Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Aug 2007
The emotional impact of medical errors on practicing physicians in the United States and Canada.
Being involved in medical errors can compound the job-related stress many physicians experience. The impact of errors on physicians was examined. ⋯ Many physicians experience significant emotional distress and job-related stress following serious errors and near misses. Organizational resources to support physicians after errors should be improved.
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The Veterans Health Administration's (VHA's) National Center for Patient Safety developed a cognitive aid to help anesthesiologists manage rare, high-mortality adverse events. ⋯ A cognitive aid for use in rare emergencies proved clinically useful to anesthesia providers.
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Jt Comm J Qual Patient Saf · Jul 2007
Using a collaborative to reduce ventilator-associated pneumonia in Thailand.
Ventilator-associated pneumonia (VAP) is a serious nosocomial infection, leading to high mortality and high costs of treatment in developed and limited-resource countries. A collaborative quality improvement (QI) project was conducted in 18 secondary and tertiary care hospitals in Thailand to address the problem. ⋯ VAP surveillance during this project revealed a gradual reduction of the VAP rate. The project's relative overall success appears to reflect, as reported elsewhere, a well-organized program, support from hospital administrators, and workshop leaders' presentation of proven QI methods and clinical interventions.
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For Ascension Health's Healthcare That Is Safe strategy, eight hospitals served as alpha sites in the program to prevent falls and eliminate falls with injury. ⋯ Although it is not possible to prevent all falls in acute care facilities, decreasing the number of falls and the risk of serious injury from falls is possible. Key steps caregivers can take to prevent falls and fall injuries include establishing a trusting relationship with patients and their significant others; frequently reorienting patients to their environments, reminding those at high risk of falls not to get out of bed without help; checking on patients frequently and keeping their personal articles within reach; and protecting patients from falls at all entry points into the health care system.
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Jt Comm J Qual Patient Saf · Jul 2007
Implementation and impact of a rapid response team in a children's hospital.
Like the previous two studies of RRS implementation in a children's hospital, this study--the first to use an RRT model--showed a decrease in the incidence of arrests (although not at a significant level). Low mortality rates and infrequent arrests in children's hospitals make changes in these measures insensitive indicators of the positive impact of RRT implementation. ⋯ Children receive significant care through the RRT, and nurse response is very favorable to having access to fast, dependable, and knowledgeable backup 24 hours a day. The RRT program is a vital component of the safety net for children's hospitals, and RRT data provides an avenue for quality improvement efforts and further research.