Journal of Patient Safety最新文献

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.

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.

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.

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.

Introduction: The operating room (OR) is a complex environment where errors significantly impact patient outcomes, and the ability of surgical teams to adapt and recover from unexpected disruptions-defined as resilience-is paramount. Frameworks offer structured approaches for analyzing resilience yet are variably applied throughout the relevant literature. This review aims to characterize how frameworks are used to study OR team resilience and examines the implications of inconsistent approaches.

Methods: After the Arksey & O'Malley framework, EMBASE, CINAHL, and MEDLINE were searched for studies published up to July 29, 2024. The search included keywords such as 'surgery' and 'resilience'. The included studies' reference lists were also manually searched. Studies focusing on the OR, examining the influence of human factors on team function and recovery, and reporting metrics for patient safety were included. Data extraction and content analysis were conducted independently by 2 reviewers, with results summarized narratively.

Results: Of 3165 studies identified, 9 met the inclusion criteria. Two utilized the systems engineering initiative for patient safety framework, and 2 incorporated the Oxford non-technical skills tool, whereas the remaining 5 developed an ad hoc approach to study operating team resilience. Notably, only 2 studies classified themselves as part of the resilience literature.

Conclusions: This review demonstrates inconsistent framework application in surgical resilience research, resulting in methodological variability and limited cross-study synthesis. Developing frameworks specific to the OR is essential for advancing this field and improving study classification. Expanding search strategies to include resilience-adjacent terms will further enhance research visibility.