Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Dec 2018
Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Analysis.
Anesthesiologists have studied adverse events during anesthesia dating back to the original critical incident studies of the 1970s. Despite improvements, adverse events continue to occur. The purpose of this study was to characterize anesthesia-related adverse events within a single large tertiary care institution and to distinguish preventable adverse events from those that are not preventable. ⋯ Anesthesia-related adverse events continue to occur even though the field is considered at the forefront of patient safety. Respiratory, trauma, and medication events were often preventable, and these represent areas to allocate resources to improve patient safety and perioperative outcomes.
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Jt Comm J Qual Patient Saf · Oct 2018
Observational StudyRedesigning Rounds in the ICU: Standardizing Key Elements Improves Interdisciplinary Communication.
Daily multidisciplinary rounds (MDR) in the ICU represent a mechanism by which health care professionals from different disciplines and specialties can meet to synthesize data, think collectively, and form complete patient care plans. It was hypothesized that providing a standardized, structured approach to the daily rounds process would improve communication and collaboration in seven distinct ICUs in a single academic medical center. ⋯ This study demonstrated that the implementation of a simple toolkit that can be incorporated into existing work flow and rounding culture in several different types of ICUs can result in improvements in engagement of nursing staff and in overall communication.
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Jt Comm J Qual Patient Saf · Sep 2018
Developing a Standard Handoff Process for Operating Room-to-ICU Transitions: Multidisciplinary Clinician Perspectives from the Handoffs and Transitions in Critical Care (HATRICC) Study.
Operating room (OR)-to-ICU handoffs place patients at risk for preventable harm. Numerous studies have described standardized handoff procedures following cardiac surgery, but no existing literature describes a general OR-to-ICU handoff system. ⋯ OR and ICU teams agreed on handoffs' importance but expressed important barriers to consistently practicing ideal handoffs. Future work is needed to determine whether the handoff procedures developed by incorporating bedside provider perspectives improve patient outcomes.
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Jt Comm J Qual Patient Saf · Sep 2018
Safety Stop: A Valuable Addition to the Pediatric Universal Protocol.
The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk. ⋯ Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong-patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.