Successful Implementation of a Model Designed to Increase Use of Patient Safety Measures

Abstract & Commentary

By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.

Dr. Hoffman reports no financial relationship to this field of study.

Synopsis: A quality improvement initiative that included a new data collection tool and a "data wall" to display results increased use of patient safety interventions.

Source: Krimsky WS, et al. A model for increasing patient safety in the intensive care unit: Increasing the implementation rates of proven safety measures. Qual Saf Health Care 2009;18:74-80.

The goals of this study were fourfold: 1) to increase implementation rates of evidence-based interventions that have been shown to reduce ICU mortality and morbidity; 2) to design tools to promote team communication and team building; 3) to develop prompts that could be incorporated into an ICU progress note to promote consistent use of these measures; and 4) to provide "real time"' feedback regarding progress.

Subjects were two groups of 40 consecutive patients admitted to the Dartmouth Hitchcock Medical Center ICU before and after the quality improvement initiative. Three evidence-based interventions were identified as targets; prophylaxis against thromboembolic disease, prophylaxis against ventilator-associated pneumonia, and prophylaxis against stress ulcers. The project was led by a quality improvement work group consisting of two fellows, the ICU's clinical nurse educator, two ICU research nurses, the ICU pharmacist, and ICU dietitian. The group identified critical implementation steps, revised the ICU progress note to incorporate a checklist with prompts regarding need for these measures, and constructed a "data wall" that depicted actual vs target implementation rates. To determine compliance, the data collection method rated whether the selected interventions were indicated, ordered when indicated, and in place during the day and night shift.

The model resulted in improved rates of utilization and was credited with fostering a team-based culture to promote patient safety.


This project, as true of many others, prompted an increase in utilization of several measures that have been proven to impact patient safety. Prior to implementation, a hospital-wide quality assurance improvement initiative identified 5 preventable deaths over a 1-month period, providing the impetus for the project. Three of these deaths were directly attributed to failure to order deep venous thrombosis and/or stress ulcer prophylaxis. The system developed as a result of this quality improvement initiative was unique in two ways. Unlike approaches that defined success as delivery of the intervention, this project assessed whether the intervention was appropriate, ordered, and delivered as indicated over a 24-hour shift. Second, it incorporated a "data wall" that graphically displayed success (or lack thereof) in reaching target goals in a manner that was readily visible to all clinicians.

Prior studies have identified the extensive amount of information that must be reviewed and assimilated by ICU clinicians on a minute-to-minute basis. Although we know that interventions tested in this study are critical in ensuring patient safety, they can easily be overlooked if there are no prompts to serve as reminders. As well, it appears important to create a visible reminder, such as the data wall, to provide a competitive stimulus to promote consistent adherence to guidelines.