AHRQ’s CUSP Helps Sinai Health System Reduce Infections and Medication Errors

Mount Sinai Hospital—a Sinai Health System facility in Chicago—used an AHRQ safety program to reduce the rate of central line-associated blood stream infections (CLABSIs) from 2.67 per 1,000 patient days in February 2014 to zero two years later. The hospital used AHRQ’s Comprehensive Unit-based Safety Program (CUSP) to assemble interdisciplinary teams that tackled CLABSIs in its neonatal intensive care unit (NICU).

"The AHRQ CUSP Toolkit was very helpful in training and coaching the teams as we started CUSP," said Naomi Seef, M.S.N., C.P.P.S., Sinai’s system director of patient safety.

More than 140 NICU staffers participated in hand hygiene training that is particularly vital in certain areas of the hospital. Patients’ care environments and their surroundings are called "patient zones" and the "health care zones." These color-coded zones identify the expected frequency of hand hygiene with posters and floor markings, as well as staff education.

Mount Sinai Hospital also developed a "Caregiver Guide to Hand Hygiene" and a parent education course, along with a parent and visitor guide in several languages.

To help sustain the commitment to proper hand hygiene in the NICU, more than 120 caregivers signed an infection control pledge. According to the pledge, caregivers were "…committed to uphold good hand hygiene practices, advocate for the patient, and be a role model and team member for other caregivers related to hand hygiene."

CUSP also helped address a problem with inpatient medication errors related to bar code scanning in Schwab Rehabilitation Hospital—another Sinai Health System facility. While the hospital had been using medication bar code scanning at patients' bedsides for several years, the nursing staff had a low rate of successful scanning.

To resolve this problem, a multidisciplinary CUSP team examined factors contributing to the low compliance rate. Partnering with the pharmacy department was critical, because there were issues identified with some medications. Some codes would not scan correctly; the pharmacy staff had to revise those bar codes so nurses could scan them.

Because bedside medication bar code scanning is vital for patient safety, the hospital’s nurse managers tracked scanning rates to assess their nursing staffs. The managers then addressed noncompliance with the nurses who were not scanning medications before administering them to patients.

"We went from a rate of 70 percent of medications being bar code-scanned upon administration to more than 95 percent being scanned. We have been above 90 percent since 2011. I am very proud of the nurses in maintaining this high rate," said Zahra Khudeira, PharmD, B.C.P.S., C.P.P.S., Sinai's medication safety officer.