The Joint Commission journal on quality improvement最新文献

{"title":"A Qualitative Analysis of Medication Use Variance Reports","authors":"David M. Krol MD,&nbsp;Lisa Stump MS, RPh (Associate Director of Pharmacy Services),&nbsp;Diane Collins RN, MS, CPHQ (Project Coordinator),&nbsp;Sarah A. Roumanis RN (Project Coordinator),&nbsp;Martha J. Radford MD (System Director)","doi":"10.1016/S1070-3241(02)28031-1","DOIUrl":"10.1016/S1070-3241(02)28031-1","url":null,"abstract":"<div><h3>Background</h3><p>This report of a process change utilized a qualitative approach to data analysis to improve medication use safety in a large hospital. The two goals were to design a strategy to analyze the qualitative data and to use that strategy to uncover previously unclassified medication use variance patterns that could be prevented. A multidisciplinary team performed the analysis in an effort to improve the quality and yield of the approach.</p></div><div><h3>Methods</h3><p>All medication use variance, incident, and event reports from Yale-New Haven Hospital during April-June 2000 were collected (<em>N</em> = 264). A 20% random sample of the reports was distributed to a five-member evaluation group (a pharmacist, two nurses, and two physicians) for independent qualitative analysis and coding. An initial coding framework was produced using a consensus process. This coding framework was applied to another sample, and the consensus and coding processes were repeated until no new domains were identified.</p></div><div><h3>Results</h3><p>Ten general medication use variance domains were determined. In addition, 21 subdomains among the various general domains were determined.</p></div><div><h3>Discussion</h3><p>Utilizing a multidisciplinary team and a qualitative strategy of analysis improved patient safety efforts. This combination led to the discovery of new variance domains, causes, and opportunities to intervene and ultimately prevent medication use variances. This analytic approach is widely applicable, adaptable, and dynamic. The design and results of this report improve on a strictly quantitative approach to medication use variance analysis. The approach employed by this report will be used to improve medication use safety within the Yale-New Haven Health System.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 6","pages":"Pages 316-323"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28031-1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461964","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 Safety Case Management Committee: Expanding the Avenues for Addressing Patient Safety","authors":"Marcia M. Piotrowski RN, MS (Clinical Risk Manager),&nbsp;Sanjay Saint MD, MPH,&nbsp;Daniel B. Hinshaw MD","doi":"10.1016/S1070-3241(02)28029-3","DOIUrl":"10.1016/S1070-3241(02)28029-3","url":null,"abstract":"<div><h3>Background</h3><p>The greatest gains in patient safety are likely to result from using a multifaceted framework of safety enhancement initiatives. The Safety Case Management Committee, which has been meeting at the VA Ann Arbor Healthcare System since early 1999, is one such initiative; it is directed at broadening organizational involvement in creating a safer clinical environment. The committee’s objective is to address fundamental issues related to patient safety and quality of care. The committee aims to develop thematic approaches to improving major systems triggered by unsafe or risky incidents that demonstrate either iatrogenic harm or risk of harm to patients.</p></div><div><h3>Committee structure and functioning</h3><p>Committee members represent top management, middle management, and front-line employees, but membership is weighted toward those in direct patient care roles. The group also includes a consumer representative. Critical issues are addressed through rigorous case discussion, literature review, and expert consultation.</p></div><div><h3>Results</h3><p>In a 3-year period (Feb 1999 through Dec 2001), 85% of the group’s 45 recommendations have been implemented. Topics have included reducing medication errors during emergency procedures, enhancing palliative care services, minimizing the risk of missed x-ray findings, optimizing anticoagulation management, reducing the risk of vascular catheter-related infection, and improving pain management.</p></div><div><h3>Summary</h3><p>The Safety Case Management Committee has successfully addressed actual and potential errors and has implemented strategic safety improvements. The dedicated efforts of highly motivated clinicians who serve on such a committee can augment and enhance risk management advances made through other channels.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 6","pages":"Pages 296-305"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28029-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461933","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":"A Web-Based Program for Implementing Evidence-Based Patient Safety Recommendations","authors":"Nancy L. Greengold MD, MBA","doi":"10.1016/S1070-3241(02)28034-7","DOIUrl":"10.1016/S1070-3241(02)28034-7","url":null,"abstract":"<div><h3>Background</h3><p>In response to increasing national concerns about medical safety, product developers from a health services research and software group recently created a commercial Web-based program to address a wide variety of patient safety issues in the acute care setting. They also wanted to provide a program with credible, referenced, and up-to-date content, not just a technology infrastructure for reporting errors.</p></div><div><h3>Safety Optimizer™</h3><p>This Web-based program, which has evolved over time, now features seven modules for assessing organizational risk and for implementing strategies to reduce risk. The Literature Module features detailed synopses that are graded and organized into summary statements to provide recommendations for improving patient safety. The Implementation/Tracking Module includes numerous risk-reduction strategies. The Incident Reporting Module enables the collection of data at the point of care on a variety of incidents, using either paper-based or on-line forms. Other modules offer opportunities to assess adherence to JCAHO patient safety standards, forecast the benefits of certain evidence-based guidelines, evaluate staff competency, and obtain information from a variety of key safety Web sites.</p></div><div><h3>Experience to date</h3><p>The program is in use at more than 30 health care organization facilities and systems. It is still too early to provide quantitative data on the impact of this program on patient safety.</p></div><div><h3>Conclusions</h3><p>It is hoped that vendor solutions such as the one described in this article will help organizations develop a practical and effective framework for addressing the wide range of issues in patient safety.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 6","pages":"Pages 340-348"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28034-7","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56462018","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 Safety Checklist Program: Creating a Culture of Safety in Intensive Care Units","authors":"Marcia M. Piotrowski RN, MS (Clinical Risk Manager),&nbsp;Daniel B. Hinshaw MD","doi":"10.1016/S1070-3241(02)28030-X","DOIUrl":"10.1016/S1070-3241(02)28030-X","url":null,"abstract":"<div><h3>Background</h3><p>In 1999 the VA Ann Arbor Healthcare System began a safety checklist program to help build a culture of safety among nurses, respiratory therapists, and unit maintenance providers in the intensive care units (ICUs). Program objectives were to (a) create the opportunity for each participating staff member to view his or her work and unit environment in a broader safety context; (b) establish clear, concise, and measurable standards that staff would identify and value as important safety factors; (c) develop a data collection methodology that would minimize confirmation bias; and (d) correct safety deficits immediately.</p></div><div><h3>Data management</h3><p>Staff measure compliance with safety standards twice daily and record results on a form specifically designed for the project. Data are transferred to a spreadsheet, and graphic presentations are posted in each ICU. Staff periodically adjust both standards and data collection procedures.</p></div><div><h3>Summary</h3><p>Staff can articulate how the program is making the ICU a safer environment. Nursing response to a recent major error reflects the growth that has occurred since the program’s inception. Safety checks performed by ICU staff are critical in maintaining a constant level of safety. Although the effect on untoward events was not measured, the potential for incidents, including medication and intravenous errors, nosocomial infections, ventilator complications, and restraint complications may be reduced. The program invests bedside clinicians in writing safety standards, creates a partnership between staff and the clinical risk manager, and provides executive leaders an opportunity to demonstrate support of a culture beyond blame.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 6","pages":"Pages 306-315"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28030-X","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461947","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":"Transformation of a Pharmacy Department: Impact on Pharmacist Interventions, Error Prevention, and Cost","authors":"Karren Crowson RPh, MBA,&nbsp;David Collette PharmD,&nbsp;Mary Dang PharmD,&nbsp;Nellie Rittase PharmD (Clinical Pharmacist)","doi":"10.1016/S1070-3241(02)28032-3","DOIUrl":"10.1016/S1070-3241(02)28032-3","url":null,"abstract":"<div><h3>Background</h3><p>Current medical literature supports the unit-based (UB) pharmacy concept as a best practice. In an effort to determine its feasibility, Huntsville Hospital (Huntsville, Alabama) conducted a pilot study to compare the central-based (CB) model with the UB model and then implemented the new model.</p></div><div><h3>Implementing the pilot study</h3><p>Data were collected for two high-volume nursing units for 10 days for each model. Pharmacists practicing in the UB setting documented more interventions than the CB pharmacist by a factor of three to one, resulting in an 85% increase in cost avoidance.</p></div><div><h3>Implementing the UB model</h3><p>Converting the pharmacy services to a UB model entailed creating 16 new pharmacist positions. Extrapolation of the savings for the UB model ($520 per day) and the CB model ($280) for 1 year suggested that adoption of the UB model would generate an additional $87,600 in cost avoidance for these two nursing units. Each new pharmacist was trained for at least 3 months before being scheduled to work independently as a UB pharmacist. Clinical interventions by pharmacists greatly increased after implementation of the UB model. The baseline monthly average of interventions for the 6 months before implementation was 239, and the monthly cost avoidance was $21,300. In October 2001, the first full month of implementation, there were 1,315 interventions and a monthly cost avoidance of $130,192.</p></div><div><h3>Summary</h3><p>Converting to the UB model has required a considerable increase in the number of pharmacist positions, yet there has been a dramatic increase in clinical pharmacy interventions, with a corresponding decrease in drug expenditures.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 6","pages":"Pages 324-330"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28032-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461979","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":"Failure Mode and Effect Analysis: An Application in Reducing Risk in Blood Transfusion","authors":"Jean Burgmeier RN (Coordinator of Organizational Learning and Development)","doi":"10.1016/S1070-3241(02)28033-5","DOIUrl":"10.1016/S1070-3241(02)28033-5","url":null,"abstract":"<div><h3>Background</h3><p>In February 2001 Good Samaritan Hospital in Dayton, Ohio, conducted a Failure Mode and Effect Analysis (FMEA) on the blood transfusion process to reduce the risk of problems inherent in the procedure.</p></div><div><h3>Developing the FMEA</h3><p>The major steps of the analysis were to identify problems (failure modes), define their causes, and surmise the effects if failures occurred. Numerical scores were assigned for the likelihood of failure occurrence, the severity of the effects, and the possibility that the failure would escape detection. These scores were multiplied and reported as a risk priority number (RPN) for each failure mode. Solutions (process redesign actions) and monitoring plans (design validation) were developed to address the failure modes with the highest RPNs.</p></div><div><h3>Presenting the FMEA</h3><p>In March 2001 the FMEA document was presented to the Safety Board, which approved design changes such as use of a blood barrier system that restricts access to the blood until a patient-specific code is dialed.</p></div><div><h3>Results</h3><p>Measures were developed to analyze results, and rapid-cycle Plan-Do-Study-Act methodology was used to test and document redesign changes; most became the standard operating procedure. The new process accomplished its purpose of preventing serious, avoidable errors. No outcome errors occurred from March 2001 through June 2001 or in the 8 months following housewide implementation on June 18, 2001.</p></div><div><h3>Discussion</h3><p>FMEA was a valuable tool in error-trapping the blood transfusion process. Yet the FMEA process was time-consuming, tedious, and difficult and should be reserved for an organization’s highest-priority processes.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 6","pages":"Pages 331-339"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28033-5","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461994","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 Administrative Data to Improve Compliance with Mandatory State Event Reporting","authors":"Deborah Tuttle RN, MPS,&nbsp;Robert J. Panzer MD,&nbsp;Tracy Baird RHIA (Senior Information Analyst)","doi":"10.1016/S1070-3241(02)28035-9","DOIUrl":"10.1016/S1070-3241(02)28035-9","url":null,"abstract":"<div><h3>Background</h3><p>The New York Patient Occurrence and Tracking System (NYPORTS) is a mandatory adverse event reporting system that was redesigned in 1998. Analysis of the first full year of its use showed large regional and hospital variation in reporting frequency not due to hospital or case mix differences. In early 2001, New York State mandated that all hospitals conduct retrospective review for unreported adverse incidents for the previous 2 years. Hospitals could submit previously unreported incidents within a defined window without penalty. The hospital used an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) analysis to screen for missed NYPORTS cases, to assist in focusing review resources.</p></div><div><h3>Methods</h3><p>NYPORTS categories were matched to corresponding combinations of inpatient ICD-9-CM diagnosis and procedure codes. Other variables considered included discharge disposition, primary or secondary coding position, readmissions, and NYPORTS exclusions.</p></div><div><h3>Results</h3><p>Among more than 60,000 discharges in 2 years, 5,500 records were identified for NYPORTS review based on the ICD-9-CM criteria; 211 cases had already been reported through normal reporting processes. Thirteen of the NYPORTS codes had a 30% or greater match rate to the ICD-9-CM codes, with an average “hit rate” of 56%. Five-hundred sixty reviews identified 187 (33.4%) reportable events for the same code the case was being screened for and 26 additional reportable events for a code other than the screening code. NYPORTS categories for procedure and operative-related occurrences had the highest yields.</p></div><div><h3>Conclusions</h3><p>This retrospective effort helped identify previously unreported occurrences, increase institutional awareness of New York State’s mandatory reporting process, and stimulate the redesign of our concurrent detection process.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 6","pages":"Pages 349-358"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28035-9","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56462036","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":"Treatment Decisions About Lumbar Herniated Disk in a Shared Decision-Making Program","authors":"Paul H. Barrett MD, MSPH (Director of Research),&nbsp;Arne Beck PhD (Research and Development Director),&nbsp;Kristie Schmid MS (Quality Assurance Analyst),&nbsp;Bruce Fireman MA (Biostatistician and Senior Investigator),&nbsp;Jonathan Betz Brown MPP, PhD (Senior Investigator)","doi":"10.1016/S1070-3241(02)28020-7","DOIUrl":"10.1016/S1070-3241(02)28020-7","url":null,"abstract":"<div><h3>Background</h3><p>An explicit process of collaborative (shared) decision making involving the patient and physician has been recommended for discretionary surgical procedures in which small-area analysis demonstrates high variation not attributable to differences in the patient population in the area. One such example is laminectomy for lumbar herniated disk (HD). An observational study was undertaken to evaluate the impact of an HD videodisk program on patient satisfaction, decision making, and treatment preferences.</p></div><div><h3>Methods</h3><p>Enrollment occurred in the outpatient offices of surgeons treating Kaiser Permanente (Colorado Region) patients with H D who had indications for surgery. Enrollment took place from May 1993 to December 1995, and follow-up surveys of patients were completed by January 1997.</p></div><div><h3>Results</h3><p>A 6.0% decrease in the undecided group and a 1.3% decrease in the group preferring nonsurgical treatment drove a shift of patients toward laminectomy, from 26.7% to 35.8% (Wilcoxon signed rank test = 349.5, <em>p</em> = .017). Postviewing preference (74.0%) was a better aggregate predictor of the ultimate treatment than previewing preference (70.0%) for laminectomy.</p></div><div><h3>Discussion</h3><p>Viewing the videodisk increased the preference for laminectomy. However, limitations in the data prevented us from determining whether this change in preference was actually reflected in patients’ ultimate decisions. The fact that the strongest predictor of choosing surgery was the patient’s valuation of his or her condition supports shared decision making, with its emphasis on patient’s values. Participation in other videodisk programs has been low; perhaps physicians should ask patients to view these videodisks before their visits.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 5","pages":"Pages 211-219"},"PeriodicalIF":0.0,"publicationDate":"2002-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28020-7","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461815","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":"Working Together but Apart: Barriers and Routes to Nurse–Physician Collaboration","authors":"Merrick Zwarenstein MB, BCh, MSc (Med), MSc (Director),&nbsp;Scott Reeves MSc (Research Fellow)","doi":"10.1016/S1070-3241(02)28024-4","DOIUrl":"10.1016/S1070-3241(02)28024-4","url":null,"abstract":"","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 5","pages":"Pages 242-247"},"PeriodicalIF":0.0,"publicationDate":"2002-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28024-4","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461874","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":"Pursuing Perfection: An Interview with Don Berwick and Michael Rothman","authors":"Andrea Kabcenell RN, MPH (Deputy Director),&nbsp;Jane Roessner PhD (writer)","doi":"10.1016/S1070-3241(02)28026-8","DOIUrl":"10.1016/S1070-3241(02)28026-8","url":null,"abstract":"","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 5","pages":"Pages 268-278"},"PeriodicalIF":0.0,"publicationDate":"2002-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28026-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461899","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}