Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jun 2010
Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit.
A culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings. ⋯ Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on a surgical inpatient unit after implementing a safety program. As part of the CUSP process, staff described safety hazards and then as a team designed and implemented several interventions. CUSP is sufficiently structured to provide a strategy for health care organizations to improve culture and learn from mistakes, yet is flexible enough for units to focus on risks that they perceive as most important, given their context. Broad use of this program throughout health systems could arguably produce substantial improvements in patient safety.
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Jt Comm J Qual Patient Saf · Jun 2010
Evolution of a rapid response system from voluntary to mandatory activation.
A policy requiring rapid response activation for all patients who met physiologic instability criteria, which was initiated four years after the rapid response system's inception, significantly increased the number of rapid response calls and was associated with a reduction in cardiorespiratory arrests outside of critical care areas.
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Jt Comm J Qual Patient Saf · Jun 2010
Editorial CommentRapid response systems: a mandatory system of care or an optional extra for bedside clinical staff.
Two articles in this issue describe different approaches to implementing a rapid response system--one approach involving a wide-ranging marketing plan, the other entailing a policy change to make activation mandatory.
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Jt Comm J Qual Patient Saf · Apr 2010
Clinical TrialClinical information system and process redesign improves emergency department efficiency.
Fueled by a decade-long increase in emergency department (ED) visits with a concomitant decrease in hospital bed capacity and the number of hospital EDs, ED crowding has reached crisis proportions. Robust information systems and process redesign are two strategies to improve the safety and quality of emergency care. At the ED at the Mount Sinai Medical Center, an urban, tertiary care academic medical center in New York City, elements of departmental work flow were redesigned to streamline patient throughput before implementation of a fully integrated emergency department information system (EDIS) with patient tracking, computerized charting and order entry, and direct access to patient historical data from the hospital data repository. Pre- and postintervention data were analyzed to examine the impact on (ED) efficiency. ⋯ Increasing the clinical information available at the bedside and improving departmental work flow through EDIS implementation and process redesign led to decreased patient throughput times and improved ED efficiency.
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Jt Comm J Qual Patient Saf · Mar 2010
Risk managers, physicians, and disclosure of harmful medical errors.
Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers. ⋯ Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.