Focus Areas

The Indianapolis Coalition for Patient Safety is committed to finding solutions to patient safety issues. Although the definition of patient safety is not universally agreed upon by experts, the intent and goal of all definitions is clear: keep patients safe in healthcare settings. The Indianapolis Patient Safety Coalition has focused on several areas in reaching that goal.

• High-alert drugs: Anticoagulants (blood thinners) and insulin are commonly used in hospitals, but are considered by experts to be "high alert drugs", meaning they could put patients at high risk of serious injury if mishandled.
  • Anticoagulants: The Joint Commission of Accreditation of Healthcare Organizations (JCAHO) has set anticoagulation safety as a national patient safety goal for 2008. In December of 2006, ICPS started work with the Institute of Safe Medicine Practices on a citywide set of anticoagulation patient safety measures designed to address anticoagulant safety.
  • IV Pump Drug Alerts: The Coalition applied for and received a research grant from Cardinal Health Corporation to study infusion pump alerts for selected high-alert drugs.  The goal of the research is to conduct a common cause analysis by trending root causes for alerts and overrides and take action to further reduce risk with use of high alert medications.
  • Insulin: Eli Lilly and Company sponsored a Six Sigma process improvement work team to address safety around the use of insulin in hospitals; Wishard Health Services was selected to participate from a pool of local providers. A multidisciplinary team of Lilly and Wishard experts - including hospital leadership, nurses, pharmacists and other providers that specialize in diabetes care - led a "be the vial" exercise, analyzing the insulin delivery and administration process from the receiving dock to the patient's bedside. Measures to improve the overall safety of insulin use in the hospital setting were identified, which may result in an even safer environment for patients. This learning will be shared with ICPS hospitals.
• Surgical Safety: Indianapolis Coalition for Patient Safety member institutions have largely implemented a standard set of best practices for surgery and procedure safety to include Site Marking and a Time Out Policy based on best current practice known at the time.  In addition to applying the best evidence to all member hospitals, the standardized set of practices will provide continuity to physicians and staff who travel between hospitals.
• Peer Reviewed Root Cause Analysis Review: Building on the work of the Indiana Medical Error Reporting System, the Indianapolis Coalition for Patient Safety, as a peer-review organization, has shared information from adverse events to facilitate member learning so as to prevent the same event from occurring in other member hospitals.
• Institute for Healthcare Improvement ‘100,000' Lives Campaign : The Coalition hospitals pledged to cooperate and implement the initiatives aimed to protect patients from incidents of medical harm in U.S. hospitals.  Work groups led by front line healthcare representatives from each of the organizations were established to collaborate and implement safe practices recommended under the IHI Campaign.
• Targeting Severe Sepsis: The Coalition uses comparative mortality data to identify significant safety improvement opportunities.  Sepsis emerged as a priority area due to increased patient length of stay and high mortality risk.  Mid-2008 the Sepsis Team obtained administrative support from all Coalition hospitals to improve utilization and implementation of evidence-based treatment order sets and evidence-based tools to screen for Sepsis.
• Methicillin Resistant Staphylococcus Aureus (MRSA): Coalition hospitals participated in Phase I of the IU Center for Health Services and Outcomes Research collaborative project aimed at reducing MRSA infection rates in Indianapolis hospitals.  The project helped improve preventive practice adherence and resulted in a significant reduction in MRSA infection rates on study units.