How Adventist Health System Improved its Adverse Event Data Accuracy
View the multimedia news release
(Oak Brook Ill.) Joint Commission Resources has announced the release of the July 2013 issue of the “The Joint Commission Journal on Quality and Patient Safety,” featuring an article on how one large health system improved its detection and tracking of adverse events by developing a uniform centralized review process.
In the lead article, “Developing and Implementing a Standardized Process for Global Trigger Tool Application Across a Large Health System,” Paul R. Garrett Jr., M.D., and his co-authors detail Adventist Health System’s implementation of the Institute for Healthcare Improvement (IHI) Global Trigger Tool in the 25 of its 42 hospitals with a common electronic medical record to more accurately gauge the number, type and severity level of its adverse events. Since implementing the Global Trigger Tool in 2009, Adventist Health System has improved and streamlined its reporting, data entry, and record review processes.
In the July 2013 issue’s editorial, “The Burden of Harm,” David C. Classen, M.D., and Roger K. Resar, M.D., call on other health care organizations to also “publically admit the total burden of harm they cause in their community, demonstrate what is being done to address this level of harm, and report whether there has been improvement as a result of these efforts over time.”
“The Joint Commission Journal on Quality and Patient Safety,” published monthly by Joint Commission Resources, is a peer-reviewed journal, available by subscription, which serves as a forum for practical approaches to improving quality and safety in health care.
Editorial: The Burden of Harm
David C. Classen, M.D.; Roger K. Resar, M.D.
Developing and Implementing a Standardized Process for Global Trigger Tool Application Across a Large Health System
Paul R. Garrett Jr., M.D.; Christine Sammer, Dr.P.H., R.N., FACHE; Antoinette Nelson, R.N., B.S.N., MSHSA; Kathleen A. Paisley, B.S.N., R.N.C.; Cason Jones, M.S.; Eve Shapiro, B.A.; Jackie Tonkel, B.S.B.A.; Michael Housman, Ph.D.
Adventist Health System successfully deployed a centralized IHI Global Trigger Tool process across 25 of its 42 hospitals to track facility-specific and system-wide adverse event rates over time.
Infection Prevention and Control
Reducing Clostridium difficile Incidence, Colectomies, and Mortality in the Hospital Setting: A Successful Multidisciplinary Approach
Leonard A. Mermel, D.O., ScM; Julie Jefferson, R.N., M.P.H.; Kerry Blanchard BS; Stephen Parenteau, M.S.; Benjamin Mathis, M.D.; Kimberle Chapin, M.D.; Jason T. Machan, Ph.D.
Rhode Island Hospital, a tertiary care, Level 1 trauma center hospital in Providence, R.I., having implemented five successive interventions, reduced the incidence of health care–associated Clostridium difficile infections by 70 percent and reduced annual associated mortality by 64 percent.
Teamwork and Communication
A Handoff Protocol from the Cardiovascular Operating Room to Cardiac ICU Is Associated with Improvements in Care Beyond the Immediate Postoperative Period
Jon Kaufman, M.D.; Mark Twite, M.A., M.B., BChir, FRCP; Cindy Barrett, M.D., M.P.H.; Christine Peyton, M.S., CPNP-AC; Julianne Koehler, M.S., CCR.N.; Michael Rannie, M.S., R.N.; Michael G. Kahn, M.D., Ph.D.; Samuel Schofield, B.B.A.; Richard J. Ing, M.B., B.Ch., FCA(SA); James Jaggers, M.D.; Daniel Hyman, M.D., M.M.M.; Eduardo M. da Cruz, M.D.
A cardiothoracic operating room to cardiac intensive care unit (CVOR-to-CICU) handoff protocol at Children’s Hospital Colorado in Aurora, Colo., in parallel with an unplanned-extubation initiative, was associated with statistically significant reductions in median ventilator times and unplanned extubations.
Return on Investment for Vendor Computerized Physician Order Entry in Four Community Hospitals: The Importance of
Eyal Zimlichman, M.D., M.S.c; Carol Keohane, B.S.N., R.N.; Calvin Franz, Ph.D.; Wendy L. Everett, Sc.D.; Diane L. Seger, R.Ph.; Catherine Yoon, M.S.; Alexander A. Leung, M.D., M.P.H.; Bismarck Cadet, M.D.; Michael Coffey, M.D.; Nathan E. Kaufman, M.D.; David W. Bates, M.D., M.Sc.
Adoption of vendor Computerized Provider Order Entry (CPOE) systems in four community hospitals in Massachusetts brought only modest returns on investment when applying cost savings attributable to prevention of adverse drug events, reflecting the lack of clinical decision support tools.
Health Professions Education
Simulation-Based Ongoing Professional Practice Evaluation in Psychiatry: A Novel Tool for Performance Assessment
Tristan Gorrindo, M.D.; Elizabeth Goldfarb; Robert J. Birnbaum, M.D., Ph.D.; Lydia Chevalier; Benjamin Meller; Jonathan Alpert, M.D.; John Herman, M.D.; Anthony Weiss, M.D.
Seventy-five of 410 clinicians participating in an interactive online psychiatric simulation focusing on a patient’s risk for violence or suicide were referred for focused professional practice evaluation after failing one or both performance measures.
Case Study in Brief
Routine Postnatal Use of the Kleihauer-Betke Test for Anti-D Administration in Rhesus D–Incompatible Pregnancies: A Medical Student Quality Improvement Project
Nikola Lilic, M.B.Ch.B.; Kalpa Jayanatha, M.B.Ch.B.; Peter Stone, M.B.Ch.B., Obs DM(Bristol), FRCOG, FRANZCOG, DDU, CMFM
In a student-led quality improvement project, use of a locally developed Anti-D Postnatal Protocol improved appropriate Anti-D administration from 85 percent to 98 percent of eligible patients.
Rapid Response Systems
Reducing Cardiopulmonary Arrest Rates in a Three-Year Regional Rapid Response System Collaborative
Mark J. Rosen, M.D.; Andrea J. Hoberman, M.P.H.; Rafael E. Ruiz, Ph.D., ScM; Zeynep Sumer, M.S.; Hillary S. Jalon, M.S.
For 26 hospitals in the New York City metropolitan region, a statistically significant increase in rapid response system (RRS) utilization was observed over time, but a clear relationship between decreased non-ICU codes and RRS utilization was not established.