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10 years after “To Err is Human” An RCA of Patient Safety Research?. Peter Pronovost, MD, PhD. Objectives. To reflect on some of the barriers to patient safety research To consider an overview for training in patient research. Bilateral cued finger movements.
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10 years after “To Err is Human” An RCA of Patient Safety Research? Peter Pronovost, MD, PhD
Objectives • To reflect on some of the barriers to patient safety research • To consider an overview for training in patient research
System Failures Slowing Progress in Patient Safety Insufficiently robust research Insufficient capacity to train researchers Failure to view the delivery of care as a science Patients continue to suffer preventable harm Insufficient partnerships Between academic and quality communities Reason Reason model
System Failures Slowing Progress in Patient Safety Insufficiently robust research Insufficient capacity to train researchers Failure to view the delivery of care as a science Focus on differences rather than similarities with other types of research Patients continue to suffer preventable harm Reason Reason model
Central Mandate x Scientifically Sound Feasible Local Wisdom
ExercisePlease answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average • How smart am I • How hard do I work • How kind am I • How tall am I • How good is the quality of care we provide
Improving Sepsis Care(n= 19 ICUs) 36% Reduction (NS) 69% Reduction (p < 0.001)
Improving Sepsis Care(n= 19 ICUs) 36% Reduction (NS) 69% Reduction (p < 0.001)
Framework for Patient Safety Research and Practice • Measuring Patient Safety • Translating Evidence Intro Practice (TRIP) • Identifying and Mitigating hazards • Improving Culture and Communication • Building Capacity and Organizing for Safety • Reducing Diagnostic Errors Pronovost Circulation in press
Patient Safety Learning Communities • Identify Hazards • ( 4. Evaluate Effectiveness of Risk Reduction 2. Analyze & Prioritize Hazards 3. Mitigate Risks Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger levels of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four- step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control.
System Failures Slowing Progress Insufficiently robust research Insufficient capacity to train researchers Failure to view the delivery of care as a science Patients continue to suffer preventable harm Focus on differences rather than similarities with other types of research Reason Reason model
Context become Mechanism Mechanism Context Outcome Pawson Tilley
System Failures Slowing Progress in Patient Safety Insufficiently robust research Insufficient capacity to train researchers Failure to view the delivery of care as a science Focus on differences rather than similarities with other types of research Patients continue to suffer preventable harm Reason Reason model
Simple Rules for Producing Researchers • Obtain formal degree • Identify willing and capable mentor • Obtain protected time to participate in research project
Epidemiology Biostatistics Health services Economics Sociology Psychology Informatics Systems analysis Qualitative Leadership Change management Project management Core Skills for Patient Safety Researchers
Improving Patient Safety in Michigan ICUs Funded by AHRQ
2 year results from 103 ICUs 24 Pronovost NEJM 2006
"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”
