Patient safety in surgical settings: A study on the challenges and improvement strategies in adverse event reporting from a nursing perspective

AIMS

To explore adverse event reporting in the surgical department through the nurses' experiences and perspectives.

DESIGN

An exploratory, descriptive qualitative study was conducted with a theoretical-methodological orientation of phenomenology.

METHODS

In-depth interviews were conducted with 15 nurses, followed by an inductive thematic analysis.

RESULTS

Themes include motives for reporting incidents, consequences, feelings and motivational factors. Key facilitators of adverse event reporting were effective communication, knowledge sharing, a non-punitive culture and superior feedback.

CONCLUSION

The study underscores the importance of supportive organisational culture for reporting, communication and feedback mechanisms, and highlights education and training in enhancing patient safety.

IMPLICATIONS

It suggests the need for strategies that foster incident reporting, enhance patient safety and cultivate a supportive organisational culture.

IMPACT

This study provides critical insights into adverse event reporting in surgical departments from nurses' lived experience, leading to two primary impacts: It offers specific solutions to improve adverse event reporting, which is crucial for surgical departments to develop more effective and tailored reporting strategies. The research underscores the importance of an open, supportive culture in healthcare, which is vital for transparent communication and effective reporting, ultimately advancing patient safety.

REPORTING METHOD

The study followed the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines.

PATIENTS OR PUBLIC CONTRIBUTION

No patients or public contribution.

Mediating Role of Rumination in Second Victim Experience to Turnover Intention in Psychiatric Nurses

BACKGROUND

Psychiatric nurses often face patient safety incidents that can cause physical and emotional harm, even leading to s econd victim syndrome and staff shortages. Rumination-a common response after nurses suffer a patient safety event-may play a specific role between the second victim experience and turnover intention. Understanding these mechanisms is crucial for supporting psychiatric nurses and retaining psychiatric nursing resources.

OBJECTIVES

The study aimed to explore the associations among second victim experience, rumination, and turnover intention in psychiatric nurses and confirm how second victim experience influences turnover intention through rumination and its subtypes.

METHODS

A descriptive, cross-sectional study was adapted to survey 252 psychiatric nurses who experienced a patient safety incident at three hospitals in China between March and April 2023. We used the Sociodemographic and Patient Safety Incident Characteristics Questionnaire (the Chinese version of the Second Victim Experience and Support Tool), the Event-Related Rumination Inventory, and the Turnover Intention Scale. Path analysis with bootstrapping was employed to accurately analyze and estimate relationships among the study variables.

RESULTS

There was a positive association between second victim experience and turnover intention. In addition, both invasive and deliberate rumination showed significant associations with second victim experience and turnover intention. Notably, our results revealed that invasive and deliberate rumination played partial mediating roles in the relationship between second victim experience and turnover intention in psychiatric nurses.

DISCUSSION

The negative experience and turnover intention of the psychiatric nurse second victims are at a high level. Our results showed that invasive rumination positively mediated the relationship between second victim experience and turnover intention, and deliberate rumination could weaken this effect. This study expands the knowledge of the mechanisms underlying the effect of the second victim experience on turnover intention. Organizations must attach importance to the professional dilemmas of the psychiatric nurses' second victims. Nurse managers can reduce nurses' turnover intention by taking measures to reduce invasive rumination and fostering deliberate meditation to help second victims recover from negative experiences.

TeamSTEPPS improves patient safety

BACKGROUND

Examine how Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) can be used to manage patient safety and improve the standard of care for patients.

METHODS

In order to improve key medical training in areas like surgical safety management, blood transfusion closed-loop management, drug safety management and identity recognition, we apply the TeamSTEPPS teaching methodology. We then examine the effects of this implementation on changes in pertinent indicators.

RESULTS

Our hospital's perioperative death rate dropped to 0.019%, unscheduled reoperations dropped to 0.11%, and defined daily doses fell to 24.85. Antibiotic usage among hospitalised patients declined to 40.59%, while the percentage of antibacterial medicine prescriptions for outpatient patients decreased to 13.26%. Identity recognition requirements were implemented at a rate of 94.5%, and the low-risk group's death rate dropped to 0.01%. Critical transfusion episodes were less common, with an incidence of 0.01%. The physician's TeamSTEPPS Teamwork Perceptions Questionnaire and Teamwork Attitudes Questionnaire scores dramatically improved following the TeamSTEPPS team instruction course.

CONCLUSION

An evidence-based team collaboration training programme called TeamSTEPPS combines clinical practice with team collaboration skills to enhance team performance in the healthcare industry and raise standards for medical quality, safety, and effectiveness.

Digital Health Interventions and Patient Safety in Abdominal Surgery: A Systematic Review and Meta-Analysis

Importance

Over the past 2 decades, several digital technology applications have been used to improve clinical outcomes after abdominal surgery. The extent to which these telemedicine interventions are associated with improved patient safety outcomes has not been assessed in systematic and meta-analytic reviews.

Objective

To estimate the implications of telemedicine interventions for complication and readmission rates in a population of patients with abdominal surgery.

Data Sources

PubMed, Cochrane Library, and Web of Science databases were queried to identify relevant randomized clinical trials (RCTs) and nonrandomized studies published from inception through February 2023 that compared perioperative telemedicine interventions with conventional care and reported at least 1 patient safety outcome.

Study Selection

Two reviewers independently screened the titles and abstracts to exclude irrelevant studies as well as assessed the full-text articles for eligibility. After exclusions, 11 RCTs and 8 cohort studies were included in the systematic review and meta-analysis and 7 were included in the narrative review.

Data Extraction and Synthesis

Data were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline and assessed for risk of bias by 2 reviewers. Meta-analytic estimates were obtained in random-effects models.

Main Outcomes and Measures

Number of complications, emergency department (ED) visits, and readmissions.

Results

A total of 19 studies (11 RCTs and 8 cohort studies) with 10 536 patients were included. The pooled risk ratio (RR) estimates associated with ED visits (RR, 0.78; 95% CI, 0.65-0.94) and readmissions (RR, 0.67; 95% CI, 0.58-0.78) favored the telemedicine group. There was no significant difference in the risk of complications between patients in the telemedicine and conventional care groups (RR, 1.05; 95% CI, 0.77-1.43).

Conclusions and Relevance

Findings of this systematic review and meta-analysis suggest that perioperative telehealth interventions are associated with reduced risk of readmissions and ED visits after abdominal surgery. However, the mechanisms of action for specific types of abdominal surgery are still largely unknown and warrant further research.

The Volume and Cost of Quality Metric Reporting

Importance

US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known.

Objective

To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts.

Design, Setting, and Participants

Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year.

Main Outcomes and Measures

Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type.

Results

A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year).

Conclusions and Relevance

Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

Trends in Adverse Event Rates in Hospitalized Patients, 2010-2019

IMPORTANCE

Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade.

OBJECTIVE

To determine the change in the rate of adverse events in hospitalized patients.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study used data from the Medicare Patient Safety Monitoring System from 2010 to 2019 to assess in-hospital adverse events in patients. The study included 244 542 adult patients hospitalized in 3156 US acute care hospitals across 4 condition groups from 2010 through 2019: acute myocardial infarction (17%), heart failure (17%), pneumonia (21%), and major surgical procedures (22%); and patients hospitalized from 2012 through 2019 for all other conditions (22%).

EXPOSURES

Adults aged 18 years or older hospitalized during each included calendar year.

MAIN OUTCOMES AND MEASURES

Information on adverse events (abstracted from medical records) included 21 measures across 4 adverse event domains: adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events (hospital-acquired pressure ulcers and falls). The outcomes were the total change over time for the observed and risk-adjusted adverse event rates in the subpopulations.

RESULTS

The study sample included 190 286 hospital discharges combined in the 4 condition-based groups of acute myocardial infarction, heart failure, pneumonia, and major surgical procedures (mean age, 68.0 [SD, 15.9] years; 52.6% were female) and 54 256 hospital discharges for the group including all other conditions (mean age, 57.7 [SD, 20.7] years; 59.8% were female) from 3156 acute care hospitals across the US. From 2010 to 2019, the total change was from 218 to 139 adverse events per 1000 discharges for acute myocardial infarction, from 168 to 116 adverse events per 1000 discharges for heart failure, from 195 to 119 adverse events per 1000 discharges for pneumonia, and from 204 to 130 adverse events per 1000 discharges for major surgical procedures. From 2012 to 2019, the rate of adverse events for all other conditions remained unchanged at 70 adverse events per 1000 discharges. After adjustment for patient and hospital characteristics, the annual change represented by relative risk in all adverse events per 1000 discharges was 0.94 (95% CI, 0.93-0.94) for acute myocardial infarction, 0.95 (95% CI, 0.94-0.96) for heart failure, 0.94 (95% CI, 0.93-0.95) for pneumonia, 0.93 (95% CI, 0.92-0.94) for major surgical procedures, and 0.97 (95% CI, 0.96-0.99) for all other conditions. The risk-adjusted adverse event rates declined significantly in all patient groups for adverse drug events, hospital-acquired infections, and general adverse events. For patients in the major surgical procedures group, the risk-adjusted rates of events after a procedure declined significantly.

CONCLUSIONS AND RELEVANCE

In the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.

Safety and effectiveness of up to 3 years' bulevirtide monotherapy in patients with HDV-related cirrhosis

The entry inhibitor bulevirtide (BLV) received conditional approval from the EMA in July 2020 for the treatment of adult patients with compensated chronic hepatitis delta. However, the effectiveness and safety of BLV administered as monotherapy beyond 48 weeks in difficult-to-treat patients with HDV-related cirrhosis is presently unknown. Herein, we describe the first patients with HDV-related compensated cirrhosis who were treated with BLV (10 mg/day as a starting dose) for up to 3 years on a compassionate use program. Patients were also monitored for HBcrAg and HBV RNA levels, and HDV- and HBV-specific T-cell markers. In the patient who stopped BLV at week 48, after achieving a virological and biochemical response, the initial virological and biochemical rebound was followed by alanine aminotransferase normalization coupled with low HDV RNA and HBsAg levels. In the 2 patients treated continuously for 3 years, virological and biochemical responses were maintained throughout the treatment period even after dose reduction. In a patient with advanced compensated cirrhosis, liver function tests significantly improved, esophageal varices disappeared, and histological/laboratory features of autoimmune hepatitis resolved. Overall, no safety issues were recorded, as bile salt increase was asymptomatic. While serum HBV RNA levels remained undetectable in all patients, HBV core-related antigen levels showed a progressive, yet modest decline during long-term BLV treatment. No HDV-specific interferon-γ-producing T cells were detected, neither after HDV reactivation (after BLV withdrawn in Patient 1) nor during 3 years of BLV treatment. In conclusion, this report shows that continuous administration of BLV monotherapy for 3 years leads to excellent virological and clinical responses in patients with HDV-related cirrhosis who had contraindications to interferon-based therapies.

Safety of Gastrointestinal Endoscopy in Korea: A Nationwide Survey and Population-Based Study

BACKGROUND

Attention should be paid to endoscopy-related complications and safety-related accidents that may occur in the endoscopy unit. This study investigated the current status of complications associated with diagnostic and therapeutic endoscopy in Korea.

METHODS

A questionnaire survey on endoscopy-related complications was conducted in a total of 50 tertiary or general hospitals in Korea. The results were compared to the population-level claims data from the Health Insurance Review & Assessment Service (HIRA), which analyzed endoscopy procedures conducted in 2017 in Korea.

RESULTS

The incidences of bleeding associated with diagnostic and therapeutic esophagogastroduodenoscopy (EGD) and with diagnostic and therapeutic colonoscopy were 0.224% and 3.155% and 0.198% and 0.356%, respectively, in the 2017 HIRA claims data, compared to 0.012% and 1.857%, and 0.024% and 0.717%, in the 50 hospitals surveyed. The incidences of perforation associated with diagnostic and therapeutic EGD and with diagnostic and therapeutic colonoscopy were 0.023% and 0.613%, and 0.007% and 0.013%, respectively, in the 2017 HIRA claims data compared to 0.001% and 0.325%, and 0.017% and 0.206%, in the 50 hospitals surveyed. In the HIRA claims data, the incidence of bleeding/perforation after diagnostic colonoscopy in clinics, community hospitals, general hospitals, and tertiary hospitals was 0.129%/0.000%, 0.088%/0.004%, 0.262%/0.009%, and 0.479%/0.030% respectively, and the corresponding incidence of bleeding/perforation after therapeutic colonoscopy was 0.258%/0.004%, 0.401%/0.007%, 0.408%/0.024%, and 0.731%/0.055%.

CONCLUSION

The incidences of complications associated with diagnostic and therapeutic EGD or colonoscopy tended to increase with the hospital volume in Korea.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0001728.

Quality and Safety Outcomes of a Hospital Merger Following a Full Integration at a Safety Net Hospital

IMPORTANCE

Hospital consolidations have been shown not to improve quality on average.

OBJECTIVE

To assess a full-integration approach to hospital mergers based on quality metrics in a safety net hospital acquired by an urban academic health system.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study analyzed outcomes for all nonpsychiatric, nonrehabilitation, non-newborn patients discharged between September 1, 2010, and August 31, 2019, at a US safety net hospital that was acquired by an urban academic health system in January 2016. Interrupted time series and statistical process control analyses were used to assess the main outcomes and measures. Data sources included the hospital's electronic health record, Centers for Medicare & Medicaid Services Hospital Compare, and nursing quality reports.

EXPOSURES

A full-integration approach to the merger that included: (1) early administrative and clinical leadership integration with the academic health system; (2) rapid transition to the academic health system electronic health record; (3) local ownership of quality metrics; (4) system-level goals with real-time actionable analytics through combined dashboards; and (5) implementation of value-based and other analytic-driven interventions.

MAIN OUTCOMES AND MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included 30-day readmission, patient experience, and hospital-acquired conditions.

RESULTS

The 122 348 patients in the premerger (September 2010 through August 2016) and the 58 904 patients in the postmerger (September 2016 through August 2019) periods had a mean (SD) age of 55.5 (22.0) years; the total sample of 181 252 patients included 112 191 women (61.9%), the payor mix was majority governmental (144 375 patients [79.7%]), and most admissions were emergent (121 469 patients [67.0%]). There was a 0.71% (95% CI, 0.57%-0.86%) absolute (27% relative) reduction in the crude mortality rate and 0.95% (95% CI, 0.83%-1.12%) absolute (33% relative) in the adjusted rate by the end of the 3-year intervention period. There was no significant improvement in readmission rates after accounting for baseline trends. There were fewer central line infections per 1000 catheter days, fewer catheter-associated urinary tract infections per 1000 discharges, and a higher likelihood of patients recommending the hospital or ranking it 9 or 10.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, a hospital merger with a full-integration approach to consolidation was found to be associated with improvement in quality outcomes.

Do medical students and residents impact the quality of patient care? An assessment from different stakeholders in an Italian academic hospital, 2019

Medical students and residents play an important role in patient care and ward activities, thus they should follow hospital procedures and ensure best practices and patient safety. A survey concerning staff on training was conducted to assess the perceived quality of healthcare from healthcare workers (HCWs), residents, medical students and patients in Udine Academic Hospital, Italy. Between December, 2018 and March, 2019, a 5-point Likert-scale questionnaire was administered in 21 units, covering four thematic areas: patients and medical staff satisfaction with the quality of care provided by residents and students, patient privacy, clinical risk management, patient perception of staff on training. Data analysis included descriptive analysis and ordered logistic regressions. A total of 596/1,863 questionnaires were collected from: HCWs (165/772), residents (110/355), students (121/389), and patients (200/347). Residents were rated high both by patients (median = 5, IQR = 4–5, OR 0.49, 95%CI 0.26–0.93) and HCWs (median = 4, IQR = 3–5, OR 0.14, 95%CI 0.08–0.26), with a lower score for medical students on the same topic, both by patients (median = 4, IQR = 3–5, OR 2.94, 95%CI 1.49–5.78) and HCWs (median = 3, IQR = 2–3, OR 0.41, 95%CI 0.25–0.67). Therefore, the role of staff on training in quality and safety of healthcare deserves integrated regular evaluation, since direct interaction with patients contributes to patients’ perception of healthcare.

The role of hospital characteristics in patient safety: a protocol for a national cohort study

BACKGROUND

Substantial expenditures on health care safety programs have been justified by their goal of reducing health care associated-harm (adverse events), but adverse event rates have not changed over the past 4 decades. The objective of this study is to describe hospital-level factors that are relevant to safety in Canadian hospitals and the impact of these factors on hospital adverse events.

METHODS

This is a protocol for a national cohort study to describe the association between hospital-level factors and adverse events. We will survey at least 90 (35%) Canadian hospitals to describe 4 safety-relevant domains, chosen based on the literature and expert consultation, namely patient safety culture, safety strategies, staffing, and volume and capacity. We will retrospectively identify hospital adverse events from a national data source. We will evaluate organization-level factors using established scales and a survey, codesigned by the study team and hospital leaders. Hospital leaders, clinical unit leaders and front-line staff will complete the surveys once a year for 3 years, with an anticipated start date of winter 2022. We will use national health administrative data to estimate the rate and type of hospital adverse events corresponding to each 1-year survey period.

INTERPRETATION

Analysis of data from this project will describe hospital organizational factors that are relevant to safety and help identify organizational initiatives that improve hospital patient safety. In addition to biyearly reports to the leaders of the participating hospitals, we have a multifaceted and tailored dissemination strategy that includes integrating the knowledge users into the study team to increase the likelihood that our study will lead to improved hospital patient safety.

Safety and Efficacy of Flexible-Dose Deutetrabenazine in Children and Adolescents With Tourette Syndrome: A Randomized Clinical Trial

IMPORTANCE

Tourette syndrome is a neurodevelopmental disorder characterized by childhood onset of motor and phonic tics; treatments for tics are associated with safety concerns. Deutetrabenazine is a selective vesicular monoamine transporter 2 inhibitor approved for the treatment of chorea associated with Huntington disease and tardive dyskinesia in adults.

OBJECTIVE

To examine whether deutetrabenazine is effective and safe for the treatment of Tourette syndrome in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This phase 2/3, randomized, double-masked, placebo-controlled, parallel-group, dose-titration study included children and adolescents (aged 6-16 years) with Tourette syndrome with active tics causing distress or impairment (ie, Yale Global Tic Severity Scale-Total Tic Score [YGTSS-TTS] ≥20). The trial was conducted over 12 weeks, with 1 week of follow-up from February 2018 to November 2019 at 36 centers in the United States, Canada, Denmark, Russia, Serbia, and Spain. Data analysis was conducted from January 31 to April 22, 2020.

INTERVENTION

Patients were randomized (1:1) to receive deutetrabenazine or placebo, titrated during 7 weeks to an optimal level, followed by a 5-week maintenance period. The maximum total daily deutetrabenazine dose was 48 mg/d.

MAIN OUTCOMES AND MEASURES

The primary efficacy end point was change from baseline to week 12 in YGTSS-TTS. Key secondary end points included changes in Tourette Syndrome-Clinical Global Impression, Tourette Syndrome-Patient Global Impression of Impact, and Child and Adolescent Gilles de la Tourette Syndrome-Quality of Life Activities of Daily Living subscale score. Safety was assessed based on treatment-emergent adverse events, vital signs, questionnaires, and laboratory parameters.

RESULTS

A total of 119 participants were randomized to deutetrabenazine (59 participants; mean [SD] age, 11.5 [2.5] years; 53 [90%] boys; 49 [83%] White; 3 [5%] Black) and placebo (60 participants; mean [SD] age, 11.5 [2.6] years; 51 [85%] boys; 53 [88%] White; 3 [5%] Black). At week 12, the difference in YGTSS-TTS score was not significant between deutetrabenazine and placebo (least squares mean difference, -0.7; 95% CI, -4.1 to 2.8; P = .69; Cohen d, -0.07). There were no nominally significant differences between groups for key secondary end points. Treatment-emergent adverse events were reported for 38 patients (66%) and 33 patients (56%) receiving deutetrabenazine and placebo, respectively, and were generally mild or moderate.

CONCLUSIONS AND RELEVANCE

In this study of deutetrabenazine in children and adolescents with Tourette syndrome, the primary efficacy end point was not met. No new safety signals were identified. These results may be informative for future studies of treatments for tics in Tourette syndrome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03452943.

Evaluation of efficacy and safety of propofol in the treatment of procedural sedation/anesthesia in neonates: A protocol for systematic review and meta-analysis

BACKGROUND

In newborns, propofol anesthesia is commonly utilized. Propofol is increasingly being shown to be effective and safe in treating procedural sedation and anesthesia in neonates. This research aims to evaluate the efficacy and safety of propofol in neonates using systematic review and meta-analysis methodologies.

METHODS

A thorough review and meta-analysis of studies on propofol anesthesia in neonates will be conducted. Conduct comprehensive searches in Web of Science, PubMed, Cochrane Library, EMBASE database, WanFang database, and Chinese biomedical literature database before May 25, 2021, to obtain published and qualified research. Two reviewers will assess the quality of the included papers and extract the data independently. Then, for meta-analysis, we will utilize RevMan 5.3 software.

RESULTS

This study will pool the data of separate trials to analyze the efficacy and safety of propofol in the treatment of procedural sedation/anesthesia in neonates.

CONCLUSION

Our findings will give strong data for determining whether propofol is an effective treatment for procedural anesthesia in neonates.

Colchicine efficacy and safety for the treatment of cardiovascular diseases

The emerging role of colchicine in the treatment of cardiovascular diseases is a strong demand for a comprehensive understanding of its efficacy and safety. This meta-analysis and systematic review aimed to study the efficacy in the reduction of adverse cardiovascular outcomes (CO), and the risk of colchicine-related adverse events (CRAEs). Fourteen thousand and nine eighty three patients from 22 randomized controlled trials (RCTs) were included, 9 in patients with coronary artery disease-CAD, 9 in patients with pericarditis, 4 in patients with atrial fibrillation-AF or heart failure. Colchicine was efficacious in the reduction of adverse CO across different settings: pericardial diseases (reduced risk of recurrent pericarditis, 17.6% vs. 35%, RR 0.50, 95% CI 0.41-0.61), CAD (reduced risk of cardiac death, myocardial infarction, stroke,coronary revascularization or hospitalization, 6.1% vs. 8.5%, RR 0.73, 95% CI 0.64-0.83), AF (reduced risk of arrhythmia recurrence, 14.2% vs. 22.7%, RR 0.62, 95% CI 0.44-0.88). Colchicine was associated with increased risk of gastrointestinal CRAEs (11.2% vs. 8.8%, RR 1.87, 95% CI 1.41-2.47) and drug discontinuation (5.4% vs. 3.7%, RR 1.58, 95% CI 1.25-1.99). In both cases, the risk was proportional to the daily dose or duration of treatment, possibly due to early drug discontinuation or tolerance. Other CRAEs (muscle-related, liver,hematologic,cutaneous, infections) were not increased by colchicine, as long as all-cause death (2.2% vs. 1.9%, RR 1.11, 95% CI 0.79-1.54) or non-cardiovascular death (1.5% vs. 1%, RR 1.43, 95% CI 0.93-2.19). Colchicine is efficacious and safe for the treatment of cardiovascular diseases. The risk of gastrointestinal CRAEs and drug discontinuation is not significant if colchicine is used at lower doses (0.5 mg daily) or for longer periods of time (> 6 months).

Evaluating Quality Improvement and Patient Safety Amongst Practicing Urologists: Analysis of the 2018 American Urological Association Census

OBJECTIVE

To describe factors associated with Quality improvement and patient safety (QIPS) participation using 2018 American Urological Association Census data. QIPS have become increasingly important in medicine. However, studies about QIPS in urology suggest low levels of participation, with little known about factors predicting non-participation.

METHODS

Results from 2339 census respondents were weighted to estimate 12,660 practicing urologists in the United States. Our primary outcome was participation in QIPS. Predictor variables included demographics, practice setting, rurality, fellowship training, QIPS domains in practice, years in practice, and non-clinical/clinical workload.

RESULTS

QIPS participants and non-participants significantly differed in distributions of age (P = .0299), gender (P = .0013), practice setting (P <.0001), employment (employee vs partner vs owner vs combination; P <.0001), and fellowship training (P <.0001). QIPS participants reported fewer years in practice (21.3 vs 25.9, P = .018) and higher clinical (45.2 vs 39.2, P = .022) and non-clinical (8.76 vs 5.28, P = .002) work hours per week. Non-participation was associated with male gender (OR = 2.68, 95% CI 1.03-6.95) and Asian race (OR = 2.59, 95% CI 1.27-5.29) for quality programs and private practice settings (ORs = 8.72-27.8) for patient safety initiatives.

CONCLUSION

QIPS was associated with academic settings. Interventions to increase rates of quality and safety participation should target individual and system-level factors, respectively. Future work should discern barriers to QIPS engagement and its clinical benefits.

Perioperative patient safety management activities: A modified theory of planned behavior

Patient safety is an important healthcare issue worldwide, and patient accidents in the operating room can lead to serious problems. Accordingly, we investigated the explanatory ability of a modified theory of planned behavior to improve patient safety activities in the operating room. Questionnaires were distributed to perioperative nurses working in 12 large hospitals in Korea. The modified theory of planned behavior data from a total of 330 nurses were analyzed. The conceptual model was based on the theory of planned behavior data, with two additional organizational factors—job factors and safety management system. Individual factors included attitude, subjective norms, perceived behavioral control, behavioral intention, and patient safety management activities. Results indicated that job factors were negatively associated with perceived behavioral control. The patient safety management system was positively associated with attitude, subjective norm, and perceived behavioral control. Attitude, subjective norm, and perceived behavioral control were positively associated with behavioral intention. Behavioral intention was positively associated with patient safety management activities. The modified theory of planned behavior effectively explained patient safety management activities in the operating room. Both organizations and individuals are required to improve patient safety management activities.

Safety Events in Children's Hospitals During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. Our objective was to compare pediatric hospitalization safety events during the pandemic versus previous years.

METHODS

In this retrospective cohort study of hospitalizations in the Pediatric Health Information System, we compared Pediatric Quality Indicator (PDI) rates from March 15 to May 31, 2017-2019 (pre-COVID-19), with those from March 15 to May 31, 2020 (during COVID-19). Generalized linear mixed-effects models with adjustment for patient characteristics (eg, diagnosis, clinical severity) were used.

RESULTS

There were 399 113 discharges pre-COVID-19 and 88 140 during COVID-19. Unadjusted PDI rates were higher during versus pre-COVID-19 for overall PDIs (6.39 vs 5.05; P < .001). In adjusted analyses, odds of postoperative sepsis were higher during COVID-19 versus pre-COVID-19 (adjusted odds ratio 1.28 [95% confidence interval 1.04-1.56]). The remainder of the PDIs did not have increased adjusted odds during compared with pre-COVID-19.

CONCLUSIONS

Postoperative sepsis rates increased among children hospitalized during COVID-19. Efforts are needed to improve safety of postoperative care for hospitalized children.

Hospital variation in responses to safety warnings about power morcellation in hysterectomy

BACKGROUND

Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes.

OBJECTIVE

This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy.

STUDY DESIGN

This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions.

RESULTS

Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72).

CONCLUSION

Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.

Adverse events experienced with intrahospital transfer of critically ill patients: A national survey

ABSTRACT

Research that focuses on transfers to and from the intensive care unit (ICU) could highlight important patients' safety issues. This study aims to describe healthcare workers' (HCWs) practices involved in patient transfers to or from the ICU.This cross-sectional study was conducted among HCWs during the Saudi Critical Care Society's annual International Conference, April 2017. Responses were assessed using Likert scales and frequencies. Bivariate analysis was used to evaluate the significance of different indicators.Overall, 312 HCWs participated in this study. Regarding transfer to ICUs, the most frequently reported complications were deterioration in respiratory status (51.4%), followed by deterioration in hemodynamic status (46.5%), and missing clinical information (35.5%). Regarding transfers from ICUs to the general ward, the most commonly reported complications were changes in respiratory status (55.6%), followed by incomplete clinical information (37.9%), and change in hemodynamic conditions (29%). The most-used models for communicating transfers were written documents in electronic health records (69.3%) and verbal communication (62.8%). One-fourth of the respondents were not aware of the Situation, Background, Assessment, Recommendation (SBAR) method of patients' handover. Pearson's test of correlation showed that the HCW's perceived satisfaction with their hospital transfer guidelines showed significant negative correlation with their reported transfer-related complications (r = -0.27, P < .010).Hemodynamic and respiratory status deterioration is representing significant adverse events among patients transferred to or from the ICU. Factors controlling the perceived satisfaction of HCWs involved in patients, transfer to and from the ICU need to be addressed, focusing on their compliance to the hospital-wide transfer and handover policies. Quality improvement initiatives could improve patient safety to transfer patients to and from the ICU and minimize the associated adverse events.

Predictors of patient safety culture in hospitals in Venezuela: A cross-sectional study

An organization's culture with regard to patient safety is important because it defines the beliefs and practices of the organization, and consequently its efficiency and productivity.Knowing the level of this and the factors that influence or not their dynamic represents a challenge, due to the degree of complexity and specificity of the elements involved.The aim of this study was to analyze predictors of patient safety culture in public and private hospitals and examining the factors that contribute to it, constructing a new and specific theoretical and methodological model.This study was carried out by reviewing medical records, detecting healthcare professionals directly involved in caring (N = 588), for patients in 2 public hospitals and 2 private hospitals in Venezuela (N = 566), conducting an "Analysis of Patient Safety Culture" questionnaire. The results were subsequently analyzed, derived 3 predictors factors and using a Patient Safety Culture Index (PSCI) for specific determination to evaluate patient safety culture level.The analysis showed that all hospitals had a "moderately unfavorable" PSCI (public = 52.96, private = 52.67, sig = 0.90). The PSCI was calculated by assessing the weight of the following factors in the index: occupational factors (factor loading = 32.03), communication factors (factor loading = 11.83), and organizational factors (factor loading = 9.10). Traumatology presented the lowest PSCI of all the care units, falling into the "unfavorable" category (36.48), and Laboratory the highest (70.02) (sig = 0.174), falling into the "moderately favorable" category. When analyzing professional groups, nurses had the highest PSCI, with a "moderately unfavorable" rating (PSCI = 61.1) and medical residents the lowest, falling into the "unfavorable" category (35.2). Adverse event reporting is determined by "management expectations and actions" (sig = 0.048) and "direct interaction with the patient" (sig = 0.049).The use of this theoretical and methodological approach in other contexts may provide a more objective system for identifying more specific needs and factors that influence in patient safety culture, and consequently, opportunities for improvement when constructing a patient safety culture in healthcare institutions. Efforts need to be made to improve safety culture in the hospitals studied, irrespective of whether they are public or private.

Manuka Honey: Feasibility and Safety in Postoperative Neurosurgical Wound Care

OBJECTIVE

To date, no reports have been published on active Leptospermum manuka honey (ALH) feasibility as a postoperative topical wound supplement in neurosurgical patients. The objective of the study is to present the authors' initial experience with using ALH in postoperative neurosurgical patients.

METHODS

A single-surgeon retrospective case series review of cranial and spinal operations between 2018 and 2020 was performed in patients with nonhealing wounds or wounds deemed "at risk" as defined by grade 1 Sandy surgical wound dehiscence grading classification. An ALH gel or ointment was applied to these incisions once a day for 2 to 4 weeks. Patients were followed up in the clinic every 2 weeks until incisions had healed.

RESULTS

Twenty-five postoperative patients (12 cranial, 13 spinal) were identified to be at high risk of operative debridement. All 25 patients were prescribed a topical application of ALH, which was easily adopted without patient-related adverse events. Seven (four cranial, three spinal) patients required operative debridement and treatment with long-term antibiotic therapy.

CONCLUSIONS

In this small case series of neurosurgical patients who were at risk of poor wound healing, the application of medical-grade ALH was well tolerated without patient-reported adverse events. The ALH may have prevented the need for operative debridement in the majority of patients. Further prospective studies are necessary to establish its efficacy in wound healing in the neurosurgical population.

Factors Associated With Job Satisfaction in Medical Oncology Practices: Results From a Multisite Survey

OBJECTIVE

The aim of this study was to examine the factors influencing job satisfaction of nurses, physicians, and advanced practice providers in ambulatory oncology settings.

BACKGROUND

Job satisfaction is essential to clinician well-being and quality of care.

METHODS

In 2017, clinicians from 29 ambulatory medical oncology practices completed anonymous paper questionnaires that examined job satisfaction, clinician-to-clinician communication, and perceptions of patient safety. Linear regression, adjusted for clustered observations, examined the relationship between job satisfaction, clinician communication, and patient safety perceptions.

RESULTS

Of 280 respondents (response rate of 68%), 85% reported that they were satisfied or very satisfied with their current position. Patient safety and accuracy of clinician communication were positively and significantly associated with job satisfaction.

CONCLUSIONS

Although most surveyed clinicians were satisfied, 15% were dissatisfied and reported communication and safety concerns. Leadership efforts to strengthen clinician communication actions and develop positive safety cultures are promising strategies to promote clinician well-being and high-quality cancer care.

Using In Situ Simulations to Improve Pediatric Patient Safety in Emergency Departments

PROBLEM

Given the complex interaction among patients, individual providers, health care teams, and the clinical environment, patient safety events with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments (EDs). With low-frequency, high-risk events such as pediatric resuscitations, health care teams working in EDs may not have the clinical opportunity to identify deficiencies, review and reinforce knowledge and skills, and problem solve in authentic clinical conditions. Without creating opportunities to safely practice, hospitals run the risk of having health care teams and environments that are not prepared to provide optimal patient care.

APPROACH

Researchers employed a case series design and used a train-the-trainer model for in situ simulation. They trained health care professionals (instructors) in 3 general, nonacademic EDs in the San Francisco Bay area of California to perform pediatric resuscitation in situ simulations in 2018-2019. In situ simulations occur in the clinical work environment with simulation participants (teams) who are health care professionals taking care of actual patients.

OUTCOMES

Teams made up of physicians, nurses, and ED technicians were evaluated for clinical performance, teamwork, and communication during in situ simulations conducted by instructors at baseline, 6 months, and 12 months. Debriefing after the simulations identified multiple latent safety threats (i.e., unidentified potential safety hazards) that were previously unknown. Each ED's pediatric readiness-its ability to provide emergency care for children-was evaluated at baseline and 12 months.

NEXT STEPS

The authors will continue to monitor and examine the impact and sustainability of the pediatric in situ simulation program on pediatric readiness scores and its possible translation to other high-risk clinical settings, as well as explore the relationship between in situ simulations and patient outcomes.

Nurse Sensemaking for Responding to Patient and Family Safety Concerns

BACKGROUND

Hospitals need to prevent, respond to, and learn from safety risks and events perceived by patients and families, who in turn rely on nurses to respond to and report their safety concerns.

OBJECTIVES

The aim of the study was to describe the process by which bedside nurses evaluate and determine the appropriate response to safety concerns expressed by patients or their families.

METHODS

A qualitative design was employed. We recruited inpatient bedside nurses in an 811-bed Midwest academic medical center. Nurses provided demographic information and participated in semistructured interviews designed to elicit narratives related to evaluation and response to patient- or family-expressed safety concerns. Data analysis and interpretation were guided by grounded theory.

RESULTS

We enrolled 25 nurses representing 22 units. Based on these nurses' experiences, we developed a grounded theory explaining how nurses evaluate a patient or family safety concern. Nurses make sense of the patient's or family's safety concern in order to take action. Achieving this goal requires evaluation of the meaningfulness and reasonableness of the concern, as well as the potential effect of the concern on the patient. Based on this nursing evaluation, nurses respond in ways designed to (a) manage emotions, (b) immediately resolve concerns, (c) involve other team members, and (d) address fear or uncertain grounding in reality. Nurses reported routinely handling safety concerns at the bedside without use of incident reporting.

DISCUSSION

Safety requires an interpersonal and evaluative nursing process with actions responsive to patient and family concerns. Safety interventions designed to be used by nurses should be developed with the dynamic, cognitive, sensemaking nature of nurses' routine safety work in mind. Being sensitive to the vulnerability of patients, respecting patient and family input, and understanding the consequences of dismissing patient and family safety concerns are critical to making sense of the situation and taking appropriate action to maintain safety. Measuring patient safety or planning improvement based on patient or family expression of safety concerns would be a difficult undertaking using only standard approaches. A more complex approach incorporating direct patient engagement in data collection is necessary to gain a complete safety picture.

Cultural adaptation of the Safety Attitudes Questionnaire - Short Form (SAQ-SF) in Poland

Background

It is essential to provide safe healthcare in complex, difficult, and quickly changing conditions. The quality of healthcare services directly influences the safety of both the patients and staff. Understanding healthcare staff attitudes toward safety in the healthcare delivery context is foundational for building a culture of safety.

Aim of the work

To adapt, via a structured translation methodology, the Safety Attitudes Questionnaire–Short Form (SAQ-SF), which assesses how employees of the health care sector perceive the safety climate in their workplace, to the Polish context.

Methods

Using a content validation approach to structure the translation process, we tested and psychometrically analysed the translated SAQ-SF. The sample comprised 322 employees of a district hospital (second referral level, which ensures 24/7 emergency care services) in Poland.

Results

The reliability of the sub-scales of the Polish version of the SAQ-SF ranged from 0.66 to 0.95. The discriminatory power of particular SAQ items ranged between 0.02 and 0.90. For 6 out of the 8 scale dimensions, the questions with the highest factor loadings were those measuring the same dimensions of the safety climate, according to the original scale.

Conclusions

The Polish version of the SAQ-SF (SAQ-SF-PL) meets the criteria of psychometric and functional validation as well as demonstrates good reliability as a measure of patient safety culture in the Polish context. The SAQ-SF-PL is an instrument that enable a valid and reliable assessment of patient safety climate in the Polish healthcare facilities and identify opportunities for improvement. International comparisons will also become easier.

Satisfaction and Technology Acceptance of Staff Regarding Use of Continuous Video Monitoring in Comparison With Sitters

OBJECTIVE

The purpose of this study was to determine staff satisfaction and technology acceptance of continuous video monitoring (CVM) in comparison to sitters.

BACKGROUND

Traditionally, sitters have been used to prevent falls in hospitals. Continuous video monitoring has emerged to reduce costs associated with sitters while maintaining safety.

METHODS

A descriptive online survey using a modified version of the Technology Acceptance Model was used to gain insight on technology acceptance and satisfaction levels of clinical staff related to CVM.

RESULTS

Only 12.73% found CVM to be as effective as sitters. Statistical significance was shown comparing sitters with CVM. A positive correlation was found with perceived ease of use and perceived usefulness of CVM.

CONCLUSIONS

Understanding staff satisfaction and technology acceptance is imperative for nurse leaders and administration when implementing new technologies.

Analysis of patient safety risk management call data during the COVID-19 pandemic

On March 11, 2020, the novel coronavirus disease, COVID-19, was declared a pandemic by the World Health Organization (WHO).¹ The pandemic evolved rapidly, forcing providers to face previously unconsidered health care delivery scenarios. Medical and dental professionals sought guidance. This article presents an overview of the questions, concerns, and requests physicians and dentists shared with patient safety risk management consultants (PSRMs) at a large medical professional liability company. During the first 5 months of the pandemic, PSRMs handled more than 1200 calls related to COVID-19. Analysis of call data provides insight into front line provider concerns as the pandemic evolved.

Death Cafés for prevention of burnout in intensive care unit employees: study protocol for a randomized controlled trial (STOPTHEBURN)

BACKGROUND

Burnout is an occupational syndrome that leads to mental health problems, job turnover, and patient safety events. Those caring for critically ill patients are especially susceptible due to high patient mortality, long hours, and regular encounters with trauma and ethical issues. Interventions to prevent burnout in this population are needed. Preliminary studies suggest debriefing sessions may reduce burnout. This study aims to assess whether participation in regular debriefing can prevent burnout in intensive care unit (ICU) clinicians.

METHODS

A randomized controlled trial will be conducted in two large academic medical centers. Two hundred ICU clinicians will be recruited with target enrollment of 100 physicians and 100 non-physicians (nurses, pharmacists, therapists). Participants must have worked in the ICU for the equivalent of at least 1 full time work week in the preceding 4 weeks. Enrolled subjects will be randomized to virtually attend biweekly debriefing sessions facilitated by a psychotherapist for 3 months or to a control arm without sessions. Our debriefs are modeled after Death Cafés, which are informal discussions focusing on death, dying, loss, grief, and illness. These sessions allow for reflection on distressing events and offer community and collaboration among hospital employees outside of work. The primary outcome is clinician burnout as measured by the Maslach Burnout Inventory (MBI) Score. Secondary outcomes include depression and anxiety, as measured by the Patient Health Questionnaire 8 (PHQ-8) and Generalized Anxiety Disorder 7-item scale (GAD-7), respectively. Questionnaires will be administered prior to the intervention, at 1 month, at 3 months, and at 6 months after enrollment. These values will be compared between groups temporally. Qualitative feedback will also be collected and analyzed.

DISCUSSION

With ICU clinician burnout rates exceeding 50%, Death Café debriefing sessions may prove to be an effective tool to avert this debilitating syndrome. With COVID-19 limiting social interactions and overloading ICUs worldwide, the virtual administration of the Death Café for ICU clinicians provides an innovative strategy to potentially mitigate burnout in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04347811 . Registered on 15 April 2020.

Development and Validation of a Deep Learning Model for Detection of Allergic Reactions Using Safety Event Reports Across Hospitals

IMPORTANCE

Although critical to patient safety, health care-related allergic reactions are challenging to identify and monitor.

OBJECTIVE

To develop a deep learning model to identify allergic reactions in the free-text narrative of hospital safety reports and evaluate its generalizability, efficiency, productivity, and interpretability.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed hospital safety reports filed between May 2004 and January 2019 at Brigham and Women's Hospital and between April 2006 and June 2018 at Massachusetts General Hospital in Boston. Training and validating a deep learning model involved extracting safety reports using 101 expert-curated keywords from Massachusetts General Hospital (data set I). The model was then evaluated on 3 data sets: reports without keywords (data set II), reports from a different time frame (data set III), and reports from a different hospital (Brigham and Women's Hospital; data set IV). Statistical analyses were performed between March 1, 2019, and July 18, 2020.

MAIN OUTCOMES AND MEASURES

The area under the receiver operating characteristic curve and area under the precision-recall curve were used on data set I. The precision at top-k was used on data sets II to IV.

RESULTS

A total of 299 028 safety reports with 172 854 patients were included. Of these patients, 86 544 were women (50.1%) and the median (interquartile range [IQR]) age was 59.7 (43.8-71.6) years. The deep learning model achieved an area under the receiver operating characteristic curve of 0.979 (95% CI, 0.973-0.985) and an area under the precision-recall curve of 0.809 (95% CI, 0.773-0.845). The model achieved precisions at the top 100 model-identified cases of 0.930 in data set II, 0.960 in data set III, and 0.990 in data set IV. Compared with the keyword-search approach, the deep learning model reduced the number of cases for manual review by 63.8% and identified 24.2% more cases of confirmed allergic reactions. The model highlighted important words (eg, rash, hives, and Benadryl) in prediction and extended the list of expert-curated keywords through an attention layer.

CONCLUSIONS AND RELEVANCE

This study showed that a deep learning model can accurately and efficiently identify allergic reactions using free-text narratives written by a variety of health care professionals. This model could be used to improve allergy care, potentially enabling real-time event surveillance and guidance for medical errors and system improvement.

Older Adults' Intention to Socially Isolate Once COVID-19 Stay-at-Home Orders Are Replaced With "Safer-at-Home" Public Health Advisories: A Survey of Respondents in Maryland

Background: The Theory of Planned Behavior (TPB) and the Health Belief Model (HBM) were used to examine the opinion and behaviors of older adults regarding Coronavirus Disease 2019 (COVID-19), social distancing practices, stay-at-home orders, and hypothetical public policy messaging strategies. Method: A convenience sample (N = 242) of adults 60 and older in the state of Maryland took part in an online survey. Respondents filled out questions regarding demographic information, political affiliation, current social distancing behaviors, and TPB and HBM constructs in our proposed model. Linear regression analysis and analysis of covariance (ANCOVA) were conducted to test the model. Results: Attitude toward social isolation was affected by perceived benefits and barriers to social distancing measures, perceived severity of COVID-19, and political affiliation. Behavior intention was influenced by attitude, subjective norms, political affiliation, and messaging strategies. Conclusion: The study provides support for the conceptual model and has public policy implications as authorities begin to lift stay-at-home orders.

Comparison of Safety and Insurance Payments for Minor Hand Procedures Across Operative Settings

IMPORTANCE

Surgical procedures can be performed in different settings, but the association between the operative setting and patient safety and cost to the patient and payer is unknown.

OBJECTIVE

To examine differences in complications, total payments, and out-of-pocket (OOP) spending for minor hand surgical procedures performed in office, ambulatory surgery center (ASC), and hospital outpatient department (HOPD) operative settings.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective, population-based cohort study was conducted using deidentified claims data from private employer-sponsored health insurance from January 1, 2009, to December 31, 2017. Patients aged 18 years or older undergoing carpal tunnel release, trigger finger release, excision of wrist ganglion, and excision of small hand masses (N = 468 365) were included.

EXPOSURES

Operative setting, defined as procedures performed in the clinic setting, ASC, and HOPD.

MAIN OUTCOMES AND MEASURES

Complications during the 90-day postoperative period, total payments (total facility and payer reimbursement), and OOP spending.

RESULTS

Of the 468 365 patients, 296 378 women (63.3%) and 171 987 men (36.7%) underwent minor hand surgical procedures from 2009 to 2017, with 284 889 procedures (60.8%) performed in HOPDs, 158 659 procedures (33.9%) performed in ASCs, and 24 817 procedures (5.3%) performed in the office setting. Ninety-day complications occurred in 3.4% of procedures performed in HOPDs, 3.3% in ASCs, and 2.9% in office settings (P < .001). After controlling for patient characteristics, procedures performed outside of the office had higher odds of complications (HOPDs: odds ratio [OR], 1.32; 95% CI, 1.22-1.43; ASCs: OR, 1.24; 95% CI, 1.14-1.34). Compared with the office setting, procedures performed in HOPDs incurred an extra $1216 in total payments (95% CI, $1184-$1248) and $115 in OOP expenses (95% CI, $109-$121). Procedures performed in ASCs cost an additional $709 (95% CI, $676-$741) and $140 in OOP expenses (95% CI, $134-$146). Transitioning ASC and HOPD procedures to the office setting could have saved an estimated $6 million annually in OOP expenses during the study period.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that minor hand surgery performed in the office setting is safe and less costly compared with ambulatory and hospital-based operations. Shifting minor surgical procedures to the office setting may lead to substantial cost savings for payers and patients without compromising care quality.

General surgery and COVID-19: review of practical recommendations in the first pandemic phase

BACKGROUND

In March, 2020, the World Health Organization declared COVID-19 a pandemic. The absence of previous knowledge of COVID-19 has made decision-making difficult for all in health care, including surgical departments. We reviewed the management recommendations for surgical activity and changes to surgical practice, identifying concordances and discrepancies, based on the literature published in the early phase of the pandemic.

METHOD

We searched the electronic datasets, PubMed Database, Google, and Google Scholar, using the keywords "SARS-CoV-2", "COVID-19", "surgery", "recommendations", "guideline", and "triage". The search was limited to the first 2 months after the pandemic began and was closed on May 6, 2020.

RESULTS

Twenty papers were included in the analysis and their recommendations are divided into the following categories: 1. general aspects, such as maintaining the safety of health personnel and indications for surgery. 2. The preoperative phase, with recommendations about activating different care pathways for COVID-19 positive patients. 3. The operative phase, with recommendations about activating safety measures for aerosol-generating procedures. 4. The postoperative phase, with recommendations for managing operating theatres and patient transfers.

CONCLUSION

The recommendations proposed in the revised documents are considered good practices aimed at keeping patients and healthcare professionals safe. However, these recommendations must be contextualized in each individual hospital.

Home Birth in the Era of COVID-19: Counseling and Preparation for Pregnant Persons Living with HIV

With the coronavirus disease 2019 (COVID-19) pandemic in the United States, a majority of states have instituted "shelter-in-place" policies effectively quarantining individuals-including pregnant persons-in their homes. Given the concern for COVID-19 acquisition in health care settings, pregnant persons with high-risk pregnancies-such as persons living with HIV (PLHIV)-are increasingly investigating the option of a home birth. Although we strongly recommend hospital birth for PLHIV, we discuss our experience and recommendations for counseling and preparation of pregnant PLHIV who may be considering home birth or at risk for unintentional home birth due to the pandemic. We also discuss issues associated with implementing a risk mitigation strategy involving high-risk births occurring at home during a pandemic. KEY POINTS: · Coronavirus disease 2019 pandemic has increased interest in home birth.. · Women living with HIV are pursuing home birth.. · Safe planning is paramount for women living with HIV desiring home birth, despite recommending against the practice..

A fellow-run clinic achieves similar patient outcomes as faculty clinics: A safe and feasible model for gynecologic oncology fellow education

OBJECTIVES

Fellow involvement in patient care is important for education, but effect on patient care is unclear. Our aim was to compare patient outcomes in gynecologic oncology attending clinics versus a fellow training clinic at a large academic medical center.

METHODS

A retrospective review of consecutive gynecologic oncology patients from six attending clinics and one faculty-supervised fellow clinic was used to analyze differences based on patient demographics, cancer characteristics, and practice patterns. Primary outcome was overall survival (OS); secondary outcomes included recurrence-free survival (RFS), postoperative complications and chemotherapy within the last 30 days of life. Survival analyses were performed using Kaplan-Meier curves with log-rank tests.

RESULTS

Of 159 patients, 76 received care in the attending clinic and 83 in the fellow clinic. Patients in the fellow clinic were younger, less likely to be Caucasian, and more overweight, but cancer site and proportion of advanced stage disease were similar. Both clinics had similar rates of moderate to severe adverse events related to surgery (15% vs. 8%, p = .76), chemotherapy (21% vs. 23%, p = .40), and radiation (14% vs. 17%, p = .73). There was no difference in median RFS in the fellow compared to attending clinic (38 vs. 47 months, p = .78). OS on both univariate (49 months-fellow clinic, 60 months-attending clinic vs. p = .40) and multivariate analysis [hazard ratio 1.3 (0.57, 2.75), P = .58] was not significantly different between groups.

CONCLUSIONS

A fellow-run gynecologic oncology clinic designed to provide learning opportunities does not compromise patient outcomes and is a safe and feasible option for fellow education.

Efficacy and safety of high-viscosity cement in percutaneous vertebroplasty for treatment of Osteoporotic vertebral compression fractures: A retrospective cohort study

To evaluate the efficacy and safety of high viscosity bone cement in the percutaneous vertebroplasty (PVP) for treatment of single-level osteoporotic vertebral compression fractures.Eighty patients were enrolled in this study. All patients were received PVP, and they were divided into 2 groups according to the viscosity of bone cement, either high viscosity bone cement (HV group) or low viscosity cement (LV group). Oswestry Disability Index questionnaire and visual analog scale as clinical assessments were quantified. The operative time and injected bone cement volume were recorded. The anterior vertebral height (AVH) and bone cement leakage were evaluated in the radiograph.No significant difference was observed in the operative time. Both groups showed significant improvements in pain relief and functional capacity status (visual analog scale and Oswestry disability index scores) after surgery. Less bone cement volume was injected into the the injured vertebra in the HV group and statistical significance was found between both groups. In the HV group, there was lower leakage rate and less patients of severe leakage compared with the LV group. However, the correction of AVH showed no significant differences between the 2 groups and no significant loss of AVH was observed in 2 groups.High-viscosity and low-viscosity PVP have the similar effects in improving quality of life and relieving pain. There were lower cement leakage rate and less patients of severe leakage in the PVP with high-viscosity bone cement.

Quality of safety reporting for complementary and alternative therapies for dysmenorrhea

OBJECTIVES

This study assessed the quality of safety reporting in complementary and alternative therapies randomized controlled trials for primary dysmenorrhea.

METHODS

Methodologic systematic review of randomized controlled trials published until August 25, 2019 without language restrictions. The adequacies of safety reporting are reported as frequencies and percentages and their predictors were analyzed by multiple least-squares and logistic regressions.

RESULTS

Thirty-nine trials were included in this review. Of 39 trials, 56% (22/39) reported that no harms were observed. Of the predictor variables, the percentage of words reporting safety in the body section of text increased significantly with sample sizes (effect size 0.14, 95% confidence interval 0.01-0.26, p = .041).

CONCLUSIONS

No harms of included trials were well-reported in complementary and alternative therapy journals. These findings will serve as sound guidance to assess the quality of safety reporting in further complementary and alternative therapies for primary dysmenorrhea.

National Trends in the Safety Performance of Electronic Health Record Systems From 2009 to 2018

IMPORTANCE

Despite the broad adoption of electronic health record (EHR) systems across the continuum of care, safety problems persist.

OBJECTIVE

To measure the safety performance of operational EHRs in hospitals across the country during a 10-year period.

DESIGN, SETTING, AND PARTICIPANTS

This case series included all US adult hospitals nationwide that used the National Quality Forum Health IT Safety Measure EHR computerized physician order entry safety test administered by the Leapfrog Group between 2009 and 2018. Data were analyzed from July 1, 2018 to December 1, 2019.

EXPOSURE

The Health IT Safety Measure test, which uses simulated medication orders that have either injured or killed patients previously to evaluate how well hospital EHRs could identify medication errors with potential for patient harm.

MAIN OUTCOMES AND MEASURES

Descriptive statistics for performance on the assessment test over time were calculated at the overall test score level, type of decision support category level, and EHR vendor level.

RESULTS

Among 8657 hospital-years observed during the study, mean (SD) scores on the overall test increased from 53.9% (18.3%) in 2009 to 65.6% (15.4%) in 2018. Mean (SD) hospital score for the categories representing basic clinical decision support increased from 69.8% (20.8%) in 2009 to 85.6% (14.9%) in 2018. For the categories representing advanced clinical decision support, the mean (SD) score increased from 29.6% (22.4%) in 2009 to 46.1% (21.6%) in 2018. There was considerable variation in test performance by EHR.

CONCLUSIONS AND RELEVANCE

These findings suggest that despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors. Hospitals using some EHR vendors had significantly higher test scores. Overall, substantial safety risk persists in current hospital EHR systems.

Patient Safety Initiative Using Peer Observations and Feedback Inspire Collegial Workplace Culture

Following Joint Commission recommendations for standardizing patient handoffs, direct peer observations and feedback were utilized in order to improve patient safety related to transitions of care in the Division of Pediatric Hospital Medicine at Kapi'olani Medical Center for Women & Children. All hospitalist attendings were trained in an evidence-based handoff bundle inclusive of team communication and feedback strategies. For the initial project, each hospitalist performed 12 peer observations and feedback sessions using validated tools for verbal and written handoffs over 6 months. For a subsequent "refresher" project, each hospitalist performed 6 handoff observations. Attendings were surveyed several times before, during, and after completion of the multiple iterations of the project. A qualitative interview was conducted 6 years after the initial handoff project. In total, 204 observations were completed by 17 hospitalists during the initial project. The perceived overall quality of the patient handoff improved significantly across shifts (P < .001 for the quality of each of two critical daily handoffs) as did pediatric hospitalists' confidence in providing peer feedback (P < .001). Downstream effects of this activity led to additional benefits towards the cohesive growth of the division. Themes from post-project qualitative interviews regarding the peer observation and feedback portion of the study included that it was "helpful," "collaborative," and inspired "camaraderie" that led to increased comfort and participation during future opportunities for observation and feedback. Performing direct peer observations with feedback strengthened the workplace culture, promoted growth through collaboration, and allowed acceptance and success of future projects involving peer observations and feedback.

Protecting Youth in the Mental Health Service Settings

The authors present the development of the field of psychiatry with the evolution of patient safeguards. They address the recent publicized events involving sexual harassment and abuse perpetrated by mental health service providers who have harmed youth who were under their direct psychiatric care. Recommendations are provided for primary care physicians and parents and legal guardians to further ensure patient safety.

A Bayesian approach to sequential analysis in post-licensure vaccine safety surveillance

With rapid development of computing technology, Bayesian statistics have increasingly gained more attention in various areas of public health. However, the full potential of Bayesian sequential methods applied to vaccine safety surveillance has not yet been realized, despite acknowledged practical benefits and philosophical advantages of Bayesian statistics. In this paper, we describe how sequential analysis can be performed in a Bayesian paradigm in the field of vaccine safety. We compared the performance of the frequentist sequential method, specifically, Maximized Sequential Probability Ratio Test (MaxSPRT), and a Bayesian sequential method using simulations and a real world vaccine safety example. The performance is evaluated using three metrics: false positive rate, false negative rate, and average earliest time to signal. Depending on the background rate of adverse events, the Bayesian sequential method could significantly improve the false negative rate and decrease the earliest time to signal. We consider the proposed Bayesian sequential approach to be a promising alternative for vaccine safety surveillance.

Impact of capnography on patient safety in high- and low-income settings: a scoping review

BACKGROUND

Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs.

METHODS

We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included.

RESULTS

The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes.

CONCLUSION

Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.