Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Sep 2015
Effect of a Real-Time Pediatric ICU Safety Bundle Dashboard on Quality Improvement Measures.
Patient daily goal sheets have been shown to improve compliance with hospital policies but might not represent the dynamic nature of care delivery in the pediatric ICU (PICU) setting. A study was conducted at Children's National Health System (Washington, DC) to determine the effect of a visible, unitwide, real-time dashboard on timeliness of compliance with quality and safety measures. ⋯ A unitwide dashboard can increase awareness for potential interventions, affecting patient safety in the PICU in a dynamic manner.
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Jt Comm J Qual Patient Saf · Aug 2015
Advancing Medication Safety: Establishing a National Action Plan for Adverse Drug Event Prevention.
Adverse drug events (ADEs) are important contributors to preventable morbidity and mortality, comprising one third of all hospital adverse events. In response to growing evidence detailing the high prevalence of ADEs, particularly among vulnerable older adults, Congress requested that the Secretary of the Department of Health and Human Services (HHS) convene a Federal Interagency Steering Committee to establish a National Action Plan to focus on ADE prevention. In August 2014, the Office of Disease Prevention and Health Promotion released the final version of the National Action Plan for Adverse Drug Event Prevention. The Action Plan directly supports the goals of the HHS Strategic Plan and the Patient Protection and Affordable Care Act by providing guidance on tracking and preventing ADEs, as well as describing evidence-based tools and resources to enhance medication safety. ADE ACTION PLAN CONTENT: The Federal Interagency Steering Committee focused the Action Plan on ADEs that are clinically significant, account for the greatest number of measurable harms as identified by using existing surveillance tools, and are largely preventable. As such, the decision was made to target three medication classes: anticoagulants, diabetes agents (insulin and oral hypoglycemic agents), and opioids. The Action Plan is organized around four key areas: surveillance; evidence-based prevention; payment, policy incentives, and oversight; and research opportunities to advance medication safety. ⋯ One measure of the ADE Action Plan's success will be the wider dissemination of information and educational resources to providers and patients (or consumers) regarding the risks associated with medications. Future Action Plan iterations are likely to consider other high-priority medication classes and update the recommendations.
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Jt Comm J Qual Patient Saf · Jul 2015
Redefining Overuse to Include Costs: A Decision Analysis for Computed Tomography in Minor Head Injury.
A study was conducted to (1) determine the testing threshold for head computed tomography (CT) in minor head injury in the emergency department using decision analysis with and without costs included in the analysis, (2) to determine which variables have significant impact on the testing threshold, and (3) to compare this calculated testing threshold to the pretest risk estimate previously reported when the Canadian CT Head Rule (CCHR) was applied. It was hypothesized that the CCHR might not identify all patients above the testing threshold. ⋯ If only effectiveness is considered, current clinical decision rules might not provide a sufficient degree of certainty to ensure identification of all patients for whom the benefits of CT outweigh its risks. However, inclusion of cost in the analysis increases the testing threshold by an order of magnitude and well outside the range of uncertainty of current clinical decision rules. These results suggest that the term overuse should be redefined to include the provision of medical services with no benefits or for which harms including cost outweigh benefits.
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Jt Comm J Qual Patient Saf · Jun 2015
Using the integrated nurse leadership program to reduce sepsis mortality.
The Integrated Nurse Leadership Program (INLP) is a collaborative improvement model focused on developing practical leadership skills of nurses and other frontline clinicians to lead quality improvement efforts. Sepsis is a major challenge to treat because it arises unpredictably and can progress rapidly. Nine San Francisco Bay Area hospitals participated in a 22-month INLP Sepsis Mortality Reduction Project to improve sepsis detection and management. ⋯ In addition to improvement in safety culture and management of septic patients, hospitals participating in the INLP Sepsis Mortality Reduction Project achieved reductions in sepsis mortality during the study period and sustained reductions for more than one year later. The INLP model can be readily applied beyond sepsis management and mortality to other quality problems.