Patient Safety Commons^™

Improving Anesthesia Provider Confidence In The Identification, Management, And Treatment Of Postoperative Delirium, Brittany M. Whistle, Charles Dustin Phelps

Scholars Week

Purpose: Postoperative Delirium (POD) is a potentially devastating complication of anesthesia that is poorly understood by clinical staff leading to poor outcomes for surgical patients. This study is meant to determine if a focused knowledge presentation accompanied by visual aids could increase anesthesia providers confidence in identifying, diagnosing, and treating Postoperative Delirium.

Methodology: Utilizing a statistical model to analyze respondents results on a standardized test administered before and after an informational presentation with visual aids on the topic of Postoperative Delirium.

Results: Results indicated a statistically significant difference between pretest and posttest scores, with a p-value of .002, t(11) = …

Intimate Partner Violence Experience, Support Seeking And Coping Strategies Among Pregnant Women In Southwestern Uganda, Eve Katushabe, John Baptist Asiimwe, John Bosco Ndinawe, Editor Abeneitwe, Agnes Katusiime, Gladys Nakidde, Vincent Batwala

School of Nursing & Midwifery, East Africa

Intimate partner violence (IPV) during pregnancy remains a global health challenge. This study aimed to explore pregnant women’s experiences of IPV, support seeking, and coping strategies in Southwestern Uganda. Pregnant women who had experienced IPV during pregnancy were purposively selected and completed in-depth interviews, with data saturation reached after 25 participants. Guided by the feminist theory, data were analyzed deductively and inductively using thematic analysis. Participating pregnant women were exposed to physical violence (e.g., the gravid abdomen being stepped on), psychological violence (e.g., verbal abuse), sexual violence (e.g., being forced into uncomfortable sexual positions), and financial control and manipulation (e.g., …

Best Practice Recommendations For Anesthesia Providers In Preventing Postoperative Delirium In The Geriatric Population Undergoing Non-Cardiac Surgery, Ana Primeaux, Ashanti Reed

Doctoral Projects

Postoperative delirium (POD) is a significant and preventable complication in geriatric patients undergoing non-cardiac surgery. Such complication is associated with foreseeable consequences, such as prolonged hospitalization, long-term cognitive decline, increased morbidity and mortality, and increased costs. Despite the emerging awareness of evidence-based nonpharmacologic and pharmacologic interventional strategies, POD still represents a clinical challenge for anesthesia providers.

Currently, there is a lack of clinical guidelines to guide formalized education and evidence-based interventions on POD prevention across anesthesia practice settings. Consequently, there is a critical need to raise awareness that the lack of clinical guidelines and the high incidence of POD may …

America's Physician Shortage: Look To Pas, Not Abroad, Raquelle Akavan, Laura Juarez

Lynchburg Journal of Medical Science

The United States has long addressed physician shortages by recruiting international medical graduates (IMGs), often from low- and- middle income countries. This "brain drain" deprives already fragile health systems and adds to worldwide health disparities. New state legislation has eased licensing standards for IMGs and generated variable training pathways creating patient safety risk in underserved groups. At the same time, the U.S. has a sustainable, highly trained, and proven ready workforce: physician associates (PA). Created in the 1960s to address physician shortages, PAs undergo intensive graduate-degree education, uniform clinical education, and national certification on par with physicians. Nonetheless, obsolete laws …

Enhancing Patient Outcomes: Developing A Comprehensive Database For Tracking Post- Dural Puncture Headache Incidence And Contributing Factors, Meredith B. Auge, Brittany Bogonovich

Doctor of Nurse Anesthesia Practice (DNAP) Manuscripts

Post-dural puncture headache (PDPH) is a debilitating complication following labor analgesia, often resulting from unintentional dural puncture (UDP). While national incidence is approximately 1.5%, institutional rates may vary due to provider experience, documentation practices, and patient factors. This Doctor of Nurse Anesthesia Practice (DNAP) quality improvement project aimed to improve identification and monitoring of UDP and PDPH through a revised tracking tool, retrospective review of 2024 data, and planning for an electronic registry. A multidisciplinary team of anesthesiologists, Certified Registered Nurse Anesthetists (CRNAs), Student Registered Nurse Anesthetists (SRNAs), and IT and quality specialists revised an existing tracking tool to better …

2025 Qi Forum Agenda, Equip Program Office Ogme

Quality Improvement & Patient Safety Forum

No abstract provided.

Developing A Culturally Sensitive Nursing Framework For Muslim Patients Practicing Ramadan: Focusing On Fasting Benefits And Islamic Dietary Recommendations, Amreen M. Munshi

Nursing | Senior Theses

Background: Muslims practice Ramadan, a month-long period of fasting from dawn to dusk, yet many healthcare providers lack knowledge of its principles and practices. Hospitals lack formal education on caring for fasting Muslim patients, leading to a knowledge deficit in cultural competence and sensitivity of Islamic practices. Purpose: This paper proposes a research design for a nurse education program on Ramadan fasting to promote cultural competence and sensitivity in nursing care. The proposed research aims to educate nurses on Islamic practices, particularly Ramadan, to bridge the cultural competency gap. The literature review also explores the health benefits of …

Resilience And Reality: Exploring The Lived Experiences Of People Living With Hiv In Texas During The Covid-19 Pandemic – A Qualitative Study., Ahmed F. Alanazi

Social Work Dissertations - Archive

This study investigated the lived experiences of individuals living with HIV (PLWH) in the Dallas-Fort Worth (DFW) area of Texas during the COVID-19 pandemic, using an Interpretative Phenomenological Analysis (IPA) framework. The research examined the intersection of health, social dynamics, and psychological resilience among PLWH, who faced compounded vulnerabilities due to systemic inequities and the dual public health crises of HIV and COVID-19. Through semi-structured interviews with ten participants from diverse backgrounds, the study captured the profound impacts of disrupted healthcare systems, heightened stigma, and social isolation on this marginalized population. The findings reveal that the pandemic exacerbated existing inequities …

Developing A Culturally Sensitive Nursing Framework For Muslim Patients Practicing Ramadan: Focusing On Fasting Benefits And Islamic Dietary Recommendations, Amreen Mahmood Munshi

Nursing | Student Research Posters

Background: Muslims practice Ramadan, a month-long period of fasting from dawn to dusk, yet many healthcare providers lack knowledge of its principles and practices. Hospitals lack formal education on caring for fasting Muslim patients, leading to a knowledge deficit in cultural competence and sensitivity of Islamic practices. Purpose: This paper proposes a research design for a nurse education program on Ramadan fasting to promote cultural competence and sensitivity in nursing care. The proposed research aims to educate nurses on Islamic practices, particularly Ramadan, to bridge the cultural competency gap. The literature review also explores the health benefits of …

Neurohospitalist Core Competencies, Jana J Wold, Jetter Robertson, Jerome A Jeevarajan, Molly G Knox, Prateek Thatikunta, Guillermo E Solorzano, Kristin Galetta, Shefali Dujari, Tarini Goyal, Matthew E Ehrlich, Jonathan P Donnelly, Elizabeth Marriott, Vishal A Mandge, Roshni S Dhoot, Matthew W Luedke, Matthew B Maas, Margaret Y Yu, Michel Toledano, Rafid Mustafa, Jamie L Palaganas, Kathryn Kvam, Rachelle Dugue, Ethan Meltzer, Lahoud Touma, Maulik P Shah, Vanja C Douglas, Karen Orjuela, Brian J Scott, Joshua P Klein, David J Likosky, Jennifer R Simpson, Megan B Richie, Carolin Dohle, Jane G Morris, Carl A Gold

Faculty, Staff and Student Publications

The Neurohospitalist Core Competencies comprise a set of competency-based learning objectives that encapsulate the knowledge, skills, and attitudes of neurohospitalitists who specialize in the care of hospitalized patients with neurologic conditions. These competencies serve to characterize the rapidly expanding field of neurohospitalist medicine. The 27 chapters are divided into 3 sections entitled: neurological conditions, clinical interventions and interpretation of ancillary studies, and neurohospitalist role in the healthcare system. Each individual learning objective in the chapters describes a specific concept with an action verb to illustrate the behavior that the neurohospitalist exhibits. The individual neurohospitalist may not exhibit mastery in each …

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

HCA Healthcare Journal of Medicine

Background

Blood cultures are vital to diagnostic workups among many hospitalized patients, providing valuable information about bloodstream infections (BSIs), which cause roughly 250 000 deaths annually between North America and Europe. Despite advances in health care, blood culture contamination remains a substantial problem, with deleterious effects on patient mortality, patient and hospital costs, and microbial resistance. This article reviews the repercussions of blood culture contamination on the health care system and delineates evidence-based strategies to decrease contamination rates.

Methods

To reduce blood culture contamination rates, our health care facility undertook a quality improvement initiative. A task force was created, consisting …

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 …

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 …

Teaching Medical Procedural Skills For Performance, Kersi Taraporewalla, Paul Barach, André Van Zundert

College of Population Health Faculty Papers

Procedures are a core element of medical professional practice. Today's training approach was formulated in the mid-twentieth century based on a computer analogue of the brain. Despite minor modifications, the system has remained relatively unchanged for the past 70 years. It delivers competence. However, competence is not reliable performance. The inability to adapt to the variety of patients and variations in the performance environments, such as the operating room, results in patient morbidity and mortality. There is a need for changes in the development and training of medical procedural skills based on current theories of skill acquisition, movement theory, and …

Stopping The Bleed At Uri, Emily Lefebre

Senior Honors Projects

The number one cause of preventable death is uncontrolled bleeding from traumatic injury. From the unlikely scenario of a school shooting, to a campus car accident or an injury during a sports or club event, possessing skills to effectively stop a life-threatening bleed becomes a matter of life or death. The American College of Surgeons Committee on Trauma (ACS COT) STOP THE BLEED® program is a campaign to teach communities how to respond effectively and efficiently to life-threatening bleeding in emergencies. STOP THE BLEED® aims to empower individuals with the knowledge and skills to stop severe bleeding by tourniquet application, …

Pcos: Comparing Inositol Supplementation To Metformin Treatment, Caitlin Liechti-Hawkins

University Honors College

The purpose of this literature review is to compare the viability of inositol versus metformin for the treatment of polycystic ovarian syndrome (PCOS). The research outlines the criteria for diagnosis and the many symptoms associated with the condition. The aim is to discover if inositol should be recommended for PCOS symptoms as a replacement for metformin. It was found that safety and popularity of the two options were important factors for physicians and patients to consider before choosing a treatment. Within these scopes, adverse effects, costs, regulation, and belief of treatment were compared. Findings indicated that inositol supplementation may possibly …

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 …

Everyone Deserves A Dental Home, Loren C. Baim Dds

The New York State Dental Journal

With knowledge and preparation, dental practices should be able to accommodate the growing population of people on the autism spectrum.

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 …

Early Immersion In Team-Based Event Review: Experiential Patient Safety Education For Pgy 1 Internal Medicine Residents, Michelle Perkons, Alexis Wickersham, Sonia Bharel, Timothy Kuchera, Rebecca Jaffe

Department of Medicine Faculty Papers

INTRODUCTION: In recent years, there has been a national push to incorporate high-fidelity quality improvement and patient safety (QIPS) education into physician training programs. In fact, integration of robust patient safety education became an Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirement for residency programs in 2017. We developed a curriculum to not only fulfill the ACGME's requirement but also provide PGY 1 internal medicine residents with the skills needed to become active participants in ongoing patient safety work throughout their training and careers.

METHODS: Our patient safety curriculum was woven into residents' existing protected educational time and …

Reimagining Equitable Care: Simulation-Based Education And The Dismantling Of Implicit Bias And Stigma Of Vulnerable Populations In Hospitals, Vanessa Smith

Nursing | Senior Theses

Background: Simulation-based education consists of using high-fidelity mannequins and equipment to provide a safe space for healthcare professionals to practice crucial skills within healthcare. Used within hospitals and schools, simulation most commonly surrounds practicing hands-on skills such as central line insertion, IV insertion, Ultrasound-guided procedures, code blue response, etc. However, a large portion of healthcare that is overlooked is tackling issues within patient-provider relationships. Simulation can help dismantle the negative behaviors and feelings providers push onto patients through the use of standardized patients and role-playing. By using these methods, simulation can reduce providers’ personal implicit biases and the stigma associated …

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 …

Evaluating Healthcare Workers’ Knowledge, Attitudes, And Practices Regarding Language Access Services In The Clinical Setting, Rachel Archibald

DNP Projects

Background: Barriers to accessing and understanding healthcare can place patients with low English proficiency at an increased risk of poor health outcomes. Language-based inequities in healthcare exist due to lack of interpretation and translation services available, lack of healthcare workers’ knowledge of resources, and/or perceptions that these services require too much time or effort. Failing to address barriers affecting this population leaves them vulnerable in the healthcare setting.

Purpose: The purpose of this DNP project was to educate nurses, providers, and staff on an inpatient unit at a rural hospital of the language interpretation resources available, best practices for implementation, …

Using Education To Confidently Identify And Report Concerns Of Child Abuse And Neglect: A Qualitative Improvement Initiative Through Staff Development, Sarah E. Neilson

Master's Theses and Capstones

BACKGROUND: Pre-licensure education on child abuse and neglect is crucial for nurses in the healthcare field. It helps to equip them with the knowledge and skills necessary to effectively identify, report, and intervene in cases of child abuse and neglect. Having this education available and understanding the signs and effects of child abuse and neglect, empowers nurses to take quick and decisive action in early intervention and prevention. Within the microsystem of a local Operating Room (OR), this quality improvement (QI) project will determine the muchneeded addition to the healthcare curriculum.

METHODS: The Plan, Do, Study, Act (PDSA) framework was …

An Interactive, Case-Based Workshop On The Patient Experience For Internal Medicine Residents, Julian Swanson, Doris Lin, Kristen A Staggers, Priti Dangayach

Faculty, Staff and Students Publications

INTRODUCTION: The technological revolution has narrowed the information gap between physician and patient. This has led to an evolution in medicine from paternalistic to patient-centric, with health care systems now prioritizing patient experience to achieve higher satisfaction scores. Therefore, it is imperative to start early in educating trainees on how to best address the holistic needs of the patient while also delivering high-quality care.

METHODS: We implemented a 1-hour workshop that was repeated weekly over 8 weeks to capture all internal medicine residents in our program. During the workshop, we reviewed the historical evolution of patient care from paternalistic to …

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 …

Evaluating The Efficacy Of Chatgpt In Navigating The Spanish Medical Residency Entrance Examination (Mir): Promising Horizons For Ai In Clinical Medicine., Francisco Guillen-Grima, Sara Guillen-Aguinaga, Laura Guillen-Aguinaga, Rosa Alas-Brun, Luc Onambele, Wilfrido Ortega, Rocio Montejo, Enrique Aguinaga-Ontoso, Paul Barach, Ines Aguinaga-Ontoso

Department of Medicine Faculty Papers

UNLABELLED: The rapid progress in artificial intelligence, machine learning, and natural language processing has led to increasingly sophisticated large language models (LLMs) for use in healthcare. This study assesses the performance of two LLMs, the GPT-3.5 and GPT-4 models, in passing the MIR medical examination for access to medical specialist training in Spain. Our objectives included gauging the model's overall performance, analyzing discrepancies across different medical specialties, discerning between theoretical and practical questions, estimating error proportions, and assessing the hypothetical severity of errors committed by a physician.

MATERIAL AND METHODS: We studied the 2022 Spanish MIR examination results after excluding …

Discordant Cardiopulmonary Resuscitation At An Academic Midwest Medical Center- Prevalence And Solutions, Jeremy Payne, Anne Skinner, David Gannon, Jenenne A. Geske

Graduate Medical Education Research Journal

Background: Code status orders are important features of patient-centered clinical decisions, patient autonomy, and end-of-life care. Despite proper documentation of “do not resuscitate” (DNR) code status, hospitalized patients may be subjected to cardiopulmonary resuscitation (CPR) efforts that go against their wishes.

Purpose: The objective of this study was to identify and describe the population of hospitalized patients receiving discordant resuscitation efforts at a Midwest academic medical center utilizing electronic health records (EHR).

Method: The study included EHR records between 01/01/2011 and 01/01/2021 for hospitalized patients 19 years and older who experienced cardiac arrest (ICD-10 I46) and were documented as DNR. …

Proactively Preventing Medical Errors: A Student-Led Approach To Patient Safety In Pre-Clinical Curriculum, Sahar Panjwani, Daniel Nwosuocha, Nelson D. Gonzalez, Ayleen Godreau

Research Symposium

Introduction: Preventable medical errors are currently the third leading cause of death in the United States following heart disease and cancer (1). This study was designed to assess the change in knowledge from earlier education of medical students during pre-clinical years.

Methods: Patient safety trainings have been conducted for two years for interested first and second-year medical students and responses are assessed through a pre-test, immediate post-test, 3-month post-test, and 6-month post-test. The survey assesses student knowledge on aspects of patient safety and has Likert scale questions assessing if the training influenced students’ desire to learn about patient safety. …