Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Dec 2013
Developing a medical emergency team running sheet to improve clinical handoff and documentation.
During medical emergency team (MET) and cardiac arrest calls, a scribe usually records events on a running sheet. There is more agreement on what data should be recorded in cardiac arrest calls than for MET calls. In addition, handoff (handover) from ward staff to the arriving MET may be variable. ⋯ The MET running sheet, tailored to the clinical events that occur during episodes of MET review, may assist handoff from ward nurses to the arriving MET and event documentation.
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Jt Comm J Qual Patient Saf · Nov 2013
Randomized Controlled TrialEvaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
After-hours telephone communications are common in patient management. Patterns of communication of key information during after-hours phone calls were evaluated, and the utility of problem-specific Situation, Background, Assessment, Recommendation (SBAR) forms in improving this communication was assessed. ⋯ In after-hours phone communication between physicians and nurses, significant information was often not communicated and physicians did not elicit the necessary information. Simply providing an SBAR-based form did not ensure complete communication of key information.
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Jt Comm J Qual Patient Saf · Oct 2013
Using "best-fit" interventions to improve the nursing intershift handoff process at a medical center in Lebanon.
Nursing intershift handoff involves communicating essential patient information between the outgoing and the oncoming nurses during shift changes. A subsequent review of reported patient safety incidents at Labib Medical Center (LMC), Saida, Lebanon, showed that medication errors, delay in treatment, wrong treatment, duplication of laboratory tests, and near-miss events were caused by patient information omissions during intershift handoffs. In response, LMC initiated a quality improvement project using a multifaceted intervention to improve the quality of nursing intershift handoffs. ⋯ The intershift handoff communication process can be improved using evidence-based strategies that target internal barriers where the shift report occurs. Regular monitoring and follow-up are essential to maintain the improvement.
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Jt Comm J Qual Patient Saf · Sep 2013
Pressure ulcers and prevention among acute care hospitals in the United States.
Most pressure ulcers can be prevented with evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities. ⋯ Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.