journal
MENU ▼
Read by QxMD icon Read
search

Joint Commission Journal on Quality and Patient Safety

journal
https://www.readbyqxmd.com/read/30503812/inter-rater-agreement-for-abstraction-of-the-early-management-bundle-severe-sepsis-septic-shock-sep-1-quality-measure-in-a-multi-hospital-health-system
#1
Seth R Bauer, Judith A Gonet, Rebecca F Rosario, Lori A Griffiths, Tracy Kingery, Anita J Reddy
BACKGROUND: The Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) quality measure is complex to abstract, which may lead to discrepancies between abstractors. This study was designed to evaluate inter-rater agreement between abstractors at individual hospitals in a health system and a lead abstractor on abstraction elements and measure compliance for SEP-1. METHODS: Patient cases qualifying for abstraction for SEP-1 over a four-month period in 2016 were initially abstracted at a local hospital and then centrally by a lead abstractor...
November 29, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30471989/self-reported-adherence-to-high-reliability-practices-among-participants-in-the-children-s-hospitals-solutions-for-patient-safety-collaborative
#2
Kelly H Randall, Donna Slovensky, Robert Weech-Maldonado, Patricia A Patrician, Paul J Sharek
BACKGROUND: Application of high reliability principles has the potential to transform the health care industry to perform with a higher level of safety than is present today. The purpose of this study was to quantitatively assess and describe the extent and variability of integration of high reliability practices among a collaborative of children's hospitals using the High Reliability Health Care Maturity (HRHCM) model. METHODS: A survey instrument based on the HRHCM model was developed to determine the extent of integration of high reliability practices across hospitals participating in the Children's Hospitals' Solutions for Patient Safety (CHSPS) network...
November 21, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30455098/frequency-of-testing-for-prostate-cancer-using-prostate-specific-antigen-among-older-men-in-a-large-health-system
#3
Theresa A Rowe, Ji Young Lee, Joshua J Meeks, Stephen D Persell
No abstract text is available yet for this article.
November 16, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30392750/first-report-of-a-multiphase-pilot-to-measure-patient-reported-outcomes-in-the-american-college-of-surgeons-national-surgical-quality-improvement-program
#4
Jason B Liu, Andrea L Pusic, Amy Matroniano, Rajee Aryal, Paul B Willarson, Bruce L Hall, Larissa K Temple, Clifford Y Ko
BACKGROUND: Incorporating the patient's perspective to evaluate national surgical quality has yet to be achieved in the United States and represents a tremendous unrealized opportunity for continuous quality improvement. The first phase of a multiphase pilot to measure patient-reported outcomes (PROs) using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is described. METHODS: After conducting a baseline knowledge assessment and stakeholder engagement activities, a pilot to capture PROs was implemented using the ACS NSQIP platform...
November 1, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30391372/a-quality-collaboration-in-heart-failure-and-pneumonia-inpatient-care-at-novant-health-standardizing-hospitalist-practices-to-improve-patient-care-and-system-performance
#5
Larry Weems, Jodi Strong, Dianne Plummer, Jenny Martin, Thomas N Zweng, Jeff Lindsay, David Paculdo, Mary Tran, John Peabody
BACKGROUND: Heart failure and pneumonia are among the most measured and expensive conditions to treat in the United States across all payer types and are top of mind for value-driven hospital organizations and payers seeking to not only improve the quality of care for patients but also reduce unnecessary spending. Care standardization potentially leads to better patient outcomes and reduced excess costs but is a difficult objective to achieve. METHODS: A pre-post analysis of clinical practice, patient outcomes, and cost was designed to determine if serial measurement and feedback using simulated patients improves patient care quality and reduces costs for two common conditions cared for by hospitalists: pneumonia and heart failure...
October 31, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30389466/wrong-patient-blood-transfusion-error-leveraging-technology-to-overcome-human-error-in-intraoperative-blood-component-administration
#6
Nadia B Hensley, Colleen G Koch, Peter J Pronovost, Bommy Hong Mershon, Joan Boyd, Susan Franklin, Dana Moore, Kristen Sheridan, Anne Steele, Tracey L Stierer
BACKGROUND: Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions...
October 30, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30482662/impact-of-hospitalist-led-interdisciplinary-antimicrobial-stewardship-interventions-at-an-academic-medical-center
#7
Stephanie J Tang, Renuka Gupta, Jennifer I Lee, Adrian M Majid, Parimal Patel, Leigh Efird, Angela Loo, Shawn Mazur, David P Calfee, Alexi Archambault, Deanna Jannat-Khah, Savira Kochhar Dargar, Matthew S Simon
BACKGROUND: Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes. METHODS: A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5)...
October 25, 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30341014/bringing-perioperative-emergency-manuals-to-your-institution-a-how-to-from-concept-to-implementation-in-10-steps
#8
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
#9
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
#10
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
#11
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
#12
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
#13
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
#14
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
#15
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
#16
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/30447762/plaintiff-attorneys-in-communication-and-resolution-programs
#17
LETTER
(no author information available yet)
No abstract text is available yet for this article.
December 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30447761/inclusion-of-plaintiff-attorneys-in-research-into-the-effects-of-harmful-events
#18
LETTER
(no author information available yet)
No abstract text is available yet for this article.
December 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30447760/choosing-wisely-in-georgia-a-quality-improvement-initiative-in-25-adult-ambulatory-medicine-offices
#19
Scott Pugel, John L Stallworth, Leslie B Pugh, Carlee Terrell, Zuwere Bailey, Thomas Gramling, Helen Ward
BACKGROUND: Scant evidence exists of effective Choosing Wisely® initiatives, which are intended to reduce the use of unnecessary care. In 2013 substantial variations existed at Kaiser Permanente Georgia in the frequency of nonbeneficial services in ambulatory care. A Choosing Wisely campaign was implemented across 25 medical offices serving approximately 300,000 members. METHODS: The initiative was designed to reduce the use of complete blood counts (CBCs) and electrocardiograms (EKGs) as routine screening tests in physical examination visits, age-inappropriate dual-energy x-ray absorptiometry (DEXA) scans, and imaging for uncomplicated headache...
December 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/30447759/implementation-of-choosing-wisely-promise-and-pitfalls
#20
EDITORIAL
R Sacha Bhatia, Eve A Kerr
No abstract text is available yet for this article.
December 2018: Joint Commission Journal on Quality and Patient Safety
journal
journal
40953
1
2
Fetch more papers »
Fetching more papers... Fetching...
Read by QxMD. Sign in or create an account to discover new knowledge that matter to you.
Remove bar
Read by QxMD icon Read
×

Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"