Joint Commission journal on quality and patient safety / Joint Commission Resources
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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.
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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.
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Jt Comm J Qual Patient Saf · Jan 2009
Multicenter StudyDisclosing errors to patients: perspectives of registered nurses.
Disclosure of medical errors has been conceptualized as occurring primarily in the physician-patient dyad. Yet, health care is delivered by interprofessional teams, in which nurses share in the culpability for errors, and hence, in responsibility for disclosure. This study explored nurses' perspectives on disclosure of errors to patients and the organizational factors that influence disclosure. ⋯ Nurses conceived of the disclosure process as a team event occurring in the context of a complex health care system rather than as a physician-patient conversation. Nurses felt excluded from these discussions, resulting in their use of ethically questionable communication strategies. The findings underscore the need for organizations to adopt a team disclosure process. Health care organizations that integrate the entire health care team into the disclosure process will likely improve the quality of error disclosure.
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Jt Comm J Qual Patient Saf · Jan 2009
Multicenter StudyBarriers to emergency departments' adherence to four medication safety-related Joint Commission National Patient Safety Goals.
Medication errors are a serious public health threat, causing patient injury and death and sharply increasing health care costs. Serious preventable errors are most likely to occur in areas of increased complexity and technology, such as the emergency department (ED). Although The Joint Commission in 2002 approved the first set of National Patient Safety Goals (NPSGs) to decrease the occurrence of health care errors, the literature suggests that the goals are not fully implemented. In 2006, the Emergency Nurses Association (ENA) conducted a national, multisite survey (1) to describe barriers to full implementation of the 2006 NPSGs related to medication safety (then known as Goals 1, 2, 3, and 8) as reported by ED registered nurses (ED nurses) and (2) to investigate factors related to those barriers. ⋯ The low response rate (4.6%) to this study inherently limits the overall generalizability of the findings to the greater population of EDs. Yet, the findings suggest that substantial barriers remain to ED adherence to the NPSGs related to medication safety. Efforts to reduce the barriers should focus on system changes that facilitate adherence. Health care providers and their organizations must commit to and enforce a zero-tolerance policy for preventable medication errors.
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Jt Comm J Qual Patient Saf · Jan 2009
Using the American Heart Association's National Registry of Cardiopulmonary Resuscitation for performance improvement.
Data suggest that the overall quality of inhospital resuscitation is suboptimal and contributes to poor patient outcomes. In 2000 the American Heart Association created the National Registry of Cardiopulmonary Resuscitation (NRCPR) as an evidence-based hospital safety program. Participating hospitals voluntarily join the registry and pay an annual fee that includes data support and report generation. The primary purpose of NRCPR is to support local facility efforts in practice management and performance improvement (PI). ⋯ NRCPR is used as both a local PI tool as well as a source of data that scientists are analyzing to further the understanding of inhospital resuscitation processes and outcomes. Over time, researchers have recognized the need to refine the Chain of Survival to reflect the unique aspects of inhospital resuscitation. A rapid response system provides a new link at the beginning, and postresuscitation care provides a new link at the end of the Chain of Survival.