Using Prospective Risk Analysis Tools to Improve Safety in Pharmacy Settings: A Systematic Review and Critical Appraisal.

abstract：OBJECTIVE:To analyze the patterns of potentially avoidable readmissions due to adverse drug events (ADEs) to identify the most appropriate risk reduction interventions. METHODS:In this observational study, we analyzed a random sample of 534 potentially avoidable 30-day readmissions from 10,275 consecutive discharges f...

journal_title：Journal of patient safety

authors： Dalleur O,Beeler PE,Schnipper JL,Donzé J

更新日期：2017-03-17 00:00:00

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：OBJECTIVES:The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS:The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained G...

journal_title：Journal of patient safety

authors： Cherara L,Sculli GL,Paull DE,Mazzia L,Neily J,Mills PD

更新日期：2018-02-13 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: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：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

authors： Kuosmanen A,Tiihonen J,Repo-Tiihonen E,Eronen M,Turunen H

更新日期：2017-11-04 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：OBJECTIVES:Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. T...

journal_title：Journal of patient safety

authors： Henriksen K,Rodrick D,Grace EN,Shofer M,Jeffrey Brady P

更新日期：2019-02-09 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：: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：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

authors： Toscano Guzmán MD,Galván Banqueri M,Otero MJ,Alfaro Lara ER,Casajus Lagranja P,Santos Ramos B

更新日期：2017-06-14 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

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

authors： Schaffer AC,Babayan A,Yu-Moe CW,Sato L,Einbinder JS

更新日期：2020-03-23 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：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：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：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: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：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：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：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：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

authors： Leung AA,Denham CR,Gandhi TK,Bane A,Churchill WW,Bates DW,Poon EG

更新日期：2015-06-01 00:00:00

abstract：OBJECTIVES:Predictions estimate supplies of filtering facepiece respirators (FFRs) would be limited in the event of a severe influenza pandemic. Ultraviolet decontamination and reuse (UVDR) is a potential approach to mitigate an FFR shortage. A field study sought to understand healthcare workers' perspectives and poten...

journal_title：Journal of patient safety

authors： Nemeth C,Laufersweiler D,Polander E,Orvis C,Harnish D,Morgan SE,O'Connor M,Hymes S,Nachman S,Heimbuch B

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：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：OBJECTIVES:The aim of this study was to identify physical design elements that contribute to potential falls in patient rooms. METHODS:An exploratory, physical simulation-based approach was adopted for the study. Twenty-seven subjects, older than 70 years (11 male and 16 female subjects), conducted scripted tasks in a...

journal_title：Journal of patient safety

authors： Pati D,Valipoor S,Cloutier A,Yang J,Freier P,Harvey TE,Lee J

更新日期：2017-02-03 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：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：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：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