Journal of Patient Safety最新文献

Purpose: We combine the results of multiple studies to describe a systems engineering approach to a well-recognized patient safety problem. The goal of the Operating Room Systems-based Medication Administration error Reduction Team (OR-SMART) patient safety learning laboratory was to study the anesthesia medication work system to identify the characteristics of technologies and interventions that might feasibly reduce anesthesia medication errors.

Scope: The work was conducted at 2 large urban academic medical centers: Johns Hopkins and the Medical University of South Carolina. We sampled across many different types of anesthesia work, understanding the challenges of work-as-done, and applying systems safety principles and evaluation frameworks.

Methods: This was a mixed-methods study. Sources of data varied, with formal and informal interviews, formal and informal observations, video-based observations, hospital and national databases, and information from local incidents. Clinically embedded human factors professionals at both hospital sites facilitated informal sources of data. We explored the variable definitions of error; individual and organizational variability in decision-making; how syringes are used, stored, and moved within an operating room (OR); and used the Systems Engineering Initiative for Patient Safety framework to model medication processes. We were able to identify more than 100 possible interventions, and then prioritized a few for development and testing.

Results: We identified medication icon labels, a syringe holder hub, and workspace design guidelines as interventions for evaluation. Significant benefits of medication label icons were found in simulation and were highly utilized in practice. The syringe hub demonstrated high acceptability at one site but substantially less at another. A virtual reality-based evaluation of the OR design found that situational awareness, visual monitoring, and available workspace were subjectively improved.

To rapidly advance patient safety research, in 2014 the US Agency for Healthcare Research and Quality launched a radically different research initiative by supporting patient safety learning laboratories (PSLLs) using systems perspectives and engineering approaches to advance patient safety. The 5-phase systems engineering methodology uses diverse methods and devotes particular attention to health care safety problem analysis, followed by design, development, implementation, and evaluation. PSLL projects have demonstrated decreases in mortality as well as increases in diagnostic accuracy, reduction in adverse drug events, decreased medication errors, improved early detection of adverse events, and reduction in the number of prenatal adverse events. PSLLs have developed guidance and resources to prevent as well as mitigate patient harm and improve the safety, efficiency, and effectiveness of health care delivery. By fusing approaches ranging from human-centered design to AI-driven analytics applied to health services research, PSLLs have produced influential, evidence-based, scalable interventions that strengthen health care delivery processes and improve outcomes for society, health care organizations, providers, and-most importantly-patients and their families.

Objective: This systematic review aimed to identify tools for measuring the quality of medication safety-related processes in nursing homes.

Methods: We systematically searched Medline, Embase, and CINAHL databases to identify studies describing tools for measuring medication safety-related processes or systems supporting medication safety in nursing homes. Databases were searched from their inception to June 2022. For each tool, the individual items included in the tool were mapped to the 9 steps and 3 background processes of the medication management pathway and the methodological quality was assessed using the Appraisal of Indicators through Research and Evaluation (AIRE) Instrument.

Results: Four tools for assessing medication safety-related processes or systems in the nursing home setting were identified. The tools varied substantially in terms of development, content (number of key elements and items), focus and quality. Only one tool, the Canadian Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC), addressed all 9 steps and 3 background processes of the medication management pathway and had a high overall quality rating as per the AIRE instrument.

Conclusions: While the Canadian MSSA-LTC tool had the widest focus and highest quality of the 4 tools identified, the choice of a tool by an individual nursing home or care organization will depend on the purpose of the assessment and processes of interest as well as the validity of the tool in the jurisdiction in which it is being used. Awareness of the differences and limitations of each tool in the relevant context should facilitate this endeavour.

Purpose: To evaluate the longitudinal safety outcomes of incorrect intraocular lens (IOL) implantation using a standardized cataract surgery operating standard operating procedure (SOP) devised at a tertiary referral eye center. This evaluation represents a critical but underrepresented topic in ophthalmic literature.

Methods: This was a quality improvement, retrospective analysis, and description of the Healthcare Failure Mode Effect and Analysis (HFMEA) and resultant SOP implemented in 2018 following incorrect IOL events. Analysis of subsequent safety events following implementation of the SOP and modifications/reassessments performed was analyzed. The main outcome measures were processes identified in the HFMEA and incorrect IOL safety events occurring following implementation of the SOP.

Results: The HFMEA identified 170 processes/subprocesses steps, 177 potential failure modes, and 75 potential failure mode causes. Twenty-nine system vulnerabilities were identified through analysis of the failure mode causes. From 2018 to 2023, 8 additional incorrect IOL safety events occurred, which led to subsequent revisions of the SOP.

Conclusion: Continuous reassessment of standardized protocols for cataract surgery is critical to ensure patient safety.

Objective: In creating an Agency for Healthcare Research and Quality (AHRQ) Patient Safety Learning Laboratory (PSLL), our objective has been to establish a multidisciplinary research environment focused on the safe care of pregnant women and newborns. This manuscript describes work performed under grants P30 HS023506 (obstetric focus) and R18 HS029123 (neonatal focus).

Methods: We follow AHRQ's 5-step approach to systems engineering in health care: problem analysis, design, development, implementation, and evaluation. Within this 5-step approach, methods used include interviews, focus groups, direct observation, teamwork scales, flow disruption analysis, the Systems Engineering Initiative for Patient Safety model, design thinking, and simulation-based testing of processes and prototypes.

Results: Grant P30 HS023506 is completed. The physical characteristics of 10 labor and delivery units were examined, finding significant heterogeneity in size, design, and organization. Task analysis revealed multiple obstacles to optimal team performance. We designed and tested a delayed cord clamping cart to address inherent ergonomic challenges. Finally, we identified common lapses in verbal communication during obstetric emergencies. Grant R18 HS029123 is ongoing. Eighteen Need Statements serve as the basis for exploratory work in mitigating threats to neonates during resuscitation, including a task analysis to determine points of intervention. We are developing (a) novel resuscitation platforms, (b) improved methods of equipment/supply organization, (c) new means of acquiring, displaying, and processing multiple data streams, and (d) innovative techniques and devices for neonatal intubation.

Conclusions: The approach to systems engineering in health care supported by AHRQ's PSLL funding mechanism fosters critical thinking about safety issues by facilitating the integration of investigators with diverse, complementary expertise. By encouraging such collaboration, AHRQ's 5-step process enables important questions to be answered. The PSLL mechanism is a valuable resource for the patient safety community.

Objectives: This observational study examines challenges and opportunities in the medication reconciliation process within the emergency department (ED). Through a human factors approach, we look to identify barriers and potential improvements for enhancing patient safety during transitions of care for older adults.

Methods: An observational study was conducted in the ED of a large teaching hospital, comprising 32 hours of observation across 12 sessions. Researchers followed pharmacists, nurses, and triage staff, documenting workflows, communication practices, and medication reconciliation processes. Recurring patterns, challenges, and opportunities for improvement were identified through a qualitative analysis.

Results: Systemic barriers to effective medication reconciliation were identified, including fragmented workflows, inconsistent documentation, and usability issues in electronic health records. Challenges were exacerbated by the fast-paced ED environment and frequent interruptions. Pharmacists played a pivotal role in synthesizing diverse information sources to construct accurate medication histories, but their workload often limited their capacity to address broader medication safety concerns. Opportunities for improvement include delegating specific tasks to trained support staff, optimizing electronic health record functionalities, and fostering interdisciplinary collaboration to streamline workflows and reduce errors.

Conclusions: Medication reconciliation in the ED is critical for patient safety but faces significant systemic and environmental challenges. Addressing these barriers through enhanced system integration, task delegation, and improved communication protocols could increase efficiency and reduce errors. Further research is needed to evaluate these interventions across diverse ED settings to optimize medication reconciliation processes and improve safety outcomes.

Retained surgical items (RSIs) are foreign objects left inside after surgery, classified as serious but preventable never events. This review aims to examine the consequences and impact of RSIs, thereby raising awareness and emphasizing prevention. The author reviewed case reports published between 2020 and 2024. A total of 37 cases were evaluated. Excluding 3 asymptomatic patients, 91.89% sought medical help due to discomfort, with 59.46% experiencing pain. On average, 2.33 additional imaging examinations were required. Of the patients, 94.59% underwent a second or more operations, 77.14% of which were open surgeries. Serious complications were observed in 29.73% of cases, and 3 patients died from complications. The average stay to discharge after surgery was 5.94 days. The median incubation time was 1.75 years. RSIs were found across various procedures and anatomic sites, with 67.57% presenting nonspecific symptoms. Only 32.43% of diagnoses were identified through imaging, and 70.27% were confirmed intraoperatively, indicating that the primary diagnosis matched the final diagnosis in only 29.73% of cases. The impact of retained surgical items on patients and health care providers is significant. Prevention is always better than cure.

Objectives: The aim of this study was to explore where and how managers facilitate arenas for collective reflections and knowledge sharing ("reflexive spaces") in homecare services during the COVID-19 pandemic. Moreover, we sought to understand how these "reflexive spaces" contributed to adaptations to challenges induced by the pandemic. Finally, we aimed to discuss how these spaces might incorporate resilience into health care.

Methods: This multiple embedded case study includes interviews with health care staff (n=16) and managers at different system levels (n=21) from 4 Norwegian municipalities. The data were analyzed in accordance with reflexive thematic analysis.

Findings: The analysis identified 2 overarching themes: (1) arenas for reflection, communication, and dialogue, and (2) establishing new solutions through collective reflection facilitated by managers. Managers who initiated dialogue and established arenas for reflection and communication were highlighted as important for discussing and sharing knowledge about challenges created by the pandemic. In these spaces, both managers and staff reflected, collaborated, and learned from each other and then designed a tactical and resilient response to the ongoing challenges.

Conclusions: Managers had a key role as facilitators for "reflexive spaces" within and across levels of responsibilities. Moreover, managers had a mediating role in bridging knowledge and understanding across levels within the health care system. Using "reflexive spaces" as part of daily practice appeared as an important measure to balance demands and capacity and respond both to crises and to everyday challenges.

Objectives: To evaluate the impact of using a simulated teletransport application compared with ad hoc phone calls between medical control physicians (MCP) and transport teams on situational awareness and communication during neonatal interfacility transports.

Methods: In this pilot study, MCPs and pediatric critical care transport teams (PCCT) participated in simulated neonatal transports with or without a simulated transport monitoring and communication (T-MAC) application. Situational awareness (perception, the recognition of the patient's status; comprehension, the understanding of the significance of patient's status; and projection, anticipation of what the patient's status will likely become) and the overall duration of communication was measured and compared between and within groups.

Results: Thirty-three subjects (20 MCP, 13 PCCT) participated in 52 simulations. MCPs had higher overall situational awareness scores with use of the T-MAC app compared with ad hoc phone calls with increased mean perception (98%, T-MAC versus 79%, no T-MAC, P = 0.003) and projection (53%, T-MAC versus 40%, no T-MAC, P = 0.004) scores before a patient event (sudden adverse change to patient status); and increased perception (83%, T-MAC versus 64%, no T-MAC, P = 0.03); comprehension (68%, T-MAC versus 48%, no T-MAC, P = 0.04); and projection (58%, T-MAC versus 30%, no T-MAC, P = 0001) scores after the event. PCCTs had higher mean perception (98%, T-MAC versus 81%, no T-MAC, P = 0.02) and projection (54%, T-MAC versus 45% no T-MAC) scores before the event. The median duration of call times decreased for adverse events (125, IQR: 45s, T-MAC versus 140, IQR: 70s, no T-MAC, P = 0.046).

Conclusions: In this simulated setting, the use of a specially designed teletransport app for neonatal interfacility transports improved situational awareness and increased the efficiency of communication for transport team stakeholders. There was greater benefit in improving situational awareness for the MCPs than for PCCT members. The development and use of a T-MAC application warrants further investigation.