Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Nov 2017
Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers.
One in four Medicare patients hospitalized for acute medical illness is discharged to a skilled nursing facility (SNF); 23% of these patients are readmitted to the hospital within 30 days. The care transition from hospital to SNF is often marked by disruptions in care and poor communication among hospital and SNF providers. A study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and the SNF. ⋯ Hospital and SNF providers are challenged to meet the needs of complex patients. They are asked to establish comprehensive care plans for patients with significant medical and psychosocial issues while navigating tense relationships between health care institutions and rising financial pressures. The concerns of both hospital and SNF providers must be considered in order to develop practices that can improve the quality, cost, and safety of care transitions.
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Jt Comm J Qual Patient Saf · Dec 2018
Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Analysis.
Anesthesiologists have studied adverse events during anesthesia dating back to the original critical incident studies of the 1970s. Despite improvements, adverse events continue to occur. The purpose of this study was to characterize anesthesia-related adverse events within a single large tertiary care institution and to distinguish preventable adverse events from those that are not preventable. ⋯ Anesthesia-related adverse events continue to occur even though the field is considered at the forefront of patient safety. Respiratory, trauma, and medication events were often preventable, and these represent areas to allocate resources to improve patient safety and perioperative outcomes.
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Jt Comm J Qual Patient Saf · Feb 2019
Inter-rater Agreement for Abstraction of the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) Quality Measure in a Multi-Hospital Health System.
The Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) quality measure is complex to abstract, which may lead to discrepancies between abstractors. This study was designed to evaluate inter-rater agreement between abstractors at individual hospitals in a health system and a lead abstractor on abstraction elements and measure compliance for SEP-1. ⋯ Concordance on SEP-1 abstraction elements between local and expert adjudicators was fair, and SEP-1 performance varied considerably from initial site-reported performance. The detailed nature of SEP-1 can lead to unreliable abstraction, which may lead to inaccurate reporting of compliance with the measure and affect comparability of performance between hospitals. Abstraction by a dedicated team for SEP-1 can reduce variability and improve efficiency.
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Jt Comm J Qual Patient Saf · Dec 2019
An Ambulatory Antimicrobial Stewardship Initiative to Improve Diagnosis and Treatment of Urinary Tract Infections in Children.
Antibiotic stewardship efforts should standardize treatment of common infections when possible. Urinary tract infections (UTIs) are common in children and require appropriate diagnostic methods and treatment. A pediatric emergency department (ED) identified an opportunity to improve care by standardizing uncomplicated UTI diagnostic testing and treatment according to local bacterial resistance patterns from January 2017 to December 2018. ⋯ This QI initiative achieved standardization of specimen collection and treatment for pediatric UTI in the ED setting, and no adverse outcomes were observed at the institution.
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Jt Comm J Qual Patient Saf · Aug 2018
Use of an Emergency Manual During an Intraoperative Cardiac Arrest by an Interprofessional Team: A Positive-Exemplar Case Study of a New Patient Safety Tool.
An emergency manual (EM) is a set of evidence-based crisis checklists, or cognitive aids, that can improve team performance. EMs are used in other safety-critical industries, and health care simulation studies have shown their efficacy, but use in clinical settings is nascent. A case study was conducted on the use of an EM during one intraoperative crisis, which entailed the assessment of the impact of the EM's use on teamwork and patient care and the identification of lessons for effectively using EMs during future clinical crises. ⋯ In this positive-exemplar case study, an EM was used to improve delivery of evidence-based patient care through effective clinical team functioning. EM use must complement rather than replace good clinician education, judgment, and teamwork. More broadly, understanding why and how things go well via analyzing positive-exemplar case studies, as a converse of root cause analyses for negative events, can be used to identify effective applications of safety innovations.