A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items.

BACKGROUND: Unintentional retention of surgical items is severe but preventable patient harm in surgical procedures. One multicenter health care organization experienced a harm event due to retained surgical items (RSIs) every eight days in 2019-2020. The research team sought to reduce the incidence of harm due to RSIs, improve near-miss reporting, and increase process reliability in operating rooms across the organization. METHODS: A total of 114 health care facilities in the organization were invited to participate in a multistate, multicenter patient safety initiative to reduce patient harm caused by RSIs. A national-level workgroup comprising various disciplines proposed an evidence-based best practice bundle with five elements: surgical stop, surgical debrief, visual counter, imaging, and reporting of deviations. The workgroup ensured that extensive education and support were accessible to all the participating sites. The researchers monitored the process reliability of bundle elements and improvement milestones of all the sites, along with rates of harm related to RSIs. RESULTS: Implementing the evidence-based RSI reduction bundle across 114 health care facilities resulted in a 14.3% reduction in the rate of harm caused by RSIs and a 59.1% increase in RSI near-miss reporting. The compliance to the RSI bundle reached an average of 70.5%, and 63.2% of the facilities are actively performing Plan-Do-Check-Act (PDCA) cycles to improve bundle compliance continually. CONCLUSION: Implementation of an RSI bundle can be done reliably, can improve near-miss reporting, and can reduce patient harm. Variation in process reliability between centers suggests the significance of overcoming cultural and organizational barriers.

Evaluation of COPD Chronic Care Management Collaborative to Reduce Emergency Department and Hospital Revisits Across U.S. Hospitals.

Background: Chronic obstructive pulmonary disease (COPD) is the third-leading cause of early readmissions. The Centers for Medicare and Medicaid instituted a financial penalty for excessive COPD readmissions galvanizing hospitals to implement effective strategies to reduce readmissions. We evaluated a 6-month COPD Chronic Care Management Collaborative to support hospitals to reduce preventable COPD-related revisits. Methods: Sites were recruited among nearly 300 Vizient, Inc., members. The Collaborative used performance improvement initiatives to assist with implementation of effective strategies. Participants submitted performance data for 2 outcome measures: emergency department (ED) and hospital revisits. Results: Forty-seven members enrolled (Part I+II: n=33; Part I: n=3; Part II: n=11) of which 23 submitted data (n=23/47). The majority (n=19/23, 83%) reduced rates of COPD-related ED and/or hospital revisits. Among all 23 sites, the change in ED visits went from 11.05% to 10.87%; among 7 sites with reductions in ED visits, the reduction was 12.7% to 9%. Among all 23 sites, there were not reductions in hospital readmissions (18.53% to 18.64%); among 7 sites with reductions, the readmission rate went from 20.1% to 15.6%. The mean reach across 17 hospitals reporting reach for their most successful measure at baseline was 35.2% (SD=26.7%) and for the other 6, reporting reach at follow-up was 73.8%% (SD=18.3%); of note, only 3 sites submitted both baseline and follow-up data. Conclusions: The Collaborative successfully supported the majority of sites in reducing COPD-related ED and/or hospital revisits using subject matter experts and coaching strategies to support hospitals' implementation of COPD quality improvement interventions.

The Relationship between High-reliability practice and Hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

Theoretically, the application of reliability principles in healthcare can improve patient safety outcomes by informing process design. As preventable harm continues to be a widespread concern in healthcare, evaluating the association between integrating high-reliability practices and patient harms will inform a patient safety strategy across the healthcare landscape. This study evaluated the association between high-reliability practices and hospital-acquired conditions. METHODS: Twenty-five pediatric organizations participating in the Children's Hospitals Solutions for patient safety collaborative participated in this nonexperimental design study. A survey utilizing the high-reliability healthcare maturity model assessed the extent of implementing high-reliability practices at each participating site. We analyzed responses for each component and a composite score of high reliability against an aggregate measure of hospital-acquired conditions. RESULTS: Of the 95 invited sites, 49 responded and 25 were included in the final results. There was a significant inverse relationship between the culture of safety component score and the Serious Harm Index (odds ratio [OR] = 0.63, 95% confidence interval [CI] 0.42-0.95, P = 0.03). There was no association between the overall high-reliability score (OR = 0.91, 95% CI 0.78-1.05, P = 0.19), the Leadership component score (OR = 0.97, 95% CI 0.70-1.33, P = 0.84), or the robust process improvement (RPI) component score (OR = 0.75, 95% CI 0.41-1.28, P = 0.26) and the Serious Harm Index. CONCLUSION: The integration of high-reliability principles within healthcare may support improved patient safety in the hospital setting. Further research is needed to articulate the breadth and magnitude of the impact of integrating high-reliability principles into healthcare.

Self-Reported Adherence to High Reliability Practices Among Participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

BACKGROUND: Application of high reliability principles has the potential to transform the health care industry to perform with a higher level of safety than is present today. The purpose of this study was to quantitatively assess and describe the extent and variability of integration of high reliability practices among a collaborative of children's hospitals using the High Reliability Health Care Maturity (HRHCM) model. METHODS: A survey instrument based on the HRHCM model was developed to determine the extent of integration of high reliability practices across hospitals participating in the Children's Hospitals' Solutions for Patient Safety (CHSPS) network. The survey was distributed with instructions for completion to obtain a single organizational response, which was then used to quantify the extent to which high reliability attributes were implemented at each organization. RESULTS: Of the 95 institutions in the CHSPS at the time of the study, 46 provided a complete response to the survey (48.4% response rate). The overall mean score for high reliability was 42.3 (range: 28-53), which places the cohort in the stage of approaching high reliability. Of the responding organizations, none fell into the beginning stage, while 15.2% landed in the developing, 4.3% in the advancing, and 80.4% in the approaching high reliability stages. CONCLUSION: Understanding high reliability attributes and assessing the location of individual and collaborative-wide sites along the high reliability continuum using this maturity model identify opportunities for organizations as they progress on their high reliability journey. Our results suggest opportunity in all domains of the high reliability maturity model for the majority of participating children's hospitals.

Association of Temporal Variations in Staffing With Hospital-Acquired Pressure Injury in Military Hospitals.

To more precisely evaluate the effects of nurse staffing on hospital-acquired pressure injury (HAPI) development, data on nursing care hours per patient day (NCHPPD), nursing skill mix, patient turnover (i.e., admissions, transfers, and discharges), and patient acuity were merged with patient information from pressure injury prevalence surveys that were collected annually for the Military Nursing Outcomes Database (MilNOD) project. The MilNOD included staffing and adverse events from 56 medical-surgical, stepdown, and critical care units in 13 military hospitals over a 4-year-period. Data on 1,643 patients were analyzed with Cox proportional hazards models and generalized estimating equations. Staffing was not associated with pressure injuries in stepdown or critical care patients. However, among the 1,104 medical-surgical patients, higher licensed practical nurse (LPN) nursing care hours per patient day (NCHPPD) 3 days and 1 week prior to the HAPI discovery date were associated with fewer HAPI (HR 0.27, p < .001), after controlling for patient age, Braden mobility score, and albumin level. Neither total staff number, nor RN NCHPPD, nor the proportion of staff who were RNs (RN skill mix) were associated with HAPI. These findings suggest that on military medical-surgical units, LPNs play a major role in HAPI prevention. Although the national trend in acute care is to staff hospital units with more RNs and patient care technicians, and fewer LPNs, hospitals should reconsider LPNs as valuable members of the nursing care team. © 2016 Wiley Periodicals, Inc.

Decreasing handoff-related care failures in children's hospitals.

BACKGROUND AND OBJECTIVE: Patient handoffs in health care require transfer of information, responsibility, and authority between providers. Suboptimal patient handoffs pose a serious safety risk. Studies demonstrating the impact of improved patient handoffs on care failures are lacking. The primary objective of this study was to evaluate the effect of a multihospital collaborative designed to decrease handoff-related care failures. METHODS: Twenty-three children's hospitals participated in a quality improvement collaborative aimed at reducing handoff-related care failures. The improvement was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Handoff-related care failures were compared between baseline and 3 intervention periods. Secondary outcomes measured compliance to specific change package elements and balancing measure of staff satisfaction. RESULTS: Twenty-three children's hospitals evaluated 7864 handoffs over the 12-month study period. Handoff-related care failures decreased from baseline (25.8%) to the final intervention period (7.9%) (P < .05). Significant improvement was observed in every handoff type studied. Compliance to change package elements improved (achieving a common understanding about the patient from 86% to 96% [P < .05]; clear transition of responsibility from 92% to 96% [P < .05]; and minimized interruptions and distractions from 84% to 90% [P < .05]) as did overall satisfaction with the handoff (from 55% to 70% [P < .05]). CONCLUSIONS: Implementation of a standardized evidence-based handoff process across 23 children's hospitals resulted in a significant decrease in handoff-related care failures, observed over all handoff types. Compliance to critical components of the handoff process improved, as did provider satisfaction.

A multicenter collaborative approach to reducing pediatric codes outside the ICU.

OBJECTIVES: The Child Health Corporation of America formed a multicenter collaborative to decrease the rate of pediatric codes outside the ICU by 50%, double the days between these events, and improve the patient safety culture scores by 5 percentage points. METHODS: A multidisciplinary pediatric advisory panel developed a comprehensive change package of process improvement strategies and measures for tracking progress. Learning sessions, conference calls, and data submission facilitated collaborative group learning and implementation. Twenty Child Health Corporation of America hospitals participated in this 12-month improvement project. Each hospital identified at least 1 noncritical care target unit in which to implement selected elements of the change package. Strategies to improve prevention, detection, and correction of the deteriorating patient ranged from relatively simple, foundational changes to more complex, advanced changes. Each hospital selected a broad range of change package elements for implementation using rapid-cycle methodologies. The primary outcome measure was reduction in codes per 1000 patient days. Secondary outcomes were days between codes and change in patient safety culture scores. RESULTS: Code rate for the collaborative did not decrease significantly (3% decrease). Twelve hospitals reported additional data after the collaborative and saw significant improvement in code rates (24% decrease). Patient safety culture scores improved by 4.5% to 8.5%. CONCLUSIONS: A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.

GENIS: gene expression of sodium iodide symporter for noninvasive imaging of gene therapy vectors and quantification of gene expression in vivo.

With the goal of optimizing adenovirus-mediated suicide gene therapy for prostate cancer, we have developed a method based on the human sodium iodide symporter (hNIS) that allows for noninvasive monitoring of adenoviral vectors and quantification of gene expression magnitude and volume within the prostate. A replication-competent adenovirus (Ad5-yCD/mutTK(SR39)rep-hNIS) coexpressing a therapeutic yeast cytosine deaminase (yCD)/mutant herpes simplex virus thymidine kinase (mutTK(SR39)) fusion gene and the hNIS gene was developed. Ad5-yCD/mutTK(SR39)rep-hNIS and a replication-defective hNIS adenovirus (rAd-CMV-FLhNIS) were injected into contralateral lobes of the dog prostate and hNIS activity was monitored in live animals following administration of Na(99m)TcO(4) using gamma camera scintigraphy. Despite the close proximity of the urinary bladder, (99m)TcO(4)(-) uptake was readily detected in the prostate using viral dose levels (10(10) to 10(12) viral particles) that have been safely administered to humans. Due to its rapid clearance and short physical half-life (6 h), it was possible to obtain daily measurements of (99m)TcO(4)(-) uptake in vivo, allowing for dynamic monitoring of reporter gene expression within the prostate as well as biodistribution throughout the body. High-resolution autoradiography of prostate sections coupled with 3D reconstruction of gene expression demonstrated that the magnitude and volume of gene expression could be quantified with submillimeter resolution. Implementation of the GENIS (gene expression of Na/I symporter) technology in the clinic will facilitate optimization of future human gene therapy trials.