Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jun 2019
Observational StudyEvaluating the Impact of Auto-Calculation Settings on Opioid Prescribing at an Academic Medical Center.
Overprescribing of opioids is a key contributor to the opioid epidemic, which has led to a substantial increase in overdose deaths. The purpose of this study was to evaluate the discontinuation of a dispense quantity automatic calculation function on prescribing of as needed (PRN) opioids. ⋯ This study suggests that removing the autocalculation functionality reduced the number of opioid units ordered. In addition, using a default dispense quantity for PRN opioid prescriptions may decrease the number of opioid dispense units per prescription.
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Jt Comm J Qual Patient Saf · Jun 2019
Reducing the Use of Ad Hoc Interpreters at a Safety-Net Health Care System.
Providing effective communication assistance is critical to ensuring that patients with limited English proficiency (LEP) receive safe and high-quality health care services. Health care providers often use ad hoc interpreters such as patients' family members or friends to communicate with LEP patients; however, this practice presents risks to communication accuracy, patient safety, quality of care, and privacy. ⋯ Changing practice to reduce the use of ad hoc interpreters in a large multisite organization is challenging and takes sustained and prolonged effort. Strong institutional policies and site-specific outreach can help stimulate change, and partnership with leadership champions is critical to success. CHA's experience provides strategies and lessons that can be leveraged by other institutions seeking to improve care for LEP patients.
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Jt Comm J Qual Patient Saf · Mar 2019
Bringing Perioperative Emergency Manuals to Your Institution: A "How To" from Concept to Implementation in 10 Steps.
Emergency manuals (EMs) are context-relevant sets of crisis checklists or cognitive aids designed to enable professional teams to deliver optimal care during critical events. Evidence from simulation and other high-risk industries have proven that use of these types of checklists can significantly improve event management and decrease omissions of key steps. However, simply printing and placing tools in operating rooms (ORs) is unlikely to be effective. How interventions are implemented influences whether clinicians actually change practice and whether patient care is affected. This article provides an in-depth description of a rigorous implementation plan with three goals: (1) place EMs in every anesthetizing location, (2) create interprofessional engagement, and (3) demonstrate that a majority of anesthesia clinicians would use the new tool in some way within the first year. ⋯ This article presents a framework and detailed description of the steps a large academic institution followed in successfully implementing EMs. In conjunction with other available resources, those interested in introducing OR EMs at large, complex institutions may benefit from the experience shared in anticipating challenges and overcoming barriers to adoption.
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Jt Comm J Qual Patient Saf · Mar 2019
Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration.
Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. ⋯ By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.
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Jt Comm J Qual Patient Saf · Feb 2019
Using a Potentially Aggressive/Violent Patient Huddle to Improve Health Care Safety.
Unexpected situations of workplace violence are occurring in the United States at increasing rates in health care environments, warranting increased attention to processes supporting safety for health care workers. At a large, academic hospital, two patient safety incidents had occurred in a two-year period in which a patient had become violent at the time of admission from the emergency department (ED) to the medical unit. ⋯ The huddle handoff communication tool and other methods to facilitate the transfer of potentially violent patients have the potential to decrease the number and severity of violent incidents in the health care workplace.