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Author: Hospitals Must Learn from Errors, Prevent Infections

Author: Hospitals Must Learn from Errors, Prevent Infections


March 01, 2010

When 18-month-old Josie King arrived at Johns Hopkins Children’s Center, she had blistering burns on 60% of her body, caused by scalding bath water produced by a broken water heater. Josie seemed to receive the best of care and had surgery to transplant skin grafts onto her scarred body.

Yet Josie’s mother, Sorrel, who slept on a cot by the girl’s side for weeks, noticed the baby getting sicker just days before she was supposed to go home. Josie was so thirsty, for example, that she resorted to sucking on a wet washcloth during her bath. Although Josie’s mother, nurses and a pain specialist all tried to voice their concerns, the surgeons in charge of the case didn’t listen.

By the time doctors recognized that Josie’s dehydration was caused by a serious infection, it was too late. Josie died after a preventable catheter infection — perhaps caused by someone who failed to take proper sanitary precautions — spread into her bloodstream.

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Josie was one of the thousands of patients who suffer as a result of a “toxic” hospital culture, in which doctors feel they need to be infallible and nurses and patients are afraid to speak up, says Peter Pronovost, a Johns Hopkins professor and author of the new book Safe Patients, Smart Hospitals (Hudson Street Press, $25.95).

Hospitals can’t improve if they don’t acknowledge their errors and try to learn from them, he says.

Doctors sometimes injure patients, for example, by inserting catheters too deep. And research shows that doctors use defibrillator machines incorrectly about 30% of the time. But Pronovost writes that no one redesigns these devices to make them easier to use safely “because no doctor wants to admit that he or she doesn’t know how to use it correctly.”

In an interview, Pronovost says Josie’s story has inspired him to help hospitals do better.

A program he developed saved 1,500 lives and $75 million in Michigan over 18 months, he says, by preventing “central line” infections like the one Josie developed. He is now working with hospitals in every state to implement his program, with funding from the federal Agency for Healthcare Research and Quality.

Pronovost says patients should be able to compare hospitals’ infection rates; however, relatively few hospitals even track them.

“In most hospitals in the country, the consumer would have no clue about what their infection rates are,” he says. “They’re entirely preventable, but there is no accountability.”

Pronovost’s safety program involves a checklist in which he condenses hundreds of pages of evidence into a few essential steps, such as making sure doctors wash their hands and wear sterile gowns before inserting central lines. To change hospital culture, he took the “unprecedented” step of putting nurses in charge of the checklist and giving them authority to stop doctors who skip a step.

Experts say Pronovost has been a leading voice in patient safety.

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