High-Risk Drugs
Anticoagulants (blood thinners), insulin, narcotics/opiates, etc. are commonly used
in hospitals, but are considered by experts to be "high risk drugs".
- Anticoagulants: A city-wide list of anticoagulant patient safety
practices was developed and implemented with assistance from the Institute for Safe
Medicine Practices (ISMP). Completed in 2008
- IV Pump High Risk Drug Alerts-Ongoing: The Coalition applied for and received a
research grant from Cardinal Health Foundation to study infusion pump alerts for selected
high risk 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
risk medications.
- Insulin: A team of experts from Lilly led a “be the vial” exercise with
hospital teams from Wishard Health Services and from the Indiana Heart Hospital. Strategies
to eliminate potentially unsafe process steps were implemented and ongoing measurement continues
to sustain the changes made to insure a safer environment for patients and staff. Completed in 2009
- Standardized names, concentrations, and dosage units for high risk IV infusion
medications: Standardizing IV infusion drug concentrations among Coalition hospitals
reduces the chance of error as nurses frequently travel between systems. Tools and resources to
assist hospitals with implementation were developed. Completed in 2009
- The Medication List-Ongoing: A patient education campaign has been launched to
stress the importance of patients maintaining a current list of their medications and presenting
that list to each provider of care. Initially education will target hospital staff and their families.
Moreover Eli Lilly and Co and Anthem Inc have joined the campaign targeting their own employees.
Goodwill Industries are targeted for 2011.
Surgical Safety-Ongoing
One standard Universal Protocol has been implemented across all hospitals. The standardized set of
practices will provide continuity to physicians and staff who travel between hospitals. Universal
guidelines to prevent respiratory failure post operative from pain analgesia which include the use of
Capnography were developed, published and implemented. Working on developing and implementing a
simulation on surgical safety during the loss of power in the Operating room.
Peer Reviewed Root Cause Analysis Review-Ongoing
Indianapolis Coalition for Patient Safety, as a peer review organization, has shared information
from more than seven adverse events to facilitate member learning so as to prevent the same event
from occurring in other member hospitals.
Institute for Healthcare Improvement (IHI) Campaigns
The Coalition hospitals implemented the “Saving 100,000 Lives” initiatives aimed to
protect patients from harm. Completed in 2008.
"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.
Coalition hospitals pledged to improve utilization and implementation of evidence based treatment
order sets and evidence based tools to screen for Sepsis. Completed in 2009.
Central Line Blood Stream Infections and Urinary Tract Infections-Ongoing
These are targeted as potential underlying causes for Sepsis .The coalition team developed and
implemented evidence based protocols to prevent and lower risk of patients developing infections.
Completed in 2010.
MRSA (Methicillin Resistant Staphylococcus Aureus)
Two Coalition hospitals are participating in Phase 2 the IU Center for Health Services and Outcomes
Research collaborative aimed at reducing MRSA infection rates in Indianapolis hospitals.
Completed in 2010.
Patient Alert Wristband Standardization
Many hospitals use color-coded patient wristbands to alert caregivers to certain patient risks such as
allergies and fall risk. Coalition hospitals are adopting the American Hospital Association standardized
colors for alert wristbands. Completed in 2009.
Preventable Congestive Heart Failure Patient Readmissions-Ongoing
The team collaborated with The Indiana Chapter of American College of Cardiology and developed
implementable tactics to improve preventable heart failure readmissions.
In process of implementing tactics.
Diabetes: Transitions In Care-Ongoing
The group has collaborated with the Robert Wood Johnson Aligning Forces Grant and Health Care Excel
and Indiana Hospital Association to improve transitions of care from hospital discharge of patients
with diabetes back to ambulatory care.
Patient Safety "Hero" Awards
Annually the Coalition recognizes an individual or a group within each member hospital
that has championed a specific patient safety project. The 2010 award winner topics
by hospital are listed below:
- IU Health: pressure ulcer prevention teams (Methodist Hospital,
Riley Hospital for Children, Indiana University Medical Center)
IU Health
pressure ulcer prevention teams (Methodist Hospital, Riley Hospital for Children, Indiana University Medical Center)
From left to right:
- Sam Odle
- Mary Sitterding
- Joyce Pittman
- Greg Larkin
- Community Health Network: MRSA reduction teams (North, South, East, The Indian Heart Hospital)
- Richard L Roudebush VA Medical Center: Acute and Critical Care Committees
Richard L Roudebush VA Medical Center
Acute and Critical Care Committees
From left to right:
- Greg Larkin
- Imtiaz Munshi
- Tom Mattice
- St Francis Hospital and Health Services:
Shelley Voelz and Dr. Douglas Johnstone, St. Francis Hospitals and Health Centers, Indianapolis
St Francis Hospital and Health Services
Shelley Voelz and Dr. Douglas Johnstone, St. Francis Hospitals and Health Centers, Indianapolis
From left to right:
- Greg Larkin
- Doug Johnstone
- Shelley Voelz
- Bob Brody
- St Vincent Health: Beverly Reed, St. Vincent Indianapolis Hospital
St Vincent Health
Beverly Reed, St. Vincent Indianapolis Hospital
From left to right:
- Greg Larkin
- Beverly Reed
- Vince Caponi
- Wishard Health Services: PCA Administration Team
Wishard Health Services
PCA Administration Team
From left to right:
- Greg Larkin
- James Fuller
- Betsy Vance
- Lisa Harris
- Suburban Health Organization: Patricia Owens, Hendricks Regional Health, Danville
Suburban Health Organization
Patricia Owens, Hendricks Regional Health, Danville
From left to right:
- Greg Larkin
- Patricia Owens
- John Sparzo