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First do no harm: integrating patient safety and quality improvement
Zubina Mawji1, Paula Stillman, Robert Laskowski
1Lehigh Valley Hospital and Health Network, 1210 S Cedar Crest Blvd, Suite 3600, Allentown, PA 18103, USA. zubina.mawji@lvh.com
The Joint Commission Journal on Quality Improvement
|July 10, 2002
Summary
Lehigh Valley Hospital improved patient safety by implementing targeted interventions for wrong-site surgery. This quality improvement initiative led to near 100% compliance and eliminated near misses.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety Initiatives
- Medical Error Reduction
Background:
- Lehigh Valley Hospital (LVH) implemented the Primum Non Nocere (PNN) quality improvement program.
- The PNN program comprises 12 projects focused on patient safety and cost-effective care.
- Projects utilize improved communication, process redesign, and evidence-based protocols.
Purpose of the Study:
- To address and reduce the incidence of wrong-site surgery.
- To improve adherence to surgical site marking policies.
- To enhance patient safety through systematic quality improvement.
Main Methods:
- Developed a policy for surgical site marking in response to an alert.
- Conducted root cause analysis for policy non-compliance.
- Implemented stepwise interventions based on subsequent alerts and analysis.
Main Results:
- Initial policy faced challenges with adherence due to unspecified procedures and lack of prompts.
- Post-intervention, compliance with the surgical site marking policy reached nearly 100%.
- No further near misses related to wrong-site surgery were reported in the year following interventions.
Conclusions:
- Overcoming institutional resistance to rapid change is crucial for quality improvement.
- Defining measurable outcomes is essential for successful process redesign.
- Project sustainability depends on addressing encountered barriers and initial project strengths.