2015 Patient Safety Core Topics and tips

ASHRM continues provide important patient safety tips and information aligned with the American Hospital Association (AHA)/Health Research & Education Trust (HRET) Hospital Engagement Network (HEN). The goal of the HEN is to assist hospitals in adopting practices to reduce inpatient harm by 40 percent and readmissions by 20 percent. ASHRM and the AHA/HRET HEN will continue to be  resources to help improve patient safety in these areas:

  1. Adverse Drug Events
  2. Catheter-Associated Urinary Tract Infections (CAUTI)
  3. Central Line Associated Blood Stream Infections (CLABSI)
  4. Injuries from Falls and Immobility
  5. Obstetrical Adverse Events
  6. Pressure Ulcers
  7. Preventable Readmissions
  8. Surgical Site Infections
  9. Venous Thromboembolisms
  10. Ventilator Associated Event/Ventilator Associated Pneumonia


1. Adverse Drug Events

Did You Know?
More than 35 years ago, the Institute for Safe Medication Practices (ISMP) started the cornerstone of its medication error prevention efforts—a voluntary practitioner error-reporting program to learn about errors happening across the nation, understand their causes, and share “lessons learned” with the healthcare community. Today, ISMP has two reporting programs—the National Medication Errors Reporting Program (ISMP MERP) and the National Vaccine Errors Reporting Program (ISMP VERP). ISMP guarantees confidentiality of information received and is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for submitted patient safety data and error reports.

Adverse events in hospitalized patients are most commonly associated with frequent interventions such as the prescription and administration of medications. At least 20 percent of all harm to hospitalized patients is associated with medication errors.

High-alert medications (HAMs) are more likely to be associated with harm than other medications—they cause harm more frequently, the harm they produce is likely to be more serious, and they “have the highest risk of causing injury even when used correctly.”

Insulin, anticoagulants, narcotics, and sedatives are responsible for the majority of harm due to high-alert medications.

The Hospital Engagement Network (HEN), part of the Health Research and Educational Trust of the American Hospital Association partnered with the U.S. Department of Health and Human Services in the Partnership for Patients Initiative. Along with Cynosure Health, they created the Adverse Drug Event Change Package with the goal of reducing the incidence of harm due to high-alert medications (specifically anticoagulation, opioids, and glycemic control) by 40 percent by December 31, 2014.

According to the organizations, the following changes should be considered to assist in reducing the incidence of harm due to high-alert medications:

Awareness, Readiness, and Education

  • Assess organizational capacity, readiness, and willingness to implement systems to prevent adverse drug events (ADEs)
  • Create awareness of high alert medications most likely to cause ADEs at the institution.

Standardized Care Processes

  • Implement Institute for Safe Medication Practices (ISMP) quarterly action agendas where appropriate
  • Develop standard order sets using safety principles using physician and pharmacist input.
  • Allow nurses to administer rescue drugs based on protocol
  • Minimize interruptions during the process of medication distribution and administration
  • Standardize concentrations and minimize or eliminate multiple drug formulations and concentrations wherever possible
  • Allow pharmacists to change anticoagulant doses per protocol based on timely review of laboratory test results
  • Include a pharmacist in direct clinical activities (ICU rounds, ambulatory medication decision making, etc.)

Decision Support

  • Include pharmacists on rounds
  • Monitor overlapping multiple medications prescribed for a patient

Prevent Failure

  • Minimize or eliminate nurse distraction during the medication administration process
  • Standardize formulation concentrations and minimize dosing choices where feasible
  • Review lab results in a timely manner with effective systems to ensure necessary action
  • Use non-pharmacological methods of pain and anxiety management where appropriate

Culture of Safety

  • Reduce staff intimidation and encourage reporting of errors and near-misses

Identification and Mitigation of Failure

  • Analyze dispensing unit override patterns
  • Prompt real-time learning from each failure

Smart Use of Technology

  • Use “smart pumps” with up-to-date libraries or double-checks for all IV infusions of high alert medications
  • Understand potential unintended consequences and errors that can occur with Patient Controlled Analgesic devices
  • Use alerts wisely
  • Use data/information from alerts and overrides to redesign standardized orders and protocols
  • Link order sets to recent lab test values and levels

Involve the Patient and Family

  • Allow patient management of insulin where safe and appropriate
  • Provide patient education in a language and at a literacy level all can understand

Medication Reconciliation to Prevent Adverse Drug Events
The Institute for Healthcare Improvement says that preventing ADEs remains a top patient safety priority not only in hospitals, but also across the continuum of care for patients.

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking—including drug name, dosage, frequency, and route—and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital.

Many organizations have demonstrated that implementing medication reconciliation at all transitions in care—at admission, transfer, and discharge—is an effective strategy for preventing ADEs.

MATCH Medication Reconciliation Toolkit
Northwestern Memorial Hospital in Chicago, Illinois, developed a comprehensive, multidisciplinary team effort to prospectively evaluate the extent of adverse events and develop interventions to improve patient safety and quality of care.

Through a grant from the Agency for Healthcare Research and Quality (AHRQ) and in collaboration with Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine and The Joint Commission, a medication reconciliation initiative—the Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation—was developed. The goal of the MATCH initiative was to measurably decrease the number of discrepant medication orders and the associated potential and actual patient harm.

Some organizations may need to address medication reconciliation across their entire facility while others only need to focus on a specific element (i.e., auditing) or practice setting (i.e. ambulatory surgery unit). Although this toolkit is based on processes developed in acute-care settings, the core processes, tools, and resources can be adapted for use in non-acute facilities.

Targeted Medication Safety Practices
According to the Institute for Safe Medication Practices (ISMP), certain medication errors that cause harm or are fatal to patients continue to recur despite repeated warnings. ISMP has launched the 2014-15 Targeted Medication Safety Practices for Hospitals to identify, inspire, and mobilize widespread national action to address these recurring problems.

The 2014-15 best practices target a group of six key safety issues and provide realistic, high-leverage strategies for error prevention; they have been reviewed by an external expert advisory panel and approved by ISMP’s Board of Trustees. Each best practice is followed by a list of related articles published in the ISMP Medication Safety Alert! newsletter for further reference.

Additional Resources
ASHRM’s Risk Management Pearls for Medication Safety: Part I and Part II
Medication safety challenges are a priority for consumers, providers, regulatory/accreditation agencies, and healthcare leaders. Although medications are intended to benefit patients, the medication-use system is a potentially high-risk and error-prone component of the healthcare delivery system in both inpatient and outpatient delivery systems. Opportunities for harm may occur at any stage of the medication-use process, from selecting, procuring and prescribing, to storing, preparing, dispensing, administering, and monitoring. ASHRM’s Risk Management Pearls for Medication Safety: Part I and Part II summarize medication error prevention strategies and practices that are effective in reducing and eliminating patient harm.

The IHI 5 Million Lives Campaign
Source: Institute for Healthcare Improvement

Medication Safety Tools and Resources
Source: Institute for Safe Medication Practices

Sentinel Event Alert, Issue 11: High-Alert Medications and Patient Safety
Source: The Joint Commission


2. Catheter-Associated Urinary Tract Infections (CAUTI)

Did You Know?
Here’s what you can do to help prevent catheter-associated urinary tract infections:

  • Always clean your hands before and after doing catheter care.
  • Always keep the urine bag below the level of the patient’s bladder.
  • Do not tug or pull on the tubing.
  • Do not twist or kink the catheter tubing.
  • Daily, evaluate if a catheter is still needed.

The Agency for Healthcare Research and Quality (AHRQ) reports catheter-associated urinary tract infections (CAUTI) are the most common type of healthcare-associated infection. As many as one-fourth of all hospital inpatients may have a short-term, indwelling urinary catheter placed during their hospital stay, with the majority of them placed in the Emergency Department (ED). Complications associated with CAUTI result in increased length of stay, patient discomfort, excess healthcare costs, and sometimes mortality. An estimated 13,000 deaths are associated with CAUTI each year. However, most cases of CAUTI are preventable.

On the CUSP: Stop CAUTI is an initiative to reduce mean rates of CAUTI in U.S. hospitals. The initiative is working with state organizations and associations, hospitals, other Hospital Engagement Networks (HENs), national groups, and quality improvement organizations (QIOs) across the country to implement the Comprehensive Unit-based Safety Program (CUSP) and CAUTI reduction practices in hospitals, with interventions tailored for both inpatient units and emergency departments.

On the CUSP: Stop CAUTI initiative is funded by the Agency for Healthcare Research and Quality (AHRQ) and is led by the Health Research and Educational Trust (HRET) of the American Hospital Association, which leads a national project team.

An implementation guide—On the CUSP: Stop CAUTI Implementation Guide—published by On the CUSP: Stop CAUTI gives recommendations to achieve CAUTI reduction and improve unit safety culture. According to the guide, to sustain these improvements, a strategy to address both technical and adaptive problems is necessary. A technical problem is a problem that is readily identified with known solutions. CAUTI and its prevention interventions are the technical component. An adaptive problem is less easily identified, and the solutions are not always apparent. A focus on adaptive components addresses the unit team’s values, attitudes, and beliefs, qualities often collectively referred to as culture. Addressing either technical or adaptive challenges—but not both—may not result in the success you are trying to achieve. The first On the Cusp: Stop CAUTI initiative interim report, Eliminating CAUTI: A National Patient Safety Imperative, shows a 16.1 percent relative reduction in CAUTI through implementation of the initiative’s strategy.

To meet the goals of this national and local initiative, all of the following pieces of the On the CUSP: Stop CAUTI project need to be implemented:

  • Adaptive and Technical Interventions
  • Education and Coaching Support
  • Measures of Success
  • Project Infrastructure

The combination of these activities and the project infrastructure makes the implementation and spread of this work possible across states, hospitals, and units. Each activity is introduced and detailed in the guide.

Additional Resources
Guidelines for Prevention of Catheter-associated Urinary Tract Infections 
Source: Centers for Disease Control and Prevention

Catheter Associated Urinary Tract Infections (CAUTI): Fact Sheet

Source: Wound, Ostomy and Continence Nurses Society (WOCN)

How-to Guide: Prevent Catheter-Associated Urinary Tract Infections

Source: Institute for Healthcare Improvement

Getting Past the Policy: Overcoming Barriers to CAUTI Prevention Practices

Source: Pennsylvania Patient Safety Authority


3. Central Line Associated Blood Stream Infections (CLABSI)

Did You Know?
The following are recommendations for healthcare providers to help prevent and eliminate CLABSI. They include:

  • Appropriate use of hand hygiene
  • Chlorhexidine skin preparation
  • Full-barrier precautions during central venous catheter insertion
  • Avoiding the femoral site when possible
  • Maintaining a sterile field while inserting the line

Improving compliance with these evidence-based practices will result in dramatic reductions in CLABSI rates on your unit. Additionally, partnering with the hospital epidemiologist or an infection control practitioner can help your CUSP team:

  • Ensure you are using National Healthcare Safety Network definitions for CLABSI
  • Educate staff members about how to reduce CLABSI
  • Ensure you have chlorhexidine in your central line kits
  • Post publicly the number of people infected per month and your quarterly infection rates

CLABSIs occur when bacteria or viruses enter the bloodstream though a central line, causing infection.
Until recently, central line associated bloodstream infections (CLABSI) were seen as an inevitable cost of doing business. Now, the success of the On the CUSP: Stop BSI project has proven that these deadly infections can be eliminated.

Through support from the Agency for Healthcare Research and Quality (AHRQ), the Health Research and Educational Trust (HRET) led On the CUSP: Stop BSI in partnership with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and the Keystone Center for Patient Safety and Quality of the Michigan Health & Hospital Association.

Through this initiative, hospital units participating in On the CUSP: Stop BSI:

  • Reported a 41 percent relative reduction in CLABSI rates
  • Prevented between 290 to 605 patient deaths, assuming a 12-25 percent CLABSI mortality rate
  • Averted an estimated $36-$40 million in excess health care costs

On the CUSP: Stop BSI provided educational and technical support to states and their hospitals for implementation of the Comprehensive Unit-based Safety Program (CUSP) and an evidence-based protocol to eliminate CLABSI.

As part of the On the CUSP: Stop BSI project, HRET developed the CUSP Toolkit, a modular resource that guides clinicians in implementing the CUSP culture change model. The CUSP Toolkit allows care teams to improve patient safety by addressing the ways in which physicians, nurses, and other clinical team members work together. CUSP builds capacity to address safety issues by combining clinical best practices and the science of safety. Each of the nine toolkit modules includes slide presentations, videos, facilitator notes, and CUSP tools that support change at the unit level.

A final report—Eliminating CLABSI, A National Patient Safety Imperative—about the national On the CUSP: Stop BSI project is available on the AHRQ website. Click here to view the Executive Summary.

Central Line Infection
Central line-associated bloodstream infection (CLABSI) continues to be one of the most deadly and costly hospital-associated infections in the U.S. Many lives have been saved in the past decade due to improvements that resulted in a 58 percent reduction of CLABSI in intensive care patients from 2001 to 2009. However, these infections continue to occur with more occurring in other areas of the hospital outside the ICU.

Strategies to prevent these infections include the IHI Central Line Bundle, implemented by many hospitals in the U.S. and UK and resulting in dozens achieving more than one year of no CLABSI in their ICU patients. Additional strategies have been identified by clinical experts at SHEA and CDC, adding to the growing evidence base as we strive to eliminate all of these deadly infections.

Additional Resources
CLABSI Toolkit – Preventing Central-Line Associated Bloodstream Infections: Useful Tools, An International Perspective
Source: The Joint Commission and Joint Commission International

Tools for Reducing Central Line-Associated Blood Stream Infections
Source: AHRQ.gov

Infection Prevention Plus Measures Toolkit

Source: Kaiser Permanente

Seven Years of Zero Central-Line-Associated Bloodstream Infections

Source: Hospitals in Pursuit of Excellence

Guidelines for the Prevention of Intravascular Catheter-Related Infections

Source: Centers for Disease Control and Prevention

The Society for Healthcare Epidemiology of America (SHEA) Patient Education Guide on CLABSI

Source: Society for Healthcare Epidemiology of America

Helpful Tips for CLABSI Reporting for the Centers for Medicare and Medicaid Services’ Hospital Inpatient Quality Reporting Program (CMS Reporting Program)

Source: Centers for Disease Control and Prevention


4. Injuries from Falls and Immobility

Did you know?

  • In acute and rehabilitation hospitals, falls resulting in injury occur in 30-51 percent of patients, and falls resulting in fracture occur in 1-3 percent of patients.
  • Falls are associated with increased lengths-of-stay, increased utilization of health care resources, and poorer health outcomes.
  • Soft tissue injuries or minor fractures can cause significant functional impairment, pain, and distress. Even “minor” falls can trigger a fear of falling in older persons, leading them to limit their activity and lose their strength and independence.

According to information included in The Joint Commission’s Speak Up Campaign, there are strategies everyone can follow to help prevent falls and associated injuries. These include:

  • Take care of your health.
  • Exercise regularly. Exercise builds strength.
  • Prevent dehydration. Dehydration can make it easier to lose your balance.
  • Have your eyes checked. Make sure you do not have any eye problems or need a new prescription.
  • Talk to your doctor if your medicine makes you sleepy, light-headed, sluggish, or confused. Ask how to reduce these side effects or if you can take another medication.

In addition, take extra precautions if you are in the hospital or nursing home. Many falls occur when patients or residents try to get out of bed either to go to the bathroom or walk around the room by themselves. If you need to get out of bed:

  • Use your call button to ask for help getting out of bed if you feel unsteady.
  • Ask for help going to the bathroom or walking around the room or in hallways.
  • Wear non-slip socks or footwear.
  • Lower the height of the bed and the side rails.

The Centers for Disease Control and Prevention (CDC) reports that among adults ages 65 and older, falls are the leading cause of injury-related death. Falls are also the most common cause of non-fatal injuries and of hospital admissions for trauma.

According to the Hospital Engagement Network (HEN), patient and family falls are among the most frequently reported incidents in hospitals and health care facilities. While many of these falls cause no harm, the high overall rate of falls indicate that they are a significant cause of hospital-acquired injury. Falls can sometimes lead to severe injuries, such as hip fractures and head trauma.

Immobility is a decrease in the amount of time spent up and moving (getting out of the bed or chair and walking, for example). It causes loss of muscle strength along with changes in the cardiac response to exercise. Immobility in the hospital increases the chances of delirium, pressure ulcers, venous thromboembolism, falls, and functional decline. Functional decline leads to increased lengths of hospitalization and readmission.

The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients initiative to cut the number of preventable fall injuries in half while maintaining or increasing patients’ mobility by 2014. Over three years, this would prevent a total of 43,750 fall injuries, while maintaining or increasing mobility.

After research and assessments, the AHA/HRET HEN developed this list of Top 10 Evidence-Based Interventions to Prevent Falls and Reduce Immobility. They include:

  • Conduct fall and injury risk assessment upon admission
  • Reassess risk daily and with changes in patient condition
  • Implement patient-specific intervention to prevent falls and injury
  • Communicate risk across the team; use handoff forms, visual cues, huddles
  • Round every 1 to 2 hours for high-risk patients; address needs (e.g., 3Ps: pain, potty, position-pressure); combine with other tasks (vital signs)
  • Individualize interventions; use non-skid floor mats, hip protectors, individualized toileting schedule; adjust frequency of rounds
  • Review medications (by pharmacist); avoid unnecessary hypnotics and sedatives
  • Incorporate multidisciplinary input for falls prevention from PT, OT, MD, RN, and PharmD
  • Include patients, families, and caregivers in efforts to prevent falls; educate regarding fall prevention measures; stay with patient
  • Hold post-fall huddles immediately after event; analyze how and why; implement change to prevent other falls

Additional resources including a detailed Change Package, can be found at

Additional Resources
ASHRM Risk Management Pearls on Principles for Developing Safe and Effective Policies and Procedures
ASHRM's Risk Management Pearls on Principles for Developing Safe and Effective Policies and Procedures guides readers through the entire process of developing and maintaining effective policies and procedures. It will help them determine which situations warrant the establishment of a policy and procedure, help them draft and review policies and procedures, and recommend approaches to complex policy issues. Click here to order the booklet.

The No-Fall Zone
Source: Health & Health Networks

National Fall Prevention Awareness Day
Source: U.S. Center for Disease Control and Prevention

Fall Prevention Awareness Toolkit
Source: Montana Fall Prevention Workgroup in collaboration with the National Council on Aging

Injuries from Falls and Immobility Case Studies
Source: Hospitals in Pursuit of Excellence

Implementation Guide to Prevention of Falls with Injury
Source: HRET-HEN

Falls Risk Assessment: A Foundational Element of Falls Prevention Programs

Source: Pennsylvania Patient Safety Authority

Sharp Memorial Hospital STOP Our Patients From Falling - Checklist
Source: Sharp Memorial Hospital

Sharp Memorial Hospital Fall Risk Stop Sign
Source: Sharp Memorial Hospital

Click here for a variety of publications available through the Centers for Medicare and Medicaid Services.


5. Obstetrical Adverse Events

Did You Know?

  • Hospital stays for mothers with pregnancy-related complications tended to be longer (2.9 days for non-delivery stays and 2.7 days for delivery stays) than stays without delivery complications (1.9 days).
  • Maternal hospital stays with complications were about 50 percent more costly ($4,100 for non-delivery stays and $3,900 for delivery stays) than stays without delivery complications ($2,600).
  • Maternal stays with pregnancy and delivery-related complications totaled $17.4 billion, nearly 5 percent of overall hospital costs in the United States.

Source: Institute for Healthcare Improvement (IHI)

The AHA/HRET Hospital Engagement Network (HEN) reports that most pregnancies result in successful outcomes, but the time around labor and delivery poses risks to both mother and infant. Obstetrical adverse events occur in approximately 9 percent of all U.S. deliveries and can result in significant harm. These adverse events range from perineal tears to hemorrhage for the mother, and skeletal or spinal cord injuries to the neonate, as well as unplanned admissions to the neonatal intensive care unit (NICU).
The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients initiative to reduce obstetrical harm by 40 percent by the end of 2014, utilizing evidenced-based practice bundles and recommendations. This included achieving an overall 40 percent reduction in the infant perinatal birth trauma rate and a 40 percent reduction in obstetric (OB) trauma rates for all vaginal deliveries, with or without instrument-assisted delivery. For 2014, the hospitals are also focused on reducing OB hemorrhage and pre-eclampsia.

The AHA/HRET HEN released the following checklist of the Top Ten Evidence-Based Interventions to Reduce Obstetrical Adverse Events. They include:

  • Educate the hospital’s governing board about the dangers of early elective delivery, and the hospital’s role in prevention
  • Use prenatal classes as an opportunity to educate patients about the dangers of early elective delivery (EED), and the hospital’s policy
  • Find a physician willing to champion the effort to reduce EED; this physician does NOT have to be an obstetrician (a neonatologist or pediatrician can be very successful in this role)
  • When writing a Hard Stop policy, have physicians and hospital leaders involved from the start
  • A Hard Stop policy must be very prescriptive in the exact steps to be taken, and by whom, in the chain of command when an elective delivery is attempted to be scheduled that does not meet the criteria determined by the medical staff
  • Use policies, scheduling forms, educational materials, and data collection tools that are already created and available publicly from the March of Dimes or CMQCC
  • Display data as concurrently as possible for all stakeholders
  • Review all early elective deliveries in the past 12 months to determine if any were admitted to the NICU and use those stories as motivation
  • Pick a system for determining gestational age in your policy and stick to it; establishing the “line in the sand” is key to success
  • Don’t get stuck in developing the policy by trying to be so prescriptive that any possible medical indication is mentioned; let the policy allow for medical judgment and a rate of less than 3 percent as a goal instead of zero

Additional Resources
ASHRM’s Healthcare Risk Management Pearls for Obstetrics: Part I and Part II.
These new Pearls provide the tools for healthcare risk managers, patient safety professionals, providers, and administrators to help decrease risk and improve safety in the delivery of care to pregnant women and their babies. All of the chapters provide succinct risk management strategies that can be easily implemented. 

HRET/HEN Obstetrical Adverse Events Change Package
Source: Hospital Engagement Network

HRET/HEN Eliminate Harm across the Board – Days Since Last OB Harm Event Checklist
Source: Hospital Engagement Network

ASHRM Forum Article: Medication Safety in Obstetrics
Reports of a pregnant woman who died after inadvertently receiving an intravenous rather than the intended epidural medication, and of newborns who mistakenly received adult doses of heparin, are difficult to ignore. The lessons learned through these events drive organizations to develop safer processes and practices to prevent these errors from recurring. Read More.

How-to Guide: Prevent Obstetrical Adverse Events
Source: Institute for Healthcare Improvement

Obstetrical Adverse Events Case Studies

Source: Hospitals in Pursuit of Excellence

Reduction of Perinatal Harm Driver Diagram 2012
Source: Hospital Engagement Network

Cobre Valley Regional Medical Center (Globe, AZ) - Hard Stop Policy for Early Elective Deliveries
Source: Hospital Engagement Network

Perinatal Injuries Gap Analysis—Component of the Perinatal Safety Roadmap
Source: Minnesota Hospital Association

Patient Safety—Obstetrics and Newborn
Source: Minnesota Hospital Association


6. Pressure Ulcers

Did You Know?

  • The prompt identification of at-risk patients using a validated risk assessment tool is essential for accurate, prompt identification of at-risk patients and timely implementation of prevention strategies. The risk assessment must include an assessment of several components. These include: mobility, incontinence, sensory deficiency, and nutritional status (including dehydration).
  • Wet skin is conducive to the development of rashes, is softer, and tends to break down more easily; therefore it is important to keep skin dry.
  • Treating dry skin with moisturizers has been shown to be especially effective in preventing pressure ulcers.

Source: Institute for Healthcare Improvement

Pressure ulcers cause significant patient harm, including pain, infections, and extended hospital lengths-of-stay. The Partnership for Patients Initiative reports that the cost of treating a single full-thickness pressure ulcer is as high as $70,000 and total costs for treatment of pressure ulcers in the U.S. is estimated at $11 billion annually. Pressure ulcer incidence rates vary considerably by clinical setting with a range between 0.4 to 38 percent in acute care, 2.2 to 23.9 percent in long-term care, and 0 to 17 percent in home care.

The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) says that hospital acquired pressure ulcers (HAPU) reduce overall quality of life due to pain, treatments, increased length of institutional stay, and may also contribute to premature mortality in some patients. Interventions that may help prevent pressure ulcers or to treat them once they occur, lead to reduction of cost of HAPU care and improve the quality of life for those affected.

HRET worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients Initiative to reduce the prevalence of hospital acquired Stage II or greater pressure ulcers by 50 percent, and to reduce the incidence of significant hospital acquired Stage III-IV pressure ulcers by 50 percent by December 31, 2013.

The AHA/HRET HEN developed a number of resources, including the Top Ten Evidence-Based Interventions for Reducing Healthcare Acquired Pressure Ulcers. They include:

  • Implement head-to-toe skin evaluation and risk assessment tool—assess the skin and risks within 4 hours of admission—risk and skin assessment should be age appropriate
  • Based on skin and risk assessment, develop and implement an individualized plan of care
  • Assess skin and risk at least daily and incorporate into other routine assessment
  • Avoid skin wetness by protecting and moisturizing as needed—use under-pads that provide a quick-drying surface and wick moisture away and use topical agents that hydrate the skin and form a moisture barrier to reduce skin damage
  • Set specific timeframes or create reminder systems to reposition the patient—such as hourly or every two hour rounding with a purpose (the 3 P's - pain, potty, position-pressure). This also aligns with fall prevention.
  • Monitor weight, nutrition, and hydration status—generate an automatic Registered Dietician consult for high risk patients
  • Use special beds, mattresses, and foam wedges to redistribute pressure (pillows should only be used for limbs)
  • Operating room tables should be covered by special overlay mattresses for high risk patients and for long cases (greater than 4 hours—some hospitals choose cases greater than 2 hours)
  • Use breathable glide sheets, and/or lifting devices to prevent shear and friction
  • Involve licensed and unlicensed staff, e.g., nurses, licensed practical nurses and nurse aides, in pressure ulcer reduction efforts such as rounding with a purpose

The Braden Scale is the most widely utilized assessment tool in the U.S. Developed in 1987, the scale helps health care professionals to assess a patient's risk of developing pressure ulcers. The scale utilizes six criteria to determine whether a patient is at a high or low risk for pressure ulcer development. The criteria are:

  • Sensory perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction and Shear

Source: Braden Scale— Agency for Healthcare Research and Quality (AHRQ)

Additional Resources
ASHRM Risk Management Pearls for Long-Term & Continuing Care, 2nd Ed.
ASHRM’s Risk Management Pearls for Long-Term & Continuing Care, 2nd Ed., is designed to meet the needs of a complex specialty where risk management duties may not be assigned to a dedicated risk manager. It details best practices for preventing pressure ulcers in bedridden and wheelchair-confined patients. Click here to order the booklet.

Preventing Hospital Acquired Pressure Ulcers Change Packet
Source: HRET-HEN

Eliminate Harm across the Board - Days Since Last Pressure Ulcer – Pressure Ulcer Prevention Poster
Source: HRET-HEN

Pressure Ulcers Case Studies
Source: Hospitals in Pursuit of Excellence

Implementation Guide to Prevention of Hospital Acquired Pressure Ulcers (HAPU)
Source: Partnership for Patients Initiative/U.S. Department of Health and Human Services

Preventing Pressure Ulcers
Source: NIH Medline Plus


7. Preventable Readmissions

Did You Know?

  • The lack of preventive and on-going care for patients with chronic conditions is cited most frequently as a major cause of readmissions.
  • Senior patients with a chronic condition are more than 100 times more likely to experience a preventable hospitalization.
  • Poor coordination among providers after a patient discharge and poor accountability for patient follow up are two key shortcomings in the care transitions process.

Source: Health Leaders Media Intelligence Unit and Amedysis Integrated Health Solutions

According to the Partnership for Patients Initiative, a 2009 study published in the New England Journal of Medicine demonstrated that almost one-fifth (19.6 percent) of Medicare patients were readmitted to the hospital within 30 days of discharge and 34 percent were readmitted within 90 days. This research estimated that only 10 percent of these readmissions were planned, and that the annual cost to Medicare of unplanned hospital readmissions exceeds $17 billion. Medicare 30-day re-hospitalization rates vary from 13-24 percent across states, and even more significantly, within states. All-cause readmission rates have fallen only 0.3 percent over the past three years (from 15.6 percent in 2009 to 15.3 percent in 2011). Today, hospitals with higher than expected readmission rates are faced with readmission penalties from Medicare. During Fiscal Year 2013, more than 2,000 hospitals experienced a drop in their inpatient hospital payments of up to 1 percent. The maximum readmission penalty will further increase to 3 percent in 2015.

The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients Initiative to reduce—by the end of 2014—hospital readmissions by 20 percent as compared to the 2010 baseline by decreasing preventable complications during transitions from one care setting to another. The Partnership for Patients says that while avoidable re-hospitalizations are common and costly, they can be reduced with effective care coordination and transitions of care.

The AHA/HRET HEN developed a number of resources, including the Top Ten Evidence-Based Interventions for Reducing Readmissions. They include:

  • Enhanced admission assessment of discharge needs and begin discharge planning upon admission
  • Formal assessment of risk of readmission—align interventions to patient’s needs and risk stratification level
  • Accurate medication reconciliation at admission, at any change in level of care, and at discharge
  • Patient education—culturally sensitive, incorporate health literacy concepts, include information on diagnosis and symptom management, medication, and post-discharge care needs
  • Identify primary caregiver, if not the patient, and include with education and discharge planning
  • Use teach-back to validate patient and caregiver’s understanding
  • Send discharge summary and after-hospital care plan to primary care provider (PCP) within 24 to 48 hours of discharge
  • Collaborate with post-acute care and community-based providers, including skilled nursing facilities, rehabilitation facilities, long-term acute care hospitals, home care agencies, palliative care teams, hospice, medical homes, and pharmacist
  • Before discharge, schedule follow-up medical appointments and post-discharge tests/labs. For patients without a primary care provider (PCP), work with health plans, Medicaid agencies, and other safety-net programs to identify and link patient to a PCP
  • Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of after-hospital care plan using teach-back and identify any unmet needs such as access to medication, transportation to follow-up appointments, etc.

Additional Resources
Preventable Readmissions Change Packet - Improving Care Transitions and Reducing Readmissions
Source: HRET-HEN

Eliminate Harm across the Board - Days Since Last Readmission – Readmissions Prevention Poster
Source: HRET-HEN

Readmissions Reduction Program

Source: CMS.gov

Reducing Avoidable Hospital Readmissions
Source: Agency for Healthcare Research and Quality

10 Proven Ways to Reduce Hospital Readmissions
Source: Becker’s Hospital Review

Institute for Healthcare Improvement How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Re-hospitalizations
Source: Institute for Healthcare Improvement

Health Care Leader Action Guide to Reduce Readmissions
Source: The Health Research & Educational Trust (HRET)


8. Surgical Site Infections 

Did You Know?

  • SSIs are the second most common type of healthcare-associated infection (HAI) in U.S. hospitals (290,000 per year), and cost between $3.5-$10 billion per year.
  • SSIs lead to significant increases in hospital readmissions, ICU admissions, long-term surgical site complications, and death.
  • With appropriate interventions, 40-60 percent of SSIs are considered preventable.

Source: Partnership for Patients Initiative

  • There are approximately 234 million surgeries worldwide annually, surpassing the number of births.
  • In industrialized countries, 3-16 percent of patients undergoing surgery experience a major complication. The peri-operative inpatient surgery death rate is 0.4-0.8 percent.
  • Nationally, the rate of surgical site infection (SSI) averages between 2-3 percent for clean cases (Class I/Clean as defined by the CDC). An estimated 40-60 percent of these infections may be preventable.
  • Studies show that patients with SSI have a longer hospital stay of 7-10 additional post-operative days and assume an added cost of approximately $3,000-$29,000 per SSI depending on the procedure and pathogen.
  • Seventy-five percent of deaths among patients with surgical site infections are directly attributable to the infections.

Source: Partnership for Patients Initiative

The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients Initiative to reduce surgical site infection rates by 40 percent by December 31, 2014. Together, they developed a number of resources, including the Top Ten Evidence-Based Interventions to Reduce Surgical Site Infections. The interventions include:

  • Develop and follow standardized order sets for each surgical procedure to include antibiotic name, timing of administration, weight-based dose, re-dosing (for longer procedures) and discontinuation
  • Ensure pre-operative skin antisepsis (basic soap and water shower; chlorhexidine (CHG) showers)
  • Develop standardized peri-operative skin antiseptic practices utilizing the most appropriate skin antiseptic for the type of surgery performed
  • Develop a standardized procedure to assure normothermia by warming ALL surgical patients
  • Develop and implement protocol to optimize glucose control in ALL surgical patients
  • Develop protocol to screen and/or decolonize selected patients with Staphylococcus aureus
  • Adhere to established guidelines (e.g. HICPAC, AORN) to assure basic aseptic technique  (e.g. traffic control, attire) is adhered to uniformly
  • Establish a culture of safety that provides an environment of open and safe communication among the surgical team
  • Establish system where surgical site infection data is analyzed and shared
  • Develop a protocol to provide guidance on blood transfusion practices, as a unit of packed red blood cells should be considered a transplant/immune modulator and has been linked to a higher risk of SSI’s

Additional Resources
HRET/HEN Surgical Site Infection Change Package
Source: HRET-HEN

HRET/HEN Eliminate Harm across the Board Days Since Last SSI Operating Room Safety and Surgical Site Infection Poster
Source: HRET-HEN

Safe Surgery 2015 Initiative

Source: Johns Hopkins Medicine Center for Innovation in Quality Patient Care

Surgical Site Infections Case Studies
Source: Hospitals in Pursuit of Excellence

National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination

Source: U.S. Department of Health and Human Services

How-to Guide: Prevent Surgical Site Infections

Source: Institute for Healthcare Improvement


9. Venous Thromboembolisms

Did You Know?
Venous thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). It is a common, lethal disorder that affects hospitalized and nonhospitalized patients, recurs frequently, is often overlooked, and results in long-term complications including chronic thromboembolic pulmonary hypertension (CTPH) and the post-thrombotic syndrome (PTS).

Venous thromboembolism results from a combination of hereditary and acquired risk factors, also known as thrombophilia or hypercoagulable states. In addition, vessel wall damage, venous stasis, and increased activation of clotting factors remain the fundamental basis for our understanding of thrombosis.

VTE is the third most common cardiovascular illness after acute coronary syndrome and stroke. Nearly two-thirds of all VTE events result from hospitalization, and approximately 300,000 of these patients die. Pulmonary embolism is the third most common cause of hospital-related death and the most common preventable cause of hospital-related death. Most hospitalized patients have at least 1 or more risk factors for VTE. Among hospitalized patients with acute medical illness, infection, the patient being older than 75 years of age, cancer, and a history of VTE are most associated with an increased VTE risk.

Source: Cleveland Clinic

The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) says venous thromboembolisms (VTE) including pulmonary emboli are the most common causes of preventable hospital death. The risk for developing VTE ranges from 10–85 percent (and varies based on the reason for admission). In addition, the Partnership for Patients Initiative reports that the rate of fatal pulmonary emboli more than doubles between the ages of 50 and 80. A U.S. multicenter registry study showed that the majority of hospitalized patients with risk factors for venous thromboembolism (VTE) did not receive prophylaxis.

HRET worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients Initiative to reduce the incidence of hospital-acquired VTE by 40 percent and to increase the utilization of appropriate VTE prophylaxis in at-risk patients to 100 percent by December 31, 2014.

The Partnership for Patients Initiative developed a number of resources, including the Top Ten Evidence-Based Interventions for Reducing VTEs. They include:

  • Adopt a VTE risk assessment screening tool, such as the 3 bucket tool from UCSD
  • Assess every patient upon admission of his/her risk for VTE using the VTE risk assessment screening tool instead of just for certain diagnoses or procedures
  • Adopt a standardized risk-linked menu of choices for prophylaxis
  • Develop standard written order sets which link the risk assessment to the choice of prophylaxis
  • Use protocols for dosing and monitoring when using unfractionated heparin
  • Use pharmacists as key real time decision support for protocols and when patients have contraindication
  • Make prophylaxis ordering an opt-out process instead of an opt-in
  • Find the stories of patients who have fallen through the cracks and ended up with a hospital- acquired VTE/PE; use these stories as motivation to make the assessment process “real”
  • Give nurses the same tools you give physicians—physicians get a hard stop CPOE process for ordering, coordinate with the IT department to utilize the EMR to identify the VTE at-risk patient for risk assessment
  • If assessments are not being done reliably, try changing roles—physicians may do the assessment instead of nurses, pharmacists may do assessments through trigger tools

Additional Resources
Preventing Venous Thromboembolism Change Packet
Source: HRET-HEN

Eliminate Harm across the Board—Days Since Last Venous Thromboembolism Prevention Poster
Source: HRET-HEN

Failure Mode and Effects Analysis Venous Thromboembolism Prophylaxis
Source: ECRI Institute

A Guide for Effective Quality Improvement—Preventing Hospital-Aquired Venous Thromboembolism
Source: Agency for Healthcare Research and Quality

Venous Thromboembolism Case Studies
Source: Hospitals in Pursuit of Excellence

Implementation Guide to Prevention of Venous Thromboembolism (VTE)
Source: Hospital Engagement Network


10. Ventilator Associated Event/Ventilator Associated Pneumonia

Did You Know?

  • For 2010, National Healthcare Safety Network (NHSN) facilities reported more than 3,525 VAPs.
  • The incidence for various types of hospital units ranged from 0.0-5.8 per 1,000 ventilator days.
  • The total annual direct medical cost for VAP in U.S. hospitals ranges between $1.03 billion- $1.5 billion.

Source: National Healthcare Safety Network (NHSN)

The Partnership for Patients Initiative reports that patients on mechanical ventilation are at high risk for Ventilator Associated Event (VAE)/Ventilator Associated Pneumonia (VAP), with attributable mortality rates up to 40 percent. In addition, VAP is the leading cause of death among hospital-acquired infections, exceeding the death rate due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated patient. VAP also prolongs time spent on the ventilator, the length of stay in the intensive care unit (ICU), and the length of hospital stay after discharge from the ICU.

The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients Initiative to decrease the rate of VAP by 40 percent and/or to a median state of 0.0/1,000 ventilator days for at least 6 months by December 31, 2014.

The AHA/HRET HEN developed a number of resources, including the Top Ten Evidence-Based Interventions for Reducing VAP/VAEs. They include the following:

  • Include all elements of the Ventilator Bundle (elevate the head of the bed to between 30-45 degrees; peptic ulcer disease (PUD) prophylaxis; venous thromboembolism (VTE) prophylaxis; ABCDE bundle, and oral care) in charge nurse rounds and nurse to charge nurse reports.
    • Elevate head of the bed (HOB) to between 30-45 degrees (use visual cues, designate one person to check for HOB every 1-2 hours, involve family)
    • Oral care—routine oral care every 2 hours with antiseptic mouthwash and chlorhexidine 0.12% every 12 hours (create visual cues, partner with respiratory therapy in performing oral care by making it a joint nursing and respiratory therapy function);  make the oral care part of the ventilator order set as an automatic order that requires the physician to actively exclude it.
    • Peptic ulcer disease prophylaxis—include on ICU admission and ventilator order sets as an automatic order that requires the physician to actively exclude it
    • Venous Thromboembolism (VTE) prophylaxis—include on ICU admission and ventilator order sets as an automatic order that would require the physician to actively exclude it
  • Spontaneous awaking and breathing trials (SAT/SBT)—designate one time of day for the SAT and SBT to be attempted
  • Coordinate SAT and SBT to maximize weaning opportunities when patient sedation is minimal—coordinate between nursing and respiratory therapy to manage SAT and SBT, perform daily assessments of readiness to wean and extubate
  • SAT and SBT should be included in the nurse to nurse handoffs, nurse to charge nurse reports, and charge nurse to charge nurse reports
  • Multidisciplinary approach is key—nursing and respiratory therapy staff can work together to ensure bundle items such as HOB, SAT/SBT, and oral care are done according to recommendations
  • Delirium management—sedation should be goal oriented and provide a daily reduction of removal of sedative support; administer sedation as ordered by the physician according to a scale such as a Richmond Agitation Sedation Scale (RASS).

Additional Resources
Preventing Ventilator Associated Pneumonia and Ventilator Associated Events Change Packet
Source: HRET-HEN

Eliminate Harm across the Board—Days Since Last Ventilator Associated Events Prevention Poster
Source: HRET-HEN

How-to Guide: Prevent Ventilator-Associated Pneumonia
Source: Institute for Healthcare Improvement

Ventilator-Associated Pneumonia Case Studies
Source: Hospitals in Pursuit of Excellence

Ventilator-Associated Pneumonia (VAP) Resources
Source: Partnership for Patients

Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals
Source: The Society for Healthcare Epidemiology of America


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