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".
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Anticoagulants: A city-wide list of anticoagulant patient safety practices was developed and
implemented with assistance from the Institute for Safe Medicine Practices (ISMP).
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IV Pump High Risk Drug Alerts: The Coalition applied for and received a research grant from
Cardinal Health Corporation 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.
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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.
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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.
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The Medication List: a patient education campaign will be 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.
Surgical Safety
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.
Peer Reviewed Root Cause Analysis Review
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 Campaigns
The Coalition hospitals pledge to cooperate and implement the initiatives aimed to protect
patients from incidents of medical harm in U.S. hospitals.
"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 pledge to improve utilization and
implementation of evidence based treatment order sets and evidence based tools to screen
for Sepsis.
Central Line Blood Stream Infections and Urinary Tract Infections
These are targeted as potential underlying causes for Sepsis with the goal of implementing
one standardized clinical bundle within all Coalition hospitals.
MRSA (Methicillin Resistant Staphylococcus Aureus)
Four 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.
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.
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 2008 award winner topics by
hospital are listed below:
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Clarian: Pediatric Culture of Safety Survey Initiative for IV Assessments
Clarian
Pediatric Culture of Safety Survey Initiative for IV Assessments
From left to right:
- Judy Monroe, MD - Indiana State Dept. of Health - State Health Commissioner
- Marilyn Cox, RN, MSN - Quaility and Patient Safety Team - Riley Hospital
- Daniel F. Evans, Jr. - President & CEO - Clarian Health Partners
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Community Health Network: Private Room Neonatal Intensive Care Unit
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Richard L Roudebush VA Medical Center: Cardiac Surgery Glucose Control
Richard L Roudebush VA Medical Center
Cardiac Surgery Glucose Control
From left to right:
- Judy Monroe, MD - Indiana State Dept. of Health - State Health Commissioner
- William Watson, RN, BSN - Cardiac Surgery Glucose Control Surgery Team
- Thomas Mattice - Medical Center Director - Roudebush VA Medical Center
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St Francis Hospital and Health Services: medication error events and analysis process
St Francis Hospital and Health Services
Medication error events and analysis process
From left to right:
- Judy Monroe, MD - Indiana State Dept. of Health - State Health Commissioner
- Charles Kinsella, MD - MEDS Team
- Theresa Staublin, PharmD - MEDS Team
- Robert Brody, President & CEO, St. Francis Hospital and Health Services
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St Vincent Health: Implementation of Hourly Rounding With Patients and Families
St Vincent Health
Implementation of Hourly Rounding With Patients and Families
From left to right:
- Vincent Caponi - CEO - St. Vincent Health
- Eileen Schneider, RN, BSN - Hourly Rounding Team
- Judy Monroe, MD - Indiana State Dept. of Health - State Health Commissioner
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Wishard Health Services: Emergency Department Diversion Avoidance
Wishard Health Services
Emergency Department Diversion Avoidance
From left to right:
- Judy Monroe, MD - Indiana State Dept. of Health - State Health Commissioner
- Tracy Martin - Director, Emergency Department - Diversion Avoidance Team
- Margie Payne - CEO, Midtown Mental Health - Vice President, Mental Health
Operations - Diversion Avoidance Team
- Lisa E. Harris, MD - CEO & Medical Director - Wishard Health Services
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Suburban Health Organization: Leadership In Patient Safety
Suburban Health Organization
Leadership In Patient Safety
From left to right:
- Judy Monroe, MD - Indiana State Dept. of Health - State Health Commissioner
- Lynn Bowers, MD - Patient Safety Leadership
- Dennis Dawes - CEO, Hendrics Regional Health - Suburban Health Organization