The Joint Commission journal on quality improvement最新文献

Effects of Hydroxyurea Treatment on Haemolysis in Patients with Sickle Cell Disease at Muhimbili National Hospital, Tanzania. 羟基脲治疗对坦桑尼亚 Muhimbili 国立医院镰状细胞病患者溶血的影响。

The Joint Commission journal on quality improvement

Pub Date : 2021-08-31 Epub Date: 2021-08-15 DOI: 10.4314/tjs.v47i3.25

Azra Gangji, Upendo Masamu, Josephine Mgaya, Joyce Ndunguru, Agnes Jonathan, Irene Kida Minja, Julie Makani, Emmanuel Balandya, Paschal Ruggajo, Siana Nkya

Tanzania is one of the countries with a high burden of sickle cell disease (SCD). Haemolytic anaemia is a clinical feature of SCD, and has been linked to major complications leading to morbidity and mortality. Treatment with hydroxyurea (HU) has shown to induce foetal haemoglobin (HbF) which in turn decreases haemolysis in patients. This study aimed to investigate the effects of HU on haemolysis in SCD patients attending Muhimbili National Hospital, Tanzania by comparing their haemolytic parameters before and after therapy. Patients meeting the criteria were initiated on HU therapy for 3 months. Two haemolytic biomarkers: unconjugated plasma bilirubin levels and absolute reticulocyte counts were measured from patients' blood samples at baseline and after 3 months of HU therapy and compared. Both absolute reticulocyte counts and indirect plasma bilirubin levels significantly declined after HU therapy. Median (IQR) plasma unconjugated bilirubin levels dropped significantly from 20.3 (12.7-34.4) μmol/L to 14.5 (9.6-24.1) μmol/L (p < 0.001) and mean (SD) absolute reticulocyte counts dropped significantly from 0.29 (0.1) × 10⁹/L to 0.17 (0.1) × 10⁹/L (p < 0.001) after therapy, thus, a decline in both haemolytic biomarkers after treatment was observed. This study found a potential for use of HU therapy in managing SCD patients in our settings evidenced by improvements in their haemolytic parameters. Clinical trials with a lager sample size conducted for a longer time period would be beneficial in guiding towards the inclusion of HU in treatment protocols for the Tanzanian population.

坦桑尼亚是镰状细胞病（SCD）发病率较高的国家之一。溶血性贫血是 SCD 的临床特征之一，与导致发病和死亡的主要并发症有关。羟基脲（HU）治疗可诱导胎儿血红蛋白（HbF），从而减少患者溶血。本研究旨在通过比较坦桑尼亚 Muhimbili 国立医院 SCD 患者治疗前后的溶血参数，研究 HU 对患者溶血的影响。符合标准的患者开始接受为期 3 个月的 HU 治疗。对患者基线和接受 HU 治疗 3 个月后的血样中的两种溶血生物标志物：未结合血浆胆红素水平和网织红细胞绝对计数进行了测量和比较。接受 HU 治疗后，网织红细胞绝对计数和间接血浆胆红素水平均显著下降。中位数（IQR）血浆非结合胆红素水平在治疗后从 20.3 (12.7-34.4) μmol/L 显著降至 14.5 (9.6-24.1) μmol/L (p < 0.001)，平均值（SD）绝对网织红细胞计数在治疗后从 0.29 (0.1) × 109/L 显著降至 0.17 (0.1) × 109/L (p < 0.001)，因此在治疗后观察到这两种溶血性生物标志物均有所下降。这项研究发现，在我们的环境中，HU疗法在管理SCD患者方面具有潜力，溶血指标的改善就是证明。在较长时间内进行的样本量较大的临床试验将有助于指导将 HU 纳入坦桑尼亚人群的治疗方案。

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引用次数: 0

To Our Readers 致读者

The Joint Commission journal on quality improvement

Pub Date : 2015-01-01 DOI: 10.1016/S1070-3241(16)30009-8

Steven Berman (Editor-in-Chief)

引用次数: 0

System Innovation: Concord Hospital 制度创新:协和医院

The Joint Commission journal on quality improvement

Pub Date : 2002-12-01 DOI: 10.1016/S1070-3241(02)28072-4

Paul N. Uhlig MD, MPA (Associate Professor of Surgery), Jeffrey Brown MEd, Anne K. Nason MS, ARNP (Cardiac Services Nurse Practitioner), Addie Camelio BSW (Social Worker), Elise Kendall RPh (Staff Pharmacist)

Background

The Cardiac Surgery Program at Concord Hospital (Concord, NH) restructured clinical teamwork for improved safety and effectiveness on the basis of theory and practice from human factors science, aviation safety, and high-reliability organization theory. A team-based, collaborative rounds process—the Concord Collaborative Care Model—that involved use of a structured communications protocol was conducted daily at each patient’s bedside.

Methods

The entire care team agreed to meet at the same time each day (8:45 am to 9:30 am) to share information and develop a plan of care for each patient, with patient and family members as active participants. The cardiac surgery team developed a structured communications protocol adapted from human factors science. To provide a forum for discussion of team goals and progress and to address system-level concerns, a biweekly system rounds process was established.

Results

Following implementation of collaborative rounds, mortality of Concord Hospital’s cardiac surgery patients declined significantly from expected rates. Satisfaction rates of open heart patients scores were consistently in the 97th–99th percentile nationally. A quality of work life survey indicated that in every category, providers expressed greater satisfaction with the collaborative care process than with the traditional rounds process. Practice patterns in the Cardiac Surgery Program at Concord Hospital have changed to a much more collaborative and participatory process, with improved outcomes, happier patients, and more satisfied practitioners. A culture of continuous program improvement has been implemented that continues to evolve and produce benefits.

康科德医院(Concord, NH)心脏外科项目在人因科学、航空安全和高可靠性组织理论和实践的基础上，对临床团队合作进行了重组，以提高安全性和有效性。一个以团队为基础的协作查房过程——康科德协作护理模式——每天在每个病人的床边进行，其中包括使用结构化的通信协议。方法整个护理团队约定每天在同一时间(上午8:45 ~ 9:30)开会，在患者和家属的积极参与下，分享信息并制定护理计划。心脏外科团队开发了一种基于人为因素科学的结构化通信协议。为了提供一个讨论团队目标和进展的论坛，并处理系统级的问题，建立了一个两周一次的系统轮询过程。结果协查房实施后，康科德医院心脏手术患者的死亡率明显低于预期。在全国范围内，心内直视患者的满意度评分始终保持在97 - 99个百分位数之间。一项工作生活质量调查表明，在每个类别中，提供者对协作护理过程的满意度都高于对传统查房过程的满意度。康科德医院心脏外科项目的实践模式已经转变为一个更具协作性和参与性的过程，结果有所改善，患者更快乐，从业人员更满意。一种持续的程序改进的文化已经被实施，它继续发展并产生效益。

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引用次数: 85

Advocacy: The Lexington Veterans Affairs Medical Center 倡导:列克星敦退伍军人事务医疗中心

The Joint Commission journal on quality improvement

Pub Date : 2002-12-01 DOI: 10.1016/S1070-3241(02)28069-4

Steve S. Kraman MD (Chief of Staff), Linda Cranfill (Quality Manager), Ginny Hamm JD (Staff Attorney), Toni Woodard (Patient Safety Officer)

Background

After the Veterans Affairs Medical Center (VAMC) in Lexington, Kentucky, lost two major malpractice cases in the mid-1980s, leaders started taking a more proactive approach to identifying and investigating incidents that could result in litigation. An informal risk management team met regularly to discuss litigation-prone incidents. During one in-depth review, the team learned that a medication error had caused the patient’s death. Although the family would probably never have found out, the team decided to honestly inform the family of exactly what had happened and assist in filing for any financial settlement that might be appropriate. This decision evolved into an organizationwide full disclosure policy and procedure.

Disclosure policy and procedure

The Lexington VAMC’s policy on full disclosure includes informing patients and/or their families of adverse events known to have caused harm or injury to the patient as a result of medical error or negligence. The disclosure includes discussions of liability and also includes apology and discussion of remedy and compensation.

Results

Full disclosure is the right thing to do and the moral and ethical thing to do. Moreover, doing the right thing actually seems to have mitigated the financial repercussions of inevitable adverse events that result in injury to patients. As reported in 1999, Lexington VAMC was in the top quarter of medical centers for number of tort claims filed but was in the lowest quarter for malpractice payouts resulting from these torts.

在肯塔基州列克星敦的退伍军人事务医疗中心(VAMC)在20世纪80年代中期输掉了两起重大医疗事故案件后，领导人开始采取更积极主动的方法来识别和调查可能导致诉讼的事件。一个非正式的风险管理小组定期开会，讨论可能发生的诉讼事件。在一次深入审查中，该小组了解到，是一次用药失误导致了病人的死亡。虽然家人可能永远不会发现，但团队决定诚实地告诉家人到底发生了什么，并协助申请任何可能合适的经济解决方案。这一决定逐渐演变为组织范围内的全面披露政策和程序。披露政策和程序列克星敦VAMC的全面披露政策包括告知患者和/或其家属已知的因医疗错误或疏忽而对患者造成伤害或伤害的不良事件。披露包括责任的讨论，也包括道歉以及补救和赔偿的讨论。结果:充分披露信息是正确的做法，也是合乎道德和伦理的。此外，做正确的事情实际上似乎减轻了不可避免的不良事件对患者造成伤害的经济影响。根据1999年的报告，列克星敦VAMC在提出侵权索赔的医疗中心中名列前茅，但在因这些侵权行为而导致的医疗事故赔付方面却名列前茅。

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引用次数: 29

John M. Eisenberg Patient Safety Awards. Research: David W. Bates, MD, MSc, Brigham and Women's Hospital. Interview by Steven Berman. John M. Eisenberg患者安全奖。研究:大卫W.贝茨，医学博士，硕士，布莱根妇女医院。Steven Berman采访。

The Joint Commission journal on quality improvement

Pub Date : 2002-12-01

David W Bates

Dr Bates discusses the challenges and rewards of computerized physician order entry and other information technology applications and describes current work in improving medication safety across clinical settings.

Bates博士讨论了计算机化医嘱输入和其他信息技术应用的挑战和回报，并描述了目前在改善临床环境中用药安全方面的工作。

引用次数: 0

Research: David W. Bates, MD, MSc, Brigham and Women’s Hospital 研究:大卫W.贝茨，医学博士，硕士，布莱根妇女医院

The Joint Commission journal on quality improvement

Pub Date : 2002-12-01 DOI: 10.1016/S1070-3241(02)28070-0

Steven Berman

引用次数: 1

Individual Lifetime Achievement: Julianne M. Morath, RN, MS 个人终身成就奖:Julianne M. Morath，注册会计师，硕士

The Joint Commission journal on quality improvement

Pub Date : 2002-12-01 DOI: 10.1016/S1070-3241(02)28068-2

Julianne M. Morath RN, MS (Chief Operating Officer), Maggie Teele

Background

This article provides a brief biography of Julianne M. Morath, describes the scope and impact of her patient safety initiatives at Children’s Hospitals and Clinics in Minneapolis and St Paul, and includes an interview in which Morath responds to questions about challenges to patient safety and medical accident reduction.

Biography in brief

With a 25-year career spanning the spectrum of health care, Morath has served in leadership positions in health care organizations in Minnesota, Rhode Island, Ohio, and Georgia.

Leadership at the front line

Morath joined Children’s Hospitals and Clinics in 1999 and launched a major patient safety initiative that put Children’s on the map. Elements of the initiative included a culture of learning, patient safety action teams, open discussion of medical accidents and error, blameless reporting, and a full accident disclosure policy.

An interview with Julie Morath

As the greatest challenge to leadership ownership of the patient safety initiative, Morath cites the need to confront the myths of the medical system and to develop the awareness of the issues of patient safety. She believes that clinicians on the front lines will be convinced that patient safety isn’t “just another fad of the month” when leadership action is disciplined and aligns with what is being espoused. She advises other leaders of health care organizations interested in establishing a culture of safety to start with a personal and passionate belief that harm-free care is possible, to commit to informed action, and to identify and develop champions throughout the organization and medical staff.

这篇文章提供了Julianne M. Morath的简要传记，描述了她在明尼阿波利斯和圣保罗儿童医院和诊所的患者安全倡议的范围和影响，并包括Morath回答有关患者安全和医疗事故减少挑战的采访。在25年的医疗保健职业生涯中，Morath曾在明尼苏达州、罗德岛州、俄亥俄州和佐治亚州的医疗保健组织担任领导职务。morath于1999年加入儿童医院和诊所，并发起了一项重大的患者安全倡议，使儿童医院成为公众关注的焦点。该倡议的内容包括学习文化、患者安全行动小组、公开讨论医疗事故和错误、无可指责的报告以及全面披露事故的政策。作为对患者安全倡议的领导所有权的最大挑战，Morath指出需要面对医疗系统的神话，并培养对患者安全问题的认识。她认为，当领导的行动受到纪律约束，并与所支持的内容保持一致时，一线的临床医生将确信，患者安全不是“本月的另一个时尚”。她建议对建立安全文化感兴趣的其他卫生保健组织领导人从个人和热情的信念开始，即无伤害护理是可能的，承诺采取知情行动，并在整个组织和医务人员中确定和发展倡导者。

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引用次数: 0

System Innovation: Veterans Health Administration National Center for Patient Safety 系统创新:退伍军人健康管理局国家患者安全中心

The Joint Commission journal on quality improvement

Pub Date : 2002-12-01 DOI: 10.1016/S1070-3241(02)28071-2

Jeffrey R. Heget (Administrative Officer), James P. Bagian MD, PE (Director), Caryl Z. Lee RN, MSN (Program Manager), John W. Gosbee MD, MS (Director)

Background

In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS’s aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities.

A novel approach

To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a nonpunitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond.

Key action items and results related to RCA

NCPS’s full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive aids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

1998年，退伍军人健康管理局(VHA)创建了国家患者安全中心(NCPS)，以领导减少全系统不良事件和紧急呼叫的努力。NCPS的目标是通过制定和提供患者安全计划，并向163个退伍军人事务部设施提供标准化工具、方法和倡议，在退伍军人事务部(VA)培养安全文化。为了创建一种面向系统的患者安全方法，NCPS在航空、核电、人为因素和安全工程等领域寻找模型。核心概念包括对患者安全活动的非惩罚性方法，强调基于系统的学习，积极寻找被视为学习和调查机会的近距离呼叫，以及使用跨学科团队通过根本原因分析(RCA)过程调查近距离呼叫和不良事件。退伍军人事务部的设施和网络是自愿参与的。NCPS一直致力于开发一个既适用于退伍军人管理局，也适用于退伍军人管理局以外的项目。从1999年11月到2000年8月，RCANCPS的完整患者安全计划的关键行动项目和结果在VA系统中进行了测试和实施。项目组成部分包括一个供前线护理人员使用的RCA系统，一个用于RCA结果汇总审查的系统，信息系统软件，警报和咨询，以及认知辅助。项目实施后，nps报告高优先级事件的近距离呼叫增加了900倍，反映了VHA领导和工作人员对项目的承诺水平。

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引用次数: 48

Developing a Comprehensive Electronic Adverse Event Reporting System in an Academic Health Center 学术医疗中心不良事件综合电子报告系统之开发

The Joint Commission journal on quality improvement

Pub Date : 2002-11-01 DOI: 10.1016/S1070-3241(02)28062-1

Coleen Kivlahan MD, MPH (Associate Dean and Director of Health Improvement), William Sangster MD, Kathryn Nelson MHA, Jennifer Buddenbaum MHA (Project Coordinator), Kenneth Lobenstein JD

Background

In September 2000 University of Missouri Health Care (MUHC) conducted an assessment of patient safety activities. At least six separate data systems for reporting adverse events, with multiple conflicting paper reports, were found during this analysis. The disparate nature of these systems and their inability to be linked ensured that few systemic prevention activities were undertaken. In January 2001 an interdisciplinary team was convened with the goal of creating a comprehensive approach to patient safety reporting and resolution.

Implementation

A secure, Web-based system, the MUHC Patient Safety Network System (PSN), was created that allows staff, physicians, patients, families, and visitors to report comments, adverse events, and near-miss events from any computer in the hospital and from home, using the Internet. Anonymous reporting is an option for near-miss events. Reports are immediately available to department managers responsible for resolution; managers are alerted to the presence of a report by e-mail. As a result, a pilot study performed in two MUHC intensive care units documented dramatic reductions in resolution time using the PSN. The pilot also demonstrated an increased willingness to report by physicians and respiratory therapists. Training was accomplished in the fall of 2001, and the PSN was successfully implemented throughout the hospital on January 1, 2002.

Next steps

Implementation of the PSN has recently been extended to all ambulatory care settings. An additional component of the PSN that is being built will allow physicians to report complications.

2000年9月，密苏里大学卫生保健中心(MUHC)对患者安全活动进行了评估。在这次分析中，至少发现了6个报告不良事件的独立数据系统，其中有多个相互冲突的论文报告。由于这些系统各不相同，又无法相互联系，因此几乎没有进行有系统的预防活动。2001年1月，成立了一个跨学科小组，目的是建立一种全面的方法来报告和解决患者安全问题。实施建立了一个安全的基于web的系统，即MUHC患者安全网络系统(PSN)，该系统允许工作人员、医生、患者、家属和访客使用互联网从医院的任何一台计算机上报告评论、不良事件和险些发生的事件。匿名报告是对侥幸事件的一种选择。报告立即提供给负责解决方案的部门经理;通过电子邮件提醒管理人员报告的存在。结果，在两个MUHC重症监护病房进行的一项试点研究表明，使用PSN可以显著缩短分辨率时间。飞行员也表现出医生和呼吸治疗师报告的意愿增加。培训于2001年秋季完成，PSN于2002年1月1日在全院成功实施。PSN的实施最近已扩展到所有门诊护理机构。正在建设的PSN的另一个组成部分将允许医生报告并发症。

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引用次数: 65

Benefits of a Mobile, Point-of-Care Anticoagulation Therapy Management Program 移动、护理点抗凝治疗管理项目的好处

The Joint Commission journal on quality improvement

Pub Date : 2002-11-01 DOI: 10.1016/S1070-3241(02)28066-9

James M. Gill MD, MPH (Director), Mark K. Landis RN, BSN (Coumadin Care Center Coordinator)

Background

Current guidelines recommend anticoagulation therapy for a number of medical conditions, but this therapy also has the potential for serious complications, particularly bleeding complications. Maintenance of anticoagulation within a narrow therapeutic window usually entails frequent monitoring with a blood test called the international normalized ratio (INR). Anticoagulation therapy management (ATM) clinics lead to improvements in quality of care, in terms of improved INR control and reduced complications. This study examined the impact of a mobile multisite, office-based ATM program that operated in seven cardiology offices in all three counties in Delaware.

ATM program

The ATM program was managed by a trained nurse who rotated among all seven offices. Patients made office visits to the nurse and received patient education, point-of-care INR testing, and medication adjustment based on a physician-approved algorithm.

Methods

This retrospective cohort study compared INR levels in the year before (May 1998–Apr 1999) and the year after (Aug 1999–Jul 2000) the start of the ATM program.

Results

From the year before to the year after implementation of the ATM program, the percentage of in-range INRs increased from 40.7% to 58.5% (p < 0.001). The percentage in the modified target range also increased (50.0% to 62.9%, p < 0.001).

Discussion

This study demonstrates the positive impact of a statewide office-based ATM program. If similar programs could be implemented in other networks of specialty offices or primary care offices, they could have a significant benefit to quality of care for patients who require anticoagulation therapy.

背景:目前的指南推荐抗凝治疗许多疾病，但这种治疗也有潜在的严重并发症，特别是出血并发症。在狭窄的治疗窗口内维持抗凝通常需要频繁监测称为国际标准化比率(INR)的血液检查。抗凝治疗管理(ATM)诊所在改善INR控制和减少并发症方面提高了护理质量。这项研究考察了移动多站点、基于办公室的ATM程序的影响，该程序在特拉华州所有三个县的七个心脏病学办公室运行。自动取款机计划自动取款机计划由一名训练有素的护士管理，他在所有七个办公室轮流工作。患者到办公室拜访护士，接受患者教育、即时INR测试，并根据医生批准的算法进行药物调整。方法回顾性队列研究比较了ATM项目开始前(1998年5月- 1999年4月)和开始后(1999年8月- 2000年7月)的INR水平。结果从实施ATM计划的前一年到实施后一年，在区间内的印度卢比比例从40.7%上升到58.5% (p <0.001)。调整后的目标区间内的比例也增加了50.0%至62.9%，p <0.001)。本研究证明了在全州范围内实施以办公室为基础的ATM计划的积极影响。如果类似的项目可以在其他专科办公室或初级保健办公室的网络中实施，它们可以显著提高需要抗凝治疗的患者的护理质量。

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引用次数: 16