Journal of Patient Safety最新文献

Objectives: The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process.

Methods: The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period. The following 5 measures were reviewed: (1) rates of reported medication administration events involving IDC medications; (2) hospital length of stay; (3) patient mortality; (4) nurses' favorability toward single checking; and (5) nursing time spent on administration of IDC medications.

Results: The rate of reported medication administration events involving IDC medications was not significantly different across the groups (95% confidence interval, 0.02%-0.08%; P = 0.4939). The intervention also did not significantly alter mortality ( P = 0.8784) or length of stay ( P = 0.4763) even after controlling for the patient demographic variables. Nursing favorability for single checking increased from 59% of nurses in favor during the double check phase, to 94% by the end of the single check phase. Each double check took an average of 9.7 minutes, and a single check took an average of 1.94 minutes.

Conclusions: Our results suggest that performing independent double checks on high-risk medications administered in a pediatric ICU setting afforded no impact on reported medication events compared with single checking.

Background: Direct admissions from clinic or home to the hospital may improve efficiency and reduce emergency room utilization, but nonoptimized processes may increase the risk of harm during the transition of care. Our multidisciplinary team aimed to understand and improve the process of directly admitting patients to inpatient medicine services at a large academic medical center.

Methods: In this single-institution quality improvement initiative, we identified key communication gaps within the direct admission process and implemented a handoff tool in the form of a templated note and order set to bridge those communication gaps. The primary outcome measure was the monthly utilization rate of the handoff note as a surrogate for handoffs and uptake of the intervention.

Results: We launched our intervention in April 2022. We achieved sustained use of the SmartText and a peak of 24% of direct admissions utilizing the SmartText in January 2023. Based on feedback during Plan-Do-Study-Act cycles, we added direct admission instructions for outpatient teams to follow in the order set and reduced text in the handoff note.

Conclusions: This study demonstrates the design and implementation of a quality improvement initiative to identify and address communication gaps for direct admissions of adult medicine patients.

Objectives: There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines.

Methods: We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests. Responses were dichotomized into "highly considered" and "less considered" factors. Frequencies of the "highly considered" factors (current and ideal) were analyzed. Write-in responses were coded into themes within a priori domains in a qualitative analysis.

Results: Of the 666 hospitalists surveyed, 238 (36%) responded. Respondents most frequently identified the need for specialty procedural and nonprocedural care and bed capacity as factors that should be considered when triaging IHT patients in current and ideal practice, whereas the least frequently considered factors were COVID-related care, insurance/financial considerations, and patient/family preference. More experienced respondents considered patient/family preference more frequently in current and ideal practice compared with less experienced respondents (33% versus 11% [ P = 0.0001] and 26% versus 9% [ P = 0.01], respectively). Qualitative analysis identified several themes in the domains of Criteria for Acceptance, Threshold for Acceptance, and Indications for Physician-to-Physician Communication.

Conclusions: This geographically diverse sample of hospitalist physicians responsible for accepting IHT patients showed general agreement between primary factors that are currently and that should be considered for IHT acceptance, with greatest weight placed on patients' need for specialty care.

Objectives: Community-dwelling older adults taking 5 or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations, such as the Food and Drug Administration, often issue guidelines to ensure medication safety, how older adults understand and mitigate the risk of harm from medication use in the home environment is poorly understood.

Methods: We conducted semistructured interviews with community-dwelling older adults 65 years and older who took 5 or more prescription medications to explore medication safety strategies they use. We also compared 2 organizations' medication safety guidelines for areas of concordance and discordance.

Results: A total of 28 older adults were interviewed. Four overarching themes of medication management strategies emerged: collaborating with prescribers, collaborating with pharmacists, learning about medications, and safe practices at home. Study findings revealed that older adults followed some of the published guidelines by the 2 government organizations, although there were some areas of discord. Some of the strategies used were unintentionally against the recommended guidelines. For example, older adults tried weaning themselves off their medications without notifying their providers.

Conclusions: Older adults and their caregivers in our study used strategies different from those recommended by government organizations in managing medications to enhance drug safety. Patient-provider collaboration and positive patient outcomes can be improved by understanding and respecting strategies older adults use at home. Future studies must effectively incorporate older adults' perspectives when developing medication safety guidelines.

Objectives: We aimed to investigate the value of adding a video monitoring (VM) system with falls and costs for patients at high risk.

Methods: We conducted a retrospective, historically controlled study of adults (≥18 y old) at high risk of fall admitted at the University of Miami Hospital and Clinics from January 1 to November 30, 2020 (pre-VM) and January 1 to November 30, 2021 (post-VM); in-person sitters were available in both periods. Fall risk assessment was conducted on admission and at every nursing shift; we defined patients as high risk if their Morse Fall Scale was ≥60. We conducted a multivariable logistic regression model to evaluate the association of period (pre- versus post-VM) with falls and performed a cost analysis.

Results: Our primary cohort consisted of 9,034 patients at high risk of falls, 4,207 (46.6%) in the pre-VM and 4,827 (53.4%) in the post-VM period. Fall rates were higher in the pre- than the post-VM periods (3.5% versus 2.7%, P = 0.043). After adjustment, being admitted during the post-VM period was associated with a lower odds of fall (odds ratio [95% confidence interval], 0.49 [0.37-0.64], P < 0.001). The median adjusted hospital cost (in 2020 dollars) was $1,969 more for patients who fell than for patients who did not (interquartile range, $880-$2,273). Considering start-up and ongoing costs, we estimate VM implementation to partly replace in-person monitoring has potential annual cost savings of >$800,000 for a hospital similar to ours.

Conclusions: Video monitoring to augment in-person sitters is an effective fall prevention initiative for patients at high risk of falls, which is likely also cost-effective.

Background: Over the past decade, the implementation of simulation education in health care has increased exponentially. Simulation-based education allows learners to practice patient care in a controlled, psychologically safe environment without the risk of harming a patient. Facilitators may identify medical errors during instruction, aiding in developing targeted education programs leading to improved patient safety. However, medical errors that occur during simulated health care may not be reported broadly in the simulation literature.

Objective: The aim of the study is to identify and categorize the type and frequency of reported medical errors in healthcare simulation.

Methods: Systematic review using search engines, PubMed/MEDLINE, CINAHL, and SCOPUS from 2000 to 2020, using the terms "healthcare simulation" AND "medical error." Inclusion was based on reported primary research of medical errors occurring during simulated health care. Reported errors were classified as errors of commission, omission, systems related, or communication related.

Results: Of the 1105 articles screened, only 20 articles met inclusion criteria. Errors of commission were the most reported (17/20), followed by systems-related errors (13/20), and errors of omission (12/20). Only 7 articles reported errors attributed to communication. Authors in 16 articles reported more than one type of error.

Conclusions: Simulationists and patient safety advocates must continually identify systems-related errors and training deficits that can lead to inaction, improper action, and poor communication. Recent dialogs in the simulation community have also underscored the potential benefits of developing a registry of errors across simulation centers, with a goal of aggregating, analyzing, and disseminating insights from various simulation exercises.