Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

5 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

n/a

Abdominal Aortic Aneurysm Repair

13 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

93 (actual volume)

50 (coalition threshold)

Esophagectomy

1 (actual volume)

7 (coalition threshold)

Low Birthweight Infants

n/a

Infants with Congenital Anomalies

n/a

Intensive Care Unit Physician Staffing (IPS)

n/a

Open Heart Surgery

Keystone ICU, Surgical Infection Prevention Initiative.

Abdominal Aortic Aneurysm Repair

Keystone ICU, Surgical Infection Prevention Initiative

Carotid Endarterectomy Surgery

Keystone ICU, Surgical Infection Prevention Initiative

Esophagectomy

Keystone ICU, Surgical Infection Prevention Initiative. The established tumor board is expanding the disciplines represented.

Healthcare Failure Mode and Effect Analysis

The institution will increase HFMEA utilization and the sharing of lessons learned within the institution, the system and with other facilities.

Root Cause Analisys

The policies for RCA utilization have recently been revised. As a result sharing of lessons learned will increase within the institution, the system and with other facilities.

General Comments on Patient Safety Activities

Keystone ICU Surgical Infection Prevention Intiative Rapid Response Teams Appropriate AMI Care Fall Prevention Program Handwashing Initiative Alarmed Beds Sled Beds Code Alerts consistent across the health system