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- Sayon Dutta, MD, MPH
- Christopher P. Landrigan, MD, MPH
- Kristen McNiff, MPH
- Richard I. Whyte, MD, MBA
Can medicine be safer with debriefing after every surgery? What about standardizing how doctors and nurses communicate about patients during shift changes? And, how do we apply patient safety research to ambulatory settings where most care is provided? Harvard researchers are investigating those questions and more as part of a patient safety grant project, now in its 20th year.
CRICO is the group of companies providing professional liability insurance and patient safety services to Harvard-affiliated medical institutions. This year, CRICO awarded $2 million in grants to fund 10 investigators who all aim to reduce medical errors and harm to patients.
“To me this is really exciting. I think it’s an opportunity to do something that’s really meaningful across different settings. Hopefully we’ll begin to change the game a bit.”
That’s Chris Landrigan, a pediatric hospitalist at Boston Children’s Hospital. He’s helping to lead a project to use standardized hand-off communication between providers going off shift and those who are coming on. It’s called I-PASS. Testing with residents, in a study published by the New England Journal of Medicine in 2014, showed a 30 percent reduction in preventable adverse events. Dr. Landrigan’s group is using the new CRICO grant to disseminate the elements of the I-PASS program in various clinical settings across several Harvard medical institutions.
“What should happen is that a team comes together—a change of shift for example—and that patient is presented in a very structured format that includes key safety elements that are very frequently ignored. They will include things like an explicit statement about how sick this patient is, a very discreet action list formatted in a certain way, a contingency plan thinking what might go wrong and what we are going to do about it, make sure everybody’s got a shared mental model about that. And as the receiving team takes ownership of the patient, they actually do a read back to make sure that they’re on the same page with the team that was passing the information off and there’s an opportunity for questions so there’s an exchange there as well.”
Along similar lines, another CRICO grant recipient is exploring the use of a debriefing session following surgery. Dr. Richard Whyte from Beth Israel Deaconess Medical Center is the principal investigator. The goals are to focus on transitions of care between the surgical procedure and postoperative period to identify where problems occur. Dr. Whyte points out that research has shown that communication failures often contribute to adverse surgical outcomes.
“Communications, it’s fertile ground for improvement. A lot of adverse outcomes, some of which are obviously just random, but the preventable ones are often attributable to communication failures. If we can improve communication between the caregivers, that’s going to hopefully decrease or improve long-term outcomes. So, the strategy is to sort of target where these communication failures occur.”
The project at Beth Israel Deaconess will also identify best practices and pilot the debriefing sessions across the hospital.
Another CRICO grant recipient is working to improve information sharing when a patient is discharged from the Emergency Department.
“So discharging somebody home is a pretty high risk thing because there’s often times where we don’t exactly know as emergency physicians what the true diagnosis is.”
Dr. Sayon Dutta is the principal investigator from Massachusetts General Hospital.
“We may think they look okay, their labs look okay, their vitals look okay and we think that they’re okay to go home. But often, because of the amount of data we generate in terms of how many things we order and how many vital signs are taken and all the documentation that nurses create and residents and PAs, there’s a lot to sift through before you actually discharge somebody. And, there are occasions where something slips through the cracks.”
As Mass General is implementing a new electronic health record system, Dr. Dutta’s team is determining whether the new data systems can flag specific areas of concern for each patient preparing for discharge. They will test an electronic alert for pending discharges when the patient still has abnormal vitals or when abnormal labs are returned.
When patients receive their care in the outpatient setting, patient safety can still feel a little bit like a new frontier. So, one of the CRICO grants is taking aim at identifying risks for adverse events in ambulatory oncology by using elements of the electronic health record as triggers. Kristen McNiff is the Vice President of Patient Safety at the Dana-Farber Cancer Institute in Boston, and principal investigator on the project.
“We’ll go through a process of testing, to make sure that the triggers that we identify—which could be things like lab results, or infections, or use of antidotes, or potentially admissions, and that sort of thing—are predictive of events if they are not events themselves.”
The patient safety risk and improvement research is new for this kind of setting, which McNiff says is different from other ambulatory care sites.
“Even if you’re looking at the oncology diagnosis itself, these are very complex and toxic treatments that we’re giving patients—again in an outpatient setting. So, it does open the door for the potential for some adverse events and we want to be sure that we are highly diligent and that we are doing everything we can to be able to identify those and to mitigate downstream risk.”
CRICO is owned by the Harvard medical institutions and has supported patient safety research, pilot innovations and the dissemination of proven solutions for decades, taking advantage of its close relationships with its insured providers and leaders at member institutions. Dr. Landrigan of Boston Children’s says the support is unique.
“I think it’s one thing to have done some prior tests that establish the proof of concept. I think it’s another thing entirely to really get institutions to move from that research mode into implementing this sort of a thing operationally. And, that to me is really the value of this funding from CRICO, where they have set things up in such a way that they really prompted the institutions to do exactly that.”
About the series
Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.