Patient Safety Commons^™

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 …

Enhancing The Eden Alternative Model With Well Standards: A Case Study Analysis, Mariah Stoner

Architecture Masters of Science Program: Theses

This thesis investigates the potential for improving the Eden Alternative Model, a person-centered approach to elder care that emphasizes creating a homelike environment and meaningful relationships, using WELL Standards, a building certification system focused on enhancing human health and well-being through improvements in environmental quality. Through a mixed-methods approach involving quantitative data analysis and qualitative case studies, this research examines how WELL Standards, which cover aspects such as air quality, water quality, lighting, and thermal comfort, can improve environmental quality and resident satisfaction within the Eden Alternative Model. This research introduces a tailored approach to elder care by combining these …

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.

The Politics Of The Black Womb: How Education And Power Reinforce The U.S. Black Maternal Health Crisis, Foluke Akinkunmi

Honors Scholar Theses

This study investigates the alarming maternal mortality rates among Black women in the U.S. today first by exploring the historical exploitation of Black maternal bodies during enslavement and with the rise of professionalized gynecology. It challenges the narrative that attributes these outcomes to individual choices or supposedly inherent biological factors, arguing instead that the devaluing of Black women’s well-being and authoritative knowledge have been constructed along with the United States itself. To advance a constructive response, the paper analyzes curriculum competencies for obstetric and midwifery healthcare providers, surveys of Black women's birthing experiences in the previous 20 years, and interviews …

Implementing A Sustainable Antimicrobial Resistance Surveillance Across Riverside County, Felipe Aperador

Electronic Theses, Projects, and Dissertations

This project focuses on improving health surveillance in remote communities, addressing antimicrobial resistance (AMR) enhancing connectivity and data collection. Geographic barriers, high shipping costs, and logistical challenges have historically hindered healthcare delivery in underserved areas. By integrating healthcare facilities into a cohesive surveillance systems, would improve specimen collection and data analysis. A systematic review of literature identified key strategies, including governmental support, strengthening laboratory capacity, addressing logistical barriers, and enhancing connectivity. Notable results include insights to integrate new facilities when creating a surveillance network, supported by training and state-funded resources. Actionable steps, such as implementing National Action Plans, establishing National …

Toward The Application Of Natural Language Processing In Electronic Health Record Analysis For Taxonomy Development, Latoya Mcdonald

All Dissertations

Electronic health records (EHRs) are pivotal resources for nurse practice because they increase the timeliness and reliability of patient information at the point of care and support access by multiple healthcare providers and the individual patients themselves. However, it is widely recognized that data extraction from EHRs is challenging due to the variability in the language used in clinical care notes and the lack of standardized terminology across healthcare systems. The broad objective of this dissertation is to develop taxonomy-based classification models for nursing care by applying feature engineering approaches to EHRs that include nursing care of ostomy patients following …

Supreme Court Case Study: The Variation In Rates Of Miscarriage Management Care And Post-Abortion Care Across The Us Before And After The Supreme Court Decision, Ted Sibrian Jr.

MUSC Theses and Dissertations

The paper examines abortion care and the management of miscarriages following the Roe v. Wade decision in restrictive states that do not allow medical intervention due to the vague legal terms. This research evaluates the need to establish protocols for providers when faced with nonviable pregnancies requiring medical intervention. Additionally, the paper highlights the impact across the US on women’s health outcomes by emphasizing the care for miscarriage management. This multi-method paper reviews the current literature on miscarriage management and spontaneous abortion MarketScan® data from commercially insured individuals with an age range of 18-50 years old by regions across the …

Lack Of Patient-Centered Care Relative To Evidence-Based Practice In Clinical Diagnosis And Treatment Of Endometriosis In The U.S.: A Review, Piper E. Scoskie

Honors Theses

This scoping review examines the impact of combining Patient-Centered Care (PCC) and Evidence-Based Care (EBC) on clinical outcomes and patient satisfaction in the diagnosis and treatment of endometriosis in the United States. In particular, the review aims to (1) examine the body of research from the United States to learn more about the connection between PCC and EBC and their collective impact on patient satisfaction and clinical outcomes in the treatment of endometriosis; (2) identify the gaps in existing research and practice, specifically regarding PCC procedures, varying patient populations, and longitudinal investigations; and (3) provide recommendation for future research and …

Sbirt Workflow, Dory Hart Emery, Tory Gamage, Sara Watts, Carol Mcclure, Anne Barker, Liz Berry, Liz Anderson

Operations Transformation

SBIRT stands for Screening – Identify patients with unhealthy substance use. Brief Intervention – A collaborative conversation that raises a person’s awareness of substance use and its consequences and encourages behavioral changes. Referral to Treatment – Actively link patients to resources when needed. It is a substance use screening tool that we ask patients 18 yrs. old and older to fill out once a year when having their CPE or AWV. SBRIT has been recognized as an integral part of primary care. It is an approach that delivers prevention, detection, and early intervention for individuals at risk of substance use …

Psychological Treatment Behind The Walls:Insights From The Inside, Rogelio Serrano

Psychology Division Scholarship

Repeated eras of mass incarceration, criminalization of marginalized communities, and substance use policies have created a revolving door of justice involved populations. The ever-increasing prison population has repeatedly become the largest contingency of mental health clientele for an overburdened mental health system. Those who work with formerly incarcerated individuals in the community often don’t know the unique set of challenges faced by practitioners within the system. Increased understanding and coordination of care can offer opportunities for sustained recovery and reduced levels of recidivism. In this presentation participants will learn about the unique insights on mental health treatment that can be …

Reevaluating Informed Consent: Integrating Shared Decision-Making Into Spinal Surgery For Better Patient Outcomes., Jeffrey N Wang, Mohamed A Elhakeem, Matthew J Mesimer, Paul G Mastrokostas, Salman Ahmad, Tim Reed, Brandon Klein, Lucas E Bartlett, Adam D Bitterman, Andrew Megas

Rowan-Virtua School of Osteopathic Medicine Departmental Research

Study Design: Narrative review.

Objectives: The objectives of this study were to answer the following questions: (1) What is the quality of informed consent in spine surgery, including both neurosurgery and orthopaedic spine surgery? (2) What limitations impede the ability of surgeons to engage in effective shared decision-making (SDM) and obtain adequate informed consent? (3) What strategies and solutions may improve the quality of informed consent and SDM? (4) What factors decrease the incidence of litigation in spine surgery?

Methods: N/A.

Results: SDM is a collaborative process where patients are involved in their treatment choices through open communication about risks, …

Revisions To The Safety Assurance Factors For Electronic Health Record Resilience (Safer) Guides To Update National Recommendations For Safe Use Of Electronic Health Records, Dean F Sittig, Trisha Flanagan, Patricia Sengstack, Rosann T Cholankeril, Sara Ehsan, Amanda Heidemann, Daniel R Murphy, Hojjat Salmasian, Jason S Adelman, Hardeep Singh

Faculty, Staff and Student Publications

The Safety Assurance Factors for Electronic Health Record (EHR) Resilience (SAFER) Guides provide recommendations to healthcare organizations for conducting proactive self-assessments of the safety and effectiveness of their EHR implementation and use. Originally released in 2014, they were last updated in 2016. In 2022, the Centers for Medicare and Medicaid Services required their annual attestation by US hospitals.

Objectives: This case study describes how SAFER Guide recommendations were updated to align with current evidence and clinical practice.

Materials and methods: Over nine months, a multidisciplinary team updated SAFER Guides through literature reviews, iterative feedback, and online meetings.

Results: We reduced …

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.