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Tuesday, February 8, 2011

Safe Patients, Smart Hospitals

Peter Pronovost, MD, PhD is a name synonymous with patient safety.  He and his team have made patient safety a respectable area of expertise within the house of medicine.  He recently published a book, Safe Patients Smart Hospitals, which explains his quest to improve patient safety, first at Johns Hopkins, and now across the country.  While well written, I wouldn't recommend it to the random reader unless you have an interest in patient safety.

As someone who has a strong interest in making my patients safer, I found many helpful pearls within the pages.  As many of you know the recent media has a myopic focus on checklists as a major way to reduce error.  This is partially due to a misunderstanding of the work that Dr. Pronovost's team has performed.  While checklists do work, and that is clear from the NEJM article listed above, 2 very important facets of their technique have been somewhat ignored: changing culture and rigorous data gathering.

As Dr. Pronovost explains, patient safety depends on 3 things: Translating Research Into Practice (TRIP), a Comprehensive Unit-based Safety Program (CUSP), and rigorous data collection.

TRIP and CUSP have since morphed together into an inseparable approach to teaching about safety.  The two are difficult to discuss as separate entities and as I learn more, I hope to share more details with you.

TRIP is the approach to a problem from a research standpoint; it is the background research.  When they first began their central line project, the team went through all of the guidelines, recommendations, and original research and boiled it down into 5 practical points that needed to occur to reduce central line infections.  This became the checklist.

CUSP is all about culture, and changing culture.  Personally, this is where the rubber meets the road.  Without addressing culture, challenging the status quo, and making people accountable to their actions, a checklist is just a piece of paper sitting in a stack somewhere.  The CUSP program works with the individuals, identifies where failures occur, and changes the status quo. It encourages people to speak up, and gives them the authority to be able to.  It was fascinating to read about the challenges their team faced when moving from one unit to another and how CUSP made all of the difference.

The final important factor in patient safety is rigorous data collection.  Remember "Measure Something?"  This is often the limiting factor in safety research.  The data must be as good if not better than any other research trial or else the conclusion cannot be supported, and therefore, the intervention will be questioned.  The point is made over and over: Physicians are scientists at heart.  It is so true.

So what does this mean to an emergency physician?  If you take the 30,000 foot view, this is a very simple and easily reproducible approach to create change:

-Identify a problem
-Look for evidence of how to fix the problem
-Simplify the solutions as much as possible, you really want a short list
-Start to institute it in your department.

Just like in education, make sure to give feedback to your team on how they're doing, as well as soliciting their input.  If you do this and combine it with strict data collection, you will likely see marked improvements in the departments' morale all while making the care you provide much, much safer.

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