2009 Annual National Patient Safety Foundation Congress: conference proceedings.

abstract：OBJECTIVES:Reporting of adverse and near miss events are essential to identify system level targets to improve patient safety. Resident physicians historically report few events despite their role as front-line patient care providers. We sought to evaluate barriers to adverse event reporting in an effort to improve rep...

journal_title：Journal of patient safety

authors： Tevis SE,Schmocker RK,Wetterneck TB

更新日期：2020-12-01 00:00:00

abstract：BACKGROUND:Patient safety issues in medical institutions have received worldwide attention. Nurses play a pivotal role in providing health care at the bedside and the interception of adverse events (AEs). A knowledge of contributory factors for these AEs is vital to individuals, institutional procedures, and also natio...

journal_title：Journal of patient safety

authors： Kim MJ,Jang SG,Kim IS,Lee W

更新日期：2020-10-01 00:00:00

abstract：OBJECTIVES:Traditional approaches to safety and quality screening in the emergency department (ED) are porous and low yield for identifying adverse events (AEs). A better approach may be in the use of trigger tool methodology. We recently developed a novel ED trigger tool using a multidisciplinary, multicenter approach...

journal_title：Journal of patient safety

authors： Griffey RT,Schneider RM,Sharp BR,Pothof J,Vrablik MC,Granzella N,Todorov AA,Adler L

更新日期：2018-07-18 00:00:00

abstract：BACKGROUND:Although more than a decade has passed since the imperative to reduce fragmentation of care, high rehospitalization rates among Medicare patients with chronic diseases persist; at least 25% of these are considered preventable. Transitional care models that emphasize coordination among providers have demonstr...

journal_title：Journal of patient safety

authors： Radhakrishnan K,Jones TL,Weems D,Knight TW,Rice WH

更新日期：2018-03-01 00:00:00

abstract：OBJECTIVES:We report on a human factors evaluation project at a major urban teaching hospital that was intended to use human factors methods to assist the selection of a new infusion device among 4 commercially available models. METHODS:The project provided an expert evaluation of the pumps, collected data on programm...

journal_title：Journal of patient safety

authors： Nemeth C,Nunnally M,Bitan Y,Nunnally S,Cook RI

更新日期：2009-06-01 00:00:00

abstract：OBJECTIVE:: This study aimed to evaluate different shortcuts of Healthcare Failure Mode and Effects Analysis (HFMEA) in a radiotherapy setting. DESIGN:: A 2 × 2 study design was set up, in which 4 similar groups analyzed separately the possible risks of the same process by using different versions of HFMEA. SETTING::...

journal_title：Journal of patient safety

authors： Vlayen A

更新日期：2011-09-01 00:00:00

abstract：BACKGROUND:Despite increasing recognition that patients could play an important role in promoting the safety of their care, little is known on this issue regarding health-care professionals' (HCPs') attitudes toward patient involvement. OBJECTIVES:To investigate physicians' and nurses' attitudes toward patient involve...

journal_title：Journal of patient safety

authors： Davis RE,Sevdalis N,Vincent CA

更新日期：2012-12-01 00:00:00

abstract：OBJECTIVES:Pazopanib received US Food and Drug Administration approval in 2009 for advanced renal cell carcinoma. During clinical development, liver chemistry abnormalities and adverse hepatic events were observed, leading to a boxed warning for hepatotoxicity and detailed label prescriber guidelines for liver monitori...

journal_title：Journal of patient safety

authors： Shantakumar S,Nordstrom BL,Hall SA,Djousse L,van Herk-Sukel MPP,Fraeman KH,Gagnon DR,Chagin K,Nelson JJ

更新日期：2019-03-01 00:00:00

abstract：OBJECTIVE:To evaluate medication boxed warning nonadherence in the inpatient setting. METHODS:This was a prospective cohort quality improvement project approved by our institution's Total Quality Council. General medicine and ICU patients 18 years and older were included if they were cared for by a prescriber-led mult...

journal_title：Journal of patient safety

authors： Kloet MA,Lohr BR,Smithburger PL,Seybert AL,Kane-Gill SL

更新日期：2017-03-01 00:00:00

abstract：OBJECTIVES:Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hi...

journal_title：Journal of patient safety

authors： Erkelens DC,Rutten FH,Wouters LT,Kirkels HG,Poldervaart JM,de Groot E,Damoiseaux RA,Hoes AW,Zwart DL

更新日期：2020-12-14 00:00:00

abstract：OBJECTIVES:Adverse drug events (ADEs) are common in ambulatory care and may result from poor patient-physician communication about medication-related symptoms. A module was developed within an electronic patient portal that was designed to enhance communication about medication symptoms and, in turn, reduce ADEs and he...

journal_title：Journal of patient safety

authors： Weingart SN,Carbo A,Tess A,Chiappetta L,Tutkus S,Morway L,Toth M,Davis RB,Phillips RS,Bates DW

更新日期：2013-09-01 00:00:00

abstract：PURPOSE:Although transparency is critical for reducing medical errors, physicians feel discomfort with disclosure. We explored whether overconfidence relates to physician's reluctance to admit that an error may have occurred. METHOD:At 3 university medical centers, a survey presented a clinical vignette of a girl with...

journal_title：Journal of patient safety

authors： Brezis M,Orkin-Bedolach Y,Fink D,Kiderman A

更新日期：2019-12-01 00:00:00

abstract：INTRODUCTION:The second victim is defined as the health professionals who commit an error and are traumatized by the event manifesting psychological, cognitive, and/or physical reactions that have a personal negative impact.The SVEST (Second Victim Experience and Support Tool) is a survey developed and validated in the...

journal_title：Journal of patient safety

authors： Brunelli MV,Estrada S,Celano C

更新日期：2018-05-03 00:00:00

abstract：OBJECTIVE:Speaking up about safety concerns by staff is important to prevent medical errors. Knowledge about healthcare workers' speaking up behaviors and perceived speaking up climate is useful for healthcare organizations (HCOs) to identify areas for improvement. The aim of this study was to develop a short questionn...

journal_title：Journal of patient safety

authors： Richard A,Pfeiffer Y,Schwappach DDL

更新日期：2017-08-28 00:00:00

abstract：OBJECTIVES:There is a pressing need to improve safety and efficiency in the operating room (OR). Postsurgical adverse events, such as surgical site infections and surgical flow disruption, occur at a significant rate in industrial countries where a considerable portion of such complications result in death. The aim of ...

journal_title：Journal of patient safety

authors： Taaffe K,Joseph A,Khoshkenar A,Machry H,Allison D,Reeves ST,RIPCHD.OR Study Group.

更新日期：2020-03-13 00:00:00

abstract：BACKGROUND:Standardized electronic order sets for venous thromboembolism prophylaxis have increased the proportion of patients receiving venous thromboembolism prophylaxis. However, ordering venous thromboembolism prophylaxis does not ensure consistent administration. OBJECTIVE:To explore causes of variability in the ...

journal_title：Journal of patient safety

authors： Elder S,Hobson DB,Rand CS,Streiff MB,Haut ER,Efird LE,Kraus PS,Lehmann CU,Shermock KM

更新日期：2016-06-01 00:00:00

abstract：OBJECTIVES:We sought to synthesize data on systemic arthroprosthetic cobaltism, a recently described syndrome that results from wear or corrosion of chrome-cobalt hip components. METHODS:We conducted a systematic literature review to identify all reported cases of systemic arthroprosthetic cobaltism. To assess the epi...

journal_title：Journal of patient safety

authors： Gessner BD,Steck T,Woelber E,Tower SS

更新日期：2019-06-01 00:00:00

abstract：:Patient safety reporting systems (PSRSs) currently operate at local, regional, and national levels within health care. This article analyzes 6 different PSRSs using a World Health Organization and public health classification system. Patient safety incidents (PSIs) are reported, analyzed, mitigated, and evaluated in a...

journal_title：Journal of patient safety

authors： Noble DJ,Panesar SS,Pronovost PJ

更新日期：2011-06-01 00:00:00

abstract：OBJECTIVES:This study aimed to explore nurses' perceptions regarding disclosure of patient safety incidents. METHODS:An anonymous online survey was conducted, and results were compared with those of the general public using the same questionnaire in a previous study. RESULTS:Among 689 nurses, 96.8% of nurses felt maj...

journal_title：Journal of patient safety

authors： Choi EY,Pyo J,Lee W,Jang SG,Park YK,Ock M,Lee H

更新日期：2020-09-08 00:00:00

abstract：OBJECTIVE:Because internal medicine hospitalist programs were developed to address issues in medicine such as a need to improve quality, improve efficiency, and decrease healthcare cost, obstetrical (OB) hospitalist models were developed to address needs specific to the obstetrics and gynecology field. Our objective wa...

journal_title：Journal of patient safety

authors： Decesare JZ,Bush SY,Morton AN

更新日期：2020-09-01 00:00:00

abstract：OBJECTIVES:In this literature review, we discuss 2 system-level, nurse-targeted patient safety practices (PSPs) that aim to reduce medication errors associated with infusion pumps, including smart pumps. One practice focuses on implementing structured process changes and redesigning workflows to improve efficiencies wi...

journal_title：Journal of patient safety

authors： Bacon O,Hoffman L

更新日期：2020-09-01 00:00:00

abstract：OBJECTIVE:The purpose of this study was to assess whether bundled team training interventions for surgeons and office staff could effectively improve the accuracy of surgery scheduling, minimizing scheduling factors that may contribute to occurrence of wrong site surgery. METHODS:This quasiexperimental observational s...

journal_title：Journal of patient safety

authors： Watson DS,Corbett CF,Oneal G,Daratha KB

更新日期：2017-02-24 00:00:00

abstract：OBJECTIVES:In recent years, several instruments for measuring patient safety culture (PSC) have been developed and implemented. Correct interpretation of survey findings is crucial for understanding PSC locally, for comparisons across settings or time, as well as for planning effective interventions. We aimed to evalua...

journal_title：Journal of patient safety

authors： Gambashidze N,Hammer A,Wagner A,Rieger MA,Brösterhaus M,Van Vegten A,Manser T,WorkSafeMed Consortium.

更新日期：2019-03-15 00:00:00

abstract：BACKGROUND:The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. OBJECTIVE:The aim of the study was to determine whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS),...

journal_title：Journal of patient safety

authors： Boussat B,Seigneurin A,Giai J,Kamalanavin K,Labarère J,François P

更新日期：2017-12-27 00:00:00

abstract：OBJECTIVES:Relatively little is known about rates of outpatient adverse drug events (ADEs), and most health systems do not routinely identify them. We developed a computerized ADE measurement process and used it to detect ADEs from electronic health records and then categorized them according to type, preventability, a...

journal_title：Journal of patient safety

authors： Gandhi TK,Seger AC,Overhage JM,Murray MD,Hope C,Fiskio J,Teal E,Bates DW

更新日期：2010-06-01 00:00:00

abstract：INTRODUCTION:Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable s...

journal_title：Journal of patient safety

authors： Denham CR,Sullenberger CB 3rd,Quaid DW,Nance JJ

更新日期：2012-03-01 00:00:00

abstract：INTRODUCTION:Significant resource is invested into investigation of adverse healthcare events. Outcomes of such investigations have varying degrees of effectiveness. The "hierarchy of effectiveness" model proposes system-focused changes have greater impact than person-focused actions. The traditional approach to invest...

journal_title：Journal of patient safety

authors： Robbins T,Tipper S,King J,Ramachandran SK,Pandit JJ,Pandit M

更新日期：2020-03-24 00:00:00

abstract：OBJECTIVES:As hospitals are increasingly consolidating into larger health systems, they are becoming better positioned to have far reaching and material impacts on safety and quality of care. When the Mount Sinai Health System (MSHS) was formed in 2013, it sought to ensure the delivery of safe, high-quality care to eve...

journal_title：Journal of patient safety

authors： Anderson R,Rosenberg A,Garg S,Nahass J,Nenos A,Egorova N,Rowland J,Mari J,LoPachin V

更新日期：2021-01-01 00:00:00

abstract：OBJECTIVE:Evaluating organizational safety culture is critical for high-stress, high-risk professions such as prehospital emergency medical services (EMS). The aim of the study was to evaluate the psychometric properties of a safety culture instrument for EMS, based on the Agency for Healthcare Research and Quality's w...

journal_title：Journal of patient safety

authors： Crowe RP,Cash RE,Christgen A,Hilmas T,Varner L,Vogelsmeier A,Gilmore WS,Panchal AR

更新日期：2018-06-11 00:00:00

abstract：OBJECTIVES:Drugs can come in concentrated solutions that require dilution before intravenous bolus administration. Upon dilution, the syringe can contain more than the required amount of drug. The user may mistakenly administer the full contents of the syringe, resulting in an overdose. In this cross-sectional study, w...

journal_title：Journal of patient safety

authors： Ng YYY,Wan PW,Chan KP,Sim GG

更新日期：2020-09-08 00:00:00