Diabetic foot is a chronic serious complication of diabetes mellitus (DM). It has a worldwide prevalence of 6.3% and accounts for hospitalization in 4-10% of diabetic patients. (1) Diabetic foot imposes a great challenge on the affected individuals, affecting both...

UMass Memorial Health System Suicide Steering Committee identified three focused areas for continuous improvement for patients at risk for suicide: incomplete evidence-based suicide risk assessments, inadequate documentation of observation levels, and gaps in environmental checklist documentation. The team implemented enhancements...

We will discuss how a virtual nursing team can support an organization’s efforts to enhance patient safety and reduce risk in the face of patient surges, work stoppages, and staff turnover. Demonstrate how we used clinician engagement and measures of...

St. Louis Children’s Hospital is a member of Solutions for Patient Safety (SPS), a network of pediatric hospitals working together to eliminate serious harm. SPS identified that a safety coach program is a crucial component of the culture of safety....

UMass Memorial Medical Center (UMMMC) identified a gap in an effective system to identify, plan, and coordinate care for pediatric behavioral health patients who board in the hospital, as they have complex needs behaviorally and/or socially. These patients experience an...

Understanding the concepts of Human Factors is imperative to building safe processes for both patients and staff. The concept of the Dirty Dozen from the Federal Aviation Administration provides a solid foundation for understanding human factors and identifying ways to...

In our five-hospital system, the swarming process published in literature was adapted to address resuscitation events outside the Intensive Care Units or Emergency Departments. The swarming process includes an interdisciplinary review that starts with the patient condition 24 hours prior...

As VHA works to continuously improve its HRO assessment process, it identified opportunities to optimize the baseline version of the VHA HRO Framework, Maturity Model, and Matrix for usability across the enterprise. This improvement cycle included a literature review and...

Harm from adverse events doesn’t stop at the patient and their family. The emotional and physical impact on professionals working in quality and safety is all too real, and too often overlooked. The result: NAHQ data reveals that 63% of...