Hospital and Healthsystem Association of Pennsylvania Hospital Improvement Innovation Network
On September 28, 2016, HAP was awarded one of the 16 primary federal contracts for HIIN. The Patient Safety Authority has formed partnerships with HAP and other Pennsylvania healthcare organizations to work with Pennsylvania hospitals to reduce healthcare-acquired conditions. The goals of the HIIN are to achieve the following:
The Authority’s success in previous partnerships with HAP has led to the leadership of the Authority on the adverse drug events, prevention of falls with harm, and culture of safety projects. The Authority is also leading a project with the Health Care Improvement Foundation to reduce emergency department radiologic diagnostic errors. The Authority issued a press release, "The Authority to Focus on Four Patient Safety Areas," in November 2016 that can be found on the Authority’s website.
The analyses upon which this publication is based were performed under Contract Number HHSM-500-2016-00066C, entitled, "Partnership for Patients Hospital Improvement Innovation Network Contract, sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services."
Preventing Wrong-Site Anesthesia Nerve Blocks
Wrong-site local and regional anesthesia nerve blocks represent a significant portion of wrong-site operating room procedures. Between July 1, 2004, and December 31, 2016, wrong-site nerve blocks performed by anesthesiologists and surgeons comprised 25.9% of all wrong-site procedures reported through PA-PSRS. Given that only a fraction of patients who are vulnerable to wrong-site surgery receive anesthesia in the form of blocks, the proportion of wrong-site anesthesia blocks is notable.
The Patient Safety Authority has partnered with the Pennsylvania Society of Anesthesiologists for the following:
To evaluate current practices for preventing wrong-site/side blocks, through interviews with expert panel members and stakeholders including anesthesiologists, surgeons, nurses, and patient representatives.
To conduct a systematic literature review that will be used as a knowledge base for developing a guidance document.
To draft and disseminate guidance and resource document(s) to address wrong-site/side regional anesthesia block prevention for physicians, nurses, and healthcare facilities.
PSA Resident Safety Program for Antibiotic Stewardship in Long-Term Care
In September 2017, the Patient Safety Authority began a collaboration with long-term care facilities to reduce overall antibiotic use and create an antibiotic stewardship program. Thirty long-term care facilities participated in the program. The program will conclude in the fall of 2018, at which time the facilities will have:
Developed and sustained a multidisciplinary antibiotic stewardship workgroup
Incorporated antibiotic stewardship into the infection control plan, policies, procedures, and QAPI program
Implemented a stewardship education and communication program for clinicians, residents and families
Leveraged monitoring and tracking outcomes to improve optimal antibiotic usage
Made use of stewardship tools to sustain improvements
Completed Collaborative Projects
The Patient Safety Authority has completed successful collaborations that have reduced falls with harm, phlebotomy mislabeling events, wrong-site surgeries, day of surgery cancellations and transfers to acute care, and long-term care catheter associated urinary tract infections. Tools can be found under Patient Safety Topics and additional information can be found in our Annual Reports.
Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care: HAIs/CAUTI
Ambulatory Surgical Facility Perioperative Screening and Assessment Collaboration
Comprehensive Unit-based Safety Program to Reduce Central Line-Associated Blood Stream infections with the Hospital and Healthsystem Association of Pennsylvania
Delaware Valley Falls Reduction with The Health Care Improvement Foundation
Delaware Valley Wrong-Site Surgery Prevention with The Health Care Improvement Foundation
PA - NSQIP, National Surgical Quality Improvement Program
Phlebotomy Specimen Labeling
Western Pa. Surgical Site Infection Prevention Collaborative (WSSI)
Hospital and Healthsystem Association of Pennsylvania (HAP) Hospital Engagement Network 1.0 and 2.0*:
- Falls Reduction and Prevention
- Preventing harmful ADE related to anticoagulants, insulin and opioids
- Preventing Wrong-Site Surgery
- Culture of Safety Education
- Assisted with HAPs HAI projects
The analyses upon which this publication is based were performed under Contract Number HHSM-500-2015-00300C, entitled, "Partnership for Patients Hospital Engagement 2.0 Contract."