Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jan 2013
Multicenter StudyA cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers.
Empirical evidence is limited that root cause analysis (RCA), an event analysis tool used in health care to evaluate the systemic factors that lead to adverse events, improves patient safety. A cross-sectional study was conducted to examine the relationship between RCA and patient safety. ⋯ Large, high-spending VAMCs conduct more RCAs per year than smaller, low-spending facilities. VAMCs that do more RCAs develop more corrective actions. VAMCs that complete fewer than four RCAs per year have higher rates of postoperative complications. It is unclear if RCAs are associated with a functional patient safety program or directly improve patient safety.
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Jt Comm J Qual Patient Saf · Jul 2009
Multicenter Study Clinical TrialImproving patient satisfaction with pain management using Six Sigma tools.
Patient satisfaction as a direct and public measure of quality of care is changing the way hospitals address quality improvement. The feasibility of using the Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) methodology to improve patient satisfaction as it relates to pain management was evaluated. ⋯ The Six Sigma DMAIC methodology can be used successfully to improve patient satisfaction. The project led to measurable improvements in patient satisfaction with pain management, which have endured past the duration of the Six Sigma project. The Control phase of DMAIC allows the improvements to be incorporated into daily operations.
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Jt Comm J Qual Patient Saf · Jun 2009
Multicenter StudySustaining and spreading reduced door-to-balloon times for ST-segment elevation myocardial infarction patients.
Prompt primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity. In 2004 the American College of Cardiology (ACC) and American Heart Association (AHA) set a goal to reduce door-to-balloon (D2B) time to < 90 minutes in 75% of STEMI cases. IMPLEMENTING THE STEMI INITIATIVE: In 2004, the STEMI/D2B leadership team broke down D2B time into four segments: door to data, data to diagnosis, diagnosis to decision, and decision to device. Each segment was examined for inefficiencies, duplication, and nonstandardization. In 2005, after the internal D2B processes and results showed improvement, the STEMI/D2B leadership team extended the project to prehospital emergency medical services. In 2006, UMass Memorial began to roll out a regional system for STEMI care to the 12 community hospitals in its service area without on-site PCI capabilities. ⋯ The D2B time process is being applied to other clinical venues; a vascular surgery project is underway to reduce "door-to-incision time" for patients with ruptured abdominal aortic aneurysms.
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Jt Comm J Qual Patient Saf · Jun 2009
Multicenter StudyParent-driven technology for decision support in pediatric emergency care.
A quasi-experimental intervention study composed of control and intervention periods was conducted to determine if a parent-driven health information technology influenced completeness of documentation and adherence to evidence-based emergency care for children. ⋯ Parent-driven health information technology intended to translate parents' knowledge into clinical practice and to support evidence-based care suggested a trend toward modest impact on pain management but did not demonstrate broad effects across diseases or care processes. The emergence and proliferation of personally controlled health records (PCHRs) presents opportunities for patients and parents to control their medical profiles. Although ParentLink is not a comprehensive PCHR, it represents a step in incorporating parent-derived information into medical decision making.
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Jt Comm J Qual Patient Saf · Jan 2009
Multicenter StudyDisclosing errors to patients: perspectives of registered nurses.
Disclosure of medical errors has been conceptualized as occurring primarily in the physician-patient dyad. Yet, health care is delivered by interprofessional teams, in which nurses share in the culpability for errors, and hence, in responsibility for disclosure. This study explored nurses' perspectives on disclosure of errors to patients and the organizational factors that influence disclosure. ⋯ Nurses conceived of the disclosure process as a team event occurring in the context of a complex health care system rather than as a physician-patient conversation. Nurses felt excluded from these discussions, resulting in their use of ethically questionable communication strategies. The findings underscore the need for organizations to adopt a team disclosure process. Health care organizations that integrate the entire health care team into the disclosure process will likely improve the quality of error disclosure.