Technological Innovations To Promote Patient Safety, Engagement
By Michael Gropper, M.D., Ph.D.
In recent years, clinicians and hospitals have paid increasing attention to safety in the care experience and avoidance of preventable adverse events (PAEs). Of course, the practice of medicine is both an art and a science and is thus subject to human error. But with a “product” as critical and as delicate as human health, a commitment to the prevention of error — and to adopting the necessary tools to be successful — must be a top priority.
Lessons from the industry may be helpful to those of us in the healthcare community. Smart businesses such as manufacturing operations have an obligation to mitigate risk of error. More than nine of 10 workplace accidents are the result of human error, so companies often rely on systems processes — essentially checklists based on best practices — to establish safety protocols.
But research shows hospital checklists have met with mixed success. A March 2014 study published by The New England Journal of Medicine found little association between surgical safety checklists and reduction on complications or deaths following surgery. But that’s less a reflection of the efficacy of checklists and more a reflection of the fact that those checklists have been created in a silo without an underlying foundation of improved communication, collaboration, and transparency. The checklists themselves, based on identification of potential risks and processes needed to mitigate the risks, are still potentially powerful tools that can help reduce medical errors and improve care when integrated into hospital care.
As anesthesiologists, we seek to do everything in our power to protect patient safety and tailor a healthcare approach based on patient preference. That’s why my colleagues at UCSF and Johns Hopkins University used a similar systems engineering approach to improve performance and stakeholder engagement in the intensive care unit to reduce patient harms. A multidisciplinary team focused on seven priority harms associated with adverse events: delirium due to improper use of medication; weakness acquired associated with critical illness; ventilator-associated harms; blood clots; central-line associated bloodstream infections; loss of dignity; and failure to respect patients’ treatment goals and preferences. Then, the team developed an inventory of the tasks and work flows required to eliminate common harms experienced by patients in the intensive care unit.
Our collaboration led to the development of Project EMERGE, an “app” that can help clinicians avoid preventable medical errors. The EMERGE app functions more proactively than a checklist: it displays a graphical presentation that allows physicians to continuously visualize a patient’s risk of one of the seven harms, click on a displayed harm, and view safety concerns that needs to be addressed (in red) or risks that have been mitigated (in green).
Through their tablet, the care team can scan the “harms monitor” to ascertain, for example, whether blood thinners have been administered to avoid deep vein thrombosis, or whether the patient is being properly oriented to avoid hospital-induced delirium. This is particularly important for physician anesthesiologists who have to make quick medical decisions when seconds count. A critical component of the program is “CUSP” training (Culture of Unit Safety Program) whereby all providers in the ICU, including physicians, nurses, therapists, and others, are trained in the science of safety. Nearly 300 providers have been trained at UCSF to date.
The UCSF Department of Anesthesia and Perioperative Care has been developing the EMERGE app since May 2014. Our colleagues at Johns Hopkins, led by Peter Pronovost, MD, have found that the app has measurably improved safety practices, and that our input, based on front-line patient care before, during, and post-surgery, has played an instrumental role in refining the app.
It will also result in a more personal, human care experience for our patients. EMERGE’s seventh harm — “failure to respect patients’ treatment goals and preferences” — is arguably the most critical. This section of the app informs physicians about the patient — everything from how that patient likes to be addressed (Mrs. Smith vs. “Edna”) and their personal and professional background, to hopes and fears and preferences about their end-of-life care. This human factor, the most fundamental component of healthcare, not only recognizes of the value of patients as people, it establishes protocols to ensure that care teams are acting in accordance with this recognition.
Change does not happen overnight. A culture of safety is a sea change at hospitals that must focus on a culture of financial sustainability. We’re proud to play a role in the development of technological innovations, such as the EMERGE app, that is part of this culture change to improve patient safety.
About The Author
Michael Gropper, MD, Ph.D., is Chair of the Department of Anesthesia and Perioperative Care at the University of California, San Francisco School of Medicine. He is the principal investigator of Project EMERGE at UCSF, a comprehensive program to prevent harm and engage patients and families in their care in the ICU. Dr. Gropper has authored over 100 peer-reviewed publications and has received both NIH and private foundation funding for his work. Project EMERGE is funded by the Gordon and Betty Moore Foundation.