements in clinical outcomes, although there was substantial confounding. Future studies should include large randomized controlled trials to control for factors not under direct experimental control including unit staffing, staff turnover, and differences in the patient population related to surges in the COVID-19 pandemic.

Objective: With the development of day surgery, the characteristics of "short, frequent and fast" ophthalmic surgery are becoming more prominent. However, nurses are not efficient in verifying patients' surgical information, and problems such as patient privacy leakage are becoming more prominent. To improve the situation, we developed a new augmented reality (AR)-based tool for visual recognition and artificial intelligent (AI) interpretation of the pattern and location of patient surgical skin markings for the verification of the correct surgical site and procedure. The tool can also display a variety of other verbally requested patient information. The purpose of this proposal is to evaluate its feasibility of use by surgical nurses in a real clinical setting.

Methods: We developed a tool with image recognition technologies to interpretation patient surgical skin markings and match the information obtained with the patients surgical records, thus, verify the patient's surgical information. Verification includes the proper surgical site and type of procedure to be performed. Nurses can interact with the device through its speech recognition capabilities and the device provides them with a variety of other requested patient information via a heads-up display. Three hundred patients in an outpatient ophthalmology clinic were divided into an AR intelligent verification experimental group and a manual verification control group. The accuracy of information verification, work time consumption, and economic cost data were compared between the 2 groups to evaluate the effectiveness of the AR Surgical Information Intelligent Verification Tool in clinical patient surgical information verification.

Results: There was no statistically difference in the correct rates of patient surgical information review between the experimental group (95.33%) and the control group (98.67%) (χ 2  = 2.934, P  = 0.087). The median time for information verification was 10.00 (10.00, 11.00) seconds in the experimental group and 21.00 (20.00, 24.00) seconds in the control group, a statistically difference (Z = 0.000, P  < 0.001). The experimental group saved 11 seconds per patient per review compared with the control group. Considering 10,531 surgeries in 2023, printing 1 page of surgical information per 9 patients and requiring 4 copies, 4680 pages of printing paper could be saved.

Conclusions: The AR Surgical Information Intelligent Verification Tool has advantages in assisting medical staff in patient surgical information verification, improving nursing efficiency, preventing surgical mark errors or nonstandardization, protecting patient privacy, and saving costs. It has certain research and application value in the scenario of patient surgical information verification in ophthalmic day ward.

Objective: The aim of the study is to explore the application of safety education based on the IMB model to prevent harm caused by magnetic resonance ferromagnetic projection accidents.

Methods: One hundred ninety-six patients undergoing magnetic resonance imaging were divided into a control group of 90 cases and an observation group of 106 cases. The control group received routine safety education, while the observation group received safety education based on the IMB model in addition to routine education. The knowledge, attitudes, and behaviors related to the prevention of ferromagnetic projection accidents, as well as fear scores, were compared before and after the intervention.

Results: A total of 90 cases in the control group and 106 cases in the observation group completed the study. There were statistically significant differences in the scores of knowledges, attitudes, and behaviors related to the prevention of ferromagnetic projection accidents, as well as fear scores between the 2 groups after the intervention (all P  < 0.01).

Conclusions: Safety education based on the IMB model can improve the knowledge, attitudes, and behaviors of magnetic resonance imaging patients and reduce the risk of ferromagnetic projection accidents.

Objectives: To examine the patient's perspective of the informed consent process, particularly with regards to reading the informed consent form, understanding and recall of the informed consent.

Methods: Between June and August 2022, 281 patients/proxies at King Fahad Medical City, Saudi Arabia, were surveyed within 7 days before having a medical procedure.

Results: In all, 66.2% of patients did not read the consent before signing. Around 76.2% of patients said they fully understood the information given, 14.9% only partially understood, and 8.9% stated that they had not understood. A total of 90.4% of patients were able to recall their diagnosis. About 27.4% were unable to state any benefit of the procedure. In all, 19.9% were unaware if there was an alternative to the procedure. Around 40.6% were unable to state any risks and only 58.4% could remember at least one risk.

Conclusions: A consent may be technically valid even when the patient has little understanding of the process; therefore, we must strive to ensure that we have ethically valid consent. From our findings, we conclude that informed consent has to be provided in an environment conducive to optimal patient understanding, for example, by ensuring that there is adequate time for explanation, preferably a day or 2 before the procedure. Informed consent should not be taken immediately before a (nonurgent) procedure. Secondly, due to the great variance in understanding between patients, it is vital for the physician to assess the patient's understanding of the consent process, this may be achieved using feedback methodology.

Objectives: The goal of this study was to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. We aimed to develop a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.

Methods: This observational study used the Delphi method to develop a taxonomy code sheet for identifying communication errors reported in the Veterans Health Administration patient safety databases between April 2018 and March 2021. We also used Natural Language Processing to create a framework tool to classify the 9 types of communication errors using this taxonomy. Finally, analysis was done to identify affected clinical locations.

Results: We identified 9 types of communication failures that impacted clinical outcomes using the taxonomy code sheet developed. The top 3 errors were related to nonadherence to facility standard operating procedures (993, 37.6%), followed by written errors (e.g., unclear documentation or not using plain language) (587, 22.3%) and no communication (347, 13.2%). The remaining categories of communication types are electronic (253, 9.6%), verbal (205, 7.8%), hand-off (124, 4.7%), visual (76, 2.9%), listening (41, 1.6%), and nonverbal (12, 0.5%). A cognitive aide was developed to demonstrate the step-by-step method for using the framework tool to classify the communication errors.

Conclusions: The cognitive aide and the framework tool developed in this study can be used in any healthcare setting to identify and classify communication failures and mitigate potential risks contributing to safety events.

Objectives: To analyze the aspects of suicide risks and their relation to patient safety attitudes among the nursing staff of a large public university hospital in Brazil.

Methods: A cross-sectional and descriptive study with 226 nursing workers from a large public university hospital in Brazil. Socioprofessional information, health conditions, and family history related to suicide risk were collected through the Mini International Neuropsychiatric Interview Plus and the Safety Attitudes Questionnaire. A 95% CI was considered, and statistical tests such as the Student t test, χ 2 , analysis of variance, and multiple linear regression were used.

Results: Most of the safety attitudes were below the average score considered positive (mean Safety Attitudes Questionnaire value >0.75), and 41 (18.1%) workers were considered to have any degree of suicide risk. Participants with parents or siblings who had attempted suicide were 3.44 times more likely to have moderate or high suicide risk. Negative safety attitudes were associated with health conditions and family history, considered suicide risk factors. Participants with moderate or high suicide risk were 2.83 times more likely to have worse patient safety attitudes concerning job satisfaction.

Conclusions: This study reveals significant associations between patient safety attitudes and the mental health of nursing workers, expanding the view of worker health management actions and, consequently, patient safety culture.