Safety

Innovations

Revamped Processes Eliminate Adverse Events and Near Misses in Hospital Endoscopy Department 01/06/10

Process improvements in a hospital endoscopy department eliminated adverse incidents and near misses and led to anecdotal improvements in staff satisfaction.

Providing Real-Time Information and Documentation Capabilities at Point of Care Reduces Documentation Time and Generates Positive Patient Feedback 12/18/09

Providing caregivers with accurate, timely information, automated prompts, and real-time documentation capabilities at the point of care reduces documentation time and leads to positive feedback from patients and generally positive feedback from nurses.

Proactive Reporting, Investigation, Disclosure, and Remedying of Medical Errors Leads to Similar or Lower Than Average Malpractice Claims Costs 12/14/09

A medical center adopted a comprehensive process that includes proactive reporting and investigation of potential errors, full disclosure and apology when errors occur, and fair remedy and compensation, leading to similar or lower than average claims costs.

Engaging Patients as Observers Represents Low-Cost, Accurate Way to Monitor and Improve Hand Hygiene in Outpatient Settings 12/08/09

Using patients to observe the hand hygiene habits of providers in outpatient clinics proves to be a low-cost, accurate way to monitor and improve adherence to recommended guidelines.

Pathology Team Provides Patient-Specific Interpretations of Test Results, Reducing Ordering Errors and Speeding Up Diagnostic Process 12/08/09

Pathologists provide a paragraph of patient-specific analysis as a supplement to traditional laboratory test results, leading to fewer ordering errors, time savings, and quicker diagnoses.

Improvement Projects Led by Unit-Based Teams of Nurse, Physician, and Quality Leaders Reduce Infections, Lower Costs, Improve Patient Satisfaction, and Nurse–Physician Communication 12/04/09

Unit-based teams of physicians, nurses, and quality leaders develop and implement unit-specific initiatives designed to improve quality and safety, leading to reductions in infections and pressure ulcers, increased adherence to medication reconciliation standards, more reporting of errors and near-misses, higher patient satisfaction, and better overall nurse/physician communication and teamwork.

Separate Emergency Center for Older Patients Leads to High Levels of Patient Satisfaction, Detection of Polypharmacy, Increased Volume of Patients, and Low Rate of Return Visits 11/24/09

A separate emergency center for older patients includes physical features to reduce anxiety and discomfort, staff trained in geriatric care, and routine followup monitoring after discharge, leading to high levels of patient satisfaction, detection of polypharmacy, increased patient volume, and a low rate of return visits.

Regular Reminders via Text Message Increase Adherence to Medication Regimen, Significantly Reduce Risk of Organ Rejection in Pediatric Liver Transplant Patients 11/20/09

Regular reminders via text message enhance adherence to medication regimens and reduce risk of organ rejection in pediatric liver transplant patients.

Standardized Communication Process Guided by Daily Goals Form Improves Nurse–Physician Communication and Increases Nurse and Patient Satisfaction on Surgical Unit 11/16/09

Clinicians on a surgical unit use a standardized communication process during daily rounds, leading to better nurse–physician communication and to higher nurse and patient satisfaction.

Program to Promote Adherence to Standards of Professional Conduct Improves Staff Perceptions of Patient Safety Culture and Reduces Disruptive Clinician Behavior 11/10/09

A system-wide strategy to set and enforce standards of professional conduct led to improvements in staff perceptions of the patient safety culture within system hospitals and to anecdotal reports of more professional conduct, including fewer instances of disruptive behavior.

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