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.

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.

Objective: The objective of this study was to determine key issues related to the safety of pediatric mental and behavioral (MBH) patients in the emergency department (ED), as well as related provider safety issues from a systems perspective.

Methods: Semistructured interviews were conducted with 55 staff members from 4 ED units in rural and urban hospitals. Utilizing the Systems Engineering Initiative for Patient Safety framework, interviews were coded in Atlas.ti for physical environment, tasks, roles, technology, organization, and safety.

Results: Self-harm, harm to others, and elopement were the frequently mentioned safety concerns. The type of ED (general adult, non-MBH unit) and presence of ligatures in patient care areas increased risks to patient safety. ED layout, patient visibility, and proximity to exits increased elopement risks. The ED environment was seen as a trigger for patient agitation, exacerbating MBH conditions. Major challenges in safety incident prevention and response included inadequate pediatric de-escalation training and ineffective use of protective shields. Technological barriers affecting safety encompass issues with the accessibility and reliability of panic buttons.

Conclusions: The study calls for a comprehensive approach to safety in the ED, integrating organizational policies, environment design, technology use, staff training, and resource management, setting the stage for future enhancements in safety for both pediatric MBH patients and health care providers.

Objectives: Children receiving care in pediatric intensive care units (PICUs) are vulnerable to decompensation and diagnostic error due to the complex and dynamic nature of pediatric critical illness. In the PICU, the few clinical decision support (CDS) tools that have been implemented to support diagnostic accuracy (i.e., the ability to detect the presence of a condition) have not led to an increase in clinician adoption of desired practices nor demonstrated clear clinical benefit.

Methods: The DISCOVER Learning Lab analyzed workflow and failure modes in diagnosing and managing clinical decompensation in the PICU, using systems safety engineering and human factors to examine intersections with established CDS. Methods employed included qualitative interviews, workflow mapping, immersive virtual reality (VR) systems testing via a digital twin environment, and a failure modes effect analysis.

Results: Workflow mapping and qualitative interviews revealed barriers to communication, workflow inefficiencies, and limited access to up-to-date clinical information during critical events in the PICU. The immersive VR systems testing elucidated how PICU staff members currently interact with CDS tools and how various tools could better integrate into or influence clinical workflows. Critical failure modes were identified with corresponding opportunity areas for intervention.

Conclusions: The application of a systems safety engineering and human factors approach to problem analysis, partnered with novel use of immersive VR and digital twin technology, led to valuable insights into common failure modes and potential opportunity areas to improve diagnostic accuracy and care delivery in a quaternary referral center PICU.

Introduction: Suboptimal transitional care from the hospital to home can result in poor health outcomes, increased costs, and readmissions. Telehealth-based transitional care programs have shown some improvements in readmission rates; however, it is unclear why some patients benefit while others do not. This study evaluated a connected transitional care (CTC) program that provided high-risk patients with timely post-discharge telehealth appointments conducted by a nurse practitioner. Our focus was on understanding why some patients participating in the program benefit and are not readmitted while others are readmitted.

Methods: We analyzed readmission rates for patients referred to the program and compared those who engaged, by completing a telehealth visit, to those who did not. For those patients who did engage, we conducted chart reviews of a subset of patients who were not readmitted compared with those who were readmitted to extract themes and understand differences that could serve to improve the CTC program.

Results: Of 1374 patients referred to the CTC program, 443 (32.2%) engaged by completing a telehealth visit. Those who engaged in the program had a readmission rate of 18.7% compared with 21.3% for those who did not, resulting in a relative risk reduction of 12%. Chart reviews comparing patients who engaged and were not readmitted (32 charts reviewed) with those who were readmitted (18 charts reviewed) revealed several differences. Patients who were not readmitted were seen sooner after discharge, had greater family/caregiver involvement, had social needs addressed, required less language interpretation, and had fewer instances of altered mental status.

Conclusions: This study suggests that a telehealth transition program may reduce readmissions, although a more rigorous statistical analysis is needed. Importantly, the qualitative chart review suggests several areas for improvement, including engaging family/caregivers, providing better social need support, and developing ways to support behavioral health.

Background: We established a Patient Safety Learning Lab (AHRQ R18HS029473) to examine the sociotechnical system that drives interprofessional communication in pediatric inpatient settings in the context of evolving communication technologies, and to co-create and evaluate solutions with clinician end users. Here, we describe the use of human-centered design and system engineering processes for the Problem Analysis phase of this project.

Methods: We applied the "Empathize" and "Define" steps of the design thinking process to our Problem Analysis. The goal of the Empathize step is to generate a comprehensive understanding of a problem(s) as experienced by the end user. We conducted interviews and observations with interprofessional clinicians from pediatric inpatient units in a single children's hospital. We used other operational and clinical data to triangulate findings (clinician secure messaging metadata, survey data, and policies/procedures). In the "Define" step, we iteratively developed user-centered problem statements.

Results: Data synthesized for the problem analysis included: interviews with 28 clinicians, 32 hours of unit observations; metadata for 433,432 secure messages; 155 free-text clinician survey responses; and 40 communication-related policies/procedures. The Problem Analysis revealed communication challenges in the following domains for clinicians providing frontline care (i.e., bedside nurses, residents, frontline fellows): (1) efficiently locating and contacting other members of the care team; (2) communicating urgency level of information; and (3) managing high volume of minimally informative messages.

Conclusions: Practical application of human-centered design and systems thinking contributed to a more holistic understanding of communication challenges, and their patient safety implications, from the perspective of multiple end-user groups.

Objectives: This study aims to advance patient safety science by identifying and addressing the systemic causes of psychosocial harm among transgender and gender nonbinary (TGNB) individuals. The 4-year TRANS-SAFE patient safety learning laboratory (PSLL) will follow a 6-phase systems engineering approach to study ways to improve the safety of TGNB patients.

Methods: This study involves conducting a systematic scoping review, interviews with patients, providers, and community members, and observations of TGNB patient and provider experiences to identify determinants of avoidable patient suffering. In addition, the PSLL will provide financial support for pre-doctorate and post-doctorate research scholars in the TGNB community. Human-centered solutions will be co-designed to mitigate psychosocial harm among TGNB individuals. Interventions will be developed through engagement with stakeholders in an iterative process of co-design and evaluation.

Results: Interventions will be evaluated in real and simulated clinical environments for effectiveness, acceptability, usability, feasibility of implementation, and sustainability. A structural innovation of this PSLL is its focus on sustainment and dissemination, which will be facilitated through the development of a TRANS-SAFE certification process for health care organizations in partnership with the World Professional Association for Transgender Health (WPATH).

Conclusions: This PSLL will address a fundamental gap in the science and practice of patient safety by assessing and addressing psychosocial patient harm in a high-risk population that has been too often neglected in the patient safety literature.

Background: There are gaps in understanding the experiences of children, parents, and providers during dental conscious sedation. This study aimed to capture and analyze these experiences to identify opportunities for improvement and enhance the quality and safety of pediatric dental conscious sedation.

Methods: A human-centered design approach was used to examine the conscious sedation experience in 2 US advanced education pediatric dental clinics. Researchers conducted field observations, interviews with providers and parents, and providers focus groups to explore experiential factors. Data were transcribed and analyzed using content thematic analysis. Insights from the data were used to explore and generate new solutions to improve dental conscious sedation quality and safety.

Results: A total of 25 observations, 18 interviews (9 providers, 9 parents), and 4 provider focus groups were conducted across both sites. The process identified 4 key improvement opportunities: helping providers navigate the ambiguity of patient behavior, facilitating rapport building between providers and patients/parents, aligning expectations and supporting sedation sensemaking, and making the sedation experience more patient-centered. A multicomponent intervention was developed to address these needs, including a parent-facing brochure, a patient educational video, and an enhanced set of sedation records for providers to document patient and sedation information.

Conclusions: This study used human-centered design to identify key challenges in pediatric dental conscious sedation and develop a multicomponent intervention in collaboration with patients, parents, and providers. The research demonstrates the potential of this approach to enhance sedation quality and safety, with future studies needed to assess its impact.

Objectives: This work aims to understand the performance of early warning scores calculated using intermittent vital signs to identify general deterioration in the medical/surgical setting and explore the feasibility of implementing near real-time scores using continuous monitoring as part of a systems approach to inpatient assessment.

Methods: This retrospective study used comparative trends and performance analyses to compare the ability of 4 early warning scores to identify patients requiring rescue and/or transfer to a higher level of care. Simulation was used to explore improvement in deterioration recognition with estimated scores calculated every 5 minutes as compared with those calculated using available intermittent vital signs to understand the potential impact of score calculation where continuous monitoring is available.

Results: The National Early Warning Score performed better than other scores in identifying patients needing rescue and/or transfer to higher levels of care, with a sensitivity versus specificity analysis area under the curve value of 0.82. The National Early Warning Score also produced clinically acceptable misclassification ratios of 1:1 at scores of 6-7 or above. Simulation using this score, estimated every 5 minutes, improved detection of rescue and transfer events by over 5 hours on average.

Conclusions: Early warning scores can be used for the detection of general deterioration events and, if calculated frequently using parameters from continuous monitoring systems, can augment alarm-based continuous monitoring to create a system to further reduce unwitnessed arrests and deaths.