Nurses' Views Highlight a Need for the Systematic Development of Patient Safety Culture in Forensic Psychiatry Nursing.

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：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: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: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: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

authors： Ng YYY,Wan PW,Chan KP,Sim GG

更新日期：2020-09-08 00:00:00

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::...

journal_title：Journal of patient safety

authors： Vlayen A

更新日期：2011-09-01 00:00:00

abstract：OBJECTIVE:To develop an objective tool designed to standardize the identification of high-alert medications (HAMs) according to patient safety risk. METHODS:Medications were evaluated using the High-Alert Medication Stratification Tool (HAMST). Tool revision occurred through assessing medications on an organization-ap...

journal_title：Journal of patient safety

authors： Washburn NC,Dossett HA,Fritschle AC,Degenkolb KE,Macik MR,Walroth TA

更新日期：2017-12-12 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：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: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：:Error disclosure is a high-stakes, emotionally charged interaction for patients and families as well as clinicians. A failed disclosure can result in emotional distress, reduced patient and family trust, litigation, and lost opportunities to learn from and prevent subsequent errors. However, many clinicians have littl...

journal_title：Journal of patient safety

authors： Shapiro J,Robins L,Galowitz P,Gallagher TH,Bell S

更新日期：2018-05-16 00:00:00

abstract：BACKGROUND:Despite increasing recognition that patients could play an important role in promoting the safety of their care, little is known on this issue regarding health-care professionals' (HCPs') attitudes toward patient involvement. OBJECTIVES:To investigate physicians' and nurses' attitudes toward patient involve...

journal_title：Journal of patient safety

authors： Davis RE,Sevdalis N,Vincent CA

更新日期：2012-12-01 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: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

authors： Nemeth C,Nunnally M,Bitan Y,Nunnally S,Cook RI

更新日期：2009-06-01 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：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：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

authors： Matulis JC 3rd,North F

更新日期：2020-09-01 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：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：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：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：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: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：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: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: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：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

authors： Gambashidze N,Hammer A,Wagner A,Rieger MA,Brösterhaus M,Van Vegten A,Manser T,WorkSafeMed Consortium.

更新日期：2019-03-15 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:This study assesses fall prevention measures and subsequent incident reporting of falls resulting in an "inpatient fracture neck of femur (FNOF)" within a single NHS Trust, with the aim of identifying potential areas of improvement and changing practice within a Trust. METHODS:Forty patients (mean age, 82.6...

journal_title：Journal of patient safety

authors： Green CM,Zeiton M,Foulkes K,Barrie J

更新日期：2018-12-01 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

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