Strengthening a Culture of Safety

Published in Dome - January/February 2016

Fifteen years ago, 18-month-old Josie King died at The Johns Hopkins Hospital from medical errors that led to sepsis, a bloodstream infection that threatens the lives of patients in hospitals and nursing homes. With 750,000 cases and 250,000 deaths per year, sepsis is the 10th leading cause of death in the United States and the leading cause of inpatient death. Every hospitalized patient is at risk for contracting it.

Managing patients with severe sepsis and septic shock has become a priority for Johns Hopkins Medicine and the Armstrong Institute for Patient Safety and Quality. A new computer-based algorithm developed at Johns Hopkins can now predict which patients are at risk for this condition more than two-thirds of the time, providing a 60 percent improvement over existing screening protocols.

This is just one of the many innovations and new initiatives we have introduced since 2001, when leaders across Johns Hopkins Medicine came together to build a culture that could better ensure the safety of our patients. The story and details of that effort are offered in this special patient safety issue.

Our mission first took on special urgency in 1999 when the Institute of Medicine published its landmark study, “To Err Is Human.” For the first time, nearly 98,000 deaths annually in this country were blamed on medical errors. Last year, the institute released another disturbing report that says a wrong or delayed diagnosis will probably affect every one of us during our lifetime. “Improving Diagnosis in Health Care” concludes that misdiagnoses are more common, and often more dangerous, than hospital-acquired infections and mistakes in medication administration.

Many of our physician-scientists are working hard to change that. For instance, one method under study uses a device that tracks minute differences in eye movements to better diagnose strokes, which are often overlooked in female, minority and young patients. A preliminary study suggests this method is 99 percent accurate.

The Armstrong Institute and others across the organization continue to make headway in finding ways to improve patient safety. We have new safety dashboards to show our teams how they are performing, we are piloting a computerized “harms monitor” in the surgical intensive care unit at The Johns Hopkins Hospital and some of our divisions have chief quality officers.

We are also improving patient handoffs—one area of health care that is particularly vulnerable to errors in communication. Bedside reporting during shift changes, where the outgoing nurse introduces the patient and the treatment plan to the incoming nurse in the patient’s presence, is one way we are strengthening safe, seamless care. At Howard County General Hospital, leaders hold a safety briefing every day to discuss the status of the hospital—such as the number of available beds—the anticipated needs for the day, and any possible safety or security issues for patients, visitors or staff members. These meetings provide a venue for working collaboratively to address problems before they become threats.

Such initiatives are bearing fruit. This past year, The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital and All Children’s Hospital were honored by the Joint Commission’s Top Performer on Key Quality Measures program. The Top Performer designation is reserved for accredited hospitals that consistently perform at a very high level, following best practices for treating people who require surgery or suffer heart attacks, heart failure, pneumonia or other serious conditions. This is the third consecutive year that The Johns Hopkins Hospital has been so recognized.

That said, there is still work to do. Under Maryland’s hospital payment system, we must show improvements in quality measures, such as readmissions and hospital-acquired infections. Similarly, U.S. News & World Report has changed the formula it uses to rank hospitals, shifting weight from reputation to a handful of patient safety indicators.

Johns Hopkins Medicine is committed to providing the safest care possible. As medical complexity rises and treatment boundaries get pushed, however, opportunities for errors also abound. Along with the tremendous effort to heal our patients must come an equal determination to protect them from harm. Ensuring patient safety is a goal for which we are all responsible.