Journal of Patient Safety最新文献

Objectives: Some patients cannot return home after hospitalization due to temporary or permanent disabilities, leading to so-called "complex discharge." This study aims to investigate the consequences and financial implications of complex discharge, and to assess a low-cost reorganization that removed a control point in the discharge process.

Materials and methods: A retrospective observational study analyzed 21,448 hospital discharge records (HDRs) for 2019, and 18,584 HDRs for 2021, of the Molinette Hospital, the third largest Italian hospital. Factors influencing length of stay (LOS) were analyzed using linear regression models. The economic impact of complex discharge was simulated by assuming its absence, calculating the gain in production expected if hospital beds were used for noncomplex patients. To assess reorganization's impact, LOS was compared before and after its implementation using linear regression and interrupted time series (ITT) models.

Results: Factors associated with increased LOS included age, emergency admission, transfers to another hospital, and expected LOS based on diagnosis-related group. Complex discharge patients had a 50.2% longer LOS ( P < 0.001, adjusted R2 of 36.47%). Simulating absence of these patients provided an expected gain in production equal to 4,522,879.93€. The reorganization reduced LOS by 6.1 days for the 72 affected patients. The ITT analysis showed that the intervention flattened the preexisting LOS upward trend ( P < 0.001, adjusted R2 of 33.21%).

Conclusions: Complex discharge significantly increases LOS, with an important economic impact. The reorganization was a low-cost intervention that significantly modified the discharge dynamics, demonstrating its potential for improving patient outcomes and reducing health care costs.

Background: In Japan, a significant number of ventilator-related medical accidents continue to be reported, with causes frequently linked to both equipment malfunctions and human errors. Conventional analytical methods often lack the methodological rigor needed for comprehensive safety analysis.

Objectives: This study explores the application of System-Theoretic Process Analysis (STPA) as a novel approach to ventilator safety analysis. The goal is to identify potential hazards arising from human errors and device failures and to establish system-level safety constraints.

Methods: STPA is employed to construct a control structure diagram of a ventilator system, offering a system-wide perspective to identify Unsafe Control Actions (UCAs) and resulting hazardous scenarios. This approach provides a structured analysis of system interactions to derive safety constraints aimed at reducing risks.

Results: STPA successfully identified UCAs and system-level interactions that could lead to hazardous outcomes. Compared with the Critical Incident Report (CIR) by the Japan Council for Quality Health Care (JCQHC), which provides retrospective insights into ventilator-related incidents, STPA demonstrates a systematic and comprehensive methodology. It analyzed the mechanisms by which incidents could arise within the system, considering both human and technical factors. The analysis identified hazardous interactions and provided a foundation for implementing preventive measures.

Conclusions: STPA offers a holistic framework for ventilator safety, surpassing traditional analysis methods by addressing complex human-technical interactions. The results contribute to enhanced ventilator safety, improved risk management, and a stronger safety culture across medical devices.

Transformational leadership plays a major role in enhancing organizational culture and service outcomes within the health care sector. Recent reports from various health care systems worldwide have highlighted systemic issues such as blame culture and inadequate leadership training in health services. Although this paper references UK-specific reports, the discussion is applicable to health care leadership challenges on a global scale, as similar issues have been documented in other countries, including the United States, Canada, Australia, and Germany. There should be a shift from a hierarchical (vertical) to a more collaborative (horizontal) structure of leadership. This will result in intellectual stimulation, idealized influence, inspirational motivation, and individualized consideration. Health care staff should be empowered through transformative leadership to improve interdisciplinary collaboration, service provision, and foster a more supportive culture internationally, especially in the post-COVID era, where global health care systems face workforce burnout and leadership crises. While acknowledging limitations, including potential over-reliance on leaders' personalities and ethical risks, the paper advocates for leadership development as a vital tool in addressing the current challenges facing health care systems globally. Transformational leadership is positioned as a powerful catalyst for cultural change and improved health care outcomes.

Objective: Efficient execution of medication management strategies, such as medication reviews, is crucial for reducing potential medication-related harms and improving treatment effectiveness. We assessed the perspectives of primary care professionals on how the rapid integration of telehealth during the COVID-19 pandemic affected medication management in primary care.

Methods: Semistructured interviews were conducted with 27 family medicine clinicians, support staff, and administrators. Interview questions focused on primary care processes, care delivery, and the use of telehealth technology during the pandemic. Codes were initially developed a priori using the interview guide and iteratively revised based on data and consensus meetings. The final coding structure was then used to analyze all transcripts.

Results: Participants were predominantly physicians (65.4%) who practiced family medicine (89.5%). Primary care professionals indicated that the swift integration of telehealth significantly affected the medication review and reconciliation procedures established within their practices, sometimes causing potential risks to medication safety, while others observed no significant changes in this process. Among the notable changes were the increased workload on providers and a reduced role of the collaborative team-based approach. Overall, providers recognized both the benefits and challenges of using telehealth for medication management.

Conclusions: The rapid adoption of telehealth during the pandemic influenced medication management strategies, posing challenges to patient safety through changes in medication reconciliation processes and lack of team-based approaches to medication management. Ensuring patient safety in primary care settings through telehealth services requires the strategic integration of evidence-based medication safety processes in telehealth service delivery designs.

Objectives: Primary care clinicians are increasingly using new technologies to improve safe opioid prescribing. One of these technologies is an opioid panel dashboard, which lists patient-level information and related opioid safety measures. This paper describes our experiences of implementing dashboards in 2 different settings and how clinicians used those dashboards and their associated attitudes and perceptions.

Methods: Two primary care programs, a single-site academic residency program [Highland Family Medicine (HFM)] and a multisite regional network [Primary Care Network (PCN)], incorporated opioid safety dashboards, differing in content and implementation strategies. We surveyed clinicians within the 2 programs in 2023 to understand how they used these dashboards and their associated attitudes and perceptions.

Results: A total of 49 eligible clinicians responded to the survey. A total of 31% of HFM clinicians and 81% of PCN clinicians found the dashboard useful. Approximately half of HFM clinicians felt badly if they had patients above 90 MMEs. Almost all clinicians reported using the dashboard to make clinical decisions, most commonly prescribing intranasal naloxone. In addition, PCN clinicians reported tapering or stopping opioid or benzodiazepine prescriptions based on the dashboard data.

Conclusions: Dashboards can be an important tool to support safe opioid prescribing, but attention needs to be given to how clinicians view and interact with the dashboards. This is critical to ensure that the information presented in dashboards is both actionable and not misinterpreted.

Objective: Despite the importance of Patient Safety (PS), it has been neglected in primary health care (PHC). Therefore, this study aimed to assess PS standards in PHC using the World Health Organization (WHO) Patient Safety-friendly Primary Care Framework (PSFPC).

Methods: This cross-sectional study was conducted in comprehensive health centers (CHCs) in East Azerbaijan Province, Iran, in 2024. The Persian version of the PSFPC framework was used. Cluster sampling was employed, and data were collected through self-assessment, document review, observation, and interviews with staff. The collected data were reported descriptively.

Results: Five CHCs were assessed by staff. The average compliance with PS standards was 70.38%. The highest compliance was in safe, evidence-based clinical practice (47.2%), while the lowest was in lifelong learning (14.0%). The average compliance with critical, core, and developmental criteria was 63.32%, 28.42%, and 52.22%, respectively. All CHCs were classified as "nonevaluable."

Conclusions: Based on a preliminary literature review and the researchers' best knowledge, this study was the first to assess PS in PHC using the WHO approach and tool. Further studies in this field and in other countries could help to highlight the issue of PS in PHC.

Objective: Clinicians are encouraged to report all health care incidents, but only those causing serious harm are routinely reviewed to improve patient care. There is no consensus on the best method of confirming ongoing nasogastric tube (NGT) position, leading to variation in practice. The aim of this study is to evaluate the clinical contexts of incidents related to ongoing NGT position testing and assess the efficacy of current clinical practices.

Method: Incident databases in Queensland Health, Australia and NHS England were searched by data custodians for incidents mentioning NGTs. A multidisciplinary team compared the extracted incidents to the inclusion and exclusion criteria. Qualitative content analysis (where incidents were coded into themes) was used to evaluate the incidents.

Results: Five of 27 Queensland incidents, 24 of 412 English incidents, and 2 of 26 English Never Events met the inclusion criteria. No incidents in Queensland resulted in harm. The 2 Never Events resulted from a displaced NGT being used. Three of the 24 incidents in England resulted in low-level harm, but were not related to NGT displacement. The themes identified: (1) outcomes related to ongoing NGT position testing, such as missing medications due to inconclusive pH testing, (2) staff interpersonal relationships impacting their ability to follow local procedures, (3) nonadherence to local procedures, and (4) poor quality of incident reports.

Conclusions: Qualitative content analysis successfully identified themes relevant to clinical practice, despite the low quality of individual incident reports. Harm from displaced NGTs was rare but delays from procedural inconsistencies warrant review of current practices, particularly the reliance on pH testing.

Background: Patient safety event reporting systems are essential for identifying potential risks and improving patient outcomes. However, traditional systems frequently face issues of under-reporting, particularly concerning near-miss and no-harm events, thereby limiting opportunities for organizational learning and harm prevention. This initiative used quality improvement principles to design a new reporting system at our institution to enhance safety culture.

Methods: Following extensive stakeholder feedback and multidisciplinary collaboration, a new system was implemented on July 22, 2022. Key features included streamlined reporting, centralized data analysis, and enhanced transparency.

Results: Overall event reporting as well as proportional reporting of near-miss and no-harm events increased significantly from around 60% preimplementation to 80% after implementation. Staff engagement also improved, as shown by a steady rise in the number of unique event reporters and reviewers.

Conclusions: The new reporting system has improved reporting overall, with increases in near-miss and no-harm events, along with increased staff engagement with the reporting and review process. Our experience offers practical lessons for institutions seeking to strengthen the learning value of event reporting systems. The principles we identified with simplifying ease of use, integrating into the EHR, improving data transparency, and encouraging greater involvement with event review, along with clear oversight protocols, apply beyond our institution and are not limited to a specific PSRS product or system. These initial outcomes support a culture of safety and bolster organizational learning, with future study needed on long-term effects on patient safety outcomes, staff involvement, and increased trust.

Objectives: The aim of this study was to explore contributing factors identified in serious incident investigations conducted by internal, independent multidisciplinary teams.

Methods: A total of 166 serious incident investigation reports, conducted between 2018 and 2023 in 11 integrated social and health care organizations in Finland, were analyzed. The reports were classified by incident type and contributing factor, which were analyzed using the WHO's Conceptual Framework for the International Classification for Patient Safety.

Results: The results indicate considerable variation in the structure and content of serious incident investigation reports, with none specifying the investigation method used. The investigation reports of serious incidents revealed that in 79 (47.6%) cases, the consequences for the client or patient were fatal. The highest number of contributing factors was identified in investigations related to medication errors and errors related to treatment or monitoring. The number of contributing factors per investigation ranged from 1 to 16, with an average of 4.6. Most of the contributing factors were organizational or staff factors.

Conclusions: Investigating serious safety incidents provides valuable insights into event chains and helps organizations learn from past damages. Effectively promoting client and patient safety requires standardized methods and practices for examining adverse events. This requires a shared perspective and clear definitions of best practices. Consistent and effective investigation processes demand national and international collaboration to enhance safety and strengthen organizational learning.

Aim: To explore the relationship and current status of coping styles, burnout, and hospital patient safety culture in patient suicide incidents. To examine whether nurse second victim coping styles in patient suicide incidents mediate the relationship between hospital patient safety culture and burnout.

Design: A cross-sectional study. The collection of information was carried out during the same period of time.

Methods: The study recruited a sample of 425 nurses, second victims who had experienced patient suicides from 6 tertiary grade A hospitals (Shanxi, China). The General Information Questionnaire, the Coping Styles Scale, the Burnout Scale, and the Hospital Patient Safety Climate Scale were used to gather data. The Pearson correlation analysis was used to study the correlation among the 3, one-way ANOVA or independent samples t tests were used to compare differences in second victim burnout among nurses with different characteristics, and the model 4 in process was employed to establish structural equation modeling and test the influence paths of hospital patient safety culture, coping styles, and burnout.

Results: In this study, the patient safety culture score of hospital patients was (134.43±4.84), which was at a medium level; the coping score was (68.70±4.94), which was at a medium level, with positive coping score (23.03±2.94), negative coping score (22.12±2.66), and problem solving score (23.55±3.10), which was at a high level. The burnout score is (71.19±3.83), which is at a high level. Hospital patient safety culture was positively correlated with coping styles ( r =0.458, P <0.001) and negatively correlated with burnout ( r =-0.754, P <0.001), and coping styles were negatively correlated with burnout ( r =-0.356, P <0.001). In the mediation models, the mediating effect of coping styles between hospital patient safety culture and burnout was -0.26, which accounted for 40.63% of the total effect.

Conclusions: A good hospital patient safety culture can improve the coping styles of nurse second victims and also reduce the burnout of nurse second victims. Hospital patient safety culture not only has a direct effect on burnout, but also indirectly affects burnout through coping styles, and reduces burnout by improving their coping styles; hospitals and administrators should take a variety of interventions to improve nurse second victims' coping styles and enhance hospital patient safety culture to reduce burnout.