A Study on the Status and Contributory Factors of Adverse Events Due to Negligence in Nursing Care.

Abstract:

BACKGROUND:Patient safety issues in medical institutions have received worldwide attention. Nurses play a pivotal role in providing health care at the bedside and the interception of adverse events (AEs). A knowledge of contributory factors for these AEs is vital to individuals, institutional procedures, and also national policy. The goals of this study are to analyze medical litigation related to nursing practice and to determine the most common contributory factors of AEs due to negligence in nursing care. METHODS:A qualitative content analysis was conducted for AEs related to nursing care to determine the general characteristics and contributory factors. The contributory factors for each case were examined using a modified version of the Yorkshire Contributory Factors Framework. RESULTS:The most common types of AEs in nursing involved surgeries, procedures/interventions, and medications. The analysis also revealed that situational factors and communication and culture factors contributed most to AEs. Individual staff factors and staff training and education were the most frequent subfactors contributing to AEs. CONCLUSIONS:Adverse events were associated with various contributory factors that varied according to AE type. Thus, strategies need to be developed based on the understanding of these contributory factors related to the different AE types so that comprehensive approaches to improving patient safety and quality of nursing care can be implemented.

journal_name

J Patient Saf

authors

Kim MJ,Jang SG,Kim IS,Lee W

doi

10.1097/PTS.0000000000000791

subject

Has Abstract

pub_date

2020-10-01 00:00:00

eissn

1549-8417

issn

1549-8425

pub_type

杂志文章
  • 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

  • Improved Safety Culture and Teamwork Climate Are Associated With Decreases in Patient Harm and Hospital Mortality Across a Hospital System.

    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

    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

  • 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

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

    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

    authors: Matulis JC 3rd,North F

    更新日期:2020-09-01 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

  • Community pharmacists' attitudes, perceptions, and barriers toward adverse drug reaction reporting in Malaysia: a quantitative insight.

    abstract:OBJECTIVES:This study was designed to explore awareness and attitudes of community pharmacists toward the national ADR reporting system activities in the northern states of Malaysia. METHODS:A cross-sectional survey using a validated self-administered questionnaire was used in this study. The questionnaire was deliver...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000051

    authors: Elkalmi RM,Hassali MA,Ibrahim MI,Jamshed SQ,Al-Lela OQ

    更新日期:2014-06-01 00:00:00

  • Implementation of a Patient-Provider Agreement to Improve Healthcare Delivery for Patients With Substance Use Disorder in the Inpatient Setting.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000721

    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

  • 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

  • Cross-Cultural Adaptation and Psychometric Evaluation of a Second Victim Experience and Support Tool (SVEST).

    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

    authors: Brunelli MV,Estrada S,Celano C

    更新日期:2018-05-03 00:00:00

  • Establishing the Foundation to Support Health System Quality Improvement: Using a Hand Hygiene Initiative to Define the Process.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000578

    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

  • An Evaluation of Shared Mental Models and Mutual Trust on General Medical Units: Implications for Collaboration, Teamwork, and Patient Safety.

    abstract:OBJECTIVES:This study examines nurse-physician teamwork and collaboration, a critical component in the delivery of safe patient care, on general medical units. To that end, we assess shared mental models and mutual trust, 2 coordinating mechanisms that help facilitate teamwork, among nurses and physicians working on ge...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000151

    authors: McComb SA,Lemaster M,Henneman EA,Hinchey KT

    更新日期:2017-12-01 00:00:00

  • Missed Acute Coronary Syndrome During Telephone Triage at Out-of-Hours Primary Care: Lessons From A Case-Control Study.

    abstract:OBJECTIVES:Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hi...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000799

    authors: Erkelens DC,Rutten FH,Wouters LT,Kirkels HG,Poldervaart JM,de Groot E,Damoiseaux RA,Hoes AW,Zwart DL

    更新日期:2020-12-14 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

  • 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

  • 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

  • Next of Kin Involvement in Regulatory Investigations of Adverse Events That Caused Patient Death: A Process Evaluation (Part I - The Next of Kin's Perspective).

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000630

    authors: Wiig S,Haraldseid-Driftland C,Tvete Zachrisen R,Hannisdal E,Schibevaag L

    更新日期:2019-10-22 00:00:00

  • Evaluation of a Program for Improving Advanced Imaging Interpretation.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000345

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

    更新日期:2019-03-01 00:00:00

  • Reducing Surgery Scheduling Errors in Multihospital System.

    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

    authors: Watson DS,Corbett CF,Oneal G,Daratha KB

    更新日期:2017-02-24 00:00:00

  • Merits of using color and shape differentiation to improve the speed and accuracy of drug strength identification on over-the-counter medicines by laypeople.

    abstract:OBJECTIVE:This study aimed to examine the utility of using color and shape to differentiate drug strength information on over-the-counter medicine packages. Medication errors are an important threat to patient safety, and confusions between drug strengths are a significant source of medication error. METHOD:A visual s...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/pts.0b013e3181eee157

    authors: Hellier E,Tucker M,Kenny N,Rowntree A,Edworthy J

    更新日期:2010-09-01 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

  • 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 Tra...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000610

    authors: Keith DS,Brown J,Andreoni K

    更新日期:2019-12-01 00:00:00

  • "Disbelief and Sadness": First-Year Health Profession Students' Perspectives on Medical Errors.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000691

    authors: Davis BP,Clevenger C,Dillard R,Moulia D,Ander DS

    更新日期:2020-03-11 00:00:00

  • High-Alert Medication Stratification Tool-Revised: An Exploratory Study of an Objective, Standardized Medication Safety Tool.

    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

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

    更新日期:2017-12-12 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

  • 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

  • Prevalence of Implanted Medical Devices in Medicine Inpatients.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000187

    authors: Kuder M,Gelman A,Zenilman JM

    更新日期:2018-09-01 00:00:00

  • Outpatient adverse drug events identified by screening electronic health records.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181dcae06

    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

  • The role of advice in medication administration errors in the pediatric ambulatory setting.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181b3a9b0

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

    更新日期:2009-09-01 00:00:00

  • Improving Allergy Documentation: A Retrospective Electronic Health Record System-Wide Patient Safety Initiative.

    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

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000711

    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