Slide 9

Priority #2: Making care safer by reducing harm caused in the delivery of care.

Examples of Federal Initiatives Related to Priorities:

• Michigan Keystone Intensive Care Unit Project: In this AHRQ-funded project, a research team at Johns Hopkins University partnered with the Michigan Health and Hospital Association to implement CDC recommendations to reduce central line blood stream infections in 100 intensive care units throughout the State. The initiative, known as the "Keystone Project," reduced the rate of these central line bloodstream infections by two-thirds within 3 months. http://www.ahrq.gov/about/annualmtg07/0928slides/goeschel/Goeschel-contents.html
• Safe Use Initiative: The U.S. Food and Drug Administration (FDA) has launched the Safe Use Initiative to create and facilitate public and private collaborations within the health care community with the goal of reducing this preventable harm. The Safe Use Initiative will identify specific, preventable medication risks and then develop, implement, and evaluate cross-sector interventions to reduce these risks. For more information, go to http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/default.htm.

Initial Goals, Opportunities for Success, and Illustrative Measures:

Goal: Eliminate preventable health care-acquired conditions.

Opportunities for success:

• Eliminate hospital-acquired infections.
• Reduce the number of serious adverse medication events.

Illustrative measures:

• Standardized infection ratio for central line-associated blood stream infection as reported by CDC's [the Centers for Disease Control and Prevention] National Healthcare Safety Network.
• Incidence of serious adverse medication events.

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