Patient Safety Learning Laboratory: Making Acute Care More Patient-Centered

Hospitalizations with the presence of any of the following: Patient Falls with Injury, Severe Hypoglycemia, Inpatient or post hospitalization venous thromboembolism, catheter associated urinary tract infection (CAUTI), Central Line Associated Blood Stream Infection (CLABSI), Opioid related severe adverse drug event, hospital acquired pressure ulcer, severe hospital acquired delirium, rapid response related to arrhythmia

monitoring time for flags to change within patient safety information technology tools

monitoring time for flags to change within patient safety information technology tools

monitoring time for flags to change within patient safety information technology tools

monitoring time for flags to change within patient safety information technology tools

Processes of care: % patient days of patients at fall risk due to a gait disturbance on sedatives

Processes of care: % patient-days of patients at fall risk due to a gait disturbance without Physical Therapy consult order

Processes of care: % patient-days on study unit with unconfirmed code status

Processes of care: % patients with diabetes or hyperglycemia with order for basal insulin

Processes of care: % patients with diabetes or hyperglycemia with orders for basal and nutritional insulin

Processes of care: % patient-days without any diet order

Processes of care:% pt-days NPO with insulin aspart ordered at same time

Processes of care: % patient-days with appropriate prophylaxis ordered based on risk and contraindications

Processes of care: % pt-days with appropriate prophylaxis administered based on risk and contraindications

Processes of care: % ordered pharmacologic prophylaxis doses administered

Processes of care: % pt-days with MED > 100 mg

Processes of care: % patient-days with opioids ordered and no adjunctive medications ordered

Processes of care: % pt-days with opioids administered and no Richmond Agitation-Sedation Scale (RASS) score recorded

Processes of care: % pt-days with patients on broad-spectrum gram-positive and broad-spectrum gram-negative antibiotics for > 72 hours

Processes of care: % patient-days with patients on broad-spectrum antibiotics for > 72 hours

Processes of care: % patient-days Confusion Assessment Method (CAM) positive

Processes of care: % patient-days of patients at high risk for delirium on sedatives

Processes of care: % patient-days of patients at high risk for delirium on ramelteon

Processes of care: % patient-days of patients with hyperactive delirium on neuroleptics

Processes of care: % patient-days with central line in place

Processes of care: % patient-days with Foley catheter in place

Processes of care: % patient-days with Foley documented but not ordered

Processes of care: % patient-days with Foley documented but NDP not ordered

Processes of care: % patient-days of high risk patients without any telemetry bottom page 5 mock tables

Processes of care: % patient-days of low risk patients on telemetry > 72h

Processes of care: % pt-days of patients on opioids and no bowel regimen ordered

Processes of care: % patient-days where on opioids, no bowel movement 2 or more days, and no bowel regimen administered

Safety Outcomes: Patient Falls based on safety reports per 1000 patient-days

Safety Outcomes: Falls with injury based on safety reports per 1000 patient-days

Safety Outcomes: Patient-day-weighted mean glucose

Safety Outcomes: Proportion of glucose readings 70-180 mg/dL, mean per patient

Safety Outcomes: Proportion of patient-days with hypoglycemia

Safety Outcomes: Proportion of patient-days with severe hypoglycemia

Safety Outcomes: proportion of hospitalizations with hospital-acquired VTE

Safety Outcomes: proportion of hospitalizations with VTE within 30 days of discharge

Safety Outcomes: proportion of hospitalizations with opioid induced depression of consciousness or respiration

Safety Outcomes: proportion of hospitalizations of patients on opioids who required narcan

Safety Outcomes: proportion of patients on opioids who had rapid response, code blue, ICU transfer, Bipap, mechanical ventilation

Safety Outcomes: proportion of hospitalizations of patients on opioids with any opioid-related Adverse Drug Event

Safety outcomes: proportion of hospitalizations with hospital-acquired pressure ulcer

Safety outcomes: proportion of hospitalizations with hospital-acquired pressure ulcer worsening in stage from admission to discharge

Safety outcomes: proportion of hospitalizations requiring mechanical restraints

Safety outcomes: proportion of hospitalizations requiring code gray and requiring security

Safety outcomes: Central Line Associated Blood Stream Infection (CLABSI) per 1000 patient-days

Safety outcomes: Central Line Associate Urinary Tract Infection per 1000 patient-days

Safety outcomes: proportion of hospitalizations for rapid response for arrhythmia

perceived teamwork climate on hospital care units based on Agency for Healthcare Research and Quality (AHRQ) patient safety climate survey

Patient and caregiver perceptions of how well clinical team kept them safe based on Patient Activation Measure (PAM 13)

usability of technology- ease of use based on Health iTues survey

cognitive burden based on direct observations

use of tool by providers and patients

Length of stay of patients

Rate of submissions into the MySafeCare reporting tool per 1000 patient days (confidence interval)

Other Clinical Outcomes: Proportion of hospitalizations with cardio-respiratory code or rapid response

Other Clinical Outcomes: Proportion of hospitalizations with ICU transfer

time of discharge averaged

Patient Activation as measured by the PAM 13 survey

30-day non-elective readmission

Patient Satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)