Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement

Examines four healthcare systems' expansion of patient safety interventions over five years through the development of practical training methods, effective tools for minimizing errors, an emphasis on goal setting and accountability, and other approaches

Advancing Patient Safety in the U.S. Department of Veterans Affairs

As part of a systemwide transformation, the VA formed its National Center for Patient Safety to foster an organizational culture of safety within its nationwide network of hospitals and outpatient clinics. A recent medical team training program designed to improve communication among operating room staff was associated with a reduction in surgical mortality and improvements in quality of care, on-time surgery starts, and staff morale. The program is now being expanded to other clinical units, along with a patient engagement program that prevents errors by facilitating communication relating to patients' daily care plans. A recognition program stimulated facilities to conduct timelier and higher-quality root-cause analyses of reported safety events to identify stronger actions for preventing their recurrence. Other initiatives have reduced rates of health care -- associated infections, patient mortality, and post-operative complications. Success factors include leadership accountability for performance and organizational support for testing, expanding, and adopting improvements

Developing minimum clinical standards for physiotherapy in South African ICUs: A qualitative study

Rationale, aims, and objectives: Physiotherapists are integral members of the intensive care unit (ICU) team. Clinicians working in ICU are dependent on their own experience when making decisions regarding individual patient management thus resulting in variation in clinical practice. No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for ICU physiotherapy. This study explored perceptions of physiotherapists on minimum clinical standards that ICU physiotherapists should adhere to for delivering safe, effective physiotherapy services to critically ill patients. Method: Experienced physiotherapists offering a service to South African ICUs were purposively sampled. Three focus group sessions were held in different parts of the country to ensure national participation. Each was audio recorded. The stimulus question posed was “What is the minimum standard of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs?” Three categories were explored, namely, knowledge, skill, and attributes. Themes and subthemes were developed using the codes identified. An inductive approach to data analysis was used to perform conventional content analysis. Results: Twenty-five physiotherapists participated in 1 of 3 focus group sessions. Mean years of ICU experience was 10.8 years (±7.0; range, 3-33). Three themes emerged from the data namely, integrated medical knowledge, multidisciplinary teamwork, and physiotherapy practice. Integrated medical knowledge related to anatomy and physiology, conditions that patients present with in ICU, the ICU environment, pathology and pathophysiology, and pharmacology. Multidisciplinary teamwork encompassed elements related to communication, continuous professional development, cultural sensitivity, documentation, ethics, professionalism, safety in ICU, and technology. Components related to physiotherapy practice included clinical reasoning, handling skills, interventions, and patient care. Conclusions: The information obtained will be used to inform the development of a list of standards to be presented to the wider national physiotherapy and ICU communities for further consensus-building activities

Differences in work environment for staff as an explanation for variation in central line bundle compliance in intensive care units.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are a common and costly quality problem, and their prevention is a national priority. A decade ago, researchers identified an evidence-based bundle of practices that reduce CLABSIs. Compliance with this bundle remains low in many hospitals. PURPOSE: The aim of this study was to assess whether differences in core aspects of work environments-workload, quality of relationships, and prioritization of quality-are associated with variation in maximal CLABSI bundle compliance, that is, compliance 95%-100% of the time in intensive care units (ICUs). METHODOLOGY/APPROACH: A cross-sectional study of hospital medical-surgical ICUs in the United States was done. Data on work environment and bundle compliance were obtained from the Prevention of Nosocomial Infections and Cost-Effectiveness Refined Survey completed in 2011 by infection prevention directors, and data on ICU and hospital characteristics were obtained from the National Healthcare Safety Network. Factor and multilevel regression analyses were conducted. FINDINGS: Reasonable workload and prioritization of quality were positively associated with maximal CLABSI bundle compliance. High-quality relationships, although a significant predictor when evaluated apart from workload and prioritization of quality, had no significant effect after accounting for these two factors. PRACTICE IMPLICATIONS: Aspects of the staff work environment are associated with maximal CLABSI bundle compliance in ICUs. Our results suggest that hospitals can foster improvement in ensuring maximal CLABSI bundle compliance-a crucial precursor to reducing CLABSI infection rates-by establishing reasonable workloads and prioritizing quality

Jefferson Digital Commons quarterly report: January-March 2020

This quarterly report includes: New Look for the Jefferson Digital Commons Articles COVID-19 Working Papers Educational Materials From the Archives Grand Rounds and Lectures JeffMD Scholarly Inquiry Abstracts Journals and Newsletters Master of Public Health Capstones Oral Histories Posters and Conference Presentations What People are Saying About the Jefferson the Digital Common

Improving Patient Satisfaction with the Virtual Handoff Process through the Utilization of Educational Pamphlets in the Emergency Department

Boarding patients in the emergency room while waiting to transfer the patient to the proper unit can be harmful to clinical care and have significant financial opportunity costs. At one local hospital it was found that on average patients were being boarded in the emergency room (ED) for approximately 85 minutes waiting to be transferred. Several barriers that caused this delay were found including, delay in room cleaning, nurse staff shortage, and inability to give report to the nurse receiving the patient. In an attempt to combat this delay which may be caused by a difficulty in giving patient report, this organization is rolling out a virtual bedside handoff process. While virtual technology is not a new concept, there are many patients that may not be comfortable with the technology. The purpose of the evidence-based project was to provide a written educational pamphlet that details the how’s and why’s of the virtual handoff process to the patient to be given upon admission. The goal of the educational pamphlet was to increase the patients’ satisfaction with the process. A pre-survey was given to a group of patients after they experienced the virtual handoff process to assess their comfort level. These results were compared to the post-survey results of patients that received the educational pamphlet prior to experiencing the virtual handoff process. Ten pre-surveys and seven post-surveys were analyzed utilizing SPSS and descriptive statistics. The analysis concluded that the participants who received the educational pamphlet felt more prepared for the virtual handoff process