Duke University Health System has been steadily working to institute several measures to ensure patient safety over the past year and is striding forward with additional plans to continue to improve safety in the future.
A significant portion of DUHS' endeavors is targeted at revolutionizing the culture associated with care, involving front-line caregivers in the patient safety discussion and updating information technology systems to adequately address the needs of the ever-evolving medical field.
"Fixing these problems is everyone's job," said Dr. Marlene Miller, director of quality and safety initiatives at Johns Hopkins Children's Center and a consultant to Duke's Pediatric Patient Safety Program, a subprogram established for the pediatrics department. "The beginning step in safety is knowing where your risks are. Unless there is a cultural change and everyone feels it's their responsibility to speak up, it's hard to change."
To create a culture change, Dr. Gary Stiles, chief medical officer for DUHS, cited the need to move away from the "shame and blame" culture, the need to be data-driven and the need for appropriate metrics to measure a different set of data.
While Duke has always emphasized patient safety, the impetus for increased safety was threefold: the high expectations set for health care services, the increased regulatory environment and the heightened awareness because of greater access to information, said Robert Clapp, chief operating officer for Duke University Hospital.
"The consequences for mistakes are much greater now," Clapp said. In 1999, the Institute of Medicine presented a report that singled Duke out as an example of unsafe patient protocols. Although Stiles said the report presented nothing unique to Duke, the information elicited much national attention.
Since the report, DUHS has been steadily working to improve patient safety, but in light of the recent requests from the Centers for Medicare and Medicaid Services, DUHS has been put in place concrete mechanisms to address this issue, headlined by a search for a patient safety officer. The search will be completed as soon as possible so the candidate can step in at the beginning of the year. The patient safety officer's task will be to develop information technology systems and determine what structures are necessary to implement an effective system, Stiles said. DUHS is also focusing resources to hire more nurses, radiology technicians and respiratory technicians.
The health system is also implementing several new technologies, designed to minimize the potential for human error and maximize efficiency of treatment.
"It's more than information technology," said Asif Ahmad, chief information officer for DUHS. "It's reorganizing the hospital." He added that the major problem with health care IT is that it is the only major industry not federally regulated. Therefore, it has not kept pace with the rapid development of technology.
The lack of a centralized IT system throughout DUHS has caused there to be no continuity of patient care between various treatment outlets, such as outpatient clinics, the community hospitals within DUHS or DUH itself, and could lead to severe issues of patient safety.
The fix for this problem, Ahmad said, is eBrowser, a "broad system deployment" allowing for common database use by a large host of hospital staff. The system also triages results to physicians so they cannot miss lab results or other diagnoses.
Another technology--picture archiving and communication system--will allow physicians to access radiology data on their patients online, eliminating the need to chase down radiology films.
This step will save residents 7,000 to 10,000 hours per year, a critical conservation due to the recent implementation of the mandatory 80-hour work week for residents. Typically, interns and residents worked between 100 and 120 hours.
"Trainees provide a substantial amount of work," said Dr. Pascal Goldschmidt, chair of medicine. "We're essentially dealing with a major reduction in our workforce."
Goldschmidt said the residents' labor now has to be supplemented with other resources, and the hospital has to invest in human resource solutions to compensate for the difference in work.
In another safety measure, Dr. Karen Frush, chief medical director for Children's Services, has applied a color-coded system to children entering the Emergency Department, in an effort to streamline their care. The system color codes children based on height. Then, hospital staff use the medication and instruments that belong to the same color category. Since children are medicated based on their weight, the system helps avoid issues of miscalculation during a stressful procedure, Frush said.
"We're working on a concept trying to figure out how it could be more broadly applied," she added.
DUHS has also put in place a system in which all hospital staff can anonymously report adverse events or the potential for them in an effort to create a culture of safety, Ahmad said. The system was implemented in May and has seen a high volume of responses.
"Self-reporting systems allow people the concept of creating culture to talk about errors and identify new ways to solve problems," Frush said.
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