# Presentation: 474772

## 10 years after “To Err is Human” An RCA of Patient Safety Research?

- Peter Pronovost, MD, PhD

## Objectives

- To reflect on some of the barriers to  patient safety research
- To consider an overview for training in patient research

## Bilateral cued finger movements

**Bilateral cued finger movements**

**Notes:**
23 year old medical student who, at dinner with friends one Friday night, had episode of transient right hand tingling and dysphasia. Went to ED and found to have left frontal mass.

This pre-operative fMRI was performed to help plan surgery. Results show fMRI signal changes elicited by bilateral finger movements. Some of the signal changes directly overly shortest path to tumor. Surgeon therefore elected to come in via dorsal para-sagittal approach (from high just-to-left of midline and go down towards mass).
Patient awoke without deficit, and has had no evidence of recurrence in the two years since surgery. Now a third year med student.

## Slide 4

## System Failures Slowing Progress in Patient Safety

***Failure to view***
***the delivery of care***
***as a science***

- Insufficiently robust research

- Insufficient partnerships
- Between academic and
- quality communities

- Insufficient capacity to
- train researchers

- Reason model

- Patients continue to suffer preventable harm

- Reason

## Translation Superhighway

## Slide 7

## System Failures Slowing Progress in Patient Safety

- Failure to view
- the delivery of care
- as a science

***Insufficiently robust research***

- Focus on differences
- rather than similarities
- with other types of research

- Insufficient capacity to
- train researchers

- Reason model

- Patients continue to suffer preventable harm

- Reason

## Central Mandate

- Local Wisdom

- Scientifically Sound

- Feasible

**x**

**Notes:**
Safety efforts are where the x is.   We need to migrate to be more scientifically sound and tap into local wisdom

## ExercisePlease answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average 

- How smart am I
- How hard do I work
- How kind am I
- How tall am I
- How good is the quality of care we provide

## Improving Sepsis Care(n= 19 ICUs)

- 69% Reduction (p < 0.001)

- 36% Reduction (NS)

**Notes:**
Data for quality improvement

## Improving Sepsis Care(n= 19 ICUs)

- 69% Reduction (p < 0.001)

- 36% Reduction (NS)

**Notes:**
Measurement error as large an issue as selection bias

## Framework for Patient Safety Research and Practice

- Measuring Patient Safety
- Translating Evidence Intro Practice (TRIP)
- Identifying and Mitigating hazards
- Improving Culture and Communication
- Building Capacity and Organizing for Safety
- Reducing Diagnostic Errors

- Pronovost Circulation in press

**Notes:**
Study design must be approprate for question

## Pronovost BMJ in press

## Slide 15

## Slide 16

## System Failures Slowing Progress 

- Failure to view
- the delivery of care
- as a science

- Insufficiently robust research

***Focus on differences ***
***rather than similarities ***
***with other types of research***

- Insufficient capacity to
- train researchers

- Reason model

- Patients continue to suffer preventable harm

- Reason

**Notes:**
Data on quality improvement; what does that mean
Context mechanism and outcomes; context becomes mechanism.   Must unite
Recent wsj, article on context of voting is now mechanism.   James Fowler political scientist from UC sandiago studies 1082 identical and fraternal twins.    He found that whether you run for office, donated to a candidate, attend a rally or join a political organization were heritable.     Without genetics you missed half the story.    

Recent advances in cancer biology.  Found two types of cancer, pancreatic and glioblastoma the one sen edward kennedy was diagnosed with and the one john eisenbergy and dan strier died from.  38,000 people will develop pancreatic cancer this year and fewer than 5% will be alive in 5 year.  Another 20000 will develop gliobloastoma with similar or worse prognosis.    Researchers form 18 ycenters discovered 83 genes in pancreatic cells and 42 in glioblastoma cells with mutations making them likely candidates for turning on uncontrolled cell growth   what is novel is that they found that rather than acting alone, these mutated genes acted in concert orchestrating pathwyas that allow unfettered growth to occur.        This changes the games for researchers looking for therapies,  rather than tarteting incidivual genes they can tartet the pathways, it is likened to stopping traffic by raising a drawbridge than then stopping individual cars.     Even more interesting conect in glioblastoma.  3 pathways covered 75% of cancers.     Defect in gene IDH1 only in 12% of cancers but half of those younder than 35.     these patients live longer. 

Without the human genone sequenting this would not be possible.  We need the human geneome project linking researchers doing safety work.   

## Context become Mechanism

**Context**

**Mechanism**

**Outcome**

- Pawson Tilley

**Notes:**
Data on quality improvement; what does that mean
Context mechanism and outcomes; context becomes mechanism.   Must unite clinicians and researchers.  
Recent wsj, article on context of voting is now mechanism.   James Fowler political scientist from UC sandiago studies 1082 identical and fraternal twins.    He found that whether you run for office, donated to a candidate, attend a rally or join a political organization were heritable.     Without genetics you missed half the story.    

Recent advances in cancer biology.  Found two types of cancer, pancreatic and glioblastoma the one sen edward kennedy was diagnosed with and the one john eisenbergy and dan strier died from.  38,000 people will develop pancreatic cancer this year and fewer than 5% will be alive in 5 year.  Another 20000 will develop gliobloastoma with similar or worse prognosis.    Researchers form 18 ycenters discovered 83 genes in pancreatic cells and 42 in glioblastoma cells with mutations making them likely candidates for turning on uncontrolled cell growth   what is novel is that they found that rather than acting alone, these mutated genes acted in concert orchestrating pathwyas that allow unfettered growth to occur.        This changes the games for researchers looking for therapies,  rather than tarteting incidivual genes they can tartet the pathways, it is likened to stopping traffic by raising a drawbridge than then stopping individual cars.     Even more interesting conect in glioblastoma.  3 pathways covered 75% of cancers.     Defect in gene IDH1 only in 12% of cancers but half of those younder than 35.     these patients live longer. 

Without the human genone sequenting this would not be possible.  We need the human geneome project linking researchers doing safety work.   
Need to advance the basic sciecne of quality. Invest in tools and measures.  

## System Failures Slowing Progress in Patient Safety

- Failure to view
- the delivery of care
- as a science

- Insufficiently robust research

- Focus on differences
- rather than similarities
- with other types of research

***Insufficient capacity to***
***train researchers***

- Reason model

- Patients continue to suffer preventable harm

- Reason

## Simple Rules for Producing Researchers

- Obtain formal degree
- Identify willing and capable mentor
- Obtain protected time to participate in research project

## Core Skills for Patient Safety Researchers

- Epidemiology
- Biostatistics
- Health services
- Economics
- Sociology
- Psychology
- Informatics
- Systems analysis

- Qualitative
- Leadership
- Change management
- Project management

**Notes:**
Clinicians in safety need to be excellend methodologist.  Need to know fatal flaws, and balance scientifically sound and feasible.     But cannot be expert so must be part of an interdisciplinary team.  

## Quality and Safety Research  Group Mixing Bowl

|  | EPI
/Stats | Psych
/Soc | HSR | Econ |
| --- | --- | --- | --- | --- |
| Critical care |  |  |  |  |
| Surgery |  |  |  |  |
| Pediatrics |  |  |  |  |
| Medicine |  |  |  |  |

## Improving Patient Safety in Michigan ICUs

- Funded by AHRQ

## 2 year results from 103 ICUs

| Time period | Median CRBSI rate | Incidence rate ratio |
| --- | --- | --- |
| Baseline | 2.7 | 1 |
| Peri intervention | 1.6 | 076 |
| 0-3 months | 0 | 0.62 |
| 4-6 months | 0 | 0.56 |
| 7-9 months | 0 | 0.47 |
| 10-12 months | 0 | 0.42 |
| 13-15 months | 0 | 0.37 |
| 16-18 months | 0 | 0.34 |

- Pronovost NEJM 2006

**Notes:**
From over 103 ICUs, we reduced the bsi rate to 0 for nearly two years after the interventions.   

## "Needs Improvement“ Statewide Michigan CUSP ICU Results 

**"Needs Improvement“ Statewide Michigan CUSP ICU Results **

- Less than 60% of respondents reporting good safety climate =“needs improvement”
- Statewide in 2004 84% needed improvement, in 2006 41%
- Non-teaching and Faith-based ICUs improved the most
- Safety Climate item that drives improvement: “*I am encouraged by my colleagues to report any patient safety concerns I may have*”

**Notes:**
We do not know exactly what the goal for safety culture should be.      We typically set a goal of 80% of staff reporting positive safety culture.    We also recognize that if safety culture is below 60% it is associated with worse clinical and economic outcomes.     We reduced the percent of teams scoring below 60% by nearly 50%.  

## Keystone ICU Safety Dashboard

|  | 2004 | 2006 |
| --- | --- | --- |
| How often did we harm (BSI) | 2.8/1000  | 0 |
| How often do we do what we should | 66% | 95% |
| How often did we learn from mistakes | 30% | 100% |
| % Needs improvement in Safety climate
Teamwork climate |    
84%
82% | 
43%
42% |

## Focus and Execute

## Slide 28