Pub Date : 2026-02-01Epub Date: 2025-11-29DOI: 10.1016/j.jcjq.2025.11.010
David R. Nerenz PhD (is Director Emeritus, Center for Health Policy and Health Services Research, Senior Staff, Department of Neurosurgery, Henry Ford Health, Detroit), Kari Jarabek BSN, RN (is Senior QI Lead, Michigan Spine Surgery Improvement Collaborative (MSSIC), Department of Neurosurgery, Henry Ford Health), Jamie Myers BSN, RN, MBA (is CQI Program Manager, MSSIC, Department of Neurosurgery, Henry Ford Health), Thomas Leyden MBA (is Director, Value Partnerships, Blue Cross Blue Shield of Michigan), John D. Syrjamaki MPH (is Analytic Advisor, Michigan Value Collaborative, University of Michigan Health System), Tanima Basu MA, MS (is Senior Analyst, Michigan Value Collaborative, University of Michigan Health System), Mark Bradshaw MSc (is Director, Michigan Value Collaborative, University of Michigan Health System), Jianhui Hu PhD (is Biotatistician, Center for Health Policy and Health Services Research, Henry Ford Health), Doris Tong MD, MSc (is Senior Staff, Department of Neurosurgery, Henry Ford Health), Ilyas Aleem MD, MS (is Orthopaedic Surgeon and Clinical Associate Professor, Departments of Orthopedic Surgery and Neurosurgery, University of Michigan Medical School), Victor Chang MD (is Co-Director, Minimally Invasive and Deformity Spine Surgery, Department of Neurosurgery, Henry Ford Health), Jad Khalil MD (is Orthopaedic Surgeon, Michigan Orthopaedic Surgeons, Southfield, Michigan), Miguelangelo Perez-Cruet MD (is Neurosurgeon, Michigan Minimally Invasive Neurosurgical Institute, Waterford, Michigan), Muwaffak Abdulhak MD (is Director, Neurosurgery Spine Program, Department of Neurosurgery, Henry Ford Health. Please address correspondence to David R. Nerenz)
Background
Quality improvement (QI) collaboratives represent a potentially powerful approach to QI, patient experience, and cost savings. In this article the authors present an estimate of direct cost savings to payers from reductions in the rate of a single adverse event (urinary retention) in the context of the Michigan Spine Surgery Improvement Collaborative (MSSIC).
Methods
Data from the MSSIC clinical registry were used to calculate reductions in rates of urinary retention (with or without readmission) from a 2016 baseline period to a 2017–2024 QI intervention period. The number of those events averted, combined with dollar cost estimates of payments for treatment of adverse events from the Michigan Value Collaborative (MVC) was used to estimate direct cost savings to payers.
Results
Direct cost savings to payers for the 2017–2024 period were estimated at $66.8 million.
Conclusion
Given the combination of direct cost savings of $66.8 million and potential indirect cost savings to employers and caregivers of $130–$180 million, collaborative QI initiatives aimed at reducing rates of adverse outcomes after spine surgery can produce significant cost savings for payers, employers, and patients.
{"title":"Cost Savings Realized Through a Statewide Quality Improvement Collaborative for Spine Surgery","authors":"David R. Nerenz PhD (is Director Emeritus, Center for Health Policy and Health Services Research, Senior Staff, Department of Neurosurgery, Henry Ford Health, Detroit), Kari Jarabek BSN, RN (is Senior QI Lead, Michigan Spine Surgery Improvement Collaborative (MSSIC), Department of Neurosurgery, Henry Ford Health), Jamie Myers BSN, RN, MBA (is CQI Program Manager, MSSIC, Department of Neurosurgery, Henry Ford Health), Thomas Leyden MBA (is Director, Value Partnerships, Blue Cross Blue Shield of Michigan), John D. Syrjamaki MPH (is Analytic Advisor, Michigan Value Collaborative, University of Michigan Health System), Tanima Basu MA, MS (is Senior Analyst, Michigan Value Collaborative, University of Michigan Health System), Mark Bradshaw MSc (is Director, Michigan Value Collaborative, University of Michigan Health System), Jianhui Hu PhD (is Biotatistician, Center for Health Policy and Health Services Research, Henry Ford Health), Doris Tong MD, MSc (is Senior Staff, Department of Neurosurgery, Henry Ford Health), Ilyas Aleem MD, MS (is Orthopaedic Surgeon and Clinical Associate Professor, Departments of Orthopedic Surgery and Neurosurgery, University of Michigan Medical School), Victor Chang MD (is Co-Director, Minimally Invasive and Deformity Spine Surgery, Department of Neurosurgery, Henry Ford Health), Jad Khalil MD (is Orthopaedic Surgeon, Michigan Orthopaedic Surgeons, Southfield, Michigan), Miguelangelo Perez-Cruet MD (is Neurosurgeon, Michigan Minimally Invasive Neurosurgical Institute, Waterford, Michigan), Muwaffak Abdulhak MD (is Director, Neurosurgery Spine Program, Department of Neurosurgery, Henry Ford Health. Please address correspondence to David R. Nerenz)","doi":"10.1016/j.jcjq.2025.11.010","DOIUrl":"10.1016/j.jcjq.2025.11.010","url":null,"abstract":"<div><h3>Background</h3><div>Quality improvement (QI) collaboratives represent a potentially powerful approach to QI, patient experience, and cost savings. In this article the authors present an estimate of direct cost savings to payers from reductions in the rate of a single adverse event (urinary retention) in the context of the Michigan Spine Surgery Improvement Collaborative (MSSIC).</div></div><div><h3>Methods</h3><div>Data from the MSSIC clinical registry were used to calculate reductions in rates of urinary retention (with or without readmission) from a 2016 baseline period to a 2017–2024 QI intervention period. The number of those events averted, combined with dollar cost estimates of payments for treatment of adverse events from the Michigan Value Collaborative (MVC) was used to estimate direct cost savings to payers.</div></div><div><h3>Results</h3><div>Direct cost savings to payers for the 2017–2024 period were estimated at $66.8 million.</div></div><div><h3>Conclusion</h3><div>Given the combination of direct cost savings of $66.8 million and potential indirect cost savings to employers and caregivers of $130–$180 million, collaborative QI initiatives aimed at reducing rates of adverse outcomes after spine surgery can produce significant cost savings for payers, employers, and patients.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 67-74"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145933384","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 : 2026-02-01Epub Date: 2025-11-20DOI: 10.1016/j.jcjq.2025.11.008
Harshini Ravi (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles), Aleeque Marselian MS (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center), Falisha Kanji MS (is Program Administrator, Department of Surgery, Cedars-Sinai Medical Center), Tara N. Cohen PhD (is Director, Surgical Safety and Human Factors Research, Department of Surgery, Cedars-Sinai Medical Center. Please address correspondence to Tara N. Cohen)
Background
The confluence of rapidly changing clinical conditions, cognitive demands, and interdisciplinary collaboration in intensive care units (ICUs) creates conditions where minor lapses in communication, judgment, or coordination can result in preventable patient harm. Because near-miss events within healthcare systems are underreported and under-analyzed, evidence-based interventions to improve system safety are limited. Therefore, this study aims to understand the conditions that enable near misses using a human factors approach, as well as identify the mechanisms that intercept them before they escalate to harm.
Methods
This study analyzed near-miss events reported between January 1 and December 31, 2024, from inpatient critical care units at a large academic medical center in southern California. Events were analyzed to identify contributing factors using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). Events were subclassified and evaluated to identify the intervention source that prevented the escalation from near miss to harm.
Results
A total of 288 near-miss events were reported, and 396 contributing factors were identified. Most events involved routine violations (n = 106, 26.77%), challenges with operational processes (n=105, 26.52%), or skill-based errors (n = 79, 19.95%). Nurses (n = 119, 41.32%) and medication scanners (n = 91, 31.60%) were the most frequent sources of successful intervention.
Conclusion
Near-miss events offer actionable insight into safety vulnerabilities and safeguards within ICU workflows. Targeted interventions, such as improving cross-disciplinary coordination, updating operational processes to reflect practical care delivery, standardizing safety checks, and encouraging the use of reporting systems, can foster a culture of shared accountability and continuous quality improvement.
{"title":"What Saves a Patient? A Human Factors Approach to Understanding Near Misses in the ICU","authors":"Harshini Ravi (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles), Aleeque Marselian MS (is Clinical Research Associate, Department of Surgery, Cedars-Sinai Medical Center), Falisha Kanji MS (is Program Administrator, Department of Surgery, Cedars-Sinai Medical Center), Tara N. Cohen PhD (is Director, Surgical Safety and Human Factors Research, Department of Surgery, Cedars-Sinai Medical Center. Please address correspondence to Tara N. Cohen)","doi":"10.1016/j.jcjq.2025.11.008","DOIUrl":"10.1016/j.jcjq.2025.11.008","url":null,"abstract":"<div><h3>Background</h3><div>The confluence of rapidly changing clinical conditions, cognitive demands, and interdisciplinary collaboration in intensive care units (ICUs) creates conditions where minor lapses in communication, judgment, or coordination can result in preventable patient harm. Because near-miss events within healthcare systems are underreported and under-analyzed, evidence-based interventions to improve system safety are limited. Therefore, this study aims to understand the conditions that enable near misses using a human factors approach, as well as identify the mechanisms that intercept them before they escalate to harm.</div></div><div><h3>Methods</h3><div>This study analyzed near-miss events reported between January 1 and December 31, 2024, from inpatient critical care units at a large academic medical center in southern California. Events were analyzed to identify contributing factors using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). Events were subclassified and evaluated to identify the intervention source that prevented the escalation from near miss to harm.</div></div><div><h3>Results</h3><div>A total of 288 near-miss events were reported, and 396 contributing factors were identified. Most events involved routine violations (<em>n</em> = 106, 26.77%), challenges with operational processes (<em>n</em>=105, 26.52%), or skill-based errors (<em>n</em> = 79, 19.95%). Nurses (<em>n</em> = 119, 41.32%) and medication scanners (<em>n</em> = 91, 31.60%) were the most frequent sources of successful intervention.</div></div><div><h3>Conclusion</h3><div>Near-miss events offer actionable insight into safety vulnerabilities and safeguards within ICU workflows. Targeted interventions, such as improving cross-disciplinary coordination, updating operational processes to reflect practical care delivery, standardizing safety checks, and encouraging the use of reporting systems, can foster a culture of shared accountability and continuous quality improvement.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 57-66"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145846337","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}
Medication reconciliation is a critical process aimed at preventing medication errors and discrepancies during hospitalization. Discrepancies, particularly unintentional ones, can occur during admission, intrahospital transfers, and discharge, potentially compromising patient safety. This study aimed to assess the prevalence of unintentional medication discrepancies at admission, transition, and discharge phases of care.
Methods
A prospective observational study was conducted on 200 inpatients in a tertiary care hospital. Medication reconciliation was assessed at three phases: admission, transition, and discharge. Discrepancies were classified and analyzed based on frequency and type, and associations with demographics and comorbidities were explored.
Results
Most patients were aged 60–74 years (51.5%) with hypertension (71.5%) being the most prevalent comorbidity. Reconciliation was performed in 87.0% of patients at admission (170 discrepancies), 93.1% at transition (23 discrepancies), and 83.5% at discharge (266 discrepancies). Discharge had the highest rate of unintentional discrepancies per patient (1.37), followed by admission (0.85) and transition (0.23).
Conclusion
This study highlights the significance of medication reconciliation in preventing medication discrepancies, particularly at discharge. The findings support the need for standardized reconciliation protocols and stronger interdisciplinary collaboration to enhance patient safety.
{"title":"Medication Reconciliation and Patient Safety in India: A Prospective Observational Study at a Tertiary Care Hospital","authors":"Ashish Kumar Dogra PharmD , Shivani Juneja MBBS, MD , Josmy Maria Job PharmD","doi":"10.1016/j.jcjq.2025.11.005","DOIUrl":"10.1016/j.jcjq.2025.11.005","url":null,"abstract":"<div><h3>Background</h3><div>Medication reconciliation is a critical process aimed at preventing medication errors and discrepancies during hospitalization. Discrepancies, particularly unintentional ones, can occur during admission, intrahospital transfers, and discharge, potentially compromising patient safety. This study aimed to assess the prevalence of unintentional medication discrepancies at admission, transition, and discharge phases of care.</div></div><div><h3>Methods</h3><div>A prospective observational study was conducted on 200 inpatients in a tertiary care hospital. Medication reconciliation was assessed at three phases: admission, transition, and discharge. Discrepancies were classified and analyzed based on frequency and type, and associations with demographics and comorbidities were explored.</div></div><div><h3>Results</h3><div>Most patients were aged 60–74 years (51.5%) with hypertension (71.5%) being the most prevalent comorbidity. Reconciliation was performed in 87.0% of patients at admission (170 discrepancies), 93.1% at transition (23 discrepancies), and 83.5% at discharge (266 discrepancies). Discharge had the highest rate of unintentional discrepancies per patient (1.37), followed by admission (0.85) and transition (0.23).</div></div><div><h3>Conclusion</h3><div>This study highlights the significance of medication reconciliation in preventing medication discrepancies, particularly at discharge. The findings support the need for standardized reconciliation protocols and stronger interdisciplinary collaboration to enhance patient safety.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 95-99"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145793859","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 : 2026-02-01Epub Date: 2025-11-23DOI: 10.1016/j.jcjq.2025.11.009
Lauren Zabel MD (is Chief Resident, Department of Internal Medicine, Carver College of Medicine, University of Iowa.), James Willey MD, MSE (is Associate Professor, Department of Internal Medicine, Carver College of Medicine, University of Iowa.), Jennifer McDanel PhD, MS (is Quality and Safety Specialist, University of Iowa Hospitals and Clinics.), Ethan Kuperman MD (is Clinical Professor, Department of Internal Medicine, Carver College of Medicine, University of Iowa. Please address correspondence to Lauren Zabel)
{"title":"Reasons for eCQM–Identified Concurrent Opioid and Benzodiazepine Prescribing at Discharge: A Cohort Study","authors":"Lauren Zabel MD (is Chief Resident, Department of Internal Medicine, Carver College of Medicine, University of Iowa.), James Willey MD, MSE (is Associate Professor, Department of Internal Medicine, Carver College of Medicine, University of Iowa.), Jennifer McDanel PhD, MS (is Quality and Safety Specialist, University of Iowa Hospitals and Clinics.), Ethan Kuperman MD (is Clinical Professor, Department of Internal Medicine, Carver College of Medicine, University of Iowa. Please address correspondence to Lauren Zabel)","doi":"10.1016/j.jcjq.2025.11.009","DOIUrl":"10.1016/j.jcjq.2025.11.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 100-101"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145846329","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 : 2026-02-01Epub Date: 2025-11-10DOI: 10.1016/j.jcjq.2025.11.003
Megan Kennelly MD (formerly Quality Improvement Chief Resident, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation, Charlotte, North Carolina, is Assistant Professor, Department of Orthopaedic Surgery, Duke University School of Medicine), Zana Percy MD, PhD (is Resident, Warren Alpert Medical School, Brown University), Jessica Kurtz MD (is Spinal Cord Injury Fellow, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation), Sima Desai MD (is Program Director, Brain Injury Medicine Fellowship Program, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation, and Assistant Professor, Department of Orthopedic Surgery and Rehabilitation, Wake Forest University), Shanti Pinto MD, MSCS (is Faculty Member, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts. Please address correspondence to Megan Kennelly)
Background
The study aimed to evaluate the effect of the Transitional Services Clinic (TSC), a clinic dedicated to time-limited care for patients after discharge from the hospital, on 30-day potentially avoidable readmissions (PARs) following acute inpatient rehabilitation.
Methods
This retrospective cohort study and post hoc analysis was conducted at a single hospital-affiliated inpatient rehabilitation facility. The research team collected data from patients discharged between January and November 2021.
Results
Of the 1,116 patients discharged from inpatient rehabilitation during the study time frame, 55 received transitional services through the TSC. There was no statistically significant difference in 30-day readmission rates between the TSC (7.3%) and non-TSC groups (9.0%). Patients who were referred to TSC but declined services had a readmission rate of 33.3%. The TSC was a protective factor in this subset, in that those who were eligible but declined services had a 6.16 greater odds of readmission within 30 days (95% confidence interval [CI] 1.24–34.71).
Conclusion
In this study, 30-day hospital readmission rates were similar between patients who received transitional services after inpatient rehabilitation and those who did not receive services. More research is needed to identify patients at high-risk of readmission that may benefit from dedicated transitional services at the time of inpatient rehabilitation discharge.
{"title":"The Effect of Transitional Services on 30-Day Avoidable Hospital Readmission Following Inpatient Rehabilitation Facility Admission","authors":"Megan Kennelly MD (formerly Quality Improvement Chief Resident, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation, Charlotte, North Carolina, is Assistant Professor, Department of Orthopaedic Surgery, Duke University School of Medicine), Zana Percy MD, PhD (is Resident, Warren Alpert Medical School, Brown University), Jessica Kurtz MD (is Spinal Cord Injury Fellow, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation), Sima Desai MD (is Program Director, Brain Injury Medicine Fellowship Program, Department of Physical Medicine and Rehabilitation, Atrium Health Carolinas Rehabilitation, and Assistant Professor, Department of Orthopedic Surgery and Rehabilitation, Wake Forest University), Shanti Pinto MD, MSCS (is Faculty Member, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts. Please address correspondence to Megan Kennelly)","doi":"10.1016/j.jcjq.2025.11.003","DOIUrl":"10.1016/j.jcjq.2025.11.003","url":null,"abstract":"<div><h3>Background</h3><div>The study aimed to evaluate the effect of the Transitional Services Clinic (TSC), a clinic dedicated to time-limited care for patients after discharge from the hospital, on 30-day potentially avoidable readmissions (PARs) following acute inpatient rehabilitation.</div></div><div><h3>Methods</h3><div>This retrospective cohort study and post hoc analysis was conducted at a single hospital-affiliated inpatient rehabilitation facility. The research team collected data from patients discharged between January and November 2021.</div></div><div><h3>Results</h3><div>Of the 1,116 patients discharged from inpatient rehabilitation during the study time frame, 55 received transitional services through the TSC. There was no statistically significant difference in 30-day readmission rates between the TSC (7.3%) and non-TSC groups (9.0%). Patients who were referred to TSC but declined services had a readmission rate of 33.3%. The TSC was a protective factor in this subset, in that those who were eligible but declined services had a 6.16 greater odds of readmission within 30 days (95% confidence interval [CI] 1.24–34.71).</div></div><div><h3>Conclusion</h3><div>In this study, 30-day hospital readmission rates were similar between patients who received transitional services after inpatient rehabilitation and those who did not receive services. More research is needed to identify patients at high-risk of readmission that may benefit from dedicated transitional services at the time of inpatient rehabilitation discharge.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 80-86"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145751831","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 : 2026-02-01Epub Date: 2025-11-19DOI: 10.1016/j.jcjq.2025.11.007
Charlotte M. ter Haar MD (formerly Resident, Department of Obstetrics & Gynecology, University of Illinois College of Medicine, Chicago, is Urogynecology Fellow, University of California, Irvine.), Quetzal A. Class PhD (is Research Associate Professor, and Director of Residency Research, Department of Obstetrics & Gynecology, University of Illinois College of Medicine.), Lopa K. Pandya MD, MS (is Associate Professor, and Director of Benign Gynecology Perioperative Surgery, Department of Obstetrics & Gynecology, University of Illinois College of Medicine. Please address correspondence to Charlotte ter Haar, [email protected])
Background
As an exploration of tray optimization, the authors examined the instrument utilization rates for cesarean sections, as well as factors that may be associated with the number of instruments used. Tray optimization is one avenue for improving healthcare sustainability.
Methods
From an urban academic hospital, investigators prospectively collected data on which instruments from the tray were used in cesarean sections. An instrument was considered used if it touched a surgeon’s hand during the procedure. The authors also documented whether the case was a primary or repeat cesarean birth; was scheduled, urgent, or emergent; and whether the birth was a primary or twin gestation. Cohort differences were examined using chi-square and analysis of variance (ANOVA) analyses using SPSS.
Results
A total of 28 cases were included: 12 primary and 16 repeat cesarean births, with 11 scheduled, 13 urgent, and 4 emergent cases. Of the 54 instruments on the tray, 8 were used ≤ 25.0% of the time, and an additional 8 instruments were used ≤ 50.0% of the time. Total instrument utilization rates did not differ between primary and repeat cases. The highest number of Ochsner artery forceps were used in emergent cases, while the fewest were used in urgent cases (F[2,25] = 3.474, p = 0.047]. The use of either one or both 5.1 cm Rich retractors was significantly higher for urgent than for scheduled or emergent cases (Χ2 [2] = 6.31, p = 0.043).
Conclusion
Based on current instrument utilization rates in cesarean sections, there are opportunities for tray optimization with positive downstream environmental and financial impacts.
背景：作为对托盘优化的探索，作者检查了剖宫产的器械使用率，以及可能与使用器械数量相关的因素。托盘优化是提高医疗保健可持续性的一个途径。方法：从一家城市学术医院，调查人员前瞻性地收集了剖宫产手术中使用托盘中的器械的数据。如果器械在手术过程中接触到外科医生的手，就被认为使用过。作者还记录了该病例是原发性还是重复剖宫产；紧急的，紧急的：被安排的，紧急的或紧急的；以及胎儿是原胎还是双胎。队列差异采用卡方分析和方差分析（ANOVA）分析使用SPSS。结果：本组共纳入28例：首次剖宫产12例，再次剖宫产16例，其中计划剖宫产11例，紧急剖宫产13例，急诊剖宫产4例。在托盘上的54台仪器中，有8台仪器的使用率≤25.0%，另有8台仪器的使用率≤50.0%。总器械使用率在原发性和重复病例之间没有差异。急诊病例使用Ochsner动脉钳最多，急诊病例使用Ochsner动脉钳最少（F[2,25] = 3.474, p = 0.047）。紧急病例使用一个或两个5.1 cm Rich牵开器的比例明显高于常规病例或紧急病例（Χ2 [2] = 6.31, p = 0.043）。结论：根据目前剖宫产手术中器械的使用率，有机会对托盘进行优化，并对下游环境和经济产生积极影响。
{"title":"Assessment of Instrument Utilization in Cesarean Births: Taking a Step Toward Sustainability","authors":"Charlotte M. ter Haar MD (formerly Resident, Department of Obstetrics & Gynecology, University of Illinois College of Medicine, Chicago, is Urogynecology Fellow, University of California, Irvine.), Quetzal A. Class PhD (is Research Associate Professor, and Director of Residency Research, Department of Obstetrics & Gynecology, University of Illinois College of Medicine.), Lopa K. Pandya MD, MS (is Associate Professor, and Director of Benign Gynecology Perioperative Surgery, Department of Obstetrics & Gynecology, University of Illinois College of Medicine. Please address correspondence to Charlotte ter Haar, [email protected])","doi":"10.1016/j.jcjq.2025.11.007","DOIUrl":"10.1016/j.jcjq.2025.11.007","url":null,"abstract":"<div><h3>Background</h3><div>As an exploration of tray optimization, the authors examined the instrument utilization rates for cesarean sections, as well as factors that may be associated with the number of instruments used. Tray optimization is one avenue for improving healthcare sustainability.</div></div><div><h3>Methods</h3><div>From an urban academic hospital, investigators prospectively collected data on which instruments from the tray were used in cesarean sections. An instrument was considered used if it touched a surgeon’s hand during the procedure. The authors also documented whether the case was a primary or repeat cesarean birth; was scheduled, urgent, or emergent; and whether the birth was a primary or twin gestation. Cohort differences were examined using chi-square and analysis of variance (ANOVA) analyses using SPSS.</div></div><div><h3>Results</h3><div>A total of 28 cases were included: 12 primary and 16 repeat cesarean births, with 11 scheduled, 13 urgent, and 4 emergent cases. Of the 54 instruments on the tray, 8 were used ≤ 25.0% of the time, and an additional 8 instruments were used ≤ 50.0% of the time. Total instrument utilization rates did not differ between primary and repeat cases. The highest number of Ochsner artery forceps were used in emergent cases, while the fewest were used in urgent cases (<em>F</em>[2,25] = 3.474, <em>p</em> = 0.047]. The use of either one or both 5.1 cm Rich retractors was significantly higher for urgent than for scheduled or emergent cases (Χ<sup>2</sup> [2] = 6.31, <em>p</em> = 0.043).</div></div><div><h3>Conclusion</h3><div>Based on current instrument utilization rates in cesarean sections, there are opportunities for tray optimization with positive downstream environmental and financial impacts.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 75-79"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145793713","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 : 2026-02-01Epub Date: 2025-11-14DOI: 10.1016/j.jcjq.2025.11.006
Jacky Hooftman MSc (is PhD Candidate, Department of Public and Occupational Health, Amsterdam UMC, Amsterdam, the Netherlands, and Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands.), Jonne J. Sikkens MD, PhD (is Internist, Department of Internal Medicine. Amsterdam UMC.), Nienke van Wingerden MD (is Internist, Acibadem International Medical Center, Amsterdam, The Netherlands.), Djoeke G. Beekman MD (is Internist, Acibadem International Medical Center, The Netherlands.), Martine C. de Bruijne MD, PhD (is Professor, Department of Public and Occupational Health, Amsterdam UMC, and Director, Amsterdam Public Health Institute.), Cordula Wagner MA, PhD (is Professor, Department of Public and Occupational Health, Amsterdam UMC, and Executive Director, Netherlands Institute for Health Services Research (Nivel), Utrecht, the Netherlands.), Laura Zwaan PhD (is Associate Professor, Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands)
Background
The medical diagnostic process is vulnerable to suboptimal decision-making (that is, decisions with any deviation from an optimal diagnostic process) due to its complex nature. It is unknown how these suboptimal diagnostic decisions and other measures of diagnostic safety (diagnostic error, diagnostic discrepancy) relate to each other.
Methods
The authors prospectively included a convenience sample of 53 hospitalized patients with fever between February and May 2023. After discharge, independent internal medicine physicians reviewed their medical records to identify suboptimal diagnostic decisions and diagnostic errors. When such suboptimal decisions were observed, involved physicians were interviewed about the thought processes behind these decisions. Established tools and taxonomies were used to identify and categorize suboptimal diagnostic decisions, diagnostic errors, and diagnostic discrepancies.
Results
The authors initially identified a total of 110 suboptimal diagnostic decisions in 38 of 53 cases (71.7%). After the physician interviews, 29 cases with suboptimal decisions remained (54.7%), with a total of 72 suboptimal diagnostic decisions across those cases (median of 2 suboptimal decisions per case; interquartile range 1–4). Cases with a higher number of suboptimal diagnostic decisions had significantly higher rates of diagnostic error and diagnostic discrepancy. No significant association between diagnostic error and diagnostic discrepancy were found. Almost all suboptimal decisions were human, and most took place during assessment of the patient and diagnostic testing.
Conclusion
Cases with more suboptimal diagnostic decisions were associated with higher rates of diagnostic error and diagnostic discrepancy, but the level of overlap between the three was relatively low, suggesting that these reflect different concepts of diagnostic safety and should be treated as such. Future research should incorporate physician interviews to enrich understanding and account for contextual factors.
{"title":"Suboptimal Diagnostic Decisions In Hospitalized Patients with Fever: A Prospective Record Review with Physician Interviews","authors":"Jacky Hooftman MSc (is PhD Candidate, Department of Public and Occupational Health, Amsterdam UMC, Amsterdam, the Netherlands, and Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands.), Jonne J. Sikkens MD, PhD (is Internist, Department of Internal Medicine. Amsterdam UMC.), Nienke van Wingerden MD (is Internist, Acibadem International Medical Center, Amsterdam, The Netherlands.), Djoeke G. Beekman MD (is Internist, Acibadem International Medical Center, The Netherlands.), Martine C. de Bruijne MD, PhD (is Professor, Department of Public and Occupational Health, Amsterdam UMC, and Director, Amsterdam Public Health Institute.), Cordula Wagner MA, PhD (is Professor, Department of Public and Occupational Health, Amsterdam UMC, and Executive Director, Netherlands Institute for Health Services Research (Nivel), Utrecht, the Netherlands.), Laura Zwaan PhD (is Associate Professor, Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands)","doi":"10.1016/j.jcjq.2025.11.006","DOIUrl":"10.1016/j.jcjq.2025.11.006","url":null,"abstract":"<div><h3>Background</h3><div>The medical diagnostic process is vulnerable to suboptimal decision-making (that is, decisions with any deviation from an optimal diagnostic process) due to its complex nature. It is unknown how these suboptimal diagnostic decisions and other measures of diagnostic safety (diagnostic error, diagnostic discrepancy) relate to each other.</div></div><div><h3>Methods</h3><div>The authors prospectively included a convenience sample of 53 hospitalized patients with fever between February and May 2023. After discharge, independent internal medicine physicians reviewed their medical records to identify suboptimal diagnostic decisions and diagnostic errors. When such suboptimal decisions were observed, involved physicians were interviewed about the thought processes behind these decisions. Established tools and taxonomies were used to identify and categorize suboptimal diagnostic decisions, diagnostic errors, and diagnostic discrepancies.</div></div><div><h3>Results</h3><div>The authors initially identified a total of 110 suboptimal diagnostic decisions in 38 of 53 cases (71.7%). After the physician interviews, 29 cases with suboptimal decisions remained (54.7%), with a total of 72 suboptimal diagnostic decisions across those cases (median of 2 suboptimal decisions per case; interquartile range 1–4). Cases with a higher number of suboptimal diagnostic decisions had significantly higher rates of diagnostic error and diagnostic discrepancy. No significant association between diagnostic error and diagnostic discrepancy were found. Almost all suboptimal decisions were human, and most took place during assessment of the patient and diagnostic testing.</div></div><div><h3>Conclusion</h3><div>Cases with more suboptimal diagnostic decisions were associated with higher rates of diagnostic error and diagnostic discrepancy, but the level of overlap between the three was relatively low, suggesting that these reflect different concepts of diagnostic safety and should be treated as such. Future research should incorporate physician interviews to enrich understanding and account for contextual factors.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Pages 87-94"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145800109","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 : 2026-02-01Epub Date: 2025-11-07DOI: 10.1016/j.jcjq.2025.11.002
Herman Joseph Johannesmeyer PharmD, BCPS (is Health Sciences Associate Clinical Professor, University of California, Irvine School of Pharmacy & Pharmaceutical Sciences), Genene Salman PharmD, BCCCP, BCPS, CNSC (is Associate Professor, Marshall B. Ketchum University College of Pharmacy, Fullerton, California), Tiffany Khieu PharmD (is Assistant Professor, Marshall B. Ketchum University College of Pharmacy. Please address correspondence to Herman Joseph Johannesmeyer)
{"title":"Medication-Related Safety Events","authors":"Herman Joseph Johannesmeyer PharmD, BCPS (is Health Sciences Associate Clinical Professor, University of California, Irvine School of Pharmacy & Pharmaceutical Sciences), Genene Salman PharmD, BCCCP, BCPS, CNSC (is Associate Professor, Marshall B. Ketchum University College of Pharmacy, Fullerton, California), Tiffany Khieu PharmD (is Assistant Professor, Marshall B. Ketchum University College of Pharmacy. Please address correspondence to Herman Joseph Johannesmeyer)","doi":"10.1016/j.jcjq.2025.11.002","DOIUrl":"10.1016/j.jcjq.2025.11.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 2","pages":"Page 105"},"PeriodicalIF":2.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145751862","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 : 2026-01-31DOI: 10.1016/j.jcjq.2026.01.008
Eric T Roberts, Gabriela Schmajuk, Jessica Fitzpatrick, Jing Li, Jinoos Yazdany
Background: Metrics with acceptable reliability are necessary to ensure that quality measures reward performance. Low metric reliability may result from a lack of differences between reporting entities or low numbers of eligible patients. The Merit-based Incentive Payment System (MIPS) incentivizes high-performing practices to report, which may lower practice-to-practice variation and lower reliability. This study evaluated the impact of voluntary participation in MIPS and measure denominator counts on practice-specific reliability estimates.
Methods: Data came from the Rheumatology Informatics System for Effectiveness (RISE) registry, which passively collects electronic health record (EHR) data. Practice-specific metric reliability was calculated on two safety measures-QPP176 (tuberculosis screening) and ACR10 (hepatitis B screening)-in two cohorts: the full sample of practices with data in RISE and the subset of practices that reported performance data on these measures to MIPS. The authors report longitudinal summary statistics on metric reliability, performance, and the number of eligible patients. The study team also examined estimates longitudinally stratified by patients counts.
Results: Both the RISE and MIPS samples had acceptable median reliability (> 0.85) but a wide range (0.04-1.0) despite differences in performance. Analyses showed that for both measures for all years, the practice-specific metric reliability remains ≥ 0.80 when the number of eligible patients was at least 20 and ≥ 0.70 when the number of eligible patients was at least 10.
Conclusion: Self-selection into the MIPS program did not reduce the reliability of the examined patient safety measures. In addition, we found acceptable metric reliability at denominator counts lower than currently required by CMS suggesting case minimums for certain measures could be lowered to further encourage quality improvement in a wider subset of practices.
{"title":"Longitudinal Reliability of Rheumatology Patient Safety Measures and Implications for CMS Case Minimums.","authors":"Eric T Roberts, Gabriela Schmajuk, Jessica Fitzpatrick, Jing Li, Jinoos Yazdany","doi":"10.1016/j.jcjq.2026.01.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.01.008","url":null,"abstract":"<p><strong>Background: </strong>Metrics with acceptable reliability are necessary to ensure that quality measures reward performance. Low metric reliability may result from a lack of differences between reporting entities or low numbers of eligible patients. The Merit-based Incentive Payment System (MIPS) incentivizes high-performing practices to report, which may lower practice-to-practice variation and lower reliability. This study evaluated the impact of voluntary participation in MIPS and measure denominator counts on practice-specific reliability estimates.</p><p><strong>Methods: </strong>Data came from the Rheumatology Informatics System for Effectiveness (RISE) registry, which passively collects electronic health record (EHR) data. Practice-specific metric reliability was calculated on two safety measures-QPP176 (tuberculosis screening) and ACR10 (hepatitis B screening)-in two cohorts: the full sample of practices with data in RISE and the subset of practices that reported performance data on these measures to MIPS. The authors report longitudinal summary statistics on metric reliability, performance, and the number of eligible patients. The study team also examined estimates longitudinally stratified by patients counts.</p><p><strong>Results: </strong>Both the RISE and MIPS samples had acceptable median reliability (> 0.85) but a wide range (0.04-1.0) despite differences in performance. Analyses showed that for both measures for all years, the practice-specific metric reliability remains ≥ 0.80 when the number of eligible patients was at least 20 and ≥ 0.70 when the number of eligible patients was at least 10.</p><p><strong>Conclusion: </strong>Self-selection into the MIPS program did not reduce the reliability of the examined patient safety measures. In addition, we found acceptable metric reliability at denominator counts lower than currently required by CMS suggesting case minimums for certain measures could be lowered to further encourage quality improvement in a wider subset of practices.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-01-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147348328","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 : 2026-01-30DOI: 10.1016/j.jcjq.2026.01.006
Milou Steenbergen, Sigrid Vervoort, Lisette Schoonhoven, Bas de Vries, Maarten Ten Berg, Debbie Vermond, Dorien Zwart
Background: The Functional Resonance Analysis Method (FRAM) helps understand daily practice and improve healthcare through a Safety-II approach. However, little guidance is provided on how to translate the results of a FRAM model into practice.
Methods: We conducted a qualitative case study to explore how FRAM worked for putting the Safety-II principles into practice by applying it to the discharge process. For this, we created a FRAM model of current discharge practices based on observations, interviews, and group discussions. Through group discussions with healthcare professionals, we explored how FRAM works for putting the principles of Safety-II into practice.
Results: We identified three themes relating to how FRAM works putting Safety-II principles into practice. The first is acknowledging the complexity of daily practice as a FRAM model raises awareness of the complexity and interdependencies involved. The second theme is learning from what works and strengthening adaptability. Based on the FRAM model, healthcare professionals can identify what works and gain a better understanding of the reasons behind it. The third theme is reverting to the "find and fix" approach. Rather than developing an understanding of how things usually go right to reinforce what works, they primarily sought to narrow the gap between work-as-imagined and work-as-done, and emphasize limiting variability.
Conclusion: We illustrate that FRAM is a useful tool for raising awareness and enhancing mutual understanding. However, FRAM requires moderated discussions on the model to maintain Safety-II principles for supporting healthcare professionals' ability to succeed under varying conditions.
{"title":"FRAM Analysis of Successful Hospital Discharge: A Case Study on Putting Safety-II Principles into Practice.","authors":"Milou Steenbergen, Sigrid Vervoort, Lisette Schoonhoven, Bas de Vries, Maarten Ten Berg, Debbie Vermond, Dorien Zwart","doi":"10.1016/j.jcjq.2026.01.006","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.01.006","url":null,"abstract":"<p><strong>Background: </strong>The Functional Resonance Analysis Method (FRAM) helps understand daily practice and improve healthcare through a Safety-II approach. However, little guidance is provided on how to translate the results of a FRAM model into practice.</p><p><strong>Methods: </strong>We conducted a qualitative case study to explore how FRAM worked for putting the Safety-II principles into practice by applying it to the discharge process. For this, we created a FRAM model of current discharge practices based on observations, interviews, and group discussions. Through group discussions with healthcare professionals, we explored how FRAM works for putting the principles of Safety-II into practice.</p><p><strong>Results: </strong>We identified three themes relating to how FRAM works putting Safety-II principles into practice. The first is acknowledging the complexity of daily practice as a FRAM model raises awareness of the complexity and interdependencies involved. The second theme is learning from what works and strengthening adaptability. Based on the FRAM model, healthcare professionals can identify what works and gain a better understanding of the reasons behind it. The third theme is reverting to the \"find and fix\" approach. Rather than developing an understanding of how things usually go right to reinforce what works, they primarily sought to narrow the gap between work-as-imagined and work-as-done, and emphasize limiting variability.</p><p><strong>Conclusion: </strong>We illustrate that FRAM is a useful tool for raising awareness and enhancing mutual understanding. However, FRAM requires moderated discussions on the model to maintain Safety-II principles for supporting healthcare professionals' ability to succeed under varying conditions.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147389863","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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