Patient Safety Research Papers - Academia.edu (original) (raw)

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- Infectious disease epidemiology, Immunology, History of Medicine, Patient Safety
- by Lilly Engineer
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- Algorithms, Radiation Oncology, Patient Safety, Quality Improvement
- by Hannele Turunen and +1
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- Nursing, Patient Safety, Focus Groups, Qualitative Research
- by Eric Poon
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- Communication, Primary Health Care, Patient Safety, Quality of Mental Health Care

The Multi-professional Patient Safety Curriculum Guide was launched by the World Health Organization to develop a patient safety-friendly curriculum in health education. The aim of this
study was to evaluate the impact of teaching related to two topics from the Patient Safety Curriculum Guide on student nurses' knowledge and attitudes toward patient safety. A pretest, posttest, nonexperimental design was used. Patient safety education questionnaires were distributed to a convenience sample of 181 nursing students before the intervention, and 141 questionnaires after the intervention in one university in the East of England. The intervention
consisted of two face-to-face lectures and one facilitated group work discussion. Seventy-one responses from pre- and posttest stages were matched. Paired t test, McNemar's test, and
frequency measures were used for data analysis. The findings suggest that there are statistically significant differences in the subscales of the error and patient safety and personal influence over safety. The differences in the students' answers on patient safety knowledge before and after the interventions were not statistically significant. Although the student nurses highly commended the teaching delivered in this study, the use of experimental design in future curriculum evaluation may provide a more complementary insight to the findings of this study

- by Mansour Mansour
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- Patient Safety

To review the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care. A systematic review of the literature. A search was carried out on the databases MEDLINE, PSYCHINFO, EMBASE, HMIC. The search strategy covered three facets: management, quality of care and the hospital setting comprising medical subject headings and key terms. Reviewers screened 15,447 titles/abstracts and 423 full texts were checked against inclusion criteria. Data extraction and quality assessment were performed on 19 included articles. The majority of studies were set in the USA and investigated Board/senior level management. The most common research designs were interviews and surveys on the perceptions of managerial quality and safety practices. Managerial activities comprised strategy, culture and data-centred activities, such as driving improvement culture and promotion of quality, strategy/goal setting and providing feedback. Significant positive ...

- by Antonio Sousa-Uva
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- Patient Safety, Quality and patient safety
- by Alan Meyers
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- Bariatric Surgery, Patient Safety, Evidence Based Medicine, Obesity
- by Søren Berg
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- Patient Safety, Accreditation, Medicine, Humans

The American Association of Physicists in Medicine (AAPM) is a nonprofit profes-sional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the qual-ity of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been sub-jected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effecti...

- by Suzanne Evans
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- Radiation Oncology, Documentation, Patient Safety, United States

In this article we discuss the medical diagnoses underlying the most common lawsuits involving pediatricians in the United States. Where applicable, specific and general risk-management techniques are noted as a means of increasing... more

- by Jorge Gonzalez
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- Pediatrics, Patient Safety, Risk Management, Medicine
- by Florian Fischer
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- Gender Studies, Patient Safety, Public Health, Medicine
- by Daniel Carpio
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- Patient Safety, Spain, Humans, Ulcerative colitis

Delivery care is regarded as safe when it is attended by a skilled birth attendant either at health facility or home. Childbirth practices differ from place to place and are determined by availability and accessibility of health services. After National Health Policy (1991), Nepal has focused on safe motherhood policies and programmes. Maternal mortality ratio decreased nearly fourfold between the years 1990 to 2011. The country is likely to achieve the Millennium Development Goal (MDG) 5. However, indicators of the MDG 5: skilled care at birth and institutional delivery rates are very far from the targets. From the initial findings of limited studies, safe delivery incentive programme has been successful for increasing the skilled care at birth and institutional delivery and reducing the maternal mortality twofold between the years 1990 to 2011. In spite of numerous efforts there is a wide difference in the utilization of skilled care at birth among the women by area of residence, ...

- by Dr. Ganesh Dangal
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- Patient Safety, Midwifery, Nepal, Maternal Mortality

Conclusion: Adult Japanese AD patients who experience severe exacerbation of symptoms immediately after discontinuation of TCS use generally improve over time. We suggest caution regarding long-term TCS treatment in AD patients. Read... more

- by Dove Medical Press and +1
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- Patient Safety, Healthcare

♦ Background: Peritoneal dialysis (PD) has limited power for liquid extraction (ultrafiltration), so fluid overload remains a major cause of treatment failure. ♦ Methods: We present steady concentration peritonal dialysis (SCPD), which increases ultrafiltration of PD exchanges by maintaining a constant peritoneal glucose concentration. This is achieved by infusing 50% glucose solution at a constant rate (typically 40 mL/h) during the 4-hour dwell of a 2-L 1.36% glucose exchange. We treated 21 fluid overload episodes on 6 PD patients with high or average-high peritoneal transport characteristics who refused hemodialysis as an alternative. Each treatment consisted of a single session with 1 to 4 SCPD exchanges (as needed). ♦ Results: Ultrafiltration averaged 653 ± 363 mL/4 h — twice the ultrafiltration of the peritoneal equilibration test (PET) (300 ± 251 mL/4 h, p < 0.001) and 6-fold the daily ultrafiltration (100 ± 123 mL/4 h, p < 0.001). Serum and peritoneal glucose stability...

- by Vicente Pérez Díaz and +3
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- Patient Safety, Quality Improvement, Treatment Outcome, Risk assessment

With the profession of radiology experiencing workforce shortages among radiologists and radiological technologists many radiological groups were beginning to hire ancillary personnel to fill efficiency gaps in practices. Many academic... more

- by Brad Short
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- Patient Safety, Medicine, Social Responsibility, Humans
- by Bedirhan Ustun
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- Patient Safety, Quality of Mental Health Care, Quality Improvement, Medicine
- by Filiz Akbıyık
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- Patient Safety, Quality Improvement, Turkey, Medicine
- by Lisa Low
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- Nursing, Patient Safety, Health Education, Midwifery

On 28 March 2018 the Australian Senate Community Affairs References Committee issued its final report on transvaginal mesh devices. It found these devices have caused unnecessary physical and emotional pain and suffering to thousands of women who were not told by their doctors of the objective material risks associated with their use. The Senate Committee concurred with the Public Health Association of Australia's (PHAA) description of the complications resulting from transvaginal mesh implants as constituting a serious public health issue requiring a response at both an individual and at a population level, including counselling, public education, clinical interventions and long-lasting protective mechanisms. The committee’s inquiry highlighted significant shortcomings in Australia's reporting systems for medical devices, with flow-on consequences for the health system's ability to respond to in a timely and effective way to related concerns. Amongst other recommendations, the Senate Committee backed the establishment on a cost recovery basis of a national registry of high risk implantable devices linked to a system of mandatory reporting of adverse events.

- by Per Nilsen
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- Patient Safety, Sweden, Library and Information Studies, Humans
- by Laurie Lyckholm
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- Psychology, Algorithms, Nursing, Patient Safety
- by Elfi Baillien and +1
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- Psychometrics, Organizational Culture, Patient Safety, Language

The aim of this paper is to describe the development of a conceptual model based on literature and understandings of design, communication, stress and model of care. The model explores potential relationships among a set of key variables... more

- by Jennifer Fenwick
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- Nursing, Communication, Patient Safety, Built Environment

Objectives: The goal of this study was to compare cost-effectiveness of sacubitril/valsartan with angiotensin-converting enzyme (ACE) inhibitors for treating chronic heart failure patients with reduced ejection fraction (HFrEF) from the published articles and explore the methodology applied in the studies.
Methods: Systematic research was conducted in February 2021 using PubMed, Cochrane, and EBSCO. A combination of MeSH terms of ‘cost-effectiveness analysis’, ‘heart failure with reduced ejection fraction’, ‘sacubitril valsartan’ and ‘angiotensin converting enzyme inhibitor’ was employed. The review selected for articles published in the last five years in English.
Results: A total of 15 studies were included in this review. We found that the studies had been conducted in 12 different countries. The United States had the greatest number of publications (5), followed by the Netherlands (2). The study method most used was the Markov decision model (73%). Almost all studies produced ICERs and QALYs that were numerically high.
Conclusions: The use of sacubitril/valsartan associates with longer life expectancy and incremental cost-effectiveness ratio than angiotensin-converting enzyme inhibitors.

- by Stefanus Erdana Putra and +1
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- Cardiology, Patient Safety, Public Health, Cardiovascular disease

As part of the Closing the Quality Gap: Revisiting the State of the Science series of the Agency for Healthcare Research and Quality (AHRQ), this systematic review sought to identify completed and ongoing evaluations of the comprehensive patient-centered medical home (PCMH), summarize current evidence for this model, and identify evidence gaps. We searched PubMed®, CINAHL®, and the Cochrane Database of Systematic Reviews for published English-language studies, and a wide variety of databases and Web resources to identify ongoing or recently completed studies. Two investigators per study screened abstracts and full-text articles for inclusion, abstracted data, and performed quality ratings and evidence grading. Our functional definition of PCMH was based on the definition used by AHRQ. We included studies that explicitly claimed to be evaluating PCMH and those that did not but which met our functional definition. Seventeen studies with comparison groups evaluated the effects of PCMH ...

- by Sheryl A Larson
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- Patient Safety, Palliative Care, Health Literacy, Medication Adherence

Transitions of care pose significant risks for patients with complex medical histories. There are few experiential medical education curricula targeting this important aspect of care. We designed and tested an internal medicine transitions of care experience integrated into interns' ambulatory curriculum. The program included 1-hour group didactics, a posthospitalization discharge visit in pairs with a home care nurse (cohort 1: 2011-2012; cohort 2: 2012-2013), and a half-day small-group visit to a skilled nursing facility led by a faculty member in geriatrics (cohort 2 only). Both visits had structured debriefings by faculty in geriatrics. For cohort 1, a quantitative follow-up survey was administered 18 to 20 months after the experience. For cohort 2, reflections were analyzed. Thirty-three of 42 second-year residents (79%) in cohort 1 who participated in didactics and a home visit completed the survey. Seventy-six percent (25 of 33) reported increased knowledge of interprofes...

- by Christina Whitehouse
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- Geriatrics, Patient Safety, Problem Based Learning, Medicine
- by Martin Stocker
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- Patient Safety, Curriculum, Humans, Resuscitation
- by Samson Tu
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- Primary Care, Mental Health, Patient Safety, Chronic Pain
- by Liam Donaldson
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- Patient Safety, Global Health, Control, Hospital Infection
- by Emilie Roth
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- Engineering, Patient Safety, Human Performance, Task analysis
- by Mary Coffey
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- Radiation Oncology, Patient Safety, Risk, Brachytherapy
- by Richard Holden
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- Information Systems, Cognitive Science, Patient Safety, Human Factors
- by Allison Williams
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- Patient Safety, Risk Management, Therapeutic drug monitoring, Humans
- by William Kearns
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- Mental Health nursing, Patient Safety, Traumatic Brain Injury, Medicine

The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (1...

- by Luc Baerdemaeker
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- Patient Safety, Evidence Based Medicine, Treatment Outcome, Humans

Benzodiazepines use in the elderly are associated with morbidity including increased falls, fractures, and mortality. The common reason for re-prescribing benzodiazepine by physicians is dependency. Our project proposal aims to enhance medication safety in the elderly. It requires a multidisciplinary approach and patient-centred care focusing on benzodiazepine deprescribing using the 3Es model of Educating, Empowering, and Engaging. The education starts with patients, providers, and the community about benzodiazepine adverse effects on the elderly and provides alternative approaches for symptoms management. Empowering patients in the decision to deprescribe will prove to be successful when the patient finds value. Engaging stakeholders in the process will facilitate adeptness and attainability in the target community. Using information technology to deliver the protocol will ensure reminders, track changes and suggest alternatives. The project goal is a 50% reduction in benzodiazepine prescription by six months. Limitations, challenges, and modifications anticipated are discussed.

- by Anhar Alhussaini
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- Patient Safety, Patient-Centered Care, Elderly, Medication Safety

Resumo: Um monitoramento eficaz da segurança do paciente precisa focar a implantação de práticas baseadas em evidências que evitem danos desnecessários ligados à assistência à saúde. O objetivo do Projeto ISEP-Brasil foi desenvolver e validar indicadores de boas práticas de segurança do paciente para o contexto brasileiro. Tomou por base a tradução e adaptação dos indicadores validados no Projeto ISEP-Espanha, além do documento Safe Practices for Better Healthcare do National Quality Forum dos Estados Unidos, que possui 34 recomendações de boas práticas. Realizou-se validação por um painel de 25 especialistas e análise da confiabilidade e viabilidade em um estudo-piloto realizado em três hospitais com diferentes tipos de gestão (estadual, federal e privada). Aprovaram-se 75 indicadores de boas práticas (39 de estrutura; 36 de processo) para 31 das 34 recomendações. Os indicadores foram considerados válidos, confiáveis e úteis para o monitoramento da segurança do paciente em hospitai...

- by eduardo faria
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- Patient Safety, Brazil, Translations, Cross-Cultural Comparison

Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today. The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the soci...

- by Charles Vincent
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- Documentation, Patient Safety, Implementation Science, Family
- by Gene Hobbs
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- Anesthesiology, Patient Safety, Humans, Nursing Education

Background Effective teamwork contributes to patient safety in the operating room (OR). For the busy rural surgeon, enhancing OR teamwork can be difficult. This manuscript describes results from the initial implementation of a preoperative briefing protocol at a rural community hospital. Methods From July 2006 to February 2007, teamwork among OR staff working with a single general surgeon at a rural hospital in Alaska was evaluated before and after introduction of a preoperative briefing protocol. After each case, participants completed a questionnaire applying a 6-point Likert-type scale targeting effectiveness of both the preoperative briefing and OR team interaction. Mean values were calculated from 20 cases before introduction of the preoperative briefing and from another 16 cases after its introduction. Statistical analysis of the difference between pre- and post-protocol team performance was conducted with Student’s t test. Mean procedure times were calculated for matched cases pre- and post-intervention and were compared with Wilcoxon’s exact test. Results Ten members of the OR staff, including the general surgeon, completed both pre- and post-protocol questionnaires. Four additional members of the OR staff completed only pre-protocol questionnaires, and three additional members of the OR staff completed only post-protocol questionnaires. After implementation of the preoperative briefing protocol, the mean score of overall preoperative briefing was 1.01 units higher than before (p p p = 0.057). Conclusions Implementation of a preoperative briefing protocol improved overall preoperative briefing and OR team interaction in the study setting. These findings are encouraging for enhancing teamwork and patient safety through implementation of a systematic protocol.

- by Sheila Chauvin
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- Surgery, Research Design, Patient Safety, Health Care
- by Mats Thorslund
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- Pharmacoepidemiology, Patient Safety, Risk assessment, Comorbidity

INTRODUCTION: When patients are transferred from intensive care units (ICUs) to general wards with a tracheostomy in situ, there is a risk of suboptimal care and increased morbidity. The aim of this study was to elucidate the management of patients with a tracheostomy in situ at discharge from the ICU to the ward.MATERIAL AND METHODS: We performed an electronic questionnaire survey among heads of unit at registered Danish ICUs.RESULTS: A total of 34 out of 43 ICUs responded. 56% of the ICUs do not document individual plans for decannulation in the patient's chart. 91% of the ICUs do not perform daily follow-up of tracheotomised patients on the ward. No guidelines for decannulation on the ward were found, and only 6% have a guideline for accidental decannulation. Furthermore, as little as 47% of the ICUs report any formalized education or training of staff nurses in the management of tracheotomised patients.CONCLUSION: Guidelines relevant to patients discharged from Danish ICUs with a tracheal cannula in situ are scarce; few ICUs employ individualized plans for tracheostomy management and decannulation; there is largely no daily intensivist-led post-ICU follow-up, and formal staff education in tracheostomy management on the ward is scarce. Altogether these factors create a potential for adverse events and increased morbidity in this high-risk, high-cost patient population. Possibly individualized plans for tracheotomised patients as well as intensivist-led follow-up on the ward can improve patient outcome and safety and this should be confirmed in a future study.FUNDING: not relevant.TRIAL REGISTRATION: not relevant.

- by Karen Skjelsager and +1
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- Patient Safety, Denmark, Humans, Hospitalization
- by Crystal Burkhardt
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- Medical Informatics, Patient Safety, Quality Improvement, Clinical Pharmacology
- by Nicola Ferrier
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- Patient Safety, Closed Loop Control, Position Control, On Robotics
- by Wim Verstappen
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- Patient Safety, Family Practice, Stroke, Humans

Abstract
Background
Handovers between hospital and primary healthcare possess a risk for patient care. It has been suggested that the
exchange of a comprehensive medical record containing both medical and patient-centered aspects of information can
support high quality handovers.
Objective
The objective of this study was to explore patient handovers between primary and secondary care by assessing the
levels of patient-centeredness of medical records used for communication between care settings and by assessing
continuity of patient care.
Methods
Quantitative content analysis was used to analyze the 76 medical records of 22 Swedish patients with chronic diseases
and/or polypharmacy.
Results
The levels of patient-centeredness documented in handover records were assessed as poor, especially in regards to
informing patients and achieving a shared understanding/agreement about their treatment plans. The follow up of
patients’ medical and care needs were remotely related to the discharge information sent from the hospital to the
primary care providers, or to the hospital provider's request for patient follow-up in primary healthcare.
Conclusion
The lack of patient-centered documentation either indicates poor patient-centeredness in the encounters or low priority
given by the providers on documenting such information. Based on this small study, discharge information sent to
primary healthcare cannot be considered as a means of securing continuity of patient care. Healthcare providers need
to be aware that neither their discharge notes nor their referrals will guarantee continuity of patient care.

- by Dr Paul Barach
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- Information Systems, Patient Safety, Learning and Teaching, In-depth Interviews
- by Dr Paul Barach
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- Assessment, Patient Safety, Evidence Based Medicine, Evidence Based Design