Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Feb 2019
Using a Potentially Aggressive/Violent Patient Huddle to Improve Health Care Safety.
Unexpected situations of workplace violence are occurring in the United States at increasing rates in health care environments, warranting increased attention to processes supporting safety for health care workers. At a large, academic hospital, two patient safety incidents had occurred in a two-year period in which a patient had become violent at the time of admission from the emergency department (ED) to the medical unit. ⋯ The huddle handoff communication tool and other methods to facilitate the transfer of potentially violent patients have the potential to decrease the number and severity of violent incidents in the health care workplace.
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Jt Comm J Qual Patient Saf · Feb 2019
Randomized Controlled TrialAudio-Recorded Discharge Instructions for Limited English Proficient Parents: A Pilot Study.
Parents with limited English proficiency (LEP) demonstrate lower comprehension of discharge instructions. A study was conducted to (1) determine the feasibility of providing a greeting card with language-specific, audio-recorded discharge instructions to LEP parents; (2) describe use of and satisfaction with the cards; and (3) evaluate card effect on instruction comfort with home care and comprehension. ⋯ Providing language-concordant, audio-recorded discharge instructions was feasible, and parents reported high satisfaction with and frequent use of the cards with multiple caregivers.
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Jt Comm J Qual Patient Saf · Feb 2019
Inter-rater Agreement for Abstraction of the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) Quality Measure in a Multi-Hospital Health System.
The Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) quality measure is complex to abstract, which may lead to discrepancies between abstractors. This study was designed to evaluate inter-rater agreement between abstractors at individual hospitals in a health system and a lead abstractor on abstraction elements and measure compliance for SEP-1. ⋯ Concordance on SEP-1 abstraction elements between local and expert adjudicators was fair, and SEP-1 performance varied considerably from initial site-reported performance. The detailed nature of SEP-1 can lead to unreliable abstraction, which may lead to inaccurate reporting of compliance with the measure and affect comparability of performance between hospitals. Abstraction by a dedicated team for SEP-1 can reduce variability and improve efficiency.