A Message from the President
May 2010
Patient Safety: A Decade Later
One of the pioneers of patient safety, Bob Wachter, MD, gave a superb talk at the Lifespan Patient Safety Symposium on April 6. Wachter, chief of the division of hospital medicine and chief of the medical service at University of California, San Francisco, Medical Center, provided an overview of the “science” of patient safety 10 years after the Institute of Medicine’s alarming initial report, “To Err is Human.” The report grabbed attention because it suggested that between 44,000 and 98,000 patients were harmed in U.S. hospitals each year. Author of 200 published articles and six books in the fields of quality, safety and health policy, Wachter’s message is best summarized by the title of his talk: “Patient Safety at Ten: Unmistakable Progress, Troubling Gaps.”
Wachter pointed out that over the past decade, a variety of forces, such as more robust accreditation standards and increased error reporting requirements, have created a stronger business case for hospitals to focus on patient safety. However, he also pointed out that several troubling gaps remain, such as the slow progress information technology has made living up to its safety promise, the dynamic tension that remains between a “no blame culture” and one of accountability, and that research in the field of patient safety remains woefully inadequate. I agree with all of these propositions and will review some of the progress we are making as an organization, as well as areas that still need our focus and attention.
In an effort to learn from some of the top academic medical centers in the country, both The Miriam Hospital and Rhode Island Hospital recently joined the leading quality and safety organization in the country: the University HealthSystem Consortium (UHC). This consortium gives us a peer group of more than 100 academic medical systems around the country to learn from and compare ourselves to. Leaders from UHC recently completed an evaluation of the quality and safety programs at all Lifespan partner hospitals and we are eagerly awaiting the results of this report. Being part of the UHC will allow us to compare our services, structure and performance with our peers around the country, helping us to see what areas we need to improve, and in which areas we excel. You will hear more about this organization and our role within it in the months to come.
In the area of operating room safety, The Miriam Hospital is continuing its innovative work with Ximedica studying the “human factors” aspect of our perioperative systems, and Rhode Island Hospital is completing its work with the Joint Commission Center for Transforming Healthcare on what we hope will become a national model for surgical protocol. Both of these initiatives demonstrate our hospitals’ true commitment to becoming the safest in the nation. We acknowledge that this is an ongoing journey and we are committed to leading the way on reducing the chance of surgical errors, a complex issue that has challenged hospitals throughout the country for the past decade.
Additionally, we are beginning to make progress in the area of information technology. Through the 2009 American Recovery and Reinvestment Act, specifically the HITECH act, the federal government launched the “meaningful use” initiative and has begun to invest in electronic health records as a way of improving patient safety and quality. While the act’s goals are stated as technology projects, the real intent of the legislation is to use technology to improve the quality of care and to drive health care organizations to be accountable for the health outcomes of their patients. Across the country, hospitals and other providers are grappling with how to make electronic health records more complete, portable, accessible and safe. Once we have succeeded — and we will succeed — we will decide how to use those records to improve quality, safety, efficiency, and reduce health disparities. It is a tall order, but one that will have a powerful and positive effect on patient care and public health.
Another project, smaller but no less important, is the transition this summer to a new statewide Medical Event Reporting System (MERS). The web-based system will replace the Occurrence System that we now use. Rhode Island Hospital and The Miriam Hospital will lead the way, making the switch in July, with the rest of the hospitals in the state implementing the system by January 2011. MERS will offer standardized data for increased patient safety statewide. It will be much easier to track trends and implement changes to further enhance patient safety at each hospital, both within Lifespan and across the state. The system also provides more information to managers and administrators, with greater involvement of operations people in reporting and follow-up. All hospitals in Rhode Island will report data through the MERS system to a national Patient Safety Organization, which will eventually lead to national tracking, trending, and better outcomes.
So, as you can see, there is tremendous work going on to make our hospitals as safe as they can be. And yet, as Wachter pointed out, there are still “troubling gaps” here and nationwide. We work in an extraordinarily complex and high-risk industry and we must remain constantly vigilant for breakdowns in our systems that could allow harm to reach our patients. We also must ensure that safety always trumps our desire to be efficient as we go about our very busy and hectic daily routines. I would like to remind everyone that we have two confidential patient safety hotlines that staff can use to report near misses or other patient safety-related concerns; 4-SAFE (4-7233) at Rhode Island Hospital and 3-SAFE (3-7233) at The Miriam Hospital. Information received from these calls is used to identify opportunities for improvement that can be shared throughout the organization.
The past decade of the patient safety movement has taught us the importance of designing systems that create and support a safe patient environment. I believe that we all have a responsibility to create systems to prevent human errors from reaching our patients. That said, I also believe that there is no substitute for personal accountability in ensuring that our patients receive the highest quality and safest care possible. We must have safe systems—that is a predicate for safe care. But we must also accept individual responsibility and accountability for our actions. One small, but striking example is that— as Dr. Wachter also pointed out in his talk — despite years of effort and focus, hand hygiene (the simple cleaning of hands between patients) is still not at satisfactory levels here or across the country. It is tough to explain that as a “system failure;” I think Nike said it best on this one—“Just do it!”
In closing, I would like to say a heartfelt and resounding thank you to all of you on both campuses as we celebrate both Nurses Week and Hospital Week. While nurses are often the face of compassion and healing for patients, every single person who works in one of our hospitals is a vital part of the team to create the best experience possible for our patients. My hat is off to you as you work hard each day to provide high-quality, safe patient care. Thank you again.
In the steadfast pursuit of excellence, I remain,
Sincerely yours,
Timothy J. Babineau, MD
President and Chief Executive Officer
Rhode Island Hospital & The Miriam Hospital
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