Improving Safety & Quality
Michigan hospitals, through the MHA Keystone Center and MHA
Patient Safety Organization, are improving patient safety and
quality by focusing on a variety of conditions, collecting data,
implementing evidence-based best practices and reducing health care
through the MHA Keystone Center and MHA PSO, are improving patient
safety and quality by focusing on a variety of conditions and
issues. They include:
Adverse Drug Events
An adverse drug
event refers to harm caused by a medication being prescribed,
monitored, dispensed or administered incorrectly (wrong patient,
wrong dose, wrong time, wrong route, wrong medication,
etc.).Michigan hospitals have voluntarily participated in a national
data collection and analysis effort to study the causes and effects
of adverse drug events, and what issues need the most attention in
our state. In addition, Michigan hospitals will soon begin
implementing evidence-based best practices to reduce the occurrence
of adverse drug events.
hospitals and community partners are working together to reduce the
number of patients who experience avoidable rehospitalizations by
addressing care coordination and improving communication among
hospitals, other health care providers and patients. These are also
referred to as hospital readmissions.
Urinary Tract Infection (CA-UTI)
A CA-UTI is an infection of the
urinary system, which can include the bladder or kidneys, resulting
from germs entering the urinary system through a catheter. Michigan
hospitals implemented evidence-based interventions for appropriate
urinary catheter use, insertion, proper care and maintenance.
Central-line-associated Bloodstream Infections (CLABSI)
CLABSI is an infection that occurs when germs enter the bloodstream
through a central line — a tube placed in a large vein (usually the
neck, chest, arm or groin) to provide blood, fluids or medications
quickly. Michigan hospitals have saved an estimated 36 lives and
$6.4 million from March 2010 to March 2011 by reducing CLABSIs.
Michigan hospitals are working to
prevent harm to emergency patients by improving safety practices and
attitudes, reducing boarding/overcrowding and wait times, and
supporting the early treatment of sepsis using
evidence-based best practices.
through the MHA PSO, began addressing falls in 2008 through a
process to standardize patient alert wristbands, helping health care
employees correctly identify patients at risk. While falls remain
challenging due to the range of factors contributing to whether a
patient is at risk, Michigan hospitals continue to explore ways to
reduce their occurrence.
Obstetrical Adverse Events
Obstetrical adverse events, many of which are preventable, may be
suffered by mothers or their babies during labor and delivery.
Obstetrical adverse events include respiratory distress syndrome,
sepsis, neonatal intensive care unit admission, hospitalization for
more than five days and rehospitalization. Michigan hospitals are
working together to eliminate preventable harm due to complications
of labor induction and management of the second stage of labor.
Organ donation is the process of taking
healthy organs or tissue from a living or deceased person and
transplanting them to another living individual. Michigan hospitals
are working with Gift of Life Michigan to improve organ donation
processes through best practices, including improved communication
between caregivers and families.
ulcers are wounds caused by prolonged pressure to certain body
parts, which damages the skin and underlying tissue. They are also
known as bed sores. Michigan hospitals are implementing
evidence-based interventions to reduce the occurrence of pressure
Sepsis is a serious medical condition, also
known as blood poisoning, characterized by a whole-body inflammatory
state caused by microbes in the blood. Michigan hospitals are
focusing on the early identification and treatment of sepsis using
early goal-directed therapy.
are focused on eliminating surgical-site infections, preventing
wrong-site surgery and retained foreign objects, eliminating
mislabeled specimens, and improving the safety and teamwork climate.
In 2010, the MHA PSO introduced hospitals to a toolkit to prevent
wrong-site surgeries, a rare but serious cause of patient harm.
Venous Thromboembolism (VTE)
VTE is a blood clot formed
within a vein. It is the umbrella term for deep vein thrombosis and
pulmonary embolism. Michigan hospitals are implementing
evidence-based best practices to prevent VTE.
Ventilator-associated Pneumonia (VAP)
VAP is pneumonia that
develops in a patient who is ventilated. Michigan hospitals
significantly reduced the number of patients experiencing VAP,
saving 79 lives and $2.2 million from March 2010 to March 2011.