Generative artificial intelligence (AI) technologies have the potential to revolutionise healthcare delivery but require classification and monitoring of patient safety risks. To address this need, we developed evaluated a preliminary system for categorising generative AI errors. Our is organised around two stages (input output) with specific error types by stage. We applied our applications assess its effectiveness in issues: patient-facing conversational large language models (LLMs) an...

Background Medical oxygen is frequently used in healthcare settings. Challenges with disruption, such as tanks running out due to communication issues between staff or not being set up properly, have been noted the limited existing literature. and patient safety associated disruption persist. Utilizing a human factors approach, our study aims understand contributing context of disruption–related event reports inpatient setting provide person-based system-based solutions. Methods Through...

Artificial intelligence–enabled ambient digital scribes may have many potential benefits, yet results from our study indicate that there are errors must be evaluated to mitigate safety risks.

Objectives The aim of the study was to determine whether race differences exist in voluntarily reported harmful patient safety events a large 10 hospital healthcare system on high reliability organization journey. Methods From July 1, 2015, June 30, 2017, employees based Washington, District Columbia, and Maryland by type using Patient Safety Event Management System. Inpatients, outpatients, observation patients were identified as “black,” “white,” or “other” (N = 5038). Using retrospective...

Abstract Objective Poor electronic health record (EHR) usability contributes to clinician burnout and poses patent safety risks. Site-specific customization configuration of EHRs require individual EHR system testing which is resource intensive. We developed pilot-tested a self-administered assessment tool, focused on computerized provider order entry (CPOE), can be used by any facility identify specific issues. In addition, the tool provides recommendations for improvement. Materials...

Effective patient- and family-centered care requires a dedication to engaging patients family members in health system redesign improve the quality, safety, experience of care. Provided here are lessons learned six years after establishing an infrastructure patient advisory councils (PFACs) focused on improving quality safety.A large regional with multiple hospitals ambulatory delivery sites eastern United States adopted systemwide approach Patient Family Advisory Councils Quality Safety...

Background: Alarms are signals intended to capture and direct human attention a potential issue that may require monitoring, assessment, or intervention play critical safety role in high-risk industries. Healthcare relies heavily on auditory visual alarms. While there some guidelines inform alarm design use, fatigue other issues challenges the healthcare setting. Automotive, aviation, nuclear industries have used science of factors develop use guidelines. These provide important insights for...

Background: Dose calculation errors are one of the most common types medication impacting children and they can result in significant harm. Technology-based solutions, such as computerized provider order entry, effectively reduce dose issues; however, these technologies not always optimized, resulting potential benefits being fully realized. Methods: We analyzed pediatric dose-related patient safety event reports submitted to Pennsylvania Patient Safety Reporting System using a task-analytic...

COVID-19 vaccines are vital tools in the defense against infection and serious disease due to SARS-CoV-2. There many challenges implementing mass vaccination campaigns for large, diverse populations from crafting vaccine promotion messages reaching individuals a timely effective manner. During this unprecedented period, with essential protecting vulnerable patient attaining herd immunity, health care systems were faced dual of outreach distribution.The aim cross-sectional study was assess...

Resilience engineering (RE) has ushered new approaches to learning about work in complex sociotechnical systems. In terms of improving safety, RE marks a shift from the traditional approach retrospectively investigating adverse events, toward proactively patterns everyday work, including how things go well. This study applied framework health care domain, by developing and implementing knowledge-elicitation protocol learn frontline providers achieve safe effective patient their work....

Background Despite their prevalence, poorly designed electronic health records (EHRs) are common, and research shows poor design consequences include clinician burnout, diagnostic error, even patient harm. One of the major difficulties EHR is visual display information, which aims to present information in an easily digestible form for user. High-risk industries like aviation, automotive, nuclear have guidelines displays based on human factors principles optimized design. Purpose In this...

This study aimed to determine if race differences exist in voluntarily reported near-miss patient safety events a large integrated, 10-hospital health care system on its journey become high reliability organization.From July 1, 2015, June 30, 2017, employees mid-Atlantic by type using an occurrence reporting referred as the Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified "Black," "White," or "other" (n = 39,390). Using retrospective...

This cross-sectional study investigates the association between day-to-day changes in telemedicine share and clinician time spent on electronic health record (EHR) use.

Background When placing orders into the electronic health record (EHR), prescribers often use free-text information to complement order. However, of these fields can result in patient safety issues. The objective our study was develop a deeper understanding conditions under which information, or special instructions, are used EHR and issues associated with their use, through an analysis event (PSE) reports. Methods We identified 847 PSE reports submitted Pennsylvania Patient Safety Reporting...

There is a growing body of research highlighting that Black women have more adverse maternal health events. Instead only focusing on severe morbidity and mortality events, patient safety events (PSEs) feedback reports are data sources can offer insights into broader spectrum safety, including near misses, unsafe conditions. In this work, we explore the racial differences in representation mothers birthing individuals' (MBIs) voices PSE reports.

Intravenous (IV) vancomycin is one of the most commonly used antibiotics in U.S. hospitals. There are several complexities associated with IV use, including need to have an accurate patient weight for dosing, provide close monitoring ensure appropriate drug levels, monitor renal function, and continue delivery medication at prescribed intervals. numerous healthcare system factors, workflow processes, policies, health information technology, clinical knowledge that impact safe use vancomycin....

This qualitative study analyzes closed legal claims data to determine whether problems with electronic health records are associated diagnostic errors, in which part of the process errors occur, and specific types that occur.

Objectives The COVID-19 pandemic has transformed how healthcare is delivered to patients. As the progresses and systems continue adapt, it important understand these changes in care have changed patient care. This study aims use community detection techniques identify facilitate analysis of themes safety event (PSE) reports better pandemic’s impact on safety. With this approach, we also seek can be used extract information from PSE reports. Methods We group 2082 January 1, 2020, 31, 2021,...

Objectives This study aimed to determine whether potential malpractice events reported by employees, involving claims, and lawsuits differ based on patient race in a large 10-hospital healthcare system. Methods Data system’s database from July 1, 2012, June 30, 2017, were stratified using “Black,” “White,” “other” categories. χ 2 Goodness-of-fit tests used compare differences proportions employee-reported observations of that could lead payment claim, claims not the court, court. Results...

Background: Medical equipment, supplies, and devices (ESD) serve a critical function in healthcare delivery how they can have patient safety consequences. ESD-related issues include malfunctions, physically missing ESDs, sterilization, usability. Describing from human factors perspective that focuses on user interactions with ESDs provide additional insights to address these issues. Methods: We manually reviewed ESD event reports submitted the Pennsylvania Patient Safety Reporting System...

Health information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These can have serious safety consequences and there has been significant effort to mitigate the risk these through national goals, in-depth research, development toolkits. Nonetheless, persist. We analyzed 1,189 event reports using a science resilience engineering approach, focuses on identifying processes...

Background: Duplicate medication orders are a prominent type of error that in some circumstances has increased after implementation health information technology. commonly defined as two or more active for the same medications within therapeutic class. While there have been several studies identified contributing factors and described potential solutions, duplicate order errors continue to impact patient safety. Methods: We analyzed 377 reports from 95 healthcare facilities granularly define...