ABOUT PATIENT SAFETY
Health care should by default help people feel better and improve their health status, but in practice that is not always the case. Many errors and mistakes are made that harm patients. Some errors are human, but systems within hospitals, doctors’ offices, and elsewhere can be designed to greatly reduce the risk of error.
- As many as 98,000 people die annually from preventable medical errors—more than from motor-vehicle accidents, breast cancer, or AIDS
- Medical errors in the United States cost about $19.5 billion in 2008.
- Medication errors—when hospitalized patients receive potentially inappropriate prescription medications—cost roughly $2 billion annually.
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Goal was to reduce errors and ensure patients receive the correct diet ordered by physicians. Satisfaction improved among nursing associates and dietary associates. Communication between the various hospital departments also improved.
The Heart Failure Performance Improvement team implemented a new process to classify LVSD patients’ condition and symptoms.
Cardiology nurse practitioners, both employed by the hospital and private, meet regularly to conduct practice reviews.
The RACE project introduced a standardized process by which each participating hospital designates a reperfusion and triage strategy for STEMI patients to decrease door-to-balloon times for percutaneous coronary intervention.
Staff at University Hospital in San Antonio developed a simple communication system between housekeeping and nurses by using jars with color-coded slips of paper that allowed staff to easily track beds that were available or that needed cleaning.
Staff created new positions for quality improvement facilitators, called patient care analysts, to help providers improve their practice patterns and use of evidence-based interventions.
Staff at Seton Family of Hospitals in Texas developed a risk assessment protocol, identifying populations at risk and using prevention tools such as alerts and patient-care rounding, which has enabled the staff to consistently meet its goal of just two falls per 1,000 patient days.
To improve the frequency and consistency of turning patients, a visual indicator was developed that could easily and immediately be seen by all front-line staff.