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 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.

Care Transitions
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 health care providers and patients. These are also referred to as hospital readmissions.

Catheter-associated 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)
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.

Emergency Department
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.

Falls
Michigan hospitals, 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
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.

Pressure Ulcers
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
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.

Surgery
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.

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.