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Joint Commission Journal on Quality and Patient Safety

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https://www.readbyqxmd.com/read/29793888/principles-of-automation-for-patient-safety-in-intensive-care-learning-from-aviation
#1
Jason Dominiczak, Lara Khansa
BACKGROUND: The transition away from written documentation and analog methods has opened up the possibility of leveraging data science and analytic techniques to improve health care. In the implementation of data science techniques and methodologies, high-acuity patients in the ICU can particularly benefit. The Principles of Automation for Patient Safety in Intensive Care (PASPIC) framework draws on Billings's principles of human-centered aviation (HCA) automation and helps in identifying the advantages, pitfalls, and unintended consequences of automation in health care...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793887/the-characteristics-of-physicians-who-are-re-disciplined-by-medical-boards-a-retrospective-cohort-study
#2
Thurarshen Jeyalingam, John J Matelski, Asim Q Alam, Jessica J Liu, Hanna Goldberg, Jason Klemensberg, Chaim M Bell
BACKGROUND: Physician misconduct adversely affects patient safety and is therefore of societal importance. Little work has specifically examined re-disciplined physicians. A study was conducted to compare the characteristics of re-disciplined to first-time disciplined physicians. METHODS: A retrospective review of Canadian physicians disciplined by medical boards between 2000 and 2015 was conducted. Physicians were divided into those disciplined once and those disciplined more than once...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793886/implementation-and-evaluation-of-a-novel-colorectal-cancer-decision-aid-using-a-centralized-delivery-strategy
#3
Channing E Tate, Daniel D Matlock, Alexandra F Dalton, Lisa M Schilling, Alexandra Marcus, Tiffany Schommer, Corey Lyon, Carmen L Lewis
BACKGROUND: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States; however, CRC screening reduces both incidence and mortality rates. Patient decision aids (DAs) are an evidence-based strategy to support patients making health-related decisions. CRC screening DAs can be unsuccessful due to provider preferences for colonoscopy and lack of effective DA implementation strategies within clinical settings. METHODS: A hybrid implementation-effectiveness study was conducted testing the feasibility of using an existing centralized preventive health screening outreach infrastructure to implement a novel CRC DA across a health care system...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793885/opportunities-to-improve-informed-consent-with-ahrq-training-modules
#4
Sarah J Shoemaker, Cindy Brach, Alrick Edwards, Salome O Chitavi, Rene Thomas, Melanie Wasserman
BACKGROUND: Informed consent is a process of communication between clinician and patient that results in the patient's decision about whether to undergo a specific intervention. However, patients often do not understand the risks, benefits, and alternatives, even after signing a consent form. METHODS: Mixed-methods pilot test of two Agency for Healthcare Research and Quality (AHRQ) informed consent training modules implemented in four hospitals. Methods included staff and patient surveys, interviews, site visits, and pre- and posttests of the modules...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793884/what-is-the-realistic-scope-of-informed-consent
#5
EDITORIAL
Justin T Clapp, Lee A Fleisher
No abstract text is available yet for this article.
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793883/reducing-serious-safety-events-and-priority-hospital-acquired-conditions-in-a-pediatric-hospital-with-the-implementation-of-a-patient-safety-program
#6
Amber R Phipps, Melisa Paradis, Kimberly A Peterson, Jill Jensen, Katie Nielsen, Mel Hall, Kari Simonsen, Bridget M Norton
BACKGROUND: A freestanding children's hospital evaluated the impact of a patient safety program on serious safety events (SSEs) and hospital-acquired conditions (HACs). METHODS: The No Harm Patient Safety Program was developed throughout the organization using a multifaceted approach that included safety moments, leadership rounding, cause analysis changes, event reporting enhancements, error prevention training, leadership training, identifying priority HACs, Eye on Safety Campaign, and safety coaches...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793882/using-an-inpatient-quality-improvement-curriculum-for-internal-medicine-residents-to-improve-pneumococcal-conjugate-vaccine-administration-rates
#7
Jonathan Jolin, Robertus van Aalst, Bryan Volpp, Thomas Taylor, Emily Cohen
BACKGROUND: Pneumococcal infections are an important source of morbidity and mortality in older adults and persons with compromised immune systems. New recommendations from the Advisory Committee on Immunization Practices (ACIP) became available September 2014, which included recommendations for the use of the 13-valent pneumococcal conjugate vaccine (PCV13). A study was conducted to increase the PCV13 vaccination rates of hospitalized patients at the White River Junction Veterans Affairs Medical Center (White River Junction, Vermont) through the use of a resident-driven quality improvement (QI) project...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793881/using-concentration-curves-to-assess-organization-specific-relationships-between-surgeon-volumes-and-outcomes
#8
Michael H Kanter, Yii-Chieh Huang, Zina Kally, Margo A Gordon, Charles Meltzer
BACKGROUND: A well-documented association exists between higher surgeon volumes and better outcomes for many procedures, but surgeons may be reluctant to change practice patterns without objective, credible, and near real-time data on their performance. In addition, published thresholds for procedure volumes may be biased or perceived as arbitrary; typical reports compare surgeons grouped into discrete procedure volume categories, even though the volume-outcomes relationship is likely continuous...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793880/early-treatment-innovation-for-opioid-dependent-newborns-a-retrospective-comparison-of-outcomes-utilization-quality-and-safety-2006-2014
#9
Julie Summey, Liwei Chen, Rachel Mayo, Elizabeth Charron, Jennifer A Hudson, Windsor Westbrook Sherrill, Lori Dickes
BACKGROUND: Few coordinated treatment programs address the needs of infants and families struggling with the effects of substance use. In 2003 a large Southeastern regional hospital launched the Managing Abstinence in Newborns (MAiN) program, providing multidisciplinary, coordinated, community-based care for neonatal abstinence syndrome (NAS). A hypothesis-generating study was conducted to compare the outcomes of MAiN infants to comparable NAS infants receiving traditional care from 2006 through 2014 in South Carolina...
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29793879/management-of-neonatal-abstinence-syndrome-the-importance-of-a-multifaceted-program-spanning-inpatient-and-outpatient-care
#10
EDITORIAL
Maya Balakrishnan, Gautham Suresh
No abstract text is available yet for this article.
June 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759264/the-association-between-the-electronic-health-record-and-patient-reported-receipt-of-tobacco-cessation-care-in-hospitalized-veterans
#11
Ethan F Kuperman, Jennifer Chapin, Kathleen M Grant, Mark W Vander Weg, David A Katz
No abstract text is available yet for this article.
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759263/a-bedside-computerized-decision-support-tool-for-intravenous-insulin-infusion-management-in-critically-ill-patients
#12
Evan D Telford, Andrew J Franck, Andrew L Hendrickson, Nicole Maltese Dietrich
Intravenous (IV) insulin infusions using a validated protocol are the recommended method for blood glucose control in critically ill patients. Computerized decision-support tools improve quality over manual paper-based protocols. However, nonproprietary computerized tools targeting the recommended blood glucose range of 140-180 mg/dL are not readily available. A bedside computerized decision-support tool was developed at a US Department of Veterans Affairs health system to assist the nursing staff with the management of patients requiring IV insulin infusion...
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759262/focus-on-the-quadruple-aim-development-of-a-resiliency-center-to-promote-faculty-and-staff-wellness-initiatives
#13
Ellen Morrow, Megan Call, Robin Marcus, Amy Locke
DEFINING THE PROBLEM: A growing body of evidence highlights the need for wellness programs to support health care professionals. Although much of the existing literature centers on practicing physicians and physician trainees, there is growing awareness that these challenges are not unique to physicians and affect all members of the health care team. Traumatic and stressful events will always be a part of health care; how these events are addressed on a personal and team level is essential to the success of a health care system...
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759261/deriving-a-framework-for-a-systems-approach-to-agitated-patient-care-in-the-emergency-department
#14
Ambrose H Wong, Halley Ruppel, Lauren J Crispino, Alana Rosenberg, Joanne D Iennaco, Federico E Vaca
BACKGROUND: The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. METHODS: A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network...
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759260/a-call-to-bridge-across-silos-during-care-transitions
#15
Fatima Sheikh, Evelyn Gathecha, Michele Bellantoni, Colleen Christmas, Justin P Lafreniere, Alicia I Arbaje
BACKGROUND: Older adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital. FACTORS CONTRIBUTING TO SUBOPTIMAL CARE TRANSITIONS: Key factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation...
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759259/1-300-days-and-counting-a-risk-model-approach-to-preventing-retained-foreign-objects-rfos
#16
Erika G Duggan, Jimmy Fernandez, Mary May Saulan, Dave L Mayers, Mira Nikolaj, Tamara M Strah, Lystra M Swift, Larissa Temple
BACKGROUND: A retained foreign object (RFO) is a devastating surgical complication that typically results in additional surgeries, increased length of stay, and risk of infections and is potentially fatal. Memorial Sloan Kettering Cancer Center (MSKCC) convened a multidisciplinary task force to undertake an improvement initiative to reduce the frequency of RFO incidents. METHODS: A needs assessment was undertaken using focus group interviews, review of past RFOs, and operating room (OR) observations, and a comprehensive intervention plan was initiated...
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759258/improving-maternal-safety-at-scale-with-the-mentor-model-of-collaborative-improvement
#17
Elliott K Main, Ravi Dhurjati, Valerie Cape, Julie Vasher, Anisha Abreo, Shen-Chih Chang, Jeffrey B Gould
BACKGROUND: Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority. METHODS: The California Maternal Quality Care Collaborative (CMQCC) developed an innovative external mentor model for large-scale collaborative improvement in which participating organizations were subdivided into small teams of six to eight hospitals, led by a paired dyad of physician and nurse leaders...
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759257/developing-a-medical-scribe-program-at-an-academic-hospital-the-hennepin-county-medical-center-experience
#18
Marc L Martel, Brian H Imdieke, Kayla M Holm, Sara Poplau, William G Heegaard, Jon L Pryor, Mark Linzer
BACKGROUND: Medical scribes are frequently incorporated into the patient care model to improve provider efficiency and enable providers to refocus their attention to the patient rather than the electronic health record (EHR). The medical scribe program was based on four pillars (objectives): (1) provider satisfaction, (2) standardized documentation, (3) documentation components for risk adjustment, and (4) revenue enhancement. METHODS: The medical scribe program was deployed in nine non-resident-supported clinics (internal medicine, ophthalmology, orthopedics, hematology/oncology, urology), with the medical scribes (who have no clinical duties) supporting both physicians and advanced practice providers (nurse practitioners and physician assistants)...
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29759256/moving-our-attention-from-keyboards-to-patients-a-way-forward-for-improving-professional-fulfillment-and-health-care-value
#19
EDITORIAL
Christine A Sinsky
No abstract text is available yet for this article.
May 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579448/improving-satisfaction-with-pediatric-pain-management-by-inviting-the-conversation
#20
Thomas J Caruso, Tiffany H Kung, Julie Good, Kristine Taylor, Michele Ashland, Christine Cunningham, Elena Gonzalez, Matthew Wood, Paul Sharek
BACKGROUND: Patient satisfaction with pain management is associated with improved patient adherence to medical management and efficient service utilization. Pediatric pain control is challenging, given the inability to elicit reliable histories, particularly in younger patients. Several studies have suggested that communication surrounding pain management can improve satisfaction, although there are limited data describing structured interventions with measurable outcomes. A quality improvement project was conducted to determine if reliably asking families about pain management was associated with improved patient satisfaction with pain management...
April 2018: Joint Commission Journal on Quality and Patient Safety
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