Case Studies
The ºÚÁÏÕýÄÜÁ¿ Association produces case studies on its member organizations across a wide range of health-care topics.
The Problem Falls are a serious problem for older people, composing the largest single category of reported incidents in hospitals, according to the Joint Commision. Falls pose an even greater risk for older hospitalized patients. Even with daily fall-risk assessments, Mercy Health Center had more…
The Problem Like many urban safety net hospitals, Hahnemann University Hospital struggled with overcrowding in its emergency department (ED). From December 2008 through February 2009, the ED had 8,821 visits. Of these, 12.7 percent of patients left without being seen. The Solution Upon joining the…
The Problem After examining hospital data to pinpoint opportunities to improve, Gundersen Lutheran focused on patient falls. Patient falls made up the second-largest category of reported incidents for Gundersen Lutheran, after medication events. 'It was clear everyone was trying hard, but there was…
The Problem The infection rate in the NICU at Charleston Area Medical Center was 18 percent in 2005. This was considerably higher than the baseline set for NICUs through the Vermont-Oxford Network, a non-profit collaboration of more than 800 NICUs around the world. The Solution
The Problem With mechanical ventilation being a large part of care for critical patients, teh need to reduce the risk of infections to a patient's endotracheal tube has become criticle. With several ways to improve this process, Bronson Methodist Hospital decided to implement a patient safety…
The Problem With the national average of hospital-acquired skin breakdown at 4.8 percent, Bronson set out to achieve the best practice benchmark of less than 1.7 percent and reduce hospital-acquired pressure ulcers. Read the solution and results by clicking 'view item.'
The Problem Bronson's patient safety committee appointed a task force to look at medication errors in pediatric patients. The team looked at all medication errors that occurred in patients 17 years and younger. There were 162 errors in the previous year wit a rate of occurrence at 7.39 per 1,…
The Problem In 2007, the Keystone Center for Patient Safety and Quality partnered with the Michigan Health and Hospital Association and Blue Cross Blue Shield of Michigan to decrease hospital-associated infections in health care organizations throughout Michigan. The initiative focused on areas…