patient safety

A powerful idea from the nuclear industry

by Peter Pronovost
September 3, 2013June 10, 2015
4 Comments

Where health care has fallen short in significantly improving quality, our peers in other high-risk industries have thrived. Perhaps we can adapt and learn from their lessons.

For example, health care can learn much from the nuclear power industry, which has markedly improved its safety track record over the last two decades since peer-review programs were implemented. Created in the wake of two nuclear crises, these programs may provide a powerful model for health care organizations.

Following the famous Three Mile Island accident, a partial nuclear meltdown near Harrisburg, Pennsylvania in spring 1979, the Institute of Nuclear Power Operators (INPO) was formed by the CEOs of the nuclear companies. That organization established a peer-to-peer assessment program to share best practices, safety hazards, problems and actions that improved safety and operational performance. In the U.S., no serious nuclear accidents have occurred since then.

A roadmap for patient safety and quality improvement

by Peter Pronovost
March 25, 2013June 10, 2015
5 Comments

This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.

An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.

A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.

Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.

Giving patients the big picture

by Peter Pronovost
October 18, 2011June 10, 2015
2 Comments

"I have a complicated medical situation that involves neurologists, surgeons, obstetricians, specialized ophthalmologists and others. I was at Johns Hopkins and very lucky to be because I had some of the best doctors in the country. What really struck me, though, was that each specialist was really very narrowly focused and really ne'er the twain did meet. I felt like it was up to me to put the pieces together into some kind of sensible picture in order to move forward to greater health. I will note that, for the most part, they had great bedside manner.”

Rhonda Wyskiel, an ICU nurse and staff member with the Armstrong Institute, was one of the guests on The Kojo Nnamdi Show last week when the radio host read these words from an e-mail, penned by a woman named Anne. Rhonda, one of three guests who appeared on the NPR-affiliated program to discuss the challenges of providing patient-centered care, acknowledged that this writer’s experience was common, and she empathized with Anne. As Rhonda pointed out, there are efforts at the hospital and national level to better coordinate care so that patients can have a central contact for when they have questions. For instance, in some ICUs, there is an intensivist who coordinates a patient’s care in that environment.

But Anne points out a problem that eats away at the quality of care that hospitals provide and leaves patients feeling confused: Too often, care is organized around providers rather than patients.