Patient Safety Commons^™

The Opioid Crisis In America As It Effects Health Care Professionals, Patients, And The Economy, Dale Russell

Lynchburg Journal of Medical Science

Abstract

There is a growing concern in America over the increasing morbidity and mortality associated

with the use and abuse of opioid pain relievers. This alarming increase has led to the term

“crisis” when referring to these facts. Addressing this crisis is multi-focused. The need to prevent

and treat opioid addiction is on the forefront. These needs are seen in both the prescription of

opioids as well as the illicit use of non-prescription opioids. Overprescribing opioids has led to

an increase of abuse and addiction to these substances. This in turn has led to a rise in street use

of ...

Multiple Regression Models To Analyze Length Of Hospitalization Due To Nosocomial Infections In U.S. Hospitals, Ernest M. Oleksy

The Downtown Review

Nosocomial diseases are a serious concern and detriment to hospitals’ abilities to provide appropriate patient care. Bearing this in mind, an effort must be made to determine whether infection surveillance and control programs have reduced the rates of nosocomial infection at U.S. hospitals. The data that were studied were obtained as part of the Study on the Efficacy of Nosocomial Infection Control (SENIC) and used to develop a model of what variables most contribute to a patient’s length of stay at the Cleveland Clinic (Quade et al, 1980).

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.

Risky Business: Millennials’ Protection Motivation Factors For Norovirus Outbreaks On College Campuses, Dylan Conrad Martinez

Theses and Dissertations

The risk and severity of hNoV transmission is obscurely recognized to foodservice millennial customers. Most commonly associated with cruise ships, consumers are not aware of its full potential to strike at other locations, especially college campuses. For the foodservice industry and the university community, it is imperative that a proactive method for increasing millennials’ motivation to practice mitigation methods emerges to reduce future hNoV outbreaks on college campuses. Research has shown that students can play a major role in the spread of hNoV on college campuses. Therefore, the purpose of these studies is to examine motivations for health protective behaviors ...

An Evidenced-Based Protocol For Eliminating Errors Associated With Intravenous Medication Errors, Susie Chaney, Blake Smith, Andrea Howard, Chanel Wilder, Suzi White Msn, Phcns-Bc

Posters-at-the-Capitol

The purpose of our research is to decrease the number of IV medication errors. IV medication errors occur due to the wrong drug, wrong dose, wrong rate, wrong concentration, incorrect aseptic technique, known allergies, omitted medications, wrong time of administration, incorrect labeling, patient identification, and no order for the infusion. Nurses’ perceptions of why medication errors occur included physicians’ medication orders are not clear, the names of many medications are similar, pharmacy did not label the medication correctly, poor communication, lack of staff to patient ratio, fatigue from hard work, nurses' heavy workload, and working night shift. This quality improvement ...

Reducing O Negative Blood Product Usage In A Tertiary Care Academic Medical Center, Wendy Weiler, Tracy Cook, Mmc Blood Bank, Mark Parker, Stephen Tyzik, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operational Excellence

MANAGEMENT OF O NEGATIVE BLOOD USE

O registered blood cells are the universal donor but it comprises only 7% of the blood supply. As a result, inappropriate use can result in shortages.

At an academic tertiary care medical center, a performance improvement goal was established that O negative blood cells would make up less than 12% of all blood type transfused by the end of their fiscal year.

A root cause analysis established reasons for the use of O negative blood cells. A number of countermeasures were initiated using the plan, do, study, act (PDSA) problem solving model. Using newly ...

Consistently Using A Transportation Department For Patient Discharge To Sustain Nursing Staffing Levels, Victoria Boutin, Joseph East, Stephen Tyzik, Joy Moody, Mark Parker, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operational Excellence

IMPROVING PATIENT FLOW BY UTILIZING A HOSPITAL TRANSPORTATION DEPARTMENT FOR DISCHARGES

Using a transportation department for transporting patients for discharge is the industry standard. At a large urban hospital, inconsistent use of this department has resulted in frontline caregivers (RNs) having to pick up this function, resulting in potentially unsafe staffing levels on the floor.

The goal of this quality improvement project was to improve the percent of discharges with the transport department from ≤10% to 70% by the end is fiscal year 2018 in an academic tertiary medical center.

Baseline metrics demonstrated the current state and a root cause ...

Improving The Management Of Nationwide Drug And Iv Bag Shortages, Inpatient Pharmacy, Supply Chain, Stephen Tyzik, Mark Parker, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operational Excellence

IMPROVING THE MANAGEMENT OF NATIONWIDE DRUG AND IV SHORTAGE

In September of 2017, Hurricane Maria struck the island of Puerto Rico where over 50 pharmaceutical factories had previously operated. The impact of this was felt not only in the drastic reduction of products that are produced on the island, but it also exacerbated the supply chain issues for key drugs nationwide.

The pharmacy department and supply chain in an academic tertiary care medical center did not have a consistent and reliable process for communication, planning and real-time updates. This resulted in a tremendous amount of wasted staff time at their ...

Strategies To Increase Early Discharges To Reduce Avoidable Patient Days And Improve Patient Flow, Cathy Palleschi, Cecilia Inman, Erica Weightman, James B. Powers, Stephen Tyzik, Joy Moody, Mark Parker, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operational Excellence

CREATING ALGORITHMS TO INCREASE THE NUMBERS OF HOSPITAL MORNING DISCHARGES RESULTING IN IMPROVED PATIENT FLOW

Discharging a percentage of patients early in the day helps to improve patient flow. This results in a reduction of Emergency Department congestion as well as peaks in patient numbers in the early to late afternoon on patient care units.

A cardiac unit in an academic tertiary medical center created a goal to increase the number of their discharges by 11 AM and to streamline key discharge planning activities. A root cause analysis was initiated and after identifying several barriers, two KPIs were developed using ...

Law, Technology And Patient Safety, Kathryn Zeiler, Gregory Hardy

Faculty Scholarship

Medical error is the third leading cause of death in the United States, In an effort to increase patient safety, various regulatory agencies require reporting of adverse events, but reported counts tend to be inaccurate. In 2005, in an effort to reduce adverse event rates, Congress proposed a list of “never events,” adverse events, such as wrong-site surgery, that should never occur in hospitals, and authorized CMS to refuse payment for care required following such events. CMS has since pushed for further regulation, “such as putting more payment at risk, increasing transparency, increasing frequency of quality data reviews, and stepping ...

Combatting Domestic Minor Sex Trafficking: An Evaluation Of The My Life, My Choice Program In Kentucky, Chelsea M. Dyer

Morehead State Theses and Dissertations

A thesis presented to the faculty of the Caudill College of Arts, Humanities, and Social Sciences at Morehead State University in partial fulfillment of the requirements for the degree of Master of Arts by Chelsea M. Dyer on July 11, 2018.

The Contributing Factors To Adolescent Depression, Josie H. Lee

Independent Study Project (ISP) Collection

Objective: This paper reviews individual, familial, peer, and societal factors influencing adolescent depression in developed countries. Background: Depression usually onsets at adolescence and contributes to high DALYs. Since depression is treatable, efforts should be made to reduce its prevalence and effect. Methods: The research consisted of looking at literature relevant to the topic and age group and conducting interviews with experts who know about and have worked with adolescent depression. Discussion: Adolescents begins at the onset of puberty, allowing different biological factors such as genetics, stress of puberty, and cognitive changes to increase vulnerability to depression. Adolescents who had substance ...

Perceptions As A Barrier To Emergency Medical Services Utilization Among Syrian Refugees In Jordan, Elizabeth Shan Wang

Independent Study Project (ISP) Collection

The purpose of this study is to evaluate perceptions of emergency medical services (EMS) among Syrian refugees living in urban host communities in Jordan. The research questions are as follows: To what extent do public perceptions of emergency medical services affect the utilization of ambulances? How does awareness about available emergency medical services shape refugees’ attitudes towards it? Because this topic is qualitative and exploratory in the case of Jordan, there was no clear hypothesis. The assumption, however, is that positive perceptions and awareness about EMS can encourage refugees to call an ambulance for transportation to the hospital during a ...

Non-Retrieval Of Inferior Vena Cava Filters As A Patient Safety Concern: Evaluation Of A New Process Improvement Project To Increase Retrieval Rates In A Vascular And Interventional Radiology Clinic, Joshua Brown, Jeffery Talbert, Ryan Pennington, Qiong Han, Driss Raissi

Pharmacy Practice and Science Faculty Publications

Background: Retrieval of inferior vena cava filters (IVCFs) is important to decrease the long-term risk of complications associated with indwelling devices. Our hospital experienced low retrieval rates and implemented a low-cost intervention and evaluation for quality improvement. The working hypothesis was that a simple, mailed letter intervention could increase retrieval rates by increasing patient and primary care provider knowledge of the need for retrieval.

Methods: For all prospective patients who received a retrievable IVCF during the intervention period from January 1, 2014 to February 29, 2016, patients and their primary care providers were mailed letters encouraging contact with the clinic ...

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.

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

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.

Cyber Threats And Healthcare Organizations: A Public Health Preparedness Perspective, Lauren Elizabeth Branch

Graduate Theses, Dissertations, and Problem Reports

Healthcare in the United States, heavily reliant on digital technology in service provision, has recently seen an increase risk of cyberattacks. Coordinated electronic medical records, imaging, pharmaceutical services, lab services and even treatment devices all rely on electronic connectivity and represent critical services that must be secured from cyber threats. Hospitals have become increasingly complex systems, and this often makes the organization more vulnerable to failure. Planning for these events is often hard for hospitals because their main charge is to provide life-saving care to patients as they need it. This is a relatively new threat to healthcare organizations, and ...

Improving Adherence To The European Society Of Cardiology’S 24-Hour To Coronary Angiogram Guideline, Rachel Malone

Masters theses/dissertations - taught courses

Abstract:

Healthcare accessibility in Ireland is the worst in Europe. The project site (north Dublin teaching hospital), had over 700 Emergency Department (ED) Non-ST- Elevated Myocardial Infarctions (NSTEMIs) in 2017. These NSTEMI's were associated with increased times to Coronary Angiogram (CA), when compared to the European Society of Cardiology's (ESC) 24-hour to CA guideline. Increased time to CA is associated with increased mortality. Using Lean Six Sigma (LSS) tools within the DMAIC (Define, Measure, Analyse, Improve, and Control) Quality Improvement (QI) model, the root causes of increased times to CA times were identified. One cause found was the ...

An Investigation Of Work-Related Risk Factors Among Sewing Machine Operators In Bangladesh, Md. Tahmidul Islam Molla, Mazed Islam

International Textile and Apparel Association (ITAA) Annual Conference Proceedings

Working extended periods of time in front of sewing machines may cause discomfort to the operators of sewing machines. Sewing machine operators sit for extended periods of time and use their hands to control, handle, or feel objects and tools in repetitive processes which makes them vulnerable to musculoskeletal symptoms. Therefore, this study aims to identify the prevalence of musculoskeletal symptoms among sewing machine operators working in the apparel industry in Bangladesh while considering job characteristics, productivity, job satisfaction, workstation design, and working environment. The results showed that working in front of the sewing machines for a long period of ...