Quality Improvement Commons^™

Remimazolam As A Sedative For Endoscopic Procedures: A Scoping Review, Hamzha Aysheh, Megan Henderson, Megan Hinkle, Sara Holton, Spencer Turner, Dwayne Accardo Dnp, Ccrn, Faana

Doctor of Nursing Practice Projects

Purpose/Background

Propofol is commonly used for procedural sedation during endoscopic procedures because of its rapid onset and short duration; however, its use is frequently associated with adverse effects such as hypotension, hypoxemia, respiratory depression, bradycardia, and injection site pain. As diagnostic endoscopic procedures continue to increase, particularly among older and medically complex patients, there is a growing need for sedative agents that provide effective sedation while minimizing perioperative risk. Remimazolam, a novel ultra–short-acting benzodiazepine metabolized by tissue esterases, has demonstrated favorable hemodynamic stability and a reduced adverse effect profile in recent literature. The purpose of this evidence-based quality improvement project …

The Effects Of Administration Policies On Patient Care Quality And Healthcare Service Costs, Rajveer Kaur

Electronic Theses, Projects, and Dissertations

This study examines how administrative policies in U.S. healthcare systems affect patient care quality and service costs. It addresses a gap by analyzing the combined effects of policy, leadership, and technology on both clinical outcomes and financial performance. Using a qualitative descriptive approach guided by the PRISMA protocol, the study systematically identified and analyzed eighteen peer-reviewed articles. The findings show that value-based purchasing policies relate to improved patient safety indicators. Standardized clinical protocols and workforce competency initiatives strengthen care consistency and reduce hospital readmissions. The use of digital health technologies, such as telehealth and predictive analytics, helps optimize resources and …

Psychological Safety In Health Care: A Prerequisite For High Reliability, Sonali Thosani

Advances in Cancer Education and Quality Improvement

This paper presents a viewpoint on how psychological safety contributes to patient safety, teamwork, and high reliability.

Enhancing Patient Safety: Yellow Gown Strategy For Fall Prevention, Kimberly Nathan, Obumneke Umerah, Lorenna Garcia-Bochas, Nayda Parisio Poldiak, Jilian Sansbury

South Atlantic Division GME Research Days 2026

No abstract provided.

Devising A Protocol For Mri Clearance In Patients With Cardiac Implantable Electronic Devices (Cied), Sienna Luk, Alvin Mathew, Darshan Bhatty, Kamran Rizvi

North Texas GME Research Forum 2026

Background: Magnetic Resonance Imaging (MRI) in patients with Cardiac Implantable Electronic Devices (CIEDs) remains a logistical challenge in many clinical settings. At Medical City Denton, the absence of a standardized institutional policy has led to significant inefficiencies, including prolonged hospital stays and increased healthcare costs. The primary objective of this project was to address these barriers by developing a streamlined, evidence-based protocol to improve care coordination and resource utilization for patients with CIEDs requiring diagnostic imaging.

Methods: Launched in 2026, this pilot initiative utilized a multi-stakeholder approach involving hospitalists, EPs, radiology staff, and device representatives. A core component of the …

Advancing Safe Medication Administration During Pediatric Emergency Care Through Nurse Education: A Quality Improvement Project, Ciera Hunter

Master's Theses and Capstones

Background: Due to the increased complexities of pediatric medication administration, preventable errors occur at a higher rate than in general adult populations. Rural emergency departments (EDs) often see fewer pediatric patients and have less specialized support available on-site. Nurse continuing education is an evidence-based intervention to reduce medication administration errors making it vital to supporting patient safety and maintaining pediatric readiness.

Local Problem: The microsystem is a rural, critical access hospital in northern New England. In 2021, the microsystem scored 66/81 on the National Pediatric Readiness Project’s (NPRP’s) ED Assessment. In 2026, the score dropped 11 points to 55/81. Contributing …

Glucometer Cleanliness On A Neuro-Medical Intensive Care Unit, Abbey Camire

Operations Transformation

Glucometers on the Neuro-Medical ICU are being docked with visible reddish/brown residue, indicating they are not properly cleaned beforehand. This poses a risk of transmitting pathogens, endangering patient and staff safety, and violates hospital policy and regulatory standards. Proper disinfection of mobile medical equipment is essential for infection control and hospital accreditation.

High Reliability Organization Journey In Healthcare – Is It Just About Patient Safety?, Victor Hassid

Advances in Cancer Education and Quality Improvement

A viewpoint about patient education

Cyber Threats In Healthcare: The Ransomware Epidemic, Mackenzie Dotson, Kasi Gorli, Alberto Coustasse

Management Faculty Research

In this presentation, we will delve into the growing ransomware crisis in healthcare, examining how these cyber threats disrupt hospital operations, jeopardize patient safety, and impose significant financial burdens. From understanding how ransomware infiltrates hospital systems to exploring real-world case studies, we will uncover the devastating impact of these attacks. Our discussion will also focus on mitigation strategies, cybersecurity best practices, and policy recommendations to safeguard healthcare institutions from future threats.

Enhancing Patient Safety Through Simulated Safety Event Analysis (Ssea) In Graduate Medical Education, Mustafa Tahir, Anthony Furiato, Salman Muddassir, Olu Oyesanmi

West Florida Division GME Research Day 2025

No abstract provided.

Chaos To Calm: Utilizing Checklists In The Icu To Improve Quality During Intubations, J Dunitz, Matthew Daniel, Will Hickman, Sarah Johnson, Erik Porter

South Atlantic Division GME Research Day 2025

No abstract provided.

Enhancing Patient Safety: The Role Of Interdisciplinary Teams In Reducing Blood Culture Contamination, Fady M. Awad, Austin Patrick-Eisenberg, Brian Watson, Mohamed Faris

South Atlantic Division GME Research Day 2025

No abstract provided.

There’S A Qr Code For That: Trauma Performance Improvement, Patient Safety, And Peer Review, April Miller, Luis Taveras, Elizabeth Kim, Kathy Galt

North Texas Research Forum 2025

In preparation for our facility’s initial ACS verification visit, a Trauma Consultative Site visit in 2021 identified the need for a streamlined process to communicate issues to the Trauma Program that were recognized during patient care. This was especially true on weekends and nights when issues were most likely to occur. A recent literature review revealed implementation of electronic communication tools increased reporting of performance improvement and patient safety (PIPS) events and improved tracking and resolution of events. The authors of that study used a virtual chatroom accessible from cell phone to post PIPS events. One perceived drawback to this …

Closing The Communication Gap: A Quality Improvement Approach To Safer Shift Changes And Transfers, Stephanie O'Kresik Jewette, Annette Santiago

East Florida Division GME Research Day 2025

No abstract provided.

Optimizing Fall Prevention: A Quality Improvement Initiative To Enhance Documentation And Intervention Accuracy Using The Hester Davis Scale In Medical-Surgical Units, Kiana Conn, Brooklin Hunter-Johnson, Jashan Kahlon, Adrian Paz

Master's Projects and Capstones

Falls among hospitalized patients remain a critical safety concern, particularly in medical-surgical units caring for geriatric and oncology patients. This quality improvement project aimed to evaluate and address gaps in adherence to fall prevention protocols by utilizing the Hester Davis Scale (HDS) in two medical-surgical units at a large metropolitan hospital in Southern California. The project focused on auditing current practices to identify inconsistencies in documentation and intervention implementation, emphasizing areas such as bed alarm activation, fall risk signage placement, and armband use. Weekly audits were conducted from October 3 to October 29, 2024, to establish baseline data and inform …

Mainehealth Medical Group Report Inventory, Holly Ward, Robin Lozinski, Stephanie Lepine, Shawn Mcglaughlin White, Tracey Shaw, Sheila Adell

Operations Transformation

Variation of Epic Quality Reports being used across MHMG following the merge of Coastal, Mountain and Southern region quality departments resulting in inconsistent workflows and processes. This can lead to inconsistent care and outcomes of Quality Data we report.

The Impact Of Electronic Health Record Unintended Consequences On Quality Of Care Within A High Complexity Healthcare Organization, Joetta Powell

ATU Theses and Dissertations 2021 - Present

“Unintended consequences are unexpected, and unwanted outcomes that can limit the value of EHR implementation and adversely affect quality of care and patient safety” (Lee & Kang, 2021, p. 898). Few organizations have redesigned the EHR to improve usability to mitigate potential patient safety concerns. This study aims to identify unintended consequences in patient care workflows and determine educational needs related to EHR usability. A mixed method approach was used to investigate unintended consequences in deidentified patient safety reports submitted Jan 1, 2020, through December 31, 2023. The data was analyzed to identify error types and educational deficits. The Acute …

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

Quality and Patient Safety Archives

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

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 …

Demonstration Of The Managing For Daily Improvement Quality Improvement Methodology In An Alcohol Withdrawal Protocol Audit, Alex Stephens, Diana Hoot, Amy Cain

HCA Healthcare Journal of Medicine

Background

The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is an assessment tool designed to standardize care and minimize the risk of complications in patients experiencing alcohol withdrawal. After discovering an increase in medication errors and late assessments under this protocol, pharmacists at a 218-bed community hospital performed an audit of protocol compliance using a performance improvement methodology known as Managing for Daily Improvement (MDI).

Methods

A daily audit of CIWA-Ar protocol compliance was performed across all hospital units, followed by discussions with frontline nurses regarding barriers to compliance. The daily audit included assessments of appropriate monitoring frequency, medication …

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 …

The Effects Of Hospital-Mandated Nurse To Patient Ratios On Patient Care, Vince Latorre

Nursing | Student Research Posters

Background Nurse to patient ratios or nurse staffing is a controversial topic that is often discussed and argued in the medical field for its pros and cons. Nonetheless, the nurse to patient ratio plays a vital role on how nurses’ deliver quality care and provide safety to patients in a hospital setting. In 1999, California’s legislation passed a mandated nurse to patient ratio (AB 394) that requires all hospitals in California to have a set amount of patients a nurse can have depending on the unit the nurse works for. In 2023, California is still the only state that has …

Measuring The Patient Safety Culture At A Tertiary Care Hospital In Pakistan Using The Hospital Survey On Patient Safety Culture (Hsopsc), Fasih Ali Ahmed, Fozia Asif, Tahir Munir, Sohail Haleem, Zehra Feroze Ali, Asim Belgaumi, Hasnain Zafar, Asad Latif

Department of Anaesthesia

Background: Patient safety is a top priority for many healthcare organisations worldwide. However, most of the initiatives aimed at the measurement and improvement of patient safety culture have been undertaken in developed countries. The purpose of this study was to measure the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC).
Methods: The HSOPSC was used to measure the patient safety culture across 12 dimensions at Aga Khan University Hospital, Karachi. 2,959 individuals, who had been working at the hospital, were administered the HSOPSC in paper form between June and …

Postnatal Venous Thrombembolism (Vte) Risk Assessment In Cesarean Section Patients, Mai-Tram Phan, Michelle Ozcan

North Florida Division GME Research Day 2022

No abstract available.

Implementation Of Lean Principles During Operating Room Turnovers, Makenzie Marshall

Doctor of Nursing Practice Projects

Background

Many operating rooms across the country face the daunting task of making their turnovers between surgical patients quicker and more efficient. Turnover time is defined as the time it takes to clean an operating room and set up the next sterile field between surgical patients. The time begins when the patient leaves the operating room suite and stops when the next patient enters the same suite. Running an operating room is a complex and costly endeavor, and even small shortfalls can have a snowball effect, leading to delays, wasteful spending, and substandard patient outcomes; therefore, it is imperative to …

Implementation Of A Nonverbal Scrub Cap Identification System To Improve Communication And Perception Of Patient Safety Among Unfamiliar, De-Identified Staff Members In The Operating Room., Keri Ann Roskowinski

Graduate Theses, Dissertations, and Problem Reports (ETD)

Background: Operating room (OR), professionals deliver patient care with brief introductions, and roles were not always identified, and although team members wear identification (ID) badges, they were usually covered by sterile gowns and other routine personal protective equipment (PPE). Purpose: The aim of this Doctor of Nursing Practice (DNP) project was to determine if a simple intervention to apply the individual’s name and role to a scrub cap could improve identification, OR team communication, and consequently, patient safety. The participants in this project consisted of nurses, physicians, anesthesia providers, scrub technicians, students, medical sales representatives, and those that identified as …

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 …

The Influence Of Covid-19 Visitation Restrictions On Patient Experience And Safety Outcomes: A Critical Role For Subjective Advocates, Geoffrey A. Silvera, Jason A. Wolf Phd, Anthony Stanowski, Quint Studer

Patient Experience Journal

With the emergence of the coronavirus (COVID-19) pandemic in the United States in early 2020, hospitals across the country made the difficult decision to alter visitation policies, by either limiting visitations or restricting visitations altogether by closing access to family, friends and care partners in an effort to reduce further spread of the virus. While there is foundational research on the impact of family and care partner presence on the experience of patients and patient safety outcomes, the actions driven by the pandemic allowed for a real-time comparison of the impact of family or care partner presence or lack thereof. …

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 …