Joint Commission journal on quality and safety最新文献_第8页

Computer Physician Order Entry and the Real World: We’re Only Humans 计算机医嘱输入和现实世界:我们只是人类

Joint Commission journal on quality and safety Pub Date : 2004-06-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30039-0

Matt Scanlon M.D. (Patient Safety Officer)

{"title":"Computer Physician Order Entry and the Real World: We’re Only Humans","authors":"Matt Scanlon M.D. (Patient Safety Officer)","doi":"10.1016/S1549-3741(04)30039-0","DOIUrl":"10.1016/S1549-3741(04)30039-0","url":null,"abstract":"<div><h3>Background</h3><p>Computer physician order entry (CPOE) may have significant benefit to reducing medical errors in the hospital setting. The belief in the promise of CPOE has led organizations such as the Leap Frog Group to advocate for the implementation of CPOE in hospitals to improve patient safety. <em>Human factors</em>, or <em>ergonomics</em>, is the study of the interaction between humans and the systems and tools they use. It is unclear whether human factors principles have been applied to commercially available CPOE systems.</p></div><div><h3>Conclusions</h3><p>CPOE’s true utility for preventing medical errors and harm is largely undetermined. The evidence that exists for error reduction with CPOE is in the setting of “homegrown” systems and not commercially available products. The cases portrayed in the two scenarios described in this article were drawn from actual events to illustrate how failure to attend to human factors and human-centered design can create or facilitate errors and harm.</p></div><div><h3>Recommendations for Organizations in Implementing CPOE</h3><p>Organizations implementing CPOE or considering doing so could evaluate potential systems on the basis of evidence for human-centered design. An organization interested in addressing human factors issues as they relate to CPOE might, for example, familiarize itself with the basics of human factors, usability, and with existing evaluation methods for CPOE; involve the people who do the daily work in the evaluation and selection process; and ask potential vendors how they have addressed human factors in their CPOE systems.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 6","pages":"Pages 342-346"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30039-0","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24576478","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: 30

Editorial Advisory Board 编辑顾问委员会

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30090-0

引用次数: 0

Hospitalwide Quality Improvement in Thailand 泰国全医院质量改进

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30027-4

Jiruth Sriratanaban M.D., Ph.D. (Associate Professor), Yuwaree Wanavanichkul M.D. (Assistant Professor)

{"title":"Hospitalwide Quality Improvement in Thailand","authors":"Jiruth Sriratanaban M.D., Ph.D. (Associate Professor), Yuwaree Wanavanichkul M.D. (Assistant Professor)","doi":"10.1016/S1549-3741(04)30027-4","DOIUrl":"10.1016/S1549-3741(04)30027-4","url":null,"abstract":"<div><h3>Background</h3><p>In 1999 King Chulalongkorn Memorial Hospital, a 1,500-bed teaching hospital in Thailand, started planning and implementing a hospitalwide quality improvement program, as required for accreditation.</p></div><div><h3>Deploying the Nine-Step Ladder Strategy</h3><p>The steps in the strategy were as follows: (1) ensure commitment and formulate mutual strategies; (2) develop teams, technical staff, and support; (3) pilot new improvement activities and expand existing quality programs; (4) improve core systems and functions; (5) expand to the whole organization; (6) perform self-assessment and internal survey, (7) complete the incomplete; (8) submit the request for accreditation; and (9) improve continuously for excellence. For example, for step 3, the hospital set up five pilot cross-functional quality lead teams: the infection control committee, emergency-care patient care team, medication system team, laboratory and x-ray services team, and operating room team.</p></div><div><h3>Results</h3><p>The hospital was accredited by the Institute of Hospital Quality Improvement and Accreditation, Thailand. Improvements were shown in inpatient mortality, patient satisfaction, and reporting of patient risk incidents and the number of serious incidents.</p></div><div><h3>Lessons Learned</h3><p>Critical success factors in implementing a hospitalwide QI program were as follows: (1) role of leadership, (2) need for “quality strategists,” (3) physician involvement and participation in QI teams, (4) vertical and horizontal communication, (5) performance drivers, (6) simplicity in continuous quality improvement, and (7) the value of a learning culture.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 5","pages":"Pages 246-256"},"PeriodicalIF":0.0,"publicationDate":"2004-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30027-4","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24527227","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

Who Left the Defibrillator On? 谁让除颤器开着?

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30031-6

John Gosbee M.D., M.S.

{"title":"Who Left the Defibrillator On?","authors":"John Gosbee M.D., M.S.","doi":"10.1016/S1549-3741(04)30031-6","DOIUrl":"10.1016/S1549-3741(04)30031-6","url":null,"abstract":"<div><h3>Background</h3><p>Two related scenarios involving defibrillator devices reveal how inadvertent hazardous design can go unnoticed until engineers or patient safety personnel use human factors engineering (HFE) analysis. The first adverse event, in which the device was inadvertently turned off while being used to externally pace the patient’s heart, resulted in an increased length of stay. The second scenario describes a similar close call and the useless acts of sanctioning the nurse and firing the engineer technician.</p></div><div><h3>Comments and Recommendations</h3><p>Feedback to the end user about a device’s status is an important design issue. It does not take much expertise to detect when there are problems with “dialogue” from the device to the person (that is, feedback). Many HFE issues have been cited in emergency care areas, and many medical devices—not just defibrillators—do not have readable and understandable feedback to the end user or the kind of automation that would make the wrong action harder to accomplish. All the interactions of multifunction devices with end users in a hectic, noisy, and dynamic environment need to be usability tested and validated. Nurses and engineering personnel can be trained to more easily see HFE design issues—and not dismiss them as individual failings or “someone else’s job.” Medical device companies are starting to follow the guidelines and regulations that should help prevent adverse events.</p></div><div><h3>Conclusion</h3><p>The defibrillator’s design problems had successfully masqueraded as “expected” glitches with hospital electrical utilities, personnel shortcomings, and personality problems. Adverse events related to seemingly simple devices can be prevented with HFE analysis.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 5","pages":"Pages 282-285"},"PeriodicalIF":0.0,"publicationDate":"2004-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30031-6","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24528247","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

From Research to Daily Clinical Practice: What Are the Challenges in “Translation”? 从研究到临床实践:“翻译”的挑战是什么?

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30026-2

Chris Feifer Dr.P.H. (Assistant Professor), Judith Fifield Ph.D. (Associate Professor), Steven Ornstein M.D., Andrew S. Karson M.D., M.P.H. (Associate Director), David Westfall Bates M.D., M.Sc. (Chief), Katherine R. Jones R.N., Ph.D. (Professor), Perla A. Vargas Ph.D. (Assistant Professor)

{"title":"From Research to Daily Clinical Practice: What Are the Challenges in “Translation”?","authors":"Chris Feifer Dr.P.H. (Assistant Professor), Judith Fifield Ph.D. (Associate Professor), Steven Ornstein M.D., Andrew S. Karson M.D., M.P.H. (Associate Director), David Westfall Bates M.D., M.Sc. (Chief), Katherine R. Jones R.N., Ph.D. (Professor), Perla A. Vargas Ph.D. (Assistant Professor)","doi":"10.1016/S1549-3741(04)30026-2","DOIUrl":"10.1016/S1549-3741(04)30026-2","url":null,"abstract":"<div><h3>Background</h3><p>Translating research findings into sustainable improvements in clinical and patient outcomes remains a substantial obstacle to improving the quality and safety of care. The Agency for Healthcare Research and Quality funded two initiatives to assess strategies for improvements—Translating Research into Practice (TRIP). The TRIP II initiative supported 13 quality improvement projects.</p></div><div><h3>Surveying the TRIP II Studies</h3><p>The principal investigators (PIs) of the 13 projects were surveyed regarding encountered barriers to implementation at 6 months and 18 months (when they were also asked about solutions).</p></div><div><h3>Results</h3><p>Seven of the 13 PIs responded to the survey at both times—6 and 18 months. For each project stage—Select a TRIP focus and develop intervention strategies (Stage 1), Conduct the intervention (Stage 2), and Measure the Impact (Stage 3)—barriers were described, and field-tested solutions were provided. For example, for Stage 2, if the target audience lacked buy-in and would not participate, solutions would be to get up-front buy-in from all staff, not just leaders; address root causes of problems; use opinion leaders and incentives; plan interventions ahead and provide make-up videos; and accept that targets vary in their readiness to change.</p></div><div><h3>Discussion</h3><p>The framework and examples provided should help overcome challenges in any work in which research findings are applied to clinical practice.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 5","pages":"Pages 235-245"},"PeriodicalIF":0.0,"publicationDate":"2004-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30026-2","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24527226","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

Information-to-Go: Publishing Organization-Specific Information for Personal Digital Assistants 信息:为个人数字助理发布组织特定信息

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30032-8

Daniel E. Haun M.T., (A.S.C.P.)H. (Director of Client Services), Argie Leach M.H.S., M.T (A.S.C.P.)S.H. (Competency Coordinator)

引用次数: 1

Altering Meperidine Prescribing Patterns in a University Teaching Hospital 某大学教学医院哌嗪处方模式的改变

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30030-4

James G. Stevenson Pharm.D. (Director of Pharmacy Services), Mark Pearlman M.D. (Chair), Carmen R. Green M.D. (Director of the Acute Pain Service), Stephanie Newland R.Ph., M.P.A. (Manager of Inpatient Pharmacy Operations), Louise Grondin M.S., A.P.R.N., B.C. (Quality Improvement Coordinator), Maureen Thompson M.S.N., R.N., C.C.R.N. (Patient Safety Coordinator), Julie Golembiewski Pharm.D., Darrell Campbell M.D. (Chief of Staff)

引用次数: 8

A Physician House Call Program for the Homebound 为回家的人准备的医生出诊计划

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30029-8

Naoko Muramatsu Ph.D. (Associate Professor), Edward Mensah Ph.D. (Associate Professor), Thomas Cornwell M.D. (Medical Director)

{"title":"A Physician House Call Program for the Homebound","authors":"Naoko Muramatsu Ph.D. (Associate Professor), Edward Mensah Ph.D. (Associate Professor), Thomas Cornwell M.D. (Medical Director)","doi":"10.1016/S1549-3741(04)30029-8","DOIUrl":"10.1016/S1549-3741(04)30029-8","url":null,"abstract":"<div><h3>Background</h3><p>A growing number of homebound frail older adults have multiple chronic diseases with frequent flare-ups of acute episodes. A physician house call program affiliated with a nonprofit community health system was deployed as a strategy to improve quality of care for homebound patients.</p></div><div><h3>Program Description</h3><p>A medical team (either a physician and a medical assistant or a nurse practitioner), with a vehicle filled with portable medical equipment and supplies, fulfills the house call and primary care physician functions, establishes diagnoses, designs a treatment plan, arranges for any other needed services, and fosters continuity of medical care.</p></div><div><h3>Evaluation</h3><p>Interviews and focus groups with selected patients, family caregivers, program staff, and other service providers indicated that the program operated consistently with its intent. For example, the patient and caregiver interviews converged on four major themes: (1) the program improves patients’ medication and health management and optimizes health, (2) caregivers felt more informed about the patients’ medical conditions and medications and relieved of the burden of transporting patients to physicians, (3) the program reduces use of hospital and emergency services, and (4) the programs enables patients to die at home.</p></div><div><h3>Discusson</h3><p>The success of any future programs and further replications will depend on creating trusting relationships with local service providers and getting decision makers of affiliated community health systems or hospitals to embrace the necessary vision.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 5","pages":"Pages 266-276"},"PeriodicalIF":0.0,"publicationDate":"2004-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30029-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24528245","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: 22

Shifting Care of Chronic Ventilator-Dependent Patients from the Intensive Care Unit to the Nursing Home 慢性呼吸机依赖患者的护理从重症监护室转移到养老院

Joint Commission journal on quality and safety Pub Date : 2004-05-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30028-6

Mark E. Lindsay M.D. (Medical Director of Lakeside Ventilator Unit and Department Chair), Jagdeep S. Bijwadia M.D. (Pulmonologist), Whitney W. Schauer R.R.T. (Director of Respiratory Therapy), John D. Rozich M.D., Ph.D., M.B.A. (Chief of Cardiology)

{"title":"Shifting Care of Chronic Ventilator-Dependent Patients from the Intensive Care Unit to the Nursing Home","authors":"Mark E. Lindsay M.D. (Medical Director of Lakeside Ventilator Unit and Department Chair), Jagdeep S. Bijwadia M.D. (Pulmonologist), Whitney W. Schauer R.R.T. (Director of Respiratory Therapy), John D. Rozich M.D., Ph.D., M.B.A. (Chief of Cardiology)","doi":"10.1016/S1549-3741(04)30028-6","DOIUrl":"10.1016/S1549-3741(04)30028-6","url":null,"abstract":"<div><h3>Background</h3><p>Among the most resource intensive and challenging of medical needs is the treatment of patients requiring long-term or chronic mechanical ventilation. Expenditures are significant, and definitions of “successful weaning,” are often inconsistent. A weaning program was initiated for patients referred to a stand-alone nursing home ventilator unit.</p></div><div><h3>Methods</h3><p>Weaning entailed standardized weaning protocols, enhanced socialization, a multidisciplinary approach to care, empowerment of staff to initiate weaning, and aggressive utilization of noninvasive positive pressure ventilation (NPPV) in selected patients.</p></div><div><h3>Results</h3><p>Sixty-eight (67%) of 102 patients were successfully weaned during a six-year period. NPPV facilitated successful weaning in 27 (26%) of 102 patients. Of the 28 chronic ventilator-dependent patients admitted with a neuromuscular etiology for respiratory failure, NPPV was utilized in 73% (8/11) of the successfully weaned patients. Total variable costs per ventilator per patient per day for the years 1998–2000 were $319.79, $302.75, and $297.59. Six-year cost savings for referring hospitals were estimated at $18.5 million.</p></div><div><h3>Discussion</h3><p>Incentives were aligned between the hospital, nursing home, and physicians to develop a financially stable model. Developing an off-site nursing home ventilator unit resulted in significant cost savings to the referring hospitals and positively affected patient flow.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 5","pages":"Pages 257-265"},"PeriodicalIF":0.0,"publicationDate":"2004-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30028-6","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24527228","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: 22

Shorter Catheters—A Simple Solution to a Rare but Deadly Complication 缩短导管——一种罕见但致命的并发症的简单解决方案

Joint Commission journal on quality and safety Pub Date : 2004-04-01 Epub Date: 2016-11-17 DOI: 10.1016/S1549-3741(04)30025-0

Susan J. Stein M.D. (Medical Director), Laura Sarff R.N., M.S.N. (Director), Robin Tyler R.N., M.S.N. (Quality Consultant)

引用次数: 0