Saver C. Beyond expectations: Part 2. Nursing Management. 2006 Nov;37(11):17-23.

This second article of a two-part series describes how nurse leaders and other members of quality improvement teams participating in IHI's 100,000 Lives Campaign were able to reduce mortality in their hospitals.

Saver C. Beyond expectations: Part 1. Nursing Management. 2006 Oct;37(10):36-42.

The Institute for Healthcare Improvement estimates that hospitals participating in the 100,000 Lives Campaign saved more than 122,300 lives in 18 months. This first article of a two-part series examines how the results were calculated and the impact on quality and the bottom line.

Resar RK, Rozich JD, Simmonds T, Haraden CR. A trigger tool to identify adverse events in the intensive care unit. Joint Commission Journal on Quality and Patient Safety. Oct 2006;32(10):585-590.

The Trigger Tool technique was used to identify the rate of occurrence of adverse events in the intensive care unit (ICU), and a subset of ICUs described those events in detail. Sixty-two ICUs in 54 hospitals (both academic and community) engaged in IHI critical care collaboratives between 2001 and late 2004. Charts were selected using a random sampling technique and reviewed using a two-stage process.

Landro L. The informed patient: Hospitals combat error at the "hand-off." The Wall Street Journal. June 28, 2006.

John Whittington, patient safety officer at OSF St. Joseph Medical Center, says the SBAR "quick briefing" model can help overcome differing communication styles, such as nurses who give long, descriptive reports and doctors who say, "just give me the headlines," and don't want a nurse's opinion. OSF started training staffers to use the SBAR communication model in 2004, offering pocket cards and laminated "cheat sheets" posted at each phone.

Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006 Oct;118(4):1332-1340.

This article discusses the use of a NICU-focused tool for adverse event detection and describes the incidence of adverse events in NICUs identified by this tool. The authors found that adverse event rates in the NICU setting are substantially higher than previously described and the majority are preventable. They concluded that the NICU-focused trigger tool appears efficient and effective at identifying adverse events.

Shannon RP, Frndak D, Grunden N, et al. Using real-time problem solving to eliminate central line infections. Joint Commission Journal on Quality and Patient Safety. 2006 Sep;32(9):479-487.

This article describes how two intensive care units (ICUs) redefined the processes of care through system redesign to deliver reliable outcomes. The ICUs implemented Toyota Production System principles to central line placement and maintenance, and within a year CLABs decreased from 49 to 6 (10.5 to 1.2 infections/1,000 line-days). Mortality also decreased from 19 to 1 (51 percent to 16 percent) despite an increase in the use of central lines and number of line-days.

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Raising the bar with bundles: Treating patients with an all-or-nothing standard. Joint Commission Perspectives on Patient Safety. 2006 Apr;6(4):5-6.

A "bundle" is a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are "bundled" together and, when combined, significantly improve patient care outcomes. This article describes the Ventilator Bundle, Central Line Bundle, and Sepsis Bundles developed by the Institute for Healthcare Improvement and others, and explains how organizations can improve clinical outcomes by using care bundles.

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Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Quality and Safety in Health Care. 2006;15(4):235-239.

Nosocomial infections occur in approximately 10 percent of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost. Implementing four changes — multidisciplinary rounds; daily "flow" assessment of bed availability; "bundles" of evidence-based practices; and culture changes to support team decision making — one hospital in Mississippi reduced both infection rates and costs per year.

Goldmann D. System failure versus personal accountability: The case for clean hands. New England Journal of Medicine. 2006 Jul 13;355(2):121-123.

This article states that if we really are serious about making care safer, we need to find the right balance between blaming mistakes on systems and holding individual providers accountable for their everyday practices.

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Evans B. Best-practice protocols: VAP prevention. Nursing Management. Dec 2005;36(12):10-16.

A standardized approach to care delivery helps intensive care units reduce VAP care complications. This article is part of a series that describes the Institute for Healthcare Improvement's 100,000 Lives Campaign recommended interventions from a nursing management perspective.

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