Improved Patient Safety and Reduced Infection Rates: An Imperative in 2010

2010 may be known as the year of renewed patient safety efforts, at least if Peter Pronovost, MD, PhD, FCCM, professor at the John Hopkins University School of Medicine, has anything to say about it. He is part of the Quality and Safety Research Group at Johns Hopkins, a small, multi-disciplinary team of individuals committed to improving quality and safety in healthcare by applying science that enhances knowledge and ultimately improves patient outcomes. The group says it is applying health services research to develop tools, educate stakeholders, engage providers, execute interventions, share knowledge and perform rigorous measurement in the patient safety movement, and emphasizes the importance of balancing scientific measurement with real-world practicality.

Pronovost underscored that latter tenet in his keynote address of the Changing Legal and Regulatory Landscape conference held in November and sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC). In his presentation, "Partnering to Improve Patient Safety," Pronovost made a passionate stand for patient safety and quality outcomes in a world where incidents related to patient safety and medical errors cost the U.S. healthcare system anywhere from $17 billion to $29 billion annually, according to the Center for Innovation in Quality Patient Care. And according to the Institute of Medicine of the National Academies, safety and error incidents in hospitals aren’t the result of recklessness; rather, flawed systems, processes and conditions that lead to mistakes or fail to prevent them are the causes.

In his presentation Pronovost described results from a ground-breaking program in Michigan in which he was involved, the Comprehensive Unit-based Safety Program (CUSP), a statewide improvement effort designed to improve patient safety, improve healthcare institutions’ safety culture, as well as reduce mortality, bloodstream infections, aspiration pneumonia and length of stay in intensive care units (ICUs). To accomplish this, a partnership was developed with the Michigan Hospital Association (MHA)’s Keystone Center for Patient Safety to implement a safety program and other interventions in a cohort of hospitals. Specific goals were to implement and evaluate the impact of the CUSP initiative that includes the ICU safety reporting system (ICUSRS) in a cohort of hospitals; to implement and evaluate the effect of an intervention to improve communication and staffing in ICUs, as well as to implement and measure the effectiveness of an intervention to reduce or eliminate catheter-related bloodstream infections (CLABSI) in ICUs, an intervention to improve the care of ventilated patients in ICUs, and an intervention to reduce ICU mortality.

Pronovost says one of the critical components of the program was to learn from one defect a month, or, in other words, address one adverse outcome that would allow stakeholders to dissect what went wrong and how the effort could be prevented in the future. “Asking clinicians to define the defects (adverse patient events) causes them to own the problem locally,” Pronovost says. But to do this, which also involves putting evidence-based practices into play, Pronovost says that all ambiguity must be eliminated. “Ambiguity is the reason why clinicians don’t comply with the evidence,” he says. “People want to do the right thing, but the barriers to compliance must be removed.”