Bliss Drinkwater



Zero Harm During Transition in Care:  Post-Implementation Evaluation 

Primary Investigator: Bliss Drinkwater, BSN, RN

Purpose: To evaluate the effectiveness of and adherence to the Zero Harm During Transitions in Care process for a full year post implementation 

Methods: This project was a continued evaluation of the Zero Harm During Transition in Care process at Parrish Medical Center, a community hospital located in Titusville, Fl. Aggregate data about patient encounters from May 2018 to May 2019 collected by honest brokers were used to evaluate the process. Effectiveness was measured by incidence of harm or near harm events, transition times, and patient satisfaction. Descriptive statistics were used to analyze data and compare pre- and post-implementation measures. 

Results: 8,577 cases/transitions in care were reviewed. Harm or near harm events were decreased from 48 events in a 15-month pre-implementation phase to 18 events in the 12-months post-implementation. There was a 42-minute reduction in time admitted patients were held in the Emergency Department.  

Discussion: Zero Harm was determined to be effective in the year following implementation with an improvement in incidences of harm, hold times and patient satisfaction. Adherence to the process was unable to be determined due to missing data points. The organization had a setback initially in the second 6 months of the post implementation evaluation, after a recommitment by the organization, times and incidences of harm ultimately improved.  

Conclusions: The results show that the initial project, Zero Harm During Transitions in Care is sustainable and can be adapted by other facilities to improve patient safety during times of transition in care. Continued education at the organization is recommended for further compliance and to maintain culture of safety.  

Major Professor: Susan Liipfert Shelton, PhD, APRN, CNM 



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