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Elizabeth Eaken Zhani
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Katie Looze
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  Institute for Safe Medication Practices (ISMP) Assesses Medication Safety in U.S. Hospitals in February 2014 issue of "The Joint Commission Journal on Quality and Patient Safety"  
(Oak Brook, Ill., January 28, 2014) Joint Commission Resources today announced the release of the February 2014 issue of The Joint Commission Journal on Quality and Patient Safety, featuring an article by Allen J. Vaida, PharmD, FASHP, and his co-authors. The article called for more widespread adoption of key medication safety strategies.

Since 2000, hospitals have used the Institute for Safe Medication Practices (ISMP) Medication Safety Self Assessment® for Hospitals to assess medication safety practices and identify opportunities for improvement. The assessment, previously updated in 2004, was updated in 2011 to include significant risks associated with medication use that were not previously addressed. The 2011 version contained 270 items organized into 10 key elements and further divided into 20 core characteristics, all intended to create a new baseline of hospital medication safety efforts and to determine if progress had been achieved.

As of October 2011, 1,310 hospitals had voluntarily submitted data. Findings showed that scores increased significantly from 2000. The largest percent improvements were in core characteristics related to communication of drug orders, patient education, and quality processes and risk management. However, hospitals scored low in areas related to patient information, staff competency and education, and drug information.

Hospitals that focused on organization culture and staff education were associated with higher scores for core characteristics related to error detection, reporting and analysis. In addition, hospitals with a medication safety officer scored higher in all key elements than hospitals without one.

The authors stated that while substantial improvements in medication safety have been achieved, opportunities for improvement still exist—and that influential groups and “external forces provide the necessary pressure via regulations, standards, public policy, or incentives.”

Other articles in the February 2014 issue are as follows:

Health Literacy
Implementing Routine Health Literacy Assessment in Hospital and Primary Care Patients
Courtney Cawthon, M.P.H.; Lorraine C. Mion, Ph.D., RN, FAAN; David E. Willens, M.D., M.P.H.; Christianne L. Roumie, M.D., M.P.H.; Sunil Kripalani, M.D., M.Sc.

Patients with inadequate health literacy often have poorer health outcomes and increased utilization. A brief health literacy screen was incorporated into the electronic health record (EHR) at a large academic medical center. The completion rate was 91.8 percent for the 55,611 adult inpatient admissions (November 2010–April 2012) and 66.6 percent for the 39,595 primary care visits made by 23,186 adult patients (November 2010–September 2011). Results suggested that it is feasible to incorporate health literacy screening into clinical assessment and EHR documentation. 
Case Study in Brief
Assigning a Team-Based Pager for On-Call Physicians Reduces Paging Errors in a Large Academic Hospital 
Lisa Shieh, M.D., Ph.D.; Jeffrey Chi, M.D.; Carol Kulik, RN, M.S.N.; Arash Momeni, M.D.; Andrew Shelton, M.D.; Cynthia DePorte, RN, M.S.N.; Joseph Hopkins, M.D., M.M.M.

Complex call schedules involving large numbers of physicians on multiple services often make it difficult to determine the physician responsible for the care of a patient at any given time. To address this problem, a team-based “ghost-pager” model was implemented. Adoption was rapid and uniform, and audits showed compliance sustained at > 90 percent. Nurses were more likely to know how to contact the correct physician for discussion of a patient’s care.

Tool Tutorial
Successful Implementation of Standardized Multidisciplinary Bedside Rounds, Including Daily Goals, in a Pediatric ICU 
Jonathan Seigel, M.D.; Lesta Whalen, M.D.; Erin Burgess, B.A.; Benny L. Joyner Jr., M.D., M.P.H.; Ashley Purdy, M.H.A.; Roger Saunders, RN, M.S.N., NEA-BC; Lindsay Thompson Munn, RN, M.S.N.; Theodore Yip, B.S.; Tina Schade Willis, M.D.

A pediatric ICU team at an academic hospital created a standardized rounding structure, including a daily goals sheet. Overall, 81 percent (25/31) of staff surveyed indicated that bedside rounds improved, and rounds’ median length decreased from 11 to 9 minutes. A standardized rounding structure can be used in many care settings and handoff situations.  

Doing Right by Our Patients When Things Go Wrong in the Ambulatory Setting 
Gordon Schiff, M.D.; Paula Griswold, M.S.; Bonnie R. Ellis, RN, B.S.N.; Ann Louise Puopolo, RN, B.S.N.; Namara Brede, B.A.; Harry Reyes Nieva, B.A.; Frank Federico, R.Ph.; Nicholas Leydon, M.P.H.; Judy Ling, B.A.; Deborah Wachenheim, M.P.P.; Lucian L. Leape, M.D.; Madeleine Biondolillo, M.D. 

In 2006, When Things Go Wrong, a consensus statement of the Harvard Hospitals, provided recommendations for hospitals regarding error disclosure and apology. The PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) malpractice and safety project is releasing a new statement. When Things Go Wrong in the Ambulatory Setting suggests that disclosure and apology represent essential first steps to deeply learning from things that go wrong and making them right for patients who may be harmed. The statement is being disseminated to coincide with this article’s publication.

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 healthcare.


Joint Commission Resources (JCR), a not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. JCR is an expert resource for healthcare organizations, providing consulting services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our Web site at