Biomedical subjects

Erin Graydon-Baker

Publications and source records attributed to Erin Graydon-Baker.

5 recordsLinked to original sources

PubMed2005

Closing the loop: follow-up and feedback in a patient safety program.

BACKGROUND: As health care organizations establish patient safety agendas, attention has focused on creating less cumbersome systems for reporting errors. However, experience at Brigham and Women's Hospital (Boston) suggests that more emphasis needs to be placed on what happens after a report is submitted. FOLLOW-UP AND FEEDBACK: Follow-up includes prioritizing opportunities and actions, assigning responsibility and accountability, and implementing the action plan. Feedback entails (1) follow-up to those who report issues and (2) communication to the hospital staff and clinicians about events and actions taken. Responsibility and accountability for improvements need to be assigned by senior administration to hospital leaders who can effect the needed changes. Hospital leaders, not just the members of the patient safety team, must own these changes or improvements. Events that require follow-up action are brought to the attention of risk management and the patient safety team through several mechanisms, including voluntary reporting of adverse events through a computerized safety reporting system, root cause analyses, and Patient Safety Leadership WalkRounds. DISCUSSION: Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item. However, it is the feedback to the reporter that perpetuates the influx of information and closes the loop. Developing the information-tracking database has made providing feedback easier and more reliable but significant effort is required to keep the database current.

Boston↗

PubMed2005

Designing an electronic medication reconciliation system.

Unintended medication discrepancies at hospital admission and discharge potentially harm patients. Explicit medication reconciliation (MR) can prevent unintended discrepancies among care settings and is mandated by JCAHO for 2005. Enterprise-wide, we are linking pre-admission and discharge medication lists in our outpatient electronic health records (EHR) with our inpatient order entry applications (OE) - currently not interoperable - to support MR and inform the development of comprehensive MR among hospitalized patients.

Hospitalization↗

PubMed2003

Patient Safety Leadership WalkRounds.

BACKGROUND: In the WalkRounds concept, a core group, which includes the senior executives and/or vice presidents, conducts weekly visits to different areas of the hospital. The group, joined by one or two nurses in the area and other available staff, asks specific questions about adverse events or near misses and about the factors or systems issues that led to these events. ANALYSIS OF EVENTS: Events in the Walkrounds are entered into a database and classified according to the contributing factors. The data are aggregated by contributing factors and priority scores to highlight the root issues. The priority scores are used to determine QI pilots and make best use of limited resources. Executives are surveyed quarterly about actions they have taken as a direct result of WalkRounds and are asked what they have learned from the rounds. RESULTS: As of September 2002, 47 Patient Safety Leadership WalkRounds visited a total of 48 different areas of the hospital, with 432 individual comments. DISCUSSION: The WalkRounds require not only knowledgeable and invested senior leadership but also a well-organized support structure. Quality and safety personnel are needed to collect data and maintain a database of confidential information, evaluate the data from a systems approach, and delineate systems-based actions to improve care delivery. Comments of frontline clinicians and executives suggested that WalkRounds helps educate leadership and frontline staff in patient safety concepts and will lead to cultural changes, as manifested in more open discussion of adverse events and an improved rate of safety-based changes.

Boston↗

PubMed2003

Creating an integrated patient safety team.

UNLABELLED: CREATING A PATIENT SAFETY TEAM: In May 2001 Brigham and Women's Hospital (Boston) created the Patient Safety Team, which was incorporated into the pre-existing safety and quality infrastructure. ESTABLISHING THE PATIENT SAFETY TEAM'S GOALS AND INITIATIVES: The goal was to create the safest possible environment for patients and staff by creating a culture of safety, increasing the capacity to measure and evaluate processes, committing to change unsafe processes, and adopting new technologies. To achieve this mission, the following initiatives were established: create a culture of safety, increase event identification, improve event analysis, close the feedback loop, assess risk proactively, improve medication safety, and involve the patient. DISCUSSION: Integrating the Patient Safety Team into pre-existing committees and departments facilitated its work while helping to reinforce the multidisciplinary nature of safety efforts. It is critical that pre-existing groups feel that patient safety represents value added and is not a threat to their current roles. SUMMARY AND CONCLUSIONS: If a patient safety strategy and team are to be effective, commitment from the organization's leaders is essential. This team should also work with individual departments and pre-existing quality structures to drive changes to the systems of care to enable health care to become as safe as possible.

Academic Medical Centers↗

PubMedDate not supplied

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Confusion about patients' medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.

Clinical Pharmacy Information Systems↗