Joint Commission journal on quality and safety最新文献_第6页

Promoting a Healing Environment: Quiet Time in the Intensive Care Unit 促进治疗环境:重症监护病房的安静时间

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30054-7

Charlene Ruggiero R.N. (Nurse Manager), Linda Dziedzic R.N. (Clinical Coordinator)

引用次数: 4

Editorial Advisory Board 编辑顾问委员会

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30093-6

引用次数: 0

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 : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30048-1

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), 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), Cuong C. Hoang (Management Engineer), Thomas E. Burroughs Ph.D., Carolyn A. Roth R.N., J.D. (Director)","doi":"10.1016/S1549-3741(04)30048-1","DOIUrl":"10.1016/S1549-3741(04)30048-1","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 name 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 8","pages":"Pages 424-431"},"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)30048-1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24674863","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: 38

An Overlooked Alliance: Using Human Factors Engineering to Reduce Patient Harm 一个被忽视的联盟:利用人为因素工程来减少对患者的伤害

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30052-3

Shawna J. Perry M.D. (Assistant Chair and Director of Clinical Operations)

{"title":"An Overlooked Alliance: Using Human Factors Engineering to Reduce Patient Harm","authors":"Shawna J. Perry M.D. (Assistant Chair and Director of Clinical Operations)","doi":"10.1016/S1549-3741(04)30052-3","DOIUrl":"10.1016/S1549-3741(04)30052-3","url":null,"abstract":"<div><h3>Background</h3><p>Although human factors engineering (HFE) is considered only in relationship to the design of medical devices or information systems technology, human factors issues arise in many aspects of work in health care organizations.</p></div><div><h3>HFE Analysis</h3><p>In one scenario, the resuscitation stretcher would not pass through the ED door closest to radiology. Many clinical work spaces were never formally designed for the work currently being performed in them; instead, they were adapted from existing space originally designed for a different use. In a second scenario, infusion pump malfunction was not apparent. The patient experienced a near miss secondary to poor design; users thought that the infusion pump had been turned off when it was not.</p></div><div><h3>Recommendations</h3><p>Health care can significantly benefit from the incorporation of HFE into the workplace. Introductory classes in medical and nursing schools on HFE will assist students in detecting HFE-related issues, making them less likely to suffer with them or overlook them once in clinical practice. More extensive training for patient safety and risk managers, that is, at a minimum, a certificate-level course from an HFE program, would enhance case and root cause analyses since these issues are rarely factored in.</p></div><div><h3>Conclusion</h3><p>Collaboration with HFE experts and use of HFE principles may not make health care foolproof, but it will make it less dependent on improvisation and ingenuity to protect patients from the system’s vulnerabilities.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 8","pages":"Pages 455-459"},"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)30052-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24674867","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: 25

Strategies for Increasing Adherence to Clinical Guidelines and Improving Patient Outcomes in Small Primary Care Practices 在小型初级保健实践中提高临床指南依从性和改善患者预后的策略

Joint Commission journal on quality and safety Pub Date : 2004-08-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30049-3

Chris Feifer Dr.PH. (Assistant Professor), Steven M. Ornstein M.D.

{"title":"Strategies for Increasing Adherence to Clinical Guidelines and Improving Patient Outcomes in Small Primary Care Practices","authors":"Chris Feifer Dr.PH. (Assistant Professor), Steven M. Ornstein M.D.","doi":"10.1016/S1549-3741(04)30049-3","DOIUrl":"10.1016/S1549-3741(04)30049-3","url":null,"abstract":"<div><h3>Background</h3><p>The best way to get research findings into practice needs to be determined, particularly in small practices. The Practice Partner Research Network (PPRNet) is a nationwide practice-based research network of small primary care practices that use the same electronic medical record (EMR). Between 2000–2003 the PPRNet Translating Research into Practice (TRIP) project tested a multimethod intervention to help practices improve primary and secondary prevention of cardiovascular disease and stroke. Intervention sites each hosted six to seven site visits and participated in two annual network meetings during the two-year intervention period. A model describing practice-based improvement strategies was validated using prospective data from 10 intervention and 9 control sites.</p></div><div><h3>Results</h3><p>The model consisted of five categories of improvement strategies: Prioritize Performance, Involve All Staff, Redesign Delivery Systems, Activate Patients, and Use EMR Tools. PPRNet-TRIP intervention practices used more of the model items than did controls (69% versus 48%, <em>p</em> = .053), as did high-performing practices versus mid-range or low performers (81% versus 39% versus 46%, <em>p</em> = .001).</p></div><div><h3>Conclusion</h3><p>The PPRNet-TRIP Improvement Model might guide small practices in their efforts to translate research into practice and improve care outcomes.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 8","pages":"Pages 432-441"},"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)30049-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24674864","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: 54

Extending the Nurse Practitioner Concurrent Intervention Model to Community-Acquired Pneumonia and Chronic Obstructive Pulmonary Disease 在社区获得性肺炎和慢性阻塞性肺疾病中扩展执业护士同步干预模式

Joint Commission journal on quality and safety Pub Date : 2004-07-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30043-2

Peter A. Gross M.D., Linda Aho R.N., A.P.N. (Pulmonary Nurse Practitioner), Hormoz Ashtyani M.D. (Director), Jerome Levine M.D. (Director Infectious Disease), Margaret McGee R.N. (Performance Improvement Coordinator), Stephen Moran R.N. (Decision Support Manager), Thomas Anton (Director), Joseph Feldman M.D. (Chairman), Arpi Kuyumjian Pharm.D. (Clinical Pharmacy Coordinator–Infectious Disease Specialist), Joan Skurnick Ph.D. (Project Statistician)

{"title":"Extending the Nurse Practitioner Concurrent Intervention Model to Community-Acquired Pneumonia and Chronic Obstructive Pulmonary Disease","authors":"Peter A. Gross M.D., Linda Aho R.N., A.P.N. (Pulmonary Nurse Practitioner), Hormoz Ashtyani M.D. (Director), Jerome Levine M.D. (Director Infectious Disease), Margaret McGee R.N. (Performance Improvement Coordinator), Stephen Moran R.N. (Decision Support Manager), Thomas Anton (Director), Joseph Feldman M.D. (Chairman), Arpi Kuyumjian Pharm.D. (Clinical Pharmacy Coordinator–Infectious Disease Specialist), Joan Skurnick Ph.D. (Project Statistician)","doi":"10.1016/S1549-3741(04)30043-2","DOIUrl":"10.1016/S1549-3741(04)30043-2","url":null,"abstract":"<div><h3>Background</h3><p>A Nurse Practitioner (NP) Concurrent Intervention Model shown effective for controlling telemetry usage was extended to patients with community-acquired pneumonia (CAP) and patients with chronic obstructive pulmonary disease (COPD).</p></div><div><h3>Methods</h3><p>In spring 2000, investigators at Hackensack University Medical Center and the University of Medicine and Dentistry of New Jersey–New Jersey Medical School began an intervention to increase compliance with the Centers for Medicare & Medicaid Services (CMS) performance measures for CAP. Cost-reduction efforts were introduced by using previously described criteria for switching from intravenous to oral medication and for hospital discharge.</p></div><div><h3>Results</h3><p>Use of the NP intervention model for patients admitted with CAP and for COPD patients resulted in significant reductions in length of stay and cost savings.</p></div><div><h3>Discussion</h3><p>Concurrent intervention by a nurse practitioner can help achieve excellent compliance with performance measures for CAP and be applied to other chronic respiratory diseases such as COPD.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 7","pages":"Pages 377-386"},"PeriodicalIF":0.0,"publicationDate":"2004-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30043-2","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40875004","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: 15

Righting Wrong Site Surgery 矫正错误部位手术

Joint Commission journal on quality and safety Pub Date : 2004-07-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30046-8

Pascale Carayon Ph.D. (Professor of Industrial Engineering and Director of the Center for Quality and Productivity Improvement), Kara Schultz (doctoral student in Industrial Engineering), Ann Schoofs Hundt Ph.D. (Research Scientist)

{"title":"Righting Wrong Site Surgery","authors":"Pascale Carayon Ph.D. (Professor of Industrial Engineering and Director of the Center for Quality and Productivity Improvement), Kara Schultz (doctoral student in Industrial Engineering), Ann Schoofs Hundt Ph.D. (Research Scientist)","doi":"10.1016/S1549-3741(04)30046-8","DOIUrl":"10.1016/S1549-3741(04)30046-8","url":null,"abstract":"<div><h3>Background</h3><p>As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), wrong site surgery includes wrong side or site of the body, wrong procedure, and wrong-patient surgeries. Although many health care organizations are implementing guidelines and procedures to decrease the occurrence of wrong site surgery, numerous barriers to their effectiveness have been identified.</p></div><div><h3>Human Factors Engineering (HFE) Analysis</h3><p>A human factors system analysis can be used to better understand how elements of a work system combine and interact to contribute to breakdowns in the system. A case study of wrong site surgery in an out-patient setting illustrates how the different work system elements can contribute to the occurrence of a wrong site surgery. In analyzing the care process, it is particularly important to identify the transitions of care, which can be sources of patient safety problems when deficits in communication and information transfer occur (for example, miscommunication, information not transmitted on time, wrong information transmitted, misunderstanding of the information transmitted).</p></div><div><h3>Recommendations</h3><p>After a wrong site surgery, conduct a root cause analysis that uses the work system model and includes a surgery care process analysis similar to the one described in the case study; collaborate with human factors engineers to learn how to apply the work system model; apply the work system model to process analysis; and optimize work systems.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 7","pages":"Pages 405-410"},"PeriodicalIF":0.0,"publicationDate":"2004-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30046-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40875008","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: 40

Editorial Advisory Board 编辑顾问委员会

Joint Commission journal on quality and safety Pub Date : 2004-07-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30092-4

引用次数: 0

Fifteen Best Practice Recommendations for Bar-Code Medication Administration in the Veterans Health Administration 退伍军人健康管理局条形码药物管理的15条最佳实践建议

Joint Commission journal on quality and safety Pub Date : 2004-07-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30041-9

Emily S. Patterson Ph.D., Michelle L. Rogers Ph.D., Marta L. Render M.D.

{"title":"Fifteen Best Practice Recommendations for Bar-Code Medication Administration in the Veterans Health Administration","authors":"Emily S. Patterson Ph.D., Michelle L. Rogers Ph.D., Marta L. Render M.D.","doi":"10.1016/S1549-3741(04)30041-9","DOIUrl":"10.1016/S1549-3741(04)30041-9","url":null,"abstract":"<div><h3>Background</h3><p>Since 2000, the Veterans Health Administration (VHA) has pioneered the development and deployment of a bar-code medication administration (BCMA) system. Based on VHA experience, 15 “best practices” for BCMA implementation, integration, and maintenance are recommended.</p></div><div><h3>Methods</h3><p>Data were collected on potential barriers to the effectiveness of BCMA to improve patient safety by direct observation of medication administration, simulated BCMA use in a laboratory setting, a survey of nursing informatics specialists regarding policies and procedures, and 30 unstructured interviews with diverse stakeholders.</p></div><div><h3>Recommendations</h3><p>Fifteen practices were proposed, categorized by implementation and continuous improvement, training, troubleshooting, contingency planning, equipment maintenance, medication administration, and maintenance of paper patient wristbands. For example, Recommendation 15 (“Periodic replacement of wristbands”) advises weekly bar-coded wristband replacement in long term care settings to improve the scanning reliability.</p></div><div><h3>Discussion</h3><p>Lessons learned about best practices to address challenges may offer insight to others considering implementation of bar-code technology.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 7","pages":"Pages 355-365"},"PeriodicalIF":0.0,"publicationDate":"2004-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30041-9","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40874389","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

Using Intranet-Based Order Sets to Standardize Clinical Care and Prepare for Computerized Physician Order Entry 使用基于内部网的订单集来标准化临床护理并为计算机化医生订单输入做好准备

Joint Commission journal on quality and safety Pub Date : 2004-07-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30042-0

John E. Heffner M.D. (Professor of Medicine), Kathleen Brower (Forms Programmer), Rosemary Ellis R.N., M.S.N (Director of Quality and Patient Safety), Shirley Brown R.N. (Outcomes Manager)

{"title":"Using Intranet-Based Order Sets to Standardize Clinical Care and Prepare for Computerized Physician Order Entry","authors":"John E. Heffner M.D. (Professor of Medicine), Kathleen Brower (Forms Programmer), Rosemary Ellis R.N., M.S.N (Director of Quality and Patient Safety), Shirley Brown R.N. (Outcomes Manager)","doi":"10.1016/S1549-3741(04)30042-0","DOIUrl":"10.1016/S1549-3741(04)30042-0","url":null,"abstract":"<div><h3>Background</h3><p>The high cost of computerized physician order entry (CPOE) and physician resistance to standardized care have delayed implementation. An intranet-based order set system can provide some of CPOE’s benefits and offer opportunities to acculturate physicians toward standardized care.</p></div><div><h3>Intranet Clinician Order Forms (COF)</h3><p>The COF system at the Medical University of South Carolina (MUSC) allows caregivers to enter and print orders through the intranet at points of care and to access decision support resources.</p></div><div><h3>Results</h3><p>Work on COF began in March 2000 with transfer of 25 MUSC paper-based order set forms to an intranet site. Physician groups developed additional order sets, which number more than 200. Web traffic increased progressively during a 24-month period, peaking at more than 6,400 hits per month to COF. Decision support tools improved compliance with Centers for Medicare & Medicaid Services core indicators.</p></div><div><h3>Discussion</h3><p>Clinicians demonstrated a willingness to develop and use order sets and decision support tools posted on the COF site. COF provides a low-cost method for preparing caregivers and institutions to adopt CPOE and standardization of care. The educational resources, relevant links to external resources, and communication alerts will all link to CPOE, thereby providing a head start in CPOE implementation.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 7","pages":"Pages 366-376"},"PeriodicalIF":0.0,"publicationDate":"2004-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30042-0","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40874390","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: 13