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  • 2017 AEIX Award and Grant Winners

    Fairview Health Services                                         

    (Award) Sylvia Moss Brown Award for Excellence

    “Achieving Safety with Insulin and Insulin Pens”

    Using a three-pronged approach, realized a dramatic reduction in the inadvertent sharing of insulin pens and accidental patient exposure to blood/body fluids by embedding safety alerts and hard stops in the electronic medical record. Implemented multiple safety strategies focused on reducing errors associated with U-500 insulin and GLP-1 agents.

    Eisenhower Medical Center                                       

    (Award)   

    “Sepsis Without Borders”

    Achieved a 32% reduction in the sepsis mortality rate using a multifaceted, hospital-wide approach to identify and treat sepsis earlier. Implemented sepsis screening protocols, formalized sepsis protocols and order sets, and developed “Code Sepsis” rapid response alerts to key hospital departments and personnel.

    MemorialCare Health System

    Long Beach Memorial Miller Children’s and Women’s Hospital

    (Grant)   

    “Applying Airline Safety Practices to Medication Administration to Decrease Distraction and Interruptions: A Medication Safety Initiative to Reduce Medication Errors”

    Medication Administration Errors (MAEs) remain the most common errors in hospitals with an estimated industry cost of $3.5 billion dollars a year. Distraction and interruptions during medication administration continue to be the leading causes of MAEs because they contribute to cognitive burden and loss of focus. Nurses are distracted or interrupted on average 31% of the time.  This project will establish a “Safe Zone”, staff protocols, and visual alerts with the goal of reducing medication errors by fifty percent.

    Mountain States Health Alliance   

    Franklin Woods Community Hospital

    (Grant)

    “Prevention of Pulmonary Complications Through the Use of a Pre-op Assessment and Post-op Clinical Pathways”

    This project plans to reduce post-operative respiratory failure and pneumonia rates by implementing the use of a research-based pre-op respiratory assessment and post-op protocols with the goal of reducing respiratory complications by twenty percent. Patients that are identified to be at a heightened risk for complications will be placed on the “Respiratory Pathway” and have pro-active respiratory pathways initiated by the nursing staff and respiratory therapists, with oversight by a board certified pulmonologist.

    MemorialCare Health System                                 

    Long Beach Memorial Miller Children’s and Women’s Hospital

    (Grant)                                                

    “Implementation of a Maternal Early Warning Trigger (MEWT) System Utilizing the Electronic Medical Record”

    Delayed response to clinical warning signs was the most common contributing factor identified for all causes of maternal death in California. This project plans to integrate the Maternal Early Warning Triggers with the hospital’s electronic medical record to provide alerts to caregivers when a patient’s clinical vital signs fall outside the acceptable range so treatment can be initiated sooner. The project also promotes the use of evidence-based order sets via “Best Practice Alerts” to standardize the staff’s response to the patient conditions that triggered the alert.

    Presbyterian Healthcare Services

    (Award)

    “Unsuspected Radiology Results: Ensuring Appropriate Notification and Follow-Up”

    Failures in communication regarding unsuspected radiology findings may result in delayed diagnosis and treatment for serious health conditions. Following a Failure Mode Effects Analysis (FMEA) on managing unsuspected radiology findings at three Presbyterian hospital emergency departments, clinicians sought to standardize the communication process to ensure prompt notification of both the patient and treating provider and improve documentation in the electronic medical record regarding the need for follow-up.