Innovations

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.

Minoritized patients continue to experience disproportionately high rates of maternal morbidity and mortality. This hospital developed a health-equity checklist to identify if bias and/or social determinants of health played a role in preventable adverse events.

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability.

Improving non-technical skills - such as teamwork and communication – is essential to safe delivery of healthcare but implementing successful training programs has been challenging.

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.¹

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Patient falls are a never event and a frequent focus of patient safety and quality improvement projects. This pediatric ICU implemented a colored alert system based on fall risk assessments for all admitted patients.

Rapid response teams are intended to improve timely identification and management of clinically deteriorating patients, such as in-hospital cardiac arrest or stroke. 

Community pharmacists encounter a wide range of challenges to medication safety. This study used a novel prospective method of predicting errors and developing remedial solutions. 

While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to identify and reduce the number of alerts clinicians encounter every day. 

Medical residents, alongside interns, nurses and attending physicians, are uniquely positioned to identify safety concerns because they are on the front lines of patient care.¹ Residents can bring a fresh perspective that is informed by their cross-department training experiences.^1,2 As a tool to leverage resident potential and improve reporting of safety events, some evidence supports the use of resident-led training and hands-on activities.^3,4 Yet, while there are many studies on patient