Journal of Patient Safety最新文献

Background: Patient admissions at a U.S. tertiary care hospital occur via the emergency department (ED), or transfer center. We aim to compare the clinical outcomes of patients admitted from the ED to admissions coordinated by the transfer center.

Methods: Admissions to Mayo Clinic Hospital, Rochester, MN, between July 2019 to June 2021 were identified in this retrospective study and categorized into two cohorts-transfer center and ED. The two cohorts were then matched for age, sex, admitting service, and Charlson Comorbidity Index. Univariate and multivariate analyses were performed to compare hospital length of stay (LOS), mortality, 30-day mortality, and 30-day readmissions between the two cohorts.

Results: 73,685 admissions were identified, of which 24,262 (33%) were transfer center admissions. In the matched cohorts (n = 19,093, each), in-hospital mortality (2.4% versus 1.9%), 30-day mortality (5.4% versus 3.9%), 30-day readmission (12.7% versus 7.2%), and LOS (6.4 days versus 5.1 days) were significantly higher ( P < 0.001) among the admissions coordinated by transfer center. A higher palliative care consultation rate (9.4% versus 6.2%, P < 0.001), and a lower proportion of home discharges home (76.2% versus 82.5%, P < 0.001) among transfer center admissions was observed. Similar findings were noted in multivariate analysis, even when adjusting for LOS.

Conclusions: Transfer center admissions had higher in-hospital mortality, LOS, 30-day mortality, and 30-day readmission compared to ED admissions. This study also highlights new considerations for palliative care consultation before transfer acceptance, especially to avoid futile transfers. Additional studies analyzing factors behind the outcomes of transfer center admissions are required.

Objectives: Pharmacists constitute a crucial component of the healthcare system, significantly influencing the provision of medication services and ensuring patient safety. This study aims to understand the characteristics and risk factors for complaints against pharmacists through Health and Disability Commissioner (HDC) published decisions.

Methods: This study adopts a retrospective, qualitative approach. An inductive content analysis technique was used to analyze 37 complaints against pharmacists published decisions from the New Zealand Health and Disability Commissioner website to investigate a range of underlying risk factors contributing to the occurrence of complaints against pharmacists.

Results: A set of 20 categories of risk factors emerged through the content analysis and were subsequently grouped into five overarching themes: pharmacist individual factors, organizational factors, system factors, medication-specific factors, and external environmental factors.

Conclusions: The findings of this study provide valuable insights that expand the understanding of risk management in pharmacist practice, serving as a valuable resource for regulatory bodies, policymakers, educators, and practitioners. It is recommended not only to focus solely on individual pharmacists but also to consider integrating their environment and individual behaviors to proactively address situations prone to errors and subsequent complaints.

Objectives: Accidental falls are among the leading hospitals' adverse events, with incidence ranging from 2 to 20 events per 1.000 days/patients. The objective of this study is to assess the relationship between in-hospital falls and the score of 3 DEPendence and Clinical-Social Fragility indexes.

Methods: A monocentric case-control study was conducted by retrieving data of in-hospital patients from the electronic health records.

Results: Significant differences between the mean scores at the hospital admission and discharge were found. The BRASS scale mean (SD) values at the admission and at the discharge were also significantly higher in cases of in-hospital falls: at the admission 10.2 (±7.7) in cases versus 7.0 (±8.0) in controls ( P = 0.003); at the discharge 10.0 (±6.4) versus 6.7 (±7.5) ( P = 0.001). Barthel index mean (SD) scores also presented statistically significant differences: at the admission 60.3 (±40.6) in cases versus 76.0 (±34.8) in controls ( P = 0.003); at discharge 51.3 (±34.9) versus 73.3 (±35.2) ( P = 0.000).Odds ratios were as follows: for Barthel index 2.37 (95% CI, 1.28-4.39; P = 0.003); for Index of Caring Complexity 1.45 (95% CI, 0.72-2.91, P = 0. 255); for BRASS index 1.95 (95% CI, 1.03-3.70, P = 0.026). With BRASS index, the area under the curve was 0.667 (95% CI, 0.595-0.740), thus indicating a moderate predictive power of the scale.

Conclusions: The use of only Conley scale-despite its sensitivity and specificity-is not enough to fully address this need because of the multiple and heterogeneous factors that predispose to in-hospital falls. Therefore, the combination of multiple tools should be recommended.

Background: Adverse events (AEs), which are associated with medical system instability, poor clinical outcomes, and increasing socioeconomic burden, represent a negative outcome of the healthcare system and profoundly influence patient safety. However, research into AEs remains at a developmental stage according to the existing literature, and no previous studies have systematically reviewed the current state of research in the field of AEs. Therefore, the aims of this study were to interpret the results of published research in the field of AEs through bibliometric analysis and to analyze the trends and patterns in the data, which will be important for subsequent innovations in the field.

Methods: A statistical and retrospective visualization bibliometric analysis was performed on July 28, 2022. The research data were extracted from the Web of Science Core Collection, and bibliometric citation analysis was performed using Microsoft Excel, VOSviewer 1.6.18, CiteSpace 6.1.R2, and the Online Analysis Platform of Literature Metrology ( http://bibliometric.com/ ).

Results: A total of 1035 publications on AEs were included in the analysis. The number of articles increased annually from 2014 to 2022. Among them, the United States (n = 318) made the largest contribution, and Chung-Ang University (n = 20) was the affiliation with the greatest influence in this field. Despite notable international cooperation, a regional concentration of research literature production was observed in economically more developed countries. In terms of authors, Stone ND (n = 9) was the most productive author in the research of AEs. Most of the publications concerning AEs were cited from internationally influential nursing journals, and the Journal of Nursing Management (n = 62) was the most highly published journal. Regarding referencing, the article titled "Medical error-the third leading cause of death in the US" received the greatest attention on this topic (51 citations).

Conclusions: After systematically reviewed the current state of research in the field of AEs through bibliometric analysis, and AEs highlighted medication errors, patient safety, according reporting, and quality improvement as essential developments and research hotspots in this field. Furthermore, thematic analysis identified 2 new directions in research, concerned with psychological safety, nurse burnout, and with important research value and broad application prospects in the future.

Abstract: Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.

Background: Medical record review is the gold standard method of identifying adverse events. However, the quality of medical records is a critical factor that can affect the accuracy of adverse event detection. Few studies have examined the impact of medical record quality on the identification of adverse events.

Objectives: In this study, we analyze whether there were differences in screening criteria and characteristics of adverse events according to the quality of medical records evaluated in the patient safety incident inquiry in Korea.

Methods: Patient safety incident inquiry was conducted in 2019 on 7500 patients in Korea to evaluate their screening criteria, adverse events, and preventability. Furthermore, medical records quality judged by reviewers was evaluated on a 4-point scale. The χ 2 test was used to examine differences in patient safety incident inquiry results according to medical record quality.

Results: Cases with inadequate medical records had higher rates of identified screening criteria than those with adequate records (88.8% versus 55.7%). Medical records judged inadequate had a higher rate of confirmed adverse events than those judged adequate. "Drugs, fluids, and blood-related events," "diagnosis-related events," and "patient care-related events" were more frequently identified in cases with inadequate medical records. There was no statistically significant difference in the preventability of adverse events according to the medical record quality.

Conclusions: Lower medical record quality was associated with higher rates of identified screening criteria and confirmed adverse events. Patient safety incident inquiry should specify medical record quality evaluation questions more accurately to more clearly estimate the impact of medical record quality.

Objectives: Food service errors are prevalent in healthcare hospital inpatient settings. Like medication administration errors, these mistakes can result in disastrous consequences. This scoping review aimed to identify the evidence describing hospitals' nutrition department service errors and subsequent patient safety interventions.

Methods: The review was conducted on four electronic databases, OVID MedlinePlus, PubMed, Scopus, and CINAHL, to search for articles reporting hospital food-related errors. All studies and reports on parenteral nutrition were excluded, and errors reported by departments other than nutrition services were excluded. A total of 245 studies published from 1984 to 2022 were identified. After removing duplicates, 98 abstracts were evaluated, with particular attention given to dietary errors, meal accuracy, and interventions.

Results: Twenty-nine articles were selected, and 14 (n = 14) were considered relevant to the review after a full-text review. More than half of the studies (n = 8) were conducted outside the United States. Eight studies (n = 8) were descriptive, retrospective, and observational; 3 were mixed-method studies (n = 3), 2 (n = 2) were quality improvement projects, and 1 was an implementation study (n = 1). Four (n = 4) studies were published before the year 2000.

Conclusions: Various types of nutrition service inaccuracies were identified. The severity, causes, and stages of food service provision where errors occur were also documented. These errors were used as the basis for interventions to improve patient safety, justify implementing computerized dietary services systems, or add resources to augment dietary department service offerings. This review also generated valuable recommendations to promote patient safety by mitigating food service errors.