Journal of Patient Safety最新文献

Objectives: To address the challenge of analyzing large volumes of patient safety event (PSE) reports, we developed and evaluated an AI-powered software tool. The primary goal was to assess the tool's potential to support analysts and uncover novel trends in patient safety databases.

Methods: A pilot evaluation was conducted with seven organizations (4 health care facilities and 3 patient safety organizations) to assess the tool's impact on analysts' workflows and their ability to uncover insights. Feedback was gathered through interviews with patient safety analysts using the tool. Two human factors experts analyzed the findings using a human cognition framework for information visualization to identify strengths and areas for improvement. Novel insights from PSE data were systematically recorded, capturing trends and themes that emerged during the analysis process.

Results: Participants from 6 of 7 institutions reported that the tool helped identify valuable insights, such as trends in procedural errors, inconsistencies in event categorization, and emerging issues with specific medications and devices. The emerging themes algorithm effectively highlighted previously undetected patterns by grouping related events and emphasizing novel keywords. However, participants noted some irrelevant keywords due to limitations in narrative data quality. The tool's design principles, including chunking information and highlighting key terms, improved efficiency in reviewing reports.

Conclusions: The AI-driven tool demonstrated potential to enhance patient safety by supporting analysts in detecting trends and patterns in PSE reports. Future iterations will address identified limitations and further refine its ability to organize data around user mental models for improved usability.

Objective: The aim of this study is to assess relationships between nursing quality measures and patient experience.

Methods: This cross-sectional study examines a 2018 six-state sample of 620 acute care hospitals in the United States, to create a pre-COVID-19 pandemic baseline for the associations between nursing quality and patient experience. Variables include 4 nurse-sensitive quality outcome measures, nursing communication (a process measure), and patient experience scores.

Results: Of the nurse sensitive quality indicators included, only central line-associated bloodstream infections were significantly (negatively) but weakly associated with overall hospital rating. Nursing communication was significantly (positively) and strongly correlated to overall hospital rating.

Conclusions: Patient experience is a valuable measure of health care quality, and the intersection of nursing quality and patient experience requires further review. The nurse-sensitive quality outcome measures included in this study are not associated with patient experience scores. The significance of nursing communication, a process measure, suggests an opportunity exists to explore and quantify acute care nursing quality outside the traditional outcome metrics.

Background: Diagnostic errors are one of the most common and costly medical errors. Most diagnostic errors are due to provider cognitive processes and biases. With the widespread adoption of electronic health records (EHRs), and other health information technology (health IT), EHRs are now the central repository for clinical information and its design and use affect the diagnostic process and diagnostic errors. The goal of this study was to analyze patient safety event reports to determine health IT contributions to diagnostic errors. Understanding how the health IT contributes to diagnostic error will help direct improvement efforts.

Methods: From a data set consisting of 1,110,029 reports entered between 2015 and 2021, from 195 unique health care organizations across the United States, 2618 likely diagnostic error reports were retrieved. A sample of these reports were reviewed and those that were diagnostic related were coded by subject matter experts for whether the diagnostic error was preventable, the stage of the diagnostic process in which the error occurred, the type of error, how much health IT contributed to the error, what health IT system was responsible for the error, whether health IT was directly or indirectly responsible for the error, the type of health IT issue, whether copy and paste was mentioned and contributed to the error, whether the health IT contribution was preventable, the outcome of the error, and the severity of the error.

Results: There were 2618 reports with a general event type category that suggested a diagnostic error. Of these, 119 reports explicitly mentioned health IT and were found to have strong or moderate evidence of health IT contributing to the error. From the remaining 2499 reports, 250 were randomly sampled and 93 (37.2% of 250) had strong or moderate evidence of a health IT contribution. Further analysis of these 212 reports showed EHRs were the most commonly described type of health IT associated with diagnostic errors (58.5%) and most diagnostic errors occurred in the test phase of the diagnostic process (74.5%). Most reports that had health IT as a contributor to the diagnostic error were associated with patient harm (74.5%). There was a trend towards a higher degree of harm when the errors were health IT-related compared with when there was little evidence of health IT contribution.

Conclusions: Health IT, and specifically the EHR, is a contributor to diagnostic errors. To address these issues, improved reporting taxonomies and improvements in health IT system design are needed.

Objectives: Patient falls are an important public health issue, preventable by nurses through risk assessment and education. Here, we conduct a pilot study aimed at improving fall prevention knowledge and attitudes, and decreasing patient falls through use of a spaced-retrieval mobile app.

Methods: We collected baseline patient fall rates and Fall TIPS (Tailoring Interventions for Patient Safety) poster completion rates in 64 patient rooms and baseline self-report ratings of self-efficacy and attitudes (including self-efficacy for preventing patient falls, perceived safety climate and performance, perceived support, and job dedication) from nursing staff participants. Fifteen participants then used a spaced-retrieval app for 6 weeks (2-3 min/workday) to retrain fall prevention knowledge. After this, we again collected Fall TIPS poster completion rates, self-reported ratings, and patient fall rates.

Results: Knowledge of fall prevention strategies, self-efficacy, perceived safety performance, perceived support, and Fall TIPS poster completion rates improved significantly from pre-to-post app use. We found no differences in the other attitudinal measures or patient falls.

Conclusions: These findings suggest that engaging in spaced review of fall prevention protocols may yield short-term improvements in fall prevention knowledge, self-efficacy, and Fall TIPS poster completion rates while requiring minimal time.

Objective: The Austrian Inpatient Quality Indicators (A-IQI) are routinely measured quality and patient safety indicators derived from administrative data. A subset of these are sentinel indicators, for which even a single case of death leads to a conspicuous indicator. The purpose of this study was to assess the value of A-IQI sentinel indicators for detecting serious adverse events.

Methods: We retrospectively reviewed all inpatient treatment cases with abnormal sentinel indicators at a large university hospital in Austria from 2013 to 2022 using structured chart reviews with the Institute for Healthcare Improvement Global Trigger Tool. The detected adverse events were classified according to their severity, preventability, and causal relationship with the outcome. Positive predictive values were calculated for the individual sentinel indicators and for all indicators combined.

Results: A total of 189 adverse events in 107 cases (1 to 6 per case; mean: 1.77; SD: 1.4) were identified. 51.9% caused temporary impairment, 3.7% caused permanent harm, 5.3% required life-sustaining interventions, and 36% contributed to the patient´s death. 63.5% of the adverse events detected were assessed as potentially preventable. The positive predictive value of all sentinel indicators combined was 78.5% (95% CI: 70.7%-86.3%) for at least one adverse event and 55.1% (95% CI: 45.7%-64.6%) for an adverse event contributing to the patient's death.

Conclusions: Our preliminary results suggest that sentinel indicators might be useful for detecting serious and preventable adverse events. Further studies with larger case numbers are required to determine the actual value of these indicators for clinical risk management.

To identify scientific evidence describing the development and/or use of mobile applications to support the education of health personnel, patients, and their caregivers, focusing on hospitalized patient safety. The review was conducted on 7 electronic databases: Medline, PubMed, Cochrane, Embase, Scopus, VHL, and Web of Science, in addition to gray literature. The study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The final findings were presented regarding authorship, year of publication, country of origin, study objective, methodological design, sample and setting, mobile application development process, and main findings. Of the 1996 studies found, after removing duplicates, 1784 abstracts were evaluated. After evaluating the full texts, 12 studies were considered relevant, and discussed essential aspects of patient safety, such as drug administration and infection prevention, following the international patient safety goals. The analyzed mobile applications covered different types of content, such as serious games, educational videos, animations, and simulations. The analysis revealed a variety of approaches, including analysis, design, development, implementation, and evaluation of the apps. Content validity and the usability of mobile applications were the main aspects investigated. There has been a growing development and use of mobile applications aimed at increasing knowledge about patient safety, showing a positive trend for educating the target audience. However, there is a lack of mobile applications that display attractive features for users.

Objectives: Recognizing the challenges of at-home recovery following a truncated presurgical pathway for emergency laparotomy (EL) patients, we sought to identify barriers and facilitators to optimal recovery. This study aimed to develop a human-centered interview guide to capture the experiences of patients recovering at home after EL.

Methods: We employed an iterative human-centered design (HCD) approach to interview guide development, structured across 3 cycles. Each cycle refined the interview guide based on mock interviews and feedback from an interdisciplinary team. In cycle 1, we focused on creating a patient-centered, understandable guide. In cycle 2, we introduced a preinterview survey to tailor and shorten the interview process. In cycle 3, we automatically integrated patient responses from the survey into the interview guide, streamlining the workflow for interviewers.

Results: The HCD process yielded a comprehensive, efficient interview guide responsive to both patient and interviewer needs. The integration of a preinterview survey reduced the cognitive load for patients and minimized interviewer preparation time, facilitating in-depth patient discussions on EL recovery experiences.

Conclusions: This study underscores the value of HCD in research measurement design and tool development. The finalized guide enhances patient-centered data collection, reduces interviewer errors, and supports meaningful insights into EL recovery. This reusable protocol may benefit other researchers working on similar patient safety studies.

Objectives: It is recognized that older adults and people with disabilities are more vulnerable and face significant obstacles in their health care. The panorama of patient safety incidents, the barriers these populations encounter in their health care, and the contexts in which they occur need clarification. This study aimed to identify, in the scientific literature, the types of patient safety incidents, the barriers that are most reported in the health care process for older adults and people with disabilities, and the environments where they are most reported.

Method: A scoping literature review was carried out using Scopus and PubMed. Search word categories were patient safety terms, barrier terms, and population terms.

Results: Twenty-seven articles focused on safety incidents, 16 reported barriers, and 7 reported on both. Medication incidents were the most common incidents reported in both populations. However, reported barriers differed between populations.

Conclusions: These populations face various factors that can affect their health care processes. The information available on patient safety and barriers for older adults and people with disabilities must be deepened and expanded.