Joint Commission journal on quality and patient safety最新文献

{"title":"Communication After Medical Error: The Need to Measure the Patient Experience","authors":"Allen Kachalia MD, JD (is Senior Vice President, Patient Safety and Quality, and Director, Director, Armstrong Institute of Patient Safety and Quality; and Professor of Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore.), Carole Hemmelgarn MS, MS (is Program Director, Executive Master's Clinical Quality, Safety and Leadership, Georgetown University, and Senior Director Education, MedStar Health, Washington, DC.), Thomas H. Gallagher MD, MACP (is Executive Director, Collaborative for Accountability and Improvement, and Associate Chair of Medicine for Patient Care, Quality, Safety, and Value, UW Medicine, Seattle; and Professor of Medicine and Professor of Bioethics & Humanities, University of Washington. Please address correspondence to Allen Kachalia)","doi":"10.1016/j.jcjq.2024.06.006","DOIUrl":"10.1016/j.jcjq.2024.06.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 618-619"},"PeriodicalIF":2.3,"publicationDate":"2024-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626824","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":"Letter to the Editor on “Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery”","authors":"Margaret V. Darko BA (is a Medical Student, Weill Cornell Medical College, NewYork-Presbyterian/Weill Cornell Medical Center, New York.), Robert White MD, MS (is an Anesthesiologist, Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center.), Deirdre C. Kelleher MD (is an Anesthesiologist, Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center. Please address correspondence to Margaret V. Darko)","doi":"10.1016/j.jcjq.2024.06.005","DOIUrl":"10.1016/j.jcjq.2024.06.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 748-749"},"PeriodicalIF":2.3,"publicationDate":"2024-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141734153","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":"Will Ambulatory Safety Nets Go Viral?","authors":"Lawrence Lurvey MD,JD (is Obstetrician/Gynecologist, Southern California Permanente Medical Group, Los Angeles.), Lyn Yasumura MD (is a Principal Consultant for Summitbridge Health Solutions LLC.), Elena Martinez MD (is Obstetrician/Gynecologist, Southern California Permanente Medical Group. Please address correspondence to Lawrence Lurvey)","doi":"10.1016/j.jcjq.2024.06.004","DOIUrl":"10.1016/j.jcjq.2024.06.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 687-689"},"PeriodicalIF":2.3,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141734154","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":"Reducing Inappropriate Stat Echocardiograms: A Quality Improvement Initiative (RISE-QI)","authors":"","doi":"10.1016/j.jcjq.2024.06.001","DOIUrl":"10.1016/j.jcjq.2024.06.001","url":null,"abstract":"<div><h3>Background</h3><div><span>A complete transthoracic echocardiogram takes approximately 45 minutes to complete, including time for image acquisition and preliminary reporting by the </span>sonographer. The process can take substantially longer if there are technical difficulties or if contrast must be administered due to suboptimal imaging windows. This can create a considerable echocardiogram backlog at high-volume institutions. At the authors’ institution, there was a concern that ordering providers were inappropriately designating studies as stat to get their patients to the front of the bottleneck. On review, the quality improvement team found that 19.9% of all echocardiograms ordered during June 2021 were designated stat, of which 44.0% contained indications that the team determined were rarely appropriate for a stat priority designation.</div></div><div><h3>Methods</h3><div>The team located a flaw in the electronic health record interface that encouraged overuse of the stat designation, so an interface change was designed and implemented to create a hard stop requiring the selection of predetermined indications for any stat order. We also reduced the number of steps required to select the less-urgent ASAP priority to encourage its use over stat priority.</div></div><div><h3>Results</h3><div>Within one month postintervention, there was a statistically significant 36.3% reduction in the order of stat echocardiograms, with a concurrent 173.9% rise in ASAP orders over the same time frame. These numbers remained steady at one-year and two-year follow-up analyses.</div></div><div><h3>Conclusion</h3><div>A quick and simple modification to the echocardiogram order user interface can lead to a considerable reduction in the number of stat orders.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 719-723"},"PeriodicalIF":2.3,"publicationDate":"2024-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141393098","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":"Going (Anti)Viral: Improving HIV and HCV Screening and HPV Vaccination in Primary Care","authors":"","doi":"10.1016/j.jcjq.2024.06.002","DOIUrl":"10.1016/j.jcjq.2024.06.002","url":null,"abstract":"<div><h3>Background</h3><p><span>Human immunodeficiency virus (HIV) and hepatitis C (HCV) screening and human papillomavirus (HPV) vaccine uptake remain suboptimal. To improve HIV and HCV<span> screening and HPV </span></span>vaccination<span>, the authors implemented a quality improvement project in three southwestern Pennsylvania family medicine residency practices.</span></p></div><div><h3>Methods</h3><p><span>From June 1 to November 30, 2021, participating practices used universal screening and vaccination guidelines and chose from multiple strategies at the office (for example, standing orders), provider (for example, multiple forms of provider reminders), and patient (for example, incentives) levels derived from published literature and tailored to local context. Age-eligible patients for each recommendation with at least one in-person office visit during the intervention period were included. To assess the interventions’ effect, the authors obtained testing and vaccination data from the electronic health record for the intervention period, contrasted it with identical data from June 1 to November 30, 2020, and used </span>logistic regression controlling for patient age, sex, and race to determine differences in screening and vaccination between intervention and baseline periods.</p></div><div><h3>Results</h3><p>A total of 14,920 and 15,523 patients were eligible in the baseline and intervention periods, respectively. Following the intervention, HIV lifetime screening but not first-time screening for patients 13–64 years old was significantly higher (78.9% vs. 76.1%, <em>p</em> = 0.004, and 39.6% vs. 36.6%, <em>p</em><span> = 0.152, respectively, adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 1.06–1.38). HCV lifetime screening for patients 18–79 years old was significantly higher postintervention (62.5% vs. 53.5%, </span><em>p</em><span> &lt; 0.001, aOR 1.51, 95% CI 1.4–1.64). For patients 9–26 years old, no change in HPV initiation was observed, but the percentage of patients who completed their HPV vaccinations in the observed period was significantly higher postintervention (7.0% vs 4.6%, </span><em>p</em> = 0.006, aOR 1.58, 95% CI 1.14–2.2). During the postintervention period, the researchers identified 0 new HIV diagnoses and 48 HCV diagnoses (19 eligible for treatment).</p></div><div><h3>Conclusion</h3><p>Family medicine residency office-based multistrategy efforts appear to successfully increase patient uptake of HIV and HCV screenings and maintain HPV vaccination rates.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 645-654"},"PeriodicalIF":2.3,"publicationDate":"2024-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141413630","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":"Multi‐Team Shared Expectations Tool (MT‐SET): An Exercise to Improve Teamwork Across Health Care Teams","authors":"","doi":"10.1016/j.jcjq.2024.05.012","DOIUrl":"10.1016/j.jcjq.2024.05.012","url":null,"abstract":"<div><div><span>Care transitions among high-intensity units caring for patients with complex needs are a critical yet undeveloped area of patient safety<span> research. In addition, effective communication and coordination across disciplines remain elusive. This study introduces and tests the Multi-Team Shared Expectations Tool (MT-SET), an exercise that aims to engage health care teams in eliciting needs and establishing agreed-upon expectations teams and individuals within a multi-team system have of one another. We piloted the exercise within hospital-based workflows for </span></span>oncology<span> inpatients and later adopted it to elicit data on mutual needs and expectations of teams across units involved in patient transitions in two patient safety projects. Our studies demonstrated that the exercise identified common cross-unit coordination problems of delays in care, unwanted variations in care, and lack of standardized communication among units. It also revealed mismatched prioritization of each of these problems between specific unit types. The participants reported that the MT-SET helped establish positive relationships for building better cross-unit and cross-disciplinary teamwork and coordination. There is a need for systematic approaches to understand and facilitate cross-unit communication and coordination in care delivery and transitions. Future studies should broaden the application of the exercise to additional types of multi-unit and multidisciplinary teams and observe intervention ideas generated from the exercise, as well as their implementation.</span></div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 737-744"},"PeriodicalIF":2.3,"publicationDate":"2024-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141277273","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":"Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application","authors":"Kyle W. Blackburn (is Medical Student, School of Medicine, Baylor College of Medicine, Houston.),&nbsp;Lisa S. Brubaker MD (is General Surgery Resident, Department of Surgery, Baylor College of Medicine.),&nbsp;George Van Buren II MD (is Associate Professor, Department of Surgery, Baylor College of Medicine and Dan L. Duncan Comprehensive Cancer Center, Houston.),&nbsp;Emily Feng (is Clinical Research Coordinator at San Francisco Otolaryngology, Department of Surgery, Baylor College of Medicine.),&nbsp;Sadde Mohamed (is Medical Student, School of Medicine, Yale University.),&nbsp;Uma Ramamurthy PhD MBA (is Associate Professor Department of Pediatrics, Baylor College of Medicine.),&nbsp;Vivek Ramanathan MS (is Software Engineer, Office of Research IT, Baylor College of Medicine.),&nbsp;Amy L. Wood MPH (is Clinical Research Manager, Department of Surgery, Baylor College of Medicine and Dan L. Duncan Comprehensive Cancer Center.),&nbsp;Martha E. Navarro Cagigas MD (is Senior Research Coordinator, Department of Surgery, Baylor College of Medicine and Dan L. Duncan Comprehensive Cancer Center.),&nbsp;William E. Fisher MD (is Professor, Baylor College of Medicine and Dan L. Duncan Comprehensive Cancer Center. Please address correspondence to William E. Fisher)","doi":"10.1016/j.jcjq.2024.02.004","DOIUrl":"10.1016/j.jcjq.2024.02.004","url":null,"abstract":"<div><h3>Background</h3><p>The surgical morbidity and mortality (M&amp;M) conference is a vital part of a resident's surgical education, but methods to collect and store M&amp;M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)–compliant, electronic health record (EHR)–connected application and database to report and store complication data.</p></div><div><h3>Methods</h3><p>The app is linked to the patient's EHR, and as a result, basic data on each surgical case—including diagnosis, surgery type, and surgeon—are automatically uploaded to the app. In addition, all data are stored in a secure SQL database—with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&amp;M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses.</p></div><div><h3>Results</h3><p>When implemented, the app improved data collection for the M&amp;M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article.</p></div><div><h3>Conclusion</h3><p>The app developed in this project significantly improves on more common methods for M&amp;M conference complication reporting—transforming M&amp;M data into a valuable resource for resident education and quality improvement.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 449-455"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140468120","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":"Evaluating the Prevalence of Four Recommended Practices for Suicide Prevention Following Hospital Discharge","authors":"Salome O. Chitavi PhD (is Research Scientist II, Department of Research, Division of Healthcare Quality Evaluation and Improvement, The Joint Commission, Oakbrook Terrace, Illinois.),&nbsp;Jamie Patrianakos PhD (is Research Scientist I, Department of Research, Division of Healthcare Quality Evaluation and Improvement. The Joint Commission.),&nbsp;Scott C. Williams PsyD (is Director, Department of Research, Division of Healthcare Quality Evaluation and Improvement, The Joint Commission.),&nbsp;Stephen P. Schmaltz PhD, MPH, MS (is Senior Biostatistician, Department of Research, Division of Healthcare Quality Evaluation and Improvement, The Joint Commission.),&nbsp;Brian K. Ahmedani PhD, LMSW (is Director, Center for Health Policy and Health Services Research, and Director of Research, Behavioral Health Services, Henry Ford Health, Detroit.),&nbsp;Kimberly Roaten PhD, ABPP (is Professor, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas.),&nbsp;Edwin D. Boudreaux PhD (is Professor, Departments of Emergency Medicine, Psychiatry, and Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School.),&nbsp;Gregory K. Brown PhD (is Associate Professor of Clinical Psychology in Psychiatry, Perelman School of Medicine, University of Pennyslvania. Please address correspondence to Salome Chitavi)","doi":"10.1016/j.jcjq.2024.02.007","DOIUrl":"10.1016/j.jcjq.2024.02.007","url":null,"abstract":"<div><h3>Background</h3><p>The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires that accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide. The proportion of hospitals meeting these requirements through use of recommended discharge practices is unknown.</p></div><div><h3>Methods</h3><p>This cross-sectional observational study explored the prevalence of suicide prevention activities among Joint Commission–accredited hospitals. A questionnaire was sent to 1,148 accredited hospitals. The authors calculated the percentage of hospitals reporting implementation of four recommended discharge practices for suicide prevention.</p></div><div><h3>Results</h3><p>Of 1,148 hospitals, 346 (30.1%) responded. The majority (<em>n</em> = 212 [61.3%]) of hospitals had implemented formal safety planning, but few of those (<em>n</em> = 41 [19.3%]) included all key components of safety planning. Approximately a third of hospitals provided a warm handoff to outpatient care (<em>n</em> = 128 [37.0%)] or made follow-up contact with patients (<em>n</em> = 105 [30.3%]), and approximately a quarter (<em>n</em> = 97 [28.0%]) developed a plan for lethal means safety. Very few (<em>n</em> = 14 [4.0%]) hospitals met full criteria for implementing recommended suicide prevention activities at time of discharge.</p></div><div><h3>Conclusion</h3><p>The study revealed a significant gap in implementation of recommended practices related to prevention of suicide postdischarge. Additional research is needed to identify factors contributing to this implementation gap.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 393-403"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725024000679/pdfft?md5=e6b6403241b88154c3809606c04f8ba4&pid=1-s2.0-S1553725024000679-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140305668","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":"Lessons Learned from a National Hospital Antibiotic Stewardship Implementation Project","authors":"Sara E. Cosgrove MD, MS (is Professor of Medicine, Johns Hopkins University School of Medicine, and Director, Department of Antimicrobial Stewardship, The Johns Hopkins Hospital, Baltimore.),&nbsp;Roy Ahn ScM, ScD (is Vice President, Public Health, NORC at the University of Chicago.),&nbsp;Prashila Dullabh MD (is Vice President and Senior Fellow, Health Sciences, and Director, Health Implementation Science Center, NORC at the University of Chicago.),&nbsp;Janna Gordon PhD (is Research Scientist, Health Sciences, NORC at the University of Chicago.),&nbsp;Melissa A. Miller MD, MS (is Medical Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland.),&nbsp;Pranita D. Tamma MD, MHS (is Associate Professor of Pediatrics, Johns Hopkins University School of Medicine. Please address correspondence to Pranita D. Tamma)","doi":"10.1016/j.jcjq.2024.04.002","DOIUrl":"10.1016/j.jcjq.2024.04.002","url":null,"abstract":"<div><h3>Background</h3><p>The goal of antibiotic stewardship programs (ASPs) is to ensure that patients receive effective therapy while minimizing adverse events. To overcome barriers commonly faced in implementing successful ASPs, the Agency for Healthcare Research and Quality (AHRQ) established a multifaceted, nationwide Safety Program for Improving Antibiotic Use in 2018. This report summarizes the lessons learned from the implementation of this initiative based on structured interviews of personnel from participating sites.</p></div><div><h3>Methods</h3><p>At the completion of the one-year initiative, semistructured exit interviews were conducted with site leaders at 151 of the 402 hospitals that participated. These interviews consisted of open-ended questions about the perceived effectiveness of components of the Safety Program. Qualitative analyses incorporated both deductive coding themes (based on existing literature) and an iteratively developed inductive coding framework (based on salient themes that emerged from a subset of interviews).</p></div><div><h3>Results</h3><p>Several components of the Safety Program were identified as effective in expanding local stewardship activities, including techniques and strategies to implement sustainable ASPs, access to Implementation Advisors to keep sites engaged, provision of local benchmarked antibiotic use data to compare to similar hospitals, and Safety Program materials such as the antibiotic time-out tool to integrate stewardship techniques into daily work flows. The biggest challenges to greater effectiveness were suboptimal frontline staff engagement and difficulty changing antibiotic prescribing culture. Some approaches used to overcome these barriers (peer-to-peer communication and education through team huddles, identifying physician champions, informal rounds to enhance collegiality and buy-in, and engagement of hospital leadership) were identified.</p></div><div><h3>Conclusion</h3><p>Lessons learned from the Safety Program can be applied by other teams looking to promote an effective ASP at their hospital or system. The themes that emerged in this study likely also have relevance across a wide range of large-scale quality improvement initiatives.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 435-441"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140775572","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":"Department of Anesthesiology Skilled Peer Support Program Outcomes: Second Victim Perceptions","authors":"Brenda Bursch PhD (is Professor, Department of Psychiatry and Biobehavioral Sciences, and Department of Pediatrics, David Geffen School of Medicine at UCLA.),&nbsp;Keren Ziv MD (is Clinical Professor, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA.),&nbsp;Shevaughn Marchese (is Faculty Development and Career Advancement Program Manager, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA.),&nbsp;Hilary Aralis PhD (is Professor, Department of Biostatistics, UCLA Fielding School of Public Health.),&nbsp;Teresa Bufford PhD (formerly Graduate Student Researcher and Biostatistician, Department of Biostatistics, UCLA Fielding School of Public Health, is Principal Statistician GSK, Wynnewood, Pennsylvania.),&nbsp;Patricia Lester MD (is Professor, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA. Please address correspondence to Brenda Bursch)","doi":"10.1016/j.jcjq.2024.03.006","DOIUrl":"10.1016/j.jcjq.2024.03.006","url":null,"abstract":"<div><h3>Background</h3><p>Most anesthesia providers experience an adverse event during their training or career. Limited evidence suggests skilled peer support programs (SPSPs) reduce initial distress and support adaptive functioning and coping. This study evaluated second victim perceptions of a voluntary SPSP.</p></div><div><h3>Methods</h3><p>An SPSP was developed and implemented for all clinical and administrative personnel in the Department of Anesthesiology and Perioperative Medicine in three hospitals and six outpatient surgery centers in December 2017. The program incorporated the Scott Three-Tiered Interventional Model of Second Victim Support. Surveys were offered to clinicians in the department prior to implementation of the SPSP and again 18 months after implementation. Among the subset of respondents who experienced a serious adverse patient event, the authors used multiple logistic regression models that adjusted for role and number of night shifts per month to examine differences in perceived resource availability and post-event support received following implementation of the program.</p></div><div><h3>Results</h3><p>There were 94 surveys (83 complete; 11 partially complete) collected prior to implementation and 84 surveys (67 complete; 17 partially complete) collected after implementation. A total of 25 individuals took the survey at both pre and post (19 complete). After implementation, 62.5% of respondents indicated that institutional support had improved since the occurrence of their serious adverse patient event. Statistical models identified a significant improvement in the probability that a clinician agreed with the statement “I think that the organization learned from the event and took appropriate steps to reduce the chance of it happening again” at post vs. pre (adjusted odds ratio [aOR] 3.9, 95% confidence interval [CI] 1.01–15.1. A statistically significant increase from pre to post in the perceived availability of formal emotional support was identified (aOR 5.2, 95% CI 1.9–22.5).</p></div><div><h3>Conclusion</h3><p>Implementation of a skilled peer support program within a large department of anesthesiology can improve institutional-based emotional support.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 442-448"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725024000746/pdfft?md5=c1cd74759868024f5c517009e4ebccbb&pid=1-s2.0-S1553725024000746-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140280918","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}