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Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out

How one doctor's checklist can help us change health care from the inside out

Date: May 15, 2010

Safe patients, Smart Hospitals

Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out
Peter Pronovost, PhD, MD; Eric Vohr (Penguin, 2010)

On February 22, 2001, Josie King, an 18-month-old girl who had been scalded severely in a home accident, died at Johns Hopkins Hospital. Her senseless death from dehydration and sepsis was entirely preventable, writes anesthesiologist and patient-safety advocate Peter Pronovost ’91. He cites an “archaic culture” of miscommunication in the PICU, which “disabled the care team so they did not recognize and act on the obvious signs” of the toddler’s deteriorating condition.

Josie King’s death forever changed Hopkins Medicine. Spearheaded by Pronovost, a professor of medicine and director of Hopkins’ Center for Innovation in Quality Patient Care, a revolutionary effort to improve patient safety was launched and ultimately spread throughout Hopkins Hospital—and to hospitals across the nation and overseas.

Others have written about the Josie King tragedy and how it inspired Pronovost to create a simple “pre-flight” checklist of safety procedures that has dramatically reduced potentially deadly central line catheter-related infections wherever it has been adopted and rigorously applied.

With Safe Patients, Smart Hospitals, Pronovost at last provides his own, deeply personal and compelling account not only of the Josie King case but of all that went before it in his life and career to motivate him to become perhaps the country’s best-known patient-safety crusader.

Pronovost’s book, written with Eric Vohr, provides a warts-and-all portrait of the sometimes dysfunctional interactions between physicians, nurses, residents, and others at Hopkins that have endangered—and sometimes ended—patients’ lives. He makes clear, however, that what he frequently describes as a “toxic culture” within various medical units “is not confined to Hopkins; it exists in all hospitals.” The checklist and other Pronovost innovations to improve communications can do much to eliminate that dysfunctional culture.

He describes the successful implementation of his ideas at Hopkins and in more than 100 intensive care units throughout the state of Michigan, as well as frustrations with their inadequate and less successful implementation in New Jersey and other states. His concepts are now being tested in Spain and the United Kingdom. Wherever properly adopted, they regularly save lives.

Although he met some resistance to his initiatives at Hopkins, Pronovost praises the support he always received from such senior Hopkins leaders as Dean/CEO Edward Miller and Hospital and Health System President Ronald Peterson.

Miller observes in the book, “Josie’s death had a huge impact on the institution and in some ways it allowed for a change of culture to occur.It is painful when you screw up, but you have to say I really screwed up. Senior leadership has to say we are going to expose our mistakes.”

Once exposed, ways must be found to prevent those mistakes from recurring—and thanks to Pronovost and his crusading colleagues, that has become Josie King’s enduring legacy, not only at Hopkins but worldwide. 

Neil A. Grauer