Performance Improvement

This JAMA Performance Improvement article summarizes the AHRQ guideline on alarm fatigue in its health care safety series, including factors important to successfully implement approaches to reduce false alarms, total alarms, and noise levels.

This JAMA Performance Improvement article summarizes the AHRQ guideline on rapid response teams in its health care safety series, including whether rapid response teams decrease mortality or rates of cardiac arrest, if their use improves patient outcomes, and what barriers hinder their success in the hospital setting.

This JAMA Performance Improvement article summarizes findings from an international survey study of hospital experience with central venous access line insertion teams to manage high procedural volume and safety during the COVID-19 pandemic.

This JAMA Performance Improvement article describes experience at Zuckerberg San Francisco General Hospital with an emergency department social medicine (EDSM) team to facilitate care of ED patients with low-acuity medical illnesses and complex psychosocial comorbidities (homelessness, mental illness, substance use, poverty).

This JAMA Performance Improvement article describes development of a protocol for workup and management of elevated liver function tests in liver transplant patients without readmission to their transplant referral center, and findings and outcomes for a case series of 80 patients managed with the new protocol from 2017 to 2019.

This JAMA Performance Improvement article reports the methods and outcomes of a cognitive screening program implemented at a US hospital to assess medical staff aged 70 years or older for clinical competency every 2 years as a requirement for reappointment.

This JAMA Performance Improvement article uses the case of a patient who presented to the emergency department but left after waiting 4 hours without being seen to discuss interdisciplinary improvement efforts for reducing system inefficiencies and improving access to care in emergency departments.

This JAMA Performance Improvement article uses the case of a patient with end-stage renal disease admitted for septic shock, peritonitis, and calciphylaxis who erroneously underwent tunneled central catheter placement after he elected to pursue only hospice care to discuss unintended errors introduced by computerized order entry and opportunities for health information technology system improvements.

This JAMA Performance Improvement article uses the case of a patient with acute myocardial infarction and heart failure who developed cardiogenic shock after being given carvedilol as part of a standard STEMI admission order set to discuss the limits of orders sets and of guideline-based care and the need to optimize each for individual patient circumstances.

This JAMA Performance Improvement article uses the case of a patient with obstructive sleep apnea who experienced cardiac arrest after sedation for magnetic resonance imaging to discuss proper handling and avoidance of oversedation in high-risk patients.

This JAMA Performance Improvement article uses the case of a patient who received an overdose of insulin to discuss proper protocol and follow-up after a medication dosing error.

This JAMA Performance Improvement article uses the case of a patient with both a cancerous mass and a benign mass in the same breast in whom the wrong mass was excised to discuss proper handling of wrong-site surgery.

This JAMA Performance Improvement article uses the case of a patient with iatrogenic phenytoin toxicity due to an excess prescribed dosage to discuss proper handling and reporting of significant adverse drug events.

This JAMA Performance Improvement article uses the case of a patient with a retained lumbar catheter tip to discuss strategies for patient communication, clinician education, and reporting of procedure-related adverse events.

This JAMA Performance Improvement article explores the case of a patient with latex allergy who had a latex catheter placed and how the health care team should handle the situation both during surgery and postoperatively.