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Journal Article > Study
A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.
Krimsky WS, Mroz IB, McIlwaine JK, et al. Qual Saf Health Care. 2009;18:74-80.
Evaluating the impact of quality and safety interventions is an evolving science. While some have argued for a new paradigm in the field, others have advocated for standards similar to clinical trials. This study developed a comprehensive approach and model to increase prophylaxis against venous thromboembolic disease, ventilator-associated pneumonia, and stress ulcers in a single intensive care unit. The model included adoption of tools that promoted team communication, prompts to providers to address the evidence-based measures on a daily basis, and a data wall to provide real-time feedback. The authors provide a detailed description of their efforts that achieved near 100% target goals and advocate for this approach in creating successful microsystems that benefit from their refined Plan-Do-Study-Act methodology.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Web Resource > Multi-use Website
This national program draws from other large collaborative efforts to engage health care organizations across Wales in reducing preventable harm.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.