Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jul 2012
2011 John M. Eisenberg Patient Safety and Quality Awards. The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. innovation in patient safety and quality at the local level.
In 2008 Henry Ford Health System launched its "No Harm Campaign," designed to integrate harm-reduction interventions into a systemwide initiative and, ultimately, to eliminate harm from the health care experience. ⋯ Building infrastructure, creating a culture of safety, providing employee training and education, and improving work process design are critical to systemwide implementation of harm-reduction efforts. Key actions for ongoing success focus on leadership, disseminating performance, putting everyone to work, and stealing ideas through national and local collaborations. A financial model was created to assess cost-savings of reducing harm events; early results total nearly $10 million in four years.
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Jt Comm J Qual Patient Saf · Jul 2012
2011 John M. Eisenberg Patient Safety and Quality Awards. The effect of a novel Housestaff Quality Council on quality and patient safety. Innovation in patient safety and quality at the local level.
In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach--the Housestaff Quality Council (HQC)--to engaging house-staff in quality and patient safety activities. ⋯ The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.
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Jt Comm J Qual Patient Saf · Jun 2012
Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.
Continuation of perioperative beta-blockers for surgical patients who are receiving beta-blockers prior to arrival for surgery is an important quality measure (SCIP-Card-2). For this measure to be considered successful, name, date, and time of the perioperative beta-blocker must be documented. Alternately, if the beta-blocker is not given, the medical reason for not administering must be documented. ⋯ To achieve high compliance for the beta-blocker measure, it is essential to (1) clearly assign a medical team to perform beta-blocker documentation and (2) enhance features in the electronic medical systems to alert the user concerning incomplete documentation.
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Communication problems among health care personnel during critical clinical situations can jeopardize patient safety. SBAR, a structured-communication technique, has been adapted from aviation and the military as a strategy for clear communication based on a statement of the situation, background, assessment, and recommendations related to a critical issue. Nurses' use of SBAR and physician perception of communication quality after SBAR implementation was assessed at a 13-hospital health care system. ⋯ SBAR was generally well understood. Challenges included inconsistent uptake across facilities, lack of physician education about SBAR, and a tendency to view SBAR as a document rather than a verbal technique. Future research will address the need for refresher education with nurses after initial SBAR education, the need for formal physician education about SBAR use, and the possibility of conducting annual competency validation of the utilization of SBAR. Research should also examine the effect of SBAR on quality of care and patient outcomes in controlled trials.
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Jt Comm J Qual Patient Saf · Jun 2012
Incorporating the World Health Organization Surgical Safety Checklist into practice at two hospitals in Liberia.
The impact of the World Health Organization's Patient Safety Programme's 19-item Surgical Safety Checklist on surgical processes and outcomes was assessed in 2008-2009 at two hospitals in the resource-limited setting of Liberia. ⋯ Although the implementation of a surgical safety checklist in Liberia was associated with significant improvements in processes and outcomes overall, differences at the hospital level suggest that the checklist's mechanism of improvement may be influenced by the availability of resources needed to complete recommended processes, variation in team functioning, and organizational context.