An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of Colorado. Trained in both geriatrics and health services research, Dr. Coleman has emerged as one of the world's leading authorities on issues surrounding transitions of care, particularly between acute and postacute settings. His care model, the Care Transitions Intervention, is being adopted by leading health care organizations around the country. The Intervention has been associated with significant decreases in rehospitalization rates.
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch the patient's name off their rounding list, and hospital staff remove the patient from the census as they clean out the room...
Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for the 6000 physicians employed/affiliated with Partners HealthCare System (which includes Massachusetts General and Brigham & Women's Hospitals). From 2002 to 2007, she was the Chief Medical Officer for Tenet Healthcare, one of the nation's largest hospital systems, where she was responsible for the development and implementation of Tenet's Commitment to Quality (C2Q). Her academic background (including her previous directorship of the Center for Health Systems Design and Evaluation in the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare) and her years of leadership at a huge multistate private sector system provide her with a unique perch from which to view patient safety implementation in complex systems.
Hospitals and health systems across the United States are struggling to put strategies and structures in place to improve patient safety at their institutions. This article will share the safety and quality journey of Adventist Heath System (AHS), the largest Protestant not-for-profit health care system in the United States.
Dr. Rosen is Medical Director of the Inpatient Specialty Program (ISP) Hospitalist service at Cedars-Sinai Medical Center. He also assists with the operation of Cedars-Sinai's innovative Procedure Center, which provides numerous procedural services for inpatients and outpatients. This Center and Dr. Rosen's work have been featured in articles in the Wall Street Journal and elsewhere. In this conversation, we explore the value of a dedicated procedure center and the emergence of specialized physicians to staff them ("proceduralists") and the challenges inherent in teaching novices how to perform risky procedures without harming patient safety.
Prior to the introduction of the Medical Procedure Service (MPS) in 2002, medical procedures at our institution (Beth Israel Deaconess Medical Center) were performed and taught using the time-honored apprenticeship model of "see one, do one, teach one." Residents were expected to independently perform and teach most medical procedures (central venous line placement, thoracentesis, paracentesis, and lumbar punctures). Procedural instruction was limited and poorly standardized; furthermore, trainee performance was infrequently supervised or assessed. In addition, the most qualified faculty were often unavailable to help teach, perform, supervise, or evaluate these procedures.
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths.
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Methicillin-Resistant Staphylococcus aureus
by Gary A. Noskin, MD
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths.(
The voices of patients are often missing from discussions of the impact of medical errors and adverse events. Ms. Constance Lehfeldt is a former nurse who developed a methicillin-resistant Staphylococcus aureus (MRSA) infection, which ultimately led to a devastating series of complications. Connie bravely describes her story, with understated eloquence, in the video interview.
The voices of patients are often missing from discussions of the impact of medical errors and adverse events. Ms. Constance Lehfeldt is a former nurse who developed a methicillin-resistant Staphylococcus aureus (MRSA) infection, which ultimately led to a devastating series of complications.
Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health and is presently working with the World Health Organization's World Alliance for Patient Safety, based in Geneva. He is a leading expert on several aspects of patient safety, including disclosure and evaluation. He recently wrote a commentary on the use of root cause analysis in patient safety in the Journal of the American Medical Association (JAMA).
Throughout most of his life, 19th century French chemist Louis Pasteur insisted that germs were the cause of disease, not the body. It wasn't until Pasteur was nearing the end of his life that he came to believe just the opposite. After reaching this conclusion, he declined treatment for potentially curable pneumonia, reportedly saying, "It is the soil, not the seed."(1) In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment.
Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School. Dr. Poon’s research has focused on using health information technology to improve patient safety. He oversees the development and implementation of clinical applications including computerized physician order entry (CPOE) and barcode-assisted electronic medication administration record, and was lead author on the first rigorous study demonstrating the impact of a bar coding system in a hospital pharmacy. We asked him to speak with us about how such technology can augment medication safety.
Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the Division of Hospital Medicine; Associate Chairman of the Department of Medicine; Lynne and Marc Benioff Endowed Chair in Hospital Medicine; and Chief of the Medical Service at UCSF Medical Center. He is also Editor of AHRQ WebM&M and AHRQ Patient Safety Network.
Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.
Prevention of Urinary Tract Infections: Lessons for Patient Safety
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
Prevention of Urinary Tract Infections: Lessons for Patient Safety
Urinary tract infection (UTI) is the most common hospital-acquired infection, accounting for 40% of all hospital-acquired infections. More than 80% of these infections are attributable to use of an indwelling urethral catheter.(1) Catheter-acquired urinary infections (cUTIs) have received significantly less attention than other health care–acquired infections, such as surgical site infections, ventilator-associated pneumonia, and bacteremia.