Showing papers in "The Joint Commission Journal on Quality and Patient Safety in 2005"

TL;DR: The observations seem sufficiently robust to support implementing the ventilator bundles to provide a focus for additional change in ICUs and demand development of the teamwork necessary to improve reliability.

TL;DR: TPS principles and tools are applicable to an endless variety of processes and work settings in health care and can be used to address critical challenges such as medical errors, escalating costs, and staffing shortages.

TL;DR: For teamwork skills to be assessed and have credibility, team performance measures must be grounded in team theory, account for individual and team-level performance, capture team process and outcomes, adhere to standards for reliability and validity, and address real or perceived barriers to measurement.

TL;DR: Clinicians and their health care organizations need to take active steps to discover, analyze, and prevent diagnostic errors.

TL;DR: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements.

TL;DR: The health care community can gain significantly from using simulation-based training to reduce errors and improve patient safety when it is designed and delivered appropriately.

TL;DR: Al forms of artificial variation in the demand and supply of health care services should be identified, and pilot programs to test operational changes should be conducted.

TL;DR: Safe Practice Recommendations to promote successful communication of results, and a "starter set" of test results sufficiently abnormal to be widely agreed to be considered "critical" are developed.

TL;DR: A serious commitment to optimizing patients' contributions to safe care requires a research-based understanding of patients' perspectives and more practical facilitation of patient involvement.

TL;DR: In the approximately 90% of U.S. hospitals currently without computerized order-entry systems, a written reminder should be considered as one method for improving the safety of hospitalized patients.

TL;DR: Standardization of processes, computerized test tracking systems, and attention to human factors issues are likely to reduce errors and harm and need confirmation in well-designed randomized trials and quality improvement initiatives.

TL;DR: A survey suggests that health care providers' intimidating behaviors are not isolated events, but many actions can be undertaken to reduce their frequency.

TL;DR: Patient Safety Leadership WalkRounds appears to be an effective tool for engaging leadership, identifying safety issues, and supporting a culture of safety.

TL;DR: Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item, however, it is the feedback to the reporter that perpetuates the influx of information and closes the loop.

TL;DR: There was no increase in hypoglycemia despite the use of the protocol in non-critical care units with higher patient-to-nurse ratios, suggests that insulin infusion therapy can be safely used outside of critical care units.

TL;DR: The framework identifies strategies and methods for planning and guiding the spread of new ideas or new operational systems, including the responsibilities of leadership, packaging the new ideas, communication, strengthening the social system, measurement and feedback, and knowledge management.

TL;DR: The IHI BTS appears to be a viable method of disseminating evidence-based depression care and on the basis of the feedback from ten successful teams, the essential change concepts for depression were establishing and maintaining a patient registry, care coordination, diagnostic assessment, and proactive follow-up.

TL;DR: In this paper, the root cause analysis of patient falls occurring in the VA system was performed and the action plans associated with these reductions focused on making specific clinical changes at the bedside rather than policy changes or educating staff.

TL;DR: Direct patient notification could theoretically reduce the burden on providers, activate and empower patients, and create a back-up system for ensuring that patients are notified of their test results.

TL;DR: Four core areas of focus include establishing safety as a core value, creating Behavior-Based Expectations for error prevention that are tailored for staff, leaders, and physicians, developing a state-of-the-art root and common-cause analysis program, and implementing an approach to focus and simplify work processes and procedure documentation.

TL;DR: Four major problematic issues encountered during the project offer potential solutions for addressing them.

TL;DR: On-site methods may yield satisfaction results that are biased in a positive direction for younger patients and for all patients in which social desirability pressures are prominent, and organizations that rely on such information may have an inflated view of the patient's satisfaction with their care delivery experience.

TL;DR: Knowing the influence of the other organizational characteristics on EMR adoption will help prepare organizational leaders for the complicated process of achieving consensus among physicians and others in medical groups on the expenditure of funds and other resources to acquire an EMR.

TL;DR: Substantial unnecessary variation in i.v. medication practices is likely associated with increased risk of harm and standardization has the potential to substantially improve i.V. medication safety.

TL;DR: In this paper, the authors identify patients with CRI (estimated creatinine clearance ≤ 50mL/min) who visited the ambulatory care clinic at least once from January 1, 2003 through December 31, 2003.

TL;DR: Proactive assessment of potential for medication errors should include evaluation of potential look-alike packaging problems in addition to the drug names, according to the Joint Commission National Patient Safety Goals.

TL;DR: The AHRQ QIs software can be applied to hospital administrative data that is available within individual institutions or from state data organizations and hospital associations and can provide valuable insights into health care quality at extremely low cost.

TL;DR: Although a variety of psychological and cultural factors may make clinicians and organizations reluctant to disclose adverse events to patients, the arguments favoring routine disclosure are compelling.

TL;DR: The Healthcare Matrix provides a blueprint to help residents to learn the core competencies in patient care, and to help faculty to link mastery of the competencies with improvement in quality of care.

TL;DR: Leading support, experience with quality improvement and teamwork, teamwork skills, and skills gained from the project were correlated with teams' abilities to achieve and maintain success.