James S. Todd Memorial Award for Patient Safety Research of 2001
Assessing Hospitals' Use of Mandatory Error Reports for Quality Improvement and Error Reduction
The Center for State Health Policy at Rutgers, the State University of New Jersey
Investigators:
Joel C. Cantor, ScD, CSHP, Kimberley S. Fox, MPA; Denise A. Davis, Dr.PH, MPA; Cara L. Cuite, MA; David M. Frankford, JD; Albert L. Siu, MD, MSPH; and, Andrea I. Kabcenell, RN, MPH
In the study, an interdisciplinary team at Rutgers' CSHP, in partnership with the Healthcare Association of New York State (HANYS) and expert consultants, will assess New York hospitals' internal use of mandatory adverse event data. This sentinel event information is collected through the state's mandatory incident reporting system for patient safety improvement and error reduction. By providing insights into how hospitals respond to and utilize incident reporting systems, CSHP's exploratory research could reveal important changes in how incident reporting could be designed and modified in the future to have the greatest impact on patient safety nationwide.
Remote Analysis of the Surgical Environment: Measuring the Effect of Debriefing Attendings on Surgical Safety Factors
Department of Surgery, University of Virginia
Investigators:
Reid B. Adams, MD, J. Forrest Calland, MD; Stephanie Guerlain, PhD; Bruce Schirmer, MD; R. Scott Jones, MD; Keith Littlewood, MD; and, Carl Lynch, MD
The University of Virginia has formed a multi-disciplinary group to develop and study the effects of patient safety initiatives in the operating room, particularly in the areas of memory aids, standardization of protocols, and development of training expertise in operative technique and team communication and coordination.
This study will enhance general ability to study holistic aspects of the operating room environment, further understanding of how to "score" a surgical case for patient safety factors, and broaden understanding of the effects of debriefing on improving performance.
Photos of J. Forrest Calland, MD (above) and Stephanie Guerlain, PhD (left).
Impact of Computerized Alerts and Reminders on Implementation of a Weight-Based Unfractionated Heparin Dosing Protocol
New York-Presbyterian Hospital (NYPH)
Investigators:
Anne Marie Greco, PharmD, NYPH; Michael I. Oppenheim, MD; Ferdinand Velasco, MD; Rudina Odeh-Ramadan, PharmD; and, Josephine Sollano, MPH
The Department of Pharmacy at NYPH recently implemented a standard weight-based protocol for administration of intravenous unfractionated heparin. Additionally, NYPH has a computerized physician order entry system in place in several areas of the institution. The goal of this project is to evaluate the use of computerized decision support tools for improving adherence to the heparin dosing protocol. These tools are designed to provide reminders to clinicians about the existence of the protocol, automate implementation of the protocol by providing dose recommendations based on patient data, and issue reminders for dose adjustments as soon as new time values are measured.
Evaluation of the tools could lead to improved utilization of the heparin protocol during the ordering process as well as in adjusting doses. In addition, improvements in accuracy during protocol execution would be enhanced through the use of computerized dose determination.