By Bruce Spiess, M.D. and Joyce A. Wahr, M.D.
In 2009, the first year of the FOCUS research project, Dr. Peter Pronovost and the Quality and Safety Research Group (QSRG) at Johns Hopkins Hospital (JHU). completed an extensive review of the cardiac patient safety literature and reviewed the National Heath Service (United Kingdom) error reporting database, focusing on cardiac surgical errors. From this rich background, QSRG developed an in-depth, two-day observational process to research operating room factors that contribute to human errors. This observational process was conducted in cardiac operating rooms at five separate hospitals. At each of the five sites, surgeons, anesthesiologists, nurses, perfusionists, surgical technicians and hospital executive management personnel participated. Each individual completed extensive surveys on motivation and patient safety culture, and observations were conducted over several days at each site. The surveys and observations have been coded into a database and used to create a taxonomy of errors and to develop interventions. The data collected are both informative and distressing. For example, errors were made in nearly every skin preparation procedure, and in nearly every programming of the “smart” intravenous pumps. These errors were made despite the high level of motivation to provide flawless care by the OR staff who were surveyed. The data are currently being analyzed and will be presented in a series of publications over the next 6-12 months.
Although the full analysis of the observations will not be complete for some time, the FOCUS Steering Committee and QSRG have identified three priorities for interventions to improve patient safety.
1. Develop a learning collaborative within the cardiac surgical teams to enhance patient safety. This process will use the Michigan Keystone model developed by Dr. Pronovost and the QSRG team that has been so successful in eliminating catheter based infections in the ICU setting. The FOCUS learning collaborative will use reduction in wound infections as the metric that will inform us of how we are doing.
2. Develop a peer-to-peer assessment tool that can be used by operating room teams to assess their own safety performance, or be used by an invited visiting team to provide feedback regarding areas for improvement in safety. This non-judgmental, for-internal-use-only peer-to-peer assessment tool will be based on the highly successful WANO (World Association of Nuclear Operators) process that has made the nuclear industry a “highly reliable” industry.
3. Design the operating room of the future. Tackle the issues of equipment and OR design to improve the interfaces between humans and the machines they use to deliver patient care in the operating room.
The FOCUS committee is looking for more sites and individuals to get involved in the project, whether it is on a committee, on a workgroup of the three priorities above, or as a site for one of the workgroups. Committees that you can be involved in include Data, Fundraising/Grants, Public and Society Relations, Patient Safety Initiatives Liaison, Publications, Site Selection, Speaker’s Bureau, and Summit Planning. To get involved and for more details, contact the SCA Foundation at firstname.lastname@example.org or call John Melleky, Executive Director at 804-565-6324.