Safety

Innovations

Common Cause Analysis: A Hospital's Review of Vulnerabilities During Which Common Themes Are Identified, Prioritized, and Addressed 05/08/08

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.

Telephone-Based Coaching Does Not Reduce Rate of Falls or Fall-Related Injuries, but Prompts Changes in Hospital Processes That May Lead to Future Improvement 05/06/08

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.

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors 04/25/08

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.

Hospital-Based Program Proactively Identifies, Addresses Delirium Risk Factors in Elderly, Leading to Less Cognitive/Functional Decline and Lower Nursing Home Costs 04/22/08

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.

Fall Prevention Program Emphasizes Proactive Identification and Addressing of Risk Factors, Leading to Fewer Falls and Fall-Related Injuries Among Seniors Receiving Home Care 04/15/08

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.

Voluntary Error Reporting Program Focusing on Systems Issues Increases Reporting and Contributes to Reduction in Liability Claims at Outpatient Clinic 04/03/08

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.

Reconciliation of Patient and Provider Medication Lists Reduces Discrepancies and Enhances Medication Safety in Physician Clinics 04/02/08

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.

Voluntary, Anonymous, Non-Punitive System Leads to a Significant Increase in Reporting of Errors in Ambulatory Pediatric Practice 03/13/08

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.

Staff Training and Support, Incentives, and Feedback Fails to Generate Sustainable Reductions in Pressure Ulcers at Nursing Home 03/05/08

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.

Computerized, Multilingual Visual Medication Schedule and Teach-Back Protocols Improve Anticoagulation Control for Low-Literacy Patients 02/26/08

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.

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