The Journal Blog

The blog of The Joint Commission Journal on Quality and Patient Safety features news and comments from the Journal’s Executive Editor, Steven Berman, and provides readers with an online forum to share opinions, concerns, and ideas about issues and approaches in improving quality and patient safety. 



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Addressing the Issue of Violence in Health Care Facilities

• 6/17/2010
• Author: Steven Berman
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A new Joint Commission Sentinel Event Alert, Preventing Violence in the Health Care Setting, warns that health care organizations and their patients and visitors are now confronting steadily increasing rates of crime, including assault, rape, and murder. The Alert advises that while it is imperative to control access to the facility and maintain ongoing surveillance of the ground... more >>

Safety of Test Result Follow-Up: Challenges, Progress, and More Challenges

• 5/15/2010
• Author: Steven Berman
• 5615 Views
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This week, Hardeep Singh and Meena S. Vij, the authors of “Eight Recommendations for Policies for Communicating Abnormal Test Results,”  which appeared in the May 2010 issue, are guests on the Journal blog. The evidence- and experience-based recommendations provided in the article are intended to help organizations ensure safe and timely abnormal test-result communicat... more >>

The Joint Commission Annual Conference on Quality and Patient Safety:

• 4/30/2010
• Author: Steven Berman
• 6510 Views
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A Preview of "Evidence-Informed Value Improvement" As you may know, The Joint Commission Annual Conference on Quality and Patient Safety will be held June 23–25 in Chicago. This conference will focus on organizational greatness and decisions and actions for health care executives seeking to improve quality, reduce errors, contain costs, increase p... more >>

Improving Tdap Vaccination Rates: A Case Study

• 4/9/2010
• Author: Steven Berman
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A recent issue of The Joint Commission Online  included a call for strategies to improve tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates in health care organizations. The Joint Commission is asking health care organizations to share their approaches for implementing vaccination programs for patients and health care workers. The information will be... more >>

An Emergency Department Clinical Information System: Continuing Improvement and Benefits

• 3/31/2010
• Author: Steven Berman
• 8189 Views
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This week, Kevin M. Baumlin, the lead author of " Clinical Information System and Process Redesign Improves Emergency Department Efficiency ” in the April 2010 issue, guests on the Journal blog. Dr. Baumlin’s article describes how Mount Sinai Medical Center, a hospital in Manhattan, coordinated a variety of efforts—including changes in patient registration... more >>

Medication Administration Article Circulates Across Switzerland

• 3/26/2010
• Author: Steven Berman
• 8097 Views
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To follow up on the previous blog, I have recently learned that Dr. David Schwappach, the Scientific Head of the Swiss Patient Safety Foundation, has selected the Kliger et al. article, “Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy” (December 2009 issue of the Journal), as “Paper of the Month.” This means that the fou... more >>

Building in Strategic Communication as Key to Leadership in Improvement

• 3/24/2010
• Author: Steven Berman
• 8551 Views
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This week, Julie Kliger, lead author of “Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy,” which appeared in the December 2009 issue, guests on the Journal blog. As you will recall, the article reported how a 36-month demonstration program led to a 87.7% reduction in medication administra... more >>

Incident Reporting Still Lacking Among Many Doctors-in-Training

• 3/13/2010
• Author: Steven Berman
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To follow up on my previous blog, the deficiencies in patient safety education described in the Lucian Leape Institute report, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, are reflected in another Journal article—cited yesterday in an article in the New York Times, “Learning to Keep Patients Safe in a Culture of Fear” (http://www.nytimes.com/2010/03/11/health/11chen.html?emc=... more >>

Quality and Patient Safety Education Needs for Physicians—and Nurses

• 3/12/2010
• Author: Steven Berman
• 8695 Views
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On March 11, 2010, the Lucian Leape Institute at the National Patient Safety Foundation released a report that finds that medical schools are failing to do an adequate job of “facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care,” resulting in greater risk to patients. Lucian L. Leape, M.D., chair of the Institute, ... more >>

Radiation Hazards and Challenges in Reporting Adverse Events: A Human Factors Perspective

• 3/5/2010
• Author: Steven Berman
• 8872 Views
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In his January 29, 2010 guest blog, Kurt Herzer commented on the two recent investigative articles in the New York Times on the incidence and impact of rare accidents in radiation therapy. Shortly after, the American Society for Radiation Oncology issued a six-point plan for improving safety and quality and reducing the chances of medical errors—including working with oth... more >>

The Joint Commission Invites Eisenberg Award Nominations

• 2/24/2010
• Author: Steven Berman
• 8283 Views
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As you may know, The Joint Commission has recently invited nominations for the 2010 John M. Eisenberg Patient Safety and Quality Award. Information about the awards and the and nomination process can be found at http://www.jointcommission.org/PatientSafety/EisenbergAward/ . Every year since 2002, when John M. Eisenberg died, it has been an honored ... more >>

Reducing Inpatient Suicide Hazards at Veterans Administration Hospitals

• 2/12/2010
• Author: Steven Berman
• 9366 Views
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This week, Peter Mills, the senior author of " A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals,” which appears in the February 2010 issue, guests on the Journal blog. In the article, Dr Mills and his colleagues report on the first study to examine the implementation and effectiveness of a standardized checklist for mental health units. Dr. Mills, a... more >>

Reflections on Integrating Electronically Generated Sign-out Documents into the EMR

• 2/4/2010
• Author: Steven Berman
• 9639 Views
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A Case Where What Is Good for Doctors May Also Be Good for Patients This week, Jonathan A. Bernstein, the lead author of “Improved Physician Work Flow after Integrating Sign-out Notes into the Electronic Medical Record,” which appears in the February 2010 issue, guests on the Journal blog. As the authors reported in t... more >>

Identifying and Mitigating Hazards in Radiation Therapy

• 1/29/2010
• Author: Steven Berman
• 11401 Views
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2:22:04 PM   This week, I asked Kurt R. Herzer, Marshall Scholar, University of Oxford, and Woodrow Wilson Research Fellow, Johns Hopkins University, to guest on the Journal blog. Mr. Herzer comments on two recent investigative articles in the New York Times reporting on the incidence and impact of rare accidents in radiation therapy, many of which can cause irrev... more >>

Adding a Layer of Safety Through Rapid Response Systems

• 1/22/2010
• Author: Steven Berman
• 10596 Views
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This week, Michael DeVita, M.D., chief editor of the Journal’s department Rapid Response Systems: The Stories, which began in the July 2006 issue, guests on the blog. Dr DeVita, Professor of both Critical and Internal Medicine in the University of Pittsburgh’s School of Medicine and Executive Vice President of Medical Affairs for West Penn Allegheny Health System, refle... more >>

Emerging Issues with the VA Shift Handoff Tool

• 1/14/2010
• Author: Steven Berman
• 10946 Views
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This week, Peter Kaboli, the senior author of “The Veterans Affairs Shift Change Physician-to-Physician Handoff Project,” which appears in the February 2010 issue, guests on the Journal blog. The development team designed an electronic medical record (EMR) handoff tool to provide a standardized approach to handoff commun... more >>

Additional Reflections on Preventing Venous Thromboembolism

• 10/29/2009
• Author: Steven Berman
• 15169 Views
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This week, Alpesh Amin, author (with Steven Deitelzweig) of “Optimizing the Prevention of Venous Thromboembolism: Recent Quality Initiatives and Strategies to Drive Improvement,” which published in the November 2009 issue, guests on the blog. In the article, they review the quality indicators, public reporting initiatives, incentive programs, and “negative rei... more >>

Hand Hygiene Leads to More Preventive Efforts

• 10/16/2009
• Author: Steven Berman
• 15644 Views
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This week, Mark Bittle, lead author of "Engaging the Patient as Observer to Promote Hand Hygiene Compliance in Ambulatory Care,” which appeared in the October 2009 issue, guests on the blog .In the article, Dr. Bittle and Suzanne LaMarche describe how involving the patient is a simple and cost-effective way to monitor hand hygiene in the ambulatory setting. In this blog, Dr... more >>

Coaching Physicians Involved in Disclosure Cases

• 10/9/2009
• Author: Steven Berman
• 15998 Views
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 This week, Randy Peto, lead author of "One System’s Journey in Creating a Disclosure and Apology Program,” which appeared in the October 2009 issue, guests on the blog. In the article, Dr. Peto and his colleagues describe the disclosure and apology program at the four-hospital Baystate Health system. In this blog, Dr. Peto discusses his experience, which occurred while the artic... more >>

Why Policy Should Not Precede the Science: The Case of Briefings and Debriefings

• 10/1/2009
• Author: Steven Berman
• 16585 Views
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This week, Sean Berenholtz, the lead author of “Implementing Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center,” which appeared in the July 2009 issue, guests on the Journal blog. Briefings and debriefings involve a discussion among all members of the surgical team before incision and then before leaving the OR. Drawing on 37,113 briefings a... more >>

Issues and Trends in Rapid Response Systems

• 9/29/2009
• Author: Steven Berman
• 16922 Views
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The Journal has been running articles in Rapid Response Systems: The Stories, since this department premiered in July 2006. As Michael DeVita, the chief editor of the series then remarked (see article, attached), we launched the series “to provide a resource to those who are just getting started or are interested in advancing their programs already underway.” I encourage you, as he did t... more >>

How to Sustain the New Practice–and Continuous Quality Improvement—After the Initial Success?

• 9/17/2009
• Author: Steven Berman
• 17118 Views
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This week, John Q. Young, author (with Robert M. Wachter) of “Applying Toyota Production System Principles to a Psychiatric Hospital: Making Transfers Safer and More Timely,” which appeared in the September 2009 issue, guests on the blog. As you may remember, they described how Langley Porter Psychiatric Hospital and Clinics at the University of California San Francis... more >>

The Joint Commission Launches its Center for Transforming Healthcare

• 9/10/2009
• Author: Steven Berman
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Today, at the National Press Club in Washington, D.C., The Joint Commission announced its Center for Transforming Healthcare. In a letter sent to more than 16,000 accredited health care organizations or programs across the United States, Mark R. Chassin, M.D., M.P.P., M.P.H., President of The Joint Commission, stated, “The Center is developing solutions by using the same Robust Process Improve... more >>

Using an Electronic Medical Record for Continuity of Care

• 8/13/2009
• Author: Steven Berman
• 19848 Views
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This week, Allen Hsiao, the lead author of  “Dropping the Baton During the Handoff from ED to Primary Care: Pediatric Asthma Continuity Errors,” which appears in the September 2009 issue, guests on the Journal blog. As part of the AHRQ-sponsored “Electronic Records to Improve Care for Children” (ERICCA) project, the authors examined the handoff of care for asthmatic children betw... more >>

What Does the U.S. House Bill Say About Hospital Complications and Payment?

• 7/23/2009
• Author: Steven Berman
• 19472 Views
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This week, Richard Averill, the lead author of Forum, “Hospital Complications: Linking Payment Reduction to Preventability,” which appeared in the May 2009 issue, guests on the Journal blog. As you’ll recall, in the article, Mr. Averill and his colleagues proposed that the Center for Medicare & Medicaid Services (CMS) policy of denying payment for certain in-hospital complica... more >>

More on Implementing E-Surveys (a Practical Enhancement to Tracer Methodology)

• 7/17/2009
• Author: Steven Berman
• 19672 Views
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This week, Frederick North, the lead author of  a Tool Tutorial, “E-Surveys as a Practical Enhancement to Tracer Methodology for Continuous Joint Commission Accreditation Readiness, “which appears in the August 2009 issue, guests on the Journal blog. In the article’s conclusion, the authors stated, “We now have regular interdisciplinary group meetings with physician, nursing, secretarial... more >>

On Developing and Adapting Tools

• 7/10/2009
• Author: Steven Berman
• 19448 Views
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Quality and patient safety professionals and clinicians need to have useful and efficient tools at their disposal to collect data to identify opportunities for improvement and to then address them. In an article in the October 2008 issue of the Journal, “Developing Process-Support Tools for Patient Safety: Finding the Balance Between Validity and Feasibility,” Jill Marsteller and her coauthors... more >>

Thinking about Patient Safety for Chronically Ill Outpatients

• 7/2/2009
• Author: Steven Berman
• 19985 Views
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  This week, Urmimala Sarkar, the lead author of “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care,” which appears in the July 2009 issue, guests on the Journal blog. She reflects on the origins of the article and on the need to engage patients, especially the large population of patients with chronic conditions, in improving safety. D... more >>

On Planning Improvement Projects as if Publishing

• 6/22/2009
• Author: Steven Berman
• 20630 Views
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In my recent blog regarding the new Joint Commission Resources book, A Guide to The Joint Commission's Medication Management Standards, Second Edition. I noted Brigham and Women's Hospital (Boston)'s efforts to improve medication safety. I recently had the opportunity to chat with the hospital's executive director of pharmacy, Bill Churchill, who took the lead with his team in writing the chap... more >>

A Guide to Medication Management Standards

• 6/15/2009
• Author: Steven Berman
• 22633 Views
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We at Joint Commission Resources have just published A Guide to The Joint Commission’s Medication Management Standards, Second Edition. In developing the book, I asked a number of hospitals and other health care organizations to describe medication management practices that they improved to address The Joint Commission standards. I vetted the topics to ensure that they would provide educationa... more >>

Antibiotic Resistance

• 6/9/2009
• Author: Steven Berman
• 21164 Views
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Have you heard about the Joint Commission Resources audioconference scheduled for June 12, 2 p.m. C.S. T., on Reducing Antibiotic Resistance and Multidrug-Resistant Organisms? Hospital executives and their leadership teams are invited to learn more about the clinical and financial cost of antibiotic resistance and effective prevention and control techniques. (Registration can be conducted at http:... more >>

Guest Blog: Laura Damshroder

• 4/30/2009
• Author: Steven Berman
• 24207 Views
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Frequently, I will be asking authors of articles published in The Joint Commission Journal on Quality and Patient Safety to “guest” on the blog to provide “the story behind the story.” Laura Damshroder, one of the authors of “How Active Resisters and Organizational Constipators Aff... more >>

An Introduction

• 4/21/2009
• Author: Steven Berman
• 23626 Views
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Greetings! I’m Steven Berman. For 20 years, I’ve had the privilege to not only witness but also participate in the tremendous growth of the field of quality and patient safety in health care. When I first started, the Joint Commission—in fact it was still the Joint Commission on Accreditation of Hospitals—journal was called Quality Review Bulletin. Later, we called it o... more >>

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