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Quality Improvement and Patient Safety Section Newsletter - September 2015

Letter From the Chair

TurelliIt has been an eventful past few months for our Quality Improvement and Patient Safety Section since our annual meeting at ACEP14 in Chicago. Through a continued tradition from our Immediate Past Chair, Dr. Beach, the section has experienced great strides in quality improvement. Of particular importance to highlight is the recently awarded QIPS section grant, "How to Choose Wisely – An Educational Campaign" thanks to the efforts of our chair-elect Jeffrey Pothof, MD. The QIPS Section Grant received approval from the ACEP Board of Directors at its June meeting in Dallas and is aimed at increasing awareness of ACEP’s “Choosing Wisely” initiatives. The grant initiative follows a long legacy of successful grant submissions by the members of the QIPS section.

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Patient Safety in an Era of Value-Based Payment: What brings you into the Emergency Department Today?

Everyone remembers where he or she was the morning of September 11, 2001. I was at ACEP in Dallas preparing to present the report from the first emergency medicine patient safety task force report, “Patient Safety in the Emergency Department Environment” to the Board of Directors. The task force had been convened in response to the Institute of Medicine report, To Err is Human, Building a Safer Health System. (1)  The report was important because it clearly delineated the unique challenges to patient safety within the ED environment at a time when ED crowding was rapidly increasing.

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The Institute of Medicine Committee on Diagnostic Error in Health Care

Over a year ago, the Institute of Medicine convened a committee to study diagnostic errors and make recommendations to reduce them. The effort was described here.

The committee has met on numerous occasions since its establishment and is now preparing to issue its report, expected in September, 2015.  Although the exact contents of the report are not yet known, the Society to Improve Diagnosis in Medicine, of which I am a board member,  recently convened a group of organizations to form a “Coalition to Improve Diagnosis.” The group’s purpose is to develop strategies and approaches to promote wide knowledge of the report’s findings and recommendations and to drive improvements that will improve diagnosis.

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Letter from the Editor

DavidSomandHello all!  I hope your summer is going well.  I’m excited to present a great QIPS Newsletter this month.  Up first, Dr. Nedza discusses patient safety in the era of value-based payment, with some very thought-provoking commentary. Drs. Sverha and Fuller discuss prevention of catheter associated UTI in the ED, and Dr. Meyers continues his commentary on diagnostic error in medicine, and the upcoming IOM report.

It has been a busy time for the QIPS section, with planning for our next webinar and the upcoming ACEP15 meeting. Dr. Turelli has details of ongoing accomplishments in his Letter from the Chair. I hope you enjoy!

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Catheter Associated Urinary Tract Infection (CAUTI) Prevention in the ED

StethoscopeAccording to the CDC, catheter associated UTIs (CAUTIs) have been a significant source of HAI mortality and injury in the US. It has been estimated that 9,000 deaths and 380,000 UTIs are caused by unnecessary or improperly place urinary catheters. (CDC CAUTI Guideline 2009 ref #22).

Because many urinary catheters (UC) are placed in the ED setting, the American Hospital Association created an ED specific resource as part of their “On the Cusp, Stop HAI” program.  Several valuable tools and resources are located on the site to enroll EDs in the practices for decreasing CAUTI.  The site does have a considerable focus on enrolling participants in a cohort for data collection, which may not be the interest of department leaders looking to achieve simple best practices for their hospital.

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