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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety. It is based on AHRQ’s Health Care Innovations Exchange, which shares many health care innovations, including those that improve patient safety. While available for anyone to search, the Health Care Innovations Exchange has not had new content added since 2016. In order to preserve and update some of the patient safety content on the Health Care Innovations Exchange, select innovations are now being integrated with PSNet. Patient safety innovations are defined as “implementation of new or altered products, tools, services, processes, systems, policies, organizational structures, or business models implemented to improve or enhance quality of care and reduce harm. Patient safety Innovations may be local, regional, national, or international in scope and those included on the AHRQ PSNet Innovation Exchange have implementation data available demonstrating impact.”

Read more about how PSNet Innovations can be used.

PSNet innovations can be used to:

  • Uncover innovations that could be implemented by a broader audience,
  • Learn about recent innovations with promising early results, and
  • Consider conditions that support the successful implementation or sustainment of a new innovation.

Future innovations will be carefully curated by subject matter experts based on their impact on the provision of health care.

Latest Innovations

All Innovations (16)

1 - 16 of 16 Results

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined.

The Behavioral Health Vital Signs (BHVS) screener is a patient questionnaire input into the electronic health record for depressive symptoms, alcohol and substance use, and interpersonal violence. Widespread staff education and a standardized workflow were developed to ensure that BHVS was implemented in all primary care clinics within the San Francisco Health Network.

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

The Hospital at Homesm program provides hospital-level care (including daily physician and nurse visits, diagnostic testing, treatment, and other support) in a patient's home as a full substitute for acute hospital care for selected conditions that are common among seniors. Studies have shown that the Hospital at Home program results in lower length of stay, costs, readmission rates, and complications than does traditional inpatient care, whereas surveys indicate higher levels of patient and family member satisfaction than with traditional care.

Care management staff (such as nurses, community health workers, health coaches, social workers, or other clinical staff) use software-based protocols to screen older clients' medications and collaborate with pharmacists and physicians to reduce the risk of medication errors and adverse effects. The HomeMeds Medication Safety Program identified and addressed targeted medication problems, leading to fewer cases of therapeutic duplication and more appropriate medication use for cardiovascular medications, NSAIDS, psychotropics and overall medication use.

Project Nurture provides patients with substance use disorder (SUD) prenatal care, inpatient maternity care, postpartum care, and infant pediatric care. Women enrolled in the program receive Level 1 addiction treatment (i.e., outpatient services) from an integrated care team that includes MDs, nurse practitioners, doulas, certified recovery mentors, certified alcohol and drug counselors, and social workers and other mental health professionals. If indicated, they can also receive medication-assisted treatment (MAT) using methadone or buprenorphine.

Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication.

The team at Geisinger sought to develop an outpatient addiction medicine specialty program that incorporated medication-assisted treatment (MAT), peer support, and connection to community counseling services that also uses data-driven insights to monitor and improve patient outcomes. As a result of this program, they have been able to reduce all-cause mortality among these patients, increase patient engagement in substance use disorder treatment, and have seen a reduction in the prescription quantities of controlled substances.

Nudges are a change in the way choices are presented or information is framed that can have a large, but predictable, impact on medical decision-making, for both patients and providers without actually restricting individual choice. The Nudge Unit at Penn Medicine focuses on a range of different care improvement projects, including safety initiatives, with this framework in mind that are designed to improve workflow, support evidence-based decision-making, and create sustained changes in patient engagement and daily behaviors.1

Multidisciplinary teams at the University of Kansas Hospital sought to improve patient outcomes from obstetric emergencies by rehearsing team responses in simulations to emergent situations that can occur during a delivery. Using the PRactical Obstetric MultiProfessional Training (or PROMPT) curriculum, teams rehearsed flexible emergency care scenarios in order to achieve an optimal response, and then used this experience to improve their response to a real emergency.

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers.

Under a program known as the Care Transitions Intervention ®, a Transitions Coach ® encourages patients who are transferring from either a hospital or a short-term skilled nursing facility stay to home to assert a more active role in their self-care. The program has consistently reduced 30-day hospital readmissions and costs as well as 180-day hospital readmissions, even in heavily penetrated Medicare Advantage markets in which the reduction of hospital use has been an explicit focus for many years.

Formerly known as the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), the University of Arkansas for Medical Sciences (UAMS) High-Risk Pregnancy Program links clinicians and patients across the state with UAMS, where the vast majority of the state's high-risk pregnancy services, maternal-fetal medicine specialists, and prenatal genetic counselors are located.

The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.

Children's Hospital Colorado requires clinicians in all inpatient and outpatient facilities to confirm any order entered into its computerized order entry system through a popup verification screen that includes a prominent photograph of the patient, along with other key information such as age and gender. The goal is to capture the clinician's attention and force him or her to verify that the order has been entered into the correct patient's chart.