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：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

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

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: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

authors： Oshel RE,Levitt P

更新日期：2020-12-01 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：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 natio...

journal_title：Journal of patient safety

authors： Kim MJ,Jang SG,Kim IS,Lee W

更新日期：2020-10-01 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: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:This study's objective was to explore the possible triggers of clinicians' disruptive behavior and to consider whether the type of trigger resulting in disruptive behavior differed by type of clinician, clinician characteristics, professional role, and ethnic background. METHODS:Using data collected from 15...

journal_title：Journal of patient safety

authors： Bae SH,Dang D,Karlowicz KA,Kim MT

更新日期：2020-09-01 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

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

authors： Matulis JC 3rd,North F

更新日期：2020-09-01 00:00:00

abstract：OBJECTIVES:In this literature review, we discuss 2 system-level, nurse-targeted patient safety practices (PSPs) that aim to reduce medication errors associated with infusion pumps, including smart pumps. One practice focuses on implementing structured process changes and redesigning workflows to improve efficiencies wi...

journal_title：Journal of patient safety

authors： Bacon O,Hoffman L

更新日期：2020-09-01 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

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：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

authors： Nemeth C,Laufersweiler D,Polander E,Orvis C,Harnish D,Morgan SE,O'Connor M,Hymes S,Nachman S,Heimbuch B

更新日期：2020-06-01 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

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

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

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

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：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：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

authors： Robbins T,Tipper S,King J,Ramachandran SK,Pandit JJ,Pandit M

更新日期：2020-03-24 00:00:00

abstract：OBJECTIVES:The relationship between medical malpractice risk and one of the fundamental characteristics of physician practice, clinical volume, remains undefined. This study examined how the annual and per-patient encounter medical malpractice claims risk varies with clinical volume. METHODS:Clinical volume was determ...

journal_title：Journal of patient safety

authors： Schaffer AC,Babayan A,Yu-Moe CW,Sato L,Einbinder JS

更新日期：2020-03-23 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

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

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

authors： Davis J,Casteel C,Peek-Asa C

更新日期：2020-03-11 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

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

更新日期：2020-03-11 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

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

更新日期：2020-03-11 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：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

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

更新日期：2019-12-01 00:00:00

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

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

更新日期：2019-12-01 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

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

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

authors： Keith DS,Brown J,Andreoni K

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

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: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：OBJECTIVES:We sought to synthesize data on systemic arthroprosthetic cobaltism, a recently described syndrome that results from wear or corrosion of chrome-cobalt hip components. METHODS:We conducted a systematic literature review to identify all reported cases of systemic arthroprosthetic cobaltism. To assess the epi...

journal_title：Journal of patient safety

authors： Gessner BD,Steck T,Woelber E,Tower SS

更新日期：2019-06-01 00:00:00

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

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

abstract：INTRODUCTION:Mortality and morbidity (M&M) meetings present a forum to discuss and review in-hospital deaths and complications to improve patient care. However, it remains an untapped resource to improve the exposure of the trainees to the principles of patient safety METHODS: We modified the departmental M&M meetings ...

journal_title：Journal of patient safety

authors： Singh HP,Durani P,Dias JJ

更新日期：2019-03-01 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: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：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: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：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

authors： Kavanagh KT,Kraman SS,Kavanagh SP

更新日期：2018-12-01 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

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