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Seth Freeman

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The Challenge of Hospital Safety: A Success Story

Posted: 07/20/10 05:00 PM ET

The nurse heard the helicopter before she saw it, appearing abruptly over the tree tops, then settling onto the roof of the UCLA Medical Center. She took the ice chest with the donated liver and rushed to the operating room where the patient, who would not survive without a transplant, was already being prepped for surgery. But when the nurse checked the numbers on the cooler, she saw that they did not match the blood type and other critical factors of the patient.

A mismatch is a serious, potentially lethal mistake. A few years ago it was national news when a top hospital on the East Coast inadvertently gave a patient a liver with the wrong blood type -- and the patient died.

So the nurse called a time-out.

She called a what?

A time-out, particularly a time-out called by a nurse, is a fairly recent invention which turns traditional hospital custom and practice on its head. It is just one of many innovations reviewed and refined at meetings of a hospital task force with the lofty designation Performance Improvement and Patient Safety Committee. More informally, PIPS.

I have the privilege of being the least educated person in the room at the monthly meetings of PIPS, where UCLA physicians, nurses and other staff convene to figure out, simply put, how to make the "Best Hospital in the West" even better. When I began attending these meetings about 10 years ago as a member of the Board of Advisers of the Medical Center, PIPS was undergoing a process of re-invigoration initiated by Tom Rosenthal, the Chief Medical Officer. The committee, chaired by then Chief of Staff, Barbara Kadell, recommitted to its mandate: Improve all aspects of patient care.

But the mandate itself was a problem -- too big, too hard, too overwhelming. So the committee proceeded deliberately, taking time to develop a preliminary list of five specific areas for improvement on which to focus. Each area had to be important -- changes would have to make a real difference to patients -- and it had to seem solvable.

At the early meetings usually about eight to 10 people would be sitting around a conference table taking up issues that seemed almost intractable because they had already been the subject of much study and effort in thousands of hospitals over the decades: How to reduce the number of hospital-acquired infections, reduce drug dosage errors, find new identification procedures to avoid mix-ups, reduce patient falls, reduce bed sores, revise procedures for "codes" and other emergencies, enhance accreditation, improve communication, improve patient education and increase patient satisfaction. All of it was difficult, but PIPS went to work.

In 2008 UCLA opened the doors on a beautiful new hospital designed by I. M. Pei, and at a recent PIPS meeting in the new building over 40 people attended, reflecting an ever-growing commitment to this process and to its demonstrable success. In fact, there were so many positive reports regarding improvements in the areas under PIPS' purview that they could have broken out the champagne -- if they hadn't been returning after the meeting to treating patients. Most gratifying, patients' satisfaction with their care, as measured by an independent agency, had steadily risen, recently achieving levels hitherto unheard of at a major academic medical center.

The most striking aspect of the PIPS meetings which I have observed is so second-nature to the participants that I doubt they've given it a second's thought -- the high level of the discussion. There is no defensiveness. Nobody speaks just to hear the sound of his own voice. Presentations are examined carefully and critically, but from a rigorous scientific point of view. There is not always agreement, but there is always respect.

The tone contrasts with the many cranky and unsatisfactory communications most of us experience during the day as we interact with our bureaucratized, phone-menu-filled culture. The contrast is particularly sharp with the often feckless communication in my own profession -- the entertainment industry -- supposedly a business of communication. I sometimes wonder how much of the defective communication we deal with daily is modeled on the pontification, rudeness and ranting that passes for conversation on cable "news" programs, and I find myself wishing that the whole world could witness a PIPS meeting as a paradigm of human beings interacting at their best to accomplish something worthwhile.

At UCLA there are two kinds of time-outs. One is routine. For example, at the beginning of every surgery there is an automatic time-out during which everyone is introduced to everyone else on the team by name, the patient's identity is double and triple checked, the planned procedure is reconfirmed, anesthesia plans (and allergies and interactions) are reviewed and possible problems are discussed and prepared for. But a second kind of time-out is now also possible -- a time-out which can be called at any time by various participants -- by, for example, an alert nurse ...

It took an anxious hour while the transplant candidate waited, but physicians and nurses contacted the hospital from which the donated liver had come and, together with their staff, reviewed all the data. Finally it was determined that the mistake was only in the labeling, that the liver itself was, in fact, a good match for this patient.

The operation proceeded. A life was saved. The patient is doing fine.