Pub Date : 2025-01-27DOI: 10.1016/j.jcjq.2025.01.010
Salome O. Chitavi PhD (Is Research Scientist II, Department of Research, The Joint Commission, Oakbrook Terrace, IL), Scott C. Williams PsyD (is Director, Department of Research, The Joint Commission), Jamie Patrianakos PhD (is Research Scientist I, Department of Research, The Joint Commission), Stephen P. Schmaltz PhD, MPH, MS (is Senior Biostatistician, Department of Research (retired), The Joint Commission), Edwin D. Boudreaux PhD (is Professor, Departments of Emergency Medicine, Psychiatry, and Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School), Brian K. Ahmedani PhD, LMSW (is Director, Center for Health Policy and Health Services Research, and Director of Research, Behavioral Health Services, Henry Ford Health, Detroit), Kimberly Roaten PhD, ABPP (is Professor, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas), Katherine Anne (Kate) Comtois PhD, MPH (is Professor, Department of Psychiatry and Behavioral Sciences, University of Washington), Farzana Akkas MSc (is Principal Associate – Suicide Risk Reduction Project, The Pew Charitable Trusts, Springfield, Virginia), Gregory K. Brown PhD (is Associate Professor of Clinical Psychology in Psychiatry, Perelman School of Medicine, University of Pennsylvania. Please address correspondence to Salome Chitavi)
Background
The Joint Commission's National Patient Safety Goal (NPSG) on suicide prevention (NPSG.15.01.01) requires accredited hospitals to screen all patients aged 12 years and older who are being evaluated or treated for behavioral health conditions as their primary reason for care for suicidal ideation using a validated screening tool. Some hospitals have expanded screening to include nonbehavioral health care patients.
Methods
This cross-sectional observational study explored the prevalence and challenges of suicide risk screening practices among Joint Commission–accredited hospitals. An online questionnaire was sent to 859 general medical/surgical hospitals. Chi-square tests were used to evaluate differences in response rates, and responses were adjusted by hospital characteristics (bed capacity, location, system, and teaching status).
Results
A total of 284 (33.1%) hospitals responded. The majority (n = 225 [79.2%]) reported screening all patients hospitalwide, and 185 (65.1%) had implemented a suicide prevention framework that includes protocols for positive screens and risk assessment. Challenges for implementing a comprehensive universal suicide risk screening and assessment protocol included insufficient staffing and lack of secure environments for at-risk patients. Of the 59 organizations not conducting hospitalwide screening, 94.9% indicated multiple reasons, including negative impact on workflow (30 [50.8%]), burden on providers (30 [50.8%]), not a requirement (29 [49.2%]), and workflow feasibility (28 [47.5%]).
Conclusion
Results suggest the majority of accredited hospitals have implemented suicide risk screening practices that exceed current Joint Commission requirements. The lack of sufficient resources to adequately address patients who screen positive for suicide risk remains a key challenge to universal screening.
{"title":"Evaluating the Prevalence of Suicide Risk Screening Practices in Accredited Hospitals","authors":"Salome O. Chitavi PhD (Is Research Scientist II, Department of Research, The Joint Commission, Oakbrook Terrace, IL), Scott C. Williams PsyD (is Director, Department of Research, The Joint Commission), Jamie Patrianakos PhD (is Research Scientist I, Department of Research, The Joint Commission), Stephen P. Schmaltz PhD, MPH, MS (is Senior Biostatistician, Department of Research (retired), The Joint Commission), Edwin D. Boudreaux PhD (is Professor, Departments of Emergency Medicine, Psychiatry, and Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School), Brian K. Ahmedani PhD, LMSW (is Director, Center for Health Policy and Health Services Research, and Director of Research, Behavioral Health Services, Henry Ford Health, Detroit), Kimberly Roaten PhD, ABPP (is Professor, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas), Katherine Anne (Kate) Comtois PhD, MPH (is Professor, Department of Psychiatry and Behavioral Sciences, University of Washington), Farzana Akkas MSc (is Principal Associate – Suicide Risk Reduction Project, The Pew Charitable Trusts, Springfield, Virginia), Gregory K. Brown PhD (is Associate Professor of Clinical Psychology in Psychiatry, Perelman School of Medicine, University of Pennsylvania. Please address correspondence to Salome Chitavi)","doi":"10.1016/j.jcjq.2025.01.010","DOIUrl":"10.1016/j.jcjq.2025.01.010","url":null,"abstract":"<div><h3>Background</h3><div>The Joint Commission's National Patient Safety Goal (NPSG) on suicide prevention (NPSG.15.01.01) requires accredited hospitals to screen all patients aged 12 years and older who are being evaluated or treated for behavioral health conditions as their primary reason for care for suicidal ideation using a validated screening tool. Some hospitals have expanded screening to include nonbehavioral health care patients.</div></div><div><h3>Methods</h3><div>This cross-sectional observational study explored the prevalence and challenges of suicide risk screening practices among Joint Commission–accredited hospitals. An online questionnaire was sent to 859 general medical/surgical hospitals. Chi-square tests were used to evaluate differences in response rates, and responses were adjusted by hospital characteristics (bed capacity, location, system, and teaching status).</div></div><div><h3>Results</h3><div>A total of 284 (33.1%) hospitals responded. The majority (<em>n</em> = 225 [79.2%]) reported screening all patients hospitalwide, and 185 (65.1%) had implemented a suicide prevention framework that includes protocols for positive screens and risk assessment. Challenges for implementing a comprehensive universal suicide risk screening and assessment protocol included insufficient staffing and lack of secure environments for at-risk patients. Of the 59 organizations not conducting hospitalwide screening, 94.9% indicated multiple reasons, including negative impact on workflow (30 [50.8%]), burden on providers (30 [50.8%]), not a requirement (29 [49.2%]), and workflow feasibility (28 [47.5%]).</div></div><div><h3>Conclusion</h3><div>Results suggest the majority of accredited hospitals have implemented suicide risk screening practices that exceed current Joint Commission requirements. The lack of sufficient resources to adequately address patients who screen positive for suicide risk remains a key challenge to universal screening.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 342-349"},"PeriodicalIF":2.3,"publicationDate":"2025-01-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143536955","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 : 2025-01-25DOI: 10.1016/j.jcjq.2025.01.011
Jenna Williams-Bader MPH (is Managing Director, National Quality Forum, Washington, DC), Kathryn M. McDonald PhD (is Bloomberg Distinguished Professor of Health Systems, Quality and Safety, Johns Hopkins University Schools of Nursing and Medicine, Baltimore, MD), Elizabeth E. Drye MD (is Chief Scientific Officer, National Quality Forum. Please address correspondence to Jenna Williams-Bader)
{"title":"Advancing Measurement of Diagnostic Excellence for Better Healthcare","authors":"Jenna Williams-Bader MPH (is Managing Director, National Quality Forum, Washington, DC), Kathryn M. McDonald PhD (is Bloomberg Distinguished Professor of Health Systems, Quality and Safety, Johns Hopkins University Schools of Nursing and Medicine, Baltimore, MD), Elizabeth E. Drye MD (is Chief Scientific Officer, National Quality Forum. Please address correspondence to Jenna Williams-Bader)","doi":"10.1016/j.jcjq.2025.01.011","DOIUrl":"10.1016/j.jcjq.2025.01.011","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 386-387"},"PeriodicalIF":2.3,"publicationDate":"2025-01-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143585802","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 : 2025-01-24DOI: 10.1016/j.jcjq.2025.01.009
Kimiyoshi J. Kobayashi MD, MBA (is Chief Quality Officer, UMass Memorial Medical Center, and Associate Professor, Departments of Medicine and Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Masschusetts), Amy C. Lu MD, MHP (is Chief Quality Officer and Vice President, University of California, San Francisco (UCSF) Health, and Professor, Department of Anesthesia and Perioperative Care, UCSF School of Medicine), Christopher S. Kim MD, MBA (is Senior Vice President and Chief Quality Officer, Wellstar Health System, Atlanta), Bela Patel MD, FCCP, FCCM, ATSF (is Professor of Medicine and Vice Dean of Healthcare Quality, University of Texas Health Science Center and Memorial Hermann Hospital, Houston), Jennifer Wiler MD, MBA, FACEP (is Professor, Department of Emergency Medicine, University of Colorado School of Medicine), Mbonu Ikezuagu MD, MHSA, FACP, CPE (is Vice President and Chief Quality Officer, ThedaCare, Neenah, Wisconsin), Jodi L. Eisenberg MHA, CPHQ (is Associate Vice President, Member Networks–Quality Executive Network, Vizient, Chicago), David M. Safley MD, FACC (is Vice President of Medical Affairs, Quality, Saint Luke's Health System, University of Missouri–Kansas City. Please address correspondence to Jodi Eisenberg)
{"title":"Demographic Profile and Oversight Duties of Today's Health Care Quality Leaders","authors":"Kimiyoshi J. Kobayashi MD, MBA (is Chief Quality Officer, UMass Memorial Medical Center, and Associate Professor, Departments of Medicine and Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Masschusetts), Amy C. Lu MD, MHP (is Chief Quality Officer and Vice President, University of California, San Francisco (UCSF) Health, and Professor, Department of Anesthesia and Perioperative Care, UCSF School of Medicine), Christopher S. Kim MD, MBA (is Senior Vice President and Chief Quality Officer, Wellstar Health System, Atlanta), Bela Patel MD, FCCP, FCCM, ATSF (is Professor of Medicine and Vice Dean of Healthcare Quality, University of Texas Health Science Center and Memorial Hermann Hospital, Houston), Jennifer Wiler MD, MBA, FACEP (is Professor, Department of Emergency Medicine, University of Colorado School of Medicine), Mbonu Ikezuagu MD, MHSA, FACP, CPE (is Vice President and Chief Quality Officer, ThedaCare, Neenah, Wisconsin), Jodi L. Eisenberg MHA, CPHQ (is Associate Vice President, Member Networks–Quality Executive Network, Vizient, Chicago), David M. Safley MD, FACC (is Vice President of Medical Affairs, Quality, Saint Luke's Health System, University of Missouri–Kansas City. Please address correspondence to Jodi Eisenberg)","doi":"10.1016/j.jcjq.2025.01.009","DOIUrl":"10.1016/j.jcjq.2025.01.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 381-385"},"PeriodicalIF":2.3,"publicationDate":"2025-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143501453","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 : 2025-01-23DOI: 10.1016/j.jcjq.2025.01.008
Audrey Moore NNP (is Neonatology Nurse Practitioner, Lucile Packard Children's Hospital Stanford, Palo Alto, California, and Center for Advanced Pediatric & Perinatal Education (CAPE), Stanford University), Louis P. Halamek MD (is Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University), Janene H. Fuerch MD (is Clinical Associate Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University), Rodrigo B. Galindo MSc, CHSOS (is CAPE Simulation Lab Manager and Operations Specialist, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University), Nicole K. Yamada MD, MS (is Clinical Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University. Please address correspondence to Audrey Moore)
Newborn resuscitation requires health care professionals to quickly assemble into a high-functioning integrated team. At the authors’ academic children's hospital, there are billions of permutations of team composition that could attend a complex newborn delivery at any given time. ResusOne, a resuscitation safety and performance improvement program, uses recorded neonatal resuscitations to identify areas for improvement. The authors identified the following key areas that would support better team performance: (1) need for role clarity and task allocation among delivery team members and (2) communication challenges when calling for neonatal delivery teams. This article describes two tools that were developed to address the issues that were identified in these two areas.
{"title":"Utilizing Recorded Resuscitations for Neonatal Team Process Improvement","authors":"Audrey Moore NNP (is Neonatology Nurse Practitioner, Lucile Packard Children's Hospital Stanford, Palo Alto, California, and Center for Advanced Pediatric & Perinatal Education (CAPE), Stanford University), Louis P. Halamek MD (is Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University), Janene H. Fuerch MD (is Clinical Associate Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University), Rodrigo B. Galindo MSc, CHSOS (is CAPE Simulation Lab Manager and Operations Specialist, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University), Nicole K. Yamada MD, MS (is Clinical Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University. Please address correspondence to Audrey Moore)","doi":"10.1016/j.jcjq.2025.01.008","DOIUrl":"10.1016/j.jcjq.2025.01.008","url":null,"abstract":"<div><div>Newborn resuscitation requires health care professionals to quickly assemble into a high-functioning integrated team. At the authors’ academic children's hospital, there are billions of permutations of team composition that could attend a complex newborn delivery at any given time. ResusOne, a resuscitation safety and performance improvement program, uses recorded neonatal resuscitations to identify areas for improvement. The authors identified the following key areas that would support better team performance: (1) need for role clarity and task allocation among delivery team members and (2) communication challenges when calling for neonatal delivery teams. This article describes two tools that were developed to address the issues that were identified in these two areas.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 368-377"},"PeriodicalIF":2.3,"publicationDate":"2025-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143476621","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 : 2025-01-21DOI: 10.1016/j.jcjq.2025.01.006
Jason S. Adelman MD, MS (Associate Dean for Quality and Patient Safety; Director, Center for Patient Safety Science; Vice Chair for Quality & Patient Safety, Department of Medicine; and Associate Professor of Medicine (in Biomedical Informatics) at Columbia University Irving Medical Center, Vagelos College of Physicians & Surgeons), Jo R. Applebaum MPH (Research Advisor, Center for Patient Safety Science, Columbia University Irving Medical Center), Nicole Krenitsky MD, MBA (Fellow in Patient Safety Research and Clinical Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center), Dena Goffman MD (Vice Chair for Quality and Patient Safety and Professor, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center), Saud Khan MBBS, MHA, MS (Data Scientist, Center for Patient Safety Science, Columbia University/NewYork-Presbyterian Hospital), Baruch S. Fertel MD (Associate Clinical Professor, Department of Emergency Medicine, Columbia University Irving Medical Center), Judy L. Aschner MD (Professor, Center for Discovery and Innovation, Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey)
{"title":"Change in US Hospital Practice After the Joint Commission Requirement to Use Distinct Methods of Newborn Identification: A Cross-Sectional 10-Year Follow-Up Survey","authors":"Jason S. Adelman MD, MS (Associate Dean for Quality and Patient Safety; Director, Center for Patient Safety Science; Vice Chair for Quality & Patient Safety, Department of Medicine; and Associate Professor of Medicine (in Biomedical Informatics) at Columbia University Irving Medical Center, Vagelos College of Physicians & Surgeons), Jo R. Applebaum MPH (Research Advisor, Center for Patient Safety Science, Columbia University Irving Medical Center), Nicole Krenitsky MD, MBA (Fellow in Patient Safety Research and Clinical Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center), Dena Goffman MD (Vice Chair for Quality and Patient Safety and Professor, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center), Saud Khan MBBS, MHA, MS (Data Scientist, Center for Patient Safety Science, Columbia University/NewYork-Presbyterian Hospital), Baruch S. Fertel MD (Associate Clinical Professor, Department of Emergency Medicine, Columbia University Irving Medical Center), Judy L. Aschner MD (Professor, Center for Discovery and Innovation, Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey)","doi":"10.1016/j.jcjq.2025.01.006","DOIUrl":"10.1016/j.jcjq.2025.01.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 378-380"},"PeriodicalIF":2.3,"publicationDate":"2025-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143433150","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 : 2025-01-20DOI: 10.1016/j.jcjq.2025.01.004
Gabriela Berlanda Ph.D. (Pharmacist, Hospital de Clínicas de Porto Alegre (HCPA) and Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil), Luiza Daniel de Souza (RN, HCPA and UFRGS), Juliana da Silva Lima MSc. (RN, HCPA), Caroline Tortato (Pharmacist, HCPA), Simone Silveira Pasin MSc. (RN, HCPA), Eloni Rotta MSc. (Pharmacist, HCPA), Melissa Hemesath MSc. (RN, HCPA), Thais Ortiz Hammes PhD. (RD, HCPA), Fernanda Rosa Indriunas Perdomini MSc. (RN, HCPA), Claudia Carolina Schnorr (MD, HCPA), Helena Barreto dos Santos PhD. (MD, HCPA), Cristiane Bauermann Leitao PhD. (MD, HCPA and Associate Professor, UFRGS), Beatriz D. Schaan PhD. (MD, HCPA and Full Professor, UFRGS. Please address correspondence to Gabriela Berlanda)
Background
The objective of this study was to reduce by 50% the occurrence of average daily blood glucose (ADBG) > 180 mg/dL among noncritical patients admitted to a surgical ward at a public tertiary care hospital.
Methods
This project ran from April 2022 to June 2023 and used the Model for Improvement (MFI) method. Health care Failure Modes and Effects Analysis was used to identify and analyze failure modes in hyperglycemia management, and a driver diagram (DD) was used to prioritize and structure changes. The Plan-Do-Study-Act (PDSA) tool facilitated the change process. Data were collected using standardized forms and monitored with run charts, considering process, outcome, and balance indicators. The DD included 12 changes focusing on protocol implementation, adequate medical prescription, correct insulin administration, proper blood glucose monitoring, appropriate diet prescription, safe care transitions between units, routine of publication and discussion of indicators, leadership engagement with frontline workers on hyperglycemia management, educational actions, and defining roles and responsibilities.
Results
A 69.0% reduction in ADBG > 180 mg/dL and a 100% reduction in ADBG > 300 mg/dL were achieved, though hypoglycemic events increased from 8 to 11 per 100 patient-days using insulin or oral antidiabetic medications. Reductions in nonconformities in medical prescription and insulin administration (50.0% and 71.4%, respectively) were also achieved.
Conclusion
In this pilot project, use of the MFI led to improved prescription practices, insulin administration, and blood glucose control, reducing the rate of hyperglycemia in hospitalized patients.
{"title":"Use of the Model for Improvement to Reduce Hyperglycemia in Adult Patients Admitted to a Public Tertiary Care Hospital","authors":"Gabriela Berlanda Ph.D. (Pharmacist, Hospital de Clínicas de Porto Alegre (HCPA) and Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil), Luiza Daniel de Souza (RN, HCPA and UFRGS), Juliana da Silva Lima MSc. (RN, HCPA), Caroline Tortato (Pharmacist, HCPA), Simone Silveira Pasin MSc. (RN, HCPA), Eloni Rotta MSc. (Pharmacist, HCPA), Melissa Hemesath MSc. (RN, HCPA), Thais Ortiz Hammes PhD. (RD, HCPA), Fernanda Rosa Indriunas Perdomini MSc. (RN, HCPA), Claudia Carolina Schnorr (MD, HCPA), Helena Barreto dos Santos PhD. (MD, HCPA), Cristiane Bauermann Leitao PhD. (MD, HCPA and Associate Professor, UFRGS), Beatriz D. Schaan PhD. (MD, HCPA and Full Professor, UFRGS. Please address correspondence to Gabriela Berlanda)","doi":"10.1016/j.jcjq.2025.01.004","DOIUrl":"10.1016/j.jcjq.2025.01.004","url":null,"abstract":"<div><h3>Background</h3><div>The objective of this study was to reduce by 50% the occurrence of average daily blood glucose (ADBG) > 180 mg/dL among noncritical patients admitted to a surgical ward at a public tertiary care hospital.</div></div><div><h3>Methods</h3><div>This project ran from April 2022 to June 2023 and used the Model for Improvement (MFI) method. Health care Failure Modes and Effects Analysis was used to identify and analyze failure modes in hyperglycemia management, and a driver diagram (DD) was used to prioritize and structure changes. The Plan-Do-Study-Act (PDSA) tool facilitated the change process. Data were collected using standardized forms and monitored with run charts, considering process, outcome, and balance indicators. The DD included 12 changes focusing on protocol implementation, adequate medical prescription, correct insulin administration, proper blood glucose monitoring, appropriate diet prescription, safe care transitions between units, routine of publication and discussion of indicators, leadership engagement with frontline workers on hyperglycemia management, educational actions, and defining roles and responsibilities.</div></div><div><h3>Results</h3><div>A 69.0% reduction in ADBG > 180 mg/dL and a 100% reduction in ADBG > 300 mg/dL were achieved, though hypoglycemic events increased from 8 to 11 per 100 patient-days using insulin or oral antidiabetic medications. Reductions in nonconformities in medical prescription and insulin administration (50.0% and 71.4%, respectively) were also achieved.</div></div><div><h3>Conclusion</h3><div>In this pilot project, use of the MFI led to improved prescription practices, insulin administration, and blood glucose control, reducing the rate of hyperglycemia in hospitalized patients.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 313-320"},"PeriodicalIF":2.3,"publicationDate":"2025-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143537010","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 : 2025-01-20DOI: 10.1016/j.jcjq.2025.01.007
Georgia Kyriakeli MBA, RN (is Deputy Director of Nursing Service, Department of Nursing Service, General Hospital Papageorgiou, Thessaloniki, Greece), Anastasia Georgiadou RM (is Registered Midwife, B’ Neonatal Intensive Care Unit, General Hospital Papageorgiou), Agapi Symeonidou MBA, RN (is Deputy Nurse Manager, 3rd Department of Internal Medicine, General Hospital Papageorgiou), Zoi Tsimtsiou PhD, MD (is Associate Professor, Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece), Theodoros Dardavesis PhD, MD (is Professor, Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, and Dean, School of Health Sciences, Aristotle University of Thessaloniki), Vasilios Kotsis PhD, MD (is Professor, 3rd Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki. Please address correspondence to Georgia Kyriakeli)
Background
Assessment of patient safety culture (PSC) is critical for health care organizations worldwide to recognize areas that require urgent attention, promote patient safety, and improve quality of care. The aim of this systematic review was to determine the overall PSC score among nurses worldwide and identify the dimensions of PSC that score the highest and the lowest, as well as any geographical differentiations.
Methods
Literature research was conducted in PubMed and Scopus search engines and the Agency for Healthcare Research and Quality (AHRQ) Research Reference List to identify studies published in English between January 2004 and May 2023 that used the Hospital Survey on Patient Safety Culture, version 1, to measure hospital nurses’ assessment of PSC. This review followed the PRISMA 2020 guidelines and was registered in PROSPERO.
Results
From 1,507 records, 21 studies were included with 10,951 participants. The overall PSC score was 3.341 (95% confidence interval [CI] 3.221–3.460). The dimension scored highest was Teamwork Within Units, with a mean score of 3.719 (95% CI 3.594–3.844). Staffing, with a mean score of 3.096 (95% CI 2.980–3.212) was scored lowest. Statistically significant differences related to geographical distribution were found for overall PSC score and five of the PSC dimensions.
Conclusion
Nurses throughout the world rated the PSC at their organizations moderate to good. Certain dimensions of PSC were reported to need reinforcement to create a strong overall safety culture in health care. Participants rated European hospitals as having a stronger PSC than South American or Middle Eastern hospitals. Differentiations need to be further studied and analyzed for effective and targeted global interventions.
背景：患者安全文化评估（PSC）对于世界各地的卫生保健组织识别需要紧急关注的领域、促进患者安全和提高护理质量至关重要。本系统回顾的目的是确定全球护士的PSC总体得分，并确定PSC得分最高和最低的维度，以及任何地理差异。方法：在PubMed、Scopus搜索引擎和AHRQ研究参考文献列表中进行文献研究，找出2004年1月至2023年5月间发表的使用《医院患者安全文化调查》第1版测量医院护士对PSC评估的英文研究。本次审查遵循PRISMA 2020指南，并在PROSPERO注册。结果：从1507份记录中，21项研究纳入了10951名参与者。PSC总分为3.341分（95%可信区间[CI] 3.221-3.460）。得分最高的维度是单位内团队合作，平均得分为3.719 （95% CI 3.594-3.844）。人员配备的平均得分为3.096 (95% CI 2.980-3.212)，得分最低。在总体PSC得分和PSC的五个维度上发现了与地理分布相关的统计学显著差异。结论：世界各地的护士对其所在组织的PSC评定为中等至良好。据报告，需要加强PSC的某些方面，以便在保健领域建立牢固的整体安全文化。参与者认为欧洲医院的PSC比南美或中东医院强。需要进一步研究和分析差异，以便进行有效和有针对性的全球干预。
{"title":"Patient Safety Culture Among Nurses in Hospital Settings Worldwide: A Systematic Review and Meta-Analysis","authors":"Georgia Kyriakeli MBA, RN (is Deputy Director of Nursing Service, Department of Nursing Service, General Hospital Papageorgiou, Thessaloniki, Greece), Anastasia Georgiadou RM (is Registered Midwife, B’ Neonatal Intensive Care Unit, General Hospital Papageorgiou), Agapi Symeonidou MBA, RN (is Deputy Nurse Manager, 3rd Department of Internal Medicine, General Hospital Papageorgiou), Zoi Tsimtsiou PhD, MD (is Associate Professor, Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece), Theodoros Dardavesis PhD, MD (is Professor, Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, and Dean, School of Health Sciences, Aristotle University of Thessaloniki), Vasilios Kotsis PhD, MD (is Professor, 3rd Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki. Please address correspondence to Georgia Kyriakeli)","doi":"10.1016/j.jcjq.2025.01.007","DOIUrl":"10.1016/j.jcjq.2025.01.007","url":null,"abstract":"<div><h3>Background</h3><div>Assessment of patient safety culture (PSC) is critical for health care organizations worldwide to recognize areas that require urgent attention, promote patient safety, and improve quality of care. The aim of this systematic review was to determine the overall PSC score among nurses worldwide and identify the dimensions of PSC that score the highest and the lowest, as well as any geographical differentiations.</div></div><div><h3>Methods</h3><div>Literature research was conducted in PubMed and Scopus search engines and the Agency for Healthcare Research and Quality (AHRQ) Research Reference List to identify studies published in English between January 2004 and May 2023 that used the Hospital Survey on Patient Safety Culture, version 1, to measure hospital nurses’ assessment of PSC. This review followed the PRISMA 2020 guidelines and was registered in PROSPERO.</div></div><div><h3>Results</h3><div>From 1,507 records, 21 studies were included with 10,951 participants. The overall PSC score was 3.341 (95% confidence interval [CI] 3.221–3.460). The dimension scored highest was Teamwork Within Units, with a mean score of 3.719 (95% CI 3.594–3.844). Staffing, with a mean score of 3.096 (95% CI 2.980–3.212) was scored lowest. Statistically significant differences related to geographical distribution were found for overall PSC score and five of the PSC dimensions.</div></div><div><h3>Conclusion</h3><div>Nurses throughout the world rated the PSC at their organizations moderate to good. Certain dimensions of PSC were reported to need reinforcement to create a strong overall safety culture in health care. Participants rated European hospitals as having a stronger PSC than South American or Middle Eastern hospitals. Differentiations need to be further studied and analyzed for effective and targeted global interventions.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 350-360"},"PeriodicalIF":2.3,"publicationDate":"2025-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143515649","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 : 2025-01-16DOI: 10.1016/j.jcjq.2025.01.003
Linda C. Alongi MSN (is Surgical Quality Improvement Coordinator, Park Nicollet Methodist Hospital, St. Louis Park, Minnesota), Brady Alsaker MSN (formerly Clinical Analyst, Park Nicollet Methodist Hospital, is Registered Nurse, Minnesota Department of Veterans Affairs, St. Paul, Minnesota), David J. Willis MD (is Surgeon, Park Nicollet Methodist Hospital, and System Medical Director of Quality Improvement, Surgical Services, HealthPartners, Minneapolis), William A. Burns (is Primary Research Assistant, HealthPartners Institute, Bloomington, Minnesota), Charles R. Watts MD, PhD (is Neurosurgeon and Chair of Neurosurgery, Park Nicollet Methodist Hospital. Please address correspondence to Charles R. Watts)
Background
To help surgeons improve quality, the American College of Surgeons National Quality Improvement Program (ACS NSQIP) Semiannual Reports and Interim Semiannual Reports provide high-level views of 30-day morbidity and mortality rates. Surgeons at one hospital requested the ability to visualize data with interactive navigation and analysis of comorbidities monthly. Using advanced visual data analytics, the authors constructed a surgical scorecard to provide the desired feedback.
Methods
The authors undertook a proof-of-concept project tracking surgical site infections (SSIs) and associated medical comorbidities. An anonymized training dataset of 3,438 patients was sampled between January 1, 2021, and October 31, 2022, from the hospital's NSQIP data. For proof-of-concept interface/system testing and to maintain data privacy, a synthetic 5,000-patient NSQIP database was generated using the Synthetic Data Vault, Python 3.7. Comorbidity variables were: diabetes mellitus, HgbA1c, immunosuppressive therapy, hypertension requiring medication, body mass index, and smoking within one year. The primary outcome was SSI. The research team generated scorecards for SSIs as a function of time, surgical department, and medical comorbidity. Odds ratios with confidence intervals and chi-square tests were used to analyze the relationships between SSI and comorbidities.
Results
Advanced visual data analytics improved the timeliness of NSQIP Semiannual Reports and Interim Semiannual Reports from 6 months to 45 days. The scorecard allowed for visualization of data trends as a function of time, specialty, and procedural group. Statistical testing allowed for the identification of surgeons who were statistical outliers with regard to SSIs.
Conclusion
Implementation of an on-demand scorecard for data visualization and analysis allowed for up-to-date analysis of the relationship between medical comorbidities and SSI and identification of performance outliers.
{"title":"Developing a Standardized Process to Visualize, Analyze, and Communicate NSQIP Data Using an Advanced Visual Data Analytics Tool","authors":"Linda C. Alongi MSN (is Surgical Quality Improvement Coordinator, Park Nicollet Methodist Hospital, St. Louis Park, Minnesota), Brady Alsaker MSN (formerly Clinical Analyst, Park Nicollet Methodist Hospital, is Registered Nurse, Minnesota Department of Veterans Affairs, St. Paul, Minnesota), David J. Willis MD (is Surgeon, Park Nicollet Methodist Hospital, and System Medical Director of Quality Improvement, Surgical Services, HealthPartners, Minneapolis), William A. Burns (is Primary Research Assistant, HealthPartners Institute, Bloomington, Minnesota), Charles R. Watts MD, PhD (is Neurosurgeon and Chair of Neurosurgery, Park Nicollet Methodist Hospital. Please address correspondence to Charles R. Watts)","doi":"10.1016/j.jcjq.2025.01.003","DOIUrl":"10.1016/j.jcjq.2025.01.003","url":null,"abstract":"<div><h3>Background</h3><div>To help surgeons improve quality, the American College of Surgeons National Quality Improvement Program (ACS NSQIP) Semiannual Reports and Interim Semiannual Reports provide high-level views of 30-day morbidity and mortality rates. Surgeons at one hospital requested the ability to visualize data with interactive navigation and analysis of comorbidities monthly. Using advanced visual data analytics, the authors constructed a surgical scorecard to provide the desired feedback.</div></div><div><h3>Methods</h3><div>The authors undertook a proof-of-concept project tracking surgical site infections (SSIs) and associated medical comorbidities. An anonymized training dataset of 3,438 patients was sampled between January 1, 2021, and October 31, 2022, from the hospital's NSQIP data. For proof-of-concept interface/system testing and to maintain data privacy, a synthetic 5,000-patient NSQIP database was generated using the Synthetic Data Vault, Python 3.7. Comorbidity variables were: diabetes mellitus, HgbA1c, immunosuppressive therapy, hypertension requiring medication, body mass index, and smoking within one year. The primary outcome was SSI. The research team generated scorecards for SSIs as a function of time, surgical department, and medical comorbidity. Odds ratios with confidence intervals and chi-square tests were used to analyze the relationships between SSI and comorbidities.</div></div><div><h3>Results</h3><div>Advanced visual data analytics improved the timeliness of NSQIP Semiannual Reports and Interim Semiannual Reports from 6 months to 45 days. The scorecard allowed for visualization of data trends as a function of time, specialty, and procedural group. Statistical testing allowed for the identification of surgeons who were statistical outliers with regard to SSIs.</div></div><div><h3>Conclusion</h3><div>Implementation of an on-demand scorecard for data visualization and analysis allowed for up-to-date analysis of the relationship between medical comorbidities and SSI and identification of performance outliers.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 361-367"},"PeriodicalIF":2.3,"publicationDate":"2025-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143531398","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 : 2025-01-14DOI: 10.1016/j.jcjq.2025.01.005
Lauren K. Stewart MD, MS (is Assistant Professor of Emergency Medicine, Indiana University School of Medicine.), Dillon Bille (is Medical Student, Indiana University School of Medicine.), Beth Fields PhD, MS (is Associate Professor, School of Education, University of Wisconsin.), Leah Kemper (formerly Microbiology Student, Indiana University, is APHL-CDC Fellow, Wadsworth Center, New York State Department of Health, Albany, New York.), Connor Pappa (is Student, Indiana University.), Eric S. Orman MD, MSCR (is Associate Professor of Medicine, Indiana University School of Medicine.), Malaz A. Boustani MD, MPH (is Professor of Medicine and Aging Research, Indiana University School of Medicine.), Edmond Ramly PhD, MS (is Associate Professor and Program Director, Department of Health & Wellness Design, Indiana University School of Public Health.), Andrew Hybarger DO (is Emergency Medical Services Fellow, Indiana University School of Medicine, and Deputy Medical Director, Indianapolis Emergency Medical Services.), Andrew K. Watters MD (is Associate Professor of Emergency Medicine Practice, Indiana University School of Medicine.), Nancy K. Glober MD (is Assistant Professor of Emergency Medicine, Indiana University School of Medicine. Please address correspondence to Lauren K. Stewart)
Background
Interfacility transfer is an integral component of the modern health care system. However, there are no commonly agreed-upon standards for interfacility processes or for patient engagement and shared decision-making in transfer, and little is known about their experience. This study used qualitative methods to better understand the patient and care partner experience with interfacility emergency department (ED)-to-ED transfer.
Methods
This mixed methods study used two distinct data sources: (1) semistructured interviews of older adult patients and their care partners, performed at bedside in a large, tertiary care hospital (receiving facility) following interfacility transfer, and (2) direct observation of the transfer consent process at two community EDs (referring facilities) in the same health system.
Results
A total of 21 patients and 14 care partners were interviewed. The authors identified several common themes related to perceptions and experiences with interfacility transfer: (1) communication (for example, perceived lack of agency), (2) logistics (for example, wait times), (3) impacts on family (for example, distance from home), (4) uncertainty about the bill (for example, transfer-associated costs), and (5) quality of care (for example, greater trust in tertiary care centers). Direct observations of the transfer consent process for 14 unique patient encounters were also conducted. The research team observed considerable variability in practice patterns among sending clinicians and identified frequent patient-reported issues related to transfer logistics and effective communication, including distractions, lack of privacy, absence of support system, physical pain and/or psychological stress, preferred language, and health literacy.
Conclusion
These data suggest several potential areas for improvement in the care of patients requiring interfacility transfer, to increase engagement and allow patients and their care partners to make better-informed decisions most consistent with their goals of care.
{"title":"Mixed Methods Study of the Interfacility Transfer System Utilizing Both Patient-Reported Experiences and Direct Observation of the Transfer Consent Process","authors":"Lauren K. Stewart MD, MS (is Assistant Professor of Emergency Medicine, Indiana University School of Medicine.), Dillon Bille (is Medical Student, Indiana University School of Medicine.), Beth Fields PhD, MS (is Associate Professor, School of Education, University of Wisconsin.), Leah Kemper (formerly Microbiology Student, Indiana University, is APHL-CDC Fellow, Wadsworth Center, New York State Department of Health, Albany, New York.), Connor Pappa (is Student, Indiana University.), Eric S. Orman MD, MSCR (is Associate Professor of Medicine, Indiana University School of Medicine.), Malaz A. Boustani MD, MPH (is Professor of Medicine and Aging Research, Indiana University School of Medicine.), Edmond Ramly PhD, MS (is Associate Professor and Program Director, Department of Health & Wellness Design, Indiana University School of Public Health.), Andrew Hybarger DO (is Emergency Medical Services Fellow, Indiana University School of Medicine, and Deputy Medical Director, Indianapolis Emergency Medical Services.), Andrew K. Watters MD (is Associate Professor of Emergency Medicine Practice, Indiana University School of Medicine.), Nancy K. Glober MD (is Assistant Professor of Emergency Medicine, Indiana University School of Medicine. Please address correspondence to Lauren K. Stewart)","doi":"10.1016/j.jcjq.2025.01.005","DOIUrl":"10.1016/j.jcjq.2025.01.005","url":null,"abstract":"<div><h3>Background</h3><div>Interfacility transfer is an integral component of the modern health care system. However, there are no commonly agreed-upon standards for interfacility processes or for patient engagement and shared decision-making in transfer, and little is known about their experience. This study used qualitative methods to better understand the patient and care partner experience with interfacility emergency department (ED)-to-ED transfer.</div></div><div><h3>Methods</h3><div>This mixed methods study used two distinct data sources: (1) semistructured interviews of older adult patients and their care partners, performed at bedside in a large, tertiary care hospital (receiving facility) following interfacility transfer, and (2) direct observation of the transfer consent process at two community EDs (referring facilities) in the same health system.</div></div><div><h3>Results</h3><div>A total of 21 patients and 14 care partners were interviewed. The authors identified several common themes related to perceptions and experiences with interfacility transfer: (1) communication (for example, perceived lack of agency), (2) logistics (for example, wait times), (3) impacts on family (for example, distance from home), (4) uncertainty about the bill (for example, transfer-associated costs), and (5) quality of care (for example, greater trust in tertiary care centers). Direct observations of the transfer consent process for 14 unique patient encounters were also conducted. The research team observed considerable variability in practice patterns among sending clinicians and identified frequent patient-reported issues related to transfer logistics and effective communication, including distractions, lack of privacy, absence of support system, physical pain and/or psychological stress, preferred language, and health literacy.</div></div><div><h3>Conclusion</h3><div>These data suggest several potential areas for improvement in the care of patients requiring interfacility transfer, to increase engagement and allow patients and their care partners to make better-informed decisions most consistent with their goals of care.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 331-341"},"PeriodicalIF":2.3,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143425320","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 : 2025-01-10DOI: 10.1016/j.jcjq.2025.01.002
Tara N. Cohen PhD, MS (is Director of Surgical Safety and Human Factors Research, Department of Surgery, and Director of Simulation Research, Department of Simulation and Interprofessional Education, Cedars-Sinai Medical Center, Los Angeles.), Teryl K. Nuckols MD, MSHS (is Vice Chair of Clinical Research and Director of General Internal Medicine, Department of Internal Medicine, Cedars-Sinai Medical Center.), Carl T. Berdahl MD, MS (is Assistant Professor, Departments of Medicine and Emergency Medicine, Cedars-Sinai Medical Center.), Edward G. Seferian MD, MS (formerly Chief Patient Safety Officer, Department of Patient Safety, Cedars-Sinai Medical Center, is Vice President, Patient Safety and Quality, Johns Hopkins Hospital, Baltimore.), Sara G. McCleskey PhD, MS (is Associate Policy Researcher, Department of Behavioral Policy and Sciences, RAND, Los Angeles.), Andrew J. Henreid MPH (is Clinical Research Associate, Department of Internal Medicine, Cedars-Sinai Medical Center, and Graduate Assistant, Department of Psychological Sciences, University of Connecticut.), Donna W. Leang PharmD, MSHS (is Associate Director, Medication Safety/Regulatory Compliance, Transitions of Care, Department of Pharmacy, Cedars-Sinai Medical Center.), Maria Andrea Lupera RN, MS (formerly Critical Care Registered Nurse, Cedars-Sinai Medical Center, is Clinical Nurse, Kaiser Permanente, Los Angeles.), Bernice L. Coleman PhD, ACNP-BC, FAAN (is Director of Nursing Research, Department of Nursing, and Assistant Professor, Department of Biomedical Sciences, Cedars-Sinai Medical Center. Please address correspondence to Tara Cohen)
Background
In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety.
Methods
The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center.
Results
An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy—a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses).
Conclusion
SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.
{"title":"Training Hospital Nurses to Write Detailed Narratives and Describe Contributing Factors in Incident Reports: The SAFER Education Program","authors":"Tara N. Cohen PhD, MS (is Director of Surgical Safety and Human Factors Research, Department of Surgery, and Director of Simulation Research, Department of Simulation and Interprofessional Education, Cedars-Sinai Medical Center, Los Angeles.), Teryl K. Nuckols MD, MSHS (is Vice Chair of Clinical Research and Director of General Internal Medicine, Department of Internal Medicine, Cedars-Sinai Medical Center.), Carl T. Berdahl MD, MS (is Assistant Professor, Departments of Medicine and Emergency Medicine, Cedars-Sinai Medical Center.), Edward G. Seferian MD, MS (formerly Chief Patient Safety Officer, Department of Patient Safety, Cedars-Sinai Medical Center, is Vice President, Patient Safety and Quality, Johns Hopkins Hospital, Baltimore.), Sara G. McCleskey PhD, MS (is Associate Policy Researcher, Department of Behavioral Policy and Sciences, RAND, Los Angeles.), Andrew J. Henreid MPH (is Clinical Research Associate, Department of Internal Medicine, Cedars-Sinai Medical Center, and Graduate Assistant, Department of Psychological Sciences, University of Connecticut.), Donna W. Leang PharmD, MSHS (is Associate Director, Medication Safety/Regulatory Compliance, Transitions of Care, Department of Pharmacy, Cedars-Sinai Medical Center.), Maria Andrea Lupera RN, MS (formerly Critical Care Registered Nurse, Cedars-Sinai Medical Center, is Clinical Nurse, Kaiser Permanente, Los Angeles.), Bernice L. Coleman PhD, ACNP-BC, FAAN (is Director of Nursing Research, Department of Nursing, and Assistant Professor, Department of Biomedical Sciences, Cedars-Sinai Medical Center. Please address correspondence to Tara Cohen)","doi":"10.1016/j.jcjq.2025.01.002","DOIUrl":"10.1016/j.jcjq.2025.01.002","url":null,"abstract":"<div><h3>Background</h3><div>In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety.</div></div><div><h3>Methods</h3><div>The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center.</div></div><div><h3>Results</h3><div>An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy—a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses).</div></div><div><h3>Conclusion</h3><div>SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 305-311"},"PeriodicalIF":2.3,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143079829","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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