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  A Lean Approach Optimizes Implementation of Bar Coding to Improve Medication Administration, According to New Article in The Joint Commission Journal on Quality and Patient Safety  
(Oak Brook, Ill., July 29, 2014) Joint Commission Resources today announced the release of the August 2014 issue of The Joint Commission Journal on Quality and Patient Safety. The issue features an article, “Using Lean ‘Automation with a Human Touch’ to Improve Medication Safety: A Step Closer to the ‘Perfect Dose,’” that describes how Virginia Mason Medical Center, Seattle, used the Lean concept of Jidoka to integrate bar code medication administration (BCMA) technology into the nursing work flow with minimal disruption.

Joan M. Ching, RN, M.N., and co-authors analyzed 16,149 medication doses for 3,617 patients during a three-year period. After BCMA implementation, the number of safe practice violations decreased from 54.8 to 29 per 100 doses, and the number of medication errors decreased from 5.9 to 3 errors per 100 doses. The number of unsafe administration practices also decreased.

In an accompanying editorial, Ross Koppel, Ph.D., FACMI, a leading scholar of health care information technology and of the interactions of people, computers and workplaces, states that the article “illustrates how technology should be introduced into health care settings—reflecting respect for and attention to clinician work flow, careful observations, ongoing monitoring, adequate materials handling, flexibility and responsiveness.” However, he cautions that even the most exemplary implementation of technology can bring trade-offs when absolute adherence to protocols is required. 

The remaining articles from the August 2014 issue are:

Performance Improvement
Implementation and Evaluation of a Multicomponent Quality Improvement Intervention to Improve Efficiency of Hepatitis C Screening and Diagnosis   
Amy A. Hirsch, Pharm.D.; Renée H. Lawrence, Ph.D.; Elizabeth Kern, M.D., M.S.; Yngve Falck-Ytter, M.D., A.G.A.F.; Davis T. Shumaker, M.B.A.; Brook Watts, M.D., M.S.

At the Louis Stokes Cleveland Department of Veterans Affairs (VA) Medical Center, viral testing was completed within six months of the first instance of a positive hepatitis C virus (HCV) antibody test for only 45 percent of patients. From 2005 through 2013, compliance peaked at 96 percent, reaching 100 percent only after HCV reflex testing was implemented.

Adverse Events
Assisted and Unassisted Falls: Different Events, Different Outcomes, Different Implications for Quality of Hospital Care  

Vincent S. Staggs, Ph.D.; Lorraine C. Mion, RN, Ph.D., FAAN; Ronald I. Shorr, M.D., M.S.

Many hospitals classify inpatient falls as assisted (if a staff member is present to ease the patient’s descent or break the fall) or unassisted for quality measurement purposes. Unassisted falls are more likely to result in injury, but there is limited research quantifying this effect. For 2011 data for 6,539 adult medical, surgical and medical-surgical units in 1,464 general hospitals, 166,883 falls (3.44 falls per 1,000 patient-days) were reported, 85.5 percent of which (excluding repeat falls) were unassisted. Fallers for whom a fall prevention protocol was not in place were more likely to fall unassisted than those for whom one was in place, and unassisted falls were more likely to result in injury—suggesting that unassisted falls should be considered a target for future prevention efforts.

Research Versus Quality Improvement: Distinct or a Distinction Without a Difference? A Case Study Comparison of Two Studies    

Susan Kirsh, M.D., M.P.H.; Wen-Chih Wu, M.D., M.P.H.; David Edelman, M.D., M.S.; David C. Aron, M.D., M.S.

Determining where research and quality improvement (QI) begins is more than an academic question. Two studies involving implementation of shared medical appointments for patients with diabetes were compared: a research-funded randomized controlled trial and a study that began as a QI project but was later reclassified as research after increased rigor was used to increase internal validity. Despite differences in the original intent, the two studies’ results were similar. Better ways are needed to address the regulatory issues governing research while ensuring that risk is minimized and patients’ confidentiality is safeguarded. 

Conference Report
Resilience and Resilience Engineering in Health Care

Rollin J. Fairbanks, M.D., M.S.; Robert L. Wears, M.D., M.S., Ph.D.; David D. Woods, Ph.D.; Erik Hollnagel, Ph.D.; Paul Plsek, M.S.; Richard I. Cook, M.D.

This report, a summary of a workshop, “Ideas to Innovation: Stimulating Collaborations in the Application of Resilience Engineering to Healthcare,” held in June 2013, describes ways to identify and enhance resilience for the improvement of patient safety.  


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