Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jul 2005
Using simulation-based training to improve patient safety: what does it take?
Through simulations health care workers can learn by practicing skills taught and experiencing mistakes before interacting with an actual patient. A number of areas within the health care industry are currently using simulation-based training to help individuals and teams improve patient safety. WHAT IS SIMULATION-BASED TRAINING? The key components of simulation-based training are as follows: performance history/skill inventory, tasks/competencies, training objectives, events/exercises, measures/metrics, performance diagnosis, and feedback and debrief. WHAT DOES IT TAKE FOR SIMULATION-BASED TRAINING TO BE EFFECTIVE? To be effective, simulation-based training must be implemented appropriately. The guidelines are as follows: understand the training needs and requirements; instructional features, such as performance measurement and feedback, must be embedded within the simulation; craft scenarios based on guidance from the learning outcomes; create opportunities for assessing and diagnosing individual and/or team performance within the simulation; guide the learning; focus on cognitive/psychological simulation fidelity; form a mutual partnership between subject matter experts and learning experts; and ensure that the training program worked. ⋯ The health care community can gain significantly from using simulation-based training to reduce errors and improve patient safety when it is designed and delivered appropriately.
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The effect of an intensive glycemic management protocol was assessed in a heterogeneous population of critically ill adult patients. ⋯ The 29.3% relative reduction in hospital mortality seen among the treatment patients following institution of the protocol probably exceeded the expectations of the initiative's champions. The culture of the ICU regarding glycemic control changed definitively. The protocol was extended to an intermediate care unit, resulting in improvement in glycemic control without an increase in hypoglycemia.
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Jt Comm J Qual Patient Saf · May 2005
Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.
A "bundle" of ventilator care processes (peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a sedation vacation), which may also reduce ventilator-associated pneumonia (VAP) rates, can serve as a focus for improvement strategies in intensive care units (ICUs). Between July 2002 and January 2004, teams of critical care clinicians from 61 health care organizations participated in a collaborative on improving care in the ICU. ⋯ The goal-oriented nature of the bundle appears to demand development of the teamwork necessary to improve reliability. The observations seem sufficiently robust to support implementing the ventilator bundles to provide a focus for additional change in ICUs.
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Jt Comm J Qual Patient Saf · Jan 2005
Comparative StudyUsing aggregate root cause analysis to reduce falls.
In certain categories of adverse events, Department of Veterans Affairs (VA) facilities may combine data to produce an aggregate review of the data. Individual root cause analyses are still required for the more serious adverse events. About 100 of the VA acute and long term care facilities contributed data to an analysis of results of 176 root cause analyses (RCAs) for patient falls occurring in the VA system. ⋯ The action plans associated with these reductions focused on making specific clinical changes at the bedside rather than policy changes or educating staff. Specific interventions most highly associated with reductions in falls and injuries included environmental assessments, toileting interventions, and interventions that directly addressed the root cause and were the responsibility of a single person (as opposed to a group).