Joint Commission journal on quality and patient safety / Joint Commission Resources
-
Jt Comm J Qual Patient Saf · Jan 2009
Multicenter StudyDisclosing errors to patients: perspectives of registered nurses.
Disclosure of medical errors has been conceptualized as occurring primarily in the physician-patient dyad. Yet, health care is delivered by interprofessional teams, in which nurses share in the culpability for errors, and hence, in responsibility for disclosure. This study explored nurses' perspectives on disclosure of errors to patients and the organizational factors that influence disclosure. ⋯ Nurses conceived of the disclosure process as a team event occurring in the context of a complex health care system rather than as a physician-patient conversation. Nurses felt excluded from these discussions, resulting in their use of ethically questionable communication strategies. The findings underscore the need for organizations to adopt a team disclosure process. Health care organizations that integrate the entire health care team into the disclosure process will likely improve the quality of error disclosure.
-
Jt Comm J Qual Patient Saf · Jan 2009
Multicenter StudyBarriers to emergency departments' adherence to four medication safety-related Joint Commission National Patient Safety Goals.
Medication errors are a serious public health threat, causing patient injury and death and sharply increasing health care costs. Serious preventable errors are most likely to occur in areas of increased complexity and technology, such as the emergency department (ED). Although The Joint Commission in 2002 approved the first set of National Patient Safety Goals (NPSGs) to decrease the occurrence of health care errors, the literature suggests that the goals are not fully implemented. In 2006, the Emergency Nurses Association (ENA) conducted a national, multisite survey (1) to describe barriers to full implementation of the 2006 NPSGs related to medication safety (then known as Goals 1, 2, 3, and 8) as reported by ED registered nurses (ED nurses) and (2) to investigate factors related to those barriers. ⋯ The low response rate (4.6%) to this study inherently limits the overall generalizability of the findings to the greater population of EDs. Yet, the findings suggest that substantial barriers remain to ED adherence to the NPSGs related to medication safety. Efforts to reduce the barriers should focus on system changes that facilitate adherence. Health care providers and their organizations must commit to and enforce a zero-tolerance policy for preventable medication errors.
-
Jt Comm J Qual Patient Saf · Jan 2009
Using the American Heart Association's National Registry of Cardiopulmonary Resuscitation for performance improvement.
Data suggest that the overall quality of inhospital resuscitation is suboptimal and contributes to poor patient outcomes. In 2000 the American Heart Association created the National Registry of Cardiopulmonary Resuscitation (NRCPR) as an evidence-based hospital safety program. Participating hospitals voluntarily join the registry and pay an annual fee that includes data support and report generation. The primary purpose of NRCPR is to support local facility efforts in practice management and performance improvement (PI). ⋯ NRCPR is used as both a local PI tool as well as a source of data that scientists are analyzing to further the understanding of inhospital resuscitation processes and outcomes. Over time, researchers have recognized the need to refine the Chain of Survival to reflect the unique aspects of inhospital resuscitation. A rapid response system provides a new link at the beginning, and postresuscitation care provides a new link at the end of the Chain of Survival.
-
Jt Comm J Qual Patient Saf · Jan 2009
Implementing a patient safety and quality program across two merged pediatric institutions.
Academic centers are among the health care organizations that have used consolidation as a strategy to improve efficiency and reduce costs. In 1997, the New York Hospital and The Presbyterian Hospital underwent a full-asset merger to become New York City's largest medical center, known as the New York-Presbyterian Hospital (NYPH). In 2006, recognition of the challenges of the Children's Service Line at NYPH led to the formation of a Patient Safety and Quality Program to deliver consistently safe and effective health care. ⋯ Developing a pediatric safety and quality program across two campuses has been challenging but has led to important improvements at both organizations.