What Can Apologies in the Electronic Health Record Tell Us About Health Care Quality, Processes, and Safety?

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: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：:Implanted medical devices (IMDs) are extremely common, yet they are not systematically documented on hospital admission. Through structured patient interviews, we determined the prevalence of IMDs in hospital inpatients. Using medical record review, we evaluated the sensitivity of the medical record reporting of IMDs ...

journal_title：Journal of patient safety

authors： Kuder M,Gelman A,Zenilman JM

更新日期：2018-09-01 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: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: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:Self-referred imaging has grown rapidly, raising concerns about increased costs and compromised quality of care. A quality improvement program using imaging interpretation criteria was designed by a national payer to ensure that noninvasive diagnostic images are interpreted by appropriately trained physician...

journal_title：Journal of patient safety

authors： Powell AC,Long JW,Kren EM,Gupta AK,Levin DC

更新日期：2019-03-01 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

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：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: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：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：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：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: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 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: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：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：OBJECTIVES:This study aimed to explore nurses' perceptions regarding disclosure of patient safety incidents. METHODS:An anonymous online survey was conducted, and results were compared with those of the general public using the same questionnaire in a previous study. RESULTS:Among 689 nurses, 96.8% of nurses felt maj...

journal_title：Journal of patient safety

authors： Choi EY,Pyo J,Lee W,Jang SG,Park YK,Ock M,Lee H

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

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: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：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：: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：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: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: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：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：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: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: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

authors： Decesare JZ,Bush SY,Morton AN

更新日期：2020-09-01 00:00:00