The Joint Commission journal on quality improvement
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Jt Comm J Qual Improv · Jun 2002
Using administrative data to improve compliance with mandatory state event reporting.
The New York Patient Occurrence and Tracking System (NYPORTS) is a mandatory adverse event reporting system that was redesigned in 1998. Analysis of the first full year of its use showed large regional and hospital variation in reporting frequency not due to hospital or case mix differences. In early 2001, New York State mandated that all hospitals conduct retrospective review for unreported adverse incidents for the previous 2 years. Hospitals could submit previously unreported incidents within a defined window without penalty. The hospital used an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) analysis to screen for missed NYPORTS cases, to assist in focusing review resources. ⋯ This retrospective effort helped identify previously unreported occurrences, increase institutional awareness of New York State's mandatory reporting process, and stimulate the redesign of our concurrent detection process.
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Jt Comm J Qual Improv · Jun 2002
The Safety Case Management Committee: expanding the avenues for addressing patient safety.
The greatest gains in patient safety are likely to result from using a multifaceted framework of safety enhancement initiatives. The Safety Case Management Committee, which has been meeting at the VA Ann Arbor Healthcare System since early 1999, is one such initiative; it is directed at broadening organizational involvement in creating a safer clinical environment. The committee's objective is to address fundamental issues related to patient safety and quality of care. The committee aims to develop thematic approaches to improving major systems triggered by unsafe or risky incidents that demonstrate either iatrogenic harm or risk of harm to patients. COMMITTEE STRUCTURE AND FUNCTIONING: Committee members represent top management, middle management, and front-line employees, but membership is weighted toward those in direct patient care roles. The group also includes a consumer representative. Critical issues are addressed through rigorous case discussion, literature review, and expert consultation. ⋯ The Safety Case Management Committee has successfully addressed actual and potential errors and has implemented strategic safety improvements. The dedicated efforts of highly motivated clinicians who serve on such a committee can augment and enhance risk management advances made through other channels.
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Jt Comm J Qual Improv · Jun 2002
The safety checklist program: creating a culture of safety in intensive care units.
In 1999 the VA Ann Arbor Healthcare System began a safety checklist program to help build a culture of safety among nurses, respiratory therapists, and unit maintenance providers in the intensive care units (ICUs). Program objectives were to (a) create the opportunity for each participating staff member to view his or her work and unit environment in a broader safety context; (b) establish clear, concise, and measurable standards that staff would identify and value as important safety factors; (c) develop a data collection methodology that would minimize confirmation bias; and (d) correct safety deficits immediately. ⋯ Staff can articulate how the program is making the ICU a safer environment. Nursing response to a recent major error reflects the growth that has occurred since the program's inception. Safety checks performed by ICU staff are critical in maintaining a constant level of safety. Although the effect on untoward events was not measured, the potential for incidents, including medication and intravenous errors, nosocomial infections, ventilator complications, and restraint complications may be reduced. The program invests bedside clinicians in writing safety standards, creates a partnership between staff and the clinical risk manager, and provides executive leaders an opportunity to demonstrate support of a culture beyond blame.
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Jt Comm J Qual Improv · Jun 2002
Developing a systemwide approach to patient safety: the first year.
Health care organizations face an imperative to ensure that care is provided to patients in the safest manner possible. In 2000 INTEGRIS Health, an Oklahoma City-based health system including ten acute care organizations, developed a patient safety framework that was built on the foundation of a culture of patient safety and began implementation in January 2001. ⋯ Challenges include keeping patient safety highly visible and demonstrating progress in our implementation, developing effective mechanisms for communicating safety solutions and ensuring that they are implemented in all the facilities, and figuring out how to measure success in a meaningful way.