Patient Safety Commons^™

Pharmacovigilance As An Act Of Awareness And Mindfulness, Mahima Silas, Hale Z. Toklu

HCA Healthcare Journal of Medicine

The term “pharmacovigilance” defines the activities related to the collection, detection, assessment, monitoring, and prevention of adverse reactions due to pharmaceuticals. While it is often framed as a technical and regulatory discipline, it can also be understood through a more reflective lens as a form of mindfulness practice. At its core, pharmacovigilance requires a way of thinking that closely mirrors mindfulness, including sustained attention, openness to uncertainty, and deep awareness of human experience. Viewing pharmacovigilance in this way reframes it not just as a safety mechanism, but as a thoughtful, patient-centered approach to medicine.

Improving Anesthesia Provider Confidence In The Identification, Management, And Treatment Of Postoperative Delirium, Brittany M. Whistle, Charles Dustin Phelps

Scholars Week

Purpose: Postoperative Delirium (POD) is a potentially devastating complication of anesthesia that is poorly understood by clinical staff leading to poor outcomes for surgical patients. This study is meant to determine if a focused knowledge presentation accompanied by visual aids could increase anesthesia providers confidence in identifying, diagnosing, and treating Postoperative Delirium.

Methodology: Utilizing a statistical model to analyze respondents results on a standardized test administered before and after an informational presentation with visual aids on the topic of Postoperative Delirium.

Results: Results indicated a statistically significant difference between pretest and posttest scores, with a p-value of .002, t(11) = …

Incidence Of High Volume Residual Gastric Content In Perioperative Patients Taking Glucagon-Like Peptide-1 Receptor Agonists, And Its Dependence On The Duration Of Preoperative Fasting And Drug Holding: A Prospective Observational Study, Marissa Huggins, Ion Hobai

Cumberland Medica

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs), including semaglutide and dulaglutide, are increasingly prescribed for type 2 diabetes mellitus and obesity. These agents delay gastric emptying and have been associated with a higher incidence of unexpected full stomachs in procedural patients. To prevent pulmonary aspiration, current recommendations include extending preoperative fasting (e.g., 24 hours instead of the standard 8 hours) and/or withholding the GLP-1RA medication before surgery (≥1 drug half-lives). However, the efficacy of these strategies have remained unclear and are evaluated in this study.

Hypothesis: GLP-1RA use in surgical patients is associated with increased incidence and volume of residual gastric …

Increasing Documentation Of Endotracheal Tube Cuff Pressures: A Quality Improvement Initiative For Flight Crew Providers, Matthew D. Noss

Graduate Theses, Dissertations, and Problem Reports (ETD)

ABSTRACT

Background: There was a lack of documentation of endotracheal tube (ETT) cuff pressures (CPs) by flight crew providers at Base 1 of HealthNet Aeromedical Services. A three-month pre-intervention data collection showed 1.8% of patients had initial CPs documented. Inadequate documentation and monitoring of ETT CPs can lead to patient complications such as tracheal injury and aspiration making this an important area for quality improvement.

Purpose: To increase documentation of ETT CPs through education and evidence-based interventions.

Intervention: This project implemented an educational in-service on ETT cuff syringe manometry for flight crew providers. The educational intervention consisted of …

Exploring The Impact Of Adverse Childhood Experiences On Preventive Healthcare Utilization In Rural Georgia, Ryan R. Traylor

College of Graduate Studies: Theses & Dissertations

This study examines the relationship between Adverse Childhood Experiences (ACEs) and preventive healthcare use among adults in Georgia, specifically within rural populations facing structural barriers. Using 2023 Georgia Behavioral Risk Factor Surveillance System (BRFSS) data, the research analyzes associations between ACE exposure, rural residence, and preventive care outcomes, including physical exams and flu vaccinations. Guided by an intersectionally adapted version of Andersen’s Behavioral Model of Health Services Use, the study evaluates how predisposing factors, enabling resources, and perceived barriers relate to healthcare engagement. Logistic regression analyses assess the correlation of ACE exposure, cost barriers, provider access, and sociodemographics with preventive …

Delayed Diagnosis Of Systemic Lupus Erythematosus Presenting As Autoimmune Hemolytic Anemia: A Case For Heightened Clinical Suspicion, Diana Acosta Pozo, Luis Álvarez Pérez

Research Colloquium

Background: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem involvement, including hematologic manifestations. Autoimmune Hemolytic Anemia (AIHA), though an established feature, is relatively uncommon and may occur early or in isolation. When AIHA presents without overt systemic symptoms, the underlying autoimmune etiology may be overlooked, resulting in delays in diagnosis and treatment. Prompt recognition is essential to prevent unnecessary interventions and prolonged morbidity.

Case Presentation: A 39-year-old woman residing in Texas presented to the Rheumatology office with persistent synovitis and severe transfusion-dependent anemia, requiring red blood cell transfusions every 48 hours for over three months. She …

A Peculiar Pancreatitis: Investigating The Adverse Effects Of Mesalamine, Elias Arellano Villanueva, Miguel Lopez, Alhasan Asaad, Jose Campo Maldonado

Research Symposium

Background: Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, accounting for approximately 300,000 emergency department visits annually. It is characterized by parenchymal and peripancreatic fat necrosis accompanied by inflammation. The clinical diagnosis of AP is based on elevated serum amylase and lipase levels, characteristic imaging findings, and epigastric pain often radiating to the back. While gallstones and alcohol use are the most common causes of AP, drug-induced pancreatitis (DIP) is a rare but increasingly recognized etiology, contributing to 0.1–5% of cases. DIP is typically diagnosed by excluding other causes and is often associated with …

Resilience And Reality: Exploring The Lived Experiences Of People Living With Hiv In Texas During The Covid-19 Pandemic – A Qualitative Study., Ahmed F. Alanazi

Social Work Dissertations - Archive

This study investigated the lived experiences of individuals living with HIV (PLWH) in the Dallas-Fort Worth (DFW) area of Texas during the COVID-19 pandemic, using an Interpretative Phenomenological Analysis (IPA) framework. The research examined the intersection of health, social dynamics, and psychological resilience among PLWH, who faced compounded vulnerabilities due to systemic inequities and the dual public health crises of HIV and COVID-19. Through semi-structured interviews with ten participants from diverse backgrounds, the study captured the profound impacts of disrupted healthcare systems, heightened stigma, and social isolation on this marginalized population. The findings reveal that the pandemic exacerbated existing inequities …

Investigating The Impact Of Phthalate Exposures From Personal Care Products On Uterine Fibroid Incidence And Prevalence In Us-Born Black Women, Ella Brissett

CMC Senior Theses

Uterine fibroids are benign tumors composed of smooth muscle cells and connective tissue that develop within or on the walls of the uterus. Despite being non-cancerous, they can severely affect quality of life by causing heavy bleeding, chronic pain, and reproductive complications. Fibroids are typically found in women of reproductive age, but they disproportionately affect Black women, who experience higher incidence and severity. The underlying causes of this disparity is poorly understood; however, an emerging body of research is highlighting the role of phthalates, endocrine-disrupting chemicals found in many personal care products, in exacerbating fibroid development. Through a critical analysis …

Rwanda's Natural Remedies: A Fresh Look At The Fight Against Malaria, Leandre Nsabimana Ndisanze

Pomona Senior Theses

Malaria remains one of the most devastating parasitic diseases globally, disproportionately affecting sub-Saharan Africa, where Rwanda continues to face high transmission rates and rising resistance to conventional interventions. Despite decades of control efforts, the emergence of drug-resistant Plasmodium falciparum and insecticide-resistant Anopheles mosquitoes threatens to reverse recent gains. This research responds to the urgent need for sustainable and culturally relevant alternatives by exploring the therapeutic potential of Rwandan traditional medicinal plants. These indigenous remedies, long used by local healers, offer an underexplored reservoir of bioactive compounds that may provide the basis for novel antimalarial drugs.

The central hypothesis of this …

The Impact Of State-Mandated Certification Of Surgical Technologists On Surgical Site Infection Rates: Evaluating Policy, Practice, And Patient Outcomes, Katherine E. Geiger

Graduate Student Theses, Dissertations, & Professional Papers

Abstract

Chairperson: Matthew Schertz, Ph.D.

Committee Member: Morgen J Alwell, Ph.D.

Committee Member: Jill Davis, M.Ed.

As a surgical technology instructor, I have witnessed firsthand the impact that certified surgical technologists (CSTs) have on patient safety, particularly in the prevention of surgical site infections (SSIs). This professional paper investigates the relationship between state-mandated certification of surgical technologists and SSI rates, with a focus on how standardized education and credentialing influence clinical outcomes. SSIs remain a significant concern in surgical environments, contributing to increased morbidity, longer hospital stays, and greater healthcare costs. The research presented here examines certification requirements across various …

Neurohospitalist Core Competencies, Jana J Wold, Jetter Robertson, Jerome A Jeevarajan, Molly G Knox, Prateek Thatikunta, Guillermo E Solorzano, Kristin Galetta, Shefali Dujari, Tarini Goyal, Matthew E Ehrlich, Jonathan P Donnelly, Elizabeth Marriott, Vishal A Mandge, Roshni S Dhoot, Matthew W Luedke, Matthew B Maas, Margaret Y Yu, Michel Toledano, Rafid Mustafa, Jamie L Palaganas, Kathryn Kvam, Rachelle Dugue, Ethan Meltzer, Lahoud Touma, Maulik P Shah, Vanja C Douglas, Karen Orjuela, Brian J Scott, Joshua P Klein, David J Likosky, Jennifer R Simpson, Megan B Richie, Carolin Dohle, Jane G Morris, Carl A Gold

Faculty, Staff and Student Publications

The Neurohospitalist Core Competencies comprise a set of competency-based learning objectives that encapsulate the knowledge, skills, and attitudes of neurohospitalitists who specialize in the care of hospitalized patients with neurologic conditions. These competencies serve to characterize the rapidly expanding field of neurohospitalist medicine. The 27 chapters are divided into 3 sections entitled: neurological conditions, clinical interventions and interpretation of ancillary studies, and neurohospitalist role in the healthcare system. Each individual learning objective in the chapters describes a specific concept with an action verb to illustrate the behavior that the neurohospitalist exhibits. The individual neurohospitalist may not exhibit mastery in each …

Does Esketamine In Cesarean Delivery Increase Postoperative Adversities And Related Diseases?, Cheryce Daniel, Kylon Coombs

Rowan-Virtua Research Day

Esketamine has emerged as a promising treatment option, particularly noted for its effectiveness in reducing postpartum depression, alleviating pain, and promoting faster recovery. Despite its therapeutic benefits, recent research has raised concerns regarding potential adverse effects associated with high doses of esketamine in patients. Specifically, there is growing interest in understanding the potential risks linked to the administration of esketamine during cesarean delivery, given its increasing use in obstetric anesthesia.

This comprehensive review aims to investigate the potential associations between the use of esketamine during cesarean delivery and the subsequent risk of related diseases or physiological disorders. The goal is …

An Integrative Review Of The Absorption Of Fda-Approved Chemical Sunscreen Filters Into The Blood, Srinidhi Banala, Samrat Gollapudi, Abhiram Gollapudi, Bhaumik Patel

Rowan-Virtua Research Day

Introduction: This integrative review examines the absorption of FDA-approved chemical sunscreen filters, specifically avobenzone and oxybenzone, into the bloodstream. The study aims to compare the levels of absorption and potential health effects of systemic exposure to these sunscreen ingredients in the United States.

Methods: The researchers conducted a literature search of 57 articles, of which 15 were used for the review. Inclusion criteria focused on studies discussing absorption levels of avobenzone and oxybenzone, as well as methods of absorption into the bloodstream. Exclusion criteria included sunscreen ingredients not approved in the United States, non-English studies, and studies on methods to …

Soluble Antimicrobial Peptide (Amp) Screening To Rationally Design Amp-Hydrogels That Selectively Prevent Biofilm Formation, Matthias Recktenwald, Muskanjot Kaur, Mohammed M. Benmassaoud, Aryanna Copling, Tulika Khanna, Michael Curry, Denise Cortes, Gilbert Fleischer, Valerie J. Carabetta, Sebastián L. Vega

Rowan-Virtua Research Day

Staphylococcus aureus is an opportunistic pathogen that lives on surfaces and skin and can cause serious infections once inside the body. While antibiotics effectively kill bacteria, there are a growing number of infections with antibiotic-resistant strains. Antimicrobial peptides (AMPs) are part of the innate immune system and can eliminate pathogens including bacteria, fungi, and viruses, and are a promising alternative to antibiotics. Although studies have reported that AMP-functionalized hydrogels can prevent bacterial adhesion and biofilm formation, these materials generally consist of one AMP at an arbitrary concentration, and AMP dosing and the combined effects of multiple AMPs are not well …

Stopping The Bleed At Uri, Emily Lefebre

Senior Honors Projects

The number one cause of preventable death is uncontrolled bleeding from traumatic injury. From the unlikely scenario of a school shooting, to a campus car accident or an injury during a sports or club event, possessing skills to effectively stop a life-threatening bleed becomes a matter of life or death. The American College of Surgeons Committee on Trauma (ACS COT) STOP THE BLEED® program is a campaign to teach communities how to respond effectively and efficiently to life-threatening bleeding in emergencies. STOP THE BLEED® aims to empower individuals with the knowledge and skills to stop severe bleeding by tourniquet application, …

Patient Characteristics Of, And Remedial Interventions For, Complaints And Medico-Legal Claims Against Doctors: A Rapid Review Of The Literature, Timothy J Schultz, Michael Zhou, Jodi Gray, Jackie Roseleur, Richard Clark, Dylan A Mordaunt, Peter D Hibbert, Georgie Haysom, Michael Wright

Faculty, Staff and Student Publications

BACKGROUND: It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised.

METHODS: We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received …

Establishing Consent: The Role Of Women Representatives In Passing Informed Consent Laws, Sophia Stockham

Department of Political Science: Dissertations, Theses, and Student Research

What predicts the adoption of informed consent laws for pelvic exams within the United States? As of January 2023, 22 states have adopted informed consent laws for pelvic examinations on women, with eleven being under Democratic control, six being Republican control, and five with divided control between the legislature and gubernatorial level at the time of adoption. Little attention, however, has been given to women’s health mandates outside the issue of abortion and to variation among state partisan adoption regarding informed consent for pelvic exams. This paper examines the impact of partisanship, the percentage of women in the legislature, and …

Development Of Solitary Keratoacanthoma From A Cutaneous Wart, Joshua M. Ninan, Veronica Salazar

Research Symposium

Background: Common cutaneous warts, referred to in medicine as verrucae vulgaris, are proliferative lesions caused by human papillomavirus. These lesions are mostly benign and usually resolve without incident, except in the case of the patient mentioned in this report. Our patient developed a solitary keratoacanthoma, currently accepted as a clinical variant of squamous cell carcinoma, as a result of several risk factors and traumatic exposure. The current literature does not have an established association of HPV with solitary keratoacanthomas. This case report explores the presentation and pathogenesis of solitary keratoacanthomas within the setting of HPV.

Case Presentation: 48-year-old Caucasian female …

A Pharmacist’S Central Role In Improving Hormonal Contraceptive Access, Aleese Smith, Urvi Patel, Alexandra Arledge, Josie Young, Erin Johanson

Annual Research Symposium

In 2019, the roles of Utah pharmacists grew with the implementation of a statewide standing order allowing prescribing abilities for hormonal contraceptives. With the rates of unplanned pregnancies in Utah up to 1 in every 5; pharmacists have a new role in birth control distribution. Pharmacists and pharmacy interns across the state of Utah are able to prescribe self-administered hormonal contraceptive medications including: oral pills, vaginal insertion medications, and birth control patches. Pharmacists are entrusted with the responsibility to evaluate the patient and their needs to ensure all women receiving birth control are educated about the risks and side effects …

Medication Errors Among Als Providers In The Prehospital Setting, Cody Vaughn Gibson, Victor Jimenez Jr

Annual Research Symposium

EMS providers administer a variety of medications to patients in the prehospital environment, and while there are numerous published studies on medication errors pertaining to the hospital environment, there are comparatively fewer studies which focus on the prehospital environment. Therefore, the purpose of this survey is to investigate the type and frequency of medication errors occurring in the prehospital environment.

Outpatient Fall Prevention In Ambulatory Adults 65 Years Old And Over, Dorothy L. Osborne-White

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background: In the United States (U.S.), falls are the leading cause of injury among adults 65 and over, resulting in 36 million falls yearly (Moreland et al., 2020). According to the Centers for Disease Control and Prevention (CDC, 2023), one in four older adults experiences a fall each year. Falls are the world's second most prominent cause of accidental deaths (World Health Organization [WHO], 2021). Falls are the leading cause of both fatal and non-fatal injuries among older adults (Moreland et al., 2020).

Methods: A quality improvement project that included a fall bundle was implemented in a primary clinic. A …

Role Of Social Determinants Of Health And The Renin- Angiotensin Aldosterone System In Risk For Hypertensive Disorders Of Pregnancy And Related Adverse Outcomes., Esther Letushila Ndashaala

Theses and Dissertations--Nutrition and Food Systems

Background: Hypertensive disorders of pregnancy (HDP) represent a significant public health issue, contributing to maternal and fetal morbidity and mortality. Women from lower socioeconomic backgrounds or marginalized racial and ethnic groups face higher risks of HDP, which have been incompletely described. In addition, risk for HDP may be linked to a reduction in the normal activity of the renin-angiotensin-aldosterone system (RAAS). This study investigates the role of socioeconomic factors and RAAS components in the risk for HDP and adverse maternal and neonatal outcomes. Methods: This study is a secondary analysis of data from 180 pregnant individuals from a high-risk maternal-fetal …

Enhancing Safety Surveillance During Clinical Trials: The Development Of A Safety Data Review Handbook To Support Pharmacovigilance Clinicians, Lauren Wilson

DNP Scholarly Projects

Abstract

BACKGROUND: Pharmacovigilance (PV) Sciences include activities related to safety surveillance of pharmaceutical products, and is critical for developing safe and effective medications, vaccines and medical devices. Safety monitoring starts with preclinical research and continues through clinical trial and post marketing phases. PV scientists ensure patient safety during clinical trials through regular review and analysis of safety data. Regulations have become increasingly complex, leading to inadequately defined methods for reviewing large clinical trial safety datasets. Inconsistent safety data review (SDR) practices can result in delayed detection of adverse drug reactions (ADRs) or safety signals.

METHODS: This quality improvement project used …

Empagliflozin In Patients Admitted To Hospital With Covid-19 (Recovery): A Randomised, Controlled, Open-Label, Platform Trial, Recovery Collaborative Group

Faculty, Staff and Student Publications

BACKGROUND: Empagliflozin has been proposed as a treatment for COVID-19 on the basis of its anti-inflammatory, metabolic, and haemodynamic effects. The RECOVERY trial aimed to assess its safety and efficacy in patients admitted to hospital with COVID-19.

METHODS: In the randomised, controlled, open-label RECOVERY trial, several possible treatments are compared with usual care in patients hospitalised with COVID-19. In this analysis, we assess eligible and consenting adults who were randomly allocated in a 1:1 ratio to either usual standard of care alone or usual standard of care plus oral empagliflozin 10 mg once daily for 28 days or until discharge …

Oral Dosages Of The Nsaid Aspirin Decreased The Growth Rate Of Species Found In The Human Gut Microbiome Including Akkermansia Muciniphila, Bacteroides Fragilis, Clostridium Sordellii, And Clostridium Difficile, Wyatt H. Greenbaum, Garrett J. Greenbaum, Anna Spiezio

PANDION: The Osprey Journal of Research and Ideas

Over past few decades, new insight has been revealed in the scientific community about the importance of the human gut microbiome relating to general health. It is known that imbalances in the species that reside in the human gut can cause organism-wide problems in humans. When prescribing or injecting oral medications, the thought of the downstream effects on the gut microbiome are not always considered. By exposing known healthy members of the gut; Akkermansia muciniphila, Bacteroides fragilis, Clostridium sordellii, and Clostridium difficile to the Aspirin, this study attempted to provide insight into the effects of the drug on bacterial growth. …

Phase Ii Trial Of Medi0457 And Durvalumab For Patients With Recurrent/Metastatic Human Papillomavirus-Associated Cancers, Van K Morris, Amir Jazaeri, Shannon N Westin, Curtis Pettaway, Solly George, Ryan W Huey, Michaela Grinsfelder, Aaron Shafer, Benny Johnson, David Vining, Ming Guo, Bryan Fellman, Michael Frumovitz

Faculty, Staff and Student Publications

BACKGROUND: Human papillomavirus (HPV) types 16/18 drive oncogenesis for most patients with cervical, anal, and penile cancers. MEDI0457, a therapeutic DNA vaccine containing plasmids for E6 and E7 HPV-16/18 viral oncogenes and IL-12 adjuvant, is safe and provokes an immune response against E6/E7. We tested MEDI0457 with the anti-PD-L1 antibody durvalumab for patients with HPV-associated cancers.

METHODS: Patients with recurrent/metastatic, treatment-refractory HPV-16/18 cervical cancer, or rare HPV-associated (anal and penile) cancers were eligible. Prior immune checkpoint inhibition was not permitted. Patients received MEDI0457 7 mg intramuscularly (weeks 1, 3, 7, 12, and every 8 weeks thereafter) and durvalumab 1500 mg …

The Ethical Dilemmas Epigenetic Editing In Utero Presents To Christians, Victoria Hendrix

Senior Honors Theses

The development of CRISPR epigenetic editing technology was initially impactful due to its potential for disease treatment. However, despite the potential benefits of epigenetic technology, there exist ethical dilemmas surrounding its use in utero. The review of the ethical dilemmas of epigenetic editing in utero from a Christian perspective showed that research in epigenetic editing is promising, yet fraught with peril. The basic ethical issues of epigenetic editing in utero stem from its inaccuracy, lack of research concerning its effects on offspring, an incomplete understanding of gene interactions, and its connection to eugenics. The ethical concerns particularly relevant to Christians …

Chewed Versus Swallowed Ticagrelor In P2y12 Inhibitor-Naïve Patients Undergoing Percutaneous Coronary Intervention, Thomas F. Wilson, Muddasir Ashraf, M. Fuad Jan, Tonga Nfor, Louie Kostopoulos, Joaquin Solis, Jayant Khitha, Ahmad Khraisat, Anthony C. Defranco, Tanvir Bajwa, Suhail Q. Allaqaband

Journal of Patient-Centered Research and Reviews

Purpose: Dual antiplatelet therapy is standard for patients undergoing percutaneous coronary intervention (PCI) with stents. Traditionally, patients swallow the loading dose of a P2Y12 inhibitor before or during PCI. Time to achieve adequate platelet inhibition after swallowing the loading dose varies significantly. Chewed tablets may allow more rapid inhibition of platelet aggregation. However, data for this strategy in patients with stable ischemic heart disease or non-ST-elevation acute coronary syndrome (NSTE-ACS) are less robust.

Methods: In this single-center prospective trial, 112 P2Y12-naïve patients with stable ischemic heart disease or NSTE-ACS on aspirin therapy and who received ticagrelor after coronary angiography but …

Support Their Sleep: Enhancing Nurses' Knowledge And Implementation Of Non-Pharmacological Sleep Protocols To Improve Patient Rest, Recovery, And Reduce Cognitive Impairment., David C. Barry

Master's Theses and Capstones

Background: Sleep and rest play an influential role in promoting recovery and healing in humans. Hospitalized patients are at risk for altered sleep from hospitalization, illness, and stimulation from a hospital environment. Non-pharmacologic interventions preformed by nurses can help to improve sleep and sleep environment for patients.

Local problem: There was no protocol or available information regarding patient sleep promotion for nurses to references when caring for patients.

Methods: Nurses in the microsystem (n=8) were administered a pre/post questionnaire containing Likert scales and a short quiz containing knowledge-based questions. Questionnaires were distributed to nurses prior to and after …