What hospitals can do to curb adverse events, preventable harm

As medical care becomes more advanced, the complexity multiplies, and so does the potential for adverse events. Sophia Bernazzani There is potential for harm at almost every step of a patient’s care. From the moment a patient walks through the door (misidentification, drug reactions, hospital-acquired infections) to when they walk out (falls, pressure ulcers, incomplete after care instructions) every interaction has the potential to put a potential harm into motion.

Preventable errors are multifactorial. A study by the RAND Corporation indicates approximately 30 percent of errors can be linked to negligence--the rest are the result of combinations of unintentional human error and system failure. These events cost hospitals an estimated $17 billion a year, according to an article published by Wolters Kluwer Law & Business.

What can hospital administrators do?

In general, hospital executives can start by employing a few basic strategies. They can set attainable, but lofty, goals for reducing preventable harm, and ensure transparency through the reporting of adverse events and communication with patients. Data also plays a critical role in reducing the frequency of adverse events. Key decision-makers must have access to useable real-time data, and strong data collection methods and process monitoring help leaders adjust plans to fit real-world conditions.


Most importantly, administrators need to make and disseminate specific plans. The following is a list of key safety strategies from the Agency for Healthcare Research and Quality:

1. Preoperative checklists and anesthesia checklists to prevent operative and post-operative events

2. Bundles that include checklists to prevent central line-associated bloodstream infections

3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders or nurse-initiated removal protocols

4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine and subglottic-suctioning endotracheal tubes to prevent ventilator associated pneumonia

5. Hand hygiene

6. “Do Not Use” list for hazardous abbreviations

7. Multicomponent interventions to reduce pressure ulcers

8. Barrier precautions to prevent healthcare-associated infections

9. Use of real-time ultrasounds for central line placement

10. Interventions to improve prophylaxis for venous thromboembolisms

11. Multi-component interventions to reduce falls

12. Use of clinical pharmacists to reduce adverse drug events

13. Documentation of patient preferences for life-sustaining treatment

14. Obtaining informed consent to improve patients’ understanding of the potential risks of procedures

15. Team training and Use of simulation exercises in patient safety efforts

Are there practical examples of change?

Most efforts to reduce harms within an organization require leadership to spearhead changes in system design, including possible reorganization of resources by top-level management.

A great example of this is Nathan Littauer Hospital in Gloversville, New York, which changed the way it reported information to the board of trustees on quality and safety to make the reports more clear and concise. With continued improvements in reporting, the board was able to execute systematic changes that lowered the health system’s harm rate significantly.

While errors in medication, surgery and diagnosis are the easiest harms to catch and detect, medical errors are just as frequently the result of problems with the organization of healthcare delivery and the way that resources are provided to the delivery system. In order to have a lasting effect, strategies and tactics to reduce harm have to be specific to the problem and targeted for a desired result. These strategic programs build upon each other--magnifying impact and creating a culture of safety and accountability system wide.

Little Company of Mary Hospital in Evergreen Park, Illinois, created just such a culture and was awarded with a coveted Truven Health Everest Award for its successful launch of several improvement initiatives, including one very successful effort to prevent catheter-associated urinary tract infections via a nurse-led campaign to reduce catheter use.

Moving forward

Everyone wants patients to have the best possible outcomes, but reducing adverse events leadership and strategy. As an administrator and executive, you must know and understand your hospital’s bottom line in patient safety and have good tracking and reporting systems in place to institute change. Continual improvement in how we use these systems will contribute to more sophisticated data outputs. This, coupled with transparency, will create opportunities to improve patient safety and ultimately affect the bottom line of health systems.

Sophia Bernazzani is the community manager for MHA@GW, the online master of health administration from the Milken Institute School of Public Health at the George Washington University.