Preventing Patient Harms Through Systems of Care

THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) recently launched Partnership for Patients, an ambitious national effort designed to substantially reduce 9 types of preventable harm and hospital readmissions. These harms include adverse drug events, catheter-associated urinary tract infections, central line– associated bloodstream infections, fall injuries, pressure ulcers, surgical site infections, venous thromboembolisms, ventilator-associated pneumonia, and obstetrical adverse events. Thousands of hospitals have agreed to participate and chose to focus on several harms because it was beyond their capacity to simultaneously address all 9 types of harm. The dilemma is that most patients are at risk of most of the 9 harms and other harms, including loss of dignity and a sense of respect for their values. Yet patients can expect physicians to focus harm-reduction efforts on just a few of these harms. Health care is addressing these harms as if each type occurs in isolation. This reaction has occurred because it is too burdensome to attempt to reduce multiple harms at the same time. The “siloing” of preventing patient harm is inefficient. Health care needs a different approach to reducing patient harm. Harms tend to cluster within patients, making these harms interdependent rather than independent. Inpatients often experience multiple harms, and patients in the intensive care unit (ICU) experience multiple complications. Thus, the solutions for harm reduction must be integrated and interdependent. For instance, patients receiving mechanical ventilation in the ICU are at risk of 8 of the 9 harms on the CMS list, such as central line–associated bloodstream infections, ventilator-associated pneumonia, and venous thromboembolism. Mechanically ventilated patients are also susceptible to harms not included on the CMS list, such as delirium, diagnostic errors, and air embolism. A patient who experiences one type of harm is at increased risk of experiencing other harms because that patient is further disabled and exposed to indwelling catheters and other devices and spends more time in the ICU and the hospital. To mitigate each type of harm, patients require a checklist of interventions, with some checklists for some patients used multiple times daily. For example, patients must receive 5 separate interventions multiple times a day to reduce their risk of developing ventilator-associated pneumonia, and they should receive subcutaneous heparin multiple times a day and continuously wear sequential compression devices (SCDs) to reduce their risk of developing deep venous thrombosis. Each type of harm requires its own list of interventions. To implement every intervention multiple times a day to keep a mechanically ventilated patient safe from all harms, the patient must reliably receive scores of interventions. The actual number of interventions, however, depends on the frequency of patient monitoring for continuous interventions (eg, SCDs) and the thoroughness of checklists (eg, oral care can be 1 or multiple items). The complexity makes achieving these goals challenging, if not impossible. Technology has not provided an effective solution. In many instances, clinicians rely on memory and checklists to complete interventions, but no list has all the required interventions. Moreover, clinician competency in performing interventions is not tested, and ambiguity increases variation. There is no continuously refreshed visual display of completed, duplicated, or missed interventions and no automated prompts to perform interventions or e-uploading of completed tasks into the electronic medical record (EMR). From a patient’s perspective, success does not equate to avoiding 2 CMS-listed harms but experiencing all other harms. Clinicians can reduce patient harm in the same way that engineers manage dynamic complexity: as a systems problem that requires an interdisciplinary systems solution. A holistic view is necessary when analyzing patient requirements. To protect a mechanically ventilated patient, for instance, requires compiling a list of that patient’s risks of harm and the evidence-based practices to reduce those harms. Those practices should be implemented efficiently by organizing them as a system of care, automating as many practices as possible, showing when practices are needed or completed, ensuring integration across devices and with the EMR,