Case Studies
The ºÚÁÏÕýÄÜÁ¿ Association produces case studies on its member organizations across a wide range of health-care topics.
In 2008, Albany Medical Center was one of 18 regional referral neonatal intensive care units to adopt central line insertion and maintenance bundles, and in 2009 agreed to use checklists to monitor maintenance-bundle adherence. Its NICU's central line-associated blood stream infection rate…
Falls increased in Thompson Health's inpatient areas in 2009 and 2010, and the number of falls was higher than the benchmark National Database of Nursing Quality Indicators data comparisons of same-size and Magnet-designated facilities. Eighty-seven percent of patients who fell on the 3-West…
In response to an increase in fall-related injuries in its skilled nursing facility, Champlain Valley Physicians Hospital Medical Center conducted a 'Kaizen' process, based on the Lean Six Sigma methodology, to identify the root causes of the falls. Results from the Kaizen were then taken to the…
The fall intervention program identified areas needing improvement including a lack of multidisciplinary attention and the need for better identification of patients at risk. At the time, green wrist bands were the only means of identification. A newly created education program included a 'STOP'…
In November 2009, a group of 12 representatives from various areas within Rochester General Health System embarked on a journey to improve patient outcomes and change the culture of the entire system. The group completed 'science of safety' training and developed a plan to involve all team members…
Performing well with the core measures has become increasingly important and challenging for health care organizations. Oswego Hospital needed to engage staff in a meaningful and innovative way to improve its performance. Launched in March 2010, 'The Right Care, Right Time, Every Time' focuses on…
Strong Memorial Hospital adopted barcode medication administration technology to reduce the incidence of medication administration errors. To prepare staff for a safe and seamless transition from traditional medication administration to the use of BCMA technology, the hospital implemented several…
St. Mary's Healthcare has an obligation to protect patients from harm and preventing adverse effects of care from reaching the patient is the primary focus of its patient safety efforts. The TeamSTEPPS program was implemented to aid in this effort.
This project was initiated by David Lyons, Director of Respiratory Therapy at St. Francis Hospital and implemented with the assistance of the performance improvement specialist, who identified an opportunity for improvement in hospital-wide oxygen cylinder safety and regulatory compliance processes…
This journey began when St. Francis Hospital gave fruit cocktail to a patient with a severe allergy to cherries noted in one part of her medical record, but not in any other. The patient knew not to eat this. A true sentinel event was prevented, but the root cause analysis team convened and…