Patient Safety: Achieving a New Standard for Care

Six Sigma Anticoagulation Improvements: Virtua Health

Process Step	Deficiency	Intervention	Anticipated Benefit
Preheparin lab studies	Inconsistency among nurses and physicians on holding heparin until results received	Clarification with physicians; default is do not wait for labs with hold option for physician	Decreased variation in nursing practice
Infusion pumps	Occasional incorrect setting leading to dosage error	Programmable pumps with drug personalities and maximum drip rate settings	Avoidance of extreme overdosage due to pump-setting errors
Use of unfractioned heparin	Complex process with complexity-related failures	Substitute low-molecular heparin	Fewer complexity-related errors

The control phase includes creation of visible metrics used by process owners to ensure gains are sustained. Study authors note their work “is not a research methodology, and the findings of this project should not be interpreted in the same light as a rigorous clinical research paper. The focus of this paper is to describe an approach for identifying opportunities for improvement and taking action that leads to results that matter to patients in a framework that is achievable in the typical community hospital setting.”³⁰

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The Pittsburgh Regional Healthcare Initiative (PRHI) is a collaborative effort by institutions and individuals that provide, purchase, insure, and support health care services in Southwestern Pennsylvania. The initiative aims to achieve “perfect patient care” in six counties in the Pittsburgh Metropolitan Statistical Area with the following goals:

Zero medication errors
Zero health care–acquired (nosocomial) infections
Perfect clinical outcomes, measured by complications, readmissions, and other patient outcomes in the following areas:

Table of Contents

Front Matter R1-R22

Executive Summary 1-28

1 Introduction 29-44

PART I: BUILDING THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE 45-51

2 Components of a National Health Information Infrastructure 52-95

3 Federal Leadership and Public-Private Partnerships 96-126

4 Health Care Data Standards 127-168

PART II: ESTABLISHING COMPREHENSIVE PATIENT SAFETY PROGRAMS 169-172

5 Comprehensive Patient Safety Programs in Health Care Settings 173-199

6 Adverse Event Analysis 200-225

7 Near-Miss Analysis 226-246

PART III: STREAMLINING PATIENT SAFETY REPORTING 247-249

8 Patient Safety Reporting Systems and Applications 250-278

9 Standardized Reporting 279-316

Appendix A: Biographies of Committee Members 317-326

Appendix B: Glossary and Acronym List 327-340

Appendix C: Examples of Federal, State, and Private Sector Reporting Systems 341-426

Appendix D: Clinical Domains for Patient Safety 427-429

Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report 430-470

Appendix F: Quality Improvement and Proactive Hazard Analysis Models: Deciphering a New Tower of Babel 471-508

Appendix G: Australian Incident Monitoring System Taxonomy 509-510

Index 511-528

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