OUR EXPERIENCES Embedded Safeguards
Cincinnati Children’s implemented a bundle of interventions—a robust detection system to accomplish real-time awareness and analysis of all failures, microsystem-level process and outcome data, and standardized pediatric process bundles—to reduce rates of specific hospital-acquired conditions.
HCA conducted a multi-year effort to reduce central line-associated bloodstream infections (CLABSIs). This program incorporates the latest evidence-based recommendations, including insertion and maintenance practices, supply standardization of central-line kits, and competency training for all HCA physicians as part of their biannual credentialing.
Kaiser Permanente established early-intervention protocols for diagnosing and treating community-acquired sepsis. Nursing, physician, informatics, and quality leaders translated existing guidelines into specific competencies, practices, and roles for the care delivery staff. Patient care protocols in the ED and ICU were changed to provide early-recognition and treatment-intervention opportunities.
Partners HealthCare implemented pharmacy barcoding at Brigham and Women’s Hospital to reduce serious medication errors. Pharmacists barcode-scan all medications dispensed from the pharmacy to ensure that the medications match the physicians’ orders. Nurses at the bedside then scan the medications prior to administration to patients, and are alerted about possible errors.
Veterans Health Administration’s Methicillin-Resistant Staphylococcus Aureus (MRSA) Prevention Initiative was implemented in 2007 to decrease MRSA infections acquired at acute care facilities nationwide. The program focused on a bundle of evidence-based best practices known to prevent MRSAs and the leadership of a MRSA Prevention Coordinator (MPC) charged with overseeing implementation at each medical center.