Postoperative hemodynamic instability after simultaneous bilateral total knee arthroplasty.

abstract：OBJECTIVES:The intensive care unit (ICU) is a complex environment in terms of data density and alerts, with alert fatigue, a recognized barrier to patient safety. The Electronic Health Record (EHR) is a major source of these alerts. Although studies have looked at the incidence and impact of active EHR alerts, little r...

journal_title：Journal of patient safety

authors： Kizzier-Carnahan V,Artis KA,Mohan V,Gold JA

更新日期：2019-09-01 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：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:To determine if there is a relationship between the risk of postoperative complications and the nonclinical hospital characteristics of bed size, ownership structure, relative urbanicity, regional location, teaching status, and area income status. METHODS:This study involved a secondary analysis of 2006 adm...

journal_title：Journal of patient safety

authors： Knight M

更新日期：2013-12-01 00:00:00

abstract：OBJECTIVE:To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. METHODS:Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia betwee...

journal_title：Journal of patient safety

authors： LeRiche T,Oppenheimer L,Caughey S,Fell D,Walker M

更新日期：2015-03-01 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:The aims of the study were to examine the reactions of first-year health profession students to medical errors and determine whether differences exist between disciplines. METHODS:After viewing the Team STEPPS Program's Susan Sheridan video that describes two separate medical errors, students from anesthesi...

journal_title：Journal of patient safety

authors： Davis BP,Clevenger C,Dillard R,Moulia D,Ander DS

更新日期：2020-03-11 00:00:00

abstract：BACKGROUND:In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a pote...

journal_title：Journal of patient safety

authors： Zerhouni YA,Krupka DC,Graham J,Landman A,Li A,Bhatt DL,Nguyen LL,Capatch K,Concheri K,Reich AJ,Wilson N,Weissman JS

更新日期：2018-11-21 00:00:00

abstract：OBJECTIVE:Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgen...

journal_title：Journal of patient safety

authors： Govindappagari S,Guardado A,Goffman D,Bernstein J,Lee C,Schonfeld S,Angert R,McGowan A,Bernstein PS

更新日期：2020-12-01 00:00:00

abstract：OBJECTIVES:Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been...

journal_title：Journal of patient safety

authors： Li L,Foer D,Hallisey RK,Hanson C,McKee AE,Zuccotti G,Mort EA,Sequist TD,Kaufman NE,Seguin CM,Kachalia A,Blumenthal KG,Wickner PG

更新日期：2020-06-01 00:00:00

abstract：OBJECTIVE:This study aimed to examine the utility of using color and shape to differentiate drug strength information on over-the-counter medicine packages. Medication errors are an important threat to patient safety, and confusions between drug strengths are a significant source of medication error. METHOD:A visual s...

journal_title：Journal of patient safety

authors： Hellier E,Tucker M,Kenny N,Rowntree A,Edworthy J

更新日期：2010-09-01 00:00:00

abstract：INTRODUCTION:Falls represent a serious problem facing hospital-admitted patients, and the severity of fall-related complications rises steadily after the age of 65 years. OBJECTIVES:The aims of this study were (a) to calculate the rate of falls among elderly patients in the internal medicine departments in Ain Shams U...

journal_title：Journal of patient safety

authors： al Tehewy MM,Amin GE,Nassar NW

更新日期：2015-12-01 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：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：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：OBJECTIVE:Adverse drug events (ADEs) are a significant concern in daily practice; however, the profile of high-risk drugs remains unclear. Our objective was to categorize high-risk medication classes according to frequency and severity of ADEs. METHODS:The JADE study is a prospective cohort study of 3459 hospitalized ...

journal_title：Journal of patient safety

authors： Sakuma M,Kanemoto Y,Furuse A,Bates DW,Morimoto T

更新日期：2020-03-01 00:00:00

abstract：BACKGROUND:In the pediatric setting, adverse events occurring at the administration stage are the most common type of preventable adverse drug events. Few data are available on the effect of advice from medical professionals on medication safety. METHODS:This is a prospective cohort study of 1685 pediatric patients, 6...

journal_title：Journal of patient safety

authors： Lemer C,Bates DW,Yoon C,Keohane C,Fitzmaurice G,Kaushal R

更新日期：2009-09-01 00:00:00

abstract：OBJECTIVES:This study aimed to review and critically appraise the published literature on 2 selected prospective risk analysis tools, Failure Mode and Effects Analysis and Socio-Technical Probabilistic Risk Assessment, as applied to the dispensing of medicines in both inpatient and outpatient pharmacy settings. METHOD...

journal_title：Journal of patient safety

authors： Stojkovic T,Marinkovic V,Manser T

更新日期：2017-06-29 00:00:00

abstract：BACKGROUND:Anemia during hospitalization is associated with poor health outcomes. Does anemia at discharge place patients at risk for hospital readmission within 30 days of discharge? Our objectives were to examine the prevalence and magnitude of anemia at hospital discharge and determine whether anemia at discharge wa...

journal_title：Journal of patient safety

authors： Koch CG,Li L,Sun Z,Hixson ED,Tang A,Chagin K,Kattan M,Phillips SC,Blackstone EH,Henderson JM

更新日期：2017-12-01 00:00:00

abstract：OBJECTIVE:The aim of this study was to explore whether information captured in falls reports in incident management systems could be used to explain how and why the falls occurred, with a view to identifying whether such reports can be a source of subsequent learnings that inform practice change. METHODS:An analysis o...

journal_title：Journal of patient safety

authors： de Jong LD,Francis-Coad J,Waldron N,Ingram K,McPhail SM,Etherton-Beer C,Haines TP,Flicker L,Weselman T,Hill AM

更新日期：2018-09-05 00:00:00

abstract：OBJECTIVE:The objective of this study was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. METHODS:A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centers. Partic...

journal_title：Journal of patient safety

authors： Carey M,Boyes AW,Bryant J,Turon H,Clinton-McHarg T,Sanson-Fisher R

更新日期：2019-12-01 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：AIMS:This study measured the effect of aviation-style team training on 3 surgical teams from different specialties. It focused on team working and communication, particularly briefing, time-out, and debriefing, and sought to understand how improvements in team skills could be implemented in a broad range of naturalisti...

journal_title：Journal of patient safety

authors： Catchpole KR,Dale TJ,Hirst DG,Smith JP,Giddings TA

更新日期：2010-09-01 00:00:00

abstract：OBJECTIVES:The use of peripherally inserted central catheters (PICCs) has increased substantially within hospitals during the past several years. Yet, the prevalence and practices of designated nurse PICC teams (i.e., specially trained nurses who are responsible for PICC insertions at a hospital) are unknown. We, there...

journal_title：Journal of patient safety

authors： Krein SL,Kuhn L,Ratz D,Chopra V

更新日期：2019-12-01 00:00:00

abstract：OBJECTIVE:This study aimed to gather qualitative feedback on patient perceptions of informed consent forms and elicit recommendations to improve readability and utility for enhanced patient safety and engagement in shared decision making. METHODS:Sixty interviews in personal interviews were conducted consisting of a l...

journal_title：Journal of patient safety

authors： Manta CJ,Ortiz J,Moulton BW,Sonnad SS

更新日期：2016-08-03 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：INTRODUCTION:The reported 90-day rate of death from living donor nephrectomy is 3 in 10,000 donations. Although this risk is low, the important question is how many deaths are preventable? METHODS:To study this question, all living donor nephrectomy cases, 139,186 procedures, recorded in the Scientific Registry of Tra...

journal_title：Journal of patient safety

authors： Keith DS,Brown J,Andreoni K

更新日期：2019-12-01 00:00:00

abstract：OBJECTIVES:There is evidence that most adverse events result from individual errors and that most malpractice suits with payouts reflect both patient injury and error. HYPOTHESIS:There are outlier physicians with regard to the frequency and total amount of malpractice payouts. METHODS:Using the public use file of the...

journal_title：Journal of patient safety

authors： Oshel RE,Levitt P

更新日期：2020-12-01 00:00:00

abstract：OBJECTIVE:The aim of the study was to explore experiences from the next of kin's perspective of a new involvement method in the regulatory investigation process of adverse events causing patient death. METHODS:The study design was a qualitative process evaluation of the new involvement method in two Norwegian counties...

journal_title：Journal of patient safety

authors： Wiig S,Haraldseid-Driftland C,Tvete Zachrisen R,Hannisdal E,Schibevaag L

更新日期：2019-10-22 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