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Quality Improvement Strategies
- Audit and Feedback
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Search results for "Audit and Feedback"
Journal Article > Study
Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
The term never event was originally coined to describe rare, devastating, and preventable events like wrong-site surgery or fatal medication errors. This definition has expanded over time to include a variety of serious adverse events; for some of them (i.e., certain health care–associated infections), the Centers for Medicare and Medicaid Services denies additional reimbursement. This article sought to determine if eight never events (mostly infectious complications of surgery) are truly preventable, by examining whether baseline patient characteristics could predict which patients would experience a never event. The authors found that incidence of most of these complications could be predicted on the basis of preexisting conditions or the specific surgical procedure performed, calling into question whether these events are truly preventable. This study exemplifies research into the "basic science" of patient safety; a prior commentary called for studies focusing on identifying truly preventable harm and developing accurate, reliable measurement standards.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.
Journal Article > Study
A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.
Krimsky WS, Mroz IB, McIlwaine JK, et al. Qual Saf Health Care. 2009;18:74-80.
Evaluating the impact of quality and safety interventions is an evolving science. While some have argued for a new paradigm in the field, others have advocated for standards similar to clinical trials. This study developed a comprehensive approach and model to increase prophylaxis against venous thromboembolic disease, ventilator-associated pneumonia, and stress ulcers in a single intensive care unit. The model included adoption of tools that promoted team communication, prompts to providers to address the evidence-based measures on a daily basis, and a data wall to provide real-time feedback. The authors provide a detailed description of their efforts that achieved near 100% target goals and advocate for this approach in creating successful microsystems that benefit from their refined Plan-Do-Study-Act methodology.