In Patient Safety, Zero is Even Better Than Being No. 1

When your job is to improve patient safety, zero is your goal: zero complications or errors that result in harm to your patient. Zero would be routine in a perfect world, but we know that healthcare is complex, processes or communication can break down, and human beings who deliver care can sometimes make mistakes. My job as a healthcare quality improvement professional is to focus on ways to prevent that from happening.

While zero is our goal, “one” is also a pretty nice number.  And I’m proud to say that New Jersey ranked number one in the nation for hospital safety in the most recent Hospital Safety Grade from the quality reporting group Leapfrog. New Jersey had the highest percent of hospitals to earn a grade of “A” than any other state in the nation. So yes, I am Jersey Proud!

In addition to aiming for zero, here’s another thing that drives nurses and other healthcare professionals when it comes to patient safety: We know our work is never done. We need to be vigilant to protect our patients every single day.  So while that number one ranking from Leapfrog is wonderful, we know we can’t rest on it. The quest for zero harm never ends.

Teamwork, communication and collaboration are keys to safe healthcare. Since 2002, Garden State hospitals have joined together under the Institute for Quality and Patient Safety at the New Jersey Hospital Association to improve the care they deliver. Hospitals, health systems, nursing homes and other providers statewide have joined in a systematic approach to address patient safety threats like infections, medication errors and pressure ulcers.

We work collaboratively, identifying evidence-based practices that have delivered the best results and then applying them consistently across care settings. We also share data so we can identify areas that need greater attention. And we talk and trade lessons learned – what worked? what didn’t? That’s essential for making care safer for our patients.

Let me use sepsis as an example. This week is Sepsis Survivor Week, so that’s only fitting. Sepsis is a life-threatening complication of infection that can overtake the entire body. The CDC reports that 1.7 million Americans annually develop sepsis, and 270,000 die from it. Sepsis is one of the areas that hospitals across the state are working on in collaboration with our Institute for Quality and Patient Safety, with a big focus on identifying sepsis early so it can be treated successfully. Through the hard work and dedication of our hospitals, the number of patients with sepsis that die while in the hospital has been reduced 14.5 percent since we started this statewide focus in 2014.

Other areas that we’re working on include medication errors (where we have achieved a 55 percent decline), patient falls (a 43 percent decline) and bloodstream infections associated with central line IVs (a 46 percent decline). Those aren’t just statistics in a chart. Those numbers represent real lives saved by reducing serious healthcare complications.

I love to see those double-digit declines in reducing patient harm. But my fellow nurses and I – along with physicians, certified nurse aides, techs, pharmacists, environmental staff and other members of the healthcare team – are back at it today. We’re focused on zero harm, and we know we can’t let up.

Shannon Davila, RN, is director of the Institute for Quality and Patient Safety at the New Jersey Hospital Association.

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Shannon Davila, RN, MSN, is the director of the Institute for Quality and Patient Safety at NJHA. She leads clinical improvement programs under the Partnership for Patients initiative. An infection prevention specialist, Davila was named a 2016 Hero of Infection Prevention by the Association for Professionals in Infection Control and Epidemiology.

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