Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jun 2007
Medical team training: applying crew resource management in the Veterans Health Administration.
Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS). ⋯ An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.
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Jt Comm J Qual Patient Saf · Jun 2007
The New York City Palliative Care Quality Improvement Collaborative.
Care for persons living with fatal chronic conditions is expensive and challenging, and can be unreliable. A quality improvement collaborative was conducted to develop capacity among health care providers in a single geographic area-New York City-to apply quality improvement methodology to palliative care services.. ⋯ Collaborative rapid-cycle QI projects in a limited geographic area can be efficient in building and sustaining improved care for persons nearing the end of their lives, especially when the work involves the broad range of organizations that care for this patient population. PC-QuIC's experience illustrates the growing strength of palliative care services, but also demonstrates the challenges that confront further refinement and expansion of high-quality palliative care.
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For Ascension Health's Healthcare That Is Safe strategy, Sacred Heart Hospital (SHH) and Columbia St. Mary's (CSM) served as alpha sites to develop strategies to eliminate perioperative adverse events (POAEs). The alpha sites set an interim goal of a 50% reduction of POAEs, then 100%, or elimination of POAEs by July 2008. ⋯ A number of key learnings were drawn from the alpha experiences, including the need to adjust to evolving definitions and guidelines for implementation and measurement of perioperative care.
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Jt Comm J Qual Patient Saf · May 2007
Randomized Controlled TrialClinical inertia: a common barrier to changing provider prescribing behavior.
A cross-sectional content analysis nested within a randomized, controlled trial was conducted to collect information on provider responses to computer alerts regarding guideline recommendations for patients with suboptimal hypertension care. ⋯ Clinical inertia was the primary reason for failing to engage in otherwise indicated treatment change in a subgroup of patients. A framework was provided as a taxonomy for classification of provider barriers.
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Jt Comm J Qual Patient Saf · May 2007
Mapping the 24-hour emergency department cycle to improve patient flow.
Intermountain Healthcare (Salt Lake City), in conjunction with emergency department (ED) staff at LDS Hospital, designed an integrated patient tracking system (PTS) and a specialized data repository (ED Data Mart) that was part of an overall enterprisewide data warehouse. After two years of internal beta testing the PTS and its associated data captures, an analysis of various ED operations by time of day was undertaken. ⋯ Although it is unclear whether or not these patterns will be applicable to other hospitals in and out of the cohort of tertiary care hospitals, ED cycle data can help all facilities anticipate the resources needed and the services required for efficient patient flow. For example, the fact that scheduling of most service departments falls off after 5:00 P.M., just when the ED is most in need of those services, illustrates a fundamental mismatch between service capacity and demand.