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Improving Patient Safety: Learning from Reported Hospital-Acquired Pressure Ulcers 改善患者安全:从报告的医院获得性压疮中学习
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-25
Anthony Octo Forkuo-Minka, Augustine Kumah, Afua Yeboaa Asomaning
A hospital-acquired pressure ulcer (HAPU) is a localized lesion or injury to the underlying tissue (wound) while the patient is on admission. It occurs when standardized nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardized care for pressure ulcers or manage HAPUs results in patient harm. We aim to share lessons from a reported HAPU incident and address the knowledge gap in patient safety risk assessment, identification, and wound management at Nyaho Medical Centre (Accra, Ghana). A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyze and evaluate the interventions over 12 weeks (Aug–Oct 2021). Development of policies and a standard operating procedure for pressure ulcers and wounds improved accuracy in identifying pressure ulcer risks and management of wounds. Eighty-three patients were assessed with the pressure ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound policy and standard operating procedure (SOP) was achieved, and the number of HAPUs decreased from five to one during the study period. This study demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.
医院获得性压疮(HAPU)是指病人在入院时出现的局部病变或下层组织(伤口)损伤。当存在摩擦力和剪切力时,如果没有正确遵循标准化护理,就会导致皮肤或下层组织破损。遗憾的是,护士对压疮的评估和标准化护理或 HAPU 的管理知识不足,导致了对患者的伤害。我们旨在分享 Nyaho 医疗中心(加纳阿克拉)发生的一起压疮事件的教训,并解决患者安全风险评估、识别和伤口管理方面的知识缺口。 我们使用质量改进工具(如因果分析)对 HAPU 事件进行了审查,以确定促成因素和根本原因。随后,利用计划-执行-研究-行动(PDSA)循环测试干预措施,以改进压疮评估和伤口管理。使用运行图对 12 周内(2021 年 8 月至 10 月)的干预措施进行分析和评估。 压疮和伤口政策及标准操作程序的制定提高了压疮风险识别和伤口管理的准确性。使用压疮评估工具对 83 名患者进行了评估。在研究期间,压疮和伤口政策及标准操作程序(SOP)得到了完全(100%)的遵守,HAPU 数量从 5 例减少到 1 例。 这项研究表明,结合使用质量方法和工具,可以有效改善高危 HAPU 患者的治疗流程和效果。
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引用次数: 0
Practices Used to Improve Patient Safety Culture Among Healthcare Professionals in a Tertiary Care Hospital 一家三甲医院医护人员改善患者安全文化的做法
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-10
Haroon Bashir, M. Barkatullah, Arslan Raza, Muddasar Mushtaq, Khanzada Sheraz Khan, Awais Saber, Shahid Ahmad
A patient safety culture primarily refers to the values, beliefs, attitudes, and behaviors within a healthcare setup in a community that assists in prioritizing patient safety and encouraging the reporting of errors and near-misses in that facility. There is a direct impact of patient safety culture on how well patient safety and quality improvement programs work. The aim of this cross-sectional descriptive study was to investigate the practices to improve patient safety culture and adverse event reporting practices among healthcare professionals in a tertiary care hospital located in Mirpur Azad Jammu and Kashmir. In the non-probability convenience sampling of this cross-sectional study, Divisional Headquarters Teaching Hospital in Mirpur, Azad Kashmir used the Agency for Healthcare Research and Quality Surveys on Patient Safety Culture Hospital Survey to collect data about the perceptions of healthcare professionals regarding patient safety culture within their hospital to assess the trends of patient safety culture by obtaining longitudinal data. A pre-validated questionnaire that has undergone a rigorous trial of testing to maximize the reliability and accuracy of the outcomes was distributed among clinical staff (healthcare professionals who interact with patients on a daily basis, such as nurses, doctors, pharmacists, and laboratory technicians) and administrative staff (medical superintendent, deputy medical superintendent, assistant medical superintendent, heads of departments). A total of 312 questionnaires were returned (response rate, 76%). The study found that the dimension “supervisor/manager expectation and action promoting safety” had the highest positive response rate (65.16%), and “nonpunitive response” had the lowest (27.4%). Higher scores in “nonpunitive response to error” were associated with lower rates of medication errors, pressure ulcers, and surgical site infections, and higher scores in “frequency of event reporting” were associated with lower rates of medication errors, pressure ulcers, falls, hospital-acquired infections, and urinary tract infections. We suggest that in order for hospital staff to continue providing excellent, clinically safe treatment, a well-structured hospital culture promoting patient safety is necessary. Moreover, further study is needed to determine strategies to improve patient safety expertise and awareness, and lower the frequency of adverse occurrences.
患者安全文化主要是指一个社区医疗机构内的价值观、信念、态度和行为,这些价值观、信念、态度和行为有助于将患者安全放在首位,并鼓励该机构报告错误和险情。患者安全文化对患者安全和质量改进计划的效果有直接影响。这项横断面描述性研究旨在调查位于查谟和克什米尔米尔普尔-阿扎德的一家三级医院的医护人员在改善患者安全文化和不良事件报告方面的做法。 在这项横断面研究的非概率方便抽样中,阿扎德-克什米尔米尔布尔的分区总部教学医院采用了医疗保健研究与质量机构的患者安全文化医院调查来收集医护人员对其医院内患者安全文化的看法,以便通过获取纵向数据来评估患者安全文化的趋势。为了最大限度地提高结果的可靠性和准确性,我们向临床医护人员(每天与患者打交道的医护人员,如护士、医生、药剂师和实验室技术人员)和行政人员(医务总监、副医务总监、助理医务总监、各部门主管)发放了一份经过严格测试的预验证问卷。 共收回 312 份问卷(回收率为 76%)。研究发现,"主管/管理者对促进安全的期望和行动 "这一维度的正面回答率最高(65.16%),而 "非惩罚性回应 "的正面回答率最低(27.4%)。对错误的非惩罚性反应 "得分越高,用药错误、压疮和手术部位感染的发生率就越低,而 "事件报告频率 "得分越高,用药错误、压疮、跌倒、医院感染和尿路感染的发生率就越低。 我们认为,为了让医院员工继续提供优质、临床安全的治疗,有必要建立一个促进患者安全的结构良好的医院文化。此外,还需要进一步研究,以确定提高患者安全专业知识和意识、降低不良事件发生频率的策略。
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引用次数: 0
Guest Editor and Reviewer Acknowledgments: 2023 特邀编辑和审稿人致谢:2023
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-x0
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引用次数: 0
Improving Venous Thromboembolism Prophylaxis Through Service Integration, Policy Enhancement, and Health Informatics 通过服务整合、政策强化和健康信息学改进静脉血栓栓塞预防措施
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-16
Yacoub Abuzied, Ahmad Deeb, Layla Alanizy, Rasmieh M. Al-amer, M. Alsheef
Venous thromboembolism (VTE) prevention and management are susceptible issues that require specific rules to sustain and oversee their functioning, as preventing VTE is a vital patient safety priority. This paper aims to investigate and provide recommendations for VTE assessment and reassessment through policy enhancement and development. We reviewed different papers and policies to propose recommendations and theme analysis for policy modifications and enhancements to improve VTE prophylaxis and management. Recommendations were set to enhance the overall work of VTE prophylaxis, where the current VTE protocols and policies must ensure high levels of patient safety and satisfaction. The recommendations included working through a well-organized multidisciplinary team and staff engagement to support and enhance VTE’s work. Nurses’, pharmacists’, and physical therapists’ involvement in setting up the plan and prevention is the way to share the knowledge and paradigm of experience to standardize the management. Promoting policies regarding VTE prophylaxis assessment and reassessment using electronic modules as a part of the digital health process was proposed. A deep understanding of the underlying issues and the incorporation of generic policy recommendations were set. This article presents recommendations for stakeholders, social media platforms, and healthcare practitioners to enhance VTE prophylaxis and management.
静脉血栓栓塞症(VTE)的预防和管理是一个易受影响的问题,需要特定的规则来维持和监督其运作,因为预防 VTE 是患者安全的重中之重。本文旨在通过加强和制定政策,对 VTE 评估和重新评估进行调查并提出建议。 我们审查了不同的论文和政策,为政策的修改和改进提出建议和主题分析,以改善 VTE 的预防和管理。 我们提出的建议旨在加强 VTE 预防的整体工作,目前的 VTE 协议和政策必须确保高度的患者安全和满意度。这些建议包括通过组织良好的多学科团队和员工参与来支持和加强 VTE 工作。护士、药剂师和理疗师参与制定计划和预防,是分享知识和经验范例以实现标准化管理的途径。作为数字健康流程的一部分,建议使用电子模块推广有关 VTE 预防评估和再评估的政策。对根本问题的深刻理解和通用政策建议的纳入是既定的。 本文为利益相关者、社交媒体平台和医疗从业人员提出了加强 VTE 预防和管理的建议。
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引用次数: 0
Improving Venous Thromboembolism Prophylaxis Through Service Integration, Policy Enhancement, and Health Informatics 通过服务整合、政策强化和健康信息学改进静脉血栓栓塞预防措施
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-16
Yacoub Abuzied, Ahmad Deeb, Layla Alanizy, Rasmieh M. Al-amer, M. Alsheef
Venous thromboembolism (VTE) prevention and management are susceptible issues that require specific rules to sustain and oversee their functioning, as preventing VTE is a vital patient safety priority. This paper aims to investigate and provide recommendations for VTE assessment and reassessment through policy enhancement and development. We reviewed different papers and policies to propose recommendations and theme analysis for policy modifications and enhancements to improve VTE prophylaxis and management. Recommendations were set to enhance the overall work of VTE prophylaxis, where the current VTE protocols and policies must ensure high levels of patient safety and satisfaction. The recommendations included working through a well-organized multidisciplinary team and staff engagement to support and enhance VTE’s work. Nurses’, pharmacists’, and physical therapists’ involvement in setting up the plan and prevention is the way to share the knowledge and paradigm of experience to standardize the management. Promoting policies regarding VTE prophylaxis assessment and reassessment using electronic modules as a part of the digital health process was proposed. A deep understanding of the underlying issues and the incorporation of generic policy recommendations were set. This article presents recommendations for stakeholders, social media platforms, and healthcare practitioners to enhance VTE prophylaxis and management.
静脉血栓栓塞症(VTE)的预防和管理是一个易受影响的问题,需要特定的规则来维持和监督其运作,因为预防 VTE 是患者安全的重中之重。本文旨在通过加强和制定政策,对 VTE 评估和重新评估进行调查并提出建议。 我们审查了不同的论文和政策,为政策的修改和改进提出建议和主题分析,以改善 VTE 的预防和管理。 我们提出的建议旨在加强 VTE 预防的整体工作,目前的 VTE 协议和政策必须确保高度的患者安全和满意度。这些建议包括通过组织良好的多学科团队和员工参与来支持和加强 VTE 工作。护士、药剂师和理疗师参与制定计划和预防,是分享知识和经验范例以实现标准化管理的途径。作为数字健康流程的一部分,建议使用电子模块推广有关 VTE 预防评估和再评估的政策。对根本问题的深刻理解和通用政策建议的纳入是既定的。 本文为利益相关者、社交媒体平台和医疗从业人员提出了加强 VTE 预防和管理的建议。
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引用次数: 0
Practices Used to Improve Patient Safety Culture Among Healthcare Professionals in a Tertiary Care Hospital 一家三甲医院医护人员改善患者安全文化的做法
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-10
Haroon Bashir, M. Barkatullah, Arslan Raza, Muddasar Mushtaq, Khanzada Sheraz Khan, Awais Saber, Shahid Ahmad
A patient safety culture primarily refers to the values, beliefs, attitudes, and behaviors within a healthcare setup in a community that assists in prioritizing patient safety and encouraging the reporting of errors and near-misses in that facility. There is a direct impact of patient safety culture on how well patient safety and quality improvement programs work. The aim of this cross-sectional descriptive study was to investigate the practices to improve patient safety culture and adverse event reporting practices among healthcare professionals in a tertiary care hospital located in Mirpur Azad Jammu and Kashmir. In the non-probability convenience sampling of this cross-sectional study, Divisional Headquarters Teaching Hospital in Mirpur, Azad Kashmir used the Agency for Healthcare Research and Quality Surveys on Patient Safety Culture Hospital Survey to collect data about the perceptions of healthcare professionals regarding patient safety culture within their hospital to assess the trends of patient safety culture by obtaining longitudinal data. A pre-validated questionnaire that has undergone a rigorous trial of testing to maximize the reliability and accuracy of the outcomes was distributed among clinical staff (healthcare professionals who interact with patients on a daily basis, such as nurses, doctors, pharmacists, and laboratory technicians) and administrative staff (medical superintendent, deputy medical superintendent, assistant medical superintendent, heads of departments). A total of 312 questionnaires were returned (response rate, 76%). The study found that the dimension “supervisor/manager expectation and action promoting safety” had the highest positive response rate (65.16%), and “nonpunitive response” had the lowest (27.4%). Higher scores in “nonpunitive response to error” were associated with lower rates of medication errors, pressure ulcers, and surgical site infections, and higher scores in “frequency of event reporting” were associated with lower rates of medication errors, pressure ulcers, falls, hospital-acquired infections, and urinary tract infections. We suggest that in order for hospital staff to continue providing excellent, clinically safe treatment, a well-structured hospital culture promoting patient safety is necessary. Moreover, further study is needed to determine strategies to improve patient safety expertise and awareness, and lower the frequency of adverse occurrences.
患者安全文化主要是指一个社区医疗机构内的价值观、信念、态度和行为,这些价值观、信念、态度和行为有助于将患者安全放在首位,并鼓励该机构报告错误和险情。患者安全文化对患者安全和质量改进计划的效果有直接影响。这项横断面描述性研究旨在调查位于查谟和克什米尔米尔普尔-阿扎德的一家三级医院的医护人员在改善患者安全文化和不良事件报告方面的做法。 在这项横断面研究的非概率方便抽样中,阿扎德-克什米尔米尔布尔的分区总部教学医院采用了医疗保健研究与质量机构的患者安全文化医院调查来收集医护人员对其医院内患者安全文化的看法,以便通过获取纵向数据来评估患者安全文化的趋势。为了最大限度地提高结果的可靠性和准确性,我们向临床医护人员(每天与患者打交道的医护人员,如护士、医生、药剂师和实验室技术人员)和行政人员(医务总监、副医务总监、助理医务总监、各部门主管)发放了一份经过严格测试的预验证问卷。 共收回 312 份问卷(回收率为 76%)。研究发现,"主管/管理者对促进安全的期望和行动 "这一维度的正面回答率最高(65.16%),而 "非惩罚性回应 "的正面回答率最低(27.4%)。对错误的非惩罚性反应 "得分越高,用药错误、压疮和手术部位感染的发生率就越低,而 "事件报告频率 "得分越高,用药错误、压疮、跌倒、医院感染和尿路感染的发生率就越低。 我们认为,为了让医院员工继续提供优质、临床安全的治疗,有必要建立一个促进患者安全的结构良好的医院文化。此外,还需要进一步研究,以确定提高患者安全专业知识和意识、降低不良事件发生频率的策略。
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引用次数: 0
Improving Patient Safety: Learning from Reported Hospital-Acquired Pressure Ulcers 改善患者安全:从报告的医院获得性压疮中学习
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-25
Anthony Octo Forkuo-Minka, Augustine Kumah, Afua Yeboaa Asomaning
A hospital-acquired pressure ulcer (HAPU) is a localized lesion or injury to the underlying tissue (wound) while the patient is on admission. It occurs when standardized nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardized care for pressure ulcers or manage HAPUs results in patient harm. We aim to share lessons from a reported HAPU incident and address the knowledge gap in patient safety risk assessment, identification, and wound management at Nyaho Medical Centre (Accra, Ghana). A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyze and evaluate the interventions over 12 weeks (Aug–Oct 2021). Development of policies and a standard operating procedure for pressure ulcers and wounds improved accuracy in identifying pressure ulcer risks and management of wounds. Eighty-three patients were assessed with the pressure ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound policy and standard operating procedure (SOP) was achieved, and the number of HAPUs decreased from five to one during the study period. This study demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.
医院获得性压疮(HAPU)是指病人在入院时出现的局部病变或下层组织(伤口)损伤。当存在摩擦力和剪切力时,如果没有正确遵循标准化护理,就会导致皮肤或下层组织破损。遗憾的是,护士对压疮的评估和标准化护理或 HAPU 的管理知识不足,导致了对患者的伤害。我们旨在分享 Nyaho 医疗中心(加纳阿克拉)发生的一起压疮事件的教训,并解决患者安全风险评估、识别和伤口管理方面的知识缺口。 我们使用质量改进工具(如因果分析)对 HAPU 事件进行了审查,以确定促成因素和根本原因。随后,利用计划-执行-研究-行动(PDSA)循环测试干预措施,以改进压疮评估和伤口管理。使用运行图对 12 周内(2021 年 8 月至 10 月)的干预措施进行分析和评估。 压疮和伤口政策及标准操作程序的制定提高了压疮风险识别和伤口管理的准确性。使用压疮评估工具对 83 名患者进行了评估。在研究期间,压疮和伤口政策及标准操作程序(SOP)得到了完全(100%)的遵守,HAPU 数量从 5 例减少到 1 例。 这项研究表明,结合使用质量方法和工具,可以有效改善高危 HAPU 患者的治疗流程和效果。
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引用次数: 0
Guest Editor and Reviewer Acknowledgments: 2023 特邀编辑和审稿人致谢:2023
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-x0
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引用次数: 0
Adopting the Klein Triple Path Model of Insight for Clinical Quality Improvement 采用克莱因三重路径洞察模型改进临床质量
Pub Date : 2024-02-01 DOI: 10.36401/jqsh-23-44
Isaac K. S. Ng
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引用次数: 0
Lomitapide: A Medication Use Evaluation and a Formulary Perspective 洛米他匹:用药评估和处方集视角
Pub Date : 2024-01-20 DOI: 10.36401/jqsh-23-32
Laila Carolina Abu Esba, Hani Alharbi
Lomitapide is approved for lowering low-density lipoprotein cholesterol (LDL-C) in homozygous familial hypercholesterolemia, which is a rare genetic disorder. The evidence regarding its safety and efficacy from a small clinical trial requires further validation for effectiveness and safety in the real world. This study aimed to use institutional data on the effectiveness and safety of lomitapide to assist in formulating a perspective on adding it to the formulary. This was a retrospective review of patients who were actively prescribed lomitapide at King Abdulaziz Medical City, Riyadh, Saudi Arabia, from 2019 to 2022. Data collection included demographics, confirmed gene mutation results, duration of lomitapide therapy, baseline, on-treatment, last LDL-C levels, percent reduction in LDL-C after 1-3 months of therapy (whichever was first available), other LDL-C lowering therapies used, liver function tests, adverse effects, and compliance. Eight adult patients were included in the review, with a mean age of 25.5 years. Approximately 75% were female, and the duration of treatment with lomitapide ranged from 9 months to 3 years. None of the patients were on continuous LDL apheresis. The mean baseline LDL-C at presentation to our facility was 17.2 mmol/L (range, 11.78–21.97 mmol/L), the mean percent drop in LDL-C with lomitapide was 34.1% (range, 0%–87%), gastrointestinal disturbances were documented in 50% of the patients, and no cases of severe liver toxicities or increase in liver enzymes were seen. In our cohort of adult patients, lomitapide showed an overall modest reduction in LDL-C, with no cases of increase in liver enzymes and documented intolerance, indicating that most patients were likely noncompliant. This review revealed important considerations when reimbursing expensive medications for rare diseases. Real-world evidence in real-time can support healthcare systems in price negotiations and reaching mutual agreements that can eventually improve patient access to care.
洛米他匹获准用于降低同卵家族性高胆固醇血症(一种罕见的遗传性疾病)患者的低密度脂蛋白胆固醇(LDL-C)。从一项小型临床试验中获得的有关其安全性和有效性的证据需要在现实世界中进一步验证其有效性和安全性。本研究旨在利用有关洛米他匹的有效性和安全性的机构数据,协助制定将其纳入处方集的观点。 本研究对沙特阿拉伯利雅得阿卜杜勒阿齐兹国王医疗城在2019年至2022年期间积极处方洛米他肽的患者进行了回顾性审查。收集的数据包括人口统计学特征、确诊基因突变结果、洛米他匹治疗持续时间、基线、治疗中、最后LDL-C水平、治疗1-3个月后LDL-C降低百分比(以最先获得的数据为准)、使用的其他降低LDL-C疗法、肝功能检测、不良反应和依从性。 本次研究共纳入了 8 名成年患者,平均年龄为 25.5 岁。约75%的患者为女性,使用洛米他匹治疗的时间从9个月到3年不等。所有患者均未持续进行低密度脂蛋白清除治疗。来我院就诊时的平均基线 LDL-C 为 17.2 mmol/L(范围为 11.78-21.97 mmol/L),使用洛美他肽后 LDL-C 的平均降幅为 34.1%(范围为 0%-87%),50% 的患者出现胃肠道紊乱,未发现严重肝毒性或肝酶升高的病例。 在我们的成年患者队列中,洛米他匹总体上显示出低密度脂蛋白胆固醇的适度降低,没有肝酶升高的病例,也没有不耐受的记录,这表明大多数患者可能没有遵从医嘱。本综述揭示了罕见病昂贵药物报销时的重要注意事项。真实世界的实时证据可以支持医疗系统进行价格谈判并达成相互协议,从而最终改善患者获得护理的机会。
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引用次数: 0
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