Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jun 2013
Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness.
In response to the increased volume, risk, and cost of medical devices, in 2001 Kaiser Permanente (KP) developed implant registries to enhance patient safety and quality, and to evaluate cost-effectiveness. ⋯ Registries are important tools to evaluate longitudinal device performance and safety, study the clinical indications for and outcomes of device implantation, respond promptly to recalls and advisories, and contribute to the overall high quality of care of our patients.
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Jt Comm J Qual Patient Saf · Jun 2013
Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.
Latent safety threats (LSTs) are errors in design, organization, training, or maintenance that may contribute to medical errors and have a significant impact on patient safety. The investigation described in this article was conducted as part of a larger prospective, longitudinal evaluation using laboratory- and in situ simulation-based training sessions to improve technical and nontechnical skills of neonatal ICU (NICU) providers at a Level III academic NICU. ⋯ The NICU setting has a high rate of previously unidentified LSTs. Conducting in situ scenarios allows for the identification of novel LSTs not detected in the simulation laboratory. The subsequent clinical improvements made to the actual clinical care environment are the best objective evidence of the benefits of simulation-based multidisciplinary team training.
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Jt Comm J Qual Patient Saf · Jun 2013
Improving recording accuracy, transparency, and performance for obstetric quality measures in a community hospital-based obstetrics department.
The obstetric arena has been typically ignored in the race to determine hospital quality measures due primarily to the fact that a large majority of patients do not have Medicare federal insurance, which has been the focus of hospital measures of quality. With "normal vaginal delivery" being the number one hospital discharge diagnosis and cesarean sections rates varying greatly between hospitals, national organizations are taking greater interest in determining differences in quality. ⋯ That performance on all six quality measures improved suggests that the improvement approach was effective and perhaps reproducible in other clinical situations to improve hospital quality outcomes. A key contributor to success was that the dashboard of results was shared with the department's physicians and the hospital administration on a monthly basis. Reinforcement of good results helped keep the project front and center with the hospital, particularly more recently, given that data reporting for four of the six measures is soon to be required.