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Joint Commission Journal on Quality and Patient Safety

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https://www.readbyqxmd.com/read/28738988/use-of-cascading-a3s-to-drive-systemwide-improvement
#1
Laura E Winner, Timothy J Burroughs, Julie A Cady-Reh, Richard Hill, Robert E Hody, Richard L Powers, Tiffany Callender, Renee Demski, Peter J Pronovost
No abstract text is available yet for this article.
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28738987/evaluation-of-sensor-technology-to-detect-fall-risk-and-prevent-falls-in-acute-care
#2
Patricia Potter, Kelly Allen, Eileen Costantinou, William Dean Klinkenberg, Jill Malen, Traci Norris, Elizabeth O'Connor, Wilhemina Roney, Heidi Hahn Tymkew, Laurie Wolf
BACKGROUND: Sensor technology that dynamically identifies hospitalized patients' fall risk and detects and alerts nurses of high-risk patients' early exits out of bed has potential for reducing fall rates and preventing patient harm. During Phase 1 (August 2014-January 2015) of a previously reported performance improvement project, an innovative depth sensor was evaluated on two inpatient medical units to study fall characteristics. In Phase 2 (April 2015-January 2016), a combined depth and bed sensor system designed to assign patient fall probability, detect patient bed exits, and subsequently prevent falls was evaluated...
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28738986/pilot-testing-fall-tips-tailoring-interventions-for-patient-safety-a-patient-centered-fall-prevention-toolkit
#3
Patricia C Dykes, Megan Duckworth, Stephanie Cunningham, Sasha Dubois, Melissa Driscoll, Zinnia Feliciano, Michael Ferrazzi, Farah E Fevrin, Stephanie Lyons, Mary Ellen Lindros, Allison Monahan, Matthew M Paley, Saby Jean-Pierre, Maureen Scanlan
BACKGROUND: Patient falls during an acute hospitalization cause injury, reduced mobility, and increased costs. The laminated paper Fall TIPS Toolkit (Fall TIPS) provides clinical decision support at the bedside by linking each patient's fall risk assessment with evidence-based interventions. Strategies were needed to integrate this evidence into clinical practice. METHODS: The Institute for Healthcare Improvement's Framework for Spread is the conceptual model for pilot implementation of Fall TIPS at Brigham and Women's Hospital (BWH; Boston) and Montefiore Medical Center (MMC; Bronx, New York)...
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28738985/intraoperative-handoffs-among-anesthesia-providers-increase-the-incidence-of-documentation-errors-for-controlled-drugs
#4
Richard H Epstein, Franklin Dexter, David M Gratch, David A Lubarsky
BACKGROUND: When electronic anesthesia records are compared to pharmacy transactions, discrepancies in total doses of controlled drugs are commonly found (≈16% of cases), potentially affecting patient safety and placing hospitals at risk for regulatory action. Errors (≈5%) persisted even with near real-time drug reconciliation feedback to providers. A study was conducted to test the hypothesis of greater risks of discrepancy for longer-duration cases and for intraoperative handoff involving a permanent handoff of care...
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28738984/transfusing-wisely-clinical-decision-support-improves-blood-transfusion-practices
#5
Ian Jenkins, Jay J Doucet, Brian Clay, Patricia Kopko, Donald Fipps, Eema Hemmen, Debra Paulson
BACKGROUND: The cost and risks of red blood cell (RBC) transfusions, along with evidence of overuse, suggest that improving transfusion practices is a key opportunity for health systems to improve both the quality and value of patient care. Previous work, which included a BestPractice Advisory (BPA), was adapted in a quality improvement project designed to reduce both exposure to unnecessary blood products and costs. METHODS: A prospective, pre-post study was conducted at an academic medical center with a diverse patient population...
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28738983/power-knowledge-and-transfusions-the-need-to-refocus-on-patient-blood-management
#6
EDITORIAL
Aryeh Shander, Sherri Ozawa, Gregg Lobel
No abstract text is available yet for this article.
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28738982/safe-practice-recommendations-for-the-use-of-copy-forward-with-nursing-flow-sheets-in-hospital-settings
#7
Emily S Patterson, Dawn M Sillars, Nancy Staggers, Esther Chipps, Laurie Rinehart-Thompson, Valerie Moore, Debora Simmons, Susan D Moffatt-Bruce
BACKGROUND: In early 2016 the Partnership for Health IT Patient Safety released safe practice recommendations for the use of copy-paste for electronic health record (EHR) documentation. These recommendations do not directly address nurses' use of copy-forward to document patient assessments in flow sheet software in hospital settings. Similar to clinicians' use of copy-paste and copy-forward with progress notes, concerns exist about patient safety issues from the use of potential inaccurate or outdated information to achieve increased efficiency of documentation...
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28738981/copy-forward-in-electronic-health-records-lipstick-on-a-pig
#8
EDITORIAL
Linda Harrington
No abstract text is available yet for this article.
August 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28648222/improving-care-teams-functioning-recommendations-from-team-science
#9
Kevin Fiscella, Larry Mauksch, Thomas Bodenheimer, Eduardo Salas
BACKGROUND: Team science has been applied to many sectors including health care. Yet there has been relatively little attention paid to the application of team science to developing and sustaining primary care teams. Application of team science to primary care requires adaptation of core team elements to different types of primary care teams. CORE TEAM ELEMENTS: Six elements of teams are particularly relevant to primary care: practice conditions that support or hinder effective teamwork; team cognition, including shared understanding of team goals, roles, and how members will work together as a team; leadership and coaching, including mutual feedback among members that promotes teamwork and moves the team closer to achieving its goals; cooperation supported by an emotionally safe climate that supports expression and resolution of conflict and builds team trust and cohesion; coordination, including adoption of processes that optimize efficient performance of interdependent activities among team members; and communication, particularly regular, recursive team cycles involving planning, action, and debriefing...
July 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28648221/designing-and-implementing-an-electronic-patient-registry-to-improve-warfarin-monitoring-in-the-ambulatory-setting
#10
Shin-Yu Lee, Roy Cherian, Irene Ly, Claire Horton, Alaya Levi Salley, Urmimala Sarkar
BACKGROUND: Warfarin requires individualized dosing and monitoring in the ambulatory setting for protection against thromboembolic disease. Yet in multiple settings, patients spend upwards of 30% of time outside the therapeutic range, subjecting them to an increased risk of adverse events. At an urban, publicly funded clinic, the electronic health record (EHR) would not support integration with extant warfarin management software, which led to the creation and implementation of an electronic patient registry and a complementary team-based work flow to provide real-time health-system-level data for warfarin patients...
July 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28648220/flying-blind-don-t-manage-warfarin-without-a-registry
#11
EDITORIAL
Adam J Rose
No abstract text is available yet for this article.
July 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28648219/primary-care-collaboration-to-improve-diagnosis-and-screening-for-colorectal-cancer
#12
Gordon D Schiff, Trudy Bearden, Lindsay Swain Hunt, Jennifer Azzara, Jay Larmon, Russell S Phillips, Sara Singer, Brandon Bennett, Jonathan R Sugarman, Asaf Bitton, Andrew Ellner
BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer death, reducible by screening and early diagnosis, yet many patients fail to receive recommended screening. As part of an academic improvement collaborative, 25 primary care practices worked to improve CRC screening and diagnosis. METHODS: The project featured triannual learning sessions, monthly conference calls, practice coach support, and monthly reporting. The project phases included literature review and interviews with national leaders/organizations, development of driver diagrams to identify key factors and change ideas, project launch and practice team planning, and a practice improvement phase...
July 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28648218/innovative-information-technology-powered-population-health-care-management-improves-outcomes-and-reduces-hospital-readmissions-and-emergency-department-visits
#13
Sharon Anderson, Michele Campbell, Donna Mahoney, Ann Kathryn Muther, Janice Nevin, Patricia Resnik, Tabassum Salam, Terri Steinberg
BACKGROUND: Patients with chronic conditions are often the most frequent users of health care. Moreover, adapting to developments in one's illness, understanding how to self-manage a chronic illness, and sharing information between primary care and specialty providers, can be a full-time job for someone with a chronic illness. In response to these challenges, Christiana Care Health System (Wilmington, Delaware) developed Care Link, an information technology (IT)-enhanced care management support to enable populations of patients to achieve better clinical outcomes at lower cost...
July 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28648217/integrating-research-quality-improvement-and-medical-education-for-better-handoffs-and-safer-care-disseminating-adapting-and-implementing-the-i-pass-program
#14
Amy J Starmer, Nancy D Spector, Daniel C West, Rajendu Srivastava, Theodore C Sectish, Christopher P Landrigan
BACKGROUND: In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow. METHODS: To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study...
July 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28648216/an-interview-with-carolyn-m-clancy
#15
Lawrence Becker
No abstract text is available yet for this article.
July 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28528625/an-organizational-framework-to-reduce-professional-burnout-and-bring-back-joy-in-practice
#16
Stephen J Swensen, Tait Shanafelt
No abstract text is available yet for this article.
June 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28528624/root-cause-analysis-of-adverse-events-in-an-outpatient-anticoagulation-management-consortium
#17
Christopher M Graves, Brian Haymart, Eva Kline-Rogers, Geoffrey D Barnes, Linda K Perry, Denise Pluhatsch, Nannette Gearhart, Helen Gikas, Noelle Ryan, Brian Kurtz
BACKGROUND: A number of factors can lead to adverse events (AEs) in patients taking warfarin. Performing a root cause analysis (RCA) of serious AEs is one systematic way of determining the causes of these events. METHODS: Multidisciplinary teams were formed at Michigan Anticoagulation Quality Improvement Initiative (MAQI(2)) sites with organized anticoagulation management services (AMS). Medical records from patients who suffered serious AEs (major bleed, embolic stroke, venous thromboembolism) were reviewed, and AMS staff were interviewed to determine the root cause using the "5 Whys" technique...
June 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28528623/organizational-perspectives-of-nurse-executives-in-15-hospitals-on-the-impact-and-effectiveness-of-rapid-response-teams
#18
Patricia L Smith, Jean McSweeney
BACKGROUND: Many hospitals use rapid response teams (RRTs) to respond to deteriorating patients, but it remains unclear what organizations actually monitor. Understanding what organizations value in an RRT may help clarify measurement choices. Interviews were conducted to determine how organizational leaders perceived and evaluated their hospitals' RRTs. METHODS: The study used a descriptive, qualitative design. Participants were nurse executives and key informants in 300- to 500-bed hospitals in the south-central United States and were recruited using purposive and snowball sampling...
June 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28528622/introductions-during-time-outs-do-surgical-team-members-know-one-another-s-names
#19
David J Birnbach, Lisa F Rosen, Maureen Fitzpatrick, John T Paige, Kristopher L Arheart
BACKGROUND: Introductions are the first item of the time-out in the World Health Organization Surgical Safety Checklist (SSC). It has yet to be established that surgical teams use colleagues' names or consider the use of names important. A study was conducted to determine if using the SSC has a measurable impact on name retention and to assess if operating room (OR) personnel believe it is important to know the names of their colleagues or for their colleagues to know theirs. METHODS: All OR personnel were individually interviewed at the end of 25 surgical cases in which the SSC was used...
June 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28528621/using-lean-to-rapidly-and-sustainably-transform-a-behavioral-health-crisis-program-impact-on-throughput-and-safety
#20
Margaret E Balfour, Kathleen Tanner, Paul J Jurica, Dawn Llewellyn, Robert G Williamson, Chris A Carson
BACKGROUND: Lean has been increasingly applied in health care to reduce waste and improve quality, particularly in fast-paced and high-acuity clinical settings such as emergency departments. In addition, Lean's focus on engagement of frontline staff in problem solving can be a catalyst for organizational change. In this study, ConnectionsAZ demonstrates how they applied Lean principles to rapidly and sustainably transform clinical operations in a behavioral health crisis facility. METHODS: A multidisciplinary team of management and frontline staff defined values-based outcome measures, mapped the current and ideal processes, and developed new processes to achieve the ideal...
June 2017: Joint Commission Journal on Quality and Patient Safety
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