Journal of Patient Safety最新文献

Objective: In creating an Agency for Healthcare Research and Quality (AHRQ) Patient Safety Learning Laboratory (PSLL), our objective has been to establish a multidisciplinary research environment focused on the safe care of pregnant women and newborns. This manuscript describes work performed under grants P30 HS023506 (obstetric focus) and R18 HS029123 (neonatal focus).

Methods: We follow AHRQ's 5-step approach to systems engineering in health care: problem analysis, design, development, implementation, and evaluation. Within this 5-step approach, methods used include interviews, focus groups, direct observation, teamwork scales, flow disruption analysis, the Systems Engineering Initiative for Patient Safety model, design thinking, and simulation-based testing of processes and prototypes.

Results: Grant P30 HS023506 is completed. The physical characteristics of 10 labor and delivery units were examined, finding significant heterogeneity in size, design, and organization. Task analysis revealed multiple obstacles to optimal team performance. We designed and tested a delayed cord clamping cart to address inherent ergonomic challenges. Finally, we identified common lapses in verbal communication during obstetric emergencies. Grant R18 HS029123 is ongoing. Eighteen Need Statements serve as the basis for exploratory work in mitigating threats to neonates during resuscitation, including a task analysis to determine points of intervention. We are developing (a) novel resuscitation platforms, (b) improved methods of equipment/supply organization, (c) new means of acquiring, displaying, and processing multiple data streams, and (d) innovative techniques and devices for neonatal intubation.

Conclusions: The approach to systems engineering in health care supported by AHRQ's PSLL funding mechanism fosters critical thinking about safety issues by facilitating the integration of investigators with diverse, complementary expertise. By encouraging such collaboration, AHRQ's 5-step process enables important questions to be answered. The PSLL mechanism is a valuable resource for the patient safety community.

Objectives: This observational study examines challenges and opportunities in the medication reconciliation process within the emergency department (ED). Through a human factors approach, we look to identify barriers and potential improvements for enhancing patient safety during transitions of care for older adults.

Methods: An observational study was conducted in the ED of a large teaching hospital, comprising 32 hours of observation across 12 sessions. Researchers followed pharmacists, nurses, and triage staff, documenting workflows, communication practices, and medication reconciliation processes. Recurring patterns, challenges, and opportunities for improvement were identified through a qualitative analysis.

Results: Systemic barriers to effective medication reconciliation were identified, including fragmented workflows, inconsistent documentation, and usability issues in electronic health records. Challenges were exacerbated by the fast-paced ED environment and frequent interruptions. Pharmacists played a pivotal role in synthesizing diverse information sources to construct accurate medication histories, but their workload often limited their capacity to address broader medication safety concerns. Opportunities for improvement include delegating specific tasks to trained support staff, optimizing electronic health record functionalities, and fostering interdisciplinary collaboration to streamline workflows and reduce errors.

Conclusions: Medication reconciliation in the ED is critical for patient safety but faces significant systemic and environmental challenges. Addressing these barriers through enhanced system integration, task delegation, and improved communication protocols could increase efficiency and reduce errors. Further research is needed to evaluate these interventions across diverse ED settings to optimize medication reconciliation processes and improve safety outcomes.

Retained surgical items (RSIs) are foreign objects left inside after surgery, classified as serious but preventable never events. This review aims to examine the consequences and impact of RSIs, thereby raising awareness and emphasizing prevention. The author reviewed case reports published between 2020 and 2024. A total of 37 cases were evaluated. Excluding 3 asymptomatic patients, 91.89% sought medical help due to discomfort, with 59.46% experiencing pain. On average, 2.33 additional imaging examinations were required. Of the patients, 94.59% underwent a second or more operations, 77.14% of which were open surgeries. Serious complications were observed in 29.73% of cases, and 3 patients died from complications. The average stay to discharge after surgery was 5.94 days. The median incubation time was 1.75 years. RSIs were found across various procedures and anatomic sites, with 67.57% presenting nonspecific symptoms. Only 32.43% of diagnoses were identified through imaging, and 70.27% were confirmed intraoperatively, indicating that the primary diagnosis matched the final diagnosis in only 29.73% of cases. The impact of retained surgical items on patients and health care providers is significant. Prevention is always better than cure.

Objectives: The aim of this study was to explore where and how managers facilitate arenas for collective reflections and knowledge sharing ("reflexive spaces") in homecare services during the COVID-19 pandemic. Moreover, we sought to understand how these "reflexive spaces" contributed to adaptations to challenges induced by the pandemic. Finally, we aimed to discuss how these spaces might incorporate resilience into health care.

Methods: This multiple embedded case study includes interviews with health care staff (n=16) and managers at different system levels (n=21) from 4 Norwegian municipalities. The data were analyzed in accordance with reflexive thematic analysis.

Findings: The analysis identified 2 overarching themes: (1) arenas for reflection, communication, and dialogue, and (2) establishing new solutions through collective reflection facilitated by managers. Managers who initiated dialogue and established arenas for reflection and communication were highlighted as important for discussing and sharing knowledge about challenges created by the pandemic. In these spaces, both managers and staff reflected, collaborated, and learned from each other and then designed a tactical and resilient response to the ongoing challenges.

Conclusions: Managers had a key role as facilitators for "reflexive spaces" within and across levels of responsibilities. Moreover, managers had a mediating role in bridging knowledge and understanding across levels within the health care system. Using "reflexive spaces" as part of daily practice appeared as an important measure to balance demands and capacity and respond both to crises and to everyday challenges.

Objectives: To evaluate the impact of using a simulated teletransport application compared with ad hoc phone calls between medical control physicians (MCP) and transport teams on situational awareness and communication during neonatal interfacility transports.

Methods: In this pilot study, MCPs and pediatric critical care transport teams (PCCT) participated in simulated neonatal transports with or without a simulated transport monitoring and communication (T-MAC) application. Situational awareness (perception, the recognition of the patient's status; comprehension, the understanding of the significance of patient's status; and projection, anticipation of what the patient's status will likely become) and the overall duration of communication was measured and compared between and within groups.

Results: Thirty-three subjects (20 MCP, 13 PCCT) participated in 52 simulations. MCPs had higher overall situational awareness scores with use of the T-MAC app compared with ad hoc phone calls with increased mean perception (98%, T-MAC versus 79%, no T-MAC, P = 0.003) and projection (53%, T-MAC versus 40%, no T-MAC, P = 0.004) scores before a patient event (sudden adverse change to patient status); and increased perception (83%, T-MAC versus 64%, no T-MAC, P = 0.03); comprehension (68%, T-MAC versus 48%, no T-MAC, P = 0.04); and projection (58%, T-MAC versus 30%, no T-MAC, P = 0001) scores after the event. PCCTs had higher mean perception (98%, T-MAC versus 81%, no T-MAC, P = 0.02) and projection (54%, T-MAC versus 45% no T-MAC) scores before the event. The median duration of call times decreased for adverse events (125, IQR: 45s, T-MAC versus 140, IQR: 70s, no T-MAC, P = 0.046).

Conclusions: In this simulated setting, the use of a specially designed teletransport app for neonatal interfacility transports improved situational awareness and increased the efficiency of communication for transport team stakeholders. There was greater benefit in improving situational awareness for the MCPs than for PCCT members. The development and use of a T-MAC application warrants further investigation.

Background: Physical restraint is commonly applied in the clinical settings despite numerous studies presenting its paucity of efficacy and safety. Despite the various tangible and intangible factors associated with moral and safety issues, nurses must make decisions on restraint use in ethical dilemmas. Health care providers often find it challenging to make appropriate decisions regarding the use of physical restraint in demanding clinical environments without a standard and objective assessment tool.

Objectives: The objectives aimed to identify effective instrument to justify the decision-making regarding the use of physical restraint in general adult ward settings.

Methods: A literature search was conducted on several electronic databases, including Medline, PubMed, CINAHL Complete, Embase, and Cochrane Library, using subject MeSH headings and relevant keywords to identify any relevant studies pertaining to the research question. Only articles written in English from January 2014 to March 2024 were considered. The search was filtered by screening for articles with the full-text availability, cohort studies that are not considered an experimental studies, systematic reviews, or meta-analysis. The reference lists of literatures were also searched to identify any further relevant studies.

Results: Eight studies were included in this review, consisting of 6 cohort studies, 1 stepped-wedge randomized controlled trial, and 1 systematic review. The quality of the studies ranged from low to moderate, with the risk of bias being moderate to high. The interventions retrieved from the included studies can be categorized as restraint decision instruments, restraint preventive interventions and restraint preventive strategies. All included studies reported a significantly improved rate of restrained patients in the intervention group comparing to the control group. The rate of restrained patient days decreased significantly in the intervention group. There was no significant difference in the rate and number of accidental catheter removal, fall incident, and length of stay.

Conclusions: Implementing the evidence-based instrument can help improve patient outcomes, reduce inappropriate use of physical restraint, and provide a structured decision-making process for health care staff. An evidence-based assessment instrument is developed to assess patients who are necessary to be given physical restraint, and further stringent research is necessary to evaluate the effect of such instrument. Training on least restrictive techniques and effective strategies is crucial for nurses to ensure adherence of nurses and appropriate care for patients.

Objectives: A framework of high-reliability principles was used to identify, investigate, and mitigate infusion pump safety concerns at a large, multisite health care system. We developed a systematic approach to address challenges associated with overinfusions, underinfusions, and the inability to clear upstream occlusion alarms. We identified 112,875 upstream occlusion events for 389,604 infusion starts (failure rate, 29%) within 6 months.

Methods: Five high-reliability principles were applied to infusion pump management. Preoccupation with failure emphasized reporting safety concerns and performing appropriate clinical and bench tests. Deference to expertise prompted the development of a multidisciplinary team with internal and external partners. Sensitivity to operations prompted assessment of human factors design, with simulations and analysis of medication-specific factors (e.g., viscosity; infusion rates). Reluctance to simplify prompted assessment of tubing characteristics (e.g., concentricity; wall thickness) with micro-computed tomography and process development for removing faulty equipment. Practice of resilience ensured ongoing engagement and commitment to a culture of safety and patient advocacy.

Results: The multidisciplinary oversight team prompted a national recall, removal of malfunctioning pumps, and development of system-wide training and mitigation protocols. Despite ongoing pump challenges, our team optimized internal patient safety systems and processes. The cause of these malfunctions remains under investigation, but serious patient harm has been prevented.

Conclusions: Key strategies for enhancing patient safety were continuous vigilance, interdisciplinary collaboration, and embracing complexity in a large health care organization. Future directions involve deeply integrating these high-reliability principles across all aspects of health care delivery to continue improving safety and quality outcomes.

Objectives: Care for black patients in the United States is concentrated in relatively few hospitals-known as black serving hospitals (BSHs). BSHs have high rates of safety events. Yet, it is unknown what aspects of patient safety culture are associated with employee assessments of patient safety or reporting safety events, and whether these patterns differ for hospitals predominantly serving black patients.

Methods: We identified hospitals as BSH if their proportion of admitted black patients exceeded the national average (12.1%). We linked BSH status to the 2021-2022 Hospital Survey on Patient Safety Culture 2.0 (HSOPS) data, identifying 128 BSHs and 243 non-BSHs (with 107,224 and 138,028 HSOPS respondents, respectively). We examined the associations of 10 aspects of patient safety culture with 2 summary measures: employee's overall rating of patient safety and whether employees reported safety events. We fit respondent-level models, overall and stratified by BSH status, controlling for respondent characteristics. We used weights accounting for hospital HSOPS observations and to make results nationally representative. t tests were obtained from a model fully interacted with BSH status to test whether the associations for BSHs and non-BSHs were different.

Results: Positive patient safety ratings were most associated with staffing/work pace, communication openness, management support of safety, and organizational learning-continuous improvement. Reporting any event was most positively associated with response to error and most negatively associated with management support. Patterns were similar for BSHs and non-BSHs, except for 4 associations: stronger positive association of organizational learning-continuous improvement with positive patient safety ratings in BSHs. Stronger negative association of staffing/work pace and communication openness with reporting any event in BSHs. Stronger positive association of communication openness with reporting any events in non-BSHs.

Conclusions: Key aspects of creating hospital workplace cultures that engage in identifying events and learning from them to support patient safety differed in BSHs and non-BSHs, warranting further investigation. This knowledge may help mitigate differences in patient safety across hospitals.