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Special Report: Fifteen Years of Patient Safety Milestones

Learn how Johns Hopkins has built a culture of accountability and advanced patient safety.

Date: 01/07/2016

Special Report: Fifteen Years of Patient Safety Milestones

Sorrel King, left, and Josie King. 

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.

Below are some of the milestones in that transformation. 

 

15 Milestones 

Compiled by Lisa Broadhead

Special Report: Fifteen Years of Patient Safety Milestones

1. “I am so sorry.” With support from Johns Hopkins leadership, Johns Hopkins Children’s Center Director George Dover apologizes to Josie King’s parents and acknowledges that preventable medical errors led to her death. The Kings use money from their settlement to fund safety programs at Johns Hopkins.

Special Report: Fifteen Years of Patient Safety Milestones

2. Safety As Top Priority. The Center for Innovation in Quality Patient Care is created with donations of $500,000 each from The Johns Hopkins University, The Johns Hopkins Hospital and the school of medicine. Richard “Chip” Davis becomes executive director, and Peter Pronovost is named medical director.

Special Report: Fifteen Years of Patient Safety Milestones

3. Better Research Oversight. Johns Hopkins overhauls its Institutional Review Board (IRB) system after Ellen Roche’s death and a temporary federal government shutdown of all research protocols. All proposals and their progress are thoroughly reviewed. Intervention plans are required in case a volunteer has an adverse reaction. An electronic medical record system also improves patient safety by ensuring that clinicians have access to research data relevant to patient care.

Special Report: Fifteen Years of Patient Safety Milestones

4. The Science of Safety. Johns Hopkins safety experts apply scientific rigor to understanding and preventing medical errors. They test possible interventions, translate the research into practice and scale programs for use in care facilities worldwide. Articles include original research, viewpoints and reviews authored by faculty and staff members actively engaged in projects in the Armstrong Institute and published in peer-reviewed journals.

Special Report: Fifteen Years of Patient Safety Milestones

5. The Checklist. Pronovost distills 120 pages of information from the Centers for Disease Control and Prevention into a five-step checklist for preventing central line-associated bloodstream infections (CLABSIs). The checklist helps reduce CLABSIs in intensive care units by 80 percent nationwide.

Special Report: Fifteen Years of Patient Safety Milestones

6. Changing the Culture, One Unit at a Time. The Comprehensive Unit-based Safety Program (CUSP) creates a culture of accountability, giving front-line staff members knowledge and support to tackle safety hazards, such as patient falls and medication errors. More than 170 CUSP teams are active across the health system, and the concept is adapted for hospitals worldwide.

Special Report: Fifteen Years of Patient Safety Milestones

7. A Patient Safety Workforce. Patient advocates are hired to develop intervention programs and rapid response protocols. With new training and orientation programs, nurses, engineers and risk managers become patient safety leaders.

Special Report: Fifteen Years of Patient Safety Milestones

8. Speaking Up and Speaking Out. Johns Hopkins implements an incident reporting system to better understand medical errors and how to prevent them. Work units take safety culture surveys to highlight successes and areas for improvement.

Special Report: Fifteen Years of Patient Safety Milestones

9. Caring for Second Victims. The Resilience in Stressful Events (RISE) program provides psychological first aid to “second victims,” the clinicians who experience stress and remorse because of adverse patient outcomes.

Special Report: Fifteen Years of Patient Safety Milestones

10. Patients as Partners. The Johns Hopkins Children’s Center creates the Pediatric Family Advisory Council steering committee with parents and staff members. Similar councils are now active in every Johns Hopkins Medicine hospital, community physicians group and home care group.

Special Report: Fifteen Years of Patient Safety Milestones

11. Building a Strong Infrastructure. Johns Hopkins creates the Armstrong Institute for Patient Safety and Quality in 2011 with a $10 million gift from C. Michael Armstrong, chairman of the Johns Hopkins Medicine board of trustees from 2005 to 2013.

Special Report: Fifteen Years of Patient Safety Milestones

12. Sharing Successes. The Armstrong Institute combines rigorous patient safety research with health system operations to create and deploy safety programs and metrics for measuring best practices. By 2015, all six hospitals are nationally recognized for high-quality care, and Johns Hopkins programs and safety metrics are adopted around the world.

Special Report: Fifteen Years of Patient Safety Milestones

13. Safety During Global Crisis. The Armstrong Institute develops a Web-based training program to educate health care workers in government-approved safety procedures for infectious disease outbreaks.

Special Report: Fifteen Years of Patient Safety Milestones

14. Helping Patients Make Informed Decisions. Johns Hopkins creates a user-friendly resource to help patients and their loved ones understand and compare quality and safety data across the institution.

Special Report: Fifteen Years of Patient Safety Milestones

15. Designing Safe Systems. Armstrong Institute leaders collaborate with Johns Hopkins engineers to develop Project Emerge, a tablet-based application that helps clinicians reduce preventable harms. Microsoft is working with the Armstrong Institute to bring Project Emerge to intensive care units across the nation.

More About the Armstrong Institute

Learn more about the Armstrong Institute and its programs: hopkinsmedicine.org/armstrong_institute