Abstract:
BACKGROUND:Although more than a decade has passed since the imperative to reduce fragmentation of care, high rehospitalization rates among Medicare patients with chronic diseases persist; at least 25% of these are considered preventable. Transitional care models that emphasize coordination among providers have demonstrated significant reductions in hospitalization rates. However, achieving effective collaboration among providers across disciplines and/or facilities through implementation of transitional care models can be challenging. OBJECTIVES:The aims of this article are to (1) describe a collaborative transitional care program implemented by a 7-hospital health care system and a postacute senior care service provider organization to pilot a transitional care program (Transitions Across Care Settings [TRACS]) for improving coordination of care for their mutual patients and (2) share results and lessons learned from this quality initiative. METHODS:The goal of the TRACS program, which used the Coleman Care Transitions Intervention model, was to reduce 30-day readmissions to lower than the national averages for an initial target population of inpatients with pneumonia, congestive heart failure, and acute myocardial infarction diagnoses. RESULTS:The overall readmission rate for 104 patients in the pilot TRACS program was 4.8%. Readmission rates were 0% for acute myocardial infarction, 7.1% for congestive heart failure, and 4.4% for pneumonia. CONCLUSIONS:A culture of patient safety was facilitated by a registered nurse transitions coach through consistent communication and flow of patient information during patient hand offs across the care continuum. More than 1000 patients are already admitted to the next iteration of the TRACS program, resulting in a sustainable enterprise.
journal_name
J Patient Safjournal_title
Journal of patient safetyauthors
Radhakrishnan K,Jones TL,Weems D,Knight TW,Rice WHdoi
10.1097/PTS.0000000000000168subject
Has Abstractpub_date
2018-03-01 00:00:00pages
e3-e5issue
1eissn
1549-8417issn
1549-8425journal_volume
14pub_type
杂志文章abstract:OBJECTIVE:To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. METHODS:Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia betwee...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3182948a51
更新日期:2015-03-01 00:00:00
abstract:OBJECTIVES:This study assesses fall prevention measures and subsequent incident reporting of falls resulting in an "inpatient fracture neck of femur (FNOF)" within a single NHS Trust, with the aim of identifying potential areas of improvement and changing practice within a Trust. METHODS:Forty patients (mean age, 82.6...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000193
更新日期:2018-12-01 00:00:00
abstract:INTRODUCTION:Significant resource is invested into investigation of adverse healthcare events. Outcomes of such investigations have varying degrees of effectiveness. The "hierarchy of effectiveness" model proposes system-focused changes have greater impact than person-focused actions. The traditional approach to invest...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000641
更新日期:2020-03-24 00:00:00
abstract:BACKGROUND:In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a pote...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000543
更新日期:2018-11-21 00:00:00
abstract:INTRODUCTION:The second victim is defined as the health professionals who commit an error and are traumatized by the event manifesting psychological, cognitive, and/or physical reactions that have a personal negative impact.The SVEST (Second Victim Experience and Support Tool) is a survey developed and validated in the...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000497
更新日期:2018-05-03 00:00:00
abstract:OBJECTIVE:To develop an objective tool designed to standardize the identification of high-alert medications (HAMs) according to patient safety risk. METHODS:Medications were evaluated using the High-Alert Medication Stratification Tool (HAMST). Tool revision occurred through assessing medications on an organization-ap...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000445
更新日期:2017-12-12 00:00:00
abstract:BACKGROUND:Standardized electronic order sets for venous thromboembolism prophylaxis have increased the proportion of patients receiving venous thromboembolism prophylaxis. However, ordering venous thromboembolism prophylaxis does not ensure consistent administration. OBJECTIVE:To explore causes of variability in the ...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000086
更新日期:2016-06-01 00:00:00
abstract:BACKGROUND:The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. OBJECTIVE:The aim of the study was to determine whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS),...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000456
更新日期:2017-12-27 00:00:00
abstract:BACKGROUND:In November 2010, the American College of Cardiology Foundation published revised appropriateness criteria (AC) for cardiac computed tomography (CT). We evaluated adherence to these criteria by providers of different subspecialties at a tertiary referral center. METHODS:Reports of 383 consecutive patients w...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000124
更新日期:2016-03-01 00:00:00
abstract:OBJECTIVES:This study aimed to review and critically appraise the published literature on 2 selected prospective risk analysis tools, Failure Mode and Effects Analysis and Socio-Technical Probabilistic Risk Assessment, as applied to the dispensing of medicines in both inpatient and outpatient pharmacy settings. METHOD...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000403
更新日期:2017-06-29 00:00:00
abstract:AIMS:This study measured the effect of aviation-style team training on 3 surgical teams from different specialties. It focused on team working and communication, particularly briefing, time-out, and debriefing, and sought to understand how improvements in team skills could be implemented in a broad range of naturalisti...
journal_title:Journal of patient safety
pub_type: 杂志文章,多中心研究
doi:10.1097/PTS.0b013e3181f100ea
更新日期:2010-09-01 00:00:00
abstract::On May 20 to 22, 2009, the National Patient Safety Foundation (NPSF) held its Annual NPSF Patient Safety Congress in National Harbor, Md. Entitled Patient Safety in Challenging Times: Now More Than Ever, A Critical Need, the meeting focused on the need to strengthen efforts to improve patient safety and quality in the...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/pts.0b013e3181b5cb8a
更新日期:2009-09-01 00:00:00
abstract:OBJECTIVES:This study aimed to explore nurses' perceptions regarding disclosure of patient safety incidents. METHODS:An anonymous online survey was conducted, and results were compared with those of the general public using the same questionnaire in a previous study. RESULTS:Among 689 nurses, 96.8% of nurses felt maj...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000781
更新日期:2020-09-08 00:00:00
abstract:BACKGROUND:Existing patient safety culture assessment tools are mostly developed in western countries and may not be suitable for Chinese primary health care institutions. Primary care plays an important role in China's medical system, and a targeted tool for its patient safety culture is urgently needed. OBJECTIVE:Th...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000733
更新日期:2020-05-13 00:00:00
abstract:OBJECTIVE:Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharm...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181d108cb
更新日期:2010-03-01 00:00:00
abstract:OBJECTIVES:Delivering health care is emotionally demanding. Emotional competencies that enable caregivers to identify and handle emotions may be important to deliver safe care, as it improves resilience and enables caregivers to make better decisions. A relevant emotional competence could be psychological detachment, w...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000479
更新日期:2018-02-26 00:00:00
abstract:OBJECTIVES:Relatively little is known about rates of outpatient adverse drug events (ADEs), and most health systems do not routinely identify them. We developed a computerized ADE measurement process and used it to detect ADEs from electronic health records and then categorized them according to type, preventability, a...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181dcae06
更新日期:2010-06-01 00:00:00
abstract:OBJECTIVES:We report on a human factors evaluation project at a major urban teaching hospital that was intended to use human factors methods to assist the selection of a new infusion device among 4 commercially available models. METHODS:The project provided an expert evaluation of the pumps, collected data on programm...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e3181a974d9
更新日期:2009-06-01 00:00:00
abstract:OBJECTIVE:This study aimed to examine the utility of using color and shape to differentiate drug strength information on over-the-counter medicine packages. Medication errors are an important threat to patient safety, and confusions between drug strengths are a significant source of medication error. METHOD:A visual s...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/pts.0b013e3181eee157
更新日期:2010-09-01 00:00:00
abstract:OBJECTIVE:Underreporting near-miss errors undermines hospitals' ability to improve patient safety. The objective of this analysis was to determine the extent to which punitive work climate, inadequate error feedback to staff, or insufficient preventative procedures are associated with decreased frequency of near-miss e...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000125
更新日期:2016-06-01 00:00:00
abstract:OBJECTIVES:The use of peripherally inserted central catheters (PICCs) has increased substantially within hospitals during the past several years. Yet, the prevalence and practices of designated nurse PICC teams (i.e., specially trained nurses who are responsible for PICC insertions at a hospital) are unknown. We, there...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000246
更新日期:2019-12-01 00:00:00
abstract:BACKGROUND:Despite increasing recognition that patients could play an important role in promoting the safety of their care, little is known on this issue regarding health-care professionals' (HCPs') attitudes toward patient involvement. OBJECTIVES:To investigate physicians' and nurses' attitudes toward patient involve...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0b013e318267c4aa
更新日期:2012-12-01 00:00:00
abstract:BACKGROUND:Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing. OBJECTIVES:The aim of this qualitative study was to describe nurses' views of...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000314
更新日期:2017-11-04 00:00:00
abstract:OBJECTIVES:Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000711
更新日期:2020-06-01 00:00:00
abstract:OBJECTIVES:Adverse drug events (ADEs) are common in ambulatory care and may result from poor patient-physician communication about medication-related symptoms. A module was developed within an electronic patient portal that was designed to enhance communication about medication symptoms and, in turn, reduce ADEs and he...
journal_title:Journal of patient safety
pub_type: 杂志文章,随机对照试验
doi:10.1097/PTS.0b013e31829e4b95
更新日期:2013-09-01 00:00:00
abstract:OBJECTIVE:The purpose of this study was to assess whether bundled team training interventions for surgeons and office staff could effectively improve the accuracy of surgery scheduling, minimizing scheduling factors that may contribute to occurrence of wrong site surgery. METHODS:This quasiexperimental observational s...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000370
更新日期:2017-02-24 00:00:00
abstract:OBJECTIVES:Many patients with cancer believe that something has gone wrong in their care but are reluctant to speak up. This pilot study sought to evaluate the impact of an intervention of active outreach to patients undergoing cancer treatment, wherein patients were encouraged to speak up if they had concerns about th...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000510
更新日期:2018-06-27 00:00:00
abstract:OBJECTIVE:To analyze the patterns of potentially avoidable readmissions due to adverse drug events (ADEs) to identify the most appropriate risk reduction interventions. METHODS:In this observational study, we analyzed a random sample of 534 potentially avoidable 30-day readmissions from 10,275 consecutive discharges f...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000346
更新日期:2017-03-17 00:00:00
abstract:OBJECTIVES:The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS:The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained G...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000475
更新日期:2018-02-13 00:00:00
abstract::Implanted medical devices (IMDs) are extremely common, yet they are not systematically documented on hospital admission. Through structured patient interviews, we determined the prevalence of IMDs in hospital inpatients. Using medical record review, we evaluated the sensitivity of the medical record reporting of IMDs ...
journal_title:Journal of patient safety
pub_type: 杂志文章
doi:10.1097/PTS.0000000000000187
更新日期:2018-09-01 00:00:00