Safety

Innovations

Comprehensive, Hospital-Based Program Significantly Reduces Pressure Ulcer Incidence and Associated Costs 02/20/08

OSF Saint Francis Medical Center in Peoria, IL, developed a comprehensive program called “Save Our Skin” that significantly reduced the incidence of pressure ulcers.

Standardized Processes Improve Adherence to Evidence-Based Protocols, Significantly Reducing Common Surgery-Related Complications 02/20/08

A hospital standardized and automated evidence-based protocols and processes, leading to a significant reduction in surgical site infections, postoperative myocardial infarction, and postoperative deep vein thrombosis.

Using Positive Deviance Employee-Generated Strategies Reduces MRSA Infections by 50 Percent 02/20/08

The Department of Veterans Affairs Pittsburgh Healthcare System used Positive Deviance to encourage all employees at two facilities to use their own experiences to brainstorm and implement strategies for reducing hospital-acquired methicillin-resistant Staphylococcus aureus infections.

Interdisciplinary Team Identifies and Addresses Risk Factors for Falls Among Nursing Home Residents, Leading to Fewer Falls and Less Use of Restraints 02/18/08

Ethica Health and Retirement Communities developed a falls management program, the cornerstone of which is an interdisciplinary “falls team” at each nursing home that regularly assesses residents for risk of falling and develops intervention plans for those found at high risk.

Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs 02/14/08

Transitions coaches encourage recently hospitalized Medicare patients with complex care needs to assert a more active role in their posthospital care, leading to fewer readmissions and lower costs.

Educational Game Increases Compliance With Appropriate Hand Hygiene Protocols Among Intensive Care Unit Staff at Academic Medical Center 02/11/08

A game to educate health care workers in intensive care units about appropriate hand hygiene increased awareness of and adherence to hand hygiene protocols at a major academic medical center, leading to increased compliance with appropriate hand hygiene protocols from 37 to 53 percent.

Comprehensive Initiative to Create a Culture of Safety Significantly Reduces Harm Caused by Medical Errors, Mortality, Length of Stay, and Hospital-Acquired Pneumonia and Infections 02/11/08

Sentara Healthcare launched a program designed to create a strong culture of safety. The initiative includes an assessment of the existing safety culture, establishment of goals related to improved safety, the development of specific strategies to identify and correct safety problems, and the use of ongoing processes and systems to monitor progress and encourage continued improvement.

Comprehensive, Multifaceted Program Doubles Staff and Physician Adherence to Hand Hygiene Protocols Over 4-Year Period 02/11/08

A multipronged strategy involving ties between hand hygiene performance and compensation systems, adoption and constant reinforcement of clear hand hygiene protocols, a comprehensive auditing program to review hand hygiene adherence, and other program elements improved adherence to appropriate hand hygiene protocols.

Medical Emergency Team Reduces Cardiopulmonary Arrests, Unexpected Mortality 02/11/08

The creation of a medical emergency team program at the University of Pittsburgh Medical Center Presbyterian Hospital has significantly reduced the number of cardiopulmonary arrests and unexpected mortality.

Medical Team Training Using Crew Resource Management Principles Enhances Provider Communication and Stimulates Improvements in Patient Care 02/11/08

A comprehensive medical team training program supported by crew resource management principles adopted from the aviation industry was developed and implemented in 79 Veterans Affairs Medical Centers, resulting in a measurable improvement in communication and patient care in 10 participating facilities that have at least a year's experience with the program.

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