Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · May 2018
Multicenter StudyImproving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement.
Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority. ⋯ The mentor model was successful in providing individualized support to teams and enabled implementation of the hemorrhage safety bundle across a diverse group of 126 hospitals.
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Jt Comm J Qual Patient Saf · May 2018
Multicenter StudyDeriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department.
The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. ⋯ Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy.
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Jt Comm J Qual Patient Saf · Jan 2016
Multicenter StudyA Tool for the Concise Analysis of Patient Safety Incidents.
Patient safety incidents, sometimes referred to as adverse events, incidents, or patient safety events, are too common an occurrence in health care. Most methods for incident analysis are time and labor intensive. Given the significant resource requirements of a root cause analysis, for example, there is a need for a more targeted and efficient method of analyzing a larger number of incidents. Although several concise incident analysis tools are in existence, there are no published studies regarding their usability or effectiveness. ⋯ A concise tool for the investigation of patient safety incidents with low or no harm was well accepted across a select group of hospitals from five countries.
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Jt Comm J Qual Patient Saf · Feb 2013
Multicenter StudyMaintaining and sustaining the On the CUSP: stop BSI model in Hawaii.
Hawaii joined the On the CUSP: Stop BSI national effort in the United States in 2009 (CUSP stands for Comprehensive Unit-based Safety Program). In the initial 18-month study evaluation, adult ICUs decreased central line-associated bloodstream infection (CLABSI) rates by 61%. The impact of a series of novel strategies/tools in reducing infections and sustaining the collaborative in ICUs and non-ICUs in Hawaii was assessed. ⋯ Hawaii successfully spread the program beyond adult ICUs and implemented a series of tools for maintenance and sustainment. Use of the tools shaped a culture around the continued belief that CLABSIs can be eradicated, and infections further reduced.