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:: In the Maastricht Radiation Oncology clinic, a radiotherapy institute in the Netherlands, treatment of cancer patients is organized within 3 different units, each focusing on a specific area (thorax, abdomen, and neck-head). The institute plans to treat all radiation areas in one generalized unit (Linac-pool). PARTICIPANTS:: All 4 teams were composed of 3 radiation technologists (1 from each working unit), 1 manager radiation technologist, and 1 facilitator. INTERVENTIONS:: Prospective risk analyses were completed in parallel within 1 month. MAIN OUTCOME MEASURES:: Time investment and cost data on the different steps of the HFMEAs were registered from the organizations' perspective. Each team suggested a number of corrective actions for the Linac-pool. The quality and feasibility of the proposed actions were assessed by an expert panel (managers and safety staff). RESULTS:: The HFMEA analyses resulted in direct costs varying from 1028.6 to 1701.6 euros. In total, the expert panel assessed 86 corrective actions, of which 43 (50%) were relevant to implement before the start of the Linac-pool. Many of these actions related to the compliance, control, and education of standard operating procedures in daily practice of radiotherapy. CONCLUSIONS:: On the basis of the results of this case study, it seems feasible to develop less time- and cost-consuming versions of HFMEA, which would increase even more the added value of prospective risk analysis tools for health care organizations.
journal_name
J Patient Safjournal_title
Journal of patient safetyauthors
Vlayen Adoi
10.1097/PTS.0b013e31822b07eesubject
Has Abstractpub_date
2011-09-01 00:00:00pages
165-8issue
3eissn
1549-8417issn
1549-8425journal_volume
7pub_type
杂志文章abstract:OBJECTIVES:Patients are a valuable, yet underutilized source of information for safety measurement and improvement in health care. The aim of this review was to identify patient-report safety climate (SC) measures described in the literature, analyze the included items to consider their alignment with previously establ...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000705
更新日期:2020-04-27 00:00:00
abstract:OBJECTIVE:In-hospital falls (IHFs) are a significant burden to the healthcare industry and patients seeking inpatient care. Many falls lead to injuries that could be considered a hospital-acquired condition (HAC). We demonstrated how administrative data can be used to quantify how many IHFs occur and identify what cond...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000637
更新日期:2020-03-11 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000585
更新日期:2019-03-15 00:00:00
abstract:OBJECTIVES:The relationship between medical malpractice risk and one of the fundamental characteristics of physician practice, clinical volume, remains undefined. This study examined how the annual and per-patient encounter medical malpractice claims risk varies with clinical volume. METHODS:Clinical volume was determ...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000706
更新日期:2020-03-23 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000310
更新日期:2016-08-03 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000504
更新日期:2018-06-11 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000456
更新日期:2017-12-27 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3182995e5b
更新日期:2013-12-01 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
pub_type: 杂志文章,随机对照试验
doi:10.1097/PTS.0b013e31829e4b95
更新日期:2013-09-01 00:00:00
abstract:BACKGROUND:Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing. OBJECTIVES:The aim of this qualitative study was to describe nurses' views of...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000314
更新日期:2017-11-04 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000086
更新日期:2016-06-01 00:00:00
abstract:OBJECTIVES:This study was designed to explore awareness and attitudes of community pharmacists toward the national ADR reporting system activities in the northern states of Malaysia. METHODS:A cross-sectional survey using a validated self-administered questionnaire was used in this study. The questionnaire was deliver...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000051
更新日期:2014-06-01 00:00:00
abstract:INTRODUCTION:This study was designed to determine whether systemic cobalt toxicity as an adverse event could be documented using the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for cobalt-chromium containing hip implant recipients. Class 3 Johnson & Johnson (J&...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000534
更新日期:2018-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000641
更新日期:2020-03-24 00:00:00
abstract:OBJECTIVE:Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharm...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181d108cb
更新日期:2010-03-01 00:00:00
abstract:INTRODUCTION:Apologizing to patients is an encouraged practice, yet little is known about how and why providers apologize and what insights apologies could provide in improving quality and safety. OBJECTIVE:The aim of the study was to determine whether provider apologies in the electronic health record could identify ...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000514
更新日期:2020-09-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3182446c51
更新日期:2012-03-01 00:00:00
abstract:OBJECTIVES:Although nursing homes provide complex care requiring attention to safety, research on safety climate in nursing homes is limited. Our study assessed differences in attitudes about safety among nursing home personnel and piloted a new survey, specifically designed for the nursing home context. METHODS:Drawi...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e31824badce
更新日期:2012-09-01 00:00:00
abstract:INTRODUCTION:ProVation Medical documentation software was introduced in our Department of Gastroenterology (GI). We evaluated the use of a simulation module to improve the introduction of new documentation software into a tertiary care center GI department. MATERIALS AND METHODS:Train-the-trainer education was provide...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e31829e4cc0
更新日期:2014-09-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000168
更新日期:2018-03-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000138
更新日期:2017-12-01 00:00:00
abstract:OBJECTIVES:This study's objective was to explore the possible triggers of clinicians' disruptive behavior and to consider whether the type of trigger resulting in disruptive behavior differed by type of clinician, clinician characteristics, professional role, and ethnic background. METHODS:Using data collected from 15...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000288
更新日期:2020-09-01 00:00:00
abstract:OBJECTIVE:Safety advocates have identified barcode verification technology as an important tool to improve health-care practices. METHODS:We evaluated the evidence for the role of barcode technology in improving a wide range of medication safety outcomes across a broad range of settings. Important implementation issue...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000049
更新日期:2015-06-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000220
更新日期:2019-06-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000770
更新日期:2020-09-08 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000516
更新日期:2018-07-18 00:00:00
abstract::On May 20 to 22, 2009, the National Patient Safety Foundation (NPSF) held its Annual NPSF Patient Safety Congress in National Harbor, Md. Entitled Patient Safety in Challenging Times: Now More Than Ever, A Critical Need, the meeting focused on the need to strengthen efforts to improve patient safety and quality in the...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/pts.0b013e3181b5cb8a
更新日期:2009-09-01 00:00:00
abstract:PURPOSE:Elderly patients with multimorbidity are especially vulnerable to adverse drug events (ADEs) and had high prevalence rates. Identifying ADEs is essential for enabling timely interventions that can mitigate the adverse events detected and for developing targeted strategies to prevent their occurrence as well as ...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000389
更新日期:2017-06-14 00:00:00
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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000333
更新日期:2020-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000117
更新日期:2015-12-01 00:00:00