A decade ago, the Institute of Medicine released To Err Is Human, a report that raised awareness about medical errors in American hospitals and launched a patient safety movement. Since then, UCSF has been on the front lines of transforming how hospitals prevent medical errors by improving systemwide procedures, developing clinical and academic patient safety experts, and building a culture that encourages learning from mistakes.
“The quality of care for a patient has as much to do with the way the system works as it does with the brilliance or technical competence of an individual doctor,” said Robert Wachter, MD, professor and associate chair of the Department of Medicine at UCSF and a national leader in patient safety.
Seven years ago, UCSF Medical Center started a Patient Safety Committee. A few years later, Ernie Ring, MD, chief medical officer of UCSF Medical Center at the time, had the idea of adopting a pioneering method of conducting root cause analysis, an approach to error analysis and problem solving. Since then, UCSF’s strategy has been emulated by hospitals around the country.
“Of all the many things we’ve done to help keep our patients safe, it is probably the most innovative,” said Wachter.
The committee’s 15 members – all senior leaders within the hospital, including the chief operating officer, chief medical officer and chief nursing officer – meet for two hours every week to discuss recent or potential medical errors tracked through the hospital’s computerized Incident Reporting System or conveyed personally to the committee.
Using root cause analysis, which was first used to help understand the complex causes of accidents like Three Mile Island and the Challenger space shuttle disaster, the committee dedicates an hour of every meeting to analyzing a single case. The facts of the case are presented by the providers who were directly involved in the error. The focus is on understanding the underlying causes that allowed the error to occur and on collaborative problem solving.
An open and vigorous discussion ends with a clear action plan, which might involve implementing a new computer system, purchasing a piece of equipment, or training the doctors and nurses in communication strategies. A task force is established to develop and implement the solution. Follow-up is provided to the committee until the interventions are complete.
“We are very, very serious about dogging the follow-up until we’ve beaten it up and are completely satisfied that we have resolved whatever problem was out there,” said Associate Chief Medical Officer Adrienne Green, MD, who chairs the Patient Safety Committee.
In the early days of the patient safety field, root cause analysis meetings were scheduled as errors arose. Establishing weekly meetings created a reliable system for addressing cross-disciplinary medical errors and demonstrated the importance that UCSF places on patient safety, an idea also endorsed in UCSF's strategic plan.
Over the years, other institutions have implemented methods, based on the UCSF model, for analyzing errors.
The root cause analysis meetings have over time revealed problem themes. Chief among them is the importance of better communication between doctors and nurses, particularly as care is handed from one team in, say, the operating room, to another in the intensive care unit. As a result of committee meetings, the hospital has standardized attending-resident oversight, and has established new communication guidelines and checklists.
Consider the problems that can arise when seriously ill patients are transported from their rooms for an X-ray or other procedure in a different part of the hospital. The process used to be haphazard and prone to error. So the safety committee implemented a checklist of criteria for whether patients could be transported and, if so, what sort of personnel and equipment should accompany them.
“If you think about this from a patient’s point of view, or from a public point of view, it’s great,” said UCSF Chancellor Susan Desmond-Hellmann, MD, MPH. “You’re saying, ‘Hammer yourself; be tough on yourself.’ Patients shouldn’t get an infection when they come to the hospital. And they shouldn’t have an accident in the hallway.”
The safety committee has become a clearinghouse for tackling complex situations, but UCSF is also advancing patient safety and quality of care through other clinical and academic changes that have yielded impressive results.
Since 2008, UCSF Medical Center has decreased the incidence of bedsores by 51 percent; bloodstream infections caused by central lines by 56 percent; and pneumonia related to the use of ventilators by 71 percent. And thanks to a nursing program funded by the Gordon and Betty Moore Foundation, the readmission of heart failure patients over the age of 65 has fallen from 24 percent to 18 percent.
A decade ago, there was no emphasis on teaching trainees about safety and quality, whereas today, it is a required part the curriculum. “Quality improvement and patient safety are not just an integral part of patient care, but also an integral part of educating all of our trainees,” said Niraj Sehgal, MD, MPH, associate professor of medicine.
That priority is reflected in UCSF’s structure. For example, the Department of Medicine has long had associate chair positions devoted to research, education and clinical affairs. Recently, it added an associate chair for quality improvement and patient safety, and selected Sehgal to take on the role.
“My new job involves getting all of our divisions in the Department of Medicine to be doing the same kind of activities around quality improvement and patient safety, and learning from each other as they go,” said Sehgal. “When these activities become part of what you’re doing every day, they shift the overall culture.”
Photos by Susan Merrell