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Press Release

For Immediate Release
March 4, 2008
For Information Contact:
Patricia Charvat

Maryland Hospitals Making Strides in Patient Safety

This week, March 2 – 8, 2008, is Patient Safety Awareness Week, a national effort to educate and raise awareness about initiatives that are improving the safety of care for patients.  In Maryland, hospitals and health care providers have been engaged in a variety of initiatives to improve safety through the Maryland Patient Safety Center.  This tip sheet provides a snapshot of the patient safety initiatives and progress being made by Maryland hospitals working with the Patient Safety Center.

Since its creation four years ago by the Maryland Legislature and the Maryland Health Care Commission, the Maryland Patient Safety Center has been working to reach the goal of making Maryland hospitals and nursing homes the safest in the nation.  The Center, jointly operated by the Maryland Hospital Association and Delmarva Foundation, brings together hospitals and health care providers to study the causes of medical errors and unsafe practices and put practical, evidence-based improvements in place to prevent errors and deliver safe patient care.

Major Milestones

Since 2004, the Maryland Patient Safety Center has:

  • trained more than 7,000 health care professionals in initiatives to improve patient safety;
  • engaged more than 150 teams from hospitals throughout the state in Safety Culture Collaboratives which, to date, have focused on hospitals reducing healthcare associated infections in intensive care units (ICUs), improving safety in emergency departments (EDs), reducing death among newborns, and reducing the spread of healthcare-associated antibiotic infections known as MRSA;
  • been redesignated as the state’s patient safety organization by the Maryland Health Care Commission; and,
  • earned the national John M. Eisenberg Award from the Joint Commission and National Quality Forum for Patient Safety and Quality in 2005.

Safety Culture Collaboratives: Making a Demonstrable Difference in Patient Safety

MRSA Prevention Initiative
Through the Maryland Patient Safety Center’s MRSA Prevention Initiatives, 39 hospitals from Maryland, Washington, D.C., and Northern Virginia are employing a unique problem-solving approach, called Positive Deviance, to combat Methicillin-Resistant Staphylococcus aureus (MRSA) infections.  Positive Deviance is an approach that is based on the philosophy that certain groups or individuals in a community have the skills to solve a problem better than other groups or individuals who have access to the same resources.  The solutions and practices developed are then shared and spread throughout the hospital, from department to department.

Two Maryland hospitals were among the six selected nationally in 2005 by the Plexus Institute to launch the first use of Positive Deviance in U.S. hospitals through a Robert Wood Johnson Foundation funded program. In 2006, the Maryland Patient Safety Center worked with an additional eight hospitals in a CareFirst-funded expansion of the Positive Deviance initiative. In late 2007, this initiative, again funded by CareFirst, was expanded to an additional 29 hospitals and long-term care centers.

Among the changes that occurred in Maryland hospitals as a result of employing positive difference are:

  • Within months of initiating Positive Deviance, hooks were placed outside the patient rooms in one hospital so doctors had a place to hang their white coats while wearing protective gowns in isolation.
  • Clergy in another institution started covering their Bibles with surgical caps - so they didn't carry infections from patient to patient.
  • Housekeeping staff developed checklists for cleaning rooms and then tested the effectiveness of their new and improved process with a glow-in-the-dark chemical that showed the spots they missed.
  • One nurse mentioned that she stocked her ICU patients’ rooms with full bottles of hand sanitizer each morning - so health care workers, therapists, family, and other visitors could easily remember to always wash their hands. Now all the nurses on her unit are doing the same thing.

Perinatal Safety Culture Collaborative
Twenty six (26) hospitals in Maryland and Washington, D.C., are participating in the Perinatal Collaborative, launched in 2007 by the Maryland Patient Safety Center in partnership with the Department of Health and Mental Hygiene, to reduce infant mortality and increase patient safety to mothers and infants in hospitals.  Nearly every Maryland hospital with an obstetrics unit is participating or sharing best practices in this Collaborative.

ED Collaborative
Twenty nine (29) Maryland hospitals’ emergency departments participated in this 18-month collaborative, which improved patient flow; reduced time in treating chest pain, sepsis, and pneumonia; and reduced catheter-associated bloodstream infections originating in ED care. 

ICU Safety Culture Collaborative
In this first Maryland Patient Safety Center Collaborative, clinical leaders from 38 hospitals representing 90 percent of the state’s ICUs significantly reduced ventilator-associated pneumonia and nearly eliminated catheter-associated bloodstream infections.

Other Maryland Patient Safety Center Initiatives

All Maryland hospitals voluntarily participate in a medication errors project to survey their medication practices and receive personalized recommendations for areas of improvement.  In the last year, a major focus was on “high alert” medications, such as chemotherapy, narcotics, and anticoagulants, for which there is a higher probability of error.

Data Collection, Reporting, and Research
The Maryland Patient Safety Center collects data and information about near-misses and errors in care, which is voluntarily submitted from hospitals, to identify high-risk aspects of care prone to errors in Maryland hospitals and develop new safety awareness initiatives to address potential areas of risk. 

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The Maryland Patient Safety Center, a joint venture of the Maryland Hospital Association and the Delmarva Foundation, was created by the legislature and established by the Maryland Health Care Commission in 2004.   Through its collaborative, non-regulatory approach, it works with hospitals and health care providers to study the causes of medical errors and unsafe practices and put practical, evidence-based improvements in place to prevent errors and deliver safe patient care.