Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Jan 2009
Multicenter StudyBarriers to emergency departments' adherence to four medication safety-related Joint Commission National Patient Safety Goals.
Medication errors are a serious public health threat, causing patient injury and death and sharply increasing health care costs. Serious preventable errors are most likely to occur in areas of increased complexity and technology, such as the emergency department (ED). Although The Joint Commission in 2002 approved the first set of National Patient Safety Goals (NPSGs) to decrease the occurrence of health care errors, the literature suggests that the goals are not fully implemented. In 2006, the Emergency Nurses Association (ENA) conducted a national, multisite survey (1) to describe barriers to full implementation of the 2006 NPSGs related to medication safety (then known as Goals 1, 2, 3, and 8) as reported by ED registered nurses (ED nurses) and (2) to investigate factors related to those barriers. ⋯ The low response rate (4.6%) to this study inherently limits the overall generalizability of the findings to the greater population of EDs. Yet, the findings suggest that substantial barriers remain to ED adherence to the NPSGs related to medication safety. Efforts to reduce the barriers should focus on system changes that facilitate adherence. Health care providers and their organizations must commit to and enforce a zero-tolerance policy for preventable medication errors.
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Jt Comm J Qual Patient Saf · Dec 2008
Using an advanced practice nursing model for a rapid response team.
Outcomes, including reductions in codes per 1,000 discharges, failure-to-rescue rates, and medical-surgical mortalities and improvement in staff satisfaction, were all indicative of the efficacy of the APN-model RRT. Future studies might compare these outcomes with those of other team models.
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Jt Comm J Qual Patient Saf · Nov 2008
The business case for preventing ventilator-associated pneumonia in pediatric intensive care unit patients.
A retrospective matched (1:1) case-control study was conducted to compare the financial impact and costs attributable to ventilator-associated pneumonia (VAP) in a 25-bed pediatric intensive care unit (PICU) in a 475-bed quaternary-care pediatric hospital from the perspective of multiple stakeholders, including the hospital and payors. ⋯ This study provides the first demonstration of significant, sustained reductions in pediatric VAP rates following the implementation of the VAP prevention bundle and the first business case analysis of this pediatric-specific intervention as described from the perspective of multiple stakeholders. A return on investment may speed health care organizations' investment in patient safety and quality improvement.