Innovations

Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal of improving communication of radiologic abnormalities. The first 13 months of the innovation resulted in shared patient findings and care plans for 888 out of 932 (95%) targeted ED patient care episodes with abnormal radiologic findings.

UNC Health is a nonprofit healthcare system of more than 500 clinics and 16 hospitals in North Carolina. In early 2021, it developed an innovation to reduce health disparities by screening patients for high priority social needs and connecting them as needed to social supports and resources. UNC Health developed the innovation in partnership with UNC Health Alliance, its physician-led clinically integrated network and population health services organization. UNC Health introduced the screening program in 92 primary care practices in July 2021. 

The Rescue Improvement Conference (RIC)¹ was designed at the University of Michigan to address failure to rescue with a particular focus on communication and complication management. Failure to rescue typically refers to a health system’s slow or ineffective response to clinical deterioration resulting from an underlying illness or a medical or surgical care complication.

Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common category of surgical never events.¹ An RSI occurs when a needle, sponge, or surgical instrument is unintentionally left behind in a patient after incision closure.² Ascension Data Science Institute, a part of Ascension health system that provides data analytic support, determined that a patient was harmed from an RSI at their facilities every eight days on average.

Suicide is the 12^th leading cause of death in the United States, and the 3^rd leading cause of death for people ages 15-24.¹ More than 4% of all emergency department visits are attributed to psychiatric conditions² and 3–8% of all patients have suicidal ideation when screened in the ED.³ In addition, there are approximately 420,000 ED visits every year for intentional self-harm.⁴ The emergency department (ED) is an ideal place to implement interventions design

North American Partners in Anesthesia (NAPA) is a nationwide anesthesia practice with more than 450 facilities in 21 states. NAPA employs anesthesiologists, certified registered nurse anesthetists, and certified anesthesiologist assistants.

This pilot study aimed to enhance the formal reporting of incivility events directed at nursing staff by patients and visitors. The CIVIC Duty program included an educational session for nursing staff to improve their ability to identify incivility behaviors and understand organizational policies, along with nurse leader support to promote the use of the electronic incident reporting system for such incidents.

This study introduces Equity M&M conferences, which focus on understanding how social and structural determinants of health (SSDH) influence patient outcomes. Presenters, trained in diversity, equity, and inclusion, use root cause analysis to explore SSDH impacts on patient care.

Discover how the TWISST process, combining simulation-based clinical systems testing and training, identified and evaluated process improvement opportunities in a pediatric emergency department.

This intervention evaluates simulation training aimed at helping emergency medicine and pediatric learners identify and mitigate bias, using a scenario involving an African American child and a biased orthopedic resident.

To improve patient care and outcomes in the intensive care unit (ICU), the Society of Critical Care Medicine (SCCM) created a multicomponent ICU care bundle called The ICU Liberation Bundle.

Adverse events resulting from medications are a common occurrence that often go undetected, unreported, and unaddressed.¹ The impact of outpatient adverse drug events (ADEs) on patients and health systems is substantial. ADEs result in more than 3.5 million physician office visits and 1 million U.S.

Medical errors (all errors in medicine), harmful errors (medical errors that specifically lead to patient harm), and adverse events (harms due to medical care) are leading causes of death and harm in patients in the hospital setting.^1,2 Communication failures are a common root cause of sentinel events, which are the most serious harmful errors.³ Minimal research has investigated whether efforts to reduce communication failures across healthcare providers, patients, and families could improve patient safety.

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.¹ Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

To address a well-documented hospital adverse outcome (in-hospital patient clinical deterioration), Kaiser Permanente Northern California (KPNC) developed and implemented the Advance Alert Monitor (AAM) program. Using predictive analytics, the team developed a model to alert clinicians up to 12 hours prior to a patient’s likely deterioration. This early detection allowed clinicians to devise and implement a care plan to prevent deterioration of the patient’s condition and/or align the care plan with the goals of the patient.

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.

Although wrong-site surgeries are rare, they can be devastating to patients. One otolaryngology (ENT) clinic developed a surgical marking procedure deemed practicable and useful by both providers and patients. 

Cognitively impaired patients may be at increased risk of adverse events, such as falls, and assessment of cognitive status and implementation of appropriate supports is needed to improve their safety.