Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Nov 2012
A case-control study of an intraoperative corneal abrasion prevention program: holding the gains made with a continuous quality improvement effort.
Corneal injury is the most frequent ocular complication during general anesthesia. Although prevention has appeared feasible, inconsistent use and timing of conventional eye ointment and eyelid tape had failed to adequately prevent intraoperative corneal injuries at a department of anesthesiology in an academic medical center. A continuous quality improvement (CQI) program was thus undertaken to prevent intraoperative corneal injury. PLAN-DO-CHECK-ACT: A departmentwide Plan-Do-Check-Act cycle, and specifically the Seven-Step Problem-Solving Model, were applied. The new standardized eye- protection method involved eye lubrication with aqueous-based gel and application of clear, square occlusive dressings that were large enough to cover the eyelids and surrounding skin. Standardized documentation of patient eye protection in the electronic anesthesia record was also implemented. A systematic approach maximized departmental awareness about this new eye-protection method and its documentation. Subsequent individual practitioner counseling and reinforcement was undertaken. ⋯ A simple and cost-effective method for preventing intraoperative corneal injuries was successfully identified, implemented, and sustained. The systematic approach involved a rigorous reiterative approach and resulted in a fundamental change in local practice pattern.
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Jt Comm J Qual Patient Saf · Sep 2012
Randomized Controlled TrialIs it possible to identify risks for injurious falls in hospitalized patients?
Patient falls are among the most commonly reported adverse hospital events with more than one million occurring annually in the United States; approximately 10% result in serious injury. A retrospective study was conducted to determine predictors and outcomes of fall injuries among a cohort of adult hospitalized patients. ⋯ Few variables were able to distinguish patients who sustained injury after a hospital fall, further challenging clinicians' efforts to minimize hospital-related fall injury.