30-Day Potentially Avoidable Readmissions Due to Adverse Drug Events.

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

authors： Bonacum D,Corrigan J,Gelinas L,Pinakiewicz DC,Stepnick L

更新日期：2009-09-01 00:00:00

abstract：INTRODUCTION:Mortality and morbidity (M&M) meetings present a forum to discuss and review in-hospital deaths and complications to improve patient care. However, it remains an untapped resource to improve the exposure of the trainees to the principles of patient safety METHODS: We modified the departmental M&M meetings ...

journal_title：Journal of patient safety

authors： Singh HP,Durani P,Dias JJ

更新日期：2019-03-01 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：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 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: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：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：OBJECTIVE:Underreporting near-miss errors undermines hospitals' ability to improve patient safety. The objective of this analysis was to determine the extent to which punitive work climate, inadequate error feedback to staff, or insufficient preventative procedures are associated with decreased frequency of near-miss e...

journal_title：Journal of patient safety

authors： Patterson ME,Pace HA

更新日期：2016-06-01 00:00:00

abstract：OBJECTIVE:The aim of this study was to investigate the influence of medical error case reporting by national newspapers on inpatient volume at acute care hospitals. DESIGN:A case-control study was conducted using the article databases of 3 major Japanese newspapers with nationwide circulation between fiscal years 2012...

journal_title：Journal of patient safety

authors： Fukuda H

更新日期：2017-06-30 00:00:00

abstract：OBJECTIVES:Improved safety and teamwork culture has been associated with decreased patient harm within specific units in hospitals or hospital groups. Most studies have focused on a specific harm type. This study's objective was to document such an association across an entire hospital system and across multiple harm t...

journal_title：Journal of patient safety

authors： Berry JC,Davis JT,Bartman T,Hafer CC,Lieb LM,Khan N,Brilli RJ

更新日期：2020-06-01 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：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:There is a growing expectation in health systems around the world that patients will be fully informed when adverse events occur. However, current disclosure practices often fall short of this expectation. METHODS:We reviewed trends in policy and practice in 5 countries with extensive experience with advers...

journal_title：Journal of patient safety

authors： Wu AW,McCay L,Levinson W,Iedema R,Wallace G,Boyle DJ,McDonald TB,Bismark MM,Kraman SS,Forbes E,Conway JB,Gallagher TH

更新日期：2017-03-01 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：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：OBJECTIVES:This study examines nurse-physician teamwork and collaboration, a critical component in the delivery of safe patient care, on general medical units. To that end, we assess shared mental models and mutual trust, 2 coordinating mechanisms that help facilitate teamwork, among nurses and physicians working on ge...

journal_title：Journal of patient safety

authors： McComb SA,Lemaster M,Henneman EA,Hinchey KT

更新日期：2017-12-01 00:00:00

abstract：OBJECTIVES:Hospital leaders lack tools to determine the financial impact of poor patient outcomes and adverse events. To provide health-care leaders with decision support for investments to improve care, we created a tool, the Healthcare Quality Calculator (HQCal), which uses institution-specific financial data to calc...

journal_title：Journal of patient safety

authors： Yarbrough WG,Sewell A,Tickle E,Rhinehardt E,Harkleroad R,Bennett M,Johnson D,Wen L,Pfeiffer M,Benegas M,Morath J

更新日期：2014-12-01 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：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

authors： Burgess LH,Cohen MR,Denham CR

更新日期：2010-03-01 00:00:00

abstract：OBJECTIVE:To identify and describe randomized controlled trials (RCTs) and systematic reviews (SRs) on patient safety published from 1973 onward. MATERIALS AND METHODS:We handsearched a total of 12 medical journals published in English with contents related to patient safety to identify RCTs and SRs published between ...

journal_title：Journal of patient safety

authors： Barajas-Nava LA,Calvache JA,López-Alcalde J,Solà I,Cosp XB

更新日期：2013-06-01 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：OBJECTIVES:After a simultaneously performed bilateral total knee arthroplasty, our institutional clinical experience suggested that there was an alarming incidence of severe postoperative hypotension and bradycardia. We therefore performed this study to define the incidence of postoperative hemodynamic instability and ...

journal_title：Journal of patient safety

authors： Reidy CM,Beach ML,Gallagher JD,Sites BD

更新日期：2010-12-01 00:00:00

abstract：OBJECTIVES:Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the ...

journal_title：Journal of patient safety

authors： Hirose M,Kawamura T,Igawa M,Imanaka Y

更新日期：2017-11-16 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：OBJECTIVES:Inpatient healthcare delivery to people who use drugs is an opportunity to provide acute medical stabilization and offer treatment for underlying substance use disorder (SUD). The process of delivering quality healthcare to people with SUD can present challenges. METHODS:We convened a group of stakeholders ...

journal_title：Journal of patient safety

authors： Wurcel AG,Yu S,Burke D,Lund A,Schelling K,Weingart SN,Freund KM

更新日期：2020-05-07 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：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

authors： Richie E,Dove C,Crowe SL,DeArment V,Manwiller J,Wallace M,Thiel DD

更新日期：2014-09-01 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

authors： Kavanagh KT,Kraman SS,Kavanagh SP

更新日期：2018-12-01 00:00:00