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.


  • 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

October 31, 2019

Reauthorization of HAP-supported PHC4 Legislation Passes PA Senate, Moves to House

The Pennsylvania Senate has passed legislation to reauthorize the Pennsylvania Health Care Cost Containment Council (PHC4).  Senate Bill 841, sponsored by Sen. Scott Martin (R-Lancaster), also modernizes the council by updating its powers and duties, and now moves to the House for consideration.

October 24, 2019

Joint News Release: Tri-State Hospital Group Partners to Improve Healthcare Quality, Patient Safety

Three hospital associations in New Jersey, Ohio and Pennsylvania today announced the creation of Q3 Health Innovation Partners (Q3HIP), a new joint venture to improve health quality and patient safety.

October 23, 2019

HAP Celebrates “Healthcare Quality Week”

Healthcare Quality Week, sponsored by the National Association for Healthcare Quality, is dedicated to celebrating the contributions professionals have made in the field and bringing greater awareness to the profession of health care quality.

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