Types of Preventable Harm in Hospitals

Some of the most common types of preventable errors in health care are hospital-acquired infections (HAIs). Some examples of typical HAIs are methicillin-resistant Staphylococcus aureus (MRSA), central line infections, ventilator-associated pneumonia (VAP), and urinary tract infections (UTIs). Another preventable error is medication error. More than 1 million serious medication errors occur every year in U.S. hospitals (Kuperman et al., 2007). To Err Is Human suggests that there are over 7,000 deaths per year from medication errors (Institute of Medicine, 1999). Two additional hospital-acquired conditions are wrong-site surgeries and objects being left in patients during surgery. Although it does not seem feasible that errors like these could happen, these serious and not-so-uncommon events do occur. Another preventable error and the focus of this case study is patient falls.

Falls are the leading cause of injury among adults sixty-five years old or older. In 2005, the total cost of falls in the entire U.S. health care system was $23.6 billion (Roudsari, Ebel, Corso, Molinari, & Koepsell, 2005). Estimates of costs for a fall in the hospital range from $4,000 to $37,000 (Inouye, Brown, & Tinetti, 2009; Rizzo et al., 1998; Wong et al., 2011). The caveat to the costs that hospitals incur to fix their mistakes is that as of October 1, 2008, the Centers for Medicare & Medicaid Services (CMS) will not reimburse costs for treating certain hospital-acquired (preventable) conditions. Falls in hospitals, along with several other hospital-acquired conditions, are among the original conditions Medicare will not cover the cost of treating due to their preventability (CMS, 2008).

Geisinger Quality Institute

The Geisinger Quality Institute (GQI) is a subdivision of the Division of Quality and Patient Safety within GHS. GQI employs full-time process improvement specialists, or coaches. These specialists travel throughout the entire Geisinger system. GQI specialists serve as coaches to facilitate improvement work that goes on in a clinical microsystem. A clinical microsystem in health care delivery is defined as a small group of people who work together on a regular basis to provide care to discrete subpopulations, including patients (Dartmouth Institute for Health Policy and Clinical Practice, 2012). GQI specialists embed themselves in a microsystem in order to address an issue or problem the group is facing. Their work is done methodically, through educational meetings and exercises using teaching tools. Groups learn quality improvement tools and apply these tools to the problems they are trying to address. The specialist also helps the microsystem implement several Plan, Do, Study, Act (PDSA) cycles in order to test potential solutions to the problems.

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