Patient Safety Commons^™

Comparison Of Selected Supply Chain Management Practices Of Three Major Regional/Metropolitan Hospitals, Alan D. Smith

Atlantic Marketing Association Proceedings

No abstract provided.

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) = …

Developing Nlp-Based Open-Source Tools To Improve Titratable Infusion Order Interpretation In Ehr Systems, Benjamin Brewer, Jay Dorris

Student Scholar Symposium

This study evaluates the feasibility of using natural language processing (NLP) tools to identify errors in titratable infusion orders for Joint Commission readiness. Titratable infusions are adjusted at the bedside by nurses based on predefined parameters, such as monitoring goals, titration rate, conditions for adjustment, and maximum dose. These parameters are often documented as free text within order sets but can be inadvertently removed during the verification process. Some electronic health records (EHRs) may not prominently display this critical information, leading to potential Joint Commission violations. A synthetic dataset was generated using artificial intelligence to simulate one year’s worth of …

Delayed Diagnosis Of Systemic Lupus Erythematosus Presenting As Autoimmune Hemolytic Anemia: A Case For Heightened Clinical Suspicion, Diana Acosta Pozo, Luis Álvarez Pérez

Research Colloquium

Background: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem involvement, including hematologic manifestations. Autoimmune Hemolytic Anemia (AIHA), though an established feature, is relatively uncommon and may occur early or in isolation. When AIHA presents without overt systemic symptoms, the underlying autoimmune etiology may be overlooked, resulting in delays in diagnosis and treatment. Prompt recognition is essential to prevent unnecessary interventions and prolonged morbidity.

Case Presentation: A 39-year-old woman residing in Texas presented to the Rheumatology office with persistent synovitis and severe transfusion-dependent anemia, requiring red blood cell transfusions every 48 hours for over three months. She …

Enhancing Colorectal Cancer Screening Awareness In A Primary Care Clinic Through Visual Aids And Posters: A Quality Improvement Initiative, Austin W. Wheeler Md

Quality Improvement & Patient Safety Forum

No abstract provided.

Un Momento: Can We Talk?, David Mas Md, Mph, Madelyn Lavergne Md, Claudius Jean Baptiste Md, Deidre Stelly Md

Quality Improvement & Patient Safety Forum

No abstract provided.

From Shrugs To Skills: Mastering The Shoulder Exam In The Family Medicine Clinic, Thomas Vu Md, Arden Lagrone Md, Patrick Orange Md, Raquelle Collins Md

Quality Improvement & Patient Safety Forum

No abstract provided.

Increasing Exposure To Interprofessional Roles: Creating A Culture Of Appreciation And Collaboration Across Manning Family Children's Interprofessional Groups, William Arnold Md, Alexandra Glaser Md, Andree Judd Do, Anne Reed Md, Courtney Suiter Md, Caroline T. Moreau Md

Quality Improvement & Patient Safety Forum

No abstract provided.

Utilization Of Lung Cancer Screening Methods In The Primary Care Setting And Proposing Methods For Improvement, Michael Olejniczak Md

Quality Improvement & Patient Safety Forum

No abstract provided.

Is The Juice Worth The Squeeze: Anti-Xa Monitoring In Trauma Patients, Megan Dupont Bs, Jennifer M. Brewer Md, Alison A. Smith Md, Phd, Patrick Greiffenstein Md, Roslyn Alexander Do, Lillian Bellfi Pharmd

Quality Improvement & Patient Safety Forum

No abstract provided.

Improving Surgical Site Preparation In Open Abdomen Cases: A Quality Improvement Protocol For The Trauma Service, Jacob Chaisson Bs, Terri Fetty Bs, Allison A. Smith Md

Quality Improvement & Patient Safety Forum

No abstract provided.

Evaluating The Implementation Of A Therapeutic Workbook To Enhance Behavioral Programming In A Pediatric Psychiatric Hospital, Mallory Granier Bs, Caroline Stallard Md, Mph, Kelly Georgis Do, Msph

Quality Improvement & Patient Safety Forum

No abstract provided.

The Military Health History: An Ongoing Educational Initiative To Improve Veteran Healthcare, Jaclyn P. Murphy Ms, Michael C. Brands Md, Caitlin P. Martin-Klinger Md, Facp, Amanda M. Raines Phd, Randolph L. Roig Md, Faapmr

Quality Improvement & Patient Safety Forum

No abstract provided.

Improving Rsv Vaccination Rates In The Resident Clinic With Rsv Vaccination Campaign, Allen Byl Do, Ilija Zecevic Md, Hannah Porter Md

Quality Improvement & Patient Safety Forum

No abstract provided.

Improving Emergency Department Management Of Febrile Seizures Through A Standardized Clinical Pathway, Hiba Elaasar Md, Andrew Harold Do, Kelly Angelle Md, Kayla Pence Md

Quality Improvement & Patient Safety Forum

No abstract provided.

Standardizing And Improving Neurodevelopmental Follow Up Of Infants With Hypoxic Ischemic Encephalopathy In The Nicu, Michael L. Evers Md, Michelle Knecht Md, Christy Mumphrey Md, Raegan Gupta Md, Julie Gallois Md

Quality Improvement & Patient Safety Forum

No abstract provided.

2025 Qi Forum Agenda, Equip Program Office Ogme

Quality Improvement & Patient Safety Forum

No abstract provided.

Enhancing Patient Education Of Antimicrobial Side Effects At Discharge, Isaac Daudelin, Md, Phd, Bojan Lazarevic, Jordan Feingold-Link, Md, Nehar Damle, Md, Pharmd, Caroline Brugger, Crnp, Rachel Carr, Pa-C, Devin Weber, Md, Daniel Taupin, Md, Mhqs

Health Equity and Quality Improvement (HEQI) Summit

Background

Problem: Patients discharged from the hospital on antimicrobial agents often receive insufficient education about potential side effects that warrant medical attention(1). We identified a critical gap in patient communication and safety that occurred during discharge at a large urban academic center.

Stakeholders

• Patients
• Physicians
• Nurses
• Pharmacists
• Outpatient providers
• Nurse practitioners
• Physician assistants

Objective: This project aimed to utilize a multidisciplinary team to:

1. Quantify a gap in patient education
2. Create an interactive navigator- which would not rely on provider memory and automatically include relevant information in patient discharge paperwork
3. Implement within 3 months into the EPIC system
4. Measure the effect …

Improving The Quality Of Internal Medicine Discharge Summaries Via Accurate Admission Medication Reconciliation, Natasa Kostic, Md, Tammy Tran, Md, Kenneth Meserole, Md, Jon Zaid, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Transitions of care are a time of vulnerability for patients.
• Nearly 20% of patients experience an adverse event within 3 weeks of hospital discharge, with adverse drug events being the most common.
• Discharge (DC) summaries serve to provide safe transition of care by describing hospital course and medication changes for review by outpatient providers.
• At TJUH, DC summaries are completed by internal medicine (IM) senior residents, but there is variability in quality of hospital course and thoroughness of medication reconciliation.
• Inaccurate admission medication reconciliation may lead to inaccurate reporting of discharge medication lists, causing confusion for both patients and …

Reducing Antibiotic Duration For Pneumonia And Sinusitis In The Emergency Department: A Quality Improvement Approach, Joshua Saucedo, Leslie Hueschen, Amanda Nedved, Marsha Dannenburg, Patricia Phillips, Jennifer Floyd, Alaina N. Burns, Rana El Feghaly

Research Days

Background: Our aim is to increase the percentage of children discharged home from the ED with a diagnosis of CAP or ABRS treated with an optimal antibiotic duration (3-5 days for CAP, 5-7 days for ABRS) from 13% to 70% by July 25.

Methods: Outcome metric is the percentage of patients receiving recommended antibiotic duration for CAP and ABRS. Process metrics include use of order set, "Quick Discharge” order set, and clinical pathway QR codes. Balancing metric is the number of return visits with the same diagnosis < 14 days. Plan-Do-Study-Act methodology was used. In Aug 23, our ASP disseminated a handbook that emphasized shorter durations. A new multidisciplinary team (infectious diseases, ED, and urgent care physicians, advanced practice providers, nurses, and pharmacy) formed in Dec 23. We utilized cause-and-effect analysis, driver diagram, and prioritization matrix, which helped identify other impactful interventions, including implementation of new internal CAP clinical pathway order set (April 24) and “Quick Discharge” order sets (May 24). Next, we surveyed prescriber comfort (June 24) with shorter duration identifying barriers and providing education, leading to posted evidence for lower duration treatment in practitioner workrooms and developing a new ABRS clinical pathway (Sept 24). Top prescribers providing optimal duration received email acknowledgement (Oct 24) and resident rotators received antibiotic handbook and CAP clinical pathway QR codes (Nov 24). New best treatment practices for ABRS were elucidated and disseminated through clinical pathway and internal article publishing to our hospital and associated clinics (Dec 24).

Results: We saw shifts in the outcome metric’s center line in Sept 23 …

Mapping Fat Embolism As A Complication Of Liposuction And Fat Grafting: A Systematic Review Of Anatomical And Technical Risk Factors, Jared Garfinkle, Jack Hennen, Wen Luo

Rowan-Virtua Research Day

Fat grafting (FG) and liposuction are widely performed aesthetic procedures with associated fat embolism risks. However, no comprehensive review has specifically mapped the anatomical distribution and technical causes of fat embolism events across these procedures. This review aims to characterize regional and procedural frequencies of fat embolism to inform safer surgical practices. A review was conducted using PubMed, Embase, Scopus, and Cochrane. Included studies were English-language case reports/series, retrospective reviews, and systematic analyses reporting fat embolism following liposuction or FG. Among 227 FG cases, the most frequent regions were the face (n=120), gluteal region (n=91), genitalia (n=9), and chest (n=7). …

Reviewing The Effect Of Antiplatelet Therapy On Lumbar Puncture Complications, John Andre Socci

Rowan-Virtua Research Day

Reviewing The Effect of Antiplatelet Therapy on Lumbar Puncture Complications aims to assess literature that discusses the possible risks of undergoing lumbar puncture while on antiplatelet therapy. Lumbar punctures offer vital information that can help guide making accurate diagnosis and creating appropriate treatment plans. However, a large portion of the population is on antiplatelet therapy for cardiovascular and cerebrovascular disease prevention. While there are many benefits to being on these medicines, patients are at increased risk for bleeding. Thus the clinical question as to whether or not proceed with lumbar puncture on patients taking antiplatelet therapy involves weighing risks and …

The Impact Of Emergency Room Overcrowding On The Incidence Of Healthcare-Acquired Infections Among Patients, Hayya Ali

Rowan-Virtua Research Day

Emergency department (ED) visits are vital components of healthcare delivery, serving as the primary site for acute medical care, particularly for individuals with urgent medical needs. The ED is among the most crowded hospital units. The fast-paced setting and over-crowdedness of an emergency room have become the reality of every hospital across the United States. Overcrowding causes problems for patients and staff, which include the risk of contracting healthcare-acquired infections. This is due to several factors that in most cases lead to an increase in the number of people within the ED, an increase in mortality and morbidity, and a …

Clinical Outcomes For Patients With Ventilator-Associated Pneumonia In Octogenarians, Nonagenarians, And Centenarians: A Population-Based Study, Tony Elias, Fady Beshara, Daniel Basta, Mena Elmalh, Matthew Ebrahim, Taha Syed, Olga Sarah, Abdallah Hussein

Rowan-Virtua Research Day

We sought to examine the national inpatient sample data-base to describe in-hospital outcomes among patients over seventy who acquire ventilator-associated pneumonia after being on the ventilator for over 48 hours.

Storm-Induced Supply Challenges: A Case Of Hurricane-Driven Iv Fluid Use And Venous Air Embolism, Davin Evanson

Tower Health Research Day

No abstract provided.

A Peculiar Pancreatitis: Investigating The Adverse Effects Of Mesalamine, Elias Arellano Villanueva, Miguel Lopez, Alhasan Asaad, Jose Campo Maldonado

Research Symposium

Background: Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, accounting for approximately 300,000 emergency department visits annually. It is characterized by parenchymal and peripancreatic fat necrosis accompanied by inflammation. The clinical diagnosis of AP is based on elevated serum amylase and lipase levels, characteristic imaging findings, and epigastric pain often radiating to the back. While gallstones and alcohol use are the most common causes of AP, drug-induced pancreatitis (DIP) is a rare but increasingly recognized etiology, contributing to 0.1–5% of cases. DIP is typically diagnosed by excluding other causes and is often associated with …

A Narrative Review Of Barriers To Utilization Of Surgical Risk Assessment Calculators, Jacob Lahti, Kaiya A. Noe, Abigail Veenstra, Sarah Gallitto, Victoria I. De Leon, Thomas C. Varkey, Nimit Agarwal

Annual Research Symposium

Over the last several decades, it has become the desire of surgical and medical teams to decrease risk levels involved for patients undergoing surgery. However, despite the advent of risk assessment calculators to help physicians obtain more accurate and objective judgements for postoperative complications, these tools are underutilized in standard clinical practices in comparison to other methods of risk assessment. This is likely due at least in part to certain barriers that decrease their functionality and ease of use. This review discusses the major barriers to the utilization of current risk calculators so as to allow for a better understanding …

Medical Student Simulation Curriculum: A Quality Improvement Initiative, Catherine Shield, Caitlin Witt, Megan Molina, Jaclyn Locklear

Quality Improvement & Patient Safety Forum

No abstract provided.

Standardization Of Screening And Inpatient Management Of Abnormal Uterine Bleeding, Kayla Griese, Mariah Humphrey, Jantzen Collette, Heather Valdin

Quality Improvement & Patient Safety Forum

No abstract provided.

Standardizing Inpatient Anti-Emetic Management For Chemotherapy Induced Nausea And Vomiting In The Pediatric Oncology Setting: A Quality Improvement Project, Heather Valdin, Mackenzie Creamer, Cori Morrison, Zachary Leblanc

Quality Improvement & Patient Safety Forum

No abstract provided.