The Patient Safety Office launched its Patient Safety and Quality Improvement Projects as part of the World Patient Safety Day Celebration on September 27, 2024. This initiative aimed to encourage hospital units and departments to develop and implement small-scale quality improvement projects that could significantly enhance patient care quality and safety. To support and guide the implementation of these initiatives, the Institutional Quality Management Office (IQMO) was tapped to provide expertise throughout the quality improvement journey.

A total of four entries were submitted for this initiative, showcasing innovative approaches to improving patient safety and healthcare quality.

BEFORE THE BLADE: Gearing Towards Preoperative Excellence

The Nursing Services Department (NSD) launched the Before the Blade project to improve compliance with preoperative requirements, ensuring safety, efficiency, and effectiveness for both patients and the healthcare team. It addresses gaps such as incomplete documentation, unavailable or faulty surgical tools, and missed preparation steps such as improper site markings or retained personal items.

By strengthening adherence to protocols, the project minimizes intraoperative risks, prevents delays and cancellations, and improves surgical outcomes. It also streamlines processes, optimizes resource use, lowers costs by preventing adverse events, and enhances patient experience through better preparation and smoother recovery.

Every Breath You Take: A Quality Improvement Journey Toward Zero VAPP

The Medical Professional Services (MPS) launched the Every Breath You Take project to address the rising incidence of Ventilator-Associated Pneumonia (VAP) in DLSUMC. Despite 100% compliance with the VAP Care Bundle since 2022, cases rose to 8.4 per 1,000 ventilator days within six months. This initiative aims to reduce VAP through enhanced monitoring, better adherence to infection prevention protocols, and expanded bundle implementation.

By lowering VAP cases, the project enhances patient safety, shortens hospital stays, minimizes prolonged antibiotic use, and reduces healthcare costs. Improved infection control also ensures safer care, boosting patient satisfaction and trust in the institution.

Time Is On The Line: The Standardization of Releasing Diagnostic Tests

The Center of Excellence (COE) launched the Time Is On The Line project to standardize the release of diagnostic tests and address turnaround time (TAT) delays across units. Inconsistencies in procedures and the lack of a standardized approach caused inefficiencies. The project aims to establish a uniform process for outpatient results, ensuring accuracy, efficiency, and better patient care. Baseline TAT data will be analyzed to measure performance, identify gaps, and track improvements.

Timely and accurate results enhance patient safety by supporting prompt decisions and treatment. Reduced wait times improve satisfaction, while workflow efficiency boosts revenue and optimizes resource use.

One Prick, Big Risk: The Alarming Reality of Needlestick Injuries

The Hospital Administrative and Support Services (HASS) launched the One Prick, Big Risk project to address the persistent issue of needlestick injuries (NSIs) at DLSUMC. NSIs pose serious health risks, including the transmission of bloodborne pathogens, affecting both primary users and secondary handlers.

The project analyzed hospital-wide NSI cases from March to July 2024 and three years of incidents in the Housekeeping Unit, identifying key factors like improper disposal and lack of awareness. These findings support improved preventive measures and policy enhancements for institution-wide adoption to strengthen safety and minimize risks.

Awarding Ceremony

The awarding ceremony was held on March 20, 2025, at Narra Hall and was attended by various

hospital representatives. Dr. Conrado Crisostomo, Vice Chancellor for Hospital Services, delivered the opening remarks, while a special message was given by Dr. Antonio Ramos, President of DLSMHSI.

Esteemed judges—Dr. Malen Gellido (former Chief Patient Safety Officer), Engr. Manuel Toledo (former TQM Administrator), and Mr. Billmore Sarte (Senior Supervisor for Medical Programs and Packages Development)—evaluated the projects based on their impact, innovation, and sustainability.

And the Winners Are…

1st Place: Every Breath You Take: A Quality Improvement Journey Toward Zero VAP (MPS)

2nd Place: Before the Blade: Gearing Towards Preoperative Excellence (NSD)

3rd Place: One Prick, Big Risk: The Alarming Reality of Needlestick Injuries (HASS)

4th Place: Time Is On the Line: The Standardization of Releasing of Diagnostic Tests (COE)

The event concluded with an inspiring message from Ms. Zarah Louise Fernandez, Senior Manager for Customer Experience, who emphasized that the journey toward patient safety is never-ending. As priorities continue to grow, so too will new challenges. She reminded everyone that the pursuit of safety and excellence is a relentless commitment—one that calls for unwavering dedication and continuous improvement. Ms. Fernandez urged all participants to embrace this challenge not only to enhance systems but to safeguard lives, build trust, and shape the future of healthcare for every patient entrusted to our care.