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- Culture of Safety 1
- Error Reporting and Analysis 2
- Legal and Policy Approaches 2
- Quality Improvement Strategies
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 2
- Medication Safety 1
- Surgical Complications
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Journal Article > Review
Shah RK, Roberson DW, Healy GB. Curr Opin Otolaryngol Head Neck Surg. 2006;14:164-169.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Journal Article > Study
Berry SA, Doll MC, McKinley KE, Casale AS, Bothe A Jr. Qual Saf Health Care. 2009;18:360-368.
This study describes the use of a continuous quality improvement intervention with a rigorous data analysis and feedback component to improve the quality of care provided to patients undergoing coronary artery bypass surgery.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
America's hospitals continued to improve the quality of care they provide for myocardial infarction, congestive heart failure, pneumonia, and surgical care, according to the newest report from The Joint Commission. Compared to the prior report published in 2007, hospitals increased their provision of evidence-based treatments across all four disease processes. In particular, significant improvements were achieved in use of measures to prevent surgical site infections. While the prior report provided data on adherence to the National Patient Safety Goals, these measures were not discussed in the current report.
Journal Article > Study
Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit.
Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010:36;252-260.
Efforts to improve safety culture within an institution may be limited by the fact that hospital units may vary widely in their perception of safety. The comprehensive unit-based safety program (CUSP) focuses on improving important determinants of safety culture—teamwork, management involvement, and reporting and learning from errors—by engaging staff at all levels in a continuous quality improvement process. The specific CUSP interventions in this study, conducted in a surgical inpatient unit at an academic hospital, included implementation of a daily goals sheet, geographic localization of patients, and integration of nurses into physicians' daily rounds. The CUSP resulted in a significant and sustained improvement in 6 of 7 safety culture domains. The study's senior author, Dr. Pronovost, recently published a book on his trailblazing patient safety career.
Journal Article > Commentary
Norton EK, Martin C, Micheli AJ. AORN J. 2012;1:109-121.
Describing an initiative to reduce count discrepancies in the operating room, this commentary found that it had sustainable positive impact.