Public Health Commons^™

Quality & Patient Safety Gazette : Volume 2, Issue 4 - 2023, The Aga Khan University Hospital, Karachi

Quality & Patient Safety - Gazette

• World Quality Day 2023
• Workshop on How to conduct a Root Cause Analysis
• Blast from the Past
• Learn with Fun!
• Stay Tuned with Us…..

Conference Proceedings: Select Abstracts Presented At 2023 Advocate Aurora Scientific Day

Journal of Patient-Centered Research and Reviews

This abstract supplement includes findings presented at the 49th annual Advocate Aurora Scientific Day on May 24, 2023. The Scientific Day symposium provides a virtual forum for the sharing of preliminary results from research and case studies conducted by faculty, fellows, residents, and other health professionals associated with Illinois-based Advocate Health Care and Wisconsin-based Aurora Health Care.

A 3- And 6- Month Follow-Up To A Student-Led Approach To Patient Safety In Pre-Clinical Curriculum, Nelson D. Gonzalez, Sahar Panjwani, Daniel Nwosuocha, Lauren Bayliss, Ayleen Godreau

Research Colloquium

Introduction: Preventable medical errors are currently the third leading cause of death in the United States following heart disease and cancer. In light of this, integration of formal patient safety education into undergraduate medical education has been encouraged by the World Health Organization. This study aimed to assess the change in patient safety knowledge, attitudes, and beliefs in students after early exposure to patient safety during pre-clinical years.

Methods: First and second-year medical students participated in the training and responses were assessed through a pre-test, immediate post-test, 3-month post-test, and 6-month post-test. The survey assessed student knowledge on aspects …

Fostering Patient Safety: Importance Of Nursing Documentation, Shamsa Samani, Salma Amin Rattani

School of Nursing & Midwifery

Background: Nurses are professionally accountable for assessing and documenting patients’ vital signs. Nurses failing to fulfill this responsibility position their patients at risk. This paper presents two real-life cases pertaining to patients’ safety resulting in fatal outcomes, leading to the professional, legal, and ethical liability of nurses as the providers of patient care.
Objective: This paper focuses on the role of organizational culture in fostering patient safety specifically in monitoring and documentation of patients’ vital signs and early recognition of warning signs.
Methodology: A comprehensive literature search was conducted using various databases, examining the significance of vital signs monitoring and …

Operationalizing A Medication Safety Gap Assessment For A Large Health System, Carley Warren, Joan Kramer, L Hayley Burgess

HCA Healthcare Journal of Medicine

Background

Medication errors continue to be a leading cause of medical errors. In the United States alone, 7000 to 9000 people die annually due to a medication error, and many more are harmed. Since 2014, the Institute for Safe Medication Practices (ISMP) has advocated for several best practices in acute care facilities derived from reports of patient harm.

Methods

The medication safety best practices chosen for this assessment were based on the 2020 ISMP Targeted Medication Safety Best Practices (TMSBP) and health system-identified opportunities. Each month, for 9 months, select best practices were covered with associated tools to assess the …

Logic Model And Data System Recommendations, Claire Devine, Natalie Royal Kenton, Kristen Lacijan, Maggie Weller

Articles, Abstracts, and Reports

No abstract provided.

J Mich Dent Assoc April 2022

The Journal of the Michigan Dental Association

Monthly, The Journal of the Michigan Dental Association brings news, information, and feature articles to our state's oral health community and the MDA's 6,200+ members. No publication reaches more Michigan dentists!

In this April 2022 issue, the reader will find the following original content:

• A cover feature “Protect Your Patients and Yourself: The Complete and Honest Medical History”
• A feature article “The Foundation for Dental Care: The Patient Interview and Dental/Medical Health History”
• A 10-Minute EBD “The Preferred Analgesia for Orthodontic Tooth Movement: Acetaminophen or NSAIDs?”
• News you need: an Editorial, a "Reminder about Antitrust Law", and regular department articles, …

The Impact Of Electronic Health Records Meaningful Use On Patient Safety And Satisfaction, Paulette Brown

Walden Dissertations and Doctoral Studies

AbstractThe widespread adoption of electronic health records (EHRs) is encouraged because of their potential to improve the quality of care provided. It was unknown to what extent the meaningful use of EHRs would impact patient safety and satisfaction in general and specialty hospitals. The researcher’s purpose for this quantitative correlational research was to examine the impact of meaningful EHR use of EHRs on patient safety and satisfaction outcomes in general and specialty hospitals in Philadelphia (PA). The constructs of the institutional theory guided the study. The hypotheses that guided the study included (a) Meaningful EHR use positively influences patient satisfaction …

Pharmacy-Led Medication Reconciliation Program Reduces Adverse Drug Events And Improves Satisfaction In A Community Hospital, L. Hayley Burgess, Joan Kramer, Carley Castelein, Joseph M. Parra, Victoria Timmons, Samantha Pickens, Sarah Fraker, Christopher Cameron Skinner

HCA Healthcare Journal of Medicine

Background

Pharmacy-led medication reconciliation identifies and corrects medication errors that can potentially cause moderate to severe harm. This research sought to identify the impact of pharmacy-led medication reconciliation on patient outcomes and describe the changes in healthcare workers’ perceptions of the program.

Methods

A pharmacy-led admission medication reconciliation program pilot started in July 2019, and a discharge medication reconciliation proof of concept was tested in September 2020 at a 432-bed hospital. The following periods were compared: August 2018 to February 2019 (pre-program implementation) and August 2019 to February 2020 (post-program implementation). Endpoints included patient outcomes, workforce productivity and interdisciplinary healthcare …

Using A Multidisciplinary Data Approach To Operationalize An Experience Framework, Kevin Spera, Garrett Holmes, Sunni Barnes

Patient Experience Journal

Like many healthcare organizations, Baylor Scott & White Health (BSWH) is awash with data. Often, this data is used in siloed departments to monitor safety and quality, make local business decisions, and motivate staff to improve processes to achieve sustained excellence and market share. As margins get thinner and competition from various disrupters increases, organizations have tried to improve the patient experience to remain viable as part of a calculated strategy. Nevertheless, these entities have struggled to focus limited resources for sustained improvement in patient experience. This article details how a large Texas-based healthcare system "operationalized" The Beryl Institute's Experience …

Preprocedure Covid-19 Testing In Early Phase Of Pandemic, Renuka Jain, Bradley Kruger, Robert Citronberg, Stacie Kroboth, Ana Cristina Perez Moreno, Bijoy K. Khandheria

Journal of Patient-Centered Research and Reviews

The COVID-19 pandemic led to a nationwide shutdown of elective medical procedures. Upon resumption of services, preprocedure nasopharyngeal swab testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was introduced for all patients requiring surgical or other aerosol-generating procedures. We investigated preprocedure COVID-19 testing in one of the largest U.S. health systems. Patients included in this retrospective, observational study were asymptomatic and scheduled for a procedure or surgery. All patients underwent a nasopharyngeal swab test for SARS-CoV-2 performed 24–72 hours prior to a planned procedure. Clinical demographics, type of procedure, test results, and subsequent procedure status were evaluated. Of 38,608 …

Measurement Matters: Changing Penalty Calculations Under The Hospital Acquired Condition Reduction Program (Hacrp) Cost Hospitals Millions, Olga A. Vsevolozhskaya, Karina C. Manz, Pierre M. Zephyr, Teresa M. Waters

Biostatistics Faculty Publications

BACKGROUND: Since October 2014, the Centers for Medicare and Medicaid Services has penalized 25% of U.S. hospitals with the highest rates of hospital-acquired conditions under the Hospital Acquired Conditions Reduction Program (HACRP). While early evaluations of the HACRP program reported cumulative reductions in hospital-acquired conditions, more recent studies have not found a clear association between receipt of the HACRP penalty and hospital quality of care. We posit that some of this disconnect may be driven by frequent scoring updates. The sensitivity of the HACRP penalties to updates in the program's scoring methodology has not been independently evaluated.

METHODS: We used …

J Mich Dent Assoc February 2020

The Journal of the Michigan Dental Association

Every month,The Journal of the Michigan Dental Association brings news, information, and features about Michigan dentistry to our state's oral health community and the MDA's 6,200+ members. No publication reaches more Michigan dentists!

In this issue, the reader will find the following original content:

• A cover story on the 2020 MDA Annual Session
• A feature covering student perspectives on the Opioid Crisis
• News you need, Editorial and regular department articles on MDA Foundation activities, Dentistry and the Law, Staff Matters, Headquarters Report, and component news

This issue also includes articles reprinted with permission:

• “Muscle Deprogramming: A Source of Confusion”, …

Comparing Psychiatric Care Experiences Shared Online With Validated Questionnaires; Do They Include The Same Content?, Rebecca Baines, John Donovan, Samantha Regan De Bere, Julian Archer, Ray Jones

Patient Experience Journal

Patient feedback is considered integral to patient safety and quality of care. However, limited research has compared the content of validated questionnaires with subjective patient experiences shared online. The aim of this study was to therefore identify and compare the content of psychiatric care experiences shared online with validated questionnaires. All research was conducted in co-production with a volunteer mental-health-patient-research-partner. We analysed all reviews published on the United Kingdom’s leading health and social care feedback platform Care Opinion, between 2005-2017 that discussed adult psychiatric care and compared findings with two validated questionnaires (ACP360 and General Medical Council patient feedback questionnaire). …

How Patients View Their Contribution As Partners In The Enhancement Of Patient Safety In Clinical Care, Marie-Pascale Pomey, Nathalie Clavel, Ursulla Aho-Glele, Noemie Ferré, Paloma Fernandez-Mcauley

Patient Experience Journal

Despite the call from the World Health Organization for more active involvement from patients in the prevention of health care-related risks, there is still insufficient evidence about how patients can be more proactive in the safety of their own care. This study helps understand the perspective of patients as partners regarding their roles, as well as their relatively untapped potential in detecting and limiting adverse events (AEs) for patient safety. 17 patients-as-partners were interviewed on five themes: 1) Behavior of patients/relatives for avoiding AEs; 2) Competencies sought in patients/relatives to play an active role in patient safety; 3) Factors limiting …

Patient Safety: Just Ask. Patients As Reporters Of Real-Time Safety Data; A Pilot Project To Improve Patient Safety In Secondary Care, Thomas A. Cairns Dr, Iain Mccallum Mr

Patient Experience Journal

The Berwick review into patient safety recommended ‘involving patients in the healthcare organisation and seeking out the patient voice as an essential asset to monitor safety.’ (1) However routine data collection from patients in our institution is retrospective and doesn't focus on safety. Our objective was to create a patient-centred mechanism to monitor patient-perceived safety concerns and provide immediate resolution of highlighted issues. A pragmatic 6-question questionnaire was developed containing 4 scored and 2 free text questions. This questionnaire was piloted and adjusted before being administered to all inpatients meeting the inclusion criteria in our institution on one day. Safety …

Implementing A Good Catch Program In Nursing Homes, Leigh Raposo

Muskie School Capstones and Dissertations

Rationale and processes for reporting near misses and evidence-based tools were collected by a literature search, seminal works by Sidney Dekker and James Reason, and websites for the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement (IHI), and the Centers for Medicare and Medicaid Services (CMS). Tools, information, and strategies found in this research were evaluated for implementation in Maine nursing homes. The tools provide a communication vehicle for nursing home staff to safely report to management near misses, or mistakes that do not harm residents. To emphasize a positive approach, the project replaces the term …

A Vision For Using Online Portals For Surveillance Of Patient-Centered Communication In Cancer Care, Hardeep Singh, Neeraj K. Arora, Kathleen M. Mazor, Richard L. Street Jr

Patient Experience Journal

The Veterans Health Administration (VHA) is charged with providing high-quality health care, not only in terms of technical competence but also with regard to patient-centered care experiences. Patient-centered coordination of care and communication are especially important in cancer care, as deficiencies in these areas have been implicated in many cases of delayed cancer diagnosis and treatment. Additionally, because cancer care facilities are concentrated within the VHA system, geographical and system-level barriers may present prominent obstacles to quality care. Systematic assessment of patient-centered communication (PCC) may help identify both individual veterans who are at risk of suboptimal care and opportunities for …

Cancer Patients’ Experiences Of Error And Consequences During Diagnosis And Treatment, Henriette Lipczak, Liv H. Dørflinger, Christine Enevoldsen, Mette M. Vinter, Jeanne L. Knudsen

Patient Experience Journal

The study objective was to investigate patient experienced error during diagnosis and treatment of cancer. The design included a nationwide patient survey on quality and safety in Danish cancer care. Responses regarding patient experienced error were separately analyzed, quantitative responses using descriptive statistics and qualitative responses using systematic text analysis. Study participants included 6,720 adult patients with a first time diagnosis of cancer registered between May 1st and August 31st 2010. The patients received a questionnaire concerning their experiences of care received by general practitioners, specialist practitioners and at the hospital. A response rate of 65% was achieved. 10 – …

Patient Complaints As Predictors Of Patient Safety Incidents, Helen L. Kroening, Bronwyn Kerr, James Bruce, Iain Yardley

Patient Experience Journal

Patients remain an underused resource in efforts to improve quality and safety in healthcare, despite evidence that they can provide valuable insights into the care they receive. This study aimed to establish whether high-level patient safety incidents (HLIs) were predictable from preceding complaints, enabling complaints to be used to prevent HLIs. For this study complaints received from November 2011 through June 2012 and HLI incident reports from April through September 2012 were examined. Complaints and HLIs were categorised according to location or specialty and the themes they included. Data were analysed to look for correlations between number of complaints and …

Book Review: Questioning Protocol, Barbara Lewis Mba

Patient Experience Journal

In her review of Questioning Protocol by Randi Redmond Oster, Barbara Lewis shares how this new and award winning book takes the reader on Randi Oster's harrowing journey of navigating the healthcare system while helping her teenage son’s battle with Crohn’s disease. Seventeen chapters build a chronological story of success, frustration and failure in dealing with modern medicine and a healthcare industry that may appear foreign to the outsider.

Technological Iatrogenesis: The Manifestation Of Inadequate Organizational Planning And The Integration Of Health Information Technology., Patrick Albert Palmieri

Patrick Albert Palmieri

The Institute of Medicine (IOM) views Health Information Technology (HIT) as an essential organizational prerequisite for the delivery of safe, reliable, and cost effective health services. However, HIT presents the proverbial double-edged sword in generating solutions to improve system performance while facilitating the genesis of novel iatrogenic problems. Incongruent organizational processes give rise to technological iatrogenesis or the unintended consequences to system integrity and the resulting organizational outcomes potentiated by incongruent organizational–technological interfaces. HIT is a disruptive innovation for health services organizations but remains an overlooked organizational development (OD) concern. Recognizing the technology–organizational misalignments that result from HIT adoption is …

Safety Culture As A Contemporary Healthcare Construct: Theoretical Review, Research Assessment, And Translation To Human Resource Management., Patrick Albert Palmieri

Patrick Albert Palmieri

Through a number of comprehensive reviews, the Institute of Medicine (IOM) has recommended that healthcare organizations develop safety cultures in order to align delivery system processes with the workforce requirements to improve patient outcomes. Until health systems can provide safer care environments, patients remain at risk for suboptimal care and adverse outcomes. Health science researchers have begun to explore how safety cultures might act as an essential system feature to improve organizational outcomes. Since safety cultures are established via modification in employee safety perspective and work behavior, human resource professionals need to contribute to this developing organizational domain. The IOM …