The Case of the 10 Pound Giant: A Near Miss Root Cause Analysis

Objectives: Through an Interprofessional Root Cause Analysis of this Near Miss event, we aimed to: 1.Identify issues contributing to the incorrect dosing of acyclovir 2.Understand relevant institutional policies and compare this to usual practice 3.Propose possible solutionshttp://jdc.jefferson.edu/patientsafetyposters/1034/thumbnail.jp

Adaptation of a Standardized Handoff System for a Radiology Residency Program

Background/Objectives: The Joint Commission has linked communication failure as a root cause for a majority of sentinel events. The “I-PASS” system is a hand-off mnemonic that has been shown to decrease medical errors, prevent adverse events, and improve communication. Multiple Jefferson residency programs have adopted I-PASS training over the last year to standardize sign-outs between treatment teams and departments. Radiology residents also participate in hand-offs with other departments, especially in cases of adverse patient reactions that occur within radiology (ie: allergic reaction, seizure, contrast extravasation). In addition, radiology residents also participate in hand offs between daytime and overnight teams, including sign out of pertinent protocols, studies, and clinician communications. The aim of this study was to assess the adaptability of I-PASS training to the needs of a diagnostic radiology residency program.https://jdc.jefferson.edu/patientsafetyposters/1098/thumbnail.jp

Utilizing feedback as a mechanism to improve resident event reporting rates

Objectives Provide feedback to 100% of residents entering a report between December 2017 and March 2018 Evaluate the degree to which residents value the feedback we were able to provide Assess a pilot process for sustainability on a larger scalehttps://jdc.jefferson.edu/patientsafetyposters/1099/thumbnail.jp

Improving Resident Confidence and Efficiency During Stroke Alerts Through Simulation Training

Objectives Teach incoming neurology residents how to respond efficiently and appropriately to stroke alerts Improve the confidence level of residents during stroke alertshttps://jdc.jefferson.edu/patientsafetyposters/1084/thumbnail.jp

Improving Medical and Endovascular Management for Acute Ischemic Stroke Through Multidisciplinary Education and Simulation

Primary goals: Reduce door to treatment times (both DTN and DTP) to meet and exceed existing guidelines metrics. Educate residents about acute stroke management, including national guidelines and new institutional protocols to improve efficiency during stroke alerts.https://jdc.jefferson.edu/patientsafetyposters/1097/thumbnail.jp

Improving Bedside Procedural Safety through Optimizing Timeout Documentation and a Pre-procedure Checklist

Aim GOAL: Improve the safety of patients undergoing bedside procedures while maintaining the full spectrum of graduated autonomy in procedure training for residents. SMART Aim: Increase the rate of timeouts documented for bedside procedures from 29% to 50% by June 2018.https://jdc.jefferson.edu/medposters/1014/thumbnail.jp

Implementation of Attending-Supervised IPASS Handoff in the Neuro-ICU

Background Duty hour restrictions, cross coverage, and the growing number of mid-level practitioners has led to an increased number of handoffs across medical specialties These handoffs are well-known points of communication breakdown which can lead to patient safety issues Factors contributing to an effective handoff include standardization of communication, appropriate training and supervision, ample time, a quiet environment, and a supportive culture We hypothesize that attending supervision of handoffs is feasible and can improve practitioner perception of transitions of carehttps://jdc.jefferson.edu/patientsafetyposters/1077/thumbnail.jp