Safety

Innovations

Nurse–Physician Infection Prevention Teams Conduct Rounds and Provide Support to Frontline Clinicians, Leading to Fewer Health Care-Associated Infections 04/28/11

Physician–nurse infection prevention teams round on hospital units at least weekly, leading to a 70-percent decline in central line–associated infections and very low rates of surgical site infections.

Imaging Protocol Sharply Reduces Overuse of Cervical Spine X-Rays for Emergency Department Trauma Patients 04/19/11

A simple protocol significantly reduces overuse of cervical spine x-rays in emergency department patients with traumatic injury.

Postdischarge Followup Calls to Skilled Nursing Facilities Reduce Heart Failure Readmissions by Two-Thirds 04/10/11

Hospital case managers telephone skilled nursing facility nurses within 48 hours of each heart failure patient's discharge to verify that appropriate care management is being provided, leading to a significant reduction in readmissions and associated cost savings.

Emergency Department Protocol Leads to Faster Identification and Treatment of Pediatric Patients With Sepsis 04/10/11

A “shock” protocol involving computerized flagging of abnormal vital signs and initiation of treatment based on standardized order sets led to faster identification and treatment of children with suspected sepsis in the emergency department.

Algorithm Guides Test Ordering for Patients With Suspected Pulmonary Embolism, Improving Patient Safety by Reducing Unnecessary Radiation Exposure 04/08/11

A hospital emergency department uses a simple algorithm and related tools to guide physician ordering of imaging studies for stable patients with suspected pulmonary embolism, leading to the provision of safer care by reducing unnecessary radiation exposure for patients.

Hospital-Wide Inpatient Screening for Alcohol Withdrawal and Algorithm-Driven Treatment Improve Care and Reduce Acute Delirium Episodes 03/30/11

An algorithm-driven program combines hospital-wide inpatient screening for alcohol withdrawal risk, monitoring of at-risk patients, and medical treatment of symptoms, leading to more patients being diagnosed, fewer acute episodes of delirium, and improved care for patients experiencing such episodes.

Electronic Alerts, Patient Education, and Performance Reports Improve Adherence to Guideline Designed to Reduce Early Elective Inductions 03/29/11

Electronic alerts, patient education, and provider performance reports promote adherence to a guideline covering early elective inductions, leading to a significant decline in such inductions, shorter average labor, and fewer newborn complications.

Electronic Alerts Related to Black Box Warnings Do Not Affect Overall Physician Prescribing Habits in Outpatient Clinics 03/28/11

Electronic alerts related to black box warnings did not affect overall physician prescribing habits in outpatient clinics; the alerts did influence prescribing related to warnings about the most serious potential drug–drug and drug–pregnancy interactions.

Electronic System for Tracking Test Results Pending at Hospital Discharge Draws Little Use or Enthusiasm From Hospitalists 03/11/11

Hospitalists used an electronic application to track the pending test results of recently discharged inpatients; the application proved to be of limited value, with nearly half of hospitalists never using it and nearly all reporting multiple barriers to doing so.

Program Modeled on Emergency Preparedness Plan Features In-Unit Vaccinations and Morning "Lockdown," Increasing Employee Influenza Immunization Rates 03/01/11

A 2-day influenza vaccination program based on emergency preparedness plans for mass vaccination or prophylaxis, features in-unit vaccinations and a morning “lockdown” where employees must enter the hospital through a single entrance manned by vaccination teams, leading to significant increases in employee vaccination rates.

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