A Framework and Methodology for Achieving Region-Wide Patient Safety Improvements

Abstract

Adverse patient events, including nosocomial (hospital-acquired) infection rates and medication errors, are among the nation's most pervasive patient safety problems. The Pittsburgh Regional Healthcare Initiative (PRHI), a regional coalition for healthcare quality improvement, has identified the elimination of medication errors and nosocomial infections as a primary goal. PRHI has facilitated the implementation and use of two different reporting systems in all 30 of its member hospitals designed to facilitate work toward this goal: 1) the Centers for Disease Control (CDC) National Nosocomial Infection Surveillance System (NNIS); and 2) the US Pharmacopeia (USP) MedMARx®, a medication error reporting system. The aims of this study are to understand 1) how well the reporting systems and their standards of use succeed in generating usable information; 2) how well feedback review systems, related to the reporting, function; and 3) the problem-solving systems through which knowledge is translated into organizational and inter-organizational learning. The methodological approach reflects a systems view, includes several levels of analysis, and utilizes triangulation of both qualitative and quantitative data. Data collection components include hospital profiles, site visit interviews, structured diaries, surveys, intervention case studies and report design feedback forms, along with data collected from the reporting systems themselves.