# Spread of Safety Interventions: Planning for Context

> **NIH AHRQ R18** · BOSTON CHILDREN'S HOSPITAL · 2020 · $399,915

## Abstract

ABSTRACT
Since the publication of To Err is Human in 1999, reductions in preventable harm have been slow. While
pockets of excellence exist, national spread of proven safety interventions has been both incomplete and
inconsistent. Contextual and implementation factors are widely recognized as root causes of this failure. Failed
spread and scale-up of proven safety interventions wastes resources and misses a critical opportunity
to reduce incalculable patient harm. As a result of these challenges, hospitals are increasingly joining quality
improvement collaboratives (QICs). However, spread and scale up, within or outside of QICs, typically follow a
“one size fits all” approach that does little to account for context because: (1) the critical contextual factors are
not usually known before scaling up and (2) there is no other known model for scale-up. We have an
opportunity to test a new model, using ‘NINJA’ as a model. Using routine surveillance, lab monitoring, and
changes in medication regimens, Nephrotoxic Injury Negated by Just-In-Time Action (NINJA) reduced
nephrotoxic medication related Acute Kidney Injury (NTMx-AKI) by 62% at one hospital. In a prospective
multisite study, four hospitals did not reduce AKI at all while five reduced it by over 50%. Hospitals with a
high rate of NTMx-AKI reduced it through one of two different implementation methods: (1) Including a
pharmacy champion and multiple pharmacists working on NINJA or (2) Ensuring the NINJA team
leader has no major competing demands drawing time away from implementation. We developed a
prototype intervention (“CUSTOM NINJA”) that plans for and addresses the specific required contextual factors
(e.g., pharmacy champion), selecting ONE of the TWO pathways to successful implementation. The proposed
aims are to: 1.Test the usability, acceptability, and effectiveness of CUSTOM NINJA to plan for and address
specific critical contextual factors and TWO different pathways for implementation. 2. Understand how context
and facilitation of implementation affect variable reduction in AKI among CUSTOM NINJA hospitals, and
compared to standard NINJA. 3. Assess the value of NINJA and CUSTOM NINJA implementation. Proposed
methods combine time-series, statistical process control, interviews, surveys, retrospective and prospective
cost assessments, and qualitative comparative analysis, which combines algebra with qualitative methods. The
experienced study team has deep knowledge of patient safety and implementation, including scale-up through
QICs. This study is set within the QIC Children’s Hospitals Solutions for Patient Safety, with more than 135
hospitals working together to eliminate preventable harm to children. The proposed study tests a scalable
approach to overcome contextual and implementation barriers to more effectively and efficiently spread patient
safety interventions nationally and internationally.

## Key facts

- **NIH application ID:** 10087709
- **Project number:** 1R18HS027401-01A1
- **Recipient organization:** BOSTON CHILDREN'S HOSPITAL
- **Principal Investigator:** Kathleen Elizabeth Walsh
- **Activity code:** R18 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2020
- **Award amount:** $399,915
- **Award type:** 1
- **Project period:** 2020-09-30 → 2024-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10087709

## Citation

> US National Institutes of Health, RePORTER application 10087709, Spread of Safety Interventions: Planning for Context (1R18HS027401-01A1). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10087709. Licensed CC0.

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