Joint Commission Journal on Quality and Patient Safety

BACKGROUND: Wrong-site surgeries are considered "never events" and continue to occur despite the implementation of the Universal Protocol by The Joint Commission in 2003. METHODS: The authors reviewed closed claims data on wrong-site surgery between 2013 and 2020 from a medical malpractice company. The claims were classified by allegations made by claimants, the responsible services, the types of procedures, the injuries, and contributing factors. Researchers performed a descriptive analysis of the available variables and reviewed the clinical summary of each case...

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BACKGROUND: Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions. METHODS: The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system...

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No abstract text is available yet for this article.

No abstract text is available yet for this article.

BACKGROUND: With an already distressed health care workforce demonstrating high levels of burnout, depression, and suicide, access to behavioral health care, particularly after an adverse event, is critical. Unfortunately, clinicians identify multiple barriers to seeking behavioral support. In 2022 the National Academy of Medicine, in its National Plan for Health Workforce Well-Being, established "Support Mental Health and Reduce Stigma" as one of its seven priority areas. FRAMEWORK: The authors developed a program called CHaMP (Center for Healthy Minds and Practice) guided by a multidisciplinary task force that developed the vision, plan, and algorithms to improve crisis response; build a peer support program; and remove barriers to accessing mental health care by establishing an on-campus behavioral health support center...

BACKGROUND: Delayed hospital and emergency department (ED) patient throughput, which occurs when demand for inpatient care exceeds hospital capacity, is a critical threat to safety, quality, and hospital financial performance. In response, many hospitals are deploying capacity command centers (CCCs), which co-locate key work groups and aggregate real-time data to proactively manage patient flow. Only a narrow body of peer-reviewed articles have characterized CCCs to date. To equip health system leaders with initial insights into this emerging intervention, the authors sought to survey US health systems to benchmark CCC motivations, design, and key performance indicators...

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Children with medical complexity (CMC) often have lengthy medication lists and are at risk of experiencing suboptimal medication management. This tool tutorial describes a novel and pragmatic strategy for the development and implementation of medication rounds, a model that promotes medication safety for hospitalized CMC. An interprofessional group designed and implemented a pharmacy-led medication rounding care model, in which clinicians and pharmacists partner weekly to conduct reviews of all patient medications on a general pediatrics CMC team using a comprehensive checklist...

BACKGROUND: Quality improvement (QI) interventions in primary care are increasingly designed and implemented by multisector partnerships, yet little guidance exists on how to best monitor or evaluate these partnerships. The goal of this project was to describe an approach for evaluating the development and effectiveness of a multisector partnership using data from the first year of the Healthy Hearts for Michigan (HH4M) Cooperative, a multisector partnership of nine organizations tasked with designing and implementing evidence-based QI strategies for hypertension management and tobacco cessation in 50 rural primary care practices...

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BACKGROUND: Electrocardiography (ECG) electrodes require special expiration tracking after the manufacturer's packaging is opened. Compliance with this requirement, however, can be inconsistent. The authors tested the efficacy of a device that provides for expiration tracking of bulk-packaged electrodes to improve compliance. METHODS: The device tested is a bin with an automated countdown timer that could be used for storing and dispensing open ECG electrodes. Seven operating rooms were inspected three times each before and after implementation of the device...

BACKGROUND: Despite evidence that measurement-based care (MBC) can help identify nonresponse and residual depressive symptoms and could improve treatment, it is underused. The aim of this study was to improve the percentage of patients with depression who received symptom monitoring using the Patient Health Questionnaire-9 (PHQ-9) from 5% to 90%. METHODS: The research team conducted a quality improvement project employing an uncontrolled before [January to September 2020] and after [October 2020 to May 2021] approach...

BACKGROUND: Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism...

BACKGROUND: Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey...

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No abstract text is available yet for this article.

BACKGROUND: To understand neurologists' experiences and perspectives on patient satisfaction feedback and its impact on personal well-being and behavior. METHODS: From May to June 2021, the researchers conducted 19 semistructured interviews with neurologists from a large academic medical center. Clinical Performance Feedback Intervention Theory informed a combined inductive and deductive thematic analysis of the qualitative data, which focused on perceptions of current feedback practices, its impact on physician behavior, and recommendations for improvement...

BACKGROUND: Anesthesiology provider handoffs are complex, occur frequently, and have been associated with adverse patient outcomes. The authors sought to determine the degree to which anesthesiology handoff studies with educational interventions incorporated tenets of educational best practices. METHODS: The research team conducted a systematic review of the peer-reviewed literature focused on handoff studies with education interventions that included anesthesiology providers...