In this issue, Richard Ricciardi, Healthcare Scientist in the Center for Evidence and Practice Improvement at AHRQ, discusses patient safety in ambulatory environments and the important role of nursing. In another article, Clark and colleagues describe their project to improve the pneumococcal immunization rate within their health system. Using the presurgical testing center, they increased the rate from 24% to 54%: the authors share their processes and tools. In a small community hospital, nurses developed an At Risk Care Plan to anticipate safety and care needs of patients at risk and communicate those needs to the health care team. This innovative intervention dramatically reduced hospital readmissions, costs, and adverse events for high risk adult inpatients. Prevention of medication errors continues to be a need. Simsic and colleagues describe the outcomes of their QI project that reduced medication errors. They implemented a multidisciplinary ICU quality committee, nursing education, shift change medication double checks, medication error huddles, a safety systems checklist, a distraction-free zone to enter orders, and medication bar coding. Becker started a bag medication reconciliation process in the hospital setting to decrease medication discrepancies at post hospitalization follow up. Patients received a green medication bag on discharge and were taught to bring the bag with all of their medications to their first follow-up appointment. This strategy worked well and is easily implemented elsewhere. Other articles in this issue describe improving delivery of primary care preventative services using Six Sigma methods, a systems redesign to improve dysphagia screening, a new volunteer service to enhance patients’ experiences, best practices for care transitions and for implementing QI interventions, the quality of hospice care, and a QI study to reduce resident pain in nursing homes. Tzeng et al. report on their innovative fall prevention intervention, iEngaging, which involves patients in their own fall prevention during hospital stays. Migration of patients toward the foot of the bed in ICUs may cause shear and friction between the patient and mattress, reduce elevation of the patient's torso, and require frequent repositioning: take time to read the article by Davis and Kotowski. It is open access so everyone can read and learn from it.
Marilyn H. Oermann, PhD, RN, ANEF, FAAN