Patient Safety Commons^™

Dentistry And The Law: Dealing With Patients Who Have Been Using Marijuana, Dan Schulte Jd

The Journal of the Michigan Dental Association

When dealing with patients who emit a strong marijuana odor, it's crucial to focus on their capacity to provide informed consent and the ability to deliver treatment up to the standard of care. Judging their level of intoxication solely by appearance and smell can be unreliable, so it's best to avoid making such judgments. Instead, inform patients that you may refuse treatment if their odor or other factors hinder your ability to provide care. To prevent last-minute issues, communicate this policy in advance, particularly to patients with a history of marijuana odor. Dismissing such patients from your practice may also …

Multicomponent Approach To Delirium Prevention In The Acute Care Setting: An Evidence-Based Quality Improvement Project., Kelley James

Doctor of Nursing Practice Papers

Background: Acutely ill, hospitalized individuals are at an increased likelihood of developing delirium. Between 30-35% of those patients admitted to the hospital will develop delirium, and as a result, these individuals will face an increased risk of mortality, adverse medical events, restraint usage, and incur a more extended hospitalization. The literature supports early screening utilizing the Confusion Assessment Method (CAM) tool and nurse-driven, multicomponent interventions to aid in preventing its development.

Environment: This project was implemented in a long-term, acute care facility specializing in patients requiring long-term mechanical ventilation, advanced wound care, pulmonary and respiratory care, and the rehabilitation of …

Real-World Third Covid-19 Vaccine Dosing And Antibody Response In Patients With Hematologic Malignancies, Michael A. Thompson, Sigrun Hallmeyer, Veronica E. Fitzpatrick, Yunqi Liao, Michael P. Mullane, Stephen C. Medlin, Kenneth Copeland, James L. Weese

Journal of Patient-Centered Research and Reviews

Purpose: This study sought to describe the changes in immune response to a third dose of either Pfizer’s or Moderna’s COVID-19 mRNA vaccine (3V) among patients with hematologic malignancies, as well as associated characteristics

Methods: This retrospective cohort study analyzed pre-3V and post-3V data on 493 patients diagnosed with hematologic malignancies across a large Midwestern health system between August 28, 2021, and November 1, 2021. For antibody testing, S1 spike antigen of the SARS-CoV-2 virus titer was used to determine serostatus.

Results: Among 493 participants, 274 (55.6%) were seropositive both pre- and post-3V (+/+) while 115 (23.3%) seroconverted to positive …

Evaluating The Extent Of Fall Prevention Knowledge Of Direct Care Clinicians In A Post-Acute Hospital Setting: A Quality Improvement Initiative, Joseph Henry Mitchell Jr

Doctor of Nursing Practice Projects

Background: Events, such as falls, continue to maintain permanence in countless public health settings and organizations, attributing to unnecessary resource utilization. Proven methods for mitigating fall occurrences transpire through reliable fall education and by creating programs that directly impact these incidents. These agendas are essential and can lessen undue stress, obligations, and associated fiscal liability.

Purpose: This DNP project aimed to ascertain and expand unit nurses' fall prevention strategy knowledge in a long-term acute care hospital, bringing awareness of evidence-based practices through a learning addendum.

Methods: This program, based on a descriptive, quasi-experimental, pre-, and post-analysis, strategically …

Language Preference Impact On The Outcomes Of Those Lost To Follow-Up After A Diagnosis Of Pregnancy Of Unknown Location, Erin A. Leestma, Mayra A. Shafique, Megan Mcnitt, Annmarie Vilkins

Medical Student Research Symposium

Pregnancy of unknown location (PUL) is a temporary diagnosis when there is a positive pregnancy test but an intrauterine gestational sac and/or fetal pole are not visualized with ultrasonography. The three potential outcomes for such a pregnancy are failed pregnancy, an early intrauterine pregnancy or an ectopic/abnormal pregnancy. Given the serious associated morbidity of ectopic pregnancy, these PUL require strict follow up of bHCG levels to help the clinician determine the likely outcome of the PUL (failed vs early vs ectopic) and choose the best intervention (expectant management, surgical management or medical management). One potential barrier to follow-up identified in …

Utilizing Training And Educational Materials To Increase Hand Hygiene Compliance Of Healthcare Providers Participating In Cesarean Sections, Christopher Natividad

Master's Projects and Capstones

Surgical site infections (SSIs) are one of the most common complications of Cesarean section (C-section) procedures. The incidence of SSIs after C-section procedures at Hospital X has increased in each of the past three years. The Labor and Delivery (L&D) unit at Hospital X performs approximately 4,500 C-sections each year. Observation of these procedures illustrated a lack of adhesion to hand hygiene policies and protocols. This quality improvement project involved informing staff members of the poor hand hygiene compliance rates, and re-educating them regarding proper hand hygiene behavior using flyers, emails, and addressing them at shift change. Data collection focused …

Understanding The State Of Lgbtqia+ Healthcare And Support In Camden County, Sayan Basu, Sana Farhat, Cindy Capps, Ali Harb

Rowan-Virtua Research Day

4.5% of American adults identify as lesbian, gay, or bisexual and about 1.4 million adults identify as transgender.

This demographic is impacted by many social determinants of health and health disparities, particularly for transgender patients.

33% of LGBTQIA+ patients ranging from a pool of 28,000 surveyed patients have had a negative experience with their health providers, and 8% of them had to educate their physicians about their needs due to physicians’ lack of knowledge about this demographic.

Research suggests that there is a reluctance to access mental health services in the LGBTQIA+ community due to homophobia,, difficulties disclosing sexual and …

The Role Of Physiologic Vision Deficits In Elderly Self Dispensing Medication Errors, Harrison Patrizio

Rowan-Virtua Research Day

Elderly populations are more prone to self-dispensing medication errors. Although some of these errors can be attributed to a patient’s disease, many errors are preventable with behavioral modification. As we age, the lens of the eye becomes yellow. This tints all light that passes through it causing deficits in color distinguishability.(Andreasen, 1980) Additionally, the lens of the eye hardens over time. This results in presbyopia, an inability to focus close objects.(Wolffsohn, 2018) These changes can cause elderly patients to misread labels or dispensed incorrect medication due to color shade similarities.(Cardarelli, 2011) Although these visual changes are well documented, current research …

Literature Review: Incidentalomas In Emergency Medicine - How Often Are They Reported And Are Patients Informed?, Mohammad Rattu, James Espinosa, Alan Lucerna, James Lee

Rowan-Virtua Research Day

The purpose of this proposed study is to look at the rate of incidental findings on CT scan in a community hospital setting, as well as to look at the rate of documentation of communication of the findings to the patient and referral for follow-up to primary care or to a specialty follow-up.

Civility And Communication Interventions To Improve Patient Outcomes, Lane Denney

The Eleanor Mann School of Nursing Undergraduate Honors Theses

Communication in health care is vital for the successful care of patients and their outcomes while they are hospitalized. Healthcare workers are responsible for communicating patient information whether it is between change of shifts or reporting to a patient’s provider. It is important that this information is communicated effectively. This review evaluates how nurses communicate in shift- report and how this affects patient outcomes and civility between nursing units and teams. Overall, bedside shift reports promoted the best patient outcomes and increased teamwork on hospital units.

Peer Review/Ethics: How Can Our Office Be More Inclusive Of Transgender Patients?, Debra Peters Dds

The Journal of the Michigan Dental Association

In this professional ethics article, Dr. Debra Peters of the ADA’s Council on Ethics, Bylaws and Judicial Affairs addresses the need for dental teams to be more inclusive of transgender patients, emphasizing the challenges faced by transgender and gender non-conforming (TGNC) individuals in accessing dental care. The article recommends providing training and resources for dental teams, highlighting the importance of first impressions and effective communication during patient interactions. Practical suggestions include incorporating affirmed name and gender options in registration forms, ensuring appropriate language in interactions, and addressing insurance claim discrepancies. The column promotes creating a respectful environment and cites the …

Responding To Sexual Abuse In Health Care: Development Of A Guide For Patients, Tristan Mcintosh, Heidi Walsh, Meredith Parsons, Erin D. Solomon, Jessica Mozersky, James M. Dubois

Journal of Patient-Centered Research and Reviews

This report details the development of a stakeholder- and evidence-informed online resource guide for patients that provides information to raise awareness about sexual abuse in health care, the value of chaperones, and options for responding to sexual abuse. The guide was developed to reflect lessons learned from 10 years of researching physician wrongdoing (ie, sexual violations, improper prescribing, and unnecessary invasive procedures), a 5-year National Institutes of Health-funded mixed-methods study of 280 cases of egregious wrongdoing in medicine, and an expert working group. Focus groups were conducted with 22 patients from diverse backgrounds to obtain feedback on the acceptability of …

Lower The Risk For Medical Emergencies, Christopher J. Smiley Dds

The Journal of the Michigan Dental Association

Clinicians focus on health and safety for our patients. The editorial highlights the importance of cultural competence in dentistry to mitigate the risk of medical emergencies. Reflecting on a recent CE program, Dr. Smiley underscores the need for proactive emergency preparedness, emphasizing detailed protocols and hands-on training. The article advocates for thorough patient screening, incorporating three questions presented by Dr. Mitchel Gardiner in an article in this month’s issue, addressing patient-specific health considerations and consulting with healthcare providers. The editorial concludes by stressing the significance of risk reduction through comprehensive assessments, team training, and preparedness.

J Mich Dent Assoc April 2022

The Journal of the Michigan Dental Association

Monthly, The Journal of the Michigan Dental Association brings news, information, and feature articles to our state's oral health community and the MDA's 6,200+ members. No publication reaches more Michigan dentists!

In this April 2022 issue, the reader will find the following original content:

• A cover feature “Protect Your Patients and Yourself: The Complete and Honest Medical History”
• A feature article “The Foundation for Dental Care: The Patient Interview and Dental/Medical Health History”
• A 10-Minute EBD “The Preferred Analgesia for Orthodontic Tooth Movement: Acetaminophen or NSAIDs?”
• News you need: an Editorial, a "Reminder about Antitrust Law", and regular department articles, …

Succinic Semialdehyde Dehydrogenase Deficiency (Ssadhd): Qualitative Needs Assessment For Patients With A Rare Neurological Disorder, Cassandra Bovee, Kayla Woodring

Annual Research Symposium

No abstract provided.

Protocols For An Aboriginal-Led, Multi-Methods Study Of The Role Of Aboriginal And Torres Strait Islander Health Workers, Practitioners And Liaison Officers In Quality Acute Health Care, Annabelle Wilson, Tamara Mackean, Liz Withall, Eileen M. Willis, Odette Pearson, Colleen Hayes, Kim O'Donnell, Janet Kelly, Kerry Taylor, Judith Dwyer, Elizabeth Bourke, Kate Hunter, Lorna Murakami-Gold, Rebecca Ivers, Fran Baum

Journal of the Australian Indigenous HealthInfoNet

Objectives
Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers play an important, often critical role providing advocacy and cultural and emotional support for Aboriginal and Torres Strait Islander patients. The main goals of this research are to explore i) how Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers are integrated in the routine delivery of care for Aboriginal and Torres Strait Islander peoples in hospital, and ii) how the role of Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers facilitates quality health outcomes.

Methods
This study is being conducted in three different hospitals using …

Planning Patient Safety: Philosophical, Political, And Economic Changes Required For Preventable Death Abolition, Catherine Kiani

CMC Senior Theses

Preventable medical errors are an epidemic. Between 250,000 and 400,000 people die from preventable errors each year in the USA. This investigation questions mechanisms for quality care improvement to eliminate preventable fatalities. I evaluated current patient safety protocols, analyzed their shortcomings, and with additional research recommended actions for better results. Such actions to improve patient safety are explored from three different perspectives: philosophical, economical, and political aspects. In chapter one, improvements within hospitals are reviewed – namely cultural changes needed from both physicians and hospital leadership. Abolishing hierarchical systems which preclude healthy collaboration among medical teams, diverting focus to patient …

Improving Egypt’S Access To Vaccines And Medicines: Communication During Covid-19 / تحسين إتاحة الوصول إلى اللقاحات والأدوية في مصر: سياسة توعية الجمهور خلال أزمة فيروس كورونا, Alaa Abdel-Rahman, Sarah Attef, Helen Gabrah, Reem El-Sayed, Sarah El-Lithy

Papers, Posters, and Presentations

Since the start of the COVID-19 pandemic, the Egyptian government has been following protocol as best as possible when it comes to responding to the needs of the health and economic sectors amid difficult times. From lockdown measures to the WHO’s recommended practices in terms of isolation of cases and treatments, Egypt has been lauded as one of the fastest and most effective countries in terms of COVID-19 emergency response. Authorities have implemented several awareness campaigns directed at citizens to inform them about the pandemic, how to prevent infection, what to do if infected and how to act accordingly. Authorities …

Improving Disinfectant Cap Use On Central Lines In The Icu To Reduce Patient Risk For Clabsi: A Quality Improvement Project, Tali Cherim

Master's Theses and Capstones

BACKGROUND: Central line-associated bloodstream infections (CLABSI) are the most common type of preventable healthcare-associated bloodstream infection, and may increase length of stay (LOS), facility treatment costs, and patient mortality rates. Intensive Care Unit (ICU) patients are especially vulnerable to CLABSI due to their critical health conditions and other comorbid factors. A literature review provided evidence supporting the use of alcohol-impregnated disinfectant caps, such as SwabCap®, on central line (CL) ports to significantly reduce patients’ risk for CLABSI. This quality improvement project took place within an adult ICU of a Level II trauma facility in New England, where the Infection Prevention …

Exploring Predictors In The Receipt Of Patient/Family-Centered Care, Arami Anwell

Theses and Dissertations

Study 1

OBJECTIVES: The research aim of this study was to identify predictors associated with the receipt of PFCC among U.S. children/families

METHODS: Caregivers of 38,803 non-institutionalized children, aged 0 to 17 years, were surveyed by the National Survey of Children’s Health (NSCH) 2018–20019. Patient/family-centered care (PFCC) was measured using five components of health care delivery that were answered on a 4-point Likert scale. Logistic regression models were analyzed for the overall receipt of PFCC and each component of PFCC, with survey weighting added to adjust for complex sampling design.

RESULTS: Many predictors were associated with the receipt of PFCC. …

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 …

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 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 …

Validation Of An Electronic Trigger To Measure Missed Diagnosis Of Stroke In Emergency Departments, Viralkumar Vaghani, Li Wei, Umair Mushtaq, Dean F Sittig, Andrea Bradford, Hardeep Singh

Faculty, Staff and Students Publications

OBJECTIVE: Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).

METHODS: Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained …

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 …

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 …