By Steve Sternberg, for U.S. News
Early in July, Mary Brennan-Taylor stepped to the head of a class of medical students at the University at Buffalo–SUNY and proceeded to describe the cascade of events that killed her mother. Alice Brennan, 88, was independent and anything but frail when she was admitted to the hospital on July 13, 2009, with a mild case of gout. "I figured she had 10 more years as the life of the party," her daughter says. But doctors prescribed a muscle relaxant that isn't used for gout—and in fact is prominently displayed on a list of drugs that should be avoided in the elderly. Unsteady on her feet as a result, Brennan suffered a scary fall in rehab and lost the ability to walk. Back in the hospital, poor infection control measures led to a series of infections, each one nastier and harder to treat than the last. On August 29 that year, Brennan died in a hospice of sepsis, a systemwide reaction to severe bloodstream infections.
"Dear God, you shouldn't go into a hospital a fairly robust 88-year-old woman with gout and die 48 days later of sepsis," says Brennan-Taylor, who directs a number of social services programs for a YWCA in the Buffalo area. "It shouldn't happen."
Brennan-Taylor's subsequent crusade to eliminate medical errors—besides lecturing to medical students, she has also shared her mother's story at a federal government hearing on medical data—places her at the forefront of one of the most urgent movements in medicine: a nationwide effort to rethink the risk-ridden and chaotic medical system and place safety and quality at its heart. It is a gargantuan task. In 1999, the Institute of Medicine report, "To Err is Human: Building a Safer Health System," charged that mistakes and unsafe practices in U.S. hospitals kill at least 44,000 patients a year and possibly twice as many, a number likened to the carnage that would occur if a jumbo jetliner went down daily in the country.
"I don't think that crashing a 727 jet every day and killing everybody aboard is a good standard of care in U.S. hospitals," says author, speaker, and corporate adviser Paul Levy, the former CEO of Beth Israel Deaconess Medical Center in Boston, whose "Not Running a Hospital" blog is about improving healthcare. "If that happened in aviation, they would shut the airlines down."
But more than a decade after that scathing report, patients are still plagued by medication errors and wrong diagnoses that lead to unnecessary surgery and chemotherapy. They still have surgery on the wrong body part, and wake up with foreign objects stitched or stapled inside. A 2010 government analysis found that 134,000 Medicare beneficiaries were suffering adverse events every month, many of which were "clearly or likely preventable." A separate five-year study of North Carolina hospitals, published in the New England Journal of Medicine in November 2010, showed that, in 25 percent of all admissions, the medical care harmed patients. And a study published in Health Affairs in April 2011 revealed that the standard methods hospitals use to detect medical errors fail over 90 percent of the time.
The trouble is, far too many hospitals take safety for granted, says Donald Berwick, former administrator of the federal Centers for Medicare and Medicaid Services and a pioneer of the patient-safety movement. "There's a sense that safety's important," he says, but the prevailing attitude is " 'we're too busy right now,' or 'we can do a few things, but not transformative work.' "
What will it take to make hospitals safer for patients? Richard Brilli, chief medical officer at Nationwide Children's Hospital in Columbus, Ohio, says there's just one acceptable course of action: Commit to eliminating medical errors and harmful practices altogether. "I couldn't look a family in the eye and say we aspire to be 50 percent better," Brilli says. "There is no higher goal than zero harm events."
Zero heroes. Three years ago Brilli and his team announced that they would aim to eliminate preventable harm to patients by 2013, by making patient safety central to every medical and surgical protocol. To track their progress, they created what they call a preventable-harm index, a simple list of all hospital-acquired infections, adverse drug events, cardiac arrests, major surgical complications, hospital-acquired pressure ulcers, and serious falls, with the total being patients who were injured but shouldn't have been. When mistakes occur, hospital staffers are encouraged to report them. "We can't fix things that we don't know are happening," Brilli says. Each report triggers a review, often leading to changes in protocols, procedures, or technology. Anyone who needs added training gets it; anyone found to have taken a shortcut could be reprimanded. Those who advance the cause, whether they're clerks or heart surgeons, are acclaimed as "Zero Heroes."
So far, Nationwide Children's has cut the number of preventable incidents and errors in half, Brilli says. At Beth Israel, Levy helped persuade the board to endorse a policy in 2008 of eliminating preventable harm over four years. Just a year earlier, the hospital documented 300 cases in which patients were hurt by their medical care. After a year of monitoring these episodes and putting fixes in place, the number dropped to 160 cases, reports Kenneth Sands, the hospital's senior vice president of healthcare quality. By the end of 2011, the hospital had reported just 96 adverse events for the year, 40 of them surgical site infections in a hospital where nearly 6,400 operations are performed each year.
The idea has caught on in Washington. The Centers for Medicare and Medicaid Services has given a consortium of Ohio children's hospitals a $5 million grant to help eliminate preventable errors; Brilli says he hopes that every children's hospital in the country will have signed on by the end of 2013. The government has set a more modest goal for adult hospitals. An initiative by the Department of Health and Human Services, "Partnership for Patients: Better Care, Lower Costs," intends to reduce preventable injuries in U.S. hospitals by 40 percent, saving 60,000 lives, by 2014.
There's proof from Michigan that zero harm may be an attainable goal. In just 18 months, a partnership between the Michigan Health and Hospital Association and Johns Hopkins University, known as the Keystone Project, reduced the rate of bloodstream infections by two thirds among patients in intensive care units receiving central lines, the catheters that carry medicines and nutrients directly into blood vessels. That translates into more than 1,500 lives, and at least $100 million, saved each year. About one quarter of the ICUs have eliminated the infections altogether. At Keystone's core is a checklist—from hand-washing to wearing masks, gowns, and gloves—that medical teams must follow. Team members tick off each item on the list to make sure that each procedure is carried out in the proper order and nothing is missed. They also relentlessly monitor infection rates, working collaboratively to identify sources of infection and wipe them out. Peter Pronovost, a Johns Hopkins anesthesiologist and critical care specialist who launched the program, says he's now received government funding to extend the program to more than 1,400 ICUs in 48 states.
And that's just the beginning, Pronovost says. Next, he plans to introduce checklists for virtually anything that could conceivably harm an ICU patient and figure out ways to prevent them all. An even more powerful approach, he says, would be to build a smart ICU, with safety procedures "baked in" to the technology. "You should be able to buy an ICU that's integrated, so that everything talks to each other," he says. In standard ICUs, doctors, nurses, or respiratory therapists must adjust ventilators manually to make sure they're delivering the right amount of air, leaving the process open to human error. In an interactive ICU, a ventilator could constantly check the patient care plan and the patient's vital signs to make sure it's delivering just enough oxygen to sustain the patient without giving too much, which can lead to a potentially fatal complication called acute lung injury. "It's engineering 101," says Pronovost, who has obtained a grant to get the project started.
Toyota tactics. Some hospitals have transformed themselves by borrowing safety practices from other industries. A decade ago, Virginia Mason Medical Center in Seattle re-engineered its approaches to patient care using Toyota's policy of encouraging everyone on the shop floor to stop the assembly line and nip small problems before they have a chance to become big ones. Virginia Mason invites everyone, including the patient's family, to interrupt the action and declare a patient-safety alert when anything raises an eyebrow, from a staffer's failure to wash his hands to a nurse's administration of an unexpected medication.
n one instance, when a new lung cancer patient was given a pink wristband for "Do Not Resuscitate," a nurse who thought it odd the patient would merit such a drastic instruction checked with the patient and sounded the alarm. It turned out that the nurse on a previous shift who had picked out the wristband was colorblind, and what the patient really needed was an orange wristband signifying drug allergies. Now, in addition to being color-coded, the wristbands spell out their meaning in words. About 500 patient-safety alerts are reported every month. Each one is thoroughly evaluated, preventive steps are taken, and the most serious are reported to the board of trustees, says the hospital's CEO, Gary Kaplan.
Medicine is also looking to lessons learned in aviation, which have made commercial air travel so much safer. One of the patient-safety movement's newest spokesmen is former US Airways Capt. Chesley B. "Sully" Sullenberger III, famous for landing Flight 1549 in New York's Hudson River in 2009 without loss of life. Sullenberger worked for decades to reduce fatalities in commercial aviation and is highly critical of medicine's failure to broadly apply safeguards to protect patients; he joined other activists in calling for change in the March issue of the Journal of Patient Safety. "We have islands of excellence in a sea of system failure," he says.
Sullenberger and others are calling for a medical version of the National Transportation Safety Board, the agency that probes air crashes. The new agency would investigate a sampling of major incidents each year, report what went wrong, and recommend fixes that would be distributed to hospitals nationwide. They'd like to see a version of the Federal Aviation Administration's Aviation Safety Action Program, too; it encourages pilots and other industry workers to confidentially report lapses that might cost lives.
Few hospitals can count on the sort of top-to-bottom buy-in they'd need to model themselves after Toyota. But certain key values should be universal in medicine, says Brent James, chief quality officer at Intermountain Healthcare in Salt Lake City. Among these, he includes basing decisions on the best medical evidence and relentlessly monitoring what works and what doesn't. James's team has taken the monitoring to a whole new level by partnering with the Mayo Clinic, Dartmouth-Hitchcock Health, and Denver Health to examine whether one hospital's procedures can serve as a model for the others.
The group tackled total knee replacement first. "Wouldn't you know it, we found big variations" in the length of the operations and complication rates, James says, noting that Intermountain relies on "tightly controlled" operating room teams led by a surgeon who routinely works with the same group of nurses and technicians and specializes in one procedure. The team sticks closely to an evidence-based approach designed to get the best results with the fewest complications. "Our complication rates and time in surgery were 30 percent below what the others were doing," James says. Such an exchange of information on a range of medical practices will ideally improve all of the hospitals' patient care.
The patient's part. Following some simple rules themselves can help patients head off mistakes. Bashfulness won't help. It's important to speak up on your own or a family member's behalf and insist that doctors and nurses fully explain procedures they plan to perform and medications they intend to prescribe. Ask questions, watch what's done, and don't be afraid to put on the brakes if you're concerned about what you see. When it's a loved one who's in the hospital, "stay at the bedside," says Berwick. "Don't leave."
Many consumers, savvier and armed with more digital information than ever before, are forming advocacy and support groups, such as the Society for Participatory Medicine, to push for better access to their own records and a bigger role in decision-making. Healthcare is "an entire industry that was built around a passive customer who didn't think he or she had the right to question anything," says Diane Pinakiewicz, president of the National Patient Safety Foundation. "Now you have educated people who want to be involved and are no longer passive recipients of care."
Mary Brennan-Taylor wishes she had known what steps to take to advocate for her mother. "I felt responsible for not being able to protect her," says Brennan-Taylor. "I was totally trusting. I never asked the doctors and nurses coming into her room to wash their hands. I never checked her medication." Brennan-Taylor hopes that by continuing to speak out, she can help educate a new generation of doctors, encourage patients to stand up for themselves, and, as a result, make hospitals safer places. All worthy goals, all long overdue.
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