Patient Safety Efforts Research Articles

The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics.

Despite the intense policy focus on reducing health-care-associated conditions, adverse events in health care settings persist. Therefore, evaluating patient safety efforts and related health policy initiatives remains critical. The aim of this study was to explore the relationship between hospital patient safety culture and hospital performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics. A pooled cross-sectional study design was used utilizing three secondary datasets from 2018 and 2021: the Hospital Survey on Patient Safety Culture, the American Hospital Association annual survey, and the Hospital Compare data from CMS. We used two multivariable linear regression models to examine the relationship between organizational patient safety culture and hospital performance. The dependent variables included the overall CMS total performance score (TPS) and the four individual TPS domain scores. Hospital patient safety culture, the independent variable, was operationalized using two measures from the Hospital Survey on Patient Safety Culture: (a) the domain score of overall perceptions of patient safety and (b) the patient safety grade. We observed positive and significant associations between hospital patient safety culture and a hospital's overall TPS and the "patient and community engagement" and "safety" domains. Findings suggest that building a strong patient safety culture has the potential to lead health care organizations to achieve high performance on HVBP metrics. Our findings have important policy implications for both the future of CMS HVBP as a motivator of patient safety and how health care managers integrate culture change into programs to meet external quality metrics.

What do patients and families observe aboutpediatric safety?: A thematic analysis of real-time narratives.

Data on inpatient safety are documented by hospital staff through incident reporting (IR) systems. Safety observations from families or patients are rarely captured. The Family Input for Quality and Safety (FIQS) study created a mobile health tool for pediatric patients and their families to anonymously report safety observations in real time during hospitalization. The study objectives were to describe these observations and identify domains salient to safety. In this observational study, we analyzed pediatric patient safety reports from June 2017 to April 2018. Participants were: English-speaking family membersand hospitalized patients ≥13 years old. The analysis had two stages: (1) assessment of whether narratives met established safety event criteria and whether there were companion IRs; (2) thematic analysis to identify domains. Of 248 enrolled participants, 58 submitted 120 narrative reports. Of the narratives, 68 (57%) met safety event criteria, while only 1 (0.8%) corresponded to a staff-reported IR. Twenty-five percent of narratives shared positive feedback about patient safety efforts; 75% shared constructive feedback. We identified domains particularly salient to safety:(1) patients and families as safety actors; (2) emotional safety; (3) system-centered care; and (4) shared safety domains, including medication, communication, and environment of care. Some domains capture data that is otherwise difficult to obtain (#1-3), while others fit within standard healthcare safety domains (#4). Patients and families observe and report salient safety events that can fill gaps in IR data. Healthcare leaders should consider incorporating patient and family observations-collected with an option for anonymity and eliciting both positive and constructive comments.

Determining the psychometric properties of a written test to assess safe dental practice

IntroductionSafe practice in medicine and dentistry has been a global priority area in which large knowledge gaps are present.Patient safety strategies aim at preventing unintended damage to patients that can...

Patient Safety Climate, Burnout, and Safety Outcome Measures among Nurses in Selected Private Hospitals in Davao City, Philippines

Background: Patient harm continues to be an essential concern in healthcare settings. Despite research, education, and collaborative efforts in patient safety, this issue remains a substantial problem and has yet to demonstrate a significant decrease in recent years. Purpose: Seeing as there is a dearth of available studies on this topic locally, the study intended to determine the relationship between patient safety climate (PSC), burnout, and safety outcome measures (SOM) among nurses employed at private tertiary level in Davao City, Philippines. Methods: The objective of this descriptive-correlational study was to establish a correlation between SOM, exhaustion, and PSC among nurses employed in private tertiary hospitals in Davao City. The snowball sampling method was utilized to select 197 respondents who met the following requirements: of legal age and currently employed as staff nurses in the study sites. The data were gathered using the Patient Safety Climate in Healthcare Organizations tool, Copenhagen Burnout Inventory, and Hospital Survey on Patient Safety Culture. Mean, standard deviation, Pearson r, and regression analysis were used in the statistical analysis. Results and Conclusions: The results showed that PSC (M=3.75, SD=0.89), burnout levels (M=3.44, SD=0.30), and SOM (M=3.81, SD=1.19) were high. PSC and SOM were significantly correlated (p=<.001; r=.280), whereas burnout and SOM (p=.843; r=.014) were not correlated. Patient safety climate (p=<.001; β=.280) was a predictor of safety outcome measures. Implications for Practice: Healthcare organizations are encouraged to cultivate a working environment where patient safety is recognized and prioritized. This will increase the frequency of event reporting, overall perceptions of safety, and patient safety grades.

Implementation of Interprofessional Collaboration (IPC) in Patient Safety Efforts at Ibnu Sina Hospital, Makassar City

Implementation of Interprofessional Collaboration (IPC) in Patient Safety Efforts at Ibnu Sina Hospital, Makassar City

Anticipating Patient Safety Events in Psychiatric Care.

Although suicide prevention often dominates patient safety efforts in psychiatry and behavioral health, patients who seek such services are also prone to other kinds of adverse events. The purpose of this study was to more fully characterize the types of safety events that occur in the context of psychiatric care. This was a retrospective study of safety events that had been reported to a hospital-based psychiatry department during a 4-year period. The authors reviewed each incident, developed new and more precise event categories, and assigned each report to a category. Events that could not be categorized were assigned to an "Other" category. The percentages of categorizable events between the new and old frameworks were compared. A total of 366 reports were filed. In the updated framework, 324 events (89%) could be categorized compared to 225 (61%) in the original registry. Understanding the kinds of safety events that clinicians are likely to encounter in the context of psychiatric care may help to expand patient safety efforts beyond suicide risk prevention.

Management and Marketing of Circulation of First-Line Antituberculosis Medicines: Use of Innovative Research Technologies

The management and marketing of first-line antituberculosis medicines are paramount for the effective containment and treatment of tuberculosis, a global health challenge. Ensuring the optimal circulation of these medicines requires a seamless integration of supply chain management, demand forecasting, and strategic marketing. The introduction of innovative research technologies has transformed the landscape, offering enhanced methods for drug distribution, patient adherence, and efficacy tracking. Digital platforms harness data analytics to predict medicine demand more accurately, ensuring timely production and distribution, minimizing wastage, and optimizing resource allocation. Furthermore, innovative technologies such as blockchain can fortify the drug supply chain against counterfeits, ensuring that only genuine products reach end-users. On the marketing front, artificial intelligence-driven tools enable targeted awareness campaigns, providing personalized patient information and improving adherence to drug regimens. As tuberculosis treatment necessitates prolonged medication courses, ensuring patient compliance is crucial. Advanced research technologies assist in real-time monitoring of patient's drug intake, identifying potential drop-offs, and intervening timely. The main principles of pharmacotherapy of tuberculosis were presented in the article. Pharmaceutical marketing of anti-tuberculosis drugs was experimentally researched. The most promising manufacturers in terms of availability, quality, and demand for doctors, pharmacists, and patients were highlighted. In summary, innovative research technologies are indispensable in the modern management and marketing strategies of first-line antituberculosis medicines, fostering improved treatment outcomes, patient safety, and global tuberculosis containment efforts.

A Literature Review: Implementation of SBAR Communication in The Implementation of Patient Safety in Hospital in Indonesia (Study in Indonesia

Background: In carrying out patient safety, the hospital has varied ways to maximize the implementation of patient safety, one of which is the use of effective communication as an effort to maximize the implementation of patient safety at the hospital. One of the effective communication methods is SBAR communication (Introduction, Situation, Background, Assessment, Recommendation) to achieve critical thinking skills and save time. SBAR communication used in effective communication is a system that is easy to remember amd a real mechanism used to convey a patient's condition that is critical or needs immediate attention and action. Purpose: The purpose of this study is to determine the application of effective SBAR communication in the implementation of patient safety in hospitals. Methods: The method used is to conduct literature reviews from various journals and articles related to the application of SBAR communication in hospitals and its implementation in patient safety in hospitals in Indonesia. The articles used are taken based on filtering through a database which is then filtered for titles, abstract to completeness and conformity with the research theme. Result: The results are implementation of the effective SBAR communication technique recommended by WHO has been used by most hospitals in Indonesia, although in practice there are still some things need to be fixed and managed but the implementation itself has proven to be effective and very influential on patient safety in the hospital. Conclusion: SBAR communication is an effective communication framework used in patient safety in hospitals. There are factors that influence the implementation of SBAR communication including experience, years of service of practitioner, equalization of perceptions and understanding of implementation related to SBAR techniques, socialization or debriefing related to the use of these techniques and the existence of SOPs in hospitals. In its implementation, SBAR communication is mostly considered effective and has a positive relationship with patient safety efforts.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports. The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated. Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54). Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

The Influence of Transformational Leadership on Patient Safety Efforts

Good leadership plays a role in implementing patient safety efforts within an established patient safety culture. This study aims to determine the influence of transformational leadership on patient safety efforts, with patient safety culture as the intervening variable. This quantitative research design is cross-sectional, with a sample size of 100 medical personnel, nurses, and medical support staff, selected using random cluster sampling. Data were collected using questionnaires, and the analysis was conducted using path analysis. The results showed that transformational leadership directly affects patient safety culture, with a t statistic measurement of 2.80 (>1.96). Transformational leadership also directly affects patient safety efforts, with a t statistic measurement of 2.26 (>1.96). Patient safety culture also directly affects patient safety efforts, with a t statistic measurement of 20.404 (>1.96). The indirect effect was measured through the indirect impact of transformational leadership on patient safety efforts through a patient safety culture, which had a t statistic measurement of 3.101. The study concludes that transformational leadership can improve patient safety efforts and culture.

A Literature Study of Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Twenty Years of Progress, an Integrated Research Framework, and Future Research Avenues.

Medical simulations have led to extensive developments in emergency medicine. Apart from the growing number of applications and research efforts in patient safety, few studies have focused on modalities, research methods, and professions via a synthesis of simulation studies with a focus on non-technical skills training. Intersections between medical simulation, non-technical skills training, and emergency medicine merit a synthesis of progress over the first two decades of the 21st century. Drawing on research from the Web of Science Core Collection's Science Citation Index Expanded and Social Science Citation Index editions, results showed that medical simulations were found to be effective, practical, and highly motivating. More importantly, simulation-based education should be a teaching approach, and many simulations are utilised to substitute high-risk, rare, and complex circumstances in technical or situational simulations. (1) Publications were grouped by specific categories of non-technical skills, teamwork, communication, diagnosis, resuscitation, airway management, anaesthesia, simulation, and medical education. (2) Although mixed-method and quantitative approaches were prominent during the time period, further exploration of qualitative data would greatly contribute to the interpretation of experience. (3) High-fidelity dummy was the most suitable instrument, but the tendency of simulators without explicitly stating the vendor selection calls for a standardised training process. The literature study concludes with a ring model as the integrated framework of presently known best practices and a broad range of underexplored research areas to be investigated in detail.

Measuring the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC)

BackgroundPatient safety is a top priority for many healthcare organisations worldwide. However, most of the initiatives aimed at the measurement and improvement of patient safety culture have been undertaken in...

Оценка культуры безопасности в медицинской организации и влияние мероприятий по культуре безопасности на отчетность об инцидентах

Study Objective: To assess the impact of safety culture measures on incident reporting and the level of safety culture in NJSC “National Scientific Cardiac Surgery Center” (hereinafter referred to as the Society). To conduct a comparative analysis of the number of reported incidents before and after the implementation of the safety culture policy. To analysis the safety culture questionnaire. Methods: Descriptive analysis was used to describe general information, work-related information of participants and statistical analysis of the results of the study was carried out in IBM SPSS 26.0 version. To analyse qualitative data, X2Pearson's test and Fisher's test were used. Differences were considered statistically significant at p≤0.05. The percentage of positive response for each item was calculated by “Hospital Survey on Patient Safety Culture (HSOPSC)” guideline. Then, the percentage of each positive composite score was calculated by using average percent of each item in the composite. The composite that was rated positively ⩾75% are identified as strengths, whereas those with score of 50% and below were regarded as weaknesses. A multiple linear regression was used to gain a better understanding of the association between overall patient safety score.Results: This study provides an overall assessment of perceptions of safety among the Society's staff. The results indicate an increased focus on patient safety and continuous improvement efforts. Safety culture is well perceived with an overall positive response rate of 79% and strengths include teamwork within the units and organisational learning/continuous improvement. However, the results also show that safety culture is not yet fully developed, with increased focus on non-punitive responses to errors and staffing.Conclusions: Measuring the responses to the survey questions has allowed us to achieve our main objective of measuring the attitudes of the Company's employees towards safety culture. The results establish a basis for future benchmarking and identify opportunities for improvement within the Society.Key words: Safety culture, incident reporting, patient safety, incidents, medical errors.

Global collaboration in teaching root cause analysis with healthcare professional students

PurposeThe purpose of this paper is to describe an example of how universities can develop unique synchronous educational opportunities to engage students in an online environment, especially since study abroad opportunities have slowed or halted due to the COVID-19 pandemic crisis.Design/methodology/approachTwo affiliated universities, in the United States and Scotland, selected a simulated root cause analysis (RCA) of a medical error for a collaborative activity.FindingsTogether the students analyzed the event within assumed roles of healthcare professions in a systematic way using the “Swiss Cheese Model,” identified opportunities for improvement, debriefed using the Promoting Excellence and Reflective Learning in Simulation (PEARLS) method and submitted a reflective assignment. The RCA resulted in several process improvement suggestions and positive feedback from the participants.Research limitations/implicationsThe approach was for graduate students from two affiliated universities, in the United States and Scotland, to simulate a RCA of a medical error as a collaborative activity.Practical implicationsThis example using simulation of healthcare roles demonstrates the application of international collaboration, problem-solving models and methodologies and recognition of the similarities and differences between the United Kingdom and the United States approaches to patient safety. Especially with the ongoing COVID-19 pandemic, the students' ability to internationally collaborate can be limited without such unique opportunities.Social implicationsThe students were provided with a side-by-side comparison of the patient safety efforts in each country and written and didactic material about an RCA and the Swiss cheese model.Originality/valueStudents come from different perspectives of health services administration, nursing and nursing leadership from Scotland and the United States to solve patient safety problems.

IMPROVING THE QUALITY OF HEALTH SERVICES WITH THE IMPLEMENTATION OF PATIENT SAFETY EFFORT IN RENGEL PUSKESMAS

Background: Patient safety is one indicator of the quality of health services. Although patient safety incident data in first-level health care facilities are not yet accurate in Indonesia, patient safety is an important issue in improving service quality. Rengel Tuban Health Center is one of the health care facilities that implement patient safety efforts as a form of efforts to improve the quality of health services as referred to in the Law of the Republic of Indonesia Number 36 of 2009.
 Objective: The purpose of this study is to identify the application of patient safety efforts at the Rengel Tuban Health Center to improve service quality.
 Methods: The data collection techniques used were observation, interviews, and literature study. Data collection was carried out at the Rengel Tuban Health Center in January-February 2021.
 Results: The results of data analysis showed that the implementation of patient safety efforts at the Rengel Tuban Public Health Center was adjusted to the standards of the Puskesmas accreditation assessment. However, in its realization there are still obstacles and shortcomings in meeting patient safety standards at the Rengel Tuban Health Center so it is necessary to optimize the application of patient safety efforts from all parties involved.
 Conclusion: It can be concluded that puskesmas must provide safe and quality services to create a healthy subdistrict. Health centers need to improve patient safety in accordance with the Minister of Health of the Republic of Indonesia Number 36 of 2009

Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity

The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage...

Is It Time for the Mental Health Field to Consider Unplanned Discharge a Key Metric of Patient Safety?

Mental health lacks robust measures to assess patient safety. Unplanned discharge is common in mental health populations and associated with poor outcomes. Clarifying whether unplanned discharge varies across settings may highlight the need to develop measures to reduce harms associated with this event. Unplanned discharge rates were compared across the Department of Veterans Affairs' acute inpatient and residential mental health treatment settings from 2009 to 2019. Logistic regression was used to create facility-level, adjusted unplanned discharge rates stratified by setting. Results were described using central tendency. Among 847,661 acute inpatient discharges, the mean unplanned discharge rate was 3.3% (range, 0%-18%). Among 358,117 residential discharges, the mean unplanned discharge rate was 17.9% (range, 1%-48.3%). Unplanned discharge is a marked problem in mental health, with large variation across treatment settings. Unplanned discharge should be measured as part of patient safety efforts.

Patient Safety Efforts in Tanzania: A Rapid Review of Two-Decades Efforts (2002-2022) to Inform Interventions towards Attainment of 2030 Targets

Introduction: The need to address the problem of patient safety has been a focus of World Health Assembly (WHA) meetings of 2002, 2019 and 2021. The 2019 WHA Resolution urged the Member States to take action on patient safety. We aimed to review patient safety efforts in Tanzania from 2002 to 2022 to inform improvement efforts towards the 2030 target. Methods: A rapid literature review was conducted between January 2002 and April 2022. We searched Google, PubMed and PubMed Central in April and May 2022 using the following search terms: PubMed—“patient safety Tanzania”, “blood safety in Tanzania”, “safe surgery Tanzania”, and “healthcare-associated infections Tanzania”; Google—“blood safety in Tanzania”, injection safety in Tanzania”, “infection prevention and control”, “radiation safety in health facilities in Tanzania”; and PubMed Central—“injection safety in Tanzania. Results: The search identified 4160 articles, of which 4053 were removed in initial screening; 21 were duplicates, giving 86 relevant articles for full screening. Of the 86 articles, 04 were removed after the full screening, hence remaining with 82 articles. Among the 82 eligible articles, 27 are on IPC, 26 on safe surgery, 12 on blood safety, 07 on radiation safety, 06 on injection safety, and 02 on medication safety. One article was relevant to—blood safety, IPC and injection safety; and one article was relevant to—IPC and injection safety. Conclusion: Most of the eligible literature was on IPC and safe surgery, followed by blood safety, radiation safety, injection safety and medication safety. The literature on IPC has highlighted the need to strengthen efforts to address AMR. Findings from the implementation of the safe surgery 2020 intervention warrants for its scale-up to other zones. There is a need to strengthen hemovigilance and pharmacovigilance functions; and strengthen quality management and assurance systems and regulatory functions to ensure radiation safety.

Promoting Clinician Well-Being and Patient Safety Using Human Factors Science: Reducing Unnecessary Occupational Stress

Our healthcare delivery system has accumulated complexity of payment, regulation systems, expectations and requirements. Often these are not designed to align with clinical thinking process flow of patient care. As a result, clinicians are utilizing enormous mental (cognitive) resource to comply with these complexities, over and above the baseline mental effort required to give good care to the patient. Recent studies suggest a significant number of physicians, advanced practice providers and nurses no longer want to stay in healthcare due to difficult work expectations and conditions that have become unreasonable. Technology has benefitted healthcare delivery, but also is a conduit of many expectations that have been grafted upon clinician workloads, exceeding the resources provided to accomplish them. Cognitive load is a measure of mental effort and is divided into Intrinsic, Germane and Extraneous Cognitive Load. Extraneous Cognitive Load (ECL) is what is not necessary and can be removed by better design. High cognitive load is associated with increased risk of both medical error and clinician burnout. Chronic high level occupational stress occurs from dealing with this job/resource imbalance and is showing serious personal health impact upon clinicians and the quality of the work they can provide for patients. Since organizational systems have become more complex, leadership methods, clinician wellbeing and patient safety efforts need to adjust to adapt and succeed. Safety efforts have tended to predominantly follow methods of a few decades ago with predominant focus upon how things go wrong (Safety I) but are now being encouraged to include more of the study of how things go right (Safety II). Human Factors/Ergonomics (HFE) science has been used in many industries to preserve worker wellbeing and improve system performance. Patient safety is a product of good system performance. HFE science helps inform mechanisms behind Safety I and II approach. HFE concepts augment existing burnout and safety interventions by providing a conceptual roadmap to follow that can inform how to improve the multiple human/technology, human/system, and human/work environment interfaces that comprise healthcare delivery. Healthcare leaders, by their influence over culture, resource allocation, and implementation of requirements and workflows are uniquely poised to be effective mitigators of the conditions leading to clinician burnout and latent medical error. Basic knowledge of HFE science is a strategic advantage to leaders and individuals tasked with achieving quality of care, controlling costs, and improving the experiences of receiving and providing care.

Detecting and diagnosing severe maternal morbidity

The identification of severe maternal morbidity (SMM) is central to patient safety efforts. In 2016 the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) published a recommendation that hospitals review all cases of SMM through the lens of quality improvement (QI). We compare contemporary strategies to identify and diagnose SMM.