Gabrielle Matias MD (is Pulmonary and Critical Care Clinical Fellow, Department of Medicine, Northwestern University Feinberg School of Medicine.), Mengou Zhu MD (is Internal Medicine Physician, Department of Medicine, Northwestern University Feinberg School of Medicine.), Nandita R. Nadig MD, MSCR (is Associate Professor, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine.), John M. Coleman III MD (is Associate Professor, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine.), Michelle Prickett MD, MS (is Associate Professor, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine.), Lindsey Gradone APRN (is Acute Care Nurse Practitioner, Northwestern Memorial Hospital, Chicago.), Susan R. Russell MD (is Associate Professor and Clinical Practice Director, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine. Please address correspondence to Gabrielle Matias)
{"title":"Evaluation of Declined Inter-ICU Transfer Requests to a Tertiary Care Hospital","authors":"Gabrielle Matias MD (is Pulmonary and Critical Care Clinical Fellow, Department of Medicine, Northwestern University Feinberg School of Medicine.), Mengou Zhu MD (is Internal Medicine Physician, Department of Medicine, Northwestern University Feinberg School of Medicine.), Nandita R. Nadig MD, MSCR (is Associate Professor, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine.), John M. Coleman III MD (is Associate Professor, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine.), Michelle Prickett MD, MS (is Associate Professor, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine.), Lindsey Gradone APRN (is Acute Care Nurse Practitioner, Northwestern Memorial Hospital, Chicago.), Susan R. Russell MD (is Associate Professor and Clinical Practice Director, Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine. Please address correspondence to Gabrielle Matias)","doi":"10.1016/j.jcjq.2025.12.003","DOIUrl":"10.1016/j.jcjq.2025.12.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 3","pages":"Pages 127-129"},"PeriodicalIF":2.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146040969","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}
Hana Shamsan MSc, PHHP (is Research Fellow, National Institute for Health and Care Research (NIHR) Yorkshire and Humber Patient Safety Research Collaboration, Bradford Institute of Health Research, Bradford, United Kingdom.), Andrew John Rea PhD (is Associate Professor, Griffith University, Brisbane, Australia.), Alison Bravington PhD, MSc (is Senior Research Fellow, NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Institute of Health Research.), Daisy Halligan MSc (is Senior Research Fellow, NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Institute of Health Research.), David Alldred PhD (is Professor of Medicines Use and Safety, University of Leeds.), Robbie Foy PhD, MSc (is Clinical Professor of Primary Care, University of Leeds.), Rebecca Lawton PhD (is Professor of Psychology of Healthcare, University of Leeds. Please address correspondence to Hana Shamsan)
{"title":"Decluttering for Safety: Can We Simply Apply Approaches Used in De-Implementing Low-Value Care?","authors":"Hana Shamsan MSc, PHHP (is Research Fellow, National Institute for Health and Care Research (NIHR) Yorkshire and Humber Patient Safety Research Collaboration, Bradford Institute of Health Research, Bradford, United Kingdom.), Andrew John Rea PhD (is Associate Professor, Griffith University, Brisbane, Australia.), Alison Bravington PhD, MSc (is Senior Research Fellow, NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Institute of Health Research.), Daisy Halligan MSc (is Senior Research Fellow, NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Institute of Health Research.), David Alldred PhD (is Professor of Medicines Use and Safety, University of Leeds.), Robbie Foy PhD, MSc (is Clinical Professor of Primary Care, University of Leeds.), Rebecca Lawton PhD (is Professor of Psychology of Healthcare, University of Leeds. Please address correspondence to Hana Shamsan)","doi":"10.1016/j.jcjq.2025.12.004","DOIUrl":"10.1016/j.jcjq.2025.12.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 3","pages":"Pages 133-137"},"PeriodicalIF":2.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146118926","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}
Frances Hand (is DPhil Candidate and Assistant Lecturer in Medical Law, University of Oxford, Law Faculty) , Morganne Wilbourne (is DPhil Candidate, Department of Women’s and Reproductive Health, University of Oxford) , Sophie McAllister MSc, BSc (Hons), RM (is Consultant Midwife, Maternity Department, Oxford University Hospitals), Nadia Muspratt-Tucker MBBS, LLM (is Consultant Obstetrician, Maternity, Department Oxford University Hospitals), Jonathan Herring DPhil (is Professor of Law, Law Faculty, University of Oxford), Sujay Chakravarti MBBS (is Consultant Obstetrician, Maternity Department, Oxford University Hospitals), Meena Bhatia MBBS, MSc (is Consultant Obstetrician, Maternity Department, Oxford University Hospitals, Please address correspondence to Morganne Wilbourne)
{"title":"Perceptions of Consent for Operative Vaginal Delivery: A Service Evaluation","authors":"Frances Hand (is DPhil Candidate and Assistant Lecturer in Medical Law, University of Oxford, Law Faculty) , Morganne Wilbourne (is DPhil Candidate, Department of Women’s and Reproductive Health, University of Oxford) , Sophie McAllister MSc, BSc (Hons), RM (is Consultant Midwife, Maternity Department, Oxford University Hospitals), Nadia Muspratt-Tucker MBBS, LLM (is Consultant Obstetrician, Maternity, Department Oxford University Hospitals), Jonathan Herring DPhil (is Professor of Law, Law Faculty, University of Oxford), Sujay Chakravarti MBBS (is Consultant Obstetrician, Maternity Department, Oxford University Hospitals), Meena Bhatia MBBS, MSc (is Consultant Obstetrician, Maternity Department, Oxford University Hospitals, Please address correspondence to Morganne Wilbourne)","doi":"10.1016/j.jcjq.2025.12.002","DOIUrl":"10.1016/j.jcjq.2025.12.002","url":null,"abstract":"<div><h3>Background</h3><div>One in five women giving birth for the first time will have an operative vaginal delivery (OVD). Despite this frequency, a considerable number of women and birthing people report feeling unprepared for OVD. This incongruence spurred our decision to further understand our service users’ perspectives on the consent process for OVD. In feedback by a local Maternity and Neonatal Voices Partnership, some maternity service users reported that they felt the consent process for OVD was inadequate, leaving them confused and upset after birth.</div></div><div><h3>Methods</h3><div>As part of a quality improvement project, an anonymous questionnaire was devised and disseminated both within the National Health Service (NHS) Maternity Unit and online. Women and birthing people were asked to fill in the survey if they had experienced OVD in the past two years. Thematic analysis was conducted based on their responses.</div></div><div><h3>Results</h3><div>A total of 88 responses were collected. Two core themes were identified: (1) the majority of women (65.9%) felt under-informed about OVD, and (2) women wanted to know more about OVD in advance of labor. A notable minority (10/86, 11.6%) claim to have consented to procedures that they did not fully understand.</div></div><div><h3>Conclusion</h3><div>Our project reflects a growing body of literature interrogating the challenges with discussing consent “in-the-moment,” as a one-time decision. Consideration must be given to ways in which we can strengthen understanding and comprehension within this process. Although the current consent model is useful in some medical procedures, the unique circumstances of childbirth may require something more. The consent process could be adapted so women can more fully engage with the conversation.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 3","pages":"Pages 115-126"},"PeriodicalIF":2.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146131821","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":"Fundamentals of Health Care Improvement: A Guide to Improving Your Patient’s Care, Fifth Edition","authors":"","doi":"10.1016/j.jcjq.2026.01.001","DOIUrl":"10.1016/j.jcjq.2026.01.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 3","pages":"Pages 138-139"},"PeriodicalIF":2.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147416424","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":"Response to: Medication-Related Safety Events","authors":"Lauren R. Bangerter PhD","doi":"10.1016/j.jcjq.2025.12.005","DOIUrl":"10.1016/j.jcjq.2025.12.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 3","pages":"Pages 140-141"},"PeriodicalIF":2.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146040993","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}
Muhammad Saqib MBBS, MD (is Intern, Department of Medicine, Khyber Teaching Hospital, Peshawar, Pakistan. Please address correspondence to Dr. Muhammad Saqib)
{"title":"Rapid Implementation of Guideline-Based Care for Acute Exacerbations of COPD in a Low-Resource Setting: An Improvement Brief","authors":"Muhammad Saqib MBBS, MD (is Intern, Department of Medicine, Khyber Teaching Hospital, Peshawar, Pakistan. Please address correspondence to Dr. Muhammad Saqib)","doi":"10.1016/j.jcjq.2025.11.004","DOIUrl":"10.1016/j.jcjq.2025.11.004","url":null,"abstract":"<div><h3>Background</h3><div>Guideline-based management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) improves patient outcomes, yet adherence in low- and middle-income country (LMIC) settings remains inconsistent. Baseline audits at a tertiary care center in Pakistan revealed significant gaps in pharmacologic management, patient education, and discharge planning, reflecting underutilization of evidence-based standards such as GOLD and NICE guidelines. Variation in AECOPD inpatient care was linked to inconsistent use of standardized care bundles, incomplete documentation, and limited integration of clinical guidelines into the electronic health record (EHR).</div></div><div><h3>Methods</h3><div>The hospital implemented a six-week, rapid-cycle quality improvement intervention combining (1) EHR–embedded prompts aligned with international standards, (2) targeted educational sessions for physicians and nurses, and (3) distribution of concise clinical pocket guides. Five process indicators were measured in 50 consecutive patients preintervention and postintervention: systemic corticosteroid use, appropriate antibiotic prescribing, smoking cessation counseling, spirometry ordering, and documented discharge planning. Data were analyzed using descriptive statistics and chi-square tests for categorical variables.</div></div><div><h3>Results</h3><div>Adherence improved for systemic corticosteroid prescription (54% to 88%), appropriate antibiotic prescribing (62% to 90%), smoking cessation counseling (22% to 74%), spirometry ordering (18% to 52%), and documented discharge planning (40% to 82%) (all <em>p</em> < 0.05). No adverse workflow disruptions or patient safety issues were identified. Follow-up at three months suggested sustained improvements.</div></div><div><h3>Conclusion</h3><div>In a resource-constrained LMIC hospital, a pragmatic, guideline-driven intervention using EHR prompts and focused education achieved rapid improvements in AECOPD inpatient care processes. This approach may be adaptable to other settings with similar constraints. Differences in clinical infrastructure, documentation systems, and staffing between Pakistan and the United States should be considered when translating these results internationally.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 102-104"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145751812","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}
David R. Nerenz PhD (is Director Emeritus, Center for Health Policy and Health Services Research, Senior Staff, Department of Neurosurgery, Henry Ford Health, Detroit), Kari Jarabek BSN, RN (is Senior QI Lead, Michigan Spine Surgery Improvement Collaborative (MSSIC), Department of Neurosurgery, Henry Ford Health), Jamie Myers BSN, RN, MBA (is CQI Program Manager, MSSIC, Department of Neurosurgery, Henry Ford Health), Thomas Leyden MBA (is Director, Value Partnerships, Blue Cross Blue Shield of Michigan), John D. Syrjamaki MPH (is Analytic Advisor, Michigan Value Collaborative, University of Michigan Health System), Tanima Basu MA, MS (is Senior Analyst, Michigan Value Collaborative, University of Michigan Health System), Mark Bradshaw MSc (is Director, Michigan Value Collaborative, University of Michigan Health System), Jianhui Hu PhD (is Biotatistician, Center for Health Policy and Health Services Research, Henry Ford Health), Doris Tong MD, MSc (is Senior Staff, Department of Neurosurgery, Henry Ford Health), Ilyas Aleem MD, MS (is Orthopaedic Surgeon and Clinical Associate Professor, Departments of Orthopedic Surgery and Neurosurgery, University of Michigan Medical School), Victor Chang MD (is Co-Director, Minimally Invasive and Deformity Spine Surgery, Department of Neurosurgery, Henry Ford Health), Jad Khalil MD (is Orthopaedic Surgeon, Michigan Orthopaedic Surgeons, Southfield, Michigan), Miguelangelo Perez-Cruet MD (is Neurosurgeon, Michigan Minimally Invasive Neurosurgical Institute, Waterford, Michigan), Muwaffak Abdulhak MD (is Director, Neurosurgery Spine Program, Department of Neurosurgery, Henry Ford Health. Please address correspondence to David R. Nerenz)
{"title":"Cost Savings Realized Through a Statewide Quality Improvement Collaborative for Spine Surgery","authors":"David R. Nerenz PhD (is Director Emeritus, Center for Health Policy and Health Services Research, Senior Staff, Department of Neurosurgery, Henry Ford Health, Detroit), Kari Jarabek BSN, RN (is Senior QI Lead, Michigan Spine Surgery Improvement Collaborative (MSSIC), Department of Neurosurgery, Henry Ford Health), Jamie Myers BSN, RN, MBA (is CQI Program Manager, MSSIC, Department of Neurosurgery, Henry Ford Health), Thomas Leyden MBA (is Director, Value Partnerships, Blue Cross Blue Shield of Michigan), John D. Syrjamaki MPH (is Analytic Advisor, Michigan Value Collaborative, University of Michigan Health System), Tanima Basu MA, MS (is Senior Analyst, Michigan Value Collaborative, University of Michigan Health System), Mark Bradshaw MSc (is Director, Michigan Value Collaborative, University of Michigan Health System), Jianhui Hu PhD (is Biotatistician, Center for Health Policy and Health Services Research, Henry Ford Health), Doris Tong MD, MSc (is Senior Staff, Department of Neurosurgery, Henry Ford Health), Ilyas Aleem MD, MS (is Orthopaedic Surgeon and Clinical Associate Professor, Departments of Orthopedic Surgery and Neurosurgery, University of Michigan Medical School), Victor Chang MD (is Co-Director, Minimally Invasive and Deformity Spine Surgery, Department of Neurosurgery, Henry Ford Health), Jad Khalil MD (is Orthopaedic Surgeon, Michigan Orthopaedic Surgeons, Southfield, Michigan), Miguelangelo Perez-Cruet MD (is Neurosurgeon, Michigan Minimally Invasive Neurosurgical Institute, Waterford, Michigan), Muwaffak Abdulhak MD (is Director, Neurosurgery Spine Program, Department of Neurosurgery, Henry Ford Health. Please address correspondence to David R. Nerenz)","doi":"10.1016/j.jcjq.2025.11.010","DOIUrl":"10.1016/j.jcjq.2025.11.010","url":null,"abstract":"<div><h3>Background</h3><div>Quality improvement (QI) collaboratives represent a potentially powerful approach to QI, patient experience, and cost savings. In this article the authors present an estimate of direct cost savings to payers from reductions in the rate of a single adverse event (urinary retention) in the context of the Michigan Spine Surgery Improvement Collaborative (MSSIC).</div></div><div><h3>Methods</h3><div>Data from the MSSIC clinical registry were used to calculate reductions in rates of urinary retention (with or without readmission) from a 2016 baseline period to a 2017–2024 QI intervention period. The number of those events averted, combined with dollar cost estimates of payments for treatment of adverse events from the Michigan Value Collaborative (MVC) was used to estimate direct cost savings to payers.</div></div><div><h3>Results</h3><div>Direct cost savings to payers for the 2017–2024 period were estimated at $66.8 million.</div></div><div><h3>Conclusion</h3><div>Given the combination of direct cost savings of $66.8 million and potential indirect cost savings to employers and caregivers of $130–$180 million, collaborative QI initiatives aimed at reducing rates of adverse outcomes after spine surgery can produce significant cost savings for payers, employers, and patients.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 67-74"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145933384","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}
Harshini Ravi (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles), Aleeque Marselian MS (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center), Falisha Kanji MS (is Program Administrator, Department of Surgery, Cedars-Sinai Medical Center), Tara N. Cohen PhD (is Director, Surgical Safety and Human Factors Research, Department of Surgery, Cedars-Sinai Medical Center. Please address correspondence to Tara N. Cohen)
{"title":"What Saves a Patient? A Human Factors Approach to Understanding Near Misses in the ICU","authors":"Harshini Ravi (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles), Aleeque Marselian MS (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center), Falisha Kanji MS (is Program Administrator, Department of Surgery, Cedars-Sinai Medical Center), Tara N. Cohen PhD (is Director, Surgical Safety and Human Factors Research, Department of Surgery, Cedars-Sinai Medical Center. Please address correspondence to Tara N. Cohen)","doi":"10.1016/j.jcjq.2025.11.008","DOIUrl":"10.1016/j.jcjq.2025.11.008","url":null,"abstract":"<div><h3>Background</h3><div>The confluence of rapidly changing clinical conditions, cognitive demands, and interdisciplinary collaboration in intensive care units (ICUs) creates conditions where minor lapses in communication, judgment, or coordination can result in preventable patient harm. Because near-miss events within healthcare systems are underreported and under-analyzed, evidence-based interventions to improve system safety are limited. Therefore, this study aims to understand the conditions that enable near misses using a human factors approach, as well as identify the mechanisms that intercept them before they escalate to harm.</div></div><div><h3>Methods</h3><div>This study analyzed near-miss events reported between January 1 and December 31, 2024, from inpatient critical care units at a large academic medical center in southern California. Events were analyzed to identify contributing factors using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). Events were subclassified and evaluated to identify the intervention source that prevented the escalation from near miss to harm.</div></div><div><h3>Results</h3><div>A total of 288 near-miss events were reported, and 396 contributing factors were identified. Most events involved routine violations (<em>n</em> = 106, 26.77%), challenges with operational processes (<em>n</em>=105, 26.52%), or skill-based errors (<em>n</em> = 79, 19.95%). Nurses (<em>n</em> = 119, 41.32%) and medication scanners (<em>n</em> = 91, 31.60%) were the most frequent sources of successful intervention.</div></div><div><h3>Conclusion</h3><div>Near-miss events offer actionable insight into safety vulnerabilities and safeguards within ICU workflows. Targeted interventions, such as improving cross-disciplinary coordination, updating operational processes to reflect practical care delivery, standardizing safety checks, and encouraging the use of reporting systems, can foster a culture of shared accountability and continuous quality improvement.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 57-66"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145846337","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":"Medication Reconciliation and Patient Safety in India: A Prospective Observational Study at a Tertiary Care Hospital","authors":"Ashish Kumar Dogra PharmD , Shivani Juneja MBBS, MD , Josmy Maria Job PharmD","doi":"10.1016/j.jcjq.2025.11.005","DOIUrl":"10.1016/j.jcjq.2025.11.005","url":null,"abstract":"<div><h3>Background</h3><div>Medication reconciliation is a critical process aimed at preventing medication errors and discrepancies during hospitalization. Discrepancies, particularly unintentional ones, can occur during admission, intrahospital transfers, and discharge, potentially compromising patient safety. This study aimed to assess the prevalence of unintentional medication discrepancies at admission, transition, and discharge phases of care.</div></div><div><h3>Methods</h3><div>A prospective observational study was conducted on 200 inpatients in a tertiary care hospital. Medication reconciliation was assessed at three phases: admission, transition, and discharge. Discrepancies were classified and analyzed based on frequency and type, and associations with demographics and comorbidities were explored.</div></div><div><h3>Results</h3><div>Most patients were aged 60–74 years (51.5%) with hypertension (71.5%) being the most prevalent comorbidity. Reconciliation was performed in 87.0% of patients at admission (170 discrepancies), 93.1% at transition (23 discrepancies), and 83.5% at discharge (266 discrepancies). Discharge had the highest rate of unintentional discrepancies per patient (1.37), followed by admission (0.85) and transition (0.23).</div></div><div><h3>Conclusion</h3><div>This study highlights the significance of medication reconciliation in preventing medication discrepancies, particularly at discharge. The findings support the need for standardized reconciliation protocols and stronger interdisciplinary collaboration to enhance patient safety.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 95-99"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145793859","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}
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