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Journals Joint Commission Journal on Qu...

Joint Commission Journal on Quality and Patient Safety

https://read.qxmd.com/read/38744622/the-challenge-of-improving-patient-safety-this-is-hard
#1
EDITORIAL
Robin R Hemphill
No abstract text is available yet for this article.
May 3, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38763793/reducing-the-risk-of-delayed-colorectal-cancer-diagnoses-through-an-ambulatory-safety-net-collaborative
#2
JOURNAL ARTICLE
Rachel Moyal-Smith, Meagan Elam, Jason Boulanger, Richard Balaban, Joanne E Cox, Rebecca Cunningham, Pat Folcarelli, Matthew C Germak, Kristin O'Reilly, Melissa Parkerton, Nathan W Samuels, Fiona Unsworth, Luke Sato, Evan Benjamin
BACKGROUND: An estimated 12 million adults in the United States experience delayed diagnoses and other diagnostic errors annually. Ambulatory safety nets (ASNs) are an intervention to reduce delayed diagnoses by identifying patients with abnormal results overdue for follow-up using registries, workflow redesign, and patient navigation. The authors sought to co-design a collaborative and implement colorectal cancer (CRC) ASNs across various health care settings. METHODS: A working group was convened to co-design implementation guidance, measures, and the collaborative model...
April 23, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38744623/a-simple-risk-adjustment-for-hospital-level-nulliparous-term-singleton-vertex-cesarean-delivery-rates-and-its-implications-for-public-reporting
#3
JOURNAL ARTICLE
Benjamin D Pollock, Leslie Carranza, Elizabeth Braswell-Pickering, Christine M Sing, Lindsay L Warner, Regan N Theiler
BACKGROUND: The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals' perinatal care quality through the Cesarean Birth measurement (PC-02). However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk adjustment paradigm of most publicly reported hospital quality measures. Here, the authors tested whether risk adjustment for readily documented maternal risk factors affected hospital-level NTSV-CD rates in a large health system...
April 16, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38762387/improving-appropriate-use-of-peripherally-inserted-central-catheters-through-a-statewide-collaborative-hospital-initiative-a-cost-effectiveness-analysis
#4
JOURNAL ARTICLE
Megan Heath, Steven J Bernstein, David Paje, Elizabeth McLaughlin, Jennifer K Horowitz, Amy McKenzie, Tom Leyden, Scott A Flanders, Vineet Chopra
BACKGROUND: Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use. METHODS: The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center...
April 10, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38644154/implementation-of-suicide-prevention-activities-at-acute-care-discharge-time-for-change
#5
EDITORIAL
Celine Larkin
No abstract text is available yet for this article.
April 9, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38744624/lessons-learned-from-a-national-hospital-antibiotic-stewardship-implementation-project
#6
JOURNAL ARTICLE
Sara E Cosgrove, Roy Ahn, Prashila Dullabh, Janna Gordon, Melissa A Miller, Pranita D Tamma
BACKGROUND: The goal of antibiotic stewardship programs (ASPs) is to ensure that patients receive effective therapy while minimizing adverse events. To overcome barriers commonly faced in implementing successful ASPs, the Agency for Healthcare Research and Quality (AHRQ) established a multifaceted, nationwide Safety Program for Improving Antibiotic Use in 2018. This report summarizes the lessons learned from the implementation of this initiative based on structured interviews of personnel from participating sites...
April 6, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38719650/screening-and-intervention-to-prevent-violence-against-health-professionals-from-hospitalized-patients-a-pilot-study
#7
JOURNAL ARTICLE
Kathryne Adams, Langley Topper, Isabelle Hashim, Aliysa Rajwani, Cristina Montalvo
BACKGROUND: Health care providers, particularly nursing staff, are at risk of physical or emotional abuse from patients. This abuse has been associated with increased use of physical and pharmacological restraints on patients, poor patient outcomes, high staff turnover, and reduced job satisfaction. METHODS: In this study, a multidisciplinary team at Tufts Medical Center implemented the Brøset Violence Checklist (BVC), a screening tool administered by nurses to identify patients displaying agitated behavior...
April 5, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38653615/clinician-well-being-and-burnout-panel-interview-with-tait-shanafelt-lisa-rotenstein-and-christine-sinsky
#8
JOURNAL ARTICLE
David W Baker
No abstract text is available yet for this article.
April 5, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38705746/standardizing-the-dosage-and-timing-of-dexamethasone-for-postoperative-nausea-and-vomiting-prophylaxis-at-a-safety-net-hospital-system
#9
JOURNAL ARTICLE
Andrew V Yurkonis, Luis Tollinche, Jonathan Alter, Samantha E Pope, Peyton Traxler, Hannah E Hill, Augusto Torres
BACKGROUND: A single dose of dexamethasone is routinely given during general anesthesia for postoperative nausea and vomiting (PONV) prophylaxis, although the exact dosage and timing of administration may vary between practitioners. The authors aimed to standardize the dosage and timing of this medication when given to adult patients undergoing general anesthesia for elective surgery. METHODS: Baseline data for 7,483 preintervention cases were analyzed. The researchers attempted to use a standard dose of 8 to 10 mg induction of anesthesia, which, based on a literature review, was effective for PONV prophylaxis, had a similar safety profile as a 4 to 5 mg dose (including in diabetic patients), and may confer additional benefits such as improved prophylaxis and quality of recovery...
April 3, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38705745/putting-the-action-in-rca-2-an-analysis-of-intervention-strength-after-adverse-events
#10
JOURNAL ARTICLE
Jessica A Zerillo, Sarah A Tardiff, Dorothy Flood, Lauge Sokol-Hessner, Anthony Weiss
BACKGROUND: Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed. METHODS: Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023...
April 1, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38553378/handoffs-and-care-transitions-interviews-with-chris-landrigan-and-theresa-murray
#11
JOURNAL ARTICLE
David W Baker
No abstract text is available yet for this article.
March 19, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38653614/evaluation-of-a-structured-review-process-for-emergency-department-return-visits-with-admission
#12
JOURNAL ARTICLE
Zoe Grabinski, Kar-Mun Woo, Olumide Akindutire, Cassidy Dahn, Lauren Nash, Inna Leybell, Yelan Wang, Danielle Bayer, Jordan Swartz, Catherine Jamin, Silas W Smith
BACKGROUND: Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis. METHODS: The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns...
March 15, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38653613/teamwork-climate-safety-climate-and-physician-burnout-a-national-cross-sectional-study
#13
JOURNAL ARTICLE
Lisa Rotenstein, Hanhan Wang, Colin P West, Liselotte N Dyrbye, Mickey Trockel, Christine Sinsky, Tait Shanafelt
No abstract text is available yet for this article.
March 14, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38594132/racial-ethnic-disparities-in-peripartum-pain-assessment-and-management
#14
JOURNAL ARTICLE
Naomi H Greene, Sarah J Kilpatrick
OBJECTIVE: This study was conducted to determine if there were racial/ethnic disparities in pain assessment and management from labor throughout the postpartum period. METHODS: This was a retrospective cohort study of all births from January 2019 to December 2021 in a single urban, quaternary care hospital, excluding patients with hysterectomy, ICU stay, transfusion of more than 3 units of packed red blood cells, general anesthesia, or evidence of a substance abuse disorder...
March 14, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38553379/optimizing-hospitalist-co-management-for-improved-patient-workforce-and-organizational-outcomes
#15
EDITORIAL
Robert Metter, Amanda Johnson, Marisha Burden
No abstract text is available yet for this article.
March 13, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38643047/frontline-providers-and-patients-perspectives-on-improving-diagnostic-safety-in-the-emergency-department-a-qualitative-study
#16
JOURNAL ARTICLE
Courtney W Mangus, Tyler G James, Sarah J Parker, Elizabeth Duffy, P Paul Chandanabhumma, Caitlin M Cassady, Fernanda Bellolio, Kalyan S Pasupathy, Milisa Manojlovich, Hardeep Singh, Prashant Mahajan
BACKGROUND: Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety. METHODS: Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems...
March 12, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38556442/department-of-anesthesiology-skilled-peer-support-program-outcomes-second-victim-perceptions
#17
JOURNAL ARTICLE
Brenda Bursch, Keren Ziv, Shevaughn Marchese, Hilary Aralis, Teresa Bufford, Patricia Lester
BACKGROUND: Most anesthesia providers experience an adverse event during their training or career. Limited evidence suggests skilled peer support programs (SPSPs) reduce initial distress and support adaptive functioning and coping. This study evaluated second victim perceptions of a voluntary SPSP. METHODS: An SPSP was developed and implemented for all clinical and administrative personnel in the Department of Anesthesiology and Perioperative Medicine in three hospitals and six outpatient surgery centers in December 2017...
March 12, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38565472/the-impact-of-using-electronic-consents-on-documentation-of-language-concordant-surgical-consent-for-patients-with-limited-english-proficiency
#18
JOURNAL ARTICLE
Karen Trang, Logan Pierce, Elizabeth C Wick
BACKGROUND: Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP)...
March 10, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38584053/enhancing-implementation-of-the-i-pass-handoff-tool-using-a-provider-handoff-task-force-at-a-comprehensive-cancer-center
#19
JOURNAL ARTICLE
Maria C Franco Vega, Mohamed Ait Aiss, Marina George, Lakeisha Day, Anayo Mbadugha, Katie Owens, Colin Sweeney, Son Chau, Carmen Escalante, Diane C Bodurka
BACKGROUND: Communication failures are among the most common causes of harmful medical errors. At one Comprehensive Cancer Center, patient handoffs varied among services. The authors describe the implementation and results of an Organization-wide project to improve handoffs and implement an evidence-based handoff tool across all inpatient services. METHODS: The research team created a task force composed of members from 22 hospital services-advanced practice providers (APPs), trainees, some faculty members, electronic health record (EHR) staff, education and training specialists, and nocturnal providers...
March 8, 2024: Joint Commission Journal on Quality and Patient Safety
https://read.qxmd.com/read/38565471/associations-between-organizational-communication-and-patients-experience-of-prolonged-emotional-impact-following-medical-errors
#20
JOURNAL ARTICLE
Lauge Sokol-Hessner, Tenzin Dechen, Patricia Folcarelli, Patricia McGaffigan, Jennifer P Stevens, Eric J Thomas, Sigall Bell
BACKGROUND: The emotional impact of medical errors on patients may be long-lasting. Factors associated with prolonged emotional impacts are poorly understood. METHODS: The authors conducted a subanalysis of a 2017 survey (response rate 36.8% [2,536/6,891]) of US adults to assess emotional impact of medical error. Patients reporting a medical error were included if the error occurred ≥ 1 year prior. Duration of emotional impact was categorized into no/short-term impact (impact lasting < 1 month), prolonged impact (> 1 month), and especially prolonged impact (> 1 year)...
March 7, 2024: Joint Commission Journal on Quality and Patient Safety
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