Joint Commission journal on quality and safety最新文献_第5页

A Cognitive Aid for Cardiac Arrest: You Can’t Use It if You Don’t Know About It 心脏骤停的认知辅助:如果你不知道就不能使用它

Joint Commission journal on quality and safety Pub Date : 2004-09-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30057-2

Peter D. Mills Ph.D., M.S., Joseph M. DeRosier P.E., C.S.P. (Patient Safety Program Manager), Julia Neily R.N., M.S., M.P.H. (Nurse Associate Director), Scott D. McKnight Ph.D. (Statistician), William B. Weeks M.D., M.B.A., C.H.E. (Director), James P. Bagian M.D., P.E. (Director)

{"title":"A Cognitive Aid for Cardiac Arrest: You Can’t Use It if You Don’t Know About It","authors":"Peter D. Mills Ph.D., M.S., Joseph M. DeRosier P.E., C.S.P. (Patient Safety Program Manager), Julia Neily R.N., M.S., M.P.H. (Nurse Associate Director), Scott D. McKnight Ph.D. (Statistician), William B. Weeks M.D., M.B.A., C.H.E. (Director), James P. Bagian M.D., P.E. (Director)","doi":"10.1016/S1549-3741(04)30057-2","DOIUrl":"10.1016/S1549-3741(04)30057-2","url":null,"abstract":"<div><h3>Background</h3><p>A cognitive aid developed by the Department of Veterans Affairs (VA) and distributed to all VA facilities provides caregivers with information to minimize omission of critical steps when diagnosing and treating cardiac arrest. In 2002, caregivers were surveyed about the usefulness of the cognitive aid and the success of its dissemination throughout the VA.</p></div><div><h3>Methods</h3><p>Fifty randomly selected VA hospitals were sent a letter to alert them of the upcoming survey. Twenty surveys were sent to each of the selected hospitals with instructions to distribute the survey to specific caregiver types.</p></div><div><h3>Results</h3><p>Nine (18%) of the VA hospitals had not used the cognitive aid tool because of dissemination problems. Of the 565 caregivers responding to the survey, 59% (332) were aware of the cognitive aid. Of these 332, 96% agreed that putting the cognitive aid on code carts is a good idea. There were 234 respondents who were both aware of the cognitive aid and had been involved in at least one code within the past 30 days. Of these 234, some 29 (12%) used the aid during a code, 28 of whom agreed that the cognitive aid was helpful during the code.</p></div><div><h3>Discussion</h3><p>Both new and experienced caregivers find the cognitive aid helpful when responding to “code” situations. However, cognitive aids cannot be helpful if the intended users are unaware of their availability. Dissemination and awareness of the aids can be problematic in large health care systems.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 9","pages":"Pages 488-496"},"PeriodicalIF":0.0,"publicationDate":"2004-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30057-2","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40906378","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: 58

To Telemedically Err Is Human 远程医疗也会犯错

Joint Commission journal on quality and safety Pub Date : 2004-09-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30061-4

George Demiris Ph.D. (Assistant Professor), Timothy B. Patrick Ph.D. (Assistant Professor of Health Informatics), Joyce A. Mitchell Ph.D. (Professor of Health Informatics), Steven E. Waldren M.D. (National Library of Medicine postdoctoral fellow in biomedical and health informatics)

{"title":"To Telemedically Err Is Human","authors":"George Demiris Ph.D. (Assistant Professor), Timothy B. Patrick Ph.D. (Assistant Professor of Health Informatics), Joyce A. Mitchell Ph.D. (Professor of Health Informatics), Steven E. Waldren M.D. (National Library of Medicine postdoctoral fellow in biomedical and health informatics)","doi":"10.1016/S1549-3741(04)30061-4","DOIUrl":"10.1016/S1549-3741(04)30061-4","url":null,"abstract":"<div><h3>Background</h3><p>As telemedicine alters the process of health care and introduces new technology, the extent to which it introduces new errors or allows for the occurrence of familiar errors needs to be examined.</p></div><div><h3>Telemedicine’s Impact on Patient Safety Features of Traditional Care</h3><p>The accuracy of diagnostic decisions reached via telemedicine can be directly affected by the technology’s limitations and the care providers’ lack of training. Telemedicine could increase the risk of familiar types of patient-provider communication failure and introduce the possibility of cumulative errors.</p></div><div><h3>Telemedicine’s Impact on New Care Features and Concepts</h3><p>Telemedical applications that use the Internet to enhance disease management and detection and monitoring of symptoms may place the privacy and confidentiality of individual health information at risk, which imposes a possible barrier to communication. In addition, home care patients’ functional limitations need to be addressed by human factors engineering.</p></div><div><h3>Recommendations</h3><p>Patient safety should be integrated in organizational readiness and budget planning for telemedical interventions in hospitals, academic settings, nursing homes, home care agencies, and other health care settings. Specific recommendations are proposed for the development and diffusion of standards in telemedical care, risk management and reduction, and continuous quality improvement.</p></div><div><h3>Summary and Conclusions</h3><p>To address patient safety and provide high-quality care, a framework for addressing and examining telemedical errors needs to be established.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 9","pages":"Pages 521-527"},"PeriodicalIF":0.0,"publicationDate":"2004-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30061-4","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40906382","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: 8

Readmissions for Venous Thromboembolism: Expanding the Definition of Patient Safety Indicators 静脉血栓栓塞再入院:扩展患者安全指标的定义

Joint Commission journal on quality and safety Pub Date : 2004-09-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30058-4

Wendy E. Weller Ph.D. (Assistant Professor), Brian K. Gallagher M.S. (Senior Healthcare Analyst), Liyi Cen M.S. (Data Analyst), Edward L. Hannan Ph.D. (Distinguished Professor and Chair)

{"title":"Readmissions for Venous Thromboembolism: Expanding the Definition of Patient Safety Indicators","authors":"Wendy E. Weller Ph.D. (Assistant Professor), Brian K. Gallagher M.S. (Senior Healthcare Analyst), Liyi Cen M.S. (Data Analyst), Edward L. Hannan Ph.D. (Distinguished Professor and Chair)","doi":"10.1016/S1549-3741(04)30058-4","DOIUrl":"10.1016/S1549-3741(04)30058-4","url":null,"abstract":"<div><h3>Background</h3><p>The Agency for Healthcare Research and Quality (AHRQ) defines its venous thromboembolism (VTE) patient safety indicator (PSI) as surgical cases with a secondary diagnosis of pulmonary embolism or deep vein thrombosis. Short-term readmissions for VTE are excluded because most state administrative databases are unable to track readmissions.</p></div><div><h3>Methods</h3><p>Patients meeting the AHRQ VTE PSI definition and those readmitted with a VTE principal diagnosis within 30 days of a prior surgical hospitalization were identified on the basis of inpatient discharge data.</p></div><div><h3>Results</h3><p>A total of 4,906 surgical discharges in New York met the AHRQ VTE PSI definition in 2001. An additional 1,059 cases of VTE were found when surgical patients with a short-term readmission for VTE were identified. Patients readmitted with VTE were less likely to die but were more likely to have a pulmonary embolism and were more likely to be white and non-Hispanic compared to those who met the AHRQ VTE PSI definition.</p></div><div><h3>Discussion</h3><p>Short-term readmissions for VTE represent potentially important cases to capture when monitoring adverse events. Prophylaxis, monitoring, and patient education may be required after hospital discharge to prevent or treat VTE as early as possible. Data systems that can track patients across multiple admissions to identify complications resulting in short-term readmissions are needed.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 9","pages":"Pages 497-504"},"PeriodicalIF":0.0,"publicationDate":"2004-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30058-4","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40906379","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: 26

What Are the Facilitators and Barriers in Physician Organizations’ Use of Care Management Processes? 医生组织使用护理管理流程的促进因素和障碍是什么?

Joint Commission journal on quality and safety Pub Date : 2004-09-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30059-6

Thomas Bodenheimer M.D. (Adjunct Professor), Margaret C. Wang Ph.D. (Researcher), Thomas G. Rundall Ph.D. (Professor), Stephen M. Shortell Ph.D. (Dean), Robin R. Gillies Ph.D. (Project Director), Nancy Oswald Ph.D. (Consultant), Lawrence Casalino M.D., Ph.D. (Assistant Professor), James C. Robinson Ph.D. (Professor)

{"title":"What Are the Facilitators and Barriers in Physician Organizations’ Use of Care Management Processes?","authors":"Thomas Bodenheimer M.D. (Adjunct Professor), Margaret C. Wang Ph.D. (Researcher), Thomas G. Rundall Ph.D. (Professor), Stephen M. Shortell Ph.D. (Dean), Robin R. Gillies Ph.D. (Project Director), Nancy Oswald Ph.D. (Consultant), Lawrence Casalino M.D., Ph.D. (Assistant Professor), James C. Robinson Ph.D. (Professor)","doi":"10.1016/S1549-3741(04)30059-6","DOIUrl":"10.1016/S1549-3741(04)30059-6","url":null,"abstract":"<div><h3>Background</h3><p>Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs.</p></div><div><h3>Methods</h3><p>Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities.</p></div><div><h3>Results</h3><p>Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy.</p></div><div><h3>Discussion</h3><p>Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 9","pages":"Pages 505-514"},"PeriodicalIF":0.0,"publicationDate":"2004-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30059-6","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40906380","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: 95

Editorial Advisory Board 编辑顾问委员会

Joint Commission journal on quality and safety Pub Date : 2004-09-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30094-8

引用次数: 0

Using “No Problem Found” in Infusion Pump Programming as a Springboard for Learning About Human Factors Engineering 以输液泵编程“无问题发现”为学习人因工程的跳板

Joint Commission journal on quality and safety Pub Date : 2004-09-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30060-2

Scott Draper M.S.B.E., A.T.P. (Clinical engineer), Gail A. Nielsen (Patient safety administrator), Mike Noland B.M.E.T. (Biomedical equipment technician)

{"title":"Using “No Problem Found” in Infusion Pump Programming as a Springboard for Learning About Human Factors Engineering","authors":"Scott Draper M.S.B.E., A.T.P. (Clinical engineer), Gail A. Nielsen (Patient safety administrator), Mike Noland B.M.E.T. (Biomedical equipment technician)","doi":"10.1016/S1549-3741(04)30060-2","DOIUrl":"10.1016/S1549-3741(04)30060-2","url":null,"abstract":"<div><h3>Background</h3><p>A hospital took a second look at a device error with a syringe pump in which a dose of fentanyl was delivered in half the anticipated time. When the nursing staff could not reproduce the error, the pump was sent to biomedical engineering where “no problem was found.” The biomedical staff subsequently performed another analysis, which led to discovery of the possible cause of the problem.</p></div><div><h3>Mobilizing for HFE</h3><p>A human factors engineering (HFE) task force, in considering the fentanyl delivery issue, identified a need to educate nursing and engineering on such incidents and to consider the consequences of override features. The HFE task force then reviewed a tool kit for briefing clinical units on education of staff on clinical safety issues.</p></div><div><h3>HFE Analysis</h3><p>Efforts to maximize device customization or simplification can have negative HFE consequences. The decision to allow for function overrides or nontraditional equipment use must be weighed against the potential compromises in patient safety.</p></div><div><h3>Summary</h3><p>The problems that arise from the interface between humans and devices are not limited to intravenous pumps or even medical devices. Awareness of the potential for HFE design flaws can be critical in reducing harm in health care.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 9","pages":"Pages 515-520"},"PeriodicalIF":0.0,"publicationDate":"2004-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30060-2","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40906381","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: 11

Using Self-Report to Improve Substance Abuse Risk Assessment in Behavioral Health Care 用自我报告改进行为保健中的药物滥用风险评估

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30051-1

G.S. (Jeb) Brown Ph.D. (Director), Richard Hermann M.D. (Director), Edward Jones Ph.D. (Vice President and Chief Clinical Officer), Jingyang Wu M.S., M.Stat. (Biostatistician)

{"title":"Using Self-Report to Improve Substance Abuse Risk Assessment in Behavioral Health Care","authors":"G.S. (Jeb) Brown Ph.D. (Director), Richard Hermann M.D. (Director), Edward Jones Ph.D. (Vice President and Chief Clinical Officer), Jingyang Wu M.S., M.Stat. (Biostatistician)","doi":"10.1016/S1549-3741(04)30051-1","DOIUrl":"10.1016/S1549-3741(04)30051-1","url":null,"abstract":"<div><h3>Background</h3><p>Primary care and behavioral health clinicians frequently fail to detect substance-related problems among their patients, thereby leading to increased morbidity and mortality and health care costs. A managed behavioral health care organization (MBHO) conducted a quality improvement initiative in which clients seeking outpatient psychotherapy were screened by self-report for substance-related problems, and clinicians were provided with feedback in cases of discrepant findings.</p></div><div><h3>Method</h3><p>Client self-report questionnaires, which included items inquiring regarding problems related to substance abuse, were administered at multiple points during treatment episodes. Clinicians were also asked to complete assessments, including indicating the presence of a substance abuse problem.</p></div><div><h3>Results</h3><p>Clinicians failed to identify substance abuse problems in > 80% of the cases where the patient endorsed items clearly related to substance abuse on the outcome questionnaire. In the quality improvement intervention, the MBHO sent letters alerting clinicians to the clients’ self-reported substance abuse problems. The concordance between clinician assessment and client self-reported problems then increased significantly.</p></div><div><h3>Discussion</h3><p>Results of the study argue for the utility of using client self-report measures as part of a comprehensive effort to measure and improve the effectiveness of behavioral health care treatment services.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 8","pages":"Pages 448-454"},"PeriodicalIF":0.0,"publicationDate":"2004-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30051-1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24674866","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: 10

Closing the Communication Loop: Using Readback/Hearback to Support Patient Safety 闭合通信回路:使用读回/听回来支持患者安全

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30053-5

Jeffrey P. Brown M.Ed. (Principal of System Safety Group)

引用次数: 29

Improving Patient Access to the Veterans Health Administration’s Primary Care and Specialty Clinics 改善患者获得退伍军人健康管理局初级保健和专科诊所的机会

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30047-X

Marie W. Schall (Director), Terrence Duffy M.D., Anil Krishnamurthy M.D. (Chief Orthopedic Surgeon), Odette Levesque R.N., M.B.A. (Clinical/QA Liaison, Chief Network Officer), Prashant Mehta M.D. (Chief of Urology), Mark Murray M.D., M.P.A. (President), Renee Parlier (Program Manager for Advanced Clinic Access), Robert Petzel M.D. (Network Director), John Sanderson M.D. (Primary Care Medical Director)

{"title":"Improving Patient Access to the Veterans Health Administration’s Primary Care and Specialty Clinics","authors":"Marie W. Schall (Director), Terrence Duffy M.D., Anil Krishnamurthy M.D. (Chief Orthopedic Surgeon), Odette Levesque R.N., M.B.A. (Clinical/QA Liaison, Chief Network Officer), Prashant Mehta M.D. (Chief of Urology), Mark Murray M.D., M.P.A. (President), Renee Parlier (Program Manager for Advanced Clinic Access), Robert Petzel M.D. (Network Director), John Sanderson M.D. (Primary Care Medical Director)","doi":"10.1016/S1549-3741(04)30047-X","DOIUrl":"10.1016/S1549-3741(04)30047-X","url":null,"abstract":"<div><h3>Background</h3><p>During the past four years the Veterans Health Administration (VHA) has been engaged in a national effort to improve access for patients to its 1,826 primary care, audiology, cardiology, eye care, orthopedics, and urology clinics by using the principles of open access or “advanced clinic access.” The strategy entailed the development of successful cases to demonstrate the methods of advanced clinic access and provide evidence of its benefits for providers as well as patients in primary care and specialty clinics.</p></div><div><h3>Results</h3><p>Four clinics—one primary care clinic and three specialty care clinics—showed dramatic improvement in waiting times for appointments (reductions range from 20 days in urology to 78 days in primary care).</p></div><div><h3>Discussion</h3><p>Beyond the four case studies, hundreds of other clinics in the VHA are also applying advanced clinic access principles in their work. The diversity across the VHA suggests that the principles of advanced clinic access are robust across settings and types of clinics. However, the experience of other organizations with different structures and patient populations needs to be reported to fully demonstrate the generalizability of these results. Many of the changes were put in place during the project’s final 18 months. Additional data will be needed to demonstrate sustained improvement.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 8","pages":"Pages 415-423"},"PeriodicalIF":0.0,"publicationDate":"2004-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30047-X","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24674862","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: 56

Remote Order Entry and Video Verification: Reducing After-Hours Medication Errors in a Rural Hospital 远程订单输入和视频验证:减少农村医院的下班后用药错误

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30050-X

Sandra C. Woodall Pharm.D. (Director of Pharmacy)

{"title":"Remote Order Entry and Video Verification: Reducing After-Hours Medication Errors in a Rural Hospital","authors":"Sandra C. Woodall Pharm.D. (Director of Pharmacy)","doi":"10.1016/S1549-3741(04)30050-X","DOIUrl":"10.1016/S1549-3741(04)30050-X","url":null,"abstract":"<div><h3>Background</h3><p>Hendry Regional Medical Center, a 66-bed facility, has 8.5hours of pharmacy staffing daily. Review of two years of medication errors indicated that 34% of all medication errors involved selection of the wrong drug from stock after pharmacy hours.</p></div><div><h3>Process Changes</h3><p>During 2003 many changes were implemented in the medication management process to enhance medication safety. For example, a limited-access area of the pharmacy was established for night entry by the nursing supervisor. The hospital then implemented services with a newly licensed remote order-entry service. These steps decreased the rate of errors involving wrong drug selection to 15%. Subsequently, a medication error involving selection of the wrong drug at night prompted another look at the process.</p></div><div><h3>Implementing the Video Verification Process</h3><p>The hospital began using a webcam to create a digital image of the medication selected for removal from the pharmacy stock by the nursing supervisor. This image is transmitted via e-mail. In six months, only one (recent) error resulting from selection of the wrong medication after normal pharmacy hours occurred; the medication selection process simply was not followed.</p></div><div><h3>Discussion</h3><p>Results of medication error reporting indicated that using Webcam/e-mail image transmission and video verification by a pharmacist further improved patient safety in the medication selection process.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 8","pages":"Pages 442-447"},"PeriodicalIF":0.0,"publicationDate":"2004-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30050-X","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24674865","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: 11