Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

262 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

838 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

79 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

180 (actual volume)

50 (coalition threshold)

Esophagectomy

2 (actual volume)

7 (coalition threshold)

Low Birthweight Infants

1 (actual volume)

70 (coalition threshold)

Infants with Congenital Anomalies

1 (actual volume)

70 (coalition threshold)

Intensive Care Unit Physician Staffing (IPS)

n/a

Open Heart Surgery

1. Newsletters for ICU/CVU staff to address new procedures and protocols as well as patient care concerns/issues. 2. Additional testing for patients to evaluate their preoperative risk morbidity and mortality (includes PFT's, A,C Hgb, carotid ultrasound).

Percutaneous Coronary Intervention

Extentive time to wire work with Heart and Vascular Center and Emergency Department.

Abdominal Aortic Aneurysm Repair

Endovascular section of Division of Surgery established in 2006. Section is charged with developing clinical guidelines and peer review.

General Comments on Patient Safety Activities

Keystone ICU Rapid Response Team IHI 100,000 Lives Stanford University Patient Safety Consortium National Patient Safety Goals Hospital wide Balanced Scorecard System Oncology Services Redesign Fall Reduction Program