Patient Safety Commons^™

Asynchronous Online Focus Groups For Research With People Living With Amyotrophic Lateral Sclerosis And Family Caregivers: Usefulness, Acceptability And Lessons Learned, Shelagh K. Genuis, Westerly Luth, Garnette Weber, Tania M. Bubela, Wendy S. Johnston

Office of the Provost

Background: People with amyotrophic lateral sclerosis (ALS) face disability- and travel-related barriers to research participation. We investigate the usefulness and acceptability of asynchronous, online focus groups (AOFGs) for research involving people affected by ALS (patients and family caregivers) and outline lessons learned.
Methods: The ALS Talk Project, consisting of seven AOFGs and 100 participants affected by ALS, provided context for this investigation. Hosted on the secure itracks Board™ platform, participants interacted in a threaded web forum structure. Moderators posted weekly discussion questions and facilitated discussion. Data pertaining to methodology, participant interaction and experience, and moderator technique were analyzed using itracks …

Analyzing African American College Student Willingness To Participate In Clinical Trials, Caitlin B. Ulmer

Senior Theses

Previous studies regarding African American participation in clinical trials have found that African Americans participate at a significantly lower rate than other ethnic/racial groups. Scholars argue that this lack of participation in clinical trials is a direct result of historical trauma linked to unethical experiments and African American distrust in the healthcare system. However, there is a gap in the literature because these studies focus on African American individuals above the age of 30. This study aimed to fill the gap by examining clinical trial participation among African American college students within the ages 18 to 23. This study also …

A Review Of Magnetic Resonance (Mr) Safety: The Essentials To Patient Safety, Aren Shah, Shima Aran

Faculty, Staff and Student Publications

Nearly 40 million magnetic resonance imaging (MRI) scans are performed each year in the United States. MRI has become a relatively safe non-invasive diagnostic tool. To maintain a safe magnetic resonance (MR) environment, specific policies and safety procedures are required. The four zones of an MR site allow MR personnel to closely monitor and restrict the area. Screening patients with a questionnaire asking about implants, allergies to contrast agents, and other relevant medical information is important to safely perform an MRI scan. Providers may need to consider anesthesia for patients with claustrophobia who are unable to remain motionless. Radiologists and …

Understanding The Gap Between Nursing Workforce In The United States And Population Needs-A Policy Brief, Mayar Al Mohajer

Faculty, Staff and Students Publications

Purpose  This report is intended to analyze the root causes for the current gap between the nursing workforce and population needs in the United States. It aims to consolidate what is known about these contributing reasons and provide evidence-based recommendations for action.

Methods  The report utilized the Sample, Phenomenon of Interest, Design, Evaluation, Research type framework to develop the research question and the 5 Whys methodology for the root cause analysis.

Results  This report highlighted six major causative problems, including workforce market mismatch, poor financing design, inadequate governance, flawed technologies, insufficient research, and suboptimal service delivery. A detailed evaluation of …

Proactively Preventing Medical Errors: A Student-Led Approach To Patient Safety In Pre-Clinical Curriculum, Sahar Panjwani, Daniel Nwosuocha, Nelson D. Gonzalez, Ayleen Godreau

Research Symposium

Introduction: Preventable medical errors are currently the third leading cause of death in the United States following heart disease and cancer (1). This study was designed to assess the change in knowledge from earlier education of medical students during pre-clinical years.

Methods: Patient safety trainings have been conducted for two years for interested first and second-year medical students and responses are assessed through a pre-test, immediate post-test, 3-month post-test, and 6-month post-test. The survey assesses student knowledge on aspects of patient safety and has Likert scale questions assessing if the training influenced students’ desire to learn about patient safety. …

The Fortify Resilience Initiative, Nausheen Jamal, Deepu George, Maria Hernandez, Evan Garcia, Myrna Ruiz, Salvador Arellano Iii

Research Symposium

Purpose: The Fortify Resilience Initiative focuses on building and sustaining a culture of wellbeing for Residents and Fellows (R/Fs) at The University of Texas Rio Grande Valley (UTRGV) School of Medicine’s (SOM) Graduate Medical Education (GME) residency and fellowship programs. In order to address the multitude of threats to physician wellness and to mitigate the silent, but pernicious effects of burnout on these physician learners serving in the RGV, this Initiative from the Office of GME will strengthen existing wellbeing pathways while expanding additional solutions that will work to sustain wellbeing. Utilizing a combination of prevention, promotion, and intervention strategies …

Interdisciplinary Integrated Primary And Behavioral Healthcare (I2pbh) Initiative, John Ronnau, Deepu George, Maria Hernandez, Evan Garcia, Myrna Ruiz

Research Symposium

Purpose: The Interdisciplinary Integrated Primary and Behavioral Healthcare (I²PBH) initiative will train University of Texas Rio Grande Valley (UTRGV) mental health graduates to deliver high quality, evidence-based Integrated Behavioral Health (IBH) services in the Rio Grande Valley (RGV) – a high-need, high-demand, medically underserved Hispanic region along the US-Mexico border. Specifically, the I²PBH initiative will train 24 UTRGV mental health graduates annually to deliver high-quality Integrated Behavioral Health (IBH) clinical services through the evidence based Primary Care Behavioral Health (PCBH) model. With a training emphasis on basic/advanced theory and clinical skills in the PCBH model, students …

Primary Care Behavioral Health Partnerships Advancing & Transforming Health Sciences (Pcbh Paths), Kristan Diaz-Rios, Deepu George, Maria Hernandez, Evan Garcia, Myrna Ruiz, Salvador Arellano Iii

Research Symposium

Purpose: Primary Care Behavioral Health Partnerships Advancing & Transforming Health Sciences (PCBH PATHS) is a workforce development pipeline project aimed at permanently augmenting UTRGV’s institutional capacity to address shortage of an Integrated Behavioral Health (IBH) competent workforce locally, regionally and nationally. Our initiative, aligned with UTRGV strategic priorities and key initiatives, will integrate basic(model specific strategy and operational elements), mid-level (role identity and profession specific behavioral competencies specific to each health profession), and advanced (behavioral medicine clinical skills) applications of the evidence based PCBH model of delivery. A PCBH focused delivery system (clinical and educational), in which primary care providers …

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. …

A Logistics Approach To Improve Medication Reconciliation In The Outpatient Clinic Setting, Aysha Khan, Demetra Antimisiaris, Madison Perkins, Luz Fernandez

The Cardinal Edge

Medication reconciliation (MR) is the process of determining the most accurate account of medication the patient is taking. Although MR seems simple, research has shown that 25% of medical errors are related to lack of medication reconciliation [1]. In the community clinic setting, the task of medication reconciliation falls on the Medical Assistants (MAs). A preliminary study of MR accuracy in an outpatient clinic found an average of 5.8 discrepancies in the chart medication list [2]. The most notable were incomplete directions, wrong directions, or wrong frequency of dosing. Unoptimized medication use is estimated to result in 275,869 deaths per …

The Effectiveness Of Disinfection Protocols In Osteopathic Family Medicine Offices, Riley Phyu, Harrison A Patrizio, Thomas Boyle, Todd Schachter

Rowan-Virtua School of Osteopathic Medicine Departmental Research

CONTEXT: Healthcare-associated infections (HAIs) pose a substantial public health threat. Despite significant strides to curb HAIs in hospital environments, outpatient settings have not received the same degree of attention. Given their emphasis on holistic, patient-centered care, osteopathic family medicine offices are pivotal in both disease prevention and comprehensive patient treatment. The importance of simple yet effective disinfection protocols, such as thorough cleaning between patient appointments, cannot be overstated in these settings because they are integral to minimizing disease transmission.

OBJECTIVES: This study aims to assess the effectiveness of the current disinfection protocols in osteopathic family medicine offices.

METHODS: A cross-sectional …

Perioperative Team-Based Morbidity And Mortality Conferences: A Systematic Review Of The Literature, Aubrey Samost-Williams, Roni Rosen, Alexander Hannenberg, Melis Lydston, Garrett M Nash, Mary Brindle

Faculty, Staff and Student Publications

OBJECTIVE: This systematic review aimed to identify key elements of perioperative team-based morbidity and mortality conferences (TBMMs) and their impact on patient safety, education, and quality improvement outcomes.

BACKGROUND: Patient safety in the perioperative period is influenced by system, team, and individual behaviors. However, despite this recognition, single-discipline morbidity and mortality conferences remain a mainstay of educational and quality improvement efforts.

METHODS: A structured search was conducted in MEDLINE Complete, Embase, Web of Science, ClinicalTrials.gov, Cochrane CENTRAL, and ProQuest Dissertations and Theses Global in July 2022. Search results were screened, and the articles meeting inclusion criteria were abstracted.

RESULTS: Seven …

Add-On Soft Electronic Interfaces For Continuous Cuffless Blood Pressure Monitoring, Myeong Namkoong, Balaji Baskar, Lakhvir Singh, Heng Guo, Justin Mcmurray, Kimberly Branan, Md Saifur Rahman, Chin-To Hsiao, Josh Kuriakose, Joanna Hernandez, Arda A Arikan, Luis E Garza-Rivera, Gerard L Coté, Limei Tian

Faculty, Staff and Student Publications

Continuous monitoring of arterial blood pressure is clinically important for the diagnosis and management of cardiovascular diseases. Soft electronic devices with skin-like properties show promise in a wide range of applications, including the human-machine interface, the Internet of things, and health monitoring. Here, we report the use of add-on soft electronic interfaces to address the connection challenges between soft electrodes and rigid data acquisition circuitry for bioimpedance monitoring of cardiac signals, including heart rate and cuffless blood pressure. Nanocomposite films in add-on electrodes provide robust electrical and mechanical contact with the skin and the rigid circuitry. We demonstrate bioimpedance sensors …

‘Making It Meaningful’: Co-Designing An Intervention To Improve Medication Safety For People From Culturally And Linguistically Diverse Backgrounds Accessing Cancer Services., Ashfaq Chauhan, Bronwyn Newman, Elsa Roberto, Ramesh Lahiru Walpola, Holly Seale, Melvin Chin, Reema Harrison

Patient Experience Journal

This study reports on the process of using an adapted Experienced-Based Co-Design (EBCD) conducted with culturally and linguistically diverse (CALD) consumers and cancer service staff to co-design the novel ‘Making it Meaningful’(MiM) instrument at a cancer service in Australia. Multi-source experiential and contextual information was gathered in phase 1 of the co-design and this evidence, coupled with knowledge gathered via a feedback event was used to inform three co-design workshops in phase 2. A series of meetings were conducted prior to and in between the workshops. Theory was progressively integrated into the workshop content. Two Mandarin speaking CALD consumers and …

Enhancing Adherence To Best Practice Guidelines Related To Pressure Injury Prevention In The Operating Room At A Children's Hospital During Comprehensive Dental Procedures., Alyce Bailey Seaver

Doctor of Nursing Practice Papers

Background: 1,600,000 patients develop a hospital-acquired pressure injury every year, and 23% of these originate during surgery. Research has demonstrated that the incidence of hospital-acquired pressure injuries developing during surgery has risen over the past 5 years. This rise has been attributed to nurse circulators exhibiting poor knowledge regarding best practices for intraoperative patient positioning and intraoperative documentation that does not follow standards of care.

Purpose: This quality improvement project aimed to enhance circulator knowledge on best practices for intraoperative patient positioning and improve documentation of intraoperative patient positioning in the electronic medical record to comply with standards of …

Identifying Contributing Factors Associated With Dental Adverse Events Through A Pragmatic Electronic Health Record-Based Root Cause Analysis, Elsbeth Kalenderian, Suhasini Bangar, Alfa Yansane, Duong Tran, Emily Sedlock, Yan Xiao, Janelle Urata, Greg Olson, Amy Franklin, Krishna Kookal, Ana Ibarra-Noriega, Sayali Tungare, Oluwabunmi Tokede, Heiko Spallek, Joel M White, Muhammad F Walji

Faculty, Staff and Student Publications

OBJECTIVE: This study assessed contributing factors associated with dental adverse events (AEs).

METHODS: Seven electronic health record-based triggers were deployed identifying potential AEs at 2 dental institutions. From 4106 flagged charts, 2 reviewers examined 439 charts selected randomly to identify and classify AEs using our dental AE type and severity classification systems. Based on information captured in the electronic health record, we analyzed harmful AEs to assess potential contributing factors; harmful AEs were defined as those that resulted in temporary moderate to severe harm, required hospitalization, or resulted in permanent moderate to severe harm. We classified potential contributing factors according …

Variability In Anesthesia And Its Implications For Improving Patient Safety, Joshua Michael Biro

All Dissertations

Improving patient safety in anesthesia has proven to be an arduous and challenging task. Despite the many strategies and interventions to improve patient safety that have been employed, patient harm in anesthesia remains a problem. The struggle to reduce patient harm in anesthesia is both attributable to and representative of the complexity of the anesthesia system. In navigating this complex system, anesthesia providers have different approaches to how they accomplish their work, which results in variability in anesthesia practice. This variability provides an immense challenge to designing and implementing efforts to improve patient safety, as rigid interventions are often met …

Communication Of Patients’ And Family Members’ Ethical Concerns To Their Healthcare Providers, Mariam Noorulhuda, Christine Grady, Paul Wakim, Talia Bernhard, Hae Lin Cho, Marion Danis

Student Papers, Posters & Projects

BACKGROUND: Little is known about communication between patients, families, and healthcare providers regarding ethical concerns that patients and families experience in the course of illness and medical care. To address this gap in the literature, we surveyed patients and family members to learn about their ethical concerns and the extent to which they discussed them with their healthcare providers.

METHODS: We surveyed adult, English-speaking patients and family members receiving inpatient care in five hospitals in the Washington DC-Baltimore metropolitan area from July 2017 to March 2020. Descriptive statistics were used to determine the frequency, comfortableness, and helpfulness of discussions regarding …

Covid-19 Proactive Disease Management Using Covid Virtual Hospital In A Rural Community, Gandhari Loomis, Regina Rhodes, Ed Bujold, Golnosh Sharafsaleh, Ellen Collett, Mark Irwin, Elizabeth W. Staton, John M. Westfall

Journal of Patient-Centered Research and Reviews

Purpose: A community teaching hospital serving a rural population established an intensive “hospital at home” program for patients with COVID-19 utilizing disease risk stratification and pulse oximeter readings to dictate nurse and clinician contact. Herein, we report patient outcomes and provider experiences resulting from this “virtual” approach to triaging pandemic care.

Methods: COVID-19-positive patients appropriate for outpatient management were enrolled in our COVID Virtual Hospital (CVH). Patients received pulse oximeters and instructions for home monitoring of vital signs. CVH nurses contacted the patient within 12–48 hours. The primary care provider was alerted of the patient’s diagnosis and held a virtual …

Previous Health Care Experiences’ Influence On Health Care Perceptions Among Residents In Six Homeless Shelters In Seattle, Washington, July–October 2021, Ashley A. Meehan, Sarah N. Cox, Nicholas B. Thuo, Julia H. Rogers, Amy C. Link, Miguel A. Martinez, Natalie K. Lo, Brian J. Manns, Melissa A. Rolfes, Eric J. Chow, Helen Y. Chu, Emily Mosites, Morhaf Al Achkar

Journal of Patient-Centered Research and Reviews

Purpose: The study purpose was to learn and describe 1) where homeless shelter residents receive health care, 2) what contributes to positive or negative health care experiences among shelter residents, and 3) shelter resident perceptions toward health care.

Methods: Semi-structured interviews (SSIs) utilizing purposive sampling and focus group discussions (FGDs) utilizing convenience sampling were conducted at 6 homeless shelters in Seattle-King County, Washington, during July–October 2021. All residents (age ≥ 18) were eligible to participate. SSIs were conducted with 25 residents, and 8 FGDs were held. Thematic analysis was conducted using Dedoose.

Results: Participants received health care …