Promote Patient Safety Research Articles

The Role of Nursing in Reducing Medical Errors: Best Practices and Systemic Solutions

Medical errors remain a significant challenge in healthcare, contributing to patient harm and increased costs. As frontline caregivers, nurses play a pivotal role in minimizing these errors by implementing best practices and advocating for systemic improvements. This article explores the various types of medical errors and emphasizes the critical role of nursing interventions in error prevention. Key best practices discussed include effective communication strategies such as SBAR, medication management protocols, and the use of technological tools like Electronic Health Records (EHR) and Barcode Medication Administration (BCMA). Additionally, the article addresses the importance of continuous training, fatigue management, and interdisciplinary collaboration in reducing error rates. Systemic solutions are also reviewed, including fostering a culture of safety, ensuring adequate staffing, and implementing evidence-based protocols. The findings suggest that while nurses are integral to preventing errors, healthcare institutions must provide the necessary support and resources to optimize their efforts in promoting patient safety. Ultimately, the article highlights the need for both individual and organizational commitment to reducing medical errors.

Promoting Patient Safety Among Nursing Students: A Mixed-method Study on Collaborative Cross-Cultural Learning

This study aimed to examine the feasibility of collaborative cross-cultural learning among university nursing students in Singapore and nursing students from Korea in developing insights on patient safety and understanding students' perspectives. Patient safety is an important part of nursing management to deliver quality care to patients. However, studies suggested that nursing students were not adhering to guidelines. This pilot study used a mixed-method embedded design. Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were employed to provide a deeper understanding of the nursing perceptions and behaviours towards collaborative learning. The study took place between August 2023 and December 2023. 12 Singaporean students participated in the online collaborative learning session with 16 Korean students. Only nursing students from Singapore were invited and completed an online pre- and post-intervention survey covering attitude and perceived knowledge on patient safety followed by the interviews. Participants reported an improvement in their perspectives towards medical errors and patient safety after the session. Four themes and 11 sub-themes were reported 1) intercultural communication, 2) curriculum design, 3) personal attributes and experiences and 4) the impact of online platforms, to understand their perspectives of cross-cultural learning on their attitudes and perspectives. Cultural collaborative learning, when aligned with connectivism, had shown its feasibility in developing insights on patient safety and understanding students' perspectives to strengthen their personal beliefs and promote patient safety in their clinical area. The challenges faced when conducting collaborative cross-cultural learning via online platforms were also explored in this study and addressed to ensure equitable participation by everyone.

Which glaucoma patients should be monitored at home and exploration of clinician perceptions on home monitoring? a survey of glaucoma specialists in the UK

ObjectivesTo identify suitable patients for glaucoma home monitoring and explore clinicians’ perceptions of the possible benefits and risks of home monitoring within the National Health Service.DesignAn online survey composed of open-ended and closed-ended questions.SettingSecondary care.ParticipantsGlaucoma specialists registered with the UK and Eire Glaucoma Society.Outcome measuresAgreement with clinical scenarios.ResultsThe estimated response rate was 68% (n=49). Of 49 participants, 92% (n=45) were consultant ophthalmologists and 71% (n=35) had over 10-year experience. There was a poor agreement regarding an ideal glaucoma patient for home monitoring, with only one scenario achieving over 60% agreement. Most participants believed that home monitoring would be most suitable for low-risk scenarios, rather than high-risk, due to fear of missing progression. In relation to acceptability, key facilitators included the potential to increase healthcare capacity and promote patient safety. However, low clinician trust in equipment reliability and fear of patient harm were reported as concerns.ConclusionsThere was no clear consensus on which patients would benefit most from glaucoma home monitoring. While many clinicians believe home monitoring may enhance healthcare, there were also many concerns about the technologies themselves. Further work to address clinician concerns is warranted.Research Registry registration number6213.

ASA Promotes Patient Safety at 2024 NCSL Legislative Summit

ASA Promotes Patient Safety at 2024 NCSL Legislative Summit

Effect of integrated medicines management on quality of discharge medication information - a secondary endpoint in a randomized controlled trial.

High-quality discharge information is important to promote patient safety when patients are transferred from hospital to primary care. Patients with multiple long-term conditions are especially vulnerable to insufficient transfer of medication information, as they use many medications and have complex interactions with the healthcare services. The aim of this study was to investigate the effect of integrated medicines management provided to hospitalized multimorbid patients on the quality of the discharge medication information. Multimorbid patients ≥18 years, using a minimum of four regular medications from a minimum of two therapeutic medication classes were recruited from the Internal Medicine ward, Oslo University Hospital, Norway, from August 2014 to March 2016 and randomly assigned, 1:1, to the intervention or control group. Intervention patients received integrated medicines management throughout the hospital stay. Control patients received standard care. This paper reports the results of a pre-specified secondary endpoint analysis of a randomized controlled trial; the difference between the intervention and control group in the quality of discharge medication information. The analysis population comprised 384 patients. Integrated medicines management improved the discharge summary quality score of the medication information from 5.8 ± 1.5 to 8.6 ± 2.6 (mean difference 2.7, 95% CI 2.3-3.2, p < 0.001). In total 171 intervention patients (89%) received a patient discharge information letter, compared to 66 control patients (35%), p < 0.001. The quality score of the medication information in the patient discharge information letter was improved from 6.0 ± 1.8 in the control group to 10.0 ± 1.3 in the intervention group (mean difference 4.0, 95% CI 3.6-4.4, p < 0.001). Integrated medicines management delivered to multimorbid patients during a hospital stay improved the quality of the medication information in discharge summaries as well as patient discharge information letters and ensured that a discharge information letter in lay language was prepared for almost all patients who were involved in the management of their medications after discharge.

MSOR9 Presentation Time: 5:40 PM: Development and Utilization of a Brachytherapy Procedure Scoring System to Optimize Clinic Schedule, Reduce Employee Burnout, and Promote Patient Safety

MSOR9 Presentation Time: 5:40 PM: Development and Utilization of a Brachytherapy Procedure Scoring System to Optimize Clinic Schedule, Reduce Employee Burnout, and Promote Patient Safety

Introducing a systematic and sustainable patient safety oversight function in a U.K. arms-length healthcare body

Background The healthcare landscape is experiencing a profound period of change with accelerating developments in medical research, new treatments, care delivery and the use of innovative technology to meet the challenges of delivering care. These changes offer opportunities but as with all innovation, require careful management to reduce the likelihood of harm and error. Objective The National Institute for Health and Care Excellence (NICE) has set out to introduce an adaptable, sustainable and systematic patient safety oversight group to ensure that patient safety is embedded at an organisation level supporting the healthcare system to overcome challenges and deliver high quality care, safely implementing the latest innovations in a timely manner. Method The patient safety oversight group was established through a scoping exercise, led by the senior responsible officer and a small project team. The article sets out the methods used, including extensive internal engagement through structured interviews with senior leadership teams, purposive sampling, data synthesis and reporting. An overview of the group is given and considerations for promoting patient safety information flows and optimising the use of safety signal intelligence are made. Conclusion Through reflection on changing needs within and surrounding the organisation, along with patient safety and complexity literature, NICE has developed an adaptable, systematic and sustainable model for managing patient safety. In addition to generating learning within NICE, the process highlights opportunities for improvement within the patient safety system. Result NICE has developed an adaptable, systematic and sustainable model for managing patient safety.

Nursing Students' Experiences and Perceived Learning Effectiveness of Patient Safety and Its Influencing Factors: An Integrative Literature Review.

To examine and synthesise the current literature to gain insights into nursing students' experiences, their perceived learning effectiveness of patient safety and its influencing factors. Integrative review. CINAHL, Medline, Scopus, and Embase databases from January 2011 to October 2023. Of the 5940 papers initially retrieved, 33 were included after title, abstract, and full-text screening. No papers were omitted through quality appraisal. Despite nursing students' generally positive attitude towards patient safety, their idealistic view did not translate into actual actions of upholding patient safety due to various factors. Moreover, their experiences and perceived effectiveness of learning patient safety were influenced by factors such as organisational safety culture and pedagogical contexts. Thematic analysis revealed four themes: 'perception, attitudes, and evaluation towards patient safety'; 'supportive organizational culture as impetus to promote patient safety'; 'perceived confidence, knowledge, and competence toward patient safety'; and 'educational contexts and pedagogies to promote learning of patient safety'. There is an inadequate focus on patient safety in clinical education compared to classroom education. Given that the clinical setting serves as an authentic learning environment of patient safety, nursing faculties play a crucial role in reforming existing nursing curricula to integrate patient safety education in both settings to ensure continuity of learning. Clinical nursing leaders should also proactively review and reform organisational culture and practices to enable nursing students' acquisition and internalisation of patient safety learning. This review highlighted the need for further collaboration between nursing faculties and healthcare institutions to advocate an environment conducive to nursing students' effective learning of patient safety. Reporting adheres to the Reporting items for systematic review and meta-analyses (PRISMA) 2020 guidelines. No patient or public contribution.

The Use of Single-Use Medical Gloves in Doctors' Practices and Hospitals.

Single-use medical gloves achieve their purpose only when properly used. Proper use also helps avoid undesired consequences such as excessive waste and CO2 emissions, as well as inadequate hand hygiene. In this selective review of the primary scientific literature, we summarize the current state of knowledge on the use of single-use medical gloves in the health-care sector. We also provide further information from national recommendations, guidelines, and regulatory provisions. Single-use medical gloves mainly serve to protect the health-care professional and are only rarely meant to promote patient safety. For reasons of occupational safety and self-protection, hand hygiene should be performed after single-use medical gloves are removed. A study on single-use medical gloves from open boxes revealed that 13% bore human pathogenic bacteria. It was found in a meta-analysis that wearing single-use medical gloves can lower the risk of nosocomial infection (incidence rate ratio, IRR: 0.77 [0.67; 0.89]. In a randomized controlled trial, adherence for putting on single-use medical gloves without prior hand disinfection was 87%. On the other hand, where hand disinfection was expected to be performed before putting on gloves, adherence was 41%. Proper use can lower the rate of occupational skin diseases and improve adherence to hand hygiene for the five moments in which it is recommended (before and after patient contact, before aseptic procedures, after contact with potentially infectious material, and after contact with the immediate patient environment). Limiting the use of single-use medical gloves to its proper indications promotes the safety of health-care professionals and patients and has beneficial ecological and economic effects as well.

Cross-cultural adaptation and validation of the Hospital Survey on Patient Safety questionnaire for a Chilean hospital

BackgroundHospital Survey on Patient Safety version 2.0 (HSOSPS 2.0) from the Agency for Healthcare Research and Quality enables hospitals to gather the information needed to evaluate the patient safety culture within their institution. However, version 2.0 has not been widely implemented in Chile. This study aims to customize and validate the original HSOSPS 2.0 for a Chilean hospital.MethodsTranslation and cross-cultural adaptation, content validity through a group of experts, and a pilot test with cognitive pretest were applied to 259 participants from the nursing team in 11 hospital services to study construct validity and reliability.ResultsIn the current study, a version of the questionnaire adapted to the Chilean cultural context showed excellent content validity with an index of 0.982 (S-CVI). After conducting exploratory factor analysis, a new model with 7 dimensions and 23 questions was proposed, down from the original 10 dimensions and 32 questions. This new model explains 71% of the variability. The model’s goodness of fit indicators were CFI=0.995, TLI=0.994, and RMSEA=0.048. The results of McDonald’s Omega showed high overall reliability with 0.9325.ConclusionsThis study provides a validated measurement instrument that contributes to improving patient safety conditions at the level of the hospital nursing team in highly complex establishments in Chile. However, the dimensions, such as the number of items, were reduced This questionnaire can be used in future nursing research by expanding the sample among health professionals in Chile.Relevance to clinical practiceApplying this version of the questionnaire will be highly beneficial for clinical administrators and nursing staff. It will improve their care practices and promote patient safety in public hospitals in Chile, as well as assist in enhancing nursing policies.

PHYSICAL CONCEPTS OF CEREBRAL ANGIOGRAPHY AND CEREBRAL ANEURYSM EMBOlIZATION AND NURSING ASSISTANCE TO PATIENTS IN THE HEMODYNAMICS LABORATORY

This paper evaluates common nursing practices related to patients undergoing cerebral angiography and embolization of cerebral aneurysms as described in the specialized literature, addressing the importance of nursing team involvement in the care of patients undergoing these hemodynamic procedures. The text outlines various aspects of nursing assistance from patient admission to discharge in the hemodynamics unit. The methodology includes a literature review highlighting care protocols, recommended practices, and specific interventions aimed at minimizing complications and promoting patient safety. Issues such as the systematization of nursing care, vital sign monitoring, pain management, infection prevention, and guidance on post-procedure care are discussed. The results indicate that well-structured, evidence-based nursing assistance significantly contributes to patient recovery and reduction of adverse events. The article emphasizes the need for further studies related to this topic, as well as the fundamental role of this category within the multidisciplinary team for faster recovery and prevention of post-intervention complications.

Shared Decision-Making in Patient Care: Advantages, Barriers and Potential Solutions

Shared Decision-Making (SDM) is a collaborative process where physicians integrate scientific evidence with patients’ goals, preferences, and values to make healthcare decisions. This approach contrasts with traditional methods, enhancing patient involvement and understanding. The BRAN questions (Benefits, Risks, Alternatives, Nothing) effectively facilitate SDM across various clinical settings, promoting patient safety. While time constraints and low health literacy pose barriers, strategies like visual aids, extended appointments, and cognitive assessments can mitigate these challenges. Training for physicians in SDM skills has been shown to improve patient outcomes and satisfaction, underscoring the importance of personalized care in outpatient and inpatient contexts.

Anesthetic challenges in pediatric robot-assisted surgeries

With the advent of minimally invasive surgeries, robot-assisted techniques have gained popularity because they overcome various shortcomings of standard laparoscopic surgeries. Despite the associated costs and limitations among the pediatric population, surgeon comfort due to the ergonomic design, in combination with enhanced three-dimensional high-fidelity imaging and tissue handling, may offer better surgical and postoperative outcomes. However, robotic surgeries require innovations with regard to patient positioning and the overall arrangement of operative equipment and personnel. Anesthesiologists should become well versed with these changes by learning the basic features of robotic surgical systems to offer appropriate anesthetic care and promote patient safety. In this original case report, we present a 3-year-old child posted for robot-assisted left heminephrectomy and excision of the lower megaureter. It provides instructive significance for anesthesia management, especially taking into account the age of the patient and associated concerns.

AHRQ's digital healthcare research program: 20 years of advancing innovation and discovery.

To reflect on the achievements of the Agency for Healthcare Research and Quality's (AHRQ) Digital Healthcare Research Program over the past 20 years, evaluate its impact on US healthcare quality and safety, and outline current and future priorities for digital healthcare research and innovation. The article reviews key milestones in AHRQ's digital healthcare initiatives, including its founding and its advances in telehealthcare and clinical decision support. It highlights AHRQ's contributions to advancing technology integration in healthcare, promoting patient safety, and addressing equity gaps. The article also examines the evolving role of artificial intelligence (AI) in healthcare delivery. AHRQ's Digital Healthcare Research Program has significantly contributed to improving healthcare quality. As digital technologies evolve, particularly with AI, the program remains focused on enhancing safety, equity, and efficiency in healthcare. Continued research and investment will be essential to maintaining progress and addressing new challenges.

Care partner engagement in patient safety at the direct care level in hospital: a qualitative systematic review protocol.

The objective of this systematic review is to understand the experiences of care partner engagement in patient safety at the direct care level from the perspective of care partners, patients, and health care professionals. Care partner engagement is a strategy for promoting patient safety in hospitals at the direct care level (ie, at the point where patient care is delivered). When present, care partners can increase safety by watching, listening, and taking action to protect admitted patients. To improve care partner presence policies and safety engagement strategies within hospitals, a comprehensive understanding of the current qualitative evidence about the breadth of experiences of care partner engagement in patient safety is required. This review will include qualitative studies that consider the experiences of care partners, adult patients, and health care professionals. The engagement of care partners in patient safety within pediatric hospital settings will not be considered. This review will follow the JBI methodology for systematic reviews of qualitative evidence. A preliminary literature search was conducted in MEDLINE and a full search strategy was developed for MEDLINE, Embase, CINAHL, and PsycINFO (all via Ovid), as well as the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis. The JBI approach to study selection, critical appraisal, data extraction, data synthesis, and assessment of confidence will be followed. Two reviewers will test the screening criteria and data extraction protocol. PROSPERO CRD42023476286.

EP427 - Are we following the RCS England Guidelines for documentation of the operation note for a laparoscopic appendicectomy: A complete audit loop

Abstract Introduction The audit outlines the importance of adhering to RCS England Guidelines for documenting laparoscopic appendicectomies. Following these guidelines ensures standardized documentation, facilitating effective communication and promoting patient safety. Moreover, it underscores the significance of recording key procedural steps and techniques employed during the operation. It highlights the guidelines' emphasis on legible, timely, and complete documentation, emphasizing the role of the operation note as a legal document. Method This audit involved collecting data from September 2022 - August 2023 for the first loop to analyse operative notes of 92 laparoscopic appendicectomy cases. For the second loop, after introducing an electronic procedure-specific checklist as a guide, we reviewed 30 notes prospectively over a 2-month period (November-December 2023). The notes were compared against RCS England ‘Good Surgical Practice’ 2014 Guidelines using 18 parameters. We assessed for compliance with the guidelines and the legibility of notes. Results After introduction of a checklist, average compliance with guidelines increased significantly in 9 of the 18 parameters assessed, 6 remained unchanged at almost 100% compliance. Two key areas for emphasis were identified: instructions for post-op antibiotics (83%), DVT prophylaxis (53%). The most noticeable lack of documentation was in the gynaecological findings of females, recorded in only 13% of cases. There has been a noticeable effort in improving the legibility of the notes. Conclusion Introduction of a checklist increased compliance with guidelines. The comprehensive documentation will ultimately promote optimal patient outcomes and advance the overall quality of surgical care.

Prescribing Errors in an Ambulatory Care Setting: Mitigating Risks in Outpatient Medication Orders, Cross-Sectional Review.

Prescribing errors (PEs) are the most common type of medication error, which may occur by prescribing the wrong medication, improper dose, dosage, and/or even prescribing a drug to the wrong patient. The present study aims to compile PEs that were generated in an ambulatory care setting at a tertiary-care hospital in Saudi Arabia. A retrospective cross-sectional review was conducted for all reported PEs in ambulatory care clinics for 3 years. The potential hazardous outcomes of these PEs were classified according to the medication error index. A total of 897 records containing 1199 PEs were retrieved. More than a third of prescribers had frequently committed PEs-ranging from 2 to 39 times. The most encountered errors were prescribing incorrect doses, medication duplication, incorrect dosing frequency, and inappropriate duration (34.5%, 14.1%, 11.6%, and 9.8%, respectively). The most frequent mistakes were when prescribing antibiotics (22.9%) and drugs for cardiovascular conditions (18.5%). Most errors were of mild to moderate severity, mostly type-B near-miss errors and did not reach patients. Only two prescription events (0.17%) had severe consequences that required intervention to avoid any subsequent harm or damage. The current investigation has revealed a substantial percentage of PEs, mostly in internal medicine and cardiology departments. Although PEs are undoubtedly not easy to avoid, monitoring and recognizing these inaccuracies is pivotal to preventing potential harm and promoting patient safety.

Evaluation of leukocyte depletion of packed red blood cells for the prevention of clinically observed transfusion reactions at a medical center in Eastern Taiwan

ABSTRACT Objectives: The incidence of febrile nonhemolytic transfusion reactions (FNHTRs) is correlated with the level of cytokines released by donor leukocytes in blood bags during storage, which is the most common transfusion reaction. The study aimed to reveal whether the use of leukocyte-poor red blood cells (LPRBCs) can reduce the incidence of transfusion reactions to promote patient safety. Materials and Methods: From January 2014 to June 2022, 158,122 blood transfusion reports were collected from a medical center in Eastern Taiwan. Data were categorized into three groups according to usage prepromotion use of LPRBCs (January 2014–April 2016), promotion use of LPRBCs (May 2016 to February 2018), and full utilization of LPRBCs (March 2018 to June 2022). According to the American Association of Blood Bank Common Transfusion Reaction Reporting Form version 2.0 reporting system, FNHTRs were classified as moderate transfusion reactions. We used these data to analyze the association between LPRBC use and transfusion reaction rate. Results: At our hospital, the LPRBC usage rate from January 2014 to April 2016, May 2016 to February 2018, and March 2018 to June 2022 was 5.37%, 34.82%, and 56.45%, respectively. The total transfusion reaction rate from January 2014 to April 2016 was 1.66%, whereas the moderate reaction rate was 1.29%. The total transfusion and moderate reaction rates from May 2016 to February 2018 were 1.41% and 1.00%, whereas those from March 2018 to June 2022 were 0.95% and 0.63%, respectively. The total transfusion and moderate reaction rates from March 2018 to June 2022 decreased by 42.8% and 51.2%, respectively, compared with those from January 2014 to April 2016. We further compared the incidence of transfusion reactions caused by packed red blood cells (PRBC) and LPRBC products in different years. The results showed that between 2014 and 2022, the types of blood transfusion reaction caused using PRBC and LPRBC products are the mild transfusion reaction rate of 0.20%/0.20%, the moderate transfusion reaction rate of 1.61%/0.69%, the severe transfusion reaction rates 0.38%/0.16%, and the total transfusion reaction rates 2.19%/1.05%. Conclusion: Our study results indicate that both total transfusion and moderate reaction rates significantly decreased with increasing LPRBC usage rate. Based on our data analysis, LPRBC is more effective in reducing moderate and severe transfusion reactions than PRBC.

Improving the secondary diagnoses capture rate in SingHealth Community Hospital discharge summaries: a quality improvement project made successful by change management principles

High-quality discharge summaries are essential for promoting patient safety during transitions between care settings. When the diagnosis list in the discharge summary is not accurate, the subsequent care provider will...

Assessing Patient Safety Culture: Insights from a Neurological Institute.

A cross-sectional descriptive study was conducted among healthcare workers exercising at a neurological institution using a validated Hospital Survey of Patient Safety Culture questionnaire containing ten safety care dimensions. A total of 123 responses to the questionnaire were analyzed, accounting for 34.5% of the total (Cronbach's alpha=0.677). Among the participants, 61.8% considered the level of awareness regarding patient safety to be acceptable. The dimensions considered as strengths were "Organizational learning and continuous improvement" with the highest positive response (60.3%) "Relationship patient-staff member" (58.9%) and "Teamwork within units" (58.9%). However, the dimensions considered as weaknesses were "Management support for patient safety" with 28.5% of positive responses and "Communication openness and non-punitive response to error" (40%). Patient safety culture among healthcare professionals is at an average with "Organizational learning and continuous improvement" being a positive aspect. However, improvements should be made in all dimensions to enhance and promote patient safety within the institution.