Improving Patient Safety

1. Improving Patient Safety Peter Pronovost, MD, PhD, Johns Hopkins University

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3. The Problem is Large In U.S. Healthcare system • 7% of patients suffer a medication error • Every patients admitted to an ICU suffer adverse event • 44,000- 98,000 deaths • $50 billion in total costs Kohn To err is human Similar results in UK and Australia 3

4. Condition Percentage of Recommended Care Received Low back pain 68.5 Coronary artery disease 68.0 Hypertension 64.7 Depression 57.7 Orthopedic conditions 57.2 Colorectal cancer 53.9 Asthma 53.5 Benign prostatic hyperplasia 53.0 Hyperlipidemia 48.6 Diabetes mellitus 45.4 Headaches 45.2 Urinary tract infection 40.7 Hip fracture 22.8 Alcohol dependence 10.5 Mistakes of Omission of Evidence-based Practice are Common McGlynn et al, NEJM 2003; 348(26):2635-2645 4

5. How can this happen? Need to view the delivery of healthcare as a science

6. How can we improve System is a set of parts interacting to achieve a goal “Every system is perfectly designed to achieve the results it gets” Caregivers are not to blame

7. System Failure Leading to this error Communication between resident and nurse Inadequate training and supervision Catheter pulled with Patient sitting Lack of protocol For catheter removal Patient suffers Venous air embolism Reason 7 Pronovost Annals IM 2004

8. Organizing Patient Safety Efforts • Translating evidence into practice • Identifying and mitigating hazards • Improving safety culture and communication • Linking organizational structures to patient outcomes 8

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10. System Factors Impact Safety Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Adopted from Vincent Adapted from Vincent BMJ 10

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12. Evidence Regarding the Impact of ICU Organization on Performance • Physicians • Nurses • Pharmacists Pronovost JAMA 1999, 2002; Pronovost ECP 2001 Pronovost JAMA 1999, 20002 12

13. Aviation Accidentsper million departures 13

14. Elizabeth Dayton, Joint Commission Journal, Jan. 2007

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16. % of respondents reporting above adequate teamwork ICUSRS data

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18. How do teams make wise decision • Diverse and Independent input • Wisdom of Crowds • Alternate between convergent and divergent thinking • Get from OR to balcony 18

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20. Don’t Play Man Down When you feel something say something Listen remember wisdom of crowds 20

21. Principles of Safe Design to Reduce Errors • Standardize what we do • Create independent check • Learn from Mistakes • Eliminate risk • Make it visible • Mitigate harm 21

22. Standardize

23. Line Cart Contents – 4 drawers 23

24. Create Independent Checks 24

25. Eliminate Defect 25

26. Make Defects Visible 26

27. Mitigate Harm 27

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29. "Needs Improvement“ Statewide Michigan CUSP ICU Results • Less than 60% of respondents reporting good safety climate =“needs improvement” • Statewide in 2004 84% needed improvement, in 2006 41% • Non-teaching and Faith-based ICUs improved the most • Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

30. 2 year results from 103 ICUs Pronovost NEJM 2006 30

31. Keystone ICU Safety Dashboard 31

32. Your Role in your hospital • Develop lenses to identify hazards in systems • Work to Mitigate Hazards • Standardize • Create independent checks • Learn from mistakes • If you feel something say something • Listen; do not play man down 32

33. Your Role as a State • Continue on going collaborative work • Ensure validity of technical work • Support local implementation and culture change • Develop scientifically sound and feasible safety scorecard 33

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