Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Mar 2019
Bringing Perioperative Emergency Manuals to Your Institution: A "How To" from Concept to Implementation in 10 Steps.
Emergency manuals (EMs) are context-relevant sets of crisis checklists or cognitive aids designed to enable professional teams to deliver optimal care during critical events. Evidence from simulation and other high-risk industries have proven that use of these types of checklists can significantly improve event management and decrease omissions of key steps. However, simply printing and placing tools in operating rooms (ORs) is unlikely to be effective. How interventions are implemented influences whether clinicians actually change practice and whether patient care is affected. This article provides an in-depth description of a rigorous implementation plan with three goals: (1) place EMs in every anesthetizing location, (2) create interprofessional engagement, and (3) demonstrate that a majority of anesthesia clinicians would use the new tool in some way within the first year. ⋯ This article presents a framework and detailed description of the steps a large academic institution followed in successfully implementing EMs. In conjunction with other available resources, those interested in introducing OR EMs at large, complex institutions may benefit from the experience shared in anticipating challenges and overcoming barriers to adoption.
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Jt Comm J Qual Patient Saf · Mar 2019
Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration.
Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. ⋯ By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.