During this pilot, the MICU was able to achieve 188 days between events which was above the three sigmas upper control limit of 111.2 days. The MICU was also able to reduce its average CLABSI rate per 1,000 central line...

We had 32 harm events in 2021 and we were able to reduce the overall number of harms to 24 in 2022 (which was our regional goal). The Quality Director, with the assistance of a physician dyad Quality Medical Director...

Standardized SDOH screenings increased awareness of unmet needs and supported partnerships between the medical and social work teams. Rapid PDSA cycles and frequent data collection were critical to improving the percentage of patients with a completed screen. Key to sustainability...

The monthly number of safety reports increased. An onboarding process was implemented. The scope of practice was integrated into policies. Foundational work integrated business and clinical operations. Business operational leaders are now contacting clinical operations for an assessment of the...

The fall with-injury rate decreased to 0.31/1,000 patient days or an 80% reduction, a 60% increase in reported near misses or assisted falls, and a new 93-day record without an injurious fall. Patients are safer today because of the collaborative...

The low volume of patients with PACs in the ICU is a challenge for clinicians to gain or maintain competencies, placing patients at risk for PACs related injury or sentinel events. Online learning, simulation, and checklists are tools for clinicians...

Missing patient safety events decreased from 12 to 9 (CY21-22) with the acute care and rehabilitation unit having no missing patients proving actions implemented were effective. High-risk areas (ED, Mental Health) are still in progress. Missing Patient Tabletop drills in...

First in VHA SUD care team, a teratogenic time-out for the safe prescribing process, partnering with experts to create successful pathway for pregnant to ensure mental health needs are met, and more. Continue to develop new ways to participate in...

Since implementation, the percent of babies actively cooled on transport and arriving to the NICU with a temperature <33°C has decreased from 21.15% in 2021 to 11.32% in 2022. The standardization of rectal temperature monitoring and documentation was essential to...