A children's hospital annually reviews all findings from root cause analysis to identify and address common themes and vulnerabilities, leading to a number of institutionwide changes that have improved patient safety and to better communication about safety issues with organizational leaders.
A telephone-based coaching intervention was designed to help hospital-based fall prevention champions identify and implement needed changes in fall-related organizational policies and clinician-specific practices.
As part of the Geriatric Resources for Assessment and Care of Elders (GRACE) program, social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors, leading to significant improvements in health status.
The Hospital Elder Life Program screens all patients aged 70 years and older at admission for the presence of six risk factors for delirium, and then implements targeted interventions to reduce these risks, leading to less cognitive and functional decline and lower costs.
A fall prevention program for seniors who receive home care uses a 12-element assessment tool to identify risk factors for falls and then develops specific interventions designed to reduce these risks; ongoing monitoring of medications and periodic reassessments help to support the effort.
A hospital outpatient clinic's confidential, voluntary error reporting system, which focuses on identifying faulty systems instead of individual mistakes, has substantially increased error reports and has been associated with a reduction in liability claims.
Reconciling patient and provider medication lists reduces discrepancies, leading to enhanced medication safety and high levels of patient and provider satisfaction in the outpatient setting.
A hospital's ambulatory pediatrics department developed a voluntary, anonymous, and nonpunitive medical error reporting system that includes a quick response team to review reports and enact interventions to prevent recurrences, leading to a significant increase in error reporting.
Guided by a university research team, a 136-bed, not-for-profit nursing home in Pennsylvania implemented a quality improvement program to reduce pressure ulcer incidence. The program included three components: education and tools to increase workers' ability to recognize and prevent pressure ulcers; financial incentives for improved performance; and ongoing performance feedback.
A randomized clinical trial at San Francisco General Hospital used visual medication schedules and brief teach-back protocols in English, Spanish, and Cantonese to improve anticoagulant control among low-literacy patients in the public hospital's anticoagulation clinic.