Case Studies
The ºÚÁÏÕýÄÜÁ¿ Association produces case studies on its member organizations across a wide range of health-care topics.
Inappropriate stress ulcer prophylaxis is a serious problem across the health care continuum. Literature has shown that the overuse of acid suppression therapy, especially proton pump inhibitors, has been associated with an increase in Clostridium difficile, diarrhea, pneumonia, osteoporotic…
A history as a resource-challenged urban safety net hospital with a high-risk population, a lack of consistent and effective leadership and the absence of hard-wired clinical practices resulted in a perinatal program that failed to meet established standards or leadership's expectations. This was…
As identified in its 2014 Culture of Safety survey, the hospital's overall mean score for the standard questions was 64.0, which was 0.4 points higher than the prior year. However, when compared to the all facility benchmark for the standard questions score, the organization was 2.4 points below,…
The health system did not have an adequate process for notifying staff when a patient was on contact precautions due to Clostridium difficile (C. diff) infection as opposed to a different drug-resistant organism, such as methicillin-resistant Staphylococcus aureus. As a result, staff members were…
Boarding patients in the emergency department (ED) is detrimental to patient care, and evidence suggests that critical care patients boarded in the ED have longer lengths of stay and higher mortality rates. From April 2013 to September 2014, the hospital had an average of more than 934 nursing…
The neurosurgery service at this Level I trauma center had experienced high rates of surgical site infections (SSIs) for several years. From January 2013 to December 2014, the SSI rate associated with spinal fusion surgery was 11.40 infections per 100 procedures, while the national average was…
The organization initiated a project identified by the Infection Control Committee to reduce Foley catheter days or prevent catheter use entirely in order to eliminate urinary tract infections. Previously, insertion of a Foley catheter was standard procedure for admission to the intensive coronary…
Patient falls during hospitalization can lead to increased inpatient care costs, decreased patient satisfaction, an increase in unnecessary tests and treatments, longer lengths of stay, functional decline, disability and death. According to the Centers for Disease Control and Prevention, the…
Medical dispense overrides allow nurses to dispense medications from the Pyxis machine without pharmacy review in emergency situations. However, increasing the incidence of medication overrides can lead to greater risk of medication errors. For the period between Jan. 1, 2014, and March 31, 2014, a…
The organization used Lean Six Sigma process techniques to identify and support improved efficiencies in Medicare wheelchair approval within a durable medical equipment hospital affiliate. The improvement process focused on reducing wait time and creating additional capacity for newly referred…