Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jun 2014
Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.
Preventable adverse events are more likely to occur among older patients because of the clinical complexity of their care. The Veterans Health Administration (VHA) National Center for Patient Safety (NCPS) stores data about serious adverse events when a root cause analysis (RCA) has been performed. A primary objective of this study was to describe the types of adverse events occurring among older patients (age > or = 65 years) in Department of Veterans Affairs (VA) hospitals. Secondary objectives were to determine the underlying reasons for the occurrence of these events and report on effective action plans that have been implemented in VA hospitals. ⋯ The RCA process identified falls and communication as important themes in serious adverse events. Concrete actions, such as process standardization and changes to communication, were reported by teams to yield some improvement. However, fewer than half of the action plans were reported to be effective. Further research is needed to guide development and implementation of effective action plans.
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Jt Comm J Qual Patient Saf · Jun 2014
Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit.
In the critical care unit, complexity of care can contribute to both medical errors and increased costs, particularly when clinicians are forced to rely on memory. Checklists can be used to improve safety and reduce cost. A number of omission-related adverse events in 2010 prompted the development of a checklist to reduce the possibility of similar future events. ⋯ By using a daily safety checklist in the pediatric critical care unit, we improved quality and safety, as well as the collaborative culture among all clinicians. Incorporating the checklist into the EMR improved compliance and accountability, ensuring its application to all patients. Clinicians now often individually address many checklist items outside the formal rounding process, indicating that the checklist content has become part of their usual practice. A successful implementation showing tangible clinical improvements can lead to interest and adoption in other clinical areas within the institution.
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Jt Comm J Qual Patient Saf · May 2014
Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.
After hospital discharge, patients are at risk for medication errors, missed test results, adverse events, and readmissions. Handoff communication between the inpatient and outpatient settings is primarily accomplished with the discharge summary. However, critical information can often be missing, such as the date of the first postdischarge follow-up visit, a complete and accurate list of discharge medications, and follow-up recommendations. There have been no studies focusing on identifying and implementing a parsimonious, clinically relevant, inpatient-to-outpatient discharge handoff tool within a fully integrated electronic medical record (EMR) system. A concise, written, electronic handoff communication tool was created to address this gap. ⋯ A standardized clinically relevant discharge handoff tool had high user uptake and sustainability and improved timeliness of communication of information between the hospital and outpatient setting. Even within a fully integrated EMR system, simple and efficient handoffs between inpatient and outpatient providers may fulfill a communication gap at the time of discharge.
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Jt Comm J Qual Patient Saf · Apr 2014
As good as it gets? Managing risks of cardiovascular disease in California's top-performing physician organizations.
The California Right Care Initiative (RCI) accelerates the adoption of evidence-based guidelines and improved care management practices for conditions for which the gap between science and practice is significant, resulting in preventable disability and death. ⋯ To accelerate improvements in managing cardiovascular risks, physician organizations may need to implement strategies involving extensive practice reorganization and work flow redesign.