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Special Report: Perspectives on Patient Safety

By Karen Nitkin

Date: 01/08/2016

Special Report: Perspectives on Patient Safety

C. Michael Armstrong

No Room for Error | Patient Safety

Fifteen years ago, a “moral moment” transformed patient safety at Johns Hopkins Medicine and around the world. Since then, Johns Hopkins has systemically eradicated errors by changing procedures, equipment, even the culture within units. The Armstrong Institute for Patient Safety and Quality leads these efforts. 

In November 1999, the institute of Medicine released “To Err is Human,”a report estimating that between 44,000 and 98,000 Americans die in hospitals every year from medical mistakes. 

In 2001, 18-month-old Josie King died at The Johns Hopkins Hospital from sepsis, a blood infection. Four months later, employee Ellen Roche died after participating in an asthma study. 

The events would change Johns Hopkins Medicine forever. 

Voices from across the health system share memories of the transformation and look to the future. 

C. Michael Armstrong

Founder, Armstrong Institute for Patient Safety and Quality
Chairman, Johns Hopkins Medicine, 2005-2013 

“Years ago, prescriptions were basically a manual process at Johns Hopkins. From the time the doctor wrote them, we flow-charted that there were almost 90 different steps before that prescription was consumed or applied to the patient. With that many different prescriptions and that many steps, thousands of mistakes were made a year. Thus we designed a system of educating and training our people to achieve milestones with objectives and measurements. Today, our prescription system is systemized and automated, from barcoding to scanning to confirming. It enables us to be error free. That level of perfection is what we need to strive for in all diseases, for all of our patients.”

“Josie King’s death was a personal and professional shock throughout Johns Hopkins. At the time, we all thought, this cannot be us. I didn’t know Josie, but I cried for her. Because it was us.”

The photo shows Matt Austin.
Matt Austin
Assistant Professor, Anesthesiology and Critical Care Medicine
Faculty, Armstrong Institute

“From the board to the bedside, everyone is now aligned around the message that quality and safety need a strong focus.” 

The photo shows Jennifer Bailey.

Jennifer Bailey

Senior Director of Quality and Transformation

“A pivotal point in patient safety was the installation of our first integrated electronic medical record (EMR) in 2003 at the Johns Hopkins Bayview Medical Center. Among the reasons for installing integrated EMRs were to address issues with care coordination and access to information. Since the first installation, our EMR use has expanded dramatically, as Epic is now the electronic medical record system for all of Johns Hopkins Medicine.”

The image shows William Baumgartner.

William Baumgartner
Senior Vice President, Office of Johns Hopkins Physicians 

"During my time as chief of cardiac surgery, checklists were introduced in the OR, which, when done correctly, resulted in a safer environment."

A photo shows Renee Blanding.

Renee Blanding
Vice President, Medical Affairs, Bayview Medical Center

“A pivotal moment in patient safety for the Johns Hopkins Health System was the decision to replace the paper incident reporting process with an electronic system.  This conversion allows us to quickly identify safety concerns by type and severity and to develop action plans. It also allows for reporting to occur from anyone with safety concerns.  I felt extremely proud when an environmental services colleague at Bayview recognized a safety issue in the emergency department and averted a true disaster by quickly raising concerns.”

A photo shows William Brody.

William Brody
President, Johns Hopkins University, 1996-2009

“When we started, our bloodstream infection rates were twice the national average. Some of our doctors said the goal should be to get to the national average. I said, if we want to be the best hospital we have to be the very best. Patients expect zero errors. On that basis, Peter Pronovost developed the whole system, including the checklist, which led to reducing central line infections to basically zero.”

A photo shows Judy Brown.

Judy Brown
Senior Vice President, Outcomes Management, Howard County General Hospital

“We recognized that most mistakes or undesirable outcomes were the result of system failures, not bad practitioners. So we began looking for solutions to make processes safer. Three of the most important equipment safety enhancements have been the implementation of the  electronic medication record with bar code scanning verification; the purchase of Alaris Smart Pumps, which ensure correct rates of IV medication infusions; and implementation of bedside laboratory specimen bar code scanning and label printing to decrease mislabeled specimens.”

The photo shows Chip Davis.

Richard “Chip” Davis

President, Sibley Memorial Hospital, 2012-present

Executive Director, Center for Innovation in Quality Patient Care, 2002-2012

“We were brutally transparent in terms of our efforts and failures. Not only internally at Hopkins but across the country and before the world. If you don’t know it’s broken, if you don’t talk about it, you can’t fix it.”

“When we said we would become the number one place in the world for patient safety and quality, everyone recognized the importance of what we were trying to do. We had some fabulous suggestions and projects from folks who don’t necessarily touch patients every day but had a lot to offer.  Bill Brody [president of Johns Hopkins University at the time] used to call it the BHAG: A Big Hairy Audacious Goal. I think it was.” 

The photo shows Lisa de Gouchy.

Lisa de Grouchy
Director, Regulatory Compliance, Johns Hopkins Health System and Johns Hopkins Community Physicians

“Patient care delivery is complex.  It takes team effort and needs to involve the patient.  Patient safety focuses on ways to identify, prioritize, standardize and mitigate breakdowns in the delivery of patient-centered health care.”

The photo shows Renee Demski.

Renee Demski
Vice President of Quality, The Johns Hopkins Hospital, Johns Hopkins Health System and Armstrong Institute for Patient Safety and Quality

“Patient safety and quality is a lifelong journey that needs to have a framework with focused effort, clinician leaders, an appropriate infrastructure, data transparency, robust improvement processes, and accountability to drive performance results.”

The photo shows George Dover.

George Dover
Director, Children’s Center

“As we strive to create a system where no patient is harmed, we have come an unimaginable way. Yet there will always be room for improvement in an age of rapid advances in the disciplines of quality, safety and medicine in general.”

The photo shows Cindy Dwyer.

Cindy Dwyer
Surgical Intensive Care Nurse

“Twenty-five years ago, family members had two-hour windows of visiting. Rarely, rarely—unless it was an end of life situation—did they have the ability to spend the night. [The family] really didn’t interact with the patient. They were almost afraid to touch the patient. They were concerned about the lines that a patient had or the drains that they might have, or that they might do something wrong that would hurt the patient. If I had a long-term patient, I might know that he preferred to go by Buddy instead of Richard, but I went home with that information. If I wasn’t there for a few days, the next nurse might not know that because there was no real place for that information to live.”

“We encourage our staff to report anything that may not look right or may be a potential safety issue.”

The photo shows E. Robert Feroli.

E. Robert Feroli
Medication Safety Officer, The Johns Hopkins Hospital 

“My passion for medication-use safety was deepened about 15 years ago when I was serving as interim director of the pharmacy department. Our pharmacy had made a grave error that resulted in a child receiving an overdose of an electrolyte. The child had a cardiac arrest and suffered an anoxic brain injury.  The parents did not want to take Hopkins to court, but they did want to speak with me.  I went to the patient's room where the parents explained to me that their child had a longstanding condition requiring substantial support. The only form of communication was a beautiful smile that served as a comforting ‘thank you’ during the daily routines of care.  The parents went on to explain that since the cardiac arrest, the child was no longer able to smile. They wanted my word that I would work to prevent other patients from being harmed by medications.  I told them I would, and I have kept my promise.”

The photo shows Dan Ford.

Dan Ford
Vice Dean for Clinical Investigation

“I recognize that researchers have to be passionate about what they want to do. They have to think that getting their study done is the most important goal for them.  But you need a countervailing voice that asks if they are taking the best and safest approach.”

 

The photo shows Elliott Haut.

Elliott Haut
Director, Trauma and Acute Care Surgery Fellowship

“We have been working for nearly 10 years to reduce deep-vein blood clots that lodge in the lungs, the most common cause of preventable hospital death. Blood thinners or mechanical devices such as compression stockings prevent clotting. But in the past, these treatments were not always prescribed, or patients refused them. Now, patients are risk-assessed and educated about the importance of prevention. As a result, we have driven prevention to new heights.”

The photo shows Down Hohl.

Dawn Hohl
Director of Customer Service, Johns Hopkins Home Care Group

“Having practiced in the home care environment for 25 years, I have always respected the fact that the transition from hospital to home is a highly vulnerable time for our patients and caregivers. Many years back, leadership at The Johns Hopkins Hospital invited me to participate in the Continuity of Care Committee.  I believe this was a pivotal moment.  I became a connector between the hospital and home care and we began addressing the very real hand-off challenges in our continuum of care.”

The photo shows Elizabeth Hunt.

Elizabeth Hunt
Associate Professor, Departments of Anesthesiology and Critical Care Medicine and Pediatrics
Director, John's Hopkins Medicine Simulation Center

“Our nurses and doctors cared about Josie and our other patients just as much back then as we do now, but things were different. Patients and parents did not have as strong of a voice in their own care. They were not empowered to intervene when they knew something was wrong.”

A photo

Nichole Jantzi
Patient Safety Program Administrator, Johns Hopkins Community Physicians

“I have a clear memory of hearing Jose's story at my new-hire orientation six years ago. It set the tone as to the type of organization Johns Hopkins is. I worked for two other organizations prior and such a transparent discussion around errors was never an emphasis, especially at a new-hire orientation. It was clear that a culture of safety was important to this organization.”

The photo shows Sorrel King.

Sorrel King
Josie King’s Mother
Patient Safety Advocate

"Nurses and the transport people, or the young residents, whoever, don’t ever, ever be afraid to speak up if you see something is not right and could lead to harm. Please, please speak up.”

The photo shows Blanka McClammer.

Blanka McClammer
Director of Nursing Excellence, Johns Hopkins Bayview Medical Center

“When I became Director of Patient Safety in 2010, I formalized the infrastructure for the patient safety department.  Among our initiatives, we started executive patient safety rounds and improved patient safety collaborations between all disciplines. Additionally, I created education programs around patient safety and the importance of creating a culture that recognizes and learns from errors."

The photo shows Edward Miller.

Edward Miller
CEO, Johns Hopkins Medicine, 1997-2012
Dean, School of Medicine, 1997-2012

"Where an issue is placed on the agenda is a measure of how important it is. Since Josie King and Ellen Roche died, trustee meetings start with safety reports instead of financial reviews."

 

The photo shows Redonda Miller.

Redonda Miller
Senior Vice President, Medical Affairs, Johns Hopkins Health System 

"Probably my favorite thing working in patient safety is awarding Patient Safety Stars at our monthly patient safety meetings.  These are employees who do extraordinary acts to protect our patients.  So many near misses are caught -- and lives saved.” 

The photo shows Brigitta Mueller.

Brigitta Mueller
Chief Safety Officer and Vice President, Medical Affairs, All Children’s Hospital
Interim Director, Johns Hopkins All Children’s Cancer and Blood Disorders Institute

“The recurring high points for me are my encounters with patients and families, especially when they point out things that we do right or things we could do better. The low points are every time we harm a child: through infections, falls, pressure ulcers or a medication error.”

The photo shows Mary Myers.

Mary Myers
Vice President and Chief Operating Officer, Johns Hopkins Home Care Group

“I was brought into the Home Care Group as a consultant to help improve the quality and the safety of the organization. My recommendations were to invest in the infrastructure and actively work to change the culture. They were accepted, and I was asked to stay on in the role of Senior Director for Quality. I am honored to work with this dedicated group of professionals.” 

The photo shows Judy Reitz.

Judy A. Reitz
Executive Vice president and Chief Operating Officer, The Johns Hopkins Hospital
Vice President of Quality Improvement, Johns Hopkins Medicine

“The Armstrong Institute has enabled the hiring of multiple rich resources. Our entire organization, including our trustees, have made safety, service and quality improvement a top priority.”

The photo shows Melinda Sawyer.

Melinda Sawyer
Assistant Director of Patient Safety, Armstrong Institute and The Johns Hopkins Hospital

“In 2002, as a bedside nurse, I attended our organization’s first patient safety conference. It was the first time Josie’s mom, Sorrel King, came and spoke to our organization. There wasn’t a dry eye in the auditorium.  After hearing her story, I was committed to work to ensure there was never such a tragedy again.  That day I also heard about a new program at our hospital called CUSP, the comprehensive unit-based safety program. Hearing about CUSP single-handedly changed my mindset from thinking that safety was someone else’s problem to something that each of us owned and was responsible to improve.”

The photo shows Jacqueline Schultz.

Jacqueline Schultz
Executive Vice President and Chief Operating Officer, Suburban Hospital

“The Armstrong Institute created a platform for patient safety that crosses entity lines. As a free standing community hospital, we did not have the resources that we now have access to as part of the system. The partnership around that expertise has been wonderful.” 

The photo shows Kristina Weeks.

Kristina Weeks
Research Associate, Anesthesiology and Critical Care Medicine and the Armstrong Institute

“With each introduction of a new practice or innovation, we need to consider what the risks might be that are introduced and how those risks apply in different populations.”

The photo shows Albert Wu.

Albert Wu
Director, Center for Health Services and Outcomes Research at Johns Hopkins Bloomberg

“I have been studying medical errors longer than most people, starting in 1988. A high point for me was the development of RISE (Resilience in Stressful Events), which appeals to the best instincts of clinicians to support one another after adverse events. This is a truly interdisciplinary effort that helps Johns Hopkins staff who are second victims of stressful patient-related events.”

“Josie King’s death immediately engaged the hearts as well as the minds of leaders and staff at Johns Hopkins and convinced them of the urgent need to focus on, understand and improve patient safety.”