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Any time a hospital pharmacy introduces new technology into the workflow there will be process changes and barriers to overcome.
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Hospitals should be alert to potential problems with giving topical thrombin intravascularly, the Institute for Safe Medication Practices (ISMP) warns hospital pharmacists.
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A new article in The Joint Commission Journal on Quality and Patient Safety1 has provided evidence-based recommendations for a process that may be especially relevant in light of the recent spate of natural disasters: debriefing.
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Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), did not pull any punches when she gave the keynote plenary address on Sept. 8 at the 2008 AHRQ Annual Meeting nor did she hold back in a follow-up interview with Healthcare Benchmarks and Quality Improvement.
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"It was pretty primitive, what we were doing," says Sarah Bland, RPh, senior clinical pharmacist, Center for Drug Policy at the University of Wisconsin Hospital and Clinics, referring to the method of screening drug orders before she began to use Premier Inc.'s web-based tools.
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The Joint Commission requires a "thorough and credible" root cause analysis (RCA) for all Sentinel Events, but the process is sometimes less effective than hoped. Quality leaders at the Mayo Clinic came up with a novel solution: An oversight group to keep the process on track.
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The National Surgical Quality Improvement Program (NSQIP) began in 1994 in response to concern over the quality of care, specifically operative mortality rates, in VA hospitals. Since then it has expanded to all hospital settings and come under the auspices of the American College of Surgeons (ACS).
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The National Quality Forum (NQF) has endorsed 67 clinician-level consensus standards related to cancer care, infectious diseases, perioperative care, and care provided by thousands of medical professionals who are not MDs.
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Which came first: the chicken or the egg? Likewise, are what the Centers for Medicare & Medicaid Services labels "never events" really never events if they happen?
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