Joint Commission journal on quality and patient safety最新文献

{"title":"Training Hospital Nurses to Write Detailed Narratives and Describe Contributing Factors in Incident Reports: The SAFER Education Program.","authors":"Tara N Cohen, Teryl K Nuckols, Carl T Berdahl, Edward G Seferian, Sara G McCleskey, Andrew J Henreid, Donna W Leang, Maria Andrea Lupera, Bernice L Coleman","doi":"10.1016/j.jcjq.2025.01.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.01.002","url":null,"abstract":"<p><strong>Background: </strong>In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety.</p><p><strong>Methods: </strong>The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center.</p><p><strong>Results: </strong>An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy-a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses).</p><p><strong>Conclusion: </strong>SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143079829","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":"PROPEL Discharge: An Interdisciplinary Throughput Initiative.","authors":"Jessica DeMaio, Olivia Purdy, Jennifer Ghidini, Jennifer Menillo, Rebecca Viney, Chelsea Hogan","doi":"10.1016/j.jcjq.2024.10.003","DOIUrl":"10.1016/j.jcjq.2024.10.003","url":null,"abstract":"<p><strong>Background: </strong>Increased care demands at a health care institution led to strained resources, emergency department (ED) congestion, safety events, and patient and employee dissatisfaction. Moreover, high volumes of afternoon discharges contributed to limited early morning bed availability and admission bottlenecks.</p><p><strong>Methods: </strong>A 29-month pre-post design quality improvement project on 19 acute care, adult medicine units across two campuses at a large academic medical center was implemented to improve discharge timeliness, length of stay (LOS), and ED throughput by increasing pre-11:00 a.m. discharges. Based on Lean Six Sigma methodology, interventions included standardized interdisciplinary discharge processes and roles, processes to ensure performance data transparency and access, a recognition program, and a barrier tracking and mitigation process for continued improvements.</p><p><strong>Results: </strong>During the intervention period, pre-11:00 a.m. discharges increased from 5.1% to 21.8% (p < 0.001), discharge orders were entered 42 minutes earlier (p < 0.001), patients were discharged 56 minutes earlier (p < 0.001), the percentage of discharges completed within 90 minutes from discharge order improved from 26.2% to 38.1% (p < 0.001), the percentage of discharges by 3:00 p.m. improved from 44.7% to 55.9% (p < 0.001), ED admissions arrived to units 44 minutes earlier (p < 0.001), median LOS decreased by 0.46 days (p < 0.001), median observed-to-expected (O:E) LOS decreased by 0.05 (p < 0.001), and opportunity day reductions contributed to increased bed capacity of 18.84 beds per day.</p><p><strong>Conclusion: </strong>Early morning discharges are associated with improved patient throughput and are safe, achievable, and sustainable via interventions focused on frontline engagement, interdisciplinary collaboration, standardization, barrier mitigation, data accessibility, and accountability.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":"19-32"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142785691","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":"Methodological Approaches for Analyzing Medication Error Reports in Patient Safety Reporting Systems: A Scoping Review.","authors":"Olga Tchijevitch, Sebrina Maj-Britt Hansen, Jesper Hallas, Søren Bie Bogh, Alma Mulac, Sisse Walløe, Mette Kring Clausen, Søren Birkeland","doi":"10.1016/j.jcjq.2024.10.005","DOIUrl":"10.1016/j.jcjq.2024.10.005","url":null,"abstract":"<p><strong>Background: </strong>Medication errors (MEs) pose risks to patient safety, resulting in substantial economic costs. To enhance patient safety and learning from incidents, health care and pharmacovigilance organizations systematically collect ME data through reporting systems. Despite the growing literature on MEs in reporting systems, an overview of methods used to analyze them is lacking. The authors aimed to identify, explore, and map available literature on methods used to analyze MEs in reporting systems.</p><p><strong>Methods: </strong>The review was based on Joanna Briggs Institute's methodology. The authors systematically searched electronic databases Embase, Medline, CINAHL, Cochrane Central, and other sources (Google Scholar, health care safety and pharmacovigilance centers' websites). Literature published from January 2017 to December 2023 was screened and extracted by two independent researchers.</p><p><strong>Results: </strong>Among the 59 extracted publications, analyses most often focused on MEs occurring in hospitals (57.6%), included both adult and pediatric patients (79.7%), and used national patent safety monitoring systems as a source (69.5%). We identified quantitative (39.0%), qualitative (11.9%), mixed methods (37.3%), and advanced computerized methods (11.9%). Descriptive quantitative analyses for categorized data were common; however, disproportionality analysis constituted a newer approach to address issues with reporting bias. Free-text data were commonly managed by content analysis, while mixed methods analyzed both categorized and free-text data. In addition, text mining, natural language processing, and artificial intelligence were used in more recent studies.</p><p><strong>Conclusion: </strong>This scoping review uncovered a notable span and diversity in methodologies. Future research should assess the use, applicability, and effectiveness of newer methods such as disproportionality analysis and advanced computerized techniques.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":"46-73"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142813078","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":"Health Care Workers' Trust in Leadership: Why It Matters and How Leaders Can Build It.","authors":"Jessica Greene, Diane Gibson, Lauren A Taylor, Daniel B Wolfson","doi":"10.1016/j.jcjq.2024.09.002","DOIUrl":"10.1016/j.jcjq.2024.09.002","url":null,"abstract":"<p><strong>Background: </strong>Rebuilding patient trust in the US health care system has received considerable attention recently, but there has been little focus on health care workers' (HCWs) trust in the leaders of health care delivery organizations. This study explores (1) the professional impact on HCWs of trusting the leaders of the organizations where they work and (2) the leadership actions that build HCWs' trust.</p><p><strong>Methods: </strong>The authors examined these questions using a survey that was crowdsourced to 353 HCWs through social media posts and e-mails from national health organizations. For each open-ended question, qualitative codes were identified, iteratively finalized, and applied to each response. Descriptive statistics were used to analyze the closed-ended questions and examine how often each qualitative code was raised.</p><p><strong>Results: </strong>One in five (20.2%) HCWs trusted leadership \"very much,\" more than a third (36.9%) trusted \"somewhat,\" and 42.9% had lower levels of trust. Almost all (97.7%) reported that the degree of trust they had in their organization's leadership affected them professionally. Among HCWs who trusted their organization's leadership, the most common impact was feeling professional satisfaction, followed by providing higher-quality work. HCWs described three main ways health care organization leaders earned their trust: communicating effectively (being transparent and soliciting HCWs' input), treating HCWs well (with respect and kindness and providing good compensation), and prioritizing patient care.</p><p><strong>Conclusion: </strong>The findings suggest health care organizations would benefit from leaders seeking to earn HCWs' trust. With trust in leadership, HCWs report higher work quality and greater professional satisfaction.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":"11-18"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142466008","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":"Housing Instability Screening and Referral Programs: A Scoping Review.","authors":"Shravan Asthana, Luis Gago, Joshua Garcia, Molly Beestrum, Teresa Pollack, Lori Post, Cynthia Barnard, Mita Sanghavi Goel","doi":"10.1016/j.jcjq.2024.08.007","DOIUrl":"10.1016/j.jcjq.2024.08.007","url":null,"abstract":"<p><strong>Background: </strong>Housing instability in the United States is a critical social determinant of health, influencing health outcomes and health care utilization. This scoping review aimed to analyze literature on US health system screening and response programs addressing housing instability, highlighting methodologies, geographic and demographic variations, and policy implications.</p><p><strong>Methods: </strong>Adhering to PRISMA-ScR guidelines, the review included studies focusing on US health systems that screen and refer for housing instability. Major scholarly databases, including PubMed and Scopus, were queried. Screening and response program characteristics, methodologies, and outcomes were characterized.</p><p><strong>Results: </strong>Thirty studies published between 2003 and 2023 were included in this study. Included studies were primarily cross-sectional (26.7%) or quality improvement (20.0%), among 9 other designs. Screening programs were predominantly implemented in academic hospital systems (46.7%) and in the Northeast (63.3%). Of the 25 adult population studies, 68.0% were in outpatient settings, and of the 23 studies providing detailed information on their process, 52.2% used electronic health record entry. Of the 22 studies that describe their screening tool, 15 used institution-specific tools, and only 4 of the remaining 7 studies used identical tools. Of the 20 studies that described their response to positive screenings, 13 provided patients with a paper or electronic referral to a collaborating community partner, while only 6 aided the patient in connecting with community resources.</p><p><strong>Conclusion: </strong>This study found significant variability in screening and response programs for housing instability among US health care providers. A lack of standardized definitions and methodologies hampers effective comparison and implementation of these programs. Future research should focus on standardizing screening methods and measurement of interventions and outcomes to address housing instability.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":"1-10"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142400262","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":"Optimization of a Sterile Processing Department Using Lean Six Sigma Methodology, Staffing Enhancement, and Capital Investment.","authors":"Michael E Natarus, Allison Shaw, Abbey Studer, Charles Williams, Cherie Dominguez, Holdemar Mangual, John Olmstead, Krystal Westmoreland, Tasha Gill, W Zeh Wellington, Derek S Wheeler, Jonathan B Ida","doi":"10.1016/j.jcjq.2024.10.006","DOIUrl":"10.1016/j.jcjq.2024.10.006","url":null,"abstract":"<p><strong>Background: </strong>Many hospitals and surgery centers have focused improvement efforts on operating room inefficiencies. A common inefficiency is missing and unusable surgical instrumentation, which can result in case delays and decreased effectiveness. Lean Six Sigma methodology, a set of process improvement tools focused on the reduction of waste and variation, has been used to identify and correct root causes of missing and unusable instrumentation.</p><p><strong>Methods: </strong>An analysis of current operations was performed within the Sterile Processing Department (SPD). The team assessed physical workflows, including decontamination, assembly, sterilization, and sterile storage, as well as digital processes. The team identified five drivers of defects: (1) staffing and training, (2) inventory management, (3) equipment and SPD physical environment, (4) standard workflows and communication, and (5) governance structure. A root cause was established for each driver, and Lean Six Sigma principles were applied. Two metrics were established to assess accuracy and efficiency in the SPD. First pass yield was defined as the proportion of trays processed that were usable after the first cycle. Tray defect rate was defined as the proportion of requested instruments that were missing or unusable.</p><p><strong>Results: </strong>After implementation, the SPD increased first pass yield from 81.0% to 97.4% (p < 0.001) and reduced the defect rate from 2.2% to < 0.10% (p < 0.001) with sustainment for more than a year.</p><p><strong>Conclusion: </strong>Application of Lean Six Sigma methodology improved tray accuracy in a hospital's SPD. It is feasible and beneficial to apply improvement methodology developed for manufacturing in the hospital setting to reduce missing and unusable instrumentation.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":"33-45"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142824212","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":"Development of a Calculator to Determine Individualized Opioid Doses for Treatment of Vaso-Occlusive Episodes for Sickle Cell Disease in the Emergency Department.","authors":"Patricia L Kavanagh, John J Strouse, Judith A Paice, Stephanie O Ibemere, Paula Tanabe","doi":"10.1016/j.jcjq.2024.10.002","DOIUrl":"10.1016/j.jcjq.2024.10.002","url":null,"abstract":"<p><p>Sickle cell disease (SCD) is a life-limiting multisystem disease primarily affecting individuals of African and Latinx descent. Its most common complication is painful vaso-occlusive episodes (VOEs), which is also the most common reason individuals with SCD seek care in the emergency department (ED). National guidelines recommend the use of standardized approaches to pain management in the ED, preferably using pain management plans tailored to each patient. However, no standard approach to developing these plans exists. This article describes the development of an opioid calculator to help SCD clinicians create individualized plans to better manage acute painful VOE in the ED setting.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":"74-79"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710300","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 Invisible Work to Manage Drug Shortages.","authors":"Erin R Fox","doi":"10.1016/j.jcjq.2024.12.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2024.12.008","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2024-12-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005628","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":"Safety Interventions in Cardiac Anesthesia: A Systematic Review.","authors":"Lauren O'Callaghan, Shane Ahern, Andrea Doyle","doi":"10.1016/j.jcjq.2024.12.004","DOIUrl":"https://doi.org/10.1016/j.jcjq.2024.12.004","url":null,"abstract":"<p><strong>Background: </strong>The cardiac operating room is a complex, high-risk, sociotechnical system. Risks in cardiac surgery and anesthesiology have been extensively categorized, but less is known about effective risk reduction strategies. A comprehensive understanding of effective, evidence-based risk reduction strategies is necessary to improve patient safety in cardiac anesthesia.</p><p><strong>Methods: </strong>An advanced literature search of MEDLINE, CINAHL, Embase, and Web of Science databases was conducted to identify studies involving the introduction of a tool or intervention to improve patient safety and human factors in cardiac anesthesia. Studies were screened independently by two authors applying prespecified inclusion and exclusion criteria. Risk reduction strategies and safety initiatives identified were classified according to the Systems Engineering Initiative for Patient Safety model. Data were extracted using a standardized form and were narratively synthesized.</p><p><strong>Results: </strong>A total of 18 studies were identified for inclusion using preoperative briefing tools, intraoperative checklists, and postoperative handover tools. Preoperative briefing tools were associated with a significant reduction in patient mortality and length of hospital stay and also led to adaptations to planned operation. Intraoperative checklists demonstrated decreased bleeding, mortality, and blood transfusion requirements. Postoperative handover tools were associated with improved information transfer and teamwork.</p><p><strong>Conclusion: </strong>This review identified three categories of tools that may be used to improve patient and organizational outcomes. Many of these tools are simple to introduce and sustainable in the long term and can be readily adapted to different centers.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143059089","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":"Adverse Events Involving Telehealth in the Veterans Health Administration.","authors":"Peter D Mills, Anne Tomolo, Edward E Yackel","doi":"10.1016/j.jcjq.2024.12.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2024.12.002","url":null,"abstract":"<p><strong>Background: </strong>Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.</p><p><strong>Methods: </strong>The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.</p><p><strong>Results: </strong>A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.</p><p><strong>Conclusion: </strong>The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143023579","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}