A recent publication of catheter-borne bloodstream infections showed that the rates of infection for the various intensive care units in The Johns Hopkins Hospital are at, or very close to, zero! That is truly amazing. Congratulations to everyone who has partnered in this extraordinary effort to do what many said was impossible.
Zero tolerance for “defects” is truly a transformative idea. When such an audacious goal was proposed, it took a while for people to buy into the concept that it might actually be feasible to eliminate almost all bloodstream infections arising from indwelling venous catheters. But once people accepted the challenge, the creativity and energy that was brought to bear was overwhelming.
Visitors coming to see what we are doing at Hopkins to promote patient safety may ask the question: “What was the single most important factor in getting to zero catheter-borne infections?” There are two answers to this question:
a) Everything
b) Getting everyone to accept responsibility for patient safety
Either response is correct. Let’s briefly consider each one.
First, reducing errors to zero requires a series of steps and changes—often no one of which is, by itself, that significant. It is, rather, the sum total of a hundred 1 percent changes that add up to achieve the 100 percent solution. Safety results from redesigning processes, simplifying them, making them less prone to error, improving communication, establishing protocols (and following them)—all the result of teams of caregivers getting together to try to meet a seemingly unreachable goal.
And second, unless everyone in the Hospital assumes personal responsibility for improving patient safety, none of the above-mentioned changes will occur. This personal commitment to patient safety is a necessary ingredient to change an unsafe system.
So, again, hats off to those who have achieved the unachievable. You have pointed the way for all of us to continue these efforts throughout The Johns Hopkins Hospital, not only for bloodstream infections, but in many other areas of patient safety as well. I dream of a Hopkins Hospital free from medical errors.
The Impossible Dream
A recent publication of catheter-borne bloodstream infections showed that the rates of infection for the various intensive care units in The Johns Hopkins Hospital are at, or very close to, zero! That is truly amazing. Congratulations to everyone who has partnered in this extraordinary effort to do what many said was impossible.
Zero tolerance for “defects” is truly a transformative idea. When such an audacious goal was proposed, it took a while for people to buy into the concept that it might actually be feasible to eliminate almost all bloodstream infections arising from indwelling venous catheters. But once people accepted the challenge, the creativity and energy that was brought to bear was overwhelming.
Visitors coming to see what we are doing at Hopkins to promote patient safety may ask the question: “What was the single most important factor in getting to zero catheter-borne infections?” There are two answers to this question:
a) Everything
b) Getting everyone to accept responsibility for patient safety
Either response is correct. Let’s briefly consider each one.
First, reducing errors to zero requires a series of steps and changes—often no one of which is, by itself, that significant. It is, rather, the sum total of a hundred 1 percent changes that add up to achieve the 100 percent solution. Safety results from redesigning processes, simplifying them, making them less prone to error, improving communication, establishing protocols (and following them)—all the result of teams of caregivers getting together to try to meet a seemingly unreachable goal.
And second, unless everyone in the Hospital assumes personal responsibility for improving patient safety, none of the above-mentioned changes will occur. This personal commitment to patient safety is a necessary ingredient to change an unsafe system.
So, again, hats off to those who have achieved the unachievable. You have pointed the way for all of us to continue these efforts throughout The Johns Hopkins Hospital, not only for bloodstream infections, but in many other areas of patient safety as well. I dream of a Hopkins Hospital free from medical errors.
