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 healthcare costs.
Michigan hospitals, 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.
Michigan 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 healthcare providers
and patients. These are also referred to as hospital readmissions.
Catheter-associated Urinary Tract Infection (CAUTI)
A CAUTI 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)
A 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
Michigan hospitals, through the MHA PSO, began
addressing falls in 2008 through a process to standardize patient
alert wristbands, helping healthcare 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
Pressure 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 ulcers.
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
Michigan hospitals 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.
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.