Designing and Implementing a Zero Harm Falls Prevention Program: A Quality Improvement Study.

BACKGROUND: Inpatient falls with harm have severe implications on patients and the health care system. PURPOSE: We implemented a zero harm approach to falls prevention, which aimed to reduce falls with injury by 25% within 1 year. METHODS: We implemented a multifaceted and multidisciplinary quality improvement falls prevention strategy that included facilitating organization-wide education, adopting the Morse Fall Risk Assessment tool, displaying real-time unit-specific falls rates, and implementing a transparent root-cause analysis process after falls. Our outcome measure was falls with injury per 1000 patient-days. RESULTS: We observed a decrease in the rate of patient falls with injury from 2.03 (baseline period) to 1.12 (1 year later) per 1000 patient-days. We also observed increases in awareness around falls prevention and patient safety incident reporting. CONCLUSIONS: Our zero harm approach reduced falls with injury while improving our patient safety culture.

A Quality Improvement Initiative to Decrease Central Line-Associated Bloodstream Infections During the COVID-19 Pandemic: A "Zero Harm" Approach.

INTRODUCTION: Central line-associated bloodstream infections (CLABSIs) are associated with significant patient harm and health care costs. Central line-associated bloodstream infections are preventable through quality improvement initiatives. The COVID-19 pandemic has caused many challenges to these initiatives. Our community health system in Ontario, Canada, had a baseline rate of 4.62 per 1000 line days during the baseline period. OBJECTIVES: Our aim was to reduce CLABSIs by 25% by 2023. METHODS: An interprofessional quality aim committee performed a root cause analysis to identify areas for improvement. Change ideas included improving governance and accountability, education and training, standardizing insertion and maintenance processes, updating equipment, improving data and reporting, and creating a culture of safety. Interventions occurred over 4 Plan-Do-Study-Act cycles. The outcome was CLABSI rate per 1000 central lines: process measures were rate of central line insertion checklists used and central line capped lumens used, and balancing measure was the number of CLABSI readmissions to the critical care unit within 30 days. RESULTS: Central line-associated bloodstream infections decreased over 4 Plan-Do-Study-Act cycles from a baseline rate of 4.62 (July 2019-February 2020) to 2.34 (December 2021-May 2022) per 1000 line days (51%). The rate of central line insertion checklists used increased from 22.8% to 56.9%, and central line capped lumens used increased from 72% to 94.3%. Mean CLABSI readmissions within 30 days decreased from 1.49 to 0.1798. CONCLUSIONS: Our multidisciplinary quality improvement interventions reduced CLABSIs by 51% across a health system during the COVID-19 pandemic.

Toward Zero Harm: Mackenzie Health's Journey Toward Becoming a High Reliability Organization and Eliminating Avoidable Harm.

OBJECTIVES: In response to an organizational survey revealing low safety culture scores, we implemented a "zero harm" approach to eliminate preventable harm across a wide variety of clinical areas. We aimed to achieve this objective within 3 years. METHODS: We developed a 5-part strategy for cultural and process redesign that included (1) engaging leadership; (2) developing an organization-specific patient safety framework; (3) monitoring specific quality aims based on high-risk, high-volume, high-cost, and problem-prone areas; (4) standardizing a 3-part review process that includes a root cause analysis for moderate and critical patient safety incidents; and (5) communicating progress to staff in real time via unit-specific electronic dashboards. RESULTS: In less than 1 year, we increased patient safety incident reporting by 37% while simultaneously decreasing falls with injury by 39%, pressure injury rates by 37%, and central line-associated blood stream infections by 34%. We also improved medication reconciliation rate by 3.3% and decreased our irretrievable specimen rate to 0. Finally, we noted increased awareness around patient safety within clinical teams, with open discussions about patient safety becoming a routine part of patient care. CONCLUSIONS: This study describes an initiative that sought to introduce system-wide changes to practice and patient safety culture in a rapid time frame. Results suggest that our 5-step approach to transformation may confer substantial gains in patient safety for peer institutions. Next steps include continuing to expand and monitor quality aims as we progress through our journey to eliminating preventable patient harm in our healthcare system.