A customized tool is helping to improve patient outcomes in Pipeline Health System’s hospitals. Called a Harm Prevention Index, the tool helps to track incidents of harm to patients – injuries that result from the patients’ care, not their disease.
Each month staff in the Infection Prevention, Pharmacy and Quality departments tabulate 10 measures in all five Pipeline hospitals:
- Adverse events not listed otherwise
- Hospital-acquired pressure ulcers
- Falls resulting in minor injuries
- Medical errors
- Adverse drug events
- Hospital-acquired blood clots
- Central-line associated blood stream infections
- Catheter-associated urinary tract infections
- difficile infections
- Antibiotic-resistant staph infections
Pipeline’s Chief Medical Officer Vincent Green, M.D., and Corporate Quality Director Percy Cupen modeled the company’s program after Harm Across the Board, a strategy developed by the American Hospital Association and the Partnership for Patients, a part of the Centers for Medicare and Medicaid Services.
A graph shows a clear reduction in the number of incidents per thousand patient discharges from Pipeline’s hospitals since the index was adopted in 2021. The line at 15 indicates a benchmark for the average harm index.
“Our employees should be proud because it’s a team effort,” Green said. “It’s not just one department or one group. It’s everything. It’s nursing and it’s housekeeping ‑- housekeeping staff help prevent slips and falls.”
Green commended concerted efforts to improve in major problem areas, such as preventing catheter-associated urinary tract infections.
“We have had the greatest success in reducing our hypoglycemic events, in which diabetic patients had their blood sugar drop too low. We put extra effort and processes in place to make sure we double check. Before we give someone their morning dose of insulin, we make sure they’re going to eat breakfast. If they’re going to have a procedure and go under general anesthesia, they would not have food,” Green said.
“The graph shows tremendous improvement, but we haven’t gone down to zero,” he said. “Now it’s time to move the goal posts. Our ultimate goal is no patients harmed ever.”
Employees with additional harm prevention ideas should contact Green directly at [email protected]. Suggestions are welcome.