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- Communication Improvement 1
- Culture of Safety 4
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- Error Reporting and Analysis 3
- Legal and Policy Approaches
- Quality Improvement Strategies
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- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 2
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications 1
Search results for "United States of America"
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- United States of America
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Oakbrook Terrace, IL: The Joint Commission; September 2011.
This report emphasizes performance on Hospitals in the United States have made significant improvements in quality of care over the past several years, according to the sixth annual Joint Commission report. This report emphasizes performance on accountability measures—quality metrics that are closely tied to patient outcomes—and cites exemplar hospitals across the country that have demonstrated outstanding performance on these metrics for patients undergoing surgery, and for patients hospitalized with myocardial infarctions, pneumonia, and asthma (in children). Beginning in 2012, The Joint Commission began to integrate performance expectations on accountability measures into their annual accreditation surveys, meaning that for the first time, hospitals must demonstrate high-quality performance in order to retain accreditation.
Journal Article > Study
DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.
Disruptive and unprofessional behavior that goes unaddressed poses a threat to patient safety by hampering development of a culture of safety. This study reports on how one academic hospital addressed this issue by developing a multidisciplinary code of professionalism accompanied by a dedicated hotline for reporting unprofessional behavior. All reported incidents resulted in a combination of feedback, coaching, or disciplinary action for involved providers. Introduction of the code and the reporting system was associated with a significant improvement in teamwork and communication, as measured by the AHRQ Hospital Survey on Patient Safety Culture. This study provides an approach for health care organizations to address the disturbingly common problem of disrespectful and hostile behavior in the workplace. Other approaches are outlined in a PSNet perspective.
Journal Article > Commentary
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
Reporting that recalled medications were found in hospital pharmacies, this article describes recommendations to improve the process for removing recalled products.
Oakbrook Terrace, IL: The Joint Commission; November 2007.
Building on its inaugural publication, this report summarizes the quality and safety of care delivered to hospitalized patients between 2002 and 2006. The report suggests that hospital performance consistently improved from year to year as measured by adherence to evidence-based treatments for heart attacks, heart failure, and pneumonia, as well as more recent measures of surgical care. While similar improvements were noted in compliance with National Patient Safety Goals, significant room for improvement remains on additional quality measures, and noted variability exists in performance by hospital and by state. The report emphasizes the Joint Commission's efforts to improve performance measurement and reporting requirements in future years to adequately reflect the organization's goal of improved health outcomes. A past AHRQ WebM&M commentary discussed the unintended consequences of the public reporting of hospital quality.
Shorr AS. Healthc Exec. March-April 2007;22:19, 21-22, 24, 26.
The author discusses executive accountability for patient safety and active involvement in creating a patient-centric culture.