Patient Safety Commons^™

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.

Potential Biological Hazards In Health Clinics: Key Strategies For Enhancing Worker Safety In Malaysia, Subki Ahmad, Normah Awang, Ermie Abdull Hamid, Anuar Ithnin, Nurul Farahana Kamaludin, Noraizah Muhd Nor

Makara Journal of Health Research

Background: Biological hazards in health clinics may lead to acute or chronic health issues for healthcare workers. This study aims to identify potential biological hazards within health clinics, with a focus on the knowledge, attitude, and practice (KAP) of healthcare workers, in order to improve their safety.

Methods: Samples from environmental surfaces were collected and cultured to identify bacterial pathogens. A cross-sectional study involving 203 healthcare workers was conducted using a questionnaire derived from CDC-adapted guidelines. Descriptive analysis and multivariate regression were used to assess KAP.

Results: Bacterial growth was observed in all clinics. The Kruskal-Wallis Test …

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 …

Bridging Diagnostic Safety And Mental Health: A Systematic Review Highlighting Inequities In Autism Spectrum Disorder Diagnosis, Abirami Srivarathan, Andrea Bradford, Sara Shearkhani, Layla Heimlich, Sheryl Jefferson, Kristen E Miller, Kelly Smith, Helen Haskell, Traber D Giardina

Faculty, Staff and Students Publications

Introduction: There is increased recognition that diagnostic errors disproportionately affect marginalised and underserved patient populations in the USA. However, evidence on diagnostic inequities in mental disorders is sparse and not well integrated into the overall diagnostic safety literature.

Objective: We systematically reviewed and narratively synthesised evidence on inequities in diagnosis of mental disorders, guided by the Diagnostic Process Framework developed by The National Academies of Sciences, Engineering, and Medicine.

Methods: We conducted a systematic review and a narrative synthesis. Medline, Embase, PsycInfo and CINAHL were searched for studies published between 2015 and 2024. Studies were eligible if they reported on …

Patient Information Needs During Ambulatory Medication Changes: A Qualitative Study, Elaine Giletta, Vanessa B. Hurley, Yushi Yang, Jessica L. Schwartz, Rabia Jalalzai, Nicole L. Mollenkopf, Raquel Mayne, Samantha I. Pitts

Journal of Patient-Centered Research and Reviews

Purpose: We performed interviews with patients and caregivers to explore whole-person, whole-regimen information needs at times of routine outpatient medication changes. We categorized information needs in this relatively unstudied context and identified which needs were commonly recognized as insufficiently met.

Methods: We explored the content of the semi-structured interviews, which involved nine patients and two caregivers of pediatric patients, all of whom experienced a recent medication change in the outpatient setting of a large urban academic healthcare system. We used inductive thematic analysis to organize information needs into categories to identify key information gaps.

Results: We identified five categories of …

Impact Of Primary Care Healthcare Providers Patient Electronic Medical Records Completion Rates Using Speech Recognition Dictation, Pepper Losely

Student Scholarly Projects

Practice Problem: Completion of electronic medical records (EMRs) is an ongoing problem for providers, facilities, and insurance reimbursement. Current completion of EMRs lack standardized processes to make EMRs completion easier for providers with their busy workday and allow optimal time for patient care.

PICOT: For healthcare providers at primary clinics (P) will implementing speech recognition dictation (SRD) for data entry into the electronic medical records (EMRs) (I) compared to the current practice of manually typing all data causing long medical record turnaround times (c) improve medical record completion within 30 days (O) over 10-weeks (T).

Evidence: Evidence that was …

The Implications Of Alpha-Gal Syndrome For Dental And Medical Treatment, Adam Degenova Mba, Kristi Soileau

New Orleans Dental Association News

Alpha-gal syndrome (AGS) is a potentially life-threatening allergic reaction to a mammalian sugar molecule introduced through tick bites. With rising U.S. diagnoses, dentists must recognize AGS symptoms and understand its implications. Many dental medications and materials contain mammalian-derived ingredients, requiring providers to adapt treatment plans and remain vigilant for delayed allergic responses in undiagnosed patients.

Care Alert Program In Chronic Emergency Department Using Patients: Expanded Study, Jonathan Leggett, Kaitlyn Phelps, David Nuñez, Brent Wright, Erica Gibbons, Jonathan Bryan, Brian Griggs

HCA Healthcare Journal of Medicine

Introduction

The Care Alert Program (CAP) is designed to help navigate encounters with patients who are high utilizers of Emergency Department (ED) resources. The CAP intends to address the needs of this challenging patient population by designing individualized care plans that are approved by a multidisciplinary committee. The patient populations that frequently use ED resources often have chronic medical conditions, a poor understanding of their conditions, unrealistic expectations regarding treatment, a lack of outpatient resources, and present with multiple complaints when using ED resources.

Methods

The CAP was adopted by our facility in the spring of 2020. The present study …

Career Impact Of The National Interprofessional Fellowship In Patient Safety: An Alumni Evaluation, Bradley V Watts, Kathleen Carluzzo, Blake F Webb, Kelley Arredondo

Faculty, Staff and Students Publications

Background: There has been a proliferation of health professions training programmes focused on quality and patient safety, but little information regarding the outcomes of these programmes. The purpose of this study was to examine the impact of an interprofessional quality and patient safety curriculum on career outcomes of interprofessional healthcare learners for the Veterans Affairs Patient Safety Fellowship.

Method: We conducted a survey-based assessment of 117 alumni of the Interprofessional Fellowship in Patient Safety assessing their satisfaction with the training program and career impacts.

Results: 84 of 117 alumni were located and participated in the assessment. Fellows entered the training …

Blueprint For A Youth Violence Intervention Program In East Baton Rouge Parish: Adapting Hospital-Based Strategies, Kristina G. Little, Elizabeth Winchester, Judith L F Rhodes

Reports

Youth violence in East Baton Rouge Parish remains a persistent public safety and public health challenge. This report proposes an adapted, evidence-informed model for East Baton Rouge Parish that retains the core components of traditional HVIPs while leveraging existing legal, hospital, and social service resources. The model is grounded in a public health framework and emphasizes trauma-informed, bedside intervention at the “teachable moment” when youth are most receptive to change, and long-term wraparound case management. The report concludes with recommendations for implementing this adapted approach, including identifying a health system champion, building referral protocols, embedding training, and developing a long-term …

Assessment Of Emergency Medicine Residents' Situational Awareness And Perception Of Patient Safety Culture In The Emergency Department, Adriana Olson, Nathan Olson, Nicholas Hartman, Casey Morrone, Morgan Battaglia, Kamna Balhara

Department of Emergency Medicine Faculty Papers

BACKGROUND: Situational awareness (SA) and positive safety climate are crucial to patient safety. Little is known about emergency medicine (EM) trainees' SA and perception of emergency department (ED) safety climate, and the interactions of those factors with safety-related behaviors.

OBJECTIVES: Our objective was to evaluate EM residents' perceptions of ED safety climate, self-reported SA, and comfort with identifying, rectifying, and reporting safety hazards.

METHODS: In this cross-sectional study at two EM residencies, residents completed the Situational Awareness Rating Technique (SART) after ED-based or simulated resuscitations as well as a survey regarding safety climate and comfort with identifying, rectifying, and reporting …

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.

Understanding Vaccine Hesitancy And Barriers To Access In Hispanic Individuals Of Metro Detroit​, Rafael Ramos, John Gallegher, Nevil Khurana, Ingrid Rocha, Rene Andino-Galva, Izabel Thomas, Deni Peterson, Alexander Eskandarian, Eliezer Arody Gomez, Md

Medical Student Research Symposium

Background:

Detroit’s Hispanic community is still disproportionally uninsured at about 2x the rate of non-Hispanic white and 3x the rate of non-Hispanic Black residents. In the post-COVID era, vaccine hesitancy and barriers to access have been well-documented. Studies suggest that minority populations, including the Hispanic population, may experience unique social determinants of health which affect their vaccination rates and outcomes. Additionally, research shows that knowledge of vaccines may correlate with levels of trust.

Methods:

We sought to describe the knowledge, barriers to access, and levels of trust regarding the influenza (flu) vaccine in Hispanic individuals of Metro Detroit. We used …

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 …

Enhancing Healthcare-Associated Infection Prevention: The Role Of Hand Hygiene, Ppe, Isolation, And Vaccination Education, Kaitlyn N. Rollo

Aurora

Healthcare-associated infections (HAIs) represent a significant threat to patient safety in hospital environments. These infections are often linked to lapses in infection prevention protocols, including inadequate hand hygiene, improper use of personal protective equipment (PPE), and insufficient isolation procedures. This project aimed to evaluate compliance with infection control policies and identify areas for improvement at Lima Memorial Hospital. By focusing on auditing, education, and data analysis, the goal was to reduce HAI rates and strengthen overall infection prevention practices.

Methods included a comprehensive review of existing hospital infection prevention policies, followed by hand hygiene and PPE audits across the hospital’s …

Stress And Burnout Among Icu Nurses, Jaspreet Kaur

2025 Spring Honors Capstone Projects - Archive

Burnout is a significant occupational hazard for Intensive Care Unit (ICU) nurses. High patient acuity, staffing shortages, and long shift hours increase stress and diminish well-being among nurses, affecting patient care outcomes. This study examined the prevalence of stress and burnout among ICU nurses to identify contributing factors and potential interventions. An anonymous online survey was conducted among 110 ICU nurses, utilizing the Maslach Burnout Inventory (MBI) and the Perceived Stress Scale(PSS). Findings revealed that 42.5% of nurses reported high emotional exhaustion, while 37.5% felt they had little to no control at work. The most frequently cited workplace stressors were …