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 Safjournal_title
Journal of patient safetyauthors
Kim MJ,Jang SG,Kim IS,Lee Wdoi
10.1097/PTS.0000000000000791subject
Has Abstractpub_date
2020-10-01 00:00:00eissn
1549-8417issn
1549-8425pub_type
杂志文章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: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
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
更新日期:2020-03-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000314
更新日期:2017-11-04 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: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
更新日期:2016-06-01 00:00:00
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
更新日期:2014-06-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000721
更新日期:2020-05-07 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000349
更新日期:2017-06-30 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: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
更新日期:2021-01-01 00:00:00
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
更新日期:2017-12-01 00:00:00
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
更新日期:2020-12-14 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: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
更新日期:2018-09-05 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000368
更新日期:2019-12-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000630
更新日期:2019-10-22 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000345
更新日期:2019-03-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000370
更新日期:2017-02-24 00:00:00
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
更新日期:2010-09-01 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: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
更新日期:2019-12-01 00:00:00
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
更新日期:2020-03-11 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: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
更新日期:2010-12-01 00:00:00
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
更新日期:2020-03-13 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000187
更新日期:2018-09-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181dcae06
更新日期:2010-06-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181b3a9b0
更新日期:2009-09-01 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
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000711
更新日期:2020-06-01 00:00:00