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How Adventist Health System Improved its Adverse Event Data Accuracy, in the July 2013 issue of "The Joint Commission Journal on Quality and Patient Safety"
(Oak Brook Ill., June 19, 2013) 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.
Developing and Implementing a Standardized Process for Global Trigger Tool Application Across a Large Health System
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
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 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.
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
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.
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
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.
For more information about the “The Joint Commission Journal on Quality and Patient Safety” please visit: http://store.jcrinc.com/the-joint-commission-journal-on-quality-and-patient-safety/.
A review copy of the Journal is available to reporters upon request. Click here to request a copy