From the Experts

Patient Safety

Dr. Peter Pronovost

Understanding the Science of Safety by Dr. Peter Pronovost

At the start of the twenty-first century, the Institute of Medicine’s (IOM) staggering estimation that up to 98,000 patients die annually from medical mistakes shook the U.S. healthcare system. While this 1999 IOM report was based on studies done up to a decade earlier, it has become one of the thrusts behind the current patient safety and quality movement. Early on in this movement, a gap in the quality of care delivered to patients was recognized. In particular, only half of patients receive evidence-based therapies known to improve their care. To the contrary, we know caregivers and hospitals are dedicated to saving lives, curing illnesses, and reducing patient suffering from chronic conditions. So why are patients still suffering preventable harm?

To understand the shortcomings of quality care and patient safety, we must view the delivery of healthcare as a science. As a science, we can organize healthcare delivery into systems; a system is a set of parts interacting to achieve a goal. For example, the medication delivery system involves the following parts: the doctor orders the drug, the pharmacy dispenses the drug, and the bedside caregiver administers the drug. Interjected in this oversimplified description is a clinician recognizing any medication allergies, the proper transmission of the order to the pharmacy, the delivery of the medication to the floor, and the time pressures dictated for best care (for example, the gold standard for antibiotic administration is one hour); any number of additional significant parts or caveats could of course be added to this list. Clearly this is a complex system for a single medication dose and errors can occur at any given time. If the fax machine, for example, to transmit a stat order to the pharmacy is damaged, or if a hospital is short staffed with no runner to transport the pill, the system is broken. Caregivers work in these complex systems, and as Paul Batalden aptly put it, “every system is perfectly designed to achieve the results it gets.”  Thus, caregivers cannot be blamed when the system fails.

Mistakes are often thought of in terms of what one can see; a drug overdose, a patient’s health begins to fail, or a death occurs. These are outcomes, but what are the causes?  We need to think about how to deliver care, how to organize our systems, and how to identify broken or risky systems. If we can fix broken systems, improvements in patient safety and quality of care will naturally follow. One solution is to separate systems of care into seven bins (often called factors).

These factors include:

  1. patient characteristics (for example, language barrier or severity of illness);
  2. task factors (like outdated protocol of evidence-based practices for mechanical ventilation);
  3. caregiver factors (including experience/skills level or degree of sleep deprivation);
  4. team factors (including  poor communication);
  5. work environment factors (for example, a tube system to deliver medications broken);
  6. department factors (like no money to buy a needed fax machine); and
  7. institutional factors (for example, budget cuts which cause understaffing).

Caregivers need to view their work as a process that is embedded in the healthcare system or context; both of these must be addressed to improve patient outcomes.

The Comprehensive Unit-Based Safety Program, called CUSP, was designed to integrate safety and quality practices into daily work. CUSP follows this six step process:

  1. the measurement of culture;
  2. the explanation of the science of safety (as described above);
  3. the education of the staff to identify problems;
  4. the education of the staff to resolve problems;
  5. the bridging of the gap between senior hospital leaders and frontline staff; and
  6. the provision of tools for caregivers that can be used to improve the seven factors mentioned in the previous paragraph.

CUSP should be implemented in each patient care area (for example, the intensive care unit or the coronary care unit) and a patient safety team involving staff from the unit should be assembled to manage the program. To be most effective, this team should include the unit director or other physician of similar leadership ability, the nurse manager, another unit nurse and physician, a risk manager or patient safety officer, and a senior executive from the institution.

The need to improve patient safety is great and the resources devoted to such change are few.  Efforts must be focused to identify and to mitigate hazards and to evaluate whether implemented changes are actually improving patient safety. With focused attention, disciplined interventions and rigorous evaluation, we can answer Sorrel’s haunting question, “Would Josie be less likely to die today than she would have a year ago?” with a resounding Yes!


Lori Paine, RN

By Lori Paine, RN

In his best-selling book, All I Really Need to Know I Learned in Kindergarten, Robert Fulghum writes about the value, and the challenge, of following simple life lessons—about sharing and apologizing, to name a couple. “I realized,” he writes, “that I already know most of what’s necessary to live a meaningful life—that it isn’t all that complicated. I know it. And have known it for a long, long time. Living it—well, that’s another matter.”

I submit that the same is true for patient safety.

When I entered nursing school in 1983 and took Nursing 101, I learned about the importance of frequent hand-washing for infection control. I was taught to ensure medication safety by ensuring that the five “rights”—the right patient, dose, drug, route and time—were verified before administration. I was trained to prevent patient falls through such practices as keeping bedrails up and the call-bell within the patient’s reach. I acquired communication skills, such as documenting treatment through SOAP notes. We were taught the value of checking one another’s work at critical points. To graduate, we had to demonstrate these fundamental skills throughout nursing school.

So why do studies suggest that handwashing habits among healthcare workers are woefully lacking? Why do we continue to see medication errors and patient falls? Why are communication failures responsible for the majority of sentinel events reported to the Joint Commission? Why do we see mistakes that could have been caught with simple cross-checks?

Simplicity has given way to complexity. Nurses and other caregivers are tending to very ill patients with complicated treatment plans, and doing so with greater dependence on other disciplines. Resident work-hour limitations have increased the number of patient handoffs—yet more opportunities for communication errors. We’re surrounded by technology intended to make work easier and less error-prone, but which can lead to new errors. We’re driven by long to-do lists that can distract us at critical points in patient care, such as medication administration or shift changes.

Demands on caregivers are greater now than ever. Our challenge, similar to Fulghum’s, is to re-acquaint ourselves with the fundamentals of patient care and safety and then find ways to give them priority with every patient, every time. We must find a way to step outside of the chaos, slow things down and ensure that the fundamentals are followed.

At Hopkins Hospital, intensive care units have demonstrated what’s possible when we focus on the basics. Simple steps, including handwashing and wearing full-barrier protection before inserting central catheters, were among simple steps that reduced bloodstream infections.

I think patient safety would benefit greatly if each of us decided, as a start, to “re-adopt” a fundamental practice that has become a challenge to follow in health care today.