Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem.

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: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

authors： Davis J,Casteel C,Peek-Asa C

更新日期：2020-03-11 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：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：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: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: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

authors： Gessner BD,Steck T,Woelber E,Tower SS

更新日期：2019-06-01 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：OBJECTIVE:Adverse drug events (ADEs) are a significant concern in daily practice; however, the profile of high-risk drugs remains unclear. Our objective was to categorize high-risk medication classes according to frequency and severity of ADEs. METHODS:The JADE study is a prospective cohort study of 3459 hospitalized ...

journal_title：Journal of patient safety

authors： Sakuma M,Kanemoto Y,Furuse A,Bates DW,Morimoto T

更新日期：2020-03-01 00:00:00

abstract：BACKGROUND:In the pediatric setting, adverse events occurring at the administration stage are the most common type of preventable adverse drug events. Few data are available on the effect of advice from medical professionals on medication safety. METHODS:This is a prospective cohort study of 1685 pediatric patients, 6...

journal_title：Journal of patient safety

authors： Lemer C,Bates DW,Yoon C,Keohane C,Fitzmaurice G,Kaushal R

更新日期：2009-09-01 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：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：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: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：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: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：OBJECTIVE:Management of vitamin K antagonists (VKAs) is difficult, and overdoses can have dramatic hemorrhagic consequences. The adverse drug event (ADE) scorecards is a tool intended for the detection and description of adverse drug reaction/ADE developed during a European computerized medical data processing project....

journal_title：Journal of patient safety

authors： Ferret L,Luyckx M,Ficheur G,Chazard E,Beuscart R

更新日期：2018-06-01 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：: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：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：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

authors： Madden C,Lydon S,O'Dowd E,Murphy AW,O'Connor P

更新日期：2020-04-27 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: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

authors： Brunelli MV,Estrada S,Celano C

更新日期：2018-05-03 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: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：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：OBJECTIVES:This study aimed to review and critically appraise the published literature on 2 selected prospective risk analysis tools, Failure Mode and Effects Analysis and Socio-Technical Probabilistic Risk Assessment, as applied to the dispensing of medicines in both inpatient and outpatient pharmacy settings. METHOD...

journal_title：Journal of patient safety

authors： Stojkovic T,Marinkovic V,Manser T

更新日期：2017-06-29 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: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：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

authors： Klein DO,Rennenberg RJMW,Koopmans RP,Prins MH

更新日期：2020-03-11 00:00:00