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Minor Mistakes, Deadly Results
Comments () | Published January 27, 2012

Dr. Pronovost began using a checklist at Johns Hopkins that led to a 90-percent drop in bloodstream infections in the hospital's intensive-care units.

Pronovost's checklist has five items: wash hands; clean the patient's skin with antiseptic; put a sterile draping over the patient; wear a mask, hat, sterile gown, and gloves; and put a sterile dressing over the insertion site once the tube is in.

Gawande's The Checklist Manifesto details how Pronovost worked with hospitals in Michigan in a study published in 2006 on using a checklist in ICUs. The hospitals reported a 66-percent drop in infections, and many got their infection rates to zero.

Joanne Ondrush, a critical-care physician at Inova Fairfax Hospital, was inspired by Gawande's book and talked her colleagues into reading it. She then worked with doctors and nurses in the intensive-care unit to create a checklist in 2010 for Inova Fairfax's ICUs that's used when doctors and nurses talk about patients on rounds.

"The biggest resistance to this was that it's more work for someone who is already stressed and busy," Dr. Ondrush says. "But when people saw that it could be implemented with minimal change in the workflow, it was adopted in a relatively short period of time."

Inova's Medical Surgical ICU--one of nine full-time ICUs at the hospital--keeps track of its infections on a whiteboard in the staff lounge. The board is next to the refrigerator so that everyone tracks their progress. Each time a patient gets an infection, the doctors and nurses hold a "huddle" in which they discuss the cause. Then someone posts a brief explanation on the wall about how the infection occurred so everyone can learn from what happened.

In September, the Medical Surgical ICU showed that there had been six infections since the start of the year.

"Zero is always our goal," Ondrush says. "But zero isn't sustainable [forever] because we are dealing with sick people and there are going to be variables that are out of control. You can do every checklist and everything right and the patient is still going to develop an infection."

On an early August morning, 200 Georgetown Medical School students gather for coffee, bagels, and a talk on patient safety. Doctors haven't traditionally been trained to see patient safety as one of their priorities. That's changing.

Dr. Stephen Evans, chairman of surgery and the leader of patient safety at Georgetown University Hospital, moves to the lectern and begins with a question.

"When patients get admitted to the hospital, what is it that a patient wants?" He calls on a student at the table in front him, who answers: "To get cured?"

"No," Evans says.

The student tries again. "To feel safe?"

Evans nods. "They want to feel safe first," he says. "After they feel safe, they want to be cured of what ails them."

Evans stresses that every medical student and soon-to-be doctor plays a key role in keeping a patient safe.

"So what does that mean? If you are in a room and the attending physician walks in and doesn't wash his hands, you--not anyone else, you--can flatten the hierarchy. You say, 'Excuse me, Dr. Evans. You forgot to wash your hands going into the room. Would you mind? I think it's important for patient safety.' "

The room erupts in nervous laughter, as it does every time Evans gives this lecture. The reason, he says, is that he's telling students to question their superior--something that hasn't historically been part of med-school curriculums.

"I'm not laughing," Evans tells the students. "You have to be in a position where you can tap someone on the shoulder regardless of their level, age, or hierarchy so the best care is delivered to the patient."

The Association of American Medical Colleges, the group that speaks for the nation's medical schools, is encouraging schools to emphasize patient safety and to push new physicians to think in teams. Doctors are also being trained in the importance of washing their hands, something that seems obvious but wasn't part of med-school discussions in the past.

"Previously it was just how to treat a patient and how to take out a gallbladder," Evans says. "Now we have tons of data showing how many near misses and mistakes and errors occur, and so we try to make that painfully transparent to everyone."

Next: Hospitals continue to struggle to get their staff to wash their hands as often as they're supposed to.


Examining the underlying factors in "near misses" and errors--known in engineering as a "root cause" analysis--is also a big change in health care. Terry Fairbanks, associate professor of emergency medicine at Georgetown and a patient-safety expert, says that among the reasons airlines are safe is that they track near misses and errors and conduct root-cause analyses.

"In the history of health care, what do we do if anyone makes a mistake?" says Dr. Fairbanks, also director of the MedStar National Center for Human Factors Engineering in Healthcare, a unit within MedStar's hospital system that focuses on patient safety. (MedStar owns Georgetown Hospital and eight others.) "We'd retrain them. We'd focus on the individual instead of recognizing that there are certain things that people will make errors with" and redesign the system accordingly.

Georgetown encourages staff to report instances in which actions nearly caused harm or caused only minor harm. These reports give an indication of where the hospital needs to bolster its processes to prevent a serious injury.

"In engineering, there are 600 misses for every adverse event," says Fairbanks. "You can build a system to prevent those near misses from turning into an adverse event, but you have to know what those near misses are."

Sometimes what's found in analyzing an injury is that hospital staff aren't following even the most basic safety precautions. Infections are known to spread through poor hand washing, for example, but hospitals continue to struggle to get their staff to wash their hands as often as they're supposed to. An estimated 1.7 million patients a year get infections in hospitals and 99,000 die from them, according to the Centers for Disease Control and Prevention.

At Shady Grove Adventist Hospital, the staff was 80 percent compliant with hand-washing rules and couldn't get that number higher until the hospital required employees to sign a letter committing to washing their hands, says Skip Margot, Shady Grove's vice president of patient-care services. The letter was then put into staff job-performance files. Compliance rose to almost 100 percent, Margot says. (Shady Grove knows its compliance rate because it periodically secretly observes staff on hand washing.)

At Shady Grove and at Georgetown, sinks and hand sanitizers have been positioned to take into account doctors' and nurses' workflows. Hand sanitizers are installed on walls near the entrance of rooms, for example. "When [doctors and nurses] don't wash their hands, it isn't a conscious decision," Fairbanks says. "You get interrupted by a nurse with a question just as you were about to wash your hands."

Georgetown says its hand-washing rate is 90 percent. Evans, the Georgetown patient-safety leader, says that as of mid-2011, there was a big decrease in the hospital's infection rate and other complications, but he declines to give specific numbers.

Another way hospitals are improving safety is by digitizing patient records. In September, the Joint Commission listed Silver Spring's Holy Cross as a top-performing hospital, one of only 405 in the country to receive that ranking. No other hospital in the region made the list. Holy Cross was judged on how well it followed recommended protocols for treating children's asthma, heart attack, heart failure, pneumonia, and surgical infection.

Dr. Yancy Phillips, Holy Cross's head of quality and care management, credits the hospital's investment in electronic records. Every patient admitted now has a digital record, and seven full-time employees comb through those records to determine if doctors and nurses are following safety protocols.

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  • It’s really horrible to see doctors do such small mistakes that leads to major incidents. One of my unforgettable moment is where my cousin had an eye surgery on his left eye but the surgery was done to the right eye.

    Had to hire a good lawyer get a compensation from the hospital.

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