Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Sep 2013
The Mortality Review Committee: a novel and scalable approach to reducing inpatient mortality.
Despite the importance of reducing inpatient mortality, little has been reported about establishing a hospitalwide, systematic process to review and address inpatient deaths. In 2006 the University of Pennsylvania Health System's Mortality Review Committee was established and charged with reducing inpatient mortality as measured by the mortality index--observed/expected mortality. ⋯ The establishment of a mortality review committee was associated with a significant reduction in the mortality index. Keys to success include interdisciplinary membership, partnerships with local providers, and a multipronged approach to identifying important clinical opportunities and to implementing effective interventions.
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Jt Comm J Qual Patient Saf · Sep 2013
Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.
A unit-based Patient Safety Leadership Walkrounds (PSWR) model was deployed in six medical/surgical units at The Children's Hospital of Philadelphia to identify patient safety issues in the clinical microsystem. Specific objectives of PSWR were to (1) provide a forum for frontline staff to freely report and discuss patient safety problems with unit local leaders, (2) improve teamwork and communication within and across units, and (3) develop a supportive environment in which staff and leaders brainstorm on potential solutions. ⋯ For participating units, the PSWR process is a situational awareness tool that helps management periodically assess new or unresolved vulnerabilities that may affect safety and care quality on the unit. Unit-based PSWR help identify safety concerns at the microsystem level while improving communication about safety events across units and to hospital leaders in the macrosystem.
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Jt Comm J Qual Patient Saf · Jul 2013
A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.
Handoff protocols from the cardiovascular operating room (CVOR) to the cardiac intensive care unit (CICU) can improve patient outcomes and delivery of care beyond the immediate postoperative period. In a prospective quality improvement study, a structured CVOR-to-CICU handoff protocol was implemented at a university-affiliated children's hospital. As a parallel project, an initiative to reduce unplanned extubations in the CICU was implemented. ⋯ Implementation of a handoff protocol from the CVOR to the CICU was associated with sustained decrease in unplanned extubations and in mean ventilator times.
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Jt Comm J Qual Patient Saf · Jul 2013
Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support.
In-hospital adverse events are a major cause of morbidity and mortality and represent a major cost burden to health care systems. A study was conducted to evaluate the return on investment (ROI) for the adoption of vendor-developed computerized physician oder entry (CPOE) systems in four community hospitals in Massachusetts. ⋯ Adoption of vendor CPOE systems in community hospitals was associated with a modest ROI at best when applying cost savings attributable to prevention of ADEs only. The modest financial returns can beattributed to the lack of clinical decision support tools.