Welcome to Episode 3: The Science of Patient Safety. I would guess that after reviewing the Luis Blackman story like I did when I first saw this video and subsequently met Hellen Hasgold, I was wondering how on earth could this have happened? How could there have been so many failures within the care system at a highly regarded academic health center that led to his death? Is this just a bad hospital or an isolated incident? The IOM report we shared in module one to err is human and many case reports from our best medical centers would suggest that events like this one are actually relatively widespread. We need to keep in mind how lessons learned from Lewis' story inform changes to minimize the likelihood of similar cascades or errors and approved patient safety. The World Health Organization defines patient safety as the prevention of errors and adverse effects to patients associated with health care. This simple definition focuses on preventing harm, and provides a starting point for our discussion. The National Quality Forum has adopted a more comprehensive view of patient safety, defining it as the prevention and mitigation of harm caused by error of omission or commission that are associated with healthcare. And involving the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur. This definition recognizes the need to have systems in place to minimize the possibility of harm. As previously noted, these systems are comprised of processes, technologies, and human behaviors, including sub systems such as those that manage work force hiring and training, obtaining and disseminating supplies, finance, and essentially all aspects of the care delivery organization. Patient safety can be thought of as an applied science that involves the systematic study of errors and the rigorous design and testing of change interventions. Some of the underlying elements of safety science include systems engineering, psychology, and human factors research. The emerging field has attracted engineers, behavioral scientists as well as clinicians. Thanks to the work of leaders such as Don Berwick, who founded the Institute for Healthcare Improvement and Dr. Peter Pronovost at Johns Hopkins University and other patient safety advocates, there is increased recognition of patient safety improvement as a systematic and methodological process. One example of Dr Pronovost pioneering work was the development, testing, and now widespread use of a checklist for insertion and maintenance of central venous lines which alone, has had a major positive infect on the rates of infection using these devices. In adopting a systems approach to patient safety its helpful to first examine help your system in a brood macro level. There are national and international standards that’s provide common framework to guide the design of safe micro level health care systems. In the US, organizations such as the Department of Health and Human Services, the National Quality Forum and the Joint Commission identified goals for patient safety. For example, each year the Joint Commission establishes national patient safety goals for different healthcare settings, including hospitals, behavioral health, and ambulatory care. These goals are established by a panel of nurses, physicians, pharmacists, risk managers, clinical engineers, and others who have hands-on experience in addressing patient safety issues in a variety of healthcare settings. The goals, establish safety targets and they also provide guidelines for achieving them. The Joint Commission, who's also responsible for codifying in 1996 a set of definitions, standard and procedures for investigating and reporting of Sentinel Events, defined as an error or series of errors which result in the death, permanent harm or severe temporary harm. The Joint Commission Accredited Institutions are required to conduct a prompt comprehensive systematic analysis of all sentinel events and to report events both within the hospital and to the Joint Commission. Institutions must also develop an action plan that includes corrective actions to reduce the likelihood of future errors and implementation plan including timelines for completion and strategies for evaluating and sustaining the actions. Arguably, the most critical element of this approach is the comprehensive, systematic analysis. It's essential to conduct a very careful, thorough and detailed examination of what actions omissions or other factors may have contributed to the incident. When carefully followed, this approach can be a powerful tool and understanding in preventing future harm. While the primary focus of the Joint Commission is on Sentinel Events, events where serious harm or death has occurred, the same analytic approach can be applied to situations such as near misses, or even where an error is noted that doesn't even reach the patient. In organizations on the cutting edge of safety, reporting and analysis of events less serious than sentinel events is routine, and a key source of information to guide safety related system change. The Joint Commission has developed a typology of harms other than sentinel events, and that includes the following categories. An adverse event is a patient safety event that results in harm to a patient. A no harm event is a patient safety event that reaches the patient, but does not cause harm. A close call, or near miss, is a patient safety event that did not reach the patient. A hazardous condition is a circumstance other than the patient's own disease process, or condition that increases the probability of an adverse event. The US is not the only country that has established standards for patient safety. Examples from other countries include the Australian Safety and Quality Framework for Healthcare. This framework is consumer centered, driven by information, organized for safety, and covers all healthcare settings. Another example comes from South Africa, where the Council for Health Services Accreditation of South Africa has established the quality standards for healthcare establishments. International organizations have also developed patient safety standards. As an example, the Joint Commission, while US based, has developed international goals for patient safety on common problems found, during their accreditation process of facilities across many countries. While we have noted that there is substantial variations in the rates of errors in different countries, the basic type of errors that occur in most settings are relatively similar. Suggesting that sharing information on safety and safety improvements is a worthwhile international endeavor. In 2004 the World Health Organization, or WHO, established a patient safety committee that works to improve patient safety worldwide. The WHO's Conceptual Framework for the International Classification for Patient Safety is intended to be a standard guideline for comparison of patient safety incidents worldwide. The classification includes ten elements, so hang in there with me. Number one, incident type, then patient outcomes, patient characteristics, incident characteristics, contributing factors or hazards, organizational outcomes, detection, mitigating factors Amelia rating actions and then finally, actions taken to reduce risk. Let's take a minute to think about how this framework in the Joint Commission tools can assist in understanding the factors contributing to Louis Blackman's death. Classifying the incident type is a useful first step. What happened to Lewis can be termed a sentinel event, because it was a series of errors that resulted in the outcome of death. Recognizing that Louis's age was an important patient characteristic, the fact he was placed in an adult unit was an incident characteristic, and the failure of staff to notify an attending physician was a contributing factor. These were some of the elements that were important in the set of circumstances that resulted in this preventable event. One of the most important lessons gained from using a structured approach is the realization that nearly all harmful events are not the result of a single person's action, but rather the complex interaction of the environment technology and the patient as well as the actions or inactions of health care providers. Hopefully, this brief illustration has helped you recognize the importance of using structured approaches to examine the different types of factors related to patient harm across multiple types of incidents. The approach will reveal key data to guide re-engineering to improve patient safety. Later in this module you'll be asked to apply this frame work in more detailed, to the Lewis Blackman case. The WHO framework and the Joint Commission's sentinel events processes are provided as supplemental resources for this module. We encourage you to take some time to further analyze the Lewis Blackman story through the lens of these frameworks and processes. Gathering and analyzing data from lapses in patient safety provides a critical first step and foundation for reducing the possibility of harm and re-engineering systems for improvement while examination of past error is essential. Ideally, we would be able to anticipate what human behaviors or breakdowns in technology led to harm, and create systems in training that minimizes the chance of harm in the first place. In our next episode, we'll look at some of the approaches used to systematically design, develop, and test improvement interventions.
