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, we evaluated user experience and perception of Syringe Brake, a dosage flow restrictor device, as part of the intravenous morphine bolus administration workflow. METHODS:From December 2018 to January 2019, doctors and nurses working in the emergency department of 3 public tertiary hospitals in Singapore were invited to complete a paper-based 11-item 5-point Likert scale survey questionnaire after 3 months of Syringe Brake implementation. RESULTS:Overall, 77.5% (290/374; 4.11 ± 0.83) of participants were satisfied with the use of Syringe Brake to prevent medication error. Our survey results showed that the top features of Syringe Brake were ease of setting the desired volume to be administered (86.1%; 4.21 ± 0.72), allowing the drug to be titrated safely (84.8%; 4.26 ± 0.77), and giving users the confidence to avoid overdosing the patient (82.1%; 4.21 ± 0.78). Those with hands-on experience with Syringe Brake rated significantly higher for all survey statements except on the perceived ability to prevent error arising from miscommunication (adjusted odds ratio, 1.58 [0.98-2.57]; P = 0.062). CONCLUSIONS:Syringe Brake shows promising potential for adoption to prevent medication errors. The device serves as a constraint to prevent accidental overdose, caused by user unfamiliarity or autopilot administration.
journal_name
J Patient Safjournal_title
Journal of patient safetyauthors
Ng YYY,Wan PW,Chan KP,Sim GGdoi
10.1097/PTS.0000000000000770subject
Has Abstractpub_date
2020-09-08 00:00:00eissn
1549-8417issn
1549-8425pub_type
杂志文章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 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
更新日期:2019-09-01 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: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: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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000514
更新日期:2020-09-01 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: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
更新日期:2015-03-01 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: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:Safety advocates have identified barcode verification technology as an important tool to improve health-care practices. METHODS:We evaluated the evidence for the role of barcode technology in improving a wide range of medication safety outcomes across a broad range of settings. Important implementation issue...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000049
更新日期:2015-06-01 00:00:00
abstract:OBJECTIVES:The aim of this study was to identify physical design elements that contribute to potential falls in patient rooms. METHODS:An exploratory, physical simulation-based approach was adopted for the study. Twenty-seven subjects, older than 70 years (11 male and 16 female subjects), conducted scripted tasks in a...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000339
更新日期:2017-02-03 00:00:00
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
更新日期:2017-08-28 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: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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000445
更新日期:2017-12-12 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: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::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
pub_type: 杂志文章
doi:10.1097/pts.0b013e3181b5cb8a
更新日期:2009-09-01 00:00:00
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
更新日期:2013-09-01 00:00:00
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
更新日期:2015-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000403
更新日期:2017-06-29 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e31822b07ee
更新日期:2011-09-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000138
更新日期:2017-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e318267c4aa
更新日期:2012-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000086
更新日期:2016-06-01 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:Significant resource is invested into investigation of adverse healthcare events. Outcomes of such investigations have varying degrees of effectiveness. The "hierarchy of effectiveness" model proposes system-focused changes have greater impact than person-focused actions. The traditional approach to invest...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000641
更新日期:2020-03-24 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: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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000781
更新日期:2020-09-08 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000534
更新日期:2018-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000251
更新日期:2020-06-01 00:00:00