Joint Commission journal on quality and patient safety最新文献

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.

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.

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.

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.

Background: Guideline-based management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) improves patient outcomes, yet adherence in low- and middle-income country (LMIC) settings remains inconsistent. Baseline audits at a tertiary care center in Pakistan revealed significant gaps in pharmacologic management, patient education, and discharge planning, reflecting underutilization of evidence-based standards such as GOLD and NICE guidelines. Variation in AECOPD inpatient care was linked to inconsistent use of standardized care bundles, incomplete documentation, and limited integration of clinical guidelines into the electronic health record (EHR).

Methods: The hospital implemented a six-week, rapid-cycle quality improvement intervention combining (1) EHR-embedded prompts aligned with international standards, (2) targeted educational sessions for physicians and nurses, and (3) distribution of concise clinical pocket guides. Five process indicators were measured in 50 consecutive patients preintervention and postintervention: systemic corticosteroid use, appropriate antibiotic prescribing, smoking cessation counseling, spirometry ordering, and documented discharge planning. Data were analyzed using descriptive statistics and chi-square tests for categorical variables.

Results: Adherence improved for systemic corticosteroid prescription (54% to 88%), appropriate antibiotic prescribing (62% to 90%), smoking cessation counseling (22% to 74%), spirometry ordering (18% to 52%), and documented discharge planning (40% to 82%) (all p < 0.05). No adverse workflow disruptions or patient safety issues were identified. Follow-up at three months suggested sustained improvements.

Conclusion: In a resource-constrained LMIC hospital, a pragmatic, guideline-driven intervention using EHR prompts and focused education achieved rapid improvements in AECOPD inpatient care processes. This approach may be adaptable to other settings with similar constraints. Differences in clinical infrastructure, documentation systems, and staffing between Pakistan and the United States should be considered when translating these results internationally.

Background: 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.

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.