Hospital Safety Superstars

Mayo Clinic Hospital, Phoenix

• Rapid-response nurse program with a nurse on call 24/7 who does rounds in every unit to talk to team leads and check on sickest patients.
• Installed "Yes Board," a computer program that combines vital signs and other care aspects on a single display to show how a patient is doing.
• Safety training includes "simulation education" with role-playing to demonstrate communication obstacles that could arise.

California Pacific Medical Center, San Francisco

Not available at this time.

Mills-Peninsula Health Services, Burlingame

• Has large private rooms with space for families to stay 24/7.
• Patient lifts in all rooms help immobilized patients get in and out of bed.
• A hand-washing station is in every room with notes reminding caregivers to wash their hands.

Stanford Hospital and Clinics, Stanford

• Hand hygiene has become an integral part of the hospital's culture. Hand gel stations are located all over the hospital for staff and visitors.
• Usage rate is above 90 percent.

Sutter Tracy Community Hospital, Tracy

• Sepsis program outlines interventions that can be done within the first 6 hours of identifying the problem.
• Interventions include: screening patients on admission, drawing blood when applicable,
  treating with antibiotic therapy.

University of California Davis Medical Center, Sacramento

• Use surgical checklists to guarantee effectiveness between operating team and patients.
• Constant assessments of at risk patients as well as follow-up phone calls to review discharge instructions and plans for follow-up care.
• Have a “wipe-down protocol” at the end of every nursing shift, which is designed to eliminate infection.
• Have an “early mobility” program, which helps patients become more active to help avoid infection, cognitive impairment and increased complications.
  

Sibley Memorial Hospital, Washington, DC

• Patients having joint surgery are given a solution to cleanse with before the operation in an attempt to reduce infections. Also screen for MRSA and give patients antibiotics at the time of surgery.
• Bed alarms alert nurses when patients who are at risk for falls are getting out of bed.
• Staff members participate in a patient safety survey every 18 months.
• Adverse events committee does a root-cause analysis of safety issues.
• 85 percent compliance in hand hygiene since placing hand gel stations outside of each room.

Cleveland Clinic Florida, Weston

• All staff get safety update training every 6 months.
• A nurse assesses patients each day to determine fall risk. Those patients that are at risk are given special yellow slippers to wear, so they can be identified.
• Nurses assess for pressure ulcers and bedsores daily. Those patients at a higher risk are transferred to beds with alternating air pressure mattresses to prevent skin problems.
• The electronic medical record (EMR) has built-in stops that prompt doctors to assess for the patient’s risk of blood clots.
• Must justify the presence of a catheter after 48 hours.

Homestead Hospital, Homestead

• E-ICU program, with cameras in every ICU patient room, links to off-site doctors who monitor patients all day.
• "Falling star" program denotes doors of patients at risk of falling with a blue star. Family or caregivers sit with these patients at all times. Hourly rounds occur for these patients.

JFK Medical Center of Atlantis, Atlantis

Not available at this time.

West Palm Hospital, West Palm Beach

Not available at this time

The Queen's Medical Center, Honolulu

• Have daily huddle with entire management team to alert staff of safety events that have happened or are anticipated.
• Executives go on rounds regularly to talk to patients and staff about safety concerns or issues.
• Staff use self- and peer-checking in their daily work.
• Use double verification when giving high-risk medications.
• 24-hour physician coverage in intensive care unit (ICU).

NorthShore University Health System — Skokie Hospital, Skokie

• Surgical care is standardized to ensure best practices.
• Nurses provide extra monitoring to patients at high risk of falling.

Northwestern Memorial Hospital, Chicago

• Staff meets each week to review safety events of the week.
• Smart pumps reduce IV medication errors.
• Has seen an 80 percent drop in preventable harm over the past 10 years.
• New master's program on patient safety and quality is one of the first in the country.

OSF St. Joseph Medical Center, Bloomington

• CPOE system provided to eliminate transcription errors, with built-in allergy checks when medicines are prescribed.
• At patient discharge, a physician, nurse and pharmacist are on hand to ensure the patient leaves safely.
• Signs posted around the hospital tell patients and staff how many days it's been since a patient fell.

Rush University Medical Center, Chicago

• Each department has a patient safety office with dedicated safety personnel.
• "Time-out" taken before each surgery to double-check site, patient and other critical details.
• Post-surgery checklist is used to account for instruments, sponges.

Indiana University Health La Porte Hospital, La Porte

Not available at this time.

St. Vincent's Indianapolis Hospital, Indianapolis

• Hospital is part of statewide coalition that meets to discuss eliminating unsafe conditions.
• Staff color-codes patient armbands so care is standardized by condition (orthopedic, postsurgical, etc.).

Grinnell Regional Medical Center, Grinnell

• To increase transparency, caregivers change shifts in the patient’s room so the patient hears condition reports and can become comfortable with new nurses and doctors.
• To eliminate mistakes, nurses repeat back physicians' orders and also tell patients the type of blood they are hanging.

Central Maine Medical Center, Lewiston

• Bar codes on medications and patient wristbands ensure patients are getting the right medication.
• Checklist for ventilator-associated pneumonia was so effective in reducing errors that for 2012 there was only one such case.

Baystate Medical Center, Springfield

• Teamwork training is provided for all units of hospital.
• Initiated plan to get to zero hospital-acquired infections in 2 years.
• Medications are bar-coded.
• Uses simulation training for insertion of central lines. Only doctors who have completed the training and used a checklist for it can insert central lines.

Beth Israel Deaconess Medical Center, Boston

• To prevent infection, patients on ventilators have teeth brushed regularly.
• Low-rise beds and socks with safety treads on both sides help prevent falls.

Brigham and Women's Hospital, Boston

• Patients are assessed at check-in for risk of blood clots, so staff can be on the lookout.
• Smart pumps reduce IV medication errors.

Lahey Clinic, Burlington

• For fall prevention, nurses do hourly rounds and patients are assessed based upon how seriously they would be hurt if they fell.
• Discreet observers judge implementation of hand hygiene.

Tufts Medical Center, Boston

• Detailed checklists help staff focus on specific issues for each patient.
• Have time outs; go over intensive checklists to guarantee all precautions are taken before surgery or injection.
• Thrive from multidisciplinary teamwork; bring in professionals from all backgrounds so each patient can be assessed from a 360-degree perspective.
• Continuous evaluation to decrease rate of secondary infection and exposure risks.

Detroit Receiving Hospital/University Health Center, Detroit

• ICU teams gather regularly to discuss issues and data.
• Checklist is used for patients on central lines and catheters to make sure they are maintained correctly and removed swiftly.
• Monthly administrator meetings include discussions of good safety catches and how to improve the system.

Harper-Hutzel Hospital, Detroit

Not available at this time.

Spectrum Health Blodgett Hospital, Grand Rapids

• Conducts daily check-in with every hospital employee in which safety events and problems are assessed.
• Offers intranet site where staff can discuss safety issues.
• Twenty trained technicians on staff are used solely for taking detailed medication histories from patients.
• Medications are bar-coded.

University of Michigan Hospitals and Health Centers, Ann Arbor

• Open disclosure policy means patients are alerted right away when mistakes happen.
• Members of hospital leadership take regular "patient safety rounds" to bring them up to speed on safety concerns.
• Devices and testing supplies ensure rooms are cleaned thoroughly.
• Risk assessments are performed on patients who might be prone to falling; hourly checks occur once these patients are admitted.

Fairview Southdale Hospital, Edina

• Majority of staff have a certification in a specialty area.
• Works on cutting ventilator-associated pneumonia by using antibacterial ointment and giving patients "sedation
  holidays," where they are woken up for a period of time.
• A pharmacist takes medication histories and goes over medication regime with patients at discharge.

Regions Hospital, St. Paul

• Use of a "time-out towel" — a sterile towel placed over the instrument stand in the operating room — acts as a physical barrier and reminder to follow standardized procedures.
• Two ID wristbands are printed for patients, one for the wrist and the other for the chart, forcing a double-check of patient information when administering medication or performing other care.

St. Marys Hospital of Rochester, Rochester

• In-depth mortality reviews, evaluating for potential management and patient safety problems.
• Voluntary reporting system; about 12,000 incidents are reported each year.
• All facilities in Mayo organization are on one computer system for easier analysis.
• Focus on team engagement for problem solving.
• Developed a formal way of handing off information to other personnel at shift change.
• All medicines are bar-coded.

Billings Clinic, Billings

• Encourage the use patient stories to advance our culture of transparency.
• Employ medication reconciliation pharmacists to advance appropriate medication reconciliation with a focus on discharge transitions of care.
  
• Prevent wrong site surgeries by implementing the WHO safe surgical checklist. This has resulted in no wrong site surgeries for 3 years.
• All medications are bar-coded.
• Use a common electronic medical record that is used and integrated among multiple providers and sites across rural communities in Montana and Northern Wyoming to provide continuity of care.

Englewood Hospital and Medical Center, Englewood

• Top-level executives set safety goals for staff.
• Ninety percent adoption of CPOE system with staff members on hand 24/7 to explicitly make sure system is working.
• At-risk patients are issued "fall kits" — a yellow wristband, lap blanket and no-skid socks.

Hackensack University Medical Center, Hackensack

• Hospital-wide safety survey conducted regularly to see where hospital stands on reporting errors.
• Comprehensive Unit-Based Safety Programs (CUSP) have staff members identify safety risks and work together to develop an action plan.

Valley Hospital, Ridgewood

• Created a "just culture" environment in which all employees feel comfortable discussing safety issues.
• Focus on patient- and family-centered care. Has an advisory committee that includes former patients.

Bellevue Hospital Center, New York

Not available at this time.

Montefiore Medical Center, Bronx

• CPOE system forces physicians to reenter certain data to prevent "wrong-patient" errors.
• Surgeons wave a wand over a patient's body to detect any remaining sponges or other instruments.

Northern Westchester Hospital, Mount Kisco

• Staff surveyed on safety issues, with results used to analyze culture and identify key areas that need improvement.
• Computerized reporting system so staff can report concerns anonymously.
• As part of catheter checklist, doctors must enter into electronic record why they are keeping it in each day.

Vassar Brothers Medical Center, Poughkeepsie

• Code Sepsis in the ER supports early identification of the disease and provision for standardized treatment. Since
  implementation, survival rate among patients diagnosed with sepsis has risen 62 percent.
• Immediate reports and debriefings after any patient falls to determine why the fall happened.
• Patient falls resulting in severe injury have decreased 86 percent. (There was only one in 2012.)

Wake Forest Baptist Medical Center, Winston-Salem

• Leadership rounds allow staff to report safety concerns and provide feedback to those who have reported concerns.
• Converted the voluntary reporting system to a computerized database to manage and investigate issues and analyze
  trends.
• Surgical services standardize communication under a crew management model.
• Code Sepsis teams review bioscores generated from vital signs to recognize and respond to sepsis earlier.
• Check-in occurs each day to make sure patients with catheters still need them.

The Christ Hospital, Cincinnati

• All administration meetings begin with stories about safety "catches."
• Patients in the hospital's three ICUs are monitored 24/7 with a computer system that allows staff to see trends developing in patients' vital signs.

Dublin Methodist Hospital, Dublin

• Staff and patients use separate hallways, to keep patient halls quiet and reduce risk of falls.
• Rails are installed around entire patient room.
• Double-wide bathroom doors in each patient room offer extra space.
• No overhead paging of doctors, which keeps halls quiet so alerts can be heard more clearly.
• Staff is required to report errors by themselves or others.
• Weekly review and analysis of all safety issues, which are then classified from nonevent to serious event.

University Hospitals Case Medical Center, Cleveland

• Electronic reporting system called Patient Advocacy and Shared Stories (PASS) helps to report, prioritize and act on incidents.
• All reports are reviewed by a committee to improve safety.

Allegheny General Hospital, Pittsburgh

• Has collaborative teams across entire health system that work together on safety issues in each unit.
• Serious Event Review Panel (SERP), consisting of hospital patient safety officers and clinical leadership, hosts weekly
  conference call during which safety events are discussed.
• Units are rated based on infection levels; five-star units advise those not doing as well.

Geisinger Medical Center, Danville

• More reporting of good catches and near misses to increase proactive performance improvement.
• Added hand-washing stations outside every room.
• Teamwork training provided around hospital-acquired infections. Checklists are used, and cultural changes were
  implemented so everyone on the team feels comfortable enough to speak up when a task is not completed correctly.
• Nurses make hourly patient rounds.

Lehigh Valley Hospital, Allentown

• Intensivists on staff care for sickest patients.
• CPOE system and bar-coding have reduced medication errors from two in 100,000 to two in 1 million.

St. Francis Hospital Downtown, Greenville

Not available at this time.

Skyline Medical Center, Nashville

Not available at this time.

Takoma Regional Hospital, Greeneville

Not available at this time.

Vanderbilt University Hospital, Nashville

• Offers clinical programs in which caregivers and board members can spend a year working with world-renowned experts on safety.
• Hand-hygiene campaign empowers colleagues to nudge one another on proper hand washing. Compliance has gone from 58 percent to 91 percent.

The Methodist Hospital, Houston

• Sepsis screening is embedded into electronic medical records.
• Because of data gathered in the records, staff members can see deterioration in a patient 5 to 6 hours earlier.

St. David's Medical Center, Austin and Georgetown

• Conducts fall-risk assessment for all patients upon admission.
• Each patient's status and safety risks are reviewed in quality nursing rounds.
• Scans 99.5 percent of patients for medication risks.
• Medications are bar-coded.

Texas Health Harris Methodist Hospital Azle, Azle

• Uses a critical communication model that involves teamwork and huddles with leadership.
• Has an observation program in which trained staff members watch providers for safety practices like hand hygiene, patient identification and time-outs before invasive procedures.
• All information and data on safety efforts, success stories and improvement opportunities are shared with staff.

USMD Hospital at Arlington, Arlington

Not available at this time.

Inova Fair Oaks Hospital, Fairfax

• Has an intensive team of safety coaches who monitor other staff members to make sure patient safety is being heavily enforced. Coaches meet twice a month to discuss ways to improve.
• Computerized physician order entry (CPOE) system electronically submits doctor’s prescription order to avoid mix-up or confusion once it reaches the pharmacy.
• In the electronic Intensive Care Unit (eICU), doctors watch patients overnight and can see chart notes, monitor prescriptions, and watch patients through a high-definition (HD) camera.
• Special protocol for patients who are extremely contagious isolate them until they receive two negative cultures permitting them to be around others again.
• Cut down visitation during flu season to reduce exposure to people coming into hospital.

Inova Loudoun Hospital, Leesburg

Not available at this time.

Sentara CarePlex Hospital, Hampton

• All employees safety trained
• Nurses do special rounds to assess skin of patients at high risk
  of developing pressure ulcers.
• Patients screened for sepsis within 4 hours of arriving to
  see if they are at risk. If they are, they receive additional care.
• Nurses monitor real-time vital signs of patients outside patient room.

Sentara Leigh Hospital, Norfolk

• All employees safety trained
• Nurses do special rounds to assess skin of patients at high risk
  of developing pressure ulcers.
• Patients screened for sepsis within 4 hours of arriving to
  see if they are at risk. If they are, they receive additional care.
• Nurses monitor real-time vital signs of patients outside patient room.

Sentara Williamsburg Regional Medical Center, Williamsburg

• All employees safety trained
• Nurses do special rounds to assess skin of patients at high risk
  of developing pressure ulcers.
• Patients screened for sepsis within 4 hours of arriving to
  see if they are at risk. If they are, they receive additional care.
• Nurses monitor real-time vital signs of patients outside patient room.

MultiCare Good Samaritan Hospital, Puyallup

• Has worked to improve nurse practices to decrease the rate of infection (particularly sepsis).
• Has simulators that nurses practice on with organized instruction from a teacher or overseer.
• Ranked in top 2 percent for electronic medical records usage. Allows all staff to be constantly aware of what's occurring within the hospital. Also boosts communication and teamwork.

Swedish Medical Center First Hill Campus, Seattle

• Each staff member must complete 3 hours of safety education.
• Staff huddles daily to air concerns about safety and improve communication between departments.
• Medical errors and falls have decreased by one-half.

Virginia Mason Medical Center, Seattle

• Special levers under mattresses alert nurses when a patient at risk of falling is trying to get out of bed.
• Parallel corridors on the orthopedic ward mean patients can walk without fear of jockeying for space.

Wyoming Medical Center, Casper

• Created Red-Zone, which prohibits staff from interrupting nurses in the process of giving medication. (This maximizes patient safety and reduces medication mix-ups.)
• Has Medication Occurrence Team that reviews and monitors all medications and which patients they're going to.