Journal of Patient Safety最新文献

Objective: Wrong-site surgery (WSS) is recognized as one of the most serious yet preventable medical errors in surgical care. It involves operations performed on the wrong anatomic site, side, patient, or at an incorrect level within the correct site. This study aims to systematically investigate prevailing themes, key research areas, and evolving scholarly trends in WSS literature, including wrong-side and wrong-organ surgeries. It also intends to provide a comprehensive resource for stakeholders focused on surgical safety.

Methods: A retrospective descriptive bibliometric analysis was conducted using data retrieved from the Web of Science database on April 9, 2025. A total of 270 articles meeting predefined inclusion criteria were identified. Descriptive and predictive analyses were carried out using Microsoft Excel and ChatGPT. Bibliometric indicators were assessed with the Bibliometrix package in RStudio, while visualizations were generated via VOSviewer.

Results: Between 1980 and 2025, 270 relevant publications were identified, with 28.52% published in the last 5 years, indicating continued academic interest. Spine was the most productive journal. The United States, the United Kingdom, and China were leading in publication output and citation impact. Core keywords such as "wrong-site surgery" and "patient safety" dominated co-occurrence networks.

Conclusions: Despite a modest annual growth rate (1.55%), WSS research remains active. Predictive models indicate a steady increase in publication volume. With an average citation rate of 20.96 per article, the literature reflects meaningful scholarly engagement. This analysis offers critical insight into the intellectual structure and progression of WSS research.

Introduction: Central line-associated bloodstream infections (CLABSI) present a major challenge in health care today. Achieving and maintaining significant reductions in CLABSI rates often requires complex, structured interventions; yet, real-world data from high-complexity settings remain scarce. This report outlines a quality improvement initiative and assesses its impact on CLABSI rates and procedural practices in a high-risk hospital setting.

Materials and methods: We conducted a single-center, quasi-experimental pre-post study. The intervention involved a layered, multifaceted approach that included: (a) the "4E" (Engage, Educate, Execute, Evaluate) model as a framework for institutional change; (b) the implementation of a standardized CVC insertion checklist; (c) targeted education on evidence-based guidelines, including optimal site selection; and (d) direct observation with performance feedback. The preintervention group (n=169) included patients from July 2022 to June 2023, with data collected retrospectively. The post-intervention group (n=227) included patients from July 2023 to December 2024, with data collected prospectively.

Results: Data analysis revealed a significant decline in the overall CLABSI rate from 12.43% before intervention to 3.52% afterward (P<0.001). At the same time, procedural practices changed notably: jugular vein insertions decreased from 14.20% to 1.76%, while basilic vein insertions rose from 31.95% to 42.73%. Bivariate analyses identified key factors associated with CLABSI risk.

Conclusion: Implementing a structured, layered quality improvement approach was associated with a significant decrease in CLABSI rates. While the study design does not allow for isolating the effects of individual components-such as the 4E framework, the checklist, or the changes in insertion practices-the results strongly suggest that a systematic strategy which combines a guiding framework, practical tools, and adherence to evidence-based practices effectively enhances patient safety in complex clinical settings.

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.

Background: Patient harm in the hospitalized palliative care population is underexplored. The distinctive areas of harm relevant to palliative care patients are not captured by existing instruments developed to identify patient harm in general patient populations. Therefore, a tailored approach could aid in the identification of patient harm and the improvement of patient safety in palliative care.

Objectives: The aim of the study was to describe the performance and suitability of a modified version of the Global Trigger Tool (GTT) applied to palliative care patients.

Design: Hospital records of 256 consecutive patients at a Norwegian palliative care ward were independently reviewed for triggers and cases of patient harm by 2 reviewers. The modified trigger tool was based on the generic GTT and primarily adhered to its methodology. Some GTT triggers not relevant for palliative care patients were omitted, and new triggers and categories of harm were introduced based on clinical experience and publications on patient harm in palliative care.

Results: Four hundred and one triggers (1.6 per hospitalization), and 109 cases of harm were identified. The most frequent triggers were Readmission within 14 days (89 triggers) and Other (60 triggers), while the majority of harm (65 cases) were classified as overtreatment/overdiagnosis or disturbed dying/poor symptom control. The positive predictive value for identifying patient harm was 0.27. Inter-rater reliability for identifying harm was κ=0.590 (95% CI: 0.461-0.718).

Conclusion: The modified trigger tool identifies patient harm and disturbed dying in palliative care patients. However, further development is required before the routine implementation of this tool.

Objectives: COVID-19 vaccines are essential public health tools for prevention and control the pandemic. There is still misinformation regarding their safety in pregnant women, particularly in countries with widely used heterologous vaccination. This study investigated the association between maternal COVID-19 vaccination during pregnancy and important neonatal outcomes.

Methods: A retrospective cohort study was conducted involving 4032 pregnant women at King Chulalongkorn Memorial Hospital, Thailand, between September 2021 and December 2023. Demographics, vaccination characteristics and adverse neonatal outcomes were collected. The analysis was done by using descriptive statistics and logistic regression.

Results: Of 4032 participants, 1657 (41.1%) received COVID-19 vaccines during pregnancy, mostly mRNA vaccines (60.6%). Vaccination was significantly associated with a lower rate of stillbirth [adjusted odds ratio (aOR): 0.41, 95% CI: 0.16-0.97] and SGA (aOR: 0.27, 95% CI: 0.08-0.90). Vaccination during the second or third trimester was specifically associated with a lower rate of abortion, stillbirth, SGA, and low 5-minute Apgar scores compared with unvaccinated pregnancies. Adequately vaccinated individuals had significantly fewer overall adverse neonatal outcomes compared with partially vaccinated individuals. In addition, mRNA vaccination was associated with a lower abortion and stillbirth rate compared with no vaccination.

Conclusions: Maternal COVID-19 vaccination during pregnancy was not associated with increased adverse neonatal outcomes and was associated with lower rate of stillbirth and small for gestational age. More favorable associations were observed for vaccination in the second or third trimester and for adequate vaccination, and mRNA vaccination showed a lower rate of abortion and stillbirth compared with no vaccination, supporting the safety of vaccination in pregnancy.

Background: The Centers for Medicare and Medicaid Services Hospital-Acquired Conditions (HAC) Reduction Program and the Agency for Healthcare Research and Quality Pediatric Quality Indicators (PDI) measure sets are commonly used in pediatric hospitals to assess patient safety and quality and rank performance. This study examined whether choice of HAC or PDI measure set matters when evaluating hospital performance ranking.

Methods: This retrospective cohort study used inpatient data from 42 hospitals in the Pediatric Health Information System (PHIS) for pediatric patients (0-17 y) discharged from 2021 to 2022. We extracted 8 HAC and 7 PDI measures, ranking hospital performance on each measure. We calculated a summary measure reflecting average performance using the geometric mean of ranks across each measure set and examined concordance in rankings.

Results: There was a moderate-to-strong linear association between hospital rankings using the HAC versus PDI measure sets (r=0.63; P<0.001), with no significant difference in overall ranking between measure sets (median difference=-0.5; P=0.84) and moderate agreement in ranking quartile (Klw=0.46). Absolute differences in ranking were ≥10 for 14 (33%) hospitals, 5 to 9 for 12 (30%), and 1 to 4 for 14 (33%), whereas only 2 (5%) hospitals were ranked identically on both measure sets.

Conclusions: Summary rankings were broadly similar between HAC and PDI measure sets. However, some hospitals exhibited large discrepancies, ranking among the top performers on one measure set but near the bottom on the other. Pediatric hospitals should consider measure definitions and applicability to hospital-specific patient populations when selecting safety and quality measure sets for performance evaluation and ranking.

Background: Regulatory bodies require the use of restraints and seclusion in health care settings to be strictly monitored and carefully documented. In our emergency department (ED), an internal audit uncovered low compliance with required patient safety documentation, the so-called "face-to-face (FTF)" assessment, within 1 hour of restraint or seclusion initiation. The primary objective of this quality improvement (QI) study is to evaluate a series of interventions as a mechanism to improve FTF documentation compliance.

Methods: This project was conducted in a single-site academic ED. Patients requiring restraints and seclusion application from November 2021 to June 2024 were included. We implemented 3 plan-do-study-act (PDSA) cycles: (1) development of FTF documentation flowsheet with delayed best practice alert (BPA) trigger, (2) direct audit and clinician feedback via email, and (3) modification to immediate BPA trigger. Our primary outcome was a change in the rate of FTF documentation completion within 60 minutes of restraint or seclusion application. We used descriptive analysis to evaluate adherence rates.

Results: There were 856 qualifying instances during the study period. Our intervention bundle was associated with an increase in documentation adherence from a preintervention baseline of 10.96% to a final performance of 81.28%, an absolute increase of 70.32% (P<0.001).

Conclusions: Our series of interventions, including direct feedback and technical solutions, was effective in increasing clinician FTF documentation adherence. By deploying these interventions iteratively, our approach supported practice change and behavioral modification among ED clinicians, highlighting the importance of an incremental process in changing practice and culture.

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.

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.