Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jul 2006
Using HFMEA to assess potential for patient harm from tubing misconnections.
Reported cases of tubing misconnections and other tubing errors prompted Columbus Children's Hospital to study their potential for harm in its patient population. A Health Failure Mode and Effects Analysis (HFMEA) was conducted in October 2004 to determine the risks inherent in the use and labeling of various enteral, parenteral, and other tubing types in patient care and the potential for patient harm. ⋯ This proactive risk assessment project has identified failure modes and possible causes and solutions; several recommendations have been implemented. No tubing misconnections have been reported.
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This tool, which takes one or two minutes to use, provides a structured approach to promote effective interdisciplinary communication and teamwork in the operating room--or any other area, such as an intensive care unit, inpatient unit, or outpatient clinic.
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Jt Comm J Qual Patient Saf · May 2006
Managing capacity to reduce emergency department overcrowding and ambulance diversions.
Shady Grove Adventist Hospital implemented a series of housewide initiatives to decrease ambulance diversions, decrease wait times in the emergency department (ED), improve poor patient satisfaction, and decrease risks to patient safety. ⋯ The initiatives helped improve access to care for the rapidly growing community. Reductions in ambulance diversions and ED overcrowding reflected a team effort, which included the executive team as well as clinical and nonclinical staff, and a holistic approach to identifying and removing throughput barriers.
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Poor communication of medical information at transition points of care--at admission, transfer, and discharge--often results in medication errors, but various strategies can reduce the likelihood of error.
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Jt Comm J Qual Patient Saf · Apr 2006
Using telemedicine to facilitate thrombolytic therapy for patients with acute stroke.
Recent stroke-care requirements state that all stroke patients should be screened for intravenous recombinant tissue plasminogen activator (rt-PA) and treated, if the appropriate inclusion and exclusion criteria are met. Two community hospitals 90-130 miles east of Houston deployed telemedicine (videoteleconferencing) to provide acute stroke consultative services. DEVELOPING A TELEMEDICINE CAPACITY: According to the Brain Attack Coalition's recommendations, neurosurgical services need to be accessible within two hours. Given their incomplete neurology coverage, the remote-site hospitals identified telemedicine as the best option, with the University of Texas Health Science Center at Houston stroke team as the provider of expertise. ⋯ Telemedicine facilitated thrombolytic therapy for acute stroke patients and is intended not to replace care provided by remote-site providers but rather to address a time- and spatially related emergency need.