Joint Commission journal on quality and safety最新文献_第2页

2004 Author Index 2004年作者索引

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30099-7

引用次数: 0

“Keeping Each Patient Safe”:Quality Safety Teaching/Learning Packets “确保每位病人的安全”:质素安全教学/学习包

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30080-8

Chris Benczo R.N., B.S.N., M.Ed. (Manager, Staff Education), Doris Gaudy R.N., B.S.N., M.S. (Senior Director, Patient Services), T. Michael White M.D. (Senior Vice President, Value and Education)

{"title":"“Keeping Each Patient Safe”:Quality Safety Teaching/Learning Packets","authors":"Chris Benczo R.N., B.S.N., M.Ed. (Manager, Staff Education), Doris Gaudy R.N., B.S.N., M.S. (Senior Director, Patient Services), T. Michael White M.D. (Senior Vice President, Value and Education)","doi":"10.1016/S1549-3741(04)30080-8","DOIUrl":"10.1016/S1549-3741(04)30080-8","url":null,"abstract":"<div><h3>Background</h3><p>University of Pittsburgh Medical Center (UPMC) McKeesport developed a tool, the UPMC McKeesport Quality Safety Teaching/Learning Packet, to provide physicians, nurses, and therapists with a common language to address complex safety issues. Teaching/learning packets were developed to “keep each patient safe”: by calling for help early; from falls and confusion; and from hospital-acquired infections (<span>http://McKeesport.upmc.com/KeepingPatientsSafe.htm</span><svg><path></path></svg>).</p></div><div><h3>Teaching/Learning Packets</h3><p>In July 2002, the concept of calling for help early became a requirement at UPMC McKeesport. The code team was to be called for any significant change in status and for traditional code arrests. In 2004, a teaching/learning packet addressed the concepts of fall risk and acute (delirium) and chronic (dementia) confusion. Strategies were implemented to reduce the rate of falls through risk screening and interventions for falls and delirium. In April 2004, a teaching/learning packet was introduced to reduce hospital-acquired infections, and professionals were positioned to better address isolation, hand hygiene, central-line–associated bacteremia, <em>Clostridium difficile</em>, and appropriate antibiotic usage.</p></div><div><h3>Summary and Conclusions</h3><p>Three quality safety teaching/learning packets, which provided the professionals in the organization with the common language (culture) to advance patient safety, accomplished rapid change and were well accepted by staff and physicians.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 12","pages":"Pages 676-680"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30080-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25069935","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}

引用次数: 3

Editorial Advisory Board 编辑顾问委员会

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30097-3

引用次数: 0

2004 Subject Index 二零零四年学科索引

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30100-0

引用次数: 0

Strategies for Consumer Protection in Health Care: The Case for Public-Private Partnerships 保健中的消费者保护战略:公私伙伴关系的案例

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30104-8

Karen H. Timmons (Chief Executive Officer and President), David Marx M.D.

{"title":"Strategies for Consumer Protection in Health Care: The Case for Public-Private Partnerships","authors":"Karen H. Timmons (Chief Executive Officer and President), David Marx M.D.","doi":"10.1016/S1549-3741(04)30104-8","DOIUrl":"10.1016/S1549-3741(04)30104-8","url":null,"abstract":"<div><h3>Background</h3><p>To address consumer protection and safety on a national basis takes a partnership of many public and private organizations and agencies. The activities of the Joint Commission on Accreditation of Health Care Organizations and Joint Commission International (JCI) include participation in national and international strategies that may be instructive to consumer advocates and stakeholders in many countries.</p></div><div><h3>Overview of the Joint Commission</h3><p>The Joint Commission, whose mission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations, also participates in numerous efforts, including setting state-of-the-art standards, maintaining a sentinel event database, establishing National Patient Safety Goals, providing consumer access to quality reports on accredited organizations, encouraging patients to take a role in preventing health care errors, and supporting safety-related legislative initiatives.</p></div><div><h3>Conclusions</h3><p>Countries are pressed to involve a wide variety of private and public agencies to make a measurable impact on consumer protection and safety. The Joint Commission has worked to address the need for safety with a multiprogram and multipartner approach in the United States. JCI has moved many of these strategies into the international arena and will seek opportunities to partner with governments, health care organizations, and consumer protection agencies as part of its mission to improve the safety and quality of health care in the international community.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 ","pages":"Pages 9-14"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30104-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72510707","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}

引用次数: 2

A Framework for Quality Improvement Translation: Understanding the Conditionality of Interventions 质量改进翻译的框架:对干预条件的理解

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30105-X

John Øvretveit M.Phil., Ph.D., C. Psychol., M.H.S.M.

{"title":"A Framework for Quality Improvement Translation: Understanding the Conditionality of Interventions","authors":"John Øvretveit M.Phil., Ph.D., C. Psychol., M.H.S.M.","doi":"10.1016/S1549-3741(04)30105-X","DOIUrl":"10.1016/S1549-3741(04)30105-X","url":null,"abstract":"<div><h3>Background</h3><p>A large literature on health care organizations’ experiences with quality and safety improvement methods and strategies is now available. Although sometimes the effort is made to immediately apply others’ experiences, more often the question is asked, “would it work for us?”</p></div><div><h3>Quality Improvement Translation (QIT)</h3><p>In a framework for valid and more systematic cross-organizational and cross-national learning, one assesses the conditions that may have been important for success elsewhere so as to replicate the essential conditions for local adaptation. For example, resource limitations may prevent the transfer of a computerized physician order entry (CPOE) system to a developing country as a method of improving safety, but there may be elements of others’ CPOE systems, such as protocols for manual checking, that can be translated with success.</p></div><div><h3>How to Translate Improvements and Strategies to Our Setting</h3><p>How then do we decide which approaches are easily transfered, and how do we go about translating other approaches that need adapting to “our” (or any) setting? A simple method is to follow five steps for QIT: define our subject and question, search for others’ experiences, assess likely context dependence, identify critical conditions, and plan implementation.</p></div><div><h3>Conclusion</h3><p>We can improve our methods for learning from others by creating our own systems for seeking out reports that describe the context of the improvement, by deciding which facilities to visit and which conferences and networking events to attend, and by developing our skills in judging transferability and in translating others’ strategies.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 ","pages":"Pages 15-24"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30105-X","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77602215","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}

引用次数: 55

The Faces of Errors: A Case-Based Approach to Educating Providers, Policymakers, and the Public About Patient Safety 错误的面孔:以案例为基础的方法来教育提供者，政策制定者和公众关于患者安全

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30078-X

Robert M. Wachter M.D. (Professor and Associate Chairman), Kaveh G. Shojania M.D.

{"title":"The Faces of Errors: A Case-Based Approach to Educating Providers, Policymakers, and the Public About Patient Safety","authors":"Robert M. Wachter M.D. (Professor and Associate Chairman), Kaveh G. Shojania M.D.","doi":"10.1016/S1549-3741(04)30078-X","DOIUrl":"10.1016/S1549-3741(04)30078-X","url":null,"abstract":"<div><h3>Background</h3><p>When patient safety became a subject of policy and research, the question was how to engage clinicians—perhaps they would respond more to case studies of dramatic adverse events than to statistics.</p></div><div><h3>The Chronology</h3><p>In 2001, we launched a case-based series in the <em>Annals of Medicine</em> which focused on diagnosing what ailed the system rather than the patient. For example, in “The Wrong Patient,” 17 discrete errors resulted in a woman’s receiving a cardiac electrophysiology procedure intended for another patient with a similar last name. The Web-based Agency for Healthcare Research and Quality (AHRQ) <em>WebM&M</em> was then developed as a forum that was part-reporting system and part-journal. Finally, we then applied this approach to writing a book for a popular audience.</p></div><div><h3>Lessons Learned</h3><p>We found that clinicians were willing to submit cases, assuming that anonymity was protected. Cases of errors that led to harm were generally more compelling than near misses. As in real life, many cases lacked complete information, but sufficient information was usually available to highlight the key lessons. All three vehicles generated substantial readerships and critical praise, indicating that there is a “market” for case-based education about patient safety.</p></div><div><h3>Conclusion</h3><p>Presenting de-identified cases of medical mistakes in a variety of public venues is an effective way to educate patients and providers about safety.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 12","pages":"Pages 665-670"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30078-X","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25069933","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}

引用次数: 9

Conclusion: You Need Human Factors Engineering Expertise to See Design Hazards That Are Hiding in “Plain Sight!” 结论:你需要人因工程专业知识来发现隐藏在“显而易见”中的设计危害!

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30083-3

John W. Gosbee M.D., M.S.

{"title":"Conclusion: You Need Human Factors Engineering Expertise to See Design Hazards That Are Hiding in “Plain Sight!”","authors":"John W. Gosbee M.D., M.S.","doi":"10.1016/S1549-3741(04)30083-3","DOIUrl":"10.1016/S1549-3741(04)30083-3","url":null,"abstract":"<div><h3>Background</h3><p>The Human Factors Engineering (HFE) series was launched to share the ideas and methods to aid deeper analyses of adverse events and provide tools to ensure more effective and lasting therapies. Articles in the series showed how human limitations and capabilities were important design issues in a variety of areas, ranging from labels and warnings to work place design and complex decision support systems.</p></div><div><h3>Remaining Questions</h3><p>After reading all the articles, one might ask a number of questions, such as who made all our “puzzle rooms?” How did it happen that so many device components “masquerade” as each other yet perform very distinct functions? What are the procurement systems that gave us medication containers, tubing, and connectors that are hard to see and easy to misconnect? Behind all those questions remains a key query: what stands in the way of developing or hiring the expertise to see and fix these catastrophic design hazards “hiding in plain sight?”</p></div><div><h3>Summary and Conclusion</h3><p>HFE has already found its way into health care organizations and industry. As with most large changes in professions and industries, many small steps will need to be taken toward applying HFE methods and principles to the large problems of patient safety. But there already ample incentives and tools to start transforming your health care delivery or manufacturing organization.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 12","pages":"Pages 696-700"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30083-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25070394","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}

引用次数: 19

Implementing a Hospitalwide Patient Safety Program for Cultural Change 为文化变革实施全院病人安全计划

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30107-3

Max M. Cohen M.D., M.H.S.A. (Vice President and Chief Medical Officer), Nancy L. Kimmel R.Ph. (Patient Safety Specialist), M. Kathleen Benage R.N. (Director, Performance Improvement), Cuong C. Hoang (Management Engineer), Thomas E. Burroughs Ph.D., Carolyn A. Roth R.N., J.D. (Director)

{"title":"Implementing a Hospitalwide Patient Safety Program for Cultural Change","authors":"Max M. Cohen M.D., M.H.S.A. (Vice President and Chief Medical Officer), Nancy L. Kimmel R.Ph. (Patient Safety Specialist), M. Kathleen Benage R.N. (Director, Performance Improvement), Cuong C. Hoang (Management Engineer), Thomas E. Burroughs Ph.D., Carolyn A. Roth R.N., J.D. (Director)","doi":"10.1016/S1549-3741(04)30107-3","DOIUrl":"https://doi.org/10.1016/S1549-3741(04)30107-3","url":null,"abstract":"<div><h3>Background</h3><p>After focus groups revealed that staff perceived a punitive culture, Missouri Baptist Medical Center (MBMC) embarked on a comprehensive patient safety program, which was initially directed at creating a just culture of patient safety.</p></div><div><h3>Interventions</h3><p>A series of structures, processes, and initiatives were introduced to change the attitudes of management and staff toward human error, to communicate broadly with staff and the community, and to provide feedback on leadership’s responses to specific events. All events reported were tracked continuously and recorded each month on a spreadsheet.</p></div><div><h3>Results</h3><p>Total medical events reported by staff increased significantly (<em>p</em> < .001) from 35 to 132 per 1,000 patient days. Reports to the hotline alone increased significantly (<em>p</em> < .001) from 3 to 23 per 1,000 patient days, and the proportion of callers who left their names increased significantly (<em>p</em> < .001) from 30% to 61%. Survey results from staff showed a small but significant increase in awareness of patient safety and in comfort with reporting.</p></div><div><h3>Conclusion</h3><p>The implementation of a carefully planned and orchestrated series of interventions designed to improve a hospital’s culture of patient safety can, if led by senior hospital executives, lead to a substantial, profound, and lasting increase in error reporting and improvement in employee perceptions of the organization’s safety culture.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 ","pages":"Pages 34-41"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30107-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138357326","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}

引用次数: 0

Clinical Practice Guidelines and Performance Indicators as Related—But Often Misunderstood—Tools 临床实践指南和绩效指标作为相关但经常被误解的工具

Joint Commission journal on quality and safety Pub Date : 2004-12-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30109-7

Ann S. O’Malley M.D., M.P.H. (Assistant Professor), Carolyn Clancy M.D. (Director), Joe Thompson M.D., M.P.H. (Associate), Ravikiran Korabathina (Medical student), Gregg S. Meyer M.D., M.Sc.

{"title":"Clinical Practice Guidelines and Performance Indicators as Related—But Often Misunderstood—Tools","authors":"Ann S. O’Malley M.D., M.P.H. (Assistant Professor), Carolyn Clancy M.D. (Director), Joe Thompson M.D., M.P.H. (Associate), Ravikiran Korabathina (Medical student), Gregg S. Meyer M.D., M.Sc.","doi":"10.1016/S1549-3741(04)30109-7","DOIUrl":"https://doi.org/10.1016/S1549-3741(04)30109-7","url":null,"abstract":"<div><h3>Background</h3><p>Widespread variation in medical practice indicates that existing scientific evidence is often not translated into appropriate clinical care. Two tools have evolved that try to address this variation: clinical practice guidelines (CPGs) and performance indicators (PIs).</p></div><div><h3>Tensions Between CPGs and PIs</h3><p>CPGs present available evidence that is subsequently reviewed and frequently adopted by professional organizations, so that clinicians may judge whether specific management recommendations are appropriate for each patient. PIs are devised to measure and document performance to motivate organizations to improve through the use of common metrics.</p></div><div><h3>Implications of These Tensions</h3><p>The increasingly widespread use of PIs with CPGs (and clinicians’ confusion of them with CPGs) risks lowering the standards of clinical care. PIs are not intended to set optimal standards of care for any individual patient. Clinicians should not restrict their quality monitoring to a focus on PIs because they could miss important opportunities to learn and to improve the care they deliver to their individual patients.</p></div><div><h3>Conclusion</h3><p>Tensions between CPGs and PIs do not mean that these tools should be abandoned but rather that they need to be refined. Recognition of the imperfections of CPGs and PIs should not blind clinicians to the ultimate goals of these tools—to promote quality (through changes in practice and/or selection) and ensure that medical care is based on scientific evidence.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 ","pages":"Pages 48-56"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30109-7","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138357321","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}

引用次数: 0