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Joint Commission Journal on Quality and Patient Safety

Alexander V Fisher, Stephanie A Campbell-Flohr, Laura Sell, Emily Osterhaus, Alexandra W Acher, Kristine Leahy-Gross, Maria Brenny-Fitzpatrick, Amy J H Kind, Pascale Carayon, Daniel E Abbott, Emily R Winslow, Caprice C Greenberg, Sara Fernandes-Taylor, Sharon M Weber
BACKGROUND: Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery. APPROACH: The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC)...
August 7, 2018: Joint Commission Journal on Quality and Patient Safety
Jennifer L Sullivan, Marlena H Shin, Ryann L Engle, Enzo Yaksic, Carol VanDeusen Lukas, Michael K Paasche-Orlow, Leigh M Starr, Joseph D Restuccia, Sally K Holmes, Amy K Rosen
BACKGROUND: Improving the process of hospital discharge is a critical priority. Interventions to improve care transitions have been shown to reduce the rate of early unplanned readmissions, and consequently, there is growing interest in improving transitions of care between hospital and home through appropriate interventions. Project Re-Engineered Discharge (RED) has shown promise in strengthening the discharge process. Although studies have analyzed the implementation of RED among private-sector hospitals, little is known about how hospitals in the Veterans Health Administration (VHA) have implemented RED...
August 7, 2018: Joint Commission Journal on Quality and Patient Safety
Clifford A Reilly, Sara Wiesel Cullen, Bradley V Watts, Peter D Mills, Douglas E Paull, Steven C Marcus
BACKGROUND: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient...
August 6, 2018: Joint Commission Journal on Quality and Patient Safety
Vijaya T Daniel, Angela M Ingraham, Jasmine A Khubchandani, Didem Ayturk, Catarina I Kiefe, Heena P Santry
BACKGROUND: Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use. METHODS: A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns), the hospital was considered an ACS hospital...
August 6, 2018: Joint Commission Journal on Quality and Patient Safety
L Dupree Hatch, Theresa A Scott, Matthew Rivard, Amanda Rivard, Joyce Bolton, Christa Sala, Wendy Araya, Melinda H Markham, Ann R Stark, Peter H Grubb
BACKGROUND: The key driver diagram (KDD) is an important tool used by improvement teams to guide and frame their work. Methods to build a KDD when little relevant literature or reliable local data exist are poorly described. This article describes the process used in our neonatal ICU (NICU) to build a KDD to decrease unplanned extubations (UE) in chronically ventilated infants. METHODS: Twenty-seven factors hypothesized to be associated with UE in our NICU were identified...
August 2, 2018: Joint Commission Journal on Quality and Patient Safety
Mark R Jones, Sergey Karamnov, Richard D Urman
BACKGROUND: Many interventional procedures are performed under moderate procedural sedation (MPS). It is important to understand the nature of and factors contributing to adverse events (AEs). Little data exist examining reportable AEs during MPS across specialties. A study was conducted to investigate adverse events during MPS and to compare associated patient and provider characteristics. METHODS: In a retrospective review, 83 MPS cases in which safety incidents were reported (out of approximately 20,000 annual cases during a 12-year period at a tertiary medical center) were analyzed...
July 27, 2018: Joint Commission Journal on Quality and Patient Safety
Darren Triller, Anne Myrka, John Gassler, Kelly Rudd, Patrick Meek, Peter Kouides, Allison E Burnett, Alex C Spyropoulos, Jack Ansell
BACKGROUND: Anticoagulated patients are particularly vulnerable to ADEs when they experience changes in medical acuity, pharmacotherapy, or care setting, and resources guiding care transitions are lacking. The New York State Anticoagulation Coalition convened a task force to develop a consensus list of requisite data elements (RDEs) that should accompany all anticoagulated patients undergoing care transitions. METHODS: A multidisciplinary panel of 15 anticoagulation experts voluntarily completed an iterative Delphi process...
July 24, 2018: Joint Commission Journal on Quality and Patient Safety
Marianne Turley, Susan Wang, Di Meng, Terhilda Garrido, Michael H Kanter
BACKGROUND: End-of-life care is patient centered when it is concordant with patient preferences. Concordance has been frequently assessed by interview, chart review, or both. These time-consuming methods can constrain sample sizes, precluding population-level quality assessment. Concordance between preferences and care as measured by automated methods is described. METHODS: Automated processes extracted and analyzed electronic health record (EHR) data to assess concordance between 15 advance care planning preference domains and 232 related end-of-life care events for 388 patients aged 65 years or older with an inpatient encounter at Kaiser Permanente Southern California who died during or after the encounter...
July 18, 2018: Joint Commission Journal on Quality and Patient Safety
Amy O'Brien, Kristin O'Reilly, Tenzin Dechen, Nicholas Demosthenes, Veronica Kelly, Lynn Mackinson, Juliann Corey, Kathryn Zieja, Jennifer P Stevens, Michael N Cocchi
BACKGROUND: Daily multidisciplinary rounds (MDR) in the ICU represent a mechanism by which health care professionals from different disciplines and specialties can meet to synthesize data, think collectively, and form complete patient care plans. It was hypothesized that providing a standardized, structured approach to the daily rounds process would improve communication and collaboration in seven distinct ICUs in a single academic medical center. METHODS: Lean-inspired methodology and information provided by frontline staff regarding inefficiencies and barriers to optimal team functioning were used in designing a toolkit for standardization of rounds in the ICUs...
July 13, 2018: Joint Commission Journal on Quality and Patient Safety
Deborah Carpenter, Susan Hassell, Russ Mardon, Shannon Fair, Maurice Johnson, Sari Siegel, Mary Nix
BACKGROUND: Diffusion of innovations can be a slow process, posing a major challenge to quality improvement in health care. Learning communities can provide a rich, collaborative environment that supports the adoption of health care innovations and motivates organizational change. From 2014-2016, the Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange established and supported three learning communities focused on adopting innovations in three high-priority areas: (1) advancing the practice of patient- and family-centered care in hospitals, (2) promoting medication therapy management for at-risk populations, and (3) reducing non-urgent emergency services...
July 9, 2018: Joint Commission Journal on Quality and Patient Safety
Jamie L Estock, Ivan-Thibault Pham, Holly K Curinga, Benjamin J Sprague, Monique Y Boudreaux-Kelly, Jeanette Acevedo, Katrina Jacobs
BACKGROUND: Blood glucose (BG) testing is the most widely performed point-of-care (POC) test in a hospital setting. Multiple adverse events reported to the Food and Drug Administration (FDA) revealed that treatment decisions may be affected by information displayed on the POC glucometer's results screen. A randomized, crossover simulation study was conducted to compare two results screen configurations for ACCU-CHEK Inform II, a POC glucometer. METHODS: Prior to the study, a heuristic evaluation of the results screen configurations and a pilot study were conducted to select the two results screen configurations for comparison...
July 9, 2018: Joint Commission Journal on Quality and Patient Safety
Bonnie B Blanchfield, Akinluwa A Demehin, Cornell T Cummings, Timothy G Ferris, Gregg S Meyer
BACKGROUND: In the United States, regulatory bodies, state licensing boards, hospital accreditation organizations, and medical specialty boards have increased their demands for data, public reporting, and improvement. Survey research suggests that as much as $15 billion is spent on reporting quality measures, but those costs, as well as those associated with improvement, have not been sufficiently characterized. A study was conducted to examine, in detail, the costs incurred by one health care organization-an academic health center (AHC) with employed physicians-in responding to quality and safety requirements...
July 8, 2018: Joint Commission Journal on Quality and Patient Safety
Sushmitha P Diraviam, Patricia G Sullivan, John A Sestito, Mary Ellen Nepps, Justin T Clapp, Lee A Fleisher
BACKGROUND: The University of Pennsylvania Health System (UPHS) implemented a risk reduction strategy in response to high malpractice costs and the broader implications these trends had for patient safety and quality. A key component of this strategy was the Risk Reduction Initiative (RRI), which uses a bottom-up approach to actively engage physicians in risk mitigation and malpractice reduction within their respective departments. METHODS: The value of clinical communities in achieving common goals has been previously recognized in quality improvement efforts...
July 7, 2018: Joint Commission Journal on Quality and Patient Safety
Christopher J Curatolo, Patrick J McCormick, Jaime B Hyman, Yaakov Beilin
BACKGROUND: Anesthesiologists have studied adverse events during anesthesia dating back to the original critical incident studies of the 1970s. Despite improvements, adverse events continue to occur. The purpose of this study was to characterize anesthesia-related adverse events within a single large tertiary care institution and to distinguish preventable adverse events from those that are not preventable. METHODS: A retrospective review of all cases referred to the Performance Improvement (PI) Committee at a large academic medical center from 2007 to 2015 was performed...
June 28, 2018: Joint Commission Journal on Quality and Patient Safety
Ashley M Kranz, Sarah Dalton, Cheryl Damberg, Justin W Timbie
BACKGROUND: Health centers provide care to vulnerable and high-need populations. Recent investments have promoted use of health information technology (HIT) capabilities for improving care coordination and quality of care in health centers. This study examined factors associated with use of these HIT capabilities and the association between these capabilities and quality of care in a census of health centers in the United States. METHODS: Cross-sectional secondary data from the 2015 Health Resources and Services Administration's Uniform Data System was used to examine 6 measures of HIT capability related to care coordination and clinical decision support and 16 measures of quality (12 process measures, 3 outcome measures, 1 composite measure) for health centers in the United States...
June 18, 2018: Joint Commission Journal on Quality and Patient Safety
Anjali Modi, Ellen Germain, Vijaya Soma, Iona Munjal, Michael L Rinke
BACKGROUND: Literature is limited on pediatric anti-infective medication errors. There is a pressing need for additional research, as studies suggest high rates of overall pediatric medication errors and known harmful side effect profiles for anti-infective medications with narrow dosing ranges. This study aimed to identify risk factors related to harmful anti-infective medication errors in pediatric patients. METHODS: A retrospective chart review of all voluntary error reports involving anti-infective medication errors and pediatric patients (0 to < 22 years old) reported June 2014-December 2015 was conducted...
June 13, 2018: Joint Commission Journal on Quality and Patient Safety
Brett G Mitchell, Anne Gardner, Patricia W Stone, Lisa Hall, Monika Pogorzelska-Maziarz
BACKGROUND: Previous literature has linked the level and types of staffing of health facilities to the risk of acquiring a health care-associated infection (HAI). Investigating this relationship is challenging because of the lack of rigorous study designs and the use of varying definitions and measures of both staffing and HAIs. METHODS: The objective of this study was to understand and synthesize the most recent research on the relationship of hospital staffing and HAI risk...
June 13, 2018: Joint Commission Journal on Quality and Patient Safety
Hyung J Cho, Andrew S Dunn, Yu Sakai, Sigal Israilov, Aishwarya Raja, Jasmine Race, Rosanne M Leipzig
No abstract text is available yet for this article.
August 2018: Joint Commission Journal on Quality and Patient Safety
Patrick C Loughlin, Frank Sebat, John G Kellett
No abstract text is available yet for this article.
August 2018: Joint Commission Journal on Quality and Patient Safety
Laura G Militello, Nicholas A Rattray, Mindy E Flanagan, Zamal Franks, Shakaib Rehman, Howard S Gordon, Paul Barach, Richard M Frankel
BACKGROUND: Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement effective measures of handoff quality...
August 2018: Joint Commission Journal on Quality and Patient Safety
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