Development and testing of Baylor Scott & White Health's "Attitudes and Practices of Patient Safety Survey".

Improving the quality of patient care requires a culture attuned to safety. We describe the development, implementation, and psychometric evaluation of the Attitudes and Practices of Patient Safety Survey (APPSS) within the Baylor Scott & White Health system. The APPSS was designed to enable safety culture data to be collected and aggregated at the unit level to identify high-priority needs.

Team consistency and occurrences of prolonged operative time, prolonged hospital stay, and hospital readmission: a retrospective analysis.

Background: Human factors research has suggested benefits of consistent teams yet no surgical team consistency measures have been established for teamwork improvement initiatives.

Methods: Retrospective analysis was conducted of teams performing consecutive elective procedures of unilateral primary total knee and hip replacement between June 2008 and May 2010 at a large tertiary medical center. Surgeons who performed fewer than 50 cases of the procedures during the study period were excluded.

Development of a tool to measure user experience following electronic health record implementation.

Objective: The aim of this study was to develop a survey tool to assess electronic health record (EHR) implementation to guide improvement initiatives.

Background: Survey tools are needed for ongoing improvement and have not been developed for aspects of EHR implementation.

Methods: The Baylor EHR User Experience (UX) survey was developed to capture 5 concept domains: training and competency, usability, infrastructure, usefulness, and end-user support.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

Objective: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

Study Setting: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

Study Design: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

Description and evaluation of adaptations to the global trigger tool to enhance value to adverse event reduction efforts.

Objective: To adapt the Global Trigger Tool (GTT) as a sustainable monitoring tool able to characterize adverse events (AEs) for organizational learning, within the context of limited resources.

Methods: Baylor Health Care System (BHCS) expanded the AE data collected to include judgments of preventability, presence on admission, relation to care provided or not provided, and narrative descriptions. To reduce costs, we focused on patients with length of stay (LOS) of 3 days or more, suspecting greater likelihood they had experienced an AE; adapted the sample size and frequency of review; and used a single nurse reviewer followed by quality assurance review within the Office of Patient Safety.

Implementing SBAR across a large multihospital health system.

Background: Communication problems among health care personnel during critical clinical situations can jeopardize patient safety. SBAR, a structured-communication technique, has been adapted from aviation and the military as a strategy for clear communication based on a statement of the situation, background, assessment, and recommendations related to a critical issue. Nurses' use of SBAR and physician perception of communication quality after SBAR implementation was assessed at a 13-hospital health care system.

Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000-2009.

Healthcare is a complex industry burdened by numerous and complicated clinical and administrative transactions that require many behavioral changes by patients, clinicians, and provider organizations. While healthcare information technology (HIT) is intended to relieve some of the burden by reducing errors, several aspects of systems such as the electronic medical record (EMR) may actually increase the incidence of certain types of errors or produce new safety risks that result in harm. Healthcare leaders must appreciate the complexity surrounding EMRs and understand the safety issues in order to mandate sound EMR design, development, implementation, and use.

Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.

Background: The Institute for Healthcare Improvement encourages use of the Global Trigger Tool to objectively determine and monitor adverse events (AEs).

Setting: Baylor Health Care System (BHCS) is an integrated healthcare delivery system in North Texas. The Global Trigger Tool was applied to BHCS's eight general acute care hospitals, two inpatient cardiovascular hospitals and two rehabilitation/long-term acute care hospitals.

Journey to no preventable risk: the Baylor Health Care System patient safety experience.

The patient safety vision at Baylor Health Care System (BHCS) has 3 components: (1) achieving no preventable deaths, (2) ensuring no preventable injuries, and (3) seeking no preventable risk. These goals require strategic efforts in the categories of culture, processes, and technology. Culture focuses on tactics such as teamwork training and quality improvement education.

Impact of the national asthma guidelines on internal medicine primary care and specialty practice.

Objective: To evaluate documentation of compliance with the National Asthma Education and Prevention Program publication Guidelines for the Diagnosis and Management of Asthma.

Design: A retrospective review of 114 charts coded as asthma. Fourteen chart evaluation questions were developed based on the 4 management components in the guidelines: assessment and monitoring of asthma, control of asthma factors, pharmacotherapy, and patient education.

A randomized controlled trial using the school for anti-inflammatory therapy in asthma.

This study investigated the impact of providing low-dose inhaled corticosteroids (ICS) at school or at home to asthmatic inner city children over a 14-week period, compared with the existing community standard. Eight elementary schools in the Dallas Independent School District with a high incidence of asthma located in predominantly urban African-American communities were randomly assigned to one of four groups. The treatment arms were school-based delivery of inhaled steroids, home-based delivery of inhaled steroids, and home-based delivery of inhaled steroids with school-based asthma education, and the control group was no change in current therapy.

Development and dissemination of minimum standards of care for asthma.

Asthma is a common illness in children and adults that is often associated with suboptimal outcomes, despite the existence and distribution of carefully considered national and international guidelines for diagnosis and treatment. The need to improve asthma care in North Texas motivated a coalition of health plans, employers, hospitals, academic medical centers, providers, and benefit consultants to collaborate in developing and implementing Minimum Standards of Care for Asthma. To gain consensus, the North Central Texas HEDIS Coalition used a panel of regional asthma experts and surveyed a large number of primary-care providers to construct a one-page document that was ultimately approved by regional stakeholders in healthcare participating in this coalition and also by specialty organizations in Texas.

Asthma disease management: friend or foe?

The evolution of health care in the United States has recently given rise to a movement commonly referred to as "Disease Management" in which improved outcomes are sought by using a data-driven process to direct appropriate resources to patients most likely to benefit from them. Related to asthma, debate has tended to focus on studies that have demonstrated better patient-centered outcomes for patients managed by asthma specialists, rather than the ability of the goals of asthma DM to serve the interests of patients, health care providers, and health plans. This article reviews the major forces that propel the disease management movement, describes the nature of DM programs, and presents a proposal that underscores the viability of specialty care in asthma disease management.

Stimulation of proximal convoluted tubule phosphate transport by epidermal growth factor: signal transduction.

The present study investigated the signal-transduction pathway responsible for the epidermal growth factor (EGF) stimulation of phosphate transport (JPhos) in the rabbit proximal convoluted tubule (PCT). Genistein, 10(-4) M, bath and lumen, an inhibitor of EGF receptor tyrosine kinase activity, blocked the EGF effect on JPhos, consistent with a role for tyrosine kinase in the signal-transduction pathway. Both staurosporine (5 x 10(-8) M) and calphostin C (10(-8) M), inhibitors of protein kinase C, blocked the EGF stimulation of JPhos, indicating that protein kinase C is involved in EGF signaling.

Purification and N-terminal sequence analysis of Streptomyces chromofuscus phospholipase D.

Partially purified commercial phospholipase D (PLD) was fractionated by dye-ligand affinity chromatography and nondenaturing polyacrylamide gel electrophoresis (PAGE). Active material migrated as three bands on SDS-PAGE. The two higher-abundance species were shown to have identical N-terminal sequences, while the third band was present in much smaller amounts and had a distinct sequence.

Comparison of diglyceride production from choline-containing phosphoglycerides in human neutrophils stimulated with N-formylmethionyl-leucylphenylalanine, ionophore A23187 or phorbol 12-myristate 13-acetate.

The turnover of choline-containing phosphoglycerides (PC) in response to agonist stimulation is well documented in human neutrophils. We have now compared the enzymic pathways of N-formylmethionyl-leucylphenylalanine (fMLP)-, A23187- and phorbol-12-myristate 13-acetate (PMA)-induced diglyceride (DG) and phosphatidic acid (PA) generation in these cells. In order to distinguish between phospholipase C- and D-mediated PC breakdown, human neutrophils were radiolabelled with 1-O-[3H]alkyl-2-acyl-glycero-3-phosphocholine and stimulated in the presence of ethanol or propranolol.

Assessment of receptor-dependent activation of phosphatidylcholine hydrolysis by both phospholipase D and phospholipase C.

Enhancement of cellular phospholipase D (PLD)-1 and phospholipase C (PLC)-mediated hydrolysis of endogenous phosphatidylcholine (PC) during receptor-mediated cell activation has received increasing attention inasmuch as both enzymes can result in the formation of 1,2-diacylglycerol (DAG). The activities of PLD and PLC were examined in purified mast cells by quantitating the mass of the water-soluble hydrolysis products choline and phosphorylcholine, respectively. Using an assay based on choline kinase-mediated phosphorylation of choline that is capable of measuring choline and phosphorylcholine in the low picomole range, we quantitated the masses of both cell-associated and extracellular choline and phosphorylcholine.

Isolation and enzymic assay of choline and phosphocholine present in cell extracts with picomole sensitivity.

Increasing interest in receptor-regulated phospholipase C and phospholipase D hydrolysis of cellular phosphatidylcholine motivates the development of a sensitive and simple assay for the water-soluble hydrolytic products of these reactions, phosphocholine and choline respectively. Choline was partially purified from the methanol/water upper phase of a Bligh & Dyer extract by ion-pair extraction using sodium tetraphenylboron, and the mass of choline was determined by a radioenzymic assay using choline kinase and [32P]ATP. After removal of choline from the upper phase, the mass of residual phosphocholine was determined by converting it into choline by using alkaline phosphatase, followed by radioactive phosphorylation.

Phosphatidylcholine is a quantitatively more important source of increased 1,2-diacylglycerol than is phosphatidylinositol in mast cells.

The widely accepted hypothesis that the increased 1,2-diacylglycerol (DAG) in stimulated cells is derived from phosphoinositides was tested by comparing the pattern of molecular species of phosphatidylinositol (PI) to that of DAG in mast cells. For any glycerol-based lipid, molecular species are defined by unique combinations of the two fatty acids esterified to glycerol. The quantitative frequency distribution of these molecular species represent a "fingerprint" that provides a sensitive approach to assessing precursor/product relationships.

An indirect pathway of receptor-mediated 1,2-diacylglycerol formation in mast cells. I. IgE receptor-mediated activation of phospholipase D.

The current studies explore the role of phospholipase D (PLD) in mast cell activation. Although most investigators believe that receptor-mediated accumulation of 1,2-diacylglycerol (DAG) occurs by phospholipase C hydrolysis of phosphoinositides, our previous work indicated a modest role for these substrates and suggested that phosphatidylcholine (PC) is the more likely substrate. PLD cleaves the terminal phosphodiester bond of phospholipids to yield phosphatidic acid (PA), but in the presence of ethanol, it transfers the phosphatidyl moiety of the phospholipid substrate to ethanol producing phosphatidylethanol (PEt); a reaction termed transphosphatidylation.

Studies of connective tissue mast cell-mediated cytotoxicity.

Although mast cells have been implicated in mediating antitumor activity, the kinetics, mechanism(s), and suspectibility of different tumors to mast cell-mediated cytotoxicity have not been defined. Rat connective tissue mast cells (CTMC) of greater than or equal to 99% purity were investigated in vitro and found to express maximal spontaneous cytotoxicity against the mouse fibrosarcoma cell line WEHI-164 (56.0% +/- 2.