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Medical Staff Quality Assurance Committee
Department: Quality Assurance & Patient Safety
Meeting Date: March 14, 2024
Meeting Time: 7:00 AM - 8:30 AM
Location: Hospital Conference Room 3A
Attendance
Physicians Present: Dr. Robert Chen (Committee Chair, Internal Medicine), Dr. Sarah Martinez (Surgery), Dr. Michael O'Brien (Emergency Medicine), Dr. Lisa Anderson (Pediatrics)
Nursing Staff: Jennifer Williams RN (Quality Manager), Patricia Johnson RN (Infection Control)
Administration: David Park (Chief Medical Officer), Amanda Foster (Risk Management)
Patient Safety Indicators Review
Jennifer Williams presented February patient safety metrics. Hospital-acquired infection rate decreased to 0.8 per 1,000 patient days (target: <1.0). Medication error rate remained stable at 2.1 per 1,000 doses. One fall with injury was reported and investigated.
Mortality & Morbidity Review
The committee reviewed three cases from February. Dr. Martinez presented a surgical case with post-operative complications. Root cause analysis identified a communication gap during shift handoff. The committee recommended implementing structured handoff protocol using SBAR format.
Quality Improvement Initiatives
Sepsis Protocol Implementation
Dr. O'Brien reported that the new sepsis screening protocol has been implemented in the Emergency Department. Early identification improved by 35%, and time to antibiotic administration decreased from 4.2 hours to 2.1 hours average.
Hand Hygiene Compliance
Patricia Johnson presented hand hygiene audit results showing 89% compliance (target: 95%). The committee discussed strategies to improve compliance including additional training and visual reminders at point of care.
Action Items
- Dr. O'Brien: Develop SBAR handoff training module (Due: April 1)
- Jennifer: Schedule hand hygiene improvement workshops for all units (Due: March 28)
- Patricia: Complete C. difficile investigation report (Due: March 21)
Next Meeting
Date: April 11, 2024 at 7:00 AM
Medical Staff Quality Assurance Committee
Department: Quality Assurance & Patient Safety
Meeting Date: March 14, 2024
Meeting Time: 7:00 AM - 8:30 AM
Location: Hospital Conference Room 3A
Attendance
Physicians Present: Dr. Robert Chen (Committee Chair, Internal Medicine), Dr. Sarah Martinez (Surgery), Dr. Michael O'Brien (Emergency Medicine), Dr. Lisa Anderson (Pediatrics)
Nursing Staff: Jennifer Williams RN (Quality Manager), Patricia Johnson RN (Infection Control)
Administration: David Park (Chief Medical Officer), Amanda Foster (Risk Management)
Patient Safety Indicators Review
Jennifer Williams presented February patient safety metrics. Hospital-acquired infection rate decreased to 0.8 per 1,000 patient days (target: <1.0). Medication error rate remained stable at 2.1 per 1,000 doses. One fall with injury was reported and investigated.
Mortality & Morbidity Review
The committee reviewed three cases from February. Dr. Martinez presented a surgical case with post-operative complications. Root cause analysis identified a communication gap during shift handoff. The committee recommended implementing structured handoff protocol using SBAR format.
Quality Improvement Initiatives
Sepsis Protocol Implementation
Dr. O'Brien reported that the new sepsis screening protocol has been implemented in the Emergency Department. Early identification improved by 35%, and time to antibiotic administration decreased from 4.2 hours to 2.1 hours average.
Hand Hygiene Compliance
Patricia Johnson presented hand hygiene audit results showing 89% compliance (target: 95%). The committee discussed strategies to improve compliance including additional training and visual reminders at point of care.
Action Items
- Dr. O'Brien: Develop SBAR handoff training module (Due: April 1)
- Jennifer: Schedule hand hygiene improvement workshops for all units (Due: March 28)
- Patricia: Complete C. difficile investigation report (Due: March 21)
Next Meeting
Date: April 11, 2024 at 7:00 AM
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