Patient Safety Commons^™

Racial Variations Of The Injection Route Of Administration Among Injection Drug Users In The United States: A Comparative Trend Analysis, Philip Danquah

Graduate & Professional Student Association Research Forum

The objective of this research is to address the variations in the injection route of administration among racial groups who are injection drug users in the United States and how that contributes to their vulnerability to HIV/AIDS behaviors and hospital admissions.

Medication Safety In Emergency Medical Services: Approaching An Evidence-Based Method Of Verification To Reduce Errors, Paul Misasi, Joseph R. Keebler

Publications

Lack of verification is often cited as a root cause of medication errors; however, medication errors occur in spite of conventional verification practices and it appears that human factors engineering (HFE) can inform the design of a more effective method. To this end, an HFE-driven process was designed and implemented in an urban, Midwestern emergency medical service agency. Medication error data were collected over a 54-month period, 27 months before and after implementation. A decrease in the average monthly error rate was realized for all medications administered (49.0%) during the post-intervention time period. The average monthly error rate for fentanyl, …

Mesenchymal Stromal Cell Therapeutic Delivery: Translational Challenges To Clinical Application, Henry Caplan, Scott D Olson, Akshita Kumar, Mitchell George, Karthik S Prabhakara, Pamela Wenzel, Supinder Bedi, Naama E Toledano-Furman, Fabio Triolo, Julian Kamhieh-Milz, Guido Moll, Charles S Cox

Faculty, Staff and Student Publications

For several decades, multipotent mesenchymal stromal cells (MSCs) have been extensively studied for their therapeutic potential across a wide range of diseases. In the preclinical setting, MSCs demonstrate consistent ability to promote tissue healing, down-regulate excessive inflammation and improve outcomes in animal models. Several proposed mechanisms of action have been posited and demonstrated across an array of in vitro models. However, translation into clinical practice has proven considerably more difficult. A number of prominent well-funded late-phase clinical trials have failed, thus calling out for new efforts to optimize product delivery in the clinical setting. In this review, we discuss novel …

Physical Therapist Views And Experiences With Patient Use Of Marijuana, Arturo De La O Basurto Jr.

Cal Poly Humboldt theses and projects

Conditions seen within physical therapy settings overlap with reasons that patients seek marijuana. For this reason, information about these professionals’ outlooks on patients’ marijuana use in prime. Purpose: Gain current views and experiences of physical therapists (PTs)/physical therapist assistants (PTAs) on their patients’ use of marijuana in the physical therapy field. Methods: PTs/PTAs were invited to complete an anonymous survey asking relative PT/PTA views, experiences, and understanding of patients’ marijuana use. Results: PTs/PTAs who have had experience (did not have experience) with patients who use marijuana received information about marijuana from news media - 61% (60%), patients …

Law, Technology And Patient Safety, Kathryn Zeiler, Gregory Hardy

Faculty Scholarship

Medical error is the third leading cause of death in the United States, In an effort to increase patient safety, various regulatory agencies require reporting of adverse events, but reported counts tend to be inaccurate. In 2005, in an effort to reduce adverse event rates, Congress proposed a list of “never events,” adverse events, such as wrong-site surgery, that should never occur in hospitals, and authorized CMS to refuse payment for care required following such events. CMS has since pushed for further regulation, “such as putting more payment at risk, increasing transparency, increasing frequency of quality data reviews, and stepping …

Syndemics Of Severity And Frequency Of Elder Abuse: A Cross-Sectional Study In Mexican Older Females, Mireya Vilar-Compte, Pablo Gaitán-Rossi

Department of Public Health Scholarship and Creative Works

Background: Elder abuse is a common phenomenon with important effects on the health and well-being of older adults. There are important gaps in elder abuse measurement, as it is usually reported as the absence or presence of elder abuse, disregarding its severity and frequency.

Objectives: Identify different ways of measuring severity and frequency of elder abuse and assess whether different experiences of severity and frequency suggest syndemic relationships.

Methods: Through a sample of 534 non-institutionalized Mexican older women, we assessed how severity (i.e., number of abusive experiences and number of types of abuses) and frequency (i.e., if abusive experiences had …

Women Are Being Cut During Childbirth Without Need Or Consent, Molly Cora Enking

Capstones

An episiotomy, a surgical cut used to enlarge the vaginal opening during childbirth, can be extremely painful, hard to recover from and can increase the risk of severe complications. In 2018, episiotomies are rarely necessary, but at some U.S. hospitals they happen much more than they should. And in the course reporting this story, New York City News Service found that it is common for doctors to cut women without the mother’s consent.

https://medium.com/@mollyenking/women-are-being-cut-during-childbirth-without-need-or-consent-7677de7eddae

Multiple Regression Models To Analyze Length Of Hospitalization Due To Nosocomial Infections In U.S. Hospitals, Ernest M. Oleksy

The Downtown Review: An Interdisciplinary Journal Written and Peer-Reviewed by Mandel Honors College Students at Cleveland State University

Nosocomial diseases are a serious concern and detriment to hospitals’ abilities to provide appropriate patient care. Bearing this in mind, an effort must be made to determine whether infection surveillance and control programs have reduced the rates of nosocomial infection at U.S. hospitals. The data that were studied were obtained as part of the Study on the Efficacy of Nosocomial Infection Control (SENIC) and used to develop a model of what variables most contribute to a patient’s length of stay at the Cleveland Clinic (Quade et al, 1980).

Failing The Mothers Of New York City, Irene Spezzamonte, Vanessa Swales

Capstones

Between 2015 and 2011, about 4,000 women lost their lives while delivering a baby in the United States. That’s 1,000 lost lives every year.

The causes of these deaths are often preventable and are the mere result of racial discrimination. African-American mothers, for instance, have a three-time higher rate of dying than White mothers. Several investigative investigations have been conducted on the racial disparities and the lack of resources offered nationwide, but, so far, none has focused on the local level. This capstone focuses solely in New York City and the three populations that are being affected the most by …

Improving Bedside Procedural Safety Through Optimizing Timeout Documentation And A Pre-Procedure Checklist, Jennifer Harris, Md, R. Benson Jones, Md, Kristin Lohr, Md, Grant Turner, Md, Drew Kotler, Md, Justine Blum, Md, Megan Margiotta, Md, Matthew Bokhari, Md, Erica Li, Md, Riti Kanesa-Thasan, Md, Bracken Babula, Md, Rebecca Jaffe, Md

Department of Medicine Posters

Aim

GOAL: Improve the safety of patients undergoing bedside procedures while maintaining the full spectrum of graduated autonomy in procedure training for residents.

SMART Aim: Increase the rate of timeouts documented for bedside procedures from 29% to 50% by June 2018.

Risky Business: Millennials’ Protection Motivation Factors For Norovirus Outbreaks On College Campuses, Dylan Conrad Martinez

Graduate Theses and Dissertations

The risk and severity of hNoV transmission is obscurely recognized to foodservice millennial customers. Most commonly associated with cruise ships, consumers are not aware of its full potential to strike at other locations, especially college campuses. For the foodservice industry and the university community, it is imperative that a proactive method for increasing millennials’ motivation to practice mitigation methods emerges to reduce future hNoV outbreaks on college campuses. Research has shown that students can play a major role in the spread of hNoV on college campuses. Therefore, the purpose of these studies is to examine motivations for health protective behaviors …

An Evidenced-Based Protocol For Eliminating Errors Associated With Intravenous Medication Errors, Susie Chaney, Blake Smith, Andrea Howard, Chanel Wilder, Suzi White Msn, Phcns-Bc

Posters-at-the-Capitol

The purpose of our research is to decrease the number of IV medication errors. IV medication errors occur due to the wrong drug, wrong dose, wrong rate, wrong concentration, incorrect aseptic technique, known allergies, omitted medications, wrong time of administration, incorrect labeling, patient identification, and no order for the infusion. Nurses’ perceptions of why medication errors occur included physicians’ medication orders are not clear, the names of many medications are similar, pharmacy did not label the medication correctly, poor communication, lack of staff to patient ratio, fatigue from hard work, nurses' heavy workload, and working night shift. This quality improvement …

Trajectory Of Thirst Intensity And Distress From Admission To 4-Week Follow Up At Home In Patients With Heart Failure, Nana Waldréus, Misook L. Chung, Martje H. L. Van Der Wal, Tiny Jaarsma

Nursing Faculty Publications

Background: Patients with heart failure (HF) can suffer from increased thirst intensity and distress. Trajectories of thirst intensity and distress from hospital to home are unclear. The aim of this study was to describe thirst intensity and distress trajectories in patients from the time of hospital admission to 4 weeks after discharge, and describe trajectories of thirst intensity and distress by patients’ characteristics (gender, age, body mass index [BMI], plasma urea, anxiety, and depression).

Patients and methods: In this observational study, data were collected from patients with HF (n=30) at hospital admission, discharge, and at 2 and 4 weeks after …

Reducing O Negative Blood Product Usage In A Tertiary Care Academic Medical Center, Wendy Weiler, Tracy Cook, Mmc Blood Bank, Mark Parker, Stephen Tyzik, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operations Transformation

MANAGEMENT OF O NEGATIVE BLOOD USE

O registered blood cells are the universal donor but it comprises only 7% of the blood supply. As a result, inappropriate use can result in shortages.

At an academic tertiary care medical center, a performance improvement goal was established that O negative blood cells would make up less than 12% of all blood type transfused by the end of their fiscal year.

A root cause analysis established reasons for the use of O negative blood cells. A number of countermeasures were initiated using the plan, do, study, act (PDSA) problem solving model. Using newly …

Patient Safety And The Ageing Physician: A Qualitative Study Of Key Stakeholder Attitudes And Experiences, Andrew A. White, William M. Sage, Paulina H. Osinska, Monica J. Salgaonkar, Thomas H. Gallagher

Faculty Scholarship

Background Unprecedented numbers of physicians are practicing past age 65. Unlike other safety-conscious industries, such as aviation, medicine lacks robust systems to ensure late-career physician (LCP) competence while promoting career longevity.

Objective To describe the attitudes of key stakeholders about the oversight of LCPs and principles that might shape policy development.

Design Thematic content analysis of interviews and focus groups.

Participants 40 representatives of stakeholder groups including state medical board leaders, institutional chief medical officers, senior physicians (>65 years old), patient advocates (patients or family members in advocacy roles), nurses and junior physicians. Participants represented a balanced sample from …

Combatting Domestic Minor Sex Trafficking: An Evaluation Of The My Life, My Choice Program In Kentucky, Chelsea M. Dyer

Morehead State Theses and Dissertations

A thesis presented to the faculty of the Caudill College of Arts, Humanities, and Social Sciences at Morehead State University in partial fulfillment of the requirements for the degree of Master of Arts by Chelsea M. Dyer on July 11, 2018.

The Contributing Factors To Adolescent Depression, Josie H. Lee

Independent Study Project (ISP) Collection

Objective: This paper reviews individual, familial, peer, and societal factors influencing adolescent depression in developed countries. Background: Depression usually onsets at adolescence and contributes to high DALYs. Since depression is treatable, efforts should be made to reduce its prevalence and effect. Methods: The research consisted of looking at literature relevant to the topic and age group and conducting interviews with experts who know about and have worked with adolescent depression. Discussion: Adolescents begins at the onset of puberty, allowing different biological factors such as genetics, stress of puberty, and cognitive changes to increase vulnerability to depression. Adolescents who had substance …

Perceptions As A Barrier To Emergency Medical Services Utilization Among Syrian Refugees In Jordan, Elizabeth Shan Wang

Independent Study Project (ISP) Collection

The purpose of this study is to evaluate perceptions of emergency medical services (EMS) among Syrian refugees living in urban host communities in Jordan. The research questions are as follows: To what extent do public perceptions of emergency medical services affect the utilization of ambulances? How does awareness about available emergency medical services shape refugees’ attitudes towards it? Because this topic is qualitative and exploratory in the case of Jordan, there was no clear hypothesis. The assumption, however, is that positive perceptions and awareness about EMS can encourage refugees to call an ambulance for transportation to the hospital during a …

Non-Retrieval Of Inferior Vena Cava Filters As A Patient Safety Concern: Evaluation Of A New Process Improvement Project To Increase Retrieval Rates In A Vascular And Interventional Radiology Clinic, Joshua Brown, Jeffery Talbert, Ryan Pennington, Qiong Han, Driss Raissi

Pharmacy Practice and Science Faculty Publications

Background: Retrieval of inferior vena cava filters (IVCFs) is important to decrease the long-term risk of complications associated with indwelling devices. Our hospital experienced low retrieval rates and implemented a low-cost intervention and evaluation for quality improvement. The working hypothesis was that a simple, mailed letter intervention could increase retrieval rates by increasing patient and primary care provider knowledge of the need for retrieval.

Methods: For all prospective patients who received a retrievable IVCF during the intervention period from January 1, 2014 to February 29, 2016, patients and their primary care providers were mailed letters encouraging contact with the clinic …

The Effectiveness Of Interventions And Bundles For Central Line-Associated Bloodstream Infections In The Neonatal Intensive Care Unit, Mohamad Alhamwi

Honors Undergraduate Theses

Introduction: Central Line-Associated Bloodstream Infections (CLABSIs) are a major cause of increased mortality, morbidity and healthcare costs in neonatal intensive care units (NICUs) patients. Despite CDC's efforts to reduce infection rates, patients often suffer consequences. The objective of this study is to perform a systematic review of strategies utilized in the neonatal population and evaluate them with the current CDC's guidelines to assess the effectiveness of bundles in preventing CLABSI in NICUs.

Methods: A systematic literature search was conducted using CINAHL Plus with Text, Cochrane Database of Systematic Reviews and MEDLINE from January 2008 up to 2018. There were multiple …

Medication Education In The Pediatric Rheumatology Clinic, Ashley M. Cooper, Julia G. Harris

Posters

No abstract provided.

Pharmacy Driven Best Possible Admission Medication History At A Pediatric Institution, Damon Pabst, Charity Thompson, Brandon French, Brian O'Neal, Garret Matthews, Zeb Benner, Joshua Meade

Posters

No abstract provided.

The Lifecycle Of A K-Card: Improving Data Collection While Improving Bundle Reliability, Tara Benton, Barb Haney, Lacey Bergerhofer, Susan Burns, Yolanda Ballam, Kaitlyn Hoch

Posters

No abstract provided.

The Good, The Bad, And The Ugly Of Calcium Supplementation: A Review Of Calcium Intake On Human Health., Kelvin Li, Xia-Fang Wang, Ding-You Li, Yuan-Cheng Chen, Lan-Juan Zhao, Xiao-Gang Liu, Yan-Fang Guo, Jie Shen, Xu Lin, Jeffrey Deng, Rou Zhou, Hong-Wen Deng

Manuscripts, Articles, Book Chapters and Other Papers

Calcium is an important integrative component of the human body and critical for human health. It has been well established that calcium intake is helpful in the prevention and treatment of osteoporosis, which has become one of the most serious public health problems across the world. However, community-dwelling adults with and without osteoporosis are rarely concerned or even not aware of the potential side effects of high or inappropriate doses of calcium intake. Some recent studies have revealed that excessive calcium intake might increase the risks of cardiovascular diseases. The purpose of this article was to review the health benefits, …

Cyber Threats And Healthcare Organizations: A Public Health Preparedness Perspective, Lauren Elizabeth Branch

Graduate Theses, Dissertations, and Problem Reports (ETD)

Healthcare in the United States, heavily reliant on digital technology in service provision, has recently seen an increase risk of cyberattacks. Coordinated electronic medical records, imaging, pharmaceutical services, lab services and even treatment devices all rely on electronic connectivity and represent critical services that must be secured from cyber threats. Hospitals have become increasingly complex systems, and this often makes the organization more vulnerable to failure. Planning for these events is often hard for hospitals because their main charge is to provide life-saving care to patients as they need it. This is a relatively new threat to healthcare organizations, and …

Sex-Dependent Effects Of Ho-1 Deletion From Adipocytes In Mice, Peter A. Hosick, Mary Frances Weeks, Michael W. Hankins, Kyle H. Moore, David E. Stec

Department of Exercise Science and Physical Education Scholarship and Creative Works

Induction of heme oxygenase-1 (HO-1) has been demonstrated to decrease body weight and improve insulin sensitivity in several models of obesity in rodents. To further study the role of HO-1 in adipose tissue, we created an adipose-specific HO-1 knockout mouse model. Male and female mice were fed either a control or a high-fat diet for 30 weeks. Body weights were measured weekly and body composition, fasting blood glucose and insulin levels were determined every six weeks. Adipocyte-specific knockout of HO-1 had no significant effect on body weight in mice fed a high-fat diet but increased body weight in female mice …

The Scoping Review Method: Mapping The Literature In “Structural Change” Public Health Interventions, Rosie Hanneke, Yuka Asada, Lisa D. Lieberman, Leah Christina Neubauer, Michael C. Fagan

Department of Public Health Scholarship and Creative Works

This case discusses how we used scoping review methodology to map the literature in an emergent area of research, “structural change” public health interventions. Scoping reviews are similar to systematic reviews in both scale and rigor; both of these literature review methodologies are comprehensive approaches to reviewing the literature on a topic. However, while a systematic review attempts to answer a specific, targeted research question, a scoping review is designed to map and categorize all of the literature on a broad topic. For this reason, it is an excellent method to employ in emergent research areas, in which researchers have …

Realizing Improved Patient Care Through Human-Centered Design In The Operating Room, Volume 3-4, Clemson Center For Health Facilities Design & Testing

Center for Health Facilities Design and Testing

This 4-year grant from the Agency for Healthcare Research and Quality supports the development of a learning lab focused on designing a safer, more ergonomic operating room. Sponsor: Agency for Healthcare Research Quality Project period: 9/1/15 to 8/31/19 Project Description: The overarching goal of the learning lab titled, “Realizing Improved Patient Care through Human-Centered Design in the Operating Room (RIPCHD.OR) is to develop an evidence-based framework and methodology for the design and operation of operating rooms such that it impacts improved perioperative outcomes including surgical site infections, surgical errors and staff injuries.

Workplace Violence And Hospital Security Programs: Regulatory Compliance, Program Benchmarks, Innovative Strategies, James D. Blando, Maryalice Nocera, Marilyn L. Ridenour, Daniel Hartley

Community & Environmental Health Faculty Publications

The authors describe the issue of workplace violence in hospitals, a New Jersey state law and regulations regarding workplace violence in healthcare, and some innovative strategies that are being utilized to help reduce the occurrence and risk of violence. The authors also discuss compliance with the New Jersey regulations.

Sneaky Salt Contributes To High Blood Pressure, Rodney Richmond

Faculty Research ​and Publications

No abstract provided.