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Checklists to Improve Patient Safety

AHA’s Health Research and Educational Trust has just released a series of 10 evidence-based checklists for improving patient safety in these areas:

  1. Adverse drug effects
  2. Catheter-associated urinary tract infections
  3. Central line-associated blood stream infections
  4. Early elective deliveries [Cesarean]
  5. Injuries from falls and immobility
  6. Hospital-acquired pressure ulcers
  7. Preventable readmissions
  8. Surgical site infections
  9. Ventilator-associated pneumonias and events
  10. Venous thromboembolisms

For additional information, ‘change packages’ for each checklist topic are available on the AHA/HRET Hospital Engagement Network [HEN] web site at www.hret-hen.org.

Source: Checklists to improve patient safety; signature leadership series. Health Research and Educational Trust in partnership with American Hospital Association, June 2013. http://www.hpoe.org/Reports-HPOE/CkLists_PatientSafety.pdf

Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Best practices for decreasing incidence of pressure ulcers

 Allina Hospitals & Clinics (MN) involved all 10 system hospitals in a pressure ulcer initiative beginning in 2008.  Components of the initiative, as described (Sendelbach, et al., 2011) include standardized surveillance and reporting, standardized education, point-of-care resources, nutritional intervention, EHR documentation, and a provider awareness campaign.  The article includes Allina’s Pressure Ulcer Prevention Algorithm.  This initiative was successful in reducing pressure ulcers — with a potential cost savings systemwide of as much as $430,000.   Another case study, featuring Buena Vista Regional Medical Center (Storm Lake, IA), has been published by the Health Research & Educational Trust (2010).  After implementing the pressure ulcer prevention bundle from the Institute for Health Improvement (2008), Buena Vista was able to cut the pressure ulcer incidence rate. 


Health Research & Educational Trust.  Decreasing pressure ulcers through skin care.  Chicago: Health Research & Educational Trust, 2010. 

Institute for Healthcare Improvement.  Getting Started Kit: Preventing Pressure Ulcers, How-To GuideCambridge, MA: IHI, 2008. 

Sendelbach, S., Zink, M., and Peterson, J.  Decreasing pressure ulcers across a healthcare systemJONA. The Journal of Nursing Administration;41(2):84-89, Feb. 2011.

Annual Cost of Medical Errors Estimated at $17.1 Billion

Analysts with the actuarial firm Milliman estimate that measurable medical errors cost the nation $17.1 billion in 2008. Pressure ulcers, postoperative infections, and post-laminectomy syndrome were the most frequently occurring errors identified in their examination of medical claims data. Ten types of errors were the most costly, accounting for two-thirds of annual medical error costs. Postoperative infections, pressure  ulcers, and mechanical complication of a noncardiac device, implant, or graft topped the most costly list of errors. Data is provided on the incidence,  expense per error,  and the national aggregate cost for each of the most frequent and most costly error types.

Source: Van Den Bos J and others. The $17.1 billion problem: the annual cost of measurable medical errors. Health Affairs, vol. 30, no.4, Apr. 2011, pp. 596-603. http://content.healthaffairs.org/content/30/4/596.abstract