Joint Commission journal on quality and patient safety最新文献

{"title":"Reasons for eCQM–Identified Concurrent Opioid and Benzodiazepine Prescribing at Discharge: A Cohort Study","authors":"Lauren Zabel MD (is Chief Resident, Department of Internal Medicine, Carver College of Medicine, University of Iowa.), James Willey MD, MSE (is Associate Professor, Department of Internal Medicine, Carver College of Medicine, University of Iowa.), Jennifer McDanel PhD, MS (is Quality and Safety Specialist, University of Iowa Hospitals and Clinics.), Ethan Kuperman MD (is Clinical Professor, Department of Internal Medicine, Carver College of Medicine, University of Iowa. Please address correspondence to Lauren Zabel)","doi":"10.1016/j.jcjq.2025.11.009","DOIUrl":"10.1016/j.jcjq.2025.11.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 100-101"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145846329","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Effect of Transitional Services on 30-Day Avoidable Hospital Readmission Following Inpatient Rehabilitation Facility Admission","authors":"Megan Kennelly MD (formerly Quality Improvement Chief Resident, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation, Charlotte, North Carolina, is Assistant Professor, Department of Orthopaedic Surgery, Duke University School of Medicine),&nbsp;Zana Percy MD, PhD (is Resident, Warren Alpert Medical School, Brown University),&nbsp;Jessica Kurtz MD (is Spinal Cord Injury Fellow, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation),&nbsp;Sima Desai MD (is Program Director, Brain Injury Medicine Fellowship Program, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation, and Assistant Professor, Department of Orthopedic Surgery and Rehabilitation, Wake Forest University),&nbsp;Shanti Pinto MD, MSCS (is Faculty Member, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts. Please address correspondence to Megan Kennelly)","doi":"10.1016/j.jcjq.2025.11.003","DOIUrl":"10.1016/j.jcjq.2025.11.003","url":null,"abstract":"<div><h3>Background</h3><div>The study aimed to evaluate the effect of the Transitional Services Clinic (TSC), a clinic dedicated to time-limited care for patients after discharge from the hospital, on 30-day potentially avoidable readmissions (PARs) following acute inpatient rehabilitation.</div></div><div><h3>Methods</h3><div>This retrospective cohort study and post hoc analysis was conducted at a single hospital-affiliated inpatient rehabilitation facility. The research team collected data from patients discharged between January and November 2021.</div></div><div><h3>Results</h3><div>Of the 1,116 patients discharged from inpatient rehabilitation during the study time frame, 55 received transitional services through the TSC. There was no statistically significant difference in 30-day readmission rates between the TSC (7.3%) and non-TSC groups (9.0%). Patients who were referred to TSC but declined services had a readmission rate of 33.3%. The TSC was a protective factor in this subset, in that those who were eligible but declined services had a 6.16 greater odds of readmission within 30 days (95% confidence interval [CI] 1.24–34.71).</div></div><div><h3>Conclusion</h3><div>In this study, 30-day hospital readmission rates were similar between patients who received transitional services after inpatient rehabilitation and those who did not receive services. More research is needed to identify patients at high-risk of readmission that may benefit from dedicated transitional services at the time of inpatient rehabilitation discharge.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 80-86"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145751831","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":"Assessment of Instrument Utilization in Cesarean Births: Taking a Step Toward Sustainability","authors":"Charlotte M. ter Haar MD (formerly Resident, Department of Obstetrics & Gynecology, University of Illinois College of Medicine, Chicago, is Urogynecology Fellow, University of California, Irvine.),&nbsp;Quetzal A. Class PhD (is Research Associate Professor, and Director of Residency Research, Department of Obstetrics & Gynecology, University of Illinois College of Medicine.),&nbsp;Lopa K. Pandya MD, MS (is Associate Professor, and Director of Benign Gynecology Perioperative Surgery, Department of Obstetrics & Gynecology, University of Illinois College of Medicine. Please address correspondence to Charlotte ter Haar, [email protected])","doi":"10.1016/j.jcjq.2025.11.007","DOIUrl":"10.1016/j.jcjq.2025.11.007","url":null,"abstract":"<div><h3>Background</h3><div>As an exploration of tray optimization, the authors examined the instrument utilization rates for cesarean sections, as well as factors that may be associated with the number of instruments used. Tray optimization is one avenue for improving healthcare sustainability.</div></div><div><h3>Methods</h3><div>From an urban academic hospital, investigators prospectively collected data on which instruments from the tray were used in cesarean sections. An instrument was considered used if it touched a surgeon’s hand during the procedure. The authors also documented whether the case was a primary or repeat cesarean birth; was scheduled, urgent, or emergent; and whether the birth was a primary or twin gestation. Cohort differences were examined using chi-square and analysis of variance (ANOVA) analyses using SPSS.</div></div><div><h3>Results</h3><div>A total of 28 cases were included: 12 primary and 16 repeat cesarean births, with 11 scheduled, 13 urgent, and 4 emergent cases. Of the 54 instruments on the tray, 8 were used ≤ 25.0% of the time, and an additional 8 instruments were used ≤ 50.0% of the time. Total instrument utilization rates did not differ between primary and repeat cases. The highest number of Ochsner artery forceps were used in emergent cases, while the fewest were used in urgent cases (<em>F</em>[2,25] = 3.474, <em>p</em> = 0.047]. The use of either one or both 5.1 cm Rich retractors was significantly higher for urgent than for scheduled or emergent cases (Χ² [2] = 6.31, <em>p</em> = 0.043).</div></div><div><h3>Conclusion</h3><div>Based on current instrument utilization rates in cesarean sections, there are opportunities for tray optimization with positive downstream environmental and financial impacts.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 75-79"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145793713","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":"Suboptimal Diagnostic Decisions In Hospitalized Patients with Fever: A Prospective Record Review with Physician Interviews","authors":"Jacky Hooftman MSc (is PhD Candidate, Department of Public and Occupational Health, Amsterdam UMC, Amsterdam, the Netherlands, and Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands.),&nbsp;Jonne J. Sikkens MD, PhD (is Internist, Department of Internal Medicine. Amsterdam UMC.),&nbsp;Nienke van Wingerden MD (is Internist, Acibadem International Medical Center, Amsterdam, The Netherlands.),&nbsp;Djoeke G. Beekman MD (is Internist, Acibadem International Medical Center, The Netherlands.),&nbsp;Martine C. de Bruijne MD, PhD (is Professor, Department of Public and Occupational Health, Amsterdam UMC, and Director, Amsterdam Public Health Institute.),&nbsp;Cordula Wagner MA, PhD (is Professor, Department of Public and Occupational Health, Amsterdam UMC, and Executive Director, Netherlands Institute for Health Services Research (Nivel), Utrecht, the Netherlands.),&nbsp;Laura Zwaan PhD (is Associate Professor, Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands)","doi":"10.1016/j.jcjq.2025.11.006","DOIUrl":"10.1016/j.jcjq.2025.11.006","url":null,"abstract":"<div><h3>Background</h3><div>The medical diagnostic process is vulnerable to suboptimal decision-making (that is, decisions with any deviation from an optimal diagnostic process) due to its complex nature. It is unknown how these suboptimal diagnostic decisions and other measures of diagnostic safety (diagnostic error, diagnostic discrepancy) relate to each other.</div></div><div><h3>Methods</h3><div>The authors prospectively included a convenience sample of 53 hospitalized patients with fever between February and May 2023. After discharge, independent internal medicine physicians reviewed their medical records to identify suboptimal diagnostic decisions and diagnostic errors. When such suboptimal decisions were observed, involved physicians were interviewed about the thought processes behind these decisions. Established tools and taxonomies were used to identify and categorize suboptimal diagnostic decisions, diagnostic errors, and diagnostic discrepancies.</div></div><div><h3>Results</h3><div>The authors initially identified a total of 110 suboptimal diagnostic decisions in 38 of 53 cases (71.7%). After the physician interviews, 29 cases with suboptimal decisions remained (54.7%), with a total of 72 suboptimal diagnostic decisions across those cases (median of 2 suboptimal decisions per case; interquartile range 1–4). Cases with a higher number of suboptimal diagnostic decisions had significantly higher rates of diagnostic error and diagnostic discrepancy. No significant association between diagnostic error and diagnostic discrepancy were found. Almost all suboptimal decisions were human, and most took place during assessment of the patient and diagnostic testing.</div></div><div><h3>Conclusion</h3><div>Cases with more suboptimal diagnostic decisions were associated with higher rates of diagnostic error and diagnostic discrepancy, but the level of overlap between the three was relatively low, suggesting that these reflect different concepts of diagnostic safety and should be treated as such. Future research should incorporate physician interviews to enrich understanding and account for contextual factors.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 87-94"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145800109","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-Related Safety Events","authors":"Herman Joseph Johannesmeyer PharmD, BCPS (is Health Sciences Associate Clinical Professor, University of California, Irvine School of Pharmacy & Pharmaceutical Sciences),&nbsp;Genene Salman PharmD, BCCCP, BCPS, CNSC (is Associate Professor, Marshall B. Ketchum University College of Pharmacy, Fullerton, California),&nbsp;Tiffany Khieu PharmD (is Assistant Professor, Marshall B. Ketchum University College of Pharmacy. Please address correspondence to Herman Joseph Johannesmeyer)","doi":"10.1016/j.jcjq.2025.11.002","DOIUrl":"10.1016/j.jcjq.2025.11.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Page 105"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145751862","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":"Impact of Note-Extracted Blood Pressures on Measured Hypertension Control Performance","authors":"Jonathan A. Handler MD (is Senior Fellow, Innovation, Clinical Intelligence and Advanced Data Lab, OSF HealthCare, Peoria, Illinois, and at the time of the study, Adjunct Associate Professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine.),&nbsp;Tiaranesha Jackson MD, MPH (is Dermatology Resident, Department of Internal Medicine - Section of Dermatology, Cook County Health, Chicago, Illinois, and earlier during this work, Preliminary Internal Medicine Resident, Department of Internal Medicine, University of Chicago Medical Center (Endeavor Health), Evanston, Illinois, and Medical Student, University of Illinois College of Medicine Peoria.),&nbsp;Kyle Espejo MD (is Internal Medicine Resident, Department of Internal Medicine, Rush University Medical Center, Chicago, and earlier during this work, Medical Student, University of Illinois College of Medicine Peoria.),&nbsp;Jeremy McGarvey MS (is Senior Statistician, Department of Healthcare Analytics, OSF HealthCare.),&nbsp;Ethan C. Handler (performed this work as Independent Researcher, Boston.),&nbsp;Mark A. Meeker DO (is Vice President and Chief Medical Officer, OSF SMMC/HFMC/SLMC, OSF HealthCare. Please address correspondence to Jonathan A. Handler.)","doi":"10.1016/j.jcjq.2025.10.007","DOIUrl":"10.1016/j.jcjq.2025.10.007","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 44-48"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145793899","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 Code Blue, Rapid Response, and Emergency Response Safety in the Veterans Health Administration: Using a Combined Proactive Risk Assessment (CPRA) Approach to Detect Failure Modes and Identify Improvement Actions","authors":"John A. Bender MSIRIA, MBA, MHA, ACHE (Health Systems Specialist, Veterans Health Administration (VHA) National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan),&nbsp;Peter D. Mills PhD, MS (Psychologist, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan),&nbsp;Stephen F. Kulju MS, CCE (Associate Director for Engineering and Recalls Programs, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan),&nbsp;James R. Turner (Supervisory Program Analyst, Statistics, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan. Please address correspondence to John A. Bender)","doi":"10.1016/j.jcjq.2025.10.005","DOIUrl":"10.1016/j.jcjq.2025.10.005","url":null,"abstract":"<div><h3>Background</h3><div>Healthcare professionals acknowledge that medical emergencies may occur any time; however, many remain unaware of the potential for systems such as equipment to unexpectedly fail. Within healthcare organizations, a patient’s condition can rapidly deteriorate, leading to decompensation and risk of mortality. Responders to code blue, rapid response, or other medical emergency responses may not be able to detect potential critical system failures during an event or be aware of actions or interventions that can be implemented to prevent these events.</div></div><div><h3>Methods</h3><div>The authors used a Combined Proactive Risk Assessment (CPRA) approach to investigate failure modes (FMs) within the code blue, rapid response, and medical emergency response processes. The study reviewed proactive risk assessments (PRAs) from 13 Veterans Health Administration (VHA) hospitals and reactive risk assessments (RRAs) such as patient safety reports and root cause analyses from 172 hospitals.</div></div><div><h3>Results</h3><div>Analysis of the RRAs revealed 1,149 FMs. Failures occurred during initial patient evaluation (15.4%), when calling the code team (15.1%), and during the code team response to the code (13.5%). The majority of FMs occurred from disruptions to safeguards (barriers and controls) (47.6%), from equipment issues (22.5%) and from communication failures (14.5%). This study also compiled a list of actions from root cause analyses to mitigate future risks and harm.</div></div><div><h3>Conclusion</h3><div>The CPRA method provided a comprehensive risk analysis of the code blue, rapid response, and medical emergency response processes and identified potential solutions to these failures.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 9-25"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145633601","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":"Evaluating a Disease-Specific Look-Back Trigger Methodology vs. Traditional Screening for Diagnostic Errors in the Emergency Department","authors":"Suresh K. Pavuluri MD, MPH (is Assistant Professor and Associate Director of Quality and Patient Safety, Department of Emergency Medicine, Yale School of Medicine.),&nbsp;Rohit B. Sangal MD, MBA (is Assistant Professor, Department of Emergency Medicine, Yale School of Medicine, and Associate Medical Director, Yale New Haven Adult Emergency Department.),&nbsp;Craig Rothenberg MPH (is Statistician, Department of Emergency Medicine, Yale School of Medicine.),&nbsp;Arjun Venkatesh MD, MBA, MHS (is Professor and Chair, Department of Emergency Medicine, Yale School of Medicine.),&nbsp;Richard Andrew Taylor MD, MHS (is Professor and Vice Chair of Research and Innovation, Department of Emergency Medicine, University of Virginia.),&nbsp;John Sather MD (is Associate Professor and Director of Quality and Pateint Safety, Department of Emergency Medicine, Yale School of Medicine. Please address correspondence to Suresh K. Pavuluri)","doi":"10.1016/j.jcjq.2025.10.002","DOIUrl":"10.1016/j.jcjq.2025.10.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 42-43"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145523371","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":"Long-Term Sustainability of QI Interventions: Outcomes in Opioid Prescribing for Postoperative Care","authors":"Andrii Khomiak MD, PhD (is Resident, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Joshua D. Billings MD (is Resident, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Victoria Huynh MD (formerly Resident, Department of Surgery, University of Colorado School of Medicine, is Assistant Professor, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham.),&nbsp;Laura D. Leonard MD (is Resident, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Viviane L. Abud MD (is Colorectal Surgery Fellow, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Teresa L. Jones MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Salvador Rodriguez Franco MD (is Resident, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Ioannis A. Ziogas MD (is Resident, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Kyle Bata MS (is Quality Data Analyst, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Nicole Christian MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Marco Del Chiaro MD, PhD (is Professor, Department of Surgery, and Chief, Division of Surgical Oncology, University of Colorado School of Medicine.),&nbsp;Ethan Cumbler MD (is Professor, and Director of Quality, Department of Surgery, University of Colorado School of Medicine.),&nbsp;Sarah E.A. Tevis MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine. Please address correspondence to Sarah E. A. Tevis, [email protected].)","doi":"10.1016/j.jcjq.2025.11.001","DOIUrl":"10.1016/j.jcjq.2025.11.001","url":null,"abstract":"<div><h3>Background</h3><div>The opioid epidemic remains a critical public health challenge. This study aimed to assess the sustainability of improved opioid prescribing practices following the implementation of an intervention in the postoperative clinical setting.</div></div><div><h3>Methods</h3><div>Conducted as a quality improvement (QI) initiative at an academic medical center, this pre-post interventional study spanned four phases: preimplementation (October 2019–June 2020), implementation (July–December 2020), and postimplementation (January–December 2021), followed by the sustainability phase (January 2022–November 2023). The authors examined opioid-naïve patients ≥ 18 years undergoing procedures under specified Current Procedural Terminology (CPT) codes. Interventions included education and monthly feedback reports based on Opioid Prescribing Engagement Network (OPEN) guidelines. Descriptive statistics were used to summarize data; chi-square test was used to compare categorical variables.</div></div><div><h3>Results</h3><div>The postimplementation cohort consisted of 2,513 patients vs. 2,290 in the preimplementation group, with statistically similar baseline characteristics. We observed a compliance increase to 68.9% vs. 45.1% (<em>p</em> &lt; 0.001). The sustainability cohort included 4,976 patients and had a further increase to 80.1% compliance compared to the postimplementation cohort (<em>p</em> &lt; 0.001). Residents (nonresident prescribers include advanced practice providers and attending surgeons) were more likely to be prescribing providers in postimplementation vs. sustainability cohort, 39.6% vs. 22.2% (<em>p</em> &lt; 0.001). Subanalysis was conducted across 12 consecutive months comparing the period with a consistent distribution of performance reports with the period when no performance reminders were sent for the previous month (November 2022–May 2023 vs. June–November 2023). The compliance rates for these two subperiods did not differ (82.04% vs. 81.98%, respectively, <em>p</em> = 0.97).</div></div><div><h3>Conclusion</h3><div>This study’s data demonstrate that a well-structured QI initiative can lead to sustained improvements in opioid prescribing practices and “enculturation” to maintain long-term change within an institution.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 26-32"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145768074","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":"Myth Busters: A Discussion of the Misconceptions Surrounding Patient Handoffs","authors":"Elizabeth H. Lazzara PhD (is Associate Professor, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida),&nbsp;Sabina M. Patel MS (is Graduate Research Assistant and Doctoral Candidate, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University),&nbsp;Scott I․ Tannenbaum PhD (is President, The Group for Organizational Effectiveness, Albany, New York),&nbsp;Rosemarie Fernandez MD (is Clinical Professor, Department of Emergency Medicine, University of Florida College of Medicine),&nbsp;Eduardo Salas MS, PhD (is Professor, Department of Psychological Sciences, Rice University),&nbsp;Joseph R. Keebler MA, PhD (is Professor, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University. Please address correspondence to Elizabeth A. Lazzara)","doi":"10.1016/j.jcjq.2025.10.001","DOIUrl":"10.1016/j.jcjq.2025.10.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 49-53"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145556945","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}