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May/June 2013 Volume 10, Issue 3<br /> CHANGE OF SCENERY<br /> Just What the Doctor Ordered<br /> Infection Control<br /> Diagnostic Error<br /> Alarm Problems in the ED<br /> Supporting Patients and Families<br /> RFID, Barcoding, RTLS28<br /> 40<br /> CONTENTS<br /> May/June 2013 Volume 10, Issue 3<br /> Features<br /> Change of Scenery: Just What the Doctor Ordered<br /> By Diane Garry, RN, BSN, MEd, and Tina Mason, ARNP, MSN, AOCN®, AOCNS®<br /> Seven Years, Zero CLABSIs: How a California Hospital Did It<br /> By Alan Reder, MA<br /> MITSS: Supporting Patients and Families for More than a Decade<br /> By Winifred N. Tobin<br /> Addressing Alarm Problems in the Emergency Department<br /> By Kathryn M. Pelczarski<br /> SPECIAL ADVERTISING SECTION: RFID, BARCODING, RTLS<br /> The Connected Hospital<br /> By Tom Ingles<a title="PSQH May/June 2013 page 1" href="http://viewer.zmags.com/publication/7f8eb36d?page=1">May/June 2013 </a> <a title="PSQH May/June 2013 page 2" href="http://viewer.zmags.com/publication/7f8eb36d?page=2"></a> <a title="PSQH May/June 2013 page 3" href="http://viewer.zmags.com/publication/7f8eb36d?page=3"></a> <a title="PSQH May/June 2013 page 4" href="http://viewer.zmags.com/publication/7f8eb36d?page=4">28 40 CONTENTS May/June 2013 Volume 10, Issue</a> <a title="PSQH May/June 2013 page 5" href="http://viewer.zmags.com/publication/7f8eb36d?page=5"></a> <a title="PSQH May/June 2013 page 6" href="http://viewer.zmags.com/publication/7f8eb36d?page=6"> </a> <a title="PSQH May/June 2013 page 7" href="http://viewer.zmags.com/publication/7f8eb36d?page=7"></a> <a title="PSQH May/June 2013 page 8" href="http://viewer.zmags.com/publication/7f8eb36d?page=8">Editor's Notebook Personal Accountability I’m </a> <a title="PSQH May/June 2013 page 9" href="http://viewer.zmags.com/publication/7f8eb36d?page=9"></a> <a title="PSQH May/June 2013 page 10" href="http://viewer.zmags.com/publication/7f8eb36d?page=10">NEWS New Joint Commission Alert Addresses Medic</a> <a title="PSQH May/June 2013 page 11" href="http://viewer.zmags.com/publication/7f8eb36d?page=11">The Joint Commission Alert recommends that healthc</a> <a title="PSQH May/June 2013 page 12" href="http://viewer.zmags.com/publication/7f8eb36d?page=12">NEWS Massachusetts Alliance Studies Pilot Progr</a> <a title="PSQH May/June 2013 page 13" href="http://viewer.zmags.com/publication/7f8eb36d?page=13">implementing the programs should expect to make a </a> <a title="PSQH May/June 2013 page 14" href="http://viewer.zmags.com/publication/7f8eb36d?page=14">AHRQ CUSP: Scaling Up a Safety Framework By Caro</a> <a title="PSQH May/June 2013 page 15" href="http://viewer.zmags.com/publication/7f8eb36d?page=15">ed into each module. Videos demonstrate desired be</a> <a title="PSQH May/June 2013 page 16" href="http://viewer.zmags.com/publication/7f8eb36d?page=16">DIAGNOSTIC ERROR Safe and Effective Communication</a> <a title="PSQH May/June 2013 page 17" href="http://viewer.zmags.com/publication/7f8eb36d?page=17">• Referrals: Lack of appropriate actions on reques</a> <a title="PSQH May/June 2013 page 18" href="http://viewer.zmags.com/publication/7f8eb36d?page=18">ultimate goal of reducing missed and delayed diagn</a> <a title="PSQH May/June 2013 page 19" href="http://viewer.zmags.com/publication/7f8eb36d?page=19"></a> <a title="PSQH May/June 2013 page 20" href="http://viewer.zmags.com/publication/7f8eb36d?page=20">ISMP Drawn Curtains, Muted Alarms, and Diverted A</a> <a title="PSQH May/June 2013 page 21" href="http://viewer.zmags.com/publication/7f8eb36d?page=21">Patients in the PACU are particularly vulnerable t</a> <a title="PSQH May/June 2013 page 22" href="http://viewer.zmags.com/publication/7f8eb36d?page=22">to improve the manner in which alarms are managed.</a> <a title="PSQH May/June 2013 page 23" href="http://viewer.zmags.com/publication/7f8eb36d?page=23"></a> <a title="PSQH May/June 2013 page 24" href="http://viewer.zmags.com/publication/7f8eb36d?page=24">CHANGE OF SCENERY: Just What the Doctor Ordered </a> <a title="PSQH May/June 2013 page 25" href="http://viewer.zmags.com/publication/7f8eb36d?page=25">Being hospitalized should not necessarily preclude</a> <a title="PSQH May/June 2013 page 26" href="http://viewer.zmags.com/publication/7f8eb36d?page=26">CHANGE OF SCENERY doors. The Center’s lush trop</a> <a title="PSQH May/June 2013 page 27" href="http://viewer.zmags.com/publication/7f8eb36d?page=27">Change of Scenery Figure 2. Moffitt Intra-insti</a> <a title="PSQH May/June 2013 page 28" href="http://viewer.zmags.com/publication/7f8eb36d?page=28">CHANGE OF SCENERY nitive dysfunction related to</a> <a title="PSQH May/June 2013 page 29" href="http://viewer.zmags.com/publication/7f8eb36d?page=29">to leaving the unit and meets the applicable crite</a> <a title="PSQH May/June 2013 page 30" href="http://viewer.zmags.com/publication/7f8eb36d?page=30">SEVEN YEARS, ZERO CLABSIs: How a California Hospit</a> <a title="PSQH May/June 2013 page 31" href="http://viewer.zmags.com/publication/7f8eb36d?page=31">completely eliminated CLABSIs for long time spans,</a> <a title="PSQH May/June 2013 page 32" href="http://viewer.zmags.com/publication/7f8eb36d?page=32">SEVEN YEARS, ZERO CLABSIs also helps us make su</a> <a title="PSQH May/June 2013 page 33" href="http://viewer.zmags.com/publication/7f8eb36d?page=33"></a> <a title="PSQH May/June 2013 page 34" href="http://viewer.zmags.com/publication/7f8eb36d?page=34">SEVEN YEARS, ZERO CLABSIs ownership and daily m</a> <a title="PSQH May/June 2013 page 35" href="http://viewer.zmags.com/publication/7f8eb36d?page=35"></a> <a title="PSQH May/June 2013 page 36" href="http://viewer.zmags.com/publication/7f8eb36d?page=36">MITSS: Supporting Patients and Families for More t</a> <a title="PSQH May/June 2013 page 37" href="http://viewer.zmags.com/publication/7f8eb36d?page=37">with others who had been through similar experienc</a> <a title="PSQH May/June 2013 page 38" href="http://viewer.zmags.com/publication/7f8eb36d?page=38">SUPPORTING PATIENTS AND FAMILIES physical recov</a> <a title="PSQH May/June 2013 page 39" href="http://viewer.zmags.com/publication/7f8eb36d?page=39">Health Care for All, the Mass. Coalition for the P</a> <a title="PSQH May/June 2013 page 40" href="http://viewer.zmags.com/publication/7f8eb36d?page=40">SUPPORTING PATIENTS AND FAMILIES Progress is sl</a> <a title="PSQH May/June 2013 page 41" href="http://viewer.zmags.com/publication/7f8eb36d?page=41">Supporting Patients and Families The circumstan</a> <a title="PSQH May/June 2013 page 42" href="http://viewer.zmags.com/publication/7f8eb36d?page=42">Addressing Alarm Problems in the Emergency Departm</a> <a title="PSQH May/June 2013 page 43" href="http://viewer.zmags.com/publication/7f8eb36d?page=43">• Heart rate and pulse oximetry alarm limits are s</a> <a title="PSQH May/June 2013 page 44" href="http://viewer.zmags.com/publication/7f8eb36d?page=44">ALARM PROBLEMS and planning. A multidisciplinar</a> <a title="PSQH May/June 2013 page 45" href="http://viewer.zmags.com/publication/7f8eb36d?page=45">• Establishing protocols for proper skin preparati</a> <a title="PSQH May/June 2013 page 46" href="http://viewer.zmags.com/publication/7f8eb36d?page=46">HEALTH IT & QUALITY American Autos Circa 1970 and</a> <a title="PSQH May/June 2013 page 47" href="http://viewer.zmags.com/publication/7f8eb36d?page=47">3. Cease dependence on inspection to achieve quali</a> <a title="PSQH May/June 2013 page 48" href="http://viewer.zmags.com/publication/7f8eb36d?page=48">SPECIAL ADVERTISING SECTION RFID, Barcoding, RTLS</a> <a title="PSQH May/June 2013 page 49" href="http://viewer.zmags.com/publication/7f8eb36d?page=49"></a> <a title="PSQH May/June 2013 page 50" href="http://viewer.zmags.com/publication/7f8eb36d?page=50">SPECIAL ADVERTISING SECTION through innovative </a> <a title="PSQH May/June 2013 page 51" href="http://viewer.zmags.com/publication/7f8eb36d?page=51"></a> <a title="PSQH May/June 2013 page 52" href="http://viewer.zmags.com/publication/7f8eb36d?page=52"></a> <a title="PSQH May/June 2013 page 53" href="http://viewer.zmags.com/publication/7f8eb36d?page=53"></a> <a title="PSQH May/June 2013 page 54" href="http://viewer.zmags.com/publication/7f8eb36d?page=54">SPECIAL ADVERTISING SECTION Besides the colored</a> <a title="PSQH May/June 2013 page 55" href="http://viewer.zmags.com/publication/7f8eb36d?page=55">SPECIAL ADVERTISING SECTION sponge, the thin, a</a> <a title="PSQH May/June 2013 page 56" href="http://viewer.zmags.com/publication/7f8eb36d?page=56">SPECIAL ADVERTISING SECTION space, by using RTL</a> <a title="PSQH May/June 2013 page 57" href="http://viewer.zmags.com/publication/7f8eb36d?page=57"></a> <a title="PSQH May/June 2013 page 58" href="http://viewer.zmags.com/publication/7f8eb36d?page=58"> SPECIAL ADVERTISING SECTION The doctors can be</a> <a title="PSQH May/June 2013 page 59" href="http://viewer.zmags.com/publication/7f8eb36d?page=59"></a> <a title="PSQH May/June 2013 page 60" href="http://viewer.zmags.com/publication/7f8eb36d?page=60">SPECIAL ADVERTISING SECTION The use of barcodes</a> <a title="PSQH May/June 2013 page 61" href="http://viewer.zmags.com/publication/7f8eb36d?page=61"></a> <a title="PSQH May/June 2013 page 62" href="http://viewer.zmags.com/publication/7f8eb36d?page=62">SPECIAL ADVERTISING SECTION The patients range </a> <a title="PSQH May/June 2013 page 63" href="http://viewer.zmags.com/publication/7f8eb36d?page=63"></a> <a title="PSQH May/June 2013 page 64" href="http://viewer.zmags.com/publication/7f8eb36d?page=64">NEWS Quality Conundrums Lynn Helmer, MD, MBA, </a> <a title="PSQH May/June 2013 page 65" href="http://viewer.zmags.com/publication/7f8eb36d?page=65">American Board of Quality Assurance and Utilizatio</a> <a title="PSQH May/June 2013 page 66" href="http://viewer.zmags.com/publication/7f8eb36d?page=66">Patient Safety and Quality Healthcare (PSQH) welco</a> <a title="PSQH May/June 2013 page 67" href="http://viewer.zmags.com/publication/7f8eb36d?page=67"></a> <a title="PSQH May/June 2013 page 68" href="http://viewer.zmags.com/publication/7f8eb36d?page=68"></a>