Patient Safety Risks Research Articles

The Covid-19 app that lasted two weeks: how technology may embody controversial public policies for health care and why we should worry about it

Abstract This paper describes the case of a Brazilian government app (TrateCov) that was deployed for only 2 weeks during the emergence of the SARS-CoV-2 Gamma variant. TrateCov was intended as a decision support tool to assist health care professionals with the diagnosis and treatment of COVID-19. After the tool was inadvertently released on a public Web site, it became accessible to anyone with an Internet connection, raising the risk of inappropriate self-management. Moreover, experts and journalists quickly spotted that almost all symptoms entered into the app resulted in a diagnosis of COVID-19, along with a recommendation to use the same ‘Covid kit’ of unproven drugs favored by leading politicians, and in the same doses for adults, children, and pregnant women. The institutional and social backlash was immediate, forcing the Brazilian Ministry of Health to take TrateCov offline. The case illustrates the potential for weak evidence and ideological bias to infiltrate digital health technologies, creating risks for patient safety and diversion of resources, thus emphasizing the importance of good governance at all stages of the innovation lifecycle. The speed of public health crises presents particular challenges for managing this phenomenon, calling for anticipatory steps to avoid such risk as part of responsible pandemic prevention strategies

Rise in pharmacists reporting patient safety risks from medicines shortages, shows survey

Rise in pharmacists reporting patient safety risks from medicines shortages, shows survey

Clinical skills for newly graduated nurses: Theory-Practice gap

Nursing education consists of classroom and clinical training to demonstrate clinical competence based on theoretical concepts learned. However, there is a lack of clinical abilities demonstrated and theoretical knowledge gained from pre-qualified nursing education and the preparation of new graduates. Furthermore, graduates often believe that the lessons learned do not reflect the actualities faced in clinical fields. This discrepancy is known as the theory-practice gap among graduate nurses who are theoretically but not practically equipped to apply theory and knowledge to practice in the clinical environment. Graduate nurses working in high-risk fields can struggle to integrate theoretical concepts into the clinical environment, leading to patient safety risks and potential adverse outcomes. Furthermore, the new graduates experience a deficit that contributed to decreased job satisfaction, increased job turnover rates, and patient care mistakes. This paper aims to address the gap between nursing education and practice in the nursing profession. Keywords : Letter to the editor

Multifactor Quality and Safety Analysis of Antimicrobial Drugs Sold by Online Pharmacies That Do Not Require a Prescription: Multiphase Observational, Content Analysis, and Product Evaluation Study.

Antimicrobial resistance is a significant global public health threat. However, the impact of sourcing potentially substandard and falsified antibiotics via the internet remains understudied, particularly in the context of access to and quality of common antibiotics. In response, this study conducted a multifactor quality and safety analysis of antibiotics sold and purchased via online pharmacies that did not require a prescription. The aim of this paper is to identify and characterize "no prescription" online pharmacies selling 5 common antibiotics and to assess the quality characteristics of samples through controlled test buys. We first used structured search queries associated with the international nonproprietary names of amoxicillin, azithromycin, amoxicillin and clavulanic acid, cephalexin, and ciprofloxacin to detect and characterize online pharmacies offering the sale of antibiotics without a prescription. Next, we conducted controlled test buys of antibiotics and conducted a visual inspection of packaging and contents for risk evaluation. Antibiotics were then analyzed using untargeted mass spectrometry (MS). MS data were used to determine if the claimed active pharmaceutical ingredient was present, and molecular networking was used to analyze MS data to detect drug analogs as well as possible adulterants and contaminants. A total of 109 unique websites were identified that actively advertised direct-to-consumer sale of antibiotics without a prescription. From these websites, we successfully placed 27 orders, received 11 packages, and collected 1373 antibiotic product samples. Visual inspection resulted in all product packaging consisting of pill packs or blister packs and some concerning indicators of potential poor quality, falsification, and improper dispensing. Though all samples had the presence of stated active pharmaceutical ingredient, molecular networking revealed a number of drug analogs of unknown identity, as well as known impurities and contaminants. Our study used a multifactor approach, including web surveillance, test purchasing, and analytical chemistry, to assess risk factors associated with purchasing antibiotics online. Results provide evidence of possible safety risks, including substandard packaging and shipment, falsification of product information and markings, detection of undeclared chemicals, high variability of quality across samples, and payment for orders being defrauded. Beyond immediate patient safety risks, these falsified and substandard products could exacerbate the ongoing public health threat of antimicrobial resistance by circulating substandard product to patients.

2033. Use of Sterile, Single-Use Bronchoscopes Reduces Procedure-Associated Readmissions Rates and Eliminates Potential Device Cross-Contamination

Abstract Background Improper reprocessing of reusable bronchoscopes poses a serious patient safety risk. The risk of patient infection resulting from use of contaminated bronchoscopes has been reported to be 2.8%. By virtue of being sterile, SFB eliminates device-related infection risk, subsequent readmission rates, and associated costs. Readmissions following bronchoscopy may occur for many reasons, but most frequently are due to infection, bleeding, or pain. These infections are preventable and can be eliminated with the use of a sterile, single-use bronchoscope when the device is used according to the manufacturer’s instructions for use. Methods Bronchoscopies with SFB and RFB were identified along with their corresponding readmission information in the Premier Healthcare Database from 2016- 2019. A logistic regression analysis was conducted with 30-day readmission as the dependent variable. Independent variables included use of a RFB, gender, race, age, payer, and discharge status. For the inpatient setting, the 3M™ APR DRG Severity of Illness classification was included as an independent variable. 30 Day Readmissions Results A total of 14,228 procedures were identified, of which 1,795 used SFB and 12,433 used a RFB. In the inpatient setting, the RFB group was ∼2.5 times more likely to be readmitted within 30 days compared to the SFB group (OR=2.5, p< 0.01), controlling for patient demographics and risk. In the outpatient setting, the RFB group was ∼1.5 times more likely to be readmitted than the SFB group (OR=1.5, p >0.05). Across all settings, the RFB group was ∼2.3 times more likely to be readmitted than the SFB group (OR=2.3, p< 0.01). The inability to fully risk-adjust in the outpatient setting may have been a factor in the smaller OR and lack of statistical significance; this limitation will be addressed with further analysis that includes an outpatient severity of illness classification variable. Conclusion Patients undergoing bronchoscopy typically have significant comorbidities which increase their risk for the development of potential device-related infections. To reduce these risks, the use of a sterile SFB should be considered to eliminate reprocessing failures, improve overall operational efficiency, and reduce potential acquisition of healthcare-associated infections. Disclosures John H. Garrett, PhD, MSN, MPH, MBA, FNP-BC, FNAP, FSHEA, FIDSA, Aerobiotix: Advisor/Consultant|Ambu: Advisor/Consultant|American Academy of Nurse Practitioners: Honoraria|Clorox Pro: Advisor/Consultant.

Smartphone Use and Security Challenges in Hospitals: A Survey among Resident Physicians in Germany.

Although mobile devices support physicians in a variety of ways in everyday clinical practice, the use of (personal) mobile devices poses potential risks for information security, data protection, and patient safety in hospitals. We used a cross-sectional survey-based study design to assess the current state of smartphone use among resident physicians in hospitals and to investigate the relationships between working conditions, current smartphone usage patterns, and security-related behavior. In total, data from 343 participating physicians could be analyzed. A large majority (98.3%) used their smartphones during clinical practice. Of the respondents who used a smartphone during clinical practice, only 4.5% were provided with a smartphone by their employer. Approximately three-quarters of the respondents who used their smartphones for professional communication never/almost never used dedicated GDPR-compliant messenger services. Using a hierarchical regression model, we found a significant effect of the organizational resources Social Support (Supervisor) and Information Security-related Communication on security-related behavior during the selection of medical apps (App Selection). Smartphones are an important part of digital support for physicians in everyday clinical practice. To minimize the risks of use, technical and organizational measures should be taken by the hospital management, resulting, for example, in a Bring-Your-Own-Device (BYOD) initiative.

Paramedics’ perceptions of job demands and resources in Finnish emergency medical services: a qualitative study

BackgroundParamedics’ fatigue is rising. Stress factors show increased risk for burnout, fatigue, leaving the profession, decreased performance and risk for patient safety. Meanwhile, paramedics’ strong community of practice, autonomy and a sense of professional respect are important factors in forming psychological resilience. We aimed to explore Finnish paramedics’ perceptions of job demands and resources.MethodsOur study design was descriptive, inductive with a constructivist approach. Using reflexive thematic analysis, we analyse open-ended questions, from a web-based survey and essays written by Finnish paramedic masters-degree students. The study followed the SRQR checklist.ResultsWe identified paramedics’ job demands as stress from a high workload, environmental factors and emotional burden. Performance expectations and a sense of inadequacy were further noted, as well as an organizational culture of hardiness, presenting lack of support and sense of inequality. Paramedics’ job resources were pressure management strategies, which were expressed as positive coping mechanisms, agency to affect workload and professional self-actualization, expressed as psychologically safe work community, professional pride and internal drive to professional development.ConclusionsFinnish paramedics exhibit resources and demands related to uncertainty and emotional burden as well as cultural hardiness and psychological safety in communities.Patient or public contributionThis study was done based on survey data collected and analysed by the authors. No patient or public contribution was utilized for this study.

Measuring drug name similarity to prioritise the application of tall-man lettering in a computerised pharmacy dispensing system

Abstract Introduction Medicine name similarity is a contributory factor to medication errors.1 Published lists exists highlighting medicine pairs that are easily confused; locally a Look-Alike-Sound-Alike (LASA) list has expanded over time with no formal system of triage. A multipronged approach is required to address LASA risks. Tall-Man Lettering (TML) is one intervention that uses uppercase lettering for the dissimilarities in look-alike drug names to alert staff to the risk of error.1 For greatest impact, it should be reserved for pairs with the highest risk for patient safety. Aim This study aimed to use Levenshtein Distance (LD), Bigram (Bi) and Trigram (Tri) methods to prioritise medicine pairs for TML in the Pharmacy dispensing system. Objectives were to: Produce a comprehensive list of medicines pairs; Establish normalised thresholds from LD, Bi and Tri to prioritise medicine pairs for TML; and, measure drug name similarity using validated software2 applying LD, Bi and Tri to medication pairs as a method of triage for orthographic assessment. Methods Approval was obtained by the Trust Pharmacy Research Committee. The need for ethical submission was waived. A LASA list was developed combining medicine name pairs from National Pharmacy Association list3, historical local list and internal incidents where medicine name confusion was cited. Duplicated, branded and non-stock pairs were excluded. A literature search was undertaken to identify published thresholds for accuracy and sensitivity of the methods in the measure of medicine name similarity. LD measures the minimum number of edit operations needed to transform one string into another; Bi and Tri measures the frequency in which two/three similar sequential strings appear within a medicine name respectively. Two assessors independently entered medicine pairs through a validated computer program2 applying LD, Bi and Tri to measure orthographic similarity. Normalised computed similarity scores (between 0-1 where higher values represent increased drug similarity) were collated on Microsoft excel for comparison against thresholds. Results Two-hundred and twelve medicine pairs were identified for review. The literature defined Bi and Tri thresholds at ≥0.3 and ≥0.1 respectively; in absence of this for LD, in-house thresholds were assessed then defined at ≥0.6. LD identified 84 medicine pairs; Bi identified 144; and Tri identified 158; none were uniquely found by LD, four by Bi and 18 by Tri. A final look-alike list with 82 medicine pairs meeting all three thresholds was identified for TML. Discussion/Conclusion Screening using all three methods led to a 61% reduction in medicines pairs allowing prioritisation of TML as an effective intervention based on look-alike pairs with the highest risk of error. This study focused on identifying orthographic similarity in ‘look-alike’ medicine pairs only. With no single intervention available to prevent LASA errors, future work can explore other interventions. In the absence of literature around normalised LD, the definition of an in-house threshold posed to be another limitation and an area where further exploratory work should be considered. As new LASA incidents arise or the Trust catalogue increases, these methods should be applied to triage their look-alike potential, confirming if TML is an appropriate intervention.

COVID-19 related negative emotions and emotional suppression are associated with greater risk perceptions among emergency nurses: A cross-sectional study

BackgroundAs the COVID-19 pandemic began, frontline nurses experienced many emotions as they faced risks relevant to both patients (e.g., making errors resulting in patient harm) and themselves (e.g., becoming infected with COVID-19). Although emotions are often neglected in the patient safety literature, research in affective science suggests that emotions may significantly impact nurses’ perceptions of risk, which can have downstream consequences. Further, the use of chronic emotion regulation strategies that are known to differ in adaptability and effectiveness (i.e., emotional suppression, reappraisal) can impact risk perceptions. ObjectiveTo investigate the relationship between nurses’ emotional experiences in response to the pandemic and their estimates of how likely they would be to experience adverse outcomes related to both patients and themselves within the next six months. Additionally, we investigated the extent to which the use of suppression and reappraisal processes to manage emotions are associated with these risk perceptions. DesignCross-sectional survey. SettingOnline survey distributed via email to emergency nurses at eight hospitals in the northeastern United States during fall 2020. Participants132 emergency nurses (Mage = 37.05; 81.1% Female; 89.4% White). MethodsNurses reported the extent to which they experienced a variety of positive (e.g., hope, optimism) and negative (e.g., fear, sadness) emotions in response to the COVID-19 pandemic, and reported their perceptions of risk to both patients and themselves. Nurses also completed the Emotion Regulation Questionnaire, a measure of chronic tendencies to engage in emotional suppression and reappraisal. Immediately prior to providing data for this study, nurses completed an unrelated decision-making study. ResultsNurses’ negative emotions in response to COVID-19 were associated with greater perceptions of both patient safety risks (b = 0.31, p < .001) and personal risks (b = 0.34, p < .001). The relationships between positive emotions and risk perceptions were not statistically significant (all p values > 0.66). Greater chronic tendencies to suppress emotions uniquely predicted greater perceptions of patient safety risks (b = 2.91, p = .036) and personal risks (b = 2.87, p = .040) among nurses; however, no statistically significant relationships with reappraisal emerged (all p values > 0.16). ConclusionsUnderstanding factors that influence perceptions of risk are important, given that these perceptions can motivate behaviours that may adversely impact patient safety. Such an understanding is essential to inform the development of interventions to mitigate threats to patient safety that emerge from nurses’ negative emotional experiences and their use of different emotion regulation strategies. Tweetable abstractCovid-related negative emotions and emotional suppression are associated with greater patient and personal risk perceptions among emergency nurses @lindamisbell @Nathan_Huff_1

Australian sonographers' perceptions of patient safety in ultrasound imaging: Part two - translation into practice.

A lack of patient safety research hampers capacity to improve safety in healthcare.Ultrasound is often considered 'safe' as it does not use ionising radiation, a simplistic view of patient safety. Understanding sonographers' actions towards patient safety is crucial; however, self-reported measures cannot always predict behaviour. This study is part of a PhD exploring patient safety in medical diagnostic ultrasound. The aim of this paper is to explore sonographers' responses to the patient safety concerns identified in Part one of this study. The ultimate aim of the study is to inform the final phase of the doctoral study which will consider the next steps in improving the quality and safety of healthcare experienced by patients. A qualitative study using semi-structured, one-on-one interviews. The Theory of Planned Behaviour (TPB) explained how sonographers respond to perceived patient safety risks in practice. Thirty-one sonographers were interviewed. Based on the seven themes identified in Part one of the study, results showed that incongruences exist between identifying patient safety risks and the actions taken in practice to manage these risks. The TPB showed that behavioural, normative and control beliefs impact sonographers' responses to perceived patient safety risks in practice and can lead to risk avoidance. Lack of regulation in ultrasound creates a challenge in dealing with Fitness to Practice issues. Collective actions are required to support sonographers in taking appropriate actions to enhance patient safety from multiple stakeholders including accreditation bodies, regulatory authorities, educational institutions and employers.

Adapting Neural-Based Models for Position Error Compensation in Robotic Catheter Systems

Robotic catheter systems with master–slave designs are employed for teleoperated navigation of flexible endovascular tools for treating calcified lesions. Despite improved tool manipulation techniques, patient safety and lowering operative risks remain top priorities. Therefore, minimizing undesirable drifts and imprecise navigation of flexible tools during intravascular catheterization is essential. In the current master–slave designs, finite displacement lag between position command and actual navigation action at the slave device affects smooth catheterization. In this study, we designed and developed a compact 2-DOF robotic catheter system and characterized the influence of displacement step values, velocity, and motion gap on the position error at the slave device. For uniform and varying motion commands from the master platform, the results indicate that the overall position error increases with the distance traveled and the displacement step values, respectively. Hence, we proposed using recurrent neural networks—long short-term memory and gated recurrent unit controllers to predict the slave robot’s position and appropriate compensation value per translation step. An analysis of in-silico studies with CoppeliaSim showed that the neural-based controllers can ensure uniform motion mapping between the master–slave devices. Furthermore, we implemented the models within the RCS for a catheterization length of 120 mm. The result demonstrates that the controllers suitably aid the slave robot’s stepwise displacement. Thus, the neural-based controllers help match the translational motion and precise tool navigation by the slave robotic device. Therefore, the neural-based controllers could contribute to alleviating patients’ safety concerns during robotic interventions.

Language barriers for primary care access in Europe: a systematic review

Abstract Background A recent increase in migration both inside Europe and from non-European countries has expanded the language profile of many European countries. As a result, there has been a significant increase in barriers to healthcare access experienced by linguistic minority migrants. This systematic review aims to explore language barriers in primary care, focusing on the experiences of linguistic minority migrants living in Europe. Methods PubMed, Embase, Scopus and Global Health were searched to identify studies published in English until May 2021. Qualitative and mixed methods studies on either linguistic minority migrants or healthcare workers working with linguistic minority migrants, exploring the impacts of language barriers in a primary care setting published were eligible. The studies were analysed using a Braun and Clarke's thematic analysis approach. Quality of the studies were assessed using the Mixed Methods Appraisal Tool. Results 16 studies from 14 different European countries were eligible. Participants in the studies included four groups: linguistic minority migrants (n = 11), healthcare workers (n = 10), interpreters (n = 1) and administrative staff (n = 1). Barriers identified included a lack of interpreters, limited cultural competence of practitioners, a lack of practitioner training and knowledge, a lack of accessible information for migrants, difficulties expressing emotions and building patient-practitioner relationships, and risks to women's bodily autonomy resulting from language barriers. Conclusions Linguistic minority migrants living in Europe face a number of barriers when accessing primary care. These barriers can risk patient safety, reduce the likelihood of seeking healthcare services, and impact patient experiences of healthcare services. There is a need for improved interpreter services, practitioner training, and information accessibility for both migrants and healthcare staff. Key messages • Linguistic minority migrants experience significant barriers to primary healthcare access across Europe. • There is a need for improved interpreter services, practitioner training, and information accessibility for both migrants and healthcare staff.

Nurses' general attitudes and caregiving-specific perceptions toward the oldest-old: A nationwide survey

BackgroundDespite the growing population of older adults worldwide, nurses may harbor negative attitudes toward older patients that might risk patient safety. Most studies have investigated general attitudes toward older adults. Only a few have focused on nurses' perceptions of caring for older patients, and there has been little focus on the oldest-old (aged ≥80 years), an age group that is particularly affected by negative attitudes. Emerging models to combat this issue suggest that education about aging and interaction with older adults are key factors. These models have primarily been evaluated using students, not healthcare professionals. ObjectiveTo examine if and to what extent education (training and education about working with older people) and interaction (professional and personal contact with older adults) are associated with nurses' general attitudes toward older persons and their perceptions of caring for older patients (aged ≥80 years). DesignA cross-sectional survey study. ParticipantsA nationwide sample of 2294 Swedish registered nurses with background characteristics reflective of the national nursing population. MethodsEmails with study information and survey links were distributed via the Swedish Association of Health Professionals' registry. The survey contained one instrument that measures general attitudes toward older adults and one that measures perceptions of caring for older patients. Following the Positive Education about Aging and Contact Experiences model, items about participants' education and their professional and personal interaction with the oldest-old adults were also included. Descriptive and comparative analyses were conducted. Multiple regression models used general attitudes and caregiving-specific perceptions as dependent variables in each model. ResultsNurses' general attitudes and caregiving-specific perceptions were correlated.Regression analyses revealed that the education and interaction variables were independently associated with general attitudes and caregiving-specific perceptions, but these associations followed different directions.An older family member/close friend, extensive work experience, and working primarily in administration were independently associated with more positive general attitudes toward the oldest-old adults. Working in home care or assisted living, having education in geriatrics/gerontology, and frequent interaction with older patients were associated with less favorable general attitudes but more positive perceptions of caring for the oldest-old patients. ConclusionsOur results highlight the complex relationship between nurses' general attitudes and their caregiving-specific perceptions toward the oldest-old persons. Education in geriatrics/gerontology and interaction with older adults are warranted to improve nurses' caregiving-specific perceptions. Appropriate scales that consider this complexity beyond general attitudes are needed to capture caregiving-specific and contextual perceptions.

Improving documentation of zoledronic acid interval in ambulatory oncology patients.

323 Background: Therapy plan orders for certain repetitive medications such as Zoledronic Acid do not always reflect the interval administered. This creates a patient safety risk as patients may get extra or fewer doses than required, a lack of clarity for pharmacy dispensing and nurses administering the medication and delays for patients while the orders are corrected. In a 3-month period, 30 safety reports of Zoledronic Acid therapy plan discrepancies were reported. Methods: Baseline data was determined using manual chart review of a sample of 50 patients, reviewing documentation of Zoledronic Acid interval in four fields in the chart. 58% of patients had an incorrect interval in therapy plan title and 12% of charts had discrepancies in other fields. In initiating this improvement project, we identified and engaged key stakeholders (nurses, providers, IT, patient safety and pharmacists) in DFCI oncology outpatient areas in a series of interactive meetings to share baseline data and use quality improvement tools (process mapping and impact-effort matrix) to identify solutions. In PDSA cycle 1, the options of Zoledronic Acid therapy plans were modified from having separate plans for each interval to a single therapy plan with options to select the interval. This was done with the goal of reducing the number of fields with the interval to reduce discrepancies in interval. In PDSA cycle 2, a team of pharmacists reviewed charts of patients who had an appointment with a provider and were on Zoledronic acid weekly, for 12 weeks. Charts with interval discrepancies were sent to the ordering provider for correction. This was done for two disease groups over a period of 6 months. Results: Post the completion of PDSA cycle 1, an analysis of 7165 dispenses showed that Zoledronic Acid therapy plans containing information apart from medication name in title decreased from 90% in 2019 to 0.4% in 2021. PDSA cycle 2 addressed discrepancies in another 126 patient charts, reducing the overall discrepancies from 12% to 7%. Conclusions: This project demonstrates multidisciplinary approach to identifying solutions to discrepancies around Zoledronic Acid intervals in patient charts has reduced this patient safety risk. The solutions implemented in PDSA cycle 1 was a system-based solution with a high impact. PDSA cycle 2 helped mitigate the safety risk further. Additional system-based solutions are essential in the long term to reduce documentation variability and improve quality and safety of care for patients receiving Zoledronic Acid.

411EMF Measurement of Cost of Boarding Code Stroke Patients in the Emergency Department Using Time-Driven Activity-Based Costing

Emergency department (ED) boarding is associated with patient care and safety risks. However, reports show it is worsening over time. There is an abundance of research on the effects of boarding on patients, staff, and emergency department operations. However, there is a clear paucity of research into the financial effects of boarding. We sought to measure the cost of boarding code stroke patients using time-driven activity-based costing and compare how this cost related to the overall cost of inpatient care.

Prevalence of Orthopaedic Knee Scooter-Related Injury: Risk Factor Analysis and Patient Safety Perceptions in a Prospective Cohort

Category: Other; Trauma Introduction/Purpose: There is a paucity of research investigating the harms associated with the orthopaedic knee scooter (OKS) and patient safety perceptions. This prospective study aimed to define the prevalence of OKS-related injuries, identify patient risk factors and describe the patient perceptions of OKS safety. Methods: This single-surgeon prospective study recruited a cohort of 134 consecutive patients undergoing surgery at a community-based orthopaedic clinic from 6/2020 to 4/2021. Our primary outcome informed an a priori power analysis. Standardized data collection protocol included three forms that patients completed. The prevalence of OKS-related injury, patient risk factors, and patient perceptions were analyzed. Alpha values of P &lt;0.05 were considered statistically significant, and a 95% confidence interval was reported (95CI). Results: There were 118 (88%) patients eligible for analysis. The prevalence of patient falls was 37.3% (44/118), and the prevalence of patient injury was 15.3% (18/118). A sedentary lifestyle was a significant risk factor (P=0.001) for injury, with a relative risk of 3.32 (1.47- 7.46 95CI) and an absolute risk difference of 26%. Age, height, weight, diabetes was not found to be risk factors for injury. Patient perception of OKS safety at study enrollment (P=0.049) and study exit (P=0.004) were significantly lower for injured patients. Conclusion: Despite a high prevalence of patient falls, there is a low absolute risk of injury. Sedentary patients are at increased risk of OKS-related injury. Patients with a history of injury perceive OKSs to be less safe and are less likely to use an OKS in the future but are not less likely to recommend an OKS to a friend. Future studies should verify prevalence data in multiple settings and assess the effectiveness of patient education or surgeon screening measures in reducing OKS-related injury.

Simulation-based mastery learning in gastrointestinal endoscopy training.

Simulation-based mastery learning (SBML) is an emerging form of competency-based training that has been proposed as the next standard method for procedural task training, including that in gastrointestinal endoscopy. Current basic gastrointestinal endoscopy training relies on the number of procedures performed, and it has been criticized for its lack of objective standards that result in variable skills among trainees and its association with patient safety risk. Thus, incorporating simulators into a competency-based curriculum seems ideal for gastrointestinal endoscopy training. The curriculum for SBML in gastrointestinal endoscopy is currently being developed and has promising potential to translate into the clinical performance. Unlike the present apprenticeship model of “see one, do one, teach one,” SBML integrates a competency-based curriculum with specific learning objectives alongside simulation-based training. This allows trainees to practice essential skills repeatedly, receive feedback from experts, and gradually develop their abilities to achieve mastery. Moreover, trainees and trainers need to understand the learning targets of the program so that trainees can focus their learning on the necessary skills and trainers can provide structured feedback based on the expected outcomes. In addition to learning targets, an assessment plan is essential to provide trainees with future directions for their improvement and ensure patient safety by issuing a passing standard. Finally, the SBML program should be planned and managed by a specific team and conducted within a developed and tested curriculum. This review discusses the current state of gastrointestinal endoscopy training and the role of SBML in that field.

New Landscape of Healthcare Quality in the Postpandemic Era from 2022~2023 Annual Taiwan Patient Safety Goals for Hospitals

&lt;p&gt;新冠肺炎疫情帶給醫療體系巨大衝擊，未來將進入新常態的時代，因此111-112年度醫療品質及病人安全工作目標納入了這三年的經驗與新法。目標一的重點是強化推動醫療團隊合作，並從政策的訊息發布與溝通來強化醫療團隊合作。目標二強調要建立醫療人員與醫療機構的韌性，預防醫療暴力事件的發生。另外醫療人員要認知資訊存在的病安風險、強化相關通報。目標三新增的重點為「落實手術麻醉整合照護，強化團隊合作」，並鼓勵術後加速恢復，以提升手術安全。目標四強調以團隊合作提供安全照護，預防病人跌倒。目標六增加推廣乾洗手設備，醫院應訂有重大疫情之因應機制。目標八後疫情的醫病溝通，要以多元數位模式與時俱進。新增目標九維護孕產兒安全，強調高危險妊娠辨識與處理能力。期望修訂後的醫療品質及病人安全工作目標能引導醫院在後疫情時代之病人安全有新的展望。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;In view of the severe impact caused by the COVID-19 pandemic and the arrival of the new normal, the 2022&amp;ndash;2023 Annual Taiwan Patient Safety Goals for Hospitals have incorporated the experience gained in the past 3 years to adopt new practices. Goal 1 emphasizes strengthening the promotian of TRM (Team Resource Management), through the communication and dissemination of policyrelated information. Goal 2 emphasizes enhancing the resilience of healthcare professionals and organizations, and to prevent medical violence. In addition, healthcare professionals should be aware of the information-related patient safety risks and strengthen reporting of such risks. Goal 3 new aims to &amp;quot;implement integrated care of surgical anesthesia and strengthen teamwork,&amp;quot; encouraging enhanced recovery after surgery to improve surgical safety. Goal 4 emphasizes the importance of teamwork in the provision of safe care, which is crucial to the prevention of fall incidents. Goal 6 promotes the use of hand sanitizers, advocating the establishment of response measures for critical epidemic diseases in healthcare organizations. Goal 8 moves with time to use the multi-digital modes to facilitate doctor-patient communication in the post-pandemic era. New goal 9 is to maintain safe maternal and newborn care, emphasizing the ability to identify and deal with high-risk pregnancies. Revisions made to the Annual Taiwan Patient Safety Goals for Hospitals are expected to guide healthcare organizations in improving post-pandemic patient safety.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Improving Clinical Documentation Compliance Pre-Gastrointestinal Endoscopy Procedures Through the Use of an Endoscopy Checklist.

Production pressure in endoscopy units, to avoid procedural delays, can lead to documentation gaps that pose a patient safety risk. Fast-paced, high-volume endoscopy units within a 673-bed academic medical center, incomplete and illegible documentation were identified during a 2018 Joint Commission survey. Pre-procedure safety checklists help ensure accurate clinical handovers. Checklists promote team communication that includes the patient to have complete and relevant information to perform a safe procedure and speak up to identify discrepancies. An endoscopy-specific safety checklist was used by the procedural team immediately pre-procedure. This quality improvement project used Plan Do Study Act cycles to incorporate changes suggested by users. Chart audits were conducted pre- and post-pilot. The results showed significant improvements in physician documentation completeness and legibility, suggesting the checklist prompted clarification of documentation and communication between the nurse and the physician. Nursing assessment saw a 27.1% improvement, suggesting clarification of clinical handover between the admitting and procedural nurses. Improved communication was perceived by staff. This project showed how a standardized tool to promote team communication and clarification of discrepancies pre-procedure can contribute to prevention of errors.

'Doing the best we can': Registered Nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

AimsTo explore registered nurses' experiences of patient safety in intensive care during COVID‐19.DesignA qualitative interview study informed by constructivism.MethodSemi‐structured interviews were conducted and audio‐recorded with 19 registered nurses who worked in intensive care during COVID‐19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework.ResultsTwo key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short‐ and long‐term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well‐being and Peer Support.ConclusionNurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an understanding of the holistic and long‐term impacts on patient safety and recovery from critical illness.ImpactThis study explored the perceived impact of COVID‐19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long‐term appreciation of patient safety. These findings should be considered as part of future nursing workforce modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.