Patient Safety Commons^™

Pharmacy-Led Medication Reconciliation Program Reduces Adverse Drug Events And Improves Satisfaction In A Community Hospital, L. Hayley Burgess, Joan Kramer, Carley Castelein, Joseph M. Parra, Victoria Timmons, Samantha Pickens, Sarah Fraker, Christopher Cameron Skinner

HCA Healthcare Journal of Medicine

Background

Pharmacy-led medication reconciliation identifies and corrects medication errors that can potentially cause moderate to severe harm. This research sought to identify the impact of pharmacy-led medication reconciliation on patient outcomes and describe the changes in healthcare workers’ perceptions of the program.

Methods

A pharmacy-led admission medication reconciliation program pilot started in July 2019, and a discharge medication reconciliation proof of concept was tested in September 2020 at a 432-bed hospital. The following periods were compared: August 2018 to February 2019 (pre-program implementation) and August 2019 to February 2020 (post-program implementation). Endpoints included patient outcomes, workforce productivity and interdisciplinary healthcare …

Improving Medication Administration Safety In A Correctional Facility With An Electronic Medication Administration System, Rosalinda Salazar

Master's Projects and Capstones

Problem: According to the World Health Organization (2020), medication errors are one of the leading causes of injury and avoidable harm in health care globally.

Context: The county jail houses approximately 700 inmates/patients on a daily basis, and the potential for error when administering medications is high as medications are prepared manually using a paper medication administration record.

Interventions: The jail began using an electronic health record/barcode administration system on October 19, 2020.

Measures: Unusual occurrence reports related to medication errors were reviewed. The time frame included 6 months before electronic implementation, and 6 months after implementation.

Results: Unusual occurrence …

Self-Measured Blood Pressure Monitoring: A Patient Empowerment Project, Alison Cusmano

Doctor of Nursing Practice Final Manuscripts

Hypertension is a public health issue estimated to affect 112 million adults by 2030. Primary care patients in an outpatient clinic in Southern California with elevated blood pressure readings in the office did not have an organized system for close follow-up. The purpose of this evidence-based project (EBP) was to educate patients on self-measured blood pressure monitoring (SMBP), Dietary Approaches to Stop Hypertension (DASH), diet interventions, and healthy weight loss to improve hypertension rates. Through these interventions, patients developed an understanding of their systolic and diastolic blood pressure goals. Nurse practitioners, medical assistants, and licensed vocational nurses screened for high …

Examining The Need For Parental Satisfaction With The Msu Extension Equine Assisted Therapy Program, Ashlyn Ann Kiker

Theses and Dissertations

Animal assisted interventions are becoming more prevalent in our society. Animal interventions have become a popular therapy technique that exist to aid a variety of disabilities. Equine therapeutic riding has become one of the most popular forms of animal assisted therapy for both children and adults. While research shows the importance and benefits of animal assisted therapy for children, there is a lack of research concerning parental satisfaction within therapeutic riding programs.

This study tested a newly developed instrument for measuring parental satisfaction for therapeutic riding programs. The Parent/Caregiver Evaluation Tool (Kerr, 2021) was administered to parents/caregivers whose children participated …

Breastfeeding Media Coverage And Beliefs During The Covid-19 Pandemic In Mexico: Implications For Breastfeeding Equity, Mireya Vilar-Compte, P. Gaitán‐Rossi, E. C. Rhodes, V. Cruz‐Villalba, R. Pérez‐Escamilla

Department of Public Health Scholarship and Creative Works

Background: Because breastfeeding offers short- and long- term health benefits to mothers and children, breastfeeding promotion and support is a public health priority. Evidence shows that SARS-CoV-2 is not likely to be transmitted via breastmilk. Moreover, antibodies against SARS-CoV-2 are thought to be contained in breastmilk of mothers with history of COVID-19 infection or vaccination. WHO recommends direct breastfeeding as the preferred infant feeding option during the COVID-19 pandemic, even among women with COVID-19; but conflicting practices have been adopted, which could widen existing inequities in breastfeeding. This study aims to describe how information about breastfeeding was communicated in Mexican …

The Yearly Financing Need Of Providing Paid Maternity Leave In The Informal Sector In Indonesia, Adiatma Y. M. Siregar, Pipit Pitriyan, Donny Hardiawan, Paul Zambrano, Mireya Vilar-Compte, Graciela Ma Teruel Belismelis, Meztli Moncada, David Tamayo, Grace Carroll, Rafael Perez-Escamilla, Roger Mathisen

Department of Public Health Scholarship and Creative Works

Background: The economic cost of not breastfeeding in Indonesia is estimated at US$1.5–9.4 billion annually, the highest in South East Asia. Half of the 33.6 million working women of reproductive age (WRA) in Indonesia (15–49 years) are informal employees, meaning they are working as casual workers or they are self-employed (small scale business) and assisted by unpaid/family worker(s). No specific maternity protection entitlements are currently available for WRA working informally in Indonesia. This study aims to estimate the financing need of providing maternity leave cash transfer (MCT) for WRA working in the informal sector in Indonesia. Method: The costing methodology …

Impact Of The Who Surgical Safety Checklist Relative To Its Design And Intended Use: A Systematic Review And Meta-Meta-Analysis, Kenji T. Sotto, Barbara K. Burian, Mary E. Brindle

Faculty Research, Scholarly, and Creative Activity

Background
The aim of this study was to identify what parts of the World Health Organization Surgical Safety Checklist (WHO SSC) are working, what can be done to make it more effective, and to determine if it achieved its intended effect relative to its design and intended use.
Study Design
We conducted a qualitative thematic analysis and meta-meta-analyses of findings in WHO SSC systematic reviews following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.
Results
Twenty systematic reviews were included for qualitative thematic analysis. Narrative information was coded in 4 primary areas with a focus on impact of …

Falls Screening In Community- Dwelling Older Adults, Hadi Kooshiar

Electronic Thesis and Dissertation Repository

Falls screening can prevent falls and their consequences. The two studies of this thesis aimed to identify the accuracy of falls screening tools and explore patient preferences and empirical validity of the self-rated Falls Risk Questionnaire (FRQ). The first study, Systematic Literature Review, found the Toulouse-St. Louis University Mini Falls Assessment and the Activities-specific Balance Confidence scale Hindi version emerged as accurate tools for predicting falls in the target population. The second study determined most of respondents, 36%, had no preference between Activities Specific Balance Confidence 6 items (ABC-6) or FRQ. The Bland & Altman approach revealed a degree of …

Development And Implementation Of An Opioid Risk-Reduction Strategy, Heather Darmetko

Student Scholarly Projects

Practice Problem: Accidental overdose is a continued concern for those who are prescribed opioids, and it is essential that healthcare members intensify prevention and response measures in order to prevent death or misuse from this medication.

PICOT: The PICOT question that guided this project was: “In adult patients at an outpatient chronic pain management clinic (P), how does development and implementation of a safe opioid risk-reduction office policy (I), compared to usual practice (C), improve patient rates of naloxone availability and health literacy (O) over eight weeks (T)?”

Evidence: The CDC’s Guideline for Prescribing Opioids for Chronic Pain, the …

Opioid Use Disorder: A Crisis Of Concern, Evangella Harville

Electronic Theses and Dissertations

According to a statement from the U.S. Centers for Disease Control and Prevention, between 2000 and 2017, approximately 700,000 people died from drug overdoses in the United States. Approximately 128 persons lose their life each day from an opioid overdose. The data for this study were collected by the vice president of operations at the study site from a preexisting database for 2019 and 2020. The participants were inpatient patients, 18 and older, both male and female, and were from all ethnicities. The study facility was located in Western New York and offered a 30-bed inpatient treatment center with 24-hour …

Hand Hygiene And Hospital-Acquired Infections During Covid-19 Increased Vigilance: One Hospital’S Experience, Alexander Kong, Carlos S. Botero Suarez, Bebe Rahamatalli, Jennifer Shankweiler, Olga Karasik

HCA Healthcare Journal of Medicine

Background

Hospital-acquired infections are associated with increased morbidity, mortality, costs and length of stay. Prior studies have linked increased hand hygiene compliance with reduced hospital-acquired infection rate. With the increased vigilance for personal and institutional hygiene practices during the COVID-19 pandemic, we hypothesized increased hand hygiene compliance and, as a result, decrease in hospital-acquired infections in our hospital.

Methods

Hand hygiene compliance data was provided by the hospital’s Quality Department. We queried and empirically analyzed local hospital-acquired infection data obtained from our Quality Department and the National Healthcare Safety Network. We compared local hand hygiene compliance rates before and after …

A Community Health Initiative: Health To The Power Of You, Stephanie Hendricks

Purdue Journal of Service-Learning and International Engagement

In April 2020, the COVID-19 pandemic impacted the number of visits to ambulatory care practices and was reported to have declined by nearly 60%. The extent of this decline is alarming as outpatient visits help manage chronic diseases in patients, such as diabetes, high blood pressure, and high cholesterol. This trend sparked an interest in pharmacist and student pharmacist, Dr. Cynthia Koh-Knox Sharp and Stephanie Hendricks, respectively, as it offered an opportunity to help serve the Greater Lafayette community. We created Health to the Power of You (Health^You), which targets two of Lafayette’s neglected populations: community members experiencing …

Advance Care Planning Within Individualized Care Plans: A Component Of Emergency Preparedness, Heather L. Church, Christina Marsack-Topolewski, Jacqueline M. Mcginley, Victoria Knoke

Developmental Disabilities Network Journal

Federally-legislated Medicaid requirements for recipients with intellectual and/or developmental disabilities (IDD) to have a person-centered plan (PCP) do not specifically require that advanced care plans (ACP) be a component of the plan. However, coronavirus disease 2019 (COVID-19) has provided a salient reminder of the importance of incorporating ACP within the PCP for people who have IDD. As demonstrated by situations arising from COVID-19, emergencies and crises can dramatically alter access to care for people with IDD. This paper synthesizes results from an environmental scan related to ACP for adults with IDD. Findings suggest that the use of ACP, particularly when …

A Novel Code Team Leader Card To Improve Leader Identification, Palak Shah, Vinod Havalad

Journal of Patient-Centered Research and Reviews

Prompt and clear code team leader identification is vital in effective cardiopulmonary resuscitation (CPR), and pediatric trainees often have limited experience in these scenarios. This project sought to develop a tangible object that provided clear leader identification and assisted in code team management and simulated team training. A Code Team Leader Card (CTLC) was designed to provide clear leader identification while simultaneously providing a cognitive aid via integration of pediatric advanced life support (PALS) algorithms. Additionally, CTLC served to occupy the leader’s hands to limit their ability to intervene on procedural tasks. The CTLC was incorporated into pediatric resident simulation …

A Rollout Of A Blood Pressure Remote Patient Monitoring Program To Improve High-Risk Maternal Outcomes At A Pilot Clinic For Systemwide Expansion, Laura Geron

Seton Hall University Dissertations and Theses (ETDs)

An existing virtual care platform provides an innovative means of early recognition, identification, and intervention for women with elevated blood pressures during pregnancy, known as preeclampsia. A pilot program took place at a Northeastern prenatal care clinic where patients were identified as high-risk for preeclampsia, enrolled, educated by their providers, and equipped with Bluetooth-enabled blood pressure cuffs.

Through remote patient monitoring (RPM) technology, blood pressure readings could transmit from a patient’s residence to a portal accessible by their clinic provider at any time. This doctoral-level quality improvement project focuses on the identification of patients at high-risk for preeclampsia, their enrollment …

Collegiate Athletic Trainers’ Experiences Planning For Return-To-Sports During Covid-19: A Qualitative Research Study, Eric G. Post, Justin S. Disanti, Christianne M. Eason, Hayley J. Root, Thomas E. Abdenour

Internet Journal of Allied Health Sciences and Practice

Purpose: The purpose of this study was to explore the role of intercollegiate head athletic trainers in the process of planning to resume sport, as well as their experiences across the course of the pandemic to identify key strategies, challenges, and future considerations during the Covid-19 pandemic. Method: This exploratory, descriptive qualitative study was conducted via one-on-one semi structured interviews through the Zoom video conference technology. Twenty-four head athletic trainers across NCAA Division I, II, and III institutions participated in the study. Results: Emerging themes included the development of detailed, institution-specific plans with shared elements such as policies for testing …

Implementación De Políticas De Prevención Y Control De La Obesidad Infantil En Estados Unidos Y Latinoamérica: Lecciones Para La Investigación Y La Práctica Transfronterizas, Mireya Vilar-Compte, Rafael Pérez-Escamilla, Elizabeth Rhodes, Olga L. Sarmiento, Camila Corvalan, Rachel Sturke, Susan Vorkoper

Department of Public Health Scholarship and Creative Works

Aunque se han hecho avances en el desarrollo y aplicación a gran escala de inter-venciones eficaces contra la obesidad infantil, los retos siguen siendo importantes. Nuestro objetivo era comprender las causas del éxito de Estados Unidos y los países latinoamericanos en la implementación de políticas y programas (PYP) contra la obe-sidad e identificar oportunidades de mejora aplicando los principios de la ciencia de la implementación. Seleccionamos tres estudios de comparación de casos: (1) el etique-tado frontal en los envases de alimentos (México y Chile), (2) los programas de calles abiertas y calles para el juego (Colombia y Estados Unidos) y …

La Migración Como Determinante De La Obesidad Infantil En Estados Unidos Y Latinoamérica, Mireya Vilar-Compte, Arturo V. Bustamante, Nancy López-Olmedo, Pablo Gaitán-Ross, Jaqueline Torres, Karen E. Peterson, Graciela Teruel, Rafael Pérez-Escamilla

Department of Public Health Scholarship and Creative Works

La migración internacional tiene consecuencias económicas y en la salud. El proceso de aculturación en el país de acogida puede estar relacionado con la obesidad infan-til. Utilizamos el marco conceptual del balance energético comunitario (CEB, por sus siglas en inglés) para analizar la relación entre migración y obesidad infantil en los hogares mexicanos con migrantes internacionales. Utilizando datos longitudinales de la Encuesta Nacional de Niveles de Vida de los Hogares de México (ENNViH), exami-namos cómo influyen las redes de migrantes sobre la obesidad infantil en las comuni-dades de origen. También revisamos programas de salud binacionales que podrían ser eficaces para …

Impact Of The Covid-19 Pandemic On Loneliness And Social Isolation: A Multi-Country Study, Roger O’Sullivan, Annette Burns, Gerard Leavey, Iracema Leroi, Vanessa Burholt, James Lubben, Julianne Holt-Lunstad, Christina Victor, Brian Lawlor, Mireya Vilar-Compte, Carla M. Perissinotto, Mark A. Tully, Mary Pat Sullivan, Michael Rosato, Joanna Mchugh Power, Elisa Tiilikainen, Thomas R. Prohaska

Department of Public Health Scholarship and Creative Works

The COVID-19 global pandemic and subsequent public health social measures have challenged our social and economic life, with increasing concerns around potentially rising levels of social isolation and loneliness. This paper is based on cross-sectional online survey data (available in 10 languages, from 2 June to 16 November 2020) with 20,398 respondents from 101 different countries. It aims to help increase our understanding of the global risk factors that are associated with social isolation and loneliness, irrespective of culture or country, to support evidence-based policy, services and public health interventions. We found the prevalence of severe loneliness was 21% during …

Listening To Current Practice: Patient Involvement In The Pharmaceutical Packaging Design Process, Giana Carli Lorenzini, Annika Olsson, Andreas Larsson

Journal of Applied Packaging Research

Multiple functional challenges in the use of pharmaceutical packaging reveal a great need of packaging to be designed inclusively. This study investigates patient involvement in the pharmaceutical packaging design process by analysing interview data from representatives of the pharmaceutical and packaging industry. Four main themes related to patient involvement were uncovered: patient expertise levels, patient involvement modes, factors encouraging patient involvement, and factors discouraging patient involvement. Passive patient involvement modes were found to be dominant due to regulations and a traditional perspective regarding physical testing. However, active patient involvement modes were identified, motivated by empathy and understanding of the lives …

Living Environment Considerations On Obesity Prevention Behaviors And Self-Efficacy Among Chinese Americans, Doreen Liou, Jessica A. Karasik

Department of Nutrition and Food Studies Scholarship and Creative Works

The aim of this study is to ascertain if the living environment (type of residential neighborhood and number of household members) will elucidate differences in obesity risk reduction behaviors and self-efficacy in Chinese Americans. A cross-sectional survey design was used to recruit participants from Los Angeles County and New York City metropolitan areas. A total of 650 adults were recruited from diverse socioeconomic backgrounds. Descriptive statistics were measured for 19 behaviors reflecting food intake and portion size control and items measuring self-efficacy and attitudes. T-tests were applied for the two categories of living environment. The mean age of the sample …

Car Ratings Take A Back Seat To Vehicle Type: Outcomes Of Suv Versus Passenger Car Crashes, Dietrich Jehle, Albert Arslan, Chirag Doshi, Clay O'Brien

HCA Healthcare Journal of Medicine

Background

Car safety ratings are routinely utilized in making automobile purchase decisions. These 1- to 5-star ratings are based on crash test data comparing vehicles of similar type, size and weight.

Objectives

We hypothesized that car safety ratings are less important than vehicle factors such as vehicle type and weight in predicting outcomes of head-on crashes.

Methods

A retrospective study was conducted on severe head-on motor vehicle crashes entered into the FARS (Fatality Analysis Reporting System) database between 1995 and 2010. This database includes all US motor vehicle crashes that resulted in a death within 30 days of the accident. …

Patient Transport In The Time Of Covid-19: Using Health Care Failure Mode And Effect Analysis With Simulation To Test And Modify A Protocol, John Kwock, Jeffrey Holmes, Shelly Chipman, Erin Siebers, Angela Berry, Sonja Orff, Victoria Boutin, Leah Mallory

Journal of Maine Medical Center

Introduction: In March 2020, in response to the COVID-19 pandemic, an interprofessional, interdisciplinary team at Maine Medical Center used Healthcare Failure Mode and Effect Analysis (HFMEA) and in situ simulation to rapidly identify and mitigate latent safety threats (LST) in patient transport protocols.

Methods: Following HFMEA steps, stakeholders representing a variety of disciplines assembled to address transport of patients with COVID-19. A process map was created to describe the process. With hazard analysis using table-top simulation followed by in situ simulation, we identified, categorized, and scored LSTs. Mitigation strategies were identified during structured debriefing.

Results: Fourteen LSTs were identified in …

Disparities In Covid-19 Rates Among Various Demographics And Lack Of Racial Representation In Medical Texts, Diangelo Gonzalez

Celebration of Learning

The 2019 novel coronavirus (COVID-19) outbreak, which originated in Wuhan, China in December of 2019, has impacted nations all over the globe. Given the health disparities which existed within the United States prior to the COVID-19 pandemic, this pandemic continued to pose a significant challenge to the health of the public. The aims of this research study were twofold: (1) to analyze the incidence rates of COVID-19 among different racial and ethnic groups within the United States and (2) to describe the occurrence of diversity within medical texts. Overall, the COVID-19 pandemic exacerbated health disparities within the United States. Understanding …

Investigating The Statistical And Policy Frameworks Used To Gauge Potential Pharmacotherapy Recalls: A Scoping Review, Benson Law

Undergraduate Student Research Internships Conference

Paramount attention is often afforded to pharmacotherapies being brought to market. The anticipation from companies, their shareholders, and the patients poised to benefit are met with stiff statistical and methodological requirements set forth by Health Canada’s Health Products and Food Branch (HPFB). Once a pharmacotherapy has been approved by the HPFB, however, the onus to monitor these drugs falls largely on the shoulders of Health Canada, the manufacturers, and to a lesser degree, the Drug Safety and Effectiveness Network (DSEN). This scoping review identified existing pharmacovigilance frameworks recommendations from SCOPUS, PubMed and EMBASE and compared the guidelines employed by Health …

Use Of Smartphone Technology To Promote Knowledge Of Home Safety, Bonnie L. Rogulj

Physical Therapy Collection

This brief article describes the use of smartphone panoramic 360-degree imaging technology to educate patients on home safety. By positioning "hot spots" on images of the home environment, a visual tool for patient education was created to illustrate safety hazards in the home.

Cost-Effectiveness Analysis Of Tisagenlecleucel, Blinatumomab, And Clofarabine For Treatment Of B-Cell Precursor Acute Lymphoblastic Leukemia, Kamron Lotfi

Pharmaceutical Sciences (MS) Theses

Acute lymphoblastic leukemia (ALL) is a common type of adolescent and young adult leukemia in the United States (U.S.). Patients who are refractory or relapsed after receiving two or more lines of systemic therapy have the option of taking tisagenlecleucel. Due to the high cost of this treatment, a cost-effectiveness analysis was performed to assess the treatments for tisagenlecleucel, clofarabine combination, and blinatumomab. Objectives

The objective of this study is to evaluate the cost-effectiveness of tisagenlecleucel; clofarabine, etoposide, cyclophosphamide; and blinatumomab for the treatment of relapse- refractory ALL for adolescents and young adults from the U.S. health care payer perspective. …

Exploration Of Patient Variables And Characteristics Best Suited For Medical Marijuana Treatment For Anxiety And Depressive Disorders, Corey Gazoo

Dissertations

Individuals with posttraumatic stress, anxiety and depressive disorders are currently being prescribed medical marijuana as a treatment in many states across the United States. However, marijuana is still considered a schedule one narcotic by the Drug Enforcement Administration and federal government, which provides several barriers and challenges to conduct research such as approval from the U.S. Food and Drug Administration and following guidelines from the National Institute on Drug Abuse issued by the DEA. Additionally, individuals prescribed medical marijuana for mental health disorders are not always thoroughly instructed on the type of medical marijuana, the dosage, and how frequently to …

Physician Burnout Among West Virginia Primary Care Providers, Kevin S. Mccann, Adam Baus, Joanna Bailey, Laura Boone, Jennifer Boyd, Martha Cook-Carter, Dan Doyle

Marshall Journal of Medicine

Introduction

Work related burnout is highly prevalent in US physicians and linked to adverse effects on patients, providers and organizations. This study measures burnout in West Virginia (WV) primary care providers, allowing for comparison of results to a similar, recent study of US physicians.

Methods

Anonymous survey through email that included Maslach Burnout Inventory, demographic, workload, and practice characteristics. Responses were analyzed using JMP Pro 13. Analysis used JMP Pro 13 for descriptive statistics, chi-square and regression modeling.

Results

Subjects = 110, female/male ratio 1.4, all primary care physicians (PCP), or advanced practice registered nurses or physician assistants (APRN/PA). PCP …

Prevalencia Mensual De Trastorno De Ansiedad Generalizada Durante La Pandemia Por Covid-19 En México, Pablo Gaitán-Rossi, Víctor Pérez-Hernández, Mireya Vilar-Compte, Graciela Teruel-Belismelis

Department of Public Health Scholarship and Creative Works

Objective. Estimate the prevalence of generalized anxiety disorder (GAD) from April to June 2020. Materials and methods. Repeated cross-sections design based in the Encovid-19, a series of monthly mobile surveys with represen- tative samples of Mexico (N= 833-1 674).The questionnaire includes the GAD-2 scale, and, in July, the GAD-7 scale was added; we examined its internal validity with confirmatory factor analysis and its concurrent validity with sociodemo- graphic variables. Using GAD-7 as criterion, we analyzed the predictive validity of the GAD-2.We estimated the monthly prevalence with the GAD-2. Results. The GAD-7 and the GAD-2 are reliable and valid.The GAD-2 has …