Joint Commission journal on quality and patient safety最新文献

{"title":"Methodological Approaches for Analyzing Medication Error Reports in Patient Safety Reporting Systems: A Scoping Review","authors":"Olga Tchijevitch PhD, MSc (is a Researcher, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Sebrina Maj-Britt Hansen MSc (is PhD student, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Jesper Hallas MD, PhD (is Professor, Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark.),&nbsp;Søren Bie Bogh PhD, MSc (is Associate Professor, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Alma Mulac PhD, MPharm (is Senior Lecturer, Department of Pharmacy, University of Oslo, and Special Advisor, Pharmacist, Oslo University Hospital.),&nbsp;Sisse Walløe MSc (is a PhD student, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Mette Kring Clausen MSc (is Consultant, Clinical Development, Odense University Hospital, Region of Southern Denmark.),&nbsp;Søren Birkeland MD, PhD (is Professor in Psychiatry- and Health Law, Department of Regional Health Research, Faculty of Health Science, University of Southern Denmark and Forensic Mental Health Research Unit Middlefart (RFM) Please address correspondence to Olga Tchijevitch)","doi":"10.1016/j.jcjq.2024.10.005","DOIUrl":"10.1016/j.jcjq.2024.10.005","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>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.</div></div><div><h3>Conclusion</h3><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"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 PhD (is Professor and Luciano Chair of Health Care Policy, Marxe School of Public and International Affairs, Baruch College, City University of New York.),&nbsp;Diane Gibson PhD (Professor, Marxe School of Public and International Affairs, Baruch College, City University of New York.),&nbsp;Lauren A. Taylor PhD, MDiv, MPH (is Assistant Professor, Department of Population Health, NYU Grossman School of Medicine.),&nbsp;Daniel B. Wolfson MHSA (is Former Executive Vice President and Chief Operating Officer, American Board of Internal Medicine (ABIM) Foundation. Please address correspondence to Jessica Greene)","doi":"10.1016/j.jcjq.2024.09.002","DOIUrl":"10.1016/j.jcjq.2024.09.002","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>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.</div></div><div><h3>Conclusion</h3><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"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":"OA","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 (is Medical Student, Northwestern University Feinberg School of Medicine.),&nbsp;Luis Gago (is Medical Student, Northwestern University Feinberg School of Medicine.),&nbsp;Joshua Garcia (is Medical Student, Northwestern University Feinberg School of Medicine.),&nbsp;Molly Beestrum MLIS (is Head of Research and Information Services, Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine.),&nbsp;Teresa Pollack MS, CPHQ (is Director, Quality Operations, Northwestern Medicine, Chicago;),&nbsp;Lori Post PhD (is Professor, Departments of Emergency Medicine and Medical Social Sciences, and Director, Buehler Center for Health Policy and Economics, Northwestern University Feinberg School of Medicine.),&nbsp;Cynthia Barnard PhD, MBA (formerly Vice President, Quality, Northwestern Medicine, is Assistant Professor, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine.),&nbsp;Mita Sanghavi Goel MD, MPH, FACP (is Professor, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine. Please address correspondence to Mita Sanghavi Goel)","doi":"10.1016/j.jcjq.2024.08.007","DOIUrl":"10.1016/j.jcjq.2024.08.007","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>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.</div></div><div><h3>Conclusion</h3><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"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":"OA","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 DPT, MBA (is Manager, Improvement Consulting, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital, Chicago.),&nbsp;Allison Shaw MPH, MS (is Senior Improvement Consultant, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Abbey Studer MBA (is Senior Director, Quality and Safety, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Charles Williams CSPDT (is Manager, Sterile Processing Department, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Cherie Dominguez CSPDT (is Lead Resource Coordinator, Sterile Processing Department, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Holdemar Mangual MSIHE, MBA (is Senior Director Strategy Execution, Ann & Robert H. Lurie Children's Hospital.),&nbsp;John Olmstead MSN, MBA (is Senior Director, Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Krystal Westmoreland MPS, CSPDT (formerly SPD Educator, Ann & Robert H. Lurie Children's Hospital, is Regional Director, Sterile Processing, Ascension, Chicago.),&nbsp;Tasha Gill MPH (is Manager, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital.),&nbsp;W. Zeh Wellington DNP, RN, NE-BC3 (is Director, Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Derek S. Wheeler MD, MMM, MBA (is Executive Vice President and Chief Operating Officer, Ann & Robert H. Lurie Children's Hospital, and Professor of Pediatrics, Northwestern University Feinberg School of Medicine.),&nbsp;Jonathan B. Ida MD, MBA, FACS (is Attending Physician, Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital, and Associate Professor of Otolaryngology - Head & Neck Surgery, Northwestern University Feinberg School of Medicine. Please address correspondence to Michael E. Natarus)","doi":"10.1016/j.jcjq.2024.10.006","DOIUrl":"10.1016/j.jcjq.2024.10.006","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>After implementation, the SPD increased first pass yield from 81.0% to 97.4% (<em>p</em> &lt; 0.001) and reduced the defect rate from 2.2% to &lt; 0.10% (<em>p</em> &lt; 0.001) with sustainment for more than a year.</div></div><div><h3>Conclusion</h3><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"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 MD (is Associate Professor, Department of Pediatrics, Chobanian & Avedisian School of Medicine, Boston University, and Research Faculty, Center of Excellence in Sickle Cell Disease, Boston Medical Center.),&nbsp;John J Strouse MD, PhD (is Associate Professor, Departments of Medicine and Pediatrics, Duke University School of Medicine, and Hematologist, Duke University Comprehensive Sickle Cell Center.),&nbsp;Judith A. Paice PhD, RN (is Research Professor, Northwestern University Feinberg School of Medicine.),&nbsp;Stephanie O. Ibemere PhD, RN (is Assistant Professor, Duke University School of Nursing.),&nbsp;Paula Tanabe PhD, RN (is Professor, Duke University School of Nursing and Duke University School of Medicine. Please address correspondence to Patricia L. Kavanagh)","doi":"10.1016/j.jcjq.2024.10.002","DOIUrl":"10.1016/j.jcjq.2024.10.002","url":null,"abstract":"<div><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"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":"Reviewer Acknowledgments","authors":"","doi":"10.1016/S1553-7250(24)00373-8","DOIUrl":"10.1016/S1553-7250(24)00373-8","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 80-81"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143142879","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 Implementation Science-Informed Strategies to Improve Transitions of Care for Patients with Venous Thromboembolism","authors":"Elizabeth L. Ciemins PhD, MPH, MA (is Senior Vice President, Research and Analytics, American Medical Group Association (AMGA), Alexandria, Virginia),&nbsp;Cori C. Grant PhD, MBA, MS (is Research Assistant Professor, College of Liberal Arts and Social Sciences and Department of Health Systems and Population Health, University of Houston),&nbsp;Meghana Tallam MPH (is Population Health Research Analyst, AMGA),&nbsp;Cori Rattelman MS (is Senior Research Analyst, AMGA),&nbsp;Curt Lindberg DMan, MHA (is Principal and Senior Consultant, Partners in Complexity, Waitsfield, Vermont),&nbsp;Rae Ann Williams MD, FACP (is Department Chair, Internal Medicine, and Regional Medical Director, Primary Care, HealthPartners Medical Group, Bloomington, Minnesota),&nbsp;Paige S. Christensen NP (is Associate Medical Director, Thrombosis and Anticoagulation, and Director, Clinical Pharmacy Anticoagulation Service, Intermountain Healthcare, Salt Lake City),&nbsp;N. Marcus Thygeson MD, MPH (is Executive Director, Adaptive Health, San Rafael, California. Please address correspondence to Elizabeth L. Ciemins)","doi":"10.1016/j.jcjq.2024.12.007","DOIUrl":"10.1016/j.jcjq.2024.12.007","url":null,"abstract":"<div><h3>Background</h3><div>Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, are common causes of preventable hospital death. Most VTEs diagnosed in the outpatient setting are directly linked to a recent hospitalization or surgery.</div></div><div><h3>Methods</h3><div>A type 2 effectiveness-implementation hybrid study was conducted to develop and implement targeted interventions to improve care for patients with VTE in six US health systems. Primary outcomes included (1) 7-day follow-up after VTE diagnosis (phone calls, office visits); (2) VTE–related hospitalizations or emergency department (ED) visits within 45 days of acute VTE diagnosis; and (3) anticoagulant-associated adverse drug events (ADEs). Qualitative comparative analysis (QCA) identified interventions associated with improved care for patients with VTE.</div></div><div><h3>Results</h3><div>Among 1,265 patients, follow-up within 7 days of an index VTE diagnosis improved from 25.2% to 33.6% (<em>p</em> &lt; 0.0001); among 2,002 patients, hospitalizations/ED visits within 45 days of VTE diagnosis decreased across settings from 7.8% to 6.3% (<em>p</em> = 0.033), and the rate of anticoagulant-associated ADEs remained low (3.1% to 3.4%, <em>p</em> = 0.528). Factors characteristic of improving 7-day follow-up included combinations of (1) safer prescribing and management of anticoagulants and standardized protocols with centralized care processes or (2) safer prescribing and management of anticoagulants with improved care team communication and expanded anticoagulation clinic access for patients prescribed direct oral anticoagulants. Factors associated with 45-day hospitalization/ED visits improvement included high baseline rates of 7-day follow-up, high rates of baseline 45-day hospitalization/ED visits (larger opportunity), improved care team communication, and improved standardization and centralization of protocols.</div></div><div><h3>Conclusion</h3><div>Combinations of interventions, tailored to local context and team dynamics, improved ambulatory follow-up rates and reduced VTE–related utilization. Health systems may benefit from considering novel, implementation science–informed strategies to foster improvement.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 241-251"},"PeriodicalIF":2.3,"publicationDate":"2024-12-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143382403","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":"The Invisible Work to Manage Drug Shortages","authors":"Erin R. Fox PharmD, MHA, BCPS, FASHP (is Associate Chief Pharmacy Officer, Shared Services, University of Utah Health, and Professor (adjunct), Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City. Please address correspondence to Erin R. Fox)","doi":"10.1016/j.jcjq.2024.12.008","DOIUrl":"10.1016/j.jcjq.2024.12.008","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 3","pages":"Pages 165-166"},"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 MB, MSc, FCAI, FJFICMI (Royal College of Surgeons in Ireland, Dublin, and Fellow in Intensive Care Medicine, Department of Anaesthesia and Intensive Care, St. Vincent's University Hospital, Dublin),&nbsp;Shane Ahern MB, MCh, MRCS (Specialist Registrar, Department of Cardiothoracic Surgery, Cork University Hospital, Wilton, Cork, Ireland),&nbsp;Andrea Doyle BSc, PhD (Senior Research Fellow and Honorary Lecturer, Royal College of Surgeons in Ireland.)","doi":"10.1016/j.jcjq.2024.12.004","DOIUrl":"10.1016/j.jcjq.2024.12.004","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>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.</div></div><div><h3>Conclusion</h3><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 293-304"},"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}