On a day when aHopkins Hospitalintensive care unitwas brimming with

postoperative patients and morewere on the way, the staff wasfinding it difficult to safely coverall of the beds. Yet, a senior nursebalked at carrying out a physi-cian’s request to call the operat-ing room and halt further trans-fers. She explained that wouldopen her up to harsh words fromsurgeons, anesthesiologists andthe OR charge nurse.

In another busy ICU, a med-ical student told a fellow in pass-ing about an abnormal labora-tory result affecting a patient’scondition. But the seriousness ofthe situation didn’t register withthe senior house staff officer,who was consumed with help-ing another critically ill person.Two hours later, when the situa-tion finally became apparent tothe fellow, he appropriatelytreated the patient.

Examples of communicationfailures like these fall into BillTaggart’s lap all the time. Hegathers similar anecdotes likeothers collects research data.Taggart is a well-known expertin interpersonal communicationskills and teamwork trainingwithin the aviation field, andnow he’s brought his forte to thehealth care industry. His four-hour training session has be-come the backbone of a jointprogram by Hopkins Hospital’spatient safety committee andHopkins Medicine’s Center forInnovation in Quality PatientCare to teach front-line medicalstaff how to improve such skillsas assertiveness, listening andgroup decision-making.

Communication breakdownsamong health care professionalsare one of the leading causes ofpatient harm. “If we can get ourcare teams to improve theircommunication,” asserts PeterPronovost, a nationally recog-nized patient safety expert andHopkins anesthesiologist, “itwill take us miles toward elimi-nating medical errors.”

Hopkins borrowed its ideafor interpersonal communica-tion training from the aviationindustry because of its successrecord in reducing communica-tion-related causes of planecrashes. During its investiga-

tions, the National Transporta-tion Safety Board discoveredthat many plane accidents mighthave been avoided had pilotsnot ignored warnings fromcopilots. This led the industry toconduct training aimed atbreaking down the hierarchalbarriers among the flight crew.

Taggart believes the leapfrom aviation to health care isn’tso unconventional. Both indus-tries have common elements:highly skilled teams, high-stakesservices, highly regulated safetyenvironments and a traditional-ly hierarchical structure.

Medicine’s complexity, how-ever, does present its own obsta-cles to breaking down communi-

cation barriers, Taggart con-cedes. “The challenge,” he says,“is to get the physicians, nurses,residents, pharmacists and othersin the same room for the train-ing. Otherwise, it’s meaningless.”

Using flip charts, video seg-ments and PowerPoint, Taggarttakes staff through the basicprinciples of effective communi-cation: briefings, assertiveness,situational awareness and teamdecision-making. A study at Or-ange County (Calif.) Hospitalshowed, for example, thatchecklists and daily briefings re-duced wrong-site surgeries by200 percent, cut the nursingturnover rate to zero and in-creased morale for all of the sur-

gical teams. “Briefings,” Taggartnotes, “put everyone on thesame page.”

In many instances, the train-ing participants learn it’s thesimple things that make a differ-ence. In the case of the medicalstudent and fellow, had thephysician-to-be addressed thesenior resident by name, madeeye contact and fully explainedthe situation, the physician’s at-tention would have been quicklydrawn to the seriousness of thesituation.

Although hospital reportcards are focusing on how alldoctors speak to patients, theseskills have been slow to takehold in medical institutions.Their importance got a boostrecently when Dean/CEO Ed-ward Miller made communica-tion training an institutionalpriority. Hopkins, Taggart feels,is positioning itself to be aleader in what this training isgoing to look like in academicmedical centers. “But right now,we’re just at the beginning ofthis journey in medicine,” hesays, “and we aren’t 100 percentcertain of how it will play out.” n

PICTURE TO THE WORLDIS A CLICK AWAY

For the past two years, the Center

for Innovation in Quality PatientCare has made its presence felt

throughout Hopkins Hospital byassisting front-line staff in devel-

oping projects that help eliminate

medical errors and improve theway care is delivered. Now, the

Center aims to share this pioneer-ing work, its tools of the trade and

the experiences of its experts

around the world through a newWeb site, www.hopkinsquality.com.

Surfing the site, visitors canexamine case studies, such as im-

proving ICU communication

with daily goal sheets, or reduc-

ing catheter-related bloodstreaminfections. It offers information

on tools that professionals canuse to start their own quality in-terventions, and updates about

Center-sponsored seminars and

symposiums on practical ap-

proaches to quality and safetyprograms. The Web site also in-

cludes an electronic version of

Quality Update.

GOING SOUTH OF THE BORDER

When the staff of a Hopkins Hos-

pital inpatient unit wants assis-

tance in piloting a project to

improve patient care, the Center

sends one of its experts across the

street. This expertise also is beingspread beyond this country’s bor-ders. Last November, for exam-

ple, in the successful quality expoorganized by the Mexican Society

for Quality in Patient Care inMexico City.

Richard Davis, the Center’s

executive director, talked about

leadership’s role in championing

quality improvement to health-

care chieftains from both private

and public sectors. Cheryl Denni-

son, Center director of research

and operations, spoke about

Hopkins’ cutting-edge work in

patient safety, and Hopkins Hos-pital and Health System Vice

President for Human ResourcesPamela Paulk explained the cor-

relation between employee andpatient satisfaction. Anothergroup of Hopkins experts has

been invited to participate in the

Mexican society’s next qualityexpo in October 2004.

Short Cuts

April 2004 • Issue 2A Newsletter from The Center for Innovation in Quality Patient Care and Johns Hopkins International

In a Manner of SpeakingAdopting communication skill training from aviation to improve teamworkamong medical staff is gaining altitude.

Bill Taggert, the aviation industy’s ace on communication skill training, explains to an ICU staff how briefings and teamwork reduce errors.

Physicians Technicians RNs

“I know the names of all thepersonnel that I worked withduring my last shift.”% of respondents who agree

83.3

45.0

19.4

• Building teamwork• Using daily briefings • Creating a culture of

safety • Getting strong leader-

ship support• Flattening the hierarchy

What medicine canlearn from aviation’sCrew ResourceManagement training

4 Points From Pronovost A devot-ed wife and a determined nursepulled together to teach a lesson ofa lifetime.

3 Spotlight On the many whoovercame barriers to cutcatheter-related bloodstreaminfections rates.

2 Director’sChair ChipDavis.

2 Conversation WithStephanie Poe onembracing evidence-based guidelines

Inside:

How did this project get started?Actually, it was a marriage of two strategies by theCenter for Innovation in Quality Patient Care, onelooking to infuse evidence-based guidelines intotreatment practices, the other to use medicationreconciliation to improve safety. The center alreadyhad supported a medication checklist in the Wein-berg ICU for transfer orders. Why target cardiovascular patients?For years, there’s been ample, scientifically support-ed data showing that certain medications andlifestyle regimens can significantly reduce the risk ofrecurring heart disease. Roger Blumenthal, directorof the Hopkins preventive cardiology center, hadbeen trying to introduce the use of these guidelinesfor some time.

So, the innovation center’s medication reconcili-ation committee and Blumenthal decided to mounta pilot project on Halsted 5, a 21-bed telemetry unit,focusing on coronary artery disease patients. We metwith the unit’s staff to design a program that incor-porates three strategies: education, medication rec-onciliation and outreach to referring physicians.What kind of project was set up there?We first educated prescribers, nursing staff and pa-tients about reducing the risk of further cardiovas-cular disease through lifestyle changes like smokingcessation, diet and exercise, and by using evidence-based medications such as anticoagulants, ACE in-hibitors and beta blockers. We then established adischarge reconciliation project to ensure that pa-tients were sent home on medications recommend-ed by AHA and the American College of Cardiolo-gy. Finally, we sent referring physicians a letter fromDean/CEO Edward Miller and Blumenthal explain-ing our program and encouraging them to have dis-cussions with their patients about using these med-ications as part of their ongoing care.

We thought about a project name and finally set-tled on ABC, because it simply is about the funda-mentals of cardiovascular disease risk reduction.Did you measure the results?We only measured the medication reconciliationpiece. The short length of stay wasn’t conducive tomeasuring the effectiveness of our education tool.How did the project stack up with medicationreconciliation?We tracked the discharge medications versus thenational guidelines over several weeks and bench-marked ourselves against a similar program atUCLA. I’ll give you a few results: We achieved 100percent compliance for prescribing aspirin andPlavix. For ACE inhibitors, we started below thebenchmark, and after a slow beginning, we’vestayed around 95 percent compliant. Beta blockershave been a tough nut to crack, but we’ve main-tained steady improvement and find our compli-ance level at 85 percent.Are you keeping a long-term eye on medica-tion guideline use?We’ve decided to do a quarterly follow-up on theHalsted 5 pilot to make sure we maintain compli-ance with the guidelines. And we’ve done grandrounds on the project for the entire Department ofMedicine to increase awareness, because it haspatients with coronary artery disease, even if theyaren’t on a cardiology unit. What’s next?There’s a second pilot under way in the 28-bed car-diac surgery intermediate care unit, where the aver-age length of stay is nine days. And we’re going touse a $10,000 grant from the Dorothy Evans LynnFund from the School of Nursing for a post-dis-charge guideline-adherence study, and we will belooking at whether providers keep these patients onthe recommended drugs. n

Q and patient safety are arguablyfast becoming the two leading issues on theradar screen of hospital professionals in theUnited States. But a three-day symposiumheld at Hopkins last October also proved

that these issues have made it to the top of the agenda forhealth leaders abroad.

Co-sponsored by the Johns Hopkins Medicine Centerfor Innovation in Quality Patient Care and Johns HopkinsInternational (JHI), the event brought to Baltimore 90hospital leaders from more than 14 countries. Accordingto Clara Marin, JHI senior manager for International Pro-

grams and symposium coordinator, participants heardmore than 30 speakers, including senior administrators,physicians and nursing staff, and took home lessonslearned from the myriad initiatives implemented on Hos-pital units here in the past year. (All plenary and track ses-sions were audiotaped and are available for purchase onCD-ROM from the Center at www.hopkinsquality.com.)

The October symposium has led to several exchangeand educational programs with Monterrey Tec, the lead-ing Mexican private university.

With the success of last fall’s seminar behind them, theCenter and JHI are preparing for a second one to take

place May 12–14 on the Hopkins medical campus. Thisevent, titled The Future is Here: Managing Change inClinical Care, will focus on how clinical, technologicaland other trends are changing the practice of medicineand how hospitals plan for the future. Workshops will in-clude techniques to improve teamwork and communica-tion to ease the work of quality-improvement teams. Forprogram details and registration information, contactClara Marin at 1-410-955-3096 or jhis@jhmi.edu, or visitwww.jhintl.net. n

Quality on Parade

A Watchful EyeFor years, groups such as the American Heart Association published guidelinesaimed at reducing cardiovascular risks. But Hopkins and other institutions hadn’ttotally embraced these standards. Now, Stephanie Poe, nursing clinical quality coor-dinator, is heading a project to show that adhering to them is as easy as ABC.

Conversation with Stephanie Poe

The Director’s Chair

Invitation to Exciting IdeasRichard “Chip” Davis, Ph.D.Executive Director

A C I Q P C continues bring-ing Johns Hopkins’ excellence in patientcare, education and research to its care

delivery models, we’re reminded that progress initiallycan involve dismay, disruption and discomfort.Dismay comes with the discovery that hospitals, over-whelmed by sophisticated technology demands,reduced resources and ever-increasing administrativetasks and accountability, may be hampered in theirefforts to heal.

Pursuing excellence also brings disruption. To craftsuccessful interventions, we must be ready to redesignor eliminate well-established systems and processes,then challenge our cultural norms. And this processcan create discomfort, particularly when achievingbetter care standards takes longer than expected.

But we work through these obstacles to find suc-cess. In some cases, it’s found in lessons learned fromother industries and disciplines. Mostly, though, it’srelying on the ingenuity and quest for excellence wefind in our people, their collaborative work and thecommitment of our leadership to successfully re-design our care models that stand the test of time.

In this Quality Update issue, we’ve highlightedsome examples of excellent redesign efforts. One arti-cle looks at how the aviation industry improved com-munication among flight crews and reduced human-error-related airplane crashes. We’re now applying theconcept, initially in our operating rooms, where facul-ty and staff are finding that it helps target problemsarising from poor communication—a major factor innearly every medical mistake.

A second article discusses Dr. Trish Perl’s work incutting catheter-related bloodstream infection rates.Perl and herEpidemiologyand InfectionControl teamintroduced evi-dence-basedprotocols andeducated med-ical staff to fol-low them.Adapting bestpractices tocurrent care delivery systems also can require a multi-disciplinary approach, a theme behind a project to re-duce cardiovascular disease risks among patients intwo hospital units. An article explains how evidence-based medication guidelines and lifestyle educationwere successfully incorporated into cardiac care deliv-ery models.

Einstein observed that “without changing our pat-terns of thought, we will not be able to solve the prob-lems we created with our current patterns ofthought.” These efforts exemplify the excellence thatevolves when we disrupt old models and work as ateam to develop new ones. n

P -

ing better than data tosupport new ways ofdoing things, and Roy

Brower is no exception. Duringthe past two years, the medicaldirector for the medical intensivecare unit (MICU) has doggedlypursued changes in proceduresfor inserting central lines, drivenby the fact that the unit had oneof the highest bloodstream infec-tion rates in Hopkins Hospital.

But Brower wanted eachchange to have the weight of thebest evidenced-based practicesbehind it. In 2002, for example,the Hospital changed its policyon central-line insertions to rec-ommend that either betadine orchlorahexidine could be used as askin prep before catheter inser-tions. Brower, however, thoughtthe evidence clearly pointed tochlorahexidine as the wash thatwould best reduce the chancesfor infection and worked with theinfection control group to makethis the preferred prep.

Through the determination ofBrower, Dana Moore, clinical

nurse specialist and the MICUclinical practice committee chair,and other staff, the unit has seen aremarkable 75 percent reductionin its bloodstream infection rates.“It’s been our best success story,”asserts Trish Perl, the Hospital’sinfection control officer.

In fact, Hospital catheter-re-lated bloodstream infection rateshave fallen significantly below thenational average in a number ofICUs over the past 18 months,from an annual high of 235 per1,000 catheter-use patient days toaround 90. This was accom-plished thanks to a convergenceof efforts spearheaded by Perland her team of physicians, theICU medical teams and, most re-cently, the Johns Hopkins Medi-cine Center for Innovation inQuality Patient Care.

Hopkins isn’t alone in battlinghospital-acquired infections.Hospitals around the UnitedStates are bedeviled by this prob-lem, according to the Centers forDisease Control and Prevention.The CDC reports that about 2million hospital patients a year—

one of every 20 admissions—contract an infection unrelated totheir condition, and more than90,000 of them die.

Perl started looking at Hop-kins’ catheter-related blood-stream infections more than sixyears ago. It was a slow process,beginning with marshaling evi-dence that showed central-lineinsertions harbored dangers topatient safety. “Next we needed apolicy to put in front of care-givers,” Perl says. “It took us sev-eral years, but by 2001, we hadone that reflected the CDC’s bestevidenced-based guidelines.”

These recommendations forcentral-line insertions, in addi-tion to using a certain kind ofskin prep, include requiring doc-tors and nurses involved in theprocedure to wear sterile gowns,masks and caps, and using largesterile drapes around the inser-tion site.

But having protocols in place,Perl found, didn’t automaticallytranslate into success. “It becamereadily apparent that we couldn’tjust legislate change.”

Using a five-year CDC grantworth $400,000 a year to instillbest practices for central-line in-sertions, Infection Controllaunched an aggressive interven-tion in August 2002 to reducebloodstream infections in theMICU and the cardiac surgery in-tensive care unit. It also sought tobuttress efforts already under wayin the surgical intensive care unitled by surgeon Pam Lipsett andanesthesiologist Todd Dorman.

The Center for Innovation inQuality Patient Care stepped in tolend salary support for epidemiol-ogist Sara Cosgrove so she couldundertake an intensive educationprogram on the units. InfectionControl also created a Web-based,

mandatory training module for allresidents rotating through theunits and made the exercise a pre-requisite for physicians to get theircredentialing renewed.

The innovations center, Perlpoints out, has been invaluable inknocking down bureaucratic bar-riers to getting products, harness-ing support from the HopkinsMedicine leadership and plug-ging the central-line-infection re-duction projects into the institu-tion’s patient safety program.

The two project ICUs alsoadopted from the SICU the ideaof buying a special cart that storesall of the sterile materials themedical staff need for central-lineinsertions. “We had found,” ex-plains nurse Debbie Hobson, theSICU’s performance improve-ment committee chair, “thatsometimes physicians and resi-dents wouldn’t use all of the ma-

terials because they wasted somuch time tracking them down.”

The units also took their ownlead in making changes beyondthe protocols. The MICU, for in-stance, purchased an ultrasoundmachine that displays the locationof veins and guides the placementof the catheter needle. “Datashows that this helps reduce in-fections by limiting unnecessaryneedle sticks,” says Dana Moore.

Since this exhaustive push byso many to address bloodstreaminfections began, Perl says, Hop-kins has achieved more successreducing infection rates than anyother institutions involved in theCDC grant, including Washing-ton University and the MedicalCollege of Virginia. “Everyonelikes to take credit for this ac-complishment,” she muses, “andthat’s OK. It shows that everyoneis invested in the program.” n

Making sure that operating-room staff follow evidence-based protocols to preventsurgical-site infections soundslike a no-brainer. After all,Hopkins Hospital’s Epidemiol-ogy and Infection Control andoperating room staff put a lotof time into researching andthen introducing the guide-lines into the OR’s daily pre-operative routine. And the re-sult was starting to reduce in-fection rates among patients.

So the Hospital’s surgical-site infection task force lastspring developed a papercompliance form containingquestions such as whether asurgical site was marked andinitialed by the surgeon,whether antibiotics weregiven at the proper time andwhether the operating room

was clean. Circulating nurses(those not scrubbed in forsurgery) filled out the forms.The completed audits werecollected and placed in filesand remained there unusedsometimes for months untilsomeone could be sprungfrom other duties to enter theinformation into a database.

What to do about this vitaldelay in compliance trackingbecame a classic use of arapid-cycle solution to a sys-tem problem, a signature toolof the Hopkins Medicine Cen-ter for Innovation in QualityPatient Care. This accelerat-ed process involves identifyingproblems, planning a solution,getting a pilot project startedquickly with small resources,adding necessary changes andmeasuring results.

Laura Winner, a quality in-novation coach for the Cen-ter, was working with CardiacSurgery to reduce its infectionrate when the issue of timelymonitoring came up. The ini-tial idea was to make an elec-tronic copy of the audit andconnect it to a CardiacSurgery database. But therewere no computers in the car-diac OR and it wasn’t sched-uled to get them for anotheryear, when a new computer-ized operating room manage-ment system (ORMS) wasready for a phased rollout.Additionally, the plan was toimplement the audit tool in alloperating rooms.

Two Cardiac Surgery infor-mation technology teammembers, Diane Alejo andJoe DiNatale, came up with a

solution: Make the electronicaudit form Web-based and tieit into a database in the De-partment of Surgery. TheCenter and cardiac surgery ITworked together to developthe application, and withinseveral weeks, the paper form

was migrated onto a secureWeb site. Operating-roomnursing leadership decided topilot the application in thecomputer-equipped Wein-berg OR.

By using the rapid-cycleprocess to get the pilot up andrunning, the Web-tool projectbypassed the time-consumingmethod of gathering informa-tion, taking it to a committeeand waiting for the right op-

portunity. “We could’ve wait-ed until all of the ORs hadcomputers to start this pro-ject,” Winner points out.“The pilot has given us thechance to make some tweaksbefore the online audit formgoes to a broader use.”

The online audit version istied to the electronic patientrecord system, making it eas-ier to get the surgical pa-tient’s name or identificationnumber. Drop-down menusand Yes and No answersallow the nurse to simplypoint and click the resultswith a computer mouse. Thetool also has a comment fieldto point out concerns thataren’t addressed by answer-ing the questions. Results foreach surgery are automati-cally submitted to thesurgery database.

The data helps to pin-point opportunities for im-provement and helped staffreach 100 percent compli-ance with evidenced-basedOR best practices. n

The Roots of DangerTwo intensive care units prove that simple steps backed byscientific evidence can drive down infections.

Spotlight

Dana Moore, the MICU’s clinical practice committee chair, helped guidea unit project that cut its catheter-related bloodstream infection rate.

Tools

Applying rapid-cycletools can help unitsdefeat bureaucraticobstacles.

Infection control experts Sara Cosgrove, left, and Trish Perl discoveredthat changing old practices requires education and evidence-based policies.

The Paper ChaseWhen tracking compliance with surgical-site infection proto-cols became sidetracked, a quick solution made a difference.

© Johns Hopkins Medicine, 2004

Center for Innovation in Quality Patient CareJohns Hopkins Outpatient Center601 North Caroline Street / Suite 2080Baltimore, MD 21287-0765

Quality Update is a joint project of Johns Hopkins Medicine’s Center forInnovation in Quality Patient Care and Johns Hopkins Internationaldeveloped with the Office of Corporate Communications. ElaineFreeman, vice president.Center for Innovation in Quality Patient CareExecutive DirectorRichard “Chip” Davis, Ph.D.Medical DirectorPeter Pronovost, M.D., Ph.D.Director of Research and OperationsCheryl Dennison, C.R.N.P., Ph.D.Johns Hopkins InternationalCEOSteve Thompson, MBADirector, Communications and MarketingEmilio WilliamsNewsletter StaffEdith Nichols, Director of PublicationsPatrick Gilbert, Editor/Writer

What an Idea!

In my seven years of attending in theICU, this was the first time I saw a familymember so involved in patient care. Rus-nak is a hero to me, for she taught me whatit means to practice patient-centered care. We use thisphrase often and loosely, butfew of us comprehend its truemeaning. I am beginning tounderstand that it meansmany things. First, it meanspatients should be united withtheir loved ones. Our ICUs arenow embarking on an effortto accomplish this by makingvisiting hours more flexible.

Patient-centered care alsomeans organizing health carearound patients rather than caregivers.This means involving patients and familyin all aspects of medical care, includingmedical decisions. Ann, for example, wasvery involved in decisions regarding Jim’smedical care and many times pushedphysicians and nurses to ensure that he re-ceived the best possible care. At first herassertiveness was felt to be offensive, buton reflection the team knew that she

brought an important perspective thatneeded to be considered. She provided thelove, comfort and intuition that no ma-chine, drug or care provider could mimic.

Rusnak recognized thiscare that only a spouse orother close family membercan provide. She showed usthat patient-centered care cantake on many faces that go be-yond a clinical procedure ortherapy. Our work must striveto relieve the physical andemotional pain and sufferingour patients and families ex-perience that no dose of mor-phine can dull. Rusnak andmany caregivers like her bring

this reality to the forefront daily and re-mind us that we are guests in the lives ofour patients.

What does patient-centered care meanto you? I am interested in hearing yourstories. Please share them with us so wecan pass them on to others and betterunderstand the many faces of patient-centered care. You can e-mail your sto-ries to CIQPC@jhmi.edu.n

As Hopkins Hospital’s newpatient safety coordinator, LoriPaine is on a critical mission.

Lori Paine’s career trajectory hastaken her from bedside nurse to thevery face of patient safety at HopkinsHospital. As the institution’s first pa-tient safety coordinator, she embodiesthe mantra of doing no harm. “Everysingle one of us would be lying toourselves if we denied that we hadever made mistakes,” she says. “Andall of us are either patients or familyof patients. Safety is something wesimply cannot ignore.”

Nationwide, other hospitals are in-stituting similar posts, as a new “scienceof safety” in health care emerges. Thisnew path comes in response to pres-sures from patient advocacy groups, ac-crediting organizations and now, inter-nally, from medical staff, as they em-brace the concept that it’s everyone’s re-sponsibility to protect patients.

Paine stepped into the new post ayear ago and began by leading the Pa-tient Safety Committee, the group thatsets and monitors the hospital’s safetyagenda, through an eight-week plan-ning process. The exercise resulted inthe safety strategy—anchored by eightgoals, such as improving communica-tion and teamwork, engaging patientsand family members in planningtreatment, and developing valid mea-sures of patient safety—that she isnow coordinating.

To key people in to the new strate-gy, for example, Paine has organized aseries of quarterly grand-rounds pre-sentations on safety for the entire hos-pital staff. To engage patients andfamilies, she works with units to makesure patients receive daily care plansand daily goals sheets. To improve the“culture of safety,” she coordinatesrounds made by senior executives.These rounds are part of the Com-prehensive Unit-based Safety Pro-gram, or CUSP, an eight-step exercisenow in place in at least 10 differentunits that begins and ends with staffassessments of safety.

Paine also was the first personhired as a quality improvement coachby the Hopkins Center for Innovationin Quality Patient Care, overseeing aninitiative to increase nurses’ “touchtime” with patients. n

EmbracingFamily in Patient Care By Peter Pronovost, M.D., Ph.D.Christine Holzmueller, BLA

T

explain what patient-centeredcare means than to recall a storyof compassion and understand-

ing that I witnessed recently between anurse and her patient. The patient (we’llcall him Jim) died in his wife’s arms asthey both lay in his hospital bed in the in-tensive care unit. Being able to hold herhusband gave Ann (alias) great comfortand meaning, something Diane Rusnakmade possible through her courageousand remarkable work as Jim’s ICU nurse.

This compassionate finale began over sixmonths ago in the surgical ICU. Jim arrivedthere with sepsis, a complication followinghis kidney transplant. He had battled morethan six life-threatening events, but this lastcrisis was different. An infection was ragingwithin him, and Jim’s medical care teamwas losing the battle to save his life.

The team included Robert Mont-gomery, the surgical attending, EdwardKraus, the transplant nephrologist, hisnurse, Diane Rusnak, and me, the ICUphysician. Realizing that Jim was slidingdownhill quickly, we decided to meet withthe family to discuss his prognosis andgoals of care. Rusnak, who had more than10 years of nursing experience, recognizedthat Jim’s dialysis machine and heatingblanket werephysical barriersfor his family.She proposedremoving both,and the familyreadily agreed.This insightfuland compas-sionate sugges-tion permittedJim’s family todraw closely around him, touch him andcelebrate his life.

Rusnak then prepared Jim’s bed tomake room for his wife. Though Jim wasunconscious, Ann knew that after manyyears of marriage, he would sense hertouch. She laid in bed with Jim for hoursuntil eventually he passed away peacefullyin her arms.

Peter Pronovost

In my sevenyears of attend-ing in the ICU,this was the firsttime I saw a family memberso involved inpatient care.

Points from Pronovost Dispatches from the Front Lines

Non-Profit Org

U.S. Postage

PAID

Permit No. 1167

Baltimore, MD

In the quest for an error-freedrug delivery system, self-re-porting currently is the bestway to track medication er-rors. Accurate and unbiasedreporting, however, hasbeen especially difficult inthe health care environ-ment up to this point,because the fear ofblame is still preva-lent.

To take fearand bias out ofthe process, amultidiscipli-nary grouphas developedan automatedmethod to reportmedication errors. Thesystem, called MedicationEvent Markers (MEM), red-flagsmistakes by the type of drug, thetime it occurred and the unit where ithappened.

Still in its infancy, MEMS is beingtested in the Weinberg and surgeryintensive care units, because it canpull information from Eclypsis, apoint-of-care clinical data system.These medication-event triggersdon’t necessarily indicate actual harmto patients, but they are valuable for

tracking error trends and highlight-ing areas for improvement.

A medication-event mark-er is an automated algo-

rithm that iden-tifies thetoxic side ef-fects, or trig-

gers, of anoverdose with

certain clinicalindicators. In set-

ting up the system,the group—intensive

care units, pharmacy,nursing, risk manage-

ment, information tech-nology, the Hopkins Hos-

pital patient safety com-mittee, and the Center for

Innovation in Quality PatientCare—focused on medicationswhose high use and mis-dosagecould have devastating conse-

quences for patients. These includenarcotics, anticoagulants and insulin.

The system’s mathematical formu-la takes into account exceptions tothe rule.

Implementation of the clinicalphysician order entry system at Hop-kins, scheduled by this autumn,should increase the potential formore widespread use of MEMS.