Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Mar 2009
Clinical triggers or rapid response teams: does the emperor need "new" clothes?
Essential to any rapid response system is certainty regarding its ability to provide an immediate and appropriate response to calls for help.
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Jt Comm J Qual Patient Saf · Mar 2009
A multidisciplinary team approach to retained foreign objects.
Retained foreign objects (RFOs) after surgical procedures are an infrequent but potentially devastating medical error. The Mayo Clinic, Rochester (MCR), undertook a quality improvement program to reduce the incidence of surgical RFOs. ⋯ MCR experienced a significant and sustained reduction in the incidents of RFOs, attributed to the multidisciplinary nature of the initiative, the active engagement of institutional leadership, and use of the principles of enhanced communication between operating room staff members to improve operating room situational awareness.
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Jt Comm J Qual Patient Saf · Mar 2009
Comparative StudyComparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals.
The debate over whether patient safety efforts should focus on adverse events or errors logically extends to voluntary incident reporting in hospitals. Reports emphasizing adverse events take an outcome-oriented approach to improving quality, whereas those emphasizing errors take a process-oriented approach. These approaches were compared in an analysis of 2,228 paper incident reports for 16,575 randomly selected inpatients at an academic hospital and a community hospital in the United States in 2001. ⋯ Many incident reports contain process information or outcome information but not both. Outcome-oriented reports lack the information needed to assess risk and formulate safety improvements; therefore, follow-up investigations are required. Because process-oriented reports include the necessary information more often, they are more directly useful for improving patient safety. Hospitals should focus voluntary incident reporting systems on capturing process-oriented reports and should train staff to describe contributing factors. This focus should not only improve the quality of the information in the reports but is consistent with efforts to promote a blame-free reporting culture.
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DHMC's clinical triggers program is a promising approach that addresses an unmet patient need. We have seen dramatic reductions in our non-ICU cardiopulmonary arrest rates, along with our ICU bounceback rates. In the context of our hospital, this program aligns well with our teaching mission while maximizing the resources that are currently available. ⋯ Although our study does not alter the weight of evidence in the literature, it does offer a new focus on the afferent limb by clarifying the expectations of the primary responders. This was the essence of the deficiency in the aforementioned case study. Death is the natural, albeit sad, endpoint of all lives; the overarching goal of DHMC's clinical triggers system is to prevent the premature death of a hospitalized patient and thereby improve patient safety.