scholarly journals Real-Time Bedside Root Cause Analysis (RCA) as a Catalyst for Clostridioides difficile Reduction

2020 ◽  
Vol 41 (S1) ◽  
pp. s366-s367
Author(s):  
Hannah Newman ◽  
Linda Kirschenbaum ◽  
Irene Macyk ◽  
Daniel Baker ◽  
Janet C Haas
Keyword(s):  
Patient Care ◽  
Real Time ◽  
Infection Risk ◽  
Frontline Staff ◽  
Cause Analysis ◽  
Clinical Leadership ◽  
Staff Members ◽  
Root Cause ◽  
The Past ◽  
Clostridioides Difficile

Background:C. difficile infection has been a significant cause of morbidity and mortality over the past decade. Our hospital had rates of hospital-onset, laboratory-identified, C. difficile infection (HO-CDI) that were significantly higher than our state and national benchmarks. HO-CDI is defined as a test positive for C. difficile occurring on or after day 4 of hospitalization, regardless of the presence of symptoms. New leadership at the hospital sought a creative way to engage staff in finding solutions to our high rates of HO-CDI. Objective: The purpose of this intervention was to engage frontline staff in reporting and solving patient care situations that may increase infection risk to decrease HO-CDI rates. Methods: Starting in July 2015, real-time bedside RCAs were performed weekly for any HO-CDI on the unit to which the infection was attributed and on any unit from which the patient had been recently transferred. Top clinical leadership of the hospital, and all services and departments, physicians, nurses, and others involved with the patient’s care were expected to attend and identify factors that may have contributed to the infection. The findings were documented, and changes to care were made based on the findings. The rate of incident hospital onset HO-CDI per 10,000 patient days was used to measure outcome because standardized infection ratios for the period before 2016 were not available. Results: Staff members suggested 6 specific actions that were undertaken to decrease HO-CDI risk (Table 1). The HO-CDI rate during the preintervention period (2012–2014) was 6.85 per 10,000 patient days (275 cases). In the postintervention period (2016–2018) the HO-CDI rate was 3.13 per 10,000 patient days (101 cases). There was a 54% reduction in the HO-CDI rate in the postintervention period (P < .001). Conclusions: The multidisciplinary bedside RCA process resulted in staff providing recommendations for actions to reduce HO-CDI risk. Implementation of staff suggestions resulted in a sustained, significant decrease in HO-CDI.Funding: NoneDisclosures: None

“SWARMing” to Improve Patient Care: A Novel Approach to Root Cause Analysis

2015 ◽  
Vol 41 (11) ◽  
pp. 494-AP3 ◽  
Author(s):  
Jing Li ◽  
Bernard Boulanger ◽  
Jeff Norton ◽  
Audrey Yates ◽  
Colleen H. Swartz ◽  
...  
Keyword(s):  
Patient Care ◽  
Improve Patient Care ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Novel Approach ◽  
Improve Patient

HIV misdiagnosis: A root cause analysis leading to improvements in HIV diagnosis and patient care

2017 ◽  
Vol 96 ◽  
pp. 84-88 ◽  
Author(s):  
Raynell Lang ◽  
Carmen Charlton ◽  
Brenda Beckthold ◽  
Kiana Kadivar ◽  
Stephanie Lavoie ◽  
...  
Keyword(s):  
Patient Care ◽  
Root Cause Analysis ◽  
Hiv Diagnosis ◽  
Cause Analysis ◽  
Root Cause

Rewind and Core Restack of AEP Conesville #5 Generator

2004 ◽  
Author(s):  
J. Timperley ◽  
J. Michalec ◽  
W. Moore ◽  
H. Moudy ◽  
J. Hutt
Keyword(s):  
Cost Effective ◽  
Original Design ◽  
Specific Design ◽  
Stator Core ◽  
Cause Analysis ◽  
Root Cause ◽  
The Core ◽  
Phase Lead ◽  
The Past ◽  
Core Damage

This paper presents an overview of the design and field installation events involved in rewinding and restacking AEP’s Conesville #5 generator. This style of generator, commonly known as a “double tube stack” machine, has been susceptible in the past to stator end winding vibration, stator coil and core deterioration, and phase lead problems. Following tests and inspections, AEP decided to rewind this generator in anticipation of the consequences of these problems. Successful pro-active maintenance, which included a complete stator rewind and stator core restack, prevented a costly forced outage. Root cause analysis of the coil failures are described, as well as details of the core laminations problems. Specific design enhancements over and above the original design will be discussed. In addition, details of the existing core damage will be discussed, as well as procedures used for core restacking. Fiber optic monitoring instruments were installed on the coil ends and the phase leads after the new coil installation was complete. Results of these initial readings will be shared. Successful startup and continued operation of this unit demonstrates that refurbishment of these large generators with inner gas cooled technology is reliable and cost-effective over other alternatives, such as conversion to water cooled technology.

scholarly journals Aviation-Modeled Investigation of Significant Obstetric Events

2020 ◽  
Vol 185 (5-6) ◽  
pp. e616-e624
Author(s):  
Nicole Powell-Dunford ◽  
Patricia Deuster ◽  
Mark McPherson ◽  
Steven J Gaydos
Keyword(s):  
Medical Error ◽  
Dental Treatment ◽  
Root Cause Analysis ◽  
Survey Study ◽  
Cause Analysis ◽  
Staff Members ◽  
Root Cause ◽  
High Profile ◽  
Treatment Facilities ◽  
Small Team

Abstract Introduction In this research, the authors attempted to ascertain whether or not the Root Cause Analysis Event Support and Engagement Team (RESET) investigates the use of U.S. Army aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred. Root cause analysis (RCA), originating in the manufacturing and engineering sectors, attempts to elucidate an underlying cause of a problem. Most recently, this process has been applied to the investigation of medical error. RESET was established in order to perform centralized investigation of significant medical error within U.S. Army medical and dental treatment facilities based on request from a hospital commander or general officer. Significant obstetric events are high profile, discussed in multiple safety forums, and an area of close RESET focus. Yet it is unclear if RESET investigates the use of aviation-based techniques by staff and/or organizations involved in serious obstetrical events. Therefore the present survey study was conducted. Materials and Methods A structured, anonymous, voluntary survey was fielded to RESET staff in order to assess whether or not the RESET investigates the use of aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred. Results Five of six members of this small team completed the survey. Prebriefs, debriefs, and checklist use were consistently investigated. The employment of a sterile cockpit, first-name introductions, annual check ride, and emergency procedure rehearsal were infrequently investigated. Conclusion Obstetric RESET investigations inconsistently ascertain whether or not some of the aviation-based techniques are utilized by staff members or organizations in which serious obstetrical events have occurred. Standardization of investigative procedures and education directed at under-investigated practices may optimize medical investigation using proven tenets of an aviation-based approach.

Fretting Fatigue Modeling and Repair Evaluation for Generator Rotors

2003 ◽  
Author(s):  
Srikanth Akkaram ◽  
Mandar Chati ◽  
Sairam Sundaram ◽  
Gary Barnes
Keyword(s):  
Fatigue Testing ◽  
Failure Mechanisms ◽  
Element Model ◽  
Fretting Fatigue ◽  
Field Observations ◽  
Cause Analysis ◽  
Operating Modes ◽  
Root Cause ◽  
The Past ◽  
Rotor Tooth

Generator Rotor Tooth Cracks have been recently observed on some long service generator rotors. The purpose of this paper is to document the root cause analysis as well as a repair methodology that was developed in support of one of these cracked units. The paper discusses the development of a finite element model to understand the operating modes and failure mechanisms that caused the initiation of these cracks. The results of the analysis agreed very well with field observations on cracked units and with some limited repair options that have been successfully used in the past. An experimental fretting fatigue testing program is currently underway to substantiate and extend the results reported in this paper.

Video real-time imaging of artificial membranes during freeze-drying by cryo-electron microscopy

1988 ◽  
Vol 46 ◽  
pp. 16-17
Author(s):  
Alan S. Rudolph ◽  
Ronald R. Price
Keyword(s):  
Real Time ◽  
Self Assembly ◽  
Freeze Drying ◽  
Video Capture ◽  
Drying Process ◽  
Artificial Membranes ◽  
The Past ◽  
Cryo Electron Microscopy ◽  
Spherical Structures ◽  
Capture Techniques

We have employed cryoelectron microscopy to visualize events that occur during the freeze-drying of artificial membranes by employing real time video capture techniques. Artificial membranes or liposomes which are spherical structures within internal aqueous space are stabilized by water which provides the driving force for spontaneous self-assembly of these structures. Previous assays of damage to these structures which are induced by freeze drying reveal that the two principal deleterious events that occur are 1) fusion of liposomes and 2) leakage of contents trapped within the liposome [1]. In the past the only way to access these events was to examine the liposomes following the dehydration event. This technique allows the event to be monitored in real time as the liposomes destabilize and as water is sublimed at cryo temperatures in the vacuum of the microscope. The method by which liposomes are compromised by freeze-drying are largely unknown. This technique has shown that cryo-protectants such as glycerol and carbohydrates are able to maintain liposomal structure throughout the drying process.

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