Accurate Weight Documentation

2020 ◽  
pp. 15-21
Author(s):  
Sonali Muzumdar
Keyword(s):  
Real Time ◽  
Process Improvement ◽  
Human Factor ◽  
Preventive Measures ◽  
Expiration Date ◽  
Staff Education ◽  
Improvement Project ◽  
Safe Medication ◽  
Process Improvements ◽  
Improvement Plan

Background: The Institute for Safe Medication Practices (ISMP) has recommended that health systems implement preventive measures to decrease weight-based dosing errors. Problem: Despite a process improvement project that was implemented to meet ISMP’s goals, weight documentation discrepancies continue to occur. Methods: The weight documentation process was reviewed and safety gaps were identified. Pharmacists were notified when patients had greater than 15% weight documentation discrepancy. Notifications were tracked before, during, and after process improvements within the electronic health record (EHR). Interventions: Streamlining of weight documentation fields within nursing assessments, locking of bed scales, setting an expiration date for the weight documentation field, including a minimum and maximum on height and weight fields, real-time alert for nursing staff upon documentation, and staff education were part of the process improvement plan. Results: Average monthly weight documentation errors decreased from 115 to 60 per month over the process improvement period. Conclusion: Human factor errors can result in weight documentation discrepancies despite implementing ISMP’s targeted safety goals around weight documentation. A real-time pharmacy notification of weight documentation discrepancies should be required for hospital pharmacists to prevent weight-based dosing errors.

Ergonomic Process Improvement for Mapping Risk and Identifying Key Interventions for Eliminating Injuries from Needles and Sharps in the OR

2020 ◽  
Vol 64 (1) ◽  
pp. 716-720
Author(s):  
Pramila Kalaga ◽  
Barbara Wolford ◽  
Matthew Mormino ◽  
Timothy Kingston ◽  
Julie Fedderson ◽  
...  
Keyword(s):  
Risk Factors ◽  
Process Improvement ◽  
Injury Risk ◽  
Best Practice ◽  
Physical Workload ◽  
Physical Factors ◽  
Improvement Project ◽  
Targeted Interventions ◽  
Effective Interventions ◽  
Sharps Injury

The risk of a needle stick or sharps injury in the operating room (OR) is high due to conditions such as minimal physical protective measures, frequent transfer of sharps, and reliance on human attention and skill for injury avoidance. An ergonomic process improvement project was initiated at a large metro teaching hospital to identify ergonomic risk factors for these OR injuries. To maximize the engagement of the front- end users, an ergonomic process improvement (EPI) team was developed, consisting of representatives from participating OR teams, an employee health nurse and two ergonomists. Surveys, observations, and interviews were conducted to quantify injury risk for the OR teams, evaluate barriers to best practice adherence, and identify opportunities for targeted interventions. Risk mapping was completed for the surgeons, surgical techs and OR nurses identifying double gloving and safe passing zone as areas in need of improvement. Through observation and interviews, researchers identified physical factors relating to musculoskeletal pain and cognitive factors leading to distractions as safety risk concerns. The overall success of the EPI was the engagement of the OR teams and surgeons in the process of identifying risk factors and potential opportunities for ergonomic solutions related to cognitive workload, physical workload, teamwork, and work design for injury prevention. The risk factors identified will provide the basis for developing targeted, effective interventions for eliminating injuries from needles and sharps within the OR.

Estimating performance from capabilities in business process improvement

2016 ◽  
Vol 22 (6) ◽  
pp. 1099-1117 ◽  
Author(s):  
Boyd A. Nicholds ◽  
John P.T. Mo
Keyword(s):  
Process Improvement ◽  
Business Process ◽  
Expected Improvement ◽  
Management Decision ◽  
Published Data ◽  
Performance Gain ◽  
Data Set ◽  
Business Process Improvement ◽  
Improvement Project ◽  
Content Type

Purpose The research indicates there is a positive link between the improvement capability of an organisation and the intensity of effort applied to a business process improvement (BPI) project or initiative. While a degree of stochastic variation in applied effort to any particular improvement project may be expected there is a clear need to quantify the causal relationship, to assist management decision, and to enhance the chance of achieving and sustaining the expected improvement targets. The paper aims to discuss these issues. Design/methodology/approach The paper presents a method to obtain the function that estimates the range of applicable effort an organisation can expect to be able to apply based on their current improvement capability. The method used analysed published data as well as regression analysis of new data points obtained from completed process improvement projects. Findings The level of effort available to be applied to a process improvement project can be expressed as a regression function expressing the possible range of achievable BPI performance within 90 per cent confidence limits. Research limitations/implications The data set applied by this research is limited due to constraints during the research project. A more accurate function can be obtained with more industry data. Practical implications When the described function is combined with a separate non-linear function of performance gain vs effort a model of performance gain for a process improvement project as a function of organisational improvement capability is obtained. The probability of success in achieving performance targets may be estimated for a process improvement project. Originality/value The method developed in this research is novel and unique and has the potential to be applied to assessing an organisation’s capability to manage change.

Process improvement project failure: a systematic literature review and future research agenda

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Jiju Antony ◽  
Bart A. Lameijer ◽  
Hans P. Borgman ◽  
Kevin Linderman
Keyword(s):  
Literature Review ◽  
Process Improvement ◽  
Systematic Literature Review ◽  
Future Research ◽  
Research Directions ◽  
Improvement Project ◽  
Project Failure ◽  
Content Type ◽  
Future Research Directions ◽  
Research Propositions

Purpose Although scholars have considered the success factors of process improvement (PI) projects, limited research has considered the factors that influence failure. The purpose of this paper is to extend the understanding of PI project failure by systematically reviewing the research on generic project failure, and developing research propositions and future research directions specifically for PI projects. Design/methodology/approach A systematic literature review protocol resulted in a total of 97 research papers that are reviewed for contributions on project failure. Findings An inductive category formation process resulted in three categories of findings. The first category are the causes for project failure, the second category is about relatedness between failure factors and the third category is on failure mitigation strategies. For each category, propositions for future research on PI projects specifically are developed. Additional future research directions proposed lay in better understanding PI project failure as it unfolds (i.e. process studies vs cross-sectional), understanding PI project failure from a theoretical perspective and better understanding of PI project failure antecedents. Originality/value This paper takes a multi-disciplinary and project type approach, synthesizes the existing knowledge and reflects upon the developments in the field of research. Propositions and a framework for future research on PI project failure are presented.

Abstract P144: Successful Regional Implementation of a Large Vessel Occlusion Screening Tool: An Interdisciplinary Process Improvement Project

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Amanda Werner ◽  
Brian L Kaiser
Keyword(s):  
Screening Tool ◽  
Retrospective Chart Review ◽  
Interdisciplinary Team ◽  
Essential Elements ◽  
Successful Implementation ◽  
Staff Education ◽  
Vessel Occlusion ◽  
Improvement Project ◽  
Adoption And Implementation ◽  
One Year

Introduction: Recommendations have recently been updated to support use of an LVO screening tool to assist in the identification and routing of eligible patients to endovascular stroke centers. Despite the recommendations for the use of an LVO screening tool, the general adoption and implementation is incomplete amongst many stroke systems nationwide. Methods: An interdisciplinary team selected the Vision, Aphasia, Neglect (VAN) tool for use amongst a series of Primary Stroke Centers and freestanding emergency departments. Educational plans surrounding the tool were developed and disseminated to prehospital EMS crews, Emergency Department nurses, and specialty transport crews. Staff education was bolstered utilizing existing EMR-based tools and the development of quick access materials for all personnel. Over a 12-month period, a combination of real time feedback and retrospective chart review were performed to ensure staff compliance and accuracy of LVO evaluations. Results: A total of 687 stroke alert patient were reviewed over a 12-month period—339 were triage arrivals and 348 were EMS arrivals. Initial compliance was low across both EMS and nursing, with only 23% of patients being screened for LVO status during the initial 6 months of implementation but increased to 66% compliance over the last 6 months. Sensitivity of VAN assessments increased from 88% to 93% and specificity increased from 80% to 86% over the same one-year period. Conclusions: Successful implementation of an LVO screening tool requires an interdisciplinary team to adopt a tool that is both user-friendly and validated for detection of LVO. Initial staff education and continuous feedback are essential elements to ensure the overall compliance and accuracy of assessments. Ongoing efforts are underway with a one-year goal of 80% compliance of screening while maintaining a high-level of accuracy. Additional staff education directed at the most common reason for a false positive screening, mistaking dysarthria for aphasia.

scholarly journals ‘CPR for Feet’ care bundle to improve foot assessment in inpatient diabetes

2018 ◽  
Vol 7 (3) ◽  
pp. e000196 ◽  
Author(s):  
Rhea O’Regan ◽  
Ross MacDonald ◽  
James G Boyle ◽  
Katherine A Hughes ◽  
Joyce McKenzie
Keyword(s):  
Quality Improvement ◽  
Nursing Staff ◽  
Quality Improvement Project ◽  
Care Bundle ◽  
Staff Education ◽  
Pressure Relief ◽  
Improvement Project ◽  
The Third ◽  
Inpatient Diabetes ◽  
Pdsa Cycle

AimsThe Scottish Inpatient Diabetes Foot Audit conducted in 2013 revealed that 57% of inpatients had not had their feet checked on admission, 60% of those at risk did not have pressure relief in place and 2.4% developed a new foot lesion. In response, the Scottish Diabetes Foot Action Group launched the ‘CPR for Feet’ campaign. The aim of this project was to raise awareness of the ‘Check, Protect and Refer’ (CPR) campaign as well as improve the assessment and management of inpatients with diabetes.MethodsA quality improvement project underpinned by Plan-Do-Study-Act (PDSA) methodology was undertaken. The first and second cycles focused on staff education and the implementation of a ‘CPR for Feet’ assessment checklist using campaign guidelines, training manuals and modules. The third and fourth cycles focused on staff feedback and the implementation of a ‘CPR for Feet’ care bundle.ResultsBaseline measurements revealed 28% of patients had evidence of foot assessment. Medical and nursing staff reported to be largely unaware of the ‘CPR for Feet’ campaign (13%). Fifty-two per cent of inpatients with diabetes had their feet assessed and managed correctly following the second PDSA cycle. After completion of the third and fourth PDSA this number improved further to 72% and all staff reported to be aware of the campaign.ConclusionsThe introduction of a ‘CPR for Feet’ care bundle improved the assessment of inpatients with diabetes.

scholarly journals Expert system of food sensory evaluation for mobile and tablet

2019 ◽  
pp. 332-339
Author(s):  
M A Nikitina ◽  
Y A Ivashkin
Keyword(s):  
Real Time ◽  
Sensory Evaluation ◽  
Analysis Of Variance ◽  
Network Architecture ◽  
Human Factor ◽  
Rank Correlation ◽  
Statistical Processing ◽  
Measurement Instruments ◽  
Multifactorial Analysis ◽  
Network Computer

One of the main directions of statistics in sensory evaluation is an assessment of the dependence between experimental variables and measured characteristics. Statistical criteria are used to assess a degree of interaction between variables, a level of experimental effects, and allow accepting or rejecting hypothesis proposed. In sensory evaluation, people act as measurement instruments, and a variation associated with the human factor arises. This proves that the use of statistical methods is necessary. This article represents a network computer system for collection and evaluation of food sensory indicators based on the methods of rank correlation and multifactorial analysis of variance in real time. The article describes information technology of expert sensory evaluation of food quality by individual panelists and sensory panels regarding the indicators that are not measured by technical means of control, based on client-server network architecture. The software implementation of system for collecting and statistical processing of sensory data based on the principles of multifactorial analysis of variance in real-time mode makes it possible to evaluate the influence of the human factor on objectiveness and reliability of sensory evaluation results, as well as to visualize the data of expert scores by various expert panels.

scholarly journals The IMPLEMENTATION OF TRACKING SYSTEM IN THE REAL TIME OF ANDROID FOR SENDING PERSONEL COORDINATION BASED ON MQTT.

2020 ◽  
Vol 2 (Oktober) ◽  
pp. 29-36
Author(s):  
Agus Faesol ◽  
Imam Ashar ◽  
Gatut Yulisusianto
Keyword(s):  
Real Time ◽  
Process Improvement ◽  
Communication Technology ◽  
Research Method ◽  
Tracking System ◽  
The World ◽  
Real Time Tracking ◽  
Access Rights ◽  
Point Data ◽  
The Military

Abstract: In the world of technology that is increasing, then as humans we will not be separated from the process improvement that occurs. From year to year, it is certain that this increase will certainly. Increasingly rapidly occurring in communication technology. Communication technology has also penetrated the military world, especially in MQTT-based communications. In this research, MQTT-based technology is applied to implement real time tracking system on android. This system is used to send the longitude and latitude coordinates of the personnel so that these points can be known directly via android. From this pure experimental research method, the coordinate point data will continue to be monitored and the existence can be known continuously. This system is designed on a VPS server or Virtual Private Server, so that all devices even though none of the networks can communicate with  each  other  as  long  as  they  have  access  rights  for application user.

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