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 reporting. Our main outcomes were as follows: resident attitudes about event reporting and the frequency of event reporting before and after interventions to address reporting barriers. METHODS:We surveyed first year residents regarding barriers to adverse event reporting and used this input to construct a fishbone diagram listing barriers to reporting. Barriers were addressed, and resident event reporting was compared before and after efforts were made to reduce obstacles to reporting. RESULTS:First year residents (97%) recognized the importance of submitting event reports; however, the majority (85%) had not submitted an event report in the first 6 months of residency. Only 7% of residents specified that they had not witnessed an adverse event in 6 months, whereas one third had witnessed 10 or more events. The main barriers were as follows: lack of knowledge about how to submit events (38%) and lack of time to submit reports (35%). After improving resident education around event reporting and simplifying the reporting process, resident event reporting increased 230% (68 to 154 annual reports, P = 0.025). CONCLUSIONS:We were able to significantly increase resident event reporting by educating residents about adverse events and near misses and addressing the primary barriers to event reporting. Moving forward, we will continue annual resident education about patient safety, focus on improving feedback to residents who submit reports, and empower senior residents to act as role models to junior residents in patient safety initiatives.
journal_name
J Patient Safjournal_title
Journal of patient safetyauthors
Tevis SE,Schmocker RK,Wetterneck TBdoi
10.1097/PTS.0000000000000333subject
Has Abstractpub_date
2020-12-01 00:00:00pages
294-298issue
4eissn
1549-8417issn
1549-8425pii
01209203-202012000-00011journal_volume
16pub_type
杂志文章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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000791
更新日期:2020-10-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e31821b8a6c
更新日期:2011-06-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000600
更新日期:2020-06-01 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: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: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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000370
更新日期:2017-02-24 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000101
更新日期:2017-03-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000397
更新日期:2020-09-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000107
更新日期:2017-03-01 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: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: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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000246
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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000497
更新日期:2018-05-03 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181a974d9
更新日期:2009-06-01 00:00:00
abstract:BACKGROUND:Existing patient safety culture assessment tools are mostly developed in western countries and may not be suitable for Chinese primary health care institutions. Primary care plays an important role in China's medical system, and a targeted tool for its patient safety culture is urgently needed. OBJECTIVE:Th...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000733
更新日期:2020-05-13 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000711
更新日期:2020-06-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3182446c51
更新日期:2012-03-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000533
更新日期:2018-09-05 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: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: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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000543
更新日期:2018-11-21 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000326
更新日期:2020-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000706
更新日期:2020-03-23 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: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: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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000577
更新日期:2019-02-09 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000368
更新日期:2019-12-01 00:00:00
abstract:OBJECTIVE:In this systematic review, we evaluate 2 of the most used trigger tools according to the criteria of the World Health Organization for evaluating methods. METHODS:We searched Embase, PubMed, and Cochrane databases for studies (2000-2017). Studies were included if medical record review (MRR) was performed wit...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000670
更新日期:2020-03-11 00:00:00
abstract:OBJECTIVES:Delivering health care is emotionally demanding. Emotional competencies that enable caregivers to identify and handle emotions may be important to deliver safe care, as it improves resilience and enables caregivers to make better decisions. A relevant emotional competence could be psychological detachment, w...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000479
更新日期:2018-02-26 00:00:00