Patient Safety, 2004
Henry Ford Health System
The Henry Ford Health System has found AHRQ's Evidence Report/Technology Assessment No. 43, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, to be a practical and valuable resource in its efforts to improve the quality and safety of health care.
The Evidence Report was initially introduced in January 2003 in a workshop for Henry Ford's Patient Safety Steering Committee. Titled "Safety Ideas to Meet the Many Challenges of Patient Safety," the workshop was held to share information on the broad scope of patient safety in health care and creative ideas to address patient safety issues. Current research on safety practices was discussed using the Evidence Report, with particular emphasis on the 11 practices most highly rated in terms of strength of evidence.
Henry Ford has employed a variety of methods to make learning about safety efficient, effective, and fun. One innovative strategy used with residents was the Patient Safety Quizitor game. Quizitor was developed at Oregon Health Sciences Center, and is an interactive learning tool modeled on the television game show Jeopardy. Safety questions were developed and organized into single, double, and final rounds with multiple levels of difficulty. AHRQ's Evidence Report was used to develop questions on "Safety Research." An example of a question is shown in Table 1.
This problem (surprising in a developed country like the U.S.) often goes unrecognized in the hospitalized patient. Early studies reported a prevalence of 30 to 50 percent in hospitalized patients. These patients suffer from increased infections, prolonged hospital stays, and increased mortality.
What is malnutrition?
Resource: "Making Health Care Safer: A Critical Analysis of Patient Safety Practices" (2001)
One of 79 practices most highly rated in terms of strength of the evidence.
"Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients."
Approximately 70 internal medicine residents attended the session. The residents were divided into four teams with winning and consolation prizes awarded. Pre- and post-tests of learner knowledge were completed and indicated learning objectives were met. Pre-test scores resulted in 45.2 percent correct answers; post-test scores were 81.7 percent correct.
Henry Ford Health System is a Michigan non-profit health care system governed by community leaders. It has more than 14,000 full-time equivalent employees, including 3,000 nurses and more than 4,000 allied health professionals. Care is provided to more than 2.5 million patient contacts annually.
Founded in 1915 by auto pioneer Henry Ford, the health system offers acute, primary, tertiary, quaternary, and preventive care. More than 65,000 patients are admitted to Henry Ford hospitals each year. Henry Ford health care providers perform more than 50,000 ambulatory surgery procedures each year.
Impact Case Study Identifier: Multi-Center 04-07 (COE, CQuIPS)
AHRQ Product: Evidence Report
Topic(s): Patient Safety
Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Summary. July 2001. AHRQ Publication No. 01-E057. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/ptsafety/summary.htm.
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Current as of September 2009
Impact Case Studies and Knowledge Transfer Case Studies: Patient Safety, 2004. September 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/casestudies/ptsafety/ps2004.htm