Pub Date : 2026-01-09DOI: 10.1016/j.jcjq.2025.12.002
Frances Hand, Morganne Wilbourne, Sophie McAllister, Nadia Muspratt-Tucker, Jonathan Herring, Sujay Chakravarti, Meena Bhatia
Background: One in five women giving birth for the first time will have an operative vaginal delivery (OVD). Despite this frequency, a considerable number of women and birthing people report feeling unprepared for OVD. This incongruence spurred our decision to further understand our service users' perspectives on the consent process for OVD. In feedback by a local Maternity and Neonatal Voices Partnership, some maternity service users reported that they felt the consent process for OVD was inadequate, leaving them confused and upset after birth.
Methods: As part of a quality improvement project, an anonymous questionnaire was devised and disseminated both within the National Health Service (NHS) Maternity Unit and online. Women and birthing people were asked to fill in the survey if they had experienced OVD in the past two years. Thematic analysis was conducted based on their responses.
Results: A total of 88 responses were collected. Two core themes were identified: (1) the majority of women (65.9%) felt under-informed about OVD, and (2) women wanted to know more about OVD in advance of labor. A notable minority (10/86, 11.6%) claim to have consented to procedures that they did not fully understand.
Conclusion: Our project reflects a growing body of literature interrogating the challenges with discussing consent "in-the-moment," as a one-time decision. Consideration must be given to ways in which we can strengthen understanding and comprehension within this process. Although the current consent model is useful in some medical procedures, the unique circumstances of childbirth may require something more. The consent process could be adapted so women can more fully engage with the conversation.
{"title":"Perceptions of Consent for Operative Vaginal Delivery: A Service Evaluation.","authors":"Frances Hand, Morganne Wilbourne, Sophie McAllister, Nadia Muspratt-Tucker, Jonathan Herring, Sujay Chakravarti, Meena Bhatia","doi":"10.1016/j.jcjq.2025.12.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.12.002","url":null,"abstract":"<p><strong>Background: </strong>One in five women giving birth for the first time will have an operative vaginal delivery (OVD). Despite this frequency, a considerable number of women and birthing people report feeling unprepared for OVD. This incongruence spurred our decision to further understand our service users' perspectives on the consent process for OVD. In feedback by a local Maternity and Neonatal Voices Partnership, some maternity service users reported that they felt the consent process for OVD was inadequate, leaving them confused and upset after birth.</p><p><strong>Methods: </strong>As part of a quality improvement project, an anonymous questionnaire was devised and disseminated both within the National Health Service (NHS) Maternity Unit and online. Women and birthing people were asked to fill in the survey if they had experienced OVD in the past two years. Thematic analysis was conducted based on their responses.</p><p><strong>Results: </strong>A total of 88 responses were collected. Two core themes were identified: (1) the majority of women (65.9%) felt under-informed about OVD, and (2) women wanted to know more about OVD in advance of labor. A notable minority (10/86, 11.6%) claim to have consented to procedures that they did not fully understand.</p><p><strong>Conclusion: </strong>Our project reflects a growing body of literature interrogating the challenges with discussing consent \"in-the-moment,\" as a one-time decision. Consideration must be given to ways in which we can strengthen understanding and comprehension within this process. Although the current consent model is useful in some medical procedures, the unique circumstances of childbirth may require something more. The consent process could be adapted so women can more fully engage with the conversation.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146131821","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.10.007
Jonathan A. Handler MD (is Senior Fellow, Innovation, Clinical Intelligence and Advanced Data Lab, OSF HealthCare, Peoria, Illinois, and at the time of the study, Adjunct Associate Professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine.), Tiaranesha Jackson MD, MPH (is Dermatology Resident, Department of Internal Medicine - Section of Dermatology, Cook County Health, Chicago, Illinois, and earlier during this work, Preliminary Internal Medicine Resident, Department of Internal Medicine, University of Chicago Medical Center (Endeavor Health), Evanston, Illinois, and Medical Student, University of Illinois College of Medicine Peoria.), Kyle Espejo MD (is Internal Medicine Resident, Department of Internal Medicine, Rush University Medical Center, Chicago, and earlier during this work, Medical Student, University of Illinois College of Medicine Peoria.), Jeremy McGarvey MS (is Senior Statistician, Department of Healthcare Analytics, OSF HealthCare.), Ethan C. Handler (performed this work as Independent Researcher, Boston.), Mark A. Meeker DO (is Vice President and Chief Medical Officer, OSF SMMC/HFMC/SLMC, OSF HealthCare. Please address correspondence to Jonathan A. Handler.)
{"title":"Impact of Note-Extracted Blood Pressures on Measured Hypertension Control Performance","authors":"Jonathan A. Handler MD (is Senior Fellow, Innovation, Clinical Intelligence and Advanced Data Lab, OSF HealthCare, Peoria, Illinois, and at the time of the study, Adjunct Associate Professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine.), Tiaranesha Jackson MD, MPH (is Dermatology Resident, Department of Internal Medicine - Section of Dermatology, Cook County Health, Chicago, Illinois, and earlier during this work, Preliminary Internal Medicine Resident, Department of Internal Medicine, University of Chicago Medical Center (Endeavor Health), Evanston, Illinois, and Medical Student, University of Illinois College of Medicine Peoria.), Kyle Espejo MD (is Internal Medicine Resident, Department of Internal Medicine, Rush University Medical Center, Chicago, and earlier during this work, Medical Student, University of Illinois College of Medicine Peoria.), Jeremy McGarvey MS (is Senior Statistician, Department of Healthcare Analytics, OSF HealthCare.), Ethan C. Handler (performed this work as Independent Researcher, Boston.), Mark A. Meeker DO (is Vice President and Chief Medical Officer, OSF SMMC/HFMC/SLMC, OSF HealthCare. Please address correspondence to Jonathan A. Handler.)","doi":"10.1016/j.jcjq.2025.10.007","DOIUrl":"10.1016/j.jcjq.2025.10.007","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 44-48"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145793899","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.10.005
John A. Bender MSIRIA, MBA, MHA, ACHE (Health Systems Specialist, Veterans Health Administration (VHA) National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan), Peter D. Mills PhD, MS (Psychologist, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan), Stephen F. Kulju MS, CCE (Associate Director for Engineering and Recalls Programs, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan), James R. Turner (Supervisory Program Analyst, Statistics, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan. Please address correspondence to John A. Bender)
Background
Healthcare professionals acknowledge that medical emergencies may occur any time; however, many remain unaware of the potential for systems such as equipment to unexpectedly fail. Within healthcare organizations, a patient’s condition can rapidly deteriorate, leading to decompensation and risk of mortality. Responders to code blue, rapid response, or other medical emergency responses may not be able to detect potential critical system failures during an event or be aware of actions or interventions that can be implemented to prevent these events.
Methods
The authors used a Combined Proactive Risk Assessment (CPRA) approach to investigate failure modes (FMs) within the code blue, rapid response, and medical emergency response processes. The study reviewed proactive risk assessments (PRAs) from 13 Veterans Health Administration (VHA) hospitals and reactive risk assessments (RRAs) such as patient safety reports and root cause analyses from 172 hospitals.
Results
Analysis of the RRAs revealed 1,149 FMs. Failures occurred during initial patient evaluation (15.4%), when calling the code team (15.1%), and during the code team response to the code (13.5%). The majority of FMs occurred from disruptions to safeguards (barriers and controls) (47.6%), from equipment issues (22.5%) and from communication failures (14.5%). This study also compiled a list of actions from root cause analyses to mitigate future risks and harm.
Conclusion
The CPRA method provided a comprehensive risk analysis of the code blue, rapid response, and medical emergency response processes and identified potential solutions to these failures.
{"title":"Enhancing Code Blue, Rapid Response, and Emergency Response Safety in the Veterans Health Administration: Using a Combined Proactive Risk Assessment (CPRA) Approach to Detect Failure Modes and Identify Improvement Actions","authors":"John A. Bender MSIRIA, MBA, MHA, ACHE (Health Systems Specialist, Veterans Health Administration (VHA) National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan), Peter D. Mills PhD, MS (Psychologist, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan), Stephen F. Kulju MS, CCE (Associate Director for Engineering and Recalls Programs, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan), James R. Turner (Supervisory Program Analyst, Statistics, VHA National Center for Patient Safety, US Department of Veterans Affairs, Ann Arbor, Michigan. Please address correspondence to John A. Bender)","doi":"10.1016/j.jcjq.2025.10.005","DOIUrl":"10.1016/j.jcjq.2025.10.005","url":null,"abstract":"<div><h3>Background</h3><div>Healthcare professionals acknowledge that medical emergencies may occur any time; however, many remain unaware of the potential for systems such as equipment to unexpectedly fail. Within healthcare organizations, a patient’s condition can rapidly deteriorate, leading to decompensation and risk of mortality. Responders to code blue, rapid response, or other medical emergency responses may not be able to detect potential critical system failures during an event or be aware of actions or interventions that can be implemented to prevent these events.</div></div><div><h3>Methods</h3><div>The authors used a Combined Proactive Risk Assessment (CPRA) approach to investigate failure modes (FMs) within the code blue, rapid response, and medical emergency response processes. The study reviewed proactive risk assessments (PRAs) from 13 Veterans Health Administration (VHA) hospitals and reactive risk assessments (RRAs) such as patient safety reports and root cause analyses from 172 hospitals.</div></div><div><h3>Results</h3><div>Analysis of the RRAs revealed 1,149 FMs. Failures occurred during initial patient evaluation (15.4%), when calling the code team (15.1%), and during the code team response to the code (13.5%). The majority of FMs occurred from disruptions to safeguards (barriers and controls) (47.6%), from equipment issues (22.5%) and from communication failures (14.5%). This study also compiled a list of actions from root cause analyses to mitigate future risks and harm.</div></div><div><h3>Conclusion</h3><div>The CPRA method provided a comprehensive risk analysis of the code blue, rapid response, and medical emergency response processes and identified potential solutions to these failures.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 9-25"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145633601","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.10.002
Suresh K. Pavuluri MD, MPH (is Assistant Professor and Associate Director of Quality and Patient Safety, Department of Emergency Medicine, Yale School of Medicine.), Rohit B. Sangal MD, MBA (is Assistant Professor, Department of Emergency Medicine, Yale School of Medicine, and Associate Medical Director, Yale New Haven Adult Emergency Department.), Craig Rothenberg MPH (is Statistician, Department of Emergency Medicine, Yale School of Medicine.), Arjun Venkatesh MD, MBA, MHS (is Professor and Chair, Department of Emergency Medicine, Yale School of Medicine.), Richard Andrew Taylor MD, MHS (is Professor and Vice Chair of Research and Innovation, Department of Emergency Medicine, University of Virginia.), John Sather MD (is Associate Professor and Director of Quality and Pateint Safety, Department of Emergency Medicine, Yale School of Medicine. Please address correspondence to Suresh K. Pavuluri)
{"title":"Evaluating a Disease-Specific Look-Back Trigger Methodology vs. Traditional Screening for Diagnostic Errors in the Emergency Department","authors":"Suresh K. Pavuluri MD, MPH (is Assistant Professor and Associate Director of Quality and Patient Safety, Department of Emergency Medicine, Yale School of Medicine.), Rohit B. Sangal MD, MBA (is Assistant Professor, Department of Emergency Medicine, Yale School of Medicine, and Associate Medical Director, Yale New Haven Adult Emergency Department.), Craig Rothenberg MPH (is Statistician, Department of Emergency Medicine, Yale School of Medicine.), Arjun Venkatesh MD, MBA, MHS (is Professor and Chair, Department of Emergency Medicine, Yale School of Medicine.), Richard Andrew Taylor MD, MHS (is Professor and Vice Chair of Research and Innovation, Department of Emergency Medicine, University of Virginia.), John Sather MD (is Associate Professor and Director of Quality and Pateint Safety, Department of Emergency Medicine, Yale School of Medicine. Please address correspondence to Suresh K. Pavuluri)","doi":"10.1016/j.jcjq.2025.10.002","DOIUrl":"10.1016/j.jcjq.2025.10.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 42-43"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145523371","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.11.001
Andrii Khomiak MD, PhD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Joshua D. Billings MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Victoria Huynh MD (formerly Resident, Department of Surgery, University of Colorado School of Medicine, is Assistant Professor, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham.), Laura D. Leonard MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Viviane L. Abud MD (is Colorectal Surgery Fellow, Department of Surgery, University of Colorado School of Medicine.), Teresa L. Jones MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine.), Salvador Rodriguez Franco MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Ioannis A. Ziogas MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Kyle Bata MS (is Quality Data Analyst, Department of Surgery, University of Colorado School of Medicine.), Nicole Christian MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine.), Marco Del Chiaro MD, PhD (is Professor, Department of Surgery, and Chief, Division of Surgical Oncology, University of Colorado School of Medicine.), Ethan Cumbler MD (is Professor, and Director of Quality, Department of Surgery, University of Colorado School of Medicine.), Sarah E.A. Tevis MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine. Please address correspondence to Sarah E. A. Tevis, [email protected].)
Background
The opioid epidemic remains a critical public health challenge. This study aimed to assess the sustainability of improved opioid prescribing practices following the implementation of an intervention in the postoperative clinical setting.
Methods
Conducted as a quality improvement (QI) initiative at an academic medical center, this pre-post interventional study spanned four phases: preimplementation (October 2019–June 2020), implementation (July–December 2020), and postimplementation (January–December 2021), followed by the sustainability phase (January 2022–November 2023). The authors examined opioid-naïve patients ≥ 18 years undergoing procedures under specified Current Procedural Terminology (CPT) codes. Interventions included education and monthly feedback reports based on Opioid Prescribing Engagement Network (OPEN) guidelines. Descriptive statistics were used to summarize data; chi-square test was used to compare categorical variables.
Results
The postimplementation cohort consisted of 2,513 patients vs. 2,290 in the preimplementation group, with statistically similar baseline characteristics. We observed a compliance increase to 68.9% vs. 45.1% (p < 0.001). The sustainability cohort included 4,976 patients and had a further increase to 80.1% compliance compared to the postimplementation cohort (p < 0.001). Residents (nonresident prescribers include advanced practice providers and attending surgeons) were more likely to be prescribing providers in postimplementation vs. sustainability cohort, 39.6% vs. 22.2% (p < 0.001). Subanalysis was conducted across 12 consecutive months comparing the period with a consistent distribution of performance reports with the period when no performance reminders were sent for the previous month (November 2022–May 2023 vs. June–November 2023). The compliance rates for these two subperiods did not differ (82.04% vs. 81.98%, respectively, p = 0.97).
Conclusion
This study’s data demonstrate that a well-structured QI initiative can lead to sustained improvements in opioid prescribing practices and “enculturation” to maintain long-term change within an institution.
{"title":"Long-Term Sustainability of QI Interventions: Outcomes in Opioid Prescribing for Postoperative Care","authors":"Andrii Khomiak MD, PhD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Joshua D. Billings MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Victoria Huynh MD (formerly Resident, Department of Surgery, University of Colorado School of Medicine, is Assistant Professor, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham.), Laura D. Leonard MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Viviane L. Abud MD (is Colorectal Surgery Fellow, Department of Surgery, University of Colorado School of Medicine.), Teresa L. Jones MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine.), Salvador Rodriguez Franco MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Ioannis A. Ziogas MD (is Resident, Department of Surgery, University of Colorado School of Medicine.), Kyle Bata MS (is Quality Data Analyst, Department of Surgery, University of Colorado School of Medicine.), Nicole Christian MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine.), Marco Del Chiaro MD, PhD (is Professor, Department of Surgery, and Chief, Division of Surgical Oncology, University of Colorado School of Medicine.), Ethan Cumbler MD (is Professor, and Director of Quality, Department of Surgery, University of Colorado School of Medicine.), Sarah E.A. Tevis MD (is Associate Professor, Department of Surgery, University of Colorado School of Medicine. Please address correspondence to Sarah E. A. Tevis, [email protected].)","doi":"10.1016/j.jcjq.2025.11.001","DOIUrl":"10.1016/j.jcjq.2025.11.001","url":null,"abstract":"<div><h3>Background</h3><div>The opioid epidemic remains a critical public health challenge. This study aimed to assess the sustainability of improved opioid prescribing practices following the implementation of an intervention in the postoperative clinical setting.</div></div><div><h3>Methods</h3><div>Conducted as a quality improvement (QI) initiative at an academic medical center, this pre-post interventional study spanned four phases: preimplementation (October 2019–June 2020), implementation (July–December 2020), and postimplementation (January–December 2021), followed by the sustainability phase (January 2022–November 2023). The authors examined opioid-naïve patients ≥ 18 years undergoing procedures under specified Current Procedural Terminology (CPT) codes. Interventions included education and monthly feedback reports based on Opioid Prescribing Engagement Network (OPEN) guidelines. Descriptive statistics were used to summarize data; chi-square test was used to compare categorical variables.</div></div><div><h3>Results</h3><div>The postimplementation cohort consisted of 2,513 patients vs. 2,290 in the preimplementation group, with statistically similar baseline characteristics. We observed a compliance increase to 68.9% vs. 45.1% (<em>p</em> < 0.001). The sustainability cohort included 4,976 patients and had a further increase to 80.1% compliance compared to the postimplementation cohort (<em>p</em> < 0.001). Residents (nonresident prescribers include advanced practice providers and attending surgeons) were more likely to be prescribing providers in postimplementation vs. sustainability cohort, 39.6% vs. 22.2% (<em>p</em> < 0.001). Subanalysis was conducted across 12 consecutive months comparing the period with a consistent distribution of performance reports with the period when no performance reminders were sent for the previous month (November 2022–May 2023 vs. June–November 2023). The compliance rates for these two subperiods did not differ (82.04% vs. 81.98%, respectively, <em>p</em> = 0.97).</div></div><div><h3>Conclusion</h3><div>This study’s data demonstrate that a well-structured QI initiative can lead to sustained improvements in opioid prescribing practices and “enculturation” to maintain long-term change within an institution.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 26-32"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145768074","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.10.001
Elizabeth H. Lazzara PhD (is Associate Professor, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida), Sabina M. Patel MS (is Graduate Research Assistant and Doctoral Candidate, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University), Scott I․ Tannenbaum PhD (is President, The Group for Organizational Effectiveness, Albany, New York), Rosemarie Fernandez MD (is Clinical Professor, Department of Emergency Medicine, University of Florida College of Medicine), Eduardo Salas MS, PhD (is Professor, Department of Psychological Sciences, Rice University), Joseph R. Keebler MA, PhD (is Professor, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University. Please address correspondence to Elizabeth A. Lazzara)
{"title":"Myth Busters: A Discussion of the Misconceptions Surrounding Patient Handoffs","authors":"Elizabeth H. Lazzara PhD (is Associate Professor, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida), Sabina M. Patel MS (is Graduate Research Assistant and Doctoral Candidate, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University), Scott I․ Tannenbaum PhD (is President, The Group for Organizational Effectiveness, Albany, New York), Rosemarie Fernandez MD (is Clinical Professor, Department of Emergency Medicine, University of Florida College of Medicine), Eduardo Salas MS, PhD (is Professor, Department of Psychological Sciences, Rice University), Joseph R. Keebler MA, PhD (is Professor, Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University. Please address correspondence to Elizabeth A. Lazzara)","doi":"10.1016/j.jcjq.2025.10.001","DOIUrl":"10.1016/j.jcjq.2025.10.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 49-53"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145556945","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.10.004
Bertie Geng MD (formerly Resident, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, is Fellow, Urogynecology, Department of Obstetrics & Gynecology, University of North Carolina School of Medicine), Nishita Pondugula MS, MD (formerly Medical Student, Yale School of Medicine, is Resident, Department of Obstetrics and Gynecology, Duke University Medical Center), Lisbet Lundsberg MPH, PhD (is Associate Research Scientist, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine), Holly Zurich MS (is Lead APP Performance Improvement, Yale New Haven Hospital.), Rohit B. Sangal MD, MBA (is Assistant Professor, Department of Emergency Medicine, Yale School of Medicine, and Associate Medical Director, Adult Emergency Department, Yale New Haven Hospital) , Linda Fan MD (is Assistant Professor, and Director of Gynecology Section, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine. Please address correspondence to Bertie Geng)
Objective
To determine if an electronic health record (EHR)–based quality improvement intervention can decrease the time to gynecologic evaluation for patients presenting to the emergency department (ED) within 30 days of gynecologic surgery.
Methods
Through a multidisciplinary approach, key drivers to delays of recognition of postoperative complications were delineated and change ideas explored. In April 2022 an EHR notification was implemented that alerted ED and gynecology providers when patients presented within 30 days postoperatively. For primary analysis, the authors compared patients who presented to the ED October 2021–April 2022 (preintervention) to those who presented April 2022–May 2023 (postintervention) who were admitted after gynecology evaluation. Secondary analysis included all postoperative patients presenting to the ED.
Results
A total of 93 patients were included in the primary analysis, 37 (39.8%) preintervention and 56 (60.2%) postintervention. Mean ages in the pre- and postintervention periods were 41.3 and 50.1 years, respectively, p = 0.01. Baseline characteristics did not otherwise differ. Average time between ED arrival and initial gynecologic evaluation was 6.08 ± 4.83 hours in the preintervention group and 4.25 ± 2.36 hours in the postintervention group. After adjusting for age, compared to the preintervention period, the postintervention period was associated with a 2.26 hour reduction (β = -2.26; 95% confidence interval [CI] -3.78 to -0.74) in the time between ED arrival and initial gynecologic evaluation, p < 0.01. The time between ED arrival and initial gynecologic evaluation also became a more predictable process postintervention. On secondary analysis, median minutes from patient rooming to gynecology first chart opening decreased from 57.1 preintervention to 11.9 postintervention, p = 0.001.
Conclusion
This process improvement project reduced the latency time from ED arrival to gynecologic evaluation.
{"title":"Reducing Delays in Postoperative Gynecologic Evaluations Through Automated Electronic Alerts","authors":"Bertie Geng MD (formerly Resident, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, is Fellow, Urogynecology, Department of Obstetrics & Gynecology, University of North Carolina School of Medicine), Nishita Pondugula MS, MD (formerly Medical Student, Yale School of Medicine, is Resident, Department of Obstetrics and Gynecology, Duke University Medical Center), Lisbet Lundsberg MPH, PhD (is Associate Research Scientist, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine), Holly Zurich MS (is Lead APP Performance Improvement, Yale New Haven Hospital.), Rohit B. Sangal MD, MBA (is Assistant Professor, Department of Emergency Medicine, Yale School of Medicine, and Associate Medical Director, Adult Emergency Department, Yale New Haven Hospital) , Linda Fan MD (is Assistant Professor, and Director of Gynecology Section, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine. Please address correspondence to Bertie Geng)","doi":"10.1016/j.jcjq.2025.10.004","DOIUrl":"10.1016/j.jcjq.2025.10.004","url":null,"abstract":"<div><h3>Objective</h3><div>To determine if an electronic health record (EHR)–based quality improvement intervention can decrease the time to gynecologic evaluation for patients presenting to the emergency department (ED) within 30 days of gynecologic surgery.</div></div><div><h3>Methods</h3><div>Through a multidisciplinary approach, key drivers to delays of recognition of postoperative complications were delineated and change ideas explored. In April 2022 an EHR notification was implemented that alerted ED and gynecology providers when patients presented within 30 days postoperatively. For primary analysis, the authors compared patients who presented to the ED October 2021–April 2022 (preintervention) to those who presented April 2022–May 2023 (postintervention) who were admitted after gynecology evaluation. Secondary analysis included all postoperative patients presenting to the ED.</div></div><div><h3>Results</h3><div>A total of 93 patients were included in the primary analysis, 37 (39.8%) preintervention and 56 (60.2%) postintervention. Mean ages in the pre- and postintervention periods were 41.3 and 50.1 years, respectively, <em>p</em> = 0.01. Baseline characteristics did not otherwise differ. Average time between ED arrival and initial gynecologic evaluation was 6.08 ± 4.83 hours in the preintervention group and 4.25 ± 2.36 hours in the postintervention group. After adjusting for age, compared to the preintervention period, the postintervention period was associated with a 2.26 hour reduction (β = -2.26; 95% confidence interval [CI] -3.78 to -0.74) in the time between ED arrival and initial gynecologic evaluation, <em>p</em> < 0.01. The time between ED arrival and initial gynecologic evaluation also became a more predictable process postintervention. On secondary analysis, median minutes from patient rooming to gynecology first chart opening decreased from 57.1 preintervention to 11.9 postintervention, <em>p</em> = 0.001.</div></div><div><h3>Conclusion</h3><div>This process improvement project reduced the latency time from ED arrival to gynecologic evaluation.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 1-8"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145556893","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.10.008
Elizabeth Harry MD , Christine Sinsky MD , Lotte N. Dyrbye MD, MHPE , Maryam S. Makowski PhD , Mickey Trockel MD, PhD , Michael Tutty PhD , Lindsey E. Carlasare MBA , Colin P. West MD, PhD , Tait D. Shanafelt MD
{"title":"Corrigendum to Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey [The Joint Commission Journal on Quality and Patient Safety 47, 2 (2021) 76-85]","authors":"Elizabeth Harry MD , Christine Sinsky MD , Lotte N. Dyrbye MD, MHPE , Maryam S. Makowski PhD , Mickey Trockel MD, PhD , Michael Tutty PhD , Lindsey E. Carlasare MBA , Colin P. West MD, PhD , Tait D. Shanafelt MD","doi":"10.1016/j.jcjq.2025.10.008","DOIUrl":"10.1016/j.jcjq.2025.10.008","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 54-55"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145633661","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}
Pub Date : 2026-01-01DOI: 10.1016/j.jcjq.2025.10.006
Yash Bhanji Boricha MBBS, DGO, MS, DNB, MRCOG (is Senior Staff Physician, Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore.), Junzhe Zhao MA, MEng, PhD (is final year MD/PhD candidate, Duke-NUS Medical School, Singapore.), Felicia Yiqian Ang (is PSQ Lead, Department of Quality, Safety and Risk Management, KK Women’s & Children’s Hospital.), Kim Teng Tan MBBS, MMed, MRACOG, FAMS (is Senior Consultant, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital. Please address correspondence to Junzhe Zhao)
Background
Mislabeling of endometrial vs. endocervical curettings was the most frequent specimen error in the Division of Obstetrics & Gynaecology at KK Women’s and Children’s Hospital, Singapore. These look-alike/sound-alike (LASA) errors can compromise patient safety and workflow efficiency. The authors aimed to reduce specimen labeling errors over a two-year quality improvement (QI) period.
Methods
Following root cause analysis, a multidisciplinary QI project was initiated in a single tertiary obstetrics & gynecology center using the Plan-Do-Study-Act (PDSA) methodology. Between 2020 and 2022, interventions were (1) a pilot system-level enhancement to the electronic ordering interface; (2) clinician education, training, and monthly feedback; (3) team-based process redesign emphasizing accountability and safety culture; and (4) a subsequent system-level enhancement to the electronic ordering interface during a second PDSA cycle. The primary outcome was the rate of endometrial vs. endocervical mislabeling events per 1,000 orders. The researchers plotted time-series run charts and u-charts and calculated pre- and postintervention incidence rate ratios (IRRs).
Results
Among 42,968 curettings from January 2020 to May 2025, 46 endometrial/endocervical mislabeling events occurred. Mislabeling rates were 3.79 per 1,000 orders at baseline (9/2,373; January–May 2020), 3.80 between two PDSA cycles (33/8,683; June 2020–April 2021), and 0.13 following the second PDSA cycle (4/31,912; from May 2021), corresponding to a 96.7% reduction vs. baseline (IRR 0.03, 95% confidence interval [CI] 0.01–0.11, p < 0.001). Time-series charts showed a sustained special cause shift since May 2021, with 30 consecutive zero-error months between January 2022 and June 2024.
Conclusion
A combination of education, feedback, process audits, and interface redesign effectively addressed mislabeling of endometrial/endocervical specimens, a high-impact patient safety concern. This approach may be transferable to other LASA error domains.
背景：在新加坡KK妇女儿童医院的妇产科中，子宫内膜与宫颈内膜刮痧的错误标记是最常见的标本错误。这些外观相似/声音相似（LASA）错误可能会危及患者安全和工作流程效率。作者的目的是在两年的质量改进（QI）期间减少标本标记错误。方法：在进行根本原因分析后，采用计划-做-研究-行动（PDSA）方法在某三级妇产科中心开展多学科质量评价项目。在2020年至2022年期间，干预措施包括：(1)试点系统级增强电子订购界面；(2)临床医师教育、培训，每月反馈；(3)基于团队的流程重新设计，强调问责制和安全文化；(4)在第二个PDSA循环期间对电子订购接口的后续系统级增强。主要结局是每1000个订单中子宫内膜与宫颈内膜错误标记事件的发生率。研究人员绘制了时序运行图和u形图，并计算了干预前和干预后的发病率比（IRRs）。结果：在2020年1月至2025年5月的42,968例子宫内膜/宫颈内膜错误标记事件中，发生了46例。基线时（9/2,373；2020年1月至5月）的误标率为3.79 / 1,000个订单，两个PDSA周期之间（33/8,683；2020年6月至2021年4月）的误标率为3.80，第二个PDSA周期后（4/31,912；2021年5月）的误标率为0.13，与基线相比降低了96.7% （IRR 0.03, 95%置信区间[CI] 0.01-0.11, p < 0.001）。时间序列图显示，自2021年5月以来，特殊原因持续变化，2022年1月至2024年6月期间连续30个月为零误差。结论：教育、反馈、流程审核和界面重新设计的结合有效地解决了子宫内膜/宫颈内膜标本标签错误的问题，这是一个影响患者安全的问题。这种方法可以转移到其他LASA错误域。
{"title":"Reducing Labeling Errors in Histopathology Specimens: A Quality Improvement Initiative on Endometrial vs. Endocervical Specimens to Promote Patient Safety in KK Women’s and Children’s Hospital","authors":"Yash Bhanji Boricha MBBS, DGO, MS, DNB, MRCOG (is Senior Staff Physician, Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore.), Junzhe Zhao MA, MEng, PhD (is final year MD/PhD candidate, Duke-NUS Medical School, Singapore.), Felicia Yiqian Ang (is PSQ Lead, Department of Quality, Safety and Risk Management, KK Women’s & Children’s Hospital.), Kim Teng Tan MBBS, MMed, MRACOG, FAMS (is Senior Consultant, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital. Please address correspondence to Junzhe Zhao)","doi":"10.1016/j.jcjq.2025.10.006","DOIUrl":"10.1016/j.jcjq.2025.10.006","url":null,"abstract":"<div><h3>Background</h3><div>Mislabeling of endometrial vs. endocervical curettings was the most frequent specimen error in the Division of Obstetrics & Gynaecology at KK Women’s and Children’s Hospital, Singapore. These look-alike/sound-alike (LASA) errors can compromise patient safety and workflow efficiency. The authors aimed to reduce specimen labeling errors over a two-year quality improvement (QI) period.</div></div><div><h3>Methods</h3><div>Following root cause analysis, a multidisciplinary QI project was initiated in a single tertiary obstetrics & gynecology center using the Plan-Do-Study-Act (PDSA) methodology. Between 2020 and 2022, interventions were (1) a pilot system-level enhancement to the electronic ordering interface; (2) clinician education, training, and monthly feedback; (3) team-based process redesign emphasizing accountability and safety culture; and (4) a subsequent system-level enhancement to the electronic ordering interface during a second PDSA cycle. The primary outcome was the rate of endometrial vs. endocervical mislabeling events per 1,000 orders. The researchers plotted time-series run charts and u-charts and calculated pre- and postintervention incidence rate ratios (IRRs).</div></div><div><h3>Results</h3><div>Among 42,968 curettings from January 2020 to May 2025, 46 endometrial/endocervical mislabeling events occurred. Mislabeling rates were 3.79 per 1,000 orders at baseline (9/2,373; January–May 2020), 3.80 between two PDSA cycles (33/8,683; June 2020–April 2021), and 0.13 following the second PDSA cycle (4/31,912; from May 2021), corresponding to a 96.7% reduction vs. baseline (IRR 0.03, 95% confidence interval [CI] 0.01–0.11, <em>p</em> < 0.001). Time-series charts showed a sustained special cause shift since May 2021, with 30 consecutive zero-error months between January 2022 and June 2024.</div></div><div><h3>Conclusion</h3><div>A combination of education, feedback, process audits, and interface redesign effectively addressed mislabeling of endometrial/endocervical specimens, a high-impact patient safety concern. This approach may be transferable to other LASA error domains.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 1","pages":"Pages 33-41"},"PeriodicalIF":2.4,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145668477","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}
Pub Date : 2025-12-29DOI: 10.1016/j.jcjq.2025.12.004
Hana Shamsan, Andrew John Rea, Alison Bravington, Daisy Halligan, David Alldred, Robbie Foy, Rebecca Lawton
{"title":"Decluttering for Safety: Can We Simply Apply Approaches Used in De-Implementing Low-Value Care?","authors":"Hana Shamsan, Andrew John Rea, Alison Bravington, Daisy Halligan, David Alldred, Robbie Foy, Rebecca Lawton","doi":"10.1016/j.jcjq.2025.12.004","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.12.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146118926","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}
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