Human error plagues hospitals, speaker says

Published in the University of Delaware -The Review, March 8, 2016. – In January 2001, 18-month-old Josie King was admitted to the Johns Hopkins Hospital as a result of suffering third degree burns from a hot bath.  Within weeks she healed and was scheduled to be released. Two days before Josie was scheduled to go home, the young toddler died as a result of careless human medical error…


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The healthier your hospital the better your outcomes

Published in: Not Running A Hospital
Written by: Paul Levy

4/29/2015 – I recently attended an Oslo meeting of the Dr Foster Global Comparators, an international group of hospitals that have been working together to share data and insights related to quality and safety.  What makes the group particularly interesting is their attempts to draw comparisons across national boundaries. This is no easy task, given the different manner (and for different purposes) in which countries collect administrative and clinical data; but the group has made good progress in several areas—notably GI, stroke, sepsis, and orthopaedics. At this session, I met committed and interesting folks from the UK, US, Denmark, Norway, China, Saudi Arabia, the Netherlands, and Australia.

While all the presentations were engaging, the one that most intrigued me was one offered by two surgical fellows from Imperial College, Christopher Nicolay and Stephen Williams. As I understand it, Christopher conducted much of the original research, and Stephen is now going to pick up on it and carry it forward. I’ll just present a quick outline here, as I’m confident they will formally present the results elsewhere, and I don’t want to steal their thunder.

The session was entitled, “The healthier your hospital the better your outcomes.” The hypothesis being tested was whether there might be a correlation between organizational health and clinical outcomes. The fellows first drew on the literature to help think about the elements of organizational health in hospitals. An initial definition by Chris Argyris (1958) set the stage: “A healthy organization is one that enables mature human functioning.” Then, a quote from Christin Shoaf et al (2004): “Organizational health blends the pursuit of individual wellness with organizational effectiveness to yield a strategy for economic resilience.”

Using interviews with many folks, a thoughtful model was derived for assessing organizational health for 22 acute care NHS trusts in the UK. Those assessments were then correlated with patient outcomes like mortality rates and critical incident reporting. Sure enough, there was a positive correlation.

While we’ll all look forward to the formal publication of these results, I can already predict two reactions to this kind of study. The naysayers will say that the concept of organizational health is just too fuzzy to quantify, much less correlate with measure of clinical outcomes (which, they will also say, are themselves too uncertain to use and rely upon.)

Others of us who have run hospitals, visited others, and studied others have seen that the quality of the work environment inevitably has an impact on patient outcomes. An organization in which staff wellbeing, effective communication, resilience, efficiency, and servant leadership are extant tends to be very good as a learning organization and tends to be more alert to the needs of its patients and more adept at clinical process improvement.

Stephen’s next step is to try to extend the research across national boundaries and investigate whether similar patterns might show up around the world. Congratulations to these two young men for taking on this topic and helping us gain deeper insights into the matter.

Click here to read the original article.


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Nursing: The most trusted profession in America

A caring career holds numerous opportunities for service

Published in:
Issue/Volume: May 2, 2013
Written by: By Cindy Atoji Keene



For more information about this press release, please contact Kate Thorne at 410-504-1866 or via email at

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‘It is almost magic in their eyes’

‘It is almost magic in their eyes’ photoQ&A with doctor who created infection-prevention checklist

Issue/Volume: Posted: 3:46 p.m. Saturday, April 27, 2013

4/27/2013Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine, has become well-known at hospitals nationwide for developing a proven method of reducing deadly infections associated with central lines. His checklist and changes to hospital culture led to astounding decreases in these infections in a landmark study conducted in Michigan. The protocol is now being used across the U.S. He recently spoke with the AJC’s Carrie Teegardin by phone. This is an edited transcript of his remarks.

Q. What first made you challenge the conventional wisdom that most hospital infections were not preventable?

A. What really made it happen was a little girl, Josie King, died in my hospital at 18 months of a catheter infection, and she looked hauntingly like my daughter. She died on my birthday. Her mother, an amazing woman, Sorrel King, was working with the hospital, and she came to me [months later] and looked me in the eye and said, “Could you tell me my daughter would be less likely to die now than a year ago?” In many senses, I made excuses: “Well, I’m doing this, I’m doing that.” And she cut me off and said, “Peter, I don’t care what you’re doing. That’s your job. Just get your infection rates down.” It was really an epiphany for me, truly like a Paul on the Road to Damascus. And I said, “Sorrel, I can’t give you an answer, but you deserve one and I will.” And that’s what really drove it. I started looking at Hopkins’ rates and our rates were sky high and it was really humbling and I said, “I don’t want to be killing little girls.”

Q. Tell us more about how your program changed the culture in hospitals?

A. We changed the social norms from “these infections are inevitable,” which was the common mental model. It was my own mental model when I started as a doc and I was causing these infections. It changed to say, “Not only are they preventable, but I am empowered to do something about it.” Many clinicians are completely disempowered and they feel like they are a cog in the wheel and say, “I’m just a nurse or a doc. Who am I to think I can change it?” What we have seen is, it is almost magic in their eyes when that switch goes off and they say, “I get it. I could actually do this.” It’s that belief system that either holds them back or launches dramatic improvements.

Q. What’s the strongest motivator to get hospitals to improve?

A. The federal government’s main approach to improving quality has been pay for performance, in other words an economic model, [and] there is essentially no data that it works. What I call extrinsic motivations — either pay for performance or public reporting [the practice in many states of requiring hospitals to provide a public accounting of their infection rates] — haven’t really realized improvements. The project we led was all intrinsic motivations. That is not to say pay for performance and public reporting don’t have a role but I think it has to supplement, not supplant, intrinsic motivations. If you have the tribe believing this is a big problem and we can solve it, then pay for performance or public reporting is like gasoline on it. It will accelerate it. If the tribe doesn’t believe they can solve it, if you haven’t garnered that intrinsic motivation, you can do all the pay for performance you want and that won’t translate into measurable improvements.

Q. What’s the most important factor in improving patient safety?

A. There’s a famous physician who was kind of the father of quality improvement, and when he was on his deathbed he was interviewed. “OK, what’s the secret of quality now that you have devoted your life to it and you have been a patient?” He said the secret of quality is love: if you have love you change the system. It may sound corny but it’s true — love your patients, love your colleagues, love your profession. The magic is not in the checklist.


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Women Who Are Changing the World

Published in: Woman’s Day
Issue/Volume: December 2009
Written by: Staff

12/11/2009 – Read Sorrel’s story and see the complete list at


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