Joint Commission journal on quality and patient safety最新文献

{"title":"Emergency Department Crowding: A Patient Safety Crisis Hidden in Plain Sight.","authors":"Timothy M Loftus, Emily G Wessling Tofovic","doi":"10.1016/j.jcjq.2025.04.007","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.007","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144132324","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Utilizing Quality Improvement Methodology to Decrease Surgical Delays.","authors":"Marina E Robson Chase, Madeline J Anderson, Wesley A Stephens, Brittany E Levy, Sherry Lantz, Jennifer Goforth, Melissa R Newcomb, Andrew M Harris","doi":"10.1016/j.jcjq.2025.04.004","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.004","url":null,"abstract":"<p><strong>Background: </strong>Surgical delays waste time and space and lead to patient safety concerns, staff and patient dissatisfaction, and increased operating room (OR) costs. Preventing delays is crucial to OR safety and efficiency. A quality improvement (QI) initiative was designed to identify common delay causes and implement targeted interventions to reduce overall case delays and first start case delays.</p><p><strong>Methods: </strong>At a facility with eight full-time ORs, up to 21.5% of cases were delayed per month. Through a preintervention audit, preoperative paperwork issues were determined to be the most common cause of delays. Examination of the current state revealed irregular processes for preoperative paperwork completion and unreliable communication between the provider and preoperative teams. The paperwork completion process and preoperative communication were standardized. Cases were audited for paperwork issues, and rates of delays were analyzed using data collected from the electronic health record and OR scheduling systems.</p><p><strong>Results: </strong>This project achieved a 39.2% relative reduction in overall delays and a 25.0% relative reduction in first start delays. The proportion of all cases delayed by paperwork was reduced by 60.1%, and the proportion of first start cases delayed due to paperwork was reduced by 49.6%. The rate of paperwork issues in all cases decreased by 43.3%. The project has matured to sustainability with lasting improvement in delay rates despite increasing surgical case volume.</p><p><strong>Conclusion: </strong>These interventions substantially decreased total and first start delays, as well as delays due to paperwork issues. Understanding current state, designing appropriate interventions, and securing frontline staff buy-in are critical to achieving a QI goal. Through these principles, simple interventions considerably reduced case delays without added cost.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144093702","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Achieving Safe Telehealth.","authors":"Jorge A Rodriguez, David W Bates","doi":"10.1016/j.jcjq.2025.04.003","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019040","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Corrigendum to: ``Leveraging approaches and tools of implementation science and configurational comparative methods in quality improvement'' [The Joint Commission Journal on Quality and Patient Safety Volume 51, Issue 4 (2025) Pages 239-240].","authors":"Gabrielle Matias, Nandita R Nadig, Reiping Huang","doi":"10.1016/j.jcjq.2025.04.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143965985","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Navigating the Pathway to Quality Leadership: Perspectives from Contemporary Quality Executives.","authors":"Christopher S Kim, Kimiyoshi J Kobayashi, David M Safley, Bela Patel, Jennifer Wiler, Mbonu Ikezuagu, Jodi L Eisenberg, Amy C Lu","doi":"10.1016/j.jcjq.2025.04.001","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019453","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In-Hospital Adverse Events in Heart Failure Patients: Incidence and Association with 90-Day Mortality","authors":"Mohammed Yousufuddin MD, MSc (is Critical Care Physician and Hospitalist, Department of Hospital Internal Medicine, Mayo Clinic Health System, Austin, Minnesota),&nbsp;Mohamad H. Yamani MD (is Cardiologist, Department of Cardiovascular Medicine, Circulatory Failure, Mayo Clinic, Jacksonville, Florida),&nbsp;Daniel DeSimone MD (is Infectious Disease Specialist and Internist, Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota),&nbsp;Ebrahim Barkoudah MD, MPH, MBA (is System Chief of Hospital Medicine and Regional Chief Medical Officer and Chief Quality Officer, Baystate Health, Springfield, Massachusetts),&nbsp;Muhammad Waqas Tahir MD (is Internist, Department of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida),&nbsp;Zeliang Ma MD, PhD (is Visiting Research Fellow, Department of Hospital Internal Medicine, Mayo Clinic Health System),&nbsp;Fatmaelzahraa Badr MBBCh (is Research Fellow, Department of Hospital Internal Medicine, Mayo Clinic Health System),&nbsp;Ibrahim A. Gomaa MD (is Research Fellow, Department of Hospital Internal Medicine, Mayo Clinic Health System),&nbsp;Sara Aboelmaaty MD (is Research Fellow, Department of Hospital Internal Medicine, Mayo Clinic Health System),&nbsp;Sumit Bhagra MD (is Chair of Endocrinology, Division of Endocrinology and Metabolism, Mayo Clinic Health System),&nbsp;Gregg C. Fonarow MD (is Professor of Clinical Medicine, Division of Cardiology, University of California, Los Angeles),&nbsp;Mohammad H. Murad MD, MPH (is Internist and General Preventive Medicine Specialist, Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota. Please address correspondence to Mohammed Yousufuddin)","doi":"10.1016/j.jcjq.2025.03.003","DOIUrl":"10.1016/j.jcjq.2025.03.003","url":null,"abstract":"<div><h3>Background</h3><div>In-hospital adverse events (IHAEs) are key patient safety indicators but are not comprehensively assessed among patients hospitalized for heart failure (HF). The authors aimed to determine the association of IHAEs with downstream outcomes.</div></div><div><h3>Methods</h3><div>This retrospective multicenter cohort study analyzed data from patients hospitalized for HF in 17 acute care hospitals (2010–2023). The research team abstracted 36 IHAEs and grouped them into eight composite categories. The primary outcome was 90-day all-cause mortality, and secondary outcomes included length of stay (LOS), in-hospital mortality, and 90-day postdischarge all-cause readmission.</div></div><div><h3>Results</h3><div>Of the 11,169 hospitalized HF patients (median age 77.7 years; 47.0% women; 7.1% non-white; 39.8% from rural counties; 78,869 hospital bed-days), IHAEs occurred at varying frequency across the composite IHAE categories: general 4.6%, cardiovascular 6.6%, pulmonary 11.7%, endocrine and metabolism 9.2%, renal and electrolyte 9.1%, gastrointestinal 4.0%, neurological 2.7%, and hospital-acquired infection (HAI) 3.2%. Except for the renal and electrolyte (hazard ratio [HR] 0.92, <em>p</em> = 0.2956), IHAE in any other category was consistently associated with higher 90-day mortality (HRs 1.50-2.42, <em>p</em> &lt; 0.0001 for all). Associations with secondary outcomes varied by IHAE categories: LOS increased in the general (incident rate ratio [IRR] 1.09), pulmonary (IRR 1.65), neurological (IRR 1.37), and HAI (IRR 1.09) categories (<em>p</em> &lt; 0.0001). In-hospital mortality was higher in all categories except gastrointestinal. The 90-day readmission rate was elevated in the gastrointestinal (HR 1.85), neurological (HR 1.89), and HAI (HR 1.66) categories (<em>p</em> &lt; 0.0001). Guideline-focused medical treatment (GFMT) was associated with reduced mortality in patients with and without IHAEs.</div></div><div><h3>Conclusion</h3><div>HF cohorts with specific composite IHAEs experience higher in-hospital and 90-day all-cause mortality and increased health care resource utilization. This elevated mortality risk may be mitigated by GFMT, with potential tailoring to each specific IHAE category.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 423-437"},"PeriodicalIF":2.3,"publicationDate":"2025-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143997745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"System Strategies to Optimize the Critical Role of the Medical Interpreter.","authors":"Kathy Sliwinski, Eileen Johnson, Ana Galli, Victor Buzeta, Cynthia Barnard","doi":"10.1016/j.jcjq.2025.03.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.03.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144025641","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Enhanced Antibiotic Stewardship Program's Effect on Antibiotic Stewardship in Four Thai Hospitals","authors":"Kittiya Jantarathaneewat PharmD, BCP, BCIDP (Research Group in Infectious Diseases Epidemiology and Prevention, Faculty of Medicine, and Center of Excellence in Pharmacy Practice and Management Research, Faculty of Pharmacy, Thammasat University, Pathum Thani, Thailand),&nbsp;Anucha Thatrimontrichai MD (Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand),&nbsp;Nattapol Pruetpongpun MD (Department of Medicine, Bangkok Phitsanulok Hospital, Phitsanulok, Thailand),&nbsp;Siriththin Chansirikarnjana MD (Division of Infectious Diseases, Lerdsin Hospital, Bangkok, Thailand),&nbsp;Sasinuch Rutjanawech MD (Research Group in Infectious Diseases Epidemiology and Prevention, Faculty of Medicine, and Division of Infectious Diseases, Faculty of Medicine, Thammasat University),&nbsp;David J. Weber MD, MPH (Gillings School of Global Public Health, University of North Carolina School of Medicine),&nbsp;Anucha Apisarnthanarak MD (Research Group in Infectious Diseases Epidemiology and Prevention, Faculty of Medicine, and Division of Infectious Diseases, Faculty of Medicine, Thammasat University. Please address correspondence to Anucha Apisarnthanarak)","doi":"10.1016/j.jcjq.2025.03.001","DOIUrl":"10.1016/j.jcjq.2025.03.001","url":null,"abstract":"<div><h3>Background</h3><div>An antimicrobial stewardship program (ASP) is crucial for reducing inappropriate antimicrobial use, improving patient outcomes, and combating increasing antimicrobial resistance. However, data on the implementation of enhanced ASP networks in Asia are limited.</div></div><div><h3>Methods</h3><div>This quasi-experimental study evaluated an ASP collaborative network across four hospitals in Thailand (two university hospitals, a tertiary care center, and a private hospital) during 2021 and 2022. Baseline ASP activities were assessed using gap analysis surveys. Effectiveness was measured through antibiotic consumption (daily defined dose, [DDD] per 1,000 patient-days), appropriateness of antibiotic use, and the incidence of multidrug-resistant organisms (MDROs).</div></div><div><h3>Results</h3><div>The enhanced ASP network addressed key challenges, leading to significant improvements in ASP implementation. Notable achievements included an increase in the overall appropriateness of target antibiotic use (86.5% vs. 74.4 %, <em>p</em> &lt; 0.05) and a reduction in target antibiotic consumptions in all hospitals. The incidence of MDROs, including carbapenem-resistant <em>Acinetobacter baumannii</em> (30.22 vs. 6.08 per 1,000 patient-days, <em>p</em> &lt; 0.05) and methicillin-resistant <em>Staphylococcus aureus</em> (1.90 vs. 0.46 per 1,000 patient-days, <em>p</em> &lt; 0.05), declined significantly in one hospital. The incidence of multidrug-resistant pathogens declined after the implementation of the enhanced ASP in two hospitals.</div></div><div><h3>Conclusion</h3><div>The enhanced networking program in this study significantly improved ASP implementation across diverse hospital settings in Thailand. It addressed challenges such as insufficient financial support. Notable improvements were observed in the appropriateness of antibiotic use and overall antibiotic consumption, potentially contributing to the reduction in multidrug-resistant pathogens. These findings highlight the effectiveness of a collaborative ASP network in Asia.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 405-414"},"PeriodicalIF":2.3,"publicationDate":"2025-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144025640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Using In Situ Simulation to Identify Latent Safety Threats Prior to the Opening of Novel Patient Care Spaces in the Emergency Department.","authors":"Briana D Miller, Andrew D Bloom, Helena Kons, Marjorie Lee White","doi":"10.1016/j.jcjq.2025.02.007","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.02.007","url":null,"abstract":"<p><strong>Background: </strong>In the era of extreme emergency department (ED) boarding, hospital systems are using novel patient care areas to provide ongoing acute care. In any new patient care environment, there is a high risk for latent safety threats (LSTs), which can negatively affect patient outcomes. A series of in situ systems-based simulations were conducted to identify potential LSTs prior to the opening of a novel mobile care unit (MCU) in a tertiary hospital.</p><p><strong>Methods: </strong>After a needs assessment in conjunction with institutional leadership, a series of in situ interprofessional simulation sessions were developed to represent realistic scenarios in the MCUs. Simulations included low-frequency high-acuity patient care scenarios as well as high-frequency day-to-day encounters. Data were collected in structured systems-based debriefing sessions via trained observers, video recordings, and participant surveys, with a primary outcome of identifying potential LSTs. The LSTs were categorized and then stratified using the Survey Analysis for Evaluating Risk (SAFER) Matrix. One simulation was repeated after mitigation strategies were employed by institutional leadership.</p><p><strong>Results: </strong>A total of 117 staff participated in five simulation sessions. In the first round of simulations, 37 LSTs were identified, primarily in the categories of Environment/Wayfinding (13/37, 35.1%) and Communication (6/37, 16.2%). LSTs risk stratified using the SAFER Matrix provided prioritized feedback for hospital leadership to guide mitigation strategies prior to the opening of the new units. One LST was initially classified as high likelihood to harm on the SAFER Matrix. The simulated scenario involving this LST was repeated two weeks later with no further high-risk LSTs identified.</p><p><strong>Conclusion: </strong>In situ simulations can serve as an effective tool to identify potential LSTs prior to the opening of novel patient care spaces.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780124","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mortality and Return Visit Frequency Among Emergency Department Patients Who Leave Without Being Seen at a Regional Health Care System.","authors":"Joshua W Joseph, Alice K Bukhman, Da'Marcus E Baymon, Melisa W Lai-Becker, Dana D Im, Lauren M Nentwich, Paul C Chen, León D Sánchez","doi":"10.1016/j.jcjq.2025.02.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.02.008","url":null,"abstract":"<p><strong>Background: </strong>The rate of emergency department (ED) patients who leave without being seen (LWBS) is a commonly reported quality metric that increased across the United States in concert with COVID-19. However, it is unclear what proportion of patients leave despite an acute medical need. The authors sought to estimate the rates at which patients who leave return, including hospitalization, relative to patients who are evaluated and discharged.</p><p><strong>Methods: </strong>This was a retrospective cohort study examining adult patients presenting between January 1, 2019, and January 1, 2023, across an integrated system including 10 EDs. Demographic variables were compared using independent chi-square tests. Clinical outcomes, including rates of return visits at 72 hours and 30 days (including inpatient admission or ICU admission), and 30-day mortality were compared using multivariate logistic regression.</p><p><strong>Results: </strong>A total of 1,474,395 visits were included, of which 17,523 (1.2%) were LWBS. Patients in the LWBS group were younger (48.1 years [95% confidence interval (CI) 48.1-48.2] vs. 44.8 years [95% CI 44.6-45.1], p < 0.001), more likely to be of Hispanic ethnicity (177,895 [17.7%] vs. 3,884 [22.2%], p < 0.001), and more likely to require a translator (131,510 [13.1%] vs. 3,184 [18.2%], p < 0.001). Independent of other clinical and demographic variables, LWBS was associated with more frequent returns within 72 hours (adjusted odds ratio [AOR] 2.56, 95% CI 2.50-2.62, p < 0.001), 30-day ICU admission (AOR 1.35, 95% CI 1.27-1.66, p < 0.001), and mortality within 30 days (AOR 2.59, 95% CI 1.90-3.53, p <0.001).</p><p><strong>Conclusion: </strong>Patients who left without being seen were more likely to return, to require admission, and to die within 30 days than those discharged. High LWBS rates, most pronounced among disadvantaged groups, should be considered as a source of harm to patients.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}