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Eliminating Errors in Follow-up of Radiology Results
Carle Foundation Hospital and Carle Clinic Association (Urbana, Illinois, USA) established a Radiology Tracking Program that has effectively eliminated the risk of missed diagnosis or delay in diagnosis of radiology findings on exams ordered from the Emergency Department.
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Safer Patients Initiative Leads to Reductions in Mortality and Adverse Events in the United Kingdom
With the support of £4.3 million in funding from The Health Foundation, an independent charity in the United Kingdom, IHI has launched an ambitious program called the Safer Patients Initiative designed to create centers of excellence in patient safety in acute care trusts (provider systems) in each of the four countries in the UK.
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Intensive, Extensive Development Helps the Patient Safety Officer
The elevation of the job of Patient Safety Officer (PSO), to the upper ranks of hospital management in many instances, has helped to improve patient safety. But to safeguard patient care and spearhead the types of change needed across any hospital requires tremendous will and increasingly specialized training.
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Reducing Pressure Ulcer Rates in Nursing Homes
Through implementation of process of care system changes in collaboration with a state quality improvement organization, twenty nursing homes in Texas showed statistically significant improvement in 8 out of 12 quality indicators and reduced pressure ulcer incidence rates.
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Reduction in Ventilator-Associated Pneumonia Rate
St Vincent Mercy Medical Center (Toledo, Ohio, USA) reduced the number of ventilator-associated pneumonia infections (VAP) from 4.6 infections/ventilator days in 2002 to 1.7 infections/ventilator days in 2003 (fourth quarter), maintained at 1.9 infections/ventilator days for the first two quarters of 2004.
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Reducing Positioning and Shielding Errors in Radiation Therapy
The Therapeutic Radiology Department, National Cancer Center (Singapore) reduced the number of positioning and shielding errors primarily by implementing processes via treatment verification software and developing a safety culture.
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Building Rapid Response Teams
Two hospitals successfully implemented Rapid Response Teams — teams that can quickly respond to a patient and assess or even transfer the patient in minutes rather than hours — and reduced adverse events and mortality rates in both hospitals as a result.
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Improvement Report: The Role of Executive Walkarounds in Redesigning Culture
Methodist LeBonheur Healthcare (Memphis, Tennessee, USA) has implemented an average of 1.76 safety-based changes per unit visited by executives using walkarounds; 100 percent of senior executives participated in the walkarounds. Over 50 percent of the associates on the pilot unit responded that delivery of care has improved since walkarounds began.
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Improvement Report: Reduction in Incidence of Post-Operative Pneumonia
Kaleida Health (Buffalo, New York, USA) reduced the incidence of post-operative pneumonia by implementing a "back to basics" approach to care: engaging patients and families early in the care process, educating them about what to expect post-operatively, and how to help facilitate a safe recovery.
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Improvement Report: Decreasing Hospital Acquired Pressure Ulcers
OSF St. Francis Medical Center (Peoria, Illinois, USA) has decreased the number of hospital acquired pressure ulcers by 55 percent, primarily by using the Six Sigma methodology.
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