Patient Safety Commons^™

Preventing The Next Fall: The Power Of A Simple Checklist In Reducing Patient Falls, Ryan P. Bialaszewski, Michael Sander, Maria Hincapie, Rita Garza, Aurora Cavazos

MEDI 9331 Scholarly Activities Clinical Years

Background:
Preventable medical errors and adverse events in US hospitals are far too common and contribute to an estimated $17 billion annually in healthcare expenditures. Falls comprise the majority of these preventable adverse events and are a significant cause of increased healthcare costs, prolonged hospital stays, and patient morbidity and mortality. The average cost per hospital fall is estimated at $62,521 ($35,365 direct costs). Despite numerous preventative measures, the complexity of managing multiple interventions can lead to inconsistent application. Inspired by the success of surgical "time-out" checklists in operating rooms, we hypothesized that a standardized checklist for fall prevention could …

Pbpa Creating Pathways To Ensure Patients Are Using Their Inhaled Medications Effectively, Suzan Michelle Collins, Heather Blake, Chandler Blodgett, Sue Vermette, Martine Eon

Operations Transformation

Problem: Patients do not consistently know how to prepare, use and/or clean their inhalers effectively.

Impact: When patients do not consistently know how to prepare, use and/or clean their inhalers effectively they are in fact, not receiving the benefit from their prescribed medication.

They experience poor patient outcomes and overall poor patient experience.

• Increased calls to provider offices for unresolved, worsening symptoms and/or complications. (Thrush, hoarseness, cardiac symptoms etc.)
• Increased same day office visits.
• Patient crowding in Urgent Care and/or Emergency Department.
• Hospital Admissions.
• Increase in emotional and financial stress from missing school and/or work.
• Increase in referrals to specialists …

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.

Mainehealth Cancer Care Network Ticket Intake Process, Lauren Couture, Brett Cropp, Gavin Carr, Ashok Kunche, Heather Boulier, Evelyn Taylor

Operations Transformation

The MaineHealth Cancer Care Network informatics team is manually submitting most reporting tickets for oncology customers. The current intake ticket process includes various communication channels to the business intelligence developers [BID] when a reporting need is identified resulting in workflow deficiencies and redundancies. As of FY23, MaineHealth has moved to a new ticket reporting system called ServiceHub which includes new customer self-service tools that have not yet been utilized.

Creating Capacity To Accommodate Additional Cardiac Catheterization Procedures, Kristin Anthony

Operations Transformation

Patient access to diagnostic outpatient (OP) cardiac catheterization is limited by a perceived lack of capacity. Outpatient cardiac cath pts flow through the ACU for pre/post procedure care. Current schedule limits pts that may be scheduled through the ACU to two OP procedures/day. Cardiologists request the ability to schedule beyond the two procedures/day allowed. Significant variation in pre/postoperative care orders exist amongst cardiologists resulting in variability in length of stay. Cardiac procedures are booked either as 60/90/120 minutes – Epic case averaging technology is not active in the cath lab. As a result, the case minutes in the cath lab …

Transition To Adult Care For Bleeding Disorders: Building A Multidisciplinary Tool, Leslie Larson, Ekaterina Funk, Dana Grass, Felicia Munster, Eric Larsen, Louise Baca, Glen Roy, Sara Artinyan

Operations Transformation

Youth with chronic illnesses often have poorer health outcomes after transitioning to adult care. Maine Health Bleeding Disorders is a Health Resources and Services Administration (HRSA) grant funded Hemophilia Treatment Center (HTC) that serves patients with congenital bleeding disorders. We provide multidisciplinary specialty care throughout the lifespan which includes pediatric and adult hematologists, family nurse practitioners, nurses, physical therapists, social worker, dietitian, genetic counselor, and research coordinator. In 2022, HRSA mandated all federally funded HTCs increase by 25 percent from baseline the number of individuals ages 12 to 26 years seen in a comprehensive clinic that have a health care …

Outcomes Of Thoracic Endovascular Aortic Repair (Tevar) Procedure In Octogenarians, Nonagenarians And Centenarians: A Population-Based Study, Dakota B. Pastore, Tony Elias, Rafail Beshai, Kyrillos Girgis, Maziyar Daneshvar, Keith Anacker

Rowan-Virtua Research Day

Introduction: Limited data exists for patients undergoing a thoracic endovascular aortic repair (TEVAR) procedure who are older than or equal to 80 years old (YO). This study sought to examine the national inpatient sample (NIS) database to describe in-hospital outcomes among these older patients.

Methods: The NIS was searched for hospitalizations of adults who underwent a TEVAR procedure in 2019 and 2020. The study compared those aged 80 YO and over to those younger than 80 YO. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay (LOS), and total hospital charges (TOTHCG).

Results: This study included …

The Effects Of Psychedelic Microdosing On Mental Health: A Systematic Review, David F. Lo, Hasan Zia, Adarsh Thakur, Praneetha Rajkumar, Don D. Shamilov

Rowan-Virtua Research Day

This poster explores the effects of psychedelic microdosing on mental health conditions. Roughly 5.5 million individuals in the U.S. utilize psychedelics to treat their mental health issues. The primary substances used for microdosing currently include LSD and psilocybin, but mescaline, DMT, and amphetamines are used less commonly. This systematic review included 16 unique articles. The types of articles included: observational, placebo, self-reported, motivational, literature review, and comparative studies. The studies indicated lower levels of anxiety, depression, and stress among those that microdose. However, drawbacks such as difficulty sleeping and headaches were reported. Various studies have been published on the effects …

Evaluation Of Unexplained Bone Fractures In A 3-Month-Old Infant – A Case Report, Hannah Ngo, Rachel Silliman Cohen

Rowan-Virtua Research Day

Child physical abuse is a significant cause of injury in infants and young children and can present in a variety of ways. Failure to recognize abuse in infants and young children can be life-threatening and is often recurrent until safety interventions occur. Consequently, it is of paramount importance that providers strongly consider child physical abuse on the differential, along with metabolic bone disease and accidental traumatic injury, when evaluating fractures in young children and infants. This case report will focus on the evaluation of a 3-month-old male infant who was admitted to the hospital with irritability and decreased right arm …

Does Esketamine In Cesarean Delivery Increase Postoperative Adversities And Related Diseases?, Cheryce Daniel, Kylon Coombs

Rowan-Virtua Research Day

Esketamine has emerged as a promising treatment option, particularly noted for its effectiveness in reducing postpartum depression, alleviating pain, and promoting faster recovery. Despite its therapeutic benefits, recent research has raised concerns regarding potential adverse effects associated with high doses of esketamine in patients. Specifically, there is growing interest in understanding the potential risks linked to the administration of esketamine during cesarean delivery, given its increasing use in obstetric anesthesia.

This comprehensive review aims to investigate the potential associations between the use of esketamine during cesarean delivery and the subsequent risk of related diseases or physiological disorders. The goal is …

Barriers In Obtaining A Naloxone Co-Prescription For Patients Who Are Prescribed Opioids For Pain Management, Sonika Vatsa

Rowan-Virtua Research Day

As the prevalence of chronic pain rises, the number of patients prescribed opioids is increasing. Consequently, the rate of opioid overdose has increased, becoming a public health concern.For these reasons, the Center for Disease Control and Prevention recommended co-prescribing naloxone, a medicine that reverses the effects of opioid overdose.While this medication can be lifesaving, it is not accessible or available to everyone in need of it. A systematic review of existing literature pertaining to the barriers in patients receiving naloxone was conducted to evaluate the major obstacles in patients receiving a naloxone co-prescription. The results show that the major deterrents …

Addressing The Black Maternal Mortality Rate, Kennedy Sanders, Venkateswar Venkataraman, Kate Whelihan

Rowan-Virtua Research Day

Introduction: As of 2021, the Black maternal mortality rate in the United States was 69.9 deaths per 100,000 live births as compared to the national average of 32.9 and the White American average of 26.61. It has been demonstrated that this discrepancy is not fully explained by socioeconomic status. Doulas are professionals who provide support and guidance throughout pregnancy, birth, and early parenthood. Encouraging the use of doulas may be an effective approach to improve the birth experience for Black mothers. Methods: A literature review was performed using PubMed and the following search strings: maternal mortality rate (+race, +race +ethnicity, …

Healthcare Provider Engagement And Its Effects On Patient Rereferral: Insights From Indonesia, Felicia Setiawan

Makara Journal of Health Research

Background: In the highly competitive landscape of healthcare, nurturing strong relationships between referring healthcare providers and healthcare facilities is essential for maintaining patient loyalty. This study explores the factors influencing referring health care provider engagement and its subsequent impact on the willingness to rerefer to healthcare facilities.

Methods: A cross-sectional quantitative survey was conducted with 181 healthcare providers who regularly refer patients to a private hospital in Jakarta. Data were collected through an online structured questionnaire consisting of 29 questions. The following dimensions were covered: specialist characteristics, practice characteristics, healthcare provider–specialist interaction, patient–specialist interaction, returning referral, training opportunity, …

Educating Nurses On Frequent Oral Care For Mechanically Ventilated Patients: An Evidence-Based Practice Project Proposal, Grace Alford, Susan Butz, Ruth Chavez, Joy Shoemaker

Doctor of Nursing Practice Scholarly Projects

The final scholarly project proposal is to implement oral care education for nurses in an intensive care unit (ICU). The proposal aims to create a guideline for an investigator to implement oral care recommendations for mechanically ventilated patients in order to reduce ventilator-associated pneumonia (VAP). The proposal consists of obtaining VAP data and oral care charting data for the unit studied, steps for providing oral care education, and analysis recommendations. Oral care involves swabbing the patient’s mouth every two hours with a swab and mouthwash. Oral care education would include handouts and direct teaching. The proposal aims to increase oral …

Implementation Of A Standardized Suicide Screening Process In A University Student Health Clinic: A Quality Improvement Project, Addie Grace Strong, Kathryn Dambrino, R. David Phillippi, Linda Wofford

DNP Projects

Background: Suicide is a leading cause of death among college age students, prompting the need for evidence-based screening tools like the Columbia Suicide Severity Rating Scale (C-SSRS) to enable early detection and timely intervention. Inconsistencies in suicide screening may pose a risk of missed intervention opportunities. This Doctor of Nursing Practice project specifically aimed to improve the quality and consistency of suicide screening in a university student health clinic by implementing the C-SSRS tool into the clinic workflow during mental health appointments. Methods: Employing a quality improvement framework, this scholarly project followed the Institute for Healthcare Improvement Model for Improvement …

J Mich Dent Assoc April 2024

The Journal of the Michigan Dental Association

Every month, The Journal of the Michigan Dental Association provides news, information, and features about Michigan dentistry to our state's oral health community and the MDA's 6,200+ members. It stands as the primary publication reaching Michigan dentists.

In the April 2024 issue, the Journal focuses on the landscape of practicing in rural settings. Original content includes:

• A cover story highlighting Michigan’s Donated Dental Service Program
• A feature on Michigan’s Revised Kindergarten Oral Health Assessment Law
• A feature article on the origins, future, and use of the CDT Code
• Profiles of the 2024-25 MDA Officer, Trustee and ADA Delegation candidate
• An …

Governmental Affairs Update, Neema Katibai Jd

The Journal of the Michigan Dental Association

The article presents the American Dental Association's federal advocacy achievements during the first half of the 118th Congress. The ADA has made significant strides in influencing policy and regulations across various categories, including workforce issues, dental insurance reform, access to care, student loan debt, Medicaid, practice management, veterans' affairs, health information technology, and public health. Their efforts span from urging legislative action to collaborating with federal agencies and Congress members. These accomplishments showcase the ADA's commitment to advancing dental profession interests nationally.

A Pharmacist’S Central Role In Improving Hormonal Contraceptive Access, Aleese Smith, Urvi Patel, Alexandra Arledge, Josie Young, Erin Johanson

Annual Research Symposium

In 2019, the roles of Utah pharmacists grew with the implementation of a statewide standing order allowing prescribing abilities for hormonal contraceptives. With the rates of unplanned pregnancies in Utah up to 1 in every 5; pharmacists have a new role in birth control distribution. Pharmacists and pharmacy interns across the state of Utah are able to prescribe self-administered hormonal contraceptive medications including: oral pills, vaginal insertion medications, and birth control patches. Pharmacists are entrusted with the responsibility to evaluate the patient and their needs to ensure all women receiving birth control are educated about the risks and side effects …

Effectiveness Of Antibiotic Stewardship For Healthcare Providers At Urgent Care Clinics, Helen T. Adewole

Electronic Theses and Dissertations

Antibiotics have revolutionized modern medicine; however, the overuse in urgent care and primary care significantly contributes to the global burden of infections resistant to available antimicrobial medicines. Approximately 30% of the antimicrobials prescribed in acute care settings are unnecessary. Patient demand for antibiotics has seemingly skyrocketed following the recent COVID-19 pandemic. Practitioners must be knowledgeable about antibiotic stewardship initiatives, such as the wait-and-see approach, to reduce antibiotic overuse and improve the trajectory of antibiotic resistance and patient health outcomes. The gap in practice was the limited awareness of scientific evidence-based tools to partner with patients and improve antibiotic prescription patterns. …

Outpatient Fall Prevention In Ambulatory Adults 65 Years Old And Over, Dorothy L. Osborne-White

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background: In the United States (U.S.), falls are the leading cause of injury among adults 65 and over, resulting in 36 million falls yearly (Moreland et al., 2020). According to the Centers for Disease Control and Prevention (CDC, 2023), one in four older adults experiences a fall each year. Falls are the world's second most prominent cause of accidental deaths (World Health Organization [WHO], 2021). Falls are the leading cause of both fatal and non-fatal injuries among older adults (Moreland et al., 2020).

Methods: A quality improvement project that included a fall bundle was implemented in a primary clinic. A …

Clinical Practice Guideline For The Management Of Depression In Primary Care, Estrella Catherine Villarreal

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background: The prevalence of depression poses a significant challenge in primary care, emphasizing the urgent need to address this issue during patient visits. Primary care providers are at the forefront of managing depression, yet they encounter difficulties in screening, diagnosing, assessing, and treating this complex condition. Clinical guidelines serve as valuable tools for primary care providers and practices, offering support in identifying and addressing depression effectively. An evidence-based approach to treating depression in primary care, with a focus on collaborative interventions with behavioral health to enhance depression management for American Indian/Alaskan Native (AI/AN) communities.

Methods: The descriptive analysis was conducted …

Role Of Social Determinants Of Health And The Renin- Angiotensin Aldosterone System In Risk For Hypertensive Disorders Of Pregnancy And Related Adverse Outcomes., Esther Letushila Ndashaala

Theses and Dissertations--Nutrition and Food Systems

Background: Hypertensive disorders of pregnancy (HDP) represent a significant public health issue, contributing to maternal and fetal morbidity and mortality. Women from lower socioeconomic backgrounds or marginalized racial and ethnic groups face higher risks of HDP, which have been incompletely described. In addition, risk for HDP may be linked to a reduction in the normal activity of the renin-angiotensin-aldosterone system (RAAS). This study investigates the role of socioeconomic factors and RAAS components in the risk for HDP and adverse maternal and neonatal outcomes. Methods: This study is a secondary analysis of data from 180 pregnant individuals from a high-risk maternal-fetal …

Wellness In Motion: A Quality Improvement Initiative To Support Resident Mobility And Reduce Falls., San N. Pham

Master's Theses and Capstones

Background: Falls are a significant concern in community living centers for older adult veterans. Promoting physical activity and resident engagement is crucial for reducing fall risk among this population.

Local Problem: A specific microsystem within this setting has a fall rate of 3 falls per month. This discrepancy underscores the need for targeted interventions to effectively address this issue.

Methods: This study measured key metrics related to falls and resident engagement in mobility programs both before and after the implementation of an exercise program within the microsystem.

Intervention: The "GIMME 10" exercise program, grounded in evidence-based practices and emphasizing resident-centric …

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…..

Exploration Of The Implementation Of An Integrated Electronic Laboratory Information Management System On Quality Diagnostics Service Indicators At A County Level Public Hospital In Western Kenya., Kelly Allen

Capstone Collection

Underinvestment in pathology and laboratory capacity caused by low visibility in research and in prioritization by public health leaders results in limited effective healthcare coverage and an estimated 1.1 million premature deaths annually in Low-and-Middle-Income Countries. Kenya’s public health laboratories provide a median 41% of the Essential Diagnostic List to their patients and in Kisumu County, as much as 44.2% of the population has little to no access to essential diagnostics. The government of Kisumu implemented the county Health Laboratory Strategic Plan 2018-2022 to address this public health challenge. Little information exists on the effectiveness of these initiatives and the …

A Helping Hand Out Of The River: Refugee Perspectives For Provider Engagement, Brian L. Isakson, Elizabeth R. Stein, Alexandra Olson, Destiny Waggoner, Jill Holtz, Sara Ali, Suha Amer, Martin Ndayisenga

Journal of Patient-Centered Research and Reviews

Purpose: A growing number of refugee groups are seeking care within the U.S. health care system for medical, psychological, and social needs. Research is limited in understanding refugee-specific conceptualizations of helping relationships and provider characteristics that improve interactions in health systems. This study aimed to identify provider characteristics that facilitate engagement and helpfulness in a refugee-specific population from refugee participant voices to inform future practices of health care clinics.

Methods: Semi-structured interviews with refugee participants were conducted to assess 1) experiences moving on from difficult experiences, 2) engagement with the health system, and 3) provider characteristics that facilitated engagement and …

Improving Access To Cardiac Catheterization, Sunitha Dharman

Student Scholarly Projects

The American Heart Association lists cardiovascular disease as the underlying cause of death for 874,613 people who lost their lives in 2019 (Tsao et al., 2022). On average, someone in the United States has a myocardial infarction every 40 seconds, and someone dies of a stroke every 3 minutes and 30 seconds. Studies support coronary artery disease as a significant contributor to cardiac arrest in a non-hospital setting (Yannopoulos et al., 2019). The authors provide evidence supporting the importance of early cardiac catheterization. There is a 10-15% survival rate with a higher level of functioning compared to delayed or no …

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 …

The Fortify Resilience Initiative, Nausheen Jamal, Deepu George, Maria Hernandez, Evan Garcia, Myrna Ruiz, Salvador Arellano Iii

Research Symposium

Purpose: The Fortify Resilience Initiative focuses on building and sustaining a culture of wellbeing for Residents and Fellows (R/Fs) at The University of Texas Rio Grande Valley (UTRGV) School of Medicine’s (SOM) Graduate Medical Education (GME) residency and fellowship programs. In order to address the multitude of threats to physician wellness and to mitigate the silent, but pernicious effects of burnout on these physician learners serving in the RGV, this Initiative from the Office of GME will strengthen existing wellbeing pathways while expanding additional solutions that will work to sustain wellbeing. Utilizing a combination of prevention, promotion, and intervention strategies …

Interdisciplinary Integrated Primary And Behavioral Healthcare (I2pbh) Initiative, John Ronnau, Deepu George, Maria Hernandez, Evan Garcia, Myrna Ruiz

Research Symposium

Purpose: The Interdisciplinary Integrated Primary and Behavioral Healthcare (I²PBH) initiative will train University of Texas Rio Grande Valley (UTRGV) mental health graduates to deliver high quality, evidence-based Integrated Behavioral Health (IBH) services in the Rio Grande Valley (RGV) – a high-need, high-demand, medically underserved Hispanic region along the US-Mexico border. Specifically, the I²PBH initiative will train 24 UTRGV mental health graduates annually to deliver high-quality Integrated Behavioral Health (IBH) clinical services through the evidence based Primary Care Behavioral Health (PCBH) model. With a training emphasis on basic/advanced theory and clinical skills in the PCBH model, students …