Living Donor Nephrectomy: Is It as Safe as It Can Be? Analysis of Living Donor Deaths in the United States.

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 Transplant Recipients database since its inception in 1987 were analyzed to determine the death rate and the number of deaths that were potentially preventable. Preventable deaths were defined as any death in the first 7 days except due to clearly unrelated events or death from hemorrhage, pulmonary embolism, infection, cardiovascular cause, or suicide in the first 90 days. RESULTS:The numbers of deaths at 7, 30, 90, and 365 days after donation were 16, 26, 38, and 86, which translated into 1.15, 1.87, 2.73, and 6.18 deaths per 10,000 donations, respectively. From 2000 onward, when coding was available for cause of death, 19 of the 30 deaths were deemed potentially preventable. The nonrisk-adjusted rate of death with laparoscopic donation was higher than open nephrectomy, but this difference did not reach statistical significance. Conversion from laparoscopic to open nephrectomy occurs in approximately 1 in 100 surgeries, and this rate has remained fairly steady since 2005. CONCLUSIONS:This analysis suggests that up to two thirds of deaths are potentially preventable. The transplant community should consider additional safety strategies such as simulation training of rare complications to lower donor risk.

journal_name

J Patient Saf

authors

Keith DS,Brown J,Andreoni K

doi

10.1097/PTS.0000000000000610

subject

Has Abstract

pub_date

2019-12-01 00:00:00

pages

274-281

issue

4

eissn

1549-8417

issn

1549-8425

pii

01209203-201912000-00002

journal_volume

15

pub_type

杂志文章
  • Does Free-Text Information in Falls Incident Reports Assist to Explain How and Why the Falls Occurred in a Hospital Setting?

    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

    authors: de Jong LD,Francis-Coad J,Waldron N,Ingram K,McPhail SM,Etherton-Beer C,Haines TP,Flicker L,Weselman T,Hill AM

    更新日期:2018-09-05 00:00:00

  • Postoperative hemodynamic instability after simultaneous bilateral total knee arthroplasty.

    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

    pub_type: 杂志文章

    doi:10.1097/pts.0b013e3181fe255d

    authors: Reidy CM,Beach ML,Gallagher JD,Sites BD

    更新日期:2010-12-01 00:00:00

  • Changes to Hospital Inpatient Volume After Newspaper Reporting of Medical Errors.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000349

    authors: Fukuda H

    更新日期:2017-06-30 00:00:00

  • Use of Designated Nurse PICC Teams and CLABSI Prevention Practices Among U.S. Hospitals: A Survey-Based Study.

    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

    authors: Krein SL,Kuhn L,Ratz D,Chopra V

    更新日期:2019-12-01 00:00:00

  • Hidden Barriers to Delivery of Pharmacological Venous Thromboembolism Prophylaxis: The Role of Nursing Beliefs and Practices.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000086

    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

  • A new leadership role for pharmacists: a prescription for change.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181d108cb

    authors: Burgess LH,Cohen MR,Denham CR

    更新日期:2010-03-01 00:00:00

  • Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

    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

    pub_type: 杂志文章,随机对照试验

    doi:10.1097/PTS.0b013e31829e4b95

    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

  • Shoulder dystocia documentation: an evaluation of a documentation training intervention.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182948a51

    authors: LeRiche T,Oppenheimer L,Caughey S,Fell D,Walker M

    更新日期:2015-03-01 00:00:00

  • A Systematic Review of Methods for Medical Record Analysis to Detect Adverse Events in Hospitalized Patients.

    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

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

    更新日期:2020-03-11 00:00:00

  • UDI2Claims: Planning a Pilot Project to Transmit Identifiers for Implanted Devices to the Insurance Claim.

    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

    authors: Zerhouni YA,Krupka DC,Graham J,Landman A,Li A,Bhatt DL,Nguyen LL,Capatch K,Concheri K,Reich AJ,Wilson N,Weissman JS

    更新日期:2018-11-21 00:00:00

  • Influence of Gender, Profession, and Managerial Function on Clinicians' Perceptions of Patient Safety Culture: A Cross-National Cross-Sectional Study.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000585

    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

  • Evaluation of a Computer Application for Retrospective Detection of Vitamin K Antagonist Treatment Imbalance.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000182

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

    更新日期:2018-06-01 00:00:00

  • The Patient Perspective on Errors in Cancer Care: Results of a Cross-Sectional Survey.

    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

    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

  • Give Intravenous Bolus Overdose a Brake: User Experience and Perception of Safety Device.

    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

    authors: Ng YYY,Wan PW,Chan KP,Sim GG

    更新日期:2020-09-08 00:00:00

  • Predictors of Patients' Intentions to Participate in Incident Reporting and Medication Safety.

    abstract:BACKGROUND:To date, there is a paucity of theory-driven research on the likely determinants of patient involvement in safety-relevant behaviors. In particular, very little work has focused on predictors of patient behaviors that do not involve direct interactions with health-care staff. OBJECTIVE:To examine predictors...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000068

    authors: Davis RE,Vincent C,Sevdalis N

    更新日期:2015-12-01 00:00:00

  • From the Patient Perspective, Consent Forms Fall Short of Providing Information to Guide Decision Making.

    abstract:OBJECTIVE:This study aimed to gather qualitative feedback on patient perceptions of informed consent forms and elicit recommendations to improve readability and utility for enhanced patient safety and engagement in shared decision making. METHODS:Sixty interviews in personal interviews were conducted consisting of a l...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000310

    authors: Manta CJ,Ortiz J,Moulton BW,Sonnad SS

    更新日期:2016-08-03 00:00:00

  • Frequency of Passive EHR Alerts in the ICU: Another Form of Alert Fatigue?

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000270

    authors: Kizzier-Carnahan V,Artis KA,Mohan V,Gold JA

    更新日期:2019-09-01 00:00:00

  • Frequency and Severity of Adverse Drug Events by Medication Classes: The JADE Study.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000235

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

    更新日期:2020-03-01 00:00:00

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

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000314

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

    更新日期:2017-11-04 00:00:00

  • Proactive Evaluation of an Operating Room Prototype: A Simulation-Based Modeling Approach.

    abstract:OBJECTIVES:There is a pressing need to improve safety and efficiency in the operating room (OR). Postsurgical adverse events, such as surgical site infections and surgical flow disruption, occur at a significant rate in industrial countries where a considerable portion of such complications result in death. The aim of ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000693

    authors: Taaffe K,Joseph A,Khoshkenar A,Machry H,Allison D,Reeves ST,RIPCHD.OR Study Group.

    更新日期:2020-03-13 00:00:00

  • Identification and description of randomized controlled trials and systematic reviews on patient safety published in medical journals.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e31827cda38

    authors: Barajas-Nava LA,Calvache JA,López-Alcalde J,Solà I,Cosp XB

    更新日期:2013-06-01 00:00:00

  • Development and Psychometric Evaluation of the Speaking Up About Patient Safety Questionnaire.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000415

    authors: Richard A,Pfeiffer Y,Schwappach DDL

    更新日期:2017-08-28 00:00:00

  • Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health Care Delivery Research: An Ongoing Assessment.

    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

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

    更新日期:2019-02-09 00:00:00

  • Involvement in Root Cause Analysis and Patient Safety Culture Among Hospital Care Providers.

    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

    authors: Boussat B,Seigneurin A,Giai J,Kamalanavin K,Labarère J,François P

    更新日期:2017-12-27 00:00:00

  • Prospective Assessment of Inpatient Boxed Warning Prescriber Adherence.

    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

    authors: Kloet MA,Lohr BR,Smithburger PL,Seybert AL,Kane-Gill SL

    更新日期:2017-03-01 00:00:00

  • Detach Yourself: The Positive Effect of Psychological Detachment on Patient Safety in Long-Term Care.

    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

    authors: Buljac-Samardžić M,Dekker-van Doorn C,Van Wijngaarden J

    更新日期:2018-02-26 00:00:00

  • Does Physician's Training Induce Overconfidence That Hampers Disclosing Errors?

    abstract:PURPOSE:Although transparency is critical for reducing medical errors, physicians feel discomfort with disclosure. We explored whether overconfidence relates to physician's reluctance to admit that an error may have occurred. METHOD:At 3 university medical centers, a survey presented a clinical vignette of a girl with...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000255

    authors: Brezis M,Orkin-Bedolach Y,Fink D,Kiderman A

    更新日期:2019-12-01 00:00:00

  • The Patient Safety Culture Scale for Chinese Primary Health Care Institutions: Development, Validity and Reliability.

    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

    authors: Cheng S,Hu Y,Pfaff H,Lu C,Fu Q,Wang L,Li D,Xia S

    更新日期:2020-05-13 00:00:00

  • 30-Day Potentially Avoidable Readmissions Due to Adverse Drug Events.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000346

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

    更新日期:2017-03-17 00:00:00

  • A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists.

    abstract:OBJECTIVE:Underreporting near-miss errors undermines hospitals' ability to improve patient safety. The objective of this analysis was to determine the extent to which punitive work climate, inadequate error feedback to staff, or insufficient preventative procedures are associated with decreased frequency of near-miss e...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000125

    authors: Patterson ME,Pace HA

    更新日期:2016-06-01 00:00:00