Joint Commission journal on quality and patient safety最新文献

{"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}

{"title":"Patient Engagement in Safety: Are We There Yet?","authors":"Tejal Gandhi MD MPH (is Chief Safety and Transformation Officer, Press Ganey Associates LLC),&nbsp;Urmimala Sarkar MD MPH (is Professor of Medicine, University of California, San Francisco)","doi":"10.1016/j.jcjq.2025.02.006","DOIUrl":"10.1016/j.jcjq.2025.02.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 447-450"},"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":"Overcoming Professional Silos and Threats to Psychological Safety: A Conceptual Framework for Successful Team-Based Morbidity and Mortality Conferences","authors":"Brian A. Campos MD (is Safe Surgery/Safe Systems Fellow, Ariadne Labs, T.H. Chan School of Public Health, Boston, and General Surgery Resident PGY3, Department of Surgery, Beth Israel Deaconess Medical Center, Boston.),&nbsp;Mary E. Brindle MD, MPH (is Principal Research Scientist, Ariadne Labs, and Professor, Department of Surgery, Cumming School of Medicine, University of Calgary.),&nbsp;Emily Cummins PhD (is Senior Qualitative Specialist, Ariadne Labs.),&nbsp;Alexander Hannenberg MD (is Core Faculty Member, Safe Surgery/Safe Systems Program, Ariadne Labs, and Adjunct Clinical Professor, Department of Anesthesiology, Tufts University School of Medicine.),&nbsp;Danielle Salley MS, BSN, RN (is Manager, Department of Quality and Clinical Projects, Children's Memorial Hermann Hospital, Houston.),&nbsp;Yves Sonnay MSPH (is Assistant Director of Project Management, Safe Surgery/Safe Systems Program, Ariadne Labs.),&nbsp;Aubrey Samost-Williams MD, MS (is Associate Faculty Member, Ariadne Labs, and Assistant Professor, Department of Anesthesia, Critical Care and Pain Medicine, University of Texas Health Science Center, Houston. Please address correspondence to Brian A. Campos)","doi":"10.1016/j.jcjq.2025.02.005","DOIUrl":"10.1016/j.jcjq.2025.02.005","url":null,"abstract":"<div><h3>Background</h3><div>Adverse events in health care are frequently discussed in morbidity and mortality conferences. However, while health care has evolved to be delivered by interprofessional teams, morbidity and mortality conferences have been slow to include all team members. One particularly potent barrier to conducting an interprofessional team–based morbidity and mortality conference is a lack of psychological safety among team members. Clinicians from various professions bring differences in perspectives, culture, perceived hierarchy, and assumptions about other professions. These perspectives may bring value to the interprofessional team–based morbidity and mortality conferences, but they may also degrade psychological safety.</div></div><div><h3>Methods</h3><div>This report explores the link between professional silos and psychological safety among the health care team in the context of an interprofessional team–based morbidity and mortality conference using the perioperative space as an example. The authors draw on the concept of team fault lines—a potential division along a team members' characteristics that can divide a group or team into subgroups. The roots of perioperative professional silos, which define these fault lines, are then traced to the historical context of the health care professions, the individual development of professional identities, and the role of organizations in maintaining these silos. From these observations, a framework for describing these foundations is proposed, which the authors use to evaluate the broader teamwork-in-health-care literature to generate specific recommendations to promote psychological safety in team-based morbidity and mortality conferences.</div></div><div><h3>Conclusion</h3><div>This framework can be used to postulate strategies for improving the ability for teams to learn from morbidity and mortality conferences. However, future work remains in implementing and studying these recommendations.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 415-422"},"PeriodicalIF":2.3,"publicationDate":"2025-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019454","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":"Nutrition Optimization in Early Dialysis","authors":"Aditya A. Khanijo MBBS (is Research Fellow, Department of Medicine, Mayo Clinic, Jacksonville),&nbsp;Lorenzo Olivero MD (is Research Fellow, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Mireille H. Hamdan DCN, RDN, LD/N (is Clinical Nutrition Manager, Department of Nutrition Services, Mayo Clinic Jacksonville),&nbsp;Karen D. Stoner BSN, RN (is Nurse Manager, Critical Care, Mayo Clinic Jacksonville),&nbsp;Angela C. Majerus MHA (is Manager, Outpatient Practices Administration, Mayo Clinic Health System (Austin)),&nbsp;Dimple B. Patel RN (is Nurse Manager, Inpatient Dialysis, Mayo Clinic Jacksonville),&nbsp;Shannon Allen MHA (is Senior Patient Experience Advisor, Department of Quality, Mayo Clinic Jacksonville),&nbsp;Christopher L. Trautman MD (is Nephrologist, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Lisa M. Heath DNP, RN, NE-BC (is Nursing Quality Specialist, Nursing Administration, Mayo Clinic Jacksonville),&nbsp;Lindsay L. Meeusen MSN, RN, NPD-BC (is Nurse Manager, Nursing Administration, Mayo Clinic Rochester),&nbsp;C.J. Hemeyer APRN (is Nephrology Nurse Practitioner, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Steph R. Jenkins MSN, RN, CNL (is Nursing Team Leader, Division of Regional Medicine, Mayo Clinic Jacksonville),&nbsp;Pranvera Dautaj APRN (is Nephrology Nurse Practitioner, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Maria M. Rose MHA (is Associate Director, Department of Food Services, Mayo Clinic Jacksonville),&nbsp;Erlinda M. Flores RN (is Registered Nurse, Inpatient Dialysis, Mayo Clinic Jacksonville),&nbsp;MaQuita D. McGhee DNP, MSN, RN (is Nursing Education Specialist, Nursing Administration, Mayo Clinic Jacksonville),&nbsp;Pablo Moreno Franco MD (is Internist and Chair of Critical Care, Department of Transplantation, Mayo Clinic Jacksonville),&nbsp;Jennifer B. Cowart MD (is Internist and Chair of Quality, Department of Medicine, Mayo Clinic Jacksonville. Please address correspondence to Jennifer B. Cowart)","doi":"10.1016/j.jcjq.2025.02.004","DOIUrl":"10.1016/j.jcjq.2025.02.004","url":null,"abstract":"<div><h3>Background</h3><div>Protein-energy wasting (PEW) syndrome is a common condition among patients suffering from end-stage renal disease (ESRD) receiving intermittent hemodialysis (IHD). Hospital nutrition barriers such as delayed meals and iatrogenic fasting can negatively affect patients’ experiences and contribute to long-standing nutritional deficits in at-risk patients. This project aimed to improve nutrition provision to inpatients with early IHD appointments by 50% (relative increase) without increasing IHD start time delays.</div></div><div><h3>Methods</h3><div>The Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) methodology was used to guide the overall framework for process improvement, while specific improvements were implemented using Plan-Do-Study-Act (PDSA) cycles. Baseline data were analyzed for early morning appointments (5:00 <span>a.m.</span>–6:00 <span>a.m.</span>), and fishbone and Pareto charts were used to identify key barriers to nutrition availability. PDSA cycles were implemented to improve nutrition provision. Chi-square tests were conducted to assess significant changes in the percentage of patients reporting improved nutrition provision and reduced delays in dialysis start times.</div></div><div><h3>Results</h3><div>Baseline data showed that 38.6% of early IHD patients with diet orders at one tertiary care center received breakfast prior to their appointment. Stakeholder analysis and Pareto charts revealed that the mismatch between IHD start times and early meal tray delivery was a root cause. The first PDSA cycle adjusted nursing workflows, substituting early meals with bento snack boxes, achieving 54.2% nutrition provision. Following patient feedback, protein shakes were added, increasing provision to 93.8%. IHD start time delays decreased from 24.6% at baseline to an average of 10.2%, with these improvements sustained beyond 30 days postintervention.</div></div><div><h3>Conclusion</h3><div>The use of quality improvement methodology effectively improved nutrition delivery for high-risk patients and was associated with reduced hemodialysis start time delays and enhanced organizational efficiency. This project addressed a specific concern relating to patients receiving dialysis due to baseline rates of undernutrition and barriers to providing nourishment in the hospital. Future studies should focus on further analysis of patients on dialysis and expand to include other hospitalized subpopulations at risk for undernutrition, to optimize and generalize these interventions more broadly.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 389-397"},"PeriodicalIF":2.3,"publicationDate":"2025-02-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143991179","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 MS (is Doctoral Candidate in Systems Modeling and Analysis, Department of Mathematics and Applied Mathematics, Virginia Commonwealth University (VCU)),&nbsp;David M. Chan PhD (is Professor, Department of Mathematics and Applied Mathematics, VCU),&nbsp;Laura Ellwein Fix PhD (is Associate Professor, Department of Mathematics and Applied Mathematics, VCU),&nbsp;Melissa Chouinard MD (is Director, Medication Safety, VCU Health, Richmond, Virginia, and Associate Professor, Division of Hospital Medicine, Department of Internal Medicine, VCU),&nbsp;Teresa M. Salgado MPharm, PhD (is Director, Center for Pharmacy Practice Innovation, VCU School of Pharmacy, and Associate Professor, Department of Pharmacotherapy and Outcomes Science, VCU),&nbsp;Le Kang PhD (is Associate Professor, Department of Biostatistics, School of Public Health, VCU),&nbsp;Gonzalo Bearman MD, MPH (is Professor, Department of Internal Medicine, and Chief, Division of Infectious Diseases, VCU. Please address correspondence to Helen Harris)","doi":"10.1016/j.jcjq.2025.02.001","DOIUrl":"10.1016/j.jcjq.2025.02.001","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>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.</div></div><div><h3>Conclusion</h3><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 398-404"},"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}