Pub Date : 2025-07-01DOI: 10.1016/j.jcjq.2024.12.002
Peter D. Mills PhD, MS (is Director, US Department of Veterans Affairs (VA) National Center for Patient Safety Field Office, White River Junction, Vermont, and Clinical Professor of Psychiatry, Geisel School of Medicine at Dartmouth.), Anne Tomolo MD, MPH (is Co-Director of the Chief Resident for Quality and Safety Program and Advanced Fellowship in Patient Safety Program, VA National Center for Patient Safety, and Associate Professor, Department of Medicine, Emory University School of Medicine.), Edward E. Yackel DNP, FNP-C, FAANP (is Executive Director, VA National Center for Patient Safety, and Adjunct Clinical Instructor, Department of Health Behavior and Biological Sciences, University of Michigan. Please address correspondence to Peter D. Mills)
Background
Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.
Methods
The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.
Results
A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.
Conclusion
The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.
{"title":"Adverse Events Involving Telehealth in the Veterans Health Administration","authors":"Peter D. Mills PhD, MS (is Director, US Department of Veterans Affairs (VA) National Center for Patient Safety Field Office, White River Junction, Vermont, and Clinical Professor of Psychiatry, Geisel School of Medicine at Dartmouth.), Anne Tomolo MD, MPH (is Co-Director of the Chief Resident for Quality and Safety Program and Advanced Fellowship in Patient Safety Program, VA National Center for Patient Safety, and Associate Professor, Department of Medicine, Emory University School of Medicine.), Edward E. Yackel DNP, FNP-C, FAANP (is Executive Director, VA National Center for Patient Safety, and Adjunct Clinical Instructor, Department of Health Behavior and Biological Sciences, University of Michigan. Please address correspondence to Peter D. Mills)","doi":"10.1016/j.jcjq.2024.12.002","DOIUrl":"10.1016/j.jcjq.2024.12.002","url":null,"abstract":"<div><h3>Background</h3><div>Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.</div></div><div><h3>Methods</h3><div>The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.</div></div><div><h3>Results</h3><div>A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.</div></div><div><h3>Conclusion</h3><div>The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 486-492"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143023579","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.04.003
Jorge A. Rodriguez MD (is Clinician-Investigator, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Assistant Professor, Harvard Medical School, Boston.), David W. Bates MD (is Medical Director of Clinical and Quality Analysis, MGB Healthcare, and Professor of Medicine, Harvard Medical School. Please address correspondence to Jorge A. Rodriguez)
{"title":"Achieving Safe Telehealth","authors":"Jorge A. Rodriguez MD (is Clinician-Investigator, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Assistant Professor, Harvard Medical School, Boston.), David W. Bates MD (is Medical Director of Clinical and Quality Analysis, MGB Healthcare, and Professor of Medicine, Harvard Medical School. Please address correspondence to Jorge A. Rodriguez)","doi":"10.1016/j.jcjq.2025.04.003","DOIUrl":"10.1016/j.jcjq.2025.04.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 456-457"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019040","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 : 2025-06-29DOI: 10.1016/j.jcjq.2025.06.012
Nick May (is Nurse Educator, Innovation and Education Directorate, Royal Perth Bentley Group, Perth, Australia.), Lucia Gillman PhD (is Coordinator of Nursing, Innovation and Education Directorate, Royal Perth Bentley Group. Please address correspondence to Nicholas May)
Background
Patient harm attributed to invasive devices is a global concern. Around 18% to 54% of all catheter-related hospital-acquired bloodstream infections (HABSIs) are attributable to peripheral intravenous cannulas (PIVCs). Between 4% and 28% of PIVCs placed in hospitalized patients and up to 50% of emergency department (ED) PIVCs are not used. Avoiding insertion of the “just in case” PIVC where safe to do so has potential to reduce patient risk.
Tool Development
The DRIP mnemonic (Deterioration, Rehydration, Intravenous medications, Procedure) was designed around four simple questions to guide clinicians’ decision-making relating to PIVC insertion. DRIP can also be used to support the daily review of existing cannulas to confirm ongoing need. Both applications align to daily workflows to promote a culture of safety.
Results
DRIP has assisted in reducing the number of idle PIVCs reported in monthly quality and safety audits from 8.3% to 1.8%. Removal of these PIVCs was possible after confirmation with treating teams that the device was not clinically indicated. This has reduced patient exposure to HABSI. During a 15-month period, independent assessment of PIVC insertion requests by the Vascular Access Team found that 3,103 PIVC requests (10.1%) were deemed not clinically indicated and were not inserted. None met DRIP criteria, which suggests independent expert clinician assessment aligns well to the DRIP criteria in practice.
Conclusion
DRIP has shown that elimination of cannulation where not clinically indicated is achievable. Use of the DRIP tool can support safe organizational culture by encouraging staff to question the need for a PIVC to reduce or eliminate the “just in case” or idle cannula. Formal validation of DRIP across multiple settings would strengthen the evidence base underpinning PIVC decision-making.
{"title":"The DRIP Criteria: Reducing the Frequency of Peripheral Intravenous Catheter Insertion in Hospitalized Patients","authors":"Nick May (is Nurse Educator, Innovation and Education Directorate, Royal Perth Bentley Group, Perth, Australia.), Lucia Gillman PhD (is Coordinator of Nursing, Innovation and Education Directorate, Royal Perth Bentley Group. Please address correspondence to Nicholas May)","doi":"10.1016/j.jcjq.2025.06.012","DOIUrl":"10.1016/j.jcjq.2025.06.012","url":null,"abstract":"<div><h3>Background</h3><div>Patient harm attributed to invasive devices is a global concern. Around 18% to 54% of all catheter-related hospital-acquired bloodstream infections (HABSIs) are attributable to peripheral intravenous cannulas (PIVCs). Between 4% and 28% of PIVCs placed in hospitalized patients and up to 50% of emergency department (ED) PIVCs are not used. Avoiding insertion of the “just in case” PIVC where safe to do so has potential to reduce patient risk.</div></div><div><h3>Tool Development</h3><div>The DRIP mnemonic (Deterioration, Rehydration, Intravenous medications, Procedure) was designed around four simple questions to guide clinicians’ decision-making relating to PIVC insertion. DRIP can also be used to support the daily review of existing cannulas to confirm ongoing need. Both applications align to daily workflows to promote a culture of safety.</div></div><div><h3>Results</h3><div>DRIP has assisted in reducing the number of idle PIVCs reported in monthly quality and safety audits from 8.3% to 1.8%. Removal of these PIVCs was possible after confirmation with treating teams that the device was not clinically indicated. This has reduced patient exposure to HABSI. During a 15-month period, independent assessment of PIVC insertion requests by the Vascular Access Team found that 3,103 PIVC requests (10.1%) were deemed not clinically indicated and were not inserted. None met DRIP criteria, which suggests independent expert clinician assessment aligns well to the DRIP criteria in practice.</div></div><div><h3>Conclusion</h3><div>DRIP has shown that elimination of cannulation where not clinically indicated is achievable. Use of the DRIP tool can support safe organizational culture by encouraging staff to question the need for a PIVC to reduce or eliminate the “just in case” or idle cannula. Formal validation of DRIP across multiple settings would strengthen the evidence base underpinning PIVC decision-making.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 10","pages":"Pages 666-672"},"PeriodicalIF":2.4,"publicationDate":"2025-06-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144731051","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 : 2025-06-23DOI: 10.1016/j.jcjq.2025.06.010
Leonor Fernández MD (is Assistant Professor of Medicine, Harvard Medical School, and Department of Medicine, Beth Israel Deaconess Medical Center, Boston), Rose L. Molina MD, MPH (is Associate Professor of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, and Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston. Please address correspondence to Rose L. Molina)
{"title":"True Dialogue Across Language Difference Is Essential to Health Care Quality","authors":"Leonor Fernández MD (is Assistant Professor of Medicine, Harvard Medical School, and Department of Medicine, Beth Israel Deaconess Medical Center, Boston), Rose L. Molina MD, MPH (is Associate Professor of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, and Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston. Please address correspondence to Rose L. Molina)","doi":"10.1016/j.jcjq.2025.06.010","DOIUrl":"10.1016/j.jcjq.2025.06.010","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Pages 523-525"},"PeriodicalIF":2.4,"publicationDate":"2025-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144649501","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 : 2025-06-22DOI: 10.1016/j.jcjq.2025.06.011
Maja Ahlberg MSc (is Podiatrist, Department of Prosthetics and Orthotics, Ottobock Care, Malmö, Sweden), Ulla Hellstrand Tang Associate Professor (Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden, and Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg), Christina Petersson PhD (is Associate Professor, Department of Quality Improvement and Leadership, School of Health and Welfare, Jönköping University, and Director, Jönköping Academy for Improvement of Health and Welfare, Jönköping University. Please address correspondence to Maja Ahlberg)
Background
Diabetic foot ulcers (DFUs) are common and serious complications in diabetes. To avoid DFUs, identification of at-risk patients through a structured foot assessment leading to appropriate risk classification is essential. However, this is often lacking in clinical practice. This study aimed to identify barriers and facilitators to guideline adherence in diabetic care and to increase the proportion of diabetic patients who receive a foot risk classification.
Methods
This quantitative evaluation of improvement interventions was conducted at a department of prosthetics and orthotics (DPO) in the south of Sweden. To identify barriers and facilitators to guideline adherence and identify potential interventions, the authors used the COM-B (Capability, Opportunity, Motivation, and Behaviour) framework and qualitative interviews designed as one pilot interview and two focus group sessions with practitioners at the DPO. To improve guideline adherence, the research team implemented several interventions targeting behaviour over multiple Plan-Do-Study-Act cycles where training, education, and easily accessible material were incorporated. Eligible patients at risk of DFUs were identified by means of their medical journal. The candidates were referred to the DPO to be provided with preventive offloading devices.
Results
The frequency of patients receiving a foot examination and risk classification increased from 32.0% to 61.9%. Practitioners described the perception of increased patient safety as a facilitator of adherence to the clinical guidelines, while time limitation and insufficient knowledge were perceived as barriers.
Conclusion
To ease implementation of evidence-based guidelines in diabetes, clinics must address behavioural mechanisms related to adherence. The result adds further knowledge about enablers and barriers in clinical practice. Future research should focus on the clinical outcomes of improvement efforts in diabetes care in DPOs to avoid DFUs.
{"title":"Enhancing Clinical Guideline Adherence in Diabetic Foot Ulcer Prevention: A Case Study on Quality Improvement Interventions","authors":"Maja Ahlberg MSc (is Podiatrist, Department of Prosthetics and Orthotics, Ottobock Care, Malmö, Sweden), Ulla Hellstrand Tang Associate Professor (Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden, and Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg), Christina Petersson PhD (is Associate Professor, Department of Quality Improvement and Leadership, School of Health and Welfare, Jönköping University, and Director, Jönköping Academy for Improvement of Health and Welfare, Jönköping University. Please address correspondence to Maja Ahlberg)","doi":"10.1016/j.jcjq.2025.06.011","DOIUrl":"10.1016/j.jcjq.2025.06.011","url":null,"abstract":"<div><h3>Background</h3><div>Diabetic foot ulcers (DFUs) are common and serious complications in diabetes. To avoid DFUs, identification of at-risk patients through a structured foot assessment leading to appropriate risk classification is essential. However, this is often lacking in clinical practice. This study aimed to identify barriers and facilitators to guideline adherence in diabetic care and to increase the proportion of diabetic patients who receive a foot risk classification.</div></div><div><h3>Methods</h3><div>This quantitative evaluation of improvement interventions was conducted at a department of prosthetics and orthotics (DPO) in the south of Sweden. To identify barriers and facilitators to guideline adherence and identify potential interventions, the authors used the COM-B (Capability, Opportunity, Motivation, and Behaviour) framework and qualitative interviews designed as one pilot interview and two focus group sessions with practitioners at the DPO. To improve guideline adherence, the research team implemented several interventions targeting behaviour over multiple Plan-Do-Study-Act cycles where training, education, and easily accessible material were incorporated. Eligible patients at risk of DFUs were identified by means of their medical journal. The candidates were referred to the DPO to be provided with preventive offloading devices.</div></div><div><h3>Results</h3><div>The frequency of patients receiving a foot examination and risk classification increased from 32.0% to 61.9%. Practitioners described the perception of increased patient safety as a facilitator of adherence to the clinical guidelines, while time limitation and insufficient knowledge were perceived as barriers.</div></div><div><h3>Conclusion</h3><div>To ease implementation of evidence-based guidelines in diabetes, clinics must address behavioural mechanisms related to adherence. The result adds further knowledge about enablers and barriers in clinical practice. Future research should focus on the clinical outcomes of improvement efforts in diabetes care in DPOs to avoid DFUs.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 10","pages":"Pages 642-651"},"PeriodicalIF":2.4,"publicationDate":"2025-06-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144812019","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 : 2025-06-20DOI: 10.1016/j.jcjq.2025.06.009
Autumn Fiester PhD (is Director, Penn Program in Clinical Conflict Management, and Associate Professor, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania. Please address correspondence to Autumn Fiester)
{"title":"Mediating Clinical Conflict: An Expanded Role for Patient Relations Offices","authors":"Autumn Fiester PhD (is Director, Penn Program in Clinical Conflict Management, and Associate Professor, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania. Please address correspondence to Autumn Fiester)","doi":"10.1016/j.jcjq.2025.06.009","DOIUrl":"10.1016/j.jcjq.2025.06.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 11","pages":"Pages 733-736"},"PeriodicalIF":2.4,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717926","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 : 2025-06-20DOI: 10.1016/j.jcjq.2025.06.002
Lynn Shesser MBA, MSN, RN (is Quality Improvement Coordinator, Children’s Hospital of Philadelphia Home Care.), John Tamasitis RRT, NPS (is Former Clinical Manager, Respiratory Services, Children’s Hospital of Philadelphia Home Care.), John Chuo MD, MS, IA (is Professor of Clinical Pediatrics, Perelman School of Medicine, University of Pennsylvania, and Quality Officer for Neonatal Network, Children’s Hospital of Philadelphia. Please address correspondence to Lynn Shesser)
Background
Children’s Hospital of Philadelphia’s Home Care respiratory therapy patient population becomes more acute and resource-intense each year. The organization's trach/vent patients have numerous clinical and equipment needs requiring complex home respiratory management. To conserve respiratory therapy resources, a remote patient management (RPM) program was integrated into the current respiratory services care model by introducing innovative technology to monitor patient data remotely. The authors expected this to reduce the number of home visits defined in the established program while maintaining safe, high-quality care. The goal was a reduction of 20%.
Methods
Biweekly, respiratory therapists (RTs) reviewed electronic health records and equipment downloads for specific patients and contacted them to assess their clinical status. RTs documented findings, planned interventions, communicated with interdisciplinary teams, and determined follow-up. Home and video contacts remained options for concerns. At minimum, RTs assessed patients in homes every three months. Chart reviews and safety rounds supported quality assessment.
Results
Results revealed a 38.7% reduction in home visits compared to the prior year and 59.6% reduction in home visits from pre–COVID-19 baseline data, with several instances of special cause variation observed on statistical process control analysis (p < 0.05). The authors found a 21.01% reduction in on-call volume for ventilator-related issues (p = 0.2) and a 5.8% increase in patient’s status changing to lower acuity (p = 0.2); neither was statistically significant due to low sample size. Results showed time and mileage savings, improved communication with interdisciplinary teams and families, improved RT quality of life, active ventilator weaning for relevant patients, and potential prevention of hospital admissions.
Conclusion
The program delivered innovation to an established care model, providing resource conservation, financial savings, and patient and staff satisfaction, and exceeded its goal.
{"title":"A Remote Patient Management Care Model for Pediatric Home Care Ventilator Patients Conserves Resources: A Quality Improvement Initiative","authors":"Lynn Shesser MBA, MSN, RN (is Quality Improvement Coordinator, Children’s Hospital of Philadelphia Home Care.), John Tamasitis RRT, NPS (is Former Clinical Manager, Respiratory Services, Children’s Hospital of Philadelphia Home Care.), John Chuo MD, MS, IA (is Professor of Clinical Pediatrics, Perelman School of Medicine, University of Pennsylvania, and Quality Officer for Neonatal Network, Children’s Hospital of Philadelphia. Please address correspondence to Lynn Shesser)","doi":"10.1016/j.jcjq.2025.06.002","DOIUrl":"10.1016/j.jcjq.2025.06.002","url":null,"abstract":"<div><h3>Background</h3><div>Children’s Hospital of Philadelphia’s Home Care respiratory therapy patient population becomes more acute and resource-intense each year. The organization's trach/vent patients have numerous clinical and equipment needs requiring complex home respiratory management. To conserve respiratory therapy resources, a remote patient management (RPM) program was integrated into the current respiratory services care model by introducing innovative technology to monitor patient data remotely. The authors expected this to reduce the number of home visits defined in the established program while maintaining safe, high-quality care. The goal was a reduction of 20%.</div></div><div><h3>Methods</h3><div>Biweekly, respiratory therapists (RTs) reviewed electronic health records and equipment downloads for specific patients and contacted them to assess their clinical status. RTs documented findings, planned interventions, communicated with interdisciplinary teams, and determined follow-up. Home and video contacts remained options for concerns. At minimum, RTs assessed patients in homes every three months. Chart reviews and safety rounds supported quality assessment.</div></div><div><h3>Results</h3><div>Results revealed a 38.7% reduction in home visits compared to the prior year and 59.6% reduction in home visits from pre–COVID-19 baseline data, with several instances of special cause variation observed on statistical process control analysis (<em>p</em> < 0.05). The authors found a 21.01% reduction in on-call volume for ventilator-related issues (<em>p</em> = 0.2) and a 5.8% increase in patient’s status changing to lower acuity (<em>p</em> = 0.2); neither was statistically significant due to low sample size. Results showed time and mileage savings, improved communication with interdisciplinary teams and families, improved RT quality of life, active ventilator weaning for relevant patients, and potential prevention of hospital admissions.</div></div><div><h3>Conclusion</h3><div>The program delivered innovation to an established care model, providing resource conservation, financial savings, and patient and staff satisfaction, and exceeded its goal.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Pages 566-573"},"PeriodicalIF":2.4,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144768662","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 : 2025-06-18DOI: 10.1016/j.jcjq.2025.06.008
Julie Dickinson JM, MBA, BSN, RN, LNCC, CPHRM (is System Director, Risk Management, Hartford HealthCare, Hartford, Connecticut.), Sebastian Placide MD (was Chief Resident in Quality Improvement and Patient Safety for Internal Medicine, Academic Year 2023–2024, VA [US Department of Veterans Affairs] Connecticut Healthcare System and Yale School of Medicine, and is Fellow in Cardiovascular Medicine, NewYork Presbyterian / Weill Cornell Medical Center.), Samantha Magier MD, MEng (was Chief Resident in Quality Improvement and Patient Safety for Internal Medicine, Academic Year 2022–2023, VA Connecticut Healthcare System and Yale School of Medicine, and is Clinical Research Fellow PGY6, Division of Gastroenterology, Hepatology and Endoscopy, Brigham & Women’s Hospital / Harvard Medical School.), Naseema B. Merchant MD (is Associate Professor, Department of Medicine, Yale School of Medicine, and Program Director, Chief Residency in Quality Improvement and Patient Safety in Internal Medicine, VA Connecticut Healthcare System. Please address correspondence to Julie Dickinson)
Background
While providing learning from adverse events, traditional morbidity and mortality conferences may not consistently discuss systems, action items, and execution plans, or engage interprofessional audiences to address adverse events. The aim of this study was to design a space to learn from adverse events and, through engaging diverse staff, develop systems-oriented action items, establish mechanisms to follow through on these items, and close the loop with staff on system improvements.
Methods
A planning group designed a quarterly conference in which involved staff review an adverse event with an interdisciplinary, interdepartmental audience. Through interactive discussion, attendees identify root causes and potential system-level solutions. Actionable solutions are implemented and communicated at the next conference. Attendee surveys were conducted to gauge the perceived impact of the conference series on safety culture. The monthly average of submitted safety reports was evaluated as a surrogate safety culture marker.
Results
Conference attendance grew by 157.5%. Participants reported increased comfort in raising concerns (from 84.0% to 100.0%), improved interprofessional teamwork (from 84.0% to 100.0%), unit-based shifts to a learning culture (from 64.0% to 93.4%), positive clinical area changes (from 52.0% to 90.0%), and positive health system changes (from 84.0% to 96.7%). The average number of monthly safety reports increased by 17.0%.
Conclusion
The morbidity, mortality, and improvement conference demonstrated improvements in reported safety attitudes, interdisciplinary collaboration, system design, learning culture, psychological safety, and safety reporting. This interdisciplinary, interdepartmental, system-focused, interactive conference with closed-loop communication is an effective tool for cultivating trust in safety culture and transforming staff into safety ambassadors and change agents.
{"title":"The Morbidity, Mortality, and Improvement Conference: An Innovative, Action-Oriented Learning Space","authors":"Julie Dickinson JM, MBA, BSN, RN, LNCC, CPHRM (is System Director, Risk Management, Hartford HealthCare, Hartford, Connecticut.), Sebastian Placide MD (was Chief Resident in Quality Improvement and Patient Safety for Internal Medicine, Academic Year 2023–2024, VA [US Department of Veterans Affairs] Connecticut Healthcare System and Yale School of Medicine, and is Fellow in Cardiovascular Medicine, NewYork Presbyterian / Weill Cornell Medical Center.), Samantha Magier MD, MEng (was Chief Resident in Quality Improvement and Patient Safety for Internal Medicine, Academic Year 2022–2023, VA Connecticut Healthcare System and Yale School of Medicine, and is Clinical Research Fellow PGY6, Division of Gastroenterology, Hepatology and Endoscopy, Brigham & Women’s Hospital / Harvard Medical School.), Naseema B. Merchant MD (is Associate Professor, Department of Medicine, Yale School of Medicine, and Program Director, Chief Residency in Quality Improvement and Patient Safety in Internal Medicine, VA Connecticut Healthcare System. Please address correspondence to Julie Dickinson)","doi":"10.1016/j.jcjq.2025.06.008","DOIUrl":"10.1016/j.jcjq.2025.06.008","url":null,"abstract":"<div><h3>Background</h3><div>While providing learning from adverse events, traditional morbidity and mortality conferences may not consistently discuss systems, action items, and execution plans, or engage interprofessional audiences to address adverse events. The aim of this study was to design a space to learn from adverse events and, through engaging diverse staff, develop systems-oriented action items, establish mechanisms to follow through on these items, and close the loop with staff on system improvements.</div></div><div><h3>Methods</h3><div>A planning group designed a quarterly conference in which involved staff review an adverse event with an interdisciplinary, interdepartmental audience. Through interactive discussion, attendees identify root causes and potential system-level solutions. Actionable solutions are implemented and communicated at the next conference. Attendee surveys were conducted to gauge the perceived impact of the conference series on safety culture. The monthly average of submitted safety reports was evaluated as a surrogate safety culture marker.</div></div><div><h3>Results</h3><div>Conference attendance grew by 157.5%. Participants reported increased comfort in raising concerns (from 84.0% to 100.0%), improved interprofessional teamwork (from 84.0% to 100.0%), unit-based shifts to a learning culture (from 64.0% to 93.4%), positive clinical area changes (from 52.0% to 90.0%), and positive health system changes (from 84.0% to 96.7%). The average number of monthly safety reports increased by 17.0%.</div></div><div><h3>Conclusion</h3><div>The morbidity, mortality, and improvement conference demonstrated improvements in reported safety attitudes, interdisciplinary collaboration, system design, learning culture, psychological safety, and safety reporting. This interdisciplinary, interdepartmental, system-focused, interactive conference with closed-loop communication is an effective tool for cultivating trust in safety culture and transforming staff into safety ambassadors and change agents.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 11","pages":"Pages 719-726"},"PeriodicalIF":2.4,"publicationDate":"2025-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717867","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 : 2025-06-17DOI: 10.1016/j.jcjq.2025.06.007
Helen Jingshu Jin MSc (is Medical Student, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada), Tsan-Hua Tung PhD (is Department of Surgery, London Health Sciences Centre, London, Ontario), Sydney Selznick MD (is Resident Physician, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery, London Health Sciences Centre), Christine Cotton RN (is Patient Blood Management Program Coordinator, Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre), Madeline Lemke MD, MSc (is General Surgery Resident, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery, London Health Sciences Centre), Lily J. Park MD, MSc (is General Surgery Resident, Department of Surgery, McMaster University), Christopher C. Harle FRCA, FRCP (is Associate Professor, Schulich School of Medicine and Dentistry, and Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre), Bradley Moffat MD, MSc, MSc(QI), FRCSC, FACS (is Assistant Professor, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery, London Health Sciences Centre), Patrick Colquhoun MD, MSc, FRCSC, FACS, FASCRS (is Professor, Schulich School of Medicine and Dentistry, Western University, and Departments of Surgery and Oncology, London Health Sciences Centre), Terry Murray Zwiep MD, MSc, FRCSC (is Assistant Professor, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery London Health Sciences Centre. Please address correspondence to Terry Murray Zwiep)
Introduction
Preoperative anemia for patients undergoing major surgery is associated with increased postoperative morbidity and mortality, including increased requirement for perioperative blood transfusion, length of hospital stay, in-hospital mortality, and ICU admissions. In this quality improvement initiative, the authors describe measures implemented to promote preoperative anemia screening rates and increase uptake in hemoglobin optimizing interventions, with the goal of decreasing perioperative blood transfusion rates.
Methods
Change ideas implemented included establishing a new relationship between the Division of General Surgery and the center’s established Patient Blood Management (PBM) program; amending the center’s electronic health record to include prebuilt order sets for anemia screening bloodwork, PBM referrals, and oral iron prescriptions; modifying surgical consent packages to include anemia screening questions; and providing education to relevant care team members.
Results
A total of 1,444 patients were included. PBM referrals for anemic patients were increased to 24.6% from 0%. In patients with anemia (n = 754), preoperative treatment was independently associated with a decrease in perioperative blood transfusion (odds ratio 0.42, p = 0.007). Patients connected with the PBM program had decreased lengths of hospital stay (6.6 vs 9.7 days, p = 0.01), admissions to the ICU (1.1% vs 6.7%, p = 0.03), and in-hospital mortality (0% vs 4.3%, p = 0.04) compared to unreferred anemic patients.
Conclusion
The interventions described were successful in decreasing the perioperative blood transfusion rates and improving postoperative outcomes for anemic patients undergoing major surgery. The initiatives were easily incorporated into the existing surgical workflow and can be expanded into other centers and surgical fields.
{"title":"Improving the Treatment of Preoperative Anemia in Colorectal and Hepato-Pancreato-Biliary Patients: A Quality Improvement Initiative","authors":"Helen Jingshu Jin MSc (is Medical Student, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada), Tsan-Hua Tung PhD (is Department of Surgery, London Health Sciences Centre, London, Ontario), Sydney Selznick MD (is Resident Physician, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery, London Health Sciences Centre), Christine Cotton RN (is Patient Blood Management Program Coordinator, Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre), Madeline Lemke MD, MSc (is General Surgery Resident, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery, London Health Sciences Centre), Lily J. Park MD, MSc (is General Surgery Resident, Department of Surgery, McMaster University), Christopher C. Harle FRCA, FRCP (is Associate Professor, Schulich School of Medicine and Dentistry, and Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre), Bradley Moffat MD, MSc, MSc(QI), FRCSC, FACS (is Assistant Professor, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery, London Health Sciences Centre), Patrick Colquhoun MD, MSc, FRCSC, FACS, FASCRS (is Professor, Schulich School of Medicine and Dentistry, Western University, and Departments of Surgery and Oncology, London Health Sciences Centre), Terry Murray Zwiep MD, MSc, FRCSC (is Assistant Professor, Schulich School of Medicine and Dentistry, Western University, and Department of Surgery London Health Sciences Centre. Please address correspondence to Terry Murray Zwiep)","doi":"10.1016/j.jcjq.2025.06.007","DOIUrl":"10.1016/j.jcjq.2025.06.007","url":null,"abstract":"<div><h3>Introduction</h3><div>Preoperative anemia for patients undergoing major surgery is associated with increased postoperative morbidity and mortality, including increased requirement for perioperative blood transfusion, length of hospital stay, in-hospital mortality, and ICU admissions. In this quality improvement initiative, the authors describe measures implemented to promote preoperative anemia screening rates and increase uptake in hemoglobin optimizing interventions, with the goal of decreasing perioperative blood transfusion rates.</div></div><div><h3>Methods</h3><div>Change ideas implemented included establishing a new relationship between the Division of General Surgery and the center’s established Patient Blood Management (PBM) program; amending the center’s electronic health record to include prebuilt order sets for anemia screening bloodwork, PBM referrals, and oral iron prescriptions; modifying surgical consent packages to include anemia screening questions; and providing education to relevant care team members.</div></div><div><h3>Results</h3><div>A total of 1,444 patients were included. PBM referrals for anemic patients were increased to 24.6% from 0%. In patients with anemia (<em>n</em> = 754), preoperative treatment was independently associated with a decrease in perioperative blood transfusion (odds ratio 0.42, <em>p</em> = 0.007). Patients connected with the PBM program had decreased lengths of hospital stay (6.6 vs 9.7 days, <em>p</em> = 0.01), admissions to the ICU (1.1% vs 6.7%, p = 0.03), and in-hospital mortality (0% vs 4.3%, <em>p</em> = 0.04) compared to unreferred anemic patients.</div></div><div><h3>Conclusion</h3><div>The interventions described were successful in decreasing the perioperative blood transfusion rates and improving postoperative outcomes for anemic patients undergoing major surgery. The initiatives were easily incorporated into the existing surgical workflow and can be expanded into other centers and surgical fields.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 10","pages":"Pages 652-658"},"PeriodicalIF":2.4,"publicationDate":"2025-06-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144731050","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 : 2025-06-13DOI: 10.1016/j.jcjq.2025.06.005
Jessica C. Schoen MD, MS (is Emergency Medicine Physician, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, and Mayo Clinic Health System, Minnesota), Janee M. Klipfel RN, MS (is Patient Safety Manager, Department of Nursing, Mayo Clinic, Rochester), Shelley M. Wolfe EdD, RN, CHSE, NPD-BC (is Nursing Education Specialist, Department of Nursing, Mayo Clinic, Rochester), Valerie D. Willis MSN, RN, CHSE (is Nursing Education Specialist, Department of Nursing, Mayo Clinic, Rochester), Vanessa E. Torbenson MD (is Obstetrician/Gynecologist, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester), Jason J. DeWitt MD (is Obstetrician/Gynecologist, Department of Obstetrics and Gynecology, Mayo Clinic Health System, Minnesota), Jennifer L. Fang MD, MS (is Neonatologist, Division of Neonatal Medicine, Mayo Clinic, Rochester), Regan N. Theiler MD, PhD (is Obstetrician/Gynecologist, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester. Please address correspondence to Jessica C. Schoen)
Background
To meet Joint Commission maternal safety standards and facilitate the implementation of acute care obstetrics telemedicine (TeleOB) consultation services throughout one health system, the authors developed a novel in situ simulation framework called STEPS: Simulation for Targeted Education, Process improvement, and Systems integration. STEPS addresses education, process improvement, and systems integration objectives within each simulation scenario, a three-in-one approach to in situ simulation that has not been previously described.
Methods
The STEPS framework was used to design and implement multidisciplinary in situ simulations in six emergency departments and four labor and delivery units in two states. Simulations and debriefs were facilitated by simulation education–trained faculty. Opportunities for improvement (OFIs) were addressed by appropriate leadership teams. Participants provided feedback via a voluntary survey after each simulation session.
Results
A total of 136 OFIs were identified. Many OFIs were observed in more than one simulation session or across multiple sites, but 33 were distinct (9 distinct educational OFIs, 16 distinct process improvement OFIs, and 8 distinct systems integration OFIs). OFIs were assigned to appropriate personnel to design and implement mitigation strategies. Simulation faculty followed up with site leadership about two weeks after each simulation session to provide feedback and review the status of mitigation efforts. Of 162 participants, 91 (56.2%) completed the post-session survey. Of those who responded, 96.7% reported increased confidence in managing similar cases in their own practice. Many also noted improved familiarity with telemedicine resources and workflows.
Conclusion
The STEPS approach is a novel and effective way to simultaneously meet education, process improvement, and systems integration objectives in each simulation scenario and across a large health system.
{"title":"Simulation for Targeted Education, Process Improvement, and Systems Integration (STEPS): A Novel Approach to Health Care Quality Improvement Using In Situ Simulation","authors":"Jessica C. Schoen MD, MS (is Emergency Medicine Physician, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, and Mayo Clinic Health System, Minnesota), Janee M. Klipfel RN, MS (is Patient Safety Manager, Department of Nursing, Mayo Clinic, Rochester), Shelley M. Wolfe EdD, RN, CHSE, NPD-BC (is Nursing Education Specialist, Department of Nursing, Mayo Clinic, Rochester), Valerie D. Willis MSN, RN, CHSE (is Nursing Education Specialist, Department of Nursing, Mayo Clinic, Rochester), Vanessa E. Torbenson MD (is Obstetrician/Gynecologist, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester), Jason J. DeWitt MD (is Obstetrician/Gynecologist, Department of Obstetrics and Gynecology, Mayo Clinic Health System, Minnesota), Jennifer L. Fang MD, MS (is Neonatologist, Division of Neonatal Medicine, Mayo Clinic, Rochester), Regan N. Theiler MD, PhD (is Obstetrician/Gynecologist, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester. Please address correspondence to Jessica C. Schoen)","doi":"10.1016/j.jcjq.2025.06.005","DOIUrl":"10.1016/j.jcjq.2025.06.005","url":null,"abstract":"<div><h3>Background</h3><div>To meet Joint Commission maternal safety standards and facilitate the implementation of acute care obstetrics telemedicine (TeleOB) consultation services throughout one health system, the authors developed a novel in situ simulation framework called STEPS: Simulation for Targeted Education, Process improvement, and Systems integration. STEPS addresses education, process improvement, and systems integration objectives within each simulation scenario, a three-in-one approach to in situ simulation that has not been previously described.</div></div><div><h3>Methods</h3><div>The STEPS framework was used to design and implement multidisciplinary in situ simulations in six emergency departments and four labor and delivery units in two states. Simulations and debriefs were facilitated by simulation education–trained faculty. Opportunities for improvement (OFIs) were addressed by appropriate leadership teams. Participants provided feedback via a voluntary survey after each simulation session.</div></div><div><h3>Results</h3><div>A total of 136 OFIs were identified. Many OFIs were observed in more than one simulation session or across multiple sites, but 33 were distinct (9 distinct educational OFIs, 16 distinct process improvement OFIs, and 8 distinct systems integration OFIs). OFIs were assigned to appropriate personnel to design and implement mitigation strategies. Simulation faculty followed up with site leadership about two weeks after each simulation session to provide feedback and review the status of mitigation efforts. Of 162 participants, 91 (56.2%) completed the post-session survey. Of those who responded, 96.7% reported increased confidence in managing similar cases in their own practice. Many also noted improved familiarity with telemedicine resources and workflows.</div></div><div><h3>Conclusion</h3><div>The STEPS approach is a novel and effective way to simultaneously meet education, process improvement, and systems integration objectives in each simulation scenario and across a large health system.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 10","pages":"Pages 609-620"},"PeriodicalIF":2.4,"publicationDate":"2025-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717866","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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