Temporal trends in rates of patient harm resulting from medical care

Quality improvement interventions to prevent healthcare-associated infections in neonates and children

PURPOSE OF REVIEW

Healthcare-associated infections cause substantial harm to hospitalized neonates and children. Efforts that prevent these infections are a major focus of current patient safety initiatives. This review focuses on the reports of quality improvement interventions to prevent central line-associated bloodstream infections (CLABSIs) in neonates and children.

RECENT FINDINGS

Single-center and multicenter collaborative studies have examined the effect of quality improvement interventions to reliably implement central line insertion and maintenance bundles on CLABSI rates in neonatal and pediatric intensive care units. Quality improvement interventions were associated with reductions in CLABSI rates in neonates and children by a half or more, although many of the studies have important methodologic limitations. Studies that utilized improvement science methodologies demonstrated larger improvement effects, but required a sizable investment of institutional support and personnel time.

SUMMARY

Quality improvement interventions to reduce CLABSI are an important component of patient safety initiatives. Future studies of quality improvement interventions to reduce HAI among hospitalized neonates and children will benefit from further investigation of methods to enhance reliable implementation of evidence-based practices, factors that enable multicenter collaboratives to be more successful, and better understanding of the causes of heterogeneity in the results at different centers.

A novel approach to implementation of quality and safety programmes in anaesthesiology

Far too many patients suffer preventable harm from medical errors that add to needless suffering and cost of care. Underdeveloped residency training programmes in patient safety are a major contributor to preventable harm. Consequently, the Institute of Medicine has called for health professionals to reform their educational programmes to advance health-care safety and quality. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) now requires education in 'systems-based practice' and 'practice-based learning and improvement' as core competencies of residency training programmes. The specific aim of this article is to describe the implementation of a novel programme designed to enhance residency education, meet ACGME core competencies and improve quality and safety education in one residency programme at an academic medical institution.

Health care research that delivers: introduction to the special issue on cognitive factors in health care

Research that addresses human factors issues in health care has made good progress since the landmark 1999 Institute of Medicine report on medical error (Kohn, Corrigan, & Donaldson, 1999), yet patient safety remains a persistent challenge for the health care system. While this challenge reflects many factors, we focus on the need for research that is sufficiently comprehensive to identify threats to patient safety, yet specific enough to explain how provider and patient factors interact with task and health context to engender these threats. Such research should be theory-based, yet also problem-driven; exert experimental control over theoretically relevant variables, yet also involve participants, tasks, and contexts that represent the problems of interest. A tension exists between theory-based, experimentally controlled research on the one hand, and problem-driven research with representative situations on the other. The studies in this special issue are both informed by theory and guided by application, reflecting what Stokes (1997) referred to as "use-inspired basic research." Collectively, these studies represent progress toward improving patient safety and the quality of health care. However, important work remains to be done to significantly improve health care by more comprehensively managing tensions between theory and application and different research methodologies. We discuss barriers to accomplishing such research in general (the challenge of testing theory in situ in rich environments), and specifically in the health care domain. Significant progress will require research programs that thoughtfully manage mixed methods across a series of converging studies.

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective

BACKGROUND

For almost a decade, public and private organizations have pressured hospitals to improve their patient safety records. Since 2008, the Centers for Medicare & Medicaid Services has no longer been reimbursing hospitals for secondary diagnoses not reported during the point of admission. This ruling has motivated some hospitals to engage in safety-oriented programs to decrease adverse events.

PURPOSE

This study examined which hospitals may engage in patient safety solutions and whether they create these patient safety solutions within their structures or use suppliers in the market.

METHODOLOGY

We used a theoretical model that incorporates the key constructs of resource dependence theory and transaction cost economics theory to predict a hospital's reaction to Centers for Medicare & Medicaid Services "never event" regulations. We present propositions that speculate on how forces conceptualized from the resource dependence theory may affect adoption of patient safety innovations and, when they do, whether the adopting hospitals will do so internally or externally according to the transaction cost economics theory.

FINDINGS

On the basis of forces identified by the resource dependence theory, we predict that larger, teaching, safety net, horizontally integrated, highly interdependent, and public hospitals in concentrated, high public payer presence, competitive, and resource-rich environments will be more likely to engage in patient safety innovations. Following the logic of the transaction cost economics theory, we predict that of the hospitals that react positively to the never event regulation, most will internalize their innovations in patient safety solutions rather than approach the market, a choice that helps hospitals economize on transaction costs.

PRACTICE IMPLICATIONS

This study helps hospital managers in their strategic thinking and planning in relation to current and future regulations related to patient safety. For researchers and policy analysts, our propositions provide the basis for empirical testing.

Improving quality in systems of care: solving complicated challenges with simulation-based continuing professional development

The delivery of quality health care depends on the successful interactions of practitioners, teams, and systems of care comprising culture. Designing educational programs to improve these interactions is a major goal of continuing professional development, and one approach for educational planners to effect desired changes is simulation-based education. Because simulation-based education affords an opportunity for educators to train health care professionals in environments that resemble clinical practice, this instructional method allows planners to integrate overarching priorities for improvement in health care practice with the training goals of individuals. Educational planners should consider how to structure scenarios to meet training objectives based on the complicated interactions within the health care system. To optimize the benefit of simulation-based experiences, evidence and insights from industrial and organizational psychology, as well as from human factors studies, provide guidance to the planning process, and interdisciplinary studies of complex health care systems can help produce educational programs that improve the quality of health care delivery.

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture.

Getting to zero: evidence-based healthcare risk management is key

In this article we call for a new approach to patient safety improvement, one based on the emerging field of evidence-based healthcare risk management (EBHRM). We explore EBHRM in the broader context of the evidence-based healthcare movement, assess the benefits and challenges that might arise in adopting an evidence-based approach, and make recommendations for meeting those challenges and realizing the benefits of a more scientific approach.

Our journey to zero: reducing serious safety events by over 70% through high-reliability techniques and workforce engagement

The techniques and best practices used to achieve a successful safety culture transformation and drive down the incidence of serious safety events are described. The Safety Transformation Initiative at Children's National resulted in national and local recognition, a financial savings of an imputed $35 million, and a greater than 70% decrease in the serious safety event rate over a 3-year period (July 1, 2008-June 30, 2011). The results were achieved during a time of significant financial constraints and with limited resources. A blueprint detailing specifics of the implementation is presented to assist others in achieving similar results. Our safety transformation was initiated in our fiscal year 2009 as part of a 3-year corporate goal. The work is continuing and we aspire to virtually eliminate serious safety events by 2016.

Real-time registration of adverse events in Dutch hospitalized children in general pediatric units: first experiences

The objectives of this study are to describe the number and nature of adverse events occurring in general pediatric practice, to describe factors contributing to the occurrence of these adverse events, and to report on the experience of pediatricians with reporting adverse events. It is a prospective study on 11 pediatric units in a 3-month period; adverse events were registered for all newly admitted patients. Ninety-four adverse events were registered in 88 of 5,669 patients, amounting to a 1.6 per 100 admissions rate and a 0.4 per 100 patient days rate. Ninety percent of the adverse events did not cause serious harm. Failed diagnostic procedures were most common.

CONCLUSION

Adverse event registration in general pediatric practice is a first step in assessing quality and safety of care. It yields a considerable number of adverse events. Compliance to adverse event registration in daily practice is difficult but also key to optimal monitoring of quality of care.

Experiences with global trigger tool reviews in five Danish hospitals: an implementation study

OBJECTIVES

To describe experiences with the implementation of global trigger tool (GTT) reviews in five Danish hospitals and to suggest ways to improve the performance of GTT review teams.

DESIGN

Retrospective observational study.

SETTING

The measurement and monitoring of harms are crucial to campaigns to improve the safety of patients. Increasingly, teams use the GTT to review patient records and measure harms in English and non-English-speaking countries. Meanwhile, it is not clear as to how the method performs in such diverse settings.

PARTICIPANTS

Review teams from five Danish pilot hospitals of the national Danish Safer Hospital Programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected harm rates, background and anecdotal information and reported patient safety incidents (PSIs) from five pilot hospitals currently participating in the Danish Safer Hospital Programme. Experienced reviewers categorised harms by type. We plotted harm rates as run-charts and applied rules for the detection of patterns of non-random variation.

RESULTS

The hospitals differed in size but had similar patient populations and activity. PSIs varied between 3 and 12 per 1000 patient-days. The average harm rate for all hospitals was 60 per 1000 patient-days ranging from 34 to 84. The percentage of harmed patients was 25 and ranged from 18 to 33. Overall, 96% of harms were temporary. Infections, pressure ulcers procedure-related and gastrointestinal problems were common. Teams reported differences in training and review procedures such as the role of the secondary reviewer.

CONCLUSIONS

We found substantial variation in harm rates. Differences in training, review procedures and documentation in patient records probably contributed to these variations. Training reviewers as teams, specifying the roles of the different reviewers, training records and a database for findings of reviews may improve the application of the GTT.

Quality and safety in medical care: what does the future hold?

CONTEXT

The rapid changes in health care policy, embracing quality and safety mandates, have culminated in programs and initiatives under the Patient Protection and Affordable Care Act.

OBJECTIVE

To review the context of, and anticipated quality and patient safety mandates for, delivery systems, incentives under health care reform, and models for future accountability for outcomes of care.

DESIGN

Assessment of the provisions of Patient Protection and Affordable Care Act, other reform efforts, and reform initiatives focusing on future quality and safety provisions for health care providers.

RESULTS

Health care reform and other efforts focus on consumerism in the context of price. Quality and safety efforts will be structured using financial incentives, best-practices research, and new delivery models that focus on reaching benchmarks while reducing costs. In addition, patient experience will be a key component of reimbursement, and a move toward "retail" approaches directed at the individual patient may supplant traditional "wholesale" efforts at attracting employers.

CONCLUSIONS

Quality and safety have always been of prime importance in medicine. However, in the future, under health care reform and associated initiatives, a shift in the paradigm of medicine will integrate quality and safety measurement with financial incentives and a new emphasis on consumerism.

Effects of a night-team system on resident sleep and work hours

OBJECTIVE

In 2009, Children's Hospital Boston implemented a night-team system on general pediatric wards to reduce extended work shifts. Residents worked 5 consecutive nights for 1 week and worked day shifts for the remainder of the rotation. Of note, resident staffing at night decreased under this system. The objective of this study was to assess the effects of this system on resident sleep and work hours.

METHODS

We conducted a prospective cohort study in which residents on the night-team system logged their sleep and work hours on work days. These data were compared with similar data collected in 2004, when there was a traditional call system.

RESULTS

In 2004 and 2009, mean shift length was 15.22 ± 6.86 and 12.92 ± 5.70 hours, respectively (P = .161). Daily work hours were 10.49 ± 6.85 and 8.79 ± 6.42 hours, respectively (P = .08). Nightly sleep time decreased from 6.72 ± 2.60 to 4.77 ± 2.46 hours (P < .001). Total sleep time decreased from 7.50 ± 3.13 to 5.47 ± 2.34 hours (P < .001).

CONCLUSIONS

Implementation of a night-team system was unexpectedly associated with decreased sleep hours. As residency programs create work schedules that are compliant with the 2011 Accreditation Council for Graduate Medical Education duty-hour standards, resident sleep should be monitored carefully.

Teleconsultation in pre-hospital emergency medical services: real-time telemedical support in a prospective controlled simulation study

BACKGROUND

Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible. In preparation for bringing such a system into practice within the research project "Med-on-@ix", a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing.

MATERIAL AND METHODS

In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario.

RESULTS

Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p=0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p=0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p=0.0421); synchronized shock (6/14 vs. 14/15; p=0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p=0.0092); mean time to inform trauma centre 547 vs. 189 s (p=0.0001). No significant impairment of performance was detected in TMA groups.

CONCLUSIONS

In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.

Patient safety culture in a Dutch pediatric surgical intensive care unit: an evaluation using the Safety Attitudes Questionnaire

OBJECTIVE

Nowadays, the belief is widespread that a safety culture is crucial to achieving patient safety, yet there has been virtually no analysis of the safety culture in pediatric hospital settings so far. Our aim was to measure the safety climate in our unit, compare it with benchmarking data, and identify potential deficiencies.

DESIGN

Prospective longitudinal survey study at two points in time.

SETTING

Pediatric surgical intensive care unit at a Dutch university hospital.

SUBJECTS

All unit personnel.

INTERVENTIONS

To measure the safety climate, the Safety Attitudes Questionnaire was administered to physicians, nurses, nursing assistants, pharmacists, technicians, and ward clerks in both May 2006 and May 2007. This questionnaire assesses caregiver attitudes through use of the six following scales: teamwork climate, job satisfaction, perceptions of management, safety climate, working conditions, and stress recognition. Earlier research showed that the Safety Attitudes Questionnaire has good psychometric properties and produced benchmarking data that can be used to evaluate strengths and weaknesses in a given clinical unit against peers.

MEASUREMENTS AND MAIN RESULTS

The response rates for the Safety Attitudes Questionnaire were 85% (May 2006) and 74% (May 2007). There were mixed findings regarding the difference between physicians and nurses: on three scales (i.e., teamwork climate, safety climate, and stress recognition), physicians scored better than nurses at both points in time. On another two scales (i.e., perceptions of management and working conditions), nurses consistently had higher mean scale scores. Probably due to the small number of physicians, only some of these differences between physicians and nurses reached the level of statistical significance. Compared to benchmarking data, scores on perceptions of management were higher than expected (p < .01), whereas scores on stress recognition were low (p < .001). The scores on the other scales were somewhat above (job satisfaction), close to (teamwork climate, safety climate), or somewhat below (working conditions) what was expected on the basis of benchmarking data, but no persistent significant differences were observed on these scales.

CONCLUSIONS

Although on most domains the safety culture in our unit was good when compared to benchmark data, there is still room for improvement. This requires us to continue working on interventions intended to improve the safety culture, including crew resource management training, safety briefings, and senior executive walk rounds. More research is needed into the impact of creating a safety culture on patient outcomes.

Impact of intelligent intravenous infusion pumps on directing care toward evidence-based standards: a retrospective data analysis

INTRODUCTION

Published literature has successfully demonstrated the impact of intravenous (IV) infusion pump safety software on improving the quality of health care delivery. Much of this literature has focused solely on the ability of these devices to prevent potential medication errors, while overlooking the devices' additional valuable advantages. One non-reported benefit is the ability of IV infusion pump safety software to consistently administer doses of IV medication, which are based on evidence. This article describes the process undertaken to implement and evaluate the impact of IV infusion pump safety software on driving care toward evidence-based standards.

METHODS

An advisory group of expert users was convened for a 2-day session to develop consensus recommendations of best practices for IV infusion pump safety software. Using these recommendations, administrative data were collected from a community hospital to assess the endpoints identified by the advisory panel.

RESULTS

Data analysis of rescue agents (ie, flumazenil, glucagon, and protamine sulfate) showed reductions in utilization in the post-implementation period of the safety software. The decreased requirement for blood transfusions in patients receiving heparin infusions suggests that heparin infusions were more safely administered in the post-implementation period. The decreased length of stay and mortality rate observed in patients with complex respiratory infections during the post-implementation period suggests that by correctly infusing antibiotics consistently, patient outcomes may be improved. Additionally, alert and edit data from the pumps demonstrated that the IV infusion pump safety software alerted to and influenced edits on many critical dose rate errors for benzodiazepines, heparin, and several antibiotics.

CONCLUSION

Intravenous infusion pump safety software improves clinical outcomes through consistent application of evidence-based standards of dose rates for IV drugs.

Major sources of critical incidents in intensive care

Introduction

In recent years, critical incident (CI) reporting has increasingly been regarded as part of ongoing quality management. CI databanks also aim to improve health and safety issues for patients as well as staff. The aim of this study was to identify frequent causes of adverse events in critical care with the potential to harm patients, staff or visitors by analysing data from a voluntary and optionally anonymous critical incident reporting system.

Methods

The study includes all critical incidents reported during a 90-month period in a 13-bed adult general intensive care unit (ICU). Reporting of incidents was performed via an electronic reporting system or by a manual critical incident report. All CIs were classified in the following main categories: equipment, administration, pharmaceuticals, clinical practice, and health & safety hazards. The overall distribution of incidents within the different categories was compared with the regional database of ICUs in the Cheshire and Mersey region of northwest England for 2008.

Results

A total of 1127 CIs were reported during the study period. The frequencies within the main categories were: equipment 338 (30%), clinical practice 257 (22.8%), pharmaceuticals 238 (21.1%), administration 213 (18.9%), health and safety hazards 81 (7.2%). The regional database had a similar frequency of critical incidents within the different categories, suggesting that our results may reflect a general distribution pattern of CIs in intensive care.

Conclusions

Critical incident reporting helps to identify frequent causes of adverse events in critical care. Improvements in quality of care following implementation of preventative strategies such as introduction of regular equipment training sessions will have to be assessed further in future studies.

Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective

Background

With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.

Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.

Discussion

The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.

In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.

Summary

It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.

The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year--and aim to do even better

A decade ago the Institute of Medicine estimated that 44,000-98,000 preventable deaths occur each year in US hospitals. The leaders of Ascension Health-one of the nation's largest health care delivery networks, with sixty-nine hospitals in twenty states and the District of Columbia-dedicated themselves to preventing equivalent numbers of deaths in their system. In 2003 they set a goal of reducing preventable deaths by 900 each year by 2008. By fiscal year 2010 Ascension Health had reduced preventable deaths by more than 1,500 people annually and, by some calculations, by more than 5,000 people annually, compared to 2004. Ascension Health had also achieved important improvements in preventing birth trauma and reducing rates of pressure ulcers and hospital-acquired infections. The health care system could achieve even greater results by adopting the safety principles used in high-reliability entities such as the nuclear power industry. The adoption of such principles can lead to impressive improvements in health care quality.

The social cost of adverse medical events, and what we can do about it

Adverse medical events-medical interventions that cause harm or injury to a patient separate from the underlying medical condition-are unfortunately an all-too-frequent occurrence in US hospitals. They may cause as many as 187,000 deaths in hospitals each year, and 6.1 million injuries, both in and out of hospitals. We estimate the annual social cost of these adverse medical events based on what people are willing to pay to avoid such risks in non-health care settings. That social cost ranges from $393 billion to $958 billion, amounts equivalent to 18 percent and 45 percent of total US health care spending in 2006. A possible solution: Patients offered voluntary, no-fault insurance prior to treatment or surgery would be compensated if they suffered an adverse event-regardless of the cause of their misfortune-and providers would have economic incentives to reduce the number of such events.

Prevention of intraoperative awareness in a high-risk surgical population

BACKGROUND

Unintended intraoperative awareness, which occurs when general anesthesia is not achieved or maintained, affects up to 1% of patients at high risk for this complication. We tested the hypothesis that a protocol incorporating the electroencephalogram-derived bispectral index (BIS) is superior to a protocol incorporating standard monitoring of end-tidal anesthetic-agent concentration (ETAC) for the prevention of awareness.

METHODS

We conducted a prospective, randomized, evaluator-blinded trial at three medical centers. We randomly assigned 6041 patients at high risk for awareness to BIS-guided anesthesia (with an audible alert if the BIS value was <40 or >60, on a scale of 0 to 100, with 0 indicating the suppression of detectable brain electrical activity and 100 indicating the awake state) or ETAC-guided anesthesia (with an audible alert if the ETAC was <0.7 or >1.3 minimum alveolar concentration). In addition to audible alerts, the protocols included structured education and checklists. Superiority of the BIS protocol was assessed with the use of a one-sided Fisher's exact test.

RESULTS

A total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, who were interviewed postoperatively had definite intraoperative awareness (a difference of 0.17 percentage points; 95% confidence interval [CI], -0.03 to 0.38; P=0.98). Thus, the superiority of the BIS protocol was not demonstrated. A total of 19 cases of definite or possible intraoperative awareness (0.66%) occurred in the BIS group, as compared with 8 (0.28%) in the ETAC group (a difference of 0.38 percentage points; 95% CI, 0.03 to 0.74; P=0.99), with the superiority of the BIS protocol again not demonstrated. There was no difference between the groups with respect to the amount of anesthesia administered or the rate of major postoperative adverse outcomes.

CONCLUSIONS

The superiority of the BIS protocol was not established; contrary to expectations, fewer patients in the ETAC group than in the BIS group experienced awareness. (Funded by the Foundation for Anesthesia Education and Research and others; BAG-RECALL ClinicalTrials.gov number, NCT00682825.).

Crisis checklists for the operating room: development and pilot testing

BACKGROUND

Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises.

STUDY DESIGN

We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios.

RESULTS

Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04-0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent.

CONCLUSIONS

Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.

Two faces of patient safety and care quality: a Franco-American comparison

Patient safety, and more broadly the quality of care, is typically discussed with reference to the reduction of preventable adverse events within hospitals and adherence to practice guidelines on care processes. We call it the ‘care-centered approach’ and recognize that the United States is a leader in the field. Another face of patient safety and care quality may be defined as the ‘system-centered approach’. It focuses on access to a timely and effective continuum of health-care services – clinical prevention, primary care and appropriate referral to and receipt of specialty care. Although France's efforts to pursue a care-centered approach to patient safety are limited, its system-centered approach yields some benefits. Based on the evidence we have reviewed for access to primary care (hospital discharges for avoidable hospital conditions), mortality amenable to medical intervention and consumer satisfaction, in the United States and France, there appear to be good grounds for bolstering the system-centered approach in the United States.