Medical errors

Innovations

Statewide Health Information Exchange Generates High Levels of Participation and Many Reports of Improved Quality and Efficiency 02/26/13

The nation's first statewide health information exchange, the Delaware Health Information Network gives clinicians immediate access to patient-specific health data from other providers, leading to higher quality and more efficient care.

Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart 10/30/12

A children's hospital requires providers to look at a patient's picture and basic demographic information on a verification screen when entering and signing an order, leading to significant reductions in patients receiving or almost receiving care intended for someone else because of an order being placed in the wrong chart.

State-Mandated Nurse Staffing Levels Alleviate Workloads, Leading to Lower Patient Mortality and Higher Nurse Satisfaction 08/31/12

As mandated by State law, the California Department of Health Services requires acute care hospitals to maintain minimum nurse-to-patient staffing ratios and to develop various systems to ensure adequate nurse coverage and quality, leading to more reasonable workloads, lower patient mortality, and higher job satisfaction.

Multidisciplinary Hospital Team Proactively Meets With Patients and/or Families, Allowing Them to Better Deal With Unexpected Deaths and Other Negative Events 02/06/12

A multidisciplinary hospital team reaches out to and meets with patients and family members in a compassionate, supportive manner, allowing them to better deal with the loss of a loved one or other unexpected, negative events.

Alerts and Decision Support for Abnormal Laboratory Values Do Not Improve Clinical Management or Reduce Adverse Events 01/11/12

The combination of clinical alerts and decision support related to abnormal laboratory values had no impact on the clinical management of patients or the frequency of adverse events.

Redesigned Inpatient Care Model Increases Quality and Patient Satisfaction, Reduces Costs and Length of Stay 11/29/11

A redesigned inpatient care model based on Toyota Production System principles uses daily multidisciplinary clinical team visits, individualized care plans, and facility and staffing changes to reduce costs and average length of stay and improve adherence to recommended care processes, nurse productivity, and patient, staff, and physician satisfaction.

Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors 05/04/11

A computerized decision support system uses algorithms and real-time patient information to guide the resuscitation of trauma patients, leading to fewer medical errors.

Dedicated Emergency Department Team Follows Up With Discharged Patients, Easing Physician Workload and Enhancing Quality of Care 01/20/11

A dedicated team of nurses and clerks provides followup support for patients discharged from the emergency department, leading to better quality care, high satisfaction among patients and primary care providers, and fewer patient walkouts.

Immediate Post-Event Debriefing Improves Multiple Aspects of Response to Codes and Increases Staff Satisfaction 12/10/10

Immediate team debriefings after a cardiopulmonary resuscitation code event improve multiple aspects of the team's response to future codes and generate high levels of staff satisfaction.

Hospital Posts Appropriate Diet for Patient on Room Door, Reducing Diet-Related Mistakes and Nursing Interruptions 09/27/10

An adjustable “diet wheel” posted on each inpatient's doorway indicates which of 15 physician-ordered diets a patient should receive and prompts dietary staff to check that food trays match the ordered diet, leading to fewer diet-related miscommunications, mistakes, and interruptions.

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