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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 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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"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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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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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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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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Any time a hospital pharmacy introduces new technology into the workflow there will be process changes and barriers to overcome.
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The Iowa Continuity of Care study's intervention arm includes extensive work on the part of a pharmacist case manager to make certain a chronically ill patient is discharged with the education and support needed to remain stable.
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The Iowa Continuity of Care project includes intensive case management by pharmacists, who begin medication reconciliation and education upon a patient's admission and continue with the education and medication reconciliation through discharge.
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