National Patient Safety Foundation

The Multidimensional Nature of Pediatric Patient Complexity

OBJECTIVE: Patient complexity is defined in a variety of ways and is associated with health care costs and use. In this study, we evaluate whether pediatric inpatient complexity represents a single construct or multiple domains using multiple measures of diagnostic burden, health...

Evaluation of a Commercial Pediatric Sepsis Early Detection Alert in the Emergency Department

Importance Screening tools have been implemented with the goal of improving early detection of pediatric sepsis, with limited evidence of effectiveness. The Epic Systems Pediatric Sepsis Early Detection Model (PESM) and its associated clinical alert have been widely implemented i...

Process mapping of a collaborative quality improvement study to optimise the use of antibiotics in intensive care units in Argentina: a Pathfinder study

Objective To systematically document the operational components, barriers, facilitators, and solutions of a quality improvement collaborative for antibiotic stewardship in intensive care units (ICUs) in the public sector of Argentina, using the Pathfinder methodological framework...

Communicating Change on Multi-item Patient-Reported Outcome Measures: What Were the Meaningful Changes in Physical Functioning Experienced by Patients on Vimseltinib in the MOTION Trial

Patients with tenosynovial giant cell tumor experience many impacts on their physical functioning associated with pain, stiffness, and limited range of motion. Clinical trials often use clinical outcome assessments to establish meaningful change in treatment; although, conceptual...

Maximum Allowable Contrast Dose and Risk of Acute Kidney Injury After Coronary Procedures

BACKGROUND: Recent studies have questioned whether iodinated contrast is causally related to acute kidney injury (AKI). AIM: We pursed a contemporary analysis to determine the impact of contrast dose on AKI following coronary procedures in an era of lower contrast doses and less...

Safety, Pharmacokinetics, and Predicted Neutralizing Activity of the SARS-CoV-2 Monoclonal Antibody Sipavibart: Results from Little DIPPER and the SUPERNOVA Substudy

The rapid evolution of SARS-CoV-2 has necessitated efforts to accelerate the clinical evaluation of neutralizing monoclonal antibodies. Little DIPPER and the SUPERNOVA substudy explored the feasibility of immunobridging efficacy from tixagevimab–cilgavimab to sipavibart using pre...

Validation of AACN’s Healthy Work Environment Assessment Tool–Team

Background In 2024, the American Association of Critical-Care Nurses (AACN) updated the Healthy Work Environment Assessment Tool (HWEAT), renamed HWEAT-Team. Objective Validating HWEAT-Team for interprofessional use. Methods This was a multisite, descriptive, nonexperimental corr...

Predictive Safety in the Era of Artificial Intelligence: Promises, Limits, and the Case for an Enterprise Lifecycle Evidence Ecosystem

Drug safety remains central to patient benefit, as maximizing the value of beneficial therapies requires recognition, appropriate characterization, and effective mitigation of treatment-related adverse drug reactions (ADRs). These challenges, particularly with the advent of artif...

Process mapping of a collaborative quality improvement study to optimise the use of antibiotics in intensive care units in Argentina: a Pathfinder study

<ns5:p>Objective To systematically document the operational components, barriers, facilitators, and solutions of a quality improvement collaborative for antibiotic stewardship in intensive care units (ICUs) in the public sector of Argentina, using the Pathfinder methodological fr...

Beyond ‘diagnostic error’: an ethnography of resilient behaviours and system adaptations in paediatric outpatient diagnosis

Background Improving paediatric diagnosis by addressing errors (Safety-I) is insufficient for diagnostic excellence. Resilience engineering’s approach to understanding adaptations to achieve success in everyday work may elucidate how individuals and systems manage diagnostic comp...

Treatment Goals for Primary Biliary Cholangitis, an Australian Perspective

ABSTRACT Primary biliary cholangitis (PBC) is an autoimmune liver disease that targets the small intrahepatic bile ducts with diagnosis based on elevated serum alkaline phosphatase (ALP) levels and the presence of anti‐mitochondrial antibodies. Untreated, it may run a progressive...

Inpatient Use of Continuous Glucose Monitors: Insights From Pennsylvania Patient Safety Event Reports

Introduction Inpatient use of continuous glucose monitors (CGMs) has historically been prohibited. Increased outpatient use, critical needs during the COVID-19 pandemic, and growing interest in allowing use of CGMs to manage blood glucose levels for hospitalized patients have pro...

Cost-effectiveness of pembrolizumab as neoadjuvant therapy and in combination with standard of care (SOC) as adjuvant therapy for stage III-IVA resectable locally advanced head and neck squamous cell carcinoma (LA HNSCC) in Switzerland

AIMS: KEYNOTE-689 trial results demonstrated that neoadjuvant pembrolizumab followed by adjuvant pembrolizumab plus standard of care (NP/AP + SOC) significantly improved event-free survival (EFS) versus SOC alone in patients with locoregionally advanced head and neck squamous cel...