Past Initiatives

Peripheral Blood Culture Contamination Reduction

Team Members and Departments/Services:

Department of Nursing NICU Peripheral Blood Culture PI Project Committee:

  • Jennifer Pacholuk, NICU Unit Educator – Team Lead
  • Scott Jensen, RN
  • David Turner, RN
  • Tina Mammone, RN, PhD, CENP, NEA-BC, Unit manager
  • Sylvia Andrade, DNP, MS, RN, Unit assistant manager
  • Elizabeth Sin, MS, BSN, CCRN, Unit assistant manager
  • Marylou Muwaswes, Clinical Nurse Specialist

NICU Identified Experts:

  • NICU Nursing Leadership group
  • Microbiology - Rohan Nadarajah, MT (ASCP), Senior supervisor
  • Pharmacy - Deepa Setty, Pharm.D

In 2005, the Neurological Intensive Care Unit (NICU) initiated a performance improvement project to decrease the contamination rate for peripheral blood cultures drawn by nurses.  The goal was to comply with the UCSF laboratory threshold of no more than a 3% contamination rate and decrease antibiotic therapy usage associated with false positive blood cultures.  We have successfully sustained the contamination reduction rate to an average of 1.2% in 2010. 

The Department of Nursing is committed to optimizing patient quality of care by improving processes such as blood cultures that impact clinical outcomes, patient safety, and efficiency.  Reducing unnecessary antibiotic therapy associated with false positives minimizes the associated side effects and risks, as well as, drug-resistant organisms. In addition, it provides cost savings with regard to nursing and pharmacy time associated with antibiotic processing, delivery, administration, monitoring, and interventions, as well as, the cost of antibiotics.

Front-line Staff Lead the Way

We believe the success of reducing blood culture contamination begins with staff engagement.  In NICU, the multidisciplinary Blood Culture Performance Improvement (PI) Project Committee developed and implemented an in-service for nurses to heighten awareness of the problem and educate regarding correct technique and benefits of compliance.  Interventions and tools were created to facilitate correct technique such as posters, a video, a case study and a competency-based module.  A major contribution to the success of this project has been the nurses submitting and reviewing their own peripheral blood culture results from microbiology.

Utilizing Innovative Practices to Prevent Blood Culture Contamination

After analyzing NICU’s data, brainstorming ideas, and discussing strategies, the committee designed and implemented a plan that began with a literature review of evidence-based practices.  After informal observation of NICU nurses drawing blood cultures, the committee found there were inconsistencies in technique.  Also identified were contributing factors to inconsistent technique such as recent changes in the skill mix of NICU nurses, knowledge gaps regarding standardized procedure, lack of awareness of the consequences associated with not following the standardized procedure as well as accessibility of peripheral blood culture collection kit components. Once these issues were clearly identified, corrective actions to improve practice were successfully implemented.     

Data Transparency and Analysis

NICU receives a monthly report from the microbiology lab with the peripheral blood culture contamination rate for the unit.  These reports assist with sustaining the clinical blood culture process and outcomes by providing direct care staff visible results of their progress.  Pre-implementation (2004) average peripheral blood culture contamination rate was 4.3% and post-implementation (2005) was reduced to 2.8%.  As of 2010, the average blood culture contamination rate was 1.2%.

Heart Failure Readmission Reductions

UCSF Medical Center is strongly committed to decreasing Heart Failure readmission rates.  Heart Failure RN Discharge Coordinators are accessible seven days a week and have been instrumental in developing a heart failure readmission reduction program at UCSF together with strong participation from a large multidisciplinary team. Heart Failure readmission rates have decreased significantly at UCSF and the program’s successes have been recognized nationally.

Heart Failure readmission rates have decreased by implementing a number of best practices that include the Teach Back method of patient education, focused attention by discharge heart failure RNs, increased referrals to palliative care service, timely and appropriate follow-up care and stronger relationships with referral home care and skilled nursing facilities.  Additionally, there has been an emphasis on increasing communication and collaboration with primary care physicians to ensure follow-up visits are scheduled appropriately.

Front-line Staff Lead the Way

Discharge teaching is an important component to reducing heart failure readmission.  Patients must be educated on a number of important interventions, including monitoring daily weights, recognizing symptoms of fluid overload, taking medications appropriately, recognizing worsening symptoms and acting on them in an appropriate and timely manner.  At UCSF, nurses utilize the Teach Back method which identifies gaps in learning and allows for reinforcement until understanding is verified.  The Heart Failure RN Discharge Coordinators also call patients after discharge to make certain that they have retained the knowledge they learned while in the hospital, are following identified interventions, and have a follow-up appointment.    

Utilizing Innovative Practices to Prevent Readmission

UCSF is initiating innovative practices, including aquapheresis, to ensure patients are in the most optimal state at discharge.  This year the GeriTraCCC Program was also started which provides home visits for high-risk patients with heart failure by a UCSF doctor specializing in care of geriatric patients.  This has been a very successful addition to the heart failure program as well as follow-up appointments with Nurse Practitioners in the Heart Failure clinic.

Data Transparency and Analysis

Heart Failure readmission rates are reported at the unit level as well as the organization-wide level.  In addition, reports on heart failure core measures are displayed on the units.  We are proud to report that our heart failure core measure discharge instructions are in the highest percentiles.  We also monitor data on follow-up phone calls, MD appointments, and compliance with Teach Back methodology.  We publicly share our heart failure readmission rates and are proud of our success!

Hourly Rounding

The Department of Nursing is committed to implementing Hourly Rounding on all the adult inpatient units.  Hourly Rounding is a practice used to assess and proactively address patient needs in the following areas:  Need to use the bathroom, need for pain medication, need to be repositioned and need for call light and other items to be easily within reach.  By anticipating our patient's needs, we aspire to continually improve nursing care excellence and patient care outcomes.  

The practice of Hourly Rounding has been shown to improve clinical outcomes (falls and pressure ulcers), decrease risk (associated with falls and pressure ulcers), increase growth and capacity (by reduced patient length of stay), reduce call light use, increase patient satisfaction and improve employee satisfaction.  Hourly rounding at UCSF Medical Center involves registered nurses and patient care assistants checking in on the patient on an hourly basis to proactively anticipate the patient’s needs, keep the nurses in control of their workflow and decrease call light use.

Front-line Staff Lead the Way

Unit-level staff are instrumental for ensuring hourly rounding is implemented on their units.  Staff are engaged in tailoring the hourly rounding process to the specific needs of their patients and the culture of the unit.  Patient Care Managers also round using the hourly rounding process and engage and educate staff and families on the process. Hourly rounding is presented at new hire orientation for all RNs and patient care assistants and is incorporated into ongoing education and service excellence training. 

Utilizing Innovative Technologies to Hardwire Hourly Rounding

The Department of Nursing created a website to showcase communication and training tools devoted to Hourly Rounding.  Posters, welcome cards and other information can be found on our intranet site.  The Nursing Performance Improvement Department continues to collaborate with our call light vendor to create reports that trend call light use and track reasons why patients are using their call lights.  By utilizing call light data reports we can better determine if we are addressing our patient’s needs.  

Data Transparency and Analysis

Hourly Rounding Dashboard data is distributed to all participating units.  The dashboards displays call light data, falls incidence, pressure ulcer incidence and patient satisfaction data.  Units can track and trend their call light use and patient satisfaction data as it relates to promptness to call lights, attention to personal needs, how well pain was controlled, if the nurse kept the patient informed, friendliness and courtesy of nurses and the nurse’s attitude towards requests.

Medication Administration Accuracy

Ensuring that medications are administered accurately is a priority at UCSF.  In 2008, the Department of Nursing initiated the Medication Administration Accuracy Project (MAAP) with the goal of standardizing the medication administration process in order to eliminate nursing medication errors.  Our vision is to establish and sustain best practices so that every patient receives safe, excellent quality of care.

Medication administration accuracy is achieved by standardizing the administration process so that all nurses are administering medications in the exact same way.  Standardization is achieved by focusing on practices that increase compliance with the “five rights” (right patient, right drug, right dose, right time and right route) and the “six processes,” which include the following: 

Compares medication with medication administration record
Limits distractions while passing medication
Ensures medication is labeled from dispensation to administration
Checks two forms of identification before administration
Explains medication to patient and family
Charts medication immediately after administration 

Front-line Staff Lead the Way

The role that front-line nurses play in direct patient care places them in a unique position to prevent medication administration errors and gives them the insight necessary to drive significant change at the unit level.  As part of the Medication Administration Accuracy Project (MAAP), each adult patient care unit nominates a Unit Team Lead (UTL) whose role is to facilitate improvement strategies based on medication administration observation data.  UTLs coordinate monthly and annual medication administration observation audits that involve front-line nurses observing one another administering medications and documenting adherence with the six processes of safe medication administration.  In addition, nurses educate patients regarding what to expect during a medication pass so that they too can play an important role as partners in their care. We believe that safe medication administration is a nursing imperative and that nurses at UCSF are taking charge and leading the way! 

Utilizing Innovative Technologies to Prevent Medication Administration Errors

UCSF uses “smart pumps” and ensures that all infusion pumps are programmed with the latest technology.  We have also begun to implement bar coding technology to ensure that labs are drawn correctly and medications are administered accurately.  In addition, we utilize special infusion pumps for high-risk medications such as patient controlled analgesia and epidural pain therapies.      

Data Transparency and Analysis

Observation data which measures medication administration processes and outcomes is shared on a monthly and annual basis with all staff.  UTLs review their data, identify opportunities and initiate and evaluate improvement interventions based on their data.  In addition, the Department of Nursing collaborates with the Department of Pharmacy to create and review medication reports with data aggregated at the unit level.

Falls Prevention

Prevention of falls, and reducing the risk of harm from falls, is a priority at UCSF.  Our falls prevention program is made up of a multidisciplinary team that strives to achieve injury-free outcomes by utilizing a nursing and patient-centered approach.  We have reduced injurious falls by 89% to a rate of less than 0.01% and we continue to strive for a rate of zero falls for all patients while they are under our care. 

Our goal is to be the leader in creating innovative and sustainable processes to ensure that every patient receives optimal care and remains fall free.  Nursing administration and hospital-wide leadership provide strong support for this initiative.  We have exceeded our goal of reducing falls by 10% – incidence was reduced by 13% and fall rates fell below the national average.  UCSF is committed to implementing and sharing best practices so that patient falls will continue to decrease across the continuum of care.

Front-line Staff Lead the Way

We believe the success of reducing falls begins with staff engagement.  Each patient care unit nominates a Fall Prevention Champion whose role is to proactively implement fall prevention strategies by first reviewing their data and ensuring fall prevention measures are implemented at the unit level.  Their expertise is shared with colleagues on their units and with other Fall Prevention Champions hospital-wide at monthly committee meetings. 
Staff education is central to our ability to provide quality care to our patients and families.  It enables us to support a culture of safety by fostering clinical expertise and professional development.  Targeted staff education for specific high-risk patient populations is provided to all nurses.  Patients and families receive education on how to prevent falls in the hospital and at home.  Knowledge is power and nurses at UCSF are utilizing knowledge to make powerful changes in patient care! 

Working Collaboratively to Target Specific Populations

Our Fall Prevention Champions are a multidisciplinary team, with members from all care settings and disciplines, working collaboratively to ensure that fall prevention measures are implemented on each unit.  In-depth falls analyses are done with multidisciplinary groups to reveal trends and create individualized unit-specific action plans. 
Daily rounds are conducted on adults assessed to be at risk for falls and injury and risk assessments are included in hand-off communications as a patient moves across the continuum of care.  Fall precautions are implemented proactively on surgical units for every patient who has had surgery within the last 48 hours.  Our Falls and Safety Team (FAST) are trained volunteers who round on patients at risk for falls and ensure compliance with fall prevention program components.  In addition, we actively collaborate with the UCSF School of Nursing to review the latest research and network with other hospitals to seek out the most innovative best practices. 

Data Transparency and Analysis

The Department of Nursing utilizes innovative and sustainable processes to reduce falls by focusing on data evaluation and unit-based, patient population-specific interventions.  We continually measure falls rates to identify opportunities for improvement and provide unit-level data in monthly reports.  Unit-specific falls analyses and action plans are reported to quality and safety councils and are submitted for benchmarking and public reporting.  Falls Prevention Champions conduct monthly falls process measure audits and front-line staff review the data to initiate improvement interventions based on their own units’ results.   

Pressure Ulcer Prevention

Hospital-acquired pressure ulcer (HAPU) prevention is a priority at UCSF and nursing administration and hospital-wide leadership provide strong support for this initiative.  A multidisciplinary team, with members from all care settings and disciplines, is actively engaged in front-line HAPU prevention.  Since 2005, we have successfully reduced our HAPU prevalence by over 70% and continue to strive to prevent all hospital-acquired pressure ulcers. 

Reducing HAPUs is a Medical Center patient safety and quality organizational goal.  A multidisciplinary team is actively engaged in HAPU prevention and patients and families are included as important members of the pressure ulcer prevention team.  Our goal is to continually improve skin care for all patients across all inpatient settings and across the continuum of care.

Front-line Staff Lead the Way

We believe the success of reducing HAPUs begins with staff engagement.  At UCSF, the Unit Skin Champions take an active role to ensure pressure ulcer (PU) prevention happens at the unit level.  Each patient care unit has an identified Unit Skin Champion(s).  The champion’s role is to facilitate unit level review of process and outcome data with the goal of identifying and implementing PU prevention strategies specific to their unit’s patient populations.  Champions share their unit-based skin expertise on the unit when providing patient care, at monthly staff meetings and through multiple unit-based forums.

Staff education is central to our ability to provide quality patient care by fostering clinical expertise and professional development.  Bi-monthly HAPU prevention classes are offered to review and continually enhance the expertise of all patient care staff.  In addition, pressure ulcer prevention committee members are supported to become certified in pressure ulcer identification and staging.  Knowledge is powerful and nurses at UCSF are utilizing knowledge to make powerful change in nursing patient care! 

Using Innovative Technologies to Prevent Pressure Ulcers

UCSF nurses are leaders in identifying HAPU prevention opportunities and implementing innovative technologies to prevent pressure ulcers.  In the intensive care units, operating rooms and the emergency and radiology departments, nurses have optimized the use of appropriate pressure redistribution surfaces.  Operating room staff identify patients who are at risk for developing pressure ulcers and ensure availability of appropriate pressure redistribution surfaces during and after surgery.  A nurse-created air mattress algorithm allows front-line staff to obtain an appropriate surface without delays.  Nurses continuously evaluate products, specifically those related to nasogastric tube securing devices, tracheostomy equipment, peripheral IVs and oxygen saturation probes.  In addition, Nursing collaborates with the UCSF School of Nursing to review the latest evidence-based literature and networks with other hospital to share best practices.

Data Transparency and Analysis

The Department of Nursing Performance Improvement provides monthly unit-level HAPU data reports to assist with identification of HAPU prevention opportunities.  Data is also obtained from quarterly prevalence study days, where every patient in the hospital is examined for evidence of skin breakdown.  Prevalence data is submitted for benchmarking and public reporting.  Unit leadership, in collaboration with their Unit Skin Champions, facilitates front-line staff review of their data reports to initiate and evaluate improvement interventions based on data. 

800 Hospitals

This is a longitudinal, multi-phase, international quality improvement project, which aims to improve the quality of care provided in hospitals for adults who require the insertion or continuing management of indwelling urinary catheterization. 

It will focus on enabling staff from participating hospitals to implement best practice recommendations in order to improve or sustain compliance with high quality recommendations from Clinical Practice Guidelines. The audit criteria for this project have been extracted from the CDC guideline for the prevention of catheter- associated urinary tract infections (2009). A quality assessment of the guideline resulted in a good AGREE II score for overall quality and for domain specific quality.


The clinical audit will be undertaken using specialist software (JBI PACES) that has been designed to facilitate the anonymous collection, collation, and analysis of data.  The point prevalence data collected is not individual patient data; it is data about the structures and processes associated with care delivery by health care professionals.


The situational analysis phase is based on the difference between baseline compliance with best practice recommendations, and optimal compliance with best practice recommendations. During this phase of the study, the JBI PACES software will be implemented to assist sites to review their baseline data, to identify barriers to improved compliance, implement strategies that are designed to promote improved compliance, and identify relevant resources to assist with implementing evidence-based practice. 
This phase will be prospective; sites will have time to embed strategies and resources at the system and clinical level within their organization and time to reinforce the implementation and sustainability of best practice in indwelling urethral catheter insertion and management for adult inpatients. The third phase will be the second point prevalence audit that utilizes the same criteria as in the baseline audit. This is an international quality improvement project, with a focus on data related to care delivery by health care practitioners. The data will be primarily drawn from healthcare professionals' documentation and will contain no patient identifiers.


UCSF Medical Center is the only participating site from the United States in this JBI-sponsored international quality improvement project.