2014 John M. Eisenberg Patient Safety and Quality Award Recipients
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(Oak Brook, Ill.) Joint Commission Resources today released the May 2015 issue of The Joint Commission Journal on Quality and Patient Safety. The issue highlights the recipients of the 2014 John M. Eisenberg Patient Safety and Quality Award, presented by the National Quality Forum and The Joint Commission. These three honorees were recognized for their efforts to improve patient safety and quality of care:
Individual Achievement – Mark L. Graber, M.D., FACP, senior fellow, Health Care Quality and Outcomes Program, RTI International, Research Triangle Park, North Carolina
Innovation in Patient Safety and Quality at the National Level – The American College of Surgeons National Surgical Quality Improvement Program, Chicago
Innovation in Patient Safety and Quality at the Local Level – North Shore-LIJ Health System, New Hyde Park, New York
Dr. Graber, co-creator of Patient Safety Awareness Week, was recognized for his efforts to address diagnostic error and bring it to the forefront of the patient safety movement. His research studies and writings about diagnostic error were sparked by a series of experiences he had in the field of nephrology. Dr. Graber convened the Diagnostic Error in Medicine conference series, formed the nonprofit Society to Improve Diagnosis in Medicine and founded the international journal Diagnosis in 2014.
In an interview in the issue, Dr. Graber states, “Success in improving diagnosis will require focusing on both global diagnostic safety issues and more specific targets. Taking the global approach leads to projects that try to improve physician training, teaching how to identify cognitive biases, or promoting patient engagement.”
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), launched in 2004, was recognized for its data collection achievements to help hospitals and health care professionals improve surgical patient care. ACS NSQIP is a nationally validated, risk-adjusted, outcomes-based program designed to measure and improve the quality of surgical care in more than 600 participating hospitals. ACS NSQIP data have been used in more than 600 peer-reviewed articles, many of which have reported improvements in surgical outcomes, including complications, lives saved and reduced costs.
North Shore-LIJ Health System was recognized for its major patient safety initiative, launched in 2009, to reduce sepsis mortality across 10 acute care hospitals (an 11th joined later). To help accelerate the pace of sepsis improvement, the health system launched a strategic partnership in August 2011 with the Institute for Healthcare Improvement. As a result, North Shore-LIJ collaborated with local, state, national and international organizations to test innovative ideas, share evidence-based best practices and raise public awareness about sepsis. As a result, the health system reduced overall sepsis mortality by approximately 50 percent during a six-year period and increased compliance with sepsis resuscitation bundle elements in its emergency departments and inpatient units.
The remaining articles from the May 2015 issue are:
Methods, Tools and Strategies
Emergency Manual Implementation: Can Brief Simulation-Based OR Staff Trainings Increase Familiarity and Planned Clinical Use?
Sara N. Goldhaber-Fiebert, M.D.; Vivian Lei, M.D.; Kiruthiga Nandagopal, Ph.D.; Sylvia Bereknyei, DrPH.
Emergency manuals—context-relevant sets of cognitive aids such as crisis checklists—are useful tools to enhance perioperative patient care. After in situ operating room (OR) training, 126 staff self-reported increases in awareness, familiarity, willingness to use for educational review, and intention to use during critical events (all at p < .01). Institutions should provide copies in accessible places in ORs and implement training mechanisms.
Use of a Glucose Management Service Improves Glycemic Control Following Vascular Surgery: An Interrupted Time-Series Study
Jessica B. Wallaert, M.D., M.S.; Sushela S. Chaidarun, M.D., Ph.D.; Danielle Basta, APRN, M.S.N.; Kathryn King APRN, M.S.N.; Richard Comi, M.D.; Greg Ogrinc, M.D., M.S.; Brian W. Nolan, M.D., M.S.; Philip P. Goodney, M.D., M.S.
In a prospective trial, use of a glucose management service (GMS) in glycemic control within 24 hours of lower-extremity revascularization (LER) significantly reduced mean hospitalization glucose (191 mg/dL Baseline versus 150 mg/dL Intervention, p < .001). In addition, the proportion of glucose values in target range increased (48 percent versus 78 percent, p = .05). Routine involvement of GMS improved glycemic control in patients undergoing LER.
Information Gaps in Newborn Care and Their Potential for Harm
Prerna Kumar, M.D.; Ashvini Biswas, M.D.; Hari Iyengar, M.D.; Praveen Kumar, M.B.B.S., D.C.H., M.D.
In a study of information in medical records, a positive maternal history not documented in the newborn medical record was counted as an information gap. Of 72 enrolled mother-infant dyads, nearly all (71 [99 percent]) of mothers had at least one positive history in the areas reviewed, 59 (82 percent) newborn records had ≥ 1 information gap, and 17 (24 percent) had ≥ 4 information gaps. These results suggest that significant information gaps are common in newborn care at birth and might adversely affect newborn care and outcomes.
Letter to the Editor: Personal Protective Equipment and Simulation: Use of Chemiluminescent Glow Sticks as a Game Changer?
Oren Guttman, M.D., M.B.A., CHSE; Aimee Gardner, Ph.D.
The University of Texas Southwestern Medical Center, Dallas, “stress-tested” its various hospital protocols for handling Ebola through simulation, including the use of glow sticks, which provided a nontoxic, inexpensive and invisible (except with black light) fluid to create a realistic experience.
A Two-Way Street: What the United States Can Learn from Resource-Limited Countries to Improve Health Care Delivery and Reduce Costs
Kedar S. Mate, M.D.; Nupur P. Mehta, M.D., M.P.H.
Five ideas for change are described, representing a small subset of the myriad ideas from resource-limited countries that could have a meaningful impact on health care quality and safety if applied in resource-rich countries.