Joint Commission journal on quality and patient safety最新文献

{"title":"Reflections on a Missed Medication and the System’s Response: The Red Box","authors":"Courtney Desy BSN, RN, OCN (is Oncology Infusion Nurse, Stronger Than Chemo Foundation Inc., Maynard, Massachusetts. Please address correspondence to Courtney Desy)","doi":"10.1016/j.jcjq.2026.02.005","DOIUrl":"10.1016/j.jcjq.2026.02.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 259-261"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147529173","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":"Beyond Awareness: Building Human Factors Capability in Healthcare Through Shared Resources","authors":"Tara N. Cohen PhD (is Director of Surgical Safety and Human Factors Research, and Associate Professor, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles.), Yuval Bitan PhD (is Associate Professor, Department of Health Policy and Management, Ben-Gurion University of the Negev, Israel. Please address correspondence to Tara N. Cohen)","doi":"10.1016/j.jcjq.2026.03.009","DOIUrl":"10.1016/j.jcjq.2026.03.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 253-258"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147698677","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":"Personalized Video Education in Surgical Consent: Lessons from a Diverse Safety-Net Population","authors":"Diego Monasterio MD (is General Surgery Resident, Community Memorial Hospital, Ventura, California.),&nbsp;Nicole Hanson DO (is General Surgery Resident, Community Memorial Hospital, Ventura, California),&nbsp;Graal Diaz PhD, MSN, MA (is Research Support Manager, Ventura County Medical Center, Ventura, California),&nbsp;June Yao DO (is General Surgery Resident, Community Memorial Hospital, Ventura, California),&nbsp;Javier Romero MD (is Program Director, General Surgery Residency, Community Memorial Healthcare, Ventura, California),&nbsp;Shawn Steen MD (is Associate Program Director, General Surgery Residency, Community Memorial Healthcare, Ventura, California. Please address correspondence to Diego Monasterio)","doi":"10.1016/j.jcjq.2026.02.002","DOIUrl":"10.1016/j.jcjq.2026.02.002","url":null,"abstract":"<div><h3>Background</h3><div>A key component of shared decision-making (SDM) is education. This article explores the role of videos as supplements to traditional decision-making, focusing on custom videos for surgical patients</div></div><div><h3>Methods</h3><div>This study aims to assess the impact of customized video education on traditional surgical consent procedures. This is a prospective cohort study that took place at a county safety-net hospital in California, involving patients undergoing surgical treatment from August 2023 through January 2025. After surgical consultation, each patient received an electronically sent customized educational video addressing indications, procedures, and risks in the patient’s preferred language. After watching the videos, SDM was evaluated using the CollaboRATE scale and questions evaluating satisfaction with video education.</div></div><div><h3>Results</h3><div>A total of 204 patients participated: 134 English speakers (EN) and 70 Spanish speakers (SP). SP were older, with 48.6% aged 45–64 versus 21.6% of EN (p &lt; 0.001). Educational differences existed, with 39.6% of EN reporting college degrees compared to 11.4% among SP (<em>p</em> &lt; 0.001). The video types watched were 52% gallbladder, 20.6% breast, 16.2% skin surgery, 5.4% appendix, and 3.9% others. Both groups (94.8% of EN and 97.1% SP) expressed preference for video education over written. EN achieved CollaboRATE Top Scores more frequently (67.9% vs. 54.3%, <em>p</em> = 0.08). EN outperformed SP in knowing available treatment options (100.0% vs. 91.0%, <em>p</em> &lt; 0.01), understanding benefits (95.5% vs. 82.9%, <em>p</em> &lt; 0.01), and recognizing risks and side effects (91.7% vs. 80.0%, <em>p</em> = 0.05).</div></div><div><h3>Conclusion</h3><div>Customized video education for surgery leads to high rates of understanding treatment options, benefits, and risks. However, disparities between English and Spanish speakers reveal that language plays a critical role in patient engagement and perceived support. This suggests a need for targeted improvements in educational resources for Spanish-speaking patients to ensure equitable access to information and support.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 208-215"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147592343","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":"Validation of the Charité Alarm Fatigue Questionnaire (CAFQa–Eng) for Use with English-Speaking Critical Care Clinicians","authors":"Halley Ruppel PhD, RN (is Research Associate Professor, Department of Family and Community Health, University of Pennsylvania School of Nursing, and Core Faculty, Clinical Futures, a Center of Emphasis in the CHOP Research Institute, Children’s Hospital of Philadelphia),&nbsp;Elena Hinz (is Physician, and Doctoral Candidate, Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany),&nbsp;Nicolas Frey MSc (is Human Factors Engineer, and Data Scientist, Institute of Medical Informatics, Charité - Universitätsmedizin Berlin),&nbsp;Maximilian Markus Wunderlich Dr. rer. medic. (is a process manager at Charité - Universitätsmedizin Berlin),&nbsp;Akira-Sebastian Poncette PD, Prof. Dr. med. (is Professor, Department of Anesthesiology and Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, and Deputy Director, Institute of Medical Informatics, Charité - Universitätsmedizin Berlin. Please address correspondence to Halley Ruppel)","doi":"10.1016/j.jcjq.2026.02.004","DOIUrl":"10.1016/j.jcjq.2026.02.004","url":null,"abstract":"<div><h3>Background</h3><div>Alarm fatigue from medical device alarms is a persistent patient safety challenge in critical care. However, quantification of alarm fatigue is inhibited by lack of standardized measurement tools. The Charité Alarm Fatigue Questionnaire (CAFQa) is a measure of alarm fatigue originally developed and validated in German. Here, the authors report on the English-language validation of CAFQa (CAFQa–Eng).</div></div><div><h3>Methods</h3><div>To establish face validity of the English translation, an expert panel was convened, and the authors conducted cognitive interviews with US–based critical care nurses. Items were iteratively edited for clarity and cultural relevance. The study team then conducted a cross-sectional survey of English-speaking clinicians for psychometric evaluation. Confirmatory factor analysis (CFA) was used to assess construct validity based on the original 2-scale structure (alarm stress and alarm coping).</div></div><div><h3>Results</h3><div>Of 412 survey submissions, 248 (60.2%) were eligible for analysis; 82.3% from nurses, 9.3% from physicians, and 2.8% from advanced practice providers. The CFA chi-square test was statistically significant (χ²(26) = 101.84, <em>p</em> &lt; 0.001), but other indices indicated adequate fit (Comparative Fit Index = 0.957, Tucker-Lewis Index = 0.940, Root Mean Square Error of Approximation = 0.079, and Standardized Root Mean Squared Residual = 0.077). Participants’ total CAFQa–Eng scores correlated with self-reported alarm fatigue (r = 0.59, <em>p</em> &lt; 0.001, 95% confidence interval [CI] 0.50–0.67), indicating convergent validity.</div></div><div><h3>Conclusion</h3><div>CAFQa–Eng is a valid instrument for measuring the construct of alarm fatigue (as defined for development of the original CAFQa instrument) among English-speaking critical care clinicians. CAFQa–Eng may be useful for quality improvement and research efforts to make relative comparisons across groups (for example, units, roles). Research is needed to identify actionable thresholds and recommended frequency of use, as well as to further validate the instrument outside nursing and in non–critical care settings.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 216-224"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147627870","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":"Push Notifications Can Be Used for Safe and Timely Communication of Critical Lab Results in the Emergency Department","authors":"Dhara P. Amin MD (is Assistant Professor, Department of Medicine, Section of Emergency Medicine, University of Chicago.),&nbsp;Matthew Bonomo MD (is Emergency Medicine Administration Fellow, Department of Medicine, Section of Emergency Medicine, University of Chicago.),&nbsp;Lorena Chesebro MBA (is Director of Laboratory Quality, Compliance and Safety, University of Chicago Medical Center.),&nbsp;Charlotte Farley MD (is Resident Physician, Department of Medicine, Section of Emergency Medicine, University of Chicago.),&nbsp;Melissa S. Pessin MD, PhD (is Medical Director, Hyde Park Clinical Laboratories and Alternative Site Testing, and Professor, Department of Pathology, University of Chicago. Please address correspondence to Dhara P. Amin)","doi":"10.1016/j.jcjq.2026.03.004","DOIUrl":"10.1016/j.jcjq.2026.03.004","url":null,"abstract":"<div><h3>Background</h3><div>Prompt notification of critical results is important for both patient safety and laboratory and hospital accreditation. Although many institutions still rely on manual pages and phone calls to notify care teams of critical results, automation could improve the efficacy of this process. Some electronic health records offer the ability to configure automatic push notifications to a provider’s secure text pager or clinical application that allows for a closed-loop result acknowledgment. It is not known if push notifications for critical results can successfully reach providers, improve acknowledgment times, or allow for sufficiently high acknowledgment rates to meet accreditation standards.</div></div><div><h3>Methods</h3><div>The authors conducted a continuous quality improvement initiative to develop a pathway that uses initial push notifications for critical results for patients in the emergency department (ED).</div></div><div><h3>Results</h3><div>A prior pathway of using solely phone calls for critical result notifications had a mean acknowledgment time of 2.93 minutes, and 97.5% of results were acknowledged within 30 minutes. The new pathway that used an initial push notification had a longer mean acknowledgment time (8.20 minutes), and fewer results acknowledged within 30 minutes (93.3%). Though the new pathway was slower than only using phone calls, it maintained an acknowledgment rate greater than 90%, in line with some accreditation standards. It also saved the medical laboratory scientist previously making these calls roughly 8.5 hours of phone calls over the five-month study period.</div></div><div><h3>Conclusion</h3><div>There are additional opportunities to iterate on this process. For the ED setting, push notifications represent a promising innovation for critical result notifications, but the best way to deploy them remains unknown and is likely clinical context dependent.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 225-230"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147698671","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":"Implementation of a Clinical Event Debriefing Program in a Large Urban Tertiary Care Center","authors":"Svetlana Duvidovich DO (is Pediatric Emergency Medicine Fellow, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York.),&nbsp;Julie Goodfriend MD (is Pediatric Resident, Department of Pediatrics, Icahn School of Medicine at Mount Sinai.),&nbsp;Patrick J. Maher MD (is Associate Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai.),&nbsp;Samuel Wurzelmann MD, MBA (formerly Emergency Medicine Resident, Icahn School of Medicine at Mount Sinai, is Emergency Medicine Physician, Mission Health, Chapel Hill, North Carolina.),&nbsp;Shefali Trivedi MD (is Emergency Medicine Physician, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai.),&nbsp;Jared Kutzin DNP, PhD, MS, MPH, RN, FSSH, FAAN (is Professor, Departments of Emergency Medicine & Medical Education Icahn School of Medicine at Mount Sinai; Senior Director Simulation, Teaching, and Research (STAR) Center, Department of Emergency Medicine, The Mount Sinai Hospital.),&nbsp;Judith E. Mathieu MD (is Assistant Professor of Pediatric Critical Care Medicine, Department of Pediatrics, Icahn School of Medicine at Mount Sinai.),&nbsp;Lauren E. Zinns MD, FAAP (is Associate Professor of Pediatrics, Emergency Medicine and Medical Education, The Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine)","doi":"10.1016/j.jcjq.2026.03.005","DOIUrl":"10.1016/j.jcjq.2026.03.005","url":null,"abstract":"<div><h3>Background</h3><div>A clinical event debriefing (CED) is a brief discussion among team members following a critical event. Despite the significant benefits of CED, including improving provider wellness and patient care, many barriers have been identified to facilitation. CED programs in single hospital units have been designed to minimize these barriers. Implementation of a multidisciplinary hospitalwide CED program including pediatric and adult departments has not previously been described. The authors describe the implementation and maintenance of a hospitalwide CED program developed to standardize the conduct of a CED across multiple departments.</div></div><div><h3>Methods</h3><div>The hospitalwide CED program was implemented through a three-pronged approach. First, the study team created a multimodal training available to all clinical providers to learn how to facilitate a CED. Second, a hospitalwide post-event debriefing tool was distributed. Third, the authors formed a multidepartment CED collaborative that reviewed documented CEDs and assisted with practice solutions.</div></div><div><h3>Results</h3><div>Seventy providers across adult and pediatric departments completed facilitator training, with significant improvement in self-reported comfort facilitating CED (median 2/5 pre-training vs. 4/5 post-training, <em>p</em> = 0.002). From July 2022 to July 2025, 309 CEDs were documented. The CED collaborative identified recurrent themes in teamwork, communication, and systems processes informing departmental practice solutions.</div></div><div><h3>Conclusion</h3><div>A hospitalwide, multidisciplinary CED program is feasible and improves provider comfort with facilitation while standardizing debriefing practices. Integration of structured training, a scripted tool with documentation, and a collaborative review process support sustainability and drive practice improvements across departments. A framework to implement and sustain a CED program, while mitigating barriers, is described here.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 239-248"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147771986","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":"Healthcare Ethics Is a Key Underrecognized Step on the Road to High Reliability","authors":"Lindsay R. Semler DNP, RN, CCRN, HEC-C (is Executive Director, Ethics Service, Brigham and Women’s Hospital, Boston, and Faculty, Department of Medicine, Brigham and Women’s Hospital.),&nbsp;William B. Feldman MD, DPhil, MPH (is an Associate Professor of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology, and Allergy, Department of Medicine, University of California, Los Angeles. Please address correspondence to Lindsay Semler)","doi":"10.1016/j.jcjq.2026.03.006","DOIUrl":"10.1016/j.jcjq.2026.03.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 249-252"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147698674","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":"From Sentinel Event to Systemwide Improvement: Development of the Behavioral Health No Harm Index","authors":"Norman Ng MA, LCADC, CPHQ (is Vice President of Quality and Safety, MaineHealth, Portland, Maine),&nbsp;Linda Durst MD (is Professor, Department of Psychiatry, University of Connecticut School of Medicine, and Medical Director, Psychiatric Outpatient Clinic, UConn Health),&nbsp;Omar Hasan MBBS, MPH, MS (is Chief Quality Officer, MaineHealth),&nbsp;Mike Sirois BA (is Associate Business Intelligence Developer, MaineHealth),&nbsp;Tania Strout PhD, RN, MS (is Director of Research, Department of Emergency Medicine, MaineHealth, and Professor, Department of Emergency Medicine, Tufts University School of Medicine. Please address correspondence to Norman Ng)","doi":"10.1016/j.jcjq.2026.02.003","DOIUrl":"10.1016/j.jcjq.2026.02.003","url":null,"abstract":"<div><h3>Background</h3><div>Behavioral health has largely remained outside the mainstream of harm measurement science. Traditional safety measurement tools such as the Global Trigger Tool or the Preventable Harm Index are not adapted for psychiatric care, where harm may manifest differently than traditional acute medical care settings. The aim of this study was to design, implement, and evaluate a Behavioral Health No Harm Index (BH-NHI) across inpatient, outpatient, and residential settings to enhance error detection, increase safety event reporting, develop a baseline for harm measurement, and establish a standardized review process for psychiatric care.</div></div><div><h3>Methods</h3><div>Following a sentinel event in summer 2022, a multidisciplinary team developed the BH-NHI through literature review, stakeholder engagement, and iterative refinement. The index was implemented across all MaineHealth Behavioral Health (MHBH) settings with high reliability organization (HRO) training, staff education, and the launch of the “Good Catch” initiative. Analysis of safety event reports across three fiscal years (FYs)—October 2021 through September 2024—examined baseline trends in harm events, severity levels, and event categories.</div></div><div><h3>Results</h3><div>Safety event submissions increased 88.2% from FY22 to FY24, reflecting our goal to increase harm event reporting. Concurrently, the rate of BH-NHI events decreased from 26.7 to 18.3 per 1,000 safety events submitted. Variation in the BH-NHI event frequency represents early descriptive findings during initial implementation, and additional data will be required to establish a casual harm reduction.</div></div><div><h3>Conclusion</h3><div>The BH-NHI provides a replicable framework for behavioral health organizations to systematically increase detection and review harm events while building upon available literature related to harm measurement science and fostering a proactive safety culture aligned with HRO principles.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 201-207"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147690220","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":"Reengineering Super-Facilitators: A Systems-Level Framework for Advancing Global Antimicrobial Stewardship Implementation","authors":"Rajesh Prasad Jayaswal PhD (is Associate Professor, University Institute of Allied Health Sciences, Chandigarh University, Mohali, India.),&nbsp;Soumendu Bhattacharya PhD (is Professor, Apex Institute of Management, Chandigarh University, Mohali, India.),&nbsp;Kanchan Kholiya PhD (is Associate Professor, Department of Physiotherapy (Neuro-Psychosomatic Disorders), Teerthanker Mahaveer University, Moradabad, India.),&nbsp;Manti Debnath PhD (is Assistant Professor, Sharda School of Allied Health Sciences, Sharda University, Greater Noida, India.),&nbsp;Rahul Kumar Ranawat MBBS, MD (is Internal Medicine Specialist, Department of Emergency, Indian Institute of Technology, Delhi, India. Please address correspondence to Rajesh Prasad Jayaswal)","doi":"10.1016/j.jcjq.2026.03.001","DOIUrl":"10.1016/j.jcjq.2026.03.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 5","pages":"Pages 262-263"},"PeriodicalIF":2.4,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147698743","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":"Enhancing Quality in Patient Transfers: A Dashboard Approach to Track Interhospital Medical ICU Transfers","authors":"Rohan Bhargava (is Medical Student, Northwestern University Feinberg School of Medicine),&nbsp;Susan R. Russell MD (is Associate Professor and Clinical Practice Director, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine),&nbsp;Gabrielle Matias MD (is Pulmonary Disease & Critical Care Medicine Fellow, Department of Medicine, Northwestern University Feinberg School of Medicine),&nbsp;Michelle L. Prickett MD, MS (is Associate Professor, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine),&nbsp;Anthony Rescan (is Senior Analytics Developer, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine),&nbsp;Ben Tan (is Data Engineer, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine),&nbsp;Jacqueline Zimmerman MS, MBA (is System Director, Clinical Documentation and Quality Utilization, Department of Medicine, Northwestern University Feinberg School of Medicine),&nbsp;Vi-An Nguyen MHA (formerly Program Manager, Canning Thoracic Institute, Northwestern Medicine, is Senior Consultant, Oak Street Health, Chicago),&nbsp;Charles Rank MHA (is System Director, Canning Thoracic Institute),&nbsp;Momen M. Wahidi MD, MBA (is Professor, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, and Medical Director, Canning Thoracic Institute),&nbsp;Jesse Meyer MBA (is Vice President Operations, Northwestern Medicine),&nbsp;Preeti Kansal MD (is Associate Professor, Division of Cardiology, Northwestern University Feinberg School of Medicine),&nbsp;Diane B. Wayne MD (is Professor, Department of Medicine, Northwestern University Feinberg School of Medicine, and Chief Medical Officer, Northwestern Memorial Hospital, Chicago),&nbsp;Nandita R. Nadig MD, MS (is Associate Professor, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine. Please address correspondence to Rohan Bhargava)","doi":"10.1016/j.jcjq.2026.01.004","DOIUrl":"10.1016/j.jcjq.2026.01.004","url":null,"abstract":"<div><h3>Background</h3><div>Interhospital transfers account for 1.5 million inpatient admissions annually. Yet post-transfer patient outcomes and resource utilization vary significantly. Visualizing these data can help health systems optimize transfer practices. The objective of this project was to develop a novel Interhospital Medical ICU (MICU) Transfer Dashboard displaying data on incoming medical MICU transfers to a tertiary health system and create a blueprint for other hospitals to follow.</div></div><div><h3>Methods</h3><div>After establishing a multidisciplinary group of physicians, nurses, administrators, data analysts, and information technology engineers, the authors used guidance from the Academic Medical Center Patient Safety Organization Inter-hospital Transfer Task Force to identify quality metrics and key variables relevant to MICU transfers. Using the Epic Clarity database and electronic health records, the authors built automated algorithms to identify transferred patients. Indicators were used to calculate relevant metrics, allowing for aggregation and visualization of desired variables.</div></div><div><h3>Results</h3><div>The developed MICU Transfer Dashboard allowed visualization of key metrics, including (1) number of transfers confirmed/canceled, (2) cancellation reasons, (3) mortality within 48 hours of transfer, (4) changes in level of care within 24 hours of transfer (downgrades/upgrades to ICU, medical/surgical floors), and (5) time from request to transfer. Additional variables added during iterative refinement included patient acuity (Sequential Organ Failure Assessment [SOFA] score), length of stay after transfer, organ transplant procedure encounter, and discharge dispositions.</div></div><div><h3>Conclusion</h3><div>To the authors’ knowledge, this is among the first published reports of a dashboard capturing quality metrics for interhospital MICU transfers. Early learnings from the dashboard have identified process gaps, refined workflows, and leveraged technology to optimize transfers at the health system.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Pages 187-193"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147306178","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}