Joint Commission journal on quality and patient safety最新文献

{"title":"Patient Engagement in Safety: Are We There Yet?","authors":"Tejal Gandhi, Urmimala Sarkar","doi":"10.1016/j.jcjq.2025.02.006","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.02.006","url":null,"abstract":"","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":"143743135","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":"Modeling Incremental Benefit of Medication Reconciliation on ICU Outcomes.","authors":"Helen A Harris, David M Chan, Laura Ellwein Fix, Melissa Chouinard, Teresa M Salgado, Le Kang, Gonzalo Bearman","doi":"10.1016/j.jcjq.2025.02.001","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.02.001","url":null,"abstract":"<p><strong>Background: </strong>Medication errors such as medication discrepancies can occur in patients who are hospitalized and may result in adverse drug events (ADEs). Pharmacist-led medication reconciliation (MR) is an intervention that can be used to address medication discrepancies. Estimating the impact of MR in a medical setting is challenging to do experimentally. In this study, researchers implemented a mathematical model for estimating impact.</p><p><strong>Methods: </strong>The authors modeled the effects of a series of incremental changes in MR completion on ADEs and conducted a cost-effectiveness analysis using a Markov chain model.</p><p><strong>Results: </strong>In a 28-bed ICU, increasing the MR completion rate resulted in decreases in the total number of yearly ADEs by as many as 106, varying by the baseline ADE rate. The financial implications of increasing MR completion ranged from $27,808 in additional costs to $1,818,440 in savings on a yearly basis, depending on the baseline ADE rate and cost per ADE.</p><p><strong>Conclusion: </strong>For institutions with low ADE rates, as MR completion increases and ADEs decrease, MR (though clinically beneficial) may not be financially worthwhile. However, MR implementation was found to produce significant savings for hospitals with average or high ADE rates.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143673934","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":"Leveraging Approaches and Tools of Implementation Science and Configurational Comparative Methods in Quality Improvement","authors":"Gabrielle Matias MD (Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL),&nbsp;Nandita R. Nadig MD, MSCR, ATSF (Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL),&nbsp;Reiping Huang PhD (Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, Please address correspondence to Reiping Huang)","doi":"10.1016/j.jcjq.2025.02.003","DOIUrl":"10.1016/j.jcjq.2025.02.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 239-240"},"PeriodicalIF":2.3,"publicationDate":"2025-02-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143704883","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":"Patient Safety Event Risk and Language Barriers: A Scoping Review.","authors":"Lucy B Schulson, Jorge A Rodriguez, Ricardo Cruz, David Flynn, Alicia Fernandez","doi":"10.1016/j.jcjq.2025.02.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.02.002","url":null,"abstract":"<p><p>Patients who experience language barriers (LBs) may be at risk for patient safety events (PSEs). We conducted a scoping review of the literature to understand the risk for and type of PSEs in those who experience LBs. We searched PubMed, Web of Science, and Embase in October 2023. The search was organized into the following concepts: language barriers and patient safety. We included English language studies where risk of a PSE was compared in patients who experience to those who do not experience LBs or where types/characteristics of PSEs were compared in patients who are and are not at risk for LBs. We identified 22 studies for inclusion. Studies were primarily based in the United States and inpatient focused. Multiple methods were used to define patients who experience LBs and to identify PSEs. Patients who experienced LBs appeared to be at risk for communication-sensitive safety events, including medication-related adverse events and events related to vaginal deliveries, but at equal or lower risk for other types of events. Studies that did not rely solely on PSEs identified by clinician/staff report were more likely to identify disparities. We found few studies on PSE risk and LBs, a reflection of the dearth of research in this area and data sources with patient language. Studies had mixed results in part due to the multiple methods used to identify patients who experience LBs and PSEs. Interventions to reduce PSEs for patients who experience LBs should focus on events resulting from communication breakdowns.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-02-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143633936","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":"The Scholarly Upside to MOC4","authors":"Glenn Seela (is a Medical Student, University of Minnesota Medical School.),&nbsp;David Satin MD (is an Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, and Affiliate Faculty Center for Bioethics, University of Minnesota.),&nbsp;Cathy Centola (is Division Administrator, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Sameer Gupta MD, MBA (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Paul Hodges MPP (is Director of Process Improvement and Clinical Quality, M Health Fairview, University of Minnesota Medical Center.),&nbsp;Jeff Louie MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Tanya E. Melnik MD, MS (is an Associate Professor, Department of Medicine, University of Minnesota Medical School.),&nbsp;David Pelletier MSE, ICBB (is Principal Consultant, Quality Improvement, M Health Fairview.),&nbsp;Christina Russell MD (is an Assistant Professor, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Andrew Thompson MBA, MBB (Principal Consultant, Performance Improvement, M Health Fairview.),&nbsp;Jordan Marmet MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School. Please address correspondence to Jordan Marmet)","doi":"10.1016/j.jcjq.2024.10.014","DOIUrl":"10.1016/j.jcjq.2024.10.014","url":null,"abstract":"<div><h3>Background</h3><div>Many medical boards require quality improvement (QI) projects for Maintenance of Certification Part IV (MOC4) credits. The American Board of Medical Specialties (ABMS) allows health care organizations that can demonstrate sufficient QI standards to become Portfolio Program Sponsors. This enables internal review and approval of QI projects, crediting all sufficiently contributing physicians. The University of Minnesota's M Health Fairview MOC4 Review Board (MMRB) was approved as an ABMS Portfolio Program Sponsor; the impact was surveyed from inception in 2016 to 2022. The objective was to examine the impact of a Portfolio Sponsor program on scholarship, sustainability, and spread of QI projects.</div></div><div><h3>Methods</h3><div>The authors developed and validated an eight-question survey directed at MOC4 principal investigators (PIs) who were awarded credits through the MMRB from 2016 to 2022. Participants reported on numbers of peer-reviewed publication or presentation, and their perception of increased preparedness for scholarship due to the application process. They also reported on sustainment or spread following their original QI project.</div></div><div><h3>Results</h3><div>Fifty projects were reviewed over a seven-year span. Of these, 44 were approved as demonstrating sufficient QI rigor per ABMS standards. Of 41 PIs, 27 (65.9%) responded to the survey; 15 (55.6%) agreed that the MMRB process helped prepare them for scholarly dissemination, 19 (70.4%) delivered oral or poster presentations, and 10 (37.0%) submitted a total of 14 manuscripts for publication, 10 of which were accepted. A total of 23 QI projects (85.2%) were sustained, and 10 (37.0%) had spread.</div></div><div><h3>Conclusion</h3><div>In addition to generating essential MOC4 credits for participating physicians, an MMRB process can help PIs prepare for scholarship, project sustainment, and spread.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 101-107"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142864222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementation of the Revised American Academy of Pediatrics Clinical Practice Guidelines for Hyperbilirubinemia Decreases Necessity for Serum Bilirubin and Phototherapy","authors":"Matthew R. Michienzi DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas.),&nbsp;Dakota K. Tomasini DO (is Neonatology Fellow, Department of Pediatrics, Brooke Army Medical Center.),&nbsp;Carleigh C. Fisher DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center.),&nbsp;Adharsh P. Ponnapakkam MD (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center. Please address correspondence to Matthew Michienzi)","doi":"10.1016/j.jcjq.2024.10.013","DOIUrl":"10.1016/j.jcjq.2024.10.013","url":null,"abstract":"<div><h3>Background</h3><div>The initial hyperbilirubinemia management recommendations published by the American Academy of Pediatrics (AAP) in 2004 and updated in 2009 led to wide variations in clinical practice among providers, with variable results. In August 2022 AAP published updated clinical practice guidelines for the management of hyperbilirubinemia. The aim of this project was to determine the effect of adaptation of the AAP guidelines on laboratory testing, readmission rates, and phototherapy.</div></div><div><h3>Methods</h3><div>Existing institutional protocol was updated to incorporate the revised AAP guidelines. The primary outcome was percentage of serum bilirubin labs obtained. Balancing measures included monthly readmission rate, need for escalation of care, and percentage of patients requiring additional labs or phototherapy. Statistical process control charts measured changes in quality over time. Chi-square analysis evaluated differences between pre- and postintervention periods.</div></div><div><h3>Results</h3><div>A total of 2,301 infants were evaluated, 1,662 of which were included in the postintervention analysis. A clinically and statistically significant decrease was seen in the percentage of patients with serum bilirubin evaluation, from 21.3% to 8.8% (<em>p</em> &lt; 0.001). There was a decrease in need for phototherapy, from 4.2% to 1.4% (<em>p</em> &lt; 0.001), but duration of treatment was longer when initiated. The authors simultaneously saw no changes in readmission rate or additional laboratory evaluation, with no incidence of bilirubin-induced encephalopathy or escalation of care.</div></div><div><h3>Conclusion</h3><div>Implementation of the revised 2022 AAP guidelines was associated with a decrease in serum bilirubin evaluation and phototherapy initiation. This integrated protocol may represent a sustainable standardized approach to management of hyperbilirubinemia.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 95-100"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142854204","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":"Simulation-Debriefing Enhanced Needs Assessment to Address Quality Markers in Health Care: An Innovation for Prospective Hazard Analysis","authors":"Lisa T. Barker MD, MHPE (is Clinical Associate Professor of Emergency Medicine, OSF HealthCare, University of Illinois College of Medicine at Peoria, and Medical Director, Jump Simulation, an OSF HealthCare and University of Illinois College of Medicine at Peoria Collaboration.),&nbsp;William F. Bond MD, MS (is Professor of Clinical Emergency Medicine, University of Illinois College of Medicine at Peoria, and Director of Research, Jump Simulation.),&nbsp;Ann M. Willemsen-Dunlap CRNA, PhD (is Director of Education Development, Jump Simulation.),&nbsp;Kimberly L. Cooley MSN, RN, CCRC (is Research Education Facilitator, OSF HealthCare.),&nbsp;Jeremy S. McGarvey MS (is Senior Statistician, Division of Healthcare Analytics, OSF HealthCare.),&nbsp;Rebecca L. Ruger (is Graduate Student, Department of Psychology, Pennsylvania State University.),&nbsp;Adam Kohlrus MS, CPHQ, CPPS (is Partner and Business Designer, Do Tank, Springfield, Illinois.),&nbsp;Michael J. Kremer PhD, CRNA, CHSE, FAAN (is Professor and Interim Chair, Department of Adult Health and Gerontological Nursing, College of Nursing, and Co-Director, Rush Center for Clinical Skills and Simulation, Rush University.),&nbsp;Michelle Sergel MD (is Co-Director, Rush Center for Clinical Skills and Simulation, Rush University and Assistant Professor of Emergency Medicine, Rush Medical College.),&nbsp;John A. Vozenilek MD (is Vice President and Chief Medical Officer for Innovation, OSF HealthCare. Please address correspondence to Lisa T. Barker)","doi":"10.1016/j.jcjq.2024.10.004","DOIUrl":"10.1016/j.jcjq.2024.10.004","url":null,"abstract":"<div><div>Simulation-Debriefing Enhanced Needs Assessment (SDENA) is a simulation-based approach to prospective hazard analysis that uses simulation and debriefing as a unit-level diagnostic tool. Scenarios address failure modes for health care improvement targets, and debriefing explores unit-specific barriers and resiliencies. Debriefing guides are structured to explore how six drivers of a behavior engineering framework (data, tools/resources, incentives, knowledge/skills, capacity, motivation) influence clinical behaviors. Illinois Hospital Association members who deployed SDENA to address specific hospital-acquired conditions found motivation to be a more significant barrier than anticipated before deployment. SDENA represents a novel approach to improving safety and may refine intervention targets.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 144-158"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142970973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How Do We Know When We Have Done Enough? Ensuring Sufficient Patient Notification Efforts After a Large-Scale Adverse Event","authors":"David Alfandre MD, MSPH (is an Internist and Senior Health Care Ethicist, US Department of Veterans Affairs (VA) National Center for Ethics in Health Care, and Associate Professor, Departments of Medicine and Population Health, New York University Grossman School of Medicine.),&nbsp;Mary Beth Foglia PhD, MA, RN (is Health Care Ethicist, VA National Center for Ethics in Health Care, and Affiliate Faculty, Department of Bioethics and Humanities, School of Medicine, University of Washington.),&nbsp;Mark Holodniy MD (is Director, VA Public Health National Program Office and Public Health Reference Laboratory, and Professor, Department of Medicine, Stanford University School of Medicine.),&nbsp;A. Rani Elwy PhD, MSc (is Research Career Scientist, Center for Health Optimization and Implementation Research, VA Boston Healthcare System, and VA Bedford Healthcare System, and Professor, Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University. Please address correspondence to David Alfandre)","doi":"10.1016/j.jcjq.2024.10.010","DOIUrl":"10.1016/j.jcjq.2024.10.010","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 159-163"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142872141","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":"Examining Patient Safety Events Using the Behaviour Change Wheel: A Cross-Sectional Analysis","authors":"Mari Somerville PhD, MPH (formerly Canadian Institutes of Health Research (CIHR) Health System Impact Fellow, IWK Health, Halifax, Nova Scotia, is Senior Policy Analyst, Nova Scotia Health Authority, and Health Systems Researcher, School of Nursing, Dalhousie University.),&nbsp;Christine Cassidy PhD, RN (is Associate Professor, School of Nursing, Dalhousie University.),&nbsp;Shannon MacPhee MD (is Pediatric Emergency Physician, IWK Health.),&nbsp;Douglas Sinclair MD (is Vice President, Medicine, Quality and Safety, IWK Health.),&nbsp;Jane Palmer MN, RN (is Director, Quality, Patient Safety and Patient Experience, IWK Health.),&nbsp;Daniel Keefe MD (is Associate Professor, Department of Urology, Dalhousie University, and Pediatric Urologist, IWK Health.),&nbsp;Shauna Best RN (is Manager, IWK Health Centre, Halifax, Nova Scotia.),&nbsp;Janet Curran PhD (is Research Chair, Quality and Patient Safety, IWK Health, and Professor, School of Nursing, Dalhousie University. Please address correspondence to Mari Somerville)","doi":"10.1016/j.jcjq.2024.11.001","DOIUrl":"10.1016/j.jcjq.2024.11.001","url":null,"abstract":"<div><h3>Background</h3><div>Precursor-level safety events (PSEs) pose greater patient risk than no-harm events but are not as severe as serious safety events. Despite their potential for harm, the underlying determinants associated with PSEs are poorly understood. This study aimed to use a behavior change framework to understand the underlying determinants of PSEs and whether associated action items aligned with the behavior.</div></div><div><h3>Methods</h3><div>This cross-sectional study took place in a maternal/pediatric hospital. A total of 58 prerecorded PSEs were analyzed using the Behaviour Change Wheel (BCW); a behavioral framework that identifies sources of behavior and proposes intervention types that address said behavior. Researchers and clinicians independently coded each PSE's underlying determinant and action items using the relevant components of the BCW. The types and frequency of underlying behavioral determinants and intervention types for each PSE were documented. A matrix, based on the BCW, reflected how often the underlying behavior aligned with the corresponding action item.</div></div><div><h3>Results</h3><div>Of the 58 PSEs, six behavioral determinants and seven intervention types were identified. Environmental context/resources was the behavioral determinant coded most often (25.4%); education was the most common intervention type (45.8%). Several underlying determinants (24.6%) and action items (8.3%) received no code due to limited information. Based on the BCW matrix, 34.2% of behavioral determinants were addressed with interventions that would target the underlying behavior, while 37.8% did not align, and 28.1% could not be coded due to missing behavioral information.</div></div><div><h3>Conclusion</h3><div>This study identified poor alignment between types of interventions and underlying determinants in more than one third of analyzed PSEs. This included using educational interventions in about 50% of events, despite this type of intervention being ineffective for most of the coded behaviors. Further, alignment of many safety events could not be determined due to limited reported information. This highlights a need to design more systematic, behavior-informed approaches to reporting PSEs and identifying interventions to effectively change behavior.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 135-143"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142846674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of Interprofessional Crisis Simulation Training in a Non-Operating Room Anesthesia Setting on Team Coordination: A Mixed Methods Study","authors":"Hedwig Schroeck MD (is Associate Professor of Anesthesiology and Pediatrics, Geisel School of Medicine at Dartmouth College, Dartmouth Hitchcock Medical Center, Lebanon, NH.),&nbsp;Bridget Hatton MPH (formerly with the Dartmouth Institute for Health Policy and Clinical Practice, is DrPH Student, Johns Hopkins Bloomberg School of Public Health.),&nbsp;Pablo Martinez-Camblor PhD (Assistant Professor, Departments of Anesthesiology and Biomedical Data Science, Geisel School of Medicine at Dartmouth College.),&nbsp;Michaela A. Whitty MPH (is Manager, Perioperative Supply Chain, Supply Chain Shared Services, Dartmouth Health, Lebanon, New Hampshire.),&nbsp;Louise Wen MD (is Assistant Professor, Department of Anesthesiology, Geisel School of Medicine at Dartmouth College, and Anesthesiologist, Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center.),&nbsp;Andreas H. Taenzer MD, MS (formerly Professor, Departments of Anesthesiology and Pediatrics, Geisel School of Medicine at Dartmouth College, is Professor, Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Children's National Hospital, George Washington University School of Medicine & Health Sciences. Please address correspondence to Hedwig Schroeck)","doi":"10.1016/j.jcjq.2024.10.009","DOIUrl":"10.1016/j.jcjq.2024.10.009","url":null,"abstract":"<div><h3>Background</h3><div>Crisis resource management in non-operating room anesthesia (NORA) locations is challenging but can potentially be improved through interprofessional crisis simulation training (ICST). This mixed methods study aimed to evaluate the effect of a one-time training on team coordination in diagnostic and interventional magnetic resonance imaging locations.</div></div><div><h3>Methods</h3><div>Personnel from anesthesia, radiology, and perioperative services (<em>n</em> = 87) underwent ICST over eight months. Team coordination among participants was assessed and compared at baseline, immediately after, and at three months after ICST using a validated instrument—the relational coordination index (RCI)—and a questionnaire on role perceptions and task confidence. Open-ended interviews on a purposive sample of participants were conducted before and after training and analyzed for recurring themes.</div></div><div><h3>Results</h3><div>Response rates for the RCI were 71.3% at baseline, 65.5% immediately after, and 36.8% three months after training. For subjects responding at baseline and at the respective post-training time point, there were no statistically significant differences in composite RCI scores immediately after or at three months after ICST. However, some individual RCI domain scores increased from baseline to three months after training. For instance, mutual respect increased from (mean ± standard deviation) 3.67 ± 0.49 to 4.42 ± 0.67 (<em>p</em> = 0.003) among non-anesthesia personnel rating anesthesia personnel; and shared knowledge rose from 3.58 ± 0.79 to 4.08 ± 0.51 (<em>p</em> = 0.010) among non-anesthesia personnel rating anesthesia personnel. Thematic analysis from 15 interviews revealed increased familiarity with roles and crisis procedures after ICST as well as improved communication.</div></div><div><h3>Conclusion</h3><div>A single interprofessional crisis simulation training in a NORA setting, though it did not change overall relational coordination scores, had positive effects on some aspects of team coordination by improving role clarity, task confidence, trust, and communication.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 115-125"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142872140","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}