Journal of Patient Safety最新文献

Objectives: It is not always possible to access ABO-compatible platelet concentrates (PCs) for reasons such as short shelf life and not always being readily available. Therefore, blood centers have to develop strategies for the use of ABO-incompatible PCs. However, there are conflicting data regarding the safety of using ABO-incompatible platelet transfusions, especially concerning transfusion reactions.

Methods: This multicenter, retrospective cohort study analyzed platelet transfusion records from 3 tertiary-level hospitals over a 9-year period (2016-2024). Data were extracted from institutional hemovigilance systems and electronic transfusion records. The transfusion outcomes were compared between ABO-compatible and ABO-incompatible PCs, focusing on the incidence of transfusion reactions (TRs).

Results: A total of 21,470 PCs were transfused to 12,305 patients. TRs occurred in 17 cases, with an incidence of 0.79 per 1000 PCs. Of these reactions, 7 were febrile nonhemolytic transfusion reactions and 10 were allergic reactions. During the study period, 2791 ABO-incompatible PCs (12.9%) were transfused to 1248 patients. No significant difference was determined in the transfusion reaction rate between the ABO-compatible and incompatible groups (0.80 per 1000 vs. 0.71 per 1000, P=0.88). The distribution of TR types was similar in both groups (P=0.787). No hemolytic reaction was observed.

Conclusion: Although no significant difference in TR incidence was detected between ABO-compatible and incompatible PCs, this retrospective study-limited by low event frequency, and potential under-reporting-was not able to establish the safety of ABO‑incompatible transfusions. However, ABO-incompatible PCs may still be an option in resource-limited settings. Larger-scale prospective studies are necessary to further evaluate safety with standardized hemovigilance reporting.

Objective: To explore health care professionals' descriptions of near-miss events and assess the validity using the World Health Organization (WHO) patient safety classification framework.

Methods: A total of 2805 near-miss reports were reviewed from a tertiary hospital from 2021 to 2024 using a retrospective, mixed-methods approach. Descriptive statistics were used to examine reporting trends and patterns. Qualitative analysis was performed through evaluating each report's narrative using a structured decision-making process based on WHO criteria to determine whether it qualified as a near miss, adverse event, no-harm incident, or reportable circumstances.

Results: Eighty-four percent were validated as true near misses, mostly related to medication safety. However, significant misclassification was observed in patient care and workplace safety reports, where many events were incorrectly labeled as near misses despite involving patient harm or reaching the patient without causing harm.

Conclusion: The findings reveal substantial near-miss detection and reporting by the pharmacy department, in particular, which signifies the pharmacists' role in validating prescriptions for patient safety. It simultaneously identifies critical reporting gaps related to the misunderstanding of safety event taxonomy by the reporting staff, which limits the accuracy of reported data and the potential resolution. Therefore, the study emphasizes the need for adopting a near-miss reporting framework that is comprehensive and standardized with a transparent definition, a structured analytical methodology, and a robust feedback mechanism to streamline the reporting process to ensure consistency of near-miss reporting across departments and optimize patient safety efforts.

Purpose: This quality improvement study aimed to address challenges in medication storage and accessibility in an acute pediatric care setting. By examining current processes, improvement opportunities were identified to enhance medication availability and reduce errors by introducing new locked medication storage boxes for multiuse, patient-specific medications.

Methods: This quality improvement study was conducted in a 38-bed medical-surgical unit at a large Midwestern pediatric hospital. The study consisted of 3 phases: preintervention, simulation, and postintervention. Preintervention included near miss frequency counts, bedside medication audits, time observation audits, and a knowledge survey. The simulation phase involved in-situ simulations over 2 shifts with ten nurses (n=10), measuring success rates, task completion times, workload, and task difficulty and confidence ratings. Postintervention activities repeated the initial measures collected during the preintervention phase.

Results: Participants showed a higher task success rate (94.6%) for the work-as-imagined procedure compared with a work-as-done (60%) and intervention (89%) processes. Overall, the intervention process decreased perceived workload according to the unweighted NASA-Task Load Index (NASA-TLX) scores and decreased task time compared with the work-as-imagined storage process. Confidence in task completion was highest for work-as-imagined, with a slight decrease in difficulty for the intervention or work-as-done.

Conclusions: This study underscores the importance of identifying and addressing gaps between organizational policies or standard operating procedures and actual practices while engaging frontline staff. The implementation of new medication lockboxes significantly improved the medication storage process, demonstrating the effectiveness of quality improvements methods in enhancing both safety and efficiency. These findings highlight the value of a collaborative, systems-based approach in driving meaningful improvements in health care settings, ultimately contributing to better patient outcomes and operational efficiency.

Background: The OWLL (Open-Wide Learning Lab) intervention was developed using Human-Centered Design to improve the quality and safety of pediatric dental sedation. The intervention includes a patient-facing informational sedation brochure and video, and an enhanced set of clinical sedation records. Here, we report on the process evaluation 6 months after implementation in daily clinical practice.

Methods: This study was conducted at the outpatient pediatric dental clinics of 2 large US academic dental institutions. We used a mixed-methods design to assess the fidelity, acceptability, appropriateness, and feasibility of the OWLL intervention. Quantitative data were gathered through chart reviews, while qualitative data were collected through surveys and interviews with providers and patients.

Results: During implementation, the intervention was used for 81 pediatric sedation patients across sites. Overall, the intervention was well-received by both clinicians and patients. Chart reviews indicated that sedation records were consistently utilized, though occasional gaps in data completeness were observed. Providers welcomed the intervention, finding it compatible with their daily routines and easy to use. However, some challenges were reported, primarily related to time constraints and the need to adjust clinical encounters for effective intervention integration. Parents appreciated the sedation brochure and video, describing them as a valuable and positive addition to the care process.

Conclusion: The findings suggest that the intervention was used and is a welcomed addition, with the potential for broader application in clinical settings to further improve patient care. Future efforts should examine the intervention's impact on patient safety outcomes across diverse clinical settings.

Objectives: Emotional exhaustion among ICU professionals poses a significant threat to both health care quality and staff well-being. While patient safety culture (PSC) is recognized as a potential buffer, its longitudinal impact on emotional exhaustion remains underexplored, particularly within high-intensity clinical environments like ICUs. This study investigates how ICU professionals' perceptions of PSC influence the progression of emotional exhaustion over a 5-year period, highlighting shifts in organizational and psychological predictors.

Methods: A 5-year longitudinal survey (2020-2024) was conducted in a regional teaching hospital in Taiwan. A total of 1213 valid responses were collected from ICU physicians and nurses using the Chinese version of the Safety Attitudes Questionnaire (CSAQ), which includes 6 PSC dimensions and an emotional exhaustion scale. Stepwise multiple regression was used annually to identify significant predictors of emotional exhaustion.

Results: Findings revealed a temporal shift in the predictors of emotional exhaustion. In 2020, organizational support factors-job satisfaction (β=-0.523, p<0.001) and perceptions of management (β=-0.443, p<0.001)-were significant negative predictors, while safety climate showed a counterintuitive positive association (β=0.264, p=0.004). From 2021 to 2024, stress recognition emerged as the most consistent protective factor (β range=-0.366 to -0.537, p<0.001). Interestingly, teamwork climate, often considered beneficial, was positively associated with emotional exhaustion in later years, suggesting added interpersonal burdens in collaborative ICU settings.

Conclusions: Emotional exhaustion in ICU professionals is shaped by dynamic interactions between organizational structures and individual-level coping resources. Early burnout prevention should focus on institutional support, while long-term strategies should promote stress awareness and carefully manage team-based expectations. These findings provide health care leaders with actionable insights to design adaptive, stage-specific interventions to sustain psychological resilience in high-stress clinical environments.

Background: Surgical outcomes depend not only on clinical expertise but also on environmental factors, among which operating room noise is an important yet often underestimated risk factor. Rather than providing an extensive background, this study focuses on mapping how operating room noise and patient outcomes have been conceptualized in the scientific literature using bibliometric scientific mapping methods to identify intellectual structures, thematic trends, and research gaps.

Method: This retrospective descriptive study analyzed 54 original research articles identified through a predefined and structured bibliometric search of the Web of Science Core Collection conducted on April 25, 2025. Search terms included combinations of "operating room," "noise," and "patient." Bibliometric analyses were performed using VOSviewer and the Bibliometrix R package, examining publication trends, citation patterns, keyword co-occurrences, and collaboration networks.

Results: The earliest publication was identified in 1986, with 41.51% of articles published in the last 5 years and a marked increase after 2020. The analyzed studies were published in 43 journals and authored by 247 researchers, with a mean of 4.74 authors and 18.72 citations per article. The United States was the most productive and most cited country. Core themes centered on "noise," "patient safety," and "communication," while recent trends highlighted "auditory alarms," "staff stress," and "surgeon workload." Author productivity followed Lotka law, and institutional contributions were concentrated in Vanderbilt University and the University of Neuchâtel.

Conclusion: The findings demonstrate increasing academic attention to operating room noise and its relationship with patient outcomes; however, the literature remains fragmented, predominantly observational, and largely single-centered. This bibliometric mapping highlights the need for multicenter, experimental, and interdisciplinary research designs, as well as clearer outcome definitions, to better capture the clinical, psychosocial, and organizational pathways through which operating room noise may influence patient safety and perioperative care quality.

Objectives: Adverse drug events (ADEs) associated with subcutaneous (SC) medication use represent an escalating public health concern. However, data regarding the severity and associated risk factors of these events in Brazil remain limited, which impedes the development of effective safety interventions. This study aimed to characterize ADE reports linked to SC drug administration in Brazil from 2019 to 2024 and to identify sociodemographic and clinical predictors of severity.

Methods: A cross-sectional analysis was conducted utilizing 4954 ADE reports from the Brazilian VigiMed pharmacovigilance database. The variables assessed included patient demographics, reporter type, drug class, and event severity (eg, hospitalization, death). Associations were evaluated using χ2 tests, and multivariate logistic regression was used to identify independent predictors of severity.

Results: The majority of reports involved female patients (69.2%) and individuals aged 60 years or older (54.9%). Endocrine and metabolic agents were the most frequently implicated drug class (54.4%). Severe ADEs accounted for approximately one-third of all reports, with hospitalization (27.3%) and death (8.3%) being the most common outcomes. After adjustment, male sex [adjusted odds ratio (aOR) 1.31], age ≥60 years (aOR 1.48), reports from health care services (aOR 3.80), and nonspontaneous notifications (eg, clinical studies; aOR 1.52) were significantly associated with increased severity.

Conclusions: Subcutaneous medications in Brazil are associated with a considerable burden of severe ADEs, particularly among older adults and male patients. Strengthening pharmacovigilance systems, enhancing professional training, and implementing robust safety protocols are essential measures to mitigate harm and ensure safer SC drug administration.

Objective: The aim of this study is to determine the frequency of opening of operating room doors during cardiovascular surgery operations, the number of personnel entering and exiting, and the reasons for these entries.

Materials and methods: This descriptive observational study was carried out in the cardiovascular surgery operating rooms of a university hospital. Using purposive sampling, 22 consecutive surgeries were observed, and data were collected with an "Intraoperative Observation Form." Descriptive statistics were used for analysis.

Results: The mean number of door openings per procedure was 74.18±41.54, corresponding to 16.92±7.33 openings per hour. Individuals opening the doors were support staff (27.8%), nurses (24.7%), perfusionists/others (18.9%), surgeons (15.6%), and anesthesiologists/anesthesia technicians (13.1%). The leading reason for entry was equipment retrieval (27.2%). Notably, 20.3% of entries were unrelated to the ongoing surgery.

Conclusion: Operating-room traffic is characterized by frequent door openings and substantial personnel movement, conditions that may degrade air quality and heighten the risk of surgical-site infection. Educational initiatives, improved equipment planning, and institutional policy development are recommended to reduce unnecessary traffic.