Patient Safety 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…..

“I Know My Body Better Than Anyone Else” Perspectives Of People Who Inject Drugs On Antimicrobial Treatment Decision Making For Serious Infections, Amy Eckland, Michael Kohut Phd, Henry Stoddard, Debra Burris, Frank Chessa, Monica Sikka, Daniel Solomon, Colleen Kershaw, Ellen Eaton, Rebecca N. Hutchinson, Peter Friedmann, Thomas Stopka, Kathleen Fairfield, Kinna Thakarar

Costas T. Lambrew Research Retreat 2023

Introduction:

• Few studies have examined the perspectives of patients with lived experience regarding outpatient treatment options for injection drug use (IDU) associated infections.

• We sought to better understand the perspectives of both community partners with lived experience who work with people who inject drugs (PWID) and hospitalized patients with IDU-associated infections on shared treatment decision making.

Understanding Travel For Families With A Physically Disabled Child Through The Occupational Therapy Lens, Dinah Adams, Karen Park, Susan Macdermott

Spring 2022 Virtual OTD Capstone Symposium

Travel is a complex occupation that involves interactions between body function, activity participation, and the environment. For families traveling with a physically disabled child this occupation becomes even more complex. The available literature on the lived experiences of these families is significantly limited. This project aims to determine participants’ experiences of commercial airline travel with a child who has a physical disability. Through the participants experiences, barriers and needs of this population can be identified. Through identification of barriers, the needs of this population are highlighted as well as ways they can be supported and advocated for.

The File Of Life: A Lifeline For First Responders In Fairfield County, Ct, Brittany Gilmore

Family Medicine Clerkship Student Projects

During a medical emergency, it can be difficult for first responders to obtain crucial medical information about their patients for a variety of reasons. The patient may be unconscious, have an altered mental status, or simply not know their medical history. This project aimed to increase awareness of the File of Life program, which many local Fire and EMS departments are implementing to improve their ability to deliver life-saving care.

Violence Against Healthcare Workers: An Epidemic Within A Pandemic, Michaela Ramandanes

College of Health Sciences Posters

Violence and harassment towards healthcare workers has been an underlying problem throughout history. However, with the rapid and evolving onset of the COVID-19 pandemic, the risks that healthcare workers face has been a focal topic of discussion among administration, staff and the public. What was once considered an occupational hazard is now being raised as a public health issue- an epidemic within a pandemic. This literature review seeks to identify the prevalence and causes of violence and harassment towards healthcare workers. Was healthcare violence as prevalent before COVID-19? Has violence increased because patient volume increased? Additionally, this review will determine …

Reducing Alarm Burden By Promoting Judicious Ordering Of Continuous Pulse Oximetry, Kathleen Berg, David Johnson, Ginny Nyberg, Andrew Ausmus, Christine Claeys, Emily Wilkinson, Nicholas Clark

Presentations

Background: Overutilization of continuous pulse oximetry (CPO) contributes to overdiagnosis and prolonged supplemental oxygen utilization. It may also negatively impact patient sleep, mobility, length of stay (LOS), and cost. Response times to actionable alarms increase with the number of non-actionable alarms. Our baseline data revealed an average of 29.6 pulse oximetry monitor alarms sounded for each admitted patient each day of their hospitalization. Most notably, 38.7% of pulse oximetry alarms were for ≥88% which is generally considered non-actionable.

Objective: We aimed to decrease both total pulse oximetry alarms per patient day and alarms for ≥88% per patient day by 20%, …

Assessing The Effects Of Social Determinants On Serious Safety Events, Lisa L. Schroeder, Jessi Van Roekel, John Cowden

Posters

Background: We have long known that various social determinants of health (SDH) such as race, gender, socioeconomic status and others can affect health outcomes, such as readmission rates and mortality. To our knowledge, the impact of SDH on safety events has not been studied.


Objective: We sought to understand the role that social determinants may play in contributing to safety events at our institution and to incorporate this information into the creation of corrective action items following the serious safety event.


Design/Methods: The Clinical Safety team partnered with the Office of Equity and Diversity to develop a standard question regarding …

Nursing: Global Impact Increases Healthcare Effectiveness, Madison Slacktish

Student Research Poster Presentations 2021

The discipline of nursing has a major impact on the world globally. Research has found when nurses collaborate across boarders, then patient outcomes tend to increase. Disease does not stop because there is a boarder from one country to the next. Therefore, worldly collaboration has positive influences on how nurse's practice and ways to change protocols to increase better patient outcomes.

Community Health Interventions To Reduce The Burden Of Radon-Related Lung Cancer, Benjamin Weaver

Family Medicine Clerkship Student Projects

Exposure to radon is the second leading cause of lung cancer in the United States. One in seven homes in Vermont has elevated levels of radon, but most patients are unaware of radon as a risk factor for lung cancer or that radon testing and mitigation services are available to them. To promote increased testing and mitigation of radon we screened patients presenting to a Family Medicine practice in Vermont about whether they had had these services done in their home. We also developed a patient education resource for providers to give to patients who had more questions about radon …

Impact Of Order Set Use On Stroke Care, Bilal Nadeem, Edward Waseleski, Meryem Maras-Casey, Sabih Alam, Adnan Faruqui, Michael Gutierrez, Maruthsakhi Molugu, Christina Oricompil, Ashar Mahmood, Katherine Torralba, Fatima Agha, Nour Tlimat, Olu Oyesanmi, Salman Muddassir, Nikolay Mitzov

West Florida Division Virtual Research Day 2020

A case control study of 118 patients from Oak Hill Hospital between the months of August 2019 and January 2020 was recently completed for a hospital research quality improvement study. The objective was to determine if the use of either Hemorrhagic or Ischemic Stroke Order Set had an effect on the length of stay (LOS) or adherence to current stroke guideline recommendations when compared to its disuse. Results indicate use of either the Hemorrhagic or Ischemic Stroke Order Set led to a decreased length of stay and an increased adherence to current stroke guideline recommendations. Limitations of the study included …

Decreasing Unplanned Extubations By Taping Technique & Creating A Culture Of Safety, Karishma Rao, Beckie Palmer, Christopher R. Nitkin, Christian Anthony Schneider, Brandy Huitt, Molly Terhune, Ashley Orwick, Dianne Wilderson, Sarah Carboneau, Jenny Mckee, Kerrie A. Meinert, Eugenia K. Pallotto

Presentations

Describes strategies used to decrease the unplanned extubation rate in the Level IV neonatal intensive care unit to less than 1.0 event per 100 ventilator days by December 2018.

"Sterile Cockpit": How Utilizing Aviation Regulations Can Reduce Errors In Ecmo Procedures, Sarah P. Jimenez, Johanna I. Orrick, Kari L. Davidson, Debra E. Newton

Posters

The "Sterile Cockpit Rule," developed in 1981 as an aviation regulation, was adapted by the ECMO core team to promote a distraction-free environment during critical ECMO procedures. Upon review of the data including tracking of interruptions, errors, and staff experience, it is evident that the concept of Sterile Cockpit has streamlined procedure efficiency, as well as safety.

Improving Bedside Procedural Safety Through Optimizing Timeout Documentation And A Pre-Procedure Checklist, Jennifer Harris, Md, R. Benson Jones, Md, Kristin Lohr, Md, Grant Turner, Md, Drew Kotler, Md, Justine Blum, Md, Megan Margiotta, Md, Matthew Bokhari, Md, Erica Li, Md, Riti Kanesa-Thasan, Md, Bracken Babula, Md, Rebecca Jaffe, Md

Department of Medicine Posters

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.

Pharmacy Driven Best Possible Admission Medication History At A Pediatric Institution, Damon Pabst, Charity Thompson, Brandon French, Brian O'Neal, Garret Matthews, Zeb Benner, Joshua Meade

Posters

No abstract provided.

The Lifecycle Of A K-Card: Improving Data Collection While Improving Bundle Reliability, Tara Benton, Barb Haney, Lacey Bergerhofer, Susan Burns, Yolanda Ballam, Kaitlyn Hoch

Posters

No abstract provided.

Medication Education In The Pediatric Rheumatology Clinic, Ashley M. Cooper, Julia G. Harris

Posters

No abstract provided.

Act-Up/Ri Fight Aids Poster, Act-Up/Ri, Risd Archives

Health

ACT-UP/RI Fight AIDS poster. "Get off your butt and demonstrate. Act Up, Fight Back, Fight AIDS"

Aids: Activism, Video, And The Media Lecture Series, John Cavallaro, Risd Archives

Health

Flyer outlining the programming for the AIDS: Activism, Video, and the Media Lecture Series.

Danger: Rhode Island Has A New Aids Law Poster, Act-Up/Ri, Risd Archives

Health

Danger: Rhode Island Has a New Aids Law, 1989 poster.

Dental X-Rays And Your Health (1977), American Dental Association

Patient Dental Health Education Brochures

No abstract provided.

Dental X-Rays And Your Health (1972), American Dental Association

Patient Dental Health Education Brochures

No abstract provided.

Dental X-Rays And Your Health (1966), American Dental Association

Patient Dental Health Education Brochures

No abstract provided.

Dental X-Rays And Your Health (1958), American Dental Association

Patient Dental Health Education Brochures

No abstract provided.