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Although electronic reporting systems for near misses and adverse events have been implemented nationwide (and recently at New York Medical College at Westchester Medical Center), physician participation in such systems has typically been limited. Previous efforts to improve such rates have met…
For 18 months, New York Medical College at Westchester Medical Center implemented several interventions to reduce inpatient morbidity and mortality related to cardiopulmonary arrests. In November 2009, a rapid response system went into full operation. Leading up to the 'go live' date, the hospital…
Flash sterilization the rapid sterilization of items using steam occurs in many operating rooms in the event that surgical instrumentation requiring immediate use becomes contaminated. However, the process is over-utilized, increasing the risk of infection in surgical patients. In the interest of…
Effective teamwork and communication techniques can improve quality and safety, decrease patient harm and promote cross professional collaboration. The TeamSTEPPS program developed by the (AHRQ) and the U.S. Department of Defense is an evidence based and comprehensive teamwork and communication…
The advent of computerized tomography (CT) has revolutionized diagnostic radiology. The use of CT for diagnostic studies throughout the nation increased more than 300 percent from 1993 to 2007, and at Lincoln Medical and Mental Health Center the increase was 40% from 2005 to 2010. By its nature, CT…
Missed or delayed cancer diagnoses are a frequent cause of patient harm and malpractice lawsuits in the ambulatory setting. Several domains have been identified that contribute to preventable delays in diagnosis, ranging from system factors (such as delays in obtaining appointments) to physician…
Timely notification of critical laboratory values ensures prompt clinical intervention for potential life-threatening conditions and is a requirement of regulatory and accreditation agencies including The Joint Commission and the College of American Pathologists.
The Jacobi Medical Center Department of Radiology analyzed the 15.3 percent rise in annual computerized tomography (CT) requests from 2007 to 2009 to identify opportunities to prevent overutilization and resulting patient harm from radiation exposure. The interdepartmental nature and…
Health Quest uses and benefits from a system wide root cause analysis policy to address adverse and near-miss events. The expressed purpose is to learn from each other, share what is learned, and help prevent similar occurrences in all of the system's hospitals. This policy is a powerful…
Continuum Health Partners' pay-for performance program (P4P) is designed to partner with physicians to help the organization improve quality and safety, and reduce inpatient resource utilization by eliminating medically unnecessary services. Goals are to implement more efficient practice…