Improving the bar-coded medication administration system at the Department of Veterans Affairs.
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Clinical Pharmacy Information Systems↗
Biomedical subjects
Julia Neily
Publications and source records attributed to Julia Neily.
Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.
BACKGROUND: Veterans possess many risk factors for suicide, making suicide prevention in the Veterans Health Administration (VHA) a particular challenge. METHODS: An analysis was conducted of 94 aggregated root cause analyses (RCAs) for parasuicidal behavior and 43 single-case suicide RCAs submitted from 75 VHA facilities to determine primary root causes for suicide and parasuicidal behaviors and to gain information about action plans, success factors and obstacles to improvement. Telephone follow-up interviews were conducted with each facility. RESULTS: The aggregate reviews included 775 individual cases of parasuicidal behavior. The top root causes of parasuicidal behavior were poor assessment and communication of patient risk, patient stressors, and need for staff and patients training. Forty-eight percent of the action plans developed to address the root causes involved a policy change, 30% involved staff training, and 14% involved making a specific clinical change. Eight-eight percent of the actions adequately addressed the root cause, of which 68.1% were fully implemented. DISCUSSION: There is little agreement on the definition of "parasuicide," and it is likely the case that parasuicide behaviors are underreported in our system. To encourage reporting, patient safety staff should collaborate with providers and use a more inclusive definition of parasuicide.
Hospitals, Veterans↗
Using aggregate root cause analysis to reduce falls.
BACKGROUND: In certain categories of adverse events, Department of Veterans Affairs (VA) facilities may combine data to produce an aggregate review of the data. Individual root cause analyses are still required for the more serious adverse events. About 100 of the VA acute and long term care facilities contributed data to an analysis of results of 176 root cause analyses (RCAs) for patient falls occurring in the VA system. METHODS: Success was measured through a decreased report of falls and major injures due to falls after each organization's action plans were implemented. In addition, telephone interviews were conducted to understand success factors as well as barriers to implementation of clinical improvements. RESULTS: Of the 745 actions generated (that addressed the root cause), 435 (61.4%) had been fully implemented and another 148 (20.9%) had been partially implemented; 34.4% of the facilities reported reducing falls and 38.9% reported reducing major injuries due to falls. DISCUSSION: The action plans associated with these reductions focused on making specific clinical changes at the bedside rather than policy changes or educating staff. Specific interventions most highly associated with reductions in falls and injuries included environmental assessments, toileting interventions, and interventions that directly addressed the root cause and were the responsibility of a single person (as opposed to a group).
Accidental Falls↗
One-year follow-up after a collaborative breakthrough series on reducing falls and fall-related injuries.
BACKGROUND: Multisite facilitated quality improvement (QI) projects, called collaborative Breakthrough Series (BTS), have been shown to improve care, but it is also important to evaluate the lasting effects and spread of changes of BTSs. A project focused on fall and injury-related prevention started in Spring 2001; after the project's end, support was provided through e-mail and periodic conference calls. METHODS: One year after project completion, team contacts were interviewed to determine if they had maintained gains or made further improvements. RESULTS: For the 34 (of 37 teams) interviewed, 82.4% reported they had stayed together as a team; 97.1%, that they continued to collect data; 93.9%, that they had maintained gains; 82.4%, that they had spread changes to new locations; and 85.3%, that they had begun to work on new topics. High team performance at one year correlated with first-meeting team characteristics Leadership Support (r = .456, p = .019) and Prior Experience with Quality Improvement and Teamwork (r = .393, p = .047) and with follow-up team characteristics Leadership Support (r = .614, p < .001), Teamwork Skills (r = .377, p = .033), and Skills Gained from the Project (r = .410, p = .020). CONCLUSIONS: Leadership support, experience with quality improvement and teamwork, teamwork skills, and skills gained from the project were correlated with teams' abilities to achieve and maintain success.
Accidental Falls↗
A cognitive aid for cardiac arrest: you can't use it if you don't know about it.
BACKGROUND: A cognitive aid developed by the Department of Veterans Affairs (VA) and distributed to all VA facilities provides caregivers with information to minimize omission of critical steps when diagnosing and treating cardiac arrest. In 2002, caregivers were surveyed about the usefulness of the cognitive aid and the success of its dissemination throughout the VA. METHODS: Fifty randomly selected VA hospitals were sent a letter to alert them of the upcoming survey. Twenty surveys were sent to each of the selected hospitals with instructions to distribute the survey to specific caregiver types. RESULTS: Nine (18%) of the VA hospitals had not used the cognitive aid tool because of dissemination problems. Of the 565 caregivers responding to the survey, 59% (332) were aware of the cognitive aid. Of these 332, 96% agreed that putting the cognitive aid on code carts is a good idea. There were 234 respondents who were both aware of the cognitive aid and had been involved in at least one code within the past 30 days. Of these 234, some 29 (12%) used the aid during a code, 28 of whom agreed that the cognitive aid was helpful during the code. DISCUSSION: Both new and experienced caregivers find the cognitive aid helpful when responding to "code" situations. However, cognitive aids cannot be helpful if theintended users are unaware of their availability. Dissemination and awareness of the aids can be problematic in large health care systems.
Audiovisual Aids↗
Reducing medication confusion in homebound patients: when the data do not conform to the initial hypothesis.
Visiting nurses often find it difficult to reconcile multiple and conflicting medication orders, particularly when more than one physician orders medications. As the authors report, resolving medication order confusion was thought to be very time-consuming--until a team started to collect data.
Aftercare↗
Using aggregate root cause analysis to improve patient safety.
The authors describe use of aggregate root cause analysis, which provides a systematic process for analyzing high-priority, frequent events.
Hospitals, Veterans↗
A cumulative meta-analysis of selective serotonin reuptake inhibitors in pediatric depression: did unpublished studies influence the efficacy/safety debate?
OBJECTIVE: The aim of this study was to assess whether unpublished trials of serotonin reuptake inhibitors in pediatric depression impacted efficacy or safety conclusions, and to examine the evolution of information contributing to the safety/efficacy debate. METHOD: From 939 potentially relevant studies extracted from Medline, Cinahl, Biosis, and Cochrane databases, and from the United Kingdom's Committee on Safety of Medicines website, we examined 38 studies: Ten published and five unpublished randomized, controlled trials, 22 observational studies, and one crossover trial. We performed cumulative and non-cumulative meta-analyses and generated pooled relative rates of response and serious adverse events for high-quality randomized, controlled trials. RESULTS: Unpublished studies did not substantially alter the risk-to-benefit determination. Cumulative meta-analyses of seven randomized, controlled trials for efficacy and 11 randomized, controlled trials for safety suggest an adverse safety/efficacy profile for selective serotonin reuptake inhibitors (SSRIs) overall. Fluoxetine and citalopram appear to offer favorable risk to benefit profiles, while shorter-acting agents pose greater risks and provide marginal benefit. CONCLUSIONS: While simple meta-analysis across all SSRIs for treatment of pediatric depression provided general efficacy and safety information, meta-analysis of individual drugs and use of cumulative meta-analytic techniques may have expedited our ability to formulate conclusions about safety and efficacy of SSRIs in pediatric depression.
Adolescent↗
Listserv use enhances quality and safety in multisite quality improvement efforts.
A listserv is an e-mail group to which people subscribe based upon common interests. We used a retrospective study to examine the relationship between listserv use and team success for health care quality improvement efforts. We hypothesized high listserv use would be associated with team success. Eighty-seven Department of Veterans Affairs teams participated in facilitated quality improvement efforts to address three areas: improving safety in high-hazard areas, improving the disability evaluation process, and reducing falls and related injuries. We coded messages sent to the listserv according to sender (faculty or participant), team, and content. We correlated the volume of messages sent per team with team success and with team and facility characteristics. Teams with high listserv contributions were more likely to complete their first test of change, report facility use of nonpunitive methods of investigating medical incidents, and report their information systems were useful. We found a negative correlation between listserv contribution and the number of face-to-face meetings and a physician as an active team member, but we found no relationship between team success and listserv contribution. Team listserv contribution was not associated with team success in multisite quality improvement efforts. Successful teams may be accessing information on the listserv but not sending a message to indicate use.
Cooperative Behavior↗