This program will support a partial pharmacist position dedicated to discharge medication reconciliation at Aurora West Allis Medical Center. This pharmacist will integrate with other aspects of the BOOST^® (Better Outcomes for Older adults through Safe Transitions) program that is already in place at the hospital. The pharmacist will reconcile the discharge medication list with the patient's pre-admission medication list and the inpatient medications. The pharmacist will review the discharge medications for completeness, accuracy and appropriateness, and provide recommendations to the physician regarding therapeutic changes and monitoring. After the discharge medication list is finalized, the pharmacist will create a medication discharge plan consisting of educational materials and a medication list for the patient that specifies indications and highlights new, changed, and discontinued drugs. Additionally, the pharmacist will coach the discharging nurse on specific counseling points that should be reviewed with the patient using the Teach-Back method. The goal is to optimize drug therapy at discharge, provide appropriate education and ultimately prevent medication-related readmissions.

This program aims to establish a new standard medication reconciliation protocol in the Departments of General Internal Medicine and Family Medicine at the Cleveland Clinic. Objectives are to design a standard protocol by the expert panel, to implement a pilot program, to evaluate and quantify the impact of the standard protocol, and to revise the standard protocol based on feedback from the participants. Potential key processes include analyzing current work flow, developing policies and procedures that assign primary responsibility for tasks to receptionists, medical assistants and physicians, identifying a time frame for completing medication reconciliation, using a standardized form in the electronic medical records (EMR) and resolving all discrepancies by the primary care physician. One of 17 Cleveland Clinic regional primary care sites will be selected to implement the pilot program. The standard protocol will be implemented with necessary work flow adjustments and EMR enhancements. The pilot program will be evaluated via both qualitative and quantitative approaches. The Clinic expects that the standard protocol will: (1) reduce EMR medication list discrepancies by 20%; (2) increase satisfaction, efficiency and patient medication compliance by 1 point out of 10 points.

The Culpeper Regional Hospital (CRH) and the Rappahannock-Rapidan Community Services Board/Area Agency on Aging (RRCSB/AAA) will expand collaborations to help residents in the rural county of Culpeper, Virginia to receive quality care during the transition from hospital to home through the Bridges of Care Partnership. The goal is to reduce thirty-day readmissions for Medicare patients who have been diagnosed with diabetes, chronic obstructive pulmonary disease (COPD), heart failure, or acute myocardial infraction. During fiscal year 2010, Culpeper Regional Hospital experienced 10.96% overall readmissions for all diagnoses. During the same time, readmission rates were twice as high for Medicare patients with diabetes (27.59%), COPD (24.22%), and heart failure (24.53%). Objectives are: 1) identify patients' RRCSB/AAA senior advocates during CRH's intake assessment, 2) establish a community design protocol of effective communication involving family, caregivers, and the RRCSB/AAA's senior advocate as full partners in assessment, discharge planning, and predicting home-going needs, 3) provide effective post-acute care follow-up, and 4) evaluate project outcomes. Outcomes include: replicable Bridges of Care Partnership model; reduction in readmissions, increase in physician appointment follow-through rates; increase in patients linked to community services; and patient satisfaction/feedback reports.

Safe Med Plus, a successful medication reconciliation and safety initiative for medically complex patients age 65 and older, seeks to improve patient outcomes and reduce costs by proactively providing pharmacist consultation to individuals of all ages who are newly diagnosed with diabetes or who have uncontrolled diabetes. This proposed research- and evidence-based program enhances the role of the pharmacist to optimize medication coordination and compliance before serious health complications develop. Patients will be identified across the continuum of care, resulting in system-wide processes for 'smoother care' for diabetes-specific common co-morbidities. An additional 900 diabetic patients will be served during the grant year, creating a more robust, medication safety program to affect quality care. The plan is for Safe Med pharmacists to provide intensive medication management and education to improve glucose, lipid and blood pressure values as well as assure adherence to diabetic standards of care. This expansion is an effective and efficient approach that improves patient outcomes and reduces medical costs by decreasing avoidable hospital admissions.

This project will dramatically increase the pharmacist's involvement in the medication process, leading to a significant reduction in adverse events and readmissions. Through this project, staff pharmacists make an initial visit with qualifying patients in the first 24 to 48 hours after their admission. At this time, they introduce themselves and let the patients know the purpose of the upcoming discharge visit: to help teach them about their medications (new and old), facilitate referral to a patient assistance program for help with payment of prescriptions (if necessary), and teach and reinforce the need to get all their prescriptions filled, take them properly, make the appointment for and attend their first post-discharge physician visit, encourage home services where appropriate, and support patients and their families. At the discharge visit, the pharmacist talks through all the patient's medications and performs a medication reconciliation with the patient. In addition, the patient is given a red file folder with a medication grid, business cards with a phone line to the pharmacy, and another card with information on Mass MedLine for assistance with prescription payment, as well as various patient education handouts, tailored to the needs of the individual patient.

Through this demonstration project, the hospital's Inpatient Pharmacy will work with Inpatient Surgical Services to streamline and improve the medication history/reconciliation process from admission to discharge for a targeted 1,350 pediatric patients who are admitted for inpatient surgery annually. The new pharmacy-led process will be continuously evaluated and updated. Based on its success, it will serve as a model for future replication.

This project builds upon The MetroHealth System's investment in electronic medical records (EMRs) for acute and long-term care (LTC) settings by optimizing the interconnectivity between two different systems coupled with intensive staff education to improve the safety of patients transitioning between levels of care. In particular, MetroHealth is focused on medication safety through medication reconciliation facilitated by the creation of readily available electronic medication administration records (MARs). Despite utilizing different MARs in LTC and acute care, MetroHealth will be able, through read-only portals, to have immediate point-of-care access to the most recent MAR even if that record appears in the alternate EMR system. Medication reconciliation at this transition is especially critical as a significant percentage of the LTC patients are unaware of the complete details of their medication regimens. MetroHealth has also chosen to include reconciliation of the treatment administration record (TAR). Although there is less written on this area, MetroHealth has identified issues with delays in initiation of CPAP/ BiPAP and potential for harm from delay in delivery of tube feeds.

The specific aim of the this project is to reduce preventable adverse drug events (ADEs) an additional 50% from the projected December 31, 2010 hospital-wide rate of 0.126 ADE per 1000 patient days. Thus, the rate of harmful ADEs would fall to 0.06 ADE per 1000 patient days or 8 harmful ADEs per month. On the CCQC patient care units, we expect to reduce the number of harmful ADEs to 4 per month over the same time period. Taken together, these reductions represent a significant improvement to the patient experience. Overall health care costs will diminish as adverse incidents become less common. But more importantly, patients will experience a safer, more effective interaction with the medical system.

This project will target medication safety for senior citizens across central Ohio. OhioHealth has partnered with National Church Residencies (NCR) to ensure proper care and follow-up for NCR's senior residents who are served in OhioHealth hospitals and making the transition back to housing. NCR service coordinators and the project nurse will work to provide follow-up monitoring and surveying of patients discharged from OhioHealth hospitals and back to NCR housing. Surveys will indicate medication usage; prescription renewals; etc. to determine better strategies for medication safety with this population. Survey outcomes will result in appropriate interventions, designed by the project nurse and other healthcare professionals involved in the project (i.e., pharmacist).

This program will be developed to have a pharmacist involved with at all patients being discharged with warfarin therapy, to focus on 3 areas: appropriateness of chosen discharge dose, education of the patient (and documentation thereof) and communication to the next level of caretaker of the dose and further INR testing.

This program is to enhance multidisciplinary collaboration within the heart failure team by the addition of a clinical pharmacist. The pharmacist will perform key activities during inpatient hospitalization and during critical transitions of care including: medication reconciliation, inpatient rounding, discharge counseling and monitoring for compliance. In addition, the pharmacist will collaborate with the outpatient heart failure clinic team to assess ongoing patient compliance through follow up phone calls and monitoring. Key outcomes include: impact on heart failure readmissions, reducing length of stay and decreasing the overall total direct costs for care by atleast $50,000.

Several of the five rights to medication administration safety demand reliable intravenous access (right drug, right route, right interval). Maintaining the integrity of a central venous catheter (CVC) is integral to maintaining safe medication administration across the continuum of care when a patient transitions from the hospital setting to home/outpatient infusion therapy. This project aims to establish evidence-based, standardized CVC maintenance care guidelines through collaboration and consensus building among The Nebraska Medical Center (TNMC) and a broad group of Omaha-area home health agencies, home infusion agencies, and TNMC Peggy D. Cowdery Patient Care Center outpatient infusion center in order to ensure safety of medication administration. Enduring educational materials will be formulated to inform and empower patients/families regarding care of their CVC in order to ensure safe medication delivery. Surveillance methodology will be developed for ongoing monitoring of CVC-complications that impede safe medication administration. It is believed that implementing standardized guidelines will reduce the incidence of CVC-associated complications, decrease the need for CVC reinsertions and hospital readmissions, and better ensure safe medication delivery. This project will benefit thousands of patients in southeast Nebraska/western Iowa since partnering agencies in this project provide medication administration to patients discharged from hospitals across this region.

The BRIDGE Healthcare Clinic is a student-run free clinic located just west of the University of South Florida (USF) in Tampa, FL in the heart of the University Area community. BRIDGE is an acronym for 'Building Relationships and Initiatives Dedicated to Gaining Equality'. The mission of the USF BRIDGE Healthcare Clinic is to provide community-based, free health care services to uninsured residents who do not qualify for state or county health insurance in the university area community. The two entities share the initiative and vision of creating an Electronic Medical Record system for patients and for the ease of care when it comes to volunteer providers in all areas, including medicine, social work, physical therapy and pharmacy. USF Bridge Clinic recognizes that electronic medical records are integral to expanding efficiency, preventing patient-related medication errors, improving patient outcomes, and providing a smoother transition of care among medical providers as the current system encompasses a multidisciplinary team approach based on 100% volunteer manpower.

The purpose of the this quality improvement process is to change behavior of hospital surgical teams to include use of the elements of the WHO surgical checklist. The project will focus on Advocate Illinois Masonic Medical Center (Chicago) and Advocate Good Shepherd Hospital (Lake County, IL) and offer important lessons for a Safer Surgery Initiative slated to roll out to 10 Advocate hospitals in 2011. During the first quarter of 2011 surgeons and surgical staff at the two project hospitals will complete full day training programs on Crew Resource Management, use of checklists, and effective handoffs. With support from a Cardinal Health E3 grant, an Advocate patient safety team will collect observation data in the operating rooms of the project hospitals. Observations of 35 surgeries at each hospital will be collected from month three through month nine of the project with observation results fed back to the surgical data teams at each hospital charged with collecting and reviewing monthly surgical patient safety indicators. The project expects to increase use of WHO checklist elements from 0 to 75%, reduce by 20% surgical mortality and post operative hemorrhage/respiratory failure and reduce by 10% over two years the reserves associated with malpractice claims.

Miscommunication among health care professionals is the leading cause of adverse patient events. It is Franklin Square Hospital Center's goal to decrease these events and improve communication skills of OR personnel.While Franklin Square Hospital Center currently has a checklist in place, theobjectives are to increase surgeon led checklists, decrease specimen errors, reduce equipment/instrument issues and decrease turnover time.

CoxHealth is a community-owned health system in Springfield, Missouri, serving as a safety net for residents of 22 counties in Southwest Missouri and Northwest Arkansas. With full support of The Board of Directors and top administration, an enterprise-wide patient safety awareness campaign, Show Me Zero, was recently launched. This campaign is modeled after the national patient safety program, Chasing Zero. With Show Me Zero, each department, unit or specialty area is encouraged to incorporate into their daily workflow comprehensive unit-based safety practices utilizing performance improvement, communication and teamwork tools to meet its unique structure and needs. The Surgical Services Department has chosen to utilize the AHRQ Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®). This is a suite of evidence-based change management tools and methods that support leaders, front-line managers, change agents and champions. A consultant will help rapidly implement enhanced team performance, communication, and excellence in patient care in our Surgical Services Department. Expected outcomes include reduced surgical mortality, reduced surgical complications, and reduced retained foreign objects. With approximately 30,000 surgeries per year, the potential for patient benefit is tremendous.

Building upon the work accomplished in the obstetric areas, Meridian Health endeavors to institute a new operating room (OR) checklist based upon the Association of peri-Operative Registered Nurses and World Health Organization's recommendations. Although a pilot is in process for this checklist, what is missing is a crucial element: an environment that fosters teamwork. Evidence of this is demonstrated in the organization's low efficiency measures and employee surveys. This proposal requests $35,000 to support efforts to test the Agency for Healthcare Research and Quality (AHRQ) TEAMSTEPPS team training program in one operating room in our 5-hospital health care system. Implementing the new checklist within the context of an improved collaborative environment should produce an improvement in satisfaction scores, an improvement in patient safety perceptions, an improvement in efficiency measures, cost savings through reduced overtime and delay reductions as well as a reduction in case complications and mortality by a minimum of 5-10%.

Otsego Memorial Hospital (OMH) defines patient safety in the operating room in many dimensions. The dimension that this project will focus on will be eliminating the risk of a healthcare acquired infection. The methodology for eliminating this risk is by having surgical patients whom will be receiving a othropedic or general surgery implant to receive hygienic care before during and after the surgery. An implant is defined as patient receiving othropedic or general surgery implants and will exclude cataracts and Ear,Nose and Throat (ENT) procedures. The number of patients in this category are 480 annually. Surgical checklist will be utilized to assure consistant compliance.

Swedish Covenant Hospital's safety program will support the implementation of a surgical safety checklist throughout its 9 operating rooms. The objectives of the project are to 1) Increase the percentage of surgical patients receiving all indicated SCIP care; 2) Decrease the clean surgical site infection rate; 3) Increase the number of near-miss surgical events reported; 4) Increase the number of surgical patient events reported; and 5) Increase overall surgical services Patient Safety Grade. These objectives will be accomplished through the provision of: 1) Hands-on training in the implementation of the SSCL for all departmental staff and physicians; 2) Human factors, effective communication, and team-building training with a special focus on effective communication in multi-cultural teams for all surgical services staff and physicians; and 3) the development and adoption of an improved system for communicating about and learning from patient safety events identified through the use of the SSCL.

The TeamSTEPPS program utilizes team training to impact communication and error management in the team setting. The overarching goal of Vassar Brothers' TeamSTEPPS Peri-operative Safe Surgery project is to improve patient safety and the quality of patient care. Team training will be focused on the interdependence of team members which empowers each member to speak up in order to catch and mitigate errors, thus preventing harm to patients. Central to the project's success is the development of checklist-based standard tools for the preparation of patients in the peri-operative setting and through handoffs across the care continuum. The project aims to achieve an enduring culture of safety within our organization by creating an in-house team of master trainers to bring the successful methods of patient-safety training to our clinical staff on an ongoing basis. Armed with this vital training tool, Vassar Brothers Medical Center expects by the end of 2011 to reduce the number of peri-operative errors by 100; reduce resultant patient injuries by 15%, saving approximately $350,000 in additional costs related to such injuries; reduce surgical re-admissions related to post-op infections by 15%; increase Surgical Care Improvement Project (SCIP) compliance to 95-100%, and save $81,000 to $216,000 in revenue resulting from improved SCIP compliance.