Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Sep 2014
Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.
A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. ⋯ Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.
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Jt Comm J Qual Patient Saf · Sep 2014
Implementation and impact of an automated group monitoring and feedback system to promote hand hygiene among health care personnel.
Despite substantial evidence to support the effectiveness of hand hygiene for preventing health care-associated infections, hand hygiene practice is often inadequate. Hand hygiene product dispensers that can electronically capture hand hygiene events have the potential to improve hand hygiene performance. A study on an automated group monitoring and feedback system was implemented from January 2012 through March 2013 at a 140-bed community hospital. ⋯ Feedback via an automated system was associated with improved hand hygiene performance in the short-term.
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Jt Comm J Qual Patient Saf · Aug 2014
Assisted and unassisted falls: different events, different outcomes, different implications for quality of hospital care.
Many hospitals classify inpatient falls as assisted (if a staff member is present to ease the patient's descent or break the fall) or unassisted for quality measurement purposes. Unassisted falls are more likely to result in injury, but there is limited research quantifying this effect or linking the assisted/unassisted classification to processes of care. A study was conducted to link the assisted/unassisted fall classification to both processes and outcomes of care, thereby demonstrating its suitability for use in quality measurement. This was only the second known published study to quantify the increased risk of injury associated with falling unassisted (versus assisted), and the first to estimate the effects of falling unassisted (versus assisted) on the likelihood of specific levels of injury. ⋯ The assisted/unassisted fall classification is associated with care processes and patient outcomes, making it suitable for quality measurement. Unassisted falls are more likely than assisted falls to result in injury and should be considered a target for future prevention efforts.
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Jt Comm J Qual Patient Saf · Jul 2014
Improving the quality of care and communication during patient transitions: best practices for urgent care centers.
Although high-quality care transitions require timely and accurate communication of clinical information between providers, such communication is inconsistent, and there are few established guidelines outside the hospital setting. ⋯ This set of best practices constitutes the first known guidelines to establish expectations and measures tailored specifically to transitions from the urgent care setting to the emergency department or primary care office. They can serve as a resource and a framework for urgent care clinicians expanding their collaboration with community partners, such as emergency departments and primary care providers, particularly in the context of emerging payment models.