10 years after To Err is Human An RCA of Patient Safety Research

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

• Peter Pronovost, MD, PhD

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Objectives

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

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Bilateral cued finger movements
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System Failures Slowing Progress in Patient Safety
Insufficiently robust research
Insufficient capacity to train researchers
Failure to view the delivery of care as a science
Patients continue to suffer preventable harm
Insufficient partnerships Between academic and
quality communities
Reason
Reason model
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Translation Superhighway
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System Failures Slowing Progress in Patient Safety
Insufficiently robust research
Insufficient capacity to train researchers
Failure to view the delivery of care as a science
Focus on differences rather than similarities
with other types of research
Patients continue to suffer preventable harm
Reason
Reason model
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Central Mandate
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Scientifically Sound
Feasible
Local Wisdom
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ExercisePlease 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

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Improving Sepsis Care(n 19 ICUs)
36 Reduction (NS)
69 Reduction (p lt 0.001)
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Improving Sepsis Care(n 19 ICUs)
36 Reduction (NS)
69 Reduction (p lt 0.001)
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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
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Pronovost BMJ in press
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System Failures Slowing Progress
Insufficiently robust research
Insufficient capacity to train researchers
Failure to view the delivery of care as a science
Patients continue to suffer preventable harm
Focus on differences rather than similarities
with other types of research
Reason
Reason model
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Context become Mechanism
Context
Mechanism
Outcome
Pawson Tilley
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System Failures Slowing Progress in Patient Safety
Insufficiently robust research
Insufficient capacity to train researchers
Failure to view the delivery of care as a science
Focus on differences rather than similarities
with other types of research
Patients continue to suffer preventable harm
Reason
Reason model
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Simple Rules for Producing Researchers

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

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Core Skills for Patient Safety Researchers

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

• Qualitative
• Leadership
• Change management
• Project management

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Quality and Safety Research Group Mixing Bowl
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Improving Patient Safety in Michigan ICUs

• Funded by AHRQ

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2 year results from 103 ICUs
Pronovost NEJM 2006
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"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

 
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Keystone ICU Safety Dashboard
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Focus and Execute
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