Case Studies
In November 2009, a group of 12 representatives from various areas within Rochester General Health System embarked on a journey to improve patient outcomes and change the culture of the entire system. The group completed 'science of safety' training and developed a plan to involve all team members…
Performing well with the core measures has become increasingly important and challenging for health care organizations. Oswego Hospital needed to engage staff in a meaningful and innovative way to improve its performance. Launched in March 2010, 'The Right Care, Right Time, Every Time' focuses on…
Strong Memorial Hospital adopted barcode medication administration technology to reduce the incidence of medication administration errors. To prepare staff for a safe and seamless transition from traditional medication administration to the use of BCMA technology, the hospital implemented several…
St. Mary's Healthcare has an obligation to protect patients from harm and preventing adverse effects of care from reaching the patient is the primary focus of its patient safety efforts. The TeamSTEPPS program was implemented to aid in this effort.
This project was initiated by David Lyons, Director of Respiratory Therapy at St. Francis Hospital and implemented with the assistance of the performance improvement specialist, who identified an opportunity for improvement in hospital-wide oxygen cylinder safety and regulatory compliance processes…
This journey began when St. Francis Hospital gave fruit cocktail to a patient with a severe allergy to cherries noted in one part of her medical record, but not in any other. The patient knew not to eat this. A true sentinel event was prevented, but the root cause analysis team convened and…
For more than ten years, St. Elizabeth Medical Center has focused on length of stay and resource utilization, and while the facility is mindful of ancillary utilization, there was never a formal process to support or promote it. In 2010, the facility, under the leadership of the director of…
In 2006, Southampton Hospital's department of nursing conducted a needs assessment focusing on the quality of patient outcomes, staff recruitment and retention, and patient safety. Part of the assessment included distribution of AHRQ Hospital Safety Survey to staff. Respondents rated 'Overall…
The average length of stay for patients undergoing single elective total joint replacement surgery at Plainview Hospital was excessive at 5.50 days. Patients were inconsistently attending the total joint replacement preoperative class. Inefficiencies in team communication led to increased LOS and…
Traditionally, primary care physicians maintain chief responsibility for treating their critically ill patients. They often bring in specialists as needed. There are clear drawbacks to this approach. For example, primary care doctors often have little experience treating critically ill patients,…