March/April 2004 Table of Contents

FEATURE ARTICLES

6	Patient Safety: A Case Study in Team Building and Interdisciplinary Collaboration Bernard J. Horak, PhD FACHE CPHQ; Joyce Pauig, RN; Ben Keidan, MD; Jennifer Kerns, MD Abstract: This case report presents specific steps taken to address potential patient safety problems, particularly those regarding collaboration between nurses and house staff at The George Washington University Hospital. Issues affecting patient care (e.g., lack of communication and teamwork) were identified through interviews, focus groups, and observations. The actions taken were team-building meetings that included a sensitivity session; coaching with nursing managers, and ground rules for nurse and physician collaboration. This report also describes the agenda for the team-building meetings, results, and lessons learned for implementation at other sites.
14	Agreement Between Pediatric Medication Orders and Medication Cardex Greg Cable, PhD MPA; Jeanne Craft, MD Abstract: This study examined the individual and temporal factors that explain whether the medication cardex agrees with a physician’s pediatric medication order. After controlling for several potentially confounding factors, it was found that, among other things, pediatric intensive care unit cardexes were 62% less likely to agree with the physician order than cardexes from other units. Cardexes for “stat” orders were twice as likely to agree with the physician order. These data support the possibility that “low-tech” changes in the process of providing care can improve the likelihood that the medication order will agree with the cardex and, as a result, reduce the likelihood of medication errors.
21	On the Road to the OSHA Voluntary Protection Program Mary Sgarlata Adamus, MHA Abstract: In 1998, representatives from the Employee Health Services, Safety and Security, Physical Therapy, Human Resources, and Legal Affairs Departments and the Risk Management Program at Robert Packer Hospital (RPH) in Sayre, PA began a project to create a “culture of safety.” The journey would ultimately lead to application to the Occupational Safety and Health Administration Voluntary Protection Program (OSHA VPP). Four years later, because of the dedication and collaboration of many individuals, RPH received notification that its application for OSHA VPP participation was approved by the Assistant Secretary of Labor. This article describes that journey and provides other healthcare organizations with the information needed to begin their own journey to successful project implementation.
31	Interview with a Quality Leader: Thomas M. Smith on Virginia Commonwealth University’s Patient Safety Fellowship Michelle Horvath, MSN RN CPHQ; Pamela Scarrow, BS CMSC CPHQ Abstract: Following his clinical nursing career that included adult and pediatric intensive care, cardio-thoracic surgical, education, teaching, consulting, and management, Thomas M. Smith moved into the utilization management and quality improvement field. Currently, he is director of operations and education for The American Health Quality Association (AHQA), based in Washington, DC. AHQA represents Quality Improvement Organizations and professions working to improve healthcare quality and patient safety. At the time of this interview, he was director of Virginia operations for the West Virginia Medical Institute (WVMI), Inc., Richmond, VA. Smith is the immediate past president of the Virginia Association for Healthcare Quality, serving on the board of directors for 6 years. His other appointments include a seat on the School Health Advisory Board for Hanover County and Virginia’s Improving Patient Care & Safety, as well as his appointment to the Governor’s Task Force for the Evaluation and Monitoring of the Comprehensive Services Act by the Commonwealth of Virginia Secretary for Health and Human Services. He also currently serves as the cochair for the NAHQ Conference Planning Team. Smith received his MA degree in administration/education from West Virginia University, Morgantown, and his BSN in nursing/biology from West Virginia Wesleyan College, Buckhannon. A member of Sigma Theta Tau and Omicron Delta Kappa, he is a certified professional in healthcare quality. He completed his executive fellowship in patient safety from Virginia Commonwealth University, Richmond, in May 2003.
36	Developing a Unit-Specific Falls Reduction Program Annette Ward, MSN RN; Lori Candela, EdD MS RN CCRN; Judy Mahoney, MA RN CPHQ  Though an extensive amount of literature addresses the significance of patient falls and mechanisms to identify those at high risk, much less has been written regarding units in which nearly every patient fits the high-risk category. In addition, little information describes specific interventions designed to protect at-risk patients. In response to a record number of falls in the Transitional Care Unit at an acute care facility, an interdisciplinary team was developed to review patient falls, design a unit-specific falls reduction program, and begin its implementation. In the subsequent 6 quarters, the number of patient falls was reduced by 57%.
42	Medical Errors: Excess Hospital Costs and Lengths of Stay Leslie D. Nordgren, MPH; Trista Johnson, PhD; Mark Kirschbaum, PhD; Michelle L. Peterson, MPH  To focus on effective patient safety strategies in an environment of intense competition for resources, a method of quantifying the effect of potential sources of medical errors was developed. This study assessed excess length of stay (LOS) and hospitalization costs associated with patients who experienced errors. The distribution of the errors occurring within the mean LOS experienced by others with the same diagnosis and severity was also examined. Patients with errors had longer stays and greater costs when compared to controls.
50	Quality Toolbox: Fishing for Good Catches: Implementing a Successful Event-Reporting System Karen Fish, MBA; Bernadette Murphy, BS RN; Evy Olson, MBA BSN RN; Robin Bowlinger, MS RN After participating in the Veterans Health Administration’s Patient Safety initiative, Medcenter One Health Systems began to work on changing the culture of the organization with regard to incident reporting.

DEPARTMENTS

JHQ ONLINE

• Brief Report: The Safety Net: Creating a Comprehensive Culture of Safety
  Mary Savitsky, MHA RN CHE CPHQ
  
• Press Call: The Joint Commission Publishes Universal Protocol with Endorsement
  Susan V. White, PhD RN CPHQ FNAHQ
  
• Quality Products and Resources

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