Joint Commission journal on quality and patient safety / Joint Commission Resources
-
Jt Comm J Qual Patient Saf · Apr 2009
The final steps in converting a health care organization to a latex-safe environment.
In a follow-up to a previous article, which described the approach at The Johns Hopkins Medical Institutions to establishing a latex-safe environment, subsequent efforts to convert all the sterile gloves to nonlatex products and thereby complete the implementation of a latex-safe program are reported. Before the complete conversion to nonlatex sterile gloves, operating room use had increased to approximately one-third of our total sterile glove use during the preceding four years. ⋯ Once financial and logistical concerns were addressed, conversion to a latex-safe environment entailed readying the organization for the change in organizational culture. Key factors were (1) general acceptance from all the chiefs of the surgical departments; (2) centralization for all purchases of medical supplies, including sterile gloves, through corporate purchasing; and (3) ongoing education and vigilance.
-
Jt Comm J Qual Patient Saf · Apr 2009
A comprehensive hand hygiene approach to reducing MRSA health care-associated infections.
Methicillin-resistant Staphylococcus aureus (MRSA) infections are the most common health care-associated infections (HAI) in the acute care setting. The major mode of transmission from patient to patient is through bedside care providers via contaminated hands. After individual projects within Novant Health proved to be ineffective, with any gains in hand hygiene compliance being short-lived, a program was implemented to address unsatisfactory hand hygiene compliance rates. Published studies have associated improvements in hand hygiene compliance with decreases in HAIs. ⋯ Understanding hand hygiene compliance is a simple matter of observing caregiver behavior during each hand hygiene opportunity and recording the actions taken. The improvements in hand hygiene compliance translated into a real decrease in the number of hospital-acquired MRSA infections.
-
From 2003-2005, a comprehensive review of all cardiac/respiratory arrests at Mission Hospital (Mission Viejo, California) uncovered deficits in knowledge and judgment in the hours preceding 75% of our non-ICU patients. Nearly half of all arrests were occurring outside the ICU, with an overall mortality rate of 60%. In addition, transfers into ICU from the floor averaged 96 patients per month. ⋯ The RRT initiative delivered measurable outcomes demonstrating the hospital's commitment to saving the vulnerable hospitalized patient population. In addition, the identification of critical system and clinical issues resulted in efforts to improve processes and identify patient subpopulations at risk (for example, patients with congestive heart failure, end-stage heart disease, high-dose narcotics).
-
DHMC's clinical triggers program is a promising approach that addresses an unmet patient need. We have seen dramatic reductions in our non-ICU cardiopulmonary arrest rates, along with our ICU bounceback rates. In the context of our hospital, this program aligns well with our teaching mission while maximizing the resources that are currently available. ⋯ Although our study does not alter the weight of evidence in the literature, it does offer a new focus on the afferent limb by clarifying the expectations of the primary responders. This was the essence of the deficiency in the aforementioned case study. Death is the natural, albeit sad, endpoint of all lives; the overarching goal of DHMC's clinical triggers system is to prevent the premature death of a hospitalized patient and thereby improve patient safety.
-
Jt Comm J Qual Patient Saf · Mar 2009
Comparative StudyComparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals.
The debate over whether patient safety efforts should focus on adverse events or errors logically extends to voluntary incident reporting in hospitals. Reports emphasizing adverse events take an outcome-oriented approach to improving quality, whereas those emphasizing errors take a process-oriented approach. These approaches were compared in an analysis of 2,228 paper incident reports for 16,575 randomly selected inpatients at an academic hospital and a community hospital in the United States in 2001. ⋯ Many incident reports contain process information or outcome information but not both. Outcome-oriented reports lack the information needed to assess risk and formulate safety improvements; therefore, follow-up investigations are required. Because process-oriented reports include the necessary information more often, they are more directly useful for improving patient safety. Hospitals should focus voluntary incident reporting systems on capturing process-oriented reports and should train staff to describe contributing factors. This focus should not only improve the quality of the information in the reports but is consistent with efforts to promote a blame-free reporting culture.