Patient Harm Prevention | HAP

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Related Information

HAP Memo 15-20
HEN 2.0 Hospital Commitment Requested (Sep 2015)


HAP Testimony
On preventing opioid addiction and related deaths (Oct 2015)


HAP Works with Pennsylvania Hospitals to Reduce Patient Harm

HAP, through its Hospital Improvement Innovation Network (HIIN) is helping Pennsylvania hospitals and health systems with analyzing the cause of harm, identifying prevention strategies, and ensuring that those strategies become part of a culture of safe, patient-centered care.

Current patient harm prevention initiatives include:

  • Adverse Drug Event Prevention—Adverse drug events can include medication errors, such as too much or too little medicine, or an unexpected reaction, such as an allergic reaction. Medication errors can result in patient harm, including death.
  • Venous Thromboembolism Prevention—Venous thromboembolism (VTE), is a condition in which unwanted blood clots form in the body. These blood clots can sometimes lead to serious health conditions or even death. Patients admitted to the hospital are at increased risk for this condition, especially if they have surgery or stay in the hospital for a long time.
  • Falls Prevention—Patient falls with injury represent the most frequently reported serious patient event by hospitals in Pennsylvania. However, falls represent a patient safety challenge for all health care facilities.
  • Pressure Ulcer Prevention—Hospitals have long been challenged to protect bed-ridden patients from getting pressure injuries (also known as bedsores). Pressure injuries constitute skin breakdown that can be painful, may impact a patient’s quality of life, and may slow recuperation from other illnesses.
  • Severe Sepsis and Septic Shock—Sepsis (also known as blood poisoning) is an often deadly disease that sometimes occurs when the body is overwhelmed by infection. Sepsis can be difficult to diagnose, because it often happens quickly, and can be confused with other conditions.
  • Healthcare Associated Infections—This can include central line-associated blood infections (CLABSI), surgical site infections (SSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated events (VAE). These infections can occur in hospitalized patients who are exposed to viral, bacterial or fungal germs.
  • Antimicrobial Stewardship, Clostridium difficile, Multi-drug Resistant Organisms—Complications can occur when patients receive unnecessary antimicrobial medications, including antibiotics. Antimicrobial stewardship refers to a coordinated effort designed to promote appropriate use of these medications. Clostridium difficile infection (CDI) refers to a serious infection which results in the disruption of normal healthy bacteria in the colon, often from antibiotics. Multi-drug resistant organisms (MDROs) are bacteria and other organisms that have developed resistance to multiple antimicrobial drugs. Widespread use of antibiotics has resulted in many MDRO’s.
  • Readmissions—Frequent and unnecessary hospital readmissions within 30 days of a hospital stay are costly, potentially harmful, and often avoidable.
  • Diagnostic Error in the Emergency Department—Imaging procedures, such as x-rays, magnetic resonance imaging (MRI) and computed tomography (CT) scans represents an understudied area of patient safety with many opportunities for improvement.
  • Computed Tomography (CT) Safety—While CT can be a lifesaving tool for diagnosing injuries and illness, reducing undue exposure to radiation is important in that too much radiation exposure can be detrimental to human health.

HAP HIIN GOALS:

  • Achieve a 20 percent reduction (from baseline) in these hospital-associated conditions:
    • Adverse Drug Events associated with the use of opioids, anticoagulants and insulin
    • Postoperative Venous Thromboembolism Prevention
    • Injury from Falls and Immobility
    • Pressure Ulcers
    • Severe Sepsis and Septic Shock Mortality
  • Device Related Infections, including CDI, SSI, CAUTI, and CLABSI
    • 10 percent increase in use of nurse driven protocols for removal of Foley catheter
    • 5 percent increase in facilities utilizing early mobility in ventilated patients
    • 30 percent compliance with delirium monitoring in ventilated patients
    • 10 percent reduction in daily defined doses of fluoroquinolones and carbapenems
    • 50 percent of hospitals performing CHG bathing pre-op
    • 25 percent increase in use of post-operative glucose monitoring for colon surgery patients
  • Achieve a 12 percent reduction in all cause 30-day readmission rates
  • Support a 12 percent reduction goal in all cause 30-day readmissions through a Community Building Coalition
  • Support a 12 percent reduction goal in all cause 30-day readmissions through the Palliative Care Collaborative

For additional information regarding these patient safety initiatives, please contact Robert Shipp, HAP's vice president, quality and population.

Related News

April 24, 2019

News Release: HAP Announces 2019 Achievement Award Winners

The Hospital and Healthsystem Association of Pennsylvania (HAP) announces its 2019 Achievement Award recipients.


April 15, 2019

Pennsylvania Hospitals Focus on Reducing Readmissions via Care Transitions

Preventing avoidable hospital readmissions continues as a priority for HAP and Pennsylvania hospitals. Research has found that acute and post-acute care organizations face unique challenges and barriers during care transitions which can affect readmissions. To address this opportunity, HAP’s Hospital Improvement Innovation Network (HIIN) has launched a series of tools during the National Care Transitions Awareness Day on April 16.


March 04, 2019

Celebrate Patient Safety Awareness Week March 10–16

Patient Safety Awareness Week, from March 10 through March 16, 2019, is intended to encourage everyone—consumers as well as health care providers—to learn more about health care safety. 


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