Journal of Patient Safety最新文献

Objectives: The objective of this project was to contribute to the understanding of how interruptions impact intravenous (IV) medication processes and identify areas for improvement. The specific aims were to evaluate the type, frequency, and duration of interruptions, including IV smart pump (IVSP) alerts and alarms, that nurses experience during IVSP activities.

Design: Real-world observational, exploratory, noninterventional design.

Methods: Level 1 academic medical center in the Northeast region of the United States. Data on interruptions were documented using an electronic Case Report Form.

Results: One hundred IVSP medication administration activities were observed, of which 25% encountered at least one IVSP alert or alarm. The mean duration for each alert/alarm was 17.9 seconds and alerts/alarms occurred every 1.69 minutes during the medication administration activity. Alarms and alerts accounted for 24.5% of the total duration of each IVSP activity, indicating that nurses spent about 25% of their medication administration time responding to alerts/alarms. Regarding other types of interruptions, 44% of the 100 IVSP medication administration activities experienced at least one interruption, averaging 1.23 per activity. The main sources of interruptions were health care professionals (20.4%), medical devices (20.4%), and other nurses (16.7%). Phone calls created the longest interruptions, averaging 48.0 seconds, followed by self-initiated interruptions at 45.7 seconds.

Conclusion: Findings reveal that interruptions, including IVSP alerts and alarms, significantly impact IV medication administration, consuming nearly 25% of nurses' activity time. Additional interruptions, often caused by health care professionals and phone calls, further disrupt workflows and extend task durations. Addressing these challenges through streamlined alert systems and improved communication protocols is essential to enhance efficiency and patient safety in clinical settings.

Objectives: Limited evidence exists about differences in patient safety culture by employee role. We examine the relationship between role and patient safety culture.

Methods: Using 2021 to 2022 Hospital Survey on Patient Safety Culture (HSOPS) cross-sectional data (245,252 HSOPS respondents, 371 hospitals), we fit separate employee/respondent-level OLS regression models for 10 aspects of patient safety culture and 2 summary measures as a function of the employee's role, controlling for year, employee and hospital characteristics with hospital-level clustered standard errors (SEs) weighted to represent the nation.

Results: C-suite/executive/senior leaders reported the highest proportions of positive ratings for overall patient safety and all 10 aspects of patient safety culture. Managers/supervisors were most likely and unit staff (assistants/secretaries/clerks) were least likely to report safety events. Physicians reported the lowest proportion of positive overall patient safety ratings and ratings for communication and improvement. Care aides reported the lowest for teamwork, staffing/work pace, and response-to-error, nurses lowest for hospital management support and pharmacists lowest for handoffs and information exchange.

Conclusions: C-suite/executives/senior leaders, supervisors and managers have different perspectives of patient safety culture than physicians, care aides, nurses, and staff, revealing the need to improve patient safety culture for those who provide direct patient care and to improve communication across leaders and all employee roles. Hospitals should focus on improving communication and management support related to patient safety for physicians and on teamwork, staffing and work pace for care aides. Understanding the root of variability in how pharmacists assist and support patient handoffs and information exchange and how physicians, care aides and staff communicate, accept managerial input, and learn from errors are critical as they may affect safety and event reporting. Hospital leaders could also hold discussions at the microclimate level (unit) for those doing well and those not doing to discuss focusing on the culture of patient safety performance. Ensuring that communication is open and transparent across all hospital employees is critical to providing safe, effective patient care.

Background: This study analyzes factors and challenges associated with adverse events reporting in Indonesian hospitals.

Methods: The mixed-method study design was used. The quantitative stage is analyzing data from the 2019 Health Facilities Research. The population in this stage is all hospitals in Indonesia, with a sample of 532 hospitals. Data were analyzed using the χ 2 test and logistic regression. The qualitative stage, semi-structured interviews were conducted with participants from 6 hospitals in 2 provinces. The data were validated using the triangulation method and analyzed using thematic analysis. Data were collected from September 2023 to April 2024.

Results: The existence of the infection control committee, quality committee, patient safety committee, internal audits, services evaluation and quality control, accreditation status, regional category, and number of beds has been positively associated with adverse events reporting in Indonesian hospitals. The implementation of accreditation standards, the roles of these committees, and evaluation and audit activities contribute to improving quality and patient safety, encouraging incident reporting, which ultimately can reduce adverse events. Challenges to reporting come from both individual and organizational aspects.

Conclusions: These committees should be the main drivers in monitoring AE reporting and implementing evaluation and quality control. Enhancing the role of hospital accreditation through government support as a regulator is also necessary to improve reporting. The main challenge to reporting is the lack of willingness to report. Policymakers and hospital managers must urge to overcome these obstacles by developing an easy-to-use reporting system, eliminating negative perceptions after reporting, and providing appreciation.

Background: Despite longstanding guidelines for safe medication administration during anesthesia care, medication errors continue to be an area of opportunity in perioperative patient safety. Analysis of closed claims can help identify contributing factors involving patients, health care providers, and medication, and suggest opportunities for reducing harm.

Methods: A claims database from a national malpractice insurer was queried for closed claims-with or without paid indemnity-from 2012 to 2022 involving medication-related liability in anesthesia. We performed a descriptive analysis of the injury severity, injuries, complications, allegations, anesthetic technique, practice setting, types of medications, clinical themes, and the financial value of the claim.

Results: We identified and reviewed 140 medication-related closed claims involving an anesthesia provider. Most medication-related closed claims involved a high severity of injury (59%, 82/140), including death or permanent injury. The most common injuries were adverse reactions (44%, 62/140), respiratory or cardiac arrest (43%, 60/140), death (41%, 57/140), and organ damage (32%, 45/140)-sum is >100% because each closed claim may be associated with multiple injuries. The most frequently identified clinical theme was oversedation with respiratory arrest with or without cardiac arrest (29%, 40/140). The mean gross total amount incurred was $704,000 (median $312,000).

Conclusions: This analysis of medication-related closed claims in anesthesiology demonstrates the continued need for addressing perioperative medication safety and in both hospital and ambulatory settings. Oversedation during anesthesia care is an area of high concern, in addition to the known risks of neuromuscular blocking drugs and local anesthetics.

Introduction: Missed nursing care refers to necessary nursing care activities that, due to various factors, are either not provided, partially provided, or delayed from the planned schedule. Missed nursing care (MNC) is a significant issue in nursing homes, undermining care quality and increasing the risk of adverse events and preventable hospitalizations. This systematic review aims to identify the most frequently reported MNC by nursing staff in nursing homes and the associated causes.

Methods: The review was conducted following the guidelines of the "JBI Manual for Evidence Synthesis" and using the PRISMA ScR checklist. A search yielded 1468 articles: 85 from PubMed, 1115 from Scopus, 164 from Embase, and 104 from CINAHL. Screening removed 1386 duplicates, identifying 82 potentially relevant articles. After title and abstract review, 72 were excluded for irrelevance, resulting in 9 studies included in this review. Study selection defined inclusion criteria, focusing on quantitative studies involving registered nurses working in nursing homes.

Results: The most frequently omitted nursing care activities in nursing homes include patient mobilization, assistance with feeding, and personal hygiene care. Key causes identified were staff shortages, high patient care complexity, and limited resource availability.

Discussion: The findings confirm that MNC in nursing homes is primarily influenced by organizational and structural factors, requiring a systemic approach to improve care quality. Targeted interventions, such as better resource planning, improved staff management, and measures to enhance nurse well-being, could significantly reduce the incidence of missed care. Future research, particularly longitudinal studies, may provide further insights into more effective prevention of MNC, while the development of specific assessment tools for nursing homes could enhance MNC measurement and support targeted interventions.

Background: Artificial intelligence (AI) technologies hold great promise for improving patient outcomes, reducing clinician workload, and enhancing patient engagement. However, improper design, implementation, and monitoring can introduce significant safety risks. Health care quality and safety leaders play a critical role in mitigating these risks. As AI adoption accelerates, understanding how these leaders perceive their institutions' progress in assessing and managing AI safety is critical for identifying gaps, addressing potential risks, and guiding safer clinical integration.

Methods: Semi-structured interviews were conducted with 22 quality and safety leaders from 19 US health care organizations between March and April 2024. Participants included leaders from both single hospitals and multi-hospital systems, with an average of 16 years of experience. None had formal AI training, but some reported practical exposure. Interviews focused on participants' knowledge of AI, organizational structures for AI governance, and barriers to safe AI implementation. Thematic analysis was used to identify common themes and knowledge gaps.

Results: Most organizations (78.9%) reported using steering committees for AI oversight, with some combining this with IT, research, or innovation teams. Barriers to AI implementation included interoperability challenges (78.9%), lack of AI expertise (68.4%), and difficulty evaluating AI effectiveness (52.6%). Participants highlighted the need for stronger governance and evidence-based tools but noted variability in their organizations' preparedness to adopt AI.

Discussion: Health care organizations lack standardized approaches to AI safety and often rely on fragmented governance structures. Leaders emphasized the need for enhanced expertise, solutions to barriers that affect implementation, and alignment of AI tools with organizational priorities.

Conclusions: Strengthening organizational knowledge, governance, and solution generation to barriers of implementation is essential to safely integrate AI into clinical care. Addressing these gaps will support patient safety and optimize AI's potential benefits.

Objectives: This study aims to identify the vulnerability of hospital-acquired infection (HAI) and differences in health care utilization among patients with HAIs across various patient and hospital factors.

Methods: Using the United States National Inpatient Sample (2016-2020), we identified hospitalized patients with a length of stay ≥3 days (n=18,931,779; national estimates=94,568,871). We examined the occurrence of HAIs, trends, and risk factors associated with HAI-occurrence, in-hospital death, and health care utilization, measured by hospital charges and length of stay (LOS). Multivariate survey logistic regression was used to identify predictors of HAIs and in-hospital death, and survey linear regression was applied to evaluate the association between HAIs and hospital charges. Subgroup analyses were conducted by sociodemographic factors.

Results: Among 94,658,871 nationwide inpatients, 23.4% experienced HAIs. The proportion of HAI cases gradually increased over time along with health care utilization. Patients who were older, female, Hispanic, low-income, or covered by Medicare/Medicaid showed significantly higher risks of HAIs. HAIs were also associated with increased odds of in-hospital death, higher hospital charges, and longer LOS.

Conclusions: Various sociodemographic and hospital factors were associated with greater vulnerability to HAIs, higher in-hospital mortality, longer hospitalizations, and greater health care costs. These findings emphasize the heterogeneity in vulnerability to HAIs across sociodemographic and hospital contexts and highlight the potential value of risk stratification in informing patient safety efforts.

Background: Safety reporting systems do not identify all adverse events affecting hospitalized patients. Patients and caregivers may identify inpatient safety events that health care staff miss.

Objective: To assess the feasibility of a text message-enabled safety reporting tool among adult inpatients and caregivers at a public hospital.

Design: Prospective, observational pilot study to gather patient or caregiver safety observations. We assessed feasibility through engagement with the tool, reporting rates, content analysis of observations by category, and comparison to staff-entered incident reports.

Participants: English-speaking and Spanish-speaking adults and caregivers age 18+ admitted to an urban, public hospital.

Intervention: Participants received a daily text message eliciting safety observations, with a link to an online reporting tool.

Main measures: Number of safety observations/100 study-days, adjusted for patient sociodemographics, patient activation, and patient electronic health literacy.

Results: Seventy-five patients and 6 caregivers participated in the study (participation rate: 50%). Of patients, 56% were Latinx and 19% Black/African American; 44% were Spanish-speaking. Of all participants, 50.6% (41/81) engaged with at least 1 text message. There were 64 total safety observations, 27 patient-entered and 37 by caregivers. In multivariable analysis, Spanish-speaking Latinx patients made 1.8 [0.04-3.5] observations/100 study-days; English-speaking Latinx patients 3.4 [0-10.2]; Black/African American patients 5.8 [1.5-10.2] and combined Asian/Multiracial/white/Other English-speaking patients 11.9 [5.9-17.9] (P=0.006). The most common category was "What Went Well" (34%), followed by Other (27%). Only one observation overlapped with a staff-entered incident report.

Conclusions: The tool feasibly gathered relevant patient-reported safety observations from admitted patients from marginalized populations. Our study found lower reporting rates among Spanish-preferring, Latinx, and Black/African American patients, despite known higher rates of adverse events for these groups. Tracking minoritized patient participation and addressing differential engagement in patient engagement safety initiatives can improve racial and ethnic equity in reporting rates and, ultimately, safety, and health outcomes.

Objective: This study aimed to describe high-risk medicine, potassium-related incidents, reported in intensive care units (ICUs) nationally, investigate the consensus of an expert panel's evaluations and the inter-rater reliability between the expert panel and the original data classifiers in evaluating the clinical severity of patient harm, and develop safeguards by the expert panel to improve potassium safety in ICUs.

Methods: Potassium-related incidents over an 11-year period were examined retrospectively and a subsample of typical errors that had caused patient harm was selected for error severity evaluation and development of safeguards, employing a prospective modified nominal group technique with an expert panel. The consensus of evaluations was determined using averages and the inter-rater reliability by using Cohen kappa. In addition, an expert panel discussion was conducted to develop recommendations for consensus-based safeguards to improve potassium safety in ICUs.

Results: Of the 440 reported potassium incidents, 34% were related to wrong concentration, and 24% to wrong medication. Twenty-six percent were reported to have caused consequences for patients. The expert panel achieved almost complete consensus on the evaluation of the clinical severity of the subsample of errors (89%, n=42/47). The inter-rater reliability between the expert panel and original data classifiers was low (κ=0.34). The expert panel suggested multilevel safeguards.

Conclusions: Most potassium-related incidents were related to wrong concentration and medication. The consequences of potassium-related errors may be more serious than reported. The quality of harm categorisation needs improvement to provide more reliable information on medication errors to improve medication safety. The expert panel suggested multilevel safeguards to improve potassium safety in ICUs.