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Joint Commission Journal on Quality and Patient Safety

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https://www.readbyqxmd.com/read/29173290/advances-in-rapid-response-patient-monitoring-and-recognition-of-and-response-to-clinical-deterioration
#1
Juan C Rojas, Claire Shappell, Michael Huber
No abstract text is available yet for this article.
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173289/user-centered-collaborative-design-and-development-of-an-inpatient-safety-dashboard
#2
Eli Mlaver, Jeffrey L Schnipper, Robert B Boxer, Dominic J Breuer, Esteban F Gershanik, Patricia C Dykes, Anthony F Massaro, James Benneyan, David W Bates, Lisa S Lehmann
Patient safety remains a key concern in hospital care. This article summarizes the iterative participatory development, features, functions, and preliminary evaluation of a patient safety dashboard for interdisciplinary rounding teams on inpatient medical services. This electronic health record (EHR)-embedded dashboard collects real-time data covering 13 safety domains through web services and applies logic to generate stratified alerts with an interactive check-box function. The technological infrastructure is adaptable to other EHR environments...
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173288/improving-the-quality-of-data-for-inpatient-claims-based-measures-used-in-public-reporting-and-pay-for-performance-programs
#3
Hazel Crews, Peter J Pronovost, Paul R Helft, J Matthew Austin
No abstract text is available yet for this article.
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173287/pragmatic-insights-on-patient-safety-priorities-and-intervention-strategies-in-ambulatory-settings
#4
Urmimala Sarkar, Kathryn McDonald, Aneesa Motala, Patricia Smith, Lorri Zipperer, Robert M Wachter, Roberta Shanman, Paul G Shekelle
No abstract text is available yet for this article.
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173286/an-airway-rapid-response-system-implementation-and-utilization-in-a-large-academic-trauma-center
#5
Joshua H Atkins, Christopher H Rassekh, Ara A Chalian, Jing Zhao
BACKGROUND: Rapid response teams mobilize resources to patients experiencing acute deterioration. Failed airway management results in death or anoxic brain injury. A codified, systems-based approach to bring personnel and equipment to the bedside for multidisciplinary airway assessment and rescue was reflected in the initial implementation of an airway rapid response (ARR) team. METHODS: A retrospective review of records of 117 ARR events in a 40-month period (August 2011-November 2014) was undertaken at the Hospital of the University of Pennsylvania, a 789-bed, academic, urban, tertiary care, Level 1 trauma center...
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173285/expanding-the-scope-of-the-rapid-response-system
#6
EDITORIAL
Michael DeVita, Kenneth M Hillman
No abstract text is available yet for this article.
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173284/development-of-patient-centered-disability-status-questions-to-address-equity-in-care
#7
Megan A Morris, Tara Lagu, Allysha Maragh-Bass, Juliette Liesinger, Joan M Griffin
BACKGROUND: Patients with disabilities experience disparities in accessing and receiving high-quality health care services as compared to patients without disabilities. To address the disparities, health care organizations need to identify which of their patients have disabilities to track quality of care and provide appropriate health care accommodations. To date, no evidence-based sets of disability questions exist that serve these purposes. A study was conducted to identify patient-centered disability questions for health care organizations to determine which patients require health care accommodations and to track the quality of care experienced by patients with disabilities...
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173283/using-lean-quality-improvement-tools-to-increase-delivery-of-evidence-based-tobacco-use-treatment-in-hospitalized-neurosurgical-patients
#8
Laurel Sisler, Oluwaseun Omofoye, Karina Paci, Eldad Hadar, Adam O Goldstein, Carol Ripley-Moffitt
BACKGROUND: Health care providers routinely undertreat tobacco dependence, indicating a need for innovative ways to increase delivery of evidence-based care. Lean, a set of quality improvement (QI) tools used increasingly in health care, can help streamline processes, create buy-in for use of evidence-based practices, and lead to the identification of solutions on the basis of a problem's root causes. To date, no published research has examined the use of Lean tools in tobacco dependence...
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29173282/using-bioinformatics-to-treat-hospitalized-smokers-successes-and-challenges-of-a-tobacco-treatment-service
#9
Thomas Ylioja, Vivek Reddy, Richard Ambrosino, Esa M Davis, Antoine Douaihy, Kristin Slovenkay, Valerie Kogut, Beth Frenak, Kathy Palombo, Anna Schulze, Gerald Cochran, Hilary A Tindle
BACKGROUND: Hospitals face increasing regulations to provide and document inpatient tobacco treatment, yet few blueprint data exist to implement a tobacco treatment service (TTS). METHODS: A hospitalwide, opt-out TTS with three full-time certified counselors was developed in a large tertiary care hospital to proactively treat smokers according to Chronic Care Model principles and national treatment guidelines. A bioinformatics platform facilitated integration into the electronic health record to meet evolving Centers for Medicare & Medicaid Services meaningful use and Joint Commission standards...
December 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056182/a-novel-process-audit-for-standardized-perioperative-handoff-protocols
#10
Vinay Pallekonda, Adam T Scholl, George M McKelvey, Hassan Amhaz, Deanna Essa, Spurthy Narreddy, Jens Tan, Mark Templonuevo, Sasha Ramirez, Michelle A Petrovic
A perioperative handoff protocol provides a standardized delivery of communication during a handoff that occurs from the operating room to the postanestheisa care unit or ICU. The protocol's success is dependent, in part, on its continued proper use over time. A novel process audit was developed to help ensure that a perioperative handoff protocol is used accurately and appropriately over time. The Audit Observation Form is used for the Audit Phase of the process audit, while the Audit Averages Form is used for the Data Analysis Phase...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056181/a-scalable-program-for-customized-patient-education-videos
#11
Ishani Ganguli, Chrisanne Sikora, Briana Nestor, Rachel Clark Sisodia, Adam Licurse, Timothy G Ferris, Sandhya Rao
PROBLEM DEFINITION: Patients must make sense of increasingly complex information to navigate their health and the health care system, with limited opportunity to do so in clinical settings. Patient education videos may help to communicate key information, but they are often impersonal and cumbersome to produce or update with new evidence. To address these limitations, a program was developed to facilitate local video creation to deliver targeted information to patients. APPROACH: The Patient Education Video Program was created at a large urban academic medical center...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056180/using-fault-trees-to-advance-understanding-of-diagnostic-errors
#12
Deevakar Rogith, M Sriram Iyengar, Hardeep Singh
PROBLEM DEFINITION: Diagnostic errors annually affect at least 5% of adults in the outpatient setting in the United States. Formal analytic techniques are only infrequently used to understand them, in part because of the complexity of diagnostic processes and clinical work flows involved. In this article, diagnostic errors were modeled using fault tree analysis (FTA), a form of root cause analysis that has been successfully used in other high-complexity, high-risk contexts. How factors contributing to diagnostic errors can be systematically modeled by FTA to inform error understanding and error prevention is demonstrated...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056179/implementing-the-comprehensive-unit-based-safety-program-cusp-to-improve-patient-safety-in-an-academic-primary-care-practice
#13
Samantha I Pitts, Nisa M Maruthur, Ngoc-Phuong Luu, Kimberly Curreri, Renee Grimes, Candace Nigrin, Heather F Sateia, Melinda D Sawyer, Peter J Pronovost, Jeanne M Clark, Kimberly S Peairs
BACKGROUND: While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. METHODS: As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056178/root-cause-analysis-of-icu-adverse-events-in-the-veterans-health-administration
#14
Gregory S Corwin, Peter D Mills, Hasan Shanawani, Robin R Hemphill
BACKGROUND: ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions. METHODS: This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056177/use-of-unit-based-interventions-to-improve-the-quality-of-care-for-hospitalized-medical-patients-a-national-survey
#15
Kevin J O'Leary, Julie K Johnson, Milisa Manojlovich, Gopi J Astik, Mark V Williams
BACKGROUND: Recent publications have drawn attention to interventions to redesign aspects of care delivery for hospitalized medical patients, including localization of physicians to specific units, nurse-physician co-leadership, interdisciplinary rounds (IDR), and access to quality performance data. Use of these interventions across hospitals has not been previously described. METHODS: A cross-sectional survey of internal medicine (IM) residency program directors and hospital medicine group (HMG) leaders in the United States was conducted to characterize use of unit-based interventions on inpatient medical services...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056176/care-transitions-between-hospitals-and-skilled-nursing-facilities-perspectives-of-sending-and-receiving-providers
#16
Meredith Campbell Britton, Gregory M Ouellet, Karl E Minges, Marcie Gawel, Beth Hodshon, Sarwat I Chaudhry
BACKGROUND: One in four Medicare patients hospitalized for acute medical illness is discharged to a skilled nursing facility (SNF); 23% of these patients are readmitted to the hospital within 30 days. The care transition from hospital to SNF is often marked by disruptions in care and poor communication among hospital and SNF providers. A study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and the SNF. METHODS: Hospital (Nā€‰=ā€‰25) and SNF (Nā€‰=ā€‰16) providers participated in qualitative interviews assessing patient transfers and experiences with unplanned hospital readmissions...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056175/examining-racial-and-ethnic-differences-in-nursing-home-quality
#17
Jennifer Gaudet Hefele, Grant A Ritter, Christine E Bishop, Andrea Acevedo, Candi Ramos, Laurie A Nsiah-Jefferson, Gabrielle Katz
BACKGROUND: Identifying racial/ethnic differences in quality is central to identifying, monitoring, and reducing disparities. Although disparities across all individual nursing home residents and disparities associated with between-nursing home differences have been established, little is known about the degree to which quality of care varies by race//ethnicity within nursing homes. A study was conducted to measure within-facility differences for a range of publicly reported nursing home quality measures...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29056174/time-for-nursing-homes-to-recognize-and-address-disparities-in-care
#18
EDITORIAL
Alexander R Green
No abstract text is available yet for this article.
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28942780/quality-of-septic-shock-care-in-the-emergency-department-perceptions-versus-reality
#19
Jennifer Roh, Craig Rothenberg, Amitkumar Patel, John Sather, Arjun K Venkatesh
No abstract text is available yet for this article.
October 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28942779/toward-more-proactive-approaches-to-safety-in-the-electronic-health-record-era
#20
Dean F Sittig, Hardeep Singh
No abstract text is available yet for this article.
October 2017: Joint Commission Journal on Quality and Patient Safety
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