At Johns Hopkins Medicine, we recently held our fourth annual Patient Safety Summit, a daylong gathering in which faculty and staff from across our health system share their work to reduce patient harm and foster a culture of safety. The event has quickly become a tradition, with more than 425 participants flocking annually to our East Baltimore campus to sample from a wide range of presentations and network with colleagues.
As I attended the summit, I was struck by how much our own internal patient safety movement has matured, and it gave me hope for the future of the larger patient safety effort.
When we held the first summit in 2010, the enthusiasm for patient safety was high, but the science was not always at the same level. While many of the poster presenters were excellent clinicians and staff who offered thoughtful suggestions on how to improve patient safety, their work was frequently weak on data, used simple methods and lacked theory.
This year’s summit featured 75 posters and 43 presentations, but the scope and quality of the science was breathtaking. Watch this video to hear highlights from this year’s poster presenters.
Posters were submitted from all corners of Johns Hopkins. The study designs were rigorous, the theory was mature, the data was high quality, and the inferences were well-supported. The presenters identified opportunities for improvement and outlined strategies to reduce harm.
One study showed that fewer than 10 percent of patients with a cardiac stent receive the recommended anticoagulation medication during surgery. This presentation and many others allowed us to identify new opportunities to reduce preventable harm. Others focused on wound healing, staff safety, infections, blood clots, patient engagement, patient satisfaction, and reducing waste in health care.
Patient safety has been a focus of health care institutions for over a decade, yet there is little evidence to show that patients are safer overall than they were at the start of the millennium. Patient harm continues unabated. A significant reason for this lack of improvement has been the lack of rigorous science in the study of patient safety.
At Johns Hopkins, we have embraced science. We took the same discipline we use in basic and clinical research and applied it to safety, and now the results are starting to pay off. We took a scientific approach to reducing bloodstream infections across the U.S. and in other countries, and we are using that sound science to reduce preventable harms across Johns Hopkins Medicine. What I've seen at the Patient Safety Summit gives hope to patients, to Hopkins, and to the world that preventable patient harm can be eliminated.
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This is indeed an impressive collection of patient safety interventions and ideas. I have been practicing for a long time, note gray hair, and over the years I think the biggest safety measures have been standardized pathways for common conditions, i.e. stroke, pneumonia, DVT, etc.The standard order sets and algorythms have led to measurably improved patient outcomes in essentially all of the pathways used. Handwashing/ gel use programs are probably a close second.
It seems like this is the harvest reaped at Johns Hopkins from the persistent efforts of CUSP teams that have been working quietly behind the scenes throughout the year.
What makes this event remarkable is that the engine and driving force for this event are not famous keynote speakers, but empowered front line staff who are showcasing work that was done primarily from a passion for patient safety, rather than top-down mandates to "try harder".
Not every hospital may be able to do this on the scale that Hopkins is doing it, but every hospital should be doing this in some form.
I appreciate the inspiration-boost, and enjoyed your piece immensely.
Dear Peter,
I have only recently become aware of your work, and write to seek how you might assist the quality agenda in Australia, beyond what appears to be "spin" and lack of accountability of our national regulator. We have recently had the Medical Board in Queensland sacked, the trial of a surgeon allowed to practice when under significant sanctions in the USA, and 55 women contracted hepatitis while the anaesthetist involved was under the supervision of the Medical board. In the meantime, there is ongoing vilification of the whistle-blower, with events being responded to with a "who" approach, rather than "what". The loss of medical manpower through a confrontational review process appears to be at the core of causation the cost blowout in medicine in Australia.
I would be interested to develop a dialogue, while I continue to work through such avenues as a current legislative council parliamentary inquiry in Victoria, Australia.