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Observation and Measurement of Hand Hygiene and Patient Identification Improve Compliance With Patient Safety Practices

Rosenthal, Tom MD; Erbeznik, Mary RN; Padilla, Tony MBA; Zaroda, Teresa RN; Nguyen, Daniel H.; Rodriguez, Marcela BSc

doi: 10.1097/ACM.0b013e3181bf6988
Quality and Safety

Measurement, a crucial step in any quality improvement activity, is difficult in two important patient safety processes: hand hygiene and patient identification. This study describes a program at the UCLA Medical Center, called Measure to Achieve Patient Safety (MAPS), which uses undergraduate student volunteers to carry out observations in the hospital. This program has been an important part of UCLA's efforts for quality improvement in patient safety efforts. Since 2004, approximately 20 students per year plus two student leaders have been selected to participate in the MAPS program. They were trained in techniques of measuring and observation and in professional behavior. They participated in weekly and monthly meetings with program leadership, received continuing education from the UCLA patient safety staff, and were trained in observational measurement. The students' observational results have been systematically reported to clinicians and departmental and hospital leadership. Handwashing increased from 50% to 93%, and nurses' checking of two identifiers at the time of medication administration increased from 50% to 95%. Compliance with proper patient identification at the time of nurse-to-transporter handoffs of patients for procedures increased to >90%. This unique program has made a significant contribution to UCLA's quality, safety, and service programs. MAPS has been widely accepted by the clinical staff and has also been valuable to the student volunteers. Such an approach is easily adaptable to other academic medical centers.

Dr. Rosenthal is chief medical officer, UCLA Hospital System, Los Angeles, California, and associate vice chancellor, David Geffen School of Medicine at UCLA, Los Angeles, California.

Ms. Erbeznik is nursing administration project director, UCLA Hospital System, Los Angeles, California.

Mr. Padilla is director of patient relations and volunteer services, UCLA Hospital System, Los Angeles, California.

Ms. Zaroda is clinical epidemiologist, Ronald Reagan UCLA Medical Center, Los Angeles, California.

Mr. Nguyen is a 2007 graduate of UCLA and, at the time of this study, was a student leader in the Measure to Achieve Patient Safety program, Ronald Reagan UCLA Medical Center, Los Angeles, California.

Ms. Rodriguez is a senior at UCLA, Los Angeles, California, and a student leader in the Measure to Achieve Patient Safety program, Ronald Reagan UCLA Medical Center, Los Angeles, California.

Correspondence should be addressed to Dr. Rosenthal, 757 Westwood Plaza, Suite 1320, Los Angeles, CA 90095-7400; telephone: (310) 267-9310; fax: (310) 267-3516; e-mail: (

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© 2009 Association of American Medical Colleges