Keeping Patients Safe

Over the past decade, patient safety has become a topic of national concern and during this period, the health care industry has learned about improving patient safety from scientific study and from studying other industries, such as the aviation industry.  Massachusetts General Hospital physicians, nurses, and scientists alike have been at the forefront of efforts to identify and address the various threats to safety in a hospital setting.  All staff and employees at MGH are now, more than ever, focused on making our patients’ hospital experiences free from harm.

Click on any of the measure names below to see a detailed description of the measure, our performance over time and what we are doing to improve. On the chart below, hover your mouse over the data columns or icons to see more information.

Measure	Our Current Performance	Comparison Group	How We Compare
Healthcare Associated Infections
MRSA Incidence	0.40 new cases Per 1000 patient days (Jul-Sep 2012 data).	0.51 Currently there is no national benchmark or target for new cases per 1000 patient days. We compare ourselves to our average from the previous year (2011).	MGH's current performance is better than the 2011 average, but not at our internal goal of no (zero) new cases.
VRE Incidence	0.33 new cases Per 1000 patient days (Jul-Sep 2012 data).	0.62 Currently there is no national benchmark or target for new cases per 1000 patient days. We compare ourselves to our average from the previous year (2011).	MGH's current performance is better than the 2011 average but not at our internal goal of no (zero) new cases.
Central-Line Associated Bloodstream Infections in the ICU	1.2 infections Per 1000 line days using Jan-Jun 2012 data.	1.4 The 2010 pooled mean for Combined Medical/Surgical ICU units from the NHSN (National Healthcare Safety Network) for infections per 1000 line days in major teaching hospitals.	Our current performance is better than the NHSN benchmark. Preventing Central Line Infections: Saving Lives and Dollars
Hand Hygiene	91% before 93% after Oct 11-Oct 12 data. Higher values are better performance.	90% before 90% after The Joint Commission (TJC) sets this compliance expectation for all hospitals.	MGH's current performance is better than the Joint Commission compliance expectation but we are not at our internal goal of 100% before and after contact. Hand Hygiene: Cleaner Hands, Safer Patients
Measure	Our Current Performance	Comparison Group	How We Compare
Nursing Sensitive
Patient Falls with Injury on Medical Units	0.63 falls with injury Per 1000 patient days (Apr11-Mar12 data).	0.72 Apr11-Mar12 average rate of falls with injury per 1000 patient days for Massachusetts hospitals with 500+ beds determined by PatientCareLink.	Difference from Group Rate (hospitals with more than 500 beds) is not statistically different according to the PatientCareLink Statistical Appendix. One Fall is Too Many: MGH working to reduce patient falls with injury
Patient Falls with Injury on Surgical Units	0.28 falls with injury Per 1000 patient days (Apr11-Mar12 data).	0.37 Apr11-Mar12 average rate of falls with injury per 1000 patient days for Massachusetts hospitals with 500+ beds determined by PatientCareLink.	Difference from Group Rate (hospitals with more than 500 beds) is not statistically significant according to the PatientCareLink Statistical Appendix. One Fall is Too Many: MGH working to reduce patient falls with injury
Pressure Ulcer Prevalence on Medical Units	1.92 pressure ulcers per 100 patients Data from 4 MGH Pressure Ulcer Prevalence Studies - Jun 11, Sep 11, Dec 11, and Mar 12.	1.32 Average per 100 patients for Massachusetts hospitals with 500+ beds determined by PatientCareLink (Jun 11, Sep 11, Dec 11, and Mar 12).	Difference from Group Rate (hospitals with more than 500 beds) is not statistically significant according to the PatientCareLink Statistical Appendix.
Pressure Ulcer Prevalence on Surgical Units	1.06 pressure ulcers per 100 patients Data from 4 MGH Pressure Ulcer Prevalence Studies - Jun 11, Sep 11, Dec 11, and Mar 12.	1.42 Average per 100 patients for Massachusetts hospitals with 500+ beds determined by PatientCareLink (Jun 11, Sep 11, Dec 11, and Mar 12).	Difference from Group Rate (hospitals with more than 500 beds) is not statistically significant according to the PatientCareLink Statistical Appendix.
Measure	Our Current Performance	Comparison Group	How We Compare
Serious Reportable Events
Surgical Events	6 MGH had 6 Surgical events in 2011.	n/a All hospitals aim for zero events.	All hospitals aim for zero events.
Product or Device Events	0 MGH had no Product or Device events in 2011.	n/a All hospitals aim for zero events.	All hospitals aim for zero events.
Patient Protection Events	0 MGH had no Patient Protection events in 2011.	n/a All hospitals aim for zero events.	All hospitals aim for zero events.
Care Management Events	9 MGH had 9 Care Management events in 2011.	n/a All hospitals aim for zero events.	All hospitals aim for zero events.
Environmental Events	7 MGH had 7 Environmental events in 2011.	n/a All hospitals aim for zero events.	All hospitals aim for zero events.
Criminal Events	0 MGH had no Criminal events in 2011.	n/a All hospitals aim for zero events.	All hospitals aim for zero events.
Measure	Our Current Performance	Comparison Group	How We Compare
Leapfrog Safety
Prevent Medication Errors (Use of CPOE)	Fully meets standard Based on 2012 survey submission.	Fully meets standard Highest rating given by the Leapfrog group.	MGH has achieved the best possible rating by the Leapfrog group.
Appropriate ICU Staffing	Fully meets standard Based on 2012 survey submission.	Fully meets standard Highest rating given by the Leapfrog group.	MGH has achieved the best possible rating by the Leapfrog group.
Steps to Avoid Harm (Safe Practice Score)	Fully meets standards Based on 2012 survey submission.	Fully meets standards Highest rating given by the Leapfrog group.	MGH has achieved the best possible rating by the Leapfrog Group.
Managing Serious Errors	Fully meets standard Based on 2012 survey submission.	Fully meets standard Highest rating given by the Leapfrog group.	MGH has achieved the best possible rating by the Leapfrog group.
Reduce Blood Stream Infections	Some progress Based on 2012 survey submission.	Fully meets standard Highest rating given by the Leapfrog group.	MGH has made some progress on this Leap.

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