Case Studies - Significant Increases to Patient Safety

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Patient Safety - Case Studies

Three case studies that speak on initiatives brought on by health care systems and health-related institutions to improve patient safety were found. In the first case study, the largest health system in the New York Metropolitan Area used a program developed by an agency within the US Department of Health and Human Services to improve its standing nationally from one of the worst to one of the best health care systems as it relates to patient safety. The second case study spoke of a city-wide effort to reduce infant mortality in hospitals, while the third case study was about a large health care system using predictive analysis to find cases of hospital-acquired pressure injuries.

CASE STUDY #1: North Shore-LIJ Health System Implements TeamSTEPPS® to Improve Patient Safety

CASE STUDY #2: 'All Hands on Deck' to Address Infant Mortality

  • For years, Milwaukee had one of the highest infant mortality rates, and in 2016, that rate was at 9.1 per 1,000 live births. This was a lot higher than the national average of 5.8 in 2014. Milwaukee is Wisconsin's largest city and county and has a population of 595,070, according to the last count done in 2016.
  • There were 14 deaths per 1,000 live births for some minority groups, versus 7.2 deaths for whites. To correct this racial disparity, Milwaukee County ran the Community Health Needs Assessment. Then in 2011, the county developed a community action plan to address this issue based on what they found through their assessments.
  • They planned to make sure that all women of childbearing age, including those with chronic medical or behavioral health issues, had access to the services that were needed for a healthy delivery. The county did this through partnerships with the Milwaukee Health Care Partnership's Connecting High-Risk Women to Care initiative and Milwaukee hospitals. Hospitals such as Ascension focused on giving women dental care, and other health systems such as Aurora Health Care shipped baby boxes to mothers.
  • Work is still ongoing, but the 2016 rate of 9.1 was the lowest when it was measured from 2014 to 2016, which means that the program is working.

CASE STUDY #3: Using Analytics to Improve Patient Safety Surveillance Makes Patients Safer

  • 10% of all deaths are caused in the US are caused by medical errors. Seeing this, Allina Health, a large healthcare system that has four large metropolitan hospitals in the Minneapolis/St. Paul area decided to take steps in improving patient safety. This large health system also has 85 clinics, eight smaller community hospitals, 5,000 physicians, and around $4 billion in revenue.
  • Their safety committee came up with three strategies to improve patient safety: assessing safety culture, assessing and redesigning reporting associated with safety events, and improving the identification of safety events through more accurate and comprehensive analytics.
  • The committee started a pilot program to evaluate three areas: administration of ephedrine, emergency department, and partial thromboplastin time. With more analysis, they decided to focus on hospital-acquired pressure injuries (HAPIs) and healthcare-associate infection (HAIs). HAIs affect at least one in 25 patients every day.
  • Because they had incomplete data on HAPI and HAI since that data mostly came from self-reporting, they developed a predictive model and used it along with a surveillance tool and machine learning to determine patients' risk level and identify events without the need for the patient to report them themselves.
  • In their test, they were able to identify 216 more cases of HAPI than in the voluntary reporting process. This enabled them to identify risks early and document them, and they were able to record a more thorough picture of the patient in their EMR.
  • With this success, they are expanding their tests to two more hospitals for their pilot program.


In finding case studies that detail successes in patient safety, we mostly did straightforward searches for case studies on the topic. We ensured that these results were from healthcare-related websites, such as the AHRQ website that is part of the Department of Health & Human Services. In our search, we were finding many case studies by singular hospitals, but to find the 'biggest' patient safety lessons, we decided to use case studies of initiatives and programs that had a wider impact based on the health system's or hospital's size or influence. We also used the metric of the number of people that were involved and that would be affected. Hence, we decided against using any examples from small towns, such as a case study we found that was based in a town in Arkansas. With this definition, the first case study we chose was about the largest health system in New York, the largest metropolitan area in the United States. The second case study was chosen because this involved multiple hospitals, health systems, clinics, etc., participating in a health initiative put on by the largest city in Wisconsin. The third case study was chosen because it involved one of the largest non-profit health systems in the United States.