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Joint Commission Journal on Quality and Patient Safety

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https://www.readbyqxmd.com/read/27535461/full-issue
#1
(no author information available yet)
No abstract text is available yet for this article.
September 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27535460/in-search-of-water-south-carolina-hospitals-apply-high-reliability-thinking-to-protect-patients-in-the-midst-of-flooding
#2
J Thornton Kirby
No abstract text is available yet for this article.
September 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27535459/improving-transitions-of-care-for-hospitalized-patients-on-warfarin
#3
Margaret Day, Molly Malone, Alyson Burkeybile, Kristen Deane
BACKGROUND: Transitions in care create challenges for warfarin management, including dosing errors, medication nonadherence, and/or insufficient monitoring. Adverse drug events from warfarin following transitions have been found to have serious consequences. Before the intervention, at the time of hospital discharge, individual physicians identified warfarin management plans on paper forms on the basis of their personal practice preferences. With the implementation of a computerized physician order entry in the electronic health record (EHR) in November 2010, the paper form became obsolete...
September 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27535458/is-the-meaningful-use-venous-thromboembolism-vte-6-measure-meaningful-a-retrospective-analysis-of-one-hospital-s-vte-6-cases
#4
Norma E Farrow, Brandyn D Lau, Eric A JohnBull, Deborah B Hobson, Peggy S Kraus, Elizabeth R Taffe, Dauryne L Shaffer, Victor O Popoola, Michael B Streiff, Peter J Pronovost, Elliott R Haut
BACKGROUND: Venous thromboembolism (VTE) is a common, often deadly cause of preventable harm for hospitalized patients. The Centers for Medicare & Medicaid Services Meaningful Use VTE-6 measure automatically captures data documented in a Meaningful Use-certified electronic health record (EHR) to identify patients with potentially preventable VTE, defined as those who developed radiologically confirmed, in-hospital VTE and did not receive prophylaxis between admission and the day prior to the diagnostic test order date...
September 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27535457/operating-room-to-icu-patient-handovers-a-multidisciplinary-human-centered-design-approach
#5
Noa Segall, Alberto S Bonifacio, Atilio Barbeito, Rebecca A Schroeder, Sharon R Perfect, Melanie C Wright, James D Emery, B Zane Atkins, Jeffrey M Taekman, Jonathan B Mark
BACKGROUND: Patient handovers (handoffs) following surgery have often been characterized by poor teamwork, unclear procedures, unstructured processes, and distractions. A study was conducted to apply a human-centered approach to the redesign of operating room (OR)-to-ICU patient handovers in a broad surgical ICU (SICU) population. This approach entailed (1) the study of existing practices, (2) the redesign of the handover on the basis of the input of hand over participants and evidence in the medical literature, and (3) the study of the effects of this change on processes and communication...
September 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27535456/applying-the-high-reliability-health-care-maturity-model-to-assess-hospital-performance-a-va-case-study
#6
Jennifer L Sullivan, Peter E Rivard, Marlena H Shin, Amy K Rosen
BACKGROUND: The lack of a tool for categorizing and differentiating hospitals according to their high reliability organization (HRO)-related characteristics has hindered progress toward implementing and sustaining evidence-based HRO practices. Hospitals would benefit both from an understanding of the organizational characteristics that support HRO practices and from knowledge about the steps necessary to achieve HRO status to reduce the risk of harm and improve outcomes. The High Reliability Health Care Maturity (HRHCM) model, a model for health care organizations' achievement of high reliability with zero patient harm, incorporates three major domains critical for promoting HROs-Leadership, Safety Culture, and Robust Process Improvement ®...
September 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27535455/building-the-road-to-high-reliability
#7
Erin DuPree, David W Baker
No abstract text is available yet for this article.
September 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27456420/patient-safety-culture-and-the-second-victim-phenomenon-connecting-culture-to-staff-distress-in-nurses
#8
Rebecca R Quillivan, Jonathan D Burlison, Emily K Browne, Susan D Scott, James M Hoffman
BACKGROUND: Second victim experiences can affect the wellbeing of health care providers and compromise patient safety. Many factors associated with improved coping after patient safety event involvement are also components of a strong patient safety culture, so that supportive patient safety cultures may reduce second victim-related trauma. A cross-sectional survey study was conducted to assess the influence of patient safety culture on second victim-related distress. METHODS: The Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPSC) and the Second Victim Experience and Support Tool (SVEST), which was developed to assess organizational support and personal and professional distress after involvement in a patient safety event, were administered to nurses involved in direct patient care...
August 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27456419/implementing-delivery-room-checklists-and-communication-standards-in-a-multi-neonatal-icu-quality-improvement-collaborative
#9
Stacie C Bennett, Neil Finer, Louis P Halamek, Nick Mickas, Mihoko V Bennett, Courtney C Nisbet, Paul J Sharek
BACKGROUND: The 2015 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) and International Liaison Committee on Resuscitation (ILCOR) resuscitation guidelines state, "It is still suggested that briefing and debriefing techniques be used whenever possible for neonatal resuscitation." Effective communication and reliable delivery of evidence-based best practices are critical aspects of the 2015 NRP guidelines. To promote optimal communication and best practice-focused checklists use during active neonatal resuscitation, the Readiness Bundle (RB) was integrated within the larger change package deployed in the California Perinatal Quality Care Collaborative's (CPQCC) 12-month Delivery Room Management Quality Improvement Collaborative...
August 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27456418/hospital-disease-specific-care-certification-programs-and-quality-of-care-a-narrative-review
#10
Eyad Musallam, Meg Johantgen, Ingrid Connerney
BACKGROUND: Disease-specific care certification (DSCC) programs have been developed to improve the quality and performance of programs or services that may be based within or associated with a hospital or other health care organization. A comprehensive summary of evidence for DSCC programs and their reported effect on the quality of care was prepared in a narrative review, the first of its kind on this topic. METHODS: A systematic search was performed to identify articles that reported about DSCC...
August 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27456417/how-does-disease-specific-care-certification-affect-quality-and-how-can-we-measure-it
#11
David W Baker, Scott Williams
No abstract text is available yet for this article.
August 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27456416/safecare-an-innovative-approach-for-improving-quality-through-standards-benchmarking-and-improvement-in-low-and-middle-income-countries
#12
Michael C Johnson, Onno Schellekens, Jacqui Stewart, Paul van Ostenberg, Tobias Rinke de Wit, Nicole Spieker
BACKGROUND: In low- and middle-income countries (LMICs), patients often have limited access to high-quality care because of a shortage of facilities and human resources, inefficiency of resource allocation, and limited health insurance. SafeCare was developed to provide innovative health care standards; surveyor training; a grading system for quality of care; a quality improvement process that is broken down into achievable, measurable steps to facilitate incremental improvement; and a private sector-supported health financing model...
August 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27456415/minding-the-gaps-assessing-communication-outcomes-of-electronic-preconsultation-exchange
#13
Erika Leemann Price, Justin L Sewell, Alice Hm Chen, Urmimala Sarkar
BACKGROUND: Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments. METHODS: All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments...
August 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27456414/electronic-referrals-not-just-more-efficient-but-safer-too
#14
Christopher Stille
No abstract text is available yet for this article.
August 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27301838/behavioral-health-integration-in-acute-medical-settings-an-opportunity-to-improve-outcomes-and-reduce-costs
#15
Mara Laderman, Kedar S Mate
No abstract text is available yet for this article.
July 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27301837/a-national-organizational-assessment-noa-to-build-sustainable-quality-management-programs-in-low-and-middle-income-countries
#16
Joshua Bardfield, Margaret Palumbo, Michelle Geis, Margareth Jasmin, Bruce D Agins
No abstract text is available yet for this article.
July 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27301836/managing-disruptions-to-patient-flow-capacity-rapid-cycle-improvement-in-a-pediatric-cardiac-procedure-complex
#17
Debbie McKetta, T Eugene Day, Virginia Jones, Alexis Perri, Susan C Nicolson
BACKGROUND: Managing service disruptions is a challenge in every health care environment. Discrete event simulation (DES)--a computer modeling tool used to build in silico (that is, in a digital computer) testbeds for potential changes in complex systems--has been deployed in health care for research and quality improvement (QI), specifically in surgical suite management. A strategy for managing a 6-week planned service disruption needed to be enacted 12 weeks after the announcement, in late October 2014, of the closure of the Hybrid Suite (operating room/catheterization laboratory) for renovation, at The Children's Hospital of Philadelphia's Cardiac Center's Cardiac Operative and Imaging Complex (COIC)...
July 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27301835/psych-a-mnemonic-to-help-psychiatric-residents-decrease-patient-handoff-communication-errors
#18
Maria Theresa Mariano, Victoria Brooks, Michael DiGiacomo
BACKGROUND: The substantial adverse impact of miscommunication during transitions in care has highlighted the importance of teaching proper patient handoff practices. Although handoff standardization has been suggested, a universal system has been difficult to adopt, given the unique characteristics of the different fields of medicine. A form of standardization that has emerged is a discipline-specific handoff mnemonic: a memory aid that can serve to assist a provider in communicating pertinent information to the succeeding treatment team...
July 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27301834/perceived-factors-associated-with-sustained-improvement-following-participation-in-a-multicenter-quality-improvement-collaborative
#19
Sohini Stone, Henry C Lee, Paul J Sharek
BACKGROUND: The California Perinatal Quality Care Collaborative led the Breastmilk Nutrition Quality Improvement Collaborative from October 2009 to September 2010 to increase the percentage of very low birth weight infants receiving breast milk at discharge in 11 collaborative neonatal ICUs (NICUs). Observed increases in breast milk feeding and decreases in necrotizing enterocolitis persisted for 6 months after the collaborative ended. Eighteen to 24 months after the end of the collaborative, some sites maintained or further increased their gains, while others trended back toward baseline...
July 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/27301833/using-literature-review-and-structured-hybrid-electronic-manual-mortality-review-to-identify-system-level-improvement-opportunities-to-reduce-colorectal-cancer-mortality
#20
Joanne E Schottinger, Michael H Kanter, Kerry C Litman, Helen Lau, Gary E Schwartz, Farah M Brasfield, Najeeb S Alshak, Louis A Difronzo
BACKGROUND: Despite colorectal cancer (CRC) screening and survival rates exceeding national averages in the United States, Kaiser Permanente Southern California (KPSC) aimed to identify system-level improvement opportunities to further reduce mortality from CRC. METHODS: To examine modifiable factors contributing to CRC mortality, a structured hybrid electronic/manual mor- tality review was used to examine 50 randomly selected cases among 524 individuals aged 25-75 years diagnosed with stage II, III, or IV CRC after July 2008 who subsequently died...
July 2016: Joint Commission Journal on Quality and Patient Safety
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