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The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency 使用电子同意书对英语水平有限的患者签署语言一致的手术同意书的影响
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.03.005
Karen Trang MD (is General Surgery Resident and Resident Research Fellow, Department of Surgery, University of California, San Francisco (UCSF).), Logan Pierce MD (is Assistant Clinical Professor, Department of Medicine, UCSF.), Elizabeth C. Wick MD (is Professor, and Vice Chair of Quality and Safety, Department of Surgery, UCSF. Please address correspondence to Karen Trang)

Background

Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).

Methods

The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.

Results

A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (p < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.

Conclusion

The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.

背景虽然获得专业医疗口译服务是联邦政府的规定,但外科医生报告称在知情同意过程中使用率不足。要改善这种情况,就必须了解失误的程度。电子同意书(eConsent)的采用与文件记录的改进和实践改进机会的识别有关。作者评估了从纸质同意书到电子同意书的过渡对英语水平有限(LEP)的患者提供语言一致的手术同意书的影响。方法研究期间(2023 年 2 月 8 日至 2023 年 6 月 14 日)与机构采用电子同意书之后的时间段相对应。纳入标准包括年龄在 18 周岁以上,有文件证明其首选语言为英语以外的语言,以及自行签署的电子同意书。作者评估了语言一致的口译员中介口头同意讨论记录,以及以语言一致模板提供的书面手术同意书。结果共纳入了 1,016 次针对 LEP 患者的电子同意书会诊,患者使用 49 种不同的语言,其中最常见的是西班牙语(46.5%)、中文(22.1%)和俄语(6.8%)。实施电子同意书后,语言一致的口译员中介同意书的总体记录率从 56.9% 提高到 83.9%(p <0.001),但不同手术服务和不同语言之间存在差异,表明仍有改进的余地。大多数患者(94.1%)的首选语言都有相关的书面同意书翻译模板(西班牙语、中文、俄语、阿拉伯语),他们都收到了语言一致的书面同意书。结论向电子同意书的过渡与手术中语言一致的知情同意书记录的改善有关,无论是在提供患者首选语言的书面材料方面,还是在口译员使用的记录方面,都是如此,而且还可以确定口译员使用方面需要改进的地方。
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引用次数: 0
The Joint Commission Journal on Quality and Patient Safety 50th Anniversary Article Collections: Maternal and Perinatal Care 联合委员会《质量与患者安全杂志》50周年文章集:孕产妇和围产期护理
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.05.013
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引用次数: 0
Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission 评估急诊科入院回访的结构化审查流程
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.03.010
Zoe Grabinski MD (is Assistant Professor, Ronald O. Perelman Department of Emergency Medicine and Department of Pediatrics, New York University Grossman School of Medicine.), Kar-mun Woo MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Olumide Akindutire MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Cassidy Dahn MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Lauren Nash PA (is Senior Physician Assistant, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Inna Leybell MD (is Clinical Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Yelan Wang MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Danielle Bayer MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Jordan Swartz MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Catherine Jamin MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Silas W. Smith MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and Institute for Innovations in Medical Education, New York University Grossman School of Medicine. Please address correspondence to Zoe Grabinski)

Background

Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.

Methods

The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.

Results

The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.

Conclusion

The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.

背景回顾急诊科(ED)入院后的再次就诊情况可以发现改进的机会。将健康公平视角应用于复诊,可以突出护理过渡中的潜在差异。目前还缺乏对这些评估的通用定义或切实可行的框架。作者旨在为这一质量保证(QA)流程开发一种结构化方法,并进行分层公平分析。方法作者开发了一种分类工具,用于识别潜在可预防的入院 72 小时复诊(PPRA-72),包括定向、无关、非预期或疾病进展的复诊。第二个评审小组对该工具的可靠性进行了评估。为了尽量减少无法归类的数据,还开发了一种自我报告种族/民族(R/E)和语言算法。使用皮尔逊卡方检验(Pearson chi-square)和费雪精确检验(Fisher's exact tests)对处置分布、回访率和 PPRA-72 分类进行了差异分析。审查小组在二元判定 PPRA-72 与非可预防性回访方面的一致性达到 93% (κ = 0.51)。在急诊室处置方面,R/E 和语言之间存在明显差异(p < 0.001),R/E 白人在指标就诊时入院的频率更高,而其他白人在 72 小时回访时入院的频率更高。不同种族/族裔的 72 小时内复诊率存在显著差异(p < 0.001),但不同语言的 72 小时内复诊率没有显著差异(p = 0.156),其中黑人 72 小时内复诊率最高。在 PPRA-72 比率方面,R/E(p = 0.446)和语言(p = 0.248)之间没有差异。该倡议通过信息学优化、分诊协议、医疗服务提供者反馈和教育来改进系统。这一质量保证流程能够识别出存在差异的领域,从而不断制定下一步措施,确保护理过渡中的健康公平。
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引用次数: 0
The Impact of a Novel Syringe Organizational Hub on Operating Room Workflow During a Surgical Case 新型注射器组织枢纽对手术病例中手术室工作流程的影响。
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.02.008
Harrison Sims (is Human Factors Engineering researcher, Department of Biomedical Engineering, Johns Hopkins University.), David Neyens PhD, MS, MPH (is Associate Professor, Departments of Industrial Engineering and Bioengineering, Clemson University.), Ken Catchpole PhD (is Professor and S.C. SmartState Endowed Chair in Clinical Practice and Human Factors, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), Joshua Biro PhD, MS (is Research Fellow, MedStar Health National Center for Human Factors in Healthcare, Washington, DC.), Connor Lusk PhD, MS (is Assistant Professor, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), James Abernathy III MD, MPH (is Associate Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University. Please send correspondence to Harrison Sims)
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引用次数: 0
Frontline Providers’ and Patients’ Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study 一线医护人员和患者对改善急诊科诊断安全的看法:定性研究
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.03.003
Courtney W. Mangus MD (is Clinical Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan.), Tyler G. James PhD (is Assistant Professor, Department of Family Medicine, University of Michigan.), Sarah J. Parker MPH (is Research Area Specialist, Department of Emergency Medicine, University of Michigan.), Elizabeth Duffy MPH (is Clinical Research Coordinator, Department of Emergency Medicine, University of Michigan.), P. Paul Chandanabhumma PhD, MPH (is Assistant Professor, Department of Family Medicine, University of Michigan.), Caitlin M. Cassady LMSW, LCSW (is PhD Candidate, Social Work and Anthropology Doctoral Program, Wayne State University.), Fernanda Bellolio MD, MS (is Emergency Medicine Physician and Health Sciences Researcher, Departments of Emergency Medicine and Health Science Research, Mayo Clinic, Rochester, Minnesota.), Kalyan S. Pasupathy PhD (is Professor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago.), Milisa Manojlovich PhD, RN (is Professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan.), Hardeep Singh MD, MPH (is Professor, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA (US Department of Veterans Affairs) Medical Center and Baylor College of Medicine, Houston.), Prashant Mahajan MD, MBA, MPH (is Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan. Please address correspondence to Courtney W. Mangus)

Background

Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.

Methods

Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED–Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.

Results

The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED–Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.

Conclusion

Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.

背景很少有研究描述一线医疗服务提供者和患者对如何改进急诊科(ED)诊断流程的见解,而急诊科是诊断错误的高发场所。作者旨在确定医疗服务提供者和患者对诊断过程的看法,并确定潜在的干预措施,以提高诊断安全性。访谈问题以 ED 适应美国国家科学、工程和医学院诊断流程框架为指导,探讨了参与者对 ED 诊断流程的看法,发现了漏洞,并寻求干预措施以提高诊断安全性。作者对转录的访谈进行了定性专题分析。结果研究小组根据 ED 适应框架将诊断过程中的薄弱环节和干预机会分为五个领域:(1) 团队动力和沟通(例如,转诊医生和急诊室团队之间的沟通欠佳);(2) 与患者表现相关的信息收集(例如,从患者或其看护人处获取病史;(3) 急诊室组织、系统和流程(例如,员工日程安排和交接);(4) 患者教育和自我管理(例如,急诊室出院时的患者教育);以及 (5) 电子病历和患者门户网站的使用(例如,自动将检查结果发布到患者门户网站)。作者确定了 33 项潜在干预措施,其中 17 项以医疗服务提供者为重点,16 项以患者为重点。需要对这些干预措施进行改进、实施和效果评估。
{"title":"Frontline Providers’ and Patients’ Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study","authors":"Courtney W. Mangus MD (is Clinical Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan.),&nbsp;Tyler G. James PhD (is Assistant Professor, Department of Family Medicine, University of Michigan.),&nbsp;Sarah J. Parker MPH (is Research Area Specialist, Department of Emergency Medicine, University of Michigan.),&nbsp;Elizabeth Duffy MPH (is Clinical Research Coordinator, Department of Emergency Medicine, University of Michigan.),&nbsp;P. Paul Chandanabhumma PhD, MPH (is Assistant Professor, Department of Family Medicine, University of Michigan.),&nbsp;Caitlin M. Cassady LMSW, LCSW (is PhD Candidate, Social Work and Anthropology Doctoral Program, Wayne State University.),&nbsp;Fernanda Bellolio MD, MS (is Emergency Medicine Physician and Health Sciences Researcher, Departments of Emergency Medicine and Health Science Research, Mayo Clinic, Rochester, Minnesota.),&nbsp;Kalyan S. Pasupathy PhD (is Professor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago.),&nbsp;Milisa Manojlovich PhD, RN (is Professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan.),&nbsp;Hardeep Singh MD, MPH (is Professor, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA (US Department of Veterans Affairs) Medical Center and Baylor College of Medicine, Houston.),&nbsp;Prashant Mahajan MD, MBA, MPH (is Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan. Please address correspondence to Courtney W. Mangus)","doi":"10.1016/j.jcjq.2024.03.003","DOIUrl":"10.1016/j.jcjq.2024.03.003","url":null,"abstract":"<div><h3>Background</h3><p>Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.</p></div><div><h3>Methods</h3><p>Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED–Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.</p></div><div><h3>Results</h3><p>The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED–Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.</p></div><div><h3>Conclusion</h3><p>Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 480-491"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140280474","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}
引用次数: 0
Putting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events RCA2 中的 "行动":不良事件后的干预力度分析。
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.03.012
Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.), Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.), Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.), Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.), Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)

Background

Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.

Methods

Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.

Results

In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (p < 0.0001).

Conclusion

Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.

背景:安全事件的报告和审查在美国医院中已经非常成熟,但确保实施改进患者安全的系统却不太完善:在美国医院中,安全事件的报告和审查已经非常成熟,但确保实施改革以提高患者安全的系统却不太完善:方法:从 2020 年到 2021 年,对提交给一家三级医疗学术医疗中心的多学科医院级安全事件评审会议的事件的诱因和纠正措施进行了前瞻性收集。对整改措施的完成情况进行了跟踪,直至 2023 年。作者使用美国退伍军人事务部/医疗保健改进研究所的行动层次工具,按类别和力度对纠正措施进行了回顾性编码:在对 67 个事件的分析中,确定了 15 个促成因素主题,并采取了 148 项纠正措施。在这些事件中,85.1%(57/67)有一个以上的纠正措施。在 148 项纠正措施中,84 项(56.8%)被评为弱,36 项(24.3%)为中等,15 项(10.1%)为强,13 项(8.8%)需要更多信息。完成率为 97.6%(弱纠正措施)、80.6%(中等)和 73.3%(强)(p < 0.0001):结论:安全事件通常通过多种纠正措施来解决。干预措施的力度与完成情况之间存在反比关系,力度最大的干预措施完成率最低。通过将行动强度和完成情况整合到纠正措施的跟踪中,医疗机构可以更有效地识别和解决完成最强干预措施的障碍,最终实现高可靠性。
{"title":"Putting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events","authors":"Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.),&nbsp;Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.),&nbsp;Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.),&nbsp;Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.),&nbsp;Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)","doi":"10.1016/j.jcjq.2024.03.012","DOIUrl":"10.1016/j.jcjq.2024.03.012","url":null,"abstract":"<div><h3>Background</h3><p>Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.</p></div><div><h3>Methods</h3><p>Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.</p></div><div><h3>Results</h3><p>In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (<em>p</em> &lt; 0.0001).</p></div><div><h3>Conclusion</h3><p>Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 492-499"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140870150","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}
引用次数: 0
The Challenge of Improving Patient Safety: This is Hard 提高患者安全的挑战:这很难
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.05.001
Robin R. Hemphill MD, MPH (is Chief of Staff, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. Please address correspondence to Robin Hemphill)
{"title":"The Challenge of Improving Patient Safety: This is Hard","authors":"Robin R. Hemphill MD, MPH (is Chief of Staff, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. Please address correspondence to Robin Hemphill)","doi":"10.1016/j.jcjq.2024.05.001","DOIUrl":"10.1016/j.jcjq.2024.05.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 478-479"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140921353","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}
引用次数: 0
A Simple Risk Adjustment for Hospital-Level Nulliparous, Term, Singleton, Vertex, Cesarean Delivery Rates and Its Implications for Public Reporting 对医院级别的无胎儿、足月、单胎、顶体、剖宫产率进行简单的风险调整及其对公开报告的影响
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.04.006
Benjamin D. Pollock PhD, MSPH (is Assistant Professor of Health Services Research and Senior Associate Consultant II–Research, Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida.), Leslie Carranza MD (is Quality Chair, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.), Elizabeth Braswell-Pickering MPH (is Senior Quality Informatics Analyst, Mayo Clinic, Rochester, Minnesota.), Christine M. Sing DPT, MBA (is Operations Manager, Quality & Value, Mayo Clinic, Rochester, Minnesota.), Lindsay L. Warner MD (is Anesthesiologist and Pediatric Anesthesiologist, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.), Regan N. Theiler MD, PHD (is Associate Professor, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota. Please address correspondence to Benjamin D. Pollock)

Background

The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals’ perinatal care quality through the Cesarean Birth measurement (PC-02). However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk adjustment paradigm of most publicly reported hospital quality measures. Here, the authors tested whether risk adjustment for readily documented maternal risk factors affected hospital-level NTSV-CD rates in a large health system.

Methods

Included were all consecutive NTSV pregnancies from January 2019 to April 2023 across 10 hospitals in one health system. Logistic regression, adjusting for age, obesity, diabetes, and hypertensive disorders. was used to calculate hospital-level risk-adjusted NTSV-CD rates by multiplying observed vs. expected ratios for each hospital by the systemwide unadjusted NTSV-CD rate. The authors calculated intrahospital risk differences between unadjusted and risk-adjusted rates and calculated the percentage of hospitals qualifying for different reporting status after risk adjustment using the 30% Joint Commission reporting threshold rate.

Results

Of 23,866 pregnancies, 6,550 (27.4%) had cesarean deliveries. Across 10 hospitals, the number of deliveries ranged from 393 to 7,671, with unadjusted NTSV-CD rates ranging from 21.0% to 30.5%. Risk-adjusted NTSV-CD rates ranged from 21.5% to 30.4%, with absolute intrahospital differences in risk-adjusted vs. unadjusted rates ranging from −1.33% (indicating lower rate after risk adjustment) to 3.37% (indicating higher rate after risk adjustment). Three of 10 (30.0%) hospitals qualified for different reporting statuses after risk adjustment.

Conclusion

Risk adjustment for age, obesity, diabetes, and hypertensive disorders is feasible and resulted in meaningful changes in hospital-level NTSV-CD rates with potentially impactful consequences for hospitals near The Joint Commission reporting threshold.

背景联合委员会通过剖宫产测量(PC-02)使用无子宫、足月、单胎、顶点、剖宫产率(NTSV-CD)来评估医院的围产期护理质量。然而,这些比率并没有根据产妇的健康因素进行风险调整,这使得该测量方法与大多数公开报道的医院质量测量方法的风险调整范式相悖。在此,作者测试了对容易记录的孕产妇风险因素进行风险调整是否会影响一个大型医疗系统的医院级 NTSV-CD 率。方法包括一个医疗系统中 10 家医院 2019 年 1 月至 2023 年 4 月期间所有连续的 NTSV 妊娠。将每家医院的观察比值与预期比值乘以全系统未调整的 NTSV-CD 率,利用逻辑回归计算出医院级别的风险调整 NTSV-CD 率,并对年龄、肥胖、糖尿病和高血压疾病进行了调整。作者计算了未调整率与风险调整率之间的院内风险差异,并使用联合委员会报告阈值率 30% 计算了风险调整后符合不同报告条件的医院比例。结果 在 23866 例妊娠中,6550 例(27.4%)为剖宫产。10家医院的分娩数量从393例到7671例不等,未经调整的NTSV-CD率从21.0%到30.5%不等。经风险调整后的 NTSV-CD 发生率为 21.5% 至 30.4%,经风险调整与未经调整的发生率在医院内的绝对差异为-1.33%(表明经风险调整后发生率较低)至 3.37%(表明经风险调整后发生率较高)。结论对年龄、肥胖、糖尿病和高血压疾病进行风险调整是可行的,并能使医院层面的 NTSV-CD 发生有意义的变化,对接近联合委员会报告阈值的医院具有潜在的影响。
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引用次数: 0
The Quest for Diagnostic Excellence in the Emergency Department 急诊科对卓越诊断的追求
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.05.004
Michael S. Pulia MD, PhD (is Associate Professor, Departments of Emergency Medicine and Industrial and Systems Engineering University of Wisconsin-Madison.), Dimitrios Papanagnou MD, MPH (is Professor, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia.), Pat Croskerry MD, PhD (is Professor, Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Please address correspondence to Michael S. Pulia)
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引用次数: 0
Communication After Medical Error: The Need to Measure the Patient Experience 医疗事故后的沟通:衡量患者体验的必要性。
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-06-28 DOI: 10.1016/j.jcjq.2024.06.006
Allen Kachalia MD, JD (is Senior Vice President, Patient Safety and Quality, and Director, Director, Armstrong Institute of Patient Safety and Quality; and Professor of Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore.), Carole Hemmelgarn MS, MS (is Program Director, Executive Master's Clinical Quality, Safety and Leadership, Georgetown University, and Senior Director Education, MedStar Health, Washington, DC.), Thomas H. Gallagher MD, MACP (is Executive Director, Collaborative for Accountability and Improvement, and Associate Chair of Medicine for Patient Care, Quality, Safety, and Value, UW Medicine, Seattle; and Professor of Medicine and Professor of Bioethics & Humanities, University of Washington. Please address correspondence to Allen Kachalia)
{"title":"Communication After Medical Error: The Need to Measure the Patient Experience","authors":"Allen Kachalia MD, JD (is Senior Vice President, Patient Safety and Quality, and Director, Director, Armstrong Institute of Patient Safety and Quality; and Professor of Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore.),&nbsp;Carole Hemmelgarn MS, MS (is Program Director, Executive Master's Clinical Quality, Safety and Leadership, Georgetown University, and Senior Director Education, MedStar Health, Washington, DC.),&nbsp;Thomas H. Gallagher MD, MACP (is Executive Director, Collaborative for Accountability and Improvement, and Associate Chair of Medicine for Patient Care, Quality, Safety, and Value, UW Medicine, Seattle; and Professor of Medicine and Professor of Bioethics & Humanities, University of Washington. Please address correspondence to Allen Kachalia)","doi":"10.1016/j.jcjq.2024.06.006","DOIUrl":"10.1016/j.jcjq.2024.06.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 618-619"},"PeriodicalIF":2.3,"publicationDate":"2024-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626824","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}
引用次数: 0
期刊
Joint Commission journal on quality and patient safety
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