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Joint Commission Journal on Quality and Patient Safety

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https://www.readbyqxmd.com/read/30341014/bringing-perioperative-emergency-manuals-to-your-institution-a-how-to-from-concept-to-implementation-in-10-steps
#1
Aalok V Agarwala, L Kelsey McRichards, Vanessa Rao, Vanessa Kurzweil, Sara N Goldhaber-Fiebert
BACKGROUND: Emergency manuals (EMs) are context-relevant sets of crisis checklists or cognitive aids designed to enable professional teams to deliver optimal care during critical events. Evidence from simulation and other high-risk industries have proven that use of these types of checklists can significantly improve event management and decrease omissions of key steps. However, simply printing and placing tools in operating rooms (ORs) is unlikely to be effective. How interventions are implemented influences whether clinicians actually change practice and whether patient care is affected...
October 16, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30341013/unintentionally-retained-foreign-objects-a-descriptive-study-of-308-sentinel-events-and-contributing-factors
#2
Victoria M Steelman, Clarissa Shaw, Laurel Shine, Abbey J Hardy-Fairbanks
OBJECTIVE: Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018...
October 16, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30337145/bachelor-s-degree-nurse-graduates-report-better-quality-and-safety-educational-preparedness-than-associate-degree-graduates
#3
Maja Djukic, Amy Witkoski Stimpfel, Christine Kovner
BACKGROUND: Readiness of the nursing workforce in quality and safety competencies is an essential indicator of a health system's ability to deliver high-quality and safe health care. A previous study identified important quality and safety education gaps between associate- and baccalaureate-prepared new nurses who graduated between 2004 and 2005. The purpose of this study was to assess changes in nursing workforce quality and safety education preparedness by examining educational gaps between associate and bachelor's degree graduates in two additional cohorts of new nurses who graduated between 2007-2008 and 2014-2015...
October 15, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30292465/evaluating-the-impact-of-the-venous-thromboembolism-outcome-measure-on-the-psi-90-composite-quality-metric
#4
Eddie Blay, Reiping Huang, Jeanette W Chung, Anthony D Yang, John O DeLancey, Ryan P Merkow, Cynthia Barnard, Karl Y Bilimoria
INTRODUCTION: Patient Safety Indicator (PSI) 90 is a composite measure widely used in federal pay-for-performance and public reporting programs. A component metric of PSI 90, venous thromboembolism (VTE) rate, has been shown to be subject to surveillance bias and not a valid measure for hospital quality comparisons. A study was conducted to examine how hospital PSI 90 scores would change if the VTE measure were removed from calculation of this composite measure. METHODS: Using 2014 Medicare inpatient claims data, PSI 90 scores were calculated with and without the VTE measure for 3,203 hospitals...
October 3, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30269964/in-hospital-sequelae-of-injurious-falls-in-24-medical-surgical-units-in-four-hospitals-in-the-united-states
#5
Anne-Marie Hill, Angela Jacques, A Michelle Chandler, Phyllis A Richey, Lorraine C Mion, Ronald I Shorr
BACKGROUND: Up to 50% of patient falls in the hospital result in injury. This study was conducted to determine whether injurious falls were associated with increased hospital length of stay (LOS), discharge to a place other than home, and in-hospital mortality. METHODS: A secondary data analysis from a prospective case-control study was conducted in 24 medical/surgical units in four hospitals in the United States. Patients who fell and sustained an injury were matched with at least one control patient who was on the same unit, at the same time, for a similar number of days on the unit at the time of the fall...
September 27, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30266247/development-and-implementation-of-a-subcutaneous-insulin-pen-label-bar-code-scanning-protocol-to-prevent-wrong-patient-insulin-pen-errors
#6
Heidemarie Windham MacMaster, Sabina Gonzalez, Andrew Maruoka, Craig San Luis, Daphne Stannard, Joshua A Rushakoff, Robert J Rushakoff
PROBLEM DEFINITION: Insulin, a high-alert medication, is regularly prescribed in the inpatient setting for hyperglycemia and diabetes mellitus. Although convenient, insulin pens carry a risk of blood-borne pathogens if the same pen is used on multiple patients. At the University of California, San Francisco (UCSF), a new nursing protocol for insulin pen administration was developed to ensure that insulin was quickly available and to identify and move to eliminate wrong-patient insulin pen errors...
September 26, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30266248/increased-hcv-screening-yields-discordant-gains-in-diagnoses-among-urban-and-rural-veteran-populations-in-texas-results-of-a-statewide-quality-improvement-initiative
#7
Daniel Wray, John D Coppin, Dawn Scott, David A Jacob, Chetan Jinadatha
BACKGROUND: Chronic hepatitis C virus (HCV) infection is a significant health burden among military veterans. Our goals were to increase monthly HCV screenings, diagnoses, and sustained virologic responses (SVR) among 88,652 unscreened birth cohort Veterans in Texas. METHODS: The interventions were enabled within six of the eight healthcare systems (HCSs) that compose Veteran's Integrated Service Network 17. The remaining two HCSs served as controls. The HCSs were separated into two groups: urban and rural; each composed of a control and three interventional HCSs...
September 25, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30262391/unintentionally-retained-guidewires-a-descriptive-study-of-73-sentinel-events
#8
Victoria M Steelman, Kokila Thenuwara, Clarissa Shaw, Laurel Shine
BACKGROUND: Unintentionally retained foreign objects remain the sentinel events most frequently reported to The Joint Commission. Many of these objects are guidewires used to facilitate placement of catheters, tubes, and other devices. The purpose of this study was to describe reports of unintentionally retained guidewires in order to make recommendations to improve patient safety. METHODS: A retrospective review was undertaken of unintentionally retained guidewires voluntarily reported to The Joint Commission from October 2012 through March 2018...
September 24, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30236510/utilization-of-prostate-cancer-quality-metrics-for-research-and-quality-improvement-a-structured-review
#9
REVIEW
Davide Gori, Rajendra Dulal, Douglas W Blayney, James D Brooks, Maria P Fantini, Kathryn M McDonald, Tina Hernandez-Boussard
BACKGROUND: The shift toward value-based care in the United States emphasizes the role of quality measures in payment models. Many diseases, such as prostate cancer, have a proliferation of quality measures, resulting in resource burden and physician burnout. This study aimed to identify and summarize proposed prostate cancer quality measures and describe their frequency and use in peer-reviewed literature. METHODS: The PubMed database was used to identify quality measures relevant to prostate cancer care, and included articles in English through April 2018...
September 18, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30197306/an-initiative-to-reduce-routine-viral-diagnostic-testing-in-pediatric-patients-admitted-with-bronchiolitis
#10
Beth L Emerson, Christopher Tenore, Matthew Grossman
BACKGROUND: Bronchiolitis is a viral lower respiratory tract infection that causes significant morbidity and mortality in the pediatric population. Viral diagnostic testing (VDT) has been used to identify specific viral pathogens. However, current guidelines suggest that routine use of this testing is not advisable. For children admitted to a children's hospital from the pediatric emergency department (PED), the rate of VDT was 63%, which was higher than the national rate. A quality improvement project was conducted to reduce the use of routine VDT...
September 6, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30190221/incidence-and-method-of-suicide-in-hospitals-in-the-united-states
#11
Scott C Williams, Stephen P Schmaltz, Gerard M Castro, David W Baker
BACKGROUND: There are no reliable estimates of hospital inpatient suicides in the United States. Understanding the rate and the methods used in suicides is important to guide prevention efforts. This study analyzed two national data sets to establish an evidence-based estimate of hospital inpatient suicides and the methods used. METHODS: The study is designed as a cross-sectional analysis of data from 27 states reporting to the National Violent Death Reporting System (NVDRS) for 2014-2015, and from hospitals reporting to The Joint Commission's Sentinel Event (SE) Database from 2010 to 2017...
September 3, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30172662/a-standardized-oxytocin-administration-protocol-after-delivery-to-reduce-the-treatment-of-postpartum-hemorrhage
#12
Jennifer L Doyle, Tiffany H Kenny, M Dave Gothard, Elizabeth Seagraves, Michele McCarroll, Angela Silber
BACKGROUND: Postpartum hemorrhage (PPH) is a leading cause of maternal death, and its rate and severity have been increasing. Oxytocin is widely recommended for PPH prophylaxis, but consensus is lacking on the dose or duration, leading to disparate and subjective practices. In this study, clinical outcomes were compared before and after introduction of a quality measure: a standardized oxytocin protocol for PPH prophylaxis. METHODS: A retrospective cohort study was conducted of postpartum women ≥24 weeks' gestation delivered from 2010 to 2015...
August 29, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30170753/a-postoperative-care-bundle-reduces-surgical-site-infections-in-pediatric-patients-undergoing-cardiac-surgeries
#13
Thomas J Caruso, Ellen Y Wang, Hayden Schwenk, Juan Luis S Marquez, Julie Cahn, Ling Loh, Jenny Schaffer, Kevin Chen, Matthew Wood, Paul J Sharek
BACKGROUND: Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries...
August 29, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30170754/failures-in-the-respectful-care-of-critically-ill-patients
#14
Anica C Law, Stephanie Roche, Alyse Reichheld, Patricia Folcarelli, Michael N Cocchi, Michael D Howell, Kenneth Sands, Jennifer P Stevens
BACKGROUND: The emotional toll of critical illness on patients and their families can be profound and is emerging as an important target for value improvement. One source of emotional harm to patients and families may be care perceived as inadequately respectful. The prevalence and risk factors for types of emotional harms is under-studied. METHODS: This prospective cohort study was conducted in nine ICUs at a tertiary care academic medical center in the United States...
August 28, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30166254/a-health-system-wide-initiative-to-decrease-opioid-related-morbidity-and-mortality
#15
Scott G Weiner, Christin N Price, Alev J Atalay, Elizabeth M Harry, Erika A Pabo, Rajesh Patel, Joji Suzuki, Shelly Anderson, Stanley W Ashley, Allen Kachalia
BACKGROUND: The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge. METHODS: An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system...
August 28, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30139564/anticoagulation-across-care-transitions-identifying-minimum-data-to-maximize-drug-safety
#16
EDITORIAL
Nadine Shehab, Jeffrey L Greenwald, Daniel S Budnitz
No abstract text is available yet for this article.
August 20, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30139563/not-missing-the-opportunity-improving-depression-screening-and-follow-up-in-a-multicultural-community
#17
Ann M Schaeffer, Diana Jolles
BACKGROUND: Screening for depression and documenting follow-up is a National Quality Forum-endorsed measure. Yet only seven states report depression screening and follow-up, making it the fourth-least-reported measure on the Medicaid Adult Core Set. In 2016 a multicultural health center found that only 9.1% of clients were screened and followed up for depression. This quality improvement project was conducted to increase the efficacy of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for depression to 75% for screen-positive clients...
August 20, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30126715/a-comprehensive-approach-to-eliciting-documenting-and-honoring-patient-wishes-for-care-near-the-end-of-life-the-veterans-health-administration-s-life-sustaining-treatment-decisions-initiative
#18
Mary Beth Foglia, Jill Lowery, Virginia Ashby Sharpe, Paul Tompkins, Ellen Fox
BACKGROUND: There is an emerging consensus that clinicians should initiate a proactive "goals of care conversation" (GoCC) with patients whose serious illness is likely to involve decisions about life-sustaining treatments (LSTs) such as artificial nutrition, ventilator support, or cardiopulmonary resuscitation. This conversation is intended to elicit the patient's values, goals, and preferences as a basis for shared decisions about treatment planning. LST decisions are often postponed until the patient is within days or even hours of death and no longer able to make his or her goals and preferences known...
August 17, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30126714/audio-recorded-discharge-instructions-for-limited-english-proficient-parents-a-pilot-study
#19
K Casey Lion, Kathleen Kieran, Arti Desai, Patty Hencz, Beth E Ebel, Ali Adem, Shannon Forbes, Juan Kraus, Colleen Gutman, Ivor Horn
BACKGROUND: Parents with limited English proficiency (LEP) demonstrate lower comprehension of discharge instructions. A study was conducted to (1) determine the feasibility of providing a greeting card with language-specific, audio-recorded discharge instructions to LEP parents; (2) describe use of and satisfaction with the cards; and (3) evaluate card effect on instruction comfort with home care and comprehension. METHODS: LEP parents of children undergoing day surgery from April to September 2016 were eligible...
August 17, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30122521/impact-of-real-time-clinical-decision-support-on-blood-utilization-and-outcomes-in-hospitalized-patients-with-solid-tumor-cancer
#20
Kelley N Wachsberg, Kevin J O'Leary, Ryan Buck, Lyndsey S O'Hara, Jungwha Lee, Gerald W Rouleau, Kimberly Koloms, Charlotta Weaver
INTRODUCTION: Patients with cancer are frequently hospitalized, and anemia is a common complication of cancer care. Transfusion is often required and commonly occurs above guideline-supported thresholds. It was hypothesized that an educational intervention, combined with real-time clinical decision support (CDS), would reduce blood utilization among hospitalized solid tumor cancer patients without adversely affecting outcomes. METHODS: A retrospective, historical control analysis was conducted comparing transfusion utilization among hospitalized solid tumor cancer patients before and after implementation of the educational intervention and CDS...
August 16, 2018: Joint Commission Journal on Quality and Patient Safety
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