Adverse Drug Events (ADE)
ADE is an injury resulting from the use of a drug. ADEs in hospitals can be caused by medication errors, such as accidental overdoses or providing a drug to the wrong patient, or by adverse drug reactions, such as allergic reactions or excessive bleeding after treatment with the intended dose of a drug that prevents dangerous blood clots.
Goal: the Partnership for Patients estimates that 50 percent of the 1.9 million ADEs that occur in hospitals each year are preventable. The goal set for hospitals is to reduce preventable ADEs by 50 percent. Over three years, this would prevent 830,000 ADEs.
Catheter-Associated Urinary Tract Infection (CAUTI)
CAUTI is one of the most common healthcare associated infections. The application of evidence-based guidelines and an increase in healthcare provider education can reduce incidence of infection. Prevention of CAUTI will improve patient health and reduce possible patient harm.
Central Line-Associated Bloodstream Infections (CLABSI)
CLABSI is a serious infection that occurs when germs enter the bloodstream through a central line. A central line is a tube that healthcare providers place in a large vein in the neck, chest or arm to give fluids, blood or medications or to perform certain medical tests quickly. The germs that cause CLABSIs are usually bacteria and can come from a variety of sources, including the patient’s own skin, the hospital environment and clinical staff. In some cases, germs are inadvertently introduced into the bloodstream when the central line is accessed days or weeks after being inserted.
Clostridium difficile (C. difficile)
C. difficile is a bacterium that causes infections within the digestive system in the intestines. In regard to hospital reporting, HIIN measures focus on hospital-acquired C.difficile and hand hygiene compliance, looking at hand washing technique.
Falls and Immobility
Falls are the most commonly reported incidents within the healthcare setting and can increase patient risk for hospital-acquired injuries and/or immobility. Providers can help to reduce the incidence of falls by utilizing evidence-based guidelines and providing patient education.
Healthcare-Associated Infections (HAIs)
HAIs develop while a patient is receiving treatment in a healthcare facility. Adverse health outcomes, including death, can occur after an individual acquires a HAI. The effects can prolong a patient’s stay, increase medical care costs and decrease patient/family’s trust in the healthcare system. Poor hand hygiene, dirty medical equipment and improper management of catheters and ventilators can cause HAIs in hospitals. Prevention measures have proven to reduce the number of HAIs occurring each year in Iowa healthcare settings.
National goals: the Partnership for Patients (PfP) has estimated the amount of preventable cases of each focus area per year. Based on that estimation, the PfP has set national reduction goals.
Hospital Culture of Safety and Worker Safety
Patient safety and the delivery of quality care go hand in hand. Each individual has a right to safety while in any healthcare organization. Though challenging, patient safety should be a serious goal for all hospitals and health care establishments. Measures focus on work-related back injuries, needle-safety and ensuring safe patient handling equipment is available for staff. A Just Culture is a method used to create a positive culture for patient safety. Created by David Marx, a system safety engineer, the original intent of the concept was to develop a system to fairly define culpability for potential or actual harm due to medication errors.
Workers safety focuses on the health and safety of staff members. Hospitals are one of the most hazardous places to work. Patient lifting, repositioning, and transfers represent some of the most common and preventable sources of injury for employees in the healthcare industry. Caregivers feel an ethical duty to “do no harm” to patient. Healthcare workers will often risk their own safety to help a patient.
Obstetrical Adverse Events
Obstetrical adverse events affect mothers and their infants. The events range from perineal tears to maternal or infant death, leading to extensive hospital admissions and/or neonatal intensive care. All pregnant women and their infants are at risk during labor and delivery.
Patients in the hospital are at risk of developing pressure ulcers if their skin is exposed to unrelieved pressure. The injuries to the skin and underlying tissue are painful and increase risk for infection or other complications. Pressure ulcers occur frequently within the hospital setting and are one of the most common hospital-acquired conditions. They are staged on severity and are localized to the skin and tissue. There are many current prevention strategies and resources to reduce the incidence of pressure ulcers within the hospital setting.
Readmissions and Care Coordination
The road to reducing readmissions is a challenging one that requires incredible endurance, stamina and the ability to constantly adapt to changing road conditions. The Partnership for Patients created a goal to reduce all-cause 30-day readmissions by 12 percent from facilities' baseline rate.
Severe Sepsis and Septic Shock
Sepsis is an inflammatory response to infection and can be life-threatening. Sepsis is also referred to as “blood poisoning.” All persons are at risk for sepsis if they have an infection.
Surgical Site Infection (SSI)
A surgical site infection (SSI) occurs after a surgery, in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections only involving the skin. Other SSIs are more serious and can involve tissues under the skin, organs, or implanted material. SSI is estimated to be 35 percent preventable and the national reduction goal is set to 20 percent.
Undue Exposure to Radiation
Radiation is used to create many images that are needed to help detect, diagnose, and manage injuries and diseases today.
Venous Thromboembolism (VTE)
VTE refers to conditions in which unwanted blood clots form in the body. These clots include both deep vein thrombosis (DVT) and pulmonary embolisms (PE). A DVT is a blood clot that forms in a vein deep in the body; most DVTs occur in the lower leg or thigh. A DVT is especially dangerous when it leads to a loose clot called an embolus, which can travel through the bloodstream and lodge in the lungs. When the clot travels to the lungs and blocks blood flow this is a PE – a very serious condition. PEs damage the lungs and some can cause death. Hospital inpatients can be at an increased risk for VTE – for example, after major surgery or lying still in a hospital bed for a long period of time.
PfP Goal: a 20 percent reduction in venous thromboembolism events.