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BACKGROUND A "bundle" of ventilator care processes (peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a sedation vacation), which may also reduce ventilator-associated pneumonia (VAP) rates, can serve as a focus for improvement strategies in intensive care units (ICUs). Between July 2002 and January(More)
Adverse drug events continue to be the single most frequent source of healthcare mishaps, continually placing patients at risk of injury. This is not unexpected, given that drug treatment is the most common medical intervention and medication use is a highly complex, multidisciplinary, and largely manual process. Assessing the actual safety of drug use has(More)
BACKGROUND Clear communication is imperative if teams in any industry expect to make improvements. An estimated 85% of errors across industries result from communication failures. PURPOSE The purpose of this study was to evaluate and improve the effectiveness of communication during patient care rounds in the intensive care unit (ICU) using a daily goals(More)
BACKGROUND The Institute for Healthcare Improvement has tested and taught use of a variety of trigger tools, including those for adverse medication events, neonatal intensive care events, and a global trigger tool for measuring all event categories in a hospital. The trigger tools have evolved as a complimentary adjunct to voluntary reporting. The Trigger(More)
Because waits, delays, and cancellations are so common in healthcare, patients and providers assume that waiting is an inevitable, but regrettable, part of the care process. For years, hospitals responded to delays by adding resources--more beds and buildings or more staff--as the only way to deal with an increasingly needy population. Furthermore, as long(More)
PURPOSE To develop and implement a set of valid and reliable yet practical measures of intensive care units (ICU) quality of care in a cohort of ICUs and to estimate, based on current performance, the potential opportunity to improve quality. METHODS We included 13 adult medical and surgical ICUs in urban community teaching and community hospitals. To(More)
What does it take to transform the safety of health care across a nation, even a small one? The Scottish Patient Safety Programme, mandated by the government, began in January 2008 with the aim of reducing mortality in Scotland's hospitals by 15 percent in five years. With the collaboration of political leaders, senior health care managers, clinicians, and(More)
Adverse drug events continue to be the single most frequent source of healthcare mishaps, continually placing patients at risk of injury. This is not unexpected, given that drug treatment is the most common medical intervention and medication use is a highly complex, multidisciplinary, and largely manual process. Assessing the actual safety of drug use has(More)
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