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

1. 10 years after �To Err is Human� An RCA of Patient Safety Research? Peter Pronovost, MD, PhD

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

3. 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.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.

5. System Failures Slowing Progress in Patient Safety

8. System Failures Slowing Progress in Patient Safety

9. Central Mandate Safety efforts are where the x is. We need to migrate to be more scientifically sound and tap into local wisdomSafety efforts are where the x is. We need to migrate to be more scientifically sound and tap into local wisdom

10. 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

11. Improving Sepsis Care(n= 19 ICUs) Data for quality improvementData for quality improvement

12. Improving Sepsis Care(n= 19 ICUs) Measurement error as large an issue as selection biasMeasurement error as large an issue as selection bias

13. 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 Study design must be approprate for questionStudy design must be approprate for question

17. System Failures Slowing Progress 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. 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.

18. Context become Mechanism 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. 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.

19. System Failures Slowing Progress in Patient Safety

20. Simple Rules for Producing Researchers Obtain formal degree Identify willing and capable mentor Obtain protected time to participate in research project

21. Core Skills for Patient Safety Researchers Epidemiology Biostatistics Health services Economics Sociology Psychology Informatics Systems analysis Qualitative Leadership Change management Project management 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. 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.

23. Improving Patient Safety in Michigan ICUs Funded by AHRQ

24. 24 From over 103 ICUs, we reduced the bsi rate to 0 for nearly two years after the interventions. From over 103 ICUs, we reduced the bsi rate to 0 for nearly two years after the interventions.

25. 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%. 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%.

26. Keystone ICU Safety Dashboard

27. Focus and Execute