Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Mar 2010
Risk managers, physicians, and disclosure of harmful medical errors.
Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers. ⋯ Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.
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Jt Comm J Qual Patient Saf · Mar 2010
Does teamwork improve performance in the operating room? A multilevel evaluation.
Medical care is a team effort, especially as patient cases are more complex. Communication, cooperation, and coordination are vital to effective care, especially in complex service lines such as the operating room (OR). Team training, specifically the TeamSTEPPS training program, has been touted as one methodology for optimizing teamwork among providers and increasing patient safety. Although such team-training programs have transformed the culture and outcomes of other dynamic, high-risk industries such as aviation and nuclear power, evidence of team training effectiveness in health care is still evolving. Although providers tend to react positively to many training programs, evidence that training contributes to important behavioral and patient safety outcomes is lacking. ⋯ The hospital system has integrated elements of TeamSTEPPS into orientation training provided to all incoming hospital employees, including nonclinical staff.
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Jt Comm J Qual Patient Saf · Mar 2010
Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.
The concept of the morbidity and mortality (M&M) review is almost 100 years old, yet no standards describe "good practice" of M&M in clinical departments. Few reports measure output and impact of M&M reviews. The M&M activities were developed in a university-affiliated pediatric anesthesia department as part of a departmental quality improvement (QI) initiative. The process was designed to identify problems within the M&M program and to introduce interventions and actions to increase the program's efficiency and impact. ⋯ M&M QI with respect to data gathering, case review, and ongoing medical education is an efficient way to demonstrate quality assurance and creative professional development.
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The environment surrounding registered nurses (RNs) has been described as fast-paced and unpredictable, and nurses' cognitive load as exceptionally heavy. Studies of interruptions and multitasking in health care are limited, and most have focused on physicians. The extent and type of interruptions and multitasking of nurses, as well as patient errors, were studied using a natural-setting observational field design. The study was conducted in seven patient care units in two Midwestern hospitals--an academic medical center and a community-based teaching hospital. ⋯ RNs observed in both hospitals and on all patient care units experienced a high level of discontinuity in the execution of their work. Although nurses manage interruptions and multitasking well, the potential for errors is present, and strategies to decrease interruptions are needed.