Journal of Patient Safety最新文献

Objective: The aim of the study is to determine diagnostic traction for shoulder dystocia and to assess whether applied traction is modifiable with force training.

Methods: We tethered a force-measuring fetal mannequin (PROMPT, Limbs & Things) within a simulated pelvis such that it would not deliver. We asked participants to apply traction to diagnose shoulder dystocia then stop. Blinded from participants' view, we recorded the peak traction. We then asked them to apply what they perceived to be 20 lb (89 N) traction. Each participant estimated the traction s/he applied. The actual force applied was then revealed to the participants and another blinded sequence was performed. We then allowed participants to view actual force measurements in real time while they practiced getting to their diagnostic traction and to 20 lb (89 N); this was followed by another blinded sequence of traction applications and estimations. Median diagnostic traction and injury threshold values (20 lb [89 N]), and mean ratio of estimated to actual force applied were compared pretraining and posttraining, using Wilcoxon signed rank sum test and t test. Rates of clinical shoulder dystocia and associated brachial plexus injury before and after the study period were compared using chi-square. Significance was set at P < 0.05.

Results: One hundred participants demonstrated a range of diagnostic traction. For 23 participants, traction exceeded injury thresholds, but the average was lowered with training. Before training, participants underestimated their own applied traction by an average of 30%.

Conclusions: Subjective diagnosis of shoulder dystocia during simulation training varies widely and exceeds possible injury threshold for 22% of participants. Accuracy of self-assessment applied delivery traction improves significantly with force training as does clinical diagnosis of shoulder dystocia and decrease in brachial plexus injury incidence.

Objectives: Nurse practitioners (NPs) are key to delivery of primary care services. However, poor organizational support for independent NP practice, such as lack of access to clinic resources, may lead to prioritizing patient physical health over emotional health. We investigated the relationship between organizational support for independent NP practice and emotional health care delivery.

Methods: This was a secondary analysis of cross-sectional survey data collected from 397 NPs in 2017. We measured organizational support for independent NP practice using the independent practice and support subscale of the NP Primary Care Organizational Climate Questionnaire. Emotional health care delivery was measured by asking NPs how frequently they addressed emotional concerns of patients. We utilized multilevel mixed effects linear regression models, adjusting for NP and practice covariates.

Results: Controlling for NP age, gender, marital status, race, and ethnicity, along with practice setting and size, as the independent practice and support score increased, NPs reported addressing emotional concerns of patients more frequently (beta = 0.34, 95% confidence interval = 0.02-0.66, P = 0.04). This indicates that as organizations provided more support for independent NP practice, NPs were able to more frequently address emotional concerns of patients.

Conclusions: Organizational support for independent NP practice is associated with addressing emotional concerns of patients. To support NP practice, primary care organizations should ensure that NPs manage patients independently and have access to ancillary staff and support for care management.

Objectives: Diagnostic errors contribute substantially to preventable medical errors. Especially, the emergency department (ED) is a high-risk environment. Previous research showed that in 15%-30% of the ED patients, there is a difference between the primary diagnosis assigned by the emergency physician and the discharge diagnosis. This study aimed to determine the number and types of diagnostic discrepancies and to explore factors predicting discrepancies.

Methods: A retrospective record review was conducted in an academic medical center. The primary diagnosis assigned in the ED was compared with the discharge diagnosis after hospital admission. For each patient, we gathered additional information about the diagnostic process to identify possible predictors of diagnostic discrepancies.

Results: The electronic health records of 200 patients were reviewed. The primary diagnosis assigned in the ED was substantially different from the discharge diagnosis in 16.0%. These diagnostic discrepancies were associated with a higher number of additional diagnostics applied for (2.4 versus 2.0 diagnostics; P = 0.002) and longer stay in the ED (5.9 versus 4.7 hours; P = 0.008).

Conclusions: A difference between the diagnosis assigned by the emergency physician and the discharge diagnosis was found in almost 1 in 6 patients. The increased number of additional diagnostics and the longer stay at the ED in the group of patients with a diagnostic discrepancy suggests that these cases reflect the more difficult cases. More research should be done on predictive factors of diagnostic discrepancies.

Objective: The objective of this paper is to assess the diagnostic value of an antithrombotic questionnaire tool compared with the hospital's medical record information tool. The hypothesis of this study was that the antithrombotic questionnaire tool could identify patients with potentially incorrect antithrombotic therapy.

Methods: This cross-sectional study was conducted in eight community pharmacies in the Netherlands. A standardized questionnaire was developed as antithrombotic questionnaire tool. The pharmacist assessed whether the antithrombotic therapy was correct or potentially incorrect based on answers given by patients and based on the medical record. The primary outcome of the study was the sensitivity and specificity of the antithrombotic questionnaire tool to identify patients with potentially incorrect antithrombotic therapy.

Results: For 95 patients, the pharmacist assessed that in 81 (85%) the antithrombotic therapy was correct and in 14 (15%) potentially incorrect. Based on the medical record, 86 patients (91%) were assessed as correct and 9 (9%) as potentially incorrect. The sensitivity of the tool was 100% and the specificity 94%.

Conclusions: This study demonstrated that the antithrombotic questionnaire tool is a suitable tool to assess whether the patient's antithrombotic therapy is potentially incorrect. It can be applied to identify patients with potentially incorrect antithrombotic therapy.

Objectives: The aims of the study are to investigate differences in rates of adverse safety events between nonelderly adult patients with Medicaid and those with private insurance and to assess whether differences are driven by differences in access to quality hospitals or differences in the quality of care delivered within hospitals.

Data source: Inpatient records from 26 states in 2017 were collected from the Agency for Health Care Research and Quality's Hospital Cost and Utilization Project.

Study design: This study measures differences in 11 patient safety indicators between patients with Medicaid coverage and patients with private insurance coverage. I use regression analysis to investigate differences in adverse safety events within hospitals. I further establish hospital-level quality based on overall rates of adverse safety events and use regression analysis to evaluate the difference in the probability of admission to high-quality hospitals.

Data collection/extraction: This study uses hospital discharge data that is restricted to adults ages 19-64 with Medicaid or private coverage.

Principal findings: Relative to privately insured patients, Medicaid patients had significantly higher rates of adverse safety events on 8 of 11 patient safety indicators, including on 6 of 7 surgery-related patient safety indicators. Medicaid patients experience respiratory failure and sepsis infections at rates that are 2.9 and 2.5 cases per 1000 greater than rates experienced by privately insured patients. After adjusting for demographic characteristics, patient diagnostic classifications and comorbidities, and geographic factors, 6 of 11 differences in patient safety indicators remained large and statistically significant. These differences were unchanged when further including hospital indicators, indicating that Medicaid and privately insured patients receive different quality of care within hospitals. There is little association between overall hospital quality and differences in the probability of admission between Medicaid and privately covered patients.

Conclusions: Medicaid patients received lower quality of care, based on patient safety metrics, relative to privately insured patients within the same hospitals. Reducing payer disparities in adverse safety events requires reforming staffing and treatment patterns for Medicaid and privately insured patients within hospitals.

Study date and location: Analysis for this study was conducted in 2023 at the Urban Institute and at Loyola University Chicago.

Objectives: Hospital-based behavioral emergency response teams (BERT) respond to acute behavioral disturbances among hospitalized patients. We aimed to examine associations between altered mental status in postanesthesia care unit (PACU) and behavioral disturbances on surgical wards requiring BERT activation.

Methods: Electronic medical records of patients who underwent general anesthesia and were admitted to the PACU between May 2018-December 2020 were reviewed for episodes of BERT activations on surgical wards. Characteristics of BERT patients were compared with the rest of surgical population during the same period to examine risk factors for BERT.

Results: Of 56,275 adult surgical patients, 133 patients had 178 BERT activations (incidence 2.4, 95% confidence interval [CI] 2.0-2.8 per 1000 admissions), with 21 being for physical assault. The risk for BERT activation was increased with each decade over age of 50 as well as younger age (30 versus 50 y), male sex (odds ratio [OR] = 2.48, 95% CI 1.69, 3.62), longer procedures (OR = 1.08 per 30 minutes, 95% CI 1.05, 1.11), and alterations in mental status in PACU, with both moderate/deep sedation (OR = 1.63, 95% CI 1.04, 2.57) and agitation/combative state (OR = 8.47, 95% CI 5.13, 14.01), P < 0.001 for all comparisons.

Conclusions: Early postoperative agitation and oversedation are associated with BERT activation on surgical wards. Altered mental status in PACU should be conveyed to accepting hospital units so healthcare staff can be vigilant for the potential development of behavioral disturbances.

Background: Raising concerns is essential for the early detection and appropriate response to patient deterioration. However, factors such as hierarchy, leadership, and organizational culture can impact negatively on the willingness to raise concerns.

Objectives: This study aims to delve into how leadership, organizational cultures, and professional hierarchies in healthcare settings influence healthcare workers, patients, and caregivers in raising concerns about patient deterioration and their willingness to do so.

Methods: The study used a qualitative approach, conducting focus group discussions (N = 27), utilizing authentic audio-visual vignettes to prompt discussions about raising concerns. Deductive thematic analysis was employed to explore themes related to hierarchy, leadership, and organizational culture.

Results: Positive leadership that challenged traditional professional hierarchies by embracing multidisciplinary teamwork, valuing the input of all stakeholders, and championing person-centered practice fostered a positive working culture. This culture has the potential to empower clinical staff, patients, caregivers, and family members to confidently raise concerns. Staff development, clinical supervision, and access to feedback, all underpinned by psychological safety, were viewed as facilitating the escalation of concerns and, subsequently, have the potential to improve patient safety.

Conclusions: This study offers crucial insights into the intricate dynamics of leadership, hierarchy, and organizational culture, and their profound impact on the willingness of staff and patients to voice concerns in healthcare settings. Prioritizing the recommendations of this study can contribute to reducing avoidable deaths and elevating the quality of care in healthcare settings.

Objectives: Patient safety is a core component of quality of hospital care and measurable through adverse event (AE) rates. A high-risk group are femoral neck fracture patients. The Dutch clinical guideline states that the treatment of choice is cemented total hip arthroplasty (THA) or hemiarthroplasty (HA). We aimed to identify the prevalence of AEs related to THA/HA in a sample of patients who died in the hospital.

Methods: We used data of a nationwide retrospective record review study. Records were systematically reviewed for AEs, preventability and contribution to the patient's death. We drew a subsample of THA/HA AEs and analyzed these cases.

Results: Of the 2998 reviewed records, 38 patients underwent THA/HA, of whom 24 patients suffered 25 AEs (prevalence = 68.1%; 95% confidence interval, 51.4-81.2), and 24 contributed to death. Patients with a THA/HA AE were of high age (median = 82.5 y) and had severe comorbidity (Charlson score ≥5). The majority of THA/HA AEs had a patient-related cause and was considered partly preventable. Examples of suggested actions that might have prevented the AEs: refraining from surgery, adhering to medication guidelines, uncemented procedures, comprehensive presurgical geriatric assessment, and better postsurgical monitoring.

Discussion: Our study shows a high prevalence of (fatal) adverse events in patients undergoing THA/HA. This seems particularly valid for cemented implants in frail old patients, indicating room for improvement of patient safety in this group. Therefore, we recommend physicians to engage in comprehensive shared decision making with these patients and decide on a treatment fitting to a patient's preexisting health status, preferences, and values.

Aims: The objectives of this study were (1) to explore the consequences of falls; (2) to find out time and place of the fall events; and (3) to explore the impact of falls on the length of hospital stays in adults' inpatient acute care.

Background: In hospitals, falls are the most common accidents that can occur to a patient during hospitalization. Injuries resulting from serious falls can cause lifelong harm to the patient due to loss of well-being and independence.

Design: A retrospective, cross-sectional, register study based on the data from electronic patient records was conducted.

Methods: The data included 114,951 inpatients, of which 743 had fallen. Data was collected between January 2014 and December 2016.

Results: One-third of falls caused injury. Most injuries were to the head area, and the most common injuries were pain or confusion. The falls usually occurred at the beginning of the treatment in the patient's room or on the way to the toilet. Falls in the hospital increased the length of stay.

Conclusions: A large proportion of falls occur at the beginning of treatment, so it is important to start fall prevention measures as soon as the patient arrives at the hospital.